Working Diagnosis:
Right wrist scaphoid fracture

Treatment:
The patient was placed in an Exos thumb spica splint during his office visit. Prior to placement of the splint, myofascial release was done on the dorsal and volar aspect of his right wrist to address the TART changes noted on exam.

Outcome:
The patient was continued in the thumb spica splint for six weeks with interval x-rays to monitor healing. During this time, he did not participate in any diving practice or competitions. At the six week mark, x-rays showed a healed fracture with remineralization of the scaphoid. Case Photo #5 The hand surgeon was confident adequate healing had occurred allowing the patient to return to diving with progressive increase in his diving volume. Since being cleared by the hand surgeon, the patient has worked with occupational therapy and is back to diving without difficulty 8-10 weeks after his initial injury.

Author's Comments:
This case highlights the importance of fully evaluating wrist pain in athletes. Scaphoid fractures can occur with low-energy trauma and lead to mild symptoms that athletes may not consider severe enough to warrant treatment. However, research has shown that it is not uncommon to find a scaphoid nonunion with a remote history of wrist sprain. Therefore, physicians should have a high index of suspicion for a scaphoid fracture in an athlete complaining of radial-sided wrist pain.
In athletes, specifically divers, it is critical to rule out a scaphoid fracture following a wrist injury. The biomechanics of diving often has the diver entering the water with their hands in pronation and wrists extended. This can lead to repetitive trauma on the carpal bones and ultimately lead to a scaphoid injury.
This case shows that further imaging is often needed in order to diagnose a scaphoid fracture. Nondisplaced fractures of the scaphoid can frequently be missed on radiographs because of subtle fracture lines and the irregular contours of the scaphoid bone. Therefore if radiographs are negative but there is a high index of suspicion, advanced imaging should be obtained with a CT or MRI. MRI is nearly 100 percent sensitive and specific for occult scaphoid injury and is often the imaging of choice in patients with suspected scaphoid fractures. Early diagnosis and treatment of a scaphoid fracture decreases the risk of scaphoid non-union and avascular necrosis, which often requires surgery with bone grafting.

Editor's Comments:
The scaphoid accounts for 70 percent of all carpal fractures and is most prevalent in 15- to 30-year-old populations. Blood supply to the scaphoid is unique due to the dorsal vessels supplying up to 70-80 percent of the blood supply. As a result a fracture within the proximal pole will have a higher rate of non union compared to distal pole fractures. There is an increased risk of scaphoid fracture when the wrist is loaded when positioned in more than 90 degrees of dorsiflexion and more than 10 degrees of radial deviation. Distal radius fractures will often occur if there is less than 90 degrees of dorsiflexion.

References:
Weller WJ, Thompson NB, Phillips SC, and Calandruccio JH. Scaphoid fractures in athletes. Orthopedic Clinics of North America, 51(4), 511-516.
Hughes TB. Acute scaphoid waist fracture in the athlete. Clinic in Sports Medicine, 39(2), 339-351.
Rettig AC, PAtel DV. Epidemiology of elbow, forearm, and wrist injuries in the athlete. Clin Sports Med, 14, 289-297.
Weber ER, Chai EY. An experimental approach to the mechanism of scaphoid waist fractures. J Hand Surg, 3A, 142-148.

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