Scaphoid Fracture

Scaphoid x-rays are indicated for a variety of settings including:

• wrist trauma
• bony tenderness at the anatomical snuffbox
• suspected fracture
• obvious deformity
• non-traumatic wrist pain

Projections

Standard projections

• PA view
• ulnar deviation to remove the scaphoid from the radius and present its axis longitudinally
• the best view to inspect the joint spaces of the carpal bones and the distal radio-ulnar joint

• PA view angled
• ulnar deviation to remove the scaphoid from the radius and present its axis longitudinally
• tube angulation to present the scaphoid en face

• oblique view
• external oblique projection 

• lateral view 
• projection 90° to the PA view
• demonstrates multiple carpal bones overlapping
• the essential view to assessing the alignment of the radius, lunate, and capitate in the setting of a suspected dislocation

Modified trauma projections

• horizontal beam lateral view
• modified lateral projection that requires little to no patient movement
• produces a diagnostic lateral projection without risking patient pain

Additional projections

• clenched fist view
• used for suspected scapholunate dissociation

Mayo classification:

 Three types according to anatomic location of the fracture line:

• middle (70%)
• distal (20%)
• proximal (10%)

Fractures of the distal third are further divided into distal articular surface or the distal tubercle fractures:

• distal tubercle third fracture
• distal articular surface fracture
• distal third fracture
• middle third fracture
• proximal third fracture

Treatment and prognosis

Management options can broadly be divided into:

• immobilisation with cast application
• internal fixation for displaced fragments, usually with a headless self-compressing screw 
• non-union can be managed with internal fixation and bone grafting 

Factors affecting prognosis:

• location 9
  • distal pole: excellent likelihood of union (~100%)
  • waist: ~10-20% chance of non-union
  • proximal pole: ~30-40% chance of non-union
• vertically oriented fracture line
• fragment displacement  of greater than 1mm
• ligamentous instability: increased scapholunate angle (i.e. >60º or radiolunate or capitolunate angle >15º)

The major complication of scaphoid fractures is non-union or malunion leading to instability and secondary osteoarthritic change. Hence surgical treatment for displaced fractures or angulation.

A number of other specific complications are encountered from time to time:

• avascular necrosis: Preiser disease
  • this usually involves the proximal portion as a result of blood supply to the scaphoid entering relatively distally
• SNAC wrist: scaphoid non union advanced collapse
• SLAC wrist: scapholunate advanced collapse

*Source extracted from :https://radiopaedia.org/articles/scaphoid-fracture