Dr. nagamunindrudu fractures of scaphoid


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  • Time since injury : these are - of course – arbitrary definitions and no one can say with certainty when a delayed union begins or endsNonunion - 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.
  • Dr. nagamunindrudu fractures of scaphoid

    1. 1. Fracture ScaphoidIntroductionAnatomyBiomechanicsMechanism of injury.ClassificationClinical picture& DiagnosisManagementConclusion.
    2. 2. Fracture Scaphoid1. It is also called Navicular,2. It is a irregular shaped bone more likea twisted peanut than boat3. Common in young adults rare in children if occurs it is distal 1/3 Fr4. The mechanism of injury is by fall on out stretched hand.5. Hyper extension of wrist ,pronation, radial deviation.6. Second commonest Fr in the wrist7. Scaphoid is the key bone in maintaining the stability of carpal articulation8. Blood supply of scaphoid9. Subtleness of presentation- wrist sprain10. Complexity of choice of treatment.
    3. 3. Fracture Scaphoid• Present on the radial side of wrist spans between two rows of carpal bones• It connected with rest of the carpal bones through various ligaments of , volar ligaments are more strong• Distally articulates with trapizium ina gliding movement gives independent movement to thumb• On the ulnar side articulates with capitate, proximally with Lunate in a rotatory movement• Proximally the convex surface articulates with distal end of radius
    4. 4. Fracture Scaphoid…Blood supply.• The blood supply to the scaphoid is similar to that of head of femur• He articular surface cover the 80%of scaphoid only small part on the dorsum of the neck and very small part in the distal part of the bone is available for the blood vessels to enter the bone.• Major blood supply is form scaphoid branches of Radial artery enters into the distal ridge just distal to the waist supplies 80% of the bone in retrograde fashion.• The second group is form the palmar and superficial branches of the radial artery, perfuses distal20-30% of distal bone and the tuberosity.• There is no anastomosis between the voalr and dorsal vessels.• 79% of the vessels enter through the dorsal ridge.
    5. 5. Fracture Scaphoid……. Biomechanics• The carpal bones -3 groups- medial ,central, lateral.• Medial –stability• Central---flexion/ extension• Lateral--- rotations• Scaphoid flexes on radialdeviation ,& palmar flexion of the wrist, extends on extension & on ulnar deviation
    6. 6. Fracture Scaphoid… Biomechanics. Contd • The stable Fr maintains the normal orientation for proximal and distal rows • Unstable Fr angulates dorsally and produces – Humpback deformity • Results in DISI • Grip weakness, late OA OA
    7. 7. Fracture Scaphoid -Mechanism of injury1. Fall on outstretched hand force absorbed on the radial side of the Hand2. Hyper extension of the wrist presses the scaphoid against the dorsal rim of the radius3. The strong volar scapho lunate, lig holds tha proximal half scaphoid the distal half is carried up, results in TS Fr that starts volarlay and proresses dorsally.4. Compression injury- un displaced Fr5. Hyperextension injury- displaced Fr
    8. 8. Fracture Scaphoid… Classification RUSSE HERBERTANATOMICAL
    9. 9. Fracture Scaphoid -Diagnosis•A strong index of suspicion is the key toearly diagnosis otherwise the injury willbe dubbed as wrist sprain•The diagnosis should be based on : • History • Clinical examination • Radiographic evaluation
    10. 10. History• Occurs after a fall on an outstretched hand, athletic injury, or MVA• Usually happens in young adult men• Pain at the radial side of the wrist• Associated injuries
    11. 11. Clinical Examination• Should demonstrate tenderness in the anatomic snuff box• Tenderness to palpation over scaphoid tuberosity and/orproximal pole just distal to Listers tubercle•Tenderness with axial compression of thumb toward thesnuff box• Tenderness as patient supinates forearm againstresistance•Radial & ulnar deviation results in pain on radial sideof wrist• Forced dorsiflexion usually elicits significanttenderness•There is usually pain at extremes of motion•Limitation of wrist motion – but not dramatically•Swelling – usually not present
    12. 12. Differential DiagnosisIt is the same DD of radial sided wrist pain 1. Lunate dislocation or fr 2. Sapholunate instability 3. Radial styloid fr 4. Trapezium fr 5. Rupture of FCR tendon 6. ECRB or ECRL avulsion
    13. 13. Radiological DiagnosisThe best method for determining the presence of a fractureMany different views have been recommendedInitial views are : PA, lateral, scaphoid view ( PA with ulnardeviationMotion views of the wrist ( flexion-extension-radial & ulnar deviation ) may demonstrate fracture displacementIf a diagnosis still can’t be confirmed with confidence on routine films, further oblique views can be takenIf Uncertainty 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
    14. 14. Radiological Diagnosis If the second radiographic examination is still equivocal , a technetium Bone scan, 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 outIf the bone scan is positive, more specific studies ( e.g. CT orMRI) can be helpful
    15. 15. Clinical presentation Time since injury • Acute fracture - less than 3 weeks old • Delayed union - 4 to 6 months old • Nonunion - more than 6 months oldAmount of fracture displacement ( stability ) : • Un displaced ---- stable • Displaced ---- unstable
    16. 16. Scaphoid Fracture….• The unstable fracture Negative prognostic factors are (displaced) is defined as : - presence of a fracture • late diagnosis gap > 1 mm on any • proximal location radiographic projection • displacement - scapho lunate angle > 60 • angulation - radio lunate angle > 15 • obliquity of the fracture line or intrascaphoid angle > • smoking 20 • carpal instability
    17. 17. Scaphoid Fracture…..Treatment STABLE UNSTABLE Is determined by: • Location • Degree of displacement • Fresh vs old fractureNon operative( cast immobilization )3-main areas of disagreement 1- the position of the wrist in the cast 2- the need to include joints other thanthe wrist in the cast 3- the duration of the immobilization CONSERVATIVE SURGERY
    18. 18. Stable Fr Cast Immobilization.• B/E or A/E Cast (Fore arm supinaton/Pronation)Long arm cast is recommended for non displaced proximal pole fr• Thumb or Three fingersTo maintain the alignment of the Scaphoid in unstable Fr• Duration of Treatment ‘’ longer the immobilization better is healing”• 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 fr heals in 6-8 weeks – Middle third fr 8-12 weeks – Proximal third fr 12-24 weeks• A 95 % union rate can be expected with this management• undisplaced, stable fractures if diagnosed and immobilized early (95 % with x-ray evidence of beginning consolidation at 6 weeks )
    19. 19. Stable Fr Cast Immobilization.• Initial delay in treatment does not preclude casting• If treatment is instituted within4weeks no effect on healing time or rate of union has been shown• Delay beyond 6 months invariably requires operative treatment• The difficulty lies in fractures between 6 weeks and 6 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
    20. 20. Stable Fr------ Surgical treatment• Indications.• Professionally high demand pt• Pt who cannot tolerate prolonged immobilizationPercutaneous Screw fixation- volar /dorsal appTechnically demandingDisplacement of fragments can occur* Pt need to be explained about the pros & cons, need for the short term cast immobilization thoroughly*
    21. 21. Problem Fractures.1. Displaced /angulated/ acute fracture2. Acute Fr associated with carpal instability3. Delayed union or nonunion when bone grafting4. is insufficient to provide adequate internal fixation5. S.Fr associated with a perilunate fr - dislocation Ligamentous injury4. Non displaced fr of proximal pole)
    22. 22. Unstable Fr- conservative TreatmentPoor risk PtPt not willing for Surgical TrClosed manipulation&cast Immobilization-- 3 point fixation with dorsal pressure on capitate & lunate ,volar pressure over the distal end of scaphoid ( rotates the lunate,proximal fragment into flexion)- cast A/E ,slight dorsi flexion radial deviation, thumb/ 3 finger cast
    23. 23. 1. Unstable Fr- surgical Treatment The choice of the surgical procedure will vary with the surgeon’s preference and experience, type of the fracture, patient’s age, periscaphoid arthrosis1. The most important aspect of the treatment is meticulous technique and not the device or equipment selected2. Reduction of the fracture should be anatomic 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 24
    24. 24. 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
    25. 25. Treatment of middle third fr• 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)
    26. 26. 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• Displaced Fr-• Fragment small- K wire fixation• Fragment is 1/3 of Scaphoid Screw fixation – Dorsal app• 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
    27. 27. 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 fr needs ORIF
    28. 28. Complications of Scaphoid Fr• Delayed union or Nonunion• Malunion (Humpback deformity)• SLAC wrist• Osteonecrosis
    29. 29. Scaphoid Fracture-- Nonunion• The incidence of scaphoid nonunion for undisplaced fr is 5-10%• The incidence increases up to 90% in displaced proximal pole frs• Risk factors : – Proximal pole fr – Displacement – Late diagnosis – Inadequate immobilization – Associated ligamentous injuries
    30. 30. Scaphoid Fracture-- Nonunion• Failure to heal after 6 months establishes the Dx of nonunion• Recent studies indicated that virtually that “all unstable non unions lead to carpal collapse and post traumatic arthritis,,• All scaphoid nonunions even if asymptomatics hould be treated aggresively.• Thin cut CT scan show more details than conventional tomograms• Sagittal views are helpful in determining the degree of carpal collapse and humpback deformity
    31. 31. Sc Fr—Nonunion… Treatment• Procedures available- 1.Bone grafting,2.Electrical stimulation• 3. Proximal pole excision 4. Salvage procedures• Look for the following……• Comminution of Fr site/ gape with collapse.• Avascularity of proximal pole• Orientation of lunate , Scapho-lunate angle, Intra scaphoid angulationProcedures of choice ….OR+ bone graftingNo collapse- Inlay grafting- RUSSECOLLAPSE + - interposion grafting-FERNANDASEproximal pole avascularity- vascular pedicle grafting 1. pronator Quadratus based 2.Supra retinacular artery based
    32. 32. Russe procedure•Volar app radial to FCR•Double coartico cancellous graftsfacing on the cancellous surface•The time to union with thisprocedure is relatively long,generally requiring castimmobilization for 6-4 months•Healing rates of 85-90 % have beenreported•Satisfactory relief of symptoms hasbeen reported ; 78 % of painful wristbecame free of symptoms and 88 %of patients were satisfied with theresults
    33. 33. Fernandez procedure• angulated nonunions with a dorsal humpback deformity• Interpositional grafting.• Trapezoidal iliac graft to correct the angulation and carpal collapse pattern.• Fixation is achieved with screws or k-wires• volar approach is used, and care must be taken to preserve the vascularity of the fragments
    34. 34. Avasularity of proximal pole Braun procedure Braun procedure Procedure similar to Russe procedure Block of radius 15-20x8-10mm raised along with distal pronator qudratusBone grafting based on supra retinacular branch ofradial arteryDorsal approach
    35. 35. Non-union… treatmentElectrical stimulation:• 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• Proximal pole excision: when a small proximal fragment is not amenable to bone grafting ,proximal pole excision and fascial hemiarthroplasty are recommended
    36. 36. Non-union… treatmentSalvage 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
    37. 37. Malunion• Malunion of the scaphoid may occur when a displaced or angulated fracture is allowed to heal without anatomic reduction• In most of cases , there is a dorsal angulation resulting in a fixed humpback deformity• DISI pattern ensues ,resulting in pain ,loss of motion, and decreased grip strength• Treatment in a young patient includes osteotomy,volar wedge bone graft, and internal fixation• Once degenerative arthritis has begun ,treatment is limited to a salvage procedure such as proximal row carpectomy, intercarpal arthrodesis,or complete wrist fusion
    38. 38. conclusionScaphoid treatment should be planned based on…1 stability of fr stable/ unstable2. Anatomical Location of fr( p1/3, waist, Distal1/3)3.Comminution at Fr site, avasclarity of proximal pole4.Delayed or early presentation5. Features of non union6.Evidence of DISI( dorsal tilting of lunate)In cast application stable Fr- thumb spica,A/E castfor unstable Frs ,Stable proximal pole fr, 3 finger/ fist cast- displaced Fr, Fr associated with carpal instability.Percuataneous fixation to be used with cation after pt is well informed and surgeon had enough open reduction experienceReduction always should be Anatomical