Arthroscopic treatment of scaphoid fractures & nonunions
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This document discusses arthroscopic treatment of scaphoid fractures and nonunions. It notes that scaphoid fractures make up 70% of all carpal fractures, most common in males aged 15-30, and are often sports-related injuries. Nonoperative treatment results in healing within 6-8 weeks for undisplaced fractures, but longer for displaced fractures. Operative treatment is recommended for displaced fractures, fractures over 1mm displaced, fractures over 35 degrees angulated, or fractures with associated soft tissue injuries. Arthroscopically assisted percutaneous fixation allows for direct visualization of fracture reduction and guide wire placement, helping ensure central screw placement which results in better fixation and union rates. This technique is described for both acute
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Arthroscopic treatment of scaphoid fractures & nonunions
- 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. www.handsurgery.gr Scaphoid Fractures • 70% of all carpal fractures • Males • Age between 15 – 30 years • Common athletic injury
- 4. www.handsurgery.gr Scaphoid Fractures • 6 – 8 weeks • 3 months • 5 – 6 months Healing Time
- 5. www.handsurgery.gr Scaphoid Fractures • Muscle atrophy • Disuse osteopenia • Joint contracture • Financial hardship • Prolonged inactivity (≥6 months) Nonoperative Treatment
- 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. www.handsurgery.gr Scaphoid Fractures • Percutaneous fixation • ORIF • Arthroscopically assisted percutaneous fixation Operative Treatment
- 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. www.handsurgery.gr Arthroscopically Assisted Percutaneous Fixation Central screw positioning • Longer screw • Better fixation • Better union rate Volar vs. Dorsal Approach
- 10. www.handsurgery.gr Dorsal Arthroscopically Assisted Fixation • Wrist flexion • Ring sign • Central axis on AP/Lat/Oblique
- 11. www.handsurgery.gr Dorsal Arthroscopically Assisted Fixation • Traction tower • Mini c-arm • 30o wrist flexion • Radiocarpal joint through 3-4 portal
- 12. www.handsurgery.gr Dorsal Arthroscopically Assisted Fixation • 6R portal • Needle in 3-4 portal • Entry point
- 13. www.handsurgery.gr Dorsal Arthroscopically Assisted Fixation • Evaluation of fracture reduction through mid-carpal portals
- 14. www.handsurgery.gr Dorsal Arthroscopically Assisted Fixation • A headless cannulated screw is inserted down the central axis
- 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. 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. 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
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.