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Scaphoid Fracture S62.009A 814.01

ICD-9 Classification / Treatment
Etiology / Natural History Associated Injuries / Differential Diagnosis
Anatomy Complications
Clinical Evaluation Follow-up Care
Xray / Diagnositc Tests Review References

synonyms: navicular fracture, carpal navicular fracture

Scaphoid Fracture ICD-10


A- initial encounter for closed fracture

B- initial encounter for open fracture

D- subsequent encounter for fracture with routine healing

G- subsequent encounter for fracture with delayed healing

K- subsequent encounter for fracture with nonunion

P- subsequent encounter for fracture with malunion

S- sequela

Scaphoid Fracture ICD-9

  • 814.01(closed)
  • 814.11(open)

Scaphoid Fracture Etiology / Epidemiology / Natural History

  • Most common carpal fx. (70% of carpal fractures)
  • Generally from fall on outstretched hand.
  • Most common mechanisms of injury include: hyperextension and "punch" mechansim. During "punch" mechanism the force is transmitted to the distal pole of the scaphoid through the index metacarpal and trapezoid.
  • typically young, working males; average age=25 years,
  • Annual incidence = 4.3/10000 people (Hove LM, Scand J Plast Reconstr Surg Hand Surg 1999; 33: 423-426).

Scaphoid Fracture Anatomy

  • Proximal pole is completely intraarticular and recieves blood supply from distal pole
  • Superficial palmar branch of radial A volarly & dorsal capsal branch of radial A dorsally(80%)
  • The majority of the blood supply to the scaphoid enters at the dorsal ridge.
  • 65%waist fx, 25%proximal pole, 10%distal pole
  • Enchondral ossification of the scaphoid begins at 5yrs 9 months in males and concludes at 15 yrs 3 months in males. It begins at 4yrs 5 months and concludes at 13 yrs 4 months in females (Stuart HC, Pediatrics 1962;29:237)
  • Bipartite scaphoid occurs rarely and may represent asymptomatic nonunion (Doman AN, J Hand Surg 1990;15Am:869).

Scaphoid Fracture Clinical Evaluation

  • Snuffbox tenderness
  • Scaphoid tubercle tenderness
  • Pain with axial loading of 1st metacarpal

Scaphoid Fracture Xray / Diagnositc Tests

  • PA, Lateral, Scaphoidviews of the wrist. Consider fisted PA view and posteroanterior grip view.
  • CT scan: demonstrates the exact amount of displacement and loss of intrascaphoid and intercarpal alignment.
  • MRI: helpful for occult acute fractures (especially proximal pole) and determining vascularity of scaphoid nonunions.
  • Bone scan diagnostic at 48hrs (100% sensitive, 98%specific)

Scaphoid Fracture Classification / Treatment

  • Stable (displacement <1mm, normal intercarpal alignment, Distal Pole fracture ): Short arm cast; consider percutaneous fixation. Contraindications to casting: displacement or angulation, small proximal pole fracture, concomitant scapholunate ligament injury, ipsilateral distal radius fracture, perilunate dislocation.
  • Unstable (displaced >1mm, any proximal pole fracture, scapholunate angle >60º, any angulation, lateral intrascaphoid angle >35°, comminution): immediate percutaneous fixation due to @10% nonunion rate with cast treatment and significant morbidity of time off work, and activitiy limitations from cast treatment. Condiser ORIF if unable to achieve anatomic reduction percutaneously. (Rettig, J Hand Surg 26A:271;2001)
  • Proximal pole fractures are unstable even when initially aligned = 30% nonunion rate with cast treatment. (Gutow AP, JAAOS 2007;15:474).

Scaphoid Fracture Associated Injuries / Differential Diagnosis

  • Scapholunate instability
  • Bennett's Fx
  • Distal radius Fx
  • Scaphoid Fx
  • Preiser's Disease

Scaphoid Fracture Complications

  • Nonunion=failure to heal in 6 months. 5-10% for undisplaced, up to 90% for displaced proximal pole. (Hambridge JE, JBJS 1999;81Br:934).
  • AVN: 30% of prox 1/3rdfx, 100% of prox 1/5 fx
  • CRPS
  • Hematoma
  • Infection
  • Nerve or vascular injury
  • Stiffness
  • Casting Complications: disuse muscle atrophy and osteopenia, delayed union, nonunion, pressure nerve palsies, cast sores / pressure sores.

Scaphoid Fracture Follow up  care

  • Post-Op: Place in volar splint. Encourage digital ROM, elevation.
  • 7-10 Days: remove splint. Place in short arm spica thumb spica cast. Consider removable splint with gentle ROM if fixation was extremely secure.
  • 6 Weeks: Cast removed. Check xrays. Started gentle ROM exercises. Activity modifications: no heavy manual labor, no contact sports, no lifting >5 lbs.
  • 3 Months: Check xrays. If union is complete return to full activities.

Scaphoid Fracture Review References

  • Greens Hand Surgery
  • Cooney WP III: Scaphoid fractures: Current treatments and techniques. Instr Course Lect 2003;52:197-208.
  • Cooney WP, Linscheid RL, Dobyns JH, Wood MB: Scaphoid nonunion: Role of anterior interpositional bone grafts.  J Hand Surg Am 1988;13:635-650.
  • Fernandez DL: A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability.  J Hand Surg Am 1984;9:733-737.
  • Stark HH, Rickard TA, Zemel NP, Ashworth CR: Treatment of ununited fractures of the scaphoid by illiac bone grafts and Kirschner-wire fixation.  J Bone Joint Surg Am 1988;70:982-991.
  • Feldman MD, Manske PR, Welch RL, Szerzinski JM: Evaluation of Herbert screw fixation for the treatment of displaced scaphoid nonunions.  Orthopedics 1997;20:325-328.

 

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