Scaphoid Fractures

Abdulaziz Al-Ahaideb
PGY2
March 23/2001

1
 Scaphoid Fractures

• Introduction • Radiographic
• Anatomy evaluation
• Biomechanics • DDx
• History • Classification
• Clinical examination • Treatment
• Complications

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 Scaphoid fractures
Introduction
• Scaphoid fractures constitute 60-70 % of all carpal
bone fractures
• Second only to the distal radius in frequency
• Due to the importance of scaphoid in wrist
mechanics and because of the frequency of the
fracture in young adult male, it has an economic as
well as physical significance
• Uncommon in children because the physis of
distal radius fails first
3
 Anatomy
• Also called Navicular
• An irregular shaped
bone ,more resembling
a twisted peanut than
the boat for which it is
named
• Scaphoid represents
floor of the anatomic
snuff box

4
 Anatomy
• Articular cartilage covers 80 % of the scaphoid
surface - only narrow area of its neck, & even
smaller distal portion, are accessible to blood
vessels
• Distally, it articulates with the trapezium and
trapezoid in a gliding motion, The articulation
with the trapezium forms a base for
independent movement of the thumb
• On the ulnar side, it articulates distally with the
capitate, and proximally with the lunate in a
rotary motion
• Proximally, its large, biconvex surface allows
5 articulation with the radius
 Anatomy -ligaments

6
 Anatomy
Blood Supply

• Major blood supply comes from the scaphoid

branches of the radial artery entering the
dorsal ridge at or just distal to waist area and
supplying 70-80 % of the bone including the
entire proximal pole - in a retrograde fashion
• Second group of vessels, arise from palmar &
superficial palmar branches of radial artery &
enter the distal tubercle, it perfuses distal 20-
30 % of bone, including tuberosity
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 Blood Supply
• There are no anastomoses between
the dorsal and palmar vessels
• Vessels enter thru dorsal ridge in 79 %,
distal to waist in 14 %, & proximal to
waist in 7 %
• Fractures across scaphoid may destroy
blood supply to its proximal part

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 Biomechanics
• Mechanically scaphoid links the proximal
and distal rows
• Scaphoid spans both carpal rows and
therefore has less mobility than other carpal
bones
• Scaphoid carries the compressive loads
from the hand across the wrist to the distal
forearm

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 Biomechanics
• Scaphoid flexes with wrist flexion &
extends with wrist extension
• It also flexes during radial deviation &
extends during ulnar deviation
• These factors make immobilization of
scaphoid fractures difficult especially
when there is displacement

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 Biomechanics
• Scaphoid is a principal bony block to
dorsiflexion of hand & wrist , and is
susceptible to frx during fall on outstretched
hand
• With scaphoid fx, distal scaphoid tends to
flex, & proximal scaphoid extends with the
proximal carpal row ,, because of this,
angulation occurs at fx site, which gradually
leads to a humpback deformity
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 Mechanism of injury
Two different mechanisms
1. Compression injury :
usually results in non displaced fx
2. Hyperextension bending injury :
usually results in displaced fx

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 Diagnosis
• A strong index of suspicion is the key to
early diagnosis
• The diagnosis should be based on :
History
Clinical examination
Radiographic evaluation

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 History
• Occurs after a fall on an outstretched hand,
athletic injury, or MVA
• Usually happens in young adult men
• Pain at the radial side of the wrist
• Associated injuries

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 Clinical Examination
• Should demonstrate tenderness in the
anatomic snuff box
• Tenderness to palpation over scaphoid
tuberosity and/or proximal pole just distal
to Lister's tubercle
• Tenderness with axial compression of
thumb toward the snuff box
• Tenderness as patient supinates
forearm against resistance
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 Clinical Examination
• Radial & ulnar deviation results in pain
on radial side of wrist
• Forced dorsiflexion usually elicits
significant tenderness
• There is usually pain at extremes of
motion
• Limitation of wrist motion – but not
dramatically
• 16Swelling – usually not present
17
 Radiographic Evaluation
• The best method for determining the
presence of a fracture
• Many different views have been
recommended
• The useful initial views are : PA, lateral,
scaphoid view ( PA with ulnar deviation )

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 Radiographic Evaluation
• Motion views of the wrist ( flexion-
extension-radial & ulnar deviation ) may
demonstrate fracture displacement
• If a diagnosis still can’t be confirmed with
confidence on routine films, further oblique
views can be taken
• If certainty still exists after all these
maneuvers , the patient should be placed in
a cast for 2 to 4 weeks and the clinical &
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radiographic evaluation repeated
 Radiographic Evaluation
• If the second radiographic examination is
still equivocal , a technetium bone scan,
polytomography, CT or MRI of the wrist is
recommended
• The bone scan is the most sensitive but the
least specific of these modalities, thus if the
bone scan is negative , a scaphoid fx is
ruled out
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 Radiographic Evaluation
• If the bone scan is positive, more specific
studies ( e.g. polytomography, CT or MRI )
can be helpful

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 DDx
• It is the same DDx of radial sided wrist pain
• Lunate dislocation or fx
• Sapholunate instability
• Radial styloid fx
• Trapezium fx
• Rupture of FCR tendon
• ECRB or ECRL avulsion

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 Classifications of scaphoid fx
A. Location of the fracture :

5 different fracture sites :

Proximal third ( proximal pole ) .. 25%
Middle third ( waist )… most common 65%
Distal third …..10%
Tuberosity
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Distal articular surface ( osteochondral fx )
24
 Classifications of scaphoid fx
B. Direction of the fracture :
Horizontal Oblique , Transverse , and
Vertical Oblique
(Russe’s Classification )

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26
 Classifications of scaphoid fx
C. Time since injury :
• Acute fracture - less than 3 weeks
old
• Delayed union - 4 to 6 months old
• Nonunion - more than 6
months old

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

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• 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

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 Herbert’s Classification

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

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 Treatment
Is determined by:
Location
Degree of displacement
Fresh vs old fracture

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 Treatment
• Undisplaced ( stable) fracture :
 Nonoperative ( cast immobilization )--- there
have been three main areas of disagreement
in non-operative treatment of acute non
displaced fractures of scaphoid :
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

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 Treatment
 Many types of cast immobilization have been
described in the literature
 No evidence exists to prove greater efficacy for
one casting position over another. Although
above elbow casts may have a slightly shorter
time to union, the final rate of union is the same
for below or above elbow casts. The key factor in
treatment of scaphoid fractures is the duration of
immobilization rather than the specific position

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• The current
recommendation is to use
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
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• 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 fx heals in 6-8 weeks
– Middle third fx 8-12 weeks
– Proximal third fx 12-24 weeks
• A 95 % union rate can be expected with
this management
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• 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
(95 % with x-ray evidence of beginning
consolidation at 6 weeks )

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• Initial delay in treatment does not preclude casting
• If treatment is instituted within four weeks no effect
on healing time or rate of union has been shown
• Delay beyond six months invariably requires
operative treatment
• The difficulty lies in fractures between six weeks
and six 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

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 Treatment
• Cast immobilization and electrical
stimulation : the M/A isn’t fully understood
• It is worthwhile to try electrical stimulation
(esp.when there is nonunion ), though there is
a lack of reliable double-blind study which
compares between series of patients treated
with immobilization alone and those treated
with immobilization and ES,

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• If the patient will not tolerate prolonged
cast immobilization (e.g. professional
athletes and manual laborers ) early internal
fixation should be performed
• Internal fixation for fresh nondisplaced
proximal pole fractures has been
recommended by some authors

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 Treatment
• Displaced fractures :
– Primary internal fixation is treatment of
choice for unstable scaphoid frxs
– Fractures treated by primary internal
fixation, average time for return to work is
3.7 weeks with union rate 97 %

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• Indications of Surgery in
Scaphoid fractures
Displaced acute fracture
Delayed union or nonunion when bone grafting is
insufficient to provide adequate internal
fixation
S.Fx associated with a perilunate fx or dislocation
Ligamentous injury
Non displaced fx of proximal pole
Non displaced fx if the pt will not tolerate
prolonged cast immobilization (e.g. professional
athletes and manual laborers )
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• The choice of the surgical procedure will
vary with the surgeon’s preference and
experience, the type of the fracture, the
patient’s age, and the presence of
periscaphoid arthrosis
• The most important aspect of the treatment
is meticulous technique and not the device
or equipment selected
• Reduction of the fracture should be
anatomic
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• ORIF of scaphoid fractures can be done by
many ways :
K-wires ( easy insertion )
Herbert screws ( headless,
multipitched,difficult insertion )
AO screws
Herbert-whipple screw
Ender’s plate
Staples

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• The surgical approaches :
– Volar approach -- is most of the time the
preferred approach to limit the injury to the
blood supply of the scaphoid
– Dorsal approach – will be used to address the
fractures of the proximal approach

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 Volar approach: between FCR
and the radial artery
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 Treatment of middle third fxs
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)

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 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
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 Proximal Pole Fractures
• There is increasing favor to proceed to ORIF
• A dorsal approach allow s direct visualization of
the fracture
• If it is a fresh fx, can be fixed by 2-3 k-wires
• The k-wires are extracted in a retrograde fashion
in 6-8 weeks
• Alternatively ,one may use a Herbert screw which
may be inserted retrograde while the fragment is
stabilized in a k-wire

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 Proximal Pole Fractures
• 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

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 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 fx needs ORIF

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 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

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 Complications of Scaphoid Fx
• Delayed union or Nonunion
• Malunion (Humpback deformity)
• SLAC wrist
• Osteonecrosis

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 Nonunion
• The incidence of scaphoid nonunion for undisplaced
fx is 5-10%
• The incidence increases up to 90% in displaced
proximal pole fxs
• Risk factors :
– Proximal pole fx
– Displacement
– Late diagnosis
– Inadequate immobilization
– Associated ligamentous injuries
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 Nonunion
• Failure to heal after 6 months establishes the Dx of
nonunion
• Recent studies indicated that virtually that all unstable
nonunions lead to carpal collapse and posttraumatic
arthritis,, for this reason treatment is recommended
for all scaphoid nonunions even if asymptomatic
• Thin cut CT scan show more details than
conventional tomograms
• Sagittal views are helpful in determining the degree
of carpal collapse and humpback deformity

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 Treatment of Nonunion
A) Bone grafting :
• 2 types of bone grafting are indicated for tx of
nonunion:

• Russe bone graft (inlay): used for

stable nonunions .the initial procedure used a
single corticocancellous strut across the
fracture line;a later modification involved two
corticocancellous struts inserted into the
scaphoid excavation with their cancellous
sides facing each other,the remainder of the
cavity is filled with cancellous chips. Usually
58 k-wires are added to secure the construct.
 Inlay graft

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 Con’t Russe bone graft

• 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

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 Con’t Bone Grafting
• Fernandez bone graft (interpositional
graft): angulated nonunions with a dorsal
humpback deformity require interpositional
grafting. Fernandez has described the use of a
trapezoidal iliac graft to correct the angulation and
carpal collapse pattern.Fixation is achieved with
screws or k-wires
• In both types of bone grafting ,a volar approach is
used, and care must be taken to preserve the
vascularity of the fragments
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 Interpositional graft

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 Treatment of Nonunion
• B) Electrical stimulation:
– Pulsed Electromagnetic Field ( PEMF )
stimulation has been investigated as a
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

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

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 Treatment of Nonunion
• D) Salvage 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
65 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
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 Osteonecrosis

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 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

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 Case # 1
J.D. 24 y.o male . Fell on his out stretched •
hand while snowboarding on March 7/2000
.C/0 pain Lt wrist , no other injuries •
O/E : Lt wrist tenderness, neurovascular •
intact
: X-rays •

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 ER x-ray

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 Lateral view

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 Post -reduction

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 ORIF March7/2000

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 May1/2000
7 wks post ORIF

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 May1/2000
7 wks post ORIF

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 May 29/2000
11 wks

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 May 29/2000

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