Scaphoid Fracture, ABOS Oral Boards Preparation

This is a 22-year-old left-hand-dominant male college football wide receiver who fell on his outstretched right hand during practice two days ago. He was evaluated at an urgent care center where wrist X-rays were read as normal and he was splinted for a presumed wrist sprain. He came to us because the pain was not improving and he wanted to get back on the field, the season was underway.

On exam, he had tenderness in the anatomical snuffbox, pain with axial loading of the thumb, and tenderness at the scaphoid tubercle volarly. Those three findings together in a young patient after a fall on the outstretched hand give me a high clinical suspicion for a scaphoid fracture, regardless of what the initial films showed.

I ordered an MRI, which revealed a non-displaced fracture through the scaphoid waist with no marrow edema in the proximal pole, suggesting intact blood supply and low risk of AVN. No associated ligamentous injury.

For a non-displaced scaphoid waist fracture, both cast immobilization and percutaneous screw fixation are reasonable options. Cast immobilization in a thumb spica cast for 8 to 12 weeks has union rates exceeding 90%. However, this is a Division I athlete mid-season who needs to use his hands. I discussed both options with him. Percutaneous fixation allows earlier return to sport with equivalent union rates and avoids prolonged immobilization. He elected for surgical fixation.

I performed percutaneous headless compression screw fixation through a volar approach under fluoroscopic guidance. A post-operative CT confirmed anatomic fracture reduction and central screw placement.

He was placed in a short arm thumb spica splint for two weeks. At two weeks, sutures were removed, the wound was healing well, and he started gentle range of motion. At six weeks, X-rays showed early healing with maintained alignment. He was transitioned to a playing cast and returned to practice for non-contact drills. At eight weeks, the fracture was healed radiographically and he returned to full contact play. At three months, he had full grip strength and painless range of motion.

He was happy, he finished the season healthy and had no long-term wrist issues. If I were to do this again, I would consider getting the CT scan preoperatively rather than only post-operatively. A preoperative CT with sagittal reconstructions would have confirmed the fracture pattern and helped me choose the optimal screw length and trajectory before I was in the OR. The result was excellent, but better preoperative planning is always something I strive for. I followed him through the season for any signs of hardware irritation or screw loosening, and he had none.