Hand Surgery Source

Scaphoid Tenderness

Test, Exam and Signs

Historical Overview

  • Scaphoid tenderness is indicative of a scaphoid fracture.
  • After examining a patient with pseudarthrosis, Struthers published the earliest report of scaphoid fracture in 18731.

Description

  • Scaphoid tenderness at the anatomical snuffbox is a highly sensitive sign of scaphoid fracture (sensitivity, 87–100%2).
  • Although sensitive, the sign has wide variations in specificity. A recent review of 8 studies reported specificity values ranging from 3–98%.2

Pathophysiology

  • Scaphoid fracture is a common injury, accounting for more than 80% of carpal fractures,3 generally resulting from a fall on an outstretched hand with radial deviation. Undisplaced fractures, which are common, are difficult to diagnose.
  • A scaphoid fracture may result in swelling of the anatomical snuffbox, which has greater specificity than tenderness alone (37–72%2).

Instructions

  1. Take patient history
  2. Apply pressure to the anatomical snuffbox on the radial side of the wrist

Variations

  • Palpate the scaphoid tubercle just proximal to the thenar eminence on the palmer side of the wrist

Related Signs and Tests

  • The poor specificity of the standard anatomical snuffbox test combined with the frequency of the injury and the limited usefulness of x-ray workups for undisplaced fractures has encouraged the consideration of other clinical signs.2
  • Several of these signs are listed below along with their reported (sensitivity and specificity)2:
    • Hematoma (22–46% and 76–77%)
    • Longitudinal thumb compression test (48–100% and 22–97%)
    • Clamp sign (26% and 79%)
    • Pain with resisted supination (83–100% and 38–98%)
Presentation Photos and Related Diagrams
  • Tip of pen in anatomic snuff box. Yellow arrow on EPL and Red arrow on AbPL
    Tip of pen in anatomic snuff box. Yellow arrow on EPL and Red arrow on AbPL
  • Palpation of scaphoid in anatomic snuff box
    Palpation of scaphoid in anatomic snuff box
  • Palpation of scaphoid in anatomic snuff box
    Palpation of scaphoid in anatomic snuff box
  • Palpating scaphoid tuberosity under distal FCR tendon
    Palpating scaphoid tuberosity under distal FCR tendon
Definition of Positive Result
  • A positive result occurs when there is tenderness and increased pain with pressure.
Definition of Negative Result
  • A negative result occurs when pressure does not elicit tenderness.
Comments and Pearls
  • The tenderness test is straightforward but, in acute cases, it may be complicated by pain and swelling.
  • No clinical tests for scaphoid fracture show clear superiority in specificity, but combining several tests may prove useful in avoiding unnecessary imaging workups and immobilizations.2
Diagnoses Associated with Tests, Exams and Signs
References
  1. Struthers J. The Subdivision of the Scaphoid Carpal Bone. J Anat Physiol 1873;8(Pt 1):113-114. PMID: 17231472
  2. Mallee WH, Henny EP, van Dijk CN, Kamminga SP, van Enst WA, Kloen P. Clinical diagnostic evaluation for scaphoid fractures: A systematic review and meta-analysis. J Hand Surg Am 2014;39(9):1683-1691. PMID: 25091335
  3. Rhemrev SJ, Ootes D, Beeres FJ, Meylaerts SA, Schipper IB. Current methods of diagnosis and treatment of scaphoid fractures. Int J Emerg Med 2011;4:4-1380-4. PMID: 25091335