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TC(1078).(05).Orthopedics Case No 154:- Scaphoid Fracture

Scaphoid Fracture — বাংলায় Clinical + Prescription-Oriented Notes

Clinical note: Scaphoid fracture-এর definitive treatment হলো immobilization বা surgery; medicine মূলত pain control, inflammation control, gastroprotection, peri-operative/open-fracture infection prevention–এর জন্য। Closed uncomplicated scaphoid fracture-এ routine antibiotic দরকার হয় না।

1) Definition — সংজ্ঞা

Scaphoid fracture হলো wrist-এর radial/thumb side-এ থাকা scaphoid carpal bone-এর fracture। সাধারণত fracture হয় scaphoid-এর waist, proximal pole, অথবা distal pole-এ। Proximal pole fracture বেশি ঝুঁকিপূর্ণ, কারণ scaphoid-এর blood supply distal থেকে proximal দিকে “retrograde” যায়—তাই proximal fragment-এর blood supply কমে গিয়ে AVN হতে পারে।

2) Cause / Etiology — কারণগুলো

  • FOOSH injury — Fall on outstretched hand: হাত মাটিতে পড়ে wrist forced hyperextension হলে scaphoid fracture বেশি হয়। BSSH অনুযায়ী forced hyperextension injury, punching injury বা major wrist trauma থাকলে scaphoid fracture suspect করতে হবে।
  • Sports injury: football goalkeeper save, cricket/volleyball/basketball fall, cycling fall, gym injury।
  • Road traffic accident / motorcycle fall: high-energy trauma হলে displaced fracture বা associated carpal instability হতে পারে।
  • Punching / direct wrist trauma: wrist radial side-এ impact পড়লে fracture হতে পারে।
  • High-risk fracture pattern: proximal pole fracture, displaced waist fracture, delayed diagnosis, smoking—এগুলো nonunion/AVN risk বাড়ায়।

3) Pathophysiology — কেন healing problem হয়

  • Scaphoid-এর main blood supply distal pole দিয়ে ঢুকে proximal pole-এ যায়; তাই proximal pole বা waist fracture হলে proximal fragment-এর blood flow কমে যায়।
  • Missed fracture বা delayed immobilization হলে fracture gap থেকে nonunion, humpback deformity, DISI, পরে SNAC wrist arthritis হতে পারে।
  • Displaced fracture হলে stability কমে, union delay হয়; BSSH displaced >2 mm হলে urgent specialist assessment/surgery consideration বলেছে।

4) Symptoms — লক্ষণগুলো

  • Thumb-side wrist pain: wrist-এর radial side/anatomical snuffbox area-এ ব্যথা।
  • Anatomical snuffbox tenderness: thumb extend করলে radial wrist-এর depression area-এ চাপ দিলে ব্যথা।
  • Scaphoid tubercle tenderness: volar radial wrist-এ scaphoid tubercle চাপ দিলে ব্যথা।
  • Axial thumb loading pain: thumb longitudinally compress করলে wrist pain। BSSH scaphoid tenderness, ASB pain on active ulnar deviation, বা axial loading pain—এসব clinical sign হিসেবে উল্লেখ করেছে।
  • Swelling and reduced grip strength: wrist swelling, grip দুর্বল, jar খুলতে/মুঠো করতে কষ্ট।
  • Pain with wrist movement: বিশেষ করে extension, radial/ulnar deviation।
  • Occult fracture presentation: X-ray normal হলেও pain persist করতে পারে; তাই clinical suspicion থাকলে immobilize + MRI/CT দরকার।

5) Clinically Diagnosis — clinical diagnosis কীভাবে করবেন

A. History

  • FOOSH / forced hyperextension / punching / RTA / sports trauma আছে কিনা।
  • Injury time, dominant hand, occupation/manual worker, sports demand।
  • Pain location: radial wrist/snuffbox।
  • Previous wrist injury, smoking, diabetes, steroid use।

B. Examination — specific signs

  • Look: swelling, bruising, deformity, wound/open fracture।
  • Palpate:
    • anatomical snuffbox tenderness
    • scaphoid tubercle tenderness
    • proximal pole tenderness, distal to Lister’s tubercle
  • Special tests:
    • axial compression of thumb
    • pain on active ulnar deviation
    • wrist ROM and grip strength
  • Must check: distal radius tenderness, scapholunate interval tenderness, neurovascular status, median nerve symptoms, associated perilunate injury.

6) Investigations — specific work-up

1. X-ray wrist with scaphoid views

Suspected scaphoid fracture হলে at least 4 radiographs:
PA, lateral, semi-prone/oblique, elongated scaphoid view। BSSH guideline এটাই recommend করে।

2. MRI wrist

  • X-ray negative কিন্তু clinical suspicion high হলে MRI best early test।
  • NICE NG38 suspected scaphoid fracture-এ thorough clinical examination-এর পরে MRI first-line imaging consider করতে বলেছে।
  • EFORT review অনুযায়ী initial radiograph negative হলে supplementary MRI বা CT 3–5 দিনের মধ্যে করা উচিত।

3. CT wrist

  • X-ray-এ fracture visible হলে CT displacement, fracture gap, comminution, humpback deformity, union assessment–এর জন্য ভালো।
  • BSSH visible scaphoid fracture হলে displacement accurately measure করতে CT এবং sagittal/coronal reconstruction recommend করেছে।

4. Follow-up imaging

  • Non-operative treatment হলে 6–8 weeks-এ out-of-cast X-ray বা CT; tenderness বা union doubt থাকলে CT। BSSH union confirmation CT-তে >50% cross-sectional union উল্লেখ করেছে।

5. Pre-operative / open injury tests

  • CBC, RBS, renal function, ECG/CXR if indicated।
  • Open fracture হলে wound swab routine নয়; debridement + antibiotic/tetanus protocol clinically।

7) Differential Diagnosis — কী কী বাদ দিতে হবে

  • Distal radius fracture / radial styloid fracture
  • Scapholunate ligament injury
  • Lunate/perilunate dislocation
  • Trapezium fracture
  • De Quervain tenosynovitis
  • Thumb CMC sprain/dislocation
  • Wrist sprain/contusion
  • Kienböck disease বা wrist osteoarthritis — chronic pain হলে

8) Complications — বাংলায় বুঝে নিন

  • Nonunion: fracture জোড়া না লাগা। Missed diagnosis, late immobilization, displacement, smoking, proximal fracture—risk বাড়ায়।
  • Avascular necrosis — AVN: proximal fragment-এ blood supply কমে bone death হতে পারে; পরে collapse/pain/stiffness হয়।
  • SNAC wrist arthritis: chronic nonunion থেকে carpal collapse + degenerative arthritis; wrist movement কমে যায়, chronic pain হয়।
  • Malunion / humpback deformity: scaphoid ভুল alignment-এ জোড়া লাগে; wrist biomechanics নষ্ট হয়।
  • DISI deformity: carpal instability pattern; scapholunate angle বাড়ে।
  • Stiffness and weak grip: দীর্ঘ immobilization বা delayed rehab-এর কারণে।
  • Complex regional pain syndrome — CRPS: disproportionate pain, swelling, color/temp change, stiffness।
  • Surgical complications: infection, screw prominence, cartilage injury, tendon irritation, persistent nonunion.

9) Treatment / Management — guideline-based

A. Initial ED / OPD management

  • Suspected fracture হলে wrist immobilize করুন — thumb-spica splint বা below-elbow wrist splint/backslab।
  • X-ray positive হলে below-elbow plaster backslab + specialist clinic referral within 7–14 days।
  • X-ray negative কিন্তু clinical suspicion থাকলে splint + MRI/CT arrangement; definitive management plan ideally 2 weeks-এর মধ্যে।
  • Pain control: paracetamol ± short-course NSAID; severe pain হলে short-course tramadol।
  • Ring/watch remove, elevation, ice, no weight-bearing/lifting with affected wrist।

B. Conservative treatment

  • Distal pole fracture বা waist fracture <2 mm displacement: below-elbow cast; BSSH thumb excluded cast উল্লেখ করেছে, তবে local practice-এ thumb-spica castও ব্যবহৃত হয়।
  • Tuberosity avulsion fracture: symptom control অনুযায়ী 4–6 weeks immobilization।
  • EFORT review: non-displaced/minimally displaced waist fracture-এর ~90% union 6 weeks-এ হতে পারে; 0.5–1.5 mm displacement হলে 8–10 weeks immobilization লাগতে পারে।

C. Surgical management — indications

  • Waist fracture >2 mm displacement — acute fixation ideally within 2 weeks।
  • Proximal pole fracture with any displacement।
  • Associated unstable carpal injury/perilunate injury বা displaced distal radius fracture।
  • Delayed immobilization >4 weeks এবং CT-তে union evidence না থাকলে surgery consider।
  • Surgery: percutaneous/open reduction + headless compression screw ± bone graft।
  • SWIFFT trial: adults with scaphoid waist fracture displaced ≤2 mm-এ initial cast immobilization with early fixation only if nonunion suspected—early surgery-এর উপর clear functional benefit দেখায়নি; surgery group-এ serious surgical complication বেশি ছিল।

10) Bangladesh Prescription-Oriented Drug List

Bangladesh doctors commonly use — practical list

  • Pain mild–moderate: Paracetamol
  • Pain + inflammation: Ibuprofen / Naproxen / Diclofenac — একসাথে multiple NSAID নয়
  • Severe acute pain: Tramadol short course
  • NSAID gastric protection: Pantoprazole, especially PUD/GERD/elderly/anticoagulant risk
  • Surgery/open wound: Cefazolin peri-operative prophylaxis; closed non-operative fracture-এ antibiotic নয়

1. Generic name: Paracetamol

  • Therapeutic category: Analgesic + antipyretic
  • Therapeutic class — MedEx: Non-opioid analgesics
  • Pharmacological class: Para-aminophenol derivative; central COX inhibition; weak anti-inflammatory action
  • Why used: Scaphoid fracture-এর mild–moderate pain control; fracture heal করায় না, pain কমায়।
  • Adult dose: 500–1000 mg PO every 6 hours PRN; maximum 4 g/day।
  • Duration: 3–5 days regularly/PRN; prolonged use হলে LFT risk assess।
  • Side effects: সাধারণত safe; overdose/hepatic disease/alcohol use-এ hepatotoxicity; rare rash, blood dyscrasia, pancreatitis।
  • Interactions: Alcohol, barbiturates, anticonvulsants/enzyme inducers liver toxicity বা effect কমাতে পারে; multiple paracetamol-containing combination avoid।
  • Bangladesh available brand name with strength — MedEx examples:
    • Napa 500 mg tablet; Napa One 1000 mg tablet — Beximco
    • Ace 500 mg tablet; Ace Power 1000 mg — Square
    • Fast 500 mg, Feva 500 mg, Xcel 500 mg, Renova 500 mg, Tamen 500 mg, Pyrex 500 mg — MedEx-listed brands

2. Generic name: Ibuprofen

  • Therapeutic category: Analgesic + anti-inflammatory
  • Therapeutic class — MedEx: NSAIDs; drugs for osteoarthritis/rheumatoid arthritis
  • Pharmacological class: Propionic acid derivative NSAID; nonselective COX inhibitor
  • Why used: Pain, swelling, inflammation কমাতে; paracetamol insufficient হলে short course।
  • Adult dose: 200–400 mg PO every 6–8 hours after food PRN; OTC-type max 1200 mg/day; prescription setting-এ patient-specific। MedEx adult mild–moderate pain dose 200–400 mg 3–4 times/day and max 1200 mg/day উল্লেখ করে।
  • Duration: 3–5 days; renal/GI/CV risk থাকলে avoid/shortest duration।
  • Side effects: dyspepsia, GI ulcer/bleeding, dizziness, headache, renal impairment, bronchospasm in NSAID-sensitive asthma।
  • Interactions: Warfarin/antiplatelet/SSRI/steroid → bleeding risk; ACEi/ARB + diuretic → AKI risk; lithium/methotrexate toxicity; other NSAIDs avoid।
  • Avoid: active PUD/GI bleed, severe renal/hepatic/heart failure, 3rd trimester pregnancy, frail elderly।
  • Bangladesh available brand name with strength — MedEx examples:
    • Advel 400 mg — Opsonin
    • Flamex 400 mg — ACI
    • Profen 400 mg — ACME
    • Reumafen 400 mg — Beximco
    • Trufen 400 mg — Modern
    • Uniflam 400 mg — Bristol

3. Generic name: Naproxen Sodium

  • Therapeutic category: Analgesic + anti-inflammatory
  • Therapeutic class — MedEx: NSAIDs; drugs for osteoarthritis/rheumatoid arthritis
  • Pharmacological class: Propionic acid derivative NSAID; nonselective COX-1/COX-2 inhibitor
  • Why used: Longer acting NSAID; moderate fracture pain/swelling, wrist inflammation।
  • Adult dose: 500 mg initially, then 250 mg every 6–8 hours PRN; alternative 500 mg twice daily; max 1000 mg/day. MedEx analgesia/musculoskeletal disorder dose 500 mg initially then 250 mg 6–8 hourly উল্লেখ করে।
  • Duration: 3–5 days; high-risk patient হলে PPI cover/avoid।
  • Side effects: heartburn, abdominal pain, nausea, diarrhea, dyspepsia, headache, drowsiness, edema, rash।
  • Interactions: ACE inhibitors, diuretics, aspirin, methotrexate, warfarin, SSRI—GI bleeding/toxicity risk।
  • Bangladesh available brand name with strength — MedEx examples:
    • Naprosyn 250/500 mg — Radiant
    • Naxin 250/500 mg, Naxin SR 500 mg — Opsonin
    • Naprox 250/500 mg — Eskayef
    • Napryn 250/500 mg — Healthcare
    • Anaflex 250/500 mg — ACI
    • Sonap 250/500 mg — Square

4. Generic name: Diclofenac Sodium

  • Therapeutic category: Analgesic + anti-inflammatory
  • Therapeutic class: NSAID
  • Pharmacological class: Phenylacetic/acetic acid derivative NSAID; nonselective COX inhibitor
  • Why used: Acute musculoskeletal pain, swelling, post-traumatic pain; severe gastritis/CVD/CKD risk থাকলে avoid।
  • Adult dose: 50 mg PO 2–3 times daily after food; max 150 mg/day. Gel 1% affected area-এ 3–4 times/day. MedEx diclofenac gel roughly one-inch band 3–4 times/day উল্লেখ করে।
  • Duration: 2–5 days; injection হলে hospital/ED setting-এ shortest possible।
  • Side effects: epigastric pain, nausea, diarrhea, dizziness/headache, edema, rash; rare GI bleed/ulcer, renal injury, CV risk।
  • Interactions: anticoagulant/antiplatelet/SSRI/steroid → bleed; ACEi/ARB/diuretic → renal risk; lithium/methotrexate; other NSAIDs avoid।
  • Bangladesh available brand name with strength — MedEx examples:
    • Diclofen 50 mg tablet; Diclofen 75 mg/3 ml injection; Diclofen 1% gel — Opsonin
    • Voltalin Forte 50 mg tablet; Voltalin SR 75/100 mg; Voltalin D 46.5 mg — Nevian
    • Clofenac 50 mg — Square; Diclorex 50 mg/75 mg injection; Voligel 1%, Voligel Max 2%; Voltagel 1%, Voltagel DS 2% — MedEx-listed brands

5. Generic name: Tramadol Hydrochloride

  • Therapeutic category: Moderate–severe pain analgesic
  • Therapeutic class — MedEx: Opioid analgesics
  • Pharmacological class: Centrally acting synthetic opioid analgesic; μ-opioid receptor agonist + serotonin/noradrenaline reuptake inhibition
  • Why used: Severe acute fracture pain, post-operative pain; NSAID contraindicated বা inadequate pain relief হলে short course।
  • Adult dose: 50–100 mg PO every 6 hours PRN; max 400 mg/day. Injection 50–100 mg IM/IV every 4–6 hours hospital setting। MedEx same dose range উল্লেখ করে।
  • Duration: 1–3 days; dependence/respiratory depression risk থাকায় prolonged use avoid।
  • Side effects: dizziness, nausea, constipation, somnolence, vomiting, pruritus, sweating, dry mouth; high dose/CNS depressant-এ respiratory depression; seizure risk।
  • Interactions: MAOI contraindicated/high caution; SSRI/SNRI/TCA/linezolid → serotonin syndrome risk; alcohol/benzodiazepine/opioid/sedative → respiratory depression; carbamazepine effect কমাতে পারে।
  • Bangladesh available brand name with strength — MedEx examples:
    • Anadol 50 mg capsule; Anadol 100 mg/2 ml injection; Anadol SR 100 mg — Square
    • Dolonil 50 mg; Dolonil 100 mg/2 ml — ACME
    • Trado 50 mg; Trado 100 mg/2 ml — Pacific
    • Tranal 50 mg; Tranal 100 mg/2 ml — Opsonin
    • Utramal 50 mg; Utramal 100 mg/2 ml; Utramal Retard 50/100 mg — UniMed UniHealth
    • Winpain 50 mg; Winpain 100 mg/2 ml — Incepta

6. Generic name: Pantoprazole Sodium

  • Therapeutic category: Gastroprotection / anti-ulcer
  • Pharmacological class: Proton pump inhibitor — PPI
  • Why used: NSAID-induced gastritis/ulcer risk কমাতে; PUD/GERD/high-risk patient-এ NSAID cover। MedEx NSAID-induced ulcer indication উল্লেখ করে।
  • Adult dose: 20 mg PO once daily before breakfast during NSAID use; high-risk/active GERD হলে 40 mg once daily।
  • Duration: NSAID চলা পর্যন্ত 3–7 days; ulcer/GERD হলে guideline অনুযায়ী longer।
  • Side effects: headache, diarrhea, abdominal pain, flatulence, rash, insomnia; long-term use-এ hypomagnesemia/B12 deficiency/infection risk consider।
  • Interactions: MedEx significant interaction uncommon বলেছে; long-term polypharmacy-এ absorption-related issue assess।
  • Bangladesh available brand name with strength — MedEx examples:
    • Pantonix 20/40 mg; Pantonix 40 mg/vial — Incepta
    • Pantobex 20/40 mg; Pantobex 40 mg/vial — Beximco
    • Pantid 20/40 mg; Pantid 40 mg/vial — Opsonin
    • Pantolok 20/40 mg; Pantolok 40 mg/vial — Ibn Sina
    • Pantogut 20/40 mg; Pantogut 40 mg/vial — Popular

7. Generic name: Cefazolin Sodium

  • Therapeutic category: Antibiotic / peri-operative prophylaxis
  • Therapeutic class — MedEx: First generation cephalosporins
  • Pharmacological class: β-lactam cephalosporin; bacterial cell-wall synthesis inhibitor
  • Why used: Closed scaphoid fracture-এ নয়; ORIF surgery prophylaxis, contaminated wound/open fracture protocol, peri-operative infection prevention। MedEx perioperative prophylaxis indication উল্লেখ করে।
  • Adult dose: ORIF prophylaxis: 1 g IV/IM 30–60 min before incision; long surgery হলে repeat 500 mg–1 g intra-op; post-op 500 mg–1 g every 6–8 hours for 24 hours. MedEx perioperative dosing similarভাবে উল্লেখ করে।
  • Duration: Clean elective ORIF-এ usually single dose/≤24 h; open fracture হলে local open-fracture protocol অনুযায়ী।
  • Side effects: injection-site pain, rash/urticaria, diarrhea, nausea/vomiting, candidiasis, rare anaphylaxis/seizure in renal impairment।
  • Interactions: Probenecid cephalosporin blood level বাড়াতে পারে; cephalosporin allergy থাকলে contraindicated।
  • Bangladesh available brand name with strength — MedEx examples:
    • Cefazol 500 mg/vial, 1 g/vial — Incepta
    • Zolibac 1 g/vial — Square
    • Cefazoline Panpharma 1 g/5 ml — City Overseas/Panpharma

11) Prevention — কীভাবে prevent করবেন

  • Fall prevention: wet floor, stairs, poor lighting, elderly fall risk address।
  • Sports protection: cycling/skating/goalkeeping/contact sports-এ wrist guard/technique training।
  • Road safety: motorcycle helmet + gloves, speed control, defensive driving।
  • Workplace safety: construction/industrial work-এ gloves, fall-arrest, safe ladder practice।
  • Bone health: osteoporosis risk থাকলে vitamin D/calcium status, DEXA if indicated; smoking cessation।
  • Early care: FOOSH-এর পর snuffbox pain থাকলে “sprain” ধরে অবহেলা নয়—splint + X-ray/MRI।
  • Treatment adherence: cast খুলে ফেলা, heavy lifting, smoking—nonunion risk বাড়াতে পারে।
  • Follow-up: 6–8 weeks imaging/clinical review miss করা যাবে না।

Overview / Summary

Scaphoid fracture হলো thumb-side wrist-এর common carpal fracture, বেশিরভাগ সময় FOOSH/forced hyperextension injury থেকে হয়। Diagnosis miss হলে nonunion, AVN, SNAC wrist arthritis হতে পারে। Clinical suspicion থাকলে X-ray normal হলেও wrist immobilize করে MRI/CT করা উচিত। Stable distal pole বা minimally displaced waist fracture cast-এ ভালো heal করে; displaced waist, proximal pole, unstable carpal injury, delayed nonunion-risk case surgery লাগে। Medicine definitive treatment নয়—pain control, NSAID-related gastric protection, এবং surgery/open injury prophylaxis-এর জন্য ব্যবহৃত হয়।

Actionable Plan / Steps

  1. FOOSH + snuffbox/scaphoid tenderness = scaphoid fracture suspect করুন।
  2. Immediate immobilization: thumb-spica/below-elbow wrist splint or backslab।
  3. X-ray: PA, lateral, oblique/semi-prone, elongated scaphoid view।
  4. X-ray negative but clinical suspicion high: MRI first-line; CT alternative/for displacement।
  5. Stable fracture: below-elbow cast 4–10+ weeks depending site/displacement; follow-up CT/X-ray।
  6. Unstable/displaced/proximal pole: hand/orthopaedic surgeon referral; ORIF ± bone graft।
  7. Prescription approach: paracetamol first; NSAID short course if no contraindication; PPI if gastric risk; tramadol only severe pain short course; antibiotics only open fracture/surgery.
  8. Follow-up: 6–8 weeks union assessment; persistent tenderness/no union → CT and surgical consideration।
  9. Patient advice: no smoking, no lifting, cast compliance, return if increasing pain/numbness/swelling.

Reference List

Textbook references

  • Apley & Solomon’s System of Orthopaedics and Trauma, latest edition, chapter on injuries of wrist/hand and carpal fractures.
  • Rockwood and Green’s Fractures in Adults, latest edition, chapter on carpal/scaphoid fractures.
  • Campbell’s Operative Orthopaedics, latest edition, chapter on hand and wrist fractures.
  • Maheshwari & Mhaskar, Essential Orthopaedics, latest edition, chapter on hand/wrist injuries.
    Page numbers vary by edition/printing; verify with your local copy.

Guidelines

  • British Society for Surgery of the Hand — BSSH Trauma Standards: Scaphoid fractures, 2024: suspicion signs, 4-view radiographs, immobilization, MRI/CT, CT union assessment, surgery indications.
  • NICE NG38: Fractures (non-complex): assessment and management, 2016: MRI first-line imaging consideration for suspected scaphoid fracture.

Peer-reviewed / DOI

  • Clementson M, Björkman A, Thomsen NO. Acute scaphoid fractures: guidelines for diagnosis and treatment. EFORT Open Reviews. 2020;5:96–103. DOI: 10.1302/2058-5241.5.190025.
  • Dias JJ, et al. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist — SWIFFT trial. The Lancet. 2020;396:390–401. DOI: 10.1016/S0140-6736(20)30931-4.
  • Sahu A, et al. Prospective comparison of MRI and CT in diagnosing occult scaphoid fractures. Acta Radiologica. 2023;64:201–207. DOI: 10.1177/02841851211064595.
  • Duckworth AD, et al. Predictors of fracture following suspected injury to the scaphoid. J Bone Joint Surg Br. 2012;94-B:961–968. DOI: 10.1302/0301-620X.94B7.28704.
  • MedEx Bangladesh drug monographs/brand listings for Paracetamol, Ibuprofen, Naproxen, Diclofenac, Tramadol, Pantoprazole, Cefazolin.

Md.Rafiqul Islam Lipu,Date:-23-06-2026 Tuesday,Time:-11-49-12 Am

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