ACUTE SCAPHOID FRACTURES IN ATHLETES
– Written by Martin Clementson and Anders Björkman, Sweden
Scaphoid fractures are common in an active population and are notorious for being difficult both to diagnose and to treat. The potentially serious consequences of a non-united scaphoid fracture with progressive osteoarthritis and carpal collapse, so called SNAC (Scaphoid Non-union Advanced Collapse, has resulted in restrictive treatment protocols with long immobilization1. A majority of scaphoid fractures are, however, non-displaced and have a good prognosis and often require limited time of immobilization2. On the other hand, displaced and comminuted fractures may benefit from early surgical treatment. Thus, it is of great importance not only to diagnose these fractures when suspected, but also to classify them correctly to limit the risk of both over- and under-treatment. Choosing the optimal treatment is especially challenging in athletes, where the whish for a fast return to sports may be in conflict with the risks for complications in a longer perspective. When treating an athlete with a scaphoid fracture It is important to recognize that different sports place different demands on the hand and wrist. In addition, the possibilities to participate in different sports wearing a cast or orthosis wary depending on different regulations. Another issue that may affect treatment is when in the season the injury has occurred3,4.
The scaphoid is the most commonly fractured carpal bone with an incidence of 29-43 fractures / 100 000 persons/year5,6. In a military population an incidence of 121 / 100 000 person/years is reported7. A 1-year survey at the Methodist Sports Medicine Center, Indianapolis USA, found that scaphoid fractures accounted for 19% of all fractures. They found that especially football and basketball players were at risk8. 1% of college football athletes are estimated to sustain a scaphoid fracture8, and as high as 2% of snowboarders9.
Most common mechanism of injury is a fall on an outstretched hand10. Fractures in the middle third, the waist, of the bone accounts for approximately 2/3 of fractures, and 60-85% of these are non-displaced. Distal fractures represent 25%, while 5-10% occur at the proximal third2,11. The so called “Goalkeeper injury” deserves to be mentioned, it is a proximal fracture following a forced hyperextension when stopping a ball, typically in soccer or handball12.
All available systems for classification of scaphoid fractures are based on conventional radiographs. The most used system, Herbert’s classification, is based on expected fracture instability, where all bicortical fractures are considered unstable and candidates for internal fixation13,14. We find that this view might lead to overtreatment.
The Mayo classification, used in these guidelines, is based on fracture location, where the scaphoid is divided into thirds. It gives a simple morphological description which we find useful in a clinical setting15.
Posttraumatic radial wrist pain should always evoke the suspicion of a scaphoid fracture. The three most commonly used clinical test are: anatomical snuff box tenderness, scaphoid tubercle tenderness and pain on axial compression of the thumb. If all tests combined are positive the sensitivity has been reported to be 100% and the specificity 75%. Pain on axial compression of the thumb has been demonstrated to have the weakest diagnostic performance16,17.
When a scaphoid fracture is suspected a conventional wrist radiograph must always be supplemented with 3-4 special projections of the scaphoid. Nonetheless the sensitivity with conventional radiographs is not higher than 70%18. Radiographs are also poor for fracture classification19.
If a scaphoid fracture is suspected but not visible on radiographs, an early MRI is recommended. MRI has a sensitivity of 99-100% and has been shown to be cost-effective compared to immobilization and repeated radiographs20. In addition an MRI in a patient with radial sided wrist pain can detect also other injuries besides a scaphoid fracture21,22.
CT, with the possibility for reconstruction of the images in the long axis of the scaphoid, gives the best possibility to evaluate fracture displacement19, 23.
If a fracture is only detected on MRI, or is only visible as a hair thin line on radiographs, we do not perform a CT, but if the fracture is clearly visible on all projections, displacement and instability can be suspected and we recommend a CT for fracture classification4.
Increased displacement increases the risk for fracture instability. However, also non-displaced fractures can be unstable, for example non-displaced fractures with a small radial fragment, are often unstable24. (Figure 1)
Patients with suspected scaphoid fracture where the MRI turns out negative can be mobilized immediately. It is however of vital importance to clinically evaluate these patients for any signs of scapho-lunate, SL- ligament injury25. MRI can’t exclude ligament injury, and if a SL-injury is suspected an arthroscopy within 6 weeks after trauma should be performed26.
90% of non- or minimally displaced waist fractures (≤0.5mm) are healed after 6 weeks in a cast. Geoghegan et al. have demonstrated that it is possible to mobilize a non-displaced fracture already at 4 weeks, if a CT doesn’t oppose ongoing union27. Those that have not healed after 6 weeks often heal with additional 4 weeks immobilization2. (Figure 2) Randomized trials have shown that the thumb doesn’t have to be included in the immobilization28, 29. Commercial or custom made well-fitted braces can be an alternative facilitating return to sports already during the period of immobilization3. (Figure 3)
Generally, a waist fracture with a displacement >1mm has been considered unstable and thereby candidate for internal fixation15. We have previously demonstrated that fractures with a displacement < 1.5mm on CT united uneventfully in a cast, although with fixations times up to 14 weeks2. We advocate internal fixation for cases with ≥ 1.5mm fracture displacement30. Operative treatment should also be considered in cases of comminution (Figure 3), DISI-pattern instability, lateral intra-scaphoid angle > 35°, and for all fractures part of a peri-lunar injury. For the competitive athlete a displacement of 0.5-1.5mm is a relative indication for surgical treatment.
Surgical treatment of non- or minimally displaced waist fractures
For athletes, surgical treatment of non-displaced fractures is often recommended in order to have a faster return to sports31. Randomized trials have shown short-term advantage of operative treatment in form of a few weeks earlier return to work or sports32-34. However, internal fixation is associated with a higher complication rate in terms of protruding hardware, infection and scar related problems, and may be followed be an increased long-term risk for development of osteoarthritis35, 36. Most studies comparing conservative and surgical treatment have included their patients based on conventional radiographs which we know underestimate the displacement of the fracture19. Hence, the previous studies probably include a mix of nondisplaced and moderately displaced fractures. Also, most previous studies have had long periods of immobilization for their conservatively treated patients. With the protocol we present here, with CT based classification and CT verified union, it is possible to sort out the true nondisplaced fractures with a better accuracy, and to shorten the period of immobilization for the conservative treatment. This probably makes the difference in time to union between surgical and conservative treatment of nondisplaced fractures even less. The benefits of surgical treatment of a minimally displaced fracture for most recreational athletes are small and do not, in our opinion, justify the risk. For the professional athlete who can’t compete with a brace, each week is important, and surgery can be considered. Surgical risks have to be taken in account, but also where in the season the injury occurred and the schedule of any coming games or tournaments4. Not even surgical treatment allows for immediate return to play3, 37, and although surgically treated patients can be mobilized earlier there are indications that conservatively treated patients may have a better mobility in a long term perspective35, 36.
Fractures in the proximal third of the scaphoid are often unstable which, in combination with a tenuous blood supply, increases the risk for delayed-, and non- union. Conservative treatment has been reported to result in a non-union rate of 10 to 14% for non-displaced fractures and as high as 50% for displaced fractures38. A distinction between non-displaced and displaced fracture is crucial, and we recommend CT investigation for all proximal fracture and internal fixation if displacement is found. However, based on CT, non-displaced fractures without signs of instability and not being part of a high energy trauma can be considered for conservative treatment, but with prolonged immobilization for 8 to 10 weeks39. (Figure 4)
The distal third of the scaphoid is well vascularized and fractures in this part of the scaphoid are often non- or minimally displaced and heal uneventful with conservative management40. An avulsion of the radio-volar tip of the tuberosity with non- or minimal articular involvement is the most common fracture type and accounts for more than 50% of all distal fractures41, 42. These fractures are sufficiently treated with 4 weeks immobilisation in a short arm cast or orthosis31. The second most common fracture type of the distal scaphoid is an intra-articular fracture in the radial half of the joint surface caused by compression or shearing forces through the trapezium. A prolonged immobilization for 4 to 6 weeks is recommended. In rare cases, a comminute fracture pattern which involves the entire articular surface of the distal scaphoid is found. In such cases, we recommend a short arm cast with immobilisation of the thumb for 4 to 6 weeks. (Figure 5)
From radiographs it can be difficult to assess displacement and congruency of the distal articular surface. CT is therefore of value if fracture displacement is suspected. If severe displacement is found, operative treatment may be considered.
For waist fractures a volar approach is generally preferred43.
For moderately displaced fractures we recommend a percutaneous retrograde fixation. This leaves the cartilage of the proximal pole undamaged. Reduction of the fracture is often accomplished by extension and ulnar deviation of the wrist.
In cases with severe dislocation or instability, an open technique can be necessary. The volar approach gives an excellent access to the bone facilitating fixation and makes fracture reduction easier than when using a dorsal approach, where you have to flex the wrist, and also risk injuring the dorsal blood supply. When a volar approach is used it is important to meticulously suture the radio-carpal ligaments to avoid future instability44.
Arthroscopic assisted retrograde fixation is an optional alternative for waist fractures. It has the advantages of direct visualization and control of the fracture and reduction, and to verify that the screw does not penetrate the proximal cortex. It also enables direct evaluation of any concomitant ligament injury. Especially in severe displaced fractures, arthroscopic fixation can be technically demanding and should only be performed by surgeons experienced in wrist arthroscopy.
Fixation with two screws antegradely has been suggested as this gives additional stability to the fixation in an experimental setting45, 46. Whether this extra stability is clinically relevant is debatable. Yildirim with colleagues still recommend a careful postoperative regime and full axial load non sooner than 6 months postoperative. Given the small size of the scaphoid bone, a two-screw technique can be hazardous with a risk for splitting the bone, and it leaves a relatively large defect in the proximal pole cartilage. It also leaves less cross-sectional area for the bone to unite. No screws can hold the fracture unless the bone unites, which, in our opinion, can be achieved with one, or none, screw as well.
For proximal fractures, a volar approach may displace the proximal fragment, and it is also difficult to securely engage the proximal fragment with the leading threads of the compression screw when inserted in the distal-to-proximal direction. Therefore, a dorsal approach is generally recommended47. At our institution, we prefer a mini-open technique to visualize the fracture line as it allows a more precise screw placement being as perpendicular to the fracture plane as possible. Small screw diameters such as 1.7 or 1.9 mm should be used to minimize the impact on the proximal cartilage.
ASSESSMENT OF FRACTURE UNION
Bone union should always be assessed by combining clinical investigation of the wrist together with radiological findings. Persistent pain over the fracture site may indicate incomplete or delayed union but may also relate to an associated injury. Still, long-term anatomical snuff box soreness after a scaphoid fracture is not uncommon48.
Scaphoid fractures unite by primary bone healing which is difficult to visualize and evaluate on radiographs49. CT with its higher spatial resolution and possibilities to reconstruct images in the longitudinal axis of the scaphoid has been demonstrated more reliable to assess bone union50. At our institution, using 1 or 2 mm thick reconstructions in the coronal and sagittal planes along the longitudinal axis of the scaphoid, we define bone union as continuous trabecular bridging over more than 50% of the cross-section of the fracture site.
With CT to evaluate bone union, 90% of all non-, or minimal displaced scaphoid waist fractures can be mobilized at 4-6 weeks2, 27. However, if bone union is < 50%, but no adverse features are identified such as increased fracture displacement, fracture line sclerosis or cystic changes, then cast immobilization should be prolonged for 4 weeks. With doubtful or delayed union at 14 weeks a change in treatment strategy towards internal fixation is recommended.
We believe, that if the patient is more or less pain free and CT demonstrates substantial bone union, no further radiological examination is needed. However, in those cases where pain in the scaphoid area has not evidently diminished, and CT despite bone contact leaves an uncertainty about trabecular bridging the fracture site, a repeat CT after 3 to 6 months should be considered.
RETURN TO SPORT
When an athlete can be allowed to return to their sport depends on many factors and scientific guidance is unfortunately sparse51.
In many sports where wrist movement is not primarily involved, such as soccer or some track and field sports, it is possible to return while in a cast or well fitted brace52, 53. The National Football League in USA allows players to compete with splints if they are padded. A similar instruction exists for the National Basketball Association. FIFA regulations (soccer) states that it is up to the judgement of the referee to ensure that the protective device does not impose a risk for other players3.
A retrospective follow-up of both surgical and non-surgical treatment of waist fractures in athletes showed comparable union rates and early return to sports in the conservatively treated group using a playing cast8.
In sports with more demand on wrist function, such as basketball, hockey and tennis, union should be confirmed with CT before allowing gradually return to full active level. This applies to surgically treated patients as well. In addition, strength and range of motion should have reach 80-90% of the uninjured hand before unrestricted return to full activity is recommended4, 54.
In sports requiring a very high load of wrist strength or motion, such as weightlifting, gymnastics and boxing, we recommend a minimum period of 6-12 weeks after union is confirmed before full activity level, for allowing the fracture to thoroughly consolidate4, 37.
Scaphoid fractures, when united, usually have a good long-term outcome and most patients report a normal hand function35, 36. Having sustained a scaphoid fracture has been shown not to diminish the participation in the National Football League55.
1. For diagnosis, in cases of suspected scaphoid fracture where the initial radiographs are negative, a supplementary MRI should be obtained.
2. Fracture classification, assessment of dislocation as well as evaluation of fracture healing is best done on CT.
3. After adequate conservative management, union is achieved at 6 weeks for approximately 90% of non- or minimally displaced (≤ 0.5mm) scaphoid waist fractures.
4. Most athletes don’t necessarily benefit from surgical fixation of nondisplaced waist fractures.
5. Scaphoid waist fractures with moderate displacement (0.5mm - ≤ 1.5mm) can be treated conservatively. But a risk for prolonged cast immobilization, about 8 to 10 weeks, makes it a relative indication for surgery in athletes.
6. Internal fixation is recommended for all scaphoid waist fractures with dislocation >1,5mm.
7. Distal scaphoid fractures can be treated conservatively. The majority heal uneventfully after 4-6weeks of immobilization, depending on fracture type.
8. In general, proximal scaphoid fractures should be treated with internal fixation.
9. When deciding the optimal treatment for a scaphoid fracture in an athlete you must take in consideration not only fracture specific factors, but also the type of sport, the level of the athlete, when in the season the injury has occurred and regulations concerning the possibility to return to the sport with a playing cast.
Martin Clementson M.D., Ph.D.
Institution of Translational Medicine, University of Lund
Section for Specialised Surgery, Department of Hand Surgery, Skåne University Hospital SUS
Anders Björkman M.D., Ph.D.
Professor and Senior Consultant in Hand Surgery
Department of Hand Surgery, Institute of Clinical Sciences
Sahlgrenska Academy, University of Gothenburg
Sahlgrenska University Hospital
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