Brittany McShane, PGY-2
Norman Regional Health System, Norman, OK

13-year-old male fell on an outstretched hand skateboarding. He has tenderness at the base of his right thumb in the anatomic snuffbox.

  • What fracture would you be concerned about with the above history?
    • You should be worried about a possible scaphoid fracture with tenderness in the anatomic snuffbox after falling on an outstretched hand.1
  • What radiographic imaging should you get?
    • Scaphoid series. Includes posteroanterior, oblique, lateral, and angled posteroanterior views.
    • The PA and PA angled view should have the hand positioned in ulnar deviation to remove the scaphoid from the radius.2
  • Why are scaphoid fractures at risk for avascular necrosis?
    • Branches of the radial artery are the major blood supply entering the scaphoid from distal to proximal. Thus, a proximal fracture can easily damage the blood supply to the proximal scaphoid leading to avascular necrosis1,2
  • How do you manage in the ED?
    • 1) Thumb spica splint holding the wrist in dorsiflexion and radial deviation.
    • 2) Orthopaedic follow up1,2
  • What if you don’t see a fracture on Xray, but are still suspicious for a scaphoid fracture?
    • 10% of initial radiographs fail at detecting a scaphoid fracture.1 So if a patient has a normal X ray, but there is high suspicion you should place them in thumb spica and repeat imaging in about 2 weeks. You can also consider CT or MRI. 1,2

References:

    1. Tintinalli, J., Stapczynski, J., Ma, O., Cline, D., Meckler, G., & Yealy, D. Tintinalli’s emergency medicine (8th ed., pp. 1801-1809). McGraw-Hill Education.
    2. Knipe, Henry, and R Bronson . “Scaphoid Fracture | Radiology Reference Article.” Radiopaedia.org, 2016, radiopaedia.org/articles/scaphoid-fracture.