21 Scaphoid Fractures in Athletes
Wrist injuries have several consequences for athletes participating in competitive sports, including loss of playing time, inability to perform at preinjury levels, and possible termination of a prospective career.1 The scaphoid remains the most commonly fractured carpal bone2 and is at greatest risk in athletes engaged in high-impact collision sports such as football or in sports with the potential for high-impact falls such as basketball and snowboarding.1 , 3 Although operative intervention remains the same in the athlete versus the nonathlete, other factors such as length and type of immobilization, rehabilitation, and ability to return safely to play need to be considered. For individual athletes, treatment of the scaphoid fracture will need to be tailored to the specific needs of the sport.
▪ Special Needs of the Athlete
When treating any athlete, a balance must be maintained between providing appropriate care for the athlete as a patient and providing adequate consideration of the athlete’s career goals and needs. Ultimately, the utmost level of care must be provided, but several sport-specific issues should be taken into consideration when developing an appropriate treatment algorithm: (1) the potential for high impact to the wrist during play (football vs soccer), (2) the need for maintaining fine motor skills and high levels of accuracy (baseball pitcher vs football linebacker), and (3) the long-term outcome of the chosen treatment modality (skeletally immature athlete vs adult professional athlete).1 In addition, the timing of the injury with regard to the athlete’s playing season may determine how quickly surgical intervention is contemplated. Last but not least, it is important to factor in the individual patient’s level of competition when developing a treatment plan. Because the sense of urgency for the high-level athlete to return to play is not present for the recreational athlete, the risk versus benefit of early return to play is very different between the two groups and should be thoroughly addressed with each patient.
Scaphoid fractures are the second most frequent upper extremity fracture following the distal radius, accounting for 11% of all hand fractures and 60 to 70% of carpal fractures.4 , 5 In the athlete, scaphoid fractures have been reported most commonly in high-impact collision sports such as football, and in sports with potentially high-impact falls such as inline skating, basketball, snowboarding, and rodeo riding. A 1-year survey of hand injuries performed by the Methodist Sports Medicine Center in Indianapolis found that scaphoid fractures accounted for 19% of all fractures, with the highest occurrences in basketball and football players.6 Ellsasser and Stein note that the scaphoid fractures they encountered in football players were all incurred by defensive players.7 Nguyen and Letts reported a 6% incidence of scaphoid fractures out of 188 upper-extremity injuries secondary to in-line skating,8 whereas the incidence of scaphoid fractures among snowboarders has been reported at ∼2%.9 , 10 Meyers et al discuss the high risk of injury to rodeo riders secondary to axial overload during both riding and dismount, noting a 30% incidence of hand and wrist fractures in their series.11 Although exact incidences are not known, other sports with potential high impact to the wrist such as rugby, soccer, hockey, wrestling, and baseball also place the scaphoid at risk.
▪ Mechanism of Injury
Scaphoid fractures are most commonly caused by a fall onto an outstretched hand. Sports at risk for this include in-line skating, baseball, basketball, and gymnastics. Other mechanisms of injury specific to athletic activity include axial load to the wrist during direct impact activities such as boxing or tackling,1 , 7 and a direct hit to the wrist by athletic equipment such as hockey or lacrosse sticks, baseballs, softballs, field hockey sticks, and so forth.1
Newer sports such as snowboarding generate the potential for much higher impact accidents. The current highest recorded speed by a snowboarder is 125 miles per hour (201 km/h).12 Falling at such speeds naturally increases the risk of associated high-energy injuries such as perilunate fracture-dislocations ( Fig. 21.1A-C ).
History and Physical Examination
The history of a sports-induced scaphoid fracture is typically consistent with an uncontrolled fall, collision, or direct blow to the wrist. Regardless of history, Rettig and Rettig advise that any contact sport athlete who presents with radial-sided wrist pain should be considered to have a scaphoid fracture until proven otherwise.13 The wrist examination following an acute injury reveals tenderness to palpation in the anatomical snuffbox and decreased wrist range of motion. Other possible findings include wrist swelling and pain with axial load applied to the thumb.13
Scaphoid fractures may also present as chronic injuries, particularly in the athlete who is reluctant to mention the injury until the playing season has ended. The patient may note an inability to perform push-ups in addition to radial-sided wrist pain. Some of the possible physical findings include decreased wrist dorsiflexion and diminished grip strength in addition to snuffbox tenderness.13
The incidence of false-negative x-rays on the initial films for scaphoid fractures has been reported as high as 20 to 25%.14 , 15 Because inadequate imaging may contribute to this, it is important to ensure that the appropriate views are acquired to sufficiently evaluate the scaphoid and include a posteroanterior view, lateral view, scaphoid view, supinated oblique view, and pronated oblique views. The standard treatment for injuries that carry a high clinical suspicion for a scaphoid fracture but with negative x-rays customarily involves application of a below-elbow thumb spica cast for 2 weeks followed by repeat radiographs.16 Because establishing a definitive diagnosis as early as possible is crucial for the in-season athlete, other imaging modalities such as magnetic resonance imaging (MRI), ultrasonography, bone scans, or computed tomography (CT) can be used.
MRI is currently the test of choice for the evaluation of suspected scaphoid fractures in patients with negative radiographs. The overall sensitivity has been reported at 95 to 100% with a specificity of 100%.17 A negative MRI scan with no bone marrow edema definitively rules out a scaphoid fracture, and no further treatment is required.18 When the traumatic event is forceful enough to produce bony edema, animal studies using MRI have revealed changes as early as 1 to 6 hours posttrauma, with even mild injury manifesting itself by 30 hours.19 Although this is beneficial in the early detection of a scaphoid injury, one of the difficulties faced by radiologists involves distinguishing bone contusions or incomplete or microtrabecular fractures from complete but nondisplaced fractures. According to Amrami, the misdiagnosis of a fracture can be avoided in most cases by an experienced radiologist who strictly adheres to the criterion of visualizing a definite scaphoid fracture line.18 However, the author does caution that the definitive differentiation between a bone contusion and a nondisplaced fracture may only come after a period of immobilization and follow-up radiographs.
The standard nonoperative treatment for nondisplaced scaphoid fractures typically entails 6 weeks to 3 months of cast immobilization20 or more. Even with extended periods of immobilization, the incidence of nonunion in nondisplaced scaphoid fractures has been reported to be as high as 15%, and with any fracture displacement this incidence increases to 50%.21 – 23 The side effects of prolonged immobilization include stiffness and muscle atrophy, which may necessitate an extensive period of therapy to return to play.24
For the athlete, decreasing the risk of developing a nonunion as well as decreasing the time to union and the length of immobilization is of paramount importance in facilitating return to play as quickly as possible. For these reasons, operative fixation of a scaphoid fracture in a high-level competitive athlete should be considered. Issues regarding the timing of surgery in relation to the playing season, however, may influence the athlete to delay surgical intervention or potentially forgo it altogether. This is a more pressing concern for the in-season professional athlete; treatment options and considerations for this specific population will be addressed later.
For the recreational athlete or young and possibly skeletally immature competitor, the longevity of the wrist outweighs the need for continuation of play. Optimal treatment for this population should maximize the chance for an anatomical union. This may involve surgical fixation followed by adequate immobilization and nonweightbearing until the fracture is united.
Midseason Injuries and Continuation of Play
For the in-season professional athlete who cannot afford to stop playing, treatment options include the following: (1) immobilization as definitive treatment, (2) immobilization until the athlete can undergo surgical fixation, and (3) surgical fixation with return to play in either a playing cast or a splint.
Immobilization as Definitive Treatment
For stable scaphoid waist fractures with less than 1 mm of step-off or gap, no angulation, and no associated carpal instability, union is possible with closed treatment in a playing cast.25 Riester et al performed a study in which 14 athletes with stable scaphoid fractures (11 waist fractures, three proximal pole fractures) were immobilized within 21 days of the injury and were allowed to return to contact sports immediately with a custom-made Silastic cast. At an average follow-up of 3.9 years, 10/11 of the scaphoid waist fractures healed with an average immobilization period of 6 months (range, 1 to 16 months). One patient went on to nonunion due to a 7-week delay in diagnosis. However, two of three proximal third fractures went on to nonunion, whereas the third healed after a prolonged period of casting.25
Although immobilization in a playing cast may be effective for stable waist and distal pole fractures, lack of absolute fracture stabilization coupled with continued engagement in forceful activity inherently increases the risk of delayed union and nonunion; these risks need to be reviewed thoroughly with the athlete, parents, and coach. Immobilization alone appears to be ineffective for proximal fractures and is not recommended for unstable or displaced fractures.25 , 26
Immobilization until Surgical Fixation Is Possible
Although casting can also be used as a temporary measure until the patient has time to undergo surgical fixation, it should be kept in mind that an initially nondisplaced fracture may either become displaced or develop into a nonunion in the interim, requiring a more complex and extended treatment plan.
▪ Surgical Treatment
Given the inherent risk of nonunion, displacement, and prolonged immobilization associated with closed treatment alone, the current optimal treatment for athletes in the opinion of the authors is surgical fixation for all scaphoid waist and proximal pole fractures. Although distal pole fractures may heal without consequence using cast immobilization, the patient may opt for surgical treatment to decrease the immobilization period.
Our preferred method for fixation of scaphoid fractures is a compression screw, with or without bone graft, depending on the degree of comminution and the acute versus chronic nature of the injury. For waist and distal pole fractures, we prefer the palmar approach. Although it has the disadvantage of an oblique trajectory versus the dorsal approach, it has the advantage of extending the wrist and therefore extending the usually flexed scaphoid fracture at the waist. If the fracture does not have to be exposed, a mini-incision is made over the scaphotrapezial joint, and soft tissues are spread down to the joint. Pearls for guide wire placement include hyperextending the wrist over a large bump and placing the guide wire as far dorsally on the scaphoid as possible, using a drill guide to lever the trapezium dorsally. This maneuver will assist in placing the guide wire longitudinally down the scaphoid axis. The morphology of the trapezium is variable and can have a palmar prominence that blocks the wire placement. In these cases, we prefer to place the guide wire through the corner of the trapezium and drill over the wire. Pitfalls include avoiding too oblique of an angle with screw placement because this will cause inadequate proximal pole capture. Also, using a screw that is too long may either distract the fracture or protrude into the joint. A 45 degree oblique supinated from lateral view shows this potential region of penetration best. We generally use a screw that is two sizes smaller than the measured amount.
We prefer a dorsal approach for proximal pole fractures. For nondisplaced fractures, a 2 cm longitudinal mini-incision is made between the third and fourth dorsal extensor compartments. Care is taken to retract the extensor tendons because Weinberg et al have shown that a pure percutaneous technique places the extensor tendons at risk for injury.27 If the fracture needs to be exposed, the Mayo ligament-sparing approach is used, performing a capsulotomy by splitting the fibers of the dorsal radiocarpal and dorsal intercarpal ligaments in line with their respective fibers and raising the capsular flap as a whole in an ulnar to radial fashion starting at the triquetrum.28 When using a dorsal approach, the elbow may be flexed to obtain an anteroposterior (AP) radiographic view because the wrist cannot be extended to neutral.
For fractures requiring bone graft for either comminution or nonunion with bone loss, an open volar approach is preferred. Distal radius autograft may be used so long as it appears healthy with adequate bleeding; otherwise, iliac crest bone autograft should be used. For cases in which the proximal pole is avascular, a vascularized graft should be used. We prefer the 1,2 intercompartmental supraretinacu-lar artery (ICSRA) graft through a dorsal-radial approach.
In regard to return to play, optimal treatment dictates no return to play for any patient until the fracture is healed. In our experience, scaphoid waist fractures treated with screw fixation typically heal in 6 to 10 weeks, distal pole fractures in 6 to 8 weeks, and proximal pole fractures in 8 to 10 weeks. Patients requiring bone graft or vascularized graft may require 10 to 12 weeks for fracture healing to occur. The patient who wishes to return to play prior to demonstrable healing must fully understand and accept the risk of malunion or nonunion.
Rettig et al performed a retrospective study of 30 in-season athletes with a stable, midthird scaphoid fracture who were assigned to either surgical or cast treatment. Eighteen athletes were treated with immediate open reduction and internal fixation using a Herbert screw (Zimmer Inc., Warsaw, IN). Twelve patients were treated nonoperatively with a playing cast. The return to sports averaged 8.0 weeks for the surgical group versus 4.3 weeks for the nonoperative group. The clinical and radiographic healing time averaged 10.8 and 11.2 weeks for the surgical group versus 13.7 and 14.2 weeks for the casted group. The authors concluded that an early return to contact sports was possible following treatment with either a playing cast or rigid internal fixation with a Herbert screw.29