Scaphoid Fracture — ABOS Oral Boards Preparation
What examiners expect and how to prepare
Clinical Scenario
A 22-year-old right-hand-dominant male college football wide receiver presents to the sports medicine clinic 2 days after falling on an outstretched hand during practice. He has pain in the radial wrist that is worse with gripping. He was initially evaluated at an urgent care center where wrist radiographs were read as normal and he was placed in a splint for a suspected sprain. He is eager to return to play — the season is underway. On exam, there is tenderness in the anatomical snuffbox, pain with axial loading of the thumb, and tenderness at the scaphoid tubercle volarly. Wrist range of motion is limited by pain. Grip strength is diminished. Neurovascular exam is normal.
Given the clinical suspicion, you ordered an MRI of the right wrist which reveals a non-displaced fracture through the scaphoid waist with intact blood supply (no marrow edema in the proximal pole suggestive of AVN). There is no associated ligamentous injury.
After discussing operative fixation versus cast immobilization, the patient elected for percutaneous screw fixation to expedite return to play. You performed percutaneous headless compression screw fixation (volar approach) under fluoroscopic guidance. The screw was placed centrally in the scaphoid on AP and lateral views. Post-operative CT confirmed anatomic fracture reduction and central screw placement. He was placed in a short arm thumb spica splint for 2 weeks, then transitioned to a playing cast for return to contact sports at 6 weeks with radiographic evidence of healing.
What Examiners Look For
- Data gathering: Why were the initial films negative? Discuss the sensitivity of plain films for acute scaphoid fractures and the role of advanced imaging.
- Diagnosis: Anatomical snuffbox tenderness in a young patient after a FOOSH — what is your clinical algorithm? When do you immobilize empirically?
- Treatment plan: Operative versus non-operative for a non-displaced waist fracture — what drives this decision? How does return-to-play timeline factor in?
- Technical skill: Volar versus dorsal percutaneous approach — describe the technique, fluoroscopic views needed, and how you confirm central placement.
- Applied knowledge: Discuss the blood supply of the scaphoid and why proximal pole fractures are at higher risk for AVN and nonunion.
- Complications: What is the nonunion rate for waist fractures treated non-operatively? How do you manage a scaphoid nonunion?
Common Pitfalls
- Dismissing a clinically suspected scaphoid fracture because initial radiographs are negative — immobilize and re-image or get an MRI.
- Not knowing the blood supply (dorsal branch of radial artery enters distal pole, flows proximal) and its clinical relevance.
- Failing to discuss non-operative management as a valid option — cast immobilization has excellent union rates for non-displaced waist fractures.
- Overexplaining the surgical technique without discussing indications — the examiner wants to know your thought process first.
- Not being prepared to discuss scaphoid nonunion management — vascularized bone grafting versus non-vascularized grafting and the decision framework.
Key Classifications
Free — takes 3 minutes