Physical assessment consists of history, examination, and imaging studies. A common mechanism for an acute fracture of the scaphoid is a fall on an extended and radially deviated wrist [1]. The history of the injury should be recorded, as well as immediate swelling, pain, and any previous injury, evaluation, or treatment. A standard physical examination of the extremity should be completed, including evaluation of proximal and distal joints. Strength testing may be helpful in cases of delayed presentation but is of limited efficacy on the acute setting due to discomfort. Tenderness and swelling may be present in the anatomic snuffbox and/or the scaphoid tubercle. Other provocative maneuvers, which are not specific for scaphoid fractures but often present, include discomfort with axial compression of the thumb, the scaphoid shift maneuver, and radial and ulnar deviation of the wrist with the forearm pronated [2]. Our patient described pain with gripping and activities, but not a rest. The pain did not preclude him from participating in activities. He had mild swelling along the radial wrist and discomfort with palpation in the snuffbox and direct pressure on the distal scaphoid. His wrist motion was slightly decreased in extension and radial deviation when compared to the opposite side. He had no discomfort or limitations of motion in the hand, forearm, or elbow .

Initial imaging consists of plain radiographs of the wrist, including posteroanterior (PA), lateral, semipronated oblique, and scaphoid view (PA with ulnar deviation) [3]. Using this technique, 84 % of scaphoid fractures can be identified, whereas 16 % could be missed, necessitating the follow-up radiographs [3]. Magnetic resonance imaging (MRI) scans have shown to be very sensitive in determining fractures of the scaphoid even in the acute setting. It has been shown that MRI in a suspected, radiographically occult fracture has a high sensitivity (100 %) and a high specificity (95–100 %) [4–6]. MRI can also provide the added benefit of identifying other injuries in the setting of wrist or hand pain, such as ligament injuries, other nondisplaced carpal or radius fractures, and, if contrast is administered, vascularity [3]. Standard MRI shows only 68 % accuracy when assessing vascularity of the proximal pole; however, gadolinium enhancement improves this to 83 % [7]. The role of computerized tomography (CT) scan is limited for acute scaphoid fractures and is dependent on the need for evaluation of displacement, comminution, or a humpback deformity to aid in surgical planning. CT scans can be used for evaluation if an MRI is contraindicated after initial negative or equivocal plain radiographs. CT scans can improve the reliability of detecting scaphoid fracture displacement but has only slightly greater accuracy of fracture identification (80 %) than plain radiographs (70 %) [8]. When a CT scan is obtained for evaluation of the scaphoid, it should be obtained in the plane of the scaphoid [9].

A useful algorithm for diagnosis of scaphoid fractures was described in Kawamura and Chung. When a nondisplaced fracture was identified on plain film, then a CT scan can be utilized if needed to determine the amount of fracture displacement. If there is high suspicion of a scaphoid fracture and plain films are negative or equivocal, then an MRI is performed to determine whether a scaphoid fracture is present or not and whether there are other sources of potential wrist pain [1].

When the fracture is nondisplaced in the waist or distal pole, it has been shown to have greater than 90 % union rate with immobilization alone [10–12]. Controversy exists over the use of long-arm thumb spica splints/casts versus short-arm thumb spica splints/casts. Till date, there have not been any studies to suggest one style cast is better [11, 13–15]. There is recent evidence suggesting there is no difference in union rates or time to union when including the thumb or leaving it free [16]. The fracture should be immobilized until healed, but there is not a consensus on how to determine healing. Many surgeons recommend CT scan to confirm healing when managing scaphoid fractures in a cast .

Any fracture with greater than 1 mm of displacement as well as nondisplaced proximal pole fractures should be treated surgically due to the higher incidence of nonunion and osteonecrosis caused by the tenuous blood supply in the proximal pole [17]. Operative treatment has also been recommended for active individuals such as laborers and athletes who cannot withstand the prolonged immobilization. Internal fixation with a compression screw can reduce the period of immobilization and shorten the time to union [18]. The anatomical orientation of the scaphoid and the vascular supply lends the volar approach to the scaphoid as the path less likely to jeopardize the tenuous blood supply over a dorsal exposure [9]. A dorsal exposure is indicated for proximal pole fractures and nondisplaced to minimally displaced waist fractures with limited open or percutaneous fixation. The extent of the dorsal exposure will be determined based on the displacement and/or comminution of the fracture. If it is a nondisplaced fracture, a more limited exposure or percutaneous stabilization may be performed. Advantages of a dorsal approach are easier and more precise screw placement with central fixation. This is compared to the volar approach, which may lead to eccentric fixation and injury to the volar carpal ligaments and trapezium [1].

The longitudinal incision is outlined from Lister’s tubercle to the base of the third metacarpal (Fig. 3.2). The length of the incision may be extended in either direction if greater exposure is needed due to the displacement or comminution of the scaphoid fracture. The skin is incised and skin flaps are elevated off the extensor retinaculum proximally and at the level of the extensor tendons over the wrist. The interval between the third and fourth compartments is identified, retracting the EPL in a radial direction and the EDC/EIP ulnarly. An oblique capsulotomy along the path of the dorsal radiocarpal ligament is made to expose the proximal scaphoid. The wrist is flexed and ulnarly deviated to expose the proximal aspect of the proximal pole (Fig. 3.3).

If greater exposure of the scaphoid is necessary for identification and reduction of the fracture line, a ligament splitting capsulotomy may be performed as described by Berger [19]. The posterior interosseous nerve (PIN) is sensory to the wrist capsule and runs along the radial aspect of the floor of the fourth compartment. Some surgeons advocate resecting a portion of this nerve to decrease pain from scarring of the nerve and resultant traction with wrist motion. The fracture is identified, and the alignment reduction is confirmed by visualization and fluoroscopy. For unstable fractures, a K-wire may be placed in the displaced fragment to aid in reduction by acting as a “joystick.” After satisfactory reduction, the K-wire for the compression screw is placed 1–2 mm radial to the scapholunate ligament and it should be directed in a radial-volar trajectory toward the base of the thumb metacarpal . The wire should be placed along the central axis of the scaphoid, centrally in both dorsal/volar and radial/ulnar dimensions [20] (Fig. 3.4a, b). Fluoroscopy is performed with the wrist in flexion due to the entry point of the K-wire in the proximal pole. Alternatively, the K-wire may be advanced distally until the tip of the wire is deep to the articular surface and imaging completed and the wrist flexed and the wire advanced back proximally. Generally, a screw length 4 mm less than measured is chosen to allow for compression and burying the screw deep to the cartilaginous surface. After the length is determined, the K-wire should be advanced into the trapezium and a 2nd K-wire should be inserted into the scaphoid as an anti-rotational point to prevent displacement during screw insertion (Fig. 3.5). A cannulated drill is advanced to the desired length. When removing the drill, try to ensure the K-wire does not pull out with the drill. If it does, the wire may often be placed back in the tract and appropriate location should be confirmed with fluoroscopy. A headless compression screw may then be placed and should be countersunk deep to the articular cartilage. Fluoroscopy should be used to confirm reduction of the fracture and the appropriate position of the screw within the bone. The two K-wires are removed and the wrist is extended, and fluoroscopy is used to confirm fracture alignment and positioning of the screw .