Scaphoid Fractures

There's loads of really good FOAMEd resources out there already about scaphoid fractures. It's common (2-7% of all fractures), and most commonly occurs in young people as result of FOOSH.

Anatomy - look at Emergency Medicine Ireland. It's fabulous, why do anything else?
 
Clinical Examination
Clinical examination is rubbish, but a combination of ASB tenderness (90% sensitivity, 40% specificity), thumb axial compression and scaphoid tubercle tenderness (57% specificity) is the best way.

Imaging
You might see:
- visualisation of the fracture +/- displacement
- soft tissue swelling and lateral displacement of the adjacent fat pads
- scaphoid fat pad sign - formation of a straight/convex line adjacent to the concave aspect of the scaphoid
- associated scapholunate ligament disruption (Terry Thomas sign)
Helpfully, 25-30% have normal x-rays.
Ultrasound is not sensitive enough. Most places go for CT  or MRI.

Management
If radiologically confirmed, no displacement, POP and fracture clinic.
        Distal 1/3 -  6-8 weeks.
        Middle 1/3 – 8-12 weeks.
        Proximal 1/3 – 12-23 weeks.
If radiologically confirmed + displacement, speak to plastics.

If no radiological evidence, splint and bring back to fracture clinic. Thumb extension is not needed, as long as there is no ulnar deviation.

Complications
Avascular necrosis occurs in 30-40% of untreated fractures. It is less than 10% in undisplaced fractures. Non-union occurs in 5-12% of treated fractures, and the incidence of complications increases with proximal pole fractures.
80% of patients are immobilised unnecessarily.

References
http://www.enlightenme.org/knowledge-bank/cem-ctr/early-ct-clinically-suspected-scaphoid-fractures
http://bestbets.org/bets/bet.php?id=2003
http://bestbets.org/bets/bet.php?id=1687
http://bestbets.org/bets/bet.php?id=1673
http://lifeinthefastlane.com/scaphoid-fractures-the-ed-perspective/
http://emergencymedicineireland.com/2012/06/anatomy-for-emergency-medicine-19-scaphoid-fractures/
http://blogs.bmj.com/bjsm/2013/12/16/current-management-of-occult-scaphoid-fractures-in-uk-emergency-departments/
http://radiopaedia.org/articles/scaphoid_fracture
http://foam4gp.com/2013/11/15/foam4gp-map-scaphoid-fractures-thumbing-through-the-research/
http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_upper_limb/wrist_trauma_x-ray.html
http://shortcoatsinem.blogspot.co.uk/2012/03/heeling-scaphoid-terrible-pun-intended.html