Links To And Excerpts From “Arun Sayal on nuances for assessment of scaphoid fractures (0:52)” From EM Quick Hits 30

In this post I link to and excerpt from “Arun Sayal on nuances for assessment of scaphoid fractures (0:52)” From EM Quick Hits 30 Scaphoid Fracture, Therapeutic Hypothermia, HEADS-ED, Pelvic Trauma, Kratom, Femoral Lines.*

*Helman, A. Sayal, A. Swaminathan, A. Klaiman, M. Reid, S. Petrosoniak, A, Morgenstern J. EM Quick Hits 30 – Scaphoid Fracture, Therapeutic Hypothermia, HEADS-ED, Pelvic Trauma, Kratom, Femoral Lines. Emergency Medicine Cases. July, 2021. Accessed 8-23-2021.

It is important to recognize that:

Conventional radiography, including dorsopalmar and lateral imaging of the wrist are obtained in neutral position. Optimal visualization of the scaphoid on the dorsopalmar projection is achieved with closed fist and ulnar deviation. The purpose of this so-called Stecher’s view is to extend and thereby project the scaphoid in its entire length. A non-displaced or minimally displaced scaphoid fracture will only be detected if the X-ray beam is pointed parallel to the fracture line, which is why three to four special projections at difference angles of the scaphoid are recommended. However, the sensitivity of radiography to detect a scaphoid fracture is no higher than 70%.

The above is from Acute scaphoid fractures: guidelines for diagnosis and treatment [PubMed Abstract]  [Full-Text HTML] [Full-Text PDF]. EFORT Open Rev. 2020 Feb 26;5(2):96-103.

The above article is designed for hand surgeons but it is very useful to primary care physicians who are charged with recognizing and referring patients with scaphoid fractures. The article will be a big help to primary care physicians to explain the probable course of treatment and thus reassure patients.

I strongly recommend that readers review Links To And Excerpts From “Acute scaphoid fractures: guidelines for diagnosis and treatment”
Posted on August 25, 2021 by Tom Wade MD

All that follows is from “Arun Sayal on nuances for assessment of scaphoid fractures (0:52-7:41)”

Scaphoid fractures: nuances of assessment

Epidemiology is important for pre-test probability assessment

  • carpal injuries represent 20% of wrist injuries in the ED, of which 70% are scaphoid fractures
  • Less likely in children < 15-years-old and adults > 50-years-old
  • 20-30% of fractures are occult on initial X-rays

Diagnostic usefulness of the 3 physical exam maneuvers for scaphoid fractures

  • Snuff box tenderness
    • Poor specificity: many patients have physiologic snuff box tenderness at baseline; tip – palpate for asymmetric snuff box tenderness (i.e. check the contralateral wrist)
    • Examination should be done with the wrist in ulnar deviation to expose the scaphoid

scaphoid snuffbox ulnar deviation

Palpate the snuffbox with the wrist in ulnar deviation to expose the scaphoid bone and compare to the contralateral wrist

  • Palmar scaphoid palpation –  tenderness at base of the thenar eminence over the palpable scaphoid tubercle with the wrist in radial deviation

palmar scaphoid in radial deviation

Palmar location of scaphoid bone brought out by putting the wrist in radial deviation

  • Axial thumb loading of 1st metacarpal to compress the scaphoid is less specific in elderly as a positive test is more likely indicative of CMC osteoarthritis rather than scaphoid fracture
  • 3 of 3 portends a 70-90% likelihood of a scaphoid fracture (30-50% likelihood if 1/3).
  • Consider adding dedicated scaphoid view if any one of the 3 exam maneuvers are positive
  • Clamp sign has a pooled +LR of 8.6 for a scaphoid fracture. Ask the patient exactly where it hurts the most. If they place their thumb and index finger like a clamp on the volar and dorsal aspects of the base of the thumb, they have a positive Clamp Sign


clamp sign scaphoid fracture

The Clamp Sign has high positive likelihood ratio for the diagnosis of scaphoid fracture. Ask the patient to show you where the pain is the greatest. Grasping their scaphoid with their thumb and index finger is a positive Clamp Sign.


  1. Duckworth AD, Jenkins PJ, Aitken SA, Clement ND, Court-Brown CM, McQueen MM. Scaphoid fracture epidemiology. J Trauma Acute Care Surg. 2012 Feb;72(2):E41-5

  2. Krastman P, Mathijssen NM, Bierma-Zeinstra SMA, Kraan G, Runhaar J. Diagnostic accuracy of history taking, physical examination and imaging for phalangeal, metacarpal and carpal fractures: a systematic review update. BMC Musculoskelet Disord. 2020 Jan 7;21(1):12.
  3. Ghane, M. R., Rezaee-Zavareh, M. S., Emami-Meibodi, M. K., & Dehghani, V. (2016). How Trustworthy Are Clinical Examinations and Plain Radiographs for Diagnosis of Scaphoid Fractures?. Trauma monthly, 21(5), e23345.
  4. Bäcker, H. C., Wu, C. H., & Strauch, R. J. (2019). Systematic review of diagnosis of clinically suspected scaphoid fractures. Journal of Wrist Surgery, 09(01), 081-089.
  5. Christopher R. C. et al. Adult Scaphoid Fracture. Academic Emergency Medicine, 201421102– 121.
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