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SplintER Series: Pain in the Snuff Box

Posted by Kayla Prokopakis, DO on

A 16-year-old male presents to the ED after injuring his wrist during a track meet. The patient was running hurdles when he fell forward, planting his wrist into the ground. The imaging is shown below (courtesy of Dr. Hani Makky ALSALAM, Radiopaedia.org).

What is your diagnosis?

Scaphoid fracture (Image 2).
  • Pearl: The scaphoid is the most frequently fractured carpal bone [1,2].
  • Pearl: Fractures occur at the waist, proximal third, and distal portion: 65%, 25%, and 10% respectively [3].

Image 2. Fracture of scaphoid. Case courtesy of Dr. Hani Makky ALSALAM, Radiopaedia.org, rID: 10398 (arrow added by authors).

What is the mechanism of injury?

Occurs when there is an axial load across hyper-dorsiflexed, pronated and ulnar deviated wrists or from a fall on the outstretched hand (FOOSH) [1-3].

What physical exam findings are suspected?

Snuff box tenderness, scaphoid tubercle tenderness over the volar aspect of the wrist, and/or positive scaphoid compression test (pain reproduced with an axial load applied through thumb metacarpal) [4-6].

Image 3. Location of scaphoid tubercle (S) at the base of the thenar eminence (left) and the location of the snuffbox (SB) on the radial aspect of the wrist (right). Images by authors.

What is the imaging modality of choice in the ED?

Plain film imaging with anterior-posterior, oblique, and lateral views to assess for injury.

  • Pearl: There is also a scaphoid view that is recommended if the department technician is trained. This image is a posterior-anterior view of the scaphoid that is obtained with the wrist in ulnar deviation [7].

What is your ED management?

Abnormal exam: If not neurovascularly intact or if there is an open fracture, consult orthopedics in the ED.

Identified scaphoid fracture: Thumb spica splint and prompt orthopedic follow-up usually within 1-3 days as though some fractures only require immobilization for treatment; surgery may be required for some fracture patterns [1-3,6].

Suspicion for fracture without radiographic evidence: Place in thumb spica splint and repeat imaging in 14 days to evaluate for occult fracture. If negative again at that time with high clinical suspicion, the patient should have an outpatient MRI [1-3,6].

  • Pearl: Initial imaging can miss 5-20% of fractures [8].

What are the complications of this injury?

Classic complications include vascular necrosis (AVN), and scaphoid nonunion advanced collapse (SNAC). Associated fractures and dislocation of the surrounding carpal bones, distal radius, ligamentous disruption may be seen as other pathology occurs secondary to a FOOSH [1-4,6].

  • Pearl: AVN is of high concern and directly correlated to the site of fracture. The scaphoid receives blood supply via retrograde flow – the more proximal the fracture, the higher the risk of AVN [1-4,6].
  • Pearl: SNAC occurs when the proximal scaphoid remains attached to the lunate and the distal fragment rotates into flexion. This results in early osteoarthritis between the distal scaphoid and radial styloid, leading to pain and decreased functionality [9].

References & Resources:

For a review of other causes of traumatic wrist pain check out the SplintER archives.

  1. Tada K, Ikeda K, Okamoto S, Hachinota A, Yamamoto D, Tsuchiya H. Scaphoid Fracture–Overview and Conservative Treatment. Hand Surg. 2015;20(2):204-209. PMID 26051761.
  2. Sabbagh MD, Morsy M, Moran SL. Diagnosis and Management of Acute Scaphoid Fractures. Hand Clin. 2019;35(3):259-269. PMID 31178084.
  3. Gupta V, Rijal L, Jawed A. Managing scaphoid fractures. How we do it?. J Clin Orthop Trauma. 2013;4(1):3-10. PMID 26403769.
  4. Basu A, Lomnassey LM, Demos TC, et al: Your Diagnosis? scaphoid fracture. Orthopedics 28:177, 2005. PMID 15751361
  5. Watson HK, Weinzweig J. Physical examination of the wrist. Hand Clin. 1997;13(1):17-34. PMID 9048180.
  6. Stapczynski, JS, Tintinalli, JE. Wrist injuries. In Tintinalli’s emergency medicine: A comprehensive study guide, 8th Edition. New York, NY: McGraw-Hill Education; 2016: 1853-1854
  7. Cheung GC, Lever CJ, Morris AD. X-ray diagnosis of acute scaphoid fractures. J Hand Surg Br. 2006;31(1):104-109.PMID 16257481.
  8. Ashmead D 4th, Watson HK, Damon C, Herber S, Paly W. Scapholunate advanced collapse wrist salvage. J Hand Surg Am. 1994;19(5):741-750. PMID 7806794.
  9. Moritomo H, Tada K, Yoshida T, Masatomi T. The relationship between the site of nonunion of the scaphoid and scaphoid nonunion advanced collapse (SNAC). J Bone Joint Surg Br. 1999;81(5):871-876. PMID: 10530853.

Author information

Kayla Prokopakis, DO

Resident
Emergency Medicine
St. Elizabeth Boardman Hospital

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