Scaphoid Fracture
The scaphoid is the most frequently fractured carpal The fracture is classified by the region of the bone in which it occurs: proximal pole, middle (waist), or distal pole.
SYNONYM
Navicular fracture
ETIOLOGY
• A scaphoid fracture most commonly occurs asthe result of a sudden impact tothe palm with the wrist hyperextended.
Less common mechanisms may involve
forced flexion and axial loading of the
wrist with the hand in a fist position.
• The waist of the scaphoid accounts for 70% of all fractures.
• The proximal pole fractures occur 20%
of the time.
• Distal pole fractures occur only 10% of
the time.
Navicular fracture
ETIOLOGY
• A scaphoid fracture most commonly occurs asthe result of a sudden impact tothe palm with the wrist hyperextended.
Less common mechanisms may involve
forced flexion and axial loading of the
wrist with the hand in a fist position.
• The waist of the scaphoid accounts for 70% of all fractures.
• The proximal pole fractures occur 20%
of the time.
• Distal pole fractures occur only 10% of
the time.
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| Scaphoid-Fracture |
• The amount of blood supply determines how fast or how complete a scaphoid fracture will heal. The majority of blood supply to the carpal, 70% to 80%, enters distally., the proximal pole has no direct blood supply, so it must depend on vessels that primarily supply the waist. Diminished blood flow to the proximal pole is noted in about one-third of fractures at the waist level.
This reduced blood supply may result in avascular necrosis of the proximal pole of the scaphoid. Almost 100% of proximal pole fractures result in aseptic necrosis. Displaced scaphoid fractures have a nonunion rate of 55% to 90%.
• Frequently, the diagnosis of a scaphoid fracture is delayed. Late diagnosis may alter the prognosis for fracture union and dramatically increase the long-term likelihood of arthritis.
• Proper immobilization, and surgery if needed will contribute to the rate of healing.
This reduced blood supply may result in avascular necrosis of the proximal pole of the scaphoid. Almost 100% of proximal pole fractures result in aseptic necrosis. Displaced scaphoid fractures have a nonunion rate of 55% to 90%.
• Frequently, the diagnosis of a scaphoid fracture is delayed. Late diagnosis may alter the prognosis for fracture union and dramatically increase the long-term likelihood of arthritis.
• Proper immobilization, and surgery if needed will contribute to the rate of healing.
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EPIDEMIOLOGY AND
DEMOGRAPHICS
• Approximately 35,000 scaphoid frac tures occur annually in the US, with occult fractures representing 12% to 16% of the total.
• Young males have a peak incidence between the ages of 15 to 35 years.
MECHANISM OF INJURY
Common mechanism of injury may involve using the hand to brace a fall or may result from an athlete running into another person or a wall during competition.
COMMON SIGNS AND
SYMPTOMS
• Swelling in the wrist
• Tenderness or pain within the anatomical snuffbox.
AGGRAVATING ACTIVITY
Heavy gripping activities such as holding a baseball bat or a tennis racket.
EASING ACTIVITY
DEMOGRAPHICS
• Approximately 35,000 scaphoid frac tures occur annually in the US, with occult fractures representing 12% to 16% of the total.
• Young males have a peak incidence between the ages of 15 to 35 years.
MECHANISM OF INJURY
Common mechanism of injury may involve using the hand to brace a fall or may result from an athlete running into another person or a wall during competition.
COMMON SIGNS AND
SYMPTOMS
• Swelling in the wrist
• Tenderness or pain within the anatomical snuffbox.
AGGRAVATING ACTIVITY
Heavy gripping activities such as holding a baseball bat or a tennis racket.
EASING ACTIVITY
Rest of the involved hand should decrease discomfort.
24-HOUR SYMPTOM PATTERN
Symptoms may or may not increase as the day progresses, depending on use of the hand.
PAST HISTORY FOR THE REGION
Patients will report persistent wrist pain and previous trauma to the hand.
PHYSICAL EXAMINATION
• Loss of wrist motion, especially radial deviation
• Snuffbox tenderness
• Pain with resisted forearm rotation
24-HOUR SYMPTOM PATTERN
Symptoms may or may not increase as the day progresses, depending on use of the hand.
PAST HISTORY FOR THE REGION
Patients will report persistent wrist pain and previous trauma to the hand.
PHYSICAL EXAMINATION
• Loss of wrist motion, especially radial deviation
• Snuffbox tenderness
• Pain with resisted forearm rotation
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IMPORTANT OBJECTIVE TESTS
CT and radiographs.
DIFFERENTIAL
• Radial sensory nerve neuritis
• de Quervain’s tenosynovitis
• CMC joint arthritis
CONTRIBUTING FACTORS
• Participation in high-contact sports such as football or basketball
• Osteoporosis or osteopenia
CT and radiographs.
DIFFERENTIAL
DIAGNOSIS
• Radial sensory nerve neuritis
• de Quervain’s tenosynovitis
• CMC joint arthritis
CONTRIBUTING FACTORS
• Participation in high-contact sports such as football or basketball
• Osteoporosis or osteopenia
TREATMENT
Fractures to the waist or distal pole that are nondisplaced can heal with closed treatment and do not require surgery
SURGICAL INDICATORS
• Poor vascularity and instability of the bone fragment
• Associated fractures of the distal radius
• Nondisplaced fractures that do not show evidence of healing after 6 weeks of immobilization
• Displaced fractures
• Displaced or unstable fractures require percutaneous pin fixation or compression screw fixation to prevent malunion.
• Internal fixation is accomplished with either smooth K-wires or a Herbert screw.
• Nonunion scaphoid fractures are the result of a patient failing to seek timely medical attention, a misdiagnosis of a wrist sprain, or failure to heal with cast immobilization. Bone grafting is necessary for healing of nonunion fractures.
Nonunions of the scaphoid can be treated with radial styloidectomy, excision of the proximal bone fragment,proximal row carpectomy,total or partial wrist arthrodesis, or traditional bone grafting.
Avascular necrosis develops in 30% to 40% of nonunion scaphoid fractures, most frequently in a fracture of the proximal third of the scaphoid bone.
SURGICAL OUTCOMES
Research has shown a return to sport occurs at an average of 7 weeks after Herbert screw fixation, compared to a 15 to 26 week return after closed treatment.
PROGNOSIS
• Prognosis is less favorable if the fracture is displaced, diagnosis is delayed, or the fracture is in the proximal or middle third of the scaphoid bone.
• Chronic pain, decreased ROM, and decreased grip strength may result.
SIGNS AND SYMPTOMS
INDICATING REFERRAL
TO PHYSICIAN
Immediate referral to a hand surgeon is essential if a scaphoid fracture is suspected. Prompt diagnosis and treatment will significantly improve prognosis and recovery of scaphoid fracture.
SUGGESTED READINGS
1- Gutow AP. Percutaneous fixation of scaphoid fractures. J Am Acad Orthop Surg.2007;15(8):474–485.
2- Yin ZG, Zhang JB, Kan SL,Wang Treatment of acute scaphoid fractures: systematic review and meta-analysis. Clin Orthop Relat Res.2007;460:142–151.
Fractures to the waist or distal pole that are nondisplaced can heal with closed treatment and do not require surgery
SURGICAL INDICATORS
• Poor vascularity and instability of the bone fragment
• Associated fractures of the distal radius
• Nondisplaced fractures that do not show evidence of healing after 6 weeks of immobilization
• Displaced fractures
SURGICAL OPTIONS
• Displaced or unstable fractures require percutaneous pin fixation or compression screw fixation to prevent malunion.
• Internal fixation is accomplished with either smooth K-wires or a Herbert screw.
• Nonunion scaphoid fractures are the result of a patient failing to seek timely medical attention, a misdiagnosis of a wrist sprain, or failure to heal with cast immobilization. Bone grafting is necessary for healing of nonunion fractures.
Nonunions of the scaphoid can be treated with radial styloidectomy, excision of the proximal bone fragment,proximal row carpectomy,total or partial wrist arthrodesis, or traditional bone grafting.
Avascular necrosis develops in 30% to 40% of nonunion scaphoid fractures, most frequently in a fracture of the proximal third of the scaphoid bone.
SURGICAL OUTCOMES
Research has shown a return to sport occurs at an average of 7 weeks after Herbert screw fixation, compared to a 15 to 26 week return after closed treatment.
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REHABILITATION
• Postsurgical
If rigid internal fixation is used, such as a Herbert screw,AROM can begin as early as 10 to 14 days when the cast is removed. A thumb spica should be fabricated for the patient to wear 24 hours a day with removal only for therapeutic ROM exercises. Edema control and ROM for the hand should begin immediately after surgery.
At 4 to 6 weeks, controlled loading of the wrist is initiated, as well as the introduction of strength training. Progression of wrist activitiesis determined by the healing of the fracture using radiograph. It is recommended that an athlete wear a Nirschl R-U wrist brace to limit extreme wrist extension on the initial return to sport.
• Nonsurgical Patient
Initially, nondisplaced fractures are treated with long-arm thumb spica cast with the wrist in neutral position for 6 weeks, followed by a a short-arm spica cast for an additional 6 weeks until roentgenographic union is evident.
Active ROM exercises to the forearm, wrist, and thumb should be performed 6 to 8 times daily after immobilization. A wrist and thumb static splint with wrist in neutral should be worn between exercise sessions and at night until ROM and strength gains have occurred.
Using this nonoperative casting technique, the expected rate of union is 95% within 10 weeks.
• Average rate of healing for a scaphoid fracture heal as follows:
Fractures of the middle third of the scaphoid heal on average in 6 to 12 weeks.
Distal third fractures of the scaphoid heal on the average in 4 to 8 weeks.
Proximal third fractures of the scaphoid heal on the average in 12 to 20 weeks.
• Postsurgical
If rigid internal fixation is used, such as a Herbert screw,AROM can begin as early as 10 to 14 days when the cast is removed. A thumb spica should be fabricated for the patient to wear 24 hours a day with removal only for therapeutic ROM exercises. Edema control and ROM for the hand should begin immediately after surgery.
At 4 to 6 weeks, controlled loading of the wrist is initiated, as well as the introduction of strength training. Progression of wrist activitiesis determined by the healing of the fracture using radiograph. It is recommended that an athlete wear a Nirschl R-U wrist brace to limit extreme wrist extension on the initial return to sport.
• Nonsurgical Patient
Initially, nondisplaced fractures are treated with long-arm thumb spica cast with the wrist in neutral position for 6 weeks, followed by a a short-arm spica cast for an additional 6 weeks until roentgenographic union is evident.
Active ROM exercises to the forearm, wrist, and thumb should be performed 6 to 8 times daily after immobilization. A wrist and thumb static splint with wrist in neutral should be worn between exercise sessions and at night until ROM and strength gains have occurred.
Using this nonoperative casting technique, the expected rate of union is 95% within 10 weeks.
• Average rate of healing for a scaphoid fracture heal as follows:
Fractures of the middle third of the scaphoid heal on average in 6 to 12 weeks.
Distal third fractures of the scaphoid heal on the average in 4 to 8 weeks.
Proximal third fractures of the scaphoid heal on the average in 12 to 20 weeks.
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PROGNOSIS
• Prognosis is less favorable if the fracture is displaced, diagnosis is delayed, or the fracture is in the proximal or middle third of the scaphoid bone.
• Chronic pain, decreased ROM, and decreased grip strength may result.
SIGNS AND SYMPTOMS
INDICATING REFERRAL
TO PHYSICIAN
Immediate referral to a hand surgeon is essential if a scaphoid fracture is suspected. Prompt diagnosis and treatment will significantly improve prognosis and recovery of scaphoid fracture.
SUGGESTED READINGS
1- Gutow AP. Percutaneous fixation of scaphoid fractures. J Am Acad Orthop Surg.2007;15(8):474–485.
2- Yin ZG, Zhang JB, Kan SL,Wang Treatment of acute scaphoid fractures: systematic review and meta-analysis. Clin Orthop Relat Res.2007;460:142–151.
