Scaphoid Fracture
Original Editor - Dawn Waugh
Top Contributors - Dawn Waugh, Mats Vandervelde, Abbey Wright, Inoa De Pauw, Admin, Chrysolite Jyothi Kommu, Kim Jackson, Evan Thomas, Rachael Lowe, Amanda Ager, Anas Mohamed, Lucinda hampton, Johnathan Fahrner, WikiSysop, Wanda van Niekerk, 127.0.0.1, Nupur Smit Shah, Vanessa Rhule, Naike De Win and Claire Knott
Search Strategy[edit | edit source]
Scaphoid fracture - Scaphoid- Scaphoid fracture therapy- Differential diagnosis Scaphoid fracture - Medical management scaphoid fracture- outcome measures scaphoid fracture- wrist disabilities- carpal navicular. We searched the most of the information at pubmed and ncib. A few things we found on PEDro ( physiotherapy evidence database).
Definition/ Description[edit | edit source]
The scaphoid bone is the most commonly fractured carpal bone. In young children and the elderly population scaphoid fractures are rare. The scaphoid bone is stronger than the relative weak distal radius compared in these age groups.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title A delay in diagnosis of scaphoid fractures can lead to a variety of adverse outcomes that include nonunion (no consolidation) , delayed union, decreased grip strength and range of motion, and osteoarthritis of the radiocarpal joint. Timely diagnosis, appropriate immobilization, and referral when indicated can decrease the likelihood of adverse outcomes.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Clinically Relevant Anatomy
[edit | edit source]
The scaphoid is one of the 8 carpal bones of the wrist. It’s an important boat-shaped carpal bone that articulates with the distal radius, trapezium, and capitate. During dorsiflexion and radial deviation of the wrist, the motion is limited by the scaphoid conflict on the radius. Stress on the scaphoid, due to a forceful motion, may have a fracture as result. Scapohid fractures make up 50-80% of all carpal fracturesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
The major blood supply comes from the radial artery (seventy to eighty percent), twenty to thirty percent of the bone receives its blood supply from volar radial artery branches, feeding the dorsal surface. The proximal portion has no direct blood supply, what is an explanation for the cause of scaphoid necrosis on the basis of the vascular anatomy and an important complication of scaphoid fractures. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title[1]
Epidemiology/ Etiology[edit | edit source]
Scaphoid fracture occur in people of all ages (10 – 70 years), although it is most common in young adult men following a fall, athletic injury, or motor vehicle accidentCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.Young male and persons between 10 and 19 years of age are at highest riskCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. Scaphoid fracture is uncommon in children because a fall results in a Salter type I or II fracture of the distal radius. Similarly, in elderly patients, the distal radial metaphysis usually fails before the scaphoid can fractureCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
Scaphoid injuries are more common in men than in women.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The scaphoid has especially joint compressive forces which result in trapezial-scaphoid shear stress, and exerts control on the scaphoid by capitolunate rotation moments. Therefore, scaphoid fractures have a high incidence of nonunion (8-10%), frequent malunion, and late sequelae of carpal instability and posttraumatic arthritisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
• Because no blood vessels enter the proximal pole of the scaphoid, a higher incidence of aseptic necrosis and nonunion is noted with fractures on this side of the scaphoid Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
• A scaphoid fracture can be presented in two ways: as a nondisplaced, stable fracture or as a displaced, unstable fracture.
The displaced fractures frequently are associated with ligamentous tears in the wrist. So evaluation and follow-up is recommendedCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
Research shows that 2,4% of all wrist fractures are scaphoid fractures and there is an estimated incidence of scaphoid fractures of 29 per 100.000 personsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
Characteristics/ Clinical Presentation[edit | edit source]
The main cause of injury is a fall on the outstretched hand with an radially deviated wrist, which results in extreme dorsiflexion at the wrist and compression to the radial side of the hand. There will be a massive force of the hand on the arm through the scaphoid boneCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. The patient experience a deep, dull ache in the radial part of the wrist. The pain, which often is mild, is aggravated by pinching and gripping. The wrist can be lightly swollen or bruised and, possibly, fullness in the anatomic snuffbox, suggesting a wrist effusion. Scaphoid fractures are most common in males 15 to 30 years of ageCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and are rare in young children and infants.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Differential Diagnosis[edit | edit source]
These diagnoses can be differentiated by the location of tenderness, pain with certain maneuvers, and radiographic abnormalities.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
| Diagnosis | Physical And Radiographic Findings |
|---|---|
| Arthritis of the carpometacarpal or radiocarpal joint | Local tenderness, abnormal radiographs |
| De Quervain’s tenosynovitis | Lateral wrist pain, tenderness over radial styloid, positive Finkelstein’s test |
| Distal radius fracture | Local tenderness and deformity, abnormal plain radiographs |
| Extensor carpi radialis strain (longus and brevis) |
Local tenderness, swelling, and pain elicited with wrist flexion |
| First metacarpal fracture | Local tenderness and deformity, abnormal plain radiographs |
| Flexor carpi radialis strain | Local tenderness, swelling, and pain elicited with wrist extension |
| Injuries to radioulnar joint | Local tenderness |
| Scapholunate dissociation | Tenderness over scapholunate ligament, increased gap between scaphoid and lunate on plain films |
| Scaphoid fracture | Anatomic snuffbox tenderness, pain with scaphoid compression test, tenderness of scaphoid tubercle |
Diagnostic Procedures[edit | edit source]
Bone scintigraphy has been advocated by many as the ideal investigation for occult scaphoid fractures. It has been shown to have 100% sensivity and 98% specificiteit for scaphoid fractures compared with only 64% for plain radiography. The clinical signs of a scaphoid fracture were swelling and tenderness in the anatomical snuff box. Research has shown that the use of MRI is effective to determinate a scaphoid fracture. Both methods found all fractures, but the MRI found some significant ligamentous and carpal instabilities. The bone scintigraphy was a cost-effective and accurate method for assessing occult scaphoid fractures compared with repeat plain radiography.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Outcome Measures
[edit | edit source]
- PRWE, a fifteen-item questionnaire was designed to measure wrist pain and disability. The reliability was excellent (ICCs > 0.90). Validity assessment demonstrated that the instrument detected significant differences over time (p < 0.01).Cite error: Invalid
<ref>tag; name cannot be a simple integer. Use a descriptive title - PEM, the Patient Evaluation Measure has a simple layout with questions asked in a visual analogue form. Patients are asked to read and comprehend the question alone and not the description of each interval answer.Cite error: Invalid
<ref>tag; name cannot be a simple integer. Use a descriptive title
Examination[edit | edit source]
When examining a patient with a suspected scaphoid injury, it is important to compare the injured wrist with the uninjured wrist. The classic hallmark of anatomic snuffbox tenderness on examination is a highly sensitive (90 percent) indication of scaphoid fracture, but it is nonspecific (specificity, 40 percent)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title For example, a false-positive result can occur when the radial nerve sensory branch, which passes through the snuffbox, is pressed and causes pain. Other physical examination maneuvers should be performed. Tenderness of the scaphoid tubercle (i.e., the physician extends the patient’s wrist with one hand and applies pressure to the tuberosity at the proximal wrist crease with the opposite hand) provides better diagnostic information; this maneuver has a similar sensitivity (87 percent) to that of anatomic snuffbox tenderness, but it is significantly more specific (57 percent)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Absence of tenderness with these two maneuvers makes a scaphoid fracture highly unlikely.
Pain with the scaphoid compression test (i.e., axially/longitudinally compressing a patient’s thumb along the line of the first metacarpal) also was shown, in a retrospective analysisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, to be helpful in identifying a scaphoid fracture, but in another studyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, this technique had a poor predictive value for identifying scaphoid fractures. Another maneuver that suggests fracture of the scaphoid is pain in the snuffbox with pronation of the wrist followed by ulnar deviation (52 percent positive predictive value, 100 percent negative predictive value)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Medical Management
[edit | edit source]
Cast immobilization is the standard treatment for treating a scaphoid fracture. With cast immobilization, chance of non-union is approximately 20%. Therefore, with displaced or unstable fractures, operative treatment is recommended.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Though this improves the rate of non-union, the complication rate for ORIF is 30%.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Nonunion of a scaphoid fracture, however, can result in carpal malalignment and progressive radiocarpal arthrosis. The real effect of malunion, however, is less clearly defined. In a series of 160 scaphoid nonunions treated with internal fixation and bone grafting, of which 90% healed, failure to achieve union was related to a proximal fracture location, avascularity of the proximal pole, instability of the fracture, and delay to surgery. Importantly, residual flexion deformity of the scaphoid did not have an effect on the outcome. Therefore, malunion was not thought to be a contributing factor to a poor result. This study, however, demonstrated that the length of immobilization negatively affects the functional outcome.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The nondisplaced stable nonunion without degenerative changes may be treated with bone grafting with or without hardware. Nonvascularized autogenous bone graft from the distal radius or iliac crest may be sufficient, although vascularized bone grafting should be considered in the presence of an avascular proximal pole as determined by MRI or intraoperative findings. In addition, there is the caveat that if the initial bone grafting fails future surgery is less likely to be successful. The fracture site should be freed from fibrous nonunion or interposed tissue, and hardware may or may not be placed. Hardware placement provides additional stability but requires bony removal for placement. Kirshner wires may be used, but screw fixation may provide the advantage of compression of fracture fragments.
In short, if degenerative arthritis is absent, and the carpus can be salvaged, one may consider bone grafting, either standard or vascularized, with or without internal fixation. However, if substantial degenerative arthritis is present, limited or complete wrist arthrodesis may yield a stable, painless result. Alternatively, proximal row carpectomy or anterior interosseous nerve (AIN) and posterior interosseous nerve (PIN) denervation neurectomy may be considered. Prior to surgery a trial of cast immobilization to simulate the fused wrist, or an AIN or PIN block may be helpful to clarify the possible effect of the desired procedure on the patient’s symptoms.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Fractures are usually classified by Herbert and Fisher's system:
Internal fixation was considered desirable in all cases where control of instability would not only ensure a satisfactory outcome, but would also allow for early functional recovery of the wrist. Thus, in the treatment of acute fractures, it became essential to differentiate between those with a good prognosis, which would unite within six to eight weeks, and those that would not. A retrospective study of over 200 scaphoid fractures indicated that undisplaced or stable fractures had a good prognosis with conservative treatment if treated early. However, those fractures presenting late, as well as those showing instability at the fracture site (of which five common patterns were recognisable), had a much poorer prognosisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. Similarly, fractures showing signs of delayed union after six to eight weeks in plaster, as well as those with clear signs of non- union, did not appear to do well with conservative treatment. Thus, all scaphoid fractures presenting for treatment during the period of this trial were classified according to their radiographic appearance. In order to recognise these different fracture types, it is essential that adequate radiographs are taken of both wrists. These should include postero-anterior views in full ulnar and radial deviation, as well as 45-degree obliques and true laterals with the wrist in neutral flexion.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
- Type A (acute stable) fractures were treated conservatively and have not been included in this series. Acute but stable fractures such as fractures of the tubercle, incomplete or undisplaced fractures of the waist
- Type B (acute unstable) fractures were treated by primary internal fixation as soon as practicable after the injury. Acute unstable fractures such as distal oblique fractures, complete waist fractures, proximal pole fractures, and fracture dislocation
- Type C fractures (which showed signs of delayed union after six or more weeks in plaster) were treated operatively. The plaster was removed at least two weeks before operation to mobilise the wrist and recalcify the bone. Similarly, “late” fractures presenting some weeks after injury were included in this group and were treated by primary screw fixation. Fractures with evidence of delayed union.
- Type D fractures (with established non-union) must be differentiated from acute fractures, even when there is no definite history of previous injury. In this group screw fixation combined with bone grafting is indicated if the patient has significant symptoms or is at risk of developing secondary degenerative changes in the radiocarpal joint.Cite error: Invalid
<ref>tag; name cannot be a simple integer. Use a descriptive title
Differential Diagnosis
[edit | edit source]
Differential diagnosis includes Colles' fracture,Salter-Harris fracture, other carpal fractures, scapholunate complex injury.[2]
Key Evidence[edit | edit source]
A systemic review suggests that percutaneous fixation may result in faster union and return to work or sport. There was no difference noted between cast fixation and ORIF. The authors suggest that cast treatment is a good treatment option for most. Surgery should be reserved for high level athletes and manual workers who cannot work in a cast.[3]
Resources
[edit | edit source]
Physical Therapy Management[edit | edit source]
Recent Related Research (from Pubmed)[edit | edit source]
Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1H9AR3ZQQCaD17U2nZhRHO0f8iHnyie26kobpe8zfqRJgmvYyC|charset=UTF-8|short|max=10: Error parsing XML for RSS
References[edit | edit source]
References will automatically be added here, see adding references tutorial.
