Scaphoid avascular necrosis with undisplaced pisiform fracture

Case contributed by Dr Paul Heyworth

Presentation

Eight weeks post left scaphoid fracture. Ongoing pain at the anatomical snuff box

Patient Data

Age: 35
Gender: Female

There is a persisting fracture through the proximal waist of the scaphoid with central lucency. The suggestion of increased density/sclerosis of the proximal pole of the scaphoid on a single (scaphoid) projection raising the possibility of developing osteonecrosis. No loss of scaphoid height. Scapholunate interval is normal .

Radiocarpal joint spacing maintained. No other fractures. No soft tissue swelling.

Minimally displaced waist fracture extending from the proximal to mid pole of the left scaphoid, with an impression of increased sclerosis in the proximal pole.  No widening of the scapholunate interval.  

Subtle lucent line (arrow) involving the pisiform may represent an undisplaced fracture.

Case Discussion

This case demonstrates the subtle finding of sclerosis on xray of the scaphoid which is suggestive of scaphoid avascular necrosis (AVN) and warrants further investigation in the appropriate clinical setting.

The patient above went on to have a CT which confirmed scaphoid non-union as well as an undisplaced pisiform fracture.

The patient proceeded to undergo internal fixation of the scaphoid.

Non-union occurs 5-10% of scaphoid fractures, with location of the fracture being one of the main determining factors:

  • distal pole: excellent likelihood of union (~100%)
  • waist: ~10-20% chance of non-union
  • proximal pole: ~30-40% chance of non-union

Other factors include a vertically oriented fracture line, fragment displacement of >1mm and ligamentous instability.

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Case information

rID: 61093
Published: 21st Jun 2018
Last edited: 21st Jun 2018
Inclusion in quiz mode: Included

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