The document provides information about scaphoid fractures, including: - Scaphoid fractures most commonly occur at the waist portion of the bone and account for 50-80% of all carpal bone fractures. - Diagnosis is based on history, clinical examination showing tenderness over the scaphoid, and imaging including x-rays and advanced imaging if needed. - Treatment depends on fracture displacement and location, with nondisplaced fractures often treated non-operatively with casting and displaced or proximal fractures often requiring surgery. - Prognosis depends on factors like timing of diagnosis, location, displacement, and smoking, with proximal fractures having higher risks of complications like nonunion.

1. Dr Rahmatullah khushal
2nd year orthopedic residence in
NRH
Scaphoid Fractures
Dr.Khushal

2. Contents
1 Introduction
2 Anatomy
3 Blood supply
4 Mechanical injuries
5 Diagnose
6 Clinical examination
7 Imaging
8 Deferential diagnose
9 Classification
10 Prognosis
11Treatment
12 Complication
Dr.Khushal

3. Introduction
• In all carple bone about 50 to 80% fracture occurs in
scaphoid bone
• About 5 to 12 % of scaphoid fractures are associated with
other fractures
• 70 to 80% percent occurs at the waist or mid portion
• 10 to 20 percent in proximal pole
• Usually occurs from a fall on the outstretched hand
• The patient usually complain from wrist pain and some
swelling
Dr.Khushal

4. Anatomy
• Anatomically the scaphoid is divided into 4 portion
proximal and distal pole a tubercle and a waist 80
percent of scaphoid is covered with articular cartilage
• The scaphoid lies at the radial border of the proximal
carpal row but it elongated shape and position allow
bridging between the 2 carpal rows because it acts as a
stabilizing rod.
• The scaphoid has five articular surfaces
with radius ,lunate , capitate , trapezoid and trapezium
Moves in all the movement of the wrist,
Dr.Khushal

5. •Picture of carpal anatomy
Dr.Khushal

7. Blood supply
Dr.Khushal
1. Radial artery
• scaphoid branch
dorsal branch entering in the dorsal ridge and supply about 70 to
80 percent of the scaphoid including the proximal pole
Volar branch The remaining distal aspect is supplied through
braches entering the tubercle by volar branch

8. Mechanisms of injuries
• Two different mechanisms
• ■ Compression injuries
•Usually result in non displace fx
■ Hyperextension bending injuries
•Usually results in displace fx
•Fracture occurs because
The proximal pole lock in the scaphoid fossa of the
redius and the distal pole moves excessively dorsal
resulting in fracture
Dr.Khushal

10. Diagnosis
• For good prognosis the early diagnose is necessary
• The diagnosis should be based on
• History
• Clinical examination
• Radiographic evaluation
Dr.Khushal

11. Clinical examination
• Should be present tenderness in the anatomic snuff box
• Tenderness to palpate over scaphoid tuberosity
• Tenderness with axial supinates forearm against
resistance
• Radial and ulnar deviation result in pain on radial side
of wrist
• in Forced dorsiflexion usually has significant tenderness
• Swelling usually not present
Dr.Khushal

12. • Scaphoid provocative tests
• The scaphoid shift test: reproduction of pain with
dorsal-volar shifting of the scaphoid
• ■ The Watson shift test: painful dorsal scaphoid
displacement as the wrist is moved from ulnar to
radial deviation with palmar pressure on the
tuberosity
• (should be with image)

14. Imaging/radiographic evaluation
■ This includes a PA view of the wrist in ulnar deviation
to extend the scaphoid, a lateral view , a supinated AP and
pronated oblique view, and a clenched supinated view in
ulnar deviation.
• ■ Initial (beginning) films are no diagnostic in up to 25%
of cases.
• ■ If the clinical examination suggests fracture but
radiographs are not diagnostic, a trial of
• immobilization with follow-up radiographs 1 to 2 weeks
after injury may show the fracture.
• Motions views of the wrist (flexion extension radial and
ulnar deviation ) may show fracture displacement
Dr.Khushal

16. • ■ Gilula lines (three smooth radiographic arcs) should be
examined on the PA view. Disruption of these arcs indicates
ligamentous instability. (bilateral view is necessary)
• ■ If there is the suspicion of carpal instability the bilateral
clenched-fist PA to look for widening of the scapholunate
interval.
• ■ The bone scan is most sensitive thus if the bone scan is
negative the scaphoid fracture is ruled out
• ■ Computed tomography (CT) scans are helpful in showing the
carpal fractures, malunion, nonunion, and bone loss.
• ■ Magnetic resonance imaging (MRI) scans are sensitive for
occult fractures and osteonecrosis , soft tissue injury and
ruptures of the scapholunate.
Dr.Khushal

18. • NOTE (why PA x-ray is necessary in ulner devistion)
• as wrist rotates from neutral to ulnar deviation proximal
row dorsiflexed and x-ray of the scaphoid appears in
longer
• and in radial deviation proximal carpal row volar flexes
and scaphoid appears foreshorten therefor ulnar
deviation PA is necessary for visualization of scaphoid
Dr.Khushal

19. Differential diagnose
• ■ Lunate dislocation or fx
• ■ Scapholunate instability
• ■ Radial styloid fx
• ■ Trapezium fx
• ■ Rapture of FCR tendon
• ■ ECRB or ECRL avulsion
• Here the same radial side wrist pain is positive
Dr.Khushal

20. Classification
• ■ Location of fracture
• 4 different fracture sites:
• Proximal third (proximal pole ) 10 to 20%
• Middle third (waist) most common about 80%
• Distal third and tuberosity 5%
• ■ direction of fx (Russes classification)
• Horizontal oblique
• Transverse
• And vertical oblique
Dr.Khushal

21. • ■ Based on displacement
• un Displaced …………….stable
• Displaced …………..unstable
• Note fracture displacement this is the most
impartment and practical classification
• Un stable or displaced is defined as
• Presence of a fracture gap more then 1 mm or any
radiographic projection
• Scaphiolunate angle more the 60
• Radiolunate angle more the 15
• Or interscaphoid angle more then 35
Dr.Khushal

22. Dr.Khushal

25. Prognosis
• Negative prognostic factors are
• ■ late diagnose
• ■ Proximal location
• ■ Displacement
• ■ Angulation
• ■ Smoking
• ■ Carpal instability
Dr.Khushal

26. Treatment
• ■ Indications for nonoperative treatment
• ■ Nondisplaced
• acute (less than 4 weeks)
• distal third fracture
• ■ Tuberosity fractures
• ■ Nonoperative treatment
• use of a long arm thumb spica cast for 6 weeks to limit
forearm rotation with the wrist in slight flexion and
slight radial deviation and replacement with a short
arm thumb spica cast at 6 weeks until united.
Dr.Khushal

27. • However, there is controversy over the use of long arm versus
short arm immobilization
• Expected time to union:
• ■ Distal third: 6 to 8 weeks
• ■ Middle third: 8 to 12 weeks
• ■ Proximal third: 12 to 24 weeks
Dr.Khushal

28. Management of suspected scaphoid fractures
• ■ In patients with an injury and positive examination
findings but normal x-rays, immobilization for 1 to 2
weeks (thumb spica) is indicated.
• ■ Repeat x-rays if the patient is still symptomatic.
• ■ If pain is still present but x-rays continue to be
normal, consider MRI.
• ■ If an acute diagnosis is necessary, consider MRI or
CT immediately.
Dr.Khushal

30. • ■ Healing rates with nonoperative treatment depend
on fracture location.
• ■ Tuberosity and distal third 100%
• ■ Waist 80% to 90%
• ■ Proximal pole 60% to 70%
• Proximal Fractures Are Prone to Nonunion and
Osteonecrosis
Dr.Khushal

31. • ■ Indications for surgery
• ■ >1-mm displacement
• ■Communated Fracture
• ■ Radiolunate angle >15 degrees
• ■ Scapholunate angle >60 degrees
• ■ Intrascaphoid angle >35 degrees
• ■ Nonunion
Operative treatment
Dr.Khushal

32. Surgical techniques
• ■ Most fixed with screws.
• ■ open versus percutaneous techniques.
• ■ Open techniques are needed for nonunions and fractures
with unacceptable displacement.
• ■ Closed techniques are appropriate for acute fractures with
minimal displacement.
• ■technique use
• the screw must be inserted on proximal surface in central axis
of the scaphoid, as this position provides the greatest stability
and improves fracture alignment, and decreases the time to
union.
Dr.Khushal

33. • ■ The volar approach between the flexor carpi radialis and the
radial artery provides good exposure for open reduction and
internal fixation (ORIF) and repair of the radioscapholunate
ligament.
• The volar approach is the least damaging to the vascular
supply of the proximal pole.
• ■ The type of postoperative immobilization usually consists of
a short arm thumb spica cast for 6 weeks.
• ■ Return to sports occurs at a minimum of 3 months.
Dr.Khushal

34. Complication
• Delayed union,
• nonunion,
• and malunion:
• These are mostly occur when there is a delay in
treatment,
• Osteonecrosis: This occurs especially with fractures of
the proximal pole,
Dr.Khushal

35. Reference
• Zuckerman
• Ebnezar
• Internet websites

36. Any question
Any Additional information