Introduction

• Hand and wrist injuries account for 3% to 9% of all athletic injuries; these are being seen more frequently as recreational and competitive sports participation increases.1,2

• The human wrist consists of eight carpal bones arranged in two rows, stabilized by numerous volar and dorsal ligaments that function synergistically to provide stability and pain-free range of motion.

• Most athletic activities involve the extremes of wrist range of motion. Therefore, physicians must identify carpal injuries early in order to prevent long-term functional decline and select operative procedures, when appropriate, that do not limit the required sport-specific wrist range of motion.

• Carpal fractures are often misdiagnosed as "wrist sprains" leading to delays in diagnosis and treatment. These delays may limit the options for both conservative and operative interventions leading to (1) longer treatment protocols, (2) more significant operative procedures, (3) extended loss of sports participation, and (4) permanent functional decline with decreased athletic performance.

• Scaphoid fractures account for the majority of carpal fractures. Hook of the hamate fractures occur with increased frequency in stick-handling sports. Appropriate diagnosis requires a high index of suspicion for each fracture type with expeditious treatment optimizing long-term outcomes. Newer percutaneous and arthroscopically assisted procedures allow improved outcomes and early return to play due to less operative morbidity.

previous scaphoid nonunion. It is critical that these two diagnoses remain separate with appropriate treatment initiated for each specific diagnosis.

Physical examination of the entire upper extremity is undertaken to diagnose concomitant upper extremity injuries and establish the clinical suspicion for a scaphoid fracture. The athlete will often demonstrate painful wrist motion, radial-side swelling, and decreased grip strength. Focused examination of the involved wrist helps the athlete define the location and quality of the pain and allows the examiner to grade the current functional impact of the injury with respect to wrist strength and range of motion. Tenderness localized to the anatomic snuff box and pain with wrist dorsiflexion/radial deviation increase the clinical suspicion for a scaphoid fracture.

Radiographic evaluation confirms the diagnosis and defines the fracture configuration and geometry. Routine radiographs of the wrist include posteroanterior, true lateral, and scaphoid (30 degrees of supination and ulnar deviation) views.6,8 These initial images identify established fracture nonunions, displaced/angu-lated fractures, and concomitant wrist injuries. However, plain radiographs are notorious for missing acute nondisplaced scaphoid fractures and are often the cause for delay in diagnosis and treatment (Fig. 39-1). Seven percent of patients with clinical evidence of scaphoid injury and negative plain radiographs will have a scaphoid fracture.9 Therefore, further imaging is often required to establish the diagnosis. Bone scinti-graphy has been the gold standard for evaluating patients with clinical suspicion of fracture and no radiographic evidence of injury.8,9 All fractures should have increased tracer uptake at 3 days after injury and most are apparent within the initial 24 hours.8 However, false positives are expected given this modality's high sensitivity but relatively low specificity.9 Therefore, magnetic resonance imaging is gaining favor as a first-line imaging modality in the diagnosis of occult scaphoid fractures.9 Studies have shown equivalent sensitivity with superior specificity compared to bone scintigraphy.9 Magnetic resonance imaging has the additional advantages of (1) excellent soft-tissue evaluation including the scapholunate ligament,8 (2) ability to assess proximal pole vascularity, (3) identification of fracture location and configuration, (4) no radiation exposure, and (5) speed of examination.9

Radiographs further establish fracture location (distal third, waist, or proximal third) and define stability based on

Figure 39-1 A, Occult scaphoid fracture: Initial presentation. B, Scaphoid waist fracture: Two-week follow-up (arrow).

radiographic evidence of fracture displacement and/or angula-tion. Computed tomography is used when fracture displacement remains uncertain given its superior definition of cortical integrity and bony anatomy.6,8 By definition, displaced scaphoid fractures have at least 1 mm of cortical offset and an increased intrascaphoid angle greater than 30 degrees.1,2,6 Therefore, a high index of clinical suspicion, thorough history and physical examination, and appropriate imaging allow early identification of scaphoid injuries and accurate determination of fracture location, geometry, and time from injury to presentation.

Treatment Options

Management of acute scaphoid fractures is guided by fracture location, displacement, and time from injury to presentation.1,2,6 Athletes require additional consideration as to sport and position as well as the athlete's specific wishes regarding return to play. Restoring precise anatomy and achieving solid fracture union are the primary goals of any treatment.

The importance of restoring precise anatomy cannot be overstated. Displacement is the hallmark of unstable fractures. Several studies evaluating closed treatment of fractures with greater than 1 mm of cortical offset have revealed nonunion rates ranging from 46% to 92%.10 Fracture nonunion and/or malunion often lead to painful wrist instability and debilitating degenerative arthritis.3 Therefore, we perform open reduction and internal fixation on all acute displaced scaphoid fractures. Alternatively, arthroscopic reduction with percutaneous fixation may be employed.11

The treatment of nondisplaced scaphoid fractures is more controversial. Historically, cast immobilization was initiated for all nondisplaced fractures, with 6 weeks in a long-arm cast followed by an additional 6 weeks or longer in a short-arm thumb spica cast.7,12,13 The prolonged periods of immobilization coupled with the continued risk of fracture nonunion spurred the development of more aggressive treatment regimens. Today, the selection of an appropriate treatment algorithm is guided by fracture location and individualized to the patient's vocational, recreational, and athletic demands.

Distal third fractures of the scaphoid occur infrequently and involve the tuberosity in isolation or the entire distal third of the bone. Fractures occurring in this location maintain an adequate blood supply and have a high propensity to heal.1,7 Successful union is most often achieved with 6 weeks of immobilization in a short-arm thumb spica cast.7

Proximal third fractures account for 20% of scaphoid fractures and are plagued by higher rates of nonunion and avascular necrosis. Casting has been the standard of care, often requiring as long as 6 months of strict immobilization to achieve successful healing.1,13 Considerable disagreement as to the appropriate type and duration of immobilization continues.6,14 Current recommendations consist of 6 weeks in a long-arm thumb spica cast followed by immobilization in a short-arm thumb spica cast until clinical and radiographic fracture union.2 Few patients can afford such lengthy periods of immobilization. Prolonged casting often leads to significant muscle atrophy, stiffness, and contractures requiring extended periods of rehabilitation prior to return to work or sport.1 Therefore, we recommend consideration of early operative intervention for all proximal scaphoid fractures occurring in active individuals. We use a dorsal approach and perform our fixation either open or percutaneously based on the need for fracture reduction.

The vast majority of scaphoid fractures (70% to 80%) are nondisplaced fractures through the anatomic waist.1 Treatment

Figure 39-1 A, Occult scaphoid fracture: Initial presentation. B, Scaphoid waist fracture: Two-week follow-up (arrow).

options include (1) cast immobilization until radiographic union, (2) cast treatment plus application of playing splints, or (3) immediate internal fixation.

Cast immobilization is an effective and appropriate treatment when initiated early for nondisplaced scaphoid waist fractures. Studies have shown 95% rates of union following 8 to10 weeks of cast immobilization initiated within 4 weeks of injury.12,15 Fractures showing no radiographic evidence of healing after 6 to 8 weeks of appropriate immobilization should be considered for internal fixation to minimize the risks of both prolonged casting and fracture nonunion.1,16 Athletes must be appropriately counseled regarding the anticipated 3 months out of competition prior to initiating cast immobilization. Few athletes are willing to undergo this prolonged regimen, and, thus, alternatives have been sought for nondisplaced scaphoid waist fractures in the athletic population.

Cast immobilization with the application of a playing splint and immediate return to competition have been described.2 The specific athletic event and the level of competition determine whether playing casts/splints are permitted. Review of this treatment regimen has revealed increased rates of fracture nonunion and subsequent operative intervention.2 Athletes must be informed of the increased risks with this treatment protocol, and we currently do not implement this as a preference in our practice.

Advances in surgical technique and internal fixation have revolutionized the operative repair of scaphoid fractures. Absolute indications for immediate internal fixation include displaced fractures, nonunions, and fractures associated with carpal insta-bility.1 Relative indications include delayed presentation (greater than 4 weeks), proximal pole fractures, and malunions.1 Immediate internal fixation for nondisplaced fractures of the scaphoid waist remains controversial, but this approach is gaining more widespread acceptance.1,2,6,13,16 Recent studies comparing immediate operative repair versus cast immobilization reveal equivalent rates of fracture healing with dramatically reduced times to return to work and sport.1,2,6,13,16 We advise our athletes about the risks and benefits of all treatment regimens and advocate immediate internal fixation of nondisplaced scaphoid waist fractures in those desiring an expeditious return to competition.

Surgery

Operative fixation of scaphoid fractures is increasing in popularity with advances in intraoperative imaging, surgical approaches/instrumentation, and trends toward less invasive surgical procedures. Currently, acute scaphoid fractures can be repaired via open volar or dorsal approaches, percutaneous techniques, or arthroscopically assisted procedures.1,6,11 Fracture location and geometry as well as surgeon skill and experience guide the appropriate selection for operative repair.

Common to all operative techniques is the use of biplanar fluoroscopy to confirm fracture reduction and appropriate guidewire/screw insertion as well as the use of headless compression screws specifically designed for scaphoid fixation. Precise restoration of anatomy and compression of the fracture surfaces are paramount to achieving successful healing. Appropriate screw placement requires critical evaluation. Biomechan-ical and clinical studies have shown superior loads to failure, stiffness, and strength with central screw placement resulting in decreased times to fracture union.16 Ideally, contact sport athletes are immobilized postoperatively in a short-arm thumb spica cast until radiographic confirmation of bony union, while noncontact athletes may be placed in a removable splint,

Figure 39-2 Dorsal, percutaneous, scaphoid stabilization. A, Placement of guidewire. B, Fluoroscopic image of starting point for insertion. C, Final guidewire placement.

Figure 39-2 Dorsal, percutaneous, scaphoid stabilization. A, Placement of guidewire. B, Fluoroscopic image of starting point for insertion. C, Final guidewire placement.

allowing immediate range-of-motion exercises and potentially earlier return to competition.

Minimally invasive techniques have been developed to reduce operative morbidity and expedite fracture healing and rehabilitation (Figs. 39-2 and 39-3). Both percutaneous and arthro-

scopic procedures are currently in practice.1,6,11,13 Cannulated, headless compression screws allow insertion via minimal incisions, and biplanar fluoroscopy confirms accurate, central screw placement. Both techniques are best suited for nondisplaced or minimally displaced scaphoid fractures.1,6 Athletes are immobilized in a postoperative cast and may immediately return to competition if permitted; alternatively, some must delay return until confirmed fracture healing and cast removal. Taras et al13 reported return to athletics averaging 5.4 weeks with successful union achieved in all patients undergoing percutaneous scaphoid fixation. These techniques are best reserved for surgeons experienced in wrist arthroscopy and operative scaphoid repair. Compromising accurate reduction and central screw placement, for the sake of a percutaneous approach, must be avoided.

Open reduction and internal fixation remains the treatment of choice for displaced, unstable scaphoid fractures.6 The operative approach is determined by fracture location. The volar approach preserves the vital dorsal blood supply and allows easy access to middle and distal third fractures. The dorsal approach provides exposure of proximal third fracture and is reserved for this indication as the vascular leash is maintained. Direct visualization of fracture reduction and guidewire placement is correlated with biplanar imaging to confirm anatomic reduction and central screw placement.

Figure 39-3 Volar, percutaneous, scaphoid stabilization. A, Placement of guidewire. B, Fluoroscopic image of volar starting point.

Figure 39-3 Volar, percutaneous, scaphoid stabilization. A, Placement of guidewire. B, Fluoroscopic image of volar starting point.

Technique: Volar Open Reduction/Internal Fixation

The volar approach to the wrist begins with a 4- to 5-cm curvilinear incision extending from the scaphoid tuberosity along the radial border of the flexor carpi radialis tendon. The flexor carpi radialis tendon sheath is exposed and longitudinally incised allowing ulnar retraction of the tendon. Commonly, the superficial palmar branch of the radial artery is encountered, requiring ligation. The volar capsule is obliquely incised exposing the radioscaphocapitate and long radiolunate ligaments. These ligaments are critical to wrist stability and are either partially divided or completely transected and tagged for later repair. The fracture is visualized and cleared of clot and debris. Preliminary reduction, usually by wrist extension, is achieved and fluoro-scopic imaging obtained to confirm reduction and correction of the "humpback" deformity. Careful scrutiny of the scapholunate angle on lateral fluoroscopy is critical. The scaphotrapezial joint is entered and 2 to 3 mm of volar trapezium excised to allow accurate guidewire and screw placement. A compression jig or free-hand technique is used to centrally place the guidewire. Biplanar imaging confirms accurate wire placement and a second Kirschner wire may be inserted to control rotation and displacement during drilling, tapping, and screw insertion. Screw placement/length and fracture reduction and stability are confirmed with biplanar imaging and both Kirschner wires removed (Fig. 39-4). The volar radiocarpal ligaments and capsule are reapproximated and repaired using 3-0 permanent figure-eight sutures. The wound is closed in layers and a sterile dressing is applied. A short-arm volar thumb spica splint is applied. The patient is seen at 1 week postoperatively for splint removal and application of a short-arm thumb spica cast.

Postoperative Rehabilitation

Immobilization is continued until radiographic confirmation of fracture healing. Computed tomography is the gold standard for defining fracture union and can be obtained on patients prior to discontinuation of immobilization. The average time to fracture union following operative repair ranges from 5 to 7 weeks.12,13 Therapy is instituted immediately following cast removal with emphasis on wrist and digital range of motion followed by strengthening.

Criteria for Return to Play

The athlete's return to play is individualized, dependent on progress in healing, sport, position, and level of competition. All

Figure 39-4 Postoperative radiographs: Percutaneous scaphoid stabilization. A, Scaphoid view. B, Oblique view.

scaphoid fractures must be protected with a cast or splint until radiographic confirmation of fracture healing.6 The goal of splint/cast immobilization is to limit wrist hyperextension upon potential impact. Noncontact sport athletes can immediately return to competition following stable internal fixation with a short-arm thumb spica cast/splint. Contact athletes and those undergoing conservative management should remain out of competition until confirmed fracture union. Athletes must demonstrate painless, full wrist range of motion and near normal strength prior to allowing unprotected athletic participation.

Results and Outcomes

Cast immobilization of a nondisplaced scaphoid fracture initiated within 4 weeks of injury has a greater than 90% chance of achieving fracture union.15 Conservative treatment of fractures with 1 mm or greater displacement is complicated by nonunion rates ranging from 46% to 92%.10 Immediate operative repair for both displaced/unstable fractures as well as nondisplaced scaphoid waist and proximal third fractures leads to fracture union rates exceeding 90%.2,12 Early diagnosis and treatment with anatomic reduction and appropriate immobilization optimize long-term results.

Complications

Scaphoid fracture nonunions and malunions alter carpal kinematics potentially leading to radiocarpal and midcarpal osteoarthritis.4 These degenerative changes often lead to chronic pain, limited motion, and diminished function.1,2,4,6 Athletes with symptomatic malunions and nonunions require thorough evaluation and consideration of scaphoid reconstruction. Athletes with an incidental finding of a scaphoid fracture nonunion and/or malunion present a treatment dilemma. The patient must understand the natural history of these clinical entities with either observation or operative intervention instituted at the conclusion of the season on an individualized basis.

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Cure Tennis Elbow Without Surgery

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