The Conservative and Operative Treatment of Carpal Fractures

Background: Carpal fractures (incidence: 30–60 per 100 000 persons per year) are one of the more commonly overlooked fracture types. They can have serious consequences, as the use of the hand is indispensable in everyday life. In the following article, we present the elements of the diagnosis and treatment of fractures of the carpal bones.

Methods: This review is based on meta-analyses and randomized controlled trials (RCTs) published from 2013 to 2023 that were retrieved by a structured literature search, supplemented by guideline recommendations and expert consensus statements. In addition, data on the administrative prevalence of carpal fractures were obtained from the German Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung, KV) and from the German Statutory Accident Insurance (Deutsche Gesetzliche Unfallversicherung, DGUV).

Results: The administrative prevalence of carpal fractures in 2022 was 44 496 outpatient cases (KV, DGUV) in one year. After clinical history-taking, physical examination and x-ray have been performed, thin-slice computed tomography is recommended as part of the diagnostic evaluation. Treatment recommendations are based on evidence of levels II to IV. Multiple RCTs have been carried out on the treatment of scaphoid fractures, and a clinical guideline exists. Proximal, dislocated and unstable scaphoid fractures should be treated surgically. Non-displaced or minimally displaced fractures of the middle third of the scaphoid bone require a shorter period of immobilization with surgical treatment (2–4 weeks) than with conservative treatment (6–8 weeks). The use of plaster casts that do not hinder elbow and thumb mobility yields healing rates similar to those obtained with the immobilization of both of these joints. Failure to treat an unrecognized scaphoid fracture can lead to pseudarthrosis, avascular bony necrosis, and misalignment. Other, rarer types of carpal fractures must be managed on an individual basis, as the available evidence is limited to expert consensus.

Conclusion: Early recognition and appropriate treatment of carpal fractures lead to healing in more than 90% of cases. Although the available evidence on their proper treatment is growing, many questions are subject to expert consensus, and decisions about treatment must be made individually.

Fractures of the carpal bones, especially scaphoid fractures, can have serious consequences for the function of the human hand as a tactile and grasping organ (1, 2). Furthermore, the majority of them affect people of working age, which is why these fractures are of such socio-economic relevance (3, 4).

Carpal fractures account for around eight percent of all hand fractures and, with an incidence of around 30 to 60 per 100 000 population, are among the least common fractures in humans (1, 5, 6). In 2022, 43 625 outpatient cases of carpal fractures were registered in Germany by the Central Research Institute of Ambulatory Health Care (Zi) and 871 cases by the German Statutory Accident Insurance (DGUV). The Zi found that slightly more than one half (53.1%) of these were scaphoid fractures, while the literature states the proportion of scaphoid fractures to be 51 to 90% (7, 8). The majority of carpal fractures (71.3%) are sustained by men, with 71 to 86% of patients affected being younger than 60 years of age (7, 8). In around 85% of cases, the cause is a fall on the outstretched hand (4). Because of the complex anatomy, carpal fractures are also commonly overlooked during conventional diagnostic investigations: The proportion of missed scaphoid fractures is estimated at up to 30% (eBox 1) (9).

eBox 1

Characteristics common to carpal fractures according to Garcia-Elias

For this reason, the current review article is focused on the elements of the diagnosis and treatment of fractures of the carpal bones. Given their functional relevance, it is also essential that colleagues who do not specialize in hand surgery are familiar with carpal fractures.

Methods

After registration (PROSPERO: ID CRD42023479061), this review article began with a literature search. It was based on the PICO framework and the PRISMA criteria and included meta-analyses and randomized controlled trials (RCTs) published from 2013 to 2023 (Table, eTable) (7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22).

Table

RCTs and meta-analyses on the treatment of carpal fractures

eTable

Included studies

Enquiries were made to the Central Research Institute of Ambulatory Health Care (Zi) and the DGUV to establish the current number of cases in Germany.

A detailed presentation of the literature searches can be found in the supplementary section (eFigure, eMethods).

eFigure

Identification of studies via databases

Basic anatomical principles

The proximal row of eight carpal bones comprises from radial to ulna the scaphoid, the lunate, the triquetrum, and the pisiform as a sesamoid, while the distal row consists of the trapezium, the trapezoid, the capitate, and the hamate. The carpal bones are located between the bases of the five metacarpal bones and the radius and ulna and form the radiocarpal and ulnocarpal joints, the midcarpal and the intercarpal joints as well as the basal joint of the thumb. This kinetic chain is stabilized by a total of around 33 ligaments. Not only does it allow a stable transfer of power from the forearm to the metacarpus and a high degree of mobility of the wrist but also mobility of the thumb, which is fundamental for the grasping function of the human hand (23). The scaphoid has a special position, as it acts as a mobile connection between the proximal and distal carpal rows and as such plays a key role in stabilizing the midcarpal joint. It preserves the “carpal height”, which is the distance between the base of the third metacarpal (MC) and the distal articular surface of radius (1, 4, 5, 24, 25). Furthermore, 70 to 80% of the scaphoid is covered by cartilage. This bone has a special blood supply situation, especially to its proximal part. Blood flow is only present in the waist from distal to palmar, as only here does the scaphoid possess a periosteal covering. This is why the scaphoid is at an increased risk of non-union and posttraumatic avascular necrosis (Figure 1) (3, 26, 27).

Figure 1

Vascularity of the scaphoid, shown from dorsal, with branches of the radial artery

Diagnostic investigations

Taking an appropriate case history includes, in particular, noting symptoms and mechanism of the accident (Figures 2 and 3). Clinical examination will reveal swelling and tenderness, both on palpation and movement, corresponding to the fracture site. The proximity of adjacent vessels, nerves, and tendons renders essential an additional assessment of circulation, sensory and motor function (CSM) (1, 5). With palpatory accuracy of the landmarks of the carpal bones being only 30 to 88%, the “polyarticular mosaic” of the carpus renders it difficult to precisely narrow down the localization of the fracture, even for the expert. For this reason, additional radiological diagnostic assessment becomes indispensable (2). X-ray examination of the wrist in two planes is fundamental for assessing the carpal structures (sensitivity: 70%, specificity 70 to 85%) (9). In addition, Stecher’s view in ulnar deviation with a closed fist is recommended when a scaphoid fracture is suspected. Additional special radiographic images, however, are not necessary, considering that computed tomography (CT) is readily available nowadays (9, 28). A thin-slice CT scan demonstrates the carpal bones exactly, not only to verify a clinically suspected fracture, but is also recommended once a carpal fracture has been confirmed for purposes of classification, assessment of associated injuries and degree of displacement, as well as for exact planning of treatment (sensitivity: 85 to 95%, specificity 95 to 100%) (9, 25, 28). With the arm positioned above the head, radiation exposure for CT is 0.03 mSi. This is equivalent to about one week of background radiation (29).

Figure 2

Fall on the hyperextended wrist

Figure 3

Different fracture sites on the scaphoid

Intraspongious fractures and ligament injuries which are occult on CT imaging, however, can be demonstrated with the aid of magnetic resonance imaging (MRI); on the other hand, MRI is inferior to thin-slice CT scan for assessing fractures (3).

Treatment and results

A search of the literature (level of evidence II to IV) shows that, in addition to a national guideline, several RCTs and meta-analyses are also available for scaphoid waist fractures comparing a surgical with a conservative approach (5, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22). As regards the other carpal bones, there is only one meta-analysis available on acute perilunate injuries, while the others refer to retrospective cohort studies and case reports (eTable) (11).

Scaphoid fractures

In 60 to 69% of cases, the fracture is located in the middle third (the waist) of the scaphoid, followed by the distal third (17 to 32%), and lastly the proximal third (3 to 16%) (3, 30). Herbert’s classification as modified by Krimmer is currently the most common classification for scaphoid fractures. It is based on CT morphological criteria and is fundamental for deciding treatment (Figure 4). The decision between operative and conservative management is based on fracture site, displacement, degree of comminution, associated instability, acceptance by the patient of the required period of immobilization, and functional demand (3).

Figure 4

Krimmer’s computed tomography-based classification of scaphoid fractures based on Herbert

Conservative management

Only type A stable scaphoid fractures, which account for 31.1%, are suitable for conservative management (31). A splint or a split plaster cast should be applied for primary immobilization until soft tissue swelling has resolved. This is followed by definitive immobilization in a circumferential cast with slight dorsal extension of the wrist (3). Whereas the metacarpophalangeal joints should be spared immobilization, there is some controversy concerning inclusion or exclusion of the thumb: Recent meta-analyses show that inclusion of the thumb offers no advantage for fracture consolidation (14, 17).

Depending on the fracture site, immobilization for four weeks is sufficient for type A1 fractures, while type A2 fractures should be immobilized for six to eight weeks. Before the immobilization period is over and depending on the clinical assessment, yet after four to eight weeks at the latest, fracture consolidation should be verified radiologically (9, 28). Immobilization should not exceed 12 weeks to avoid stiffness and associated imminent loss of wrist function. If the fracture persistently fails to heal, the alternative of surgical treatment should be planned. This will result in healing of minimally displaced fractures in over 90% of cases (3, 14, 17).

Surgical treatment

Surgical treatment is indicated for Krimmer type B scaphoid fractures and above, due to the instability of the fracture (28). Standard care comprises minimally invasive anatomical reconstruction with a cannulated double-threaded screw which is fully buried in the cancellous bone. In principle, the screw may be inserted antegrade from dorsal or retrograde from palmar for fractures of the middle third, whereas fractures of the proximal third should be managed with an antegrade approach (eFigures 1 and 2) (28). Recent data show no superiority between the different access routes with regard to nonunion rates (non-consolidation rates) (3 to 4%), functional outcome, and complications (eTable) (10, 20). Navigated management to optimize screw placement has so far brought no improvement to outcome results. Indeed, operating time is significantly longer, and radiation exposure is increased (12). If a bone defect or cystic changes within the scaphoid are present, a corticocancellous or cancellous bone graft should be inserted after debriding the fracture site (28).

eFigure 1

40-year old (male) patient with a proximal scaphoid fracture

eFigure 2

21-year-old (male) patient with a scaphoid waist fracture

There is international consensus on the recommendation of conservative treatment for distal fractures and recommendation of surgical treatment for proximal scaphoid fractures. However, there is some controversy concerning to what extent middle-third scaphoid fractures with a displacement of less than one to two millimeters benefit from surgical management or aggressive non-surgical treatment as with type A2 fractures. Surgical treatment can indeed result in a more rapid return to work and faster time to union, the functional outcome and nonunion rates are comparable, while the minor complication rates are increased (7, 8, 13, 15, 16, 18, 19, 21, 22, 32). Shen et al. demonstrated that the number needed to treat (NNT) in order to prevent one delayed union is 20 (13). From the patient’s perspective, a potentially more rapid return to work due to an operative approach can be highly relevant.

Complications

Apart from general perioperative complications such as infection, soft-tissue damage, bleeding, adhesions, and the development of complex regional pain syndrome (CRPS), scaphoid fractures carry in particular the risk of nonunion and avascular bone necrosis (32, 33). A detailed presentation of the complications can be found in the supplement section (eBox 2).

eBox 2

Complications

Fractures of the triquetrum

Fractures of the triquetrum are the second most common carpal fractures at 10 to 15% (1, 5, 34). A distinction is made between fractures of the dorsal and palmar cortex as well as triquetral body fractures. Ninety-three percent are due to chip fractures which are the result of either a bony avulsion of the dorsal V-ligament (dorsal intercarpal ligament) or a forced dorsal extension of the wrist which produces a chisel action of the ulnar styloid upon the dorsum of the triquetrum (1, 5, 35, 36). Palmar fractures are an indication of an avulsion of the lunotriquetral (LT) ligament, which can result in functional malalignment of the proximal carpal row with palmar rotation of the lunate (palmar intercalated segment instability, PISI). As with DISI malalignment, this can lead to carpal collapse (scapholunate advanced collapse, SLAC wrist) (1, 37). Triquetral body fractures are the consequence of high-energy trauma. They can result in a clinically relevant dislocation and therefore require exclusion of associated ligament and dislocation injuries (1, 36).

Therapy focusses on restoring carpal stability, particularly with palmar fractures. Small dorsal and undisplaced fractures may be immobilized with a splint for three to six weeks, while displaced and unstable fractures as well as large dorsal fragments should be surgically stabilized. This is usually accomplished by minimally invasive Kirschner (K-) wire fixation or with an open approach and fracture fixation using a mini-screw (36).

Fractures of the trapezium

Fractures of the trapezium are the third most common carpal fractures at less than five percent (38). Their cause is commonly a fall on the outstretch thumb associated with an axial transmission of force through the first metacarpal bone (1). Walker distinguishes between axial transarticular, transversal, dorsoradial, and palmar tuberosity fractures, and comminuted fractures (39). Undisplaced fractures are immobilized in a plaster splint with inclusion of the proximal phalanx of the thumb for four to six weeks. Regular radiological reviews are required due to the risk of secondary displacement. Displaced fractures may be managed percutaneously by K-wire fixation or by open reduction and screw fixation (1). Congruent reduction is decisive in order to prevent secondary basal thumb osteoarthritis (40). Painful nonunion or troublesome bone fragments/bony edges can produce secondary carpal tunnel syndrome and tendinitis, even ruptures of the flexor carpi radialis (FCR) tendon, and should therefore be removed in due course (1, 38, 40).

Fractures of the hamate

The incidence of fractures of the hamate is around two percent (38, e1). A distinction is made between body and hook fractures (eFigure 3) (e2). Apart from acute traumatic events, causes of hook fractures also include repetitive microtrauma injury, for example during racket sports (1). In addition to paresthesia in the territory of the ulnar nerve, pain on flexion of the ring and small fingers against resistance in a wrist held in ulnar deviation (hook of hamate pull test) is diagnostically suggestive (e2). Undisplaced fractures of the hamate are immobilized for four to six weeks. Screw fixation should be performed initially for displaced fractures, and in particular before deciding to excise the hook of hamate, bearing in mind the function of the hook as a fulcrum for the ulnar-sided flexor tendons. It is possible that these tendons are restricted in their function after hook resection (eFigure 3) (1, e2). Excision is therefore primarily recommended for established nonunion (e3, e4).

eFigure 3

48-year-old (female) patient with a hamate fracture close to the base

Fractures of the pisiform

Two percent of all carpal fractures involve the pisiform. They arise from direct trauma. The indication for operative treatment is displacement and consists of internal fixation or excision (1). Despite being located in the flexor carpi ulnaris tendon, in the insertions of the pisohamate ligament, and the abductor digiti minimi tendon, removal of the pisiform does not appear to have any functional consequences (e5).

Fractures of the capitate

One to two percent of all carpal bone fractures involve the capitate. Usually, transverse body fractures are sustained by a fall on the outstretched hand and the subsequent impaction of the distal radius, resulting in complete detachment of the proximal pole of the capitate (38). This is often associated with a fracture of the middle third of the scaphoid (scapho-capitate fracture). If the proximal pole of the capitate rotates by 180 degrees, then this is referred to as Fenton syndrome (e6, e7). As with the scaphoid, perfusion of the capitate is from distal, which increases the risk of delayed union, nonunion, and necrosis for fractures of the proximal pole (e1, e8, e9, e10). Undisplaced transverse fractures may be treated non-operatively, although some of them require months of immobilization until the bone has fully united. For this reason, the indication for surgery should be considered, even in the presence of only slight displacement. As a rule, displaced fractures should be managed with screw or miniplate fixation to restore the anatomical carpal height and thus avoid overloading the adjacent joints (1, 37, e2).

Fractures of the lunate

Isolated lunate fractures are rare because of its protected position in the lunate facet of the distal radius. A fracture can develop in the late stage of avascular necrosis of the lunate (Kienbock’s disease) – this should be included in the differential diagnosis, especially in the absence of trauma. For this reason, an MRI scan should be obtained for diagnostic purposes, in addition to a CT scan (1, e2). Ligament instability should be excluded in every case of lunate fracture. Undisplaced fractures with no sign of instability can be managed conservatively in a forearm splint for four to six weeks. On the other hand, open reduction and internal fixation with mini-screws, double-threaded screws, or K-wires are indicated for displaced fractures. Reconstruction with bone anchor sutures and K-wire fixation are required for avulsion fractures. Proximal row carpectomy may be necessary for unreconstructable comminuted fractures and nonunion.

Fractures of the trapezoid

With fewer than one percent, these are the least common fractures of the carpal bones and are often part of a multiple traumatic injury secondary to high-velocity trauma (5, 38). Here too, displacement will require surgery with K-wires or screws. Excision is not advised on the other hand because of the risk of painful proximal metacarpal migration (MC 2) (1). Second carpometacarpal joint fusion (CMC 2) should be undertaken for comminuted fractures or osteoarthritis (5, 38).

Conclusion

Guidelines, RCTs, and meta-analyses are only available for scaphoid fractures. There is unanimous recommendation for surgical treatment of fractures of the proximal third. Bicortical displaced fractures of the middle third should undergo surgery. However, the authors’ personal opinion is that an individualized approach in the spirit of “informed consent” should be considered for undisplaced fractures – with a shorter immobilization period of two to four weeks for surgical treatment, compared with up to 12 weeks for conservative management. The currently available data do not allow a general therapeutic recommendation for fractures of the other carpal bones.

Conflict of interest statement
MFL is a member of the advisory boards of the AO Hand Expert Group and KLS Martin Group as well as the Executive Committee of the German Society for Hand Surgery. He has received payments for lectures and has been reimbursed for travel expenses and congress fees from AO, Johnson & Johnson, Medartis, IBRA, KLS Martin Group, and BIRG.

FU has received consulting fees from Medartis. He has been reimbursed for congress fees and travel expenses by IBRA. He is Editor in Chief of the journal “Archives of Orthopaedic and Trauma Surgery” (Springer Publishing Company), publisher of the journal “Operative Orthopädie und Traumatologie” (Springer Publishing Company), and is on the scientific advisory board of the journal “Handchirurgie Scan” (Thieme Publishing Company).

The other authors declare that there are no conflicts of interest.

Manuscript received on 2 January 2024, revised version accepted on 3 May 2024

Translated from the original German by Dr. Grahame Larkin

Corresponding author:
Dr. med. Adrian Cavalcanti Kußmaul
Department of Hand Surgery, Clinic, Vulpiusstrasse 29, 74906 Bad Rappenau

Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), Munich University Hospital, LMU Munich, Marchioninistr.15, 81377 Munich

Cite this as:
Cavalcanti Kußmaul A, Kuehlein T, Langer MF, Löw S, Ayache A, Unglaub F: The conservative and operative treatment of carpal fractures. Dtsch Arztebl Int 2024; 121: 594–600. DOI: 10.3238/arztebl.m2024.0102

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