Carpal Fractures Treatment & Management
- Author: Robert R Schenck, MD; Chief Editor: Harris Gellman, MD more...
The accepted indications for surgical intervention in the treatment of carpal fractures include the presence of an unstable or displaced fracture, an open fracture, and failure of nonoperative treatment with established nonunion. Treatment of carpal fractures has no absolute contraindications. The key to treatment is to obtain and maintain anatomic alignment with the most appropriate method.
Operative fracture repair has traditionally revolved around the use metal implants, including pins, plates, and screws. In most cases, this hardware is later removed, sometimes with an open procedure. The future of bone fixation may involve resorbable prosthetic implants. Most bioabsorbable implants are made of polymers that degrade slowly over time, eliminating the need for a second retrieval operation. Bioresorbable materials with mechanical properties comparable to those of traditional pins, plates, and screws are being investigated. These may perhaps provide an alternative approach to carpal fracture fixation.
Options for specific fractures
Scaphoid fractures are classified as fractures of the proximal pole, wrist, distal one third, or distal tubercle. They are then further categorized as stable or unstable. Stable fractures are nondisplaced and have minimal comminution, whereas unstable fractures are displaced and have considerable comminution. A standard series of radiographs, including those in the anteroposterior (AP), lateral, and oblique views, are necessary to evaluate a scaphoid fracture (see Workup).
A stable scaphoid fracture is usually treated with cast immobilization. On average, a period of 12 weeks is required for union of the scaphoid to occur. If radiographic evidence of scaphoid nonunion persists after 4 months of immobilization, operative intervention may be indicated.
Should a strong clinical suspicion be present, even in the presence of apparently normal radiographic findings, a possible scaphoid fracture should be diagnosed on the basis of the history and clinical findings. When a scaphoid fracture is suspected without radiographic confirmation, treatment consists of cast immobilization for 2-3 weeks followed by repeat radiographic examination. If plain radiographic findings are equivocal after 2 weeks, the scaphoid can be evaluated with comuted tomography (CT).
An unstable scaphoid fracture and scaphoid nonunion should be treated surgically with open reduction and internal fixation (ORIF; see the image below). The scaphoid is approached volarly through a longitudinal incision beginning several centimeters proximal to the flexion crease of the wrist. The incision is made along the tendon sheath of the flexor carpi radialis. It is then curved radially toward the trapezium. The sheath of the flexor carpi radialis is opened, and the tendon is retracted radially. The radioscaphocapitate ligament is identified and divided sharply in such a way that it can later be repaired. The scaphoid is located deep to this ligament.
With the fracture exposed, the appropriate procedure should be chosen. Repair may involve Kirschner-wire (K-wire) fixation, screw fixation, bone grafting, or a combination of these techniques.[24, 25]
After fixation is achieved, it should be confirmed intraoperatively with fluoroscopy to ensure full reduction. Postoperative immobilization is then provided for 6-12 weeks with application of a thumb spica cast.
Lunate fracture patterns are classified into the following four stages on the basis of radiographic findings:
Stage I demonstrates no significant radiographic changes
Stage II is characterized by the presence of some degree of bone fragmentation without evidence of collapse
Stage III shows fragmentation and collapse
Stage IV demonstrates evidence of fragmentation, collapse, and arthritis
Treatment of lunate fractures varies according to the stage of the disease. Most treatment options revolve around stress reduction, revascularization, or replacement of the lunate. Salvage procedures are reserved for advanced disease.
Treatment options for stage I include no treatment or immobilization. The remaining stages are surgically treated with a variety of techniques. In stages II and III, the treatment options are surgical and include stress reduction, revascularization, and lunate replacement. Stage IV is also treated surgically with salvage procedures, such as scaphocapitate arthrodesis, total wrist arthrodesis, or proximal row carpectomy.
Triquetral fractures are radiologically separated into peripheral chip fractures or body fractures. Standard AP, lateral, and oblique radiographs are usually sufficient for their diagnosis.
Triquetral chip fractures are treated symptomatically with 2-3 weeks of immobilization if discomfort becomes significant. Once symptoms resolve or become less significant, range-of-motion exercises can be initiated. Fractures of the body of the triquetrum require more significant attention. If the fracture is minimally displaced, it should be treated with cast immobilization for 4-6 weeks, with range-of-motion (ROM) exercises beginning after cast removal.
Displaced triquetral chip fractures that fail to unite after conservative immobilization are rarely symptomatic enough to warrant surgical excision. On the contrary, displaced fractures involving the body of the triquetrum should be surgically treated with either closed reduction and percutaneous pinning or ORIF.
The pisiform fracture patterns commonly include transverse body fractures, comminuted fractures, or avulsion fractures. Standard radiographs, including AP, lateral, and oblique views, are usually sufficient for diagnosis. Pisiform fractures are almost universally treated conservatively with cast immobilization for 6 weeks. ROM exercises should be initiated after cast removal.
Trapezial fractures involve either the body or the trapezial ridge. Fractures of the body are either comminuted or vertical in orientation. Trapezial ridge fractures have been separated into two types as follows:
Type I fractures occur through the base of the trapezial ridge
Type II fractures involve the tip of the trapezial ridge
Standard radiographs, including carpal tunnel views, may help in making the diagnosis.
Nondisplaced trapezial body fractures are treated conservatively with the application of a thumb spica cast for 6 weeks. Displaced trapezial body fractures require surgical attention. Both type I and type II trapezial ridge fractures are treated conservatively with closed reduction in a thumb spica cast for 6 weeks. Displaced trapezial fractures are approached volarly. Trapezial body fractures are treated with ORIF by using K-wire fixation. If symptoms persist despite conservative treatment, small type II fractures involving the trapezial ridge may be excised.
Capitate fractures are classified into the following two categories:
A fracture pattern known as scaphocapitate syndrome, consisting of a scaphoid wrist fracture and a proximal capitate fracture
An isolated capitate fracture
Plain radiography is usually sufficient to make the diagnosis. Isolated capitate fractures may be difficult to diagnose with standard plain radiography, and CT is often required to establish the diagnosis.
Nondisplaced capitate fractures should be treated with closed reduction and immobilization. Displaced capitate fractures require operative reduction and internal fixation. The capitate is usually approached dorsally. Alignment is typically achieved and maintained by using K-wire or screw fixation. If comminution is extensive, bone grafting may be performed concomitantly.
Fractures involving the hamate are separated into two categories as follows:
Hamate hook fractures
Hamate body fractures
AP, lateral, and oblique radiographs usually depict the fracture. Carpal tunnel views are useful in diagnosing hamate hook fractures, but CT may provide the most definitive findings.
Nondisplaced hamate hook fractures (see the image below) and nondisplaced hamate body fractures are both treated conservatively and immobilized with a cast for 6 weeks. ROM exercises are started when the cast is removed. Displaced hamate hook fractures and displaced hamate body fractures are treated surgically with ORIF. Hamate hook fractures are approached volarly. Hook fractures are surgically reduced, and alignment is maintained with K-wire fixation. In contrast, hamate body fractures are approached dorsally. Typically, K-wire fixation is used to maintain alignment.
Postoperative immobilization is maintrained for 8 weeks for hamate hook fractures, whereas hamate body fractures may heal after 6 weeks of immobilization.
The treating physician must carefully consider the patient's age and occupation and the nature of the injury before selecting the appropriate fixation method. Furthermore, obtaining written informed consent is imperative. This means that the patient understands the complexity of the injury and the estimated time required for healing. The operative risks and potential complications, including nonunion, risk of infection, and the need to later remove hardware (if indicated), should also be discussed. Thorough patient education cannot be overemphasized, because it is critical to the success of treatment.
With the upper extremity anesthetized, the arm is prepared and draped in the standard fashion. A pneumatic tourniquet on the upper arm is inflated to maintain a bloodless operative field. Depending on the nature and location of the fracture, a volar or dorsal approach may be used to expose the injury. Reduction may be achieved by using K-wires as joysticks. Fixation may proceed with either K-wires or a bone screw. Bone grafting may be considered for injuries with extensive comminution. Intraoperative fluoroscopy is used to determine the effectiveness of the reduction. After the wound is closed, a protective cast is then applied for immobilization.
Various postoperative management strategies exist. Bone healing after internal fixation may take 6-12 weeks and, in a few cases, longer. Postoperative cast immobilization is maintained until healing is confirmed radiographically or clinically. K-wires can be removed after radiographs show evidence of bony union. Mobilization is initiated once the fixation is deemed stable. Thereafter, ROM and strengthening exercises can be initiated with the supervision and guidance of a physical therapist.
Nonunion is the most common complication after scaphoid fracture treatment, and it may occur in as many as 5-10% of cases despite proper treatment. Over several years or longer, patients may then experience pain, instability, and eventual collapse that leads to intercarpal or radiocarpal arthritis. Observation alone has no role in the treatment of scaphoid nonunion, and all cases should be corrected surgically.[27, 28]
Most pisiform fractures heal with conservative measures. However, chronic pain at the pisotriquetral joint may persist as a result of pisotriquetral joint degenerative changes. Pisotriquetral arthrosis is suspected when pain symptoms persist after a period of immobilization. Pisiform excision is the accepted treatment for this condition.
The incidence of nonunion is higher with fractures involving the tip of the trapezial ridge than with fractures of the base of the trapezial ridge. The accepted treatment for painful nonunion of either type is excision, which is generally well tolerated.
Nonunion of the hamate hook is a potential complication after operative reduction and fixation. Excision is the accepted treatment for symptomatic hamate hook nonunion.
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