The Conservative and Operative Treatment of Carpal Fractures

Abstract

Background: Carpal fractures (incidence: 30-60 per 100 000 persons per year) are one of the more commonly overlooked fracture types. They can have serious consequences, as the use of the hand is indispensable in everyday life. In the following article, we present the elements of the diagnosis and treatment of fractures of the carpal bones.

Methods: This review is based on meta-analyses and randomized controlled trials (RCTs) published from 2013 to 2023 that were retrieved by a structured literature search, supplemented by guideline recommendations and expert consensus statements. In addition, data on the administrative prevalence of carpal fractures were obtained from the German Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung, KV) and from the German Statutory Accident Insurance (Deutsche Gesetzliche Unfallversicherung, DGUV).

Results: The administrative prevalence of carpal fractures in 2022 was 44 496 outpatient cases (KV, DGUV) in one year. After clinical history-taking, physical examination and x-ray have been performed, thin-slice computed tomography is recommended as part of the diagnostic evaluation. Treatment recommendations are based on evidence of levels II to IV. Multiple RCTs have been carried out on the treatment of scaphoid fractures, and a clinical guideline exists. Proximal, dislocated and unstable scaphoid fractures should be treated surgically. Non-displaced or minimally displaced fractures of the middle third of the scaphoid bone require a shorter period of immobilization with surgical treatment (2-4 weeks) than with conservative treatment (6-8 weeks). The use of plaster casts that do not hinder elbow and thumb mobility yields healing rates similar to those obtained with the immobi - lization of both of these joints. Failure to treat an unrecognized scaphoid fracture can lead to pseudarthrosis, avascular bony necrosis, and misalignment. Other, rarer types of carpal fractures must be managed on an individual basis, as the available ev idence is limited to expert consensus.

Conclusion: Early recognition and appropriate treatment of carpal fractures lead to healing in more than 90% of cases. Although the available evidence on their proper treatment is growing, many questions are subject to expert consensus, and decisions about treatment must be made individually.

Figure 1

Vascularity of the scaphoid, shown from dorsal, with branches of the radial artery Courtesy of © M.F. Langer. All rights reserved

Figure 2

Fall on the hyperextended wrist. The distal pole of the scaphoid is firmly fixed to the trapezium on contact of the hand with the ground and by the ligamentous system; dorsally, the radial margin acts like a chisel, while on the palmar side the radioscaphocapitate ligaments push the proximal pole in a dorsal direction. Courtesy of © M.F. Langer. All rights reserved

Figure 3

Different fracture sites on the scaphoid for different positions of the wrist during a fall. Arrows indicating the force vector. Courtesy of © M.F. Langer. All rights reserved

Figure 4

Krimmer’s computed tomography-based classification of scaphoid fractures based on Herbert (3, 28): stable fractures (type A) and unstable fractures (type B) A1: fractures of the tubercle A2: undisplaced transverse fractures in the middle or distal third B1: long oblique fractures B2: displaced or mobile fractures B3: proximal pole fractures B4: trans-scaphoid perilunate fracture dislocation Courtesy of © M.F. Langer. All rights reserved.

eFigure

Identification of studies via databases Flow diagram showing the process of the systematic literature search in accordance with PRISMA criteria *¹ Automatic program analysis used, individually reviewed by reviewers *² Automatic program analysis not used

eFigure 1

40-year old (male) patient with a proximal scaphoid fracture (Krimmer type B3) (3, 28) Indication for surgical management due to fracture located at the proximal third Top row from left to right: preoperative X-rays AP, lateral, Stecher’s view Bottom row from left to right: postoperative X-rays (AP, lateral, Stecher’s view) after minimally invasive management using an antegrade 2.2 mm double-threaded screw (dorsal approach to the scaphoid).

eFigure 2

21-year-old (male) patient with a scaphoid waist fracture (Krimmer type B2) (3, 28) Displacement as the indication for surgical management Top row from left to right: preoperative X-rays AP, lateral, Stecher’s view, and coronal and sagittal computed tomography Bottom row from left to right: intraoperative fluoroscopic images (AP and lateral) after minimally invasive management using a retrograde 3.0 mm double-threaded screw (palmar approach to the scaphoid).

eFigure 3

48-year-old (female) patient with a hamate fracture close to the base Top row from left to right: preoperative X-rays AP and lateral views and sagittal computed tomography Bottom row from left to right: postoperative X-rays AP and lateral views and preoperative axial computed tomography. The hook fracture close to its base is well recognizable on the section images (top and bottom right). Because of the recognizable bone defect, the fracture was treated with a cancellous bone graft taken from the ipsilateral distal radius and a double-threaded screw.