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Acute Scaphoid fracture
Dr. Anil K BhatAssociate Professor
Department of OrthopaedicsKasturba Medical College
Manipal
Mechanism of injury
Hyperextended and radially deviated wrist
Physical Examination
Palpable AnatomyProximal pole – dorsum of wrist
Lister’s tubercle
Sulcus (radiocarpal joint) Prominence (scapholunate joint)
Move radial for proximal pole
Waist of ScaphoidDorsal : distal to rim of distal radius towards styloid
Waist of ScaphoidLateral : In anatomical snuff box, proximal to radial artery in ulnar deviation
Distal pole
• Dorsal : between EPL and ECRL
Distal pole
• Lateral : proximal to radial artery in anatomical snuff box with wrist in neutral position.
Distal pole
• Volar : along with FCR as it enters fibro-osseous tunnel
Provocative tests
Snuff box tenderness
Scaphoid compression test
Scaphoid tubercle tenderness
Painful resisted pronation
Painful attempted Scaphoid shift test
Physical examination
• Snuff box tenderness 100% sensitivity
• Scaphoid tubercle tenderness 20% specific
• Adding Scaphoid compression test :
Specificity reaches 74% (Parvizi et al)
Radiographic evaluation
• Wrist PA, Lateral, Oblique, Scaphoid views
• 25 degrees pronated and supinated oblique views
6 views increased sensitivity and specificity to almost 100% ( Mehta &Brautigan,1990)
Wrist PA
Wrist lateral
Scaphoid view
Supinated Oblique
Anil K. Bhat, Kumar Bhaskaranand, Ashwath Acharya, “Radiographic imaging of the wrist”: Indian Journal of Plastic Surgery, Vol 44,Issue 2, May-Aug,2011.
Pronated Oblique
What if radiographs are inconclusive?
Bone Scan-Scintigraphy
• Fast and reliable diagnostic tool• 100% Sensitivity
Disadvantages:• Lacks specificity• Little information regarding location• 15% False positive
Ultrasound
• Inter-observer variability
• Useful in patients with cortical irregularity and hemarthrosis
• Structural integrity of scaphoid or other injuries – little information
Computed Tomography
• Scan oriented to longitudinal axis of scaphoid for hump back deformity
• For surgical planning & assessment of healing• To diagnose additional bony injuries
Disadvantages • False positives in diagnosing occult fractures.
Krimmer H: Management of acute fractures and nonunions of the proximal pole of the scaphoid. J.Hand Surg Br 2002; 27:245-248
MRI• 2nd line test in negative radiographs• Identifying fractures of other carpal bones,
ligament injuries• Highest sensitivity and specificity
Spin echo T1 Fluid sensitivity T2
Breitenseher MI, Metz VM, Gilula LA et al. Radiographically occult scaphoid fractures: value of MR imaging in detection. Radiology 1997;203: 245-250
Herbert Classification
Mayo classification
•Based on location
• Stability
Mayo Classification
Distal pole
Distal third
Midwaist
Proximal pole
Distal pole
Stable Fractures
• < 1mm displacement • Normal carpal alignment • Normal interscaphoid angulation
(< 35 degrees)• No bone loss or comminution• No reduction needed
Determinants of treatment
• Stability of fracture
• Location
• Psycho socio-economic factors
Marco Rizzo, Alexander Y. Shin, William P.Cooney. A.A.O.S.
Closed treatment
• Stable non displaced fractures
• Cast immobilization To prevent displacement To maintain immobilization long enough
for healing
Nigel R.Clay, Joseph J.Dias, P.S. Costigan, P.J. Gregg, N.J. Barton. Need The Thumb To be Immobilized In Scaphoid Fractures.
Closed treatment
• Stable non displaced fractures
• Short arm for 6-8 weeks in tubercle or distal pole fractures
• Upto 12 weeks in waist fractures• Long arm cast for non compliant patients• Position- wrist in neutral position
Nigel R.Clay, Joseph J.Dias, P.S. Costigan, P.J. Gregg, N.J. Barton. Need The Thumb To be Immobilized In Scaphoid Fractures.
Surgical treatment
• Displaced
• Comminuted
• Unstable fractures
Surgical treatment
Volar approach (Russe) • Distal 3rd and waist fractures• Excellent visualization • Angulation deformity correction
Disadvantages• Capsular scarring• Limited wrist extension• Instability
Dorsal radial approach (McLaughlin)
• Proximal pole fractures • Scapholunate ligament visualization
Disadvantages
• Can’t visualize entire scaphoid • Intraoperative imaging
Percutaneous technique
• Stable scaphoid fractures
• Decreased period of immobilization
• Decreased wrist stiffness
• Athletes and young patients
Complications
• Fracture displacement
• Inadequate purchase
• Mal reduced fractures
Arthroscopically assisted percutaneous fixation
• Unstable fractures: displaced or non displaced
• Delayed presentation• Proximal pole fractures• Combined injuries of scaphoid and ipsilateral
displaced distal radius fractures• Scaphoid fractures with associated
ligamentous injury
Aggressive Conservative Treatment
All undisplaced fractures- cast Immobilisation for 6 weeks.
If persistence of Fracture gap / no evidence of healing.
Gap <2mmcast immobilisation
Gap >2mm Herbert screw fixation
CT wrist at 6 weeks
J.J. Dias, C.J. Wildin, B. Bhowal, J.R. Thompson. Should Acute Scaphoid Fractures Be Fixed? 2005. JBJS ,2160.
Thank you for your kind attention