Simultaneous distal radius and scaphoid fractures are rare. If diagnosed, rule out or confirm if they are part of a trans-styloid, trans-scaphoid perilunate fracture dislocation (greater arc) with CT or MRI.
These injuries are most often caused by high-energy trauma, sometimes as part of polytrauma which will affect how to manage the fractures.
There is low-grade evidence that they should be treated, operatively.
A 36-year-old male sustains an isolated injury to his left dominant wrist after a motorcycle road traffic accident. There is an obvious deformity to the wrist. Radiographs reveal a comminuted volarly angulated distal radius fracture with a minimally displaced scaphoid waist fracture and an ulnar styloid fracture ( Fig. 1 ). What are your options for further diagnosis and treatment?
Importance of the Problem
In contrast to isolated distal radius fractures, simultaneous fractures of the distal radius and scaphoid are rare with studies reporting prevalence of 0.5%–5%.
The second recognized pattern of injury is the fracture part (greater arc) of a perilunate (PL) dislocation with a distal radius fracture that most often is a radial styloid injury. These two patterns of injury will be addressed as separate questions in this chapter.
Most of these injuries are due to high-energy trauma mechanisms. That means that patients may have other fractures as part of polytrauma where lower limb or pelvis fractures may dictate how the upper limb injuries are managed.
Scaphoid fractures are less common than distal radius fractures, but account for 2%–7% of all fractures and are the most frequently injured carpal bone. They usually affect young males. Nonunion rates of up to 50% are reported for displaced scaphoid fractures. Untreated nonunion often leads to early development of arthritis. As the scaphoid fracture seen with a distal radius fracture is often undisplaced, it can commonly be missed. Therefore, a high index of suspicion is necessary and a CT or MRI may be required to prevent nonunion of missed injuries.
What is the most effective treatment of simultaneous fractures of the distal radius and scaphoid?
What is the most effective treatment of simultaneous fractures of the distal radius and scaphoid in patients with a trans-styloid, trans-scaphoid perilunate (greater arc) dislocation?
Simultaneous fractures of the scaphoid and distal radius are most often diagnosed and treated as bony injuries although some surgeons argue that they can only co-exist with a trauma mechanism of a greater arc injury, like in complete perilunate dislocations, with a variable extent of partial or complete intercarpal ligament tears. Most surgeons will opt for an open reduction and internal fixation of a simultaneous distal radius and scaphoid fracture to allow early mobilization, which in turn may improve functional outcome. Although this is a common opinion, it is not clear if there is any evidence to support it.
Finding the Evidence
We provide below our EMBASE search algorithm used to construct this chapter:
exp *”RADIUS FRACTURES”/ OR exp *”WRIST INJURIES”/ OR exp *”COLLES’ FRACTURE”/ OR (exp *”SCAPHOID BONE”/ AND exp *”FRACTURES, BONE”/) OR (exp *”DISTAL RADIUS”/ AND exp *”FRACTURES, BONE”/) OR ((((radi*).ti,ab OR (wrist*).ti,ab OR (colles).ti,ab OR (scaphoid).ti,ab) AND (fractur*).ti,ab) AND (distal*).ti,ab)) AND (simultaneous OR concurrent OR coinciding OR together OR “same time” OR concomitant).ti,ab.
We did a systematic review of the literature and extracted appropriate papers for detailed analysis. Unfortunately, all papers did not present data in a coherent way, hence our results are presented with various numbers.
Quality of the Evidence
We found 20 studies of simultaneous distal radius and scaphoid fractures. However, no studies were found that compared treatment. The evidence in relation to these is as follows:
Retrospective noncomparative studies: 14
Case reports: 6
We found 13 studies covering simultaneous fractures of the distal radius and scaphoid in patients with a trans-styloid, trans-scaphoid perilunate (greater arc) dislocation. However, no studies compared treatment. The evidence in relation to these is as follows:
Retrospective noncomparative studies: 6
Case reports: 7
Simultaneous fracture of the distal radius and the scaphoid are most often clear on normal wrist radiographs, although sometimes proper scaphoid views are needed. As these fractures can be part of a greater arc mechanism in young patients a high level of suspicion is needed and additional imaging with CT, to find further fractures, and/or MRI, to potentially find intercarpal ligament or TFCC tears, is useful. In specialized centers, arthroscopy is a useful adjunct to fully assess both bony and soft-tissue injuries.
As a bare minimum, patients who have been operated on should at the end of the procedure be re-examined with a C-arm regarding intercarpal ligament injuries, by radial and ulnar deviation of the wrist to rule out any gaps or steps. They should also have a clinical assessment of DRU-joint stability with a DRU-joint ballotment test.
Isolated Distal Radius and Scaphoid Fractures
As there were no comparative studies or prospective randomized trials of the treatment of simultaneous scaphoid and distal radius fractures, it is not possible to evaluate the most effective treatment.
In the 20 included studies, there were a total of 178 patients with 182 simultaneous fractures of the distal radius and scaphoid ( Table 1 ). From those studies where it was possible to ascertain the mechanism of injury, most cases (134/155) were due to high-energy trauma mechanisms. Only 5/182 fractures were reported to be open.
|No. of Patients||Fractures||Age (Range)||Gender (Male/Female)||Mechanism High Energy/Low Energy||Associated Injury Polytrauma/Upper Limb Only||Distal Radius Fractures Intra/Extra Articular||Distal Radius Fracture Treatment Open/Closed/Plaster||Scaphoid Displacement Displaced/Un displaced||Scaphoid Anatomy Proximal/Waist/Distal||Scaphoid Fracture Treatment Operative/Nonoperative||Union||Complications|
|Oskam (1996)||23||23||39 (18–74)||13F:10M||23/0||–||8/15||1/4/18||4/19||0/21/2||4/19||100%||2/23|
|Fowler (2018)||23||23||37 (19–74)||19M:4F||19/4||–||17/6||18/5/0||1/22||4/17/2||23/0||95% scaphoid 100% distal radius||1/23|
|Gurbuz (2018)||21||22||34.9 (18–92)||17M:4F||22/0||1/10||22/0||14/8/0||–||0/22/0||22/0||100%||1/22|
|Rutgers (2008)||10||10||27 (19–41)||4M:6F||9/1||3/5||9/1||6/2/2||6/4||2/7/1||9/1||90% scaphoid 100% distal radius||4/10|
|Smith (1988)||9||9||34 (21–90)||7M:2F||6/3||2/1||0/9||1/4/4||0/9||0/9/0||0/9||100%||1/9|
|Hove (1994) a||9||9||38.6 (16–73)||5M:4F||7/2||1/3||5/4||0/0/9||–||0/7/2||0/9||100%||1/9|
|Moller (1983)||9||9||46.8 (27–69)||4M:5F||5/4||–||6/3||0/0/9||0/9||0/6/3||0/9||100%||–|
|Chang (2000)||8||8||55 (38–90)||5M:3F||4/4||3/0||7/1||2/5/1||1/7||0/8/0||5/3||100%||3/8|
|Komura (2012)||7||8||36.6 (19–68)||6M:1F||7/0||0/3||8/0||4/0/4||2/6||3/2/3||3/5||100%||–|
|Slade (2005)||7||7||30 (18–58)||5M:2F||5/2||0/1||4/3||7/0/0||7/0||1/6/0||7/0||100%||1/7|
|Tountas (1987)||7||7||30 (16–59)||7M||7/0||5/0||5/2||4/3/0||1/6||0/5/2||3/4||100%||4/7|
|Trumble (1993)||6||6||31.5 (14–49)||4M:2F||6/0||6/0||4/2||5/1/0||3/3||1/5/0||6/0||100%||4/6|
|Stother (1976)||3||4||41 (26–65)||3M||4/0||2/0||0/4||0/0/4||0/4||0/4/0||0/4||100%||1/4|
|Helm (1992) a||3||3||20.3 (20–21)||3M||3/0||0/0||3/0||3/0/0||–||–||3/0||100%||–|
|Proubasta (1991)||2||2||30 (28–32)||2M||2/0||0/1||2/0||0/2/0||0/2||0/2/0||2/0||100%||–|
|Richards (1992)||2||2||29 (20–38)||2M||2/0||0/0||2/0||1/1/0||0/2||0/2/0||2/0||100%||–|