Acute scaphoid and carpal bone fractures - Treatment algorithm

1. AHSS Registrar Hand Surgery Review Course
Acute Scaphoid and Carpal bone fractures –
Indications for fixation and technique
Avanthi Mandaleson
Consultant Hand Surgeon

2. Declaration of Interest
I declare that in the past three years I have:
• held shares in: Nil
• received royalties from: Nil
• done consulting work for: Nil
• given paid presentations for: Nil
• received institutional support from: Medartis
Signed:

3. Aims
• Understandepidemiologyofscaphoidfractures
• Understandrationaleforsurgicalapproach
• Developalgorithmforscaphoidfixation
• Identifyothercarpal bonefractureandassociatedpatternsofinjury
• Understandindicationsforsurgeryinother carpalbonefractures

4. Scaphoid fractures –Epidemiology1
Incidence 50-70% all carpal#’s 11% all hand
#’s
Mean age 22years
M:F 7:1
Mechanism of
Injury
FOOSH in extension and radialdeviation Torque injury
Fracture location 1) Tubercle
2) Distal intra-articular surface
3) Distal 1/3
4) Waist
5) Proximalpole
Fracture
orientation
Horizontal oblique (HO) –35%
Transverse (T) – 60%
Vertical oblique (VO) – 5%
Fracture stability Stable
1) Displacement <1mm
2) Normal intercarpal alignment
3) No humpback deformity
4) Distal fracture
Unstable
1) Displacement >1mm
2) DISIalignment
3) Humpback deformity

5. Fracture stability –Mayoclassification
Scaphoidlength anddisplacementcontributeto carpalinstabilityandfractureinstability

6. Imaging of scaphoid2,3,4
• CT – Parasagittal(plane of scaphoid)
• Sensitivity 94%
• Specificity 96%
• MRI – T1
• Sensitivity 98%
• Specificity 99%
Imaging Sensitivity (%) Specificity(%) Views Scaphoid/Wrist Deformity
(Normal values)
Pros Cons
XR 75% 85-90% PA
Lateral
PA+Ulna deviation
Pronated oblique
Capitolunate angle (<15°)
Scapholunate angle (<60°)
Access 20-40% occult
CT 94 96 Parasagittal scaphoid
views
Humpback deformity
- Dorsal cortical angle (DCA <160°)
- Lateral intrascaphoid angle (LISA)
- Height tolength ratio(H/L < 0.65)
Displacement
Fracture configuration –
surgical planning
Radiation exposure
(low)
MRI 98 99 T1 – fractureline
T2 – bone oedema
Avascular necrosis - Identifies assoc. injuries
- No radiation
Access
Earlyadvancedimaging techniquesguide management

7. Imaging of scaphoid4

8. Imaging of scaphoid
• LowthresholdforCT to
determinefracturestability
• Parasagittalscaphoidviews
increasesensitivity

9. Scaphoid fractures –Union rates5,6,7
Location Displacement
Proximal Pole Waist Distal pole Translation Humpbackdeformity
<1mm >1mm >1.5mm
Incidence 5% 65% 20%
Timeto union (days)
–
conservative/operati
ve
113 65/49 53
Unionrate
(Conservative)
66% 94% 100% 88% 73% 47% 78%vs 96%
Unionrate
(Operative)
87% 100% -
Locationandfracturedisplacement affectstabilityandunionrates

10. Scaphoid fractures –Vascular anatomy2
Vascularsupplydetermines unionrates at
proximal pole

11. Treatmentoptions
• Cast immobilization – below elbow cast excluding thumb8
• Undisplaced or minimallydisplaced (<1mm)waist fractures
• No difference in time to union@10 weeks
• Overall unionrate98%
• ORIF or percutaneous fixation– single cannulated headless screw
• Dorsalantegrade approach(percutaneous or mini-open)
• Long axis scaphoid position
• Best for proximal pole #’s
• Risks to EPL/ECRB and dorsal blood supply
• Volarretrogradeapproach or transtrapezial approach
• Best for distal 1/3#’s
• Risk to ST joint

12. Treatmentaims
• Aims of treatment
Achieve scaphoidunionwithnormalscaphoidandcarpalalignment
• Goals of surgery
• Restorescaphoidlength andcorrectDISI deformity
• Compressionacrossfracturesitewithstablerigid fixationusing a variablepitchintramedullaryscrew
• Screwconfigurationperpendiculartofracturesiteorcentrallong axis

13. Screwfixation –Surgical approach2,9
DORSAL MINI-OPEN APPROACH

14. Treatment algorithm –Acute Scaphoid
Yes
Early MRI or CT
ORIF
Displaced >1mm
or humpback
deformity
Fracture
visible on XR
Location
Proximal
pole
Waist
Distal
pole
Closed
fracture
CT
Cast
immobilization 8
weeks
No Yes
No
Yes No
Patient preference

15. Other carpal fractures10
Carpal bone Incidence Mechanism Pathoanatomy Treatment
Triquetrum 15%
Dorsal cortical Wrist DFand UD Avulsion DRC andDIC
ligaments
Wrist immobilisation 4weeks thenprogress ROM and
strengthening
Body Crush,axial load, direct
blow
Can be associated with
perilunate injuriesor other
carpal #’s
High indexof suspicion for LT injury – K-wirepinning
Displaced - ORIF
Volar avulsion UTor LTligament avulsion Treatmentdirected addressing carpal instability
Trapezium 1-5% Axial load on thumb Shearforces causing vertical
shear fracture
Undisplaced – Thumbspica cast immobilization 4-6weeks
Displaced – ORIFor K-wire fixation
Capitate fractures Direct axial load • Isolated
• Associated with
perilunate injury
High risk of non-union
RecommendORIF unless undisplaced

16. Other carpal fractures10
Triquetrum– Dorsalavulsion fractures Trapeziumshearfractures

17. Other carpal fractures10
Carpal bone Incidence Mechanism Pathoanatomy Treatment
Pisiform 2% Direct blow Cast immobilization
Pisiform excision
Hamate 2%
Hook Racquetsports, golfers –
direct blow to hook
Associated symptoms – Ulnar
nerveparaesthesia or pain on
resisted flexion LF and RF
High non-unionrate 50%
Excision of hookof hamate through Guyon’scanal
approach
Body Shear, direct blow, axial load,
high energytrauma eg
punchinginjury
Impaction injury4th and 5th CMC
joint fracture dislocation
4th and 5th CMCjoint ORIF or k-wirestabilization
Restore joint congruityand stability for power grip
function
Trapezoid <1% High energytrauma,Index MC
axial load
Associated with other carpal
fracturesor CMCdislocations
Undisplaced – Cast 4-6weeks
Displaced – ORIFor K-wire fixation
Severecomminution – Primaryarthrodesis 2nd CMCJ

18. Other carpal fractures10
Hamatefractures
Pisiformfracture

19. Summary
• Scaphoid
• Location of fracture, fracture orientation and displacement affect union
• CT with parasagittal scaphoid views aids decision making
• Understand goals and principles of surgical treatment
• Carpal fractures
• Identify commonly missed carpal bone injuries
• Understand indications and rationale for surgery

20. References
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2. Sabbagh, M. Diya, Mohamed Morsy, and Steven L. Moran. “Diagnosis and Management of Acute Scaphoid Fractures.” Hand Clinics 35, no.
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10. Suh, Nina, Eugene T. Ek, and Scott W. Wolfe. “Carpal Fractures.” The Journal of Hand Surgery 39, no. 4 (April 2014): 785–91; quiz 791.
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21. Thankyou