The scaphoid bone forms the radial part of the wrist and is susceptible to fractures due to its oblique orientation crossing two rows of carpus bones. It receives its blood supply from three main arterial groups. Common mechanisms of injury involve falls onto outstretched hands and forced wrist motions. Clinical evaluation for scaphoid fractures includes wrist pain, swelling over the anatomical snuffbox, and tenderness over the scaphoid tubercle. While initial x-rays may not detect up to 25% of fractures, other imaging like bone scans, MRI, CT, and ultrasound provide higher sensitivity. Fractures are classified based on location and displacement, with displaced fractures or those in the proximal pole requiring operative treatment

1. Blood Supply -Scaphoid
And Its Clinical
Importance
Moderator Maj.Dr Bishnu B. Thapa
Dr Gajendra Mani Shah
MS-OrthoResident
1st year NAMS
S

2. General features
S Forms radial part of the carpus.
S Lies obliquely 45 degree to longitudinal axes to 2 rows.
S Articulates with 5 bones…..
S Since it crosses two rows of carpus, it is more susceptible to
fracture.

5. Blood Supply
S Obletz & halbestin’s
1. 67% of scaphoid have arterial foramina throughout their length
2. 13%have blood supply predominately in the distal third.
3. 20 %have most foramina in the waist and one foramina near the
proximal pole.

6. S Talesnic & kelly
1. Lateral volar group
2. Dorsal group
3. Distal group

7. Gelberman & Menon

8. Mechanism of Injury
a. Fall onto outstretched hand
b. Forced dorsiflexion (usually beyond 95 degrees extension),
radially deviated wrist with intercarpal supination.
c. Palmar flexion in 3 % of cases (Leslie & Dickenson; Clay et al)

10. Clinical evaluation
(high diagnostic sensitivity, specificity approaches 74-80 %)
a. Wrist pain
b. Swelling and fullness off anatomical snuffbox - indicates effusion
c. Tender palpation of Scaphoid tubercle and anatomical snuffbox
d. Pronation followed by ulnar deviation cause pain
e. Slight reduction in range of motion
f. Reduced grip strength

11. Anatomical Snuffbox
Scaphoid tubercle palpation tenderness has a sensitivity of 87% and a specificity of
57% as an indicator of a scaphoid fracture

12. g. Provocative tests
S Scaphoid lift test: painful dorsal and volar ballottement.
S Watson test: painful dorsal Scaphoid displacement as the wrist is
moved from ulnar to radial deviation with compression of the
tuberosity.
S Scaphoid compression test: longitudinal force along 1 metacarpal
elicits pain.
S Resisted pronation causes pain.

13. Scaphoid compression test: The sensitivity 70.5% but the specificity is only 21.8%

14. Radiographic evaluation
(70 % sensitivity)
a. Standard PA
b. Lateral (wrist neutral)
c. 45 degree pronated oblique (STTJ)
d. 45 degree supinated oblique (Radio-scaphoid joint)
e. Scaphoid view (PA with ulnar deviation)
f. Others:
S PA with wrist in slight extension (Ziter view)
S AP with clenched fist to detect a ligamentous injury
Initial films non-diagnostic in 15-25 % of cases.

15. Other special investigations
S a. Technetium bone scan (92-95 % sensitivity; 60-95 %
specificity)
S b. MRI (90-100 % sensitivity; 90% specificity - false positives
because of bone bruises)

16. c. CT
S i. Less costly and readily available
S ii. Clearer visualization of fracture displacement
d. Ultrasound evaluation

17. Classification
Russe classification -Fracture pattern based
S Horizontal oblique (HO) 35 %, Transverse (T) 60 %, Vertical
oblique (VO) 5 %

18. S Herbert classification of Scaphoid fractures
Displacement based (stable or unstable)

20. Based on location
a. Tuberosity : 17-20 %
b. Distal pole : 10-12 %
c. Waist : 66-70 %
i. Horisontal oblique: 13-14 %
ii. Vertical oblique: 8-9 %
iii. Transverse: 45-48 %
d. Proximal pole 5-7 %

21. Avascular Necrosis

22. Management
a. Non-operative treatment
i. Indications:
1. Non-displaced distal third fractures
2. Tuberosity fractures

23. Expected time to union
Healing rate and prognosis
1. Distal third 6-8 weeks
1. Tuberosity and distal third - 100 %
2. Middle third 8-12 weeks
2. Waist - 80-90 %
3. Proximal third 12-24 weeks
3. Proximal pole - 60-70 %

24. b. Operative treatment
Indications:
1. Fracture displacement > 1 mm
5. Scapholunate angle > 60 degrees
2. Trans-Scaphoid peri-lunar dislocation
6. Humpback deformity
3. Unstable fractures (Herbert classification)
7. Non-union
4. Fractures known for AVN
• Proximal pole
• Vertical oblique
• Comminuted
• Diagnosed late (after 4/52)

26. References
1.
Apley`s System of Orthopaedics and Fractures
2.
Miller`s Review of Orthopaedics
3.
Campbell`s Operative Orthopaedics
4.
Chapman`s Orthopaedic surgery
5.
Internet