scaphoid - tips to fix scaphoid fractures & non union management
DESCRIPTION
Scaphoid fractures management including precutaneous fixation and management of non unionsTRANSCRIPT
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Scaphoid FixationDr Vaibhav BAGARIA
Orthopedic Surgeon
CARE hospital & ORIGYN Clinic
Nagpur, INDIA
www.drbagaria.com
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Background
First described By French surgeon Destot in 1905
2 – 7% of all fractures in young adults
5 – 15% non union rates
Derived from Greek word skaphos which means boat.
Term based on its unique shape and articulations
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Scaphoid Anatomy
Articulates with five bones: Distal radius, capitate, lunate trapezium and trapezoid
80% scaphoid is covered by articular cartilage leaving little space for the nutrient artery
Main blood supply is through retrograde branches of the radial artery
80% through the foraminal artery which is part of dorsal branch of radial artery
Palmar branch reaches through dorsal tubercle
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Scaphoid Anatomy
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Scaphoid Anatomy
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Scaphoid Vascular Supply
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Scaphoid Anatomy
Distal part has independent blood supply
In contrast the proximal part depends on the distal part for supply through the intra osseous part
This leaves proximal part vulnerable in case of fractures of the proximal pole which is dependent on distal part for this.
Healing is thus difficult for proximal pole which often goes into AVN
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Clinical Presentation
Fall on the out-stretched hand with wrist in radial deviation
Proximal pole fractures occurs when the wrist in Abduction
The same trauma mechanism causes supracondylar fracture in kids and distal radius fractures in elderly
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Imaging for Scaphoid fractures
X ray
CT scan
MRI
Scintigram
Sonography
Each has its own advantage and disadvantage and are applied at different stage of the management
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Radiographs
Initial X Ray may miss up to 30% of scaphoid fractures
Apart from standard AP and Lat X Rays, two additional views are required
Some people recommend routine screening 10 -1 2 day post trauma in case of high degree of suspicion and initial negative x ray – a lucency/ sclerosis may provide clue
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AP Lat and Oblique views
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Diagnosis
Scintigraphy has close to 100% sensitivity
MRI has less initial sensitivity but high degree of sensitivity at later stage, good for delayed presentation & to r/o AVN
CT Scan helps in preoperative planning and assessing cortical and trabecular pattern
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Scaphoid Imaging: MRI, CT, Scinti
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Scaphoid Fracture Classification
Herbert’s, Russe and Mayo classification is commonly used
Herbert’s is based on the stability & russe is based on the predictability of healing depending on the fracture line
As per Herbert unstable fractures are: displacement greater than 1 mm or angulation greater than 15 degree. Additional fractures ,trans-scaphoid-perilunate dislocations, multi- fragment fractures and proximal pole fractures are also classified as unstable.
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Mayo’s Classification
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Modified Staging System
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Herbert’s Classification
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Treatment Approaches
The aim of the treatment is to achieve fracture consolidation and functional recovery whilst avoiding complications such as non- or mal-union
Direct Functional treatment
Cast Immobilization
Fixation: Open/ Percutaneous
Managing complication & delayed presentation
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TREATMENT
Functional treatment involves bandaging or orthosis and is used only occasionally and in suspected fractures before immobilisation in cast is done.
Casting is indicated for undisplaced fractures only
Prolonged period of casting upto 12 weeks is required.
Casting has inherent disadvantages of stiffness, probability of non union, chances of developing CRPS
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Operative Treatment
All Proximal pole and displaced scaphoid fractures should be treated operatively.
Percutaneous fixation using careful dorsal approach is the preferred method.
In case of proximal pole fracture a reverse approach may be required
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Surface Anatomy
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Per cut Fixation steps: Reduction
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Skin Incision - Landmarks
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Guide wire trajectory
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Guide wire insertion
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Confirm under II ( C ARM)
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Correct Placement
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Post Fixation radiographs
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Approach to Non Union /AVN
Bone Grafting & Fixation
Vascularized Bone grafting – Pronator Quadratus/ Dorsal
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Bone Graft fixation
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Approach To Vascular BG
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Planes
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Vascular anatomy in Cadaver
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Vascular pedicle BG
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Temporary Fixation with BG
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Pre & Post Vascular Graft
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Take Home!
Do not miss the fracture on initial X rays
Prolonged immobilization is often required
Percut fixation is preferred management in majority cases
Non unions and AVN are common and need bone graft and fixation.
Pronator quadratus vascularized Bone grafting is often an excellent method for fixing Non unions with AVN.
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Thank You!
ORIGYN Healthcare Nagpur & Indrapuram
Dr Vaibhav BAGARIA