The Case
An 18 year old football player presents to the ED 2 days after a thumb injury. He says he hyperextended it while trying to make a tackle. He saw his PMD the next day, and despite pain in his thumb, the X-Rays were read as negative by his PMD. He was cleared to return to play, but had continued pain. He is seeking the ever popular “second opinion.”
On exam he has pain at the following location
You order the following X-Ray – which is different than what his PMD got – based on the location of his pain
The Diagnosis
This is a fracture of the scaphoid bone. The pain was in the classic location of the “anatomic snuff box,” so named because it was a location in which powdered tobacco, AKA “snuff,” was placed and then snorted.
You may not see the injury on hand or wrist films, and instead get the scaphoid view which includes specific views to isolate the unique geometry of the scaphoid bone. You can just order it in your EMR or you could check out the following page which is fascinating – don’t worry, I’ll wait.
Management
Scaphoid fractures should be managed by immobilization in a thumb spica splint.
They should then be referred to Orthopedics/Hand Surgery. Many will need pinning. In general the portion of the scaphoid closer to the wrist has a poorer blood supply, and thus is at higher risk for nonunion.
