:Scaphoid Fracture of the Wrist

A scaphoid (navicular) fracture is a break in one of the small bones of

the wrist. This type of fracture occurs most often after a fall onto an
outstretched hand. Symptoms of a scaphoid fracture typically include
pain and tenderness in the area just below the base of the thumb. These
.symptoms may worsen when you try to pinch or grasp something
Treatment for a scaphoid fracture can range from casting to surgery,
depending on the fracture's severity and location on the bone. Because
portions of the scaphoid have a poor blood supply—and a fracture can
further disrupt the flow of blood to the bone—complications with the
.healing process are common
:Incidence
Scaphoid fractures are among the most common traumatic injuries to
the upper extremity and altogether account for 50–80% of carpal
injuries. They are most prevalent among active young adults, who fall
on an outstretched hand with the wrist forced into extension
(dorsiflexion) . Prompt diagnosis and timely treatment decreases the
occurrence of non-union of these fractures. Nevertheless, the difficulty
in diagnosing such fractures using radiographic studies or clinical exam
alone can sometimes allow subtle scaphoid fractures to go
undiagnosed. A failure to diagnose these fractures can lead to
inadequate healing, avascular necrosis, and ultimately the development
of osteoarthritis and limited range of wrist motion. When accurately
recognized, hand surgeons will commonly recommend minimally
invasive surgery to internally stabilize this troublesome bone. Headless
screw fixation can greatly reduce the frequency of non-unions and the
.potential for scaphoid fracture complications

Pathophysiology
The scaphoid is one of, and the largest of, the eight carpal
bones. Anatomically, the scaphoid has proximal and distal poles with a
.waist between the two
Blood supply to the scaphoid bone is predominantly from branches of
.the radial artery (dorsal carpal branch)
These enter the dorsal ridge and supply the 80% of proximal pole via
.retrograde flow
The second source is from the superficial palmar arch, a branch of the
volar radial artery, which enters at the distal tubercle and supplies the
.distal pole
The retrograde nature of the blood supply means that fractures at the
waist of the scaphoid leave the proximal pole at high risk of avascular
.necrosis
The majority of fractures (approximately 65%) occur at the waist, with
.a quarter at the proximal third and 10% the distal third
The incidence of avascular necrosis carries a strong association with
the location of the fracture; the proximal segment has a 100% rate of
.AVN, reducing to 33% at the distal segment of the scaphoid
Etiology
Patients typically present with wrist pain following a fall onto an
.outstretched hand
Axial loading of the wrist with it in forced hyperextension and radial
deviation can cause the fracture as the scaphoid impacts on the dorsal
.rim of the radius
Contact sports and road traffic accidents are also common causes

CLASSIFICATION
Russe classified scaphoid fractures as horizontal oblique, transverse, or
vertical oblique, depending on the obliquity of the fracture
line.5 Vertical oblique fractures, accounting for only 5%, are more
likely to be displaced by shear forces, whereas horizontal oblique and
transverse fractures have greater compressive forces and are less likely
to be displaced. Herbert and Fisher defined scaphoid fractures as stable
and unstable, as well as delayed union and nonunion (Table 1). Type A
fractures are stable acute fractures, and type B fractures are unstable
acute fractures. Although type A fractures can potentially be treated
nonoperatively, other types of fractures usually require surgical
treatment. Type A fractures include tubercle fractures (A1) and
incomplete waist fractures (A2). Type B fractures include distal
oblique fractures (B1), complete waist fractures (B2), proximal pole
fractures (B3), transscaphoid perilunate dislocation fractures (B4), and
comminuted fractures (B5). Type C fractures are delayed unions, and
type D fractures are established nonunions, either fibrous (D1) or
sclerotic (D2). Based on this classification, other than tubercle and
incomplete waist fractures, all other types are considered unstable and
surgical treatment should be considered. Prosser and colleagues
expanded the classification of distal pole fractures. Type I fractures
indicate tuberosity fractures; type II, distal intra-articular fractures; and
type III, osteochondral fractures. Approximately 70% to 80% of
scaphoid fractures occur at the waist, 10% to 20% at the proximal pole,
and the remainder at the distal pole. The least common fractures
.occurring at the distal pole are more common in children than in adults

Type A: Stable acute fractures

A1: Tubercle fracture  
A2: Incomplete waist fracture  
Type B: Unstable acute fractures
B1: Distal oblique  
fracture
B2: Complete or   
displaced waist
fracture
B3: Proximal pole   
fracture
B4: Transscaphoid   
perilunate dislocation
fracture
B5: Comminuted   
fracture
Type C: Delayed
union
Type D: Established
nonunion
D1: Fibrous union  
D2: Pseudarthrosis  

Symptoms and signs

:The signs of a scaphoid fracture include
pain on the thumb side of the wrist
swelling and bruising at the base of the thumb
difficulty gripping objects
Many patients are diagnosed with a wrist sprain, when in actuality they
.have a broken scaphoid bone

Cause
A scaphoid fracture usually occurs when you fall onto an outstretched
hand, with your weight landing on your palm. The end of the larger
forearm bone (the radius) may also break in this type of fall, depending
.on the position of the hand on landing
The injury can also happen during sports activities or motor vehicle
.collisions
Fractures of the scaphoid occur in people of all ages, including
.children
There are no specific risk factors or diseases that make you more likely
to experience a scaphoid fracture. Some studies have shown that using
wrist guards during high-energy activities like inline skating and
snowboarding can help decrease your chance of breaking a bone
.around the wrist
Physical Examination

During the exam, your doctor will talk with you about your general
health and will ask you to describe your symptoms. He or she will want
.to know how your injury occurred
Your doctor will examine your wrist. With most fractures, there will be
tenderness directly over the scaphoid in the anatomic snuffbox. Your
:doctor will also look for
Swelling
Bruising
Loss of motion
Tests
X-rays. X-rays provide images of dense structures, such as bone. Your
doctor will order an x-ray to help determine if you have a scaphoid
fracture and whether the broken pieces of bone are displaced. An x-ray
.will also help your doctor determine if you have any other fractures
In some cases, a scaphoid fracture does not show up on an x-ray right
away. If your doctor suspects that you have a fracture but it is not
visible on x-ray, he or she may recommend that you wear a wrist splint
or cast for 2 to 3 weeks and then return for a follow-up x-ray. Often,
scaphoid fractures become visible on x-ray only after a period of time.
During this waiting period, you should wear your splint or cast and
.avoid activities that might cause further injury
Magnetic resonance imaging (MRI) scan. Your doctor may order an
MRI to learn more about the bones and soft tissues in your wrist. An
MRI can sometimes show a fracture of the scaphoid before it can be
.seen on x-ray
Computerized tomography (CT) scan. A CT scan can be helpful in
revealing a fracture of the scaphoid and can also show whether the
bones are displaced. Your doctor will use information from the CT
scan to help determine your treatment plan

Treatment
The treatment your doctor recommends will depend on a number of
:factors, including
The location of the break in the bone
Whether the bone fragments are displaced
How long ago your injury occurred

Nonsurgical Treatment
Fracture near the thumb. Scaphoid fractures that are closer to the thumb
(distal pole) usually heal in a matter of weeks with proper protection
and restricted activity. This part of the scaphoid bone has a good blood
.supply, which is necessary for healing
For this type of fracture, your doctor may place your forearm and hand
in a cast or a splint. The cast or splint will usually be below the elbow
.and include your thumb
Healing time varies from patient to patient. Your doctor will monitor
.your healing with periodic x-rays or other imaging studies
Fracture near the forearm. If the scaphoid is broken in the middle of the
bone (waist) or closer to the forearm (proximal pole), healing can be
more difficult. These areas of the scaphoid do not have a very good
.blood supply
If your doctor treats this type of fracture with a cast, the cast may
include the thumb and extend above the elbow to help stabilize the
fracture
Bone stimulator. In some cases, your doctor may recommend the use of
a bone stimulator to assist in fracture healing. This small device
delivers low-intensity ultrasonic or pulsed electromagnetic waves that
.stimulate healing
Surgical Treatment
If your scaphoid is broken at the waist or proximal pole or if pieces of
bone are displaced, your doctor may recommend surgery. The goal of
surgery is to realign and stabilize the fracture, giving it a better chance
.to heal
Reduction. During this procedure, your doctor will administer an
anesthetic or anesthesia and manipulate the bone back into its proper
position. In some cases, this is done using a limited incision and special
guided instruments. In other cases, it is performed through an open
incision with direct manipulation of the fracture. For some fractures,
your doctor may use a tiny camera called an "arthroscope" to aid in the
.reduction
Internal fixation. During this procedure, metal implants—including
screws and/or wires—are used to hold the scaphoid in place until the
.bone is fully healed
Complications 
Risk factors

Fracture complications are often variably defined, and

there is a lack of consensus in their assessment, which
makes their incidence difficult to estimate. Complications
clearly vary with fracture site and nature and with quality
of surgery but many also vary with patient attributes such
as:

 Age.

 Nutritional status.

 Smoking status.

 Alcohol use.

 Diabetes (type 1 or type 2).

 Use of non-steroidal anti-inflammatory drugs (NSAIDs)

within 12 months.

 A recent motor vehicle accident (one month or less

prior to fracture).

 Oestrogen-containing hormone therapy (although this

may be a proxy for osteoporosis).

Early complications

Life-threatening complications

 These include vascular damage such as disruption to

the femoral artery or its major branches by femoral
fracture, or damage to the pelvic arteries by pelvic
fracture.

 Patients with multiple rib fractures may develop

pneumothorax, flail chest and respiratory compromise[1].
 Hip fractures, particularly in elderly patients, lead to
loss of mobility which may result in pneumonia,
thromboembolic disease or rhabdomyolysis.

Local

 Vascular injury.

 Visceral injury causing damage to structures such as

the brain, lung or bladder.

 Damage to surrounding tissue, nerves or skin.

 Hemarthrosis.

 Compartment syndrome (or Volkmann's ischemia)[2].

 Wound Infection - more common for open fractures.

 Fracture blisters[3]. 

Systemic

 Fat embolism[4].
 Shock.

 Thromboembolism (pulmonary or venous).
 Exacerbation of underlying diseases such as diabetes
or coronary artery disease (CAD).
 Pneumonia.

Late complications of fractures

Local

 Delayed union (fracture takes longer than normal to

heal).

 Malunion (fracture does not heal in normal alignment).

 Non-union (fracture does not heal).

 Joint stiffness.

 Contractures.

 Myositis ossificans[5].
 Avascular necrosis.

 Ageostrophic (or Subdeck's atrophy).

 Osteomyelitis.
 Growth disturbance or deformity.

Systemic

 Gangrene, tetanus, septicemia.
 Fear of mobilizing.

Problems with bone healing (non-union, delayed union and

malunion)
Delayed union is failure of a fracture to consolidate within the expected time -
which varies with site and nature of the fracture and with patient factors such as
age. Healing processes are still continuing, but the outcome is uncertain.

Non-union occurs when there are no signs of healing after >3-6 months
(depending upon the site of fracture). Non-union is one endpoint of delayed
union. The distinction between delayed union and non-union can be slightly
arbitrary: whilst fractures can generally be expected to heal in 3-4 months, this
will vary in the case of open fractures and those associated with vascular injury,
and also in the presence of patient risk factors described below. However, non-
union is generally said to occur when all healing processes have ceased and union
has not occurred.

Malunion occurs when the bone fragments join in an unsatisfactory position,

usually due to insufficient reduction.

Factors predisposing to delayed union[6]

 Severe soft tissue damage.

 Inadequate blood supply.

 Infection.
  Insufficient splintage.

 Excessive traction.

 Older age.

 Severe anemia.

Management of non-union
Non-surgical approaches:
 Early weight bearing and casting may be helpful for
delayed union and non-union.

 Bone stimulation can sometimes be used. This delivers

pulsed ultrasonic or electromagnetic waves to stimulate
new bone formation. It needs to be used for up to an
hour every day, and may take several weeks to be
effective.

 Medical treatments such as teriparatide have also been

used to promote fracture healing, particularly in patients
with osteoporosis[7].