Anatomy Msk · Year 1 · from Anatomy Msk
Case 1: Scaphoid Fracture
Clinical Image
Source: Wikimedia Commons - Scaphoid Fracture - CC BY-SA 3.0
Case Presentation
An 18-year-old college student presents to urgent care 2 days after falling off his skateboard. He landed on his outstretched right hand and has had persistent wrist pain since. He initially thought it was "just a sprain" but the pain has not improved. He reports pain at the base of his thumb that worsens with gripping and thumb movement. Physical examination reveals tenderness in the anatomical snuffbox (bordered by the extensor pollicis longus medially and extensor pollicis brevis/abductor pollicis longus laterally), as well as pain with axial loading of the thumb and tenderness over the scaphoid tubercle on the volar wrist. Initial radiographs, including scaphoid views, appear normal without obvious fracture. Given the high clinical suspicion, a thumb spica splint is applied and he is scheduled for repeat X-rays in 2 weeks. Follow-up radiographs reveal a nondisplaced fracture through the scaphoid waist with early resorption at the fracture line. MRI is obtained which confirms the waist fracture without evidence of avascular necrosis. He is placed in a thumb spica cast for 8 weeks, and follow-up imaging confirms union.
Key Learning Points
- The scaphoid is the most commonly fractured carpal bone, typically from a fall on an outstretched hand (FOOSH)
- The anatomical snuffbox is the classic location of tenderness for scaphoid fractures
- Initial radiographs may be negative in up to 20% of scaphoid fractures; follow-up imaging or early MRI is essential
- The scaphoid blood supply enters distally, placing proximal pole fractures at high risk for avascular necrosis
- Delayed diagnosis leads to nonunion, avascular necrosis, and scaphoid nonunion advanced collapse (SNAC) arthritis