9.23 Scaphoid (Carpal Navicular) Fracture
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agk's Library of Common Simple Emergencies

Presentation
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The patient (usually 14-40 years old) fell on 
an outstretched hand, with the wrist held rigid 
and extended, and now complains of pain, 
swelling, and decreased range of motion in the 
wrist, particularly on the radial side. 
Physical examination discloses no deformity, 
but pain with motion and palpation and often 
swelling, especially in the anatomic snuff box 
(on the radial side of the wrist, between the 
tendon of the extensor pollicis longus and the 
tendons of the abductor pollicis longus and 
extensor pollicis brevis). A good sign is axial 
loading along the proximal phalanx of the 
thumb, eliciting pain at the base.

What to do:
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- Apply ice and a temporary splint, check for 
    distal sensation and movement and other 
    injuries; and order x rays of the wrist, 
    with special attention to the scaphoid bone 
    and its fat pad.
- Regardless of whether a scaphoid fracture 
    shows on x ray, splint or cast the wrist in 
    extension, with the thumb out in opposit- 
    ion, and immobilized to its interphalangeal 
    joint.
- Explain to the patient the frequent 
    difficulty of visualizing scaphoid 
    fractures on x rays, the frequent 
    difficulty in healing of scaphoid fractures 
    due to variable blood supply, and the 
    resultant necessity of keeping this splint 
    or cast in place for a week.
- Arrange for re-evaluation and further 
    treatment within the next few days.

Discussion
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Because fractures of the scaphoid bone are 
common, because they are often invisible on x 
ray until weeks later, because the blood supply 
to the fractured area may be tenuous and 
non-union or avascular necrosis likely, and 
because the resultant pain and arthritis may 
severely limit hand function, it is prudent 
practice to splint or cast all potential 
scaphoid fractures with a thumb spica until 
orthopedic re-evaluation in 1-2 weeks.

References:
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- Waeckerle JF: A prospective study identifying 
    the sensitivity of radiographic findings 
    and the efficacy of clinical findings in 
    carpal navicular fractures. *Ann Emerg Med* 
    1987;16:733-737.

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