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Current Concepts and Review of Fractures of the Scaphoid Samantha Muhlrad, MD Assistant Clinical Professor of Orthopaedic Surgery Hand and Microsurgery.

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Presentation on theme: "Current Concepts and Review of Fractures of the Scaphoid Samantha Muhlrad, MD Assistant Clinical Professor of Orthopaedic Surgery Hand and Microsurgery."— Presentation transcript:

1 Current Concepts and Review of Fractures of the Scaphoid Samantha Muhlrad, MD Assistant Clinical Professor of Orthopaedic Surgery Hand and Microsurgery Stony Brook University Medical Center

2 Fractures of the Scaphoid 345,000 in the US annually 345,000 in the US annually 60 to 70 percent of all carpal fractures 60 to 70 percent of all carpal fractures Approximately 10% are associated with wrist fractures Approximately 10% are associated with wrist fractures Young active men (athletics or manual labor) Young active men (athletics or manual labor) Highest incidence in lacrosse, football, snowboarding Highest incidence in lacrosse, football, snowboarding 5% fail to unite (even when treated appropriately) 5% fail to unite (even when treated appropriately)

3 Anatomy/ Mechanism of Injury Links the proximal and the distal carpal rows Links the proximal and the distal carpal rows Waist is susceptible to fracture Waist is susceptible to fracture 2 mechanisms: 2 mechanisms: Hyperextension and bending** Hyperextension and bending** Punchers Scaphoid- axial force along the second metacarpal with the wrist in neutral. Punchers Scaphoid- axial force along the second metacarpal with the wrist in neutral. Associated with open metacarpal fractures Associated with open metacarpal fractures

4 Diagnosis of Scaphoid Fractures HIGH INDEX OF SUSPICION HIGH INDEX OF SUSPICION History of fall on palm of hand History of fall on palm of hand Tenderness in anatomic snuffbox Tenderness in anatomic snuffbox Tenderness to dorsum of wrist or volar scaphoid tuberosity Tenderness to dorsum of wrist or volar scaphoid tuberosity Bruising/swelling of the hand Bruising/swelling of the hand Radiographs Radiographs PA PA Ulnar deviation PA Ulnar deviation PA True lateral (radius, lunate, capitate all colinear) True lateral (radius, lunate, capitate all colinear) 45 degree pronation PA view 45 degree pronation PA view

5 Scaphoid Fracture Diagnosis In the case of a suspected scaphoid fracture In the case of a suspected scaphoid fracture CT- CT- Sensitivity- 84% Sensitivity- 84% Specificity- 98% Specificity- 98% Bone Scan- Bone Scan- Sensitivity 92% Sensitivity 92% Specificity 89% Specificity 89% MRI- MRI- Sensitivity 98% Sensitivity 98% Specificity 99% Specificity 99% US- US- Sensitivity 93% Sensitivity 93% Specificity 89% Specificity 89% Calderon, Ring. The diagnostic performance characteristics of imaging techniques used in the management o f scaphoid fractures. Current Option in Orthopaedics. Vol 18(4), July 2007,

6 Scaphoid Fracture Diagnosis Initial xrays are often negative. Initial xrays are often negative. If patient has clinical signs or symptoms they should be treated presumptively and referred to an orthopedist or hand surgeon for further evaluation. If patient has clinical signs or symptoms they should be treated presumptively and referred to an orthopedist or hand surgeon for further evaluation. Initial treatment is immobilization in a thumb spica splint. Initial treatment is immobilization in a thumb spica splint.

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8 Guidelines for Decision Making Based On: Based On: Duration Duration Location Location Orientation Orientation Displacement Displacement Comminution Comminution Associated Injuries Associated Injuries

9 Scaphoid Fracture Evaluation Duration Duration <3 weeks old- better prognosis <3 weeks old- better prognosis If >4 weeks old drastically lower union rates when treated with cast alone If >4 weeks old drastically lower union rates when treated with cast alone Location Location Distal 1/3 (Pole) (5%) Distal 1/3 (Pole) (5%) Middle 1/3 (Waist) (80%) Middle 1/3 (Waist) (80%) Proximal 1/3 (Pole) (15%)- Proximal 1/3 (Pole) (15%)- poor healing due to limited blood supply, osteonecrosis rate close to 100 % 1- dorsal scaphoid branch of the radial artery. 2- volar scaphoid branch.

10 Scaphoid Fracture Evaluation Orientation Orientation Vertically oriented fractures are less stable. Vertically oriented fractures are less stable. Herbert classification (Herbert & Fisher, 1984) of scaphoid fractures. (Reproduced with permission from Amadio, P.C.; Taleisnik, J. Fractures of the carpal bones. In: Green, D.P., ed. Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, pp. 809–864.)

11 Scaphoid Fracture Evaluation Displacement- Nonunion rates in displaced fractures reach 92% Displacement- Nonunion rates in displaced fractures reach 92% >1 mm step off on any view >1 mm step off on any view Scapholunate angle of >60 degrees Scapholunate angle of >60 degrees Lunocapitate angle of greater than 15 degrees Lunocapitate angle of greater than 15 degrees Lateral intrascaphoid angle of more than 20 degrees Lateral intrascaphoid angle of more than 20 degrees Comminution – is it shattered? Comminution – is it shattered? Associated Injuries: i.e., perilunate dislocations, distal radius fracture Associated Injuries: i.e., perilunate dislocations, distal radius fracture

12 Scaphoid Fracture Treatment Acute undisplaced fracture- Acute undisplaced fracture- Above elbow thumb spica cast Above elbow thumb spica cast wrist in neutral position wrist in neutral position 6 weeks. 6 weeks. If union is not evident at 6 weeks If union is not evident at 6 weeks a short arm cast is applied until CT reveals solid union. a short arm cast is applied until CT reveals solid union. This is the textbook answer but hand surgeons vary greatly.

13 Scaphoid Fracture Treatment Acute Displaced and Unstable Fractures Acute Displaced and Unstable Fractures Surgical treatment required Surgical treatment required Closed reduction and percutaneous pin or screw fixation Closed reduction and percutaneous pin or screw fixation Arthroscopically assisted pin or screw fixation Arthroscopically assisted pin or screw fixation Open reduction internal fixation Open reduction internal fixation

14 Scaphoid Fracture Treatment Delayed Union Delayed Union Tuberosity fractures 4-6 weeks Tuberosity fractures 4-6 weeks Waist fractures weeks Waist fractures weeks Proximal pole fractures weeks Proximal pole fractures weeks Therefore normal healing time is considered up to 4 months Therefore normal healing time is considered up to 4 months

15 Scaphoid Frracture Treatment Competitive athletes- Competitive athletes- Early operative intervention for non-displaced proximal pole fractures Early operative intervention for non-displaced proximal pole fractures ? Early surgical intervention for non-displaced waist fractures. ? Early surgical intervention for non-displaced waist fractures. Return to contact sports depends on sport, level of athlete and risk/reward ratio. Return to contact sports depends on sport, level of athlete and risk/reward ratio. If patient returns prior to union they should return in a CAST or FRACTURE BRACE If patient returns prior to union they should return in a CAST or FRACTURE BRACE

16 Scaphoid Fracture Treatment Nonunion- Nonunion- Common clinical scenario- Common clinical scenario y/o male y/o male Skateboarder/ lacrosse player/ snowboarder/ football player Skateboarder/ lacrosse player/ snowboarder/ football player I hurt my wrist about a year agosort of ignored it but now it really hurts when I try to [bench press, do push ups, use power tools, etc] I hurt my wrist about a year agosort of ignored it but now it really hurts when I try to [bench press, do push ups, use power tools, etc]

17 Scaphoid Fracture Treatment Nonunion-( > 6months) Nonunion-( > 6months) If diagnosed in the middle of an athletic season it is OK to finish the season and treat later. If diagnosed in the middle of an athletic season it is OK to finish the season and treat later. Operative indication: Operative indication: Symptomatic Symptomatic ? asymptomatic- untreated leads to wrist malalignment and arthritis in 5-10 years SNAC wrist ? asymptomatic- untreated leads to wrist malalignment and arthritis in 5-10 years SNAC wrist

18 Patients need to understand that this is not like treating the distal radius buckle fracture they had when they were 11. Patients need to understand that this is not like treating the distal radius buckle fracture they had when they were 11.

19 Thank You. Official Team Physicians Center

20 References: Calderon, Ring. The diagnositic performance characteristics of imaging techniques used in the managmeent o f scaphoid fractures. Current Opioin in Orthopaedics. Vol 18(4), July 2007, Gelberman R.H., Menon J.: The vascularity of the scaphoid bone. J Hand Surg [Am] 1980; 5: Gelberman R.H., Menon J.: The vascularity of the scaphoid bone. J Hand Surg [Am] 1980; 5: Gelberman R.H., Wolock B.S., Siegel D.B.: Fractures and nonunions of the carpal scaphoid. J Bone Joint Surg Am 1989; 71: Gelberman R.H., Wolock B.S., Siegel D.B.: Fractures and nonunions of the carpal scaphoid. J Bone Joint Surg Am 1989; 71: Herbert, T.J.; Fisher, W.E. J Bone Joint Surg Br 66:114–123, Jorgensen T.M., Andresen J., Thommesen P., Hansen H.H.: Scanning and radiology of the carpal scaphoid bone. Acta Orthop Scand 1979; 50: Jorgensen T.M., Andresen J., Thommesen P., Hansen H.H.: Scanning and radiology of the carpal scaphoid bone. Acta Orthop Scand 1979; 50: Lindstrom G., Nystrom A.: Natural history of scaphoid nonunion with special reference to "asymptomatic" cases. J Hand Surg [Br] 1992; 17: Lindstrom G., Nystrom A.: Natural history of scaphoid nonunion with special reference to "asymptomatic" cases. J Hand Surg [Br] 1992; 17: Ruby, Leonard and Cassidy, Charles. Browner: Skeletal Trauma: Basic Science, Management, and Reconstruction, 3 rd ed. Chapter 39- Fractures and Dislocations of the Carpus. Ruby, Leonard and Cassidy, Charles. Browner: Skeletal Trauma: Basic Science, Management, and Reconstruction, 3 rd ed. Chapter 39- Fractures and Dislocations of the Carpus. Toby, E, Butler, T et al. A Comparison of Fixation Screws for the Scaphoid during Application of Cyclical Bending Loads. JBJS 79: (1997). Toby, E, Butler, T et al. A Comparison of Fixation Screws for the Scaphoid during Application of Cyclical Bending Loads. JBJS 79: (1997).

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22 Internal Fixation: Herbert Screws- (classic) Herbert Screws- (classic) Smooth shaft with threads at both ends and differing pitch Smooth shaft with threads at both ends and differing pitch Compression device Compression device Headless Headless Jig placed with the hook around the proximal pole, barrel at distal pole. Jig placed with the hook around the proximal pole, barrel at distal pole. Most common error is too anterior. Most common error is too anterior. A, The pilot drill for the trailing end of the screw. B, The long drill for the leading end of the screw. C, The tap for the leading end of the screw. D, Inserting the screw. E, The screw in use, with a corticocancellous wedge graft to retain scaphoid alignment. (A–E, From Herbert, T.J.; Fisher, W.E. J Bone Joint Surg Br 66:114–123, 1984.)

23 Internal Fixation: AO Cannulated Screw AO Cannulated Screw Guide wire is drilled from distal to proximal across the scaphoid Guide wire is drilled from distal to proximal across the scaphoid Cannulated 2.5mm drill bit is advanced to the appropriate depth under C-arm guidance. Cannulated 2.5mm drill bit is advanced to the appropriate depth under C-arm guidance. Cannulated screw is inserted ensuring that all the threads are across the fracture site. Cannulated screw is inserted ensuring that all the threads are across the fracture site.

24 Toby, E, Butler, T et al. A Comparison of Fixation Screws for the Scaphoid during Application of Cyclical Bending Loads. JBJS 79: (1997). 35 matched pairs/ matched pairs/100 Osteotomy of Scaphoid Waist Osteotomy of Scaphoid Waist Fixated with selected screw Fixated with selected screw Ramped intensity cyclical bending loads Ramped intensity cyclical bending loads Each screw compared against the Herbert Screw Each screw compared against the Herbert Screw L to R: Herbert, AO cannulated, Herbert- Whipple, Acutrak cannulated, Universal Compression Screw

25 Toby, E, Butler, T et al. A Comparison of Fixation Screws for the Scaphoid during Application of Cyclical Bending Loads. JBJS 79: (1997). Results: Results: Accutrak, AO, Herbert- Whipple demonstrated superior resistance compared to Herbert Screw. Accutrak, AO, Herbert- Whipple demonstrated superior resistance compared to Herbert Screw. Universal Compression screw caused fractures with insertion Universal Compression screw caused fractures with insertion The AO screw and Herbert screw showed Worse fixation when volar cortex was removed. The AO screw and Herbert screw showed Worse fixation when volar cortex was removed.

26 Salvage Procedures: Radial Styloidectomy- Radial Styloidectomy- Indicated as an adjunct to bone grafting or internal fixation Indicated as an adjunct to bone grafting or internal fixation Good when there is OA at distal pole of scaphoid and radial styloid Good when there is OA at distal pole of scaphoid and radial styloid Excised bone can be used as a graft. Excised bone can be used as a graft. CAVEAT: wrist can be destabilized if radioscaphocapitate and long radiolunate ligaments are detached. CAVEAT: wrist can be destabilized if radioscaphocapitate and long radiolunate ligaments are detached.

27 Scaphoid Fracture Treatment Nonunion- Nonunion- Operative choices: Operative choices: ORIF, ORIF, bone grafting, bone grafting, ORIF with bone grafting, ORIF with bone grafting, salvage arthroplasty, salvage arthroplasty, proximal row carpectomy, proximal row carpectomy, complete or partial arthrodesis and combinations. complete or partial arthrodesis and combinations. So which do you do?????? So which do you do??????

28 Operative Technique Bone Grafting- Bone Grafting- Autogenous- osteoconductive and osteoinductive, osteogeneritive and can be structural Autogenous- osteoconductive and osteoinductive, osteogeneritive and can be structural Donor sites Donor sites Iliac crest, distal radius, proximal ulna Iliac crest, distal radius, proximal ulna Vascularized autogenous bone graft- all of the above with the added benefit of its own blood supply Vascularized autogenous bone graft- all of the above with the added benefit of its own blood supply

29 Matti-Russe Bone Grafting Technique Volar incision over FCR ending distally at scaphoid tuberosity Volar incision over FCR ending distally at scaphoid tuberosity Opening made in volar nonarticular cortex Opening made in volar nonarticular cortex Opposing cavities excavated Opposing cavities excavated Cancellous graft packed into defect Cancellous graft packed into defect +/- 2 K wires distal to proximal +/- 2 K wires distal to proximal

30 Fish-Fernandez Bone Grafting Technique When angulation is present at fracture site When angulation is present at fracture site Volar approach similar to Matti-Russe Volar approach similar to Matti-Russe Laminar spreader used to open volar site Laminar spreader used to open volar site Fracture site is curetted Fracture site is curetted Corticocancellous bone graft is harvested. May need to be wedge shaped or trapezoidal. Corticocancellous bone graft is harvested. May need to be wedge shaped or trapezoidal. (Stabilize with 0.045inch K wires driven proximal to distal.) (Stabilize with 0.045inch K wires driven proximal to distal.)

31 Vascularized Bone Grafts- Vascularized Bone Grafts- Often useful for proximal pole fractures or nonunion with signs of AVN Often useful for proximal pole fractures or nonunion with signs of AVN Many choices: Many choices: Volar pronator pedicle graft. Volar pronator pedicle graft. Dorsal Zaidemberg 1,2 intercompartmental artery pedicle graft ( can also use 3,4) Dorsal Zaidemberg 1,2 intercompartmental artery pedicle graft ( can also use 3,4) (Free vascularized iliac crest graft). (Free vascularized iliac crest graft).

32 Salvage Procedures: Proximal Row Carpectomy: Proximal Row Carpectomy: Lower demand patient Lower demand patient Failed grafting Failed grafting Lunate, triquetrum, scaphoid (may only excise proximal 2/3) Lunate, triquetrum, scaphoid (may only excise proximal 2/3) Head of the capitate is then seated in lunate facet. Head of the capitate is then seated in lunate facet. A inch K wire can be driven transarticularly. A inch K wire can be driven transarticularly. Immobilize x 4-6 weeks Immobilize x 4-6 weeks Contra-indication: lunate facet or capitate arthritis Contra-indication: lunate facet or capitate arthritis

33 Salvage Procedures Total Wrist Arthrodesis Total Wrist Arthrodesis Indications Indications Persistent nonunion Persistent nonunion Severe arthritis Severe arthritis Extensive AVN or collapse Extensive AVN or collapse

34 Salvage Procedures- Total Wrist Arthrodesis Technique Technique Straight oblique incision made over Listers tubercle Straight oblique incision made over Listers tubercle Tubercle osteotomized Tubercle osteotomized Capsule incised Capsule incised Joint surfaces decorticated Joint surfaces decorticated Cancellous bone graft packed into joint (autograft or allograft) Cancellous bone graft packed into joint (autograft or allograft) Wrist is fused with prebent low profile fusion plate Wrist is fused with prebent low profile fusion plate

35 Other Salvage Procedures: Partial Fusions: Partial Fusions: Some professions require some wrist motion Some professions require some wrist motion Some patients will tolerate some pain to preserve motion Some patients will tolerate some pain to preserve motion May try scaphoid excision with 4 corner fusion if the radiolunate joint is preserved. May try scaphoid excision with 4 corner fusion if the radiolunate joint is preserved. Patients can expect less than 50% ROM and about 75% grip strength (this compares with PRC) Patients can expect less than 50% ROM and about 75% grip strength (this compares with PRC)

36 Complications of Scaphoid Silicone Arthroplasty Complications of Scaphoid Silicone Arthroplasty JM Kleinert, PJ Stern, GD Lister and RJ Kleinhans JBJS Am JM Kleinert, PJ Stern, GD Lister and RJ Kleinhans JBJS Am Between 1971 and 1982, 33 patients – (23 with 3 y f/u) NO improvement in strength or motion Complaints of increased pain in > ½ of the patients 10 patients underwent 13 reconstructive surgeries afterwards Mutiple poor radiographic paramaters

37 Salvage Procedures DISTAL SCAPHOID RESECTION ARTHROPLASTY FOR SCAPHOID NONUNION DISTAL SCAPHOID RESECTION ARTHROPLASTY FOR SCAPHOID NONUNION WITH RADIOSCAPHOID ARTHRITIS WITH RADIOSCAPHOID ARTHRITIS Pavel Draca*, Pavel Manaka, Lucie Pieranovab Pavel Draca*, Pavel Manaka, Lucie Pieranovab a Department of Traumatology, University Hospital, Olomouc, Czech Republic a Department of Traumatology, University Hospital, Olomouc, Czech Republic b Clinic of Radiology, University Hospital, Olomouc b Clinic of Radiology, University Hospital, Olomouc 8 patients treated by distal scaphoid resection arthroplasty for scaphoid nonunion with symptomatic wrist arthritis before surgery 8 patients treated by distal scaphoid resection arthroplasty for scaphoid nonunion with symptomatic wrist arthritis before surgery Minimum follow-up of 6 months. Minimum follow-up of 6 months. There was a significantly better range of radial deviation and grip strength at the time of re- examination. There was a significantly better range of radial deviation and grip strength at the time of re- examination. Significantly fewer patients complained of resting pain Significantly fewer patients complained of resting pain


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