Carpal fractures and dislocations
Carpal fractures occur usually either after a fall on an outstretched hand or secondary to a direct blow. The most common carpal bone fracture is that of the scaphoid, and this is also the most important one as it both has a poor blood supply and, if missed, will go on to early onset irreversible wrist arthritis with dire consequences.
Patients with scaphoid fractures present with radial sided wrist pain and are exquisitely tender in the ‘anatomical snuff box’, just distal to the wrist on the thumb side. It is important to maintain a high index of suspicion as some of these fractures will not be visible on Xray, even with specialist scaphoid views. In premier centres internationally, the acute scaphoid fracture management pathway includes an MRI as this is diagnostic of the injury immediately.
The blood supply is more tenuous more proximally on the scaphoid, so the closer the fracture is to the proximal pole, the greater the chance of the fracture interrupting the blood supply and that area dying. The diagnosis is usually made on clinical exam and Xray findings, but if there is a high index of suspicion and the Xray does not show a fracture, an MRI is required. In more chronic cases a CT is requested in order to accurately assess the injury.
- Management
All scaphoid fractures should be managed by a specialist
Non-operative
Absolutely non-displaced scaphoid fractures may be treated in a cast, usually for 8-12 weeks as the scaphoid is slow to heal due to its poor blood supply. This may be cumbersome for a patient and literature now advocates compression screw fixation in even non-displaced scaphoid fractures, as they heal quicker and the patient or sportsman/woman may get back to their work/activities much quicker.
Operative
All displaced fractures (more than 1mm) should be treated surgically with either percutaneous screw fixation or an open reduction and internal fixation.
Chronic scaphoid fractures are usually managed with a reduction, additional bone graft and screw fixation to reorient and heal the fracture.
Other carpal bone fractures
Any of the remaining 7 carpal bones may be fractured and each is treated on its merit, based on the presence of an open injury, the degree of displacement of the fracture and its involvement of the surrounding joints. A notable injury that sometimes occurs in golfers or racquet sports is a fracture of the hook of the hamate bone, which presents as deep pain in the palm of the hand, following striking a ball, turf, tree, the golf bag or other objects, never in frustration!
Conditions Managed
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