Acute Scaphoid fracture

Dr. Anil K BhatAssociate Professor

Department of OrthopaedicsKasturba Medical College

Manipal

Mechanism of injury

Hyperextended and radially deviated wrist

Physical Examination

Palpable AnatomyProximal pole – dorsum of wrist

Lister’s tubercle

Sulcus (radiocarpal joint) Prominence (scapholunate joint)

Move radial for proximal pole

Waist of ScaphoidDorsal : distal to rim of distal radius towards styloid

Waist of ScaphoidLateral : In anatomical snuff box, proximal to radial artery in ulnar deviation

Distal pole

• Dorsal : between EPL and ECRL

Distal pole

• Lateral : proximal to radial artery in anatomical snuff box with wrist in neutral position.

Distal pole

• Volar : along with FCR as it enters fibro-osseous tunnel

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

All undisplaced fractures- cast Immobilisation for 6 weeks.

If persistence of Fracture gap / no evidence of healing.

Gap <2mmcast immobilisation

Gap >2mm Herbert screw fixation

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.

Thank you for your kind attention