Edited by Christina Liu and CJ Nessralla - 7/1/2021
Descriptors
Pole fractures (proximal and distal) and waist fractures
Exam Pearls
Exam-hand
Scaphoid specific exam maneuvers:
Anatomic snuffbox or scaphoid tubercle tenderness
Scaphoid compression test - Axial load applied through thumb MC results in pain at the scaphoid
Workup
Radiographs:
PA/lateral/oblique XR of wrist (sometimes PA/lateral XR of hand will have already been done, no need to get wrist films)
If no obvious scaphoid fracture on standard wrist films, can ask for scaphoid view (AP XR with wrist supinated 30deg and in ulnar deviation), pronated oblique view, or CT of carpus
Other imaging: None (MRI/CT can be considered on outpatient basis at provider's discretion)
Labs: None
Other: None
Management
Hand consults should be staffed with attending/fellow prior to definitive management.
Need for acute intervention: Yes, immobilization in a thumb spica splint, can plan for repeat XR in 2 weeks to evaluate for occult fx vs CT of the wrist in the ED.
Weight-bearing and range of motion: NWB, no wrist ROM
Type of immobilization: Thumb spica splint
Admission or discharge status: Discharge, follow up 1-2 weeks in hand clinic for repeat XR (often will become visible by 2 week period)
Anticoagulation: NA
Antibiotics: NA
Surgical Indications
Absolute: NA
Relative: Young healthy/active patients with proximal third fx (risk AVN/nonunion)
10deg angulation
1mm displacement
Comminuted
Radiolunate angle >15deg
SL angle > 60deg
Intrascaphoid angle > 35deg
Nonunion
Not an indication: distal ⅓ fractures, tuberosity fx, elderly/low activity
Nondisplaced or minimally displaced (<1mm) fractures of the waist is a relative indication for surgery to come out of cast sooner and sooner return to play.