Scaphoid and Suspected Scaphoid Fractures

 

All scaphoid and suspected scaphoid fracture investigation and management is provided by Secondary Care.

The information below is to direct patients should they present in Primary Care.  Please note this guidance excludes children under 10 years old as occult scaphoid fracture is very unlikely in this age group.

Suspicion of scaphoid fracture following injury:

Direct patient to Minor Injuries Unit for assessment

Mechanism of injury to provide sufficient force or energy to make it more likely for example, fall from height or at speed such as skateboarding or cycling, fall whilst intoxicated, fall with more energy such as jumping or being landed on.  Caution to ensure consideration of scaphoid fractures in delayed presentations of falls of outstretched hand and hyperextension injuries with persistent pain. 

The following examination findings makes scaphoid fracture more likely: focal tenderness over the scaphoid tubercle and anatomical snuffbox, pain on axial loading/grind test of thumb, pain on ulnar deviation.
 

Patients presenting later than 2 weeks following injury

If the patient presents later than 2 weeks where the injury raises the suspicion of scaphoid fracture and they are out of remit for assessment in ED/MIU, perform an Xray as soon as possible:

If there is a clear fracture refer urgently to Hand Trauma Clinic

If there is no obvious fracture but scaphoid fracture may still be possible, make an urgent referral to Hand Orthopaedics.

 

RCHT/MIU Pathway for scaphoid fractures

Visible scaphoid fractures on Xray

Scaphoid tubercle fractures are managed non-operatively with rest in a wrist splint for 4 weeks, avoid heavy lifting, manual tasks and contact sports for 6 weeks.

All other scaphoid fractures are placed in a volar slab and referred to hand clinic internally.

 

Scaphoid fracture not visible on initial Xray in ED/MIU but still strong clinical suspicion in MIU

Patients aged 10-60

If seen within 48 hours of injury, the patient will be placed in a wrist splint or volar plaster slab and reassessed at 48 hours in MIU.  This will be booked by ED/MIU.

If clinical suspicion for scaphoid fracture remains at 48 hours:

Patients aged 10-40 will be placed in a wrist splint, analgesia and advised to elevate.  MIU will organise an MRI (aged 10-15 years) or CT (aged 15+ years).  MIU will be responsible for the result and contact the patient.  If a fracture is confirmed, the patient will be followed up in fracture clinic.  If there is no fracture, the patient will be advised to remove the wrist splint and mobilise when able, MIU can organise MSK Physiotherapy if needed straight away.  Consider MSK Physiotherapy if ongoing concerns and negative imaging.

Patients aged 41 to 59

Acute scaphoid fracture is still possible but less likely.

Patients are placed in a wrist splint, analgesia, rest, elevation and placed on patient initiated follow up (PIFU).  They are advised if they remain symptomatic at 2 weeks, the patient to contact the Hand Trauma Admin Lead by phone 01736 758800.

The Hand Trauma Admin team will liaise with Hand Clinic who will arrange a CT scan and follow up the patient with the result. 

Patients aged 60 and over

Acute scaphoid fracture is unlikely.

The patient is placed in a wrist splint and advised to rest, ice, elevate, MIU can organise MSK Physiotherapy if needed straight away.  The patient will be advised that the wrist may be sore for up to 4 weeks, as the pain settles, gradually remove the splint for more of the day as pain allows.

If there is ongoing pain or reduced function after 4 weeks, consider MSK Physiotherapy.  If there is severe pain or significantly reduced function then consider fracture clinic advice.

 

 

References

Royal Cornwall Hospitals NHS Trust.  Suspected Scaphoid Fracture Guidelines, February 2023.

Contributors

Miss Rebecca Dunlop, Consultant Orthopaedic Surgeon, Royal Cornwall Hospitals NHS Trust

Dr Mark Jadav, Consultant Emergency Medicine, Royal Cornwall Hospitals NHS Trust

Dr Kim Farmer, Consultant Radiologist, Royal Cornwall Hospitals NHS Trust

Matthew Allen, Hand Occupational Therapist, Royal Cornwall Hospitals NHS Trust

Dr Rebecca Hopkins, GP and RMS Orthopaedic Guidelines Lead, Cornwall and IOS ICB

 

Date                 12 December 2023

Review date     12 December 2024