current concepts and review of fractures of the scaphoid samantha muhlrad, md assistant clinical...

Current Concepts and Review of Current Concepts and Review of Fractures of the ScaphoidFractures of the Scaphoid

Samantha Muhlrad, MDSamantha Muhlrad, MDAssistant Clinical Professor of Orthopaedic Assistant Clinical Professor of Orthopaedic

SurgerySurgeryHand and MicrosurgeryHand and Microsurgery

Stony Brook University Medical CenterStony Brook University Medical Center

Fractures of the ScaphoidFractures of the Scaphoid

345,000 in the US annually345,000 in the US annually60 to 70 percent of all carpal 60 to 70 percent of all carpal

fracturesfracturesApproximately 10% are Approximately 10% are

associated with wrist fracturesassociated with wrist fractures

Young active men Young active men (athletics or (athletics or manual labor)manual labor) Highest incidence in lacrosse, football, Highest incidence in lacrosse, football,

snowboardingsnowboarding

5% fail to unite 5% fail to unite (even when treated (even when treated appropriately)appropriately)

Anatomy/ Mechanism of InjuryAnatomy/ Mechanism of Injury Links the proximal and the Links the proximal and the

distal carpal rowsdistal carpal rows Waist is susceptible to Waist is susceptible to

fracturefracture 2 mechanisms:2 mechanisms:

Hyperextension and Hyperextension and bending**bending**

Puncher’s Scaphoid- axial Puncher’s Scaphoid- axial force along the second force along the second metacarpal with the wrist in metacarpal with the wrist in neutral.neutral.

Associated with open Associated with open metacarpal fracturesmetacarpal fractures

Diagnosis of Scaphoid FracturesDiagnosis of Scaphoid Fractures

HIGH INDEX OF SUSPICIONHIGH INDEX OF SUSPICION History of fall on palm of handHistory of fall on palm of hand Tenderness in anatomic snuffboxTenderness in anatomic snuffbox Tenderness to dorsum of wrist or volar scaphoid tuberosityTenderness to dorsum of wrist or volar scaphoid tuberosity Bruising/swelling of the handBruising/swelling of the hand

RadiographsRadiographs PAPA Ulnar deviation PA Ulnar deviation PA True lateral (radius, lunate, True lateral (radius, lunate,

capitate all colinear)capitate all colinear) 45 degree pronation PA view45 degree pronation PA view

Scaphoid Fracture DiagnosisScaphoid Fracture Diagnosis In the case of a suspected In the case of a suspected

scaphoid fracturescaphoid fracture

CT-CT- Sensitivity- 84%Sensitivity- 84% Specificity- 98%Specificity- 98%

Bone Scan-Bone Scan- Sensitivity 92%Sensitivity 92% Specificity 89%Specificity 89%

MRI-MRI- Sensitivity 98%Sensitivity 98% Specificity 99%Specificity 99%

US-US- Sensitivity 93%Sensitivity 93% Specificity 89%Specificity 89%

Calderon, Ring. The diagnostic performance characteristics of imaging techniques used in the management o f scaphoid fractures. Current Option in Orthopaedics. Vol 18(4), July 2007, 309-314.

Scaphoid Fracture DiagnosisScaphoid Fracture Diagnosis

Initial xrays are often negative.Initial xrays are often negative. If patient has clinical signs or symptoms they If patient has clinical signs or symptoms they

should be treated presumptively and referred should be treated presumptively and referred to an orthopedist or hand surgeon for further to an orthopedist or hand surgeon for further evaluation.evaluation.

Initial treatment is immobilization in a thumb Initial treatment is immobilization in a thumb spica splint.spica splint.

Guidelines for Decision MakingGuidelines for Decision Making

Based On:Based On:Duration Duration LocationLocationOrientationOrientationDisplacementDisplacementComminutionComminutionAssociated InjuriesAssociated Injuries

Scaphoid Fracture EvaluationScaphoid Fracture Evaluation

DurationDuration <3 weeks old- better prognosis<3 weeks old- better prognosis If >4 weeks old drastically lower union If >4 weeks old drastically lower union

rates when treated with cast alonerates when treated with cast alone

LocationLocation Distal 1/3 (Pole) (5%)Distal 1/3 (Pole) (5%) Middle 1/3 (Waist) (80%)Middle 1/3 (Waist) (80%) Proximal 1/3 (Pole) (15%)-Proximal 1/3 (Pole) (15%)- poor healing

due to limited blood supply,

osteonecrosis rate close to 100%

1- dorsal scaphoid branch of the radial artery.2- volar scaphoid branch.


OrientationOrientationVertically oriented fractures are less stable.Vertically oriented fractures are less stable.

Herbert classification (Herbert & Fisher, 1984) of scaphoid fractures. (Reproduced with permission from Amadio, P.C.; Taleisnik, J. Fractures of the carpal bones. In: Green, D.P., ed. Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, pp. 809–864.)


Displacement- Displacement- Nonunion rates in displaced fractures reach Nonunion rates in displaced fractures reach 92%92% >1 mm step off on any view>1 mm step off on any view Scapholunate angle of >60 degreesScapholunate angle of >60 degrees Lunocapitate angle of greater than 15 degreesLunocapitate angle of greater than 15 degrees Lateral intrascaphoid angle of more than 20 degreesLateral intrascaphoid angle of more than 20 degrees

Comminution – is it “shattered”?Comminution – is it “shattered”? Associated Injuries: i.e., perilunate Associated Injuries: i.e., perilunate

dislocations, distal radius fracturedislocations, distal radius fracture

Scaphoid Fracture TreatmentScaphoid Fracture Treatment

Acute undisplaced fracture-Acute undisplaced fracture- Above elbow thumb spica cast Above elbow thumb spica cast wrist in neutral positionwrist in neutral position 6 weeks. 6 weeks. If union is not evident at 6 If union is not evident at 6

weeks weeks a short arm cast is applied until CT a short arm cast is applied until CT

reveals solid union.reveals solid union.

This is the “textbook” This is the “textbook” answer but hand answer but hand surgeons vary greatly.surgeons vary greatly.

Scaphoid Fracture TreatmentScaphoid Fracture Treatment Acute Displaced and Unstable Acute Displaced and Unstable

FracturesFractures Surgical treatment requiredSurgical treatment required

Closed reduction and Closed reduction and percutaneous pin or screw percutaneous pin or screw fixationfixation

Arthroscopically assisted pin or Arthroscopically assisted pin or screw fixationscrew fixation

Open reduction internal fixationOpen reduction internal fixation


Delayed UnionDelayed UnionTuberosity fractures 4-6 weeksTuberosity fractures 4-6 weeksWaist fractures 10-12 weeksWaist fractures 10-12 weeksProximal pole fractures 12-20 weeksProximal pole fractures 12-20 weeksTherefore “normal” healing time is considered Therefore “normal” healing time is considered

up to 4 monthsup to 4 months

Scaphoid Frracture TreatmentScaphoid Frracture Treatment

Competitive athletes-Competitive athletes-Early operative intervention for non-displaced Early operative intervention for non-displaced

proximal pole fracturesproximal pole fractures? Early surgical intervention for non-displaced ? Early surgical intervention for non-displaced

waist fractures.waist fractures.Return to contact sports depends on sport, Return to contact sports depends on sport,

level of athlete and risk/reward ratio.level of athlete and risk/reward ratio. If patient returns prior to union they should If patient returns prior to union they should

return in a CAST or FRACTURE BRACEreturn in a CAST or FRACTURE BRACE


Nonunion- Nonunion- Common clinical scenario-Common clinical scenario-

18-25 y/o male18-25 y/o male Skateboarder/ lacrosse player/ Skateboarder/ lacrosse player/

snowboarder/ football playersnowboarder/ football player““I hurt my wrist about a year I hurt my wrist about a year

ago—sort of ignored it but ago—sort of ignored it but now it really hurts when I try now it really hurts when I try to [bench press, do push to [bench press, do push ups, use power tools, etc]”ups, use power tools, etc]”


Nonunion-( > 6months)Nonunion-( > 6months) If diagnosed in the middle of an If diagnosed in the middle of an

athletic season it is OK to finish athletic season it is OK to finish the season and treat later.the season and treat later.

Operative indication:Operative indication: SymptomaticSymptomatic ? asymptomatic- untreated leads to ? asymptomatic- untreated leads to

wrist malalignment and arthritis in wrist malalignment and arthritis in 5-10 years “SNAC wrist”5-10 years “SNAC wrist”

Patient’s need to understand that Patient’s need to understand that this is not like treating the distal this is not like treating the distal radius buckle fracture they had radius buckle fracture they had when they were 11.when they were 11.

Thank You.Thank You.

Official

Team

Center

References:References: Calderon, Ring. The diagnositic performance characteristics of imaging

techniques used in the managmeent o f scaphoid fractures. Current Opioin in Orthopaedics. Vol 18(4), July 2007, 309-314.

Gelberman R.H., Menon J.: The vascularity of the scaphoid bone. Gelberman R.H., Menon J.: The vascularity of the scaphoid bone. J Hand J Hand Surg [Am]Surg [Am] 1980; 5:508-513. 1980; 5:508-513.

Gelberman R.H., Wolock B.S., Siegel D.B.: Fractures and nonunions of the Gelberman R.H., Wolock B.S., Siegel D.B.: Fractures and nonunions of the carpal scaphoid. carpal scaphoid. J Bone Joint Surg AmJ Bone Joint Surg Am 1989; 71:1560-1565. 1989; 71:1560-1565.

Herbert, T.J.; Fisher, W.E. J Bone Joint Surg Br 66:114–123, 1984. Jorgensen T.M., Andresen J., Thommesen P., Hansen H.H.: Scanning and Jorgensen T.M., Andresen J., Thommesen P., Hansen H.H.: Scanning and

radiology of the carpal scaphoid bone. radiology of the carpal scaphoid bone. Acta Orthop ScandActa Orthop Scand 1979; 50:663- 1979; 50:663-665. 665.

Lindstrom G., Nystrom A.: Natural history of scaphoid nonunion with special Lindstrom G., Nystrom A.: Natural history of scaphoid nonunion with special reference to "asymptomatic" cases. reference to "asymptomatic" cases. J Hand Surg [Br]J Hand Surg [Br] 1992; 17:697-700. 1992; 17:697-700.

Ruby, Leonard and Cassidy, Charles. Browner: Skeletal Trauma: Basic Ruby, Leonard and Cassidy, Charles. Browner: Skeletal Trauma: Basic Science, Management, and Reconstruction, 3Science, Management, and Reconstruction, 3rdrd ed. Chapter 39- Fractures ed. Chapter 39- Fractures and Dislocations of the Carpus.and Dislocations of the Carpus.

Toby, E, Butler, T et al. A Comparison of Fixation Screws for the Scaphoid Toby, E, Butler, T et al. A Comparison of Fixation Screws for the Scaphoid during Application of Cyclical Bending Loads. JBJS 79:1190-7 (1997).during Application of Cyclical Bending Loads. JBJS 79:1190-7 (1997).

Internal Fixation:Internal Fixation:

Herbert Screws- (“classic”)Herbert Screws- (“classic”)Smooth shaft with threads at Smooth shaft with threads at

both ends and differing pitchboth ends and differing pitchCompression deviceCompression deviceHeadlessHeadlessJig placed with the hook Jig placed with the hook

around the proximal pole, around the proximal pole, barrel at distal pole. barrel at distal pole.

Most common error is too Most common error is too anterior.anterior.

A, The pilot drill for the trailing end of the screw. B, The long drill for the leading end of the screw. C, The tap for the leading end of the screw. D, Inserting the screw. E, The screw in use, with a corticocancellous wedge graft to retain scaphoid alignment. (A–E, From Herbert, T.J.; Fisher, W.E. J Bone Joint Surg Br 66:114–123, 1984.)

Internal Fixation:Internal Fixation:

AO Cannulated ScrewAO Cannulated ScrewGuide wire is drilled from distal to proximal Guide wire is drilled from distal to proximal

across the scaphoidacross the scaphoidCannulated 2.5mm drill bit is advanced to the Cannulated 2.5mm drill bit is advanced to the

appropriate depth under C-arm guidance.appropriate depth under C-arm guidance.Cannulated screw is inserted ensuring that all Cannulated screw is inserted ensuring that all

the threads are across the fracture site.the threads are across the fracture site.

Toby, E, Butler, T et al. A Comparison of Fixation Screws Toby, E, Butler, T et al. A Comparison of Fixation Screws for the Scaphoid during Application of Cyclical Bending for the Scaphoid during Application of Cyclical Bending

Loads. JBJS 79:1190-7 (1997).Loads. JBJS 79:1190-7 (1997).

35 matched pairs/10035 matched pairs/100Osteotomy of Scaphoid WaistOsteotomy of Scaphoid WaistFixated with selected screwFixated with selected screwRamped intensity cyclical bending Ramped intensity cyclical bending

loads loads Each screw compared against the Each screw compared against the

Herbert ScrewHerbert Screw

L to R: Herbert, AO cannulated, Herbert-Whipple, Acutrak cannulated, Universal Compression Screw

Toby, E, Butler, T et al. A Comparison of Fixation Screws Toby, E, Butler, T et al. A Comparison of Fixation Screws for the Scaphoid during Application of Cyclical Bending for the Scaphoid during Application of Cyclical Bending

Loads. JBJS 79:1190-7 (1997).Loads. JBJS 79:1190-7 (1997).

Results:Results: Accutrak, AO, Herbert- Accutrak, AO, Herbert-

Whipple demonstrated Whipple demonstrated superior resistance compared superior resistance compared to Herbert Screw.to Herbert Screw.

Universal Compression Universal Compression screw caused fractures with screw caused fractures with insertioninsertion

The AO screw and Herbert The AO screw and Herbert screw showed Worse fixation screw showed Worse fixation when volar cortex was when volar cortex was removed.removed.

Salvage Procedures:Salvage Procedures:

Radial Styloidectomy-Radial Styloidectomy- Indicated as an adjunct to bone grafting or Indicated as an adjunct to bone grafting or

internal fixationinternal fixationGood when there is OA at distal pole of Good when there is OA at distal pole of

scaphoid and radial styloidscaphoid and radial styloidExcised bone can be used as a graft.Excised bone can be used as a graft. CAVEAT: wrist can be destabilized if CAVEAT: wrist can be destabilized if

radioscaphocapitate and long radiolunate ligaments radioscaphocapitate and long radiolunate ligaments are detached.are detached.


Nonunion- Nonunion-

Operative choices: Operative choices: ORIF, ORIF, bone grafting, bone grafting, ORIF with bone grafting, ORIF with bone grafting, salvage arthroplasty, salvage arthroplasty, proximal row carpectomy,proximal row carpectomy, complete or partial arthrodesis and complete or partial arthrodesis and

combinations.combinations.

So which do you do??????So which do you do??????

Operative TechniqueOperative Technique

Bone Grafting- Bone Grafting- Autogenous- osteoconductive and Autogenous- osteoconductive and

osteoinductive, osteogeneritive and can be osteoinductive, osteogeneritive and can be structuralstructuralDonor sites Donor sites

Iliac crest, distal radius, proximal ulnaIliac crest, distal radius, proximal ulna

Vascularized autogenous bone graft- all of the Vascularized autogenous bone graft- all of the above with the added benefit of it’s own blood above with the added benefit of it’s own blood supplysupply

Matti-Russe Bone Grafting Matti-Russe Bone Grafting TechniqueTechnique

Volar incision over FCR ending Volar incision over FCR ending distally at scaphoid tuberositydistally at scaphoid tuberosity

Opening made in volar Opening made in volar nonarticular cortexnonarticular cortex

Opposing cavities excavatedOpposing cavities excavated Cancellous graft packed into Cancellous graft packed into

defectdefect +/- 2 K wires distal to proximal+/- 2 K wires distal to proximal

Fish-Fernandez Bone Grafting Fish-Fernandez Bone Grafting TechniqueTechnique

When angulation is present at fracture When angulation is present at fracture sitesiteVolar approach similar to Matti-RusseVolar approach similar to Matti-RusseLaminar spreader used to open volar siteLaminar spreader used to open volar siteFracture site is curettedFracture site is curettedCorticocancellousCorticocancellous bone graft is bone graft is

harvested. May need to be harvested. May need to be wedge shaped wedge shaped or trapezoidalor trapezoidal..

(Stabilize with 0.045inch K wires driven (Stabilize with 0.045inch K wires driven proximal to distal.)proximal to distal.)

Vascularized Bone Vascularized Bone Grafts- Grafts- Often useful for Often useful for proximal proximal

pole fractures or nonunion pole fractures or nonunion with signs of AVNwith signs of AVN

Many choices:Many choices: Volar pronator pedicle graft.Volar pronator pedicle graft. Dorsal Zaidemberg 1,2 Dorsal Zaidemberg 1,2

intercompartmental artery intercompartmental artery pedicle graft ( can also use pedicle graft ( can also use 3,4)3,4)

(Free vascularized iliac crest (Free vascularized iliac crest graft).graft).

Salvage Procedures:Salvage Procedures: Proximal Row Carpectomy:Proximal Row Carpectomy:

Lower demand patient Lower demand patient Failed graftingFailed grafting Lunate, triquetrum, scaphoid Lunate, triquetrum, scaphoid

(may only excise proximal 2/3)(may only excise proximal 2/3) Head of the capitate is then Head of the capitate is then

seated in lunate facet.seated in lunate facet. A 0.062 inch K wire can be A 0.062 inch K wire can be

driven transarticularly.driven transarticularly. Immobilize x 4-6 weeksImmobilize x 4-6 weeks

Contra-indication: lunate Contra-indication: lunate facet or capitate arthritisfacet or capitate arthritis

Salvage ProceduresSalvage Procedures Total Wrist ArthrodesisTotal Wrist Arthrodesis

IndicationsIndications Persistent nonunionPersistent nonunion Severe arthritis Severe arthritis Extensive AVN or collapseExtensive AVN or collapse

Salvage Procedures- Salvage Procedures- Total Wrist ArthrodesisTotal Wrist Arthrodesis

TechniqueTechnique

Straight oblique incision made Straight oblique incision made over Lister’s tubercleover Lister’s tubercle

Tubercle osteotomizedTubercle osteotomized Capsule incisedCapsule incised Joint surfaces decorticatedJoint surfaces decorticated Cancellous bone graft packed Cancellous bone graft packed

into joint (autograft or allograft)into joint (autograft or allograft) Wrist is fused with prebent low Wrist is fused with prebent low

profile fusion plateprofile fusion plate

Other Salvage Procedures:Other Salvage Procedures:

Partial Fusions:Partial Fusions: Some professions require some wrist Some professions require some wrist

motionmotion Some patients will tolerate some pain Some patients will tolerate some pain

to preserve motionto preserve motion May try scaphoid excision with 4 May try scaphoid excision with 4

corner fusion if the radiolunate joint is corner fusion if the radiolunate joint is preserved. preserved.

Patients can expect less than 50% Patients can expect less than 50% ROM and about 75% grip strength ROM and about 75% grip strength (this compares with PRC(this compares with PRC))

Complications of Scaphoid Silicone Complications of Scaphoid Silicone ArthroplastyArthroplasty

JM Kleinert, PJ Stern, GD Lister and RJ Kleinhans JBJS Am. JM Kleinert, PJ Stern, GD Lister and RJ Kleinhans JBJS Am. 19851985

Between 1971 and 1982, Between 1971 and 1982,

33 patients – (23 with 3 y f/u)33 patients – (23 with 3 y f/u)

NO improvement in strength or motionNO improvement in strength or motion

Complaints of increased pain in > ½ of the patientsComplaints of increased pain in > ½ of the patients

10 patients underwent 13 reconstructive surgeries 10 patients underwent 13 reconstructive surgeries afterwardsafterwards

Mutiple poor radiographic paramatersMutiple poor radiographic paramaters

Salvage ProceduresSalvage Procedures

DISTAL SCAPHOID RESECTION ARTHROPLASTY FOR DISTAL SCAPHOID RESECTION ARTHROPLASTY FOR SCAPHOID NONUNIONSCAPHOID NONUNION

WITH RADIOSCAPHOID ARTHRITISWITH RADIOSCAPHOID ARTHRITIS Pavel Draca*, Pavel Manaka, Lucie PieranovabPavel Draca*, Pavel Manaka, Lucie Pieranovab a Department of Traumatology, University Hospital, Olomouc, Czech Republica Department of Traumatology, University Hospital, Olomouc, Czech Republic b Clinic of Radiology, University Hospital, Olomoucb Clinic of Radiology, University Hospital, Olomouc

8 patients 8 patients treated by distal scaphoid resection treated by distal scaphoid resection arthroplasty for scaphoid nonunion with arthroplasty for scaphoid nonunion with symptomatic wrist arthritis before surgery symptomatic wrist arthritis before surgery

Minimum follow-up of Minimum follow-up of 6 months6 months. . There was a significantly better range of radial There was a significantly better range of radial

deviation and grip strength at the time of re-deviation and grip strength at the time of re-examination. examination.

Significantly fewer patients complained of Significantly fewer patients complained of resting painresting pain