Fracture of carpal bone(s)

Fracture of carpal bone(s)

Scaphoid Fracture:

The scaphoid is one of the small bones in the wrist. It is the wrist bone that is most likely to break. 

Causes:

A fracture of the scaphoid usually happens from a fall on an outstretched hand, with the weight landing on the palm. The end of one of the forearm bones (the radius) may also break in this type of fall, depending on the position of the hand on landing. Pain and swelling in the wrist will usually cause a person with a scaphoid fracture to see a doctor. 

Fractures of the scaphoid occur in people of all ages, including children. The injury often happens during sports activities or a motor vehicle accident. Men aged 20 to 30 years are most likely to experience this injury. 

There are no specific risks or diseases that increase the chance of having a scaphoid fracture. Some studies have shown that use of wrist guards during activities like inline skating and snowboarding can decrease the chance of breaking a bone around the wrist. 

Symptoms:

Unless the wrist is deformed, it might not be obvious that the scaphoid bone is broken. Sometimes, it might seem to be just a sprained wrist. 

It is important to see a doctor if there is pain on the thumb side of the wrist that starts after a fall or accident and does not go away within a few days. 

Scaphoid fractures usually cause pain in the base of the thumb, with swelling in the same area. The pain may be severe when the thumb or wrist is moved or the hand grips anything. In some cases, the pain is not severe, and may be mistaken for a sprain. 

Diagnosis:

This X-ray shows the location of the scaphoid and the surrounding bones of the hand and wrist.

X-rays will be used to assess the bone. Sometimes, a broken scaphoid does not show up on an X-ray right away. If this is the case, the wrist might be put in a splint for a week or two. A new X-ray will be taken to see if the fracture will become visible. The splint should be worn during this waiting period, and heavy lifting should be avoided. 

An MRI (magnetic resonance image) may be taken to visualize the bones and soft tissues. This sometimes shows a fracture of the scaphoid before it can be seen on an X-ray.

TREATMENT:

Nonsurgical Treatment:Treatment of scaphoid fractures depends on the location of the break in the bone. 

Fractures of the scaphoid at the end near the thumb usually heal in a matter of weeks with proper protection. This part of the bone has a good supply of blood. Most fractures here heal well when they are placed in a cast. The cast will usually be below the elbow. It may or may not include the thumb. The time frame for healing is best determined by X-rays or other imaging studies such as a computed tomography (CT) scan. These imaging studies are used to confirm that the bone has healed. 

If the scaphoid is broken in the middle (waist) or at the part closer to the forearm (proximal pole), healing is more difficult. These areas of the scaphoid do not have very good blood supply. This makes it more difficult to heal. If a fracture of the scaphoid in these locations is treated in a cast, it will probably include the thumb. The cast will extend above the elbow. 

Surgical Treatment: When the scaphoid is broken at the waist or proximal pole, surgery may be recommended. A screw or wire may be used to stabilize the scaphoid while the bone heals.

Where the incision is placed and how large it is depends on what part of the scaphoid is broken. The incision will be on the front or the back of the wrist. Sometimes the screw or wire can be placed in bone fragments with a small incision. In other cases, a larger incision is needed to ensure that the fragments of the scaphoid are aligned properly

Nonunion, Avascular Necrosis, and Arthritis:

A bone that fails to heal is called a nonunion. Nonunions are more common after scaphoid fractures because blood supply to the scaphoid bone is poor. Blood supply to the bone is very important in its healing. Bones need blood to carry oxygen and nutrients to the site of the fracture. 

When the scaphoid is broken, especially when the fragments have moved apart (displaced), the blood supply to those fragments may be disrupted. Sometimes, the blood supply to one of the fragments is so poor that the piece does not get enough nutrients and the cells in that fragment die. This is called avascular necrosis.

Over time, nonunion and avascular necrosis of the scaphoid can lead to arthritis of the wrist. Symptoms of arthritis in the wrist that results from scaphoid nonunion or avascular necrosis include: 

  • Aching in the wrist
  • Decreased range of motion of the wrist
  • Pain with activities such as lifting or gripping

If X-rays show arthritis in the wrist as a result of an old break in the scaphoid, treatment focuses on improving the symptoms of arthritis. At first, this may include taking anti-inflammatory medicine and wearing a splint when the wrist is painful. Sometimes, the doctor may inject a steroid into the wrist to help to lessen wrist pain.

If this does not work, surgery may be recommended. Many types of operations can be performed for wrist arthritis.

Rehabilitation:

A cast or splint will need to be worn while the scaphoid fracture is healing. This may be for as long as six months. During this period of healing,

  •  Avoid heavy lifting, carrying, pushing, pulling or throwing with the injured arm
  • Do not participate in contact sports
  • Do not climb ladders or trees
  • Avoid activities with a risk of falling onto hand (for example, inline skating, jumping on a trampoline)

Some people have stiffness in the wrist after scaphoid fractures. This is more common when a cast was needed for a long time or when surgery was done through a long incision. Hand therapy may be recommended to help regain the motion and strength in the wrist. Even with therapy, some people do not recover the same motion and strength in their wrists that they had before the injury.