The document discusses carpal bone fractures and the anatomy of the carpal bones. It describes the bones that make up the proximal and distal rows of carpal bones. Key carpal bones like the scaphoid, lunate, and capitate are highlighted. The document outlines the ligaments of the wrist, blood supply, ossification process, biomechanics including concepts like the link and column concepts, and common injuries like carpal instability and fractures. Clinical evaluation including history, exam, and radiographic evaluation is also summarized.

1. CARPAL BONE FRACTURES
By:
Dr. Pavan
Moderator:
Dr. Vamsi

2. CARPAL BONES
Carpal bones are arranged in two rows
From lateral to medial and when viewed
from anteriorly
• PROXIMAL ROW
1. the boat-shaped scaphoid;
2. the lunate, which has a 'crescent shape';
3. the three-sided triquetrum bone;
4. the pea-shaped pisiform
• DISTAL ROW
1. the irregular four-sided trapezium bone;
2. the four-sided trapezoid;
3. the capitate, which has a head;
4. the hamate, which has a hook
She Looks Too Pretty Try To Catch Her

3. CARPAL BONES IN 3D VIEW

4. SOME IMPORTANT CARPAL BONES
• Pisiform is a sesamoid bone in the tendon of flexor carpi
ulnaris and articulates with the anterior surface of the
Triquetrum.
• Scaphoid has a prominent tubercle on its lateral palmar
surface that is directed anteriorly.
• Trapezium articulates with the metacarpal bone of the thumb
and has a distinct tubercle on its palmar surface that projects
anteriorly.
• LARGEST of the carpal bones, the CAPITATE, articulates
with the base of the metacarpal III.
• Hamate, which is positioned just lateral and distal to the
pisiform, has a prominent hook (hook of hamate) on its
palmar surface that projects anteriorly.

5. • Ossification of the carpal bones occurs in a
predictable sequence, starting with the
capitate and ending with the pisiform.
• At birth, there is no calcification in the
carpal bones. Although there is great
individual variability, approximate
ossification times are as follows :
 capitate: 1-3 months
 hamate: 2-4 months
 triquetral: 2-3 years
 lunate: 2-4 years
 scaphoid: 4-6 years
 trapezium: 4-6 years
 trapezoid: 4-6 years
 pisiform: 8-12 years
CARPAL BONE OSSIFICATION CENTRES

6. • Excluding the
pisiform, a handy
way to remember
the order of
ossification is to
start at the
capitate then
move in a
counterclockwise
direction on the
volar surface of
the right carpus.
 Ossification centres
of the distal radius
and ulna
 distal radius: 1 year
 distal ulna: 5-6 years

7. • The carpal bones do not lie
in a flat coronal plane;
rather, they form an arch,
whose base is directed
anteriorly .
• The lateral side of this base
is formed by the tubercles of
the scaphoid and trapezium.
• The medial side is formed by
the pisiform and the hook of
hamate. The flexor
retinaculum attaches to, and
spans the distance between,
the medial and lateral sides
of the base to form the
anterior wall of the so-called
carpal tunnel. The sides and
roof of the carpal tunnel are
formed by the arch of the
carpal bones.

8. LIGAMENTS OF WRIST
They are divided in to
1.Extrinsic ligaments
2.Intrinsic ligaments
Extrinsic ligaments :
1. bridge carpal bones to the radius or
metacarpals
2. include volar and dorsal ligaments
Intrinsic ligaments:
1. originate and insert on carpal bones

9. CHARACTERISTICS OF WRIST
LIGAMENTS
– volar ligaments are secondary stabilizers of
the scaphoid
– volar ligaments are stronger than dorsal ligaments
– dorsal ligaments converge on the triquetrum

10. EXTRINSIC LIGAMENTS
• Divided into
– Volar radiocarpal ligaments
– Volar ulnocarpal ligaments
– Dorsal ligaments

11. VOLAR RADIOCARPAL LIGAMENTS
• Radial Collateral
• Radioscaphocapitate
– at risk for injury with excessively large radial styloid
– from radial styloid to capitate, creating a sling to
support the waist of the scaphoid
• Radioscapholunate
– Ligament of Testut and Kuentz
– only functions as neurovascular conduit
– not a true ligament
• does not add mechanical strength
• Long Radiolunate
– also called radiolunotriquetral or volar radiolunate
ligament
– counteracts ulnar-distal translocation of the lunate
– abnormal in Madelung's deformity
• Short radiolunate
– stabilizes lunate

12. VOLAR ULNOCARPAL LIGAMENTS
• Volar ulnocarpal
ligaments
– ulnotriquetral
– ulnolunate
– ulnocapitate

13. DORSAL LIGAMENTS
• Radio Triquetral (RT)
• Dorsal Intercarpal (DIC)
• Radio Lunate (RL)
• Radio Scaphoid (RS)

14. • The distal portions of the
radio and ulno capitate
ligaments do not attach
to the head of the
capitate, but form a
support sling with center
of a double "V" shape
covergence of ligaments
• Between these two rows
of ligaments is a thinned
area termed the Space of
Poirier

15. SPACE OF PORIER
• Ligament free area in
palmar aspect of
capitolunate space is
area of potential
weakness
• This area expands when
the wrist is dorsiflexed
and disappears in
palmar flexion.
• A rent develops during
dorsal dislocations, and
it is through this
interval that the lunate
displaces into the carpal
canal.

16. TFCC(Triangular Fibrocartilage Complex)
• Major stabilizer of the
ulnar carpus and distal
radio ulnar joint.
• Absorbs 20% of the axial
load across wrist joint
• Consists of
– Ulnotriquetral ligament
– Meniscal homologue
– Articular disc
– Dorsal radio ulnar ligament
– Volar radio ulnar ligament
– Ulnolunate ligament
– Ulnar collateral ligament

17. INTRINSIC LIGAMENTS
The intra-articular intrinsic ligaments
connect adjacent carpal bones.
Proximal row
scapholunate ligament
lunotriquetral ligament
Distal row
trapeziotrapezoid ligament
trapeziocapitate ligament
capitohamate ligament
Palmar midcarpal
scaphotrapeziotrapezoid
scaphocapitate
triquetralcapitate
triquetralhamate

18. VASCULAR SUPPLY OF CARPAL BONES
• The RADIAL,ULNAR and
ANTERIORINTEROSSEOUS arteries
combine to form a network of
transverse arterial arches both
dorsal and volar to the carpus.
• SCAPHOID BLOOD SUPPLY:
primarily from radial artery,both
dorsally and volarly.
• Volar scaphoid branch supply
distal 20%-30%
• branch entering dorsal ridge
supplies proximal 70%-80%
• LUNATE BLOOD SUPPLY:
recieves supply from both its
dorsal and volar surfaces.

19. ARTERIAL SUPPLY OF DORSUM OF WRIST.
• R.radial artery
• U.ulnar artery
• 1.dorsal branch of
anterior interosseous
artery
• 2.dorsal radiocarpal arch
• 3.branch to dorsal ridge
of scaphoid
• 4.dorsal intercarpal arch
• 5.basal metacarpal arch
• 6.medial branch of ulnar
artery.

20. ARTERIAL SUPPLY OF PALMAR ASPECT OF WRIST
• R, radial artery
• U, ulnar artery
• 1, palmar branch of anterior
interosseous artery
• 2, palmar radiocarpal arch
• 3, palmar intercarpal arch
• 4, deep palmar arch
• 5, superficial palmar arch
• 6, radial recurrent artery
• 7, ulnar recurrent artery
• 8, medial branch of ulnar artery
• 9, branch off ulnar artery
contributing to dorsal intercarpal
arch.

21. ARTERIAL SUPPLY OF LATERAL ASPECT OF WRIST
• R, radial artery;
• 1, superficial palmar artery;
• 2, palmar radiocarpal arch;
• 3, dorsal radiocarpal arch;
• 4, branch to scaphoid tubercle and trapezium;
• 5, artery to dorsal ridge of scaphoid;
• 6, dorsal intercarpal arch;
• 7, branch to lateral trapezium and thumb metacarpal.

22. KINEMATICS
• The global motion of the wrist is composed of flexion, extension,
radioulnar deviation at the radiocarpal joint, and axial rotation
around the distal radioulnar joint (DRUJ)
• The radiocarpal articulation acts as a universal joint allowing a small
degree of intercarpal motion around the longitudinal axis related to
the rotation of individual carpal bones.
• forearm accounts for about 140 degrees of rotation.
• Radiocarpal joint motion is primarily flexion and extension of nearly
equal proportions (70 degrees) and radial and ulnar deviation of 20
degrees and 40 degrees, respectively.
• The scaphoid rests on the radioscaphocapitate ligament at its
waist.using this ligament as axis it rotates from volar flexed
perpendicular position to dorsiflexed longitudnal position.
• Wrist in radial deviation scaphoid flexes and in ulnar deviation
scaphoid extends.

23. • Conjunct rotation of the
entire proximal row occurs
in flexion during radial
deviation (upper left).
• The axes of the radius and
carpal rows are collinear in
neutral (middle left), and
• the proximal row extends
with ulnar deviation (lower
left).
• Angulatory excursions of
the proximal and distal rows
are essentially equal in
amplitude and direction
during extension (upper
right) and flexion (lower
right). This has been
described as synchronous
angulation.

24. WRIST BIOMECHANICS
• Biomechanic concepts that have been proposed for
better understanding of functioning,movements and
various types of forces acting.some of them are:
1. LINK CONCEPT
2. COLUMN CONCEPT
3. ROWS CONCEPT
4. TALEISNIK’S CONCEPT
5. LICHTMAN’S RING CONCEPT

25. LINK CONCEPT
• three links in a chain composed of
radius, lunate and capitate
– head of capitate acts as center of
rotation
– proximal row (lunate) acts as a unit and
is an intercalated segment with no
direct tendon attachments
– distal row functions as unit
• advantage
– efficient motion (less motion at each
link)
– strong volar ligaments enhance stability
• disadvantage
– more links increases instability of the
chain
– scaphoid bridges both carpal rows
• resting forces/radial deviation push the
scaphoid into flexion and push the
triquetrum into extension
• ulnar deviation pushes the scaphoid
into extension

26. COLUMN CONCEPT
• lateral (mobile) column
– comprises scaphoid, trapezoid and trapezium
– scaphoid is center of motion and function is
mobile
• central (flexion-extension) column
– comprises lunate, capitate and hamate
– luno-capitate articulation is center of motion
– motion is flexion/extension
• medial (rotation) column
– comprises triquetrum and distal carpal row
– motion is rotation

27. ROWS CONCEPT
• comprises proximal and
distal rows
– scaphoid is a bridge
between rows
• motion occurs within
and between rows

28. TALEISNIK’S CONCEPT
• Taleisnik’s concept of
central (flexion-
extension) column
involves entire distal
row and lunate
• Scaphoid (S) is lateral
(mobile) column, and
• Triquetrum (Tq) is rotary
medial column.

29. LICHTMAN’S RING CONCEPT
• proximal and distal rows are
semirigid posts stabilized by
interosseous ligaments;
• Normal controlled mobility
occurs at scaphotrapezial
and triquetrohamate joints.
• Any break in ring, either
bony or ligamentous
(arrows), can produce
dorsal intercalated
segmental instability or
volar intercalated segmental
instability deformity.

30. PATHOMECHANICS
• The Radius, Lunate and Capitate have been
described as a central link that is colinear in
sagittal plane
• The Scaphoid serves as a connecting
STRUT.Any flexion moment transmitted across
the scaphoid is balanced by an extension at
the triquetrum.

31. CARPAL INSTABILITY
• Scaphoid instability by fracture or
scapholunate ligament disruption
,the lunate and triquetrum
assume a position of excessive
dorsiflexion(DISI-Dorsal
Intercalated Segmental
Instability) scapholunate angle
becomes abnormally (high>70
degrees)
• When triquetrum is destabilized
(disruption of the lunotriquetral
ligament complex) the opposite
pattern (VISI-Volar Intercalated
Segment Instability) is seen as the
intercalated lunate segment volar
flexes

32. LOAD-CARRYING STRUCTURES (WEBER AND CHAO)
.
• These forces are related to fixed coordinate system
(XYZ) and to vector representation of applied load
(P).
• Four ligamentous components (cb, ed, ih, kj)
potentially transmit tensile loads when wrist is in
strong dorsiflexion.
• Dorsal ligamentous structures eliminated from
analysis because in dorsiflexion structures would
be lax.
• Articular surface between radius and scaphoid and
between radius and lunate potentially transmit
compressive forces Ff and Fg.
• cb, radiocollateral ligament complex;
• ed, radiocapitate ligament;
• Ff, radioscaphoid contact force;
• Fg, radiolunate contact force;
• ih, radiolunate ligament;
• kj, ulnar capsular ligament;
• XYZ, cartesian coordinate system.

33. MECHANISM OF INJURY
• The most common mechanism of carpal injury is a
fall onto the outstreched hand, resulting in an axial
compressive force with wrist hyperextension. The
volar ligaments are placed under tension with
compression and shear forces applied dorsally,
especially when the wrist is extended beyond its
physiological limits.
• Excessive ulnar deviation and intercarpal supination
result in predictable pattern of perilunate injury,
progressing from the radial side of the carpus to the
mid carpus and finally to the ulnar carpus.

34. Relative Incidence of Carpal Bone
Fractures
• Scaphoid 68.2%
• Triquetrum 18.3%
• Trapezium 4.3%
• Lunate 3.9%
• Capitate 1.9%
• Hamate 1.7%
• Pisiform 1.3%
• Trapezoid 0.4%

35. CLINICAL EVALUATION
• HISTORY
– age,
– hand dominance,
– occupation,
– hobbies,
– date of injury or onset of symptoms,
– correlation of symptoms with activities
– modifying factors
• LOCAL EXAMINATION
– Well localised tenderness
– Deformity
– Mechanical symptoms, such as clicking, popping, snapping, and
grating
– Provocative test

36. RADIOGRAPHIC TECHNIQUES
Various radiographic techniques useful in
evaluating a painful wrist include
 routine radiographic series consisting of four
views
1. posteroanterior,
2. lateral,
3. oblique, and
4. ulnardeviated posteroanterior scaphoid view
 spot views of the carpal bones for detail (carpal
tunnel view)
 fluoroscopic spot views of the wrist;

37. GILULA'S LINES.
A. PA views show three smooth Gilula arcs in a normal wrist. These arcs outline
proximal and distal surfaces of the proximal carpal row and the proximal cortical
margins of capitate and hamate.
B. Arc I is broken, which indicates an abnormal lunotriquetral joint due to a
perilunate dislocation. Additional findings are the cortical ring sign produced by
the cortical outline of the distal pole of the scaphoid and a trapezoidal shape of
the lunate.

38. Carpal tunnel view shows avulsion fracture of hamate hook (arrow) and trapezium
(arrowheads).

39. fluoroscopic spot views of the wrist
A, Posteroanterior view of capitate shows no definite abnormality.
B, On angled view, cystic defect with fracture is seen in capitate waist (arrows).

40.  series of views for instability
1. anteroposterior clenched fist;
2. posteroanterior in neutral, radial, and ulnar
deviation;
3. lateral in neutral and full flexion and
extension;
4. semipronated oblique 30 degrees from the
posteroanterior
5. semisupinated oblique 30 degrees from the
lateral
 Diagnostic ultrasound
 Cine or Video Fluoroscopy
 Bone Scanning
 Arthrography of the wrist (triple injection
when indicated)
 CT
 MRI.

41. OTHER DIAGNOSTIC TECHNIQUES
1. differential local anesthetic injection,
2. wrist arthroscopy, and
3. various other operative procedures.

42. Positioning of patient
A, Standard radiocarpal portals.
B, Standard midcarpal portals.

43. SCAPHOID FRACTURES

44. SCAPHOID FRACTURES
• irregularly shaped tubular bone, twisted and bent into an
S-shape
• resembles a deformed peanut or a boat (from the Greek
word for boat, skaphos).
• more than 80% of its surface being covered by articular
cartilage
• The scaphoid receives most of its blood supply from two
major vascular pedicles .
• One enters the scaphoid tubercle and supplies its distal
20% to 30% and the other arises from the dorsal scaphoid
branch of the radial artery .
• The dorsal ridge vessels enter through numerous small
foramina along the spiral groove and dorsal ridge. This
source accounts for about 80% of the blood supply.
• unusual retrograde vascular supply, the scaphoid has a
high risk of nonunion and Osteonecrosis after fracture.
• Temporary interruption of the blood supply to the
proximal fragment is virtually certain with proximal pole
fractures.

46. EPIDEMIOLOGY
 incidence
• accounts for up to 15% of acute wrist injuries
 location
• incidence of fracture by location
o waist -65%
o proximal third - 25%
o distal third - 10%
distal pole is most common location in kids due to
ossification sequence

47. CLINICAL EVALUATION OF SCAPHOID
FRACTURE
• complain of wrist pain after a fall on the outstretched hand
• Minimal or gross swelling
• snuffbox tenderness
• scaphoid tubercle tenderness
• Palpable deformity distal to radial styloid
• pain with longitudinal axial compression/tension
• Pain with dorsiflexion, radial deviation
• pain with resisted pronation
• PROVOCATIVE TESTS
 THE SCAPHOID SHIFT TEST: Reproduction of pain with dorsal-volar shifting
of scaphoid.
 THE WATSON TEST: Painful dorsal scaphoid displacement as the wrist is
moved from ulnar to radial deviation with palmar pressure on the
tuberosity.

48. PATHOANATOMY
– most common mechanism of injury is axial load
across hyper-extended and radially deviated wrist
• common in contact sports
– transverse fracture patterns are considered more
stable than vertical or oblique oriented fractures

49. SCAPHOID FRACTURE IMAGING
• Radiographs
– Recommended views
• AP and lateral
• scaphoid view
– 30 degree wrist
extension, 20 degree
ulnar deviation
• 45° pronation view
– Findings
• if radiographs are
negative and there is a
high clinical suspicion
– should repeat
radiographs in 14-21
days

50. •The four scaphoid views
(PA, true lateral, radial
oblique, ulnar oblique)
detect most of carpal
fractures.
•A fisted PA view can be
helpful in detecting
scaphoid fractures.

51. UNSTABLE FRACTURE
• Greater than 1
mm stepoff
• Lunocapitate
angulation > 15
degrees (lateral)
• Scapholunate
angulation > 45
degrees (lateral)

52. • Bone scan
– effective to
diagnose occult
fractures at 72
hours
• specificity of
98%, and
sensitivity of
100%, PPV 85%
to 93% when
done at 72 hours
.

53. • MRI
– most
sensitive method to
diagnose of occult
fractures within 24
hours
– allows immediate
identification of
fractures and
ligamentous injuries
in addition to
assessment of
vascular status of
bone (vascularity of
proximal pole)

54. • CT scan with 1mm
cuts
– less effective than
bone scan and MRI
to diagnose occult
fracture
– can be used to
evaluate location
of fracture, size of
fragments, extent
of collapse,
andprogression of
nonunion or union
after surgery

55. The MRI scan demonstrates a clear fracture line of the scaphoid (proximal pole). B. It is
difficult to identify the proximal fracture by native x-rays.

56. • MRI is useful for diagnosis of “occult”
scaphoid fractures (A) and for evaluation of
vascularity of fractured scaphoid(B).

57. CLASSIFICATION OF SCAPHOID
FRACTURES

59. HERBERT AND FISHER'S CLASSIFICATION OF
FRACTURES OF THE SCAPHOID

61. NONDISPLACED, STABLE SCAPHOID FRACTURES
NONOPERATIVE
 THUMB SPICA CAST IMMOBILIZATION
• INDICATIONS
– stable nondisplaced fracture (majority of fractures)
– Tuberosity fracture
– Patient with injury and positive examination findings but normal x-rays, immobilize
for 1-2 weeks.
• TECHNIQUE
– start immobilization early (nonunion rates increase with delayed immobilization of
> 4 weeks after injury).
– long arm spica vs short arm casting is controversial
» with no consensus
– duration of casting depends on location of fracture
» distal-third for 6-8 weeks
» mid-third for 8-12 weeks
» proximal third for 12-24 weeks
» athletes should not return to play until imaging shows a healed fracture
– may opt to augment with pulsed electomagnetic field (studies show beneficial in
delayed union)
• OUTCOMES
– scaphoid fractures with <1mm displacement have union rate of 90%

62. THUMB SPICA CAST IMMOBILIZATION
• Forearm cast from just
below the elbow
proximally to the base of
the thumbnail and the
proximal palmar crease
distally (thumb spica) with
the wrist in slight Radial
deviation and in Dorsi
flexion. The thumb is
maintained in a functional
position, and the fingers
are free to move from the
metacarpophalangeal
joints distally.

64. • Using nonoperative casting techniques, the
expected rate of union is 90% to 95% within 10 to
12 weeks.
• During this time, the fracture is observed
radiographically for healing.
• If collapse or angulation of the fractured
fragments occurs, surgical treatment usually is
required.
• Surgery may be considered if new healing activity
is not evident and if union is not apparent after a
trial of cast immobilization for about 20 weeks.

65. DISPLACED, UNSTABLE SCAPHOID
FRACTURES
• Displaced,unstable fracture in which the
fragments are offset more than 1 mm in the
anteroposterior or oblique view, or
lunocapitate angulation is > 15 degrees, or the
scapholunate angulation is > 45 degrees in the
lateral view (range 30 to 60 degrees).

66. OPERATIVE
– ORIF vs percutaneous screw fixation
• INDICATIONS
– in unstable fractures as shown by
» proximal pole fractures
» displacement > 1 mm
» 15° scaphoid HUMPBACK DEFORMITY
» radiolunate angle > 15° (DISI)
» intrascaphoid angle of > 35°
» scaphoid fractures associated with perilunate dislocation
» comminuted fractures
» unstable vertical or oblique fractures
– in non-displaced waist fractures
» to allow decreased time to union, faster return to work/sport,
similar total costs compared to casting
• OUTCOMES
– union rates of 90-95% with operative treatment of scaphoid fractures
» CT scan is helpful for evaluation of union

68. HUMPBACK DEFORMITY
• Humpback deformity of the
scaphoid results from angulation
of the proximal and distal parts
of a scaphoid in the setting
of scaphoid fracture through the
waist .
• It can result in progressive
collapse of the scaphoid with
non-union and destabilisation of
the wrist.
• Associated with a Dorsal
Intercalated Segment
Instability(DISI).
• Managed operatively with
internal fixation + / - bone
grafting.

69. TECHNIQUE
• ORIF vs percutaneous screw fixation
– Approach
• Dorsal approach
– indicated in proximal pole fractures
– care must be taken to preserve the blood supply when entering the dorsal
ridge by limiting exposure to the proximal half of the scaphoid
– percutaneous has higher risk of unrecognized screw penetration of
subchondral bone
• Volar approach
– indicated in waist and distal pole fractures and fractures with humpback
flexion deformities
– allows exposure of the entire scaphoid
– uses the interval between the FCR and the radial artery
• Arthroscopic assisted approach
– has also been described
– Fixation
• rigidity is optimized by long screw placed down the central axis of the
scaphoid
– Radial styloidectomy
• should be performed if there is evidence of impaction osteoarthritis
between radial styloid and scaphoid

71. OPEN REDUCTION AND INTERNAL FIXATION OF ACUTE
DISPLACED FRACTURES OF THE SCAPHOID—VOLAR APPROACH

72. OPEN REDUCTION AND INTERNAL FIXATION OF ACUTE
DISPLACED FRACTURES OF THE SCAPHOID—DORSAL APPROACH

73. EXPOSURE AND INTERNAL FIXATION OF SCAPHOID
FRACTURES THROUGH A DORSOLATERAL APPROACH
• A: Skin incision.
• B: Exposure of the
dorsal radiocarpal joint
capsule after isolating
and protecting the
superficial radial nerve
and radial artery.
• C: Scaphoid exposure
through dorsal
radiocarpal
capsulotomy.
• D:Reduction of
scaphoid fracture.
• E:Use of double-
guidewire technique
for placement of screw
and counter-rotation.
The second guidewire
is removed after
placement of the
screw.

74. PERCUTANEOUS SCAPHOID FIXATION
THROUGH A VOLAR APPROACH.
• With
longitudinal
traction and
ulnar deviation,
the guidewire is
inserted through
a 5-mm incision
directly over the
scaphoid
tubercle.

75. PERCUTANEOUS FIXATION OF SCAPHOID
FRACTURES
A, Central axis of scaphoid is located on posteroanterior
view.
B, Wrist is pronated until scaphoid poles are aligned.
C, Wrist is flexed until scaphoid has “ring” appearance on
fluoroscopy.
Guidewire in central axis of scaphoid for placement of
screw.

76. COMPLICATIONS OF SCAPHOID
FRACTURES
• Osteoarthritis
• Delayed union
• Malunion
• Nonunion
• Nonunion SNAC wrist
(scaphoid nonunion
advanced collapse)
• Osteonecrosis (PREISER'S DISEASE )

77. Algorithm for treatment of scaphoid
nonunion developed by Knoll and
Trumble

78. SCAPHOID NONUNION AND SCAPHOID NONUNION
ADVANCED COLLAPSE (SNAC WRIST)
• Radiographic findings of
arthritis usually seen with
scaphoid nonunion include
radioscaphoid narrowing,
capitolunate narrowing, cyst
formation, and pronounced
Dorsal Intercalated Segment
Instability.
• This is the so-called
SCAPHOID NONUNION
ADVANCED COLLAPSE
PATTERN.

79. • The following operations can be useful for
nonunions of the scaphoid:
(1) Radial Styloidectomy.
(2) Excision of the proximal fragment, the distal
fragment, and, occasionally, the entire
scaphoid.
(3) Proximal row Carpectomy.
(4) Traditional Bone Grafting.
(5) Vascularized Bone Grafting.
(6) Partial or Total Arthrodesis of the wrist.

80. PROXIMAL ROW CARPECTOMY

82. Arthroscopic proximal row carpectomy
Arthroscopic proximal row carpectomy .
A, Initial removal of distal ulnar pole of scaphoid.
B, Entire proximal row has been excised.
C, After release of traction.

83. BONE GRAFT TECHNIQUES

84. STARK ET AL. GRAFTING TECHNIQUE

85. VASCULAR BONE GRAFT FROM RADIUS
– VASCULAR BONE GRAFT
FROM RADIUS
• gaining popularity and a
good option for proximal
pole fractures with
osteonecrosis confirmed
by MRI
• 1-2 intercompartmental
supraretinacular
artery (branch of radial
artery) is harvested to
provide vascularized graft
from dorsal aspect of
distal radius

87. PREISER'S DISEASE (SCAPHOID AVN)
• Osteonecrosis of the scaphoid can occur as a late
complication of scaphoid fractures, especially
those involving the proximal pole.
• Epidemiology
– Rare condition
– Mostly idiopathic
– Average Age of onset is 45 years
• Operative treatment options:
 microfracture drilling, revascularization procedure, or
allograft replacement
 proximal row carpectomy or scaphoid excision with four
corner fusion

88. TRIQUETRAL FRACTURES

89. TRIQUETRUM FRACTURES
• 2 nd most common carpal bone fracture after scaphoid
• Mode of injury:
wrist in extension and ulnar deviation
• Clinical evaluation:
tenderness on palpation on the dorsolunar aspect of the wrist
directly dorsal to pisiform,painful wrist motion
• Radiological evaluation:
1.tranverse fracture of body identified on PA view
2.Dorsal triquetrum visualized by oblique ,pronated lateral view
• Treatment:
nondisplaced fractures of the body or dorsal chip fractures may
be treated in short arm cast or splint for 6 wks.
displaced with ORIF.

90. TRAPEZIAL FRACTURES

91. TRAPEZIUM FRACTURES
• 3-5% of carpal bone fractures
• 60% unsatisfactory due to secondary
degenerative changes
• Ridge avulsion or vertical fracture of body

92. MODE OF INJURY OF TRAPEZIAL
FRACTURES
• Axial loading of adducted thumb
• Driving base of 1st metacarpal into articular
surface of trapezium
• Avulsion fractures- forceful
deviation,traction,rotation of thumb
• Direct trauma to palmar arch- avulsion of trapezial
ridge by transvers carpal ligament

93. CLINICAL EVALUATION OF TRAPEZIAL
FRACTURES
• Tenderness of radial wrist
• Painful range of motion of 1st carpometacarpal
joint

94. RADIOGRPHIC EVALUATION
• Along with standard PA and Lateral
views
• Robert view
• True PA of 1st CMC joint and
trapezium with hand in maximum
pronation
• Carpal tunnel view-dorsal ridge
visualization

95. TREATMENT OF TRAPEZIUM
• Non displaced:
– Thumb spica splinting for 6 weeks
• Displaced, Comminuted, Carpometacarpal
Articulation involvement
– ORIF +- Bone Grafting

96. LUNATE FRACTURES

97. LUNATE FRACTURES
• 4TH most fractured
• CARPAL KEYSTONE
– lunate sits like a keystone in the proximal carpal row in the well-protected
concavity of the lunate fossa of the radius, anchored on either side by the
interosseous ligaments to the scaphoid and triquetrum with which it
articulates. Distally, the convex capitate head fits into the concavity of the
lunate

98. BLOOD SUPPLY TO LUNATE
• vascular supply of the lunate is primarily through the
proximal carpal arcade both dorsally and palmarly.
However, the literature suggests that 7% to 26% of
lunates may have a single volar or dorsal blood supply
and are therefore vulnerable to Osteonecrosis because
of disruption of extraosseous blood supply

99. MECHANISM OF INJURY
• Outstreched hand
• Wrist in hyperextension
• Strenous push with wrist in extension

100. CLINICAL EVALUATION FOR LUNATE
FRACTURES
• Tenderness on dorsal wrist overlying the distal
radius and lunate
• Painful ROM

101. RADIOGRAPHIC EVALUATION OF
LUNATE
• PA & Lateral views inadequate
• Oblique views may be helpful
• CT best demonstrates fractures
• MRI increasingly used for vascular changes
associated with injury and healing.
– test of choice for evaluation of Kienbock Disease.

102. ACUTE LUNATE FRACTURE
CLASSIFICATION
• acute fractures of the lunate are classified into
five groups:
1. Frontal fractures of the palmar pole with
involvement of the palmar nutrient arteries.
2. Osteochondral fractures of the proximal articular
surface without substantial damage to the nutrient
vessels.
3. Frontal fractures of the dorsal pole.
4. Transverse fractures of the body.
5. Transarticular frontal fractures of the body of the
lunate.

104. TREATMENT OF LUNATE FRACTURES
• Non displaced:
Most fractures of the lunate can be treated by cast
immobilization for 4 weeks.
• Displaced :
displaced or angulated fractures treated surgically for
adequate apposition for vascular anastomosis.
• Fractures with more than 1 mm offset and avulsion
fractures usually require open reduction.
• Internal fixation techniques vary depending on the
requirements of the individual situation and may
include Kirschner wires,small cannulated screws, and
suture anchors

105. COMPLICATIONS OF LUNATE
FRACTURES
• The lunates believed to be most at risk for
osteonecrosis are those with a single vessel or
one surface exposed to the blood supply,
representing about 20% of lunates.
• Kienböck disease is a painful disorder of the
wrist of IDIOPATHIC cause in which
radiographs eventually show osteonecrosis of
the carpal lunate.

106. KIENBOCK'S DISEASE
• Avascular necrosis of the luntate leading to
abnormal carpal motion
• Epidemiology
– incidence
• most common in males between 20-40 years old
– risk factors
• history of trauma

107. CLINICAL PRESENTATION of
KIENBOCK’S DIESEASE
• Symptoms
– dorsal wrist pain
• usually activity related
• more often in dominant hand
• Physical exam
– inspection and palpation
• +/- wrist swelling
• often tender over radiocarpal joint
– range of motion
• decreased flexion/extension arc
• decreased grip strength

108. • Prognosis
– potentially debilitating condition if unrecognized
and untreated
• Blood supply to lunate
– 3 variations
• Y-pattern
• X-pattern
• I-pattern
– 31% of patients
– postulated to be at the highest risk for avascular necrosis

109. PATHOPHYSIOLOGY OF KIENBOCK’S
DIESEASE
• thought to be caused
by multiple factors
– biomechanical factors
• ulnar negative variance
– leads to increased radial-lunate
contact stress
• repetitive trauma
– anatomic factors
• geometry of lunate
• vascular supply to lunate
– patterns of arterial blood supply
have differential incidences of AVN
– disruption of venous outflow

110. IMAGING OF KIENBOCK’S
• Radiographs
– recommended views
• AP, lateral, oblique views of wrist
• CT
– most useful once lunate collapse has already occurred
– best for showing
• extent of necrosis
• trabecular destruction
• lunate geometry
• MRI
– best for diagnosing early disease
– findings
• decreased T1 signal intensity
• reduced vascularity of lunate

111. LICHTMAN CLASSIFICATION AND
TREATMENT RECOMMENDATIONS

115. CAPITATE FRACTURES

116. CAPITATE FRACTURES
• Isolated capitate fractures
uncommon
• Associated with Greater Arc
Injury Pattern (Transscaphoid
Transcapitate Perilunate
Fracture-Dislocation )
• Naviculocapitate syndrome
variation in which capitate
and scaphoid fractured
without associated
dislocation
• Mechanism
– Direct trauma or crushing
injuries associated with
carpal or metacarpals

117. CAPITATE FRACTURES
• CLINICAL EVALUATION:
– Point tenderness
– Painful dorsiflexion of wrist as capitate impinges
on dorsal rim of radius
• RADIOGRAPHIC EVALUATION
– Standard scaphoid views
– CT scan

118. CAPITATE FRACTURES
• Treatment
– CRIF or ORIF with Kirschner wires or Lag screws to
restore normal anatomy to reduce risk of
Osteonecrosis
• Complications
– Midcarpal arthritis
– osteonecrosis

119. HAMATE FRACTURES

120. HAMATE FRACTURES
• May be fractured through
– Through Hook(most common)
– Through Hamulus
– Through Distal articular surface
– Through Other articular surface
• Present with history of blunt trauma to palm of hand
– often seen in racquet sports
hockey
golf (miss ball and hit ground)
tennis
• Must distinguish from bipartite hamate (will have
smooth cortical surfaces)

121. CLINICAL EVALUATION OF HAMATE
FRACTURES
• Symptoms
– hypothenar pain
– decreased grip strength
– paresthesias in ring and small finger
• Ulnar & Median Neuropathy
– ulnar nerve compression in Guyon's canal
– occasionally in thumb, index, middle and ring finger due to
median nerve compression in carpal tunnel
– motor weakness of intrinsics (ulnar nerve
compression in Guyon's canal)

122. RADIOGRAPHIC EVALUATION OF
HAMATE FRACTURES
• Radiographs
– recommended views
 difficult to visualize fracture on AP
 best seen on a carpal tunnel view
• CT
– best study to make diagnosis

124. TREATMENT OF HAMATE FRACTURES
• Nonoperative
– immobilization in a short arm splint/cast for 6 weeks
• Operative
– excision of hamate fracture fragment
• indications
– chronic hook of hamate fractures
– ORIF
• With k-wires or screws
• Complications
– Symptomatic non union
– Ulnar and median neuropathy
– Rupture of the flexor tendons to the small finger

126. PISIFORM FRACTURES

127. PISIFORM FRACTURES
• The Pisiform is a sesamoid bone located within the Flexor Carpi
Ulnaris tendon
– origin for Abductor Digiti Minimi
• Epidemiology
– incidence
• 1%-3% of carpal fractures
• Mechanism
– Fall on outstretched hand
– Fall on Dorsiflexed hand
– Direct blow to volar aspect of wrist
• Associated conditions
– 50% of pisiform fractures occur with distal radius, hamate, or
triquetral fractures

128. PISIFORM FRACTURES
• CLINICAL EVALUATION
– Tenderness on volar aspect,ulnar side of wrist. With
painful passive extension of wrist as flexor carpi
ulnaris is tensed.
• RADIOGRAPHIC EVALUATION
– Radiographs
• recommended views
– lateral view of wrist with forearm supination of 20-45 degrees
– utilizing the carpal tunnel view of 20 degree supination oblique
view demonstrating an oblique projection of the wrist in radial
deviation and semisupination.
– CT

129. TREATMENT OF PISIFORM FRACTURES
• NONOPERATIVE
– IMMOBILIZATION
• indications
– first line of treatment
– short arm cast with 30 degrees of wrist flexion and ulnar deviation
for 6 weeks
• outcomes
– patients that sustain fracture of pisiform most often go on to heal
without posttraumatic osteoarthritis
• OPERATIVE
– PISIFORMECTOMY
• indications
– painful nonunion
• outcomes
– studies show a pisiformectomy is a reliable way to relieve this pain
and does not impair wrist function

130. TRAPEZOIDAL FRACTURES

131. TRAPEZOID FRACTURES
• Rare
• Axial load and crush injuries associated with
other carpal fractures
• Clinical evaluation
– Tenderness and painful range of motion proximal
to base of 2nd metacarpal

132. TRAPEZOID FRACTURES
• Radiographic evaluation
– Radiographs
 PA views compared with contralteral, uninjured wrist
 Oblique views
– CT scan
• Treatment
– Short arm Splint/cast for 6 weeks in undisplaced fractures
– ORIF with K-wires with restoration of articular congruity
• Complication
– 2nd CMC articulation joint congruity of not restores leads to
post traumatic osteoarthritis

133. PUTMAN AND MEYER TABULATED THE TYPES OF FRACTURES OF CARPAL BONES OTHER THAN
THE SCAPHIOD

135. REFERENCES
• CAMPBELL’S OPERATIVE ORTHOPAEDICS,
TWELFTH EDITION.
• Rockwood & Green's Fractures in Adults, 6th
Edition.
• GRAY’S Anatomy for Students.
• World Wide Net

136. THANK YOU