Blood supply of scaphoid fractures

Blood supply of wrist and carpus

 Radial
 Ulnar
 Anterior interosseous arteries
 Deep palmar arch

Anastomotic network

 Three dorsal and three palmar arches connect longitudinally at their medial and lateral borders
by radial and ulnar arteries
 Dorsal to palmar interconnections between dorsal and palmar branches of interosseous artery

Interosseous blood supply

3 groups

 Group I : scaphoid, lunate and 20% of lunate supplied by single vessel – risk of osteonecrosis
 Group II : trapezoid and hamate which have 2 vessels but no interconnections between them.
When fractured – can have avascular fragments
 Group III : trapezium, triquetrum, pisiform and 80% of lunate have two vessels with consistent
interosseous anastomosis

- Carpal bones in Group I have high risk of AVN

- One of 2 bones in Group I (i.e. scaphoid and capitate) each is the largest bone in its row

- Scaphoid – most mobile in proximal row

- Capitate – most stable in distal row

- Mobile scaphoid more prone to injury

Blood supply of scaphoid

 Major blood supply – dorsal carpal branch (branch of radial artery)

 Enters scaphoid in a non-articular ridge on the dorsal surface and supplies proximal 80% of
scaphoid via retrograde blood flow
 Minor blood supply from superficial palmar arch (branch of volar radial artery)
 Enters distal tubercle and supplies distal 20% of scaphoid
 Single perforator (20%) proximal to the waist of scaphoid
 Unusual retrograde vascular supply – high risk of non-union and AVN after fracture
Management of non-union scaphoid fractures

Classification of scaphoid non-union

 Type I: Simple non-union

o Stable, non-displaced
o no degenerative change
 Type II: Unstable non-union
o Significant displacement or instability
o Dorsal intercalary segmental instability
o No degenerative change
 Type III: Non-union with early degenerative change
o Radio-scaphoid arthritis with joint space narrowing
o Subchondral sclerosis
o Pointing of radial Styloid
 Type IV: Scaphoid non-union advanced collapse
o Arthritis in radio-scaphoid and midcarpal joint
 Type V: Scaphoid non-union advance collapse plus
o Generalized arthritis and radio-lunate joint involved

Scaphoid fractures

 Most common : boys and men 15-40 years

 Rare : boys <10 years
 Late presentations are common (maybe years or decades)

Clinical features

 Minimally symptomatic as most patients adapt to symptoms

 Most common sign : restricted wrist motion
 Suggestive signs :
o tenderness in anatomical snuff box or scaphoid tubercle
o dorsal swelling
o persistent pain at extremes of motion (especially extension)
o limitation of radial and ulnar deviations
o decreased grip strength
Investigations

 X-ray : (AP, lat, oblique, scaphoid)

o widening of fracture cleft
o cyst formation
o sclerosis of # surfaces

- Radiographic diagnosis of union is unreliable in first 4 months of injury

- Requires an interval of 6-12 months after injury

(Or)

 CT scan :
o will likely show area of non-union clearly
o can analyze angular deformity
o evaluate pathologic scapho-lunate angle
o calculate the resection and size of graft needed

 MRI :
o to diagnose AVN

- Two different patterns of displacement: dorsal and volar

Goals of treatment

 Union
 Correct deformity
 Relief of symptoms
 Limitation of arthrosis

Factors influencing poor outcome

 Long duration of non-union

 No punctate bleeding of proximal pole with tourniquet released during surgery
 Failed previous surgery

1. Internal fixation without bone grafting

 Percutaneous screw fixation without BG: suggested for stable non-union

 Well-aligned delayed union or non-union require rigid fixation to achieve healing
2. Non-vascularized bone grafting

The Matti-Russe procedure

 Traditional treatment but not restore accurate alignment

 Consists of
o Volar approach
o Defect is packed with cortical struts and Cancellous bone
o Fix with K-wires : when scaphoid does not move as a unit after BG

Fisk-Fernandez technique

 Anterior wedge graft

 Improves alignment of scaphoid
 Decrease dorsal tilt of lunate

- Pre-op planning to measure the normal scaphoid to determine:

 Amount of bone to be resected

 Size and shape of BG

- Both methods need to resect portions of scaphoid to promote healing

- Recommended to use small screws but K-wire is acceptable

- In a structured unstable non-union series

o Screw fixation and grafting (94% union)

o K-wire and wedge grafting (77% union)

Disadvantages

 High failure rate in case of diminish or absence of punctate bleeding in surgery

 Short-term donor site morbidity
 Longer surgery

3. Vascularized bone grafting

 Faster rate of incorporation

 Greater durability
 Increase viability
 Most commonly used : distal radius
  To enhance vascular supply
o superficial radial artery pedicle (Hori, 1979)
o volar pronator quadratus pedicle (Kawai and Yamamoto, 1988)
o BG, internal fixation and vascular pedicle from second dorsal metacarpal artery
(Fernandez and Eggli, 1995)
o Pedicle from radial aspect of DR including 1,2 intercompartmental supraretinacular
artery (1,2-ICSRA, Zaidemberg technique, 1991)
 Free vascularized BG from iliac crest and medial femoral condyle

Revisions and salvage procedures

 When union can’t be achieved after one or more surgery

(Or)
 Arthrosis established

Salvage options

 Wrist denervation
 Radial styloidectomy
 Excision of distal pole of scaphoid
 Proximal role carpectomy
 Scaphoid excision
 4-corner arthrodesis (C,H,Tq,L)
 Total wrist arthrodesis