1. Normal wrist joint
Fig : -

2. Scaphoid fracture (skaphe=a boat, eidos=form)
Features :
1 . This bone forms the radial part of the carpus.
2 . Articulates with 5 bones : -
radius (proximally) , ,
Trapezoid and trapezium(distally)
Lunate and capitate (medially )
3 . Central indentation is called waist
4 . Since it crosses 2 rows of carpus , it is more susceptible to fracture
5 . Lies obliquely at 45 degree to longitudinal axes of 2 rows

3. Scaphoid fracture
Fig : - AP view

4. Scaphoid fracture
Fig : -

5. Aetiology Two different mechanisms Common in young
Can be seen in patients of 10 – 70 years of age
Mechanism of injury
Two different mechanisms
Compression injury : usually results in non displaced fx
Hyperextension bending injury : usually results in displaced fx

6. Diagnosis The diagnosis should be based on : History
Clinical examination
Radiographic evaluation

7. History fall on an outstretched hand, athletic injury etc.
Common in young adult men
Pain at the radial side of the wrist
Associated injuries

8. Clinical Examination tenderness in the anatomic snuff box
Tenderness to palpation over scaphoid tuberosity
Tenderness with axial compression of thumb toward the snuff box
Tenderness as patient supinates forearm against resistance

9. Anatomic snuff box
Fig :

10. Clinical Examination
Radial & ulnar deviation results in pain on radial side of wrist
Forced dorsiflexion usually elicits significant tenderness
Limitation of wrist motion
Swelling – usually not present

11. Fig :-

12. Radiographic Evaluation
PA ,
lateral,
scaphoid view ( PA with ulnar deviation )

13. Radiographic Evaluation
Motion views of the wrist ( flexion-extension-radial & ulnar deviation ) may demonstrate fracture displacement
If a diagnosis still can’t be confirmed (oblique views )
If a diagnosis still can’t be confirmed (cast for 2 to 4 weeks and the clinical & radiographic evaluation repeated)

14. Radiographic Evaluation
If the second radiographic examination is still equivocal , a technetium bone scan, CT or MRI of the wrist is recommended
if the bone scan is negative , a scaphoid fx is ruled out
If the bone scan is positive, more specific studies ( e.g. CT or MRI ) can be helpful

15. DDx Radial styloid fx Trapezium fx
Lunate dislocation or fx Scapholunate instability
Radial styloid fx
Trapezium fx

16. Classifications of scaphoid fx
Anatomical classification : different fracture sites :
1 . Proximal third ( proximal pole ) .. 25%
2 . Middle third ( waist )… most common 65%
3 . Distal third …..10%
4 . Tuberosity
5 . Distal articular surface ( osteochondral fx )

18. Russe’s Classification : -
Direction of the fracture :
- Horizontal Oblique ,
- Transverse , and
- Vertical Oblique (unstable)

19. Cont..

20. Cont.. Time since injury : Acute fracture - less than 3 weeks old
Delayed union to 6 months old
Nonunion more than 6 months old

21. Classifications of scaphoid fx
Amount of fracture displacement ( stability ) :
Undisplaced stable
Displaced unstable

22. The unstable fracture (displaced) is defined as :
- presence of a fracture gap > 1 mm on any radiographic projection
- scapholunate angle > 60
- radiolunate angle > 15
- or intrascaphoid angle > 20

23. Scaphoid axis
The true axis of the scaphoid is the line through the midpoints of its proximal and distal poles. Since the midpoint of the proximal pole is often difficult to appreciate, an almost parallel line can be used that is traced along the most ventral points of the proximal and distal poles of the bone (figure

24. Scapholunate angle Normal: ° Questionably abnormal: ° Abnormal: > 80° This indicates instability of the wrist.
Lunate axis: The axis of the lunate runs through the midpoints of the convex proximal and concave distal joint surfaces and can best be drawn by finding the perpendicular to a line joining the distal palmar and dorsal borders of the bone as demonstrated on the left
Scapholunate angle Normal: ° Questionably abnormal: ° Abnormal: > 80° This indicates instability of the wrist.

25. Capitolunate angle Normal: < 30° Abnormal: > 30°
Capitolunate angle Normal: < 30° Abnormal: > 30°.This indicates instability of the wrist
Capitate axis
The capitate axis joins the midportion of the proximal convexity of the third metacarpal and that of the proximal surface of the capitate. Capitolunate angle Normal: < 30° Abnormal: > 30°.This indicates instability of the wrist

26. Herbert’s Classification

27. Treatment Undisplaced ( stable) fracture :
Nonoperative ( cast immobilization )---
above elbow casts

28. a short arm thumb spica with the thumb interphalangeal joint free
a short arm thumb spica with the thumb interphalangeal joint free. The wrist is placed in radial deviation
Long arm cast is recommended for nondisplaced proximal pole fx

29. Time to healing by location :
Distal third fx heals in 6-8 weeks
Middle third fx weeks
Proximal third fx weeks

30. Removal of the cast should not occur until union has been documented on CT or tomography
Prognosis is excellent in undisplaced, stable fractures if diagnosed and immobilized early

31. Treatment Displaced fractures :
Primary internal fixation (for unstable scaphoid fx )
treated by primary internal fixation, average time for return to work is 3 – 4 weeks with union rate 97 %

32. Indications of Surgery in Scaphoid fractures
- Displaced acute fracture
- Delayed union or nonunion
- S.Fx associated with a perilunate fx or dislocation
- Ligamentous injury
- Non displaced fx if the pt will not tolerate prolonged cast immobilization (e.g. professional athletes and manual laborers )

33. ORIF of scaphoid fractures can be done by many ways :
- K-wires ( easy insertion )
- Herbert screws
- AO screws
- Staples
AO SCREW
Herbert screw

34. Treatment of middle third fxs
- commonest (65%)
- If stable: short-arm thumb spica cast
- If undisplaced fx older than 3 wks : long-arm thumb spica cast
- If displaced : ORIF (k-wires or screws)

35. ORIF

36. Proximal Pole Fractures
If it is a fresh fx, can be fixed by 2-3 k-wires
Alternatively ,one may use a Herbert screw

37. Distal Pole Fractures undisplaced should heal in 4-8 wks in a cast
Displaced fx needs ORIF

38. Complications of Scaphoid Fx
Delayed union or Nonunion
Malunion (Humpback deformity)
SLAC wrist
Osteonecrosis
Treatment of Nonunion
Bone grafting

39. Malunion
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
Treatment : -osteotomy, bone graft,and internal fixation

40. SLAC
scapholunate advanced collapse (SLAC) refers to a specific pattern of osteoarthritis and subluxation which results from untreated chronic scapholunate dissociation or from chronic scaphoid nonunion

41. Post -reduction