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A carpal fracture is a break of one of the eight small bones of the wrist (carpus). These bones are the scaphoid, lunate, capitate, triquetrum, hamate, pisiform, trapezium, and trapezoid.
Fractures of a carpal bone usually do not involve a break in the skin (closed fracture). Carpal fractures may be either stable or unstable. The fragments can be out of the normal positioning (displaced) or in normal alignment (nondisplaced). Carpal fractures can occur with or without joint dislocation. Minimally displaced fractures are the most common.
The usual cause of a carpal fracture is a fall onto the outstretched hand. Other causes include a motor vehicle accident (when the individual straightens the arm for protection before an impact), collisions between sports participants, or a sudden blow to the palm by a baseball bat or golf club. Carpal fractures are fairly common injuries in athletes. Stress fractures of the carpal bones can occur in individuals experiencing repetitive trauma such as those who use a jackhammer.
The specific carpal bone that is fractured depends on the position of the hand at impact and the exact forces exerted on the hand. For example, when golf clubs, baseball bats, or sports racquets mistakenly strike a stationary object with great force, the hooked portion of the hamate bone can fracture. The scaphoid is the most frequently fractured carpal bone. Scaphoid fractures are the most disabling, require more prolonged treatment (surgery is common), and are more prone to complications than fractures of the other carpal bones.
The triquetrum is the second most common carpal fracture. The triquetrum is usually fractured due to a fall on the outstretched hand with the wrist in ulnar deviation.
The lunate is the third most common carpal fracture (Hoynak). Fracture of the lunate can lead to Kienböck's disease (lunate osteonecrosis or avascular necrosis) where the bone becomes soft, granular, and fragmented. Kienböck's disease is thought to be due to repetitive stress.
Risk: Individuals at risk for sustaining a carpal fracture include athletes, laborers, and those whose activity places them at risk for high impact repetitive hand or wrist trauma (e.g., use of a jackhammer, participation in gymnastics). Incidence and Prevalence: Carpal bone fractures account for 18% of hand fractures (Kouris). The bones of the proximal carpal row are the most frequently fractured. The scaphoid accounts for 60% to 70% of all carpal fractures (Hoynak). This type of fracture occurs at a high incidence in football players, at 1 per 100 players per year (Steinberg).
About 345,000 scaphoid fractures occur annually in the US (Boles). These fractures occur most often to individuals between the ages of 15 to 60 years (Boles).
Scaphoid fractures account for 10% of all hand fractures. The incidence of fracture of each of the remaining carpal bones is low—between 0.2% and 5% (Kouris). |
Source: Medical Disability Advisor
| History: The individual reports a trauma, most commonly a fall onto the hand that is immediately followed by wrist pain. The individual may experience decreased grip strength or pain while moving the wrist. Physical exam: Swelling (edema), bruising (ecchymosis), and localized tenderness may be evident at the site of injury. The wrist may appear visibly deformed. The injured hand is compared closely with the uninjured (contralateral) one. The arm and elbow are examined for any signs of associated injury. Pain caused by pinching the thumb or pressing the triangular depression at the lateral side of the wrist (anatomical snuff box) is characteristic of a fractured scaphoid bone. Range of motion in the wrist is limited, with pain at the extremes of motion. Instability of the wrist can be demonstrated by several stress tests. Numbness and weakness may occur in the distribution of the median nerve on the palm side of the thumb and the index and long fingers. Tests: Plain x-rays can diagnose most carpal fractures. Special views may be required for some of the carpal bones, but despite careful attention, a carpal fracture can easily be missed or belatedly diagnosed. A repeat plain x-ray taken 1 to 2 weeks after injury may detect a subtle scaphoid fracture not visible on x-rays taken on the day of injury. Stress x-rays can demonstrate an unstable fracture.
Occasionally other tests such as a CT scan, MRI, or a bone scan may be needed if pain persists and plain x-rays remain normal. |
Source: Medical Disability Advisor
| Treatment of nondisplaced fractures usually consists of immobilization of the wrist in a cast extending from the proximal forearm to just above (proximal to) the knuckles, leaving the thumb and fingers free to move. However, if the scaphoid bone is involved, the cast often extends above the elbow for the first 6 weeks, and also incorporates the thumb. Follow-up x-rays are needed to monitor healing and detect any displacement of the fracture (loss of the reduction). The wrist may be immobilized for up to 3 to 4 months.
Fractures where the bones have moved out of alignment (displaced fractures) and or do not stay aligned (unstable fractures) often require surgery (open reduction) to re-align the bones, ensure proper healing, and restoration of function. This surgery is usually an open procedure (arthrotomy), but some surgeons prefer to reduce wrist fractures arthroscopically, using minimally invasive incisions and a pencil-sized camera and lens (arthroscope). Surgery may involve external or internal fixation with pins, wires, screws, or plates, especially if there is also a fracture of the lateral forearm bone (distal radius) extending into the wrist joint. The hardware may need to be removed later.
A bone graft may be done when the bone is broken into many pieces (comminuted fracture) with bone loss, especially if the joint with the thumb is involved. When fracture healing is delayed (delayed union) or has failed (nonunion), electromagnetic bone stimulation may be used. Bone grafting also may be done for nonunion. Other late surgery for post-traumatic arthritis or avascular necrosis may involve fusion (arthrodesis) or removal of several wrist bones (proximal row carpectomy). |
Source: Medical Disability Advisor
| About 90% of scaphoid fractures heal in 8 to 12 weeks when treated in a timely fashion (Boles), but malalignment can occur, even with surgery, and some wrist stiffness is common. Lunate fractures are rare but usually heal. Fractures of the other carpal bones have a generally satisfactory outcome. Surgical treatment of carpal fractures has a favorable outcome. Nonunion, avascular necrosis, or post-traumatic arthritis of a carpal fracture may lead to permanent disability. |
Source: Medical Disability Advisor
| Note on research and authorship The duration and type of rehabilitation for a carpal fracture is related to the location, type and severity of the fracture. The most common fracture of the carpal bones is a scaphoid fracture. Protocols for rehabilitation of fractured carpal bones must be based upon stability of the fracture and fracture management (operative, nonoperative). As with all fractures, resumption of pre-injury status is the goal with consideration of any residual deficit. Hand dominance and the involved extremity will greatly influence the individual's degree of disability. Rehabilitation may be administered by a physical therapist, occupational therapist or hand therapist (Bucholz; Cooney; Dell; Koval).
The goal of rehabilitation is to decrease pain and to return the individual to full function with a painless wrist. Local cold application may be beneficial for controlling pain. As blood supply to the bone may be compromised due to the trauma associated with the fracture, immobilization may be required for at least six weeks. Rehabilitation primarily emphasizes restoring full range of motion and strength while maintaining independence in as many of the activities of daily living as is possible. Range of motion exercises of the adjacent joints may be beneficial unless contraindicated based on fracture stability. When indicated, range of motion and strengthening exercises should be started at the wrist and hand. Exercise intensity and difficulty should progress until full function is achieved. Rehabilitation must emphasize functional use of the hand, which includes the therapist's assessment of the individual's ability to perform activities of daily living (Dell).
If the carpal fracture is operatively managed, the rehabilitation protocol will be guided by the treating physician.
Bone healing may occur within 6 to 18 weeks; however the bone strength and the ability of the bone to sustain a heavy load may take up to several years (Chapman). Once healing has occurred, the individual may resume full activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician. |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical ‡ | |
| Physical, Occupational or Hand Therapist | | Up to 24 visits within 10 weeks | | | | | | | | Surgical | |
| Physical, Occupational or Hand Therapist | | Up to 16 visits in 8 weeks | |
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| ‡ Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture. |
| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Incorrect alignment (malunion), nonunion (especially the scaphoid), delayed union, and collapse of the bone (avascular necrosis) can occur. For example, the scaphoid has a 10% to 15% rate of nonunion, as well as frequent malunion (Boles). The hamate fracture is difficult to detect on x-ray and may not show x-ray (radiographic) changes until much later, when it is more difficult to treat.
Joint pain, stiffness, limitation in wrist movement, and weakness of grip can persist. There can be wrist instability and post-traumatic arthritis, especially if there is also an associated fracture of the radius. As a late complication, post-traumatic arthritis can damage the tendons to the fingers with the possibility of tendon rupture.
A median nerve injury can result from excessive flexion of the wrist in a cast, by direct injury, stretching, or compression from bleeding. Carpal tunnel syndrome can occur. Pressure on the local blood vessels from swelling while wearing a cast can result in compartment syndrome that can cause permanent muscle and nerve damage and persistent clawing of the fingers. Shoulder stiffness and pain can develop if the arm stays immobile in a sling after the injury (shoulder-hand syndrome). Complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy (RSD), is a serious complication with potential long-term disability. |
Source: Medical Disability Advisor
| Immobilization in a cast strictly limits use of the injured arm. The individual is temporarily unable to lift and carry heavy or bulky objects, operate equipment, drive a motor vehicle, or perform other tasks that require use of both hands. Some individuals may find ergonomically adjusted or pneumatic tools useful during the healing period. If the dominant arm or hand is affected, the individual may be unable to write legibly or type well. In some cases, alternatives to a standard keyboard, such as speech recognition software or one-handed keyboards, may be appropriate accommodations. Likewise, carpal fracture in the dominant hand affects fine motor skills such as those needed to work in a laboratory or on an assembly line. Therefore, individuals whose dominant arm or hand is affected may require a temporary or permanent reassignment of duties. After the cast or splint is removed, work may have to be temporarily modified to allow for stiffness, weakness, and lack of endurance in the hand and shoulder. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Did individual present with a sudden onset of pain in the wrist?
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Has diagnosis of carpal fracture been confirmed through plain x-rays?
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If fracture was not visible on plain x-ray films, were repeat films taken 1 to 2 weeks later? Were at least four different views obtained?
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If plain x-rays were negative for carpal fracture even though the symptoms strongly suggested a fracture, were MRI, CT, or bone scans conducted?
Regarding treatment:
- Was fracture nondisplaced? If so, were closed reduction and immobilization indicated?
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Has fracture failed to heal even after 3 to 4 months of immobilization in a cast?
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Were follow-up x-rays done to monitor healing?
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Has individual experienced any complications related to fracture or treatment of fracture (malunion, nonunion, avascular necrosis, nerve injury, etc)? If so, have complications been addressed in the treatment plan?
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Did surgery involve external or internal fixation with pins, wire, screws, or plates?
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Will hardware need to be removed later?
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Was bone graft required?
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If needed, has individual received physical or occupational therapy?
Regarding prognosis:
- Does individual have an underlying condition (i.e., osteoarthritis, rheumatoid arthritis, or associated injuries) that may affect recovery?
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Did individual have an established nonunion from a previous, undiagnosed injury that was aggravated by a recent injury?
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Does a nonunion of the carpal fracture persist despite appropriate treatment and adequate time for healing?
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Has avascular necrosis occurred?
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Is individual now a candidate for surgical intervention?
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Has individual experienced any long-term potentially disabling sequelae (nerve injury, regional pain syndrome) from the fracture?
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Source: Medical Disability Advisor
| Boles, Carol A. "Wrist, Scaphoid Fractures and Complications." eMedicine. Eds. Bernard D. Coombs, et al. 16 Nov. 2007. Medscape. 4 Feb. 2009 <http://emedicine.com/radio/topic747.htm>.Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, 2002. Chapman, Michael W. Chapman's Orthopaedic Surgery. Philadelphia: Lippincott, Williams & Wilkins, 2001. Cooney, W. P. "Scaphoid Fractures: Current Treatments and Techniques." Instructional Course Lectures 52 (2003): 197-208. National Center for Biotechnology Information. National Library of Medicine. 26 Nov. 2008 <PMID 12690849>. Dell, P. C., and R. B. Dell. "Management of Carpal Fractures and Dislocations." Hunter - Mackin - Callahan Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002. 1171-1184. Hoynak, Bryan, and Laura Hopson. "Fractures, Wrist." eMedicine. Eds. Michelle Ervin, et al. 6 Sep. 2007. Medscape. 4 Feb. 2009 <http://emedicine.medscape.com/article/828746-overview>. Kouris, George J., and Robert R. Schenck. "Carpal Fractures." eMedicine. Eds. Michael S. Clarke, et al. 12 Mar. 2008. Medscape. 4 Feb. 2009 <http://emedicine.medscape.com/article/1238278-overview>. Koval, K. J., and Joseph Zuckerman. Handbook of Fractures. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins, 2002. Slade, J. F., J. N. Grauer, and J. D. Mahoney. "Arthroscopic Reduction and Percutaneous Fixation of Scaphoid Fractures with a Novel Dorsal Technique." Orthopedic Clinics of North America 32 2 (2001): 247-261. National Center for Biotechnology Information. 1 Apr. 2001. National Library of Medicine. 4 Feb. 2009 <PMID: 11331539>. Steinberg, R. B. "Acute Wrist Injuries in the Athlete." Orthopedic Clinics of North America 33 3 (2002): 535-545. National Center for Biotechnology Information. 1 Jun. 2002. National Library of Medicine. 4 Feb. 2009 <PMID: 12483949>. |
Source: Medical Disability Advisor
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