149. Scaphoid Fractures & the High Cost of Poor Management

In this episode of PT Snacks podcast, we dive deep into scaphoid fractures, a common yet often mismanaged injury in younger and active individuals. Listeners will learn about the anatomy of the scaphoid bone, the typical mechanisms of injury, common diagnostic challenges, and both conservative and surgical treatment options. We explain the importance of recognizing and adequately managing these fractures to prevent complications like avascular necrosis and non-union. Tune in to enhance your knowledge and clinical skills regarding this significant topic in physical therapy.

00:00 Introduction and Welcome

00:44 Topic Overview: Scaphoid Fractures

01:21 Anatomy of the Scaphoid

03:29 Mechanisms and Risk Factors

04:27 Diagnosis and Imaging

05:11 Differential Diagnosis

05:59 Symptoms and Clinical Examination

06:36 Treatment Options

07:40 Conclusion and Additional Resources

References

1. Steinmann S, et al. Scaphoid fractures and nonunions: diagnosis and treatment. J Orthop Sci. 2006.
2. Rhemrev S, et al. Current methods of diagnosis and treatment of scaphoid fractures. Int J Emerg Med. 2011.
3. Clementson M, et al. Acute scaphoid fractures: guidelines for diagnosis and treatment. EFORT Open Rev. 2020.
4. Krasin E, et al. Review of the current methods in the diagnosis and treatment of scaphoid fractures. Postgrad Med J. 2001.
5. Krimmer H, et al. [Scaphoid fractures—diagnosis, classification and therapy]. Unfallchirurg. 2000.
6. Clementson M, et al. [Scaphoid fractures – Guidelines for diagnosis and treatment]. Lakartidningen. 2019.
7. Pickrell BB, et al. Update on management of scaphoid fractures. Plast Reconstr Surg. 2024.

Transcript

0:31

Hi everyone. Welcome to PT Snacks podcast. This is Kasey, your host, and if you're tuning in for the very first time, first of all, welcome. But what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals and by sci segments of time. Now, today we're gonna be covering scaphoid fractures, but before we do if you've been listening to the show and you've listened to at least three and found them to be helpful, if you would not mind leaving a review wherever you listen to reviews, that would mean the world to me.'Cause those really do make a big difference for the show. And if you've already done so, thank you so much. I really appreciate you taking the time to, help Peet snacks really. But today, diving into the topic, scaphoid fractures, you might be wondering, ugh, why are we going over a wrist and hand depending on what your patient population is. But this is actually one of the most common carpal fractures to happen. Happens in a lot of younger and active people, and it's oftenly mismanaged. So I do feel it's important to cover, just to have on your radar and. Be able to recognize it so that we can do right by these patients. So we're gonna cover anatomy, how it happens, what we assess for differentials, and what do we do about it. Diving into anatomy, if there's a lot of stuff in the wrist and hand and a lot of detailed stuff. But keep in mind that the scaphoid is the largest of eight carpal bones. The special thing about it in this scenario is that it gets its blood supply from two different sources. So one source is from a branch of the radial artery, the dorsal carpal branch that enters the dorsal ridge and supplies 80% of the proximal pole via retrograde flow. That's an important component, retrograde. The other source is from the superficial Palmer branch, which is a branch of the Vola Radiar, the vola radial artery, and that enters the distal tubercle and supplies the distal pole. So we have two different pulses. We have proximal and distal, and in the middle portion we call the waist. Now, fractures at the waist of the scaphoid do have a high risk of avascular necrosis at the waist. It's common for 65% of these fractures to develop a VN. And it can even go up to as high as a hundred percent risk of avascular necrosis at the proximal segment. Why you might wonder keep in mind the blood flow, right? So the proximal pole gets its blood supply from retrograde flow. But if there is a fracture and it is not able to get that retrograde flow, it can't get. Blood supply and we know that blood supply is extremely important for healing. Therefore, if it is not able to heal, there can be a high risk of Non-Union disability. Avascular necrosis, all those things. So we don't really want this to happen, but unfortunately, scaphoid fractures account for two to 7% of all fractures and 60 to 70% of carpal bone fractures. And even more, unfortunately, it's often misdiagnosed as wrist pain. So when we are talking about how this happens. Usually the mechanisms of the injury is from a foche or a fallen outstretched hand. More specifically falling on that outstretched hand. What we're doing is we're adding an axial load to the wrist, enforced hyperextension and radial deviation, and this can cause a fracture as the scaphoid impacts the dorsal rim of the radius. So pretty common in contact sports, road traffic accidents, but it can also be from tumors, infections, other pathological sources. The most common age is gonna be a mean of 29, and it's higher in males. Reasoning. Why is in pediatric patients, usually the FSIS is gonna fracture first, and in the elderly, the distal radius is more likely to fracture first. So won't see this quite as often. Hence young adults, right? Now these patients may have imaging usually the first line of defense is gonna get an x-ray, but an x-ray, it's estimated to miss 25% of fractures. So if there's a high suspicion things are just not making sense or your patient's symptoms are. Really, they seem more severe. An MRI or a CT is gonna be definitely recommended because they have a lot higher sensitivity to be able to catch a scaphoid fracture. But if they do have an x-ray, it's most likely gonna be PA and lateral views of the wrist with scaphoid views. So let's say maybe they don't have imaging, or maybe they do and you're looking at, okay, what is going on here? Some good lists to. To think through on your differentials in terms of other potential fractures or things of that sort would be, is this a distal radial fracture? Or another carpal bone fracture. That's why it's important to review your anatomy and have good palpation skills. Could it be a scapholunate dissociation? Or is it even bone related at all? Does it make sense with their history? Was there a traumatic mechanism of injury or was it something that kind of just happened? Mildly out of nowhere, are we actually looking at something like a que vein, tenino synovitis, or tendonitis of some sort. So the symptoms should line up pretty well with their history. That's why it's important to ask lots of good questions. Now beyond asking questions, we do wanna look and see if there's potentially some pain and swelling at the base of the thumb, especially in the anatomic snuff box. They may have decreased pain-free range of motion in their wrist. We can palpate the snuff back. Snuff box and the scaphoid tubercle to see if it's tender or add compression to the scaphoid. See if that reproduces their pain or if they have pain in the anatomic snuff box with ulnar deviation, which is the opposite direction. Now, in terms of treatment, let's say we're pretty sure that they have a scaphoid fracture. What happens next really depends on. The degree of fracture that there is. So if the fracture is minimally displaced or non-displaced, it can be managed conservatively with a cast and mobilization and you're just waiting for a union to happen. But where the fracture occurs on the scaphoid definitely has an impact on healing time. For instance, the proximal pole, a fracture there can take as long as 12 to 24 weeks, whereas at the distal pole, it can take six to eight weeks. It's a totally different thing. And if surgery is on the table for this patient, that probably means that they had a displacement greater than one millimeter. They have a humpback deformity. They had a fracture at the proximal pole because there's a high risk of malunion, so they just wanted to go ahead and fixate it. Or if it's a commun communed, common muted. A comminuted fracture. There's just so many pieces. They wanna make sure that they're all approximated together while they're healing. So that is scaphoid fracture. Important thing, review your anatomy. Understand how blood flow affects potential for healing if things are altered and and get really good at being able to identify this, whether this is someone that's coming into your clinic or you're working sideline at a game, things like that it's good to know right now. If you have any questions, feel free to reach out at PTs x podcast@gmail.com. I don't take patients via podcast, if that makes sense. So if you're asking for personal reasons, it's definitely best to go in and see a clinic. But if you have. Questions relating to content, podcasts, et cetera. Feel free to reach me there. Other news, med Bridge is actually offering listeners over a hundred dollars off their subscription just for being a listener. So definitely check out the show notes for that promo code. But basically what they offer is. Tons and tons of CEU courses. They have lots of webinars and even specialty exam prep. I used their resources for studying for my OCS and it has a ton of practice exams resources, study materials. Super helpful. So definitely check that out. And if you're a student, there's an even better deal for you. The promo code is also in the show notes, but make sure you use that one'cause you get a better deal. But other than that, I hope you guys have a great rest of your day and until next time.