손목질환은 꽤 많은 편이다.
체중부하가 걸리지 않기 때문에 통증이 심하지 않기 때문에 흔히 치료가 방치되는 경우가 많다.
손목통증은 크게 두가지
1) acute traumatic injury
2) overuse injury
The wrist common injuries and management.pdf
Introduction
Wrist injuries are common in athletes. They may result from a single, traumatic force or as a result of repetitive-loading activity. Complex wrist and hand anatomy can make diagnosis of wrist injuries an challenging task. A good understanding of wrist anatomy, as discussed elsewhere in this issue in ‘‘The Wrist: Clinical Anatomy and Physical Examination—an Update’’ by Eathorne, and an awareness of the common presentations of sportspecific injuries will facilitate accurate diagnosis.
- 손목손상은 운동선수에게 흔함.
- 복잡한 손목과 손의 해부학을 잘 알아야 정확한 진단을 내릴 수 있음.
Labeling an athlete’s injury as a ‘‘wrist sprain’’ without a specific diagnosis may allow a competitive athlete to continue to play through the pain without proper treatment and exacerbate an injury. Management of a wrist injury in the athlete requires that the physician balance the athlete’s objective to return to sport promptly with treatment that allows healing and prevents long-term complications of an injury. It is important for the primary care physician to have an awareness of the broad range of injuries that occur in the athlete’s wrist, to be familiar with appropriate conservative management, and to refer appropriately.
- 특별한 진단없이 손목염좌라고 이름붙이는 것은 반복사용하는 운동선수에게 흔히 진단함.
- 운동선수 손목 손상의 치료는 즉시 복귀와 장기간 합병증을 막기 위해 중요함.
Epidemiology
Child and adolescent athletes suffer relatively more wrist injuries than adult athletes. Three percent to 9% of all athletic injuries involve the hand and wrist [1]. This number is as high as 14% in high school football [2], and 46 to 87% of gymnasts suffer wrist injuries or have chronic wrist pain [3,4]. Injuries of the wrist can be divided into acute traumatic injuries and overuse injuries.
Acute wrist fractures are common injuries among athletes. In a study of football players aged 9 to 15, 35% of injuries were to the upper extremities, and most were distal radius fractures [5]. Distal radius metaphyseal and physeal fractures are common in skating, football, basketball, and snowboarding. The scaphoid is the most commonly injured carpal bone, accounting for 70% of carpal fractures [2]. An athlete falling on an outstretched hand with the wrist dorsiflexed is a common mechanism. The triquetral bone is the second most commonly injured carpal bone. It typically occurs from a fall on a wrist in ulnar deviation. Pisiform fractures occur due to a direct blow, such as from a pitched ball.
Stress fractures occur in athletes whose sport requires repetitive motion involving wrist compression or twisting. Sports such as gymnastics and weightlifting place large repetitive compressive forces across the wrist. Distal radius physis stress syndrome, avascular necrosis of the capitate, and stress fracture of the scaphoid have been reported in these athletes [4,6]. Reportedly, up to 87% of elite gymnasts sustain distal radial physeal injuries [3]. Hook of hamate fractures have been seen in baseball, golf, and tennis players from the repetitive stress of bat, club, or racquet, respectively [7]. Repetitive stress is also thought to be a cause of avascular necrosis of the lunate or Kienbo¨ ck’s disease.
Soft-tissue injuries may either be due to acute trauma or overuse. Overuse syndromes such as deQuervain’s tenosynovitis, extensor carpi ulnaris tendonitis, and sprains of pisotriquetral ligament [8] are associated with
throwing and racquet sports. Dislocation of the distal radioulnar joint(DRUJ), midcarpal instability, and triangular fibrocartilage complex(TFCC) tears can occur due to a traumatic fall, or due to repetitive twisting motion as seen in gymnasts. Carpal dislocation typically requires significant force, such as a collision in football or a fall from a height in cheerleading.
General approach to wrist injuries
To begin, be familiar with the most common wrist injuries in active people and the common sport-specific injuries. Obtain a careful history regarding the athlete’s wrist complaint, including how the complaint is related to activity and rest. It is important to have good clinical knowledge of the functional anatomy of the wrist in order to maximize the information
gathered on examination. The evaluation of wrist complaints requires at least two radiographic views of the wrist (Fig. 1).
An oblique view, in addition to a posterior-anterior (PA) and true lateral, is useful in identifying fractures. Special radiographic views of the wrist are also useful and will be addressed further in the discussion of specific injuries (Table 1).
Several things are important to consider as treatment is initiated for a wrist injury including: the athletes sport, his or her desires regarding return to play, and the impact of injury management on the athletes future participation in his or her sport. The primary care physician should understand that many injuries have a poor outcome if unrecognized. If the diagnosis is not clear, the athlete’s wrist can be protected with a splint and referred for additional evaluation.
Management of all wrist injuries should include rehabilitation of muscles weakened and motion lost by pain, inflammation, and immobilization. Rehabilitation should proceed through five goal-oriented phases.
Rehabilitation goals include:
(1) decreasing pain and minimizing inflammation and edema
(2) increasing pain-free range of motion
(3) strengthening and improving general condition
(4) increasing sport-specific skill, coordination, and flexibility
(5) return to sport with prevention of injury, which may include use of protective equipment. Physical therapists and athletic trainers can play a key role the safe and expeditious return to play of the athlete.
Tendonopathies
1. DeQuervain’s tenosynovitis
DeQuervain’s tenosynovitis is the most common tendonopathy of the wrist in athletes [9]. DeQuervain’s tenosynovitis is inflammation of the tenosynovium of the first dorsal compartment tendons, the abductor pollicis longus (APL) and extensor pollicis brevis (EPB). These tendons course under the extensor retinaculum in a groove along the radial styloid process. Repetitive wrist motion causes shear stress on the tendons in their small compartment, which results in inflammation of the tenosynovium. DeQuervain’s tenosynovitis is common in racquet sports, fishing, and golf. On examination, the athlete will be tender over the APL and EPB, and will have pain with Finklestein’s test (Fig. 2).
Fibrous thickening of the tendon sheath and a ganglion cyst may be present in chronic cases. Acute deQuervain’s tenosynovitis responds best to corticosteroid injection into the tendon sheath (Fig. 3).
- 드퀘방병이 오래되면 건초와 강긍리온 시스트의 fibrous thickening이 흔함.
- 이때는 스테로이드 주사로 반응????
Results of a recent meta-analysis of treatments for deQuervain’s tenosynovitis showed that there was an 83% cure rate with injection alone. This rate was much higher than any other therapeutic modality (61% for injection and splint, 14% for splint alone, and 0% for rest or nonsteroidal anti-inflammatory drugs [NSAIDs]) [10]. If conservative treatment fails, surgical decompression of the first dorsal compartment should be considered. Surgical candidates should expect 7 to 10 days of postoperative splinting, followed by rehabilitation and return to sport in 6 to 9 weeks [9].
Intersection syndrome 교차증후군
Intersection syndrome is a painful inflammatory condition located at the crossing point of the muscles of the first dorsal compartment (APL and EPB) and second dorsal compartment tendons. (extensor carpi radialis longus [ECRL] and extensor carpi radialis brevis [ECRB]). The site of crossover is 6 to 8 cm proximal to the radial-carpal joint in the dorsal forearm (Fig. 4).
This site is tender and may be swollen. There is often a palpable crepitus at the intersection with moving the wrist through flexion and extension, leading to the name ‘‘squeakers syndrome.’’ It is seen in athletes who play sports requiring forceful, repetitive wrist flexion and extension (rowing, weight lifting, gymnastics, and racquet sports). The pathophysiology is still unclear, but it is thought to be a tenosynovitis of the second dorsal compartment tendons, or inflammation of an adventitial bursa between the APL and ECRB due to friction at the intersection. This syndrome responds well to conservative treatment of rest, local icing, and NSAIDs, with a gradual return to sports. Splinting with a thumb spica splint in 15 of wrist extension for 2 weeks is helpful to rest the muscles [11]. Injection with local anesthetic and steroid may be needed if symptoms do not resolve with NSAIDs and rest [12]. Range-of-motion and strengthening
therapy should follow splinting before return to sports. Surgery is rarely needed, but cases recalcitrant to conservative therapy for greater than 6 weeks may undergo release of the second dorsal compartment and debridement of inflammatory tissues [9].
Extensor carpi ulnaris tendonopathy
Extensor carpi ulnaris (ECU) tendonitis is the second most common sports-related overuse injury of the wrist [13]. This should be included in the differential diagnosis of an athlete with ulnar wrist pain. It is commonly seen in racquet sports, rowing, and squash [14]. Patients present with the complaint of dorsal-ulnar wrist pain after repetitive activity.
Diagnosis is made by physical examination. There is tenderness and swelling over the ECU tendon sheath, dorsal to the ulnar styloid. Pain is reproduced with resisted dorsiflexion with the wrist in ulnar deviation and forearm supination [11]. Wrist radiographs are negative. Treatment includes rest, splinting, and NSAIDs [9]. If not improved after 2 weeks
of conservative therapy, corticosteroid injection often resolves symptoms. Injection of the ECU tendon sheath requires good knowledge of the wrist anatomy, so as not to damage the dorsal sensory branch of the ulnar nerve (Fig. 5). Lastly, surgery may be required to decompress the sixth dorsal compartment.
ECU subluxation is a less common injury, but is important to consider in
the differential diagnosis of chronic ulnar wrist pain. ECU subluxation
occurs with forceful supination, palmar flexion, and ulnar deviation of the
wrist [15] . This injury is seen in tennis players hitting a low forehand, or in
the trailing hand of a baseball player at the end of a swing [14] . It may also
occur after a fall on an outstretched hand (FOOSH) [15,16] . Patients
typically complain of dorsal ulnar wrist pain and ‘‘snapping’’ that are
aggravated by forearm rotation [15] . Tenderness and swelling are elicited
over the ECU in the area of the ulnar head. Marked pronation or supination
may reproduce the ‘‘ping’’ as the tendon subluxes out of its groove. Wrist
radiographs are normal. A 6-week period of immobilization in a long arm
cast may be tried [9] ; however, in several case reports [15,16] this
conservative therapy has not been successful. For symptomatic patients,
surgical repair of the ruptured tendon subsheath is recommended [17,18] ,
followed by 4 to 6 weeks of immobilization, with return to sport anticipated
8 to 10 weeks following surgery [9] .
Flexor carpi ulnaris tendinopathy
Flexor carpi ulnaris (FCU) tendonitis presents with palmar-ulnar side
wrist pain, and is seen in racquet sport athletes. Examination reveals
tenderness along the FCU and pain with wrist flexion. Dorsal wrist splinting
with 25 of flexion for 1 to 2 weeks and a short course of NSAIDs typically
resolve symptoms [14]. Corticosteroid injection is considered for recalcitrant
cases. Excision of the pisiform and Z-plasty lengthening of the FCU has
been described for chronic cases [14].
Flexor carpi radialis tendinopathy
Flexor carpi radialis (FCR) tendonitis presents with pain in the palmarradial
wrist with repetitive wrist flexion. Tenderness is over the FCR at its
insertion on the base of the second and third metacarpals, and pain is
reproducible with resisted wrist flexion. As with FCU tendonitis, treatment
is rest with brief splinting, NSAIDs, and stretching, and if symptoms are
prolonged, surgical release may be indicated.
Distal radioulnar joint and triangular fibrocartilage complex
DRUJ and TFCC injuries are often discussed together, due to closely
related anatomy and frequently overlapping symptoms. The DRUJ is
located between the distal radius and the head of the ulna. Five structures
are important in ensuring the stability of the DRUJ: (1) the triangular
fibrocartilage (TFC), (2) the ulnocarpal ligament complex, (3) the infratendinous
extensor retinaculum (ie, the ECU tendon sheath), (4) the pronator
quadratus muscle, and (5) the interosseous membrane [19]. Intimately
related to the DRUJ is the TFCC. The TFCC (Fig. 6) is composed of the
semicircular biconcave fibrocartilage or articular disc called the TFC, the
palmar and dorsal distal radioulnar ligaments, a meniscus homolog, and
the ulnolunate and ulnotriquetral ligaments [20]. The distal radioulnar
ligaments arise from dorsal and palmar edges of the distal radius and are
often indistinguishable from peripheral fibers of the TFC.
Distal radioulnar joint instability
Because of the intimate relationship and overlapping structures of the
DRUJ and TFCC, injury to either can occur by a similar mechanism, such
as traumatic axial load with rotational stress (eg, FOOSH). Both injuries
typically present with ulnar-sided wrist pain. Because the TFCC adds
stability to the DRUJ, an injury to the TFCC can result in DRUJ
instability; however, DRUJ instability can also occur as a result of other
injuries, such as a distal radius fracture or disruption of any of the five stabilizers mentioned above (eg, distal radioulnar ligaments or interosseous
membrane).
DRUJ injuries may present acutely at dislocation or with chronic ulnar
wrist pain due to instability. A patient who has an acute DRUJ dislocation
without associated fracture usually complains of pain over the ulnar aspect
of the wrist accentuated by pronation and supination [19] . On examination,
there is moderate swelling and tenderness over the DRUJ. In dorsal
dislocations, there is a prominence of the distal ulna dorsally when the wrist
is flexed. In palmar dislocations, the normal prominence of the ulnar head at
the wrist may be obscured by soft-tissue swelling. DRUJ dislocation can be
difficult to diagnose with plain radiography. A true lateral radiograph may
demonstrate the dorsal or palmar displacement of the distal ulnar relative to
the radius. PA radiographs may show a greater than normal gap between
the head of the ulna and distal radius if the ulna is dorsally dislocated.
In palmar DRUJ dislocations, the ulna and radius may be superimposed
on the PA view [19] . Bilateral wrist comparison views may be helpful. If
concern for DRUJ injury exists and radiographs are inconclusive, CT or
MRI may be warranted.
Isolated acute DRUJ dislocations need to be reduced and immobilized in
a long arm cast with forearm neutral for 6 weeks [19] . If there is an
associated injury (eg, TFCC tear) and the soft tissue is interposed between
the radius and ulna, healing with closed reduction may be unsuccessful.
DRUJ dislocations with associated fractures are generally not amenable to
nonoperative management [19] .
DRUJ subluxation is a cause of chronic ulnar wrist pain. The ulnar head
is prominent in pronation as it rides onto the dorsal lip of the radius.
Supination may then be restricted, often followed by a distinct snap during
forearm rotation [19] . The ‘‘piano key sign’’ indicates distal radioulnar joint
instability [1] , which allows subluxation of the ulna on the radius. This sign
is elicited by having the patient place both palms on the examining table and
forcefully press downward. There is exaggerated dorsal-palmar translation
of the distal radius compared with the opposite side. Alternatively, this sign
can be elicited by depressing the ulnar head while supporting the forearm in
pronation; the ulnar head springs back like a piano key, indicating laxity
of the DRUJ [21] . Patients who have chronic subluxation may receive
temporary relief with a distal forearm splint that exerts a relocating force on
the ulnar head. Definitive treatment for the symptomatic athlete, however, is
typically surgical [19] .
Triangular fibrocartilage complex injury
The TFCC is a cartilaginous and ligamentous structure important in the
stabilization of the distal radial ulnar joint (as mentioned above). The
articular disc of the TFCC separates the ulna and the proximal carpal row,
and carries about 20% of the axial load from wrist to forearm [22] . There is
a relative lack of blood supply to the central portion of the TFCC, leading
to poor healing of tears [23] . Injuries to the TFCC occur with repetitive
ulnar loading (eg, bench press, racquet sports) or acute traumatic axial load
with rotational stress (eg, FOOSH). Most injuries to the TFCC have
a component of hyperextension of the wrist and rotational load. Ulnar-sided
wrist pain made worse with ulnar deviation, wrist extension, or heavy use is
the common complaint of an athlete who has a TFCC injury. TFCC injuries
are more commonly seen in such sports as gymnastics, hockey, racquet
sports, boxing, and pole vaulting [24] .
The TFCC is palpated in the hollow between the pisiform, FCU, and
ulnar styloid. It is most easily palpated with the wrist in pronation. Injury to
the TFCC is indicated by tenderness on palpation of the TFCC, with or
without distal radioulnar joint instability. TFCC compression by forced
ulnar deviation and axial compression with repeated flexion and extension
will impact the ulnar styloid and TFCC. This will result in pain or clicking
if the TFCC is involved [3] . The ‘‘press test’’ reproduces the patient’s pain
when the patient lifts herself out of a chair while bearing weight on the
extended wrists [25] . The ‘‘supination lift test’’ has also been described for
localized tear to the peripheral, dorsal TFCC. With this test, pain is
reproduced when the patient attempts to lift the examination table with the
palm flat on the underside of the table [26] This forces a load across the TFCC with the wrist supinated and extended, causing dorsal impingement,
and is useful in the diagnosis of peripheral, dorsal TFCC tear.
Radiographs are usually normal in TFCC injuries. The PA view may,
however, demonstrate positive ulnar variance, which is a risk factor for
TFCC injury. Ulnar variance is the relationship of the length of the radius
and ulna. This relationship, which is categorized as positive (long ulna
relative to radius) or negative (short ulna relative to radius), influences the
distribution of compressive force across the wrist. Most forearms are within
2 mm of ulnar positive or 4 mm ulnar negative. Pathologic conditions are
more prevalent at the extremes of ulnar variance [27] . Positive ulnar
variance is associated with a thinner TFCC [28] and increased forces
transmitted across the TFCC [29] , making it more prone to injury. Highresolution
MRI and MR arthrogram may detect TFCC tears. CT scan of
the wrist in neutral, pronation, and supination may reveal distal radioulnar
joint instability that may be due to TFCC injury [1] . Rest, activity
modification to remove the inciting force of injury, ice, splint immobilization
for 3 to 6 weeks, and subsequent physical therapy may be effective for
some TFCC injuries [1,3] . Buterbaugh et al [26] recommend a trial of
6 weeks of splinting and NSAIDs for patients presenting with ulnar-sided
wrist pain, normal plain films, and suspected TFCC injury. Failure of
conservative treatment necessitates further imaging or arthroscopy. For
high-level athletes (elite high school, collegiate, or professional) who have
negative initial imaging and persistent symptoms limiting participation,
diagnostic (and potentially therapeutic) arthroscopy may be indicated after
as little as 2 to 3 weeks of splinting [1] . Arthroscopy is used to debride
central tears and repair peripheral tears. Some injuries require open surgery
with an ulnar shortening procedure. Return to sport after surgery ranges
from 6 to 12 weeks following arthroscopic debridement to 6 months after an
open procedure [29] .
Our knowledge of ulnar-sided wrist pain, including TFCC injury and
DRUJ instability, is advancing with MRI and arthroscopic technology. The
complexity and variability of these injuries is becoming more evident. The
TFCC may be injured centrally or peripherally. There may be other
associated injuries or fractures. The type of injury and extent of the injury
determines the efficacy of conservative treatment. Ninety percent good-toexcellent
results have been reported from arthroscopic repair of central or
peripheral TFC tears with a stable DRUJ [1] .
Fractures
Distal radius fracture
Distal radius fractures are very common in sports. This injury typically
occurs with a FOOSH with hyperextension, impacting the distal radius. The
athlete presents with pain, swelling, ecchymosis, and tenderness about the wrist. Initial radiographs should include PA, lateral, and oblique views of
the wrist. The examiner needs to determine the type of distal radial fracture
and assess displacement, shortening, and intra-articular involvement. The
goal of treatment is to correct and maintain radial inclination, palmar tilt,
length, and congruity of the distal radial articulations (carpal and ulnar).
A Colles’ fracture, the most common distal radius fracture, is a closed
fracture of the distal radial metaphysis in which the apex of the distal
fragment points in the palmar direction and the hand and wrist are dorsally
displaced (Fig. 7 ). This fracture usually occurs within 2 cm of the articular
surface. Colles’ fractures are common in adults and rare in children, because
children tend to sustain injuries through the distal radial physis.
Stable distal radius fractures may be managed in a short arm cast. All
others should be referred for reduction and fixation. A stable distal radius
fracture is extra-articular, without comminution, and with minimal or no
displacement, which, when reduced to anatomical alignment, does not
redisplace back to the original deformity [30] . For optimal outcome, it is
important that anatomic alignment of the radius is maintained (either at
presentation or with reduction); however, authors differ slightly on the
definition of acceptable anatomical alignment. Certainly, fractures must be
referred for orthopedic consultation if there is greater than 20 dorsal tilt,
loss of radial inclination (20 to 30 need to be maintained), articular stepoff
greater than 2 mm, or radial shortening greater than 5 mm (Fig. 8 ) [31] .
Maintaining radial inclination of 20 to 30 , 4 to 8 palmar tilt, and radial
shortening no greater than 2 mm is recommended by Rettig and Trusler [32] .
Some texts report that less than 20 of dorsal tilt is stable for closed
reduction of a Colles’ fracture [30,33] ; however, the reduction needs to be close to anatomic alignment. Laboratory studies demonstrate that alteration
of palmar inclination by 20 or more can cause dorsal shift in the scaphoid
and lunate, leading to decreased range of motion and high pressure areas on
the distal radius [34] . In an individual who normally has 11 of palmar
tilt, the maximum acceptable alteration in palmar inclination is 9 of dorsal
tilt. Clinical studies also demonstrate that patients who have excessive
dorsal tilt are more likely to have poor outcome. McQueen and Jaspers [35]
reported on 30 patients who had a Colles’ fracture at 4 years follow-up.
Patients who had as little as 10 dorsal tilt were much more likely to have
pain, stiffness, weakness, and poor function.
Fractures may ‘‘settle’’ or displace in the cast. If healing occurs with
a displaced fracture fragment, wrist range of motion will be compromised. A
distal radius fracture that is considered stable is managed with a short arm
cast, but must be followed with weekly radiographs for at least 3 weeks to
ensure that the fracture does not displace in the cast. If cast immobilization
is not able to maintain less than 10 of dorsal radial inclination and less than
5 mm radial shortening, internal fixation is recommended [30] .
Some surgeons are electing to manage even traditionally stable distal
radius fractures with internal fixation. The reason seems to be twofold. The
closer to anatomical alignment the fracture is maintained, particularly in
palmar tilt, the better the outcome. Also, ‘‘stable’’ fractures may displace
with cast immobilization, termed ‘‘secondary instability,’’ and require
internal fixation. In a prospective radiological study performed on 170
Colles’ fractures that were treated with closed reduction and cast
immobilization [36] , 29 fractures displaced, requiring further reduction
and external fixation. Seventeen additional fractures suffered malunion,
with significant increase in radial angulation and decrease in radius length.
Common distal radius fractures in children include torus, greenstick, and
physeal fractures. A torus fracture occurs when the tough periosteum, while
remaining intact, buckles circumferentially at the fracture site. If one side of
the periosteum buckles but the other side breaks, it is called a ‘‘greenstick’’
fracture. Physeal injuries are typically classified radiographically using the
Salter-Harris classification. Type I fracture is a disruption of the physis.
Type II is a fracture through the physis extending obliquely through the
metaphysis. Type III is an intra-articular fracture through the epiphysis that
extends across the physis to the periphery. Type IV fractures cross the
epiphysis, physis, and metaphysis. Type V fractures are compression injuries
of the physis, typically diagnosed retrospectively due to growth disturbance.
Type III and IV fractures are also at risk of growth disturbance, and
frequently require surgical fixation. Stable distal radius fractures (eg, torus
fracture, Salter I or II fractures) may be treated in a short arm cast for 4 to
6 weeks, followed by protective splinting and rehabilitation [31] . A
protective splint should be used upon return to sports for at least 2 weeks.
Intra-articular, comminuted, angulated, or shortened fractures, or those
that demonstrate loss of radial inclination, may require operative treatment and should be managed by an orthopedist. Salter-Harris III–V injuries
require orthopedic consultation.
A related injury, a stress injury to the distal radius physis, has been
reported in high-level gymnasts. This stress fracture should be suspected in
the athlete who presents with dorsal wrist pain made worse by stress
loading, such as vaulting or hand-walking. There is no history of acute
trauma or loss of motion, and examination reveals tenderness over the distal
radial epiphysis. Radiographs may be normal or may demonstrate widening
or haziness of the epiphysis [37] . Treatment is immobilization, followed by
wrist range-of-motion and strengthening rehabilitation. Noncompliance or
inappropriate treatment places the athlete at risk for growth disturbance of
the distal radius.
Scaphoid fracture
Clinicians must have a high index of suspicion for scaphoid fracture when
presented with the complaint of radial wrist pain in any contact-sport
athlete. The scaphoid bone is unique for two reasons. First, it spans both the
proximal and distal carpal row, making an intact scaphoid imperative for
carpal stability. Second, the scaphoid relies on an interosseous blood supply
from branches of the radial artery that enter the scaphoid distal to the
middle third and provide the sole blood supply to the proximal pole [38] .
Therefore, fractures through the proximal third disrupt the blood supply
and are prone to osteonecrosis and nonunion.
Scaphoid fractures are most common in those aged 15 to 30 years, and
are rare under the age of 10 [39] ; however, among wrist injuries in children,
the scaphoid is the most commonly fractured bone, accounting for over
70% of all carpal fractures [3] . FOOSH while skating, skateboarding, and
bicycling is often the mechanism of injury. Physical examination may
reveal tenderness over the scaphoid in the ‘‘anatomic snuff box,’’ and
tenderness over the scaphoid tuberosity in the palm or at the scapholunate
area distal to Lister’s tubercle dorsally. Scaphoid compression tenderness
may be elicited by applying axial pressure to the scaphoid via the first
metacarpal. Usually there is no swelling or ecchymosis. Wrist range of
motion may be only slightly decreased. Initial wrist radiographs should
include PA in neutral position, PA in ulnar deviation (scaphoid view),
lateral with wrist in neutral, 45 pronated oblique, 45 supinated oblique,
and anteriorposterior clenched fist. The ulnar deviation performed for the
scaphoid view (Fig. 9 ) distracts unstable fracture fragments, allowing
visualization of the fracture. Clenched-fist views allow assessment of the
scapholunate gap, which is useful in excluding associated scapholunate
dissociation.
Most simply, fractures are divided into anatomical location: distal pole,
middle third, and proximal pole. There are several more complex classifications
of scaphiod fractures based on location and stability for healing. One example is the Herbert Classification, outlined in Box 1 [40] . RuAN sse [41]
also proposed that, in addition to location, the obliquity of the fracture
relative to the long axis of the scaphoid has a role in healing. Adults most
commonly sustain middle-third fractures, and children most commonly
fracture the distal pole or middle third (Fig. 10 ) [3,38] . Distal fractures heal
most rapidly, often within 6 weeks. In contrast, proximal fractures, due to
the tenuous blood supply as described above, may take 6 months [38] .
If the patient has scaphoid tenderness without radiographic evidence of
a fracture, the wrist is immobilized in a short arm thumb spica cast, with the
wrist in mild extension and the thumb interphalangeal joint free, for 10 to
14 days. Follow-up radiographs at 2 weeks may reveal bone resorption
adjacent to the fracture site, or early callus formation if occult fracture was
present. Often athletes require a more urgent diagnosis to facilitate return to
play. A bone scan, CT, or MRI may be considered for additional imaging. A bone scan may be positive 24 hours after the injury; however, it can take 4
days for abnormal uptake to appear at the fracture site. A normal bone scan
4 days after injury is accurate in excluding scaphoid fracture [38,42] . MRI is
very sensitive and will have abnormal bone marrow signal 48 hours postfracture
[43] ; however, it may not clarify fracture displacement. CT scan
gives clearer fracture visualization, and is more accurate for determination
of displacement [43] . The evaluation and treatment of scaphoid fractures is
controversial and continues to evolve. One method of evaluating suspected
scaphoid injury is outlined in Fig. 11 .
Treatment of an acute scaphoid fracture in an athlete depends on the
location and stability of the fracture, as well as the sport and the desires of
the athlete. A scaphoid fracture is considered displaced and unstable if
displacement is 1 mm or greater, or if a step-off is visible on any radiograph
view [38] . Displacement of fractures may be difficult to recognize on
standard radiography alone; CT may be required to better define the
fracture anatomy. Although a complete, nondisplaced scaphoid fracture
may heal with cast treatment, internal fixation may be more appropriate for
the athlete because less time is required in a cast (some greater than 10 weeks
casted, versus 5 to 6 weeks if primarily surgically repaired [44] ). Nondisplaced
fracture of the distal pole and transverse incomplete fractures of
the middle third of the scaphoid are the most stable scaphoid fractures, and
the most amenable to cast treatment [45] . Some middle-third scaphoid fractures, particularly vertical oblique fractures, are less stable, take greater
than 12 weeks to heal, and have a higher rate of nonunion. These are
primarily fixed by some surgeons [45] . Displaced fractures and proximal
pole fractures, which have a greater risk of nonunion and malunion (see
below), should be referred for operative treatment Fig. 12 .
A nondisplaced distal scaphoid fracture or incomplete fracture may be
immobilized in a short-arm thumb spica cast for 4 to 8 weeks, with followup
visits and radiograph every 2 weeks until radiographic union. Healing
time is typically 6 to 8 weeks. Nondisplaced middle-third fractures are
treated with long arm cast for 3 to 4 weeks, followed by a short arm cast for
another 6 to 8 weeks [1] . Healing takes 9 to 12 weeks, with a minimum of
3 months out of sport. Ninety to 100% of transverse, nondisplaced, middlethird
fractures will heal with casting if treatment is started within 3 weeks of injury [46] . Delay in immobilization beyond 3 weeks from fracture has
a higher incidence of nonunion, and should be referred to an orthopedic
surgeon [47] . For some sports, such as football and soccer, a playing cast
may be used after the initial 4 weeks of casting; however, one study noted
a higher nonunion rate (39%), ultimately requiring surgery, with playing
casts, compared with a rate of 15% with traditional casting and no sports
participation [1] .
Open reduction and internal fixation has become standard for proximal
pole fractures, and is required for unstable fractures. It is also becoming
more accepted to surgically repair minimally displaced or nondisplaced
middle-third fractures, particularly for earlier return to sport, when a playing
cast is not an option [44,48]. Inoue and Shionoya [44] compared cast
treatment of nondisplaced middle-third scaphoid fractures with internal
fixation in laborers, and noted return to work in an average of 10.2 weeks in
the cast group and 5.8 weeks in the internal fixation group, with nearly
100% union in both groups. Another study [41] compared the effectiveness
of immediate open reduction and internal fixation with the Herbert screw
versus nonoperative treatment with a playing cast, in an athletic population.
Return to sport was earlier in the cast-treated group (4.3 weeks) than in
the surgical fixation group (8.0 weeks); however, a subsequent study [49] demonstrated that return to sport averaged 5.8 weeks for acute midthird
scaphoid fractures. Both treatment methods yield union rates comparable
with those in other studies. The athletes in this study did not have increase
risk of nonunion secondary to participation in sports. A playing cast is an
acceptable option for a stable fracture after an initial 4 weeks of
immobilization. Internal fixation of an acute scaphoid fracture allows safe
and early return to sports between 5 to 6 weeks [1,38,44,49], when a playing
cast is not an acceptable option and when an athlete accepts the risks of
surgery.
To summarize, patients who have proximal, displaced, angulated, or
complex scaphoid fractures (scaphoid fracture associated with distal radius
fracture, open fracture, or perilunate fracture dislocation), or those who
have delayed diagnosis or nonunion should be referred for surgery.