Virginia Research Day 2021

WRIST FUNCTION RECOVERY COURSE IN A SCAPHOID NONUNION FRACTURE WITH AVASCUALR NECROSIS: A CASE REPORT Arianna Vessal OMSII, Lin Shen DO, Reginald Pinder DO, Bradley McCrady DO

Edward Via College of Osteopathic Medicine, Virginia Tech Athletics, VCOM Sports and Osteopathic Medicine

The MRI showed that the fracture was indeed older and demonstrated avascular necrosis of the proximal pole. He was diagnosed with a right scaphoid fracture nonunion with proximal pole avascular necrosis. After discussion of treatment options and referral to Orthopedics, he elected to proceed with surgical treatment of the wrist.

Discussion

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. 1 Firstline treatment for a nondisplaced scaphoid fracture is typically cast immobilization. 2,3 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.

Conclusion References 1 Jennifer B. Green, et al. Hand, Wrist, and Digit Injuries. Pathology and Intervention in Musculoskeletal Rehabilitation (2 nd Edition), 2016 2 Nicholas Goddard MB, FRCS, Pediatric Carpal Fractures. Principles and Practice of Wrist Surgery, 2010 3 Chris Stutz, Peter M. Waters, Fractures and Dislocations of the Forearm, Wrist, and Hand. Green's Skeletal Trauma in Children (Fifth Edition), 2015 4 Hearnden, Anthony, et al. Scaphoid Non Union , Blackbox Ecom, 2010, www.guildfordupperlimb.co.uk/wrist/scaphoid-non-union. 5 Adams, Brian D., et al. “Scaphoid Fracture.” Orthobullets , Lineage Medical, Inc, 9 Sept. 2020, www.orthobullets.com/hand/6034/scaphoid-fracture. Two months post-operative, he was healing well in a waterproof cast which allowed him to use a kickboard while in the pool. Nonunion repair using distal radius bone graft and screw fixation was completed without complication and he is hopeful to make a full recovery. 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 schoolwork, 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.

Anatomy of the Scaphoid

The blood supply for the scaphoid is unidirectional and turbulent. When the proximal pole was separated from the blood supply, the rate of union fell to below 60%, ultimately leading to necrosis. 4,5

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