Scaphoid Fractures and management

DR.MAJIDPG IN M.S ORTHOPAEDICS

GANDHI HOSPITAL

Fracture Scaphoid1. It is also called Navicular,2. It is a irregular shaped bone more like a twisted peanut than

boat3. Common in young adults rare in children if occurs it is distal

1/3 Fr 4. The mechanism of injury is by fall on out stretched hand.5. Hyper extension of wrist ,pronation, radial deviation.6. Second commonest Fr in the wrist7. Scaphoid is the key bone in maintaining the stability of carpal

articulation8. Blood supply of scaphoid 9. Subtleness of presentation- wrist sprain10. Complexity of choice of treatment.

Fracture Scaphoid• Present on the radial side of wrist

spans between two rows of carpal bones

• It connected with rest of the carpal bones through various ligaments of , volar ligaments are more strong

• Distally articulates with trapezium in a gliding movement gives independent movement to thumb

• On the ulnar side articulates with capitate, proximally with Lunate in a rotatory movement

• Proximally the convex surface articulates with distal end of radius

Fracture Scaphoid…Blood supply.• The blood supply to the scaphoid is

similar to that of head of femur• He articular surface cover the 80%of

scaphoid only small part on the dorsum of the neck and very small part in the distal part of the bone is available for the blood vessels to enter the bone.

• Major blood supply is form scaphoid branches of Radial artery enters into the distal ridge just distal to the waist supplies 80% of the bone in retrograde fashion.

• The second group is form the palmar and superficial branches of the radial artery, perfuses distal20-30% of distal bone and the tuberosity.

• There is no anastomosis between the voalr and dorsal vessels.

• 79% of the vessels enter through the dorsal ridge.

Mechanism of injury

Hyperextended and radially deviated wrist

Fracture Scaphoid -Mechanism of injury

1. Fall on outstretched hand force absorbed on the radial side of the Hand2. Hyper extension of the wrist presses the scaphoid against the

dorsal rim of the radius3. The strong volar scapho lunate, lig holds tha proximal half scaphoid

the distal half is carried up, results in TS Fr that starts volarlay and proresses dorsally.

4. Compression injury- un displaced Fr5. Hyperextension injury- displaced Fr

Fracture Scaphoid……. Biomechanics

Scaphoid flexes on radialdeviation ,& palmar flexion of the wrist, extends on extension & on ulnar deviation

Fracture Scaphoid… Biomechanics. Contd

• The stable Fr maintains the normal orientation for proximal and distal rows

• Unstable Fr angulates dorsally and produces –Humpback deformity

• Results in DISI• Grip weakness, late OA

Provocative tests

Snuff box tenderness

Scaphoid compression test

Scaphoid tubercle tenderness

Painful resisted pronation

Painful attempted Scaphoid shift test

Physical examination

• Snuff box tenderness 100% sensitivity

• Scaphoid tubercle tenderness 20% specific

• Adding Scaphoid compression test :

Specificity reaches 74% (Parvizi et al)

Radiographic evaluation

• Wrist PA, Lateral, Oblique, Scaphoid views

• 25 degrees pronated and supinated oblique views

6 views increased sensitivity and specificity to almost 100% ( Mehta &Brautigan,1990)

Wrist PA

Wrist lateral

Scaphoid view

Supinated Oblique

Anil K. Bhat, Kumar Bhaskaranand, Ashwath Acharya, “Radiographic imaging of the wrist”: Indian Journal of Plastic Surgery, Vol 44,Issue 2, May-Aug,2011.

Pronated Oblique

What if radiographs are inconclusive?

Bone Scan-Scintigraphy

• Fast and reliable diagnostic tool• 100% Sensitivity

Disadvantages:• Lacks specificity• Little information regarding location• 15% False positive

Ultrasound

• Inter-observer variability

• Useful in patients with cortical irregularity and hemarthrosis

• Structural integrity of scaphoid or other injuries – little information

Computed Tomography

• Scan oriented to longitudinal axis of scaphoid for hump back deformity

• For surgical planning & assessment of healing

• To diagnose additional bony injuries

Disadvantages • False positives in diagnosing occult

fractures.

Krimmer H: Management of acute fractures and nonunions of the proximal pole of the scaphoid. J.Hand Surg Br 2002; 27:245-248

MRI

• 2nd line test in negative radiographs• Identifying fractures of other carpal

bones, ligament injuries• Highest sensitivity and specificity

Spin echo T1 Fluid sensitivity T2

Breitenseher MI, Metz VM, Gilula LA et al. Radiographically occult scaphoid fractures: value of MR imaging in detection. Radiology 1997;203: 245-250

Herbert Classification

Mayo classification

• Based on location

• Stability

Mayo Classification

Distal pole

Distal third

Midwaist

Proximal pole

Distal pole

Stable Fractures

• < 1mm displacement • Normal carpal alignment • Normal interscaphoid angulation

(< 35 degrees)• No bone loss or comminution• No reduction needed

Determinants of treatment

• Stability of fracture

• Location

• Psycho socio-economic factors

Marco Rizzo, Alexander Y. Shin, William P.Cooney. A.A.O.S.

Closed treatment

• Stable non displaced fractures

• Cast immobilization To prevent displacement To maintain immobilization long

enough for healing

Nigel R.Clay, Joseph J.Dias, P.S. Costigan, P.J. Gregg, N.J. Barton. Need The Thumb To be Immobilized In Scaphoid Fractures.

Closed treatment

• Stable non displaced fractures

• Short arm for 6-8 weeks in tubercle or distal pole fractures

• Upto 12 weeks in waist fractures• Long arm cast for non compliant patients• Position- wrist in neutral position

Nigel R.Clay, Joseph J.Dias, P.S. Costigan, P.J. Gregg, N.J. Barton. Need The Thumb To be Immobilized In Scaphoid Fractures.

Surgical treatment

• Displaced

• Comminuted

• Unstable fractures

Surgical treatment

Volar approach (Russe) • Distal 3rd and waist fractures• Excellent visualization • Angulation deformity correction

Disadvantages• Capsular scarring• Limited wrist extension• Instability

Dorsal radial approach (McLaughlin)

• Proximal pole fractures • Scapholunate ligament visualization

Disadvantages

• Can’t visualize entire scaphoid • Intraoperative imaging

Percutaneous technique

• Stable scaphoid fractures

• Decreased period of immobilization

• Decreased wrist stiffness

• Athletes and young patients

Complications

• Fracture displacement

• Inadequate purchase

• Mal reduced fractures

Arthroscopically assisted percutaneous fixation

• Unstable fractures: displaced or non displaced

• Delayed presentation• Proximal pole fractures• Combined injuries of scaphoid and ipsilateral

displaced distal radius fractures• Scaphoid fractures with associated

ligamentous injury

Aggressive Conservative Treatment

CT wrist at 6 weeks

J.J. Dias, C.J. Wildin, B. Bhowal, J.R. Thompson. Should Acute Scaphoid Fractures Be Fixed? 2005. JBJS ,2160.

Clinical presentationTime since injury• Acute fracture - less than 3 weeks old• Delayed union - 4 to 6 months old• Nonunion - more than 6 months old

Amount of fracture displacement ( stability ) :

• Un displaced ---- stable• Displaced ---- unstable

Scaphoid Fracture….

• The unstable fracture (displaced) is defined as :

- presence of a fracture gap > 1 mm on any radiographic projection - scapho lunate angle > 60 - radio lunate angle > 15 or intrascaphoid angle >

20

Negative prognostic factors are • late diagnosis• proximal location• displacement • angulation• obliquity of the fracture line• smoking• carpal instability

Scaphoid Fracture…..TreatmentIs determined by:• Location • Degree of displacement• Fresh vs old fracture

STABLE UNSTABLE

CONSERVATIVE SURGERY

Non operative( cast immobilization )3-main areas of disagreement

1- the position of the wrist in the cast 2- the need to include joints other than the wrist in the cast 3- the duration of the immobilization

Stable Fr Cast Immobilization.• B/E or A/E Cast (Fore arm supinaton/Pronation)Long arm cast is recommended for non displaced proximal pole fr• Thumb or Three fingers To maintain the alignment of the Scaphoid in unstable Fr

• Duration of Treatment ‘’ longer the immobilization better is healing”

• Consider changing the cast every 10-14 days for the first 6 weeks so that it remains firm around forearm muscles and the wrist

• Time to healing by location : – Distal third fr heals in 6-8 weeks – Middle third fr 8-12 weeks – Proximal third fr 12-24 weeks

• A 95 % union rate can be expected with this management

• undisplaced, stable fractures if diagnosed and immobilized early (95 % with x-ray evidence of beginning consolidation at 6 weeks )

Stable Fr Cast Immobilization.

• Initial delay in treatment does not preclude casting • If treatment is instituted within4weeks no effect on healing time or rate of union has been shown • Delay beyond 6 months invariably requires operative treatment • The difficulty lies in fractures between 6 weeks and 6 months. ---If no evidence of bony resorption exists, casting may result in union. ---- If bony resorption or displacement, greater than 1 mm exists, operative reduction and bone grafting will be needed

Stable Fr------ Surgical treatment• Indications.• Professionally high demand pt • Pt who cannot tolerate prolonged immobilizationPercutaneous Screw fixation- volar /dorsal appTechnically demandingDisplacement of fragments can occur

* Pt need to be explained about the pros & cons, need for the short term cast immobilization thoroughly*

Problem Fractures.1. Displaced /angulated/ acute fracture 2. Acute Fr associated with carpal instability3. Delayed union or nonunion when bone grafting 4. is insufficient to provide adequate internal fixation5. S.Fr associated with a perilunate fr - dislocation Ligamentous injury4. Non displaced fr of proximal pole)

Unstable Fr- conservative Treatment

Poor risk PtPt not willing for Surgical TrClosed manipulation& cast Immobilization-- 3 point fixation with dorsal pressure

on capitate & lunate ,volar pressure over the distal end of scaphoid ( rotates the lunate,proximal fragment into flexion)- cast A/E ,slight dorsi flexion radial deviation, thumb/ 3 finger cast

Unstable Fr- surgical Treatment1. The choice of the surgical

procedure will vary with the surgeon’s preference and experience, type of the fracture, patient’s age, periscaphoid arthrosis

2. The most important aspect of the treatment is meticulous technique and not the device or equipment selected

3. Reduction of the fracture should be anatomic

57

Volar approach -- is most of the time the preferred approach to limit the injury to the blood supply of the scaphoidDorsal approach – will be used to address the fractures of the proximal approach

After treatment care• After achieving a rigid fixation , there is a big controversy about the need for immobilization

• Some authors recommend a long arm cast after k-wire or compression screw fixation for 2- 3 weeks • New literature is in favor of early mobilization

Treatment of middle third fr

• They are the commonest (65%)• If fresh stable: short-arm thumb spica cast• If fresh undisplaced but potentially unstable

(e.g. vertical oblique) and stable fx older than 3 wks : long-arm thumb spica cast

• If fresh displaced : ORIF (k-wires or screws)

Proximal Pole Fractures• challenging• Often difficult to heal• Prolonged immobilization- snug , well molded long arm cast-

(sometimes exceeds 9 mos) has been necessary with conventional casting

• Early incorporation of PES has been recommended• Displaced Fr-• Fragment small- K wire fixation• Fragment is 1/3 of Scaphoid Screw fixation – Dorsal app• Determination of bony union is not easy• Tomography or CT is needed• Multiple follow up films should be obtained for several

months after the assumed healing

Distal Pole Fractures

• These are often avulsion injuries of the tuberosity and can be expected to heal promptly with cast treatment

• Fresh and undisplaced should heal in 4-8 wks in a cast

• Displaced fr needs ORIF

Complications of Scaphoid Fr

• Delayed union or Nonunion• Malunion (Humpback deformity)• SLAC wrist• Osteonecrosis

Scaphoid Fracture-- Nonunion

• The incidence of scaphoid nonunion for undisplaced fr is 5-10%

• The incidence increases up to 90% in displaced proximal pole frs

• Risk factors :– Proximal pole fr– Displacement– Late diagnosis– Inadequate immobilization– Associated ligamentous injuries

Scaphoid Fracture-- Nonunion

• Failure to heal after 6 months establishes the Dx of nonunion

• Recent studies indicated that virtually that “all unstable non unions lead to carpal collapse and post traumatic arthritis,,

• All scaphoid nonunions even if asymptomatics hould be treated aggresively.

• Thin cut CT scan show more details than conventional tomograms

• Sagittal views are helpful in determining the degree of carpal collapse and humpback deformity

Sc Fr—Nonunion… Treatment• Procedures available- 1.Bone grafting,2.Electrical stimulation• 3. Proximal pole excision 4. Salvage procedures• Look for the following……• Comminution of Fr site/ gape with collapse.• Avascularity of proximal pole• Orientation of lunate , Scapho-lunate angle, Intra scaphoid

angulationProcedures of choice ….OR+ bone grafting No collapse- Inlay grafting- RUSSECOLLAPSE + - interposion grafting-FERNANDASEproximal pole avascularity- vascular pedicle grafting

1. pronator Quadratus based2.Supra retinacular artery based

Russe procedure•Volar app radial to FCR•Double coartico cancellous grafts facing on the cancellous surface

•The time to union with this procedure is relatively long ,generally requiring cast immobilization for 6-4 months•Healing rates of 85-90 % have been reported•Satisfactory relief of symptoms has been reported ; 78 % of painful wrist became free of symptoms and 88 % of patients were satisfied with the results

Fernandez procedure

• angulated nonunions with a dorsal humpback deformity

• Interpositional grafting.• Trapezoidal iliac graft to

correct the angulation and carpal collapse pattern.

• Fixation is achieved with screws or k-wires

• volar approach is used, and care must be taken to preserve the vascularity of the fragments

Avasularity of proximal poleBraun procedure

Braun procedureProcedure similar to Russe procedure Block of radius 15-20x8-10mm raised along with distal pronator qudratus

Bone grafting based on supra retinacular branch of radial artery

Dorsal approach

Non-union… treatment

Electrical stimulation:• Noninvasive treatment for scaphoid nonunion. Although

controversial, there appears to be some benefit (shorter healing time)when electric stimulation is combined with bone grafting procedures

• Proximal pole excision: when a small proximal fragment is not amenable to bone grafting ,proximal pole excision and fascial hemiarthroplasty are recommended

Non-union… treatmentSalvage procedures :

• Are indicated when nonunion has lead to carpal collapse and secondary degenerative changes

• Proximal row carpectomy,intercarpal arthrodesis, or radiocarpal arthrodesis is recommended in patients with chronic wrist pain and stiffness

• Radial styloidectomy and scaphoid interposition arthroplasty may be combined with other procedures or performed independently in the younger patient with less severe symptoms

• Silicone implants have been used in the past but are now avoided because of silicone synovitis

Malunion

• Malunion of the scaphoid may 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

• DISI pattern ensues ,resulting in pain ,loss of motion, and decreased grip strength

• Treatment in a young patient includes osteotomy,volar wedge bone graft, and internal fixation

• Once degenerative arthritis has begun ,treatment is limited to a salvage procedure such as proximal row carpectomy, intercarpal arthrodesis,or complete wrist fusion

conclusionScaphoid treatment should be planned based on…1 stability of fr stable/ unstable2. Anatomical Location of fr( p1/3, waist, Distal1/3)3.Comminution at Fr site, avasclarity of proximal pole4.Delayed or early presentation5. Features of non union6.Evidence of DISI( dorsal tilting of lunate)In cast application stable Fr- thumb spica,A/E castfor unstable

Frs ,Stable proximal pole fr, 3 finger/ fist cast- displaced Fr, Fr associated with carpal instability.

Percuataneous fixation to be used with cation after pt is well informed and surgeon had enough open reduction experience

Reduction always should be Anatomical

Thank you