4/5/2020 Scaphoid Fractures and Nonunions – RP's Ortho Notes

RP's Ortho Notes

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TOPICS May 22, 2013May 26, 2013

Scaphoid Fractures and Nonunions

(h ps://learningorthopaedics.com/2013/05/22/scaphoid-fractures-and-nonunion/)
Epidemiology

Account for 3-4% of all fractures.

Second most common fracture of the upper limb after distal radius fractures.
Most commonly missed fracture in the body.
Highest incidence seen between 20-30 years of age.
Male female ratio is 2:1.

Anatomy

Got its name from the Greek word “skaphe” which means boat.
4 Parts
Tubercle
Distal pole
Waist
Proximal pole
80% covered by articular cartilage. Its implications are that 1, articular cartilage may be damaged
by screw insertion, 2, Absence of periosteum results in minimal callus and 3, poor blood supply
predisposes to osteonecrosis.
Tubercle of scaphoid is overlaid by flexor carpi radialis (FCR)
Male scaphoid is longer. Hence longer and larger screws may be required in males.
Trabecular density is maximum at the proximal pole and thinnest at the waist. Waist is the
commonest site of fracture.
Blood vessels enter through the dorsal ridge and tuberosity. 70-80% of blood supply enters
through the dorsal ridge.
Scaphoid links the proximal and the distal carpal rows.
There is significant intercarpal motion between scaphoid and lunate, which questions the validity
of present kinematic models of carpal motion.
Scaphocapitate and scaphotrapezial ligaments control the movements of the distal pole.

Imaging

X-rays needed for diagnosis are PA view, Lateral view, Semipronated oblique view,
Semisupinated oblique view and AP in ulnar deviation.
Intrascaphoid angle is measured by first drawing a line connecting the widest part of proximal
and distal poles, then draw lines perpendicular to it. The angle formed by their intersection is the
intrascaphoid angle.
Normal intrascaphoid angle is 400 in the coronal plane and in the sagi al plane it is 300.
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Intrascaphoid angle more than 350 indicates humpback deformity.

Normal height length ratio is greater than 0.65.
Sensitivity of CT for detection of an undisplaced fracture is 89% and specificity is 91%.
MRI is the most sensitive and specific investigation for detection of occult fractures.
Normal scapholunate interval is 9mm at 7years of age and 3mm at 15 years of age.

Classification

Russe Classification

Horizontal Oblique
Transverse
Vertical Oblique

Herbert & Fisher Classification

A. Stable Acute Fractures

A1- Tuberosity fractures

A2- Incomplete waist fractures

B. Unstable Acute Fractures

B1- Oblique fractures of distal third

B2- Displaced waist fractures

B3- Proximal pole fractures

B4- Trans-scaphoid Perilunate instability

B5- Comminuted fractures

C. Delayed union (After 6 weeks of immobilization)

D. Established nonunions

D1- Fibrous nonunions

D2- Sclerotic

Distal pole fractures can be of 2 types

1. Avulsion fractures of the volar radial lip

2. Impaction fracture of the volar half

Management

Management depends on the fracture pa ern, reduction and bone quality. It also depends on the
patient’s occupation and the need to return to work early. Those who need to return to work early are
currently treated by percutaneous screw fixation.

General guidelines

Undisplaced distal pole fractures are treated by 4-6 weeks of immobilization.

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Undisplaced waist fractures are treated by immobilization and percutaneous screw fixation.
Undisplaced waist fractures are treated by 6 weeks of long arm scaphoid cast followed by 6 weeks
of short arm scaphoid cast.
Displaced fractures are treated by internal fixation by screws.

Indications for surgery

Displaced fractures.
Unstable fractures.
Associated carpal injury.
Associated distal radius fracture.
More than 3-4 weeks delay in initial presentation.
Undisplaced fractures in those who want early return to work. Some authors have reported high
incidence of complications with percutaneous fixation.

Definition of displaced and unstable fractures

According to Cooney

More than 1 mm displacement.

More than 100 angular displacement.
Fracture comminution.
Radiolunate angle more than 150.
Scapholunate angle more than 600.
Intrascaphoid angle more than 350.

Approaches to scaphoid fixation

The approach to fix may be dorsal or volar.

These approaches may be open, mini-open or percutaneous.
Proximal pole fractures need dorsal approach and distal third fractures are approached volar.
Waist fractures may be approached dorsal or volar.
Volar approaches need osteotomy of the volar radial lip of trapezium to expose the entry point;
hence dorsal approach is becoming more popular.
Dorsal approaches carry the risk of damage to blood supply entering the scaphoid through the
dorsal ridge.
Current best practice for the treatment of displaced acute scaphoid fractures is by percutaneous
approach

Indications for open approach

Scaphoid nonunions
Irreducible fractures
Comminuted fractures.

Volar open approach

Incision from a point 2 cm proximal to the scaphoid tuberosity in line with FCR and distally in
line with thumb metacarpal.
Open the sheath of FCR and retract the tendon medially.
Avoid dissection on the ulnar side of FCR to avoid injury to palmar branch of median nerve.
Incise the dorsal sheath of FCR.
Superficial branch of radial artery may need cauterization.
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