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Arthroscopic treatment of scaphoid fractures & nonunions

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Arthroscopic treatment of scaphoid fractures & nonunions

  1. 1. Arthroscopic Treatment of Scaphoid Fractures & Nonunions Aaron Venouziou, MD Orthopaedic Hand and Upper Extremity Surgeon St. Luke’s Hospital Thessaloniki www.handsurgery.gr
  2. 2. www.handsurgery.gr Scaphoid Fractures • 70% of all carpal fractures • Males • Age between 15 – 30 years • Common athletic injury
  3. 3. www.handsurgery.gr Scaphoid Fractures Healing Rate
  4. 4. www.handsurgery.gr Scaphoid Fractures • 6 – 8 weeks • 3 months • 5 – 6 months Healing Time
  5. 5. www.handsurgery.gr Scaphoid Fractures • Muscle atrophy • Disuse osteopenia • Joint contracture • Financial hardship • Prolonged inactivity (≥6 months) Nonoperative Treatment
  6. 6. www.handsurgery.gr Scaphoid Fractures • Proximal pole fractures • Displacement > 1 mm • Bone loss or comminution • Angulated fractures (>35o) • DISI deformity • Perilunate fracture-dislocation Operative Treatment
  7. 7. www.handsurgery.gr Scaphoid Fractures • Percutaneous fixation • ORIF • Arthroscopically assisted percutaneous fixation Operative Treatment
  8. 8. www.handsurgery.gr Arthroscopically Assisted Percutaneous Fixation • Fracture reduction • Optimal guide wire positioning • Evaluation of rigidity of fixation • Assessment of screw length • Assessment of associated soft tissue injuries
  9. 9. www.handsurgery.gr Arthroscopically Assisted Percutaneous Fixation Central screw positioning • Longer screw • Better fixation • Better union rate Volar vs. Dorsal Approach
  10. 10. www.handsurgery.gr Dorsal Arthroscopically Assisted Fixation • Wrist flexion • Ring sign • Central axis on AP/Lat/Oblique
  11. 11. www.handsurgery.gr Dorsal Arthroscopically Assisted Fixation • Traction tower • Mini c-arm • 30o wrist flexion • Radiocarpal joint through 3-4 portal
  12. 12. www.handsurgery.gr Dorsal Arthroscopically Assisted Fixation • 6R portal • Needle in 3-4 portal • Entry point
  13. 13. www.handsurgery.gr Dorsal Arthroscopically Assisted Fixation • Evaluation of fracture reduction through mid-carpal portals
  14. 14. www.handsurgery.gr Dorsal Arthroscopically Assisted Fixation • A headless cannulated screw is inserted down the central axis
  15. 15. www.handsurgery.gr Scaphoid Nonunions I Delayed presentation at 4-12 wk II Fibrous union, minimal fx line III Minimal sclerosis < 1 mm IV Cystic formation, 1-5 mm V Humpback deformity VI Wrist arthrosis Slade-Geissler Classification
  16. 16. www.handsurgery.gr Scaphoid Nonunions I Delayed presentation at 4-12 wk II Fibrous union, minimal fx line III Minimal sclerosis < 1 mm IV Cystic formation, 1-5 mm V Humpback deformity VI Wrist arthrosis Slade-Geissler Classification Dorsal Arthroscopically Assisted Fixation
  17. 17. www.handsurgery.gr Scaphoid Nonunions I Delayed presentation at 4-12 wk II Fibrous union, minimal fx line III Minimal sclerosis < 1 mm IV Cystic formation, 1-5 mm V Humpback deformity VI Wrist arthrosis Slade-Geissler Classification Dorsal Arthroscopically Assisted Fixation + Bone Graft
  18. 18. www.handsurgery.gr

Editor's Notes

  • Healing rate 85% to 90%
  • Healing time between 8 – 12 weeks
  • Complications associated with open reduction fixation include avascular necrosis, carpal instability, donor site pain, infection, screw protrusion, and reflex sympathetic dystrophy resulting from the significant soft tissue dissection that is required. The most commonly reported complication in one series was hypertrophic scarring.
  • Arthroscopy can aid optimal guide wire positioning witha dorsal approach. It is invaluable in assessing the qualityof fracture reduction. It is especially indicated followingpercutaneous fi xation of a comminuted fracture to evaluatethe rigidity of fi xation because seemingly good screw pur-chase may not adequately stabilize a comminuted segment.One can assess screw length and ensure that there is noradiocarpal penetration with retrograde (volar) insertion orconversely to check that the screw threads are well buriedin the proximal pole with dorsal (antegrade) insertion. It is auseful adjunct to rule out associated soft tissue injuries.

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