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Simultaneous Fractures of the Ipsilateral Scaphoid and Distal Radius

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Simultaneous Fractures of the Ipsilateral Scaphoid and Distal Radius Scientific Article 303 Simultaneous Fractures of the Ipsilateral Scaphoid and Distal Radius Timothy P. Fowler, MD1 Elizabeth Fitzpatrick, MD1 1 Department of Orthopaedics and Rehabilitation, Address for correspondence Timothy P. Fowler, MD, Department of University of Iowa Hospitals and Clinics, Iowa City, Iowa Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242-1009 J Wrist Surg 2018;7:303–311. (e-mail: [email protected]). Abstract Background Ipsilateral fractures of the distal radius and scaphoid are rare, with few reports describing mechanisms of injury, fracture patterns, and treatment approaches. Purpose This article describes the clinical and radiographic features of ipsilateral distal radius and scaphoid fractures occurring simultaneously. Materials and Methods Electronic databases from 2007 to 2017 at a single Level 1 trauma center were reviewed for patients with concurrent fractures of the distal radius and scaphoid. Patient demographics, injury mechanism, scaphoid and distal radius fracture pattern, treatment approach, and radiographic healing were studied. Results Twenty-three patients were identified. Nineteen of the 23 (83%) were males, and 19 of 23 (83%) of the injury mechanisms were considered high energy. Twenty-two of the 23 (96%) scaphoid fractures were nondisplaced, all treated with screw fixation. Most distal radius fractures were displaced and comminuted, 17 of 23 (74%) were intra- articular. All distal radius fractures were treated surgically with internal and/or external fixation. Three patients were lost to follow-up. Average follow-up of the remaining 20 was to 19.8 weeks. Nineteen of the 20 (95%) scaphoids healed, one scaphoid went on to nonunion with avascular necrosis. All 20 radius fractures healed, 16 of 20 (80%) in anatomic alignment. Conclusion Ipsilateral fractures of the distal radius and scaphoid are rare and are usually result of high-energy mechanisms. The scaphoid fracture is usually a non- Keywords displaced fracture at the waist. The distal radius fracture pattern varies but most are ► distal radius fractures displaced and comminuted. The union rate of the scaphoid is high, even if subjected to ► scaphoid fractures radiocarpal distraction required for distal radius management. ► ipsilateral fractures Level of Evidence Therapeutic level IV study. Simultaneous fractures of the ipsilateral scaphoid and distal rates of, and decrease time to, fracture healing resulting in – This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. radius are rare. The relatively few published reports on this shorter convalescence,15 17 although this remains a subject – injury combination demonstrate varying patient demo- of debate.18 20 – graphics, injury mechanisms, and modes of treatment.1 13 Simultaneous fractures may necessitate use of competing Classification schemes and treatment methods for both forms of fracture stabilization, since traction is usually fractures have evolved during this time period, most notably applied to reduce distal radius fractures and scaphoids are influenced by the introduction of volar locking plates for compressed. Some have expressed concern over displacing a distal radius fractures in 2002.14 Minimally displaced sca- fractured scaphoid when reducing a distal radius or using phoid fractures treated with screw fixation may increase distal radius external fixation.5,6 received Copyright © 2018 by Thieme Medical DOI https://doi.org/ October 6, 2017 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0038-1641719. accepted after revision New York, NY 10001, USA. ISSN 2163-3916. March 6, 2018 Tel: +1(212) 584-4662. published online April 10, 2018 304 Simultaneous Fractures of the Ipsilateral Scaphoid and Distal Radius Fowler, Fitzpatrick The purpose of this retrospective study is to describe the other 17 (74%) sustained other injuries including head simultaneous scaphoid and distal radius fractures that pre- injuries (10), spine or pelvic fractures (6), other upper or sented to a single Level 1 trauma center since 2007, noting lower extremity fractures (8), and one brachial plexus avul- fracture patterns, mechanisms of injury, treatment approach sion injury. All patients identified were treated surgically, and complications, and radiographic healing rate. addressing both the scaphoid fracture and the distal radius fracture (►Table 1). Materials and Methods Plain radiographs were used to determine the scaphoid fracture location and presence of displacement. Given the Patients presenting to our institution with acute injuries to lack of consensus regarding the utility of scaphoid fracture the upper limb were eligible for inclusion in this report. classification systems,21 fractures were descriptively classi- Electronic billing databases from 2007 to 2017 were fied by location, noting any comminution or fracture line searched to identify patients assigned International Classi- extension. Fractures were classified as displaced if > 1mm fication of Diseases (ICD) diagnosis codes (813/814 group- of translation or angulation was present in any plane. The ings) and/or Current Procedural Terminology (CPT) codes scaphoid fracture was a nondisplaced fracture in 22 patients (25628 þ25606/25607/25608/25609/20690) for scaphoid (96%), and a displaced fracture in 1. The scaphoid fractures and distal radius fractures occurring on the same encounter. were located at the waist in 17 cases and at the junction ICD codes were assigned by certified coding specialists based between the waist and the proximal one-third in 4 cases. In on clinic documentation. CPT codes were assigned by the the remaining 2 cases, the fracture was at the junction coders with oversight and approval by the treating physician. between the waist and the distal one-third, and both of Patients with simultaneous fractures of both bones to the these had a fracture line that extended distally toward the ipsilateral limb were identified. Patients presenting with triscaphe joint. In all cases, the scaphoid fracture was treated perilunate dislocations were excluded. The clinical and via internal fixation with a headless compression screw. radiographic record for each of these patients was reviewed. Twenty of the 23 screws were placed from a dorsal starting Demographic information, mechanisms of injury, concomi- point (antegrade), and 3 from a volar starting point (retro- tant injuries, scaphoid fracture pattern, distal radius fracture grade) based on surgeon preference. pattern, method of treatment, and radiographic healing was Plain radiographs were used to characterize and classify the recorded. Distal radius and scaphoid fractures were classi- distal radius fractures. Six were extra-articular and classified fied by both a board-certified hand surgeon and senior as Arbeitsgemeinschaft Osteosynthesefragen/Association for orthopaedic resident. This study was approved by the Uni- the Study of Internal Fixation (AO/ASIF) 23A1 in 1 case and versity of Iowa Hospitals Institutional Review Board. 23A3 in 5 cases. The 17 intra-articular fractures classified as AO/ASIF 23B1 in 3 cases, 23C2 in 7 cases, and 23C3 in 7 cases ► Results ( Fig. 1). The distal radius fracture was addressed with a volar plate only in 14 cases, a volar plate supplemented by a dorsal The database search yielded a total of 33 skeletally mature bridge plate in 2 cases, a dorsal bridge plate only in 1 case, an patients. Three patients were excluded because their wrist external fixator and a volar plate in 1 case, an external fixator injury included a perilunate dislocation. An additional seven and supplemental percutaneous pins in 3 cases, and external patients were excluded because they did not meet the criteria fixator alone in 1 case, and percutaneous pins alone in 1 case. In of having simultaneous, ipsilateral distal radius and scaphoid all cases inwhich a bridge plate or an external fixator was used, fractures. Several of these patients had distal radius fractures the compression screw in the scaphoid was placed first. In all and scaphoid fractures in separate encounters, or a chronic cases in which a volar plate was used, the compression screw scaphoid injury with an acute distal radius fracture, which lead was placed after scaphoid internal fixation (►Fig. 2). In two to their erroneous inclusion. Thus, twenty-three patients were cases, the distal radioulnar joint (DRUJ) was unstable after identified with simultaneous fractures of the ipsilateral sca- distal radius internal fixation. This was treated by reducing and phoid and distal radius for this 10-year period. Our search did cross-pinning the DRUJ in 1 patient, and reducing and repair- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. not yield concomitant injuries in any skeletally immature ing the ulnar styloid/triangular fibrocartilage complex (TFCC) patients. During this same period, 2,999 skeletally mature in the other patient. A triquetral avulsion fracture was present patients underwent treatment of an isolated distal radius in 1 case and ulnar styloid fracture in 11 cases. No other fracture and 446 skeletally mature patients underwent treat- concomitant carpal injuries were identified. Computed tomo- ment for an isolated scaphoid fracture. graphy (CT) scans were not performed preoperatively. The average age of the patients was 37 years, with a range Three patients (13%) presented with symptoms suggestive of 19 to 74 years. Only 3 patients were aged 60 years or older.
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