1. Blood supply & Fracture of Scaphoid

3. Blood Supply of Wrist and Carpus
 Radial
 Ulnar
 Anterior interosseous arteries
 Deep palmar arch

4. Anastomotic network
 three dorsal & three palmar arches connected
longitudinally at their
 medial and lateral borders by
 radial & ulnar arteries
 dorsal to palmar interconnections b/w
 dorsal and palmar branches of
anterior interosseous artery

6. Intrinsic blood Supply
 The scaphoid, capitate & 20% of lunate
supplied by a single vessel - at risk for
osteonecrosis.
 The trapezium, triquetrum, pisiform & 80% of
lunate receive nutrient arteries through two
nonarticular surfaces
 consistent intraosseous anastomoses. ON is
rare.
 The trapezoid and hamate lack an intraosseous
anastomosis and after fracture, can have
avascular fragments.

7. Scaphoid Anatomy
 skaphos (Greek) – boat
 Cashew shaped
 within the wrist joint
 more than 80% of its surface(except tubercle) -
covered by articular cartilage

9. Scaphoid - blood supply
 two major vascular pedicles
1.Volar branch enters the scaphoid tubercle and
supplies its distal 20% to 30%
2. Dorsal scaphoid branch of the radial artery.
 Enter through numerous small foramina along
the spiral groove and dorsal ridge. (80% of the
blood supply).

11.  No vascular supply (13%) or
 only a single perforator (20%) proximal to the waist
of scaphoid.
 Unusual retrograde vascular supply - high risk of
nonunion and
 ON after fracture.

12. Scaphoid Fracture
 Most commonly fractured carpal bone
 68% of carpal fractures
 Fall on outstretched hand – forced dorsiflexion of
hand &
radial deviation

13.  When fractured,
proximal pole - extend with attached lunate
distal pole - remains flexed, creating -hump-back
deformity.

15. Classification
 Russe -
1)Horizontal oblique - compressive forces across
fracture site.
2)Transverse –combination of compressive & shear
forces.
3)Vertical oblique – 5% , shear forces across fracture
site.

16. Russe

18. Herbert classification-
 stability and delayed & nonunion of fractures.
 Type A fractures- stable
Type A1- fracture of tubercle
Type A2 – incomplete fractures through waist

19.  Type B –Acute and Unstable fractures
 Type B1- Distal oblique fractures
 Type B2- Complete fractures through waist
Type B3- Proximal pole fractures
Type B4- Transscaphoid & Perilunate
dislocations of carpus
Type B5-Comminuted

20.  Type C fractures – Delayed unions
 Type D fractures – established Nonunions

22. Prosser classification
 Classification of Distal pole fractures
 Type 1 – Tuberosity fracture.
 Type 2 - Distal intra-articular fracture.
 Type 3 – Osteochondral fracture.

23. Prosser Classification

24. Diagnosis
 Wrist pain
 Tenderness & fullness in anatomic snuffbox.
 Axial compression of thumb elicits pain
 Forced ulnar deviation of pronated wrist also
elicits pain

28.  Even if initial radiographs –ve, immobilise in wrist
splint/shortarm thumb cast
 Rpt after 10- 14 days
 If still –ve and suspecting #,take MRI/ CT Scan
 Fast,convenient, sensitive and specific.

29. Associated Injuries
 Fractures of the distal radius
 Perilunate dislocation and
 Transscaphoid perilunate fracture dislocations
 Joint and ligament damage that inevitably
accompanies this injury (x-ray never reveals the
true degree of injury)

30. Management
 Cast Immobilization
 Open: Volar
Dorsal
 Percutaneous stabilization
 Arthroscopy

31. Cast Immobilization
 Undisplaced Stable Fractures
 A1 - 4 weeks
 A2 - 8 to 12 weeks until radiographic union.
 decision for conservative Mx - CT scan shows
no displacement.
 patient reviewed 6 weeks after cast removal for
clinical and radiological examination and
 then every 3 months until the outcome is clear.
 Patients should be seen for a final check up
after 1 year.

32. Cast Immobilization
 Position of wrist has no affect over healing.
 No difference b/w longarm & short arm cast.
 Needs to be continued till fracture has healed.
 Proximal pole fractures-12 weeks or longer

33. Surgery - indication
 Displaced fracture
 Proximal pole fractures regardless of displacement
 Associated perilunate injuries
 Open fractures
 Polytrauma pts

34. Percutaneous Fixation
 Guidewire placed percutaneously
 along central axis of scaphoid to use cannulated screw
system.
 Main key is to achieve most centrally placed screw
while holding fracture in compression

35.  Risk of open procedures can be Avoided.
 Healing time found to be same as cast
immobilization
 Bond etal reported average healing time to be 7
weeks in these pts,compared to 12 weeks Rx in cast
 No functional difference after 2 yrs

36.  Volar percutaneous approach – distal scaphoid
used as entry point.
 Preferred for distal pole fractures.
 Use 16 gauge needle to find entry point of
guidewire.
 Proximal cartilaginous surface of scaphoid
preserved.

37.  Dorsal percutaneous approach:
 Proximal pole is entry point
 Wrist in flexion & ulnar deviation

38. Arthroscopic
 Allows assessment of intraarticular injuries like
ligamentous structures
 Many choices for percutaneous fixation
-Herbert screw
-Herbert-whipple screw
-Acutrak screw

42. Open-Palmar
 Classic Russe approach
 For stable and unstable non union
 Advantages
-
-Excellent visualization
-Less risk of vascular injury

43.  Disadvantages
-potential for scarring
-limitation of wrist extension
-injury to volar radiocarpal ligament
-inability to assess and address dorsal scapholunate
ligament.

44. Open - Dorsal
 Centered over Lister’s tubercle
 Transverse incision over prox.scaphoid
 Do not disturb dorsal ridge
 Excellent visualization of prox.pole,esp with in maximum
flexion
 Prefered open approac for prox. Pole fracture.

45. Disadvantages of immobilization
 Frequent visits to check cast fit.
 Frequent radiographs to check alignment.
 Potential skin breakdown
 Prolonged immobilization till complete healing
 Stiffness of immobilized joints

46. Disadvantages of Surgery
 Potential for infection
 Wound complications
 Injury to nerves,ligaments or tendons
 Injury to vascular supply to scaphoid
 Hardware failure or need for its removal
 Associated aneasthesia complications.

47. Complications
 Non Union
 Malunion
 Osteonecrosis – Preiser’s disease
 Management –
 arthroscopic debridement and drilling of the
lesion, rest, splintage, and electrical
stimulation
 vascularized bone graft
 harvesting a pronator quadratus graft.

48. Pearls
 Occult scaphoid fractures are easily detected by
MRI scans.
 Percutaneous stabilization of scaphoid
fractures significantly reduces the rate of
nonunion, as well as reducing the time lost
from work and sports.
 Proximal pole fractures can also be stabilized
percutaneously by a dorsal approach.

49. Pitfalls
 Scaphoid fractures are easily missed in children.
This can result in nonunion and serious problems.
 Malalignment of scaphoid fractures is often
undiagnosed. CT scans are helpful.
 Conservative treatment often ends in delayed
healing. An aggressive operative approach is
recommended.