scaphoidfractures - newcastle university · the scaphoid •5 articulating surfaces •radius,...
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Scaphoid Fractures
Lisa Tourret
Consultant Upper Limb Surgeon
Sunderland Royal Hospital
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Scaphoid fractures
• 2nd commonest
fracture of upper
extremity
• Only distal Radius
fractures more
frequent
• 60-80% of all Carpal
fractures
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The Scaphoid
• 5 articulating surfaces
• Radius, Lunate, Capitate, Trapezium,
Trapezoid
• Almost entirely covered in articular
cartilage
• Flexes in Radial deviation
• Extends in Ulnar deviation
• Fracture under compression/ torsion
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Diagnosis
• Plain X-rays have limitations
• Bone scan 100% sensitive 93% specific
• MRI reports vary but some suggest 100%
• Radiation/cost implications?
• Duration in cast awaiting confirmation?
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Herbert and Russe classification
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Blood supply to the Scaphoid
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Surgical approaches
• Percutaneous volar
dorsal
• Volar – FCR bed
• Dorsal – Mini-capsulotomy
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Percutaneous
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Volar Percutaneous
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Dorsal Percutaneous
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Displaced Fractures
Percutaneous
technique
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Arthroscopically assisted
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Volar
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Dorsal
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Non-Union Surgery
• Volar Wedge Graft
• (Cortico)cancellous graft
• Vascular pedicle graft
• Dorsal inlay graft
• Percutaneous grafting
• Consider supplementary temporary
stabilisation
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Volar – opening wedge graft
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Dorsal Inlay Graft
• In a proximal pole fracture non-union, a
dorsal inlay graft is most appropriate.
• Remove fibrous tissue from the non-union
site with curettes.
• With a high-speed burr, prepare a slot that
spans the fracture site to receive the bone
graft
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Cancellous Graft
• Dorsal approach provides a well-visualized reduction and alignment attainment.
• Leave exposed cancellousbone between the proximal and distal poles.
• Operate early rather than late, although malunions greater than 5 years can heal with grafting 60% of the time.
• Avoid compression screws in cases where cortical contact is contraindicated because of shortening.
• Do not use high-speed drills or burrs in forming cavities.
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Supplementary Fixation
Combinations
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Vascularised Pedicle Graft• Pedicled bone grafts based on the 1,2 ICSRA are useful for most scaphoid nonunions.
• Single dorsal approach for both graft harvest and exposure of the scaphoid.
• Elevate so vessels not empty
• Protect Superficial Radial nerve
• Open the first and second dorsal extensor compartments to either side of the bone graft site, creating a cuff of retinaculum that includes the 1,2 ICSRA.
• Center the graft approximately 1.5 cm proximal to the radiocarpaljoint to include the nutrient vessels.
• Before elevating the bone graft, make a transverse dorsal–radial capsulotomy to expose the scaphoid nonunion site
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Biomechanical considerations• Scaphoid waist fractures
– Central axis placement to allow longest screw
• Biomechanical strength are equal - Dorsal or volar screw implantation
• Proximal pole scaphoid fractures– Dorsal screw best compression
– Need a minimum of four threads across fracture site
– Pull-out strength drops with decreasing number of threads
• Strength is equal to number of threads
• Large core diameter screw increases strength
• Use monobloc screws
• Scaphoid is long lever arm– Fixation must balance these forces
– Unstable fixation requires addition construct to transfer forces away from the fracture site
– Locking mid-carpal joint with miniscrew or 0.062-inch Kirschner-wire between distal pole and capitate
• Stabilize the proximal pole with wires or screw between the proximal pole and lunate
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Absolute Indications for Fixation
• Displaced fractures
• Lateral intrascaphoid angle more than 35
degrees
• Bone loss or comminution
• Perilunate fracture
• Dorsal intercalated segmental instability (DISI)
alignment
• Proximal pole fractures
• Fractures with delayed presentation (>4 weeks)
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Relative Indications
• Stable, nondisplaced scaphoid fractures in
patients desiring an early return to work or
hobby
• Combined injuries of the scaphoid,
including the distal radius or other carpal
bones
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Contraindication for Fixation
• Degenerative change Radiocarpal joint
• Degenerative change Midcarpal joint
• Salvage resection/partial fusion indicated
in these cases
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Summary
• Complex range of considerations in planning management
• Significant non-union rate
• Attention to detail and solid fixation at first surgery gives highest success rate of union
• Salvage procedures complex and experience required – consider early referral
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Concluding statements
• Do not sit and wait
• If you cannot decide what to do refer on to
someone who does
• Age is not a reason to not operate
• Other factors are more important
• Know the approaches for the exam
• Know about shift in current opinion