Episode 867: Occult Scaphoid Fractures

<p dir="ltr"><strong>Contributor: Nick Tsipis MD</strong></p> <p dir="ltr"><strong>Educational Pearls:</strong></p> <ul> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">The scaphoid bone is the most proximal carpal bone just distal to the radius</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Fractures of the scaphoid bone are sometimes missed by plain X-rays</p> </li> <ul> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">A 2020 review found a 21.8% incidence of missed scaphoid fractures later diagnosed by advanced imaging modalities</p> </li> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">Only MRI has a sensitivity above 90% for diagnosing scaphoid fractures</p> </li> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">Sensitivity of plain-film radiography is low unless it is a displaced fracture</p> </li> </ul> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Physical examination techniques fail to definitively rule out scaphoid fractures</p> </li> <li dir="ltr" aria-level="1">A 2023 systematic review assessed the sensitivity and specificity of several common physical exam maneuvers:</li> <ul> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">Tenderness of the anatomical snuffbox has a sensitivity of 92.1% and specificity of 48.4%; i.e. absence reduces the likelihood of an occult scaphoid fracture but does not rule it out</p> </li> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">Another common physical exam maneuver is pain with ulnar deviation, which carries a sensitivity of 55.2% and specificity of 76.4%.</p> </li> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">Elicitation of pain with supination against resistance demonstrated a sensitivity of 100% and specificity of 97.9% in the study, so the authors recommend externally validating this method</p> </li> </ul> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Patients should be counseled on the importance of