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

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

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

5. Scaphoid Fracture Diagnosis
In the case of a suspected scaphoid fracture
CT-
Sensitivity- 84%
Specificity- 98%
Bone Scan-
Sensitivity 92%
Specificity 89%
MRI-
Sensitivity 98%
Specificity 99%
US-
Sensitivity 93%
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.
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.

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

9. Scaphoid Fracture Evaluation
Duration
<3 weeks old- better prognosis
If >4 weeks old drastically lower union rates when treated with cast alone
Location
Distal 1/3 (Pole) (5%)
Middle 1/3 (Waist) (80%)
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
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%
>1 mm step off on any view
Scapholunate angle of >60 degrees
Lunocapitate angle of greater than 15 degrees
Lateral intrascaphoid angle of more than 20 degrees
Comminution – is it “shattered”?
Associated Injuries: i.e., perilunate dislocations, distal radius fracture

12. Scaphoid Fracture Treatment
Acute undisplaced fracture-
Above elbow thumb spica cast
wrist in neutral position
6 weeks.
If union is not evident at 6 weeks
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
Surgical treatment required
Closed reduction and percutaneous pin or screw fixation
Arthroscopically assisted pin or screw fixation
Open reduction internal fixation

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

15. Scaphoid Frracture Treatment
Competitive athletes-
Early operative intervention for non-displaced proximal pole fractures
? Early surgical intervention for non-displaced waist fractures.
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

16. Scaphoid Fracture Treatment
Nonunion-
Common clinical scenario-
18-25 y/o male
Skateboarder/ lacrosse player/ snowboarder/ football player
“I hurt my wrist about a year ago—sort 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)
If diagnosed in the middle of an athletic season it is OK to finish the season and treat later.
Operative indication:
Symptomatic
? asymptomatic- untreated leads to wrist malalignment and arthritis in 5-10 years “SNAC wrist”

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

19. Thank You.
Center
Official
Team
Physicians

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., 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, 1984.
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:
Ruby, Leonard and Cassidy, Charles. Browner: Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd 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).

22. Internal Fixation: Herbert Screws- (“classic”)
Smooth shaft with threads at both ends and differing pitch
Compression device
Headless
Jig placed with the hook around the proximal pole, barrel at distal pole.
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
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 screw is inserted ensuring that all the threads are across the fracture site.

24. Osteotomy of Scaphoid Waist Fixated with selected screw
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/100
Osteotomy of Scaphoid Waist
Fixated with selected screw
Ramped intensity cyclical bending loads
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:
Accutrak, AO, Herbert- Whipple demonstrated superior resistance compared to Herbert Screw.
Universal Compression screw caused fractures with insertion
The AO screw and Herbert screw showed Worse fixation when volar cortex was removed.

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

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

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

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

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

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

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

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

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

35. Other Salvage Procedures:
Partial Fusions:
Some professions require some wrist motion
Some patients will tolerate some pain to preserve motion
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)

36. Complications of Scaphoid Silicone Arthroplasty
JM Kleinert, PJ Stern, GD Lister and RJ Kleinhans JBJS Am. 1985
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
WITH RADIOSCAPHOID ARTHRITIS
Pavel Draca*, Pavel Manaka, Lucie Pieranovab
a Department of Traumatology, University Hospital, Olomouc, Czech Republic
b Clinic of Radiology, University Hospital, Olomouc
8 patients treated by distal scaphoid resection arthroplasty for scaphoid nonunion with symptomatic wrist arthritis before surgery
Minimum follow-up of 6 months.
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