SCAPHOID FRACTURE

EPIDEMIOLOGY AND ETIOLOGY OF

SCAPHOID FRACTURES
• ACUTE SCAPHOID FRACTURES ACCOUNT FOR 2% TO 3%
OF ALL FRACTURES, APPROXIMATELY 10% OF ALL HAND
FRACTURES AND BETWEEN 60% AND 80% OF ALL CARPAL
FRACTURES
• THE INCIDENCE OF SCAPHOID FRACTURES QUOTED IN THE
LITERATURE IS INCONSISTENT WITH A RANGE FROM 1.5
TO 121 FRACTURES PER 100,000 PERSONS PER YEAR
 CLINICAL ANATOMY OF SCAPHOID
FRACTURES
• THE SCAPHOID BONE IS LOCATED IN THE PROXIMAL CARPAL ROW ON
THE RADIAL ASPECT OF THE WRIST AND IS A SMALL IRREGULAR S-
SHAPED TUBULAR BONE
• IT LIES ENTIRELY WITHIN THE WRIST JOINT AND IS LOCATED AT A 45-
DEGREE PLANE TO THE LONGITUDINAL AND HORIZONTAL AXES OF
THE WRIST
• IT HAS A REDUCED CAPACITY FOR PERIOSTEAL
HEALING AND AN INCREASED TENDENCY FOR
DELAYED UNION AND NONUNION BECAUSE JUST
OVER 80% OF ITS SURFACE IS ARTICULAR
CARTILAGE
• THE SHORT INTRINSIC LIGAMENTS PROVIDE
STABILITY TO THE SCAPHOID THROUGH
ATTACHMENTS TO THE OTHER CARPAL BONES, IN
PARTICULAR THE LUNATE, AND MERGE WITH THE
EXTRINSIC LIGAMENTS AND CAPSULE OF THE
WRIST
 VASCULAR SUPPLY

• DORSAL BRANCH: ENTERS VIA THE SMALL FORAMINA

ALONG THE SPIRAL GROOVE AND DORSAL RIDGE OF
THE SCAPHOID AND SUPPLIES 70% TO 80% OF THE
SCAPHOID PROXIMALLY, INCLUDING THE PROXIMAL
POLE
• VOLAR BRANCH: ENTERS VIA THE SCAPHOID TUBERCLE
AND SUPPLIES THE REMAINING 20% TO 30% OF
DISTAL SCAPHOID
 SCAPHOID FRACTURES CLINICAL
ASSESSMENT
AND DIAGNOSIS
• THE DIAGNOSIS OF A FRACTURE TO THE SCAPHOID IS MADE BY A
COMBINATION OF CLINICAL HISTORY, EXAMINATION, AND
RADIOGRAPHIC ASSESSMENT
• PATIENTS CLASSICALLY PRESENT WITH WRIST PAIN FOLLOWING A
FALL ONTO THE OUTSTRETCHED HAND, WITH ALMOST 90%
RECALLING A HYPEREXTENSION INJURY
• CLINICAL EXAMINATION USES A COMBINATION OF
CLINICAL SIGNS, GENERALLY PAIN, SWELLING,
ECCHYMOSIS, AND TENDERNESS AROUND THE REGION OF
THE SCAPHOID MAY BE PRESENT IN THE ACUTE PHASE
 SYMPTOMS
• HYPEREXTENSION TO THE WRIST, OFTEN
FOLLOWING A FALL, SPORTS, OR PUNCH INJURY
• THE MAIN COMPLAINT IS OF RADIAL-SIDED WRIST
PAIN, WITH LOCALIZED TENDERNESS OVER THE
SCAPHOID IN THE REGION OF THE ASB
 SIGNS

• NO SINGLE SIGN HAS BEEN FOUND TO BE ADEQUATELY

SENSITIVE OR SPECIFIC
• ASB TENDERNESS
• SCAPHOID TUBERCLE TENDERNESS
• ASB PAIN ON LONGITUDINAL COMPRESSION
 RADIOGRAPHS
• NEUTRAL PA AND LATERAL
RADIOGRAPHIC VIEWS
• ZITER VIEW, OR THE “BANANA
VIEW,” USES A PA VIEW OF THE
WRIST IN ULNAR DEVIATION WITH
20-DEGREE TUBE ANGULATION TO
THE ELBOW
 CT
• MANY AUTHORS ADVOCATE THE
USE OF CT FOR DIAGNOSING
TRUE FRACTURES AMONG
SUSPECTED SCAPHOID FRACTURES
ALTHOUGH SOME HAVE
CAUTIONED AGAINST ITS USE FOR
UNDISPLACED FRACTURES
 MRI

• OF THE 26 STUDIES, 9 USED 6-WEEK

RADIOGRAPHIC FOLLOW-UP AS THEIR REFERENCE
STANDARD. BONE SCINTIGRAPHY AND MRI WERE
SHOWN TO HAVE COMPARABLE HIGH SENSITIVITY
RATES, THOUGH MRI WAS MORE SPECIFIC
 CLASSIFICATION AND ASSOCIATED
INJURIES OF SCAPHOID FRACTURES
• RUSSE CLASSIFICATION
• AO CLASSIFICATION
• HERBERT AND FISHER CLASSIFICATION
• MAYO CLASSIFICATION
HERBERT AND FISHER CLASSIFICATION
 MAYO CLASSIFICATION

• >1 MM OF FRACTURE DISPLACEMENT103,143

• A LATERAL INTRASCAPHOID ANGLE OF >35 DEGREES
• BONE LOSS OR COMMINUTION
• FRACTURE MALALIGNMENT
• PROXIMAL POLE FRACTURES
• DISI DEFORMITY
• PERILUNATE FRACTURE-DISLOCATION
 MANAGEMENT OF SCAPHOID
FRACTURES
SUSPECTED SCAPHOID FRACTURES
• SIMPLE BELOW-ELBOW FOREARM CAST WITH OR
WITHOUT THUMB IMMOBILIZATION FOR 6 WEEK
SCAPHOID TUBERCLE FRACTURES
• PREFER CAST IMMOBILIZATION FOR 4 WEEKS
NONDISPLACED SCAPHOID FRACTURES
• A BELOW-ELBOW CAST WITH THE THUMB FREE
• RETURN TO SPORT AND USE OF THE HAND
WITH FORCE IS DELAYED UNTIL THERE IS CLEAR
RADIOGRAPHIC EVIDENCE OF UNION OR 4 TO
6 MONTHS HAVE PASSED
• PERCUTANEOUS SCREW FIXATION
UNSTABLE AND/OR DISPLACED SCAPHOID
FRACTURES
• ARTHROSCOPIC-ASSISTED FIXATION OR ORIF
OF THE SCAPHOID IS RECOMMENDED
• A SPLINT IS APPLIED FOR COMFORT AFTER
OPERATIVE FIXATION
PROXIMAL POLE SCAPHOID FRACTURES
•RECOMMEND OPERATIVE TREATMENT
USING A SMALL OPEN DORSAL
APPROACH TO CHECK ALIGNMENT IN
CASE THE FRACTURE IS UNSTABLE
 APPROACH TO SCAPHOID

VOLAR APPROACH TO THE SCAPHOID

• POSITION
PLACE THE PATIENT SUPINE ON THE OPERATING TABLE
• LANDMARKS
PALPATE THE TUBEROSITY OF THE SCAPHOID ON THE
VOLAR ASPECT OF THE WRIST, JUST DISTAL TO THE SKIN
CREASE OF THE WRIST JOINT.
 APPROACH TO SCAPHOID

VOLAR APPROACH TO THE SCAPHOID

• LANDMARKS
THE FLEXOR CARPI RADIALIS MUSCLE LIES RADIAL TO THE
PALMARIS LONGUS MUSCLE AT THE LEVEL OF THE WRIST. IT
CROSSES THE SCAPHOID BEFORE INSERTING INTO THE BASE
OF THE SECOND AND THIRD METACARPAL JUST ON THE
ULNAR SIDE OF THE RADIAL PULSE.
 APPROACH TO SCAPHOID

VOLAR APPROACH TO THE SCAPHOID

• INCISION
MAKE A VERTICAL OR CURVILINEAR INCISION ON THE VOLAR
ASPECT OF THE WRIST, ABOUT 2 TO 3 CM LONG. BASE IT ON
THE TUBEROSITY OF THE SCAPHOID AND EXTEND IT PROXIMALLY
BETWEEN THE TENDON OF THE FLEXOR CARPI RADIALIS MUSCLE
AND THE RADIAL ARTERY
 APPROACH TO SCAPHOID

VOLAR APPROACH TO THE SCAPHOID

• INTERNERVOUS PLANE
THERE IS NO TRUE INTERNERVOUS PLANE; THE ONLY
MUSCLE MOBILIZED IS THE FLEXOR CARPI RADIALIS (WHICH IS
SUPPLIED BY THE MEDIAN NERVE).
 APPROACH TO SCAPHOID
VOLAR APPROACH TO THE SCAPHOID
• SUPERFICIAL SURGICAL DISSECTION
INCISE THE DEEP FASCIA IN LINE WITH THE SKIN INCISION AND IDENTIFY THE
RADIAL ARTERY ON THE LATERAL (RADIAL) SIDE OF THE WOUND. RETRACT THE RADIAL
ARTERY AND LATERAL SKIN FLAP TO THE LATERAL SIDE. IDENTIFY THE TENDON OF THE
FLEXOR CARPI RADIALIS MUSCLE AND TRACE IT DISTALLY, INCISING THAT PORTION OF
THE FLEXOR RETINACULUM THAT LIES SUPERFICIAL TO IT. AFTER THE TENDON HAS BEEN
FREED FROM ITS TUNNEL IN THE FLEXOR RETINACULUM, RETRACT IT MEDIALLY TO
EXPOSE THE VOLAR ASPECT OF THE RADIAL SIDE OF THE WRIST JOINT
 APPROACH TO SCAPHOID

VOLAR APPROACH TO THE SCAPHOID

• DEEP SURGICAL DISSECTION
INCISE THE CAPSULE OF THE WRIST JOINT OVER THE
SCAPHOID TO EXPOSE THE DISTAL TWO THIRDS OF THE SCAPHOID.
THIS ANTERIOR AREA OF BONE IS NONARTICULAR. TO GAIN THE
BEST VIEW OF THE PROXIMAL THIRD OF THE BONE, PLACE THE
WRIST IN MARKED DORSIFLEXION.
 APPROACH TO SCAPHOID

VOLAR APPROACH TO THE SCAPHOID

• DANGER
THE RADIAL ARTERY LIES CLOSE TO THE LATERAL BORDER
OF THE WOUND AND CAN BE INCISED ACCIDENTALLY AT
ANY TIME DURING THE DISSECTION. THEREFORE, IT MUST BE
IDENTIFIED EARLY IN THE PROCEDURE.
 APPROACH TO SCAPHOID

DORSOLATERAL APPROACH TO THE SCAPHOID

• POSITION
PLACE THE PATIENT SUPINE ON THE OPERATING TABLE
• LANDMARKS
THE RADIAL STYLOID PROCESS, THE ANATOMIC SNUFF-
BOX, AND THE FIRST METACARPAL.
 APPROACH TO SCAPHOID
DORSOLATERAL APPROACH TO THE SCAPHOID
• INCISION
MAKE A GENTLY CURVED, S-SHAPED INCISION CENTERED OVER THE
SNUFF-BOX. THE CUT SHOULD EXTEND FROM THE BASE OF THE FIRST
METACARPAL TO A POINT ABOUT 3 CM ABOVE THE SNUFF-BOX.
• INTERNERVOUS PLANE
THERE IS NO TRUE INTERNERVOUS PLANE, BECAUSE THE PLANE OF
DISSECTION FALLS BETWEEN THE TENDONS OF THE EXTENSOR POLLICIS
LONGUS AND EXTENSOR POLLICIS BREVIS MUSCLES, BOTH OF WHICH ARE
SUPPLIED BY THE POSTERIOR INTEROSSEOUS NERVE.
 APPROACH TO SCAPHOID
DORSOLATERAL APPROACH TO THE SCAPHOID
• SUPERFICIAL SURGICAL DISSECTION
IDENTIFY THE TENDONS OF THE EXTENSOR POLLICIS LONGUS MUSCLE
DORSALLY AND THE EXTENSOR POLLICIS BREVIS MUSCLE VENTRALLY. TO CONFIRM
THEIR IDENTITY, PULL ON THE TENDONS AND OBSERVE THEIR ACTION ON THE THUMB.
OPEN THE FASCIA BETWEEN THE TWO TENDONS, TAKING CARE NOT TO CUT THE
SENSORY BRANCH OF THE SUPERFICIAL RADIAL NERVE, WHICH LIES SUPERFICIAL TO
THE TENDON OF THE EXTENSOR POLLICIS LONGUS MUSCLE. THE RADIAL NERVE
USUALLY HAS DIVIDED INTO TWO OR MORE BRANCHES AT THIS LEVEL. BOTH
BRANCHES CROSS THE INTERVAL BETWEEN THE TENDONS OF THE EXTENSOR POLLICIS
BREVIS AND THE EXTENSOR POLLICIS LONGUS, LYING SUPERFICIAL TO THE TENDONS.
THEIR COURSE IS VARIABLE, AND THEY MUST BE SOUGHT AND PRESERVED DURING
SUPERFICIAL DISSECTION.
 APPROACH TO SCAPHOID
DORSOLATERAL APPROACH TO THE SCAPHOID
• SUPERFICIAL SURGICAL DISSECTION
NOW, SEPARATE THE TENDONS, RETRACTING THE EXTENSOR
POLLICIS LONGUS DORSALLY AND TOWARD THE ULNA, AND THE
EXTENSOR POLLICIS BREVIS VENTRALLY. IDENTIFY THE RADIAL ARTERY AS IT
TRAVERSES THE INFERIOR MARGIN OF THE WOUND, LYING ON THE BONE.
FIND THE TENDON OF THE EXTENSOR CARPI RADIALIS LONGUS MUSCLE
AS IT LIES ON THE DORSAL ASPECT OF THE WRIST JOINT. MOBILIZE IT AND
RETRACT IT IN A DORSAL AND ULNAR DIRECTION, TOGETHER WITH THE
TENDON OF THE EXTENSOR POLLICIS LONGUS MUSCLE, TO EXPOSE THE
DORSORADIAL ASPECT OF THE WRIST JOINT.
 APPROACH TO SCAPHOID

DORSOLATERAL APPROACH TO THE SCAPHOID

• DEEP SURGICAL DISSECTION
INCISE THE CAPSULE OF THE WRIST JOINT
LONGITUDINALLY. REFLECT THE CAPSULE DORSALLY AND IN A
VOLAR DIRECTION TO EXPOSE THE ARTICULATION BETWEEN
THE DISTAL END OF THE RADIUS AND THE PROXIMAL END OF
THE SCAPHOID. THE RADIAL ARTERY RETRACTS RADIALLY AND
IN A VOLAR DIRECTION WITH THE JOINT CAPSULE.
 APPROACH TO SCAPHOID

DORSOLATERAL APPROACH TO THE SCAPHOID

• DEEP SURGICAL DISSECTION
PLACE THE WRIST IN ULNAR DEVIATION AND CONTINUE
STRIPPING THE CAPSULE OFF THE SCAPHOID TO EXPOSE THE
JOINT COMPLETELY. TRY TO PRESERVE AS MUCH SOFT-TISSUE
ATTACHMENTS TO THE BONE AS POSSIBLE. MODERN AIMING
GUIDES HAVE SUBSTANTIALLY REDUCED THE NEED FOR
RADIAL DISSECTION IN OPEN REDUCTION AND INTERNAL
FIXATION OF SCAPHOID FRACTURES.
 APPROACH TO SCAPHOID

DORSOLATERAL APPROACH TO THE SCAPHOID

• DANGER
THE SUPERFICIAL RADIAL NERVE IS AT RISK DURING THIS
EXPOSURE.
 COMPLICATIONS
• MALUNION
• CORRECTIVE OSTEOTOMY THAT CORRECTS THE INTRASCAPHOID
ANGLES, RESTORES PALMAR LENGTH TO THE SCAPHOID, AND
REDUCES DISI DEFORMITY OF THE CARPUS
• NONUNION
• TREATMENT OPTIONS INCLUDE BONE GRAFTING, FIXATION
WITHOUT BONE GRAFTING, FIXATION WITH EITHER A
VASCULARIZED OR A NONVASCULARIZED GRAFT
• AVASCULAR NECROSIS
• TREATMENT OPTION IS A VASCULARIZED BONE GRAFT
THANK YOU