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Current Concepts and Review of Fractures of the Scaphoid

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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

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