presentation that provides a sneak peak into scaphoid fractures for orthopaedics post graduates

2. SCAPHOID FRACTURES
MODERATORS:
Dr G C BASAVARAJA
Dr RAVI GO
PRESENTED BY:
Dr KAUSHIK Y S
22ND APRIL 2015
JJM MEDICAL COLLEGE
DEPT OF ORTHOPAEDICS

3. Introduction
 Scaphoid is one of the smallest bone of human body.
 It is derived from Greek word SKAPHOS meaning boat.
 It acts as a link between proximal and distal carpal rows.
 Scaphoid fractures constitute 60-70 % of all carpal bone fractures.
 Second only to the distal radius in frequency.
 Due to the importance of scaphoid in wrist mechanics and because
of the frequency of the fracture in young adult male, it has an
economic as well as physical significance.
 Uncommon in children because the physis of distal radius fails first.
 M:F-4:1
 AGE- 10-70 yrs. 20-30 yrs (peak)

4. Rule of 70’s for scaphoid
70% of all carpal fractures occur at scaphoid.
70% of blood supply is by the dorsal branch of
the radial artery.
70% of fractures occur at the waist of scaphoid.
70% of the scaphoid fractures unite .

5. Anatomy
 Scaphoid is the largest bone of proximal carpal row.
 It is an irregularly shaped tubular bone, twisted and
bends into s-shape.
 Scaphoid represent floor of the anatomic snuff box.
 Narrow area of its waist and even smaller distal portion,
are accessible to blood vessels
 Distally, it articulates with the trapezium and trapezoid
in a gliding motion, the articulation with the trapezium
forms a base for independent movement of the thumb.
 On the ulnar side, it articulates distally with the
capitate, and proximally with the lunate in a rotatory
motion.
 Proximally, its large, biconvex surface allows articulation
with the radius.

6. LIGAMENTS
Volar

7. Dorsal

8. Blood supply of scaphoid
30% 70%

9. Biomechanics
 Mechanically scaphoid links the proximal and distal
rows.
 Scaphoid spans both carpal rows and therefore has less
mobility than other carpal bones.
 Scaphoid carries the compressive loads from the hand
across the wrist to the distal forearm.
 Scaphoid flexes with wrist flexion & extends with wrist
extension, it also flexes during radial deviation &
extends during ulnar deviation.
 These factors make immobilization of scaphoid
fractures difficult especially when there is
displacement.

10. Mechanism of injury
Two different mechanisms
 Compression injury: Usually results in non-
displaced fracture
 Hyperextension bending injury: usually results in
displaced fracture.

11. Fall on outstretched hand
Forced dorsiflexion of wrist(beyond
95degree)
Compression occurs dorsally and
tension on palmar surface of wrist.
Bending forces applied to waist and
distal pole of scaphoid as proximal
pole is tightly held between
capitate,dorsal lip of radius and taut
palmar capsule.
Leads to fracture scaphoid most
commonly waist

12. Diagnosis
 A strong index of suspicion is the key to early
diagnosis
 The diagnosis should be based on :
1. History
2. Clinical examination
3. Radiographic evaluation.

13. History
 Occurs after a fall on an outstretched hand,
athletic injury, or Motor Vehicle accident
 Usually happens in young adult men
 Pain and swelling at the radial side of the wrist
 Inability or difficulty in moving the involved wrist
 Any Associated injuries.

14. Clinical examination
 Swelling and tenderness present in the anatomical
snuff box

15. Scaphoid provocative tests

16. Scaphoid compression test

17. Scaphoid tubercle tenderness

18. Painful resisted pronation

19. Painful attempted Scaphoid shift
test WATSON TEST

20. Radiographic evaluation
Wrist PA, Lateral, Oblique, Scaphoid views
45 degrees pronated and supinated oblique
views
5 views increased sensitivity and specificity
to almost 100% ( Mehta &Brautigan,1990)

21. Wrist PA

22. Wrist lateral

23. Scaphoid view

24. Supinated Oblique

25. Pronated Oblique

27. Important angles
SCAPHOLUNATE ANGLE
Normal---30 – 60 deg
CAPITOLUNATE ANGLE
Normal---<30 deg
INTRASCAPHOID ANGLE
Normal---AP < 35 deg
LAT < 45 deg

28. Bone Scan-Scintigraphy
Fast and reliable
diagnostic tool
100% Sensitivity
Disadvantages:
Lacks specificity
Little information regarding
location
15% False positive

29. Computed Tomography
Scan oriented to longitudinal axis of scaphoid
for hump back deformity
For surgical planning & assessment of healing
To diagnose additional bony injuries
Disadvantages
False positives in diagnosing occult fractures.

31. MRI
2nd line test in negative radiographs
Identifying occult scaphoid fractures,fractures
of other carpal bones, ligament injuries
Highest sensitivity and specificity

33. Classifications of scaphoid fractues

34. Anatomical
65 % 25 %10 %

35. Russe’s classification

36. Conny’s Dobny’s and Linscheid
 Undisplaced—stable
 Displaced—unstable , results in “HUMP BACK” deformity
 The displaced fracture is defined as :
I. Presence of a fracture gap > 1 mm on any radiographic
projection
II. Scapholunate Angle > 60
III. Capitolunate Angle > 15
IV. Intrascaphoid angle Lateral > 45deg AP > 35deg

37. Herbert and Fischer classification

38. Time since injury
 Acute fracture - less than 3 weeks old
 Delayed union - 4 to 6 months old
 Nonunion - more than 6 months old

39. Occult(hidden) scaphoid fractures
 These are the undisplaced fractures of the
scaphoid which are not seen on xrays.
 These fractures must be dignosed with a high
index of suspicion. MRI is diagnostic aid in these
fractures
 Patients presenting with history of wrist pain and
postive scaphoid tests and negative xray picture
must be presumed to be fracture scaphoid and
managed aggresively
 Treatment of these is cast immobilisation with
serial xrays every 2 weeks.

40. Prognosis
 The negative prognostic factors are:
 late diagnosis
 proximal location
 displacement
 angulation
 obliquity of the fracture line
 smoking
 Associated carpal instability

41. Treatment of scaphoid fractures

42. Acute < 3 weeks
Undisplaced/
stable
Displaced/
unstable
Cast
immobilization
for 6 wks
Athletically
active patients
Percutaneous
fixation
If no union
after 6 wks
Serial xrays
every 2
weeks till 12
weeks
Still no signs of
union
ORIF

43. Delayed presentation
6weeks- 6 months
Undisplaced or no bone
resorption
Cast immobilization for 6
weeks
No signs of consolidation
ORIF with or without bone
grafting
Displaced or bone resorption
With AVN Without AVN
ORIF with vasular
bone grafting
Or
Wrist arthrodesis
ORIF with
bone grafting

44. Cast application
 There have been three main areas of disagreement in non-
operative treatment of acute non displaced fractures of
scaphoid with cast immobilization:
 The position of the wrist in the cast
 The need to include joints other than the wrist.
 The duration of the immobilization.
 Although above elbow casts may have a slightly shorter
time to union, the final rate of union is the same for below
or above elbow casts. The key factor in treatment of
scaphoid fractures is the duration of immobilization rather
than the specific position
 The current recommendation is to use a short arm thumb
spica with the thumb interphalangeal joint free and mcp
joints of other fingers free. The wrist is placed in radial
deviation i.e. the glass holding position
 Long arm cast is recommended for nondisplaced proximal
pole fractures.

45.  Average time to healing by location :
 Distal third fracture heals in 6-8 weeks
 Middle third fracture 8-12 weeks
 Proximal third fracture 12-24 weeks
 A 95 % union rate can be expected with this
management.
 Prognosis is excellent in undisplaced, stable
fractures if diagnosed and immobilized early (95 %
with x-ray evidence of beginning consolidation at 6
weeks ).

46. Operative treatment
Indications
 Displaced acute fracture
 Scaphoid fracture associated with a perilunate
fracture dislocation
 Ligamentous injury
 Non displaced fracture of proximal pole
 Non displaced fracture if the patient will not
tolerate prolonged cast immobilization (e.g.
professional athletes and manual laborers).

47. Open reduction and internal fixation
 Can be done by
 K wires
 Staples
 Screws
 plates

48. K wires
 Used in minimal displaced
fracture.
 Inserted percutaneously or
through surgical exposure.
 preffered in pediatric group.
 Advantages-
 Easy to insert and remove.
 Provides satisfactory stability
 Disadvantages-
 pin tract infections
 Less stable than screws.

49. Staples
 It has been in use
since 1980
 Popularised by
Carpenter et al
1990 and Korkala et
al 1992
 Technically
demanding
 staples made of
Nickel - Titanium
Alloys.

50. Plates
 Ender's blade Plate
 Plate needs removal
 Not popular.

51. Screws
A. Herbert screw
B. Herbert Whipple
cannulated screw
C. Acutrak screw
D. Twin-Fix two-part
variable screw
E. AO cannulated( 3.5
mm)

52. Herbert screw
Advantages
 Reduces the time of external
immobilization
 Provides relatively strong internal
fixation
 Produces compression at the
fracture.
 Headless screw remains below the
bone surface, removal usually is
unnecessary.
 Can be used with a bone graft to
correct scaphoid angulation.
Disadvantages
 Cannot be used in immature bone
 Cannot be used if fracture
fragment is too small
 Use of jig for insertion and
demanding surgical technique
Contra indications
o Avascular crumbling of the proximal
pole of the scaphoid
o Extensive trauma or osteoarthritis
involving the adjacent carpals or
articular surface of the radius
o Gross carpal collapse
o Severe osteoporosis.

53. Percutaneous fixation

54. Volar approach
• Distal 3rd and waist fractures
• Excellent visualization
• Angulation deformity correction
Disadvantages
• Capsular scarring
• Limited wrist extension
• Instability

55. Dorsal approach
• Proximal pole fractures
• Scapholunate ligament visualization
Disadvantages
• Can’t visualize entire scaphoid
• Intraoperative imaging

56. COMPLICATIONS OF SCAPHOID
FRACTURES:
 1. Delayed union (middle 1/3rd, 20%).
 2. Malunion.
 3. Non union.
 4. AVN (Proximal l/3rd, 15-40%).
 5. OA of radiocarpal or intercarpal joint

57. Non union of scaphoid
 A scaphoid fracture becomes a non-union when it fails to unite
for any reason within 6 months of injury.
 Age: 2nd and 3rd decade (Common) 12% rate of non-union.
 Etiology:
 Severity of initial injury.
 Fracture pattern and location. (Proximal l/3rd and vertical oblique)
 Displacement of fracture fragments > 1mm.
 Associated ligamentous and carpal injury.
 DISI(distal intercalated segment instabilty)
 Inadequate immobilization.
 Delayed treatment.
 Nonunion is expected more often if the scaphoid # is untreated
for 4 or more weeks.
 This can result in nonunion rate of 88%.

58. Symptoms:
 Wrist pain
 Loss of motion - especially dorsiflexion
 Weakness of grip.
Radiologic criteria for non-union:
 Resorption at fracture site.
 Subchondral bony sclerosis (increased bone density)
 Subchondral bony collapse and reduction of carpal
height
 Cystic changes.
 Loss of trabecular pattern.
 Deformity of osseous segment

59. SNAC(scaphoid non union advanced
collapse) stages

60. Treatment
Treatment principle:
 1. Preservation of blood supply
 2. Bone apposition by inlay graft
 3. Internal fixation for fracture stability
 4. Correction of carpal instability.

61.  Following operations are done at different stages:
ORIF with vascularised bone grafting
ORIF with traditional Bone grafting
 Radial styloidectomy
 Excision of proximal fragment
 Proximal row carpectomy
 Partial or total arthrodesis of wrist.

62. ORIF with Bone grafing operations
Three basic types of bone grafting:
 In situ inlay grafts - best for undisplaced stable non
union.
 Interposition grafts - for displaced non union to
correct angulation secondary to volar resorption.
 Vascularized bone grafts - most appropriate for
specific circumstances like longstanding nonunion,
AVN and in which conventional grafting is likely to
fail.

63. Inlay grafting by RUSSE for
undisplaced non union Through the volar approach
scaphoid is exposed and
sclerotic bone ends are
freshened and cavity is
formed by removing a
sclerotic bone.
 A corticocancellous graft
from the iliac crest is taken
and shaped according to the
cavity and the graft is placed.
 Two K-wires are passed from
distal to proximal.
 Long arm thumb spica cast is
applied for 6 weeks.

64. Interposition grafting by Fernandez
 Calculate the amount of
resection, size of graft and
deformity on tracing paper
from X-rays of uninjured and
injured wrist.
 Approach b/w FCR and radial
artery
 Incise capsule, expose non
union
 Carryout resections as planned
 Distract the osteotomy site to
correct flexion deformity and
shortening
 Correct dorsal rotation of
lunate
 Shape the graft from iliac crest,
cortical part of the graft should
be palmar
 Flush the protruding edges
 Scaphoid fixed with K wires
(one or two).

65. Vascular pedicle bone grafting by
KAWAI & YAMAMOTO
 Through volar approach bone
exposed, sclerotic bone ends are
excised.
 Large oval cavity 10-20mm long
created, pronatus quadratus
identified and block of bone graft
15-20mm outlined at its distal
insertion on the distal radius close
to the abductor pollicis longus
tendon.
 Outline margin of the graft with K-
wire holes and separate with fine
osteotomy. Dissect muscle towards
ulna to secure a pedicle 20mm
thick.
 Align fracture fragments and insert
into the cavity and introduce two K-
wires from the tuberosity.

66. VASCULARISED BONE GRAFT by
ZAIDEMBERG
 Oblique skin incision on dorsoradial side of wrist centered
on radiocarpal joint, retract superficial radial nerve and
incise extensor retinaculum and retract EPB and APL
palmarly and wrist and finger extensors ulnarly.
 On distal radial periosteum identify the longitudinal course
of intra compartmental supraretinacular branch of radial
artery.
 Design a bone graft with longitudinal vessel at its center and
use a small gauge to harvest a small graft beneath the
periosteal vessel and transpose it in the long trough created
in the scaphoid and stabilize it with K-wires.

67. Salvage procedures
 Radial styloidectomy-
• Arthritic changes involving only the scaphoid fossa of the
radiocarpal Joint
• In older patients with radioscaphoid arthritis .
• SNAC 1 and 2
 Excision of proximal fragment-
• When the fragment consists of 1/4th or less of the scaphoid
regardless of its viability, grafting of such small fragment fails.
• When the fragment consists of 1/4th or less of the scaphoid, and
is sclerotic, communited or severely displaced.
• When arthritic changes are present in the region of the radial
styloid, styloidectomy with excision of proximal fragment is
done.

68.  Proximal row carpectomy.
• Post traumatic degenerative conditions involving scaphoid
and lunate
• Primary PRC can be done in treatment of open carpal fracture
dislocations in which there is significant disruption of bony
architecture.
• Comminuted fractures of scaphoid and lunate
• Disruption of blood supply to lunate and scaphoid
 Limited wrist arthrodesis
• Midcarpal joint degeneration.
• SNAC Stage 3
 Total wrist arthrodesis
• Involvement of radiolunate joint
• SNAC Stage 4

69. Malunion
 Malunion of the scaphoid may occur when a displaced or
angulated fracture is allowed to heal without anatomic
reduction
 In most of cases , there is a dorsal angulation resulting in a
fixed humpback deformity resulting in pain ,loss of motion,
and decreased grip strength
 Treatment in a young patient includes osteotomy,volar
wedge bone graft,and internal fixation
 Once degenerative arthritis has begun ,treatment is limited
to a salvage procedure such as proximal row
carpectomy,intercarpal arthrodesis,or complete wrist fusion

70. Avascular necrosis
 Is commonly seen it proximal pole fractures due to
inadequate blood supply prevalence Is 35%.
 Can be detected at earliest by MRI followed by CT
and plain Xrays.
 Seen as patchy sclerosis on X-rays.
Treatment-
 Prolonged immobilization which is frequently used
for proximal pole when not displaced. Casting is done
up to 9 months.
 Operative revascularization (bone or muscle pedicle
graft or muscle transplantation).