Carpal fractures account for many hand/wrist fractures. The most common carpal fracture involves the scaphoid and the usual mechanism is a fall on the outstretched hand. As the patient’s pain may settle soon after the fall, he or she may not present to a clinician until sometime after the injury. The key examination finding is tenderness in the anatomical snuffbox. This may be accompanied by swelling and loss of grip strength. Snuffbox tenderness should be compared with the other wrist, as some degree of tenderness is normal. Swelling in the snuffbox should also be sought.
Clinical Features
- A more specific clinical test for scaphoid fracture is pain on axial compression of the thumb towards the radius or direct pressure on the scaphoid tuberosity with radial deviation of the wrist.
- Plain radiographs with special scaphoid views will usually demonstrate the fracture.
- If a scaphoid fracture is suspected clinically but the radiograph is normal, a fracture cannot be ruled out.
- MRI is an ideal, and increasingly used, diagnostic test for an acute injury; it may be a cost-effective routine investigation for scaphoid fractures in some settings.
- Bone scan also has excellent sensitivity for scaphoid fracture.
Note that it can take 24 hours for the injury to be revealed on MRI or bone scan. If these imaging modalities are not available, the wrist should be immobilized for 12 days as if fractures were present, and then the radiograph should be repeated. Note that scaphoid fracture is the most commonly missed fracture leading to litigation. If there is no bony damage, scapholunate instability should also be considered.
Treatment of Stable and Unstable Scaphoid Fractures
A stable scaphoid fracture should be immobilized for eight weeks in a scaphoid cast extending from the proximal forearm to, but not including, the interphalangeal joint of the thumb. Upon removing the cast, re-evaluate the fracture clinically and radiologically. As with all fractures, clinical union precedes radiological union and determines readiness to return to sport. Radiological union of the scaphoid should occur before finally discharging the patient.
Unstable or significantly displaced fractures require immediate percutaneous fixation or open reduction and internal fixation.
Complications of Scaphoid Fracture
- The blood supply to the scaphoid originates distally; flow to the proximal pole can be diminished, which can then be at risk of necrosis after a fracture.
- Scaphoid fractures have a risk of delayed union or non-union and, if there is clinical evidence of incomplete union when the cast is removed, the fracture should be immobilized for a further four to six weeks.
- Further immobilization beyond this time is unlikely to prove beneficial CT scan is the investigation choice to detect non-union, but MRI can be used if CT is not available.
- Contemporary treatment of non-union is the compression screw fixation.
Post-Immobilization Rehabilitation
- Successful treatment of a scaphoid fracture, the patient is invariably left with stiff wrist joint and wasted muscles.
- Mobilization and strengthening of the wrist and other stiff structures should begin immediately after cast removal.
- Post-fracture, it is prudent to ensure there has been no ligamentous involvement by using the clenched-fist radiograph or MR plus/minus arthroscopy if clinical suspicion is high.
- If the wrist is intact, the athlete may be able to return to certain activities using a protective device.
- Compression tubing worn under the protective splint reduces edema and improves comfort.
- Different sports have different rules about what constitutes an allowable protective cast.
If you are being affected by chronic pain then Come Instantly in Rehabilitation Centers. Accessible Physical Therapy Services provide fast recovery from accident, sports, work related injuries, lower back, neck, leg pain (sciatica), strains, sprains, fractures, arthritis, burns, amputations, stroke, multiple sclerosis, and conditions such as cerebral palsy, For More Information Call Now at: (301) 552-8700
No comments:
Post a Comment