Scaphoid fracture

Clinical History

The patient attended the emergency room with intense pain in the right anatomical snuffbox after a fall. The X-ray was interpreted as normal and the patient discharged.
A week after the patient returned and did another X -ray where a fracture could was depicted, and CT was performed for better evaluation.

Imaging Findings

Initial X-ray:
Interpreted as normal by the resident physician but with careful attention a fracture can be depicted.
2nd X-ray:
Line of fracture can be clearly depicted in the frontal projection.
CT at the 2 visit.

Fracture of the proximal 1/3 of the right scaphoid not consolidated, aligned, persisting central non-union with cystic transformation.
No other fractures associated or complications of any kind.
No small parts alteration.
Without articular effusion.

Discussion

The eight carpal bones and their corresponding ligaments can be divided into two horizontal rows with the proximal consisting of the scaphoid, lunate, and triquetrum. [2, 3]
Scaphoid fracture is the most common carpal fracture most often affecting active men [4]. The most common mechanism is hyperextension, after a fall on an outstretched hand with forced dorsifexion of the wrist [4].
They are often missed with the use of conventional radiographs alone. Initial radiographs detect at most 70% of all scaphoid fractures [1]. Anterior-posterior and lateral radiographs should be standard.
Even on the repeated radiographic exam after 10-14 days propagated by many clinicians in case of an occult fracture, a scaphoid fracture may be missed [1].

CT has an increasing role in the evaluation of patients with suspected scaphoid fractures but negative radiographs. The reported sensitivities and specificities of CT are 89%–97% and 85%– 100%, respectively [3, 5, 6]
Several fracture classification systems exist for the documentation of scaphoid fracture. Russe classification system [5] based on the orientation. Vertical oblique fractures were considered the least stable and most likely to require surgical intervention. Cooney et al [5] proposed that scaphoid fractures be considered as either nondisplaced or displaced. Herbert [6] proposed a more detailed classification scheme. Because each of these classifications emphasizes a particular aspect of the fracture, the radiologist should fully characterize the fracture and include the orientation of the fracture, displacement, and angulation.
Scaphoid non-union has been associated with the development of late arthritis of the wrist, and this pattern is commonly referred to as scaphoid non-union advanced collapse [7].
Inconspicuous radiographs in the presence of snuffbox tenderness, and wrist trauma history demand immobilization or imaging [6]. When immobilized, repeat radiographs should be done after 7 to 10 days [7]. Cystic changes and fragmentation may occur.
Any intervention may be modified based on patient hand dominance, effort, and fracture location [8]. Patient factors notwithstanding, nondisplaced stable fractures can be treated with a cast, with success of almost 95% [8]. Healing times average 8–12 weeks for the nondisplaced fracture [7, 8]. A scaphoid fracture is not considered united unless progressive loss of fracture line visibility on imaging is documented (8). In our case the orthopaedic surgeon decides to place a cast in the hand and the patient will go to rehabilitation after healing.
Take Home messages
- Scaphoid fracture is not necessarily excluded with conventional radiography
- Sequelae of scaphoid fracture are common
- Close follow-up is mandatory

Differential Diagnosis List

Final Diagnosis

Scaphoid fracture

URL:	https://www.eurorad.org/case/13912
DOI:	10.1594/EURORAD/CASE.13912
ISSN:	1563-4086