THIEME

Original Article 247

Distal Radial Fractures with Scaphoid Fractures

Fraturas do rádio distal associadas à fratura do escafoide
Caio Kzan Geyer Nogueira1 Vinícius Ynoe de Moraes1 Lucas Pereira Sarmento2
Luís Renato Nakachima 1 João Baptista Gomes dos Santos 1 João Carlos Belloti1

1 Hand and Upper Limb Discipline, Escola Paulista de Medicina, Address for correspondence Caio Kzan Geyer Nogueira, Rua Borges
Universidade Federal de São Paulo, São Paulo, SP, Brazil Lagoa, N 778, Vila Clementino, 04038-002, São Paulo, SP, Brasil
2 Orthopedics and Traumalogy, Escola Paulista de Medicina, (e-mail: caiokzan@hotmail.com).
Universidade Federal de São Paulo, São Paulo, SP, Brazil

Rev Bras Ortop 2024;59(2):e247–e253.

Abstract Objective This study evaluated the epidemiological data and functional outcomes from
patients with concomitant distal radial and scaphoid fractures treated in a single center
specialized in hand surgery. Functional outcomes analysis used validated instruments.
Methods Patients diagnosed with distal radial and scaphoid fractures treated from
January 2011 to December 2021 underwent assessments using the Disabilities of the
Arm, Shoulder and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), Visual Analog Scale
(VAS) for pain, goniometry, radiographic consolidation, and complications six months after
surgery.
Results The study included 23 patients, 73.9% men and 26.1% women. Most (56.5%)
fractures occurred on the right side, and 43.5% happened on the left side. Treatment of
most (56%) distal radial fractures used a locked volar plate. Functional assessment by
Keywords PRWE resulted in a mean score of 35.9 points (range, 14 to 71 points), while DASH
► general surgery showed a mean score of 37.8 points (range, 12 to 78 points). The mean VAS was 2.33
► functional status during activities (range, 0.6 to 6.2).
► radius fractures Conclusion Distal radial fractures associated with scaphoid fractures resulted from
► wrist fractures high-energy trauma, and most patients were males. There was a low rate of
► scaphoid bone complications with surgical treatment, and the patients had satisfactory functional
► therapeutics evolution with a low level of pain.

Resumo Objetivo Avaliar os resultados epidemiológicos e funcionais dos pacientes que

apresentaram fraturas concomitantes do rádio distal e do escafoide e foram tratados
Palavras-chave em um único centro especializado em cirurgia da mão, através de instrumentos
► cirurgia geral validados para analisar os desfechos funcionais desses pacientes.
► estado funcional Métodos Foram avaliados os pacientes com diagnóstico de fratura do rádio distal e
► fraturas do rádio escafoide tratados de janeiro de 2011 até dezembro de 2021, através dos questionários
► fraturas do punho Disabilities of the Arm, Shoulder and Hand (DASH), Patient Rated Wrist Evaluation (PRWE) e
► osso escafoide Escala Visual Analógica da dor (EVA); goniometria; consolidação radiográfica; com-
► terapêutica plicações em seis meses de pós-operatório.

Work developed at the Hand and Upper Limb Discipline, Escola Paulista
de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.

received DOI https://doi.org/ © 2024. The Author(s).

August 18, 2023 10.1055/s-0044-1785464. This is an open access article published by Thieme under the terms of the
accepted ISSN 0102-3616. Creative Commons Attribution 4.0 International License, permitting copying
November 6, 2023 and reproduction so long as the original work is given appropriate credit
(https://creativecommons.org/licenses/by/4.0/).
Thieme Revinter Publicações Ltda., Rua do Matoso 170, Rio de
Janeiro, RJ, CEP 20270-135, Brazil
248

Resultados Vinte e três pacientes foram incluídos no estudo, sendo 73,9% homens e
26,1% mulheres; 56,5% das fraturas ocorreram à direita e 43,5% à esquerda. A maioria
das fraturas do rádio distal foi tratada com placa volar bloqueada, totalizando 56%. Na
avaliação funcional pelo PRWE, obteve-se média de 35,9 pontos (variação de 14 a 71
pontos) e pelo DASH média de 37,8 pontos (variação de 12 a 78 pontos). A EVA
apresentou uma média de 2,33 durante a atividade (variação de 0,6 a 6,2).
Conclusão Verificou-se que as fraturas do rádio distal associadas a fraturas do
escafoide foram causadas por traumas de alta energia, com o sexo masculino mais
acometido. Houve baixo índice de complicações com tratamento cirúrgico e os
pacientes tiveram evolução funcional satisfatória, com baixo índice de dor.

Introduction Patients with fractures in other carpal bones, complete

injuries of the scapholunate ligament (visualized on stress
Isolated distal radial fractures are common, and their inci- radiographs with an opening greater than 5 mm), fractures
dence in the population is high.1 Meanwhile, scaphoid with neurotendinous injuries, fractures with loss of skin cover-
fractures are the most frequent among carpal bones. How- age, and patients with sequelae of previous traumatic, degen-
ever, the simultaneous occurrence of distal radial and scaph- erative, or both injuries with functional deficits in the affected
oid fractures is rare2, and it often results from high-energy hand or contralateral wrist were excluded from this study.
trauma. The literature reports its incidence in 0.5 to 5% of The same surgeon specialized in hand surgery and micro-
distal radial fractures.3 surgery operated on all selected patients and followed the
Concomitant radial and scaphoid fractures represent a same fracture fixation steps, first performing scaphoid fixa-
treatment challenge. At surgery, scaphoid fractures require tion using a percutaneous method and then a radial fracture
anatomical reduction and compression fixation. On the other fixation. The surgeon followed these steps regardless of the
hand, distal radial fractures require traction for proper reduc- method chosen.
tion and fixation.4,5 This implies careful operative planning After identifying the patients, we recruited those selected
adapted to each fracture type. Postoperative management also by telephone, telegram, or both for an in-person clinical
involves conflicting principles: scaphoid fractures require a assessment of the outcomes analyzed in this study.
longer immobilization period for consolidation, but distal The clinical outcomes evaluated, i.e., PRWE and DASH
radial fractures require a shorter immobilization period fol- questionnaires, were the primary outcomes for functional
lowed by early rehabilitation to avoid wrist joint stiffness.6 assessment. Secondary outcomes included active and passive
In 2022, in a systematic review of 20 case series about wrist range of motion measurements (flexion, extension,
concomitant distal radial da scaphoid fractures, Blackburn radial deviation, ulnar deviation, pronation, supination), grip
et al.3 noted that the main limitation of these studies was the strength measured with a Jamar dynamometer, pain mea-
lack of functional and quality of life assessments using surement using the Visual Analog Scale (VAS), and radio-
validated instruments, such as the Disabilities of the Arm, graphic evaluation. All patients were assessed for a minimum
Shoulder, and Hand (DASH) questionnaire and the Patient- follow-up period of 6 months.
Rated Wrist Evaluation (PRWE) questionnaire. The DASH questionnaire is a tool to assess the impact of
The primary objective of this study was to evaluate the the disease on the function of the affected upper limb. It has
functional outcomes of patients with concomitant distal 37 questions about upper limb function, and its score ranges
radial and scaphoid fractures. The secondary objective was from 0 (no complaints) to 100 (highly limiting conditions for
to analyze the epidemiological aspects of patients treated in the limb).7
a single center specialized in hand surgery, using validated The PRWE questionnaire consists of 15 questions specifi-
instruments to determine their functional outcomes. cally about wrist function. It has five questions about pain,
six about function in specific activities, and four about daily
activities. The final score ranges from 0 (no complaints) to 10
Methods
(highly limiting conditions for the limb).8
We collected medical records from January 2011 to Decem- The radiographic analysis included the evaluation of
ber 2021 of all patients diagnosed with an acute distal radial orthogonal radiographs of the wrist and measured the
fracture (up to 15 days) registered in the surgical schedule of radiographic values of radial height, ulnar variance, radial
the only medical center specialized in hand surgery. Of the angulation, and volar inclination. Fracture consolidation
patients initially selected (N ¼ 957), only those diagnosed and the occurrence of osteoarthritis were also determined
with a concomitant distal radial and ipsilateral scaphoid according to the Knirk and Jupiter classification,9 in which
fracture (N ¼ 38) who underwent surgical treatment were grade 0 represents the absence of osteoarthritis signs,
included. grade I indicates decreased joint space, grade II implies a

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higher decrease in joint space with osteophyte formation,

and grade III denotes direct bone contact with the osteo-
phyte and subchondral cyst formation. The researcher in
charge of data analysis conducted the radiographic
evaluation.
Complications include any complications during the in-
tervention or clinical follow-up of patients requiring surgical
treatment and not foreseen in the initial surgery. The defini-
tion of pseudarthrosis was the absence of signs of clinical and
radiographic consolidation of the distal radial or scaphoid
fracture after 6 months of osteosynthesis10 at radiographs in
orthogonal planes.
The Ethics Committee approved this project under CAAE
number 60074522.2.0000.5505.
For statistical analysis, the data were stored in an Excel®
for Mac spreadsheet and subsequently imported into the
SPSS® 23 for Mac Software. Descriptive statistics of categor-
ical data used absolute frequency of occurrence and its
respective proportion. Continuous data were analyzed for
distribution subjectively using a histogram and objectively
using the Shapiro-Wilk test. Due to the non-symmetric
nature of continuous data, the description employed median
and the 25th and 75th percentile values.
The non-parametric Spearman correlation test deter-
mined correlations between variables. For statistical infer-
ence, p-values <0.05 were considered for type I error. The
Cohen index11 assessed the magnitude of the correlations
using the following classification: values >0.8 indicate Fig. 1 Organizational chart of patient acquisition.
great magnitude, values ranging from 0.5 to 0.8 indicate
medium magnitude, and values ranging from 0.2 to 0.3 show
small magnitude. Analysis of radiographic aspects revealed an average of
0.65 mm (2 mm to 3 mm) for ulnar variance, 11.43 mm
(14 mm to 8 mm) for radial height, 20.57 degrees (24 degrees
Results
to 18 degrees) for radial tilt, and 15.30 degrees (24 degrees to
We analyzed 957 medical records of patients undergoing 6 degrees) for volar tilt. The AO/ASIF system for distal radial
surgical treatment from January 2011 to December 2021 due fractures classified two fractures as A3, 11 as C2, and ten as
to a distal radial fracture. Of these patients, 38 also presented C3. Per the IDEAL classification system,12 20 patients were
an ipsilateral scaphoid fracture, resulting in a 3.7% preva- potentially unstable, and three were complex. When evalu-
lence. We excluded two records because their fractures were ating the presence of arthrosis in the participants’ wrists
at the great arch, and the final sample had 36 patients. After using the Knirk-Jupiter classification, twelve subjects were
telephone and telegram attempts, we could not locate 11 grade 0, nine were grade 1, and only two were grade 2
patients, and two had died from unrelated causes. In the end, (►Fig. 2 and ►Table 2).
23 patients were evaluated (►Fig. 1). Of the 23 participants, only three had complications. The
Concerning demographic characteristics, there were first was a surgical wound infection one week post-opera-
73.9% men and 26.1% women, with 82.6% right-handed tively, treated with antibiotics and evolving to complete
and 7.4% left-handed subjects. Regarding the lesion side, resolution. Two patients required removal of the radius
the distribution was similar, with 56.5% fractures on the synthesis due to tenosynovitis of the flexor tendons associ-
right side and 43.5% on the left side. Treatment of most ated with the blocked volar plate.
distal radial fractures used a volar locked plate (56%), The mean immobilization time was 8 weeks (range, 6 to
followed by a dorsal locked plate (21.7%), while the remain- 12 weeks), while the average return to work took 18.81
ing patients received other fixation methods. Scaphoid weeks (range, 8 weeks to 1 year). One patient required 2 years
fracture fixation mostly employed compressive screws, and 3 months before returning to work due to a complex
and only two patients underwent fixation with Kirschner regional pain syndrome requiring treatment in conjunction
wires (►Table 1). with the specialized pain team (►Table 3).
Regarding the results of the questionnaires, the mean According to the Spearman correlation index, there was a
PRWE score was 35.9 points (range, 14 to 71), the mean DASH pattern of great magnitude in the measured range of motion
score was 37.8 points (range, 12 to 78), and the mean VAS was values (active flexion, active extension, active radial devia-
2.33 during activities (range, 0.6 to 6.2). tion, active ulnar deviation) (►Table 4). The correlation index

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Table 1 General characteristics and treatment from 23

patients with distal radial and scaphoid fractures

n %
Gender
Female 6 26.1
Male 17 73.9
Total 23 100.0
Dominance
Right 19 82.6
Left 4 17.4
Total 23 100.0
Lesion side
Right 13 56.5
Left 10 43.5
Total 23 100.0
Radius fixation method
External fixation 2 8.7
Kirschner wire 1 4.34
Hebert 2 8.7
Dorsal plate 5 21.7
Volar plate 13 56.5
Total 23 100.0
Fig. 2 45-year-old male patient with a history of high-energy trauma.
Scaphoid fixation method Treatment consisted of osteosynthesis of the distal radius with a volar
Kirschner wire 2 8.7 plate and osteosynthesis of the scaphoid with a compressive screw.

Anterograde screw 10 43.5

Retrograde screw 11 47.8
fracture, including 36 subjects presenting a concomitant,
Total 23 100.0
ipsilateral scaphoid fracture, resulting in an incidence of
3.7%. Among these, we included 23 patients in this study to
analyze their outcomes. This represents a significant sample
between PRWE and DASH questionnaires was 0.773, consid- given the low prevalence of this injury and the researched
ered as medium magnitude. The same occurred between literature, which reportedly has only five publications with
PRWE and VAS during activities. The other correlations considerable sample sizes.2–4,13,19 The largest series identi-
exhibited effects of small magnitude effects (►Table 5). fied was published by Vukov et al. (1988)13 and had 26
patients. However, all subjects received conservative treat-
ment, which resulted in a high rate of complications (57%).
Discussion
In this study, a single surgeon performed the surgical
Among distal radial fractures, the concomitant association treatment of the injuries; therefore, the surgical tactic for
with ipsilateral scaphoid fractures is rare, with an incidence lesion treatment always started with the distal radial frac-
ranging from 0.5% to 5% according to the literature. All ture followed by scaphoid fixation using a percutaneous,
patients in this series suffered high-energy trauma mecha- antegrade, or retrograde technique chosen for each case. We
nisms. Most subjects were males (73.4%), in the fourth adopted this strategy since most scaphoid fractures were
decade of life (average age, 38.4 years old), consistent with non-displaced, not requiring reduction maneuvers for
the literature.2,4,7,9,13–19 The fractures presented a commi- fixation.
nuted pattern, strengthening the hypothesis of high-energy Our results demonstrated that all patients presented
trauma, corresponding to subgroup C per the AO/ASIF Clas- consolidation of both radius and scaphoid fractures. Only
sification (21 patients). Most (86%) scaphoid fractures pre- one patient faced difficulties in returning to his original work
sented a simple line at waist level without displacement, and activity due to complex regional pain syndrome. Similarly,
the remaining 14% of fractures occurred at the proximal pole Fowler et al. (2018),4 in a series of 23 patients treated
of the scaphoid. surgically, obtained a scaphoid consolidation rate of 93%. A
In the present study, including 10 years (2011-2021) of single subject had a displaced scaphoid fracture and, at the
records, we evaluated 957 patients with surgical distal radial postoperative evaluation, only one case did not present

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Table 2 Functional assessment, classification, and pain in 23 patients with distal radial and scaphoid fractures

Mean Standard Median 1st interquartile 3rd interquartile

deviation range range
Immobilization time (weeks) 8.00 2.54 8.00 6.00 8.00
Time to resume work (weeks) 18.81 20.52 12.00 12.00 16.00
Active flexion (degrees) 50.09 10.37 52.00 42.00 58.00
Passive flexion (degrees) 54.78 9.89 56.00 48.00 63.00
Active extension (degrees) 54.70 11.59 54.00 49.00 62.00
Passive extension (degrees) 59.65 11.87 58.00 53.00 69.00
Active radial deviation (degrees) 9.96 2.93 10.00 8.00 10.00
Passive radial deviation (degrees) 12.52 2.91 12.00 12.00 14.00
Active ulnar deviation (degrees) 19.04 5.08 18.00 16.00 20.00
Passive ulnar deviation (degrees) 22.70 5.10 22.00 20.00 24.00
VAS in rest (centimeters) 0.82 1.02 0.30 0.05 1.25
VAS during activity (centimeters) 2.33 1.71 1.40 1.20 3.20
PRWE 35.96 14.03 34.00 27.00 41.50
DASH 37.83 14.77 34.00 30.00 40.00
Ulnar variance (millimeters) 0.65 1.56 1.00 1.00 2.00
Radial height (millimeters) 11.43 1.80 12.00 10.00 12.50
Radial tilt(degrees) 20.57 1.97 20.00 19.50 22.00
Volar tilt (degrees) 15.30 6.89 16.00 14.50 19.00
Jamar on the operated side (N/Kg) 27.32 7.29 30.34 22.67 32.67
Jamar on the non-operated side (N/Kg) 31.46 9.92 33.33 24.67 36.67

VAS, Visual analog scale; DASH, Disabilities of the Arm, Shoulder and Hand; PRWE, Patient-Rated Wrist Evaluation.

Table 3 Arthrosis presence per the Knirk-Jupiter classification consolidation (corresponding to a patient with an ipsilateral
brachial plexus injury).
Knirk-Jupiter classification The complication rate presented in this study was 13%,
G0 9 39.1% reinforcing the effectiveness of surgical treatment for
patients’ functional outcomes. Blackburn et al. (2022)3 in a
G1 9 39.1%
systematic review of the literature, identified 20 case series
G2 5 21.7%
involving concomitant ipsilateral fractures of the scaphoid
G3 0 0.0% and distal radius. This review noted the association with
high-energy mechanisms and supported the need for a

Table 4 Correlations with motion arc measurements

Passive Passive Passive radial Ulnar radial

flexion extension deviation deviation
Active flexion Correlation coefficient 0.990 – – –
p-value <0.01
Active extension Correlation coefficient – 0.978 – –
p-value <0.01
Active radial deviation Correlation coefficient – – 0.845 –
p-value <0.01
Ulnar active deviation Correlation coefficient – – – 0.826
p-value <0.01

Valores acima de 0.8 são considerados valores de grande magnitude.

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Table 5 Correlações dos resultados dos questionários PRWE, DASH e EVA

PRWE DASH EVA Repouso Eva Esforço


PRWE Correlation coefficient – 0.773 0.462 0.739
p-value <0.01 0.026 <0.01

DASH Correlation coefficient – – 0.210 0.418
p-value 0.336 0.047
VAS in rest Correlation coefficient – – – 0.642
p-value <0.01
  
VAS during activity Correlation coefficient 0.739 0.418 0.642 –
p-value <0.01 0.047 <0.01

VAS, Visual analog scale; DASH, Disabilities of the Arm, Shoulder and Hand; PRWE, Patient-Rated Wrist Evaluation.

Medium magnitude values.

Small magnitude values.
The correlation had a great magnitude in the measured range of motion values (active flexion, active extension, active radial deviation, active ulnar
deviation). The correlation index of PRWE and DASH questionnaires had a medium magnitude, of 0.773, just like the correlation between PRWE and
VAS under activity. The other correlations showed small effect magnitudes. ►Table 4 and ►Table 5 show these correlations.

surgical approach for this injury. However, the authors also 2 Gürbüz Y, Sügün TS, Kayalar M. Combined fractures of the
realized the scarcity of studies presenting adequate param- scaphoid and distal radius: evaluation of early surgical fixation
eters for comparison with postoperative assessment, identi- (21 patients with 22 wrists). J Wrist Surg 2018;7(01):11–17
fying a single paper using questionnaires such as PRWE. 3 Blackburn J, Johnson N, Pocnetz S, Lindau TR. Effective Treatment
of Simultaneous Distal Radius and Scaphoid Fractures. J Wrist
Given the low prevalence of this injury, prospective
Surg 2021;11(01):89–94
randomized multicenter studies are needed to provide 4 Fowler TP, Fitzpatrick E. Simultaneous fractures of the ipsilateral
more robust evidence. Although our study was retrospective, scaphoid and distal radius. J Wrist Surg 2018;7(04):303–311
we contributed to the analysis of outcomes by employing 5 Caporrino FA, Dos Santos JBG, Penteado FT, de Moraes VY, Belloti
validated functional assessment tools and demonstrating JC, Faloppa F. Dorsal vascularized grafting for scaphoid nonunion:
a comparison of two surgical techniques. J Orthop Trauma 2014;
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28(03):e44–e48
tions, an association previously not identified in the litera-
6 Komura S, Yokoi T, Nonomura H, Tanahashi H, Satake T, Watanabe
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allowed us to statistically identify a correlation index of concurrently with distal radius fractures. J Hand Surg Am 2012;
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Conclusion 8 MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient
rating of wrist pain and disability: a reliable and valid measure-
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oid fractures were more prevalent in young male patients 9 Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the
and resulted from high-energy trauma. Surgical treatment radius in young adults. J Bone Joint Surg Am 1986;68(05):
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proved effective according to the evaluation of clinical,
10 Brashear HR. Treatment of ununited fractures of the long bones;
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11 Cohen J. Statistical Power Analysis for the Behavioral Sciences.
2nd ed. New York: Routledge; 1988. Disponível em: https://doi.
Financial Support
org/10.4324/9780203771587
This study received no financial support from public, 12 Belloti JC, dos Santos JB, de Moraes VY, Wink FV, Tamaoki MJ,
commercial, or not-for-profit sources. Faloppa F. The IDEAL classification system: a new method for
classifying fractures of the distal extremity of the radius -
Conflict of Interests description and reproducibility. Sao Paulo Med J 2013;131(04):
252–256
The authors declare no conflict of interests.
13 Vukov V, Ristić K, Stevanović M, Bumbasirević M Simultaneous
fractures of the distal end of the radius and the scaphoid bone. J
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Rev Bras Ortop Vol. 59 No. 2/2024 © 2024. The Author(s).