What complications of scaphoid fracture should be monitored and what nursing assessments should be performed while waiting for an orthopedic appointment?

Complications of Scaphoid Fracture and Nursing Assessment Protocol

While awaiting orthopedic evaluation over the next 2 days, nursing staff should systematically monitor for neurovascular compromise, compartment syndrome signs, and early indicators of the major scaphoid-specific complications: nonunion, avascular necrosis (particularly of the proximal pole), malunion, and progression to post-traumatic osteoarthritis.

Critical Complications to Monitor

Immediate/Acute Complications (Priority for 48-Hour Window)

Neurovascular compromise requires serial assessment every 4-6 hours:

• Assess distal perfusion: capillary refill in thumb and fingers, radial pulse quality, skin temperature and color changes 1
• Evaluate median nerve function: sensation in thumb, index, and middle fingers; ability to oppose thumb to little finger (median nerve distribution) 1
• Monitor for compartment syndrome: increasing pain out of proportion to injury, pain with passive finger extension, tense forearm/hand compartments, paresthesias 1

Scaphoid-Specific Complications (Develop Over Time but Assessment Begins Now)

Avascular necrosis (AVN) of the proximal pole is a critical concern:

• The proximal pole has tenuous blood supply, making it highly vulnerable to AVN 2
• Displaced fractures (>1mm offset) carry 50% risk of AVN 3
• Early clinical indicators: persistent severe pain despite immobilization, lack of improvement in tenderness over anatomic snuffbox 3, 1

Nonunion is the most common complication:

• Displaced fractures have 55% nonunion rate compared to 5-10% in undisplaced fractures 3
• Risk factors to document: smoking status, occupation (manual laborers have higher risk), exact fracture displacement on imaging 4
• Early warning signs: persistent point tenderness over scaphoid tubercle (volar wrist) and anatomic snuffbox (dorsal wrist) 1

Malunion and carpal instability:

• Displaced fractures that unite without anatomic reduction lead to painful malunion and altered carpal mechanics 3, 5
• Assess for dorsal lunate rotation (instability collapse pattern) if lateral radiographs available 5

Post-traumatic osteoarthritis:

• Long-term consequence of malunion/nonunion, but assessment begins with documenting baseline pain and range of motion 3, 6

Specific Nursing Assessment Protocol (Every 4-6 Hours)

Neurovascular Assessment

• Circulation: Radial pulse, capillary refill <2 seconds in all digits, skin color/temperature 1
• Sensation: Light touch in median, ulnar, and radial nerve distributions; two-point discrimination in fingertips 1
• Motor function: Thumb opposition, finger flexion/extension, grip strength (compare to unaffected side) 1
• Pain assessment: Rate pain 0-10, note if increasing despite immobilization and analgesia 1

Scaphoid-Specific Examination

• Anatomic snuffbox tenderness: Palpate the depression between extensor pollicis longus and brevis tendons with wrist in ulnar deviation 1
• Scaphoid tubercle tenderness: Palpate volar wrist at base of thenar eminence 1
• Pain with axial loading: Compress thumb longitudinally toward wrist (positive suggests scaphoid fracture) 1
• Watson's scaphoid shift test: While not diagnostic alone, increasing pain with this maneuver suggests worsening instability 1

Immobilization Assessment

• Cast/splint integrity: Check for loosening, pressure points, skin breakdown 5
• Position verification: Wrist should be in slight volar flexion and radial deviation (optimal for scaphoid healing) 5
• Edema monitoring: Increasing swelling may indicate cast is too tight or compartment syndrome developing 1

Documentation Requirements

• Fracture characteristics from imaging: Displacement >1mm, proximal pole involvement, associated carpal instability 3, 5
• Patient risk factors: Smoking status, occupation, hand dominance, mechanism of injury 4
• Baseline functional status: Pre-injury grip strength, range of motion, pain level 4

Red Flags Requiring Immediate Physician Notification

Call immediately if any of the following develop:

• Progressive numbness or tingling in median nerve distribution (thumb, index, middle fingers) 1
• Absent or diminished radial pulse 1
• Capillary refill >3 seconds in any digit 1
• Pain increasing despite adequate analgesia, especially pain with passive finger extension 1
• Tense, swollen forearm or hand compartments 1
• Skin color changes (pallor, cyanosis, mottling) 1
• New inability to move fingers or thumb 1

Critical Pitfalls to Avoid

Do not assume normal radiographs exclude fracture: Up to 25% of scaphoid fractures are radiographically occult initially, so clinical examination findings (snuffbox tenderness, scaphoid tubercle tenderness) take precedence 7, 8, 6

Do not delay immobilization: Even suspected scaphoid fractures require immediate thumb spica splinting to prevent displacement and subsequent complications 5

Do not overlook displacement: Fractures with >1mm displacement or dorsal lunate tilting on lateral view are unstable and have dramatically higher complication rates (55% nonunion, 50% AVN) requiring urgent orthopedic evaluation 3, 5

Do not miss proximal pole fractures: These have the highest AVN risk due to retrograde blood supply and may require surgical intervention even if minimally displaced 2, 6

Document smoking status: Smokers have significantly higher nonunion rates, though this should not delay treatment 4