Presentation on theme: "Current Concepts and Review of Fractures of the Scaphoid"— Presentation transcript:
1 Current Concepts and Review of Fractures of the Scaphoid Samantha Muhlrad, MDAssistant Clinical Professor of Orthopaedic SurgeryHand and MicrosurgeryStony Brook University Medical Center
2 Fractures of the Scaphoid 345,000 in the US annually60 to 70 percent of all carpal fracturesApproximately 10% are associated with wrist fracturesYoung active men (athletics or manual labor)Highest incidence in lacrosse, football, snowboarding5% fail to unite (even when treated appropriately)
3 Anatomy/ Mechanism of Injury Links the proximal and the distal carpal rowsWaist is susceptible to fracture2 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 SUSPICIONHistory of fall on palm of handTenderness in anatomic snuffboxTenderness to dorsum of wrist or volar scaphoid tuberosityBruising/swelling of the handRadiographsPAUlnar deviation PATrue lateral (radius, lunate, capitate all colinear)45 degree pronation PA view
5 Scaphoid Fracture Diagnosis In the case of a suspected scaphoid fractureCT-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:DurationLocationOrientationDisplacementComminutionAssociated Injuries
9 Scaphoid Fracture Evaluation Duration<3 weeks old- better prognosisIf >4 weeks old drastically lower union rates when treated with cast aloneLocationDistal 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 OrientationVertically 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 viewScapholunate angle of >60 degreesLunocapitate angle of greater than 15 degreesLateral intrascaphoid angle of more than 20 degreesComminution – is it “shattered”?Associated Injuries: i.e., perilunate dislocations, distal radius fracture
12 Scaphoid Fracture Treatment Acute undisplaced fracture-Above elbow thumb spica castwrist in neutral position6 weeks.If union is not evident at 6 weeksa 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 FracturesSurgical treatment requiredClosed reduction and percutaneous pin or screw fixationArthroscopically assisted pin or screw fixationOpen reduction internal fixation
14 Scaphoid Fracture Treatment Delayed UnionTuberosity fractures 4-6 weeksWaist fractures weeksProximal pole fractures weeksTherefore “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 maleSkateboarder/ 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.
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 pitchCompression deviceHeadlessJig 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 scaphoidCannulated 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/100Osteotomy of Scaphoid WaistFixated with selected screwRamped intensity cyclical bending loadsEach screw compared against the Herbert ScrewL 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 insertionThe 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 fixationGood when there is OA at distal pole of scaphoid and radial styloidExcised 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 structuralDonor sitesIliac crest, distal radius, proximal ulnaVascularized 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 tuberosityOpening made in volar nonarticular cortexOpposing cavities excavatedCancellous graft packed into defect+/- 2 K wires distal to proximal
30 Fish-Fernandez Bone Grafting Technique When angulation is present at fracture siteVolar approach similar to Matti-RusseLaminar spreader used to open volar siteFracture site is curettedCorticocancellous 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 AVNMany 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 patientFailed graftingLunate, 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 weeksContra-indication: lunate facet or capitate arthritis
33 Salvage Procedures Total Wrist Arthrodesis Indications Persistent nonunionSevere arthritisExtensive AVN or collapse
34 Salvage Procedures- Total Wrist Arthrodesis TechniqueStraight oblique incision made over Lister’s tubercleTubercle osteotomizedCapsule incisedJoint surfaces decorticatedCancellous 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 motionSome patients will tolerate some pain to preserve motionMay 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. 1985Between 1971 and 1982,33 patients – (23 with 3 y f/u)NO improvement in strength or motionComplaints of increased pain in > ½ of the patients10 patients underwent 13 reconstructive surgeries afterwardsMutiple poor radiographic paramaters
37 Salvage ProceduresDISTAL SCAPHOID RESECTION ARTHROPLASTY FOR SCAPHOID NONUNIONWITH RADIOSCAPHOID ARTHRITISPavel Draca*, Pavel Manaka, Lucie Pieranovaba Department of Traumatology, University Hospital, Olomouc, Czech Republicb Clinic of Radiology, University Hospital, Olomouc8 patients treated by distal scaphoid resection arthroplasty for scaphoid nonunion with symptomatic wrist arthritis before surgeryMinimum 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