This 35 year old female patient fell from her bike and suffered a hyperextension of her wrist. There was considerable swelling and tenderness in the anatomic snuffbox. Note on the oblique radiograph that there is a lucent line representing a fracture through the waist of the scaphoid bone. The scaphoid bone is the most commonly fractured carpal bone, accounting for 50-60% of all carpal injuries.

If undisplaced, these fractures are managed with a thumb spica cast which immobilizes the wrist and the thumb. If displaced, they require urgent orthopedic consultation for reduction. Failure to recognize and appropriately manage these fractures can result in avascular necrosis of the scaphoid bone and/or non-union of the fracture. These can lead to chronic pain and instability of the wrist.

If a patient has tenderness in the area of the anatomic snuffbox, but no fracture is apparent on x-ray, he/she should be immobilized in a thumb spica cast and instructed to return for repeat x-rays in 2 weeks. With healing, there is reabsorption of bone along the fracture line, making it more visible at 2 weeks.

More examples:

Fractures of the scaphoid bone can be very subtle and even missed on the initial radiograph. The first radiograph below shows a fractured scaphoid appearing as a small break in the cortex. The second radiograph shows a fracture appearing as an irregular lucent line through the waist of the scaphoid. The third radiograph shows a very subtle fracture appearing as a fine, irregular lucency through the waist.

Occasionally, patients can present with snuffbox tenderness after a fall on an outstretched hand, and will have no radiographic abnormalities. These patients should be placed in a thumb spica cast for 2 weeks and return for repeat radiography. If a fracture is present, it will usually be apparent on repeat films because of reabsorption of bone along the fracture site.