Virginia Research Day 2021

Medical Student Research Case Reports

04 Wrist Function Recovery Course in a Scaphoid Nonunion Fracture with Avascular Necrosis: A Case Report

Arianna Vessal, OMS II; Lin Shen, DO; Reginald Pinder, DO; Bradley McCrady, DO Corresponding author: avessal@vcom.vt.edu

Virginia Tech Athletics VCOM Sports and Osteopathic Medicine

Introduction: The scaphoid is the most frequently fractured bone of the wrist, accounting for 60-70% of carpal fractures, commonly occurring after a fall onto an outstretched hand. Due to the unique blood supply of the scaphoid, evidence has shown that up to 30% of scaphoid fractures may display some level of avascular necrosis, particularly of the proximal pole. Firstline treatment for a nondisplaced scaphoid fracture is typically cast immobilization.1 In this case, we will explore the course of treatment for a division 1 swimmer, who is not only on the Spanish National team but also a prospective Olympic competitor, that suffers from a nonunion scaphoid fracture with avascular necrosis. In a sport where form depends on proper wrist movement, our goal is to return full function of the wrist with minimal to no sequelae. We will also compare different treatment options and their likely outcomes, surgical techniques, and management of this wrist injury. Case Description: An 18-year-old male presented for an entrance physical and found to have right anatomic snuffbox tenderness. He had three notable

wrist injuries in the past. He had a confirmed right scaphoid fracture five years prior which was treated nonoperatively and healed. Approximately a year ago he had a significant fall on the same extremity, which was never evaluated, and then a day prior to presenting in office he had fallen on it again. In the past year he noted pain with weightbearing exercises as well as intermittent soreness and pain 5-10% of the time. He was placed in a thumb spica for protection and an x-ray was acquired demonstrating a fracture through the scaphoid. Due to his history, the age of the fracture was unclear, and therefore further imaging was warranted. The MRI showed that the fracture was indeed older and demonstrated avascular necrosis of the proximal pole. After discussion of treatment options and referral to Orthopedics, he elected to proceed with surgical treatment of the wrist. Discussion: Based on this presenting injury, there were two treatment options: conservative management and surgical fixation. A waterproof cast would have allowed a nonoperative approach with

the opportunity to continue swimming. However, there would be a risk that his wrist may not heal or continue to worsen, leading to further complications in his future. Alternatively, a surgical approach would allow a definitive fix, although it would halt his training and would risk possible change in stroke form. In any high-level athlete, our responsibility is to provide all viable options so that the patient can make an informed decision, understanding that this may impact their competitive career as well as school work, and in this case possibly the makeup of his native Olympic swim team and their prospects. Recognizing the weight of our patient’s decision is pertinent to our care for not only his physical well- being, but also his mental and spiritual wellness. Outcome: Two months post-operative, he is healing well in a waterproof cast which allows him to use a kickboard while in the pool. Surgical fixation was completed without complication and he is hopeful to make a full recovery.

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