This document provides information on scaphoid fractures, including anatomy, blood supply, biomechanics, mechanisms of injury, diagnosis, classification, prognosis, and treatment options. Scaphoid fractures are common injuries that can be difficult to diagnose and treat due to the scaphoid's anatomy and blood supply. Treatment depends on factors such as fracture location, stability, and timing of diagnosis, and may involve casting or surgical intervention like internal fixation or bone grafting. Complications can include nonunion, malunion, and post-traumatic arthritis if not properly treated.

1. P R E S E N T E D B Y :
D R . N . B E N T H U N G O T U N G O E
P . G , M S ( O R T H O P E D I C S )
C E N T R A L I N S T I T U T E O F O R T H O P E D I C S
V M M C & S A F D A R J U N G H O S P I T A L
N E W D E L H I
SCAPHOID FRACTURES

2. SCAPHOPID FRACTURES: INTRODUCTION
 Scaphoid fractures constitute 60-70 % of all carpal bone
fractures
 Second only to the distal radius in frequency
 Due to the importance of scaphoid in wrist mechanics and
because of the frequency of the fracture in young adult
male, it has an economic as well as physical significance
 Uncommon in children because the physis of distal radius
fails first

3. ANATOMY
 Also called Navicular
 An irregular shaped bone ,more resembling a twisted
peanut than the boat for which it is named
 Scaphoid represents floor of the anatomic snuff box
 Articular cartilage covers 80 % of the scaphoid surface -
only narrow area of its neck, & even smaller distal portion,
are accessible to blood vessels
 Distally, it articulates with the trapezium and trapezoid in
a gliding motion, The articulation with the trapezium forms
a base for independent movement of the thumb
 On the ulnar side, it articulates distally with the capitate,
and proximally with the lunate in a rotary motion
 Proximally, its large, biconvex surface allows articulation
with the radius

5. BLOOD SUPPLY
 Major blood supply comes from the scaphoid branches of the
radial artery entering the dorsal ridge at or just distal to waist
area and supplying 70-80 % of the bone including the entire
proximal pole - in a retrograde fashion
 Second group of vessels, arise from palmar & superficial
palmar branches of radial artery & enter the distal tubercle, it
perfuses distal 20-30 % of bone, including tuberosity.
 There are no anastomoses between the dorsal and palmar
vessels
 Fractures across scaphoid may destroy blood supply to its
proximal part

6. BIOMECHANICS
 Mechanically scaphoid links the proximal and distal
rows
 Scaphoid spans both carpal rows and therefore has less
mobility than other carpal bones
 Scaphoid carries the compressive loads from the hand
across the wrist to the distal forearm
 Scaphoid flexes with wrist flexion & extends with wrist
extension
 It also flexes during radial deviation & extends during
ulnar deviation
 These factors make immobilization of scaphoid fractures
difficult especially when there is displacement

7. NOTE: as wrist rotates from neutral to ulnar deviation,
proximal row dorsiflexes & x-ray profile of the scaphoid
appears longer; - in radial deviation, proximal carpal row
volar flexes & scaphoid appears foreshortened; - hence,
ulnar deviation AP is necessary for visualization of
scaphoid;
 Scaphoid is a principal bony block to dorsiflexion of hand & wrist
, and is susceptible to fracture during fall on outstretched hand
 With scaphoid fx, distal scaphoid tends to flex, & proximal
scaphoid extends with the proximal carpal row ,, because of this,
angulation occurs at fx site, which gradually leads to a
humpback deformity

8. MECHANISMS OF INJURY
Two different mechanisms
1. Compression injury :
usually results in non displaced fx
2. Hyperextension bending injury :
usually results in displaced fx.
 NOTE: Compression injury results from a more longitudinal load or impaction of the wrist
leads to intraction of the scaphoid without displacement

 Hyperextension bending injury :tensile stresses generated palmarly when excessive
hyperextension is applied to the wrist and when the excessive tensile forces exceed bone
strength produce a fx thru the scaphoid that commonly results in fx displacement

9. DIAGNOSIS
 A strong index of suspicion is the key to early
diagnosis
 The diagnosis should be based on :
History
Clinical examination
Radiographic evaluation

10. CLINICAL SIGNS AND SYMPTOMS
 Should demonstrate tenderness in the anatomic snuff
box
 Tenderness to palpation over scaphoid tuberosity
and/or proximal pole just distal to Lister's tubercle
 Tenderness with axial compression of thumb toward the
snuff box
 Tenderness as patient supinates forearm against
resistance
 Radial & ulnar deviation results in pain on radial side of
wrist
 Forced dorsiflexion usually elicits significant
tenderness
 There is usually pain at extremes of motion
 Limitation of wrist motion – but not dramatically
 Swelling – usually not present

11. IMAGING/ RADIOGRAPHIC EVALUATION
 The best method for determining the presence of a
fracture
 Many different views have been recommended
 The useful initial views are : PA, lateral, scaphoid view (
PA with ulnar deviation )
 Motion views of the wrist ( flexion-extension-radial &
ulnar deviation ) may demonstrate fracture
displacement
 If a diagnosis still can’t be confirmed with confidence on
routine films, further oblique views can be taken
 If certainty still exists after all these maneuvers , the
patient should be placed in a cast for 2 to 4 weeks and the
clinical & radiographic evaluation repeated

12.  NOTE: The same x-rays should be repeated if the initial
films were negative because resorption may assist
identification by widening the fracture line,,,, it is
imperative for the orthopedist to make the Dx at this
time because a delay in the Dx increases the incidence of
the scaphoid nonunion
 -- Terry and Ramin have called attention to a small
radiolucent area normally present next to the scaphoid in
anteroposterior view radiographs,which they named the
navicular fat stripe, a fracture on the radial side of the
wrist can either displace or obliterate this line. A
preserved fat stripe is a strong indication that a fracture
has not occurred. This sign is valuable only in fresh
fracture..

13.  If the second radiographic examination is still
equivocal , a technetium bone scan,
polytomography, CT or MRI of the wrist is
recommended
 The bone scan is the most sensitive but the least
specific of these modalities, thus if the bone scan is
negative , a scaphoid fx is ruled out
 If the bone scan is positive, more specific studies (
e.g. polytomography, CT or MRI ) can be helpful

15. DIFFERENTIAL DIAGNOSIS
 It is the same DDx of radial sided wrist pain
Lunate dislocation or fx
Sapholunate instability
Radial styloid fx
Trapezium fx
Rupture of FCR tendon
ECRB or ECRL avulsion

16. CLASSIFICATION
A. Location of the fracture :
5 different fracture sites :
Proximal third ( proximal pole ) .. 25%
Middle third ( waist )… most common 65%
Distal third …..10%
Tuberosity
Distal articular surface ( osteochondral fx )

18. B. Direction of the fracture :
Horizontal Oblique , Transverse , and Vertical
Oblique (Russe’s
Classification )

20. C. Time since injury :
 Acute fracture - less than 3 weeks old
 Delayed union - 4 to 6 months old
 Nonunion - more than 6 months
old
 NOTE:
 Nonunion - more than 6 months old ----
however many clinicians diagnose these fractures as
nonunions regardless of the time period if bone
resorption ,cyst formation , or sclerosis is present.

21. D. Amount of fracture displacement (
stability ) :
 Undisplaced ---- stable
 Displaced ---- unstable
 NOTE: Amount of fracture displacement this is the
most important classification and the practical one.
 As mentioned earlier undisplaced fx results from
an impaction injury while the displaced fx results
from hyperextension bending injury


22. NOTE:
 The unstable fracture (displaced) is defined as :
- presence of a fracture gap > 1 mm on any radiographic
projection
- scapholunate angle > 60
- radiolunate angle > 15
- or intrascaphoid angle > 20

23. HERBERT’S CLASSIFICATION

24. PROGNOSIS
 Negative prognostic factors are :
 late diagnosis
 proximal location
 displacement
 angulation
 obliquity of the fracture line
 smoking
 carpal instability

25. TREATMENT
Is determined by:
Location
Degree of displacement
Fresh vs old fracture

26.  Undisplaced ( stable) fracture :
 Nonoperative ( cast immobilization )--- there have been
three main areas of disagreement in non-operative
treatment of acute non displaced fractures of scaphoid :
1- the position of the wrist in the cast
2- the need to include joints other than the wrist in the cast
3- the duration of the immobilization

27. Many types of cast immobilization have been described in the
literature.
No evidence exists to prove greater efficacy for one casting position
over another. Although above elbow casts may have a slightly
shorter time to union, the final rate of union is the same for
below or above elbow casts. The key factor in treatment of
scaphoid fractures is the duration of immobilization rather than
the specific position.
 The current recommendation is to use a short arm thumb spica
with the thumb interphalangeal joint free. The wrist is placed in
radial deviation
 Long arm cast is recommended for nondisplaced proximal pole
fx

28.  Consider changing the cast every 10-14 days for the
first 6 weeks so that it remains firm around forearm
muscles and the wrist
 Time to healing by location :
Distal third fx heals in 6-8 weeks
Middle third fx 8-12 weeks
Proximal third fx 12-24 weeks
 A 95 % union rate can be expected with this
management
 Removal of the cast should not occur until union has been
documented on CT or tomography
 Prognosis is excellent in undisplaced, stable fractures if
diagnosed and immobilized early (95 % with x-ray evidence of
beginning consolidation at 6 weeks )

29.  Initial delay in treatment does not preclude casting
 If treatment is instituted within four weeks no effect on
healing time or rate of union has been shown
 Delay beyond six months invariably requires operative
treatment
 The difficulty lies in fractures between six weeks and six
months. If no evidence of bony resorption exists, casting
may result in union. If bony resorption or displacement
greater than 1 mm exists, operative reduction and bone
grafting will be needed

30.  Cast immobilization and electrical stimulation :
the M/A isn’t fully understood
 It is worthwhile to try electrical stimulation (esp.when there is
nonunion ), though there is a lack of reliable double-blind study
which compares between series of patients treated with
immobilization alone and those treated with immobilization and
ES,
 If the patient will not tolerate prolonged cast
immobilization (e.g. professional athletes and manual
laborers ) early internal fixation should be performed
 Internal fixation for fresh nondisplaced proximal pole
fractures has been recommended by some authors

31.  Displaced fractures :
 Primary internal fixation is treatment of choice for unstable
scaphoid frxs
 Fractures treated by primary internal fixation, average time
for return to work is 3.7 weeks with union rate 97 %

32.  Indications of Surgery in Scaphoid
fractures
Displaced acute fracture
Delayed union or nonunion when bone grafting is insufficient
to provide adequate internal fixation
S.Fx associated with a perilunate fx or dislocation
Ligamentous injury
Non displaced fx of proximal pole
Non displaced fx if the pt will not tolerate prolonged cast
immobilization (e.g. professional athletes and manual laborers )

33.  The choice of the surgical procedure will vary with
the surgeon’s preference and experience, the type of
the fracture, the patient’s age, and the presence of
periscaphoid arthrosis
 The most important aspect of the treatment is
meticulous technique and not the device or
equipment selected
 Reduction of the fracture should be anatomic

34.  ORIF of scaphoid fractures can be done by many
ways :
K-wires ( easy insertion )
Herbert screws ( headless, multipitched,difficult
insertion )
AO screws
Herbert-whipple screw
Ender’s plate
Staples

35.  The surgical approaches :
 Volar approach -- is most of the time the preferred approach to limit
the injury to the blood supply of the scaphoid
 Dorsal approach – will be used to address the fractures of the
proximal approach
 NOTE:
 Volar approach : between FCR tendon and the radial
artery
 Dorsal approach:through the third dorsal
compartment,,the incision is centered over Lister’s
tubercle,,retracting EPL

36. Treatment of middle third fxs
They are the commonest (65%)
If fresh stable: short-arm thumb spica cast
If fresh undisplaced but potentially unstable (e.g.
vertical oblique) and stable fx older than 3 wks :
long-arm thumb spica cast
If fresh displaced : ORIF (k-wires or screws)

37. Proximal Pole Fractures
 challenging
 Often difficult to heal
 Prolonged immobilization- snug , well molded long arm
cast- (sometimes exceeds 9 mos) has been necessary with
conventional casting
 Early incorporation of PES has been recommended
 There is increasing favor to proceed to ORIF
 A dorsal approach allow s direct visualization of the fracture
 If it is a fresh fx, can be fixed by 2-3 k-wires
 The k-wires are extracted in a retrograde fashion in 6-8 weeks
 Alternatively ,one may use a Herbert screw which may be
inserted retrograde while the fragment is stabilized in a k-wire

38.  Determination of bony union is not easy
 Tomography or CT is needed
 Multiple follow up films should be obtained for
several months after the assumed healing

39. Distal Pole Fractures
 These are often avulsion injuries of the tuberosity
and can be expected to heal promptly with cast
treatment
 Fresh and undisplaced should heal in 4-8 wks in a
cast
 Displaced fx needs ORIF

40. After treatment care
 After achieving a rigid fixation , there is a big
controversy about the need for immobilization
 Some authors recommend a long arm cast after k-
wire or compression screw fixation for 2-3 weeks
 New literature is in favor of early mobilization

41. Complications of Scaphoid Fx
 Delayed union or Nonunion
 Malunion (Humpback deformity)
 SLAC wrist
 Osteonecrosis

42. NON UNION
 Failure to heal after 6 months establishes the Dx of
nonunion
 Recent studies indicated that virtually that all unstable
nonunions lead to carpal collapse and posttraumatic
arthritis,, for this reason treatment is recommended for all
scaphoid nonunions even if asymptomatic
 Thin cut CT scan show more details than conventional
tomograms
 Sagittal views are helpful in determining the degree of
carpal collapse and humpback deformity

43. Treatment of Nonunion
A) Bone grafting :
• 2 types of bone grafting are indicated for tx of nonunion:
• Russe bone graft (inlay):used for stable
nonunions .the initial procedure used a single corticocancellous
strut across the fracture line;a later modification involved two
corticocancellous struts inserted into the scaphoid excavation with
their cancellous sides facing each other,the remainder of the cavity
is filled with cancellous chips. Usually k-wires are added to secure
the construct.
 NOTE: Bone grafting is the oldest method for nonunion and
delayed union treatment.
 The original Matti technique as described in 1937 consisted
of excavation of the proximal and distal fragments through
adorsal approach and placement of a cancellous strut within
these two cavities to act as an internal fixationdevice as well
as a nidus for osteogenesis
 In 1960,Russe described a volar approach .

44.  The time to union with this procedure is relatively long
,generally requiring cast immobilization for 6-4 months
 Healing rates of 85-90 % have been reported
 Satisfactory relief of symptoms has been reported ; 78 %
of painful wrist became free of symptoms and 88 % of
patients were satisfied with the results
 Fernandez bone graft (interpositional
graft): angulated nonunions with a dorsal humpback
deformity require interpositional grafting. Fernandez has
described the use of a trapezoidal iliac graft to correct the
angulation and carpal collapse pattern.Fixation is
achieved with screws or k-wires
 In both types of bone grafting ,a volar approach is used,
and care must be taken to preserve the vascularity of the
fragments

46.  B) Electrical stimulation:
 Pulsed Electromagnetic Field ( PEMF ) stimulation has been
investigated as a noninvasive treatment for scaphoid
nonunion.Although controversial, there appears to be some
benefit (shorter healing time)when electric stimulation is
combined with bone grafting procedures
 C) Proximal pole excision:
when a small proximal fragment is not amenable to bone
grafting ,proximal pole excision and fascial hemiarthroplasty
are recommended

47.  D) Salvage procedures :
Are indicated when nonunion has lead to carpal collapse and
secondary degenerative changes
Proximal row carpectomy,intercarpal arthrodesis, or radiocarpal
arthrodesis is recommended in patients with chronic wrist pain
and stiffness
Radial styloidectomy and scaphoid interposition arthroplasty may
be combined with other procedures or performed independently in
the younger patient with less severe symptoms
Silicone implants have been used in the past but are now avoided
because of silicone synovitis