Ext.Kanokpol Seejui Student ID 5422001

1. Orthopedics Case Conference
Ext. Kanokpol Seejui

2. • ผู้ป่วยชายไทย อายุ 25 ปี
• ภูมิลาเนาอาเภอพิมาย จังหวัดนครราชสีมา
• สิทธิ์การรักษา บัตรทอง 30 บาท
• CC : มีแผลที่ข้อมือข้างขวา 3 ชั่วโมงก่อนมารพ

3. Present illness
• สาเหตุการบาดเจ็บ : ถูกตู้ล้มทับกระจกตู้บาดที่ข้อมือด้านขวา
• ได้รับบาดเจ็บบริเวณ : ข้อมือด้านขวา มีแผลฉีกขาด มีเลือดไหล เห็น
เส้นเอ็นฉีกขาด กางและหุบนิ้วมือข้างขวาได้ กระดกข้อมือขึ้นลงได้ งอนิ้ว
ได้ทุกนิ้ว ปวดเวลากามือและกระดกข้อมือ มีอาการชาที่บริเวณปลายมือ
นิ้วโป้ง นิ้วชี้นิ้วกลาง นิ้วนาง

4. Primary Survey
A: Can speak, Can flex neck
B: equal breath sound both lung
C: BP 127/87 mmHg, PR 73 bpm
D: E4V5M6 pupil 3 mm react to light both eyes
E: Laceration wound at right wrist volar side size
~ 6x3 cm , seen tear flexor tendon

6. Secondary Survey
A : No drug allergy
M : No current medication
P : No underlying disease
L : NPO time 18.00 น. (ข้าว)
E : ขณะนั่งกินเหล้ากับเพื่อน ถูกตู้ล้มทับกระจกตู้แตกบาดที่แขนข้างขวา

10. Impression
1.Tear flexor tendon right wrist
2.Close fracture scaphoid bone right hand

11. Management
• Set OR for debridement with repair tendon
• Right thumb spica slab

15. Scaphoid Fracture
Epidemiology
• incidence
– accounts for up to 15% of acute wrist injuries
• location
– incidence of fracture by location
• waist -65%
• proximal third - 25%
• distal third - 10%
– distal pole is most common location in kids due to ossification
sequence

16. Scaphoid Fracture
• Pathoanatomy
– 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
• Associated conditions
– SNAC (Scaphoid Nonunion Advanced Collapse)
• advanced collapse and progressive arthritis of the wrist
that results from a chronic scaphoid nonunion

17. SNAC (Scaphoid Nonunion Advanced
Collapse)
• Prognosis
– patients with scaphoid nonunions of > 5 years
duration or proximal pole necrosis have less
favorable outcomes
– punctate bleeding of bone during surgery is a
good prognostic indicator of union
• 92% union with obvious bleeding, 71% with
questionable bleeding, 0% with no bleeding
• results show decreased rate of arthritis (down to 40-
50%)

18. Anatomy

19. Blood Supply
• major blood supply is dorsal carpal
branch (branch of the radial artery)
– enters scaphoid in a nonarticular ridge on the
dorsal surface and supplies proximal 80% of
scaphoid via retrograde blood flow
• minor blood supply from superficial palmar
arch (branch of volar radial artery)
– enters distal tubercle and supplies distal 20% of
scaphoid

20. Motion
• both intrinsic and extrinsic ligaments attach
and surround the scaphoid
• the scaphoid flexes with wrist flexion and
radial deviation and it extends during wrist
extension and ulnar deviation (same as
proximal row)

21. Presentation
Physical exam
• anatomic snuffbox tenderness dorsally
• scaphoid tubercle tenderness volarly
• pain with resisted pronation

22. 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

23. Imaging
• 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
• 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, and progression
of nonunion or union after surgery

24. imaging
• MRI
– indications
• most sensitive for diagnosis occult fractures < 24 hours
• immediate identification of fractures / ligamentous
injuries
• assessment of vascular status of bone (vascularity of
proximal pole)
– proximal pole AVN best determined on T1 sequences

25. Treatment
Nonoperative
• thumb spica cast immobilization
– indications
• stable nondisplaced fracture (majority of fractures)
• if patient has normal xrays but there is a high level of
suspicion can immobilize in thumb spica and reevaluate
in 12 to 21 days

26. Treatment
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

27. Treatment
– 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

28. Thank You