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Evaluation and Management of Nondisplaced Scaphoid Waist Fractures in the Athlete
Evaluation and Management of Nondisplaced Scaphoid Waist Fractures in the Athlete Genevieve M. Rambau, MD, and Peter C. Rhee, DO, MS Scaphoid waist fractures are one of the most common carpal injuries in athletes, and their management can be challenging for orthopaedists. Athletes are best served by individual treatment plans based on their position, demands of their sport, and skill level. The anatomy of the scaphoid makes these injuries susceptible to malunions or nonunions and can lead to significant morbidity and lost playing time. Physical examination and imaging studies are paramount to timely and accurate diagnosis and can help guide treatment decisions. Depending on the athletes' required skill set, they may be able to return to sport participation with a playing cast or benefit from early surgical fixation to hasten their return to play. The nonoperative and operative management options and rehabilitation are further outlined to help guide orthopaedists in the most appropriate treatment for athletes that result in good outcomes and minimize the time required to return to athletic participation. Oper Tech Sports Med ]:]]]-]]] Published by Elsevier Inc.
KEYWORDS Scaphoid waist fractures, nondisplaced scaphoid waist fractures, percutaneous scaphoid fixation, scaphoid fractures in athletes
Introduction
T
he scaphoid is the most commonly injured carpal bone, with over two-thirds of scaphoid fractures occurring at the waist.1 Although the treatment of nondisplaced proximal pole and distal pole scaphoid fractures is not widely debated, nondisplaced scaphoid waist fractures present a unique challenge in deciding between nonoperative and operative treatment, particularly in an athlete. Inaccurate diagnosis or a delay in treatment can result in significant morbidity which can affect an athlete's season and even career. For athletes, management is best individualized based on their position, level of skill required, and other individual circumstances. Early and accurate diagnosis is paramount to improve outcomes for athletes. These injuries are commonly missed and mismanaged, as evidenced by a study by Muramatsu et al,2 which reported that up to 45% (9 of 16) of athletes with late presentation of a scaphoid fracture were initially diagnosed
Department of Orthopedics, San Antonio Military Medical Center, Fort Sam Houston, TX. Address reprint requests to Peter Charles Rhee, DO, MS, Department of Orthopedics, San Antonio Military Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234. E-mail: [email protected], [email protected]
http://dx.doi.org/10.1053/j.otsm.2016.01.005 1060-1872//Published by Elsevier Inc.
with a sprain by an orthopaedic provider and an additional 35% (7 of 20) chose not to seek care either based on their own judgment or advice from their coach. Delay of even 4 weeks for treatment can lead to significantly higher rates of delayed union and nonunion, highlighting the importance of early diagnosis and treatment.1,2
Anatomy An understanding of the unique anatomy of the scaphoid elucidates the importance of appropriate management as it can be prone to nonunion. Proximally, the scaphoid is covered almost entirely with articular cartilage and is dependent on a distally based blood flow.3,4 The radial artery contributes dorsal and volar branches, which supply 70%-80% and 20%30% of the blood supply, respectively. These branches enter the distal aspect of the scaphoid providing retrograde flow, making the waist and proximal pole of the scaphoid especially susceptible to nonunion and avascular necrosis. The scaphoid is commonly divided into 3 zones; the distal pole, the waist, and the proximal pole. Several fracture classification schemes have been proposed. Herbert and Fisher5 described fractures based on stability, in which they defined stable fractures as those involving the scaphoid 1
G.M. Rambau, P.C. Rhee
2 tubercle or incomplete fractures. Cooney et al6 defined unstable fractures as displacement greater than 1 mm, lateral intrascaphoid angle 4301, scapholunate angle 4601, radiolunate angle 4151, bone loss or comminution, perilunate fracture dislocation, dorsal intercalated segmental instability (DISI), and proximal pole fractures. Scaphoid waist fractures can further be characterized by the direction of the fracture line. There can be horizontal oblique, vertical oblique, and transverse fractures. Of these, transverse fractures comprise over two-thirds of the patterns seen.1,7
Mechanism of Injury Fractures at the scaphoid most frequently occur at the which may be explained by both carpal mechanics and osseous structure.1 The dynamic positioning of the scaphoid during wrist motion puts it at significant risk for fracture, particularly with the wrist extended. Athletes commonly endorse a history of falling onto an outstretched hand, which causes the wrist to deviate ulnarly and the scaphoid to be pulled into an extended position. The radioscaphocapitate ligament originates on the radial styloid, courses volar to the scaphoid waist, and inserts onto the capitate, creating a fulcrum upon which the scaphoid may be impinged on the dorsal rim of the radius when the wrist is forced into hyperextension.3,8,9 The scaphoid waist is composed of thinner and less dense trabeculea when compared with the stronger proximal pole, which also may explain why waist fractures are the most common location of injury.1,10
Physical Examination Patients with an acute scaphoid fracture may exhibit edema and ecchymosis at the dorsal-radial aspect of the wrist. However, occult and subacute scaphoid fractures may be difficult to recognize. Patients may complain of nonspecific pain in the wrist, yet evaluation for a scaphoid fracture is often focused on tenderness over the anatomical snuffbox or the dorsal-radial aspect of the wrist.11 Parvizi et al12 examined 215 patients within 24 hours of injury and noted a 100% sensitivity for detecting a scaphoid fracture when a combination of tenderness at the snuffbox and scaphoid tubercle, pain on axial loading of the thumb, and discomfort with thumb base range of motion was present.
Imaging Studies Radiographic evaluation should begin with standard posterioranterior, semipronated oblique, semisupinated oblique, and lateral views of the wrist. If a concern for a scaphoid fracture exists, a scaphoid view can be obtained that positions the wrist slightly supinated with ulnar deviation while clenching the hand into a fist. This maneuver extends the scaphoid and permits thorough evaluation of its entire length. Initial radiographs can be falsely negative in 20%-33% of scaphoid fracture.13,14 Based on traditional treatment
algorithms, if clinical suspicion for a scaphoid fracture is high, the athlete should be immobilized and should undergo repeat physical examination and radiographs in 10-14 days.8,15 Based on that management plan, advanced imaging is only recommended if the repeat radiographs are negative, and there has been no interval improvement on their examination. However, following these alogrithms, athletes without a fracture may be subject to unnecessary immobilization in the absence of a fracture. Shetty et al reported that 75% of patients (37 of 50) that were initially immobilized and later obtained advanced imaging studies with either bone scan, computed tomography (CT), or magnetic resonance imaging (MRI), at a mean of 30 days after the injury were found to have normal studies. Only 6% of patients were found to have a scaphoid fracture.15 We therefore recommend that athletes, with negative initial radiographs but examination findings concerning for a scaphoid fracture, should obtain an MRI as soon as possible to permit early return to play if no fracture or other wrist injuries are identified or to facilitate prompt treatment if a fracture is detected. Arguments against advanced imaging are regarding cost; however, the risk of missing a scaphoid fracture and risk of nonunion outweighs the cost of acquiring early advanced imaging such as MRI, CT, or bone scan in this population.16 A recent meta-analysis showed that MRI, CT, and bone scans are equivalent in sensitivity in detecting nondisplaced scaphoid fractures. However, bone scans had inferior specificity when compared with MRI and CT, which were found to be equivalent.17 Bone scintigraphy was found to be less accurately immediately after injury with higher heterogeneity in radioisotope uptake if performed within 72 hours, but this was improved with obtaining the scans at a greater time from injury. MRI can also be reliable for determining occult scaphoid fractures with the benefit of not subjecting patients to radiation. However, in a comparison study by Beeres et al13 investigating 100 patients with a clinical concern for fracture and negative radiographs, 16 fractures were detected on MRI and 28 on bone scintigraphy. False-negative results were seen in 4 patients with MRI and false-positive results in 8 patients with bone scintigraphy. This study suggests that early MRI may not be superior to bone scan in detecting occult scaphoid fracutres. In addition to fracture detection, CT scans serve a valuable role in fracture characterization, determining the degree of displacement, and detecting comminution, which may aid in counseling the patient for or against surgical fixation. Axial CT scans should be obtained along the long axis of the scaphoid with sagittal reconstructions orthogonal to this line to maximize assessment of displacement or deformity.18
Management Options The decision of operative vs nonoperative treatment of nondisplaced scaphoid waist fractures in the athlete's wrist must be made on a case-by-case basis. In athletes, operative fixation may be prudent to aim toward rapid recovery, early return to sports participation, and minimize the risk of malunions or
Nondisplaced scaphoid waist fractures nonunion. However, patients may also be treated nonoperatively with cast immobilization, with or without early return to play in playing casts.
Indications for Surgery Unstable fractures require rigid fixation; however, nondisplaced scaphoid waist fractures can be successfully managed with or without surgery. Several studies have reported equivalent clinical outcomes at long-term follow-up. However, earlier return to work and shorter immobilization periods with operative treatment have consistently been reported 7,19-22. For athletes, the difference of weeks or months of treatment can result in substantial loss of playing time. Longer periods of immobilization can also lead to longer periods of rehabilitation.7,8 For this reason, consideration of the player's position in team sports, demands of the sport, the functional requirement of the wrist or hand to effectively participate, the regulations of the referees on equipment and immobilization allowed in play, and the risks involved in early return to sports must be considered.
Nonoperative Management Nonoperative treatment consists of cast immobilization for 2-6 months; however, this may be modified for the athlete. Nonoperative treatment has union rates anywhere from 78%-100%.7,20 The type of cast treatment has also been extensively researched with equivalent outcomes of long vs short arm cast, with or without thumb spica, and with or without thumb interphalangeal joint immobilization.7,21-25 Riester et al25 advocated immediate return to sports with use of playing casts. They reported on 14 scaphoid fractures in 13 athletes involved in high-contact sports, including football and basketball, who returned to athletic competition in short arm, thumb spica casts with the interphalangeal joint free. Before each game, custom silastic short arm, thumb spica casts were applied, and upon completion of the game a new cast was placed. All 11 nondisplaced scaphoid waist fractures that were treated in this manner healed. The only nonunion resulted from a delayed diagnosis of 50 days. Although the players were immobilized for an average of 6 months, this was based on the decision to continue immobilization throughout the current season, not because of radiographic findings. This option may be suitable for players who do not require significant hand and wrist motion or dexterity, such as kickers and linemen in football, to allow them to return to practice or games if regulations allow.25 Despite adequate union rates with nonoperative treatment, it is pertinent to monitor healing regularly regardless of return to play. Any evidence of displacement during nonoperative treatment or failure to demonstrate signs of healing at 2-3 months should be reevaluated for possible surgical fixation.1 Prolonged cast immobilization in a fracture that is slow to heal has its own risks to include muscle atrophy, joint contracture, disuse osteopenia, and prolonged loss of playing time.26
3
Operative Treatment Multiple techniques are available for operative treatment ranging from open to percutaneous fixation. Percutaneous fixation, volar or dorsal, is often reserved for nondisplaced or minimally displaced fractures. Open techniques allow for improved visualization and protection of structures; however, it requires dissection of the radiocarpal ligaments or dorsal capsular structures that leads to further soft tissue dissection and may affect healing or require longer periods of immobilization.27
Surgical Technique—Volar Percutaneous Scaphoid Fixation The patient is placed in the supine position with a hand table applied to the operating room table. A nonsterile tourniquet is applied to the brachium in the event that conversion from a percutaneous to open procedure may be necessary; otherwise, the procedure is performed without tourniquet control. The upper extremity is prepped and draped in standard sterile fashion. The surgeon should be positioned in a manner to allow for his or her dominant hand to maneuver the drill in retrograde fashion relative to the patient's wrist. For example, a right-handed surgeon would sit in the axilla of the patient's left upper extremity. A draped minifluoroscopy machine is brought in toward the patient with the image intensifier
Figure 1 Surgeon and patient positioning for volar percutaneous fixation of a nondisplaced scaphoid waist fracture. The surgeon is positioned to allow for his or her dominant hand to operate the drill in retrograde fashion with the minifluoroscopy machine image intensifier closer to the surgeon to minimize image magnification. (Color version of figure is available online.)
G.M. Rambau, P.C. Rhee
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Figure 2 Obtaining orthogonal trajectory of the scaphoid with fluoroscopy. A guide pin is placed over the long axis of the scaphoid in the posterior-anterior or lateral view (A) and marked on the skin (B) to provide a visual guide for guide pin insertion. (Color version of figure is available online.)
typically toward the surgeon's chest (Fig. 1) in horizontal fashion to minimize magnification of the extremity. Posterior-anterior and lateral images are obtained of the wrist, and a guide pin is placed on the skin to mark out the long axis of the scaphoid on orthogonal images to provide an approximation for screw trajectory (Fig. 2). The wrist is positioned in dorsiflexion, facilitated with a sterile bump (Fig. 2B), to allow for translation of the trapezium dorsally to provide guide pin access to the starting point on the distal pole of the scaphoid (Fig. 3). Using fluoroscopy, the guide pin is inserted percutaneously along the long axis of the scaphoid toward the proximal pole until it is positioned at the subchondral bone (Fig. 4). The surgeon should be aware that with the volar percutaneous approach, the guide pin and subsequent headless compression screw (HCS) would be positioned slightly oblique to the central axis of the scaphoid. However, this has not been shown to effect clinical or radiographic outcomes.20,27 A stab incision is made over the guide pin and the screw length is measured. Approximately 510 mm should be subtracted from the measured screw length to permit burying the screw under the chondral surface of the distal pole without breaching the chondral surface of the proximal pole (in most cases, a 20-mm screw is sufficient). If the trapezium continues to impede access to the proper starting point, the guide pin can be inserted through the volar
Figure 3 Starting point for guide pin insertion on the distal pole of the scaphoid. Wrist and thumb extension results in dorsal translation of the trapezium to permit adequate guide pin access at the distal pole of the scaphoid.
lip of the trapezium; however, this should be accounted for with final screw length selection. An additional K-wire (0.035 or 0.045 in) is placed parallel to and sufficiently away from the HCS guide pin to provide antirotation control without prohibiting drilling or HCS insertion. The guide pin is inserted into the distal radius, to prevent unintended pin migration or removal, and the cannulated drill is placed over the guide pin and the scaphoid is drilled under fluoroscopic surveillance (Fig. 5). The guide pin is retrieved out of the distal radius, and the cannulated HCS is inserted under fluoroscopy to ensure maintenance of reduction and final screw positioning. After removal of the guide and antirotation pins, final multiplanar views of the scaphoid are obtained with the fluoroscopy unit including a posterior-anterior, lateral, semipronated, semisupinated, and carpal navicular views (Fig. 6). The wound is copiously irrigated with sterile saline, and the wound is closed with 4-0 nonabsorbable simple sutures. The extremity is placed into a well-padded, short arm, thumb spica plaster splint.
Rehabilitation and Return to Play Edema-controlling maneuvers and digit range of motion is initiated immediately. At 2 weeks, the patient is placed into a removable short arm, thumb spica orthosis that is removed for hygiene purposes and for wrist range of motion. It is the authors' preference to allow unrestricted return to athletic participation without wrist immobilization once radiographic union occurs (typically 6-7 weeks) and full wrist and hand range of motion has been obtained. Accurate determination of union with radiographs alone can be difficult and inaccurate.28 CT has been shown to have high sensitivity and specificity for accurately diagnosing union with high interobserver reliability.7,28-30 Earlier return to play with 2-4 weeks of immobilization following surgery has shown good results in patients who were diagnosed and treated acutely and started on early rehabilitation.2,5 Saedén et al19 only immobilized patients for 2 weeks postoperative in a short arm cast, with the thumb free, and
Nondisplaced scaphoid waist fractures
5
Figure 4 Proper guide pin positioning for volar percutaneous headless compression screw fixation. Posterior-anterior (A) and lateral (B) fluoroscopic images after guide pin insertion. The lateral image illustrates the slightly oblique trajectory of the guide pin relative to the central axis of the scaphoid with the volar percutaneous approach because of the volar lip of the trapezium.
reported return to full work duties in manual laborers at a mean of 7 weeks postoperative. Rettig and Kollias31 immobilized patients in a removable short arm, thumb spica orthosis with an early motion protocol until radiographic union was achieved, which permitted return to active sports participation at a mean of 5.2 weeks for all athletes (1-10 weeks), 8 weeks for high-impact athletes (3-21 weeks) postoperative. Herbert and Fisher5 allowed patients to return to gentle sports, such as swimming, within a few weeks from surgery, but heavy sports were deferred until evidence of union. Muramatsu et al2 demonstrated radiographic union as early as 6 weeks postoperatively allowing return to sports at that time.
Outcomes Haddad and Goddard32 treated 15 athletes with nondisplaced scaphoid fractures, 4 of which were oblique distal third and 11 of which were scaphoid waist fractures, using a volar percutaneous technique with HCSs. Plaster immobilization
Figure 5 Cannulated drill insertion adjacent to an antirotation pin. Note that the headless compression screw guide pin has been inserted into the distal radius to prohibit inadvertent guide pin removal with drill removal.
postoperatively was optional and patients were started on an early range of motion protocol. They were allowed to return to sedentary work immediately and were given a removable wrist splint for sports. The mean duration until return to unrestricted active sports ranged from 43-75 days once union was confirmed on radiographs. Patients regained full wrist flexion, extension, and ulnar deviation within 6 weeks, with mean power grip of 90% when compared with the contralateral extremity at 6 weeks and 98% at 3 months postoperative.32 Despite screw placement outside of the central axis of the scaphoid in 3 of the 15 patients, they noted no complications attributed to this. Taras et al33 described their experience with volar percutaneous fixation in 5 athletes with nondisplaced scaphoid fractures, who were treated with 2 weeks of immobilization in a short arm, thumb spica cast postoperative, followed by a soft splint with an early range of motion protocol. Patients were allowed return to sport immediately with a short arm, thumb spica playing cast if permitted by the regulations of the sport. They demonstrated union in all patients with return to full athletic participation at 6-7 weeks postoperative.33 Bond et al randomized active duty military patients with nondisplaced scaphoid waist fractures to volar percutaneous screw fixation (n ¼ 11) or long arm, thumb spica cast immobilization (n ¼ 14) for 6 weeks, which was then transitioned to short arm, thumb spica cast until union.20 The mean time to union was 7 ⫾ 0.5 weeks and mean time to return to full work duties was 8 ⫾ 0.7 weeks with no nonunions at 2-year follow-up after percutaneous HCS fixation. They reported only 1 complication of a prominent screw head that was removed 7 months postoperatively. For the nonoperative group, mean time to union was 12 ⫾ 0.7 weeks with mean return to duty being 15 ⫾ 0.7 weeks, with no reported complications or nonunions. A dorsal percutaneous approach, both with and without arthroscopic assistance, has been described.34 In addition to the operative complications noted previously, an additional risk noted with a dorsal approach is iatrogenic displacement of fractures with hyperflexion of the wrist during screw insertion. This may lead to a humpback deformity and may necessitate conversion to an open procedure.34
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6
Figure 6 Final intraoperative fluoroscopic images after headless compression screw fixation for a nondisplaced scaphoid waist fracture. Posterior-anterior (PA) and lateral (B) images.
Complications The union rate for nonoperative treatment ranges between 88 and 95%, with operative union rates approaching 100%.5,7 Surgical complication rates range from 3%-30%.7,18,22 Most complications are considered minor, including screw malpositioning, partial injury of the flexor carpi radialis tendon, and partial injury of the volar scapholunate interosseous ligament.22 Other complications include fracture displacement, malunions, prominent intra-articular screw placement, and injury to the volar branch of the radial artery.20,22,27 A concern for operative treatment is the radiographic evidence of osteoarthritis of the scaphotrapezial joint seen in several studies.7,19 The significance of this finding has yet to be elucidated but is unique to the operative group. However, long-term follow-up is needed to determine the clinical relevance of this finding. Of note, scaphotrapezial osteoarthritis was seen in the same percentage of open and percutaneous patients.7,19
Conclusion Nondisplaced scaphoid waist fractures are common among athletes and must be promptly diagnosed and treated to ensure the best outcome and fastest recovery. Nonoperative treatment with playing casts is a reasonable treatment option in athletes that do not require complex wrist or hand dexterity or are at the end of their season. Nonoperative treatment relies upon close radiographic surveillance, and any concern for progressive displacement or delayed healing must be addressed immediately to limit prolonged immobilization, malunion, or nonunion. High-demand athletes may benefit from early fixation allowing faster return to unencumbered play; however, the risks of surgery must be considered. Union should be confirmed with CT scans, and full range of motion obtained to determine at which point athletes may be released to unrestricted participation in their given sport.
References 1. Leslie IJ, Dickson RA: The fractured carpal scaphoid. J Bone Joint Surg 63-B(2):225-230, 1981 2. Muramatsu K, Doi K, Kuwata N, et al: Scaphoid fracture in the young athlete—Therapeutic outcome of internal fixation using the Herbert screw. Arch Orthop Trauma Surg 122:510-513, 2002
3. Trumble TE, Salas P, Barthel T, et al: Management of scaphoid nonunions. J Am Acad Orthop Surg 11:380-391, 2003 4. Gelberman RH, Menon J: The vascularity of the scaphoid bone. J Hand Surg 5(5):114-123, 1980 5. Herbert TJ, Fisher WE: Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg 66B(1):114-123, 1984 6. Cooney WP, Dobyns JH, Linscheid RL: Fractures of the scaphoid: A rational approach to management. Clin Orthop 149:90-97, 1980 7. Dias JJ, Wildin CJ, Bhowal B, et al: Should acute scaphoid fractures be fixed? A randomized controlled trial. J Bone Joint Surg 87-A (10):2160-2168, 2005 8. Geissler WB, Slade JF: (ed 6). Fractures of the Carpal Bones in Green's Operative Hand Surgery. Edinburgh: Churchill Livingstone, 2010 9. Belsky MR, Leibman MI, Ruchelsman DE: Scaphoid fracture in the elite athlete. Hand Clin 28:269-278, 2012 10. Heinzelmann AD, Archer G, Bindra RR: Anthropometry of the human scaphoid. J Hand Surg Am 32:1005-1008, 2007 11. Morgan WJ, Slowman LS: Acute handand wrist injuries in athletes: Evaluation and management. J Am Acad Orthop Surg 9:389-400, 2001 12. Parvizi J, Wayman J, Moran CG: Combining the clinical signs improves diagnosis of scaphoid fractures. A prospective study with follow-up. J Hand Surg Br 23(3):324-327, 1998 13. Beeres FJP, Rhemrev SJ, Hollander PD, et al: Early magnetic resonance imaging compared with bone scintigraphy in suspected scaphoid fractures. J Bone Joint Surg 90-B(9):1205-1209, 2008 14. Kusano N, Churel Y, Shiraishi E, et al: Diagnosis of occult carpal scaphoid fracture: A comparison of magnetic resonance imaging and computed tomography techniques. Tech Hand Up Extrem Surg 6(3):119-123, 2002 15. Shetty S, Sidharthan S, Jacob J, et al: ‘Clinical scaphoid fracture’: Is it time to abolish this phrase? Ann R Coll Surg Engl 93:146-148, 2011 16. Yin ZG, Zhang JB, Gong KT: Cost-effectiveness of diagnostic strategies for suspected scaphoid fractures. J Orthop Trauma 29:e245-e252, 2015 17. Yin ZG, Zhang JB, Kan SL, et al: Diagnosing suspected scaphoid fractures. A systematic review and meta-analysis. Clin Orthop Relat Res 468 (3):723-734, 2010 18. Moser VL, Krimmer H: Minimal invasive treatment for scaphoid fractures using the cannulated herbert screw system. Tech Hand Up Extrem Surg 7 (4):141-146, 2003 19. Saedén B, Törnkvist H, Ponzer S, et al: Fracture of the carpal scaphoid. J Bone Joint Surg Br 83-B(2):230-234, 2001 20. Bond CD, Shin AY, McBride MT, et al: Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg 83A(4):483-488, 2001 21. Adolfsson L, Lindau T, Arner M: Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist fractures. J Hand Surg Br 26(3):192-195, 2001 22. Vinnars B, Pietreanu M, Bodestedt A, et al: Nonoperative compared with operative treatment of acute scaphoid fractures: A randomized clinical trial. J Bone Joint Surg Am 90:1176-1185, 2008 23. Kawamura K, Chung KC: Treatment of scaphoid fractures and nonunions. J Hand Surg Am 33(6):988-997, 2008
Nondisplaced scaphoid waist fractures 24. Buijze GA, Goslings JC, Rhemrey SJ, et al: Cast immobilization with and without immobilization of the thumb for nondisplaced and minimally displaced scaphoid waist fractures: A multicenter, randomized, controlled trial. J Hand Surg Am 39(4):621-627, 2014 25. Riester JN, Baker BE, Mosher JF, et al: A review of scaphoid fracture healing in competitive athletes. Am J Sports Med 13(3):159-161, 1985 26. Geissler WB, Adams JE, Bindra RR, et al: Scaphoid fractures: What's hot, what's not. J Bone Joint Surg 94-A(2):169-181, 2012 27. Shin AY, Hofmeister EP: Percutaneous fixation of stable scaphoid fractures. Tech Hand Up Extrem Surg 8(2):87-94, 2004, 2004 28. Temple CL, Ross DC, Bennett JD, et al: Comparison of sagittal computed tomography and plain film radiography in a scaphoid fracture model. J Hand Surg Am 30(3):534-542, 2005 29. Buijze GA, Doornberg JN, Ham JS, et al: Surgical compared with conservative treatment for acute nondisplaced or minimally
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30. 31. 32. 33.
34.
displaced scaphoid fractures. A systematic review and meta-analysis of randomized controlled trials. J Bone Joint Surg Am 92:1534-1544, 2010 Grewal R, King GJW: An evidence-based approach to the management of acute scaphoid fractures. J Hand Surg 34 A:732-734, 2009 Rettig AC, Kollias SC: Internal fixation of acute stable scaphoid fractures in athletes. Am J Sports Med 24(2):182-186, 1996 Haddad FS, Goddard NJ: Acute percutaneous scaphoid fixation: A pilot study. J Bone Joint Surg Br 80:95-99, 1998 Taras JS, Sweet S, Shum W, et al: Percutaneous and arthroscopic screw fixation of scaphoid fractures in athletes. Wrist and Hand Arthroscopy 15 (3):467-473, 1999 Slade 3rd JF, Geissler WB, Gutow AP, et al: Percutaneous internal fixation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach. J Bone Joint Surg Am 4:20-32, 2003
KEYWORDS Scaphoid waist fractures, nondisplaced scaphoid waist fractures, percutaneous scaphoid fixation, scaphoid fractures in athletes
Introduction
T
he scaphoid is the most commonly injured carpal bone, with over two-thirds of scaphoid fractures occurring at the waist.1 Although the treatment of nondisplaced proximal pole and distal pole scaphoid fractures is not widely debated, nondisplaced scaphoid waist fractures present a unique challenge in deciding between nonoperative and operative treatment, particularly in an athlete. Inaccurate diagnosis or a delay in treatment can result in significant morbidity which can affect an athlete's season and even career. For athletes, management is best individualized based on their position, level of skill required, and other individual circumstances. Early and accurate diagnosis is paramount to improve outcomes for athletes. These injuries are commonly missed and mismanaged, as evidenced by a study by Muramatsu et al,2 which reported that up to 45% (9 of 16) of athletes with late presentation of a scaphoid fracture were initially diagnosed
Department of Orthopedics, San Antonio Military Medical Center, Fort Sam Houston, TX. Address reprint requests to Peter Charles Rhee, DO, MS, Department of Orthopedics, San Antonio Military Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234. E-mail: [email protected], [email protected]
http://dx.doi.org/10.1053/j.otsm.2016.01.005 1060-1872//Published by Elsevier Inc.
with a sprain by an orthopaedic provider and an additional 35% (7 of 20) chose not to seek care either based on their own judgment or advice from their coach. Delay of even 4 weeks for treatment can lead to significantly higher rates of delayed union and nonunion, highlighting the importance of early diagnosis and treatment.1,2
Anatomy An understanding of the unique anatomy of the scaphoid elucidates the importance of appropriate management as it can be prone to nonunion. Proximally, the scaphoid is covered almost entirely with articular cartilage and is dependent on a distally based blood flow.3,4 The radial artery contributes dorsal and volar branches, which supply 70%-80% and 20%30% of the blood supply, respectively. These branches enter the distal aspect of the scaphoid providing retrograde flow, making the waist and proximal pole of the scaphoid especially susceptible to nonunion and avascular necrosis. The scaphoid is commonly divided into 3 zones; the distal pole, the waist, and the proximal pole. Several fracture classification schemes have been proposed. Herbert and Fisher5 described fractures based on stability, in which they defined stable fractures as those involving the scaphoid 1
G.M. Rambau, P.C. Rhee
2 tubercle or incomplete fractures. Cooney et al6 defined unstable fractures as displacement greater than 1 mm, lateral intrascaphoid angle 4301, scapholunate angle 4601, radiolunate angle 4151, bone loss or comminution, perilunate fracture dislocation, dorsal intercalated segmental instability (DISI), and proximal pole fractures. Scaphoid waist fractures can further be characterized by the direction of the fracture line. There can be horizontal oblique, vertical oblique, and transverse fractures. Of these, transverse fractures comprise over two-thirds of the patterns seen.1,7
Mechanism of Injury Fractures at the scaphoid most frequently occur at the which may be explained by both carpal mechanics and osseous structure.1 The dynamic positioning of the scaphoid during wrist motion puts it at significant risk for fracture, particularly with the wrist extended. Athletes commonly endorse a history of falling onto an outstretched hand, which causes the wrist to deviate ulnarly and the scaphoid to be pulled into an extended position. The radioscaphocapitate ligament originates on the radial styloid, courses volar to the scaphoid waist, and inserts onto the capitate, creating a fulcrum upon which the scaphoid may be impinged on the dorsal rim of the radius when the wrist is forced into hyperextension.3,8,9 The scaphoid waist is composed of thinner and less dense trabeculea when compared with the stronger proximal pole, which also may explain why waist fractures are the most common location of injury.1,10
Physical Examination Patients with an acute scaphoid fracture may exhibit edema and ecchymosis at the dorsal-radial aspect of the wrist. However, occult and subacute scaphoid fractures may be difficult to recognize. Patients may complain of nonspecific pain in the wrist, yet evaluation for a scaphoid fracture is often focused on tenderness over the anatomical snuffbox or the dorsal-radial aspect of the wrist.11 Parvizi et al12 examined 215 patients within 24 hours of injury and noted a 100% sensitivity for detecting a scaphoid fracture when a combination of tenderness at the snuffbox and scaphoid tubercle, pain on axial loading of the thumb, and discomfort with thumb base range of motion was present.
Imaging Studies Radiographic evaluation should begin with standard posterioranterior, semipronated oblique, semisupinated oblique, and lateral views of the wrist. If a concern for a scaphoid fracture exists, a scaphoid view can be obtained that positions the wrist slightly supinated with ulnar deviation while clenching the hand into a fist. This maneuver extends the scaphoid and permits thorough evaluation of its entire length. Initial radiographs can be falsely negative in 20%-33% of scaphoid fracture.13,14 Based on traditional treatment
algorithms, if clinical suspicion for a scaphoid fracture is high, the athlete should be immobilized and should undergo repeat physical examination and radiographs in 10-14 days.8,15 Based on that management plan, advanced imaging is only recommended if the repeat radiographs are negative, and there has been no interval improvement on their examination. However, following these alogrithms, athletes without a fracture may be subject to unnecessary immobilization in the absence of a fracture. Shetty et al reported that 75% of patients (37 of 50) that were initially immobilized and later obtained advanced imaging studies with either bone scan, computed tomography (CT), or magnetic resonance imaging (MRI), at a mean of 30 days after the injury were found to have normal studies. Only 6% of patients were found to have a scaphoid fracture.15 We therefore recommend that athletes, with negative initial radiographs but examination findings concerning for a scaphoid fracture, should obtain an MRI as soon as possible to permit early return to play if no fracture or other wrist injuries are identified or to facilitate prompt treatment if a fracture is detected. Arguments against advanced imaging are regarding cost; however, the risk of missing a scaphoid fracture and risk of nonunion outweighs the cost of acquiring early advanced imaging such as MRI, CT, or bone scan in this population.16 A recent meta-analysis showed that MRI, CT, and bone scans are equivalent in sensitivity in detecting nondisplaced scaphoid fractures. However, bone scans had inferior specificity when compared with MRI and CT, which were found to be equivalent.17 Bone scintigraphy was found to be less accurately immediately after injury with higher heterogeneity in radioisotope uptake if performed within 72 hours, but this was improved with obtaining the scans at a greater time from injury. MRI can also be reliable for determining occult scaphoid fractures with the benefit of not subjecting patients to radiation. However, in a comparison study by Beeres et al13 investigating 100 patients with a clinical concern for fracture and negative radiographs, 16 fractures were detected on MRI and 28 on bone scintigraphy. False-negative results were seen in 4 patients with MRI and false-positive results in 8 patients with bone scintigraphy. This study suggests that early MRI may not be superior to bone scan in detecting occult scaphoid fracutres. In addition to fracture detection, CT scans serve a valuable role in fracture characterization, determining the degree of displacement, and detecting comminution, which may aid in counseling the patient for or against surgical fixation. Axial CT scans should be obtained along the long axis of the scaphoid with sagittal reconstructions orthogonal to this line to maximize assessment of displacement or deformity.18
Management Options The decision of operative vs nonoperative treatment of nondisplaced scaphoid waist fractures in the athlete's wrist must be made on a case-by-case basis. In athletes, operative fixation may be prudent to aim toward rapid recovery, early return to sports participation, and minimize the risk of malunions or
Nondisplaced scaphoid waist fractures nonunion. However, patients may also be treated nonoperatively with cast immobilization, with or without early return to play in playing casts.
Indications for Surgery Unstable fractures require rigid fixation; however, nondisplaced scaphoid waist fractures can be successfully managed with or without surgery. Several studies have reported equivalent clinical outcomes at long-term follow-up. However, earlier return to work and shorter immobilization periods with operative treatment have consistently been reported 7,19-22. For athletes, the difference of weeks or months of treatment can result in substantial loss of playing time. Longer periods of immobilization can also lead to longer periods of rehabilitation.7,8 For this reason, consideration of the player's position in team sports, demands of the sport, the functional requirement of the wrist or hand to effectively participate, the regulations of the referees on equipment and immobilization allowed in play, and the risks involved in early return to sports must be considered.
Nonoperative Management Nonoperative treatment consists of cast immobilization for 2-6 months; however, this may be modified for the athlete. Nonoperative treatment has union rates anywhere from 78%-100%.7,20 The type of cast treatment has also been extensively researched with equivalent outcomes of long vs short arm cast, with or without thumb spica, and with or without thumb interphalangeal joint immobilization.7,21-25 Riester et al25 advocated immediate return to sports with use of playing casts. They reported on 14 scaphoid fractures in 13 athletes involved in high-contact sports, including football and basketball, who returned to athletic competition in short arm, thumb spica casts with the interphalangeal joint free. Before each game, custom silastic short arm, thumb spica casts were applied, and upon completion of the game a new cast was placed. All 11 nondisplaced scaphoid waist fractures that were treated in this manner healed. The only nonunion resulted from a delayed diagnosis of 50 days. Although the players were immobilized for an average of 6 months, this was based on the decision to continue immobilization throughout the current season, not because of radiographic findings. This option may be suitable for players who do not require significant hand and wrist motion or dexterity, such as kickers and linemen in football, to allow them to return to practice or games if regulations allow.25 Despite adequate union rates with nonoperative treatment, it is pertinent to monitor healing regularly regardless of return to play. Any evidence of displacement during nonoperative treatment or failure to demonstrate signs of healing at 2-3 months should be reevaluated for possible surgical fixation.1 Prolonged cast immobilization in a fracture that is slow to heal has its own risks to include muscle atrophy, joint contracture, disuse osteopenia, and prolonged loss of playing time.26
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Operative Treatment Multiple techniques are available for operative treatment ranging from open to percutaneous fixation. Percutaneous fixation, volar or dorsal, is often reserved for nondisplaced or minimally displaced fractures. Open techniques allow for improved visualization and protection of structures; however, it requires dissection of the radiocarpal ligaments or dorsal capsular structures that leads to further soft tissue dissection and may affect healing or require longer periods of immobilization.27
Surgical Technique—Volar Percutaneous Scaphoid Fixation The patient is placed in the supine position with a hand table applied to the operating room table. A nonsterile tourniquet is applied to the brachium in the event that conversion from a percutaneous to open procedure may be necessary; otherwise, the procedure is performed without tourniquet control. The upper extremity is prepped and draped in standard sterile fashion. The surgeon should be positioned in a manner to allow for his or her dominant hand to maneuver the drill in retrograde fashion relative to the patient's wrist. For example, a right-handed surgeon would sit in the axilla of the patient's left upper extremity. A draped minifluoroscopy machine is brought in toward the patient with the image intensifier
Figure 1 Surgeon and patient positioning for volar percutaneous fixation of a nondisplaced scaphoid waist fracture. The surgeon is positioned to allow for his or her dominant hand to operate the drill in retrograde fashion with the minifluoroscopy machine image intensifier closer to the surgeon to minimize image magnification. (Color version of figure is available online.)
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Figure 2 Obtaining orthogonal trajectory of the scaphoid with fluoroscopy. A guide pin is placed over the long axis of the scaphoid in the posterior-anterior or lateral view (A) and marked on the skin (B) to provide a visual guide for guide pin insertion. (Color version of figure is available online.)
typically toward the surgeon's chest (Fig. 1) in horizontal fashion to minimize magnification of the extremity. Posterior-anterior and lateral images are obtained of the wrist, and a guide pin is placed on the skin to mark out the long axis of the scaphoid on orthogonal images to provide an approximation for screw trajectory (Fig. 2). The wrist is positioned in dorsiflexion, facilitated with a sterile bump (Fig. 2B), to allow for translation of the trapezium dorsally to provide guide pin access to the starting point on the distal pole of the scaphoid (Fig. 3). Using fluoroscopy, the guide pin is inserted percutaneously along the long axis of the scaphoid toward the proximal pole until it is positioned at the subchondral bone (Fig. 4). The surgeon should be aware that with the volar percutaneous approach, the guide pin and subsequent headless compression screw (HCS) would be positioned slightly oblique to the central axis of the scaphoid. However, this has not been shown to effect clinical or radiographic outcomes.20,27 A stab incision is made over the guide pin and the screw length is measured. Approximately 510 mm should be subtracted from the measured screw length to permit burying the screw under the chondral surface of the distal pole without breaching the chondral surface of the proximal pole (in most cases, a 20-mm screw is sufficient). If the trapezium continues to impede access to the proper starting point, the guide pin can be inserted through the volar
Figure 3 Starting point for guide pin insertion on the distal pole of the scaphoid. Wrist and thumb extension results in dorsal translation of the trapezium to permit adequate guide pin access at the distal pole of the scaphoid.
lip of the trapezium; however, this should be accounted for with final screw length selection. An additional K-wire (0.035 or 0.045 in) is placed parallel to and sufficiently away from the HCS guide pin to provide antirotation control without prohibiting drilling or HCS insertion. The guide pin is inserted into the distal radius, to prevent unintended pin migration or removal, and the cannulated drill is placed over the guide pin and the scaphoid is drilled under fluoroscopic surveillance (Fig. 5). The guide pin is retrieved out of the distal radius, and the cannulated HCS is inserted under fluoroscopy to ensure maintenance of reduction and final screw positioning. After removal of the guide and antirotation pins, final multiplanar views of the scaphoid are obtained with the fluoroscopy unit including a posterior-anterior, lateral, semipronated, semisupinated, and carpal navicular views (Fig. 6). The wound is copiously irrigated with sterile saline, and the wound is closed with 4-0 nonabsorbable simple sutures. The extremity is placed into a well-padded, short arm, thumb spica plaster splint.
Rehabilitation and Return to Play Edema-controlling maneuvers and digit range of motion is initiated immediately. At 2 weeks, the patient is placed into a removable short arm, thumb spica orthosis that is removed for hygiene purposes and for wrist range of motion. It is the authors' preference to allow unrestricted return to athletic participation without wrist immobilization once radiographic union occurs (typically 6-7 weeks) and full wrist and hand range of motion has been obtained. Accurate determination of union with radiographs alone can be difficult and inaccurate.28 CT has been shown to have high sensitivity and specificity for accurately diagnosing union with high interobserver reliability.7,28-30 Earlier return to play with 2-4 weeks of immobilization following surgery has shown good results in patients who were diagnosed and treated acutely and started on early rehabilitation.2,5 Saedén et al19 only immobilized patients for 2 weeks postoperative in a short arm cast, with the thumb free, and
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Figure 4 Proper guide pin positioning for volar percutaneous headless compression screw fixation. Posterior-anterior (A) and lateral (B) fluoroscopic images after guide pin insertion. The lateral image illustrates the slightly oblique trajectory of the guide pin relative to the central axis of the scaphoid with the volar percutaneous approach because of the volar lip of the trapezium.
reported return to full work duties in manual laborers at a mean of 7 weeks postoperative. Rettig and Kollias31 immobilized patients in a removable short arm, thumb spica orthosis with an early motion protocol until radiographic union was achieved, which permitted return to active sports participation at a mean of 5.2 weeks for all athletes (1-10 weeks), 8 weeks for high-impact athletes (3-21 weeks) postoperative. Herbert and Fisher5 allowed patients to return to gentle sports, such as swimming, within a few weeks from surgery, but heavy sports were deferred until evidence of union. Muramatsu et al2 demonstrated radiographic union as early as 6 weeks postoperatively allowing return to sports at that time.
Outcomes Haddad and Goddard32 treated 15 athletes with nondisplaced scaphoid fractures, 4 of which were oblique distal third and 11 of which were scaphoid waist fractures, using a volar percutaneous technique with HCSs. Plaster immobilization
Figure 5 Cannulated drill insertion adjacent to an antirotation pin. Note that the headless compression screw guide pin has been inserted into the distal radius to prohibit inadvertent guide pin removal with drill removal.
postoperatively was optional and patients were started on an early range of motion protocol. They were allowed to return to sedentary work immediately and were given a removable wrist splint for sports. The mean duration until return to unrestricted active sports ranged from 43-75 days once union was confirmed on radiographs. Patients regained full wrist flexion, extension, and ulnar deviation within 6 weeks, with mean power grip of 90% when compared with the contralateral extremity at 6 weeks and 98% at 3 months postoperative.32 Despite screw placement outside of the central axis of the scaphoid in 3 of the 15 patients, they noted no complications attributed to this. Taras et al33 described their experience with volar percutaneous fixation in 5 athletes with nondisplaced scaphoid fractures, who were treated with 2 weeks of immobilization in a short arm, thumb spica cast postoperative, followed by a soft splint with an early range of motion protocol. Patients were allowed return to sport immediately with a short arm, thumb spica playing cast if permitted by the regulations of the sport. They demonstrated union in all patients with return to full athletic participation at 6-7 weeks postoperative.33 Bond et al randomized active duty military patients with nondisplaced scaphoid waist fractures to volar percutaneous screw fixation (n ¼ 11) or long arm, thumb spica cast immobilization (n ¼ 14) for 6 weeks, which was then transitioned to short arm, thumb spica cast until union.20 The mean time to union was 7 ⫾ 0.5 weeks and mean time to return to full work duties was 8 ⫾ 0.7 weeks with no nonunions at 2-year follow-up after percutaneous HCS fixation. They reported only 1 complication of a prominent screw head that was removed 7 months postoperatively. For the nonoperative group, mean time to union was 12 ⫾ 0.7 weeks with mean return to duty being 15 ⫾ 0.7 weeks, with no reported complications or nonunions. A dorsal percutaneous approach, both with and without arthroscopic assistance, has been described.34 In addition to the operative complications noted previously, an additional risk noted with a dorsal approach is iatrogenic displacement of fractures with hyperflexion of the wrist during screw insertion. This may lead to a humpback deformity and may necessitate conversion to an open procedure.34
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Figure 6 Final intraoperative fluoroscopic images after headless compression screw fixation for a nondisplaced scaphoid waist fracture. Posterior-anterior (PA) and lateral (B) images.
Complications The union rate for nonoperative treatment ranges between 88 and 95%, with operative union rates approaching 100%.5,7 Surgical complication rates range from 3%-30%.7,18,22 Most complications are considered minor, including screw malpositioning, partial injury of the flexor carpi radialis tendon, and partial injury of the volar scapholunate interosseous ligament.22 Other complications include fracture displacement, malunions, prominent intra-articular screw placement, and injury to the volar branch of the radial artery.20,22,27 A concern for operative treatment is the radiographic evidence of osteoarthritis of the scaphotrapezial joint seen in several studies.7,19 The significance of this finding has yet to be elucidated but is unique to the operative group. However, long-term follow-up is needed to determine the clinical relevance of this finding. Of note, scaphotrapezial osteoarthritis was seen in the same percentage of open and percutaneous patients.7,19
Conclusion Nondisplaced scaphoid waist fractures are common among athletes and must be promptly diagnosed and treated to ensure the best outcome and fastest recovery. Nonoperative treatment with playing casts is a reasonable treatment option in athletes that do not require complex wrist or hand dexterity or are at the end of their season. Nonoperative treatment relies upon close radiographic surveillance, and any concern for progressive displacement or delayed healing must be addressed immediately to limit prolonged immobilization, malunion, or nonunion. High-demand athletes may benefit from early fixation allowing faster return to unencumbered play; however, the risks of surgery must be considered. Union should be confirmed with CT scans, and full range of motion obtained to determine at which point athletes may be released to unrestricted participation in their given sport.
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