Intended for healthcare professionals

Practice Easily Missed?

Fractures of the scaphoid

BMJ 2020; 369 doi: (Published 27 May 2020) Cite this as: BMJ 2020;369:m1908
  1. Onur Berber, consultant orthopaedic hand surgeon1,
  2. Imtiaz Ahmad, general practitioner, head of medical services23,
  3. Sam Gidwani, consultant orthopaedic hand surgeon4 5
  1. 1The Whittington Hospital, London, UK
  2. 2South Lambeth Road Practice, London, UK
  3. 3Queens Park Rangers Football Club
  4. 4Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  5. 5London Bridge Hospital, London, UK
  6. Correspondence to Sam Gidwani

What you need to know

  • The most sensitive clinical sign of scaphoid fracture is anatomical snuffbox tenderness, but it has low specificity (ie, a high rate of false positives)

  • The first line investigation is a four-view scaphoid radiograph series, but negative radiography does not rule out fracture

  • For patients with a clinically suspected scaphoid fracture but normal radiographs, the next step is wrist immobilisation and further imaging, preferably a magnetic resonance imaging scan

  • Patients with scaphoid fractures that are missed are more likely to develop a non-union, and potentially post-traumatic osteoarthritis of the wrist

A 25 year old man sustains an extension injury of his right wrist while playing football as a goalkeeper, and presents to the emergency department the same day with wrist pain. Examination reveals tenderness over the radial side of the wrist, including within the “anatomical snuffbox,” as well as tenderness over the tubercle of the scaphoid. However, he has no pain on longitudinal compression of his thumb. Standard posteroanterior and lateral wrist radiographs are performed (fig 1) and as no fracture is seen, he is discharged. He re-attends six weeks later with ongoing pain, and a series of scaphoid radiographs (fig 2) show a fracture of the proximal third of the scaphoid.

Fig 1

Initial radiographs obtained in the emergency department with and without labels. These only included standard (a) posteroanterior and (b) lateral views of the wrist. No scaphoid fracture was visible on these views. Scaphoid (Sc) marked with a dashed white line; trapezium (Tm) marked with dotted white line, and trapezoid (Td) marked with dotted black line

Fig 2

Scaphoid views performed six weeks after the injury. Three of the standard scaphoid series are presented including (a) posteroanterior, (b) pronated oblique, and (c) Ziter views. A proximal pole fracture is clearly seen on the pronated oblique and the Ziter views. The fracture is …

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