Fractures and Nonunions of the Carpal Bones: Clinical Guidelines

List of Abbreviations

AB – antibacterial drugs

ATOR – All-Russian Public Organization "Association of Traumatologists and Orthopedists of Russia"

CT – computed tomography

MRI – magnetic resonance imaging

AVN (Avascular necrosis) – avascular bone necrosis

SNAC (Scaphoid Nonunion Advanced Collapse) – scaphoid nonunion advanced collapse

N (norm) – norm

l (length) – length

h (height) – height

LISA (lateral intrascaphoid angle) – lateral intrascaphoid angle

DCA (dorsal cortical angle) – dorsal cortical angle

SSI – surgical site infection

MDRT – multidisciplinary rehabilitation team

Terms and Definitions

1) Undisplaced bone fracture – a fracture without angular, width, or rotational displacement of bone fragments [11].

2) Displaced scaphoid fracture – usually includes 1 of 4 signs [11, 12]:

a) displacement of 1 mm, typically on the radial or dorsal surface;

b) gap between fragments > 1 mm;

c) volar angular displacement of the fragments, manifested by:

• Dorsal cortical angle > 160 degrees (N≤160º) (Fig. A);

• Lateral intrascaphoid angle > 35 degrees (N≤35º) (Fig. B);

• Scaphoid height-to-length ratio > 0.65 (N≤0.65) (Fig. C);

d) rotation of the fragments.

3) Occult scaphoid fracture – a scaphoid fracture with no radiographic evidence of fracture on initial radiographs [13].

4) Malunited scaphoid fracture – consolidation in a malposition with scaphoid deformation (most commonly flexion and pronation of the distal fragment relative to the proximal one) [11].

5) Humpback deformity – an angular displacement between the proximal and distal fragments resulting from volar tilt of the distal fragment and dorsal tilt of the proximal fragment [13, 14].

6) Dorsal intercalated segment instability (DISI) – occurs as a result of extension of the lunate in concert with the proximal fragment of the scaphoid linked by the scapholunotriquetral ligament, which can occur independently or as a result of a humpback deformity, leading to disruption of wrist biomechanics and the potential development of osteoarthritis [15].

7) Hypothenar – a group of intrinsic hand muscles located on the ulnar border of the palm, forming the eminence of the little finger.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Fractures of the carpal bones and hand – traumatic injuries to the carpal bones, metacarpals, or phalanges resulting in a breach of their integrity.

Carpal bone nonunion – a fracture that fails to heal despite an adequate period for consolidation. It may develop following non-operative treatment, in untreated patients, or after inadequate treatment [11].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The etiology of carpal and hand bone fractures involves external force exceeding the bone's structural strength. Most commonly, this is a direct mechanical impact to the bone, a fall onto an outstretched hand with the wrist in extreme flexion or extension, or extreme loading via an extended wrist during sports activities (gymnastics and weightlifting) [1, 45, 46].

The blood supply to the scaphoid affects its bone healing and the development of complications [13]. The blood supply to the distal 20–30% of the scaphoid is derived from palmar branches of the radial artery, which pass near the tubercle of the distal pole and supply the latter as well as the waist region of the bone. The blood supply to 70–80% of the scaphoid is provided by dorsal branches of the radial artery, which supply the proximal pole via a tenuous intraosseous blood supply. Scaphoid fractures disrupt the intraosseous vascular network, which can potentially lead to:

• ischemia and occasionally necrosis of the proximal pole;

• development of nonunion.

1.2.1 Specifics of etiology and pathogenesis of the disease or condition (group of diseases or conditions) in children

Carpal bone fractures in children are rare injuries. Their low incidence is largely due to their structural characteristics, requiring greater force to fracture than in adults [76]. At birth, the carpal bones are cartilaginous. Ossification centers initially appear between 1 and 6 months of age in the capitate (most commonly at 2 months) and the hamate (most commonly by 3 months). Subsequently, ossification centers appear in the triquetrum from 2 to 4 years, the lunate from 3 to 5 years, the trapezium and trapezoid from 4.5 to 6 years, and the scaphoid at 5–6 years. Lastly, at 10–12 years of age, an ossification center appears in the pisiform. An accessory ossification center may be present in the hook of the hamate up to 11 years of age. By 13–15 years of age, the structure of the carpal bones is indistinguishable from that of adults [86, 81]. Considering the timeline of ossification, carpal bone fractures in children are more frequently located in the distal segment [84, 82]. Carpal bone fractures in the pediatric population have a low-energy mechanism and are associated with falls in 80% of cases. However, high-energy injuries have also been described, such as trauma resulting from direct blows, crush injuries, and motor vehicle accidents [77]. The capitate, triquetrum, and hamate are most susceptible to such forces. Fractures occur as a result of bones impacting each other due to high-energy external forces [78].

In addition to isolated fractures, simultaneous multiple carpal bone fractures can occur in children [79], as well as combined scaphoid and capitate fractures associated with a radius fracture [90].

1.3 Epidemiology of the Disease or Condition

According to Russian-language literature, hand bone fractures account for 9 to 13% of all human skeletal fractures, with carpal fractures comprising up to 10% of these [2]. According to various sources, wrist and hand injuries account for 25–65% of all wrist joint traumas [3]. In the overall structure of specialized upper extremity surgery departments, post-traumatic sequelae account for 40–56% of all patients with hand pathologies [4]. In 18.5% of cases, carpal bone fractures occur concurrently with fractures of the radius, the radial and ulnar styloid processes, as well as fractures and dislocations of other carpal bones, metacarpals, and phalanges [5]. The scaphoid is most frequently injured (scaphoid fractures account for 70 to 90% of all carpal bone fractures, 11% of hand fractures, and 2.4% of all human skeletal fractures) [6–8]. Approximately 18% of all carpal fractures are triquetral fractures, trapezium fractures account for about 3–5%, lunate fractures – 4%, capitate fractures – 2%, hamate fractures – 2%, pisiform fractures – 1–2%, and trapezoid fractures – less than 1% [45].

Scaphoid fractures are more common in men, with a ratio of 2:1 [12]. These injuries are most frequently seen in young patients with high activity levels, including males aged 15–29 years and girls aged 10–14 years; they are rare in toddlers and elderly individuals, the latter due to lower bone density in the distal metaphysis of the radius compared to the scaphoid, which typically predisposes to distal radius fractures [16].

1.3.1 Specific epidemiology of the disease or condition (group of diseases or conditions) in children

Scaphoid fractures are the most common carpal fractures, accounting for 0.5% of upper extremity fractures and less than 3% of hand and wrist fractures in this patient population. Such injuries are most commonly observed in adolescents aged 11 to 17 years and are very rare in children under 8 years of age [82].

Injuries to other carpal bones in children are quite rare; clinical cases of capitate, trapezoid, triquetral, pisiform, and lunate bone injuries have been reported (0.3–24.4%) [87, 76].

Isolated trapezium fractures are rare injuries, particularly among adolescents, accounting for only 0.4% of all carpal fractures [80].

Capitate fractures are the second most frequent carpal fracture after scaphoid fractures, accounting for approximately 0.3% of all carpal bone fractures [87].

The incidence of scaphoid nonunion in children is reported in the literature to average 1.5%, which primarily results from missed or misdiagnosed injuries. Unlike adult patients, the distal third of the scaphoid is most frequently affected, while proximal fractures are rare due to the large cartilaginous cap of the proximal pole [82].

1.4 Features of Coding the Disease or Condition

These clinical guidelines provide information on fractures and dislocations of the carpal and hand bones, as well as their sequelae:

- S62 Fracture at wrist and hand level

- S63.0 Dislocation of wrist

- S63.1 Dislocation of finger

- T92.2 Sequelae of fracture at wrist and hand level

1.5 Classification of the disease or condition

Carpal fractures are considered acute up to 4 weeks from the time of injury; delayed union is defined from 4 weeks to 6 months; and nonunion is diagnosed when there is no consolidation within 6 months post-injury [9, 10].

The anatomical classification of scaphoid fractures is based on the location of the fracture line within the bone [12–14]:

• Proximal third (in approximately 5% of patients);

• Middle third (waist) (in approximately 70% of patients);

• Distal third (in approximately 10–20% of patients);

• Scaphoid tubercle (in approximately 5% of patients).

Modified Herbert classification of scaphoid fractures (1996) [10]:

Triquetral fractures are classified into:

1. Dorsal cortical (avulsion) fracture,

2. Body fracture,

3. Volar avulsion fracture – avulsion of the palmar ulnotriquetral and lunotriquetral ligaments [44, 46].

Trapezium fractures are classified into [46, 101]:

Fractures of the lunate bone are divided into:

1. Fractures of the volar column,

2. Fracture of the dorsal column,

3. Transverse fracture,

4. Osteochondral,

5. Transarticular body fracture [46].

Fractures of the capitate bone are divided into:

1. transverse body fracture,

2. transverse pole fracture,

3. vertical-frontal,

4. parasagittal.

Fractures of the hamate bone are classified into:

1. Fractures of the hook.

2. Fractures of the hamate body:

A. fracture of the proximal pole

B. of the medial tuberosity

C. oblique sagittal

D. dorsal coronal [46]

Fractures of the pisiform bone are classified into:

1. Transverse fracture,

2. Parasagittal fracture,

3. Comminuted fracture,

4. Pisotriquetral compression fracture.

Isolated fractures of the trapezoid bone are divided into fractures of the dorsal margin and the body.

1.6 Clinical presentation of the disease or condition

General symptoms of carpal bone fractures:

- local pain syndrome in the projection of the injured bone,

- range of motion in the wrist joint limited by pain,

- edema in the injury zone.

Clinical signs of a scaphoid fracture:

- pain along the radial aspect of the wrist joint upon pressure on the tendon of the flexor carpi radialis [12] (manifests as deep dull pain, worsening with fist clenching or wrist movements [17]; "pain in the anatomical snuffbox" area, or as pain in the projection of the scaphoid bone, which is not observed in all patients [18]),

- pain syndrome upon movement in the joints of the first digit [18],

- decreased range of motion in the wrist joint [14],

- decreased grip strength [14],

- edema in the projection of the fracture (inconsistent sign) [17].

2. Diagnostics, medical indications and contraindications for diagnostic methods

2.1 Complaints and Anamnesis

Comments: collection of complaints and medical history is included in the scope of the corresponding medical service provided to the patient from section "B" of the nomenclature of medical services (approved by Order of the Russian Ministry of Health No. 804n dated October 13, 2017, with subsequent amendments and additions).

1. the nature of the sustained injury, whether there was a fall onto an outstretched hand or a direct high-energy impact to the wrist [11];

2. the time elapsed since the injury and the dynamics of changes in the nature of the pain syndrome, including the diagnosis and treatment of other wrist injuries [11];

3. the presence of the dominant hand, the nature of primary work, and hobbies [19];

4. lifestyle factors associated with an increased risk of scaphoid fracture, including participation in:

• high-contact team sports such as football and basketball [12];

• other sports, including cycling, skateboarding, rollerblading, and snowboarding [20].

2.2 Physical Examination

Comments: during the visual examination, it is possible to diagnose edema in the fracture zone, and limitation of wrist joint movements (see section 1.6).

Comments: in case of a scaphoid fracture, palpation reveals:

1. Pain syndrome in the projection of the anatomical snuffbox, increasing with ulnar deviation of the wrist [17];

2. Pain syndrome in the projection of the scaphoid tubercle upon axial loading or upon palpation in the projection of the scaphoid tubercle itself [11, 12];

3. Pain syndrome upon axial loading of the first ray of the injured hand [11];

4. Positive scaphoid shift test (Watson test) [21].

During this test, the examiner places the thumb over the scaphoid tubercle, grasps the distal radius with the II–V fingers, and holds the patient's wrist in ulnar deviation. While moving the wrist into radial deviation, the examiner applies increasing pressure to the scaphoid tubercle. Pain during this test may indicate a possible scaphoid fracture, while a "click" or "clunk" suggests scapholunate instability.

Palpation findings in triquetral fracture include:

1. Local tenderness over the triquetrum;

2. Pain along the ulnar border of the wrist;

3. Local pain over the triquetrum upon wrist flexion.

Palpation findings in trapezium fracture include:

1. Focal tenderness over the trapezium;

2. Tenderness at the base of the thumb, increasing with resisted wrist flexion (inconstant symptom);

3. Palpation of the injury site should be supplemented with the grinding test.

Palpation findings in lunate fracture include:

1. Pain over the dorsal aspect of the wrist;

2. Swelling over the lunate.

Palpation findings in hamate fracture include:

1. Pain along the ulnar palmar aspect over the hook (increasing with active grip, ulnar deviation, and wrist extension);

2. Swelling and hematoma in the hypothenar region (in hook fracture), dorsal hand swelling over the hamate (in body fracture);

3. Ulnar nerve paresthesias (inconstant symptom).

Palpation findings in pisiform fracture include:

1. Pain along the ulnar border of the wrist, directly over the pisiform;

2. Signs of ulnar neuropathy (inconstant symptom).

Palpation findings in trapezoid fracture include:

1. Mildly localized pain in the region of the base of the second metacarpal and the anatomic snuffbox;

2. Swelling on the dorsal aspect of the hand over the trapezoid.

Comments: palpation of the injury site is part of the corresponding medical service provided to the patient, falling under section "B" of the nomenclature of medical services (approved by Order of the Russian Ministry of Health No. 804n of October 13, 2017, with subsequent amendments and additions).

2.3 Laboratory Diagnostics

• All patients diagnosed with carpal bone fractures for whom surgical treatment is planned are recommended to undergo the following laboratory tests for preoperative preparation [22, 75]:

  • Determination of ABO blood groups and Rh factor (D antigen);

  • Blood creatinine level test;

  • Blood glucose level test;

  • Determination of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activity in blood;

  • Determination of antibodies to Treponema pallidum;

  • Determination of IgM and IgG antibodies to Hepatitis B surface antigen (HBsAg) in blood;

  • Determination of IgM and IgG antibodies to Hepatitis C virus in blood (including total anti-HCV antibodies);

  • Determination of IgM and IgG antibodies to Human immunodeficiency virus (HIV-1) in blood;

  • Determination of antibodies of classes M, G (IgM, IgG) to human immunodeficiency virus HIV 2 in the blood.

CGR CLEL 5Level of recommendation validity — C (level of evidence reliability — 5).

Comments: these laboratory tests are not definitive for establishing the diagnosis, but are necessary for planning surgical intervention, further treatment tactics, and postoperative laboratory monitoring. Additional diagnostic methods should be applied if the patient has comorbid conditions.

2.4 Instrumental Diagnostics

Comments: "radiography of the injury site," at the discretion of the ordering medical professional, corresponds to one or more medical services of the "radiological examinations with subsequent description and radiotherapy" type, including—but not limited to—the following medical services:

- upper extremity radiography;

- radius and ulna radiography;

- wrist radiography;

- metacarpal radiography;

- hand radiography;

- radiography of hand phalanges;

- radiography of finger phalangeal bones of the hand;

- radiography of the thumb.

In case of suspected scaphoid fracture:

Three projections must be performed: anteroposterior and lateral projections plus an additional view (semi-pronation). Options for additional views include: An external oblique anteroposterior radiograph centered on the scaphoid with the wrist in pronation and ulnar deviation. An anteroposterior radiograph with the hand clenched into a fist and in ulnar deviation, taken with a proximal tilt (where the X-ray beam is directed toward the elbow), outlines the scaphoid length and helps detect occult fractures. Repeat radiographs for diagnostic purposes are performed 10–14 days after the initiation of suspected plaster immobilization if other instrumental diagnostic procedures are unavailable.

In case of suspected triquetral fracture:

- anteroposterior radiographs,

- anteroposterior radiographs in radial deviation of the wrist,

- lateral radiographs,

- lateral radiographs with 45-degree wrist pronation [45, 46].

In case of suspected trapezium fracture:

- anteroposterior radiographs,

- anteroposterior radiographs in pronation (Bett view),

- lateral radiographs,

- carpal tunnel view radiographs [44, 45].

In case of suspected lunate fracture, standard anteroposterior, lateral, and ¾ view radiographs are performed, along with corresponding radiographs of the contralateral limb to identify carpal anatomy variants [45, 46].

In case of suspected capitate fracture, standard anteroposterior and lateral radiographs are performed, or a CT scan if there is no fragment displacement [44, 45].

In case of suspected capitate fracture, standard anteroposterior and lateral radiographs are performed, or a CT scan if there is no fragment displacement [44, 45].

In case of suspected hamate fracture, carpal tunnel view radiographs or a CT scan is performed [44, 45].

In case of suspected pisiform fracture:

- lateral radiographs,

- lateral radiographs in ulnar deviation and wrist extension,

- anteroposterior radiographs with clenched fist and ulnar deviation of the wrist [44, 45]. If diagnosis is difficult based on radiographs, a CT scan is performed.

When a trapezoid fracture is suspected, standard radiographs of the wrist in anteroposterior, lateral, and ¾ views are performed, which can reveal subluxation of the second metacarpal bone in the presence of a trapezoid fracture.

2.4.1 Features of instrumental diagnostic studies in children

Comments: in children, standard radiography of the carpal bones may yield false-negative results in 90.9% of cases because the cartilaginous structure is not visible on X-rays.

Computed tomography and magnetic resonance imaging help identify isolated carpal bone fractures in children [87, 85, 92, 94, 95, 96]. However, in children under 7–8 years of age, MRI may be as uninformative as radiography because the cartilaginous cover of the carpal bones is elastic, durable, and may remain visibly undamaged when the ossification center is fractured [83].

MRI is most informative for detecting avascular necrosis and determining the presence or absence of union [88, 89].

2.5 Other Procedures

No.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative treatment in adults

• If a stable, nondisplaced scaphoid fracture or an occult fracture is detected, it is recommended to apply a short palmar plaster cast (application of a plaster cast for bone fractures) from the middle third of the forearm to the distal palmar crease with or without fixation of the first ray of the hand [8].

Gle BLE 3Grading of Recommendations Assessment, Development and Evaluation (GRADE) — B (Level of Evidence – 3).

Comments: application of a short plaster cast without immobilizing the thumb is comparable in efficacy to fixation with thumb immobilization [11, 12, 14].

Plaster immobilization is maintained until bone union is confirmed at 4–8 weeks via follow-up CT scanning [11, 14]. For isolated nondisplaced scaphoid tubercle fractures, a computed tomography scan of the upper extremity (wrist) must be performed for evaluation 4 weeks after the start of plaster immobilization; for fractures at the waist or distal third of the scaphoid, at 8 weeks [13]. If there are no signs of union on the follow-up CT scan after 8 weeks of plaster immobilization, immobilization is continued for another 4–6 weeks; if union is still absent (per CT) after this period, surgical treatment should be considered.

Comments: postoperative immobilization is carried out using a palmar plaster slab from the proximal third of the forearm to the distal palmar crease of the hand until signs of union are detected on follow-up CT imaging (at 6–8 weeks post-surgery).

• If a dorsal cortical fracture of the triquetrum with minor displacement or a nondisplaced fracture is detected, it is recommended to apply a short palmar plaster cast (application of a plaster cast for bone fractures) from the middle third of the forearm to the distal palmar crease without fixation of the first ray of the hand, with the aim of achieving triquetral fracture union over 4–6 weeks, followed by computed tomography of the upper extremity (wrist) [44-46].

CGR CLEL 5Level of recommendation validity — C (level of evidence reliability — 5).

Comments: if pain persists after the immobilization period, consider early excision of the crest.

3.1.2 Features of conservative treatment in children

• If there is a clinical suspicion of a carpal bone fracture in a child (even in the absence of radiological findings), it is recommended to apply plaster immobilization with fixation of the first metacarpophalangeal joint, followed by a follow-up radiographic examination in 7–14 days [92].

Gle BLE 3Grading of Recommendations Assessment, Development and Evaluation (GRADE) — B (Level of Evidence – 3).

3.2 Surgical treatment in adults and children

Comments: surgical treatment of scaphoid fractures can shorten return-to-work time and improve functional outcomes compared to nonoperative treatment.

1. Surgical treatment of displaced scaphoid fractures includes:

   - fragment reduction under arthroscopic control and internal fixation with 1.0 Kirschner wires or a screw,

   - open reduction with internal fixation using 1.0 Kirschner wires or a screw.

   Surgical treatment of nondisplaced scaphoid fractures consists of percutaneous screw fixation of the bone.

2. Surgical treatment of long-standing ununited scaphoid fractures without displacement or bone deformity is performed via percutaneous screw or Kirschner wire fixation. In the presence of bone deformity or DISI, internal screw fixation is supplemented by open or arthroscopic reduction and cancellous bone grafting.

3. Surgical treatment of scaphoid nonunions, depending on the department's capabilities and the surgeon's skills, involves resection of the nonunion zone (using open or arthroscopic techniques) within well-perfused bone tissue, followed by:

   - correction of scaphoid deformities, cancellous bone autografting, and Kirschner wire fixation.

   - grafting with a vascularized pedicled bone graft from the radial metaphysis (or a free vascularized femoral condyle bone flap) with simultaneous correction of scaphoid deformities and screw fixation,

Comments: surgical treatment of triquetral fractures involves open reduction, pin or screw fixation with fixation of the lunotriquetral joint (in case of perilunate ligament injury), or osteosynthesis of the triquetrum with a compression screw/pins for an isolated fracture [44–46].

Comments: surgical treatment of trapezium fractures involves open reduction and fixation with screw(s) or pins with bone autografting if indicated [44–47].

Comments: in case of a lunate body fracture, open reduction and screw osteosynthesis of the bone are performed,

- for dorsal rim fractures with injury to the scapholunate and/or lunotriquetral ligaments, ligament repair with bone tunnels and fixation devices is performed,

- volar rim fractures require fixation with a screw or pins,

- severe comminuted fractures require an individualized approach, with possible partial healing or proximal row carpectomy [44, 45].

Comments: surgical treatment of capitate fractures involves open reduction and screw fixation, with bone autografting if indicated, or percutaneous pin fixation [44, 45].

Comments:

1) for hook fractures, excision or open reduction and screw osteosynthesis is performed.

2) for displaced body fractures, open reduction, fixation with screws, plates, or Kirschner wires should be performed [46].

Comments: surgical treatment consists of excision of the pisiform bone followed by repair or reconstruction of the flexor carpi ulnaris, if necessary.

Comments: surgical treatment consists of open reduction, osteosynthesis with a screw or Kirschner wires, followed by plaster immobilization for 6–8 weeks.

3.3 Other Treatment

3.3.1 Surgical antibiotic prophylaxis

• During the surgical treatment of adults and children with carpal bone fractures and nonunions requiring metal implant placement, it is recommended to perform surgical antibiotic prophylaxis (SAP) to prevent surgical site infections via a single preoperative administration of an antibacterial drug to reduce the risk of infectious complications [50, 51].

GCR CLEL 5Recommendation Consensus Level — C (Level of Evidence – 5).

Comments. In accordance with international clinical guidelines for the prevention of surgical site infections [50, 52], the objective of surgical antimicrobial prophylaxis (SAP) is to establish bactericidal concentrations of an antibacterial drug in tissues undergoing microbial contamination during surgery to prevent surgical site infections. The necessity of SAP is determined by the surgical wound class of the upcoming operation: SAP is not required for "clean" surgical wounds not associated with the implantation of orthopedic and metallic devices. SAP should be performed: for clean-contaminated and contaminated surgical wounds; for "clean" surgical wounds involving the implantation of orthopedic and metallic devices. In infected ("dirty") wounds, SAP is not indicated; antibiotic therapy is administered instead.

• In patients with fractures and nonunions of the carpal bones, it is recommended to use first- and second-generation cephalosporins (1st and 2nd generation, ATC J01DB, J01DC) (cefazolin**, cefuroxime**) as first-line drugs for surgical antimicrobial prophylaxis in traumatology and orthopedic surgery; as alternatives in case of beta-lactam antibiotic intolerance – glycopeptide antibacterial drugs (vancomycin**), lincosamides (#clindamycin**) [50]. The use of these medicinal products is carried out taking into account the age restrictions specified in the instructions for medical use.

Leveled Clinical Recommendation CLevel of Evidence 5Level of recommendation validity — C (level of evidence – 5).

Comments. For patients with an unremarkable allergic history and without significant risk factors for methicillin-resistant staphylococcus carriage, first- and second-generation (1st and 2nd generation) cephalosporins (cefazolin**, cefuroxime**) are used for SAP, administered intravenously 30 to 60 minutes before skin incision. In case of beta-lactam antibiotic intolerance, vancomycin** should be prescribed, administered over at least 60 minutes with the start of intravenous infusion 2 hours before the incision, or #clindamycin**. In the presence of significant risk factors for methicillin-resistant staphylococcus carriage (MRS), the SAP regimen should include systemic antibacterial drugs (ATC: J01) with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of a systemic antibacterial drug is sufficient for effective prophylaxis. For prolonged procedures (more than 3 hours) or massive blood loss, an additional intraoperative dose of a systemic antibacterial drug (ATC: J01) should be administered (estimated timing of intraoperative administration is two half-lives after the preoperative dose). Administration of systemic antibacterial drugs (ATC: J01) after wound closure in the operating room is inappropriate, even in the presence of inserted drains.

A prospective randomized clinical trial showed that administering an antibacterial drug for SAP 1 minute after tourniquet application demonstrated a statistically significant advantage in terms of reducing the incidence of surgical site infection, wound healing time, and overall patient satisfaction compared to administering the antibiotic before tourniquet application [53].

Single doses of main antibacterial drugs for SAP in traumatology and orthopedic surgical interventions in adults: cefazolin** 2 g (if patient weight ≥120 kg – 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, vancomycin** 15 mg/kg as a slow IV infusion [50].

Single doses for children should be calculated based on actual weight: cefazolin** 30 mg/kg, cefuroxime** 50 mg/kg, #clindamycin** 10 mg/kg, vancomycin** 15 mg/kg; the use of fluoroquinolones (ATC: J01MA) during the period of musculoskeletal system development is contraindicated due to the risk of arthropathy [50, 54, 55].

Comments. In cases of open fractures, prophylactic antibiotic administration is effective in preventing early infection, and the drug should be administered as soon as possible after trauma. Cefazolin** is the antibiotic of choice; however, in patients with high-energy open fractures, major vascular injury, or heavily contaminated wounds, it is advisable to broaden the spectrum of prescribed antibiotics to cover gram-negative pathogens. In such cases, for adult patients, it is possible to consider adding #gentamicin** (at a dose of 6 mg/kg once daily) to cefazolin** [57,58]. An alternative to this combination for patients over 18 years of age may be #ampicillin + sulbactam** (at a dose of 3.0 g every 8 hours for 3 days) [59]; the latter is particularly relevant in cases of the risk of clostridial infection. According to the majority of researchers, in Gustilo-Anderson type III open fractures, antibiotics should not be continued for more than 72 hours after soft tissue wound closure [60].

• During the surgical treatment of patients with fractures and nonunions of the carpal bones, it is recommended to administer surgical site infection prophylaxis for no more than 24 hours [61].

GCR CLEL 5Recommendation Consensus Level — C (Level of Evidence – 5).

Comments: in accordance with the regulatory documentation in force in the Russian Federation (SanPiN 3.3686-21) and clinical guidelines [61], in order to achieve an effective concentration of the antibacterial drug in tissues and blood serum at the time of the skin incision, antibiotics for surgical site infection prophylaxis should be administered intravenously within 30 to 60 minutes prior to the skin incision, or within 2 hours prior to the incision when using vancomycin**. The maximum duration of prophylactic systemic antibacterial drug administration should not exceed 24 hours after the completion of the surgery. In most cases, a single dose of a systemic antibacterial drug is sufficient for effective prophylaxis. Additional doses should be administered during prolonged surgeries when the half-life of the administered systemic antibacterial drug has elapsed since preoperative administration, creating a risk of the antibacterial drug concentration dropping below the bactericidal level and increasing the risk of surgical site infections.

3.3.2 Postoperative analgesia

• For the purpose of adequate analgesia in patients with fractures and nonunions of the carpal bones, it is recommended to use multimodal analgesia for adults and children, taking into account age restrictions, which may include NSAIDs (from group M01A Non-steroidal anti-inflammatory and antirheumatic products), paracetamol**, and immediate-release opioids (ATC group code N02A) considering age restrictions in the package leaflet, or monomodal analgesia if multimodal administration is not feasible [65, 66, 67, 68].

GCR ALOCE 1Grade of Recommendations — A (Level of Evidence — 1).

Comments: it is necessary to ensure adequate pain relief for the patient with a fracture prior to any manipulations and throughout the entire treatment period, the duration of which varies significantly depending on the chosen management strategy. When providing analgesia in a hospital setting, it is necessary to take into account prescriptions administered at the emergency medical care stage. In the acute trauma period, for pain relief purposes, proper fragment immobilization must be provided using a vacuum splint, vacuum mattress, or external fixation device.

Among pharmacological strategies, the current consensus is the use of multimodal analgesia (MMA), which involves the administration of multiple analgesics (opioid and non-opioid) from the N02 Analgesics group with different mechanisms of action, along with non-pharmacological interventions targeting the peripheral and/or central nervous system [69]. This combination provides more effective pain relief by potentiating the effects of various drugs, which in most cases leads to a reduced frequency of prescriptions and/or lower doses of opioid analgesics. Thus, MMA improves the risk profile of each medication while ensuring synergistic pain control through different drug classes. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol**, regional anesthesia (single-shot or continuous peripheral nerve catheter placement), local injections, and opioids [66, 70].

In modern literature, authors emphasize using the lowest effective doses of opioids for the shortest possible duration, avoiding extended-release opioids. As an adjuvant during MMA in adult patients, a single intravenous dose of #dexamethasone** 1.25–20 mg can be administered prior to surgery (60 minutes before the incision), which significantly reduces pain severity [65].

It must be kept in mind that the duration of parenteral administration of most NSAIDs from the ATC group M01A "Anti-inflammatory and antirheumatic products, non-steroids" (ketorolac**, ketoprofen**, diclofenac**) is limited to two days in accordance with the instructions for medical use, which requires timely switching of the patient to oral administration, changing the drug, or approving further use with the medical commission. The specific choice of local anesthesia method and medicinal products is made by the attending physician individually, in accordance with the patient's characteristics, local protocols, and the equipment of the medical organization.

When prescribing analgesic therapy for children, a single dose should be chosen taking into account the child's weight and age. Preference should be given to analgesics with oral or rectal administration routes, avoiding intramuscular injections.

Recommended analgesics from the N02 Analgesics group are listed in Appendices A3.1, A3.2, A3.3.

3.3.3 Prevention of venous thromboembolic complications

• Routine pharmacological VTE prophylaxis is not recommended for upper extremity surgeries performed under local or regional anesthesia [62].

GCR CLEL 5Recommendation Consensus Level — C (Level of Evidence – 5).

Comments: issues regarding VTE prophylaxis in orthopedic trauma patients are discussed in detail in the 2022 clinical guidelines [63] and the 2023 Russian expert recommendations [64].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Wrist injuries can lead not only to impaired hand and finger function, but also to difficulties with daily activities and self-care, which impairs the patient's quality of life. Trauma care is crucial in treating this injury, but complete recovery is impossible without rehabilitation. Regardless of the treatment method—conservative with cast immobilization or surgical—rehabilitation begins from the first days and continues through all stages until full recovery. A multidisciplinary, comprehensive, yet individualized approach helps shorten recovery times. Conducting staged rehabilitation using therapeutic exercise (exercise therapy), massage, physiotherapy, and occupational therapy accelerates functional recovery and improves the patient's quality of life [32, 36, 39, 42].

Comments: given the great importance of the hand and fingers as an organ of self-care and labor operations, rehabilitation is essential and aimed at restoring impairments caused by trauma and immobilization. Following a wrist dislocation, joint mobility can be severely restricted, requiring specialized mobilization techniques. Muscle weakness following immobilization is invariably noted, and its recovery is necessary to maintain joint stability and perform occupational tasks. Coordination of movements and control over fine motor skills are lost, requiring specialized proprioceptive training. The ultimate goal of rehabilitation is to restore a person's ability to perform daily activities and tasks, starting with self-care, writing, handling objects, housework, and labor tasks, which requires the use of occupational therapy [29, 31, 32, 36, 37].

Comments: the duration of the immobilization period varies and averages 4 weeks for acute dislocations after closed reduction, 6 weeks for chronic dislocations after open reduction and K-wire fixation, up to 3 months for acute carpal bone fractures without displacement, and up to 8 weeks for acute carpal bone fractures following open reduction and internal fixation with wires/screws [31, 32, 34, 36, 37].

The duration of the period is determined in consultation with an orthopedic trauma surgeon.

The rehabilitation program is designed individually by a PRM/exercise therapy physician and consists of therapeutic gymnastics (formulating a therapeutic exercise course plan, prescribing a set of therapeutic exercise routines, exercise therapy physician appointment (examination, consultation)):

- active movements of the fingers and in the elbow joint - flexion/extension, gripping a soft ball and small objects to prevent joint stiffness,

- isometric forearm muscle contractions to improve blood circulation and prevent muscle atrophy,

- ideomotor exercises,

- dynamic exercises for healthy limbs.

During a brief hospital stay after surgical treatment, local cryotherapy and magnetotherapy (magnetic field therapy) through the cast are prescribed to reduce edema and pain.

Comments: in the early stage of the recovery period (6–12 weeks) after cast removal, the rehabilitation program consists of:

- therapeutic gymnastics (A19.04.001.003) with joint mobilization exercises (active finger movements, passive flexion/extension using the healthy hand at the wrist joint, circular wrist movements (clockwise/counterclockwise));

- to improve muscle strength (dynamic exercises with resistance and light weights (holding a light weight (0.5 kg) with slow extension, resistance to flexion/extension with an elastic band;

- coordination and proprioception recovery exercises [26, 27, 35];

- passive mechanotherapy (A19.30.006.001 robotic mechanotherapy);

- ultrasound therapy (A17.30.034 medicinal ultraphonophoresis) and thermotherapy [38, 39] for scar softening;

- manual hand and forearm massage and/or electrostatic field massage to reduce pain (medical upper extremity massage, alternating electrostatic field exposure);

- local underwater whirlpool massage;

- hydrokinesitherapy (A19.03.003.023 hydrokinesitherapy for bone fractures).

Comments: the rehabilitation program includes:

- therapeutic gymnastics (A19.04.001.003) to restore muscle strength: wrist flexion/extension with dumbbells (1–2 kg) and resistance, with resistance during supination/pronation using an expander;

- occupational therapy (modeling real-life activities such as picking up small objects or turning a doorknob, faucet, etc.), grasping and holding, transferring small objects (coins, balls), modeling with clay, writing, etc. [42, 43];

- hand and forearm massage;

- vibration therapy as an element of manual or hardware massage [33];

- soft tissue manual therapy techniques (A21.03.004);

- proprioception training [26, 27, 35] on biofeedback training devices (A19.04.001.014).

Important: proprioception can and should be trained even during the immobilization period using visualization and mirror therapy methods. Studies (e.g., Rosenkranz et al., J Hand Ther 2022 [41]) show that early proprioceptive stimulation reduces recovery time by 17-23%. However, these methods are rarely used in our country and are not included in the nomenclature of medical services.

5. Prevention and Dispensary Observation

Specific prevention of fractures and dislocations of hand phalanges and metacarpal bones has not been developed. Measures to reduce traumatism and comply with safety regulations at home and in the workplace are relevant. Dispensary observation for hand bone fractures is not regulated.

• To prevent carpal bone fractures, it is recommended to include the use of special protective equipment (such as wrist guards for snowboarders, etc.) in sports associated with an increased risk of injury [48].

Gle ALE 2Grading of Recommendations Assessment, Development and Evaluation (GRADE) — A (Level of Evidence – 2).

6. Organization of Medical Care

Clinical application of recommendations: Traumatology and Orthopedics, Anesthesiology and Intensive Care, Medical Rehabilitation, Health Organization and Public Health.

Purpose of the clinical guidelines: Clinical guidelines are developed to improve the quality of medical care, standardize diagnostic and treatment algorithms for patients with carpal bone fractures and nonunions.

Indications for hospitalization are clinical situations requiring surgical treatment (see section 3.2).

Indications for discharge of a patient from a medical organization are: clear regression of pain syndrome, absence of signs of active inflammation, patient mobilization and initiation of medical rehabilitation, or refusal of the patient/guardians in case of legally established incapacity of the patient to continue inpatient treatment (the reason for refusal must be documented in the medical record with the personal signature of the patient or their guardians).

7. Additional Information

In the postoperative period, there remains a probability of post-immobilization contractures, purulent-inflammatory processes, and Sudeck's atrophy, which require prolonged comprehensive treatment and monitoring [49].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Avdeichik NV, Candidate of Medical Sciences, trauma surgeon at the Department of Reconstructive Microsurgery and Hand Surgery, National Medical Research Center for Children's Traumatology and Orthopedics named after H.I. Turner of the Russian Ministry of Health.

2. Balyura GG, Candidate of Medical Sciences, member of the interregional public organization "Hand Surgery Society — Hand Group", Moscow; member of ATOR.

3. Galkina NS, trauma surgeon at the Department of Reconstructive Microsurgery and Hand Surgery, National Medical Research Center for Children's Traumatology and Orthopedics named after H.I. Turner of the Russian Ministry of Health.

4. Geroeva IB, Doctor of Medical Sciences, Professor, National Medical Research Center for Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow.

5. Golubev IO, Doctor of Medical Sciences, Chairman of the interregional public organization "Hand Surgery Society — Hand Group", Moscow; member of ATOR.

6. Grankin DYU, trauma surgeon at the Department of Reconstructive Microsurgery and Hand Surgery, National Medical Research Center for Children's Traumatology and Orthopedics named after H.I. Turner of the Russian Ministry of Health.

7. Kokorev AI, Candidate of Medical Sciences, trauma surgeon, Head of the Department for Organization of Traumatological and Orthopedic Services, National Medical Research Center for Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, member of ATOR.

8. Nazarenko AG, Doctor of Medical Sciences, Corresponding Member of the Russian Academy of Sciences, Director of the National Medical Research Center for Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow, Vice President of ATOR.

Conflict of interest: the members of the working group declare no conflict of interest in the development of this clinical guideline.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Trauma and orthopedic surgeons

2. Surgeons

3. Pediatric surgeons

4. General practitioners (family physicians)

5. Medical rehabilitation physicians

Stages of assessing levels of evidence and grades of recommendation:

1. Definition of search and selection criteria for publications on clinical trials (CT) regarding the efficacy and/or safety of the medical intervention described in the recommendation statement.

2. Systematic search and selection of CT publications in accordance with the previously defined criteria.

Systematic search and selection of publications on clinical trials:

The evidence base for the guidelines consisted of publications selected through information retrieval in the databases of the Central Scientific Medical Library "Russian Medicine", MEDLINE (US National Medical Library) and COCHRANE Library, scientific electronic libraries eLibrary.ru and "CyberLeninka", as well as on the Internet using search engines Yandex, Google and Google Scholar, by reviewing leading specialized peer-reviewed domestic medical journals on this topic and treatment guidelines for fracture management from the international Association for Osteosynthesis AO/ASIF.

Table 1.Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2.Scale for assessing levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, rehabilitation interventions)

Table 3. Rating scale for grades of recommendation (GR) for preventive, diagnostic, therapeutic, and rehabilitation methods (interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1. Guidelines for pain management in major musculoskeletal trauma (surgical interventions for long bone fracture fixation or complex articular fracture, extensive soft tissue trauma, major surgery, etc.) in adults

The table presents analgesic drugs and their dosage regimens in accordance with the Clinical Guidelines for Pain Management in Acute Musculoskeletal Trauma [69].

Appendix A3.2. Guidelines for pain management in musculoskeletal trauma without surgery (closed fractures, superficial wounds, etc.) in adults

The table presents analgesic drugs and their dosage regimens in accordance with the Clinical Guidelines for Pain Management in Acute Musculoskeletal Trauma [69].

Appendix A3.3 Analgesic dosage regimen for children

¹ In children under 12 years of age, morphine** is preferred when opioid analgesics need to be prescribed, as the use of tramadol** is associated with a higher risk of adverse reactions [72, 73].

² Not recommended for use in children, as its metabolite accumulates in the body and can provoke seizures upon repeated administration [74].

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

During the first days after applying a plaster splint, the condition of the fingers must be monitored. Excessive compression by the plaster cast can cause increased edema and lead to hemodynamic and neurological complications. In case of circulatory disorders, the soft bandage is cut and the edges of the splint are slightly bent. Active movements of the fingers are permitted from day 1 after the fracture and limb immobilization, or from day 1 after surgical treatment. Once the edema and pain syndrome subside, active movements in the elbow joint must be initiated, including pronation and supination under the supervision of a physical and rehabilitation medicine physician (or a medical rehabilitation physician, or an exercise therapy physician, or a physical therapist).

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

No.