Question:My 18-year-old son broke his wrist skateboarding. When I went with him to the emergency room, there was an orthopedic surgeon on-call, so I thought we were in the hands of the right expert. Even so, it seemed to me like they took way too many X-rays. And then they did a CT scan on top of it. They finally said it was a broken scaphoid bone and surgery was needed. Was this really all necessary? Should I question the bill when I get it?
Answer:Wrist fractures can be very difficult to treat. Just choosing the most appropriate treatment can be a challenge. The best treatment for acute scaphoid fractures remains unknown. Sometimes the wrist is immobilized in a short arm cast. Other times, a long arm cast (including the elbow) is used. The thumb may or may not be included in the casting.
Surgery can be open or closed. Open surgery means an incision is made and the skin and soft tissues are pulled apart. This way the surgeon can get down to the bone. In other cases, arthroscopic surgery is possible. The surgeon inserts a long thin needle with a tiny TV camera on the end. This gives him or her a clear picture of the wrist joint and bones.
More recently, screw fixation has been improved and used much more often. The procedure can be done percutaneously or through the skin. A specially designed screw is inserted fully into the bone.
In order to make the right decision about the best method of treatment, the surgeon must know which bone(s) are involved. The location and type of fracture are important in choosing wisely. Because the scaphoid is an odd shape with several angles, it can take multiple X-rays to get all the views needed.
If the radiologist suspects the bone is displaced, a CT scan may be ordered. A displaced fracture means the broken pieces of bone have shifted or moved. They may not line up correctly. Having this kind of information can be very helpful when planning surgery. The CT scan shows any loss of joint space, changes in bone alignment, and the exact amount of fracture displacement called step-off.
In some cases, after X-rays and CT scan, an MRI may be ordered. Again, this additional imaging method offers useful information in identifying the problem and planning the treatment. Choosing the right kind of surgery and method can make a difference in the final outcome. Wrist motion and function is important in daily function. Taking a few extra images is a wise investment in a successful result.Andrew P. Gutow, MD. Percutanous Fixation of Scaphoid Fractures. In Journal of the American Academy of Orthopaedic Surgeons. August 2007. Vol. 15. No. 8. Pp. 474-485.
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