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Scaphoid - Tips to fix Scaphoid fractures & Non union management

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Scaphoid fractures management including precutaneous fixation and management of non unions

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Scaphoid - Tips to fix Scaphoid fractures & Non union management

  1. 1. Scaphoid Fixation Dr Vaibhav BAGARIA Orthopedic Surgeon CARE hospital & ORIGYN Clinic Nagpur, INDIA www.drbagaria.com E: drbagaria@gmail.com
  2. 2. Background  First described By French surgeon Destot in 1905  2 – 7% of all fractures in young adults  5 – 15% non union rates  Derived from Greek word skaphos which means boat.  Term based on its unique shape and articulations
  3. 3. Scaphoid Anatomy  Articulates with five bones: Distal radius, capitate, lunate trapezium and trapezoid  80% scaphoid is covered by articular cartilage leaving little space for the nutrient artery  Main blood supply is through retrograde branches of the radial artery  80% through the foraminal artery which is part of dorsal branch of radial artery  Palmar branch reaches through dorsal tubercle
  4. 4. Scaphoid Anatomy
  5. 5. Scaphoid Anatomy
  6. 6. Scaphoid Vascular Supply
  7. 7. Scaphoid Anatomy  Distal part has independent blood supply  In contrast the proximal part depends on the distal part for supply through the intra osseous part  This leaves proximal part vulnerable in case of fractures of the proximal pole which is dependent on distal part for this.  Healing is thus difficult for proximal pole which often goes into AVN
  8. 8. Clinical Presentation  Fall on the out-stretched hand with wrist in radial deviation  Proximal pole fractures occurs when the wrist in Abduction  The same trauma mechanism causes supracondylar fracture in kids and distal radius fractures in elderly
  9. 9. Imaging for Scaphoid fractures  X ray  CT scan  MRI  Scintigram  Sonography Each has its own advantage and disadvantage and are applied at different stage of the management
  10. 10. Radiographs  Initial X Ray may miss up to 30% of scaphoid fractures  Apart from standard AP and Lat X Rays, two additional views are required  Some people recommend routine screening 10 -1 2 day post trauma in case of high degree of suspicion and initial negative x ray – a lucency/ sclerosis may provide clue
  11. 11. AP Lat and Oblique views
  12. 12. Diagnosis  Scintigraphy has close to 100% sensitivity  MRI has less initial sensitivity but high degree of sensitivity at later stage, good for delayed presentation & to r/o AVN  CT Scan helps in preoperative planning and assessing cortical and trabecular pattern
  13. 13. Scaphoid Imaging: MRI, CT, Scinti
  14. 14. Scaphoid Fracture Classification  Herbert’s, Russe and Mayo classification is commonly used  Herbert’s is based on the stability & russe is based on the predictability of healing depending on the fracture line  As per Herbert unstable fractures are: displacement greater than 1 mm or angulation greater than 15 degree. Additional fractures ,trans-scaphoid-perilunate dislocations, multi-fragment fractures and proximal pole fractures are also classified as unstable.
  15. 15. Mayo’s Classification
  16. 16. Modified Staging System
  17. 17. Herbert’s Classification
  18. 18. Treatment Approaches The aim of the treatment is to achieve fracture consolidation and functional recovery whilst avoiding complications such as non- or mal-union  Direct Functional treatment  Cast Immobilization  Fixation: Open/ Percutaneous  Managing complication & delayed presentation
  19. 19. TREATMENT  Functional treatment involves bandaging or orthosis and is used only occasionally and in suspected fractures before immobilisation in cast is done.  Casting is indicated for undisplaced fractures only  Prolonged period of casting upto 12 weeks is required.  Casting has inherent disadvantages of stiffness, probability of non union, chances of developing CRPS
  20. 20. Operative Treatment  All Proximal pole and displaced scaphoid fractures should be treated operatively.  Percutaneous fixation using careful dorsal approach is the preferred method.  In case of proximal pole fracture a reverse approach may be required
  21. 21. Surface Anatomy
  22. 22. Per cut Fixation steps: Reduction
  23. 23. Skin Incision - Landmarks
  24. 24. Guide wire trajectory
  25. 25. Guide wire insertion
  26. 26. Confirm under II ( C ARM)
  27. 27. Correct Placement
  28. 28. Post Fixation radiographs
  29. 29. Approach to Non Union /AVN  Bone Grafting & Fixation  Vascularized Bone grafting – Pronator Quadratus/ Dorsal
  30. 30. Bone Graft fixation
  31. 31. Approach To Vascular BG
  32. 32. Planes
  33. 33. Vascular anatomy in Cadaver
  34. 34. Vascular pedicle BG
  35. 35. Temporary Fixation with BG
  36. 36. Pre & Post Vascular Graft
  37. 37. Take Home!  Do not miss the fracture on initial X rays  Prolonged immobilization is often required  Percut fixation is preferred management in majority cases  Non unions and AVN are common and need bone graft and fixation.  Pronator quadratus vascularized Bone grafting is often an excellent method for fixing Non unions with AVN.
  38. 38. Thank You!  ORIGYN Healthcare Nagpur & Indrapuram  Dr Vaibhav BAGARIA

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