Extern conference Ext. ณัฐนรี 28 มีค.61

1. EXTERN CONFERENCE
EXTERN NUTNAREE YUENYONGDECHAWAT

2. PATIENT PROFILE
หญิงไทยคู่อายุ 67 ปี
อาชีพ แม่บ้าน
ภูมิลาเนา จ.นครราชสีมา

3. CHIEF COMPLIANT
ล้ม + ปวดข้อมือขวา 12 ชม ก่อนมา รพ.

4. PRIMARY SURVEY
A can talk clearly, no cervical midline tenderness
B clear and equal breath sound both lungs
C BP 96/57 mmHg, PR 64 bpm
D E4V5M6, pupils 3 mm RTLBE
E tenderness and mild swelling at Rt. anatomical
snuff box, limited ROM of Rt. wrist joint
radial pulse 2+, cap. refill < 2 sec
XX

5. SECONDARY SURVEY
A no drug or food allergy
M no current medication
P no known underlying disease
L last meal 18.00 น.
E 12 hr ก่อนมา รพ. สะดุดล้ม มือขวายันพื้น หลังจากนั้นปวดบวมที่ข้อมือขวา กดเจ็บ
ขยับข้อมือลาบาก

6. INVESTIGATION
Film right wrist (AP, lateral)
Film right hand (AP, oblique, scaphoid view)

7. Film Rt wrist
(AP, lateral)

8. Film right hand (AP)

9. Film right hand (oblique)

10. Film right scaphoid view

11. SCAPHOID FRACTURE

12. ANATOMY
 is located in the proximal
carpal row on the radial
aspect of the wrist
 Articulates with 5 bones:
distal radius, capitate, lunate,
trapezium, and trapezoid
 Over 80% of its surface is
articular cartilage.

13.  Blood supplies: Branches of the radial artery
- Dorsal branch which supplies 70% to 80%
of the scaphoid proximally, including the proximal
pole.
- Volar branch which supplies the
remaining 20% to 30% of distal scaphoid.
 Function
provides wrist joint movement and
congruency, as well as force transmission between
the forearm and the hand.

16. EPIDEMIOLOGY AND ETIOLOGY
 account for 2% to 3% of all fractures
 approximately 10% of all hand fractures
 between 60% and 80% of all carpal fractures
 Scaphoid fractures usually occur after a fall on to the outstretched hand or during
sports.

17. SIGNS & SYMPTOMS
 Patients classically present with wrist pain following a fall onto the outstretched
hand, with almost 90% recalling a hyperextension injury.
 Pain at the ‘snuff box’ exacerbated with grip
 Swelling at the base of the thumb
 Deformity of the wrist
 Bruising
 Stiffness/inability to move the thumb

18. Signs
 No single sign has been found to
be adequately sensitive or specific
 That individual sign had a negative
predictive value (NPV) of 100% and
the authors concluded that
patients with a negative test could
be safely discharged at
presentation as they did not have
a scaphoid fracture.

19. Anatomical snuff-box tenderness

22. INVESTIGATION
▪ Plain film
▪ CT
▪ MRI
▪ Bone scan

23. PA view

24. Lateral wrist

25. oblique

26. PA with ulnar deviation

27. clenched fist view

28. CLASSIFICATIONS
 Russe classification
 AO classification
 Herbert and Fisher classification
 Mayo classification

29. The Russe classification predicts instability according to the inclination of the
fracture line; for example, vertical oblique fractures.
The AO classification breaks the fracture down into simple anatomic location (distal
pole, waist, proximal pole) and comminution.

31. The Herbert and Fisher classification

32. The Herbert and Fisher classification

33. The Mayo classification
The criteria for instability they set out are as follows:
▪ >1 mm of fracture displacement
▪ A lateral intrascaphoid angle of >35 degrees
▪ Bone loss or comminution
▪ Fracture malalignment
▪ Proximal pole fractures
▪ DISI deformity
▪ Perilunate fracture-dislocation
Lateral intrascaphoid angle

34. MANAGEMENT
Suspected Scaphoid Fractures
- up to 30% to 40% of scaphoid fractures are not identified on initial assessment and
investigation
- Patients who are subsequently found to have a fracture confirmed on repeated
assessment and radiologic imaging, most frequently at 10 to 14 days post injury.
- When clinical suspicion is present but radiographs are negative, immobilization is
recommended with repeat examination and radiographs performed within 10 to 14 days of
injury.

35. Non-operative Px
Operative Px

36. Thumb spica cast immobilization
Indications
1. Stable nondisplaced fracture (majority of fractures)
2. Suspected scaphoid fracture
Technique
- start immobilization early (nonunion rates increase with delayed immobilization of
> 4 weeks after injury)
- Wrist in neutral position with full palmar abduction of thumb
NON-OPERATIVE

37. Duration of casting
depends on location of fracture
distal-waist 2-3 months
mid-waist 3-4 months
(proximal third 4-5 months)
Outcomes
scaphoid fractures with <1mm displacement* have union rate of 90%

38. OPERATIVE
Indications
Unstable fractures as shown by
1) proximal pole fractures
2) displacement > 1 mm
3) radiolunate angle > 15 degree (DISI)
4) intrascaphoid angle of > 35 degree
5) scaphoid fractures associated with perilunate dislocation
6) comminuted fractures
7) unstable vertical or oblique fractures

40. Technique
ORIF
percutaneous screw fixation
Outcomes
union rates of 90-95% with operative treatment of scaphoid fractures

41. COMPLICATIONS
 Scaphoid Malunion
- Usually with a humpback deformity associated with DISI
- The effect of this malalignment on symptoms and wrist function is debatable.
- believed to be at risk of wrist pain, reduced wrist extension and diminished grip
strength

44. ▪ Scaphoid Nonunion
- leads to a specific type of post-
traumatic wrist arthrosis labeled
scaphoid nonunion advance collapse
(SNAC).

45. ▪ Scaphoid AVN
- can occur as a late complication
of scaphoid fractures, especially those
involving the proximal pole.
- increasing pain and stiffness of
the wrist.
There is sclerosis of the proximal segment of this scaphoid.
This represents avascular necrosis secondary to
interruption of blood supply due to trauma.

46. REFERENCES
 Rockwood and Green's Fractures in Adults 8edition
 Orthobullets.com
 เวชปฏิบัติทางออร์โธปิดิกส์ ภาควิชาออร์โธปิดิกส์ รพ.มหาราชนครราชสีมา: Wrist and Hand
Trauma โดย พญ.ศุภมาส ลิ่วศิริรัตน์