흔한 손목관절 질환의 이해와 치료법 - 정리해야 할 논문

[문형철]

손목질환은 꽤 많은 편이다.

체중부하가 걸리지 않기 때문에 통증이 심하지 않기 때문에 흔히 치료가 방치되는 경우가 많다.

손목통증은 크게 두가지

1) acute traumatic injury

2) overuse injury

The wrist common injuries and management.pdf

Introduction

Wrist injuries are common in athletes. They may result from a single, traumatic force or as a result of repetitive-loading activity. Complex wrist and hand anatomy can make diagnosis of wrist injuries an challenging task. A good understanding of wrist anatomy, as discussed elsewhere in this issue in ‘‘The Wrist: Clinical Anatomy and Physical Examination—an Update’’ by Eathorne, and an awareness of the common presentations of sportspecific injuries will facilitate accurate diagnosis. 

- 손목손상은 운동선수에게 흔함. 

- 복잡한 손목과 손의 해부학을 잘 알아야 정확한 진단을 내릴 수 있음. 

Labeling an athlete’s injury as a ‘‘wrist sprain’’ without a specific diagnosis may allow a competitive athlete to continue to play through the pain without proper treatment and exacerbate an injury. Management of a wrist injury in the athlete requires that the physician balance the athlete’s objective to return to sport promptly with treatment that allows healing and prevents long-term complications of an injury. It is important for the primary care physician to have an awareness of the broad range of injuries that occur in the athlete’s wrist, to be familiar with appropriate conservative management, and to refer appropriately.

- 특별한 진단없이 손목염좌라고 이름붙이는 것은 반복사용하는 운동선수에게 흔히 진단함.

- 운동선수 손목 손상의 치료는 즉시 복귀와 장기간 합병증을 막기 위해 중요함. 

Epidemiology

Child and adolescent athletes suffer relatively more wrist injuries than adult athletes. Three percent to 9% of all athletic injuries involve the hand and wrist [1]. This number is as high as 14% in high school football [2], and 46 to 87% of gymnasts suffer wrist injuries or have chronic wrist pain [3,4]. Injuries of the wrist can be divided into acute traumatic injuries and overuse injuries.

Acute wrist fractures are common injuries among athletes. In a study of football players aged 9 to 15, 35% of injuries were to the upper extremities, and most were distal radius fractures [5]. Distal radius metaphyseal and physeal fractures are common in skating, football, basketball, and snowboarding. The scaphoid is the most commonly injured carpal bone, accounting for 70% of carpal fractures [2]. An athlete falling on an outstretched hand with the wrist dorsiflexed is a common mechanism. The triquetral bone is the second most commonly injured carpal bone. It typically occurs from a fall on a wrist in ulnar deviation. Pisiform fractures occur due to a direct blow, such as from a pitched ball.

Stress fractures occur in athletes whose sport requires repetitive motion involving wrist compression or twisting. Sports such as gymnastics and weightlifting place large repetitive compressive forces across the wrist. Distal radius physis stress syndrome, avascular necrosis of the capitate, and stress fracture of the scaphoid have been reported in these athletes [4,6]. Reportedly, up to 87% of elite gymnasts sustain distal radial physeal injuries [3]. Hook of hamate fractures have been seen in baseball, golf, and tennis players from the repetitive stress of bat, club, or racquet, respectively [7]. Repetitive stress is also thought to be a cause of avascular necrosis of the lunate or Kienbo¨ ck’s disease.

Soft-tissue injuries may either be due to acute trauma or overuse. Overuse syndromes such as deQuervain’s tenosynovitis, extensor carpi ulnaris tendonitis, and sprains of pisotriquetral ligament [8] are associated with

throwing and racquet sports. Dislocation of the distal radioulnar joint(DRUJ), midcarpal instability, and triangular fibrocartilage complex(TFCC) tears can occur due to a traumatic fall, or due to repetitive twisting motion as seen in gymnasts. Carpal dislocation typically requires significant force, such as a collision in football or a fall from a height in cheerleading. 

General approach to wrist injuries 

To begin, be familiar with the most common wrist injuries in active people and the common sport-specific injuries. Obtain a careful history regarding the athlete’s wrist complaint, including how the complaint is related to activity and rest. It is important to have good clinical knowledge of the functional anatomy of the wrist in order to maximize the information

gathered on examination. The eval‎uation of wrist complaints requires at least two radiographic views of the wrist (Fig. 1). 

An oblique view, in addition to a posterior-anterior (PA) and true lateral, is useful in identifying fractures. Special radiographic views of the wrist are also useful and will be addressed further in the discussion of specific injuries (Table 1). 

Several things are important to consider as treatment is initiated for a wrist injury including: the athlete
s sport, his or her desire
s regarding return to play, and the impact of injury management on the athlete
s future participation in his or her sport. The primary care physician should understand that many injuries have a poor outcome if unrecognized. If the diagnosis is not clear, the athlete’s wrist can be protected with a splint and referred for additional eval‎uation.

Management of all wrist injuries should include rehabilitation of muscles weakened and motion lost by pain, inflammation, and immobilization. Rehabilitation should proceed through five goal-oriented phases. 

Rehabilitation goals include: 

(1) decreasing pain and minimizing inflammation and edema

(2) increasing pain-free range of motion

(3) strengthening and improving general condition

(4) increasing sport-specific skill, coordination, and flexibility

(5) return to sport with prevention of injury, which may include use of protective equipment. Physical therapists and athletic trainers can play a key role the safe and expeditious return to play of the athlete.

Tendonopathies

1. DeQuervain’s tenosynovitis

DeQuervain’s tenosynovitis is the most common tendonopathy of the wrist in athletes [9]. DeQuervain’s tenosynovitis is inflammation of the tenosynovium of the first dorsal compartment tendons, the abductor pollicis longus (APL) and extensor pollicis brevis (EPB). These tendons course under the extensor retinaculum in a groove along the radial styloid process. Repetitive wrist motion causes shear stress on the tendons in their small compartment, which results in inflammation of the tenosynovium. DeQuervain’s tenosynovitis is common in racquet sports, fishing, and golf. On examination, the athlete will be tender over the APL and EPB, and will have pain with Finklestein’s test (Fig. 2). 

Fibrous thickening of the tendon sheath and a ganglion cyst may be present in chronic cases. Acute deQuervain’s tenosynovitis responds best to corticosteroid injection into the tendon sheath (Fig. 3). 

- 드퀘방병이 오래되면 건초와 강긍리온 시스트의 fibrous thickening이 흔함. 

- 이때는 스테로이드 주사로 반응????

Results of a recent meta-analysis of treatments for deQuervain’s tenosynovitis showed that there was an 83% cure rate with injection alone. This rate was much higher than any other therapeutic modality (61% for injection and splint, 14% for splint alone, and 0% for rest or nonsteroidal anti-inflammatory drugs [NSAIDs]) [10]. If conservative treatment fails, surgical decompression of the first dorsal compartment should be considered. Surgical candidates should expect 7 to 10 days of postoperative splinting, followed by rehabilitation and return to sport in 6 to 9 weeks [9].

Intersection syndrome 교차증후군

Intersection syndrome is a painful inflammatory condition located at the crossing point of the muscles of the first dorsal compartment (APL and EPB) and second dorsal compartment tendons. (extensor carpi radialis longus [ECRL] and extensor carpi radialis brevis [ECRB]). The site of crossover is 6 to 8 cm proximal to the radial-carpal joint in the dorsal  forearm (Fig. 4). 

This site is tender and may be swollen. There is often a palpable crepitus at the intersection with moving the wrist through flexion and extension, leading to the name ‘‘squeakers syndrome.’’ It is seen in athletes who play sports requiring forceful, repetitive wrist flexion and extension (rowing, weight lifting, gymnastics, and racquet sports). The pathophysiology is still unclear, but it is thought to be a tenosynovitis of the second dorsal compartment tendons, or inflammation of an adventitial bursa between the APL and ECRB due to friction at the intersection. This syndrome responds well to conservative treatment of rest, local icing, and NSAIDs, with a gradual return to sports. Splinting with a thumb spica splint in 15
of wrist extension for 2 weeks is helpful to rest the muscles [11]. Injection with local anesthetic and steroid may be needed if symptoms do not resolve with NSAIDs and rest [12]. Range-of-motion and strengthening

therapy should follow splinting before return to sports. Surgery is rarely needed, but cases recalcitrant to conservative therapy for greater than 6 weeks may undergo release of the second dorsal compartment and debridement of inflammatory tissues [9].

Extensor carpi ulnaris tendonopathy

Extensor carpi ulnaris (ECU) tendonitis is the second most common sports-related overuse injury of the wrist [13]. This should be included in the differential diagnosis of an athlete with ulnar wrist pain. It is commonly seen in racquet sports, rowing, and squash [14]. Patients present with the complaint of dorsal-ulnar wrist pain after repetitive activity.

Diagnosis is made by physical examination. There is tenderness and swelling over the ECU tendon sheath, dorsal to the ulnar styloid. Pain is reproduced with resisted dorsiflexion with the wrist in ulnar deviation and forearm supination [11]. Wrist radiographs are negative. Treatment includes rest, splinting, and NSAIDs [9]. If not improved after 2 weeks

of conservative therapy, corticosteroid injection often resolves symptoms. Injection of the ECU tendon sheath requires good knowledge of the wrist anatomy, so as not to damage the dorsal sensory branch of the ulnar nerve (Fig. 5). Lastly, surgery may be required to decompress the sixth dorsal compartment.

 ECU subluxation is a less common injury, but is important to consider in

the differential diagnosis of chronic ulnar wrist pain. ECU subluxation

occurs with forceful supination, palmar flexion, and ulnar deviation of the

wrist [15] . This injury is seen in tennis players hitting a low forehand, or in

the trailing hand of a baseball player at the end of a swing [14] . It may also

occur after a fall on an outstretched hand (FOOSH) [15,16] . Patients

typically complain of dorsal ulnar wrist pain and ‘‘snapping’’ that are

aggravated by forearm rotation [15] . Tenderness and swelling are elicited

over the ECU in the area of the ulnar head. Marked pronation or supination

may reproduce the ‘‘ping’’ as the tendon subluxes out of its groove. Wrist

radiographs are normal. A 6-week period of immobilization in a long arm

cast may be tried [9] ; however, in several case reports [15,16]  this

conservative therapy has not been successful. For symptomatic patients,

surgical repair of the ruptured tendon subsheath is recommended [17,18] ,

followed by 4 to 6 weeks of immobilization, with return to sport anticipated

8 to 10 weeks following surgery [9] .

 Flexor carpi ulnaris tendinopathy

Flexor carpi ulnaris (FCU) tendonitis presents with palmar-ulnar side

wrist pain, and is seen in racquet sport athletes. Examination reveals

tenderness along the FCU and pain with wrist flexion. Dorsal wrist splinting

with 25 of flexion for 1 to 2 weeks and a short course of NSAIDs typically

resolve symptoms [14]. Corticosteroid injection is considered for recalcitrant

cases. Excision of the pisiform and Z-plasty lengthening of the FCU has

been described for chronic cases [14].

 Flexor carpi radialis tendinopathy

Flexor carpi radialis (FCR) tendonitis presents with pain in the palmarradial

wrist with repetitive wrist flexion. Tenderness is over the FCR at its

insertion on the base of the second and third metacarpals, and pain is

reproducible with resisted wrist flexion. As with FCU tendonitis, treatment

is rest with brief splinting, NSAIDs, and stretching, and if symptoms are

prolonged, surgical release may be indicated.

 Distal radioulnar joint and triangular fibrocartilage complex

DRUJ and TFCC injuries are often discussed together, due to closely

related anatomy and frequently overlapping symptoms. The DRUJ is

located between the distal radius and the head of the ulna. Five structures

are important in ensuring the stability of the DRUJ: (1) the triangular

fibrocartilage (TFC), (2) the ulnocarpal ligament complex, (3) the infratendinous

extensor retinaculum (ie, the ECU tendon sheath), (4) the pronator

quadratus muscle, and (5) the interosseous membrane [19]. Intimately

related to the DRUJ is the TFCC. The TFCC (Fig. 6) is composed of the

semicircular biconcave fibrocartilage or articular disc called the TFC, the

palmar and dorsal distal radioulnar ligaments, a meniscus homolog, and

the ulnolunate and ulnotriquetral ligaments [20]. The distal radioulnar

ligaments arise from dorsal and palmar edges of the distal radius and are

often indistinguishable from peripheral fibers of the TFC.

Distal radioulnar joint instability

Because of the intimate relationship and overlapping structures of the

DRUJ and TFCC, injury to either can occur by a similar mechanism, such

as traumatic axial load with rotational stress (eg, FOOSH). Both injuries

typically present with ulnar-sided wrist pain. Because the TFCC adds

stability to the DRUJ, an injury to the TFCC can result in DRUJ

instability; however, DRUJ instability can also occur as a result of other

injuries, such as a distal radius fracture or disruption of any of the five  stabilizers mentioned above (eg, distal radioulnar ligaments or interosseous

membrane).

DRUJ injuries may present acutely at dislocation or with chronic ulnar

wrist pain due to instability. A patient who has an acute DRUJ dislocation

without associated fracture usually complains of pain over the ulnar aspect

of the wrist accentuated by pronation and supination [19] . On examination,

there is moderate swelling and tenderness over the DRUJ. In dorsal

dislocations, there is a prominence of the distal ulna dorsally when the wrist

is flexed. In palmar dislocations, the normal prominence of the ulnar head at

the wrist may be obscured by soft-tissue swelling. DRUJ dislocation can be

difficult to diagnose with plain radiography. A true lateral radiograph may

demonstrate the dorsal or palmar displacement of the distal ulnar relative to

the radius. PA radiographs may show a greater than normal gap between

the head of the ulna and distal radius if the ulna is dorsally dislocated.

In palmar DRUJ dislocations, the ulna and radius may be superimposed

on the PA view [19] . Bilateral wrist comparison views may be helpful. If

concern for DRUJ injury exists and radiographs are inconclusive, CT or

MRI may be warranted.

Isolated acute DRUJ dislocations need to be reduced and immobilized in

a long arm cast with forearm neutral for 6 weeks [19] . If there is an

associated injury (eg, TFCC tear) and the soft tissue is interposed between

the radius and ulna, healing with closed reduction may be unsuccessful.

 DRUJ dislocations with associated fractures are generally not amenable to

nonoperative management [19] .

DRUJ subluxation is a cause of chronic ulnar wrist pain. The ulnar head

is prominent in pronation as it rides onto the dorsal lip of the radius.

Supination may then be restricted, often followed by a distinct snap during

forearm rotation [19] . The ‘‘piano key sign’’ indicates distal radioulnar joint

instability [1] , which allows subluxation of the ulna on the radius. This sign

is elicited by having the patient place both palms on the examining table and

forcefully press downward. There is exaggerated dorsal-palmar translation

of the distal radius compared with the opposite side. Alternatively, this sign

can be elicited by depressing the ulnar head while supporting the forearm in

pronation; the ulnar head springs back like a piano key, indicating laxity

of the DRUJ [21] . Patients who have chronic subluxation may receive

temporary relief with a distal forearm splint that exerts a relocating force on

the ulnar head. Definitive treatment for the symptomatic athlete, however, is

typically surgical [19] .

Triangular fibrocartilage complex injury

 The TFCC is a cartilaginous and ligamentous structure important in the

stabilization of the distal radial ulnar joint (as mentioned above). The

articular disc of the TFCC separates the ulna and the proximal carpal row,

and carries about 20% of the axial load from wrist to forearm [22] . There is

a relative lack of blood supply to the central portion of the TFCC, leading

to poor healing of tears [23] . Injuries to the TFCC occur with repetitive

ulnar loading (eg, bench press, racquet sports) or acute traumatic axial load

with rotational stress (eg, FOOSH). Most injuries to the TFCC have

a component of hyperextension of the wrist and rotational load. Ulnar-sided

wrist pain made worse with ulnar deviation, wrist extension, or heavy use is

the common complaint of an athlete who has a TFCC injury. TFCC injuries

are more commonly seen in such sports as gymnastics, hockey, racquet

sports, boxing, and pole vaulting [24] .

The TFCC is palpated in the hollow between the pisiform, FCU, and

ulnar styloid. It is most easily palpated with the wrist in pronation. Injury to

the TFCC is indicated by tenderness on palpation of the TFCC, with or

without distal radioulnar joint instability. TFCC compression by forced

ulnar deviation and axial compression with repeated flexion and extension

will impact the ulnar styloid and TFCC. This will result in pain or clicking

if the TFCC is involved [3] . The ‘‘press test’’ reproduces the patient’s pain

when the patient lifts herself out of a chair while bearing weight on the

extended wrists [25] . The ‘‘supination lift test’’ has also been described for

localized tear to the peripheral, dorsal TFCC. With this test, pain is

reproduced when the patient attempts to lift the examination table with the

palm flat on the underside of the table [26]  This forces a load across the   TFCC with the wrist supinated and extended, causing dorsal impingement,

and is useful in the diagnosis of peripheral, dorsal TFCC tear.

Radiographs are usually normal in TFCC injuries. The PA view may,

however, demonstrate positive ulnar variance, which is a risk factor for

TFCC injury. Ulnar variance is the relationship of the length of the radius

and ulna. This relationship, which is categorized as positive (long ulna

relative to radius) or negative (short ulna relative to radius), influences the

distribution of compressive force across the wrist. Most forearms are within

2 mm of ulnar positive or 4 mm ulnar negative. Pathologic conditions are

more preval‎ent at the extremes of ulnar variance [27] . Positive ulnar

variance is associated with a thinner TFCC [28]  and increased forces

transmitted across the TFCC [29] , making it more prone to injury. Highresolution

MRI and MR arthrogram may detect TFCC tears. CT scan of

the wrist in neutral, pronation, and supination may reveal distal radioulnar

joint instability that may be due to TFCC injury [1] . Rest, activity

modification to remove the inciting force of injury, ice, splint immobilization

for 3 to 6 weeks, and subsequent physical therapy may be effective for

some TFCC injuries [1,3] . Buterbaugh et al [26]  recommend a trial of

6 weeks of splinting and NSAIDs for patients presenting with ulnar-sided

wrist pain, normal plain films, and suspected TFCC injury. Failure of

conservative treatment necessitates further imaging or arthroscopy. For

high-level athletes (elite high school, collegiate, or professional) who have

negative initial imaging and persistent symptoms limiting participation,

diagnostic (and potentially therapeutic) arthroscopy may be indicated after

as little as 2 to 3 weeks of splinting [1] . Arthroscopy is used to debride

central tears and repair peripheral tears. Some injuries require open surgery

with an ulnar shortening procedure. Return to sport after surgery ranges

from 6 to 12 weeks following arthroscopic debridement to 6 months after an

open procedure [29] .

Our knowledge of ulnar-sided wrist pain, including TFCC injury and

DRUJ instability, is advancing with MRI and arthroscopic technology. The

complexity and variability of these injuries is becoming more evident. The

TFCC may be injured centrally or peripherally. There may be other

associated injuries or fractures. The type of injury and extent of the injury

determines the efficacy of conservative treatment. Ninety percent good-toexcellent

results have been reported from arthroscopic repair of central or

peripheral TFC tears with a stable DRUJ [1] .

Fractures

Distal radius fracture

 Distal radius fractures are very common in sports. This injury typically

occurs with a FOOSH with hyperextension, impacting the distal radius. The

athlete presents with pain, swelling, ecchymosis, and tenderness about the  wrist. Initial radiographs should include PA, lateral, and oblique views of

the wrist. The examiner needs to determine the type of distal radial fracture

and assess displacement, shortening, and intra-articular involvement. The

goal of treatment is to correct and maintain radial inclination, palmar tilt,

length, and congruity of the distal radial articulations (carpal and ulnar).

A Colles’ fracture, the most common distal radius fracture, is a closed

fracture of the distal radial metaphysis in which the apex of the distal

fragment points in the palmar direction and the hand and wrist are dorsally

displaced (Fig. 7 ). This fracture usually occurs within 2 cm of the articular

surface. Colles’ fractures are common in adults and rare in children, because

children tend to sustain injuries through the distal radial physis.

Stable distal radius fractures may be managed in a short arm cast. All

others should be referred for reduction and fixation. A stable distal radius

fracture is extra-articular, without comminution, and with minimal or no

displacement, which, when reduced to anatomical alignment, does not

redisplace back to the original deformity [30] . For optimal outcome, it is

important that anatomic alignment of the radius is maintained (either at

presentation or with reduction); however, authors differ slightly on the

definition of acceptable anatomical alignment. Certainly, fractures must be

referred for orthopedic consultation if there is greater than 20  dorsal tilt,

loss of radial inclination (20  to 30  need to be maintained), articular stepoff

greater than 2 mm, or radial shortening greater than 5 mm (Fig. 8 ) [31] .

Maintaining radial inclination of 20  to 30 , 4  to 8  palmar tilt, and radial

shortening no greater than 2 mm is recommended by Rettig and Trusler [32] .

Some texts report that less than 20  of dorsal tilt is stable for closed

reduction of a Colles’ fracture [30,33] ; however, the reduction needs to be  close to anatomic alignment. Laboratory studies demonstrate that alteration

of palmar inclination by 20  or more can cause dorsal shift in the scaphoid

and lunate, leading to decreased range of motion and high pressure areas on

the distal radius [34] . In an individual who normally has 11  of palmar

tilt, the maximum acceptable alteration in palmar inclination is 9  of dorsal

tilt. Clinical studies also demonstrate that patients who have excessive

dorsal tilt are more likely to have poor outcome. McQueen and Jaspers [35]

 reported on 30 patients who had a Colles’ fracture at 4 years follow-up.

Patients who had as little as 10  dorsal tilt were much more likely to have

pain, stiffness, weakness, and poor function.

Fractures may ‘‘settle’’ or displace in the cast. If healing occurs with

a displaced fracture fragment, wrist range of motion will be compromised. A

distal radius fracture that is considered stable is managed with a short arm

cast, but must be followed with weekly radiographs for at least 3 weeks to

ensure that the fracture does not displace in the cast. If cast immobilization

is not able to maintain less than 10  of dorsal radial inclination and less than

5 mm radial shortening, internal fixation is recommended [30] .

Some surgeons are electing to manage even traditionally stable distal

radius fractures with internal fixation. The reason seems to be twofold. The

closer to anatomical alignment the fracture is maintained, particularly in

palmar tilt, the better the outcome. Also, ‘‘stable’’ fractures may displace

with cast immobilization, termed ‘‘secondary instability,’’ and require

internal fixation. In a prospective radiological study performed on 170

Colles’ fractures that were treated with closed reduction and cast

immobilization [36] , 29 fractures displaced, requiring further reduction

and external fixation. Seventeen additional fractures suffered malunion,

with significant increase in radial angulation and decrease in radius length.

Common distal radius fractures in children include torus, greenstick, and

physeal fractures. A torus fracture occurs when the tough periosteum, while

remaining intact, buckles circumferentially at the fracture site. If one side of

the periosteum buckles but the other side breaks, it is called a ‘‘greenstick’’

fracture. Physeal injuries are typically classified radiographically using the

Salter-Harris classification. Type I fracture is a disruption of the physis.

Type II is a fracture through the physis extending obliquely through the

metaphysis. Type III is an intra-articular fracture through the epiphysis that

extends across the physis to the periphery. Type IV fractures cross the

epiphysis, physis, and metaphysis. Type V fractures are compression injuries

of the physis, typically diagnosed retrospectively due to growth disturbance.

Type III and IV fractures are also at risk of growth disturbance, and

frequently require surgical fixation. Stable distal radius fractures (eg, torus

fracture, Salter I or II fractures) may be treated in a short arm cast for 4 to

6 weeks, followed by protective splinting and rehabilitation [31] . A

protective splint should be used upon return to sports for at least 2 weeks.

Intra-articular, comminuted, angulated, or shortened fractures, or those

that demonstrate loss of radial inclination, may require operative treatment  and should be managed by an orthopedist. Salter-Harris III–V injuries

require orthopedic consultation.

A related injury, a stress injury to the distal radius physis, has been

reported in high-level gymnasts. This stress fracture should be suspected in

the athlete who presents with dorsal wrist pain made worse by stress

loading, such as vaulting or hand-walking. There is no history of acute

trauma or loss of motion, and examination reveals tenderness over the distal

radial epiphysis. Radiographs may be normal or may demonstrate widening

or haziness of the epiphysis [37] . Treatment is immobilization, followed by

wrist range-of-motion and strengthening rehabilitation. Noncompliance or

inappropriate treatment places the athlete at risk for growth disturbance of

the distal radius.

Scaphoid fracture

 Clinicians must have a high index of suspicion for scaphoid fracture when

presented with the complaint of radial wrist pain in any contact-sport

athlete. The scaphoid bone is unique for two reasons. First, it spans both the

proximal and distal carpal row, making an intact scaphoid imperative for

carpal stability. Second, the scaphoid relies on an interosseous blood supply

from branches of the radial artery that enter the scaphoid distal to the

middle third and provide the sole blood supply to the proximal pole [38] .

Therefore, fractures through the proximal third disrupt the blood supply

and are prone to osteonecrosis and nonunion.

Scaphoid fractures are most common in those aged 15 to 30 years, and

are rare under the age of 10 [39] ; however, among wrist injuries in children,

the scaphoid is the most commonly fractured bone, accounting for over

70% of all carpal fractures [3] . FOOSH while skating, skateboarding, and

bicycling is often the mechanism of injury. Physical examination may

reveal tenderness over the scaphoid in the ‘‘anatomic snuff box,’’ and

tenderness over the scaphoid tuberosity in the palm or at the scapholunate

area distal to Lister’s tubercle dorsally. Scaphoid compression tenderness

may be elicited by applying axial pressure to the scaphoid via the first

metacarpal. Usually there is no swelling or ecchymosis. Wrist range of

motion may be only slightly decreased. Initial wrist radiographs should

include PA in neutral position, PA in ulnar deviation (scaphoid view),

lateral with wrist in neutral, 45  pronated oblique, 45  supinated oblique,

and anteriorposterior clenched fist. The ulnar deviation performed for the

scaphoid view (Fig. 9 ) distracts unstable fracture fragments, allowing

visualization of the fracture. Clenched-fist views allow assessment of the

scapholunate gap, which is useful in excluding associated scapholunate

dissociation.

Most simply, fractures are divided into anatomical location: distal pole,

middle third, and proximal pole. There are several more complex classifications

of scaphiod fractures based on location and stability for healing.  One example is the Herbert Classification, outlined in Box 1 [40] . RuAN sse [41]

 also proposed that, in addition to location, the obliquity of the fracture

relative to the long axis of the scaphoid has a role in healing. Adults most

commonly sustain middle-third fractures, and children most commonly

fracture the distal pole or middle third (Fig. 10 ) [3,38] . Distal fractures heal

most rapidly, often within 6 weeks. In contrast, proximal fractures, due to

the tenuous blood supply as described above, may take 6 months [38] .

If the patient has scaphoid tenderness without radiographic evidence of

a fracture, the wrist is immobilized in a short arm thumb spica cast, with the

wrist in mild extension and the thumb interphalangeal joint free, for 10 to

14 days. Follow-up radiographs at 2 weeks may reveal bone resorption

adjacent to the fracture site, or early callus formation if occult fracture was

present. Often athletes require a more urgent diagnosis to facilitate return to

play. A bone scan, CT, or MRI may be considered for additional imaging. A  bone scan may be positive 24 hours after the injury; however, it can take 4

days for abnormal uptake to appear at the fracture site. A normal bone scan

4 days after injury is accurate in excluding scaphoid fracture [38,42] . MRI is

very sensitive and will have abnormal bone marrow signal 48 hours postfracture

[43] ; however, it may not clarify fracture displacement. CT scan

gives clearer fracture visualization, and is more accurate for determination

of displacement [43] . The eval‎uation and treatment of scaphoid fractures is

controversial and continues to evolve. One method of eval‎uating suspected

scaphoid injury is outlined in Fig. 11 .

Treatment of an acute scaphoid fracture in an athlete depends on the

location and stability of the fracture, as well as the sport and the desires of

the athlete. A scaphoid fracture is considered displaced and unstable if

displacement is 1 mm or greater, or if a step-off is visible on any radiograph

view [38] . Displacement of fractures may be difficult to recognize on

standard radiography alone; CT may be required to better define the

fracture anatomy. Although a complete, nondisplaced scaphoid fracture

may heal with cast treatment, internal fixation may be more appropriate for

the athlete because less time is required in a cast (some greater than 10 weeks

casted, versus 5 to 6 weeks if primarily surgically repaired [44] ). Nondisplaced

fracture of the distal pole and transverse incomplete fractures of

the middle third of the scaphoid are the most stable scaphoid fractures, and

the most amenable to cast treatment [45] . Some middle-third scaphoid  fractures, particularly vertical oblique fractures, are less stable, take greater

than 12 weeks to heal, and have a higher rate of nonunion. These are

primarily fixed by some surgeons [45] . Displaced fractures and proximal

pole fractures, which have a greater risk of nonunion and malunion (see

below), should be referred for operative treatment Fig. 12 .

A nondisplaced distal scaphoid fracture or incomplete fracture may be

immobilized in a short-arm thumb spica cast for 4 to 8 weeks, with followup

visits and radiograph every 2 weeks until radiographic union. Healing

time is typically 6 to 8 weeks. Nondisplaced middle-third fractures are

treated with long arm cast for 3 to 4 weeks, followed by a short arm cast for

another 6 to 8 weeks [1] . Healing takes 9 to 12 weeks, with a minimum of

3 months out of sport. Ninety to 100% of transverse, nondisplaced, middlethird

fractures will heal with casting if treatment is started within 3 weeks of  injury [46] . Delay in immobilization beyond 3 weeks from fracture has

a higher incidence of nonunion, and should be referred to an orthopedic

surgeon [47] . For some sports, such as football and soccer, a playing cast

may be used after the initial 4 weeks of casting; however, one study noted

a higher nonunion rate (39%), ultimately requiring surgery, with playing

casts, compared with a rate of 15% with traditional casting and no sports

participation [1] .

Open reduction and internal fixation has become standard for proximal

pole fractures, and is required for unstable fractures. It is also becoming

more accepted to surgically repair minimally displaced or nondisplaced

middle-third fractures, particularly for earlier return to sport, when a playing

cast is not an option [44,48].  Inoue and Shionoya [44]  compared cast

treatment of nondisplaced middle-third scaphoid fractures with internal

fixation in laborers, and noted return to work in an average of 10.2 weeks in

the cast group and 5.8 weeks in the internal fixation group, with nearly

100% union in both groups. Another study [41]  compared the effectiveness

of immediate open reduction and internal fixation with the Herbert screw

versus nonoperative treatment with a playing cast, in an athletic population.

Return to sport was earlier in the cast-treated group (4.3 weeks) than in

the surgical fixation group (8.0 weeks); however, a subsequent study [49]  demonstrated that return to sport averaged 5.8 weeks for acute midthird

scaphoid fractures. Both treatment methods yield union rates comparable

with those in other studies. The athletes in this study did not have increase

risk of nonunion secondary to participation in sports. A playing cast is an

acceptable option for a stable fracture after an initial 4 weeks of

immobilization. Internal fixation of an acute scaphoid fracture allows safe

and early return to sports between 5 to 6 weeks [1,38,44,49],  when a playing

cast is not an acceptable option and when an athlete accepts the risks of

surgery.

To summarize, patients who have proximal, displaced, angulated, or

complex scaphoid fractures (scaphoid fracture associated with distal radius

fracture, open fracture, or perilunate fracture dislocation), or those who

have delayed diagnosis or nonunion should be referred for surgery.

[공병희]

일단 사진만 봤는데!ㅎ 좋아요ㅎㅎ

[heoss]

감사합니다.

[큰목소리]

잘 보고 갑니다.