Scaphoid stress fractures are rare injuries that have been described in young, high-level athletes who exhibit repetitive loading with the wrist in extension. We present a case of an occult scaphoid stress fracture in a 22-year-old female Division I collegiate shot-putter. She was successfully treated with immobilization in a thumb spica splint for 6 weeks. Loaded wrist extension activities can predispose certain high-level athletes to sustain scaphoid stress fractures, and a high index of suspicion in this patient population may aid prompt diagnosis and management of this rare injury.
Scaphoid fractures are common in young adults and athletes and can lead to significant morbidity even with early diagnosis and appropriate treatment. While scaphoid fractures are most commonly associated with acute wrist trauma, it is notable that chronic repetitive loaded wrist extension can lead to scaphoid stress fractures [
Although rare, scaphoid stress fractures have been described in young, high-level athletes who exhibit repetitive loading with the wrist in extension, most commonly in gymnasts [
A 22-year-old female Division I collegiate right-hand dominant shot-putter initially presented with a two-month history of progressive, activity-related right wrist pain, with no report of prior trauma. She noted worsening pain with wrist extension during throwing the shot-put but had no complaints of pain or dysfunction with the discus nor with activities of daily living. The patient had been training for three to four hours per day, five times per week, alternating between the shot-put and discus as well as doing Olympic-style weight lifting for seven years prior to presentation.
Physical exam revealed tenderness to palpation at the anatomic snuffbox and the scaphoid tuberosity. Wrist flexion, extension, and supination were symmetric, but painful with loaded terminal extension in the dominant wrist. Radiographs of the affected wrist at the time of presentation, demonstrated −1 mm ulnar negative variance, with no evidence of abnormality (Figures
Posteroanterior radiographic view of the wrist at the time of initial evaluation that shows no abnormality in the scaphoid.
An oblique radiographic view at the time of initial evaluation without evidence of abnormality of the scaphoid.
A lateral view of the wrist at the time of initial evaluation without radiographic abnormality of the scaphoid.
(a) A 1.5-Tesla MRI T2 sagittal cut demonstrating palmar scaphoid waist bone edema consistent with incomplete scaphoid waist stress fracture obtained at the time of initial presentation. (b) A 1.5-Tesla MRI T2 coronal cut showing scaphoid waist bone edema consistent with incomplete scaphoid waist stress fracture obtained at the time of initial presentation. (c) A 1.5-Tesla MRI T2 axial cut showing palmar scaphoid waist bone edema consistent with incomplete scaphoid waist stress fracture obtained at the time of initial presentation.
The patient was placed in a removable thumb spica wrist splint and was instructed to avoid any loaded extension of the wrist, including throwing the shot-put and weight-training. She was allowed to throw discus as it did not cause any pain. After three weeks, the patient reported no symptoms or pain with wrist extension. Radiographs obtained at 6 weeks after thumb spica immobilization were negative for any evidence of scaphoid fracture (Figures
A scaphoid view obtained 6 weeks after presentation without radiographic evidence of a scaphoid waist fracture.
An oblique radiographic view obtained 6 weeks after presentation with no radiographic abnormality of the scaphoid.
A lateral radiographic view obtained at 6 weeks after initial presentation showing a normal appearing scaphoid.
Scaphoid stress fractures are very rare injuries, with only case reports available for analysis in the peer-reviewed literature. In each reported case, the patients were competitive, high-level athletes training for multiple hours per day for several years prior to their presentation (Table
Clinical characteristics, imaging evaluation, and treatment method for scaphoid stress fractures published in the literature.
Author | Sport | Age (years)/ |
Laterality | Pain duration | Time to diagnosis after presentation | Imaging presentation | Treatment | Scaphoid fracture location |
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Manzione and Pizzutillo [ |
Gymnast | 16 M | Left | 6 weeks | 2 weeks | Negative XR; positive bone scan | Thumb spica cast ×10 weeks | Waist |
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Hanks et al. [ |
Shot-putter | 19 M | Right | 1.5 years | 2 months | Negative initial XR; positive repeat XR at 2 months | Thumb spica cast/splint ×11 weeks | Waist |
Gymnast |
18 M | Left | 2 years | 1 year, 2 weeks | Positive XR; positive bone scan prior to XR | Thumb spica cast ×4 months | Waist | |
Right | 3 weeks | No delay | Positive bone scan; negative XR | Thumb spica cast ×6 weeks | Waist | |||
Gymnast | 18 M | Left | 2 months | No delay | Positive bone scan; negative XR | Thumb spica cast ×6 weeks | Waist | |
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Engel and Feldner-Busztin [ |
Gymnast | 18 M | Bilateral | 1 year | Not mentioned | Positive bone scan & XR | Not mentioned | Waist |
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Inagaki and Inoue [ |
Badminton | 16 M | Right | 7 weeks | No delay | Positive XR | Thumb spica cast ×8 weeks | Waist |
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Matzkin and Singer [ |
Gymnast | 13 F | Right | 3 months | 3 months | Negative initial XR; positive XR 3 months later | Long arm spica ×8 weeks, short arm thumb spica ×4 weeks | Waist |
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Brutus and Chahidi [ |
Badminton | 23 M | Right | 8 weeks | No delay | Positive XR | Thumb spica cast ×8 weeks and then ORIF: Herbert screw & graft | Waist |
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Hosey et al. [ |
Diver | 13 F | Right | 2 months | No delay | Positive XR; confirmed on MRI | ORIF: Herbert screw | Waist |
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Rethnam et al. [ |
Cricketer | 38 M | Right | 2 years | No delay | Positive XR | ORIF: Herbert screw & graft | Waist |
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Yamagiwa et al. [ |
Gymnast | 18 M | Right | Not mentioned | No delay | Positive MRI; negative XR | Thumb spica cast ×8 weeks and then ORIF: Herbert screw | Waist |
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Nakamoto et al. [ |
Gymnast | 18 M | Right | 3 months | No delay | Positive XR; confirmed on MRI | ORIF: Herbert screw | Waist |
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Pidemunt et al. [ |
Goalkeeper | 13 M | Bilateral | 2 years | No delay | Positive XR; confirmed on CT | ORIF: graft & Herbert screw | Waist |
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Mohamed Haflah et al. [ |
Diver | 16 M | Bilateral | 18 months (right) | 1 year (right), no delay (left) | Positive XR R wrist (nonunion); incidental positive XR L wrist | ORIF: headless compression screw & graft | Waist |
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Saglam et al. [ |
Goalkeeper | 19 M | Bilateral | 4 years | No delay | Positive XR; confirmed on MRI | Thumb spica cast ×12 weeks | Waist |
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Kohyama et al. [ |
Tennis | 18 M | Right | 4 months | No delay | Positive XR; confirmed on CT & MRI | Thumb spica cast/splint ×12 weeks | Waist |
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Kohring et al. (current report) | Shot-putter | 22 F | Right | 2 months | No delay | Negative XR; positive MRI | Thumb spica splint ×6 weeks | Waist |
Common to all of these athletic activities is the act of repetitive loaded wrist extension. Although the exact factors that lead to stress fractures of the scaphoid remain unclear, it has been suggested that repetitive stress and microtrauma to the bone can exceed native osseous repair mechanisms [
Loaded wrist extension creates stresses that are typically centered at the scaphoid waist. In a cadaver study, Weber and Chao reported that 460 to 960 pounds of force applied to an extended wrist was required to acutely fracture the scaphoid, at the waist [
Interestingly, the majority of scaphoid stress fractures have been reported in young male athletes, with 14 male and only 2 female patients reported in the available literature. The exact mechanism for this apparent gender discrepancy remains unclear but may be related to males reaching skeletal maturity at a later age than females, as adolescence appears to be a risk factor for suffering a scaphoid stress fracture. Similarly, while a direct link to age, sex, and athletic participation remains speculative, scaphoid stress fractures may be in part due to more intense participation in higher-level, longer-duration athletic training during adolescence.
Importantly, many of the published case reports regarding scaphoid stress fractures have noted a delay in diagnosis with this injury, with the majority of cases being recognized only after the fracture became apparent on plain radiographs [
There are no current guidelines specific to the treatment of scaphoid stress fractures. However, for displaced or chronic scaphoid fractures or nonunions, surgical intervention is typically recommended. For nondisplaced or incomplete fractures, as in this case, nonsurgical treatment with immobilization is usually appropriate. Of the cases described in the literature, nine of the cases were treated nonoperatively [
In summary, stress fractures of the scaphoid are exceedingly rare but potentially devastating if not recognized and treated promptly. Clinicians should have a high index of suspicion when evaluating an athlete or patient who presents with an insidious onset of activity-related wrist pain and snuffbox tenderness and who is involved in a sport that requires repetitive loaded wrist extension. While the majority of cases described have involved male athletes, scaphoid stress fractures also occur in females. A low-threshold to obtain advanced imaging when radiographs appear negative for scaphoid pathology may aid in the early diagnosis of this rare entity, avoid fracture nonunion, and reduce the need for complex surgical intervention.
The authors declare that there are no competing interests regarding the publication of this paper.