Treatment:
The patient was placed in a long arm, radial gutter thumb spica splint initially, and transitioned into a short arm thumb spica with the interphalangeal joint free.

Eight days post-injury, the patient underwent a debridement of the triangular fibrocartilage complex, scapholunate ligament thermal shrinkage, and arthroscopically assisted reduction and internal fixation of the proximal pole scaphoid fracture with a compression screw oriented perpendicular to the fracture site. Case Photo #9


Case Photo #9 - Post-operative radiograph of the right wrist demonstrate satisfactory placement of a countersunk compression screw (red arrow) across the proximal pole scaphoid fracture.

Outcome:
The patient tolerated surgery well, and was placed in a long arm thumb spica cast for two weeks and transitioned to a short arm thumb spica cast. He regained full strength and range of motion and had no pain by his two week surgical follow-up.

Author's Comments:
This case highlights the utility of diagnostic ultrasound in evaluating sports related trauma in an acute setting. In athletes with a Fall On Out Stretch Hand (FOOSH) injury without radiographic abnormality, ultrasound can provide additional information confirming the suspected diagnosis of a scaphoid fracture. Sonographic evaluation of the scaphoid can be easily performed on the sideline to help evaluate for cortical irregularities consistent with a fracture and guide return to play decisions. To our knowledge, this is the first reported case of a primary care sports medicine physician diagnosing a scaphoid fracture with ultrasound.

Editor's Comments:
Scaphoid fractures account for 70% of all carpal fractures. They are among the most challenging fractures to treat as 70-80% of the scaphoid vascularity is along the dorsal aspect of the scaphoid with the vessels entering along the dorsal ridge before transversing to the proximal end which puts the scaphoid's vascularity at risk with most fracture types. Particularly the proximal and mid pole fractures have a high rate of non union due to the limited blood supply to the proximal pole of the scaphoid. The risk of non union and carpal arthrosis increases with time from injury prompting early identification essential to scaphoid fracture management. Unfortunately, radiographs are often negative at the time of injury and the physician's suspicion prompts interval evaluation or more advanced imaging options. Musculoskeletal ultrasound has provided physicians with an extension of their physical examination allowing for dynamic and rapid imaging that ultimately influences return to play decisions.

References:
(1)Retting, Arthur. Athletic Injuries of the wrist and hand. Part 1: Traumatic Injuries of the Wrist. American Journal of Sports Medicine 2003; 31(6): 1038-1048
(2) Jaworski, C. et al. Rehabilitation of the Wrist and Hand Following Sports Injury. Clinical Sports Medicine 2010; 29: 61-80

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