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Case study: 25 year old male presents with left wrist pain. He was playing ultimate Frisbee when he came down and landed awkwardly on an outstretched hand. Mild swelling. Diffuse pain through the wrist and thumb. No previous injury.

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On examination, active and passive range of motion are essentially full with some discomfort at end ranges. Distal ulna and distal radius are mildly ttp. Majority of TTP is over the anatomic snuffbox.

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Patient has a mildly displaced left scaphoid fracture. This one is pretty straightforward. You don't have any excuse to miss this. You can even see it on the lateral view. Not all x-rays are this notable though, and some scaphoid fractures are easy to miss. Even radiologists will miss them. If you have a patient that suffers a FOOSH injury, and they have ttp over the snuffbox, ttp over the scaphoid on the volar aspect, you have to assume there is a scaphoid fracture.

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If you only put them into a splint or don't immobilize them properly, it commonly can go on to non-union. The scaphoid has terrible blood supply, especially in the proximal pole. This one is in the middle or the waist, and might heal if it wasn't displaced. Because of the displacement here, it needs a pin to bring it back together.
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If you suspect a scaphoid fracture but aren't 100% certain, you can either a) treat them as such with a thumb spica cast, either short-arm or long-arm depending who you ask or b) obtain further imaging in a CT scan of the scaphoid with 1mm cuts or an MRI of the wrist.
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