Work Up for Scaphoid Frx

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- History and Exam:
    - fracture of the scaphoid is suspected w/ fall on an outstretched hand;
    - snuff box tenderness (see clinical differential diagnosis:)
            - scaphoid impaction syndrome
    - tenderness to palpation over scaphoid tuberosity and/or proximal pole just distal to Lister's tubercle;
    - limitation of wrist flexion and extension;
    - tenderness w/ axial compression of thumb toward the snuff box;
    - tenderness as pt supinates forearm against resistance;
    - radial & ulnar deviation results in pain on radial side of wrist;
    - forced dorsiflexion usually elicts significant tenderness;
    - references:
            Diagnosis of scaphoid fractures. A prospective multicenter study of 1,052 patients with 160 fractures.
            New clinical test for fracture of the scaphoid.
            Clinical fracture of the carpal scaphoid--an illusionary diagnosis.
            Scaphoid tubercle tenderness: a better indicator of scaphoid fractures

- Radiographs for Scaphoid Frx:
    - non diagnostic radiograph   (bone scan)
    - classification: tubercle, waist, or proximal 1/3;
    - specific views:
            - scaphoid view: (AP w/ 30 deg supination & ulnar deviation);
            - pronated olblique (for the STT joint)
            - lateral view
            - PA of wrist w/ ulnar & radial deviation;
                  - any displacement that is shown at frx site indicates significant
                        instability, making internal fixation rx of choice;
    - determination of stability;   (CT scan)
            - differentiate between stable and unstable acute frxs, since it appears
                  that former have a low incidence of complications and thus require
                  only minimal immobilization in plaster;
            - as determined from CT or X-ray;
                  - > 1 mm of step off ... or...
                  - > 60 deg of scapholunate angulation ... or ...
                  - > 15 deg of lunocapitate angulation
                  - w/ CT Scan: PA angulation > 35 deg; or lateral interscaphoid angulation > 25 deg;
                  - displacement or angulation w/ radial or ulnar deviation;
    - associated injuries:
            - distal radius frx
            - transscaphoid perilunate dislocation:

- Treatment:
      - non-displaced fractures
            - casting of scaphoid frx
      - surgical treatment of displaced frx
            - Herbert screw fixation of scaphoid fractures:
            - 3.5 mm cannulated screw fixation

- Complications:
      - nonunion of scaphoid
            - non union of proximal pole
            - Russe technique
      - avascular necrosis of the scaphoid
      - SLAC or SNAC wrist

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