Joe A Shaw PA-C - 2/15/2008

Question
QUESTION: Hi. I am a little confused about what my husband's orthopedic doctor said about his injury.  He went to the ER after falling on his hand...the ER doctor at first said he saw no sign of fracture.  Then he came back a few minutes later and said he saw a chip fracture. They put him in splint and referred him to and orthopedic surgeon. The ortho doctor took more xrays three days after the injury and the diagnosis was "questionable hairline fracture of the scaphoid waist". He showed us what he was seeing on the xray, but said he wasn't sure if it is a fracture. They put him in a cast and said to come back for more xrays in two weeks.  He said if there is still sign of a fracture, it will be treated as such...and if there is no more sign of fracture, it will be treated as a sprain.
I do understand that scaphoid fractures do not always show up on xrays right away. I'm just wondering if it is possible for there to be a "questionable" hairline fracture, and then two weeks later the xrays show NO fracture. What could be showing up on the xray at this time if there is not a fracture?  
Also, is a hairline fracture at the scaphoid waist treated any different than a complete break? Would he still need to be treated in a cast?
Thank you!

ANSWER: Debi,
You're husband is being treated appropriately. Unless there is a clear or obvious fracture(fx) these injuries can be difficult to diagnose...so, what you do is treat it LIKE it is fractured then you are covered. You have the pt come back in 2-3 wks for xrays to see if there is any "fluff" at the questionable fx site on the repeat xray, this is decalcification around the fx line...if so it means it was fx'd and your bone is healing...if not then it was not fx'd. If it is still not clear and he is still in pain and has swelling they may could get a bone scan of the wrist.

The blood supply for this bone enters through the topside of the bone, so if a fx occurs at the mid-portion or waist, then the blood supply at the bottom of the bone may be compromised (ie doesn't get enough blood) and that portion of the bone dies..called avascular necrosis. I would say that a ?hairline fx at the waist has an excellent prognosis for 100% recovery. If you had a complete break and or these pieces were displaced (not in line with each other)...these are the types of scaphoid fx's that may not do well...where the bones don't grow back together and blood supply is damaged.

---------- FOLLOW-UP ----------

QUESTION: Thank you for your answer. It did clear some questions up for us. Yet there are two questions that I can't quite get anyone to answer for me.

First off, I understand that there is often NO sign of fracture in initial xrays, and that scaphoid fractures will often show up in later films.  But is it common for there to be some signs of fracture in initial xrays, and then have NO sign of fracture in subsequent xrays taken two weeks later? (It seems sort of like a backwards scenario...). If he goes back and there is no fracture, then what is it that the ortho could be seeing there right now?

And secondly, are hairline fractures of the scaphoid waist treated in the same way a complete break would be treated -which from what I understand would be several weeks in a cast, short or full arm?
Thanks again, I really appreciate you taking the time to help shed a little light on this for us! I know these questions could be answered better by his own doctor, but I have been unable to reach him.  

Answer
1.With these scaphoid injuries that are (?)questionable..you are better served to "over-read" and say that may be a fx..and treat it like one...vs saying no fx and not treating it then having the guy come back a month later and a new set of xrays showing that it was fx'd because NOW the bone has had time to respond and release calcium to try and heal itself...and this is what shows up on the xray..but it is not immediate! takes 2-3 wks. We have to put something down on the report..we can't say well it maybe kind of sort of looks like a fx...so we say ? fx..because that lets everyone know that we saw the ? area but we can't for sure 100% say it IS a fx at that instant.

2. Again it is just as easy to go ahead and treat it almost like a complete break..now if it was a complete break then yeah you will be in a cast longer than a ? fx, and thats when you tell pt that there may be complications due to the blood supply thing and location of the break etc..I have this talk with any questionable scaphoid fx's..but it is unlikely with a ? fx. It also depends on the pt and or spouse..if they are really anxious and have a lot of questions or if it is a work comp case etc..then I will go ahead and treat it like a full fledge fx just to be on the safe side. Some orthos prefer short arm some long arm...For this I would suspect a short arm would be fine.