- A 64-year-old Thai female presented with right wrist pain after falling and catching herself with her right hand in the bathroom. - Examination found swelling and tenderness over the right wrist and pain with grip and wrist movement. - X-rays showed a non-displaced fracture of the right scaphoid bone. - She was placed in a thumb spica cast to immobilize the fracture.

1. Extern conference
Extern Irin Chaikangwan

2. Patient profile
• ผู้ป่วยหญิงไทยคู่ อายุ 64 ปี
• CC : ปวดมือขวา 10 hr PTA
• PI : 10 hrPTA ลื่นล้มในห้องน้าใช้มือขวายันพื้น ปวดบริเวณข้อมือขวา บวม ขยับแล้ว
เจ็บ ไม่มีส่วนอื่นกระแทกพื้น ไม่มีประวัติวูบหรืออ่อนแรงนามาก่อน ไม่ได้ไปรักษาที่ไหน วันนี้
อาการปวดข้อมือขวาไม่ดีขึ้นจึงมารพ.

3. Primary survey
• A : can speak, can active neck movement, not tender
along c-spine area
• B : no wound, symmetrical movement, clear no
adventitious sound
• C : BP 136/84 mmHg PR 84 bpm, capillaries refill < 2 sec
• D : E4V5M6, pupil 2 mm RLTBE
• E : no external wound, swelling right wrist

4. Secondary survey
• Allergy : none
• Medication : none
• Past Hx : no underlying disease, no smoking/ alcohol
drinking
• Last meal : 4hr PTA (19.00 น.)
• Event : as mention before

5. Head to toe examination
• Head & Maxillofacial : no wound
• Cervical spine & Neck : not tender along c spine are, full ROM of neck
• Chest : symmetrical movement, clear no adventitious sound
• Abdomen : Soft not tender
• Perineum : no wound, no abnormal bleeding
• Musculoskeletal : swelling of right wrist no external wound, tender at right
snuffbox, tender at scaphoid tubercle, limit hand grip wrist flexion and
extension due to pain, capillaries refill < 2 sec, intact pinprick sensation, pain
at scaphoid area on axial load
• Neurological : symmetrical movement all extremities

7. Investigation
• Film right wrist AP, Lat, Scaphoid view

11. Management
• Dx : non - displace right scaphoid fracture
• on thumb spica slab

12. Scaphoid fracture

13. Epidemiology
• Incidence
- most frequently fractured carpal bone
- 15% of acute wrist injuries
- incidence of fracture by location : waist 65%, proximal
third 25%, distal third 10% (esp. kid)

14. Mechanism of injury
• most common : axial load across hyper-extended and
radially deviated wrist

15. Anatomy
major branch
80% proximal via
retrograde blood flowminor branch
20% distal scaphoid

16. Physical examination
• Dorsal : Anatomical snuffbox tenderness
• Volar : Scaphoid tubercle tenderness
• Pain with resisted pronation

17. Imaging
• wrist AP and lateral

18. Imaging
• Scaphoid view
- extend wrist 30°
- 20° ulnar deviation
• *** if highly suspicious but radiographic negative should
repeat radiograph at 14-21 days

19. Imaging
• Bone scan : effective to diagnose occult fractures at 72 hr
- specificity 98% sensitivity 100%
• MRI : most sensitive for diagnosis occult fracture < 24 hr,
can also assessment vascular status ; AVN
• CT scan with 1 mm cuts

20. Treatment
• non-operative
- Thumb spica cast immobilization
indication : stable non displaced fracture
normal x-rays but highly suspicious
technique : early immobilization ( delay immobilization > 4wk increase non-union
rate )
duration : distal waist 3 mo
mid-waist 4 mo
proximal third 5 mo
athletes waiting until imaging show a healed fracture

21. Treatment
• Operative
- ORIF with percutaneous screw fixation
- indication “unstable fracture”
proximal pole fracture
displacement > 1 mm
15° scaphoid humpback deformity
radiolunate angle > 15°
intrascaphoid angle > 35°
comminuted fractures
unstable vertical or oblique fracture

22. Complication
• Non-union
• Malunion
• Delayed union
• Avascular necrosis
• DISI ( dorsal intercalated segmental instability ) - instability of
wrist from disruption of dorsal intercarpal ligament
• SNAC wrist : advanced collapse and progressive arthritis of
the wrist that results from chronic scaphoid non-union