Scaphoid fracture / scaphoid fracture

• Classification of the scaphoid fracture

Synonyms in a broader sense

• Scaphoid fracture
• Fracture of the scaphoid bone
• Fracture of the scaphoid (formerly navicular bone)
• Scaphoid pseudarthrosis
• Carpal fracture
• Scaphoid pseudarthrosis
• Hand injury

Definition of a scaphoid fracture

Of the Scaphoid fracture is the most common wrist fracture. Usually the scaphoid bone (os scaphoideum) ruptures in a fall on the extended one wrist.

Of the Scaphoid fracture can be difficult to diagnose initially. If there is no therapy, the fracture usually does not heal and so-called scaphoid pseudarthrosis develops.

anatomy

The Scaphoid (Scaphoid bone, earlier Navicular bone) is on the thumb side in the first row of carpal roots. It is one of the most important Carpal bones. It forms with that Moon leg (Lunate bone) and the spoke (radius) the wrist. The scaphoid bone has a special blood flow. The blood flow is from the distal, i.e. away from the wrist, to the proximal direction (close to the wrist). Therefore the proximal third of the navicular bone is most critically supplied with blood. See more anatomy at Carpal.

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Epidemiology

The typical age is between 20 and 30 years of age. The gender ratio is male / female 5: 1. Overall, the scaphoid fracture affects about 2% of all fractures.

Symptoms

The typical mechanism of an accident is a fall on the outstretched wrist. To a Scaphoid fracture Great forces are necessary to suffer. Theoretical calculations suggest a force of 200 - 400 kg to cause a scaphoid fracture. The navicular bone is pinched between the spoke and the second row of carpal roots and breaks. Sometimes the scaphoid bone fractures and is not noticed. A second fall now causes complaints in the area of ​​the scaphoid bone and the X-ray shows the old scaphoid fracture.

Pain in a scaphoid fracture is typically reported in the area of ​​the wrist on the thumb side. A print in the so-called Snuffbox is reported as painful, as is the thumb compression test.

In some cases, the Symptoms of complaints are very mild fail.

introduction

The scaphoid fracture is classified in two ways:

• with regard to the localization
• regarding the Fracture course

The scaphoid bone is divided into three thirds.

5% of all fractures affect the third distal from the wrist (distal third), 80% affect the middle third and approx. 15% affect the third near the wrist (proximal third). Due to the blood circulation situation, proximal fractures have the worst prognosis with regard to fracture healing.

A distinction is made between horizontal, transversal and vertically oblique breaks from the course of the break.

Classification of the scaphoid fracture

1. Breakage of the distal part
2. Break of the middle part
3. Rupture of the proximal part
4. Oblique break
5. Transverse fracture
6. Transverse-transverse break

diagnosis

The first measure to be taken when a scaphoid fracture is suspected is this X-ray image of the scaphoid in four levels (scaphoid quartet). If a scaphoid fracture cannot initially be detected, but the clinical symptoms indicate a scaphoid fracture, the X-ray images can be repeated after 10-14 days.

In order to gain further information, a CT (Computed tomography) of the wrist can be useful. The course of the fracture can be precisely assessed on the CT.

In one MRI of the hand (Magnetic resonance tomography of the hand), the bony structures cannot be assessed as well as in a computer tomography. MRI has advantages with regard to the assessment of ligament structures. In the case of a fresh break, reactive water retention (Bone bruise) in the MRI.

X-ray wrist

1. Scaphoid bone (os scaphoideum)
2. Moon bone (os lunatum)
3. Pea bone (os pisiforme)
4. Triangular bone (os triquetum)
5. Hook bone (os hamatum)
6. Head bone (os capitatum)
7. small polygonal bone (os trapezoidum)
8. large polygonal bone (os trapezium)

Compared to the image above, the image on the right is an MRI image.

The red arrow points to the navicular bone (yellow). The red-brown area shows a spot that is strongly colored when contrast agent is administered, as a sign of increased water retention. This can also be referred to as a bump in the bone and can only be seen on an MRI. It is evidence of an accident that has taken place.

A Skeleton graph shows after one week a significantly increased bone metabolism in the area of ​​the scaphoid bone within the framework of fracture healing.

In summary, computed tomography (CT), magnetic resonance tomography (MRT) and skeletal scintigraphy are diagnostic procedures that are only used in exceptional cases to confirm the diagnosis Scaphoid fracture not to be overlooked.

Therapy of a scaphoid fracture

The therapy one Scaphoid fracture depends on the exact location of the break.
Depending on this, the therapy is also differently difficult: Due to the anatomical conditions, the blood supply to the scaphoid bone is remote from the body - i.e. from the fingers instead of coming from the trunk, as is usual - fractures of the third of the scaphoid near the fingers heal much faster than fractures of the body-hugging third.

In any case, however, a healing time of over 6 weeks can be assumed, usually in the range 8-12 weeks. The wrist and forearm are fixed with a plaster splint for this period. Since fractures in the extremities are considered to be particularly restrictive in everyday life, there are various ways to shorten the duration of therapy:

Using the so-called Herbert screw - A double-threaded screw could fix the fragmented parts of the navicular bone against each other. It is a special implant that was specially developed for treating scaphoid fractures in the 1970s. One end of the screw is screwed into the part near the body and one end into the part of the fractured navicular bone remote from the body.
Since the thread close to the body has a smaller pitch than the thread distant from the body, the distal scaphoid bone fragment is screwed onto the near body. Due to the pressure that now acts on the two fragments (also called interfragmentary compression), the healing process is accelerated. The Herbert screw has no head and is completely buried in the bone. It is usually inserted through a small incision on the inside of the wrist. Their great advantage is that they noticeably shorten the duration of the therapy: the patient has to wear the plaster of paris for significantly less time and therefore has to deal with restrictions less long. If the scaphoid fracture is distant from the body, it is usually only necessary to immobilize it for two weeks, and in the case of a fracture close to the body, only two to four weeks. If the therapy option is chosen without the Herbert screw, other complications such as muscle relaxation and joint stiffening should also be considered if the patient is immobilized for up to twelve weeks. Since the joint can no longer be moved for such a long period of time, the supplying muscles consistently decrease in mass. It can also lead to calcification and restricted mobility. After a 12-week period of immobilization, you should also consider physiotherapy or rehab, which follow the actual therapy of the scaphoid fracture as consecutive forms of therapy.

Treat the scaphoid fracture with a splint

A splint is - as the name suggests - necessary for splinting the scaphoid fracture. This must be done, otherwise there is a risk that the bone grows crookedly together, resulting in a permanent malalignment that cannot be easily reversed.
In addition to restricted movement, it can also result in permanent Tendons- and Muscle shortening, Nerve compressions and Loss of function up to Stiffening of the wrist result.
There are different types of splints, which mostly only differ in their type and material, but not in their function.The classic plaster splint is usually put on in a hospital and consists of a fast-hardening plaster of paris which, after contact with water, forms a solid framework around the fracture within 10 minutes. The disadvantage here is that it cannot be removed for washing and has to be cut open to change, i.e. it cannot be reused. Therefore, others have changed over the past few years Rail systems with Velcro fasteners established, which, however, always run the risk of misuse.

If an awkward movement is made while the splint is too loose or not seated at all, the unstable bone healing can be damaged and the fracture recurrent. On the other hand, these types of splints are more comfortable to wear and easier to change.

Healing of the scaphoid fracture

At a Scaphoid fracturethat is discovered in good time and treated appropriately, sooner or later a complete cure can be assumed. The prognosis of uncomplicated fractures is usually very good.
After about 12-week immobilization of the forearm and wrist with a cast, the fracture is in most cases completely healed.
If the navicular bone is broken very close to the wrist, an operation with a screw connection of the navicular bone usually has to be performed.
The original mobility in wrist is not yet restored at the time the cast is removed or directly after the operation. However, this is done using a consistent physiotherapy and regained some patience after a while.
Unfortunately, healing the scaphoid conservatively with plaster of paris or surgically is prone to complications.
You should therefore also read more extensive information on this topic at: Healing of the scaphoid fracture

How long does it take to heal a scaphoid bone fracture?

Depending on the type, location and therapeutic treatment of the scaphoid fracture, the duration of the therapy can vary between two and twelve weeks vary. Scaphoid fractures in the wrist-near two scaphoid thirds are particularly difficult. On the other hand, there are fractures of the third close to the finger, which usually heal faster.

Conservative care is provided by means of Plaster splint is for a fracture close to the finger with a healing time of 6-8 weeks to be expected. The more complicated two-thirds near the wrist usually only heal after 10-12 weeks of immobilization. In the case of an operative supply using Herbert screw and interfragmentary compression there are also differences in duration.
Scaphoid fractures close to the fingers usually only need to be immobilized for 2 weeks after the operation using a cast. Fractures near the wrist take two to four weeks. How long it takes to heal the scaphoid fracture, of course, also depends on the age and general condition of the patient. It should also be borne in mind that after a 12-week immobilization, follow-up care by means of physiotherapy and / or rehab may be necessary, as that joint has not been moved for a very long time!
You should therefore also read more extensive information on this topic at: Healing of the scaphoid fracture

In addition to the restricted range of motion (which usually results directly from the immobilization of the muscles and joints and not from the fracture itself), there may be other residual complaints after conservative treatment. These include, among other things Swelling, Numbness in arm and hand and / or a raised one Weather sensitivity.

Even after a surgery certain complaints can occur. Because of the fact that during the procedure in the forearm annoy can be irritated, it can also be here too Tingling or numbness the affected areas. These symptoms then disappear completely within a few months, but ultimately also in almost everyone, so that the wrist is just as functional again as it was before the accident.

From time to time, however, it can also happen that the healing process is rather unfavorable. The risk of this is especially high if there is a small piece of bone blasted off which cannot be supplied with sufficient blood and thereby slows down the healing process and makes it more difficult, or if a scaphoid bone fracture takes a long time undetected and therefore untreated remains. Then in some cases one forms Pseudarthrosis of the scaphoid. This means that the bone fragments will not grow back together properly. That then ultimately leads to complaints that one arthrosis resemble. Bone rubs on bone, causing the patient Pain prepares and becomes a restricted agility leads in the joint. In such a case, the indication for a (further) surgical intervention given to prevent the symptoms from becoming chronic and the hand no longer being used properly.

Plaster of paris for a scaphoid fracture

At a Scaphoid fracture surgical treatment is not always necessary. If possible, try one surgery to bypass. This can usually be tried safely with such fractions that are right fresh, stable and not postponed are. The classic variant of conservative therapy is putting on a Plaster or plastic bandage and the resulting immobilization of the forearm and wrist.

In most cases this cast will extend over the entire forearm and also includes that thumb with a. The wrist, thumb saddle joint and metacarpophalangeal joint are fixed so that they cannot move and the bone can heal together again without the risk of certain pieces slipping and the wrist growing back together crookedly. The Thumb joint and all Finger joints however, they are released so that they can remain mobile.
A cast that goes beyond the elbow is seldom put on, but this is a controversial procedure among doctors.

How long the cast has to be worn depends on the extent of the injury. On average, it is believed that the wrist is sufficient for about 12 weeks immobilize. When the plaster of paris is removed, the patient should be aware that, ideally, the scaphoid fracture has healed completely, but that the hand is still not fully operational again because it has not been moved at all for several weeks. For this reason, the increase in agility and force be done slowly step by step. Warm Hand baths are used in which the hand can be moved in all directions without great stress. It is often advisable to have a physiotherapy to be carried out under the guidance of a doctor or physiotherapist. Should be with certain movements Pain occur, it should be interpreted as a serious warning signal from the body, meaning that it is probably too early for this movement.

In addition to the plaster cast, various Painkiller from the antirheumatic group of forms (non-steroidal anti-inflammatory drugs, NSAIDs) such as Voltaren or Ibuprofen can be used. However, this should only be done after consulting a doctor.

Duration of healing

The time it takes to fully heal depends on the extent of the fracture. As a rule, however, it can be stated that fractures of the scaphoid bone and the carpal bones as a whole are often due to poor blood supply heal slowlyn. The location of the fracture in the navicular bone also determines the healing time. That leads to that, especially in the Conservative treatment, immobilization in a cast for up to 12 weeks must be done. If the half of the navicular bone that is closer to the wrist is affected, immobilization in the cast is particularly long. In the case of fractures further down, 6 weeks are sometimes sufficient. On average, exposure is possible again after 10 weeks. Follow-up treatment through further immobilization is, however, an advantage. Complete healing with maximum resilience is often only achieved after six months.

If conservative therapy does not bring the desired success after many weeks, the fracture must be treated with an operation. After this Fixation of the bone components with screws takes a renewed healing for another 10-12 weeks. At least one x-ray check should be carried out every 6 weeks to check the progress of the therapy.