Scaphoid fractures management including precutaneous fixation and management of non unions

1. Scaphoid Fixation
Dr Vaibhav BAGARIA
Orthopedic Surgeon
CARE hospital & ORIGYN Clinic
Nagpur, INDIA
www.drbagaria.com
E: drbagaria@gmail.com

2. Background
 First described By French surgeon Destot in 1905
 2 – 7% of all fractures in young adults
 5 – 15% non union rates
 Derived from Greek word skaphos which means boat.
 Term based on its unique shape and articulations

3. Scaphoid Anatomy
 Articulates with five bones: Distal radius, capitate, lunate
trapezium and trapezoid
 80% scaphoid is covered by articular cartilage leaving little
space for the nutrient artery
 Main blood supply is through retrograde branches of the radial
artery
 80% through the foraminal artery which is part of dorsal branch
of radial artery
 Palmar branch reaches through dorsal tubercle

4. Scaphoid Anatomy

5. Scaphoid Anatomy

6. Scaphoid Vascular Supply

7. Scaphoid Anatomy
 Distal part has independent blood supply
 In contrast the proximal part depends on the distal part for
supply through the intra osseous part
 This leaves proximal part vulnerable in case of fractures of the
proximal pole which is dependent on distal part for this.
 Healing is thus difficult for proximal pole which often goes into
AVN

8. Clinical Presentation
 Fall on the out-stretched hand with wrist in radial deviation
 Proximal pole fractures occurs when the wrist in Abduction
 The same trauma mechanism causes supracondylar fracture
in kids and distal radius fractures in elderly

9. Imaging for Scaphoid fractures
 X ray
 CT scan
 MRI
 Scintigram
 Sonography
Each has its own advantage and disadvantage and are applied at
different stage of the management

10. Radiographs
 Initial X Ray may miss up to 30% of scaphoid fractures
 Apart from standard AP and Lat X Rays, two additional views
are required
 Some people recommend routine screening 10 -1 2 day post
trauma in case of high degree of suspicion and initial negative
x ray – a lucency/ sclerosis may provide clue

11. AP Lat and Oblique views

12. Diagnosis
 Scintigraphy has close to 100% sensitivity
 MRI has less initial sensitivity but high degree of sensitivity at
later stage, good for delayed presentation & to r/o AVN
 CT Scan helps in preoperative planning and assessing cortical
and trabecular pattern

13. Scaphoid Imaging: MRI, CT, Scinti

14. Scaphoid Fracture Classification
 Herbert’s, Russe and Mayo classification is commonly used
 Herbert’s is based on the stability & russe is based on the
predictability of healing depending on the fracture line
 As per Herbert unstable fractures are: displacement greater
than 1 mm or angulation greater than 15 degree. Additional
fractures ,trans-scaphoid-perilunate dislocations, multi-fragment
fractures and proximal pole fractures are also
classified as unstable.

15. Mayo’s Classification

16. Modified Staging System

17. Herbert’s Classification

18. Treatment Approaches
The aim of the treatment is to achieve fracture consolidation and
functional recovery whilst avoiding complications such as non- or
mal-union
 Direct Functional treatment
 Cast Immobilization
 Fixation: Open/ Percutaneous
 Managing complication & delayed presentation

19. TREATMENT
 Functional treatment involves bandaging or orthosis and is
used only occasionally and in suspected fractures before
immobilisation in cast is done.
 Casting is indicated for undisplaced fractures only
 Prolonged period of casting upto 12 weeks is required.
 Casting has inherent disadvantages of stiffness, probability of
non union, chances of developing CRPS

20. Operative Treatment
 All Proximal pole and displaced scaphoid fractures should be
treated operatively.
 Percutaneous fixation using careful dorsal approach is the
preferred method.
 In case of proximal pole fracture a reverse approach may be
required

21. Surface Anatomy

22. Per cut Fixation steps: Reduction

23. Skin Incision - Landmarks

24. Guide wire trajectory

25. Guide wire insertion

26. Confirm under II ( C ARM)

28. Correct Placement

29. Post Fixation radiographs

30. Approach to Non Union /AVN
 Bone Grafting & Fixation
 Vascularized Bone grafting – Pronator Quadratus/ Dorsal

31. Bone Graft fixation

32. Approach To Vascular BG

33. Planes

34. Vascular anatomy in Cadaver

35. Vascular pedicle BG

37. Temporary Fixation with BG

38. Pre & Post Vascular Graft

39. Take Home!
 Do not miss the fracture on initial X rays
 Prolonged immobilization is often required
 Percut fixation is preferred management in majority cases
 Non unions and AVN are common and need bone graft and
fixation.
 Pronator quadratus vascularized Bone grafting is often an
excellent method for fixing Non unions with AVN.

40. Thank You!
 ORIGYN Healthcare Nagpur & Indrapuram
 Dr Vaibhav BAGARIA