MISDIAGNOSED

Dr. Rehberg
13 March 13, 2016
ATEP 3750

SCAPHOID FRACTURE
Ameer Shihadeh
 Misdiagnosed Scaphoid Fracture 1

Abstract

The scaphoid is the most fractured carpal bone in the hand and the most complicated and

difficult to recover from. This injury typically is a result from a fall onto an outstretched hand.

The purpose of this study is to explain treatment methods and complications to this injury.

Casting and percutaneous fixation using a screw are the treatment measures that is being

described and compared. The case subject is a 20 year old male soccer player in the collegiate

level and has sustained a distal scaphoid fracture and had experienced both treatment methods

explained in this study. Results reveal that fixation had a better outcome on the athlete than

casting did, and the athlete had a successful return to play. After rehab was completed, the athlete

regained most of his ROM and strength. Casting showed no results after 6 weeks of

immobilization, but fixation resulted in full union and recovery after 6 weeks. The literature

discussed that fixation is a more beneficial approach to scaphoid fracture treatment because

mobilization of the joint, full ROM, and muscular strength is regained considerably quicker than

casting methods.

Key words Percutaneous fixation Casting Scaphoid Carpal Waist fracture -

Complications

Introduction

The scaphoid is the most common fractured carpal bone 1, and because it is avascular, the

union rate is low without medical intervention. If the fracture goes untreated, it can lead to

prolonged casting, carpal collapse, and degenerative arthritis. 2 The usual mechanism of injury is

falling on an outstretched hand. Typically, an injury to the scaphoid is not diagnosed as such, it is

frequently diagnosed as a wrist sprain. Treating a scaphoid fracture as a sprain and allowing the

least amount of time for a sprain to fully heal which is 6 weeks, can cause complications to a
 Misdiagnosed Scaphoid Fracture 2

scaphoid fracture. Early detection of a fracture is a key factor in a successful and rapid union of

the bone. This study will explain invasive and non-invasive methods of healing a scaphoid

fracture and the complications that occur with this injury.

Literature Review

The scaphoid is one of the hardest bones in the body to recover from after it has been

fractured. If misdiagnosed or unseen under radiographs, it can create scar tissue and develop

avascular necrosis over time if not treated.3 Because the scaphoid does not develop callus and is

composed of more than 80% of cartilage, an acute scaphoid fracture goes unnoticed under

radiographic images.3 The scaphoid is broken up into 3 waists: proximal, middle and distal. The

scaphoid becomes less vascular from proximal to distal. Depending on the fracture site, the union

rate is different due to the lack of blood supply that fracture site may receive. As a result,

intervention methods may differ as well.

Depending on the patient, their age, occupation, or if they are athletes, methods of

medical intervention may vary from non-operative treatment to percutaneous fixation. Casting

immobilizations yields 90% of union rates in scaphoid fractures, although, immobilization is

prolonged and can last up to at least 12 weeks.4 On the other hand, percutaneous fixation has a

quicker union time and allows for quick return of wrist movement.4 In more cases, orthopedist

would rather go the non-invasive method if the fracture has minimal displacement, and if the

injury is acute and has not been overseen for a period of time. A displacement fracture is defined

as the fracture gap being larger than 1mm, and a minimal displacement is a fracture with a gap

less than 1mm.3 In some instances where the patient is an athlete or needs to perform manual

labor, they may look into percutaneous fixation. Fixation will reduce the chances of patients
 Misdiagnosed Scaphoid Fracture 3

having a disruption in collagen homeostasis, which is what allows tendons to glide and the joint

capsule to stretch.4

The patient with this injury may have inflammation around the wrist and into the

phalanges. Pain usually occurs over the anatomical snuff box which is located directly over the

scaphoid, it is also present when the patient performs radial deviation and wrist flexion.5

Immediate care for this injury is ice, compression and immobilization, the patient should see a

physician and have radiographic images made of the wrist to rule out a fracture. As previously

stated, radiographic images may not show the fracture of the scaphoid if the injury is acute, that

is why follow-up radiographs should be taken. A fractured scaphoid is usually mistaken for a

wrist sprain. Once a fracture has been diagnosed, the patient then have the option for non-

invasive or invasive methods of healing.

Whether or not the scaphoid fracture has healed and has achieved full union via casting

or fixation, the wrist and hand has been immobilized for a number of weeks. As a result, stiffness

and lack of range of motion (ROM) may be present.5 Restoring ROM is crucial to obtain full

mobility of the hand and wrist, thus ROM exercises must begin as soon as the cast or splint has

been removed post-operation/treatment. Proprioception, muscular strength, endurance and power

exercises must follow up after normal ROM has been achieved. 5

Case Presentation

A 20 year old male soccer player at the collegiate level had sustained a right wrist injury

after falling onto an outstretch hand. The right hand was his dominant hand. The injury had

occurred during a practice in the preseason months of the sport. The athletic trainer (AT) on site

evaluated the injury and gave the impression that the injury may have been a wrist sprain. The

athlete was prescribed ice, and an ace bandage for compression, and was instructed to rest for a
 Misdiagnosed Scaphoid Fracture 4

few weeks until the pain had subsided. A few days have passed and the athletes whole hand,

including his fingers had severe swelling. The AT referred the athlete to his physician to get x-

rays done to rule out any possible fractures. When the athlete reported back to his AT, he stated

that the x-rays were negative for any fractures and was prescribed nonsteroidal anti-

inflammatory drugs (NSAIDs) for the swelling and pain. A few more days had passed after the

results were negative and the swelling had subsided. The athlete purchased a splint and was able

to function within normal limits, although was not able to perform any upper body strength

exercises like push-ups, and bench pressing. He also stated he had sharp pains turning door

knobs and turning the key in his car ignition.

6 to 7 weeks have passed since the initial injury, and the athlete was still experiencing

sharp pains. The athlete came in the athletic training room (ATR) for therapeutic modalities, but

the pain did not decrease. ROM was normal but sharp pains were present at the end ranges of

wrist extension and flexion, and radial and ulnar deviation. The athlete then took it upon himself

to have another x-ray done to have found that there was indeed a fracture in the distal waist of

the scaphoid. He was referred to an orthopedist, and was told that non-invasive method will be

done by using a short arm thumb spica cast for 6 weeks. The cast totally immobilized the hand

and wrist, and pronation and supination was limited. The athlete was cleared to play as long as

there was no physical contact involved.

After the 6 weeks, the athlete returned to have x-rays done to see if the fracture has

healed, the results showed that the fracture had not achieved union. The orthopedist suggest that

a few more months in the cast may be necessary. The athlete did not want to be in the cast for

much longer so the orthopedist suggested to get a second opinion from a hand specialist since he

was just a general orthopedist. The athlete went to a colleague of the orthopedist and he
 Misdiagnosed Scaphoid Fracture 5

explained to the athlete that surgical method should have been done based on the placement and

size of the fracture. The cast remained on until the surgery was scheduled. The hand specialist

explained that a pin was to be inserted, and a hallow screw was screwed in over the pin. Once the

screw has been put into place, the pin is to be pulled out.

The surgery was a success, the fracture gap was closed, but a fracture line was still

present. The hand specialist placed the athlete in a hard thumb spica splint, and is to remain in it

for 2 weeks. The hand specialist informed the athlete that scar tissue formed in between the

fracture which delayed the union of the bones. The athlete was instructed to ice and elevate the

hand to reduce the swelling that was caused after surgery. After the 2 weeks passed, the athlete

returned to the specialist to remove the stitches where the incision was made during the

operation. He was then placed back into a short arm thumb spica cast for an additional 4 weeks,

and was instructed to return for another x-ray. The athletes last x-ray revealed no fracture line

was present and the scaphoid had fully healed.

Finally the cast was removed and the athlete began his rehabilitation. The athlete was to

complete his rehabilitation at his universitys ATR. The AT caring for the athlete initiated a

passive stretching regimen to increase ROM. The AT would place the athletes arm on a table

with their hand hanging off the edge and would take them into either flexion or extension and

hold each stretch for 10 seconds and repeat. He was giving exercises like wall push-ups, wrist

curls with light weights, ulnar and radial deviation with a hammer, etc. The athlete was instructed

to perform stretches under warm waters, and was given paraffin that covered the hand

afterwards.
 Misdiagnosed Scaphoid Fracture 6

Results

After a total of 18 weeks after the initial injury, the athlete fully healed and returned to

play without further complications. A follow-up evaluation was given to the athlete to assess his

wrist strength which was back to normal and the athlete was able to lift heavy on his wrist. He

gain full ROM in flexion in comparison to his other hand, but lost 25o of extension. The athlete

gets his wrist tapped for additional support when exercising, lifting, and when on the field. Minor

pain is still present at the end ranges of motion in radial and ulnar deviation. The athlete could

not do push-ups, for his wrist could not flatten and support his weight due to the lack of ROM, a

sharp pain occurs when an attempt is made.

Because the buildup of scar tissue was discovered upon surgery, the hand surgeon stated

that he had to shave off that scar tissue for the bone to fuse. The scar tissue build up was caused

because the fracture gap was too large for the bone to union properly. 12 weeks were wasted, and

some avascular necrosis developed which caused some tissue to die, since there was a lack of

blood flow. The doctor stated to the athlete, if he had come to him right after the injury occurred,

the injury could have been healed in 6 weeks after surgery without any complications and major

stiffness. The athlete gained greater use of his left hand in the course of the 18 weeks.

The athlete sometimes complained of sudden aches that occurs from time to time. He

notices aches are most often present in rainy days or in cold weather as well. He found that

cracking his thumb is soothing. The doctor explained to him the possibility of having severe

arthritis in his wrist is great because of the condition the scaphoid was in prior to surgery.

Discussion

As previously stated, an acute injury to the scaphoid is not so often detected in

radiographs, and is frequently mistaken as a wrist sprain instead. The case was the same in the
 Misdiagnosed Scaphoid Fracture 7

athlete in this case study. Usually orthopedists typically refrain from invasive methods as much

as possible and would rather immobilize the patient in a cast. Studies show that union of bones

using immobilizing casts have a success rate of 85-90% if the injury was diagnosed early. 3 Since

the injury was discovered 6-7 weeks after the initial injury, and the joint was not immobilized,

the union rate decreased as time passed. 6 weeks in the cast showed no improvements in the

fracture, immobilization may have had to be prolonged for up to 3 months for possible full union

to occur. Patient compliance in a cast for that long would be unsatisfactory, thus leading to more

complications to the injury. 3

When the athlete was referred to the hand specialist, surgery was strongly recommended

because of the fracture site. Because the blood supply is compromised in a scaphoid fracture,

percutaneous fixation is aimed to reduce these complication and allowing the patient early

mobilization.3 Union rates with surgical intervention was 98.5% and has an average union time of

46 days and a return to play time of 40 days 3 which was optimal in the athletes circumstance.

Evidence in other studies show that percutaneous screw fixation verses cast

immobilization provide better results for patients who need to return to activity that involves

physical demands.3 There was a 5 week union time and a 7 week return to physical activity

difference between fixation and immobilization, fixation being faster in time.3 Unless the patient

is not an athlete, does not have an occupation that requires excessive hand/wrist motion, and if

the patient did not injure their dominant hand, immobilization casting would be recommended.

Otherwise, it would be beneficial in all aspects, especially to regain normal strength and ROM in

the wrist and hand, to consider percutaneous fixation.

 Misdiagnosed Scaphoid Fracture 8

References
1. Kohyama S, Kanamori A, Tanaka T, Hara Y, Yamazaki M. Stress fracture of the
scaphoid in an elite junior tennis player: a case report and review of the
literature. J Med Case Rep. 2016;10(1):8.
2. Rancy SK, Zelken JA, Lipman JD, Wolfe SW. Scaphoid Proximal Pole Fracture
Following Headless Screw Fixation. J Wrist Surg. 2016;5(1):71-6.
3. Majeed H. Non-operative treatment versus percutaneous fixation for
minimally displaced scaphoid waist fractures in high demand young manual
workers. J Orthop Traumatol. 2014;15(4):239-44.
4. Shen L, Tang J, Luo C, Xie X, An Z, Zhang C. Comparison of operative and non-
operative treatment of acute undisplaced or minimally-displaced scaphoid
fractures: a meta-analysis of randomized controlled trials. PLoS ONE.
2015;10(5):e0125247.
5. Anderson MK, Parr GP. Foundations of Athletic Training, Prevention,
Assessment, and Management. Lippincott Williams & Wilkins; 2012.