"Bone scintigraphy has high sensitivity (pooled 97%) but lower specificity (pooled 89%) for diagnosing occult scaphoid fractures 10. Optimal sensitivity is achieved 3-4 days post-injury ref. Findings include:"
"Patients undergoing operative fixation generally have better functional outcomes measured up to at least 12 months post-injury 22. Operative management is associated with shorter periods of immobilisation, less stiffness, better grip strength and faster return to work/sport 23."
"Operative management "
"Patients typically present following a fall on an outstretched hand (FOOSH). Clinical features include:"
"The usual mechanism is a FOOSH, generating an axial load through an extended, pronated wrist in ulnar deviation. Stress fractures are less common and are predominantly seen in athletes engaged in repetitive high-impact loading, such as shot putters or gymnasts."
"MRI is the most sensitive modality for detecting trabecular fractures and is capable of identifying completely undisplaced injuries within the first 24 hours of trauma. A meta-analysis of 2,507 patients reported pooled sensitivity of 94% and specificity of 98% for MRI, superior to CT, bone scintigraphy, and ultrasound 7. The American College of Radiology (ACR) recognises MRI as the preferred second-line investigation alongside CT when initial radiographs are negative but clinical suspicion persists 16,26. Additional value includes identification of occult injuries in adjacent carpal bones, TFCC tears, and intercarpal ligament injuries, which may account for symptoms in a significant proportion of patients referred with a suspected scaphoid fracture 16."
"scaphoid nonunion/scaphoid non-union advanced collapse (SNAC wrist)"
"scapholunate advanced collapse (SLAC wrist)"
"Fracture characterisation"
"Alignment and associated injuries"
"K wire fixation 25"
Expected headings
"Mechanism"
"Non-operative management"
"Operative management "
"Union rates of surgical management approach"
"Complications"
"Herbert and Fisher classification of scaphoid fractures, divides fractures into stable acute fractures (Type A), unstable acute fractures (Type B), delayed union (Type C), and established non-union (Type D)"
"Terry Thomas sign - widened scapholunate interval suggesting ligamentous disruption; best accentuated on a clenched fist view"
"Ultrasonography may serve as an adjunctive modality for acute fracture detection. Direct evidence of fracture is provided by focal cortical interruption. Associated haematomas may be identified as overlying heterogeneous collections that do not deform with transducer compression. A finding of cortical disruption combined with articular effusion has high sensitivity for fracture; apparent cortical disruption in isolation has a high false-positive rate 6."
"MRI is routinely used to assess proximal pole vascularity in the setting of non-union; the classic finding of diffuse T1 hypointensity in the proximal pole is used to suggest avascular necrosis, however unenhanced MRI has limited sensitivity for avascular necrosis (~55-72%) despite high specificity. Gadolinium-enhanced MRI improves sensitivity for avascular necrosis (sensitivity 76-89%, specificity 97-99%), however avascular necrosis may be patchy on histology."
"Vascularised bone grafting (VBG) is considered in established non-union where local biology is compromised. The rationale is that direct vascular supply to the graft accelerates incorporation and supports healing in an avascular environment. However, current evidence does not demonstrate a consistently superior union rate for VBG over non-vascularised bone grafting (NVBG) across all non-union subtypes; overall pooled union rates are comparable (VBG ~90%, NVBG ~84-87%) 25,26."
"CT is the preferred second-line investigation alonside MRI when plain films are negative but clinical suspicion persists, owing to its availability, speed and superior delineation of cortical anatomy 5,26. A 2020 meta-analysis reported pooled sensitivity and specificity for CT at 82% and 96% respectively 7. Spectral CT has shown improved performance in more recent series, with pooled sensitivity of 93% and specificity of 98% 8."
"unstable, comminuted or oblique fractures 23,27"
"The major complication of scaphoid fractures is non-union or malunion, leading to instability, deformity and secondary osteoarthritic change. Hence, surgical treatment of displaced fractures or angulation."
"associated fractures (e.g. Colles fracture, other carpal bones)"
"fractures with >1 mm displacement but no significant deformity or angulation (e.g. humpback deformity)"
"There are several factors that affect prognosis:"