The patient was initially diagnosed with a left wrist strain and treated with a splint for 4 weeks. Initial recommendations for splinting and activities for the patient were nonspecific. It is clear that either the patient was noncompliant or the urgent care clinic was not explicit enough in their recommendations that the patient be immobilized, avoid wrist activities, and seek follow-up care.

When the non-displaced scaphoid fracture was suspected at 4 weeks, the patient was removed from sports, placed in a splint, and sent for an MRI. It was appropriate for the patient to be immobilized at this point (although some may recommend inclusion of the thumb in the splint, which was not done) and removed from football. It is unclear what specific advantage the MRI provided in diagnosis, treatment, or stratification of risks for this patient. After the non-displaced scaphoid waist fracture was discovered on MRI, he was immobilized in a cast for 7 weeks .

The cast was removed when there was radiographic evidence of scaphoid healing (11 weeks post-injury), and the patient had some wrist stiffness but no snuffbox tenderness. He was given a removable thumb spica splint and range of motion exercises for the wrist, but no formal physical therapy and he was not allowed to return to sport. The patient was encouraged to increase his activity as tolerated, but he continued to be restricted from participating in heavy lifting, football, or any sports. Fifteen weeks after the injury, X-rays demonstrated good healing of the fracture and the splint was recommended for comfort only. He was released to return to activities as tolerated, including football. At 15 weeks post-injury, X-rays revealed progressive healing of the mid-body fracture with good consolidation (Fig. 2.4). He had full range of motion of the left wrist, no pain, and he was able to return to normal activities .

The 15-year-old patient with a football injury in this case study represents a classic presentation of a scaphoid fracture. These fractures are most commonly seen in young adult males (age 15–40 years) after sports-related injuries or a fall on an outstretched hand. In recent decades, an increasing percentage of scaphoid fractures are occurring in young women, possibly because of increased participation in athletics [1, 2]. A typical description of the injury is a traumatic hyperextension of the wrist with radial deviation, such as described by the current patient during football practice. Patients often complain of generalized wrist or thumb pain and may not have pain over the scaphoid. Common physical exam findings include point tenderness over the anatomic snuffbox or thumb, decreased wrist range of motion, and weakened grip [1]. The current patient suffered from severe point tenderness over the thumb and weak grip of the left hand though radiographs interpreted as normal. The sensitivity of radiographs for scaphoid fractures can be as low as 70 % and highly subject to the experience of the reader, resulting in easily missed fractures on initial testing [3]. Missed or untreated scaphoid fractures are at increased risk of nonunion, carpal collapse, and degenerative arthritis. Therefore, physicians should have a high degree of clinical suspicion for these injuries. In patients with vague symptoms about the radial wrist and thumb, the diagnosis must be excluded definitively prior to discharging the patient. Patients who are at risk for a scaphoid fracture should be placed in full-time immobilization, including the thumb, until the diagnosis is confirmed or eliminated .

Further testing with serial radiographs, a computed tomography (CT) or magnetic resonance imaging (MRI) scan is recommended. Serial radiographs may be effective. However, since several weeks of immobilization and activity modification are required between X-rays, there is a significant opportunity cost to this method of treatment. In order to return patients to sport and work faster, early advanced imaging can be helpful.

While CT scans are faster, widely available, and expensive, they are less reliable for identifying non-displaced scaphoid fractures . CT scans do provide a better resolution of the anatomy of the fracture, in particular if the fracture is displaced and requires reduction. While some studies have shown CT scans to have poor sensitivity to displacement, it remains the best test available to assess displacement. In cases where initial radiographs are normal, it is very unlikely that displacement has occurred, and CT scans are probably unnecessary. However, in cases where there is an obvious fracture at initial presentation, CT scanning should be considered to assess displacement.