Scaphoid Fracture

GENERAL INFORMATION

It is one of the 8 small bones in the wrist and the fracture on this bone.

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8 small bones and Scaphoid bone on the wrist

Thwe wrist joint has the capacity to maket he most complicated movements; which makes it different from the other joints.

While the elbow joint can only open and close (like a hinge), the wrist joint can move to the four sides and can turn 360 degrees.

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All of these have the aim to maximise the practicability of our hand.

The more a joint has the practicability and capabilities, the more complicated it gets on biomechanical base. The wrist joint is the best example for this. The said 8 small bones can make many adjustments and position changes even during a simple movement of the wrist. During all of these, the fundamental structure of the biomechanics is the bone called scaphoid.

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To explain in a simple way, the 8 bones in the wrist joint is arranged in two lines as four each. The connection and order between these two lines are provided through the scaphoid bone.

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In other words, almost all the movements and position changes are made on the scaphoid bone.

The aforementioned explanation has the answer of two observations. One of them is why the scaphoid bone is the most commonly seen fracture. The second one is why the pain and loss of function after the fracture is so severe.

The diagnose and the treatment of scaphoid fractures have always been a problem. The problems that may occur during the diagnose and treatment process are as follows:

1- The diagnose may not be establihes after the scaphoid fracture occurs: ;After the fracture occurs, it may not be observed in the direct x-rays taken upon a typical history and physical examination.

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This is unique to scaphoid fracture and has lots of reasons. In order to overcome this situation, a logic Schedule has been developed with the help of the experiences acquired during the process. In summary;

a- The occurence type of the trauma: Scaphoid fractures generally occur upon falling down on the naked arm.

When we start to fall down for any reason, the main reflexes activate and we move forward our arms involuntarily. At this time, the whole weight of our body falls on our arm; there occurs a fracture on the weak link of the chain. In such falls, a fracture may occur on one of the bones of our arm. However, as mentioned before, since the scaphoid bone can get different positions to provide the movements of the wrist, it is generally caught in the worst position (shear).

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Scaphoid fracture is generally caught on the worst position while falling down (shear)

b- Findings after the trauma: Even not the same for every patients, some findings are thought to indicate scaphoid trauma. The most important of them is the severe pain on the radial side of the wrist. Increase of the pain with wrist movements indicates the fracture possibility, as well. Another negative finding is the swelling on the area called snuffbox.

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Pain and swelling on the area called snuffbox indicate to the scaphoid fracture.

c- Examinations: The most important and easliy performed examination right after the trauma is the x-ray graphies. As mentioned before, the fracture may not be observed at this stage. Detailed information can be acquired though Computerised Tomography (CT) and Magnetic Resonance (MR) examinations.

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However, at the early stages, applying further examinations is not generally preferred. Since MR examination is performed not to skip any findings, its sensitivity rate is high. It might be difficult to correlate some findings detected in the MR examination after the trauma with scaphoid fracture due to specificity problem. The best approach at this stage is to proceed as if there is a fracture and apply a splint on the effected wrist. The pain can be relieved by keeping the hand above the heart level, cold application and some medication. Besides, keeping the hand stabile will gain some time, as well. This period may take 2 to 3 weeks. At the end of this period, x-ray is taken again. If the fracture is started to be observed, no time will be lost since the stabilized time by the splint shall be added to the treatment. If no fracture is observed upon the x-ray, clinical examination is repeated. At this stage, consultation findings are very important. There are two options for both the doctor and the patient. Either further examinations (CT, MR) are performed or observation period is started.

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2- Scaphoid fracture union is generally difficult. There are some reasons of this:

a- The amount of blood reaching to the bone for the union of a fracture should be at normal levels. Due to its structure, scaphoid bone is not good at vascularizing and blood stream. This condition gets more significant after the fracture.

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b- As mentioned before, scaphoid bone is contiously moving and changing positions due to the load brought by the wrist biomechanics. In every move of the wrist, it gets different positions. Altough it is tried to be kept stabile with some treatment methods like plaster or splint after the fracture, micro motions generally cannot be prevented. Movements on the fracture surface are generally misconcived by the body and it is resulted in false cartilage tissues (fibrosis non-union).

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c- The fracture occurring on the scaphoid fracture stays within the joint contrary to the long bone fractures. This condition causes to the contact of fracture surface with the joint liquid and non-occurence of the hemotoma that will heal the fracture.

3-After the fracture of scaphoid bone, one of the fracture pieces may be lost. This condition is called avascular necrosis or aseptic necrosis.

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Avascular necrosis is more commonly seen after the scaphoid bone fractures than the other fractures. The factors are almost the same with the factors mentioned before:

a- Difficulty in blood stream of the scaphoid bone.

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b- A fracture left within the joint.

c- Non-prevention of the fracture movements

d- Another factor is related with the sizes of the pieces occuring after the fracture. If the fracture is divided into two equal pieces, avascular necrosis is more unlikely to happen. However, if one of the pieces is much smaller than the other one and adjacent to the joint, avascular necrosis risk is higher.

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DIAGNOSING METHODS

During diagnosing process, the hsitory, physical examination findings and direct x-rays of the patient are main information sources. In case of having a problem in diagnosing and treatment planning with these sources, further examinations like CT or MR examination can be applied.

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TREATMENT

Plaster treatment: As in every fracture, the aim is to find out the appropriate treatment method fort he union of the fracture in the position closest to the former anatomy and to minimise the function losses.

Although each scaphoid fracture is different, it has been observed that the treatment of similar fractures has resulted in similar ways. The groupings made in this way are called classifications. Scaphoid fractures have also some classification shemes. The aim here is to follow-up the algorithm performed in similar fractures and acquired positive results and to make the patient have maximum benefits.

Despite all the negativenesses mentioned, some scaphoid fractures respond positively to the non-surgical treatment called conservative treatment. Such fractures are generally transverse and close to the middle of the scaphoid bone.

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These fracture are generally called as stabile by the doctors as they do not tend to move. The probablity of avascular necrosis is too low in such fractures and plaster treatment can be applied. There is a common agreement that the plaster should also cover the thumb.

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Besides, there are different opinions regarding the appliance of the plaster as short arm (up to the elbow joint) or long arm (up to the shoulder joint). Under both conditions, the necessity that the plaster should be kept at least 12 weeks (as to be cnotrolled on the sixth week) causes may problems. During this period, the arm’s being unusable will cause many problems in the working environment, daily life quality and hygene. Besides, long term of plaster use will result in immobility of the joints and weakness of the muscles. All of these factors are explained to the patient by the doctor and the treatment method is decided together. The intolerance to all of these aforementioned negative situations is a real reason for surgical treatment (indication.)

It should be specified that only a few scaphoid fractures can be treated with the plaster.

Surgical treatment: The fractured bone returned to its former anatomical position (before the fracture) with surgical treatment and fixed with some devices to stay in this position until union. This intervention is called “open reduction-internal fixation”.

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During the surgical treatment, the fracture is tried to be returned to its former position as much as possible. At first, the fractured scaphoid bone should be reached. To minimise the damage of the surgical intervention to the adjacent tissues, some methods have been developed to approach the scaphoid bone. The laceration can be made through the dorsum or palmar area of the wrist. This decision is related with the type of the fracture. After the fracture is detected and returned to its former anatomic position, it is fixed. At this stage, some devices can be used. The most commonly used fixation devices are the screws specially produced for this fracture type.

After the surgical treatment, the arm is encased in plaster as mentioned. Surgical treatment generally will not remove the necessity for applying plaster. However, the term of plaster is shortened. Another important point is that surgical treatment is performed in the cases with low possibility of healing with the plaster treatment.

LATE DIAGNOSING AND TREATMENT

The treatment period will be more troubled for the patients undiagnosed or consuşting late. As mentioned before, scaphoid bone is in charge with every movements of the wrist joint. The deterioration of the integrity of the bone after the fracture will negatively effect the biomechanics of the whole wrist. Ununion tissue and false joint develop on the scaphoid bone. Deformity occurs on the bone due to the wrist movements (hump deformity). There occur some movements between the wrist bones which are not expected to occur. These are called as “instability” and highly complicated. With each movement, the load on the other bones of the wrist joint increases abnormally. The bones changes place in time and there occurs collapse (migration) on the wrist joint. As a result, there will be premature abrasion corrosion on the cartilage surfaces constituting the joint. Such conditions are generally called as “arthritis”. This type of collapse unique to wrist joint is called as SNAC (scaphoid-nonunion-advanced-collapse).

All this process extends over time; thus the surgical treatment methods that can be performed are different.

1- Fixation and grafting: The fracture is fixed and graft is applied to prompt the union. The bone to be used in grafting is generally taken from the patient (pelvis). Another aim in grafting is to return the shothened and humped scaphoid bone to its former shape. It has nothing to do with appearance, a scaphoid bone which is unioned not in normal sizes cannot provide the wrist biomechanics to return normal. At this stage, even the union is acquired and the normal sizes of the scaphoid bone are preserved, the destruction occurred in time can not be recovered. The pain may relieve. However, it is difficult to estimate how much of the loss in the wrist movements will be recovered.

2- Salvage interventions: This is the method to be performed for late diagnosed cases with ununion after the scaphoid fracture, avascular necrosis or arthritis. The normal anatmoy or biomechanics of the wrist joint cannot be preserved with these mehods. Some of the bones and joint structures may be sacrificed and acquiring a painless joint is aimed. By taking out the whole scaphoid and the two adjacent bones, preserving the joint movements without pain is aimed.

WHAT IS THE PROGRESS OF THE SURGICAL TREATMENT, WHAT IS AHEAD OF US?

The Orthopedician or Hand Surgeon will ask for x-rays after the consultation. MRI, bone scintigraphy or CT (computerised tomography) may also be required in accordance with the period after the fracture. What is aimed here is not only the diagnosis but also the staging. The stage of the disease is highly important in determining the surgical treatment method. In most of the surgical methods, one day of hospitalization will be sufficient. It is very important for you to mention about your special conditions (chronic diseases, regularly taken medication etc.) during your consultation with the anesthesiologist. Most of the surgeries regarding the scaphoid bone can be performed under local anesthesia. In the postop early period (the first 3 to 5 days), cold application and keeping the hand above the heart level will relieve the pain and the throbbing. After the surgery, a plaster or splint generally up to the elbow joint is applied. The term of the plaster or the splint may vary from 3 weeks to 3 months in accordance with the surgical treatment performed. At the end of this period, physical therapy and rehabilitation period starts. The aim is to regain the hand, wrist and arm strenght and to minimise the loss of movement. The term will chage in accordance with the surgery performed and the condition of your wrist.

PROBABLE COMPLICATIONS

Hematoma on the surgical wound area, infection, pressure feeling due to the plaster, limitation of finger movements due to the tissue adhesion on the surgery area, chrınic pain (RSD), receving late or never receiving the expected results are the most common complications.

It should not be forgotten that the scaphoid fracture treatment may take months. In case of ununion, a second surgery may be needed.