1. Acute Scaphoid fracture
Dr. Anil K Bhat
Associate Professor
Department of Orthopaedics
Kasturba Medical College
Manipal

2. Mechanism of injury
Hyperextended and radially deviated wrist

3. Physical Examination

4. Palpable Anatomy
Proximal pole – dorsum of wrist
Lister’s tubercle
Sulcus (radiocarpal joint)
Prominence
(scapholunate joint)
Move radial for proximal pole

5. Waist of Scaphoid
Dorsal : distal to rim of distal radius towards
styloid

6. Waist of Scaphoid
Lateral : In anatomical snuff box, proximal to radial
artery in ulnar deviation

7. Distal pole
• Dorsal : between EPL and ECRL

8. Distal pole
• Lateral : proximal to radial artery in
anatomical snuff box with wrist in neutral
position.

9. Distal pole
• Volar : along with FCR as it enters
fibro-osseous tunnel

10. Provocative tests

11. Snuff box tenderness

12. Scaphoid compression test

13. Scaphoid tubercle tenderness

14. Painful resisted pronation

15. Painful attempted Scaphoid shift test

16. Physical examination
• Snuff box tenderness 100% sensitivity
• Scaphoid tubercle tenderness 20% specific
• Adding Scaphoid compression test :
Specificity reaches 74% (Parvizi et al)

17. Radiographic evaluation
• Wrist PA, Lateral, Oblique, Scaphoid views
• 25 degrees pronated and supinated oblique
views
6 views increased sensitivity and specificity
to almost 100% ( Mehta &Brautigan,1990)

18. Wrist PA

19. Wrist lateral

20. Scaphoid view

21. Supinated Oblique
Anil K. Bhat, Kumar Bhaskaranand, Ashwath Acharya,
“Radiographic imaging of the wrist”: Indian Journal of Plastic
Surgery, Vol 44,Issue 2, May-Aug,2011.

22. Pronated Oblique

23. What if radiographs are
inconclusive?

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

25. Ultrasound
• Inter-observer variability
• Useful in patients with cortical irregularity
and hemarthrosis
• Structural integrity of scaphoid or other
injuries – little information

26. 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.
Krimmer H: Management of acute fractures and nonunions of the proximal
pole of the scaphoid. J.Hand Surg Br 2002; 27:245-248

28. MRI
• 2nd
line test in negative radiographs
• Identifying fractures of other carpal bones,
ligament injuries
• Highest sensitivity and specificity
 Spin echo T1
 Fluid sensitivity T2
Breitenseher MI, Metz VM, Gilula LA et al. Radiographically occult
scaphoid fractures: value of MR imaging in detection. Radiology
1997;203: 245-250

30. Herbert Classification

32. Mayo classification
• Based on location
• Stability

33. Mayo Classification
Distal pole
Distal third
Midwaist
Proximal pole
Distal pole

34. Stable Fractures
• < 1mm displacement
• Normal carpal alignment
• Normal interscaphoid angulation
(< 35 degrees)
• No bone loss or comminution
• No reduction needed

35. Determinants of treatment
• Stability of fracture
• Location
• Psycho socio-economic factors
Marco Rizzo, Alexander Y. Shin, William P.Cooney. A.A.O.S.

36. Closed treatment
• Stable non displaced fractures
• Cast immobilization
 To prevent displacement
 To maintain immobilization long enough
for healing
Nigel R.Clay, Joseph J.Dias, P.S. Costigan, P.J. Gregg, N.J. Barton.
Need The Thumb To be Immobilized In Scaphoid Fractures.

37. Closed treatment
• Stable non displaced fractures
• Short arm for 6-8 weeks in tubercle or distal
pole fractures
• Upto 12 weeks in waist fractures
• Long arm cast for non compliant patients
• Position- wrist in neutral position
Nigel R.Clay, Joseph J.Dias, P.S. Costigan, P.J. Gregg, N.J. Barton.
Need The Thumb To be Immobilized In Scaphoid Fractures.

40. Surgical treatment
• Displaced
• Comminuted
• Unstable fractures

41. Surgical treatment
Volar approach (Russe)
• Distal 3rd
and waist fractures
• Excellent visualization
• Angulation deformity correction
Disadvantages
• Capsular scarring
• Limited wrist extension
• Instability

43. Dorsal radial approach (McLaughlin)
• Proximal pole fractures
• Scapholunate ligament visualization
Disadvantages
• Can’t visualize entire scaphoid
• Intraoperative imaging

44. Percutaneous technique
• Stable scaphoid fractures
• Decreased period of immobilization
• Decreased wrist stiffness
• Athletes and young patients

47. Complications
• Fracture displacement
• Inadequate purchase
• Mal reduced fractures

48. Arthroscopically assisted percutaneous fixation
• Unstable fractures: displaced or non
displaced
• Delayed presentation
• Proximal pole fractures
• Combined injuries of scaphoid and ipsilateral
displaced distal radius fractures
• Scaphoid fractures with associated
ligamentous injury

49. Aggressive Conservative
Treatment
All undisplaced fractures-
cast Immobilisation for 6 weeks.
If persistence of Fracture gap / no evidence of healing.
Gap <2mm
cast immobilisation
Gap >2mm
Herbert screw fixation
CT wrist at 6 weeks
J.J. Dias, C.J. Wildin, B. Bhowal, J.R. Thompson. Should Acute Scaphoid Fractures Be
Fixed? 2005. JBJS ,2160.

50. Thank you for your kind attention