Scaphoid fracture

FARIVAR A LAHIJI M.D

Scaphoid fracturePOTA SEASONAL MEETING

FARIVAR LAHIJI M.D

Epidemiology • The most frequent fractured bone of the wrist• 10-15% of hand and wrist fractures• 60-80% of carpal fractures• Waist 65%• 1/3 distal 10%• 1/3 proximal 15%

Mechanism• Axial load over

hyperextended and radially deviated wrist

Anatomy • 75-80% covered by

articular cartilage

Blood supply• major blood supply is

dorsal carpal branch (branch of the radial artery) supplies proximal 80% of

scaphoid via retrograde blood flow• minor blood supply from

superficial palmar arch (branch of volar radial artery) supplies distal 20% of

scaphoid

Clinical presentation • 26-y-o male football

player with hx of FOOSH, presented with right wrist pain

Physical exam• ASB• Scaphoid tubercle

tenderness• Longitudinal thumb

compression• Decrease thumb

movement• ASB swelling

Table 1

Sensitivity 100%Specificity 74%

1- PA2- LAT3- Radial oblique4- Ulnar oblique

1

2

3

4

Ziter view

Table 1

Scapholunate angle

Ultra sound• Operator dependent• Sensitivity 37-93%• Specifitcity 61-91%

Bone scan• Specificity 90%• Sensitivity 100%

CT• Sensitivity 94.4%• Specificity 100%• NPV 96.8%• PPV 100%

MRI• Sensitivity and

specificity 100%• NPV 88%• Bone bruise no fx

• GOLD STANDARD XRAY AT 6 WEEKS

Classification • Russe• AO• Herbert fischer• Mayo

Russe classification

Mayo Classification

Mayo

Delayed union • Widening of fracture line• Cyst development near the fracture line• Density of proximal line

Case II• 31 year-old man,

presented with left wrist pain and has hx of foosh,

• Xray showed un displaced fracture of the waist

What is your treatment offer

Review articlesSurgeon. 2012 Aug;10(4):218-29. doi: 10.1016/j.surge.2012.03.004. Epub 2012 May 15.Acute fractures of the scaphoid bone: Systematic review and meta-analysis.Alshryda S1, Shah A, Odak S, Al-Shryda J, Ilango B, Murali SR.

Scaphoid fracture can be treated by Colles cast for up to 12 weeks.

There is no advantage of an above elbow cast over a below elbow cast

J Trauma. 2011 Oct;71(4):1073-81. doi: 10.1097/TA.0b013e318222f485.Nonoperative treatment for acute scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials.Doornberg JN1, Buijze GA, Ham SJ, Ring D, Bhandari M, Poolman RWThere is no evidence from randomized controlled trials on physician-based or patient-based outcome to favor any nonoperativetreatment method for acute scaphoid fractures.

http://www.ncbi.nlm.nih.gov/pubmed/?term=alshryda+scaphoid

http://www.ncbi.nlm.nih.gov/pubmed/?term=Alshryda%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22595773

http://www.ncbi.nlm.nih.gov/pubmed/?term=Shah%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22595773

http://www.ncbi.nlm.nih.gov/pubmed/?term=Odak%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22595773

http://www.ncbi.nlm.nih.gov/pubmed/?term=Al-Shryda%20J%5BAuthor%5D&cauthor=true&cauthor_uid=22595773

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ilango%20B%5BAuthor%5D&cauthor=true&cauthor_uid=22595773

http://www.ncbi.nlm.nih.gov/pubmed/?term=Murali%20SR%5BAuthor%5D&cauthor=true&cauthor_uid=22595773

http://www.ncbi.nlm.nih.gov/pubmed/?term=Doornberg+JN,+Buijze+GA,+Ham+SJ,+et+al.+Nonoperative+treatment+for+acute+scaphoid+fractures

http://www.ncbi.nlm.nih.gov/pubmed/?term=Doornberg%20JN%5BAuthor%5D&cauthor=true&cauthor_uid=21986747

http://www.ncbi.nlm.nih.gov/pubmed/?term=Buijze%20GA%5BAuthor%5D&cauthor=true&cauthor_uid=21986747

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ham%20SJ%5BAuthor%5D&cauthor=true&cauthor_uid=21986747

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ring%20D%5BAuthor%5D&cauthor=true&cauthor_uid=21986747

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bhandari%20M%5BAuthor%5D&cauthor=true&cauthor_uid=21986747

http://www.ncbi.nlm.nih.gov/pubmed/?term=Poolman%20RW%5BAuthor%5D&cauthor=true&cauthor_uid=21986747

Case II• 31 year-old man,

presented with left wrist pain and has hx of foosh,

• Xray showed un displaced fracture of the waist

PCP screw fixation• Volar pcp• Dosal pcp• Herbert • Twin fix• Headless screw

J Hand Surg Am. 2011 Nov;36(11):1759-1768.e1. doi: 10.1016/j.jhsa.2011.08.033.Surgical versus nonsurgical treatment of acute minimally displaced and undisplaced scaphoid waist fractures: pairwise and network meta-analyses of randomized controlled trials.Ibrahim T1, Qureshi A, Sutton AJ, Dias JJThe cumulative evidence at present does not support routine surgical treatment, and aggressive conservative management should remain the mainstay for scaphoid waist fractures

J Orthop Traumatol. 2014 Dec;15(4):239-44. doi: 10.1007/s10195-014-0293-z. Epub 2014 Apr 30.Non-operative treatment versus percutaneous fixation for minimally displaced scaphoid waist fractures in high demand young manual workersMajeed H1

Cast treatment has the disadvantages of longer immobilisation time, joint stiffness, reduced grip strength, and longer time to return to manual work. Percutaneous fixation is aimed at reducing damage to the blood supply and soft tissues, allowing early mobilisation of the wrist and early return to manual work. The best available evidence for percutaneous screw fixation versus cast treatment suggests that percutaneous fixation allows a faster time to union by 5 weeks and an earlier return to manual work by 7 weeks, with similar union rates.

http://www.ncbi.nlm.nih.gov/pubmed/22036276

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ibrahim%20T%5BAuthor%5D&cauthor=true&cauthor_uid=22036276

http://www.ncbi.nlm.nih.gov/pubmed/?term=Qureshi%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22036276

http://www.ncbi.nlm.nih.gov/pubmed/?term=Sutton%20AJ%5BAuthor%5D&cauthor=true&cauthor_uid=22036276

http://www.ncbi.nlm.nih.gov/pubmed/?term=Dias%20JJ%5BAuthor%5D&cauthor=true&cauthor_uid=22036276

http://www.ncbi.nlm.nih.gov/pubmed/?term=Majeed%20H%5BAuthor%5D&cauthor=true&cauthor_uid=24781245

Acta Orthop Traumatol Turc. 2012;46(5):339-45.Comparison of dorsal and volar percutaneous screw fixation methods in acute Type B scaphoid fractures.Gürbüz Y1, Kayalar M, Bal E, Toros T, Küçük L, Sügün TS.The surgical approach does not affect the clinical and functional outcomes in percutaneous screw fixation of Type B scaphoidfractures. Percutaneous fixation is a valuable treatment method for Type B scaphoid fractures as it enables early wrist motion and high patient satisfaction.

J Hand Surg Am. 2011 Nov;36(11):1753-8. doi: 10.1016/j.jhsa.2011.08.031.Incidence of scaphotrapezial arthritis following volar percutaneous fixation of nondisplaced scaphoid waistfractures using a transtrapezial approach.Geurts G1, van Riet R, Meermans G, Verstreken F.Volar percutaneous screw fixation of nondisplaced scaphoid waist fractures using a transtrapezial approach does not lead to symptomatic scaphotrapezial osteoarthritis at short- to medium-term follow-up.

J Hand Surg Am. 2009 Feb;34(2):228-36.e1. doi: 10.1016/j.jhsa.2008.10.016.Percutaneous screw fixation for scaphoid fracture: a comparison between the dorsal and the volar approaches.Jeon IH1, Micic ID, Oh CW, Park BC, Kim PT Screws are placed more parallel to the long axis of the scaphoid and perpendicular to the fracture line via the dorsal approach; however, there was no significant difference with regard to functional outcome and bone union.