Phillips TG, Reibach AM, Slomiany WP: Diagnosis and management of scaphoid fractures. Am Fam Physician 2004;70(5):879-84.

Young men who fall with their hands outstretched are more likely to receive a scaphoid fracture than similar injuries in young children or the elderly that result in a fracture of the distal radius. It is important to identify scaphoid fractures and provide correct therapy because nonunion related to a poor blood supply can complicate healing. Because early imaging is often negative, the practitioner needs a high index of clinical suspicion to catch this diagnosis. The pain may be dull and deep in the radial wrist, worsened by gripping or squeezing. Anatomic snuffbox tenderness is a very sensitive test (90%), but it is nonspecific (40%). In a second maneuver, tenderness over the scaphoid tubercle is elicited with the patient's wrist extended. This maneuver is also sensitive (87%), but more specific (57%). Absence of tenderness with these two maneuvers makes a scaphoid fracture highly unlikely. The authors suggest that a patient with clinically suspected scaphoid fracture but negative initial radiographs should have a short arm thumb spica cast applied and be reevaluated in 2 weeks because the fracture can worsen if the injury is not cast. Either magnetic resonance imaging or a bone scan are equally appropriate to confirm a fracture when the initial radiographs are negative.