Hand disorders
ELBS Question 1 of 10* A 42 year old lady who has systemic lupus erythematosus presents to the clinic with a 5
day history of a painful purple lesion on her index finger. On examination, she has a tender red lesion on the index
finger. What is the diagnosis?
Heberdens nodes
Oslers nodes
Bouchards nodes
Malignant fibrous histiocytoma
Osteoclastoma
Correct Aneswer: Oslers nodes
Osler nodes are normally described as tender, purple/red raised lesions with a pale centre. These lesions occur as a
result of immune complex deposition. These occur most often in association with endocarditis. However, other
causes include SLE, gonorrhoea, typhoid and haemolytic anaemia.
Hand diseases
Dupuytrens contracture
Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully
extended.
Caused by underlying contractures of the palmar aponeurosis . The ring finger and little finger are the
fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger
and the thumb are nearly always spared.
Progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the
palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The
palmar aponeurosis becomes hyperplastic and undergoes contracture.
Commonest in males over 40 years of age.
Association with liver cirrhosis and alcoholism. However, many cases are idiopathic.
Treatment is surgical and involves fasciectomy. However, the condition may recur and many surgical
therapies are associated with risk of neurovascular damage to the digital nerves and arteries.
Carpal tunnel syndrome
Idiopathic median neuropathy at the carpal tunnel.
Characterised by altered sensation of the lateral 3 fingers.
The condition is commoner in females and is associated with other connective tissue disorders such as
rheumatoid disease. It may also occur following trauma to the distal radius.
Symptoms occur mainly at night in early stages of the condition.
Examination may demonstrate wasting of the muscles of the thenar eminence and symptoms may be
reproduced by Tinels test (compression of the contents of the carpal tunnel).
Formal diagnosis is usually made by electrophysiological studies.
Treatment is by surgical decompression of the carpal tunnel, a procedure achieved by division of the flexor
retinaculum. Non - surgical options include splinting and bracing.
Miscellaneous hand lumps
Osler's Osler's nodes are painful, red, raised lesions found on the hands and feet. They are the result of the
nodes deposition of immune complexes.
Bouchard's Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of
nodes fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the
2442
articular cartilage.
Heberden's Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the
nodes sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and
pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the
fingertip sideways. It typically affects the DIP joint.
Ganglion Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the
wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise.
They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the
cysts are troublesome they may be excised.
ELBS Question 2 of 10* A 62 year old lady presents with a non tender lump overlying the distal interphalangeal
joint of the index finger. On examination, she has a hard, non tender lump overlying the joint and deviation of the tip
of the finger. What is the nature of the lesion?
Oslers nodes
Bouchards nodes
Heberdens nodes
Osteosarcoma
Infective collection
Correct Aneswer: Heberdens nodes
Heberdens nodes may produce swelling of the distal interphalangeal joint with deviation of the finger tip.
Hand diseases
Dupuytrens contracture
Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully
extended.
Caused by underlying contractures of the palmar aponeurosis . The ring finger and little finger are the
fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger
and the thumb are nearly always spared.
Progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the
palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The
palmar aponeurosis becomes hyperplastic and undergoes contracture.
Commonest in males over 40 years of age.
Association with liver cirrhosis and alcoholism. However, many cases are idiopathic.
Treatment is surgical and involves fasciectomy. However, the condition may recur and many surgical
therapies are associated with risk of neurovascular damage to the digital nerves and arteries.
Carpal tunnel syndrome
Idiopathic median neuropathy at the carpal tunnel.
Characterised by altered sensation of the lateral 3 fingers.
The condition is commoner in females and is associated with other connective tissue disorders such as
rheumatoid disease. It may also occur following trauma to the distal radius.
Symptoms occur mainly at night in early stages of the condition.
Examination may demonstrate wasting of the muscles of the thenar eminence and symptoms may be
reproduced by Tinels test (compression of the contents of the carpal tunnel).
Formal diagnosis is usually made by electrophysiological studies.
Treatment is by surgical decompression of the carpal tunnel, a procedure achieved by division of the flexor
retinaculum. Non - surgical options include splinting and bracing.
2443
Miscellaneous hand lumps
Osler's Osler's nodes are painful, red, raised lesions found on the hands and feet. They are the result of the
nodes deposition of immune complexes.
Bouchard's Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of
nodes fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the
articular cartilage.
Heberden's Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the
nodes sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and
pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the
fingertip sideways. It typically affects the DIP joint.
Ganglion Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the
wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise.
They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the
cysts are troublesome they may be excised.
ELBS Question 3 of 10* A 43 year old man falls over landing on his left hand. Although there was anatomical
snuffbox tenderness; no x-rays either at the time, or subsequently, have shown evidence of scaphoid fracture. He has
been immobilised in a futura splint for two weeks and is now asymptomatic. What is the most appropriate course of
action?
Application of tubigrip bandage and fracture clinic review
Admission and surgical debridement
Application of futura splint and fracture clinic review
Application of below elbow cast for 6 weeks
Discharge with reassurance
Correct Aneswer: Discharge with reassurance
This patient is at extremely low risk of having sustained a scaphoid injury and may be discharged.
Scaphoid fractures
- Incidence of scaphoid fractures in UK ranges from 12.4 per 100,000 to 29 per 100,000
Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture
risks blood supply)
Forms floor of anatomical snuffbox
Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third)
A series of 4 scaphoid radiographs should be undertaken (PA, pronated oblique, Ziter view and lateral
view). The Ziter view is a PA view with the wrist in ulnar deviation and beam angulated at 20 degrees
Sensitivity of scaphoid radiographs in 1st week of injury is 80%
Immobilization of scaphoid fractures difficult
Repeat imaging should be done at 10 days. MRI should be done in cases of diagnostic uncertainty
Classification of scaphoid fractures
Scaphoid tubercle
Distal pole
Waist
Proximal pole
Management
Undisplaced fractures of the waist of the scaphoid and most distal pole fractures can be managed in a cast for 6
2444
weeks with high rates of union.
Displaced scaphoid waist fractures (more than 1-2mm) should be viewed as unstable and surgically fixed.
All proximal pole fractures should be fixed surgically.
Complications
Non union of scaphoid
Avascular necrosis of the scaphoid
Scapholunate disruption and wrist collapse
Degenerative changes of the adjacent joint
Reference
Berber O et al. Fractures of the scaphoid. BMJ 2020 (369): 414-416.
ELBS Question 4 of 10* A 17 year old boy is brought to the clinic by his mother who is concerned about a lesion
that has developed on the dorsal surface of his left hand. On examination, he has a soft fluctuant swelling on the
dorsal aspect of the hand, it is most obvious on making a fist. What is the nature of the lesion?
Ganglion
Osteosarcoma
Malignant fibrous histiocytoma
Bouchards nodes
Oslers nodes
Correct Aneswer: Ganglion
Ganglions commonly occur in the hand and are usually associated with tendons. They are typically soft and
fluctuant. They do not require removal unless they are atypical or causing symptoms.
Hand diseases
Dupuytrens contracture
Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully
extended.
Caused by underlying contractures of the palmar aponeurosis . The ring finger and little finger are the
fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger
and the thumb are nearly always spared.
Progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the
palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The
palmar aponeurosis becomes hyperplastic and undergoes contracture.
Commonest in males over 40 years of age.
Association with liver cirrhosis and alcoholism. However, many cases are idiopathic.
Treatment is surgical and involves fasciectomy. However, the condition may recur and many surgical
therapies are associated with risk of neurovascular damage to the digital nerves and arteries.
Carpal tunnel syndrome
Idiopathic median neuropathy at the carpal tunnel.
Characterised by altered sensation of the lateral 3 fingers.
The condition is commoner in females and is associated with other connective tissue disorders such as
rheumatoid disease. It may also occur following trauma to the distal radius.
Symptoms occur mainly at night in early stages of the condition.
Examination may demonstrate wasting of the muscles of the thenar eminence and symptoms may be
reproduced by Tinels test (compression of the contents of the carpal tunnel).
2445
Formal diagnosis is usually made by electrophysiological studies.
Treatment is by surgical decompression of the carpal tunnel, a procedure achieved by division of the flexor
retinaculum. Non - surgical options include splinting and bracing.
Miscellaneous hand lumps
Osler's Osler's nodes are painful, red, raised lesions found on the hands and feet. They are the result of the
nodes deposition of immune complexes.
Bouchard's Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of
nodes fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the
articular cartilage.
Heberden's Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the
nodes sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and
pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the
fingertip sideways. It typically affects the DIP joint.
Ganglion Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the
wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise.
They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the
cysts are troublesome they may be excised.
ELBS Question 5 of 10* A 62 year old man presents after his wife commented on the unusual shape of his fingers.
On examination, he has a hard swelling adjacent to the distal interphalangeal joint of his index finger of the right
hand with lateral deviation of the finger tip. There is no sensory disturbance and the swelling is not tender. Which
pathological process underpins the underlying diagnosis?
Rheumatoid arthritis
Osteoarthritis
Infection with atypical organisms
Deposition of immune complexes
Malignancy
Correct Aneswer: Osteoarthritis
The description fits with Heberdens nodes. These are bony outgrowths that occur in the distal interphalangeal joint
in association with osteoarthritis. They may skew the finger tip sideways. Bouchards nodes are similar, but affect the
proximal interphalangeal joint.
Hand diseases
Dupuytrens contracture
Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully
extended.
Caused by underlying contractures of the palmar aponeurosis . The ring finger and little finger are the
fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger
and the thumb are nearly always spared.
Progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the
palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The
palmar aponeurosis becomes hyperplastic and undergoes contracture.
Commonest in males over 40 years of age.
Association with liver cirrhosis and alcoholism. However, many cases are idiopathic.
Treatment is surgical and involves fasciectomy. However, the condition may recur and many surgical
therapies are associated with risk of neurovascular damage to the digital nerves and arteries.
Carpal tunnel syndrome
Idiopathic median neuropathy at the carpal tunnel.
Characterised by altered sensation of the lateral 3 fingers.
2446
The condition is commoner in females and is associated with other connective tissue disorders such as
rheumatoid disease. It may also occur following trauma to the distal radius.
Symptoms occur mainly at night in early stages of the condition.
Examination may demonstrate wasting of the muscles of the thenar eminence and symptoms may be
reproduced by Tinels test (compression of the contents of the carpal tunnel).
Formal diagnosis is usually made by electrophysiological studies.
Treatment is by surgical decompression of the carpal tunnel, a procedure achieved by division of the flexor
retinaculum. Non - surgical options include splinting and bracing.
Miscellaneous hand lumps
Osler's Osler's nodes are painful, red, raised lesions found on the hands and feet. They are the result of the
nodes deposition of immune complexes.
Bouchard's Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of
nodes fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the
articular cartilage.
Heberden's Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the
nodes sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and
pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the
fingertip sideways. It typically affects the DIP joint.
Ganglion Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the
wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise.
They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the
cysts are troublesome they may be excised.
Next question
ELBS Question 6 of 10* A 52 year old male presents with discomfort in the fingers of his left hand. On
examination, the ring and little fingers of his left hand are flexed and unable to extend completely. He is able to
make a fist with the hand. Palpation reveals thickened nodules on the medial half of the palm. What is the most
likely diagnosis?
de Quervain's tenosynovitis
Tendon sheath infection
Dupuytren's contracture
Ganglion
Heberden's nodes
Correct Aneswer: Dupuytren's contracture
Discomfort of the hand is not uncommon in Dupuytren's contracture, true pain is unusual. The disease most
commonly affects the ring and little fingers.
Hand diseases
Dupuytrens contracture
Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully
extended.
Caused by underlying contractures of the palmar aponeurosis . The ring finger and little finger are the
fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger
and the thumb are nearly always spared.
Progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the
palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The
palmar aponeurosis becomes hyperplastic and undergoes contracture.
2447
Commonest in males over 40 years of age.
Association with liver cirrhosis and alcoholism. However, many cases are idiopathic.
Treatment is surgical and involves fasciectomy. However, the condition may recur and many surgical
therapies are associated with risk of neurovascular damage to the digital nerves and arteries.
Carpal tunnel syndrome
Idiopathic median neuropathy at the carpal tunnel.
Characterised by altered sensation of the lateral 3 fingers.
The condition is commoner in females and is associated with other connective tissue disorders such as
rheumatoid disease. It may also occur following trauma to the distal radius.
Symptoms occur mainly at night in early stages of the condition.
Examination may demonstrate wasting of the muscles of the thenar eminence and symptoms may be
reproduced by Tinels test (compression of the contents of the carpal tunnel).
Formal diagnosis is usually made by electrophysiological studies.
Treatment is by surgical decompression of the carpal tunnel, a procedure achieved by division of the flexor
retinaculum. Non - surgical options include splinting and bracing.
Miscellaneous hand lumps
Osler's Osler's nodes are painful, red, raised lesions found on the hands and feet. They are the result of the
nodes deposition of immune complexes.
Bouchard's Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of
nodes fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the
articular cartilage.
Heberden's Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the
nodes sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and
pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the
fingertip sideways. It typically affects the DIP joint.
Ganglion Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the
wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise.
They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the
cysts are troublesome they may be excised.
ELBS Question 7 of 10* A 42 year old skier falls and impacts his hand on his ski pole. On examination, he is
tender in the anatomical snuffbox and on bimanual palpation. X-rays with scaphoid views show no evidence of
fracture. What is the most appropriate course of action?
Admission and surgical debridement
Application of tubigrip bandage and fracture clinic review
Application of futura splint and fracture clinic review
Admission for open reduction and fixation
Discharge with reassurance
Correct Aneswer: Application of futura splint and fracture clinic review
A fracture may still be present and should be immobilised until repeat imaging can be performed. If clinical
suspicion persists then subsequent imaging should be with MRI scanning or CT if MRI is contra-indicated.
Scaphoid fractures
- Incidence of scaphoid fractures in UK ranges from 12.4 per 100,000 to 29 per 100,000
2448
Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture
risks blood supply)
Forms floor of anatomical snuffbox
Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third)
A series of 4 scaphoid radiographs should be undertaken (PA, pronated oblique, Ziter view and lateral
view). The Ziter view is a PA view with the wrist in ulnar deviation and beam angulated at 20 degrees
Sensitivity of scaphoid radiographs in 1st week of injury is 80%
Immobilization of scaphoid fractures difficult
Repeat imaging should be done at 10 days. MRI should be done in cases of diagnostic uncertainty
Classification of scaphoid fractures
Scaphoid tubercle
Distal pole
Waist
Proximal pole
Management
Undisplaced fractures of the waist of the scaphoid and most distal pole fractures can be managed in a cast for 6
weeks with high rates of union.
Displaced scaphoid waist fractures (more than 1-2mm) should be viewed as unstable and surgically fixed.
All proximal pole fractures should be fixed surgically.
Complications
Non union of scaphoid
Avascular necrosis of the scaphoid
Scapholunate disruption and wrist collapse
Degenerative changes of the adjacent joint
Reference
Berber O et al. Fractures of the scaphoid. BMJ 2020 (369): 414-416.
ELBS Question 8 of 10* A 63 year old lady presents with a three month history of pins and needles in the fingers of
the right hand, particularly at night. On examination, there is some loss of the sensation over the palmar aspect of the
lateral three fingers and wasting of the thenar eminence. What is the underlying diagnosis?
Radial nerve injury
Ulnar nerve injury
Psychosomatic illness
Wrist arthritis
Carpal tunnel syndrome
Correct Aneswer: Carpal tunnel syndrome
Carpal tunnel syndrome commonly produces pain at night as the wrists are flexed during sleep. Compromise of the
median nerve may produce wasting of the thenar eminence muscles.
Hand diseases
Dupuytrens contracture
Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully
extended.
2449
Caused by underlying contractures of the palmar aponeurosis . The ring finger and little finger are the
fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger
and the thumb are nearly always spared.
Progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the
palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The
palmar aponeurosis becomes hyperplastic and undergoes contracture.
Commonest in males over 40 years of age.
Association with liver cirrhosis and alcoholism. However, many cases are idiopathic.
Treatment is surgical and involves fasciectomy. However, the condition may recur and many surgical
therapies are associated with risk of neurovascular damage to the digital nerves and arteries.
Carpal tunnel syndrome
Idiopathic median neuropathy at the carpal tunnel.
Characterised by altered sensation of the lateral 3 fingers.
The condition is commoner in females and is associated with other connective tissue disorders such as
rheumatoid disease. It may also occur following trauma to the distal radius.
Symptoms occur mainly at night in early stages of the condition.
Examination may demonstrate wasting of the muscles of the thenar eminence and symptoms may be
reproduced by Tinels test (compression of the contents of the carpal tunnel).
Formal diagnosis is usually made by electrophysiological studies.
Treatment is by surgical decompression of the carpal tunnel, a procedure achieved by division of the flexor
retinaculum. Non - surgical options include splinting and bracing.
Miscellaneous hand lumps
Osler's Osler's nodes are painful, red, raised lesions found on the hands and feet. They are the result of the
nodes deposition of immune complexes.
Bouchard's Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of
nodes fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the
articular cartilage.
Heberden's Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the
nodes sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and
pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the
fingertip sideways. It typically affects the DIP joint.
Ganglion Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the
wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise.
They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the
cysts are troublesome they may be excised.
ELBS Question 9 of 10* A 13 year old boy falls onto an outstretched hand and is brought to the emergency
department. He is examined by a doctor and a bony injury is cleared clinically. He re-presents a week later with pain
in his hand. What is the most likely underlying injury?
Fracture of the distal radius
Fracture of the scaphoid
Dislocation of the lunate
Rupture of flexor pollicis longus tendon
Bennett's fracture
Correct Aneswer: Fracture of the scaphoid
Scaphoid fractures in children are rare, will usually involve the distal pole and are easily missed. The initial clinical
examination (and sometimes x-rays) may be normal and repeated clinical examination and imaging is advised for
2450
this reason. Whilst the other injuries may be sustained from a fall onto an outstretched hand they are less likely to be
overlooked on clinical examination. In the case of a Bennetts fracture, the injury mechanism is less compatible with
this type of injury.
Scaphoid fractures
- Incidence of scaphoid fractures in UK ranges from 12.4 per 100,000 to 29 per 100,000
Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture
risks blood supply)
Forms floor of anatomical snuffbox
Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third)
A series of 4 scaphoid radiographs should be undertaken (PA, pronated oblique, Ziter view and lateral
view). The Ziter view is a PA view with the wrist in ulnar deviation and beam angulated at 20 degrees
Sensitivity of scaphoid radiographs in 1st week of injury is 80%
Immobilization of scaphoid fractures difficult
Repeat imaging should be done at 10 days. MRI should be done in cases of diagnostic uncertainty
Classification of scaphoid fractures
Scaphoid tubercle
Distal pole
Waist
Proximal pole
Management
Undisplaced fractures of the waist of the scaphoid and most distal pole fractures can be managed in a cast for 6
weeks with high rates of union.
Displaced scaphoid waist fractures (more than 1-2mm) should be viewed as unstable and surgically fixed.
All proximal pole fractures should be fixed surgically.
Complications
Non union of scaphoid
Avascular necrosis of the scaphoid
Scapholunate disruption and wrist collapse
Degenerative changes of the adjacent joint
Reference
Berber O et al. Fractures of the scaphoid. BMJ 2020 (369): 414-416.
ELBS Question 10 of 10* A 25 year old man is diagnosed as having an undisplaced fracture of the proximal pole
of the scaphoid. What is the best course of action?
Immobilisation in future splint for 5 weeks
Arrange an MRI scan
Immobilisation in plaster cast for 4 weeks
Surgical fixation
Initial immobisation in plaster cast for 2 weeks with check radiographs at that stage
Correct Aneswer: Surgical fixation
It is generally accepted that proximal pole fractures of the scaphoid should be surgically fixed as non union rates of
up to 34% can be seen when cast immobilization alone is attempted.
2451
Scaphoid fractures
- Incidence of scaphoid fractures in UK ranges from 12.4 per 100,000 to 29 per 100,000
Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture
risks blood supply)
Forms floor of anatomical snuffbox
Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third)
A series of 4 scaphoid radiographs should be undertaken (PA, pronated oblique, Ziter view and lateral
view). The Ziter view is a PA view with the wrist in ulnar deviation and beam angulated at 20 degrees
Sensitivity of scaphoid radiographs in 1st week of injury is 80%
Immobilization of scaphoid fractures difficult
Repeat imaging should be done at 10 days. MRI should be done in cases of diagnostic uncertainty
Classification of scaphoid fractures
Scaphoid tubercle
Distal pole
Waist
Proximal pole
Management
Undisplaced fractures of the waist of the scaphoid and most distal pole fractures can be managed in a cast for 6
weeks with high rates of union.
Displaced scaphoid waist fractures (more than 1-2mm) should be viewed as unstable and surgically fixed.
All proximal pole fractures should be fixed surgically.
Complications
Non union of scaphoid
Avascular necrosis of the scaphoid
Scapholunate disruption and wrist collapse
Degenerative changes of the adjacent joint
Reference
Berber O et al. Fractures of the scaphoid. BMJ 2020 (369): 414-416.
2452
