Orthopedics Case Conference

Ext. Kanokpol Seejui

• ผู้ ป่วยชายไทย อาย ุ25 ปี

• ภมูิล าเนาอ าเภอพิมาย จงัหวดันครราชสีมา

• สทิธ์ิการรักษา บตัรทอง 30 บาท

• CC : มีแผลท่ีข้อมือข้างขวา 3 ชัว่โมงก่อนมารพ

Present illness

• สาเหตกุารบาดเจ็บ : ถกูตู้ ล้มทบักระจกตู้บาดท่ีข้อมือด้านขวา

• ได้รับบาดเจ็บบริเวณ : ข้อมือด้านขวา มีแผลฉีกขาด มีเลือดไหล เห็นเส้นเอ็นฉีกขาด กางและหบุนิว้มือข้างขวาได้ กระดกข้อมือขึน้ลงได้ งอนิว้ได้ทกุนิว้ ปวดเวลาก ามือและกระดกข้อมือ มีอาการชาท่ีบริเวณปลายมือนิว้โปง้ นิว้ชี ้นิว้กลาง นิว้นาง

Primary Survey

A: Can speak, Can flex neck

B: equal breath sound both lung

C: BP 127/87 mmHg, PR 73 bpm

D: E4V5M6 pupil 3 mm react to light both eyes

E: Laceration wound at right wrist volar side size ~ 6x3 cm , seen tear flexor tendon

Secondary Survey

A : No drug allergy

M : No current medication

P : No underlying disease

L : NPO time 18.00 น. (ข้าว)

E : ขณะนัง่กินเหล้ากบัเพื่อน ถกูตู้ ล้มทบักระจกตู้แตกบาดท่ีแขนข้างขวา

Impression

1.Tear flexor tendon right wrist

2.Close fracture scaphoid bone right hand

Management

• Set OR for debridement with repair tendon

• Right thumb spica slab

Scaphoid Fracture

Epidemiology

• incidence– accounts for up to 15% of acute wrist injuries

• location– incidence of fracture by location

• waist -65%

• proximal third - 25%

• distal third - 10%– distal pole is most common location in kids due to ossification

sequence

Scaphoid Fracture

• Pathoanatomy– axial load across hyper-extended

and radially deviated wrist• common in contact sports

– transverse fracture patterns are considered more stable than vertical or oblique oriented fractures

• Associated conditions– SNAC (Scaphoid Nonunion Advanced Collapse)

• advanced collapse and progressive arthritis of the wrist that results from a chronic scaphoid nonunion

SNAC (Scaphoid Nonunion Advanced Collapse)

• Prognosis

– patients with scaphoid nonunions of > 5 years duration or proximal pole necrosis have less favorable outcomes

– punctate bleeding of bone during surgery is a good prognostic indicator of union

• 92% union with obvious bleeding, 71% with questionable bleeding, 0% with no bleeding

• results show decreased rate of arthritis (down to 40-50%)

Anatomy

Blood Supply

• major blood supply is dorsal carpal branch (branch of the radial artery)

– enters scaphoid in a nonarticular ridge on the dorsal surface and supplies proximal 80% of scaphoid via retrograde blood flow

• minor blood supply from superficial palmararch (branch of volar radial artery)

– enters distal tubercle and supplies distal 20% of scaphoid

Motion

• both intrinsic and extrinsic ligaments attach and surround the scaphoid

• the scaphoid flexes with wrist flexion and radial deviation and it extends during wrist extension and ulnar deviation (same as proximal row)

Presentation

Physical exam

• anatomic snuffbox tenderness dorsally

• scaphoid tubercle tenderness volarly

• pain with resisted pronation

Imaging

Radiographs

• recommended views– AP and lateral

– scaphoid view• 30 degree wrist extension, 20 degree ulnar deviation

– 45° pronation view

• findings– if radiographs are negative and there is a high clinical

suspicion• should repeat radiographs in 14-21 days

Imaging

• Bone scan– effective to diagnose occult fractures at 72 hours

• specificity of 98%, and sensitivity of 100%, PPV 85% to 93% when done at 72 hours

• CT scan with 1mm cuts– less effective than bone scan and MRI to diagnose

occult fracture

– can be used to evaluate location of fracture, size of fragments, extent of collapse, and progression of nonunion or union after surgery

imaging

• MRI

– indications

• most sensitive for diagnosis occult fractures < 24 hours

• immediate identification of fractures / ligamentousinjuries

• assessment of vascular status of bone (vascularity of proximal pole)– proximal pole AVN best determined on T1 sequences

Treatment

Nonoperative

• thumb spica cast immobilization

– indications

• stable nondisplaced fracture (majority of fractures)

• if patient has normal xrays but there is a high level of suspicion can immobilize in thumb spica and reevaluate in 12 to 21 days

Treatment

Operative

• ORIF vs percutaneous screw fixation– indications

• in unstable fractures as shown by– proximal pole fractures

– displacement > 1 mm

– 15° scaphoid humpback deformity

– radiolunate angle > 15° (DISI)

– intrascaphoid angle of > 35°

– scaphoid fractures associated with perilunate dislocation

– comminuted fractures

– unstable vertical or oblique fractures

Treatment

– in non-displaced waist fractures

• to allow decreased time to union, faster return to work/sport, similar total costs compared to casting

• outcomes

– union rates of 90-95% with operative treatment of scaphoid fractures

• CT scan is helpful for evaluation of union

Thank You