Scaphoid Fracture (YHT)

Scaphoid Fracture
Capt Ye Htut Thu

PG – 2
Outline
Incidence and Etiology
Clinical anatomy
Classification
Management
Complications
Nonunion of scaphoid and its management
References
2 Green, Campbell and Rockwood & Green 07/28/2023

Incidence
Most commonly carpal bone fracture(60-70%)
Low-energy injuries,
- sporting event (59%)
- fall onto an outstretched wrist (35%)
High energy trauma
- fall from a height
- motor vehicle injury
82% of scaphoid fractures occur in males (Green operative
hand surgery 6th edition )

Clinical Anatomy
The scaphoid lies at the radial border of the proximal
carpal row
Scaphoid represents the floor of the anatomical snuff
box
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.
Parts of scaphoid: Tubercle, distal pole, waist and
proximal pole
Articulations
The scaphoid articulates
with five bones: the
radius, trapezoid,
trapezium, lunate and
capitate.
Proximal surface: radius
Distal surface: laterally
with the trapezoid and
trapezium; medially
with the capitate
Ulnar surface: lunate
Wrist Ligaments
The ligaments of the wrist include-
Extrinsic ligaments: include volar and dorsal ligaments
Bridge carpal bones to the radius or metacarpals
Intrinsic ligaments
Originate and insert on carpal bones
The most important intrinsic ligaments are the scapholunate
interosseous ligament and lunotriquetral interosseous ligament
Characteristics
1. Volar ligaments are secondary stabilizers of the scaphoid
2. Volar ligaments are stronger than the dorsal ligaments
3. Dorsal ligaments converge on the triquetrum

Volar Ligaments
Volar radiocarpal ligaments:
1. Radial collateral ligament
2. Radioscaphocapitate
ligament
3. Long radiolunate ligament
4. Short radiolunate ligament
5. Radioscapholunate ligament
Volar ulnocarpal ligaments:
1. Ulnotriquetral
2. Ulnolunate
3. Ulnocapitate

Dorsal Ligaments
Radiotriquetral ligament
Dorsal intercarpal
ligament
Radiolunate
Radioscaphoid

Intrinsic (Interosseous) Ligaments
Proxomal row
1. Scapholunate ligament
 Disruption leads to lunate
extension when the scaphoid
flexes creating DISI deformity
2. Lunotriquetral ligament
 Disruption lunate flexion
when the scaphoid is normally
aligned creating VISI deformity
(in combination with rupture of
dorsal Radiotriquetral rupture)

Distal row
1. Trapeziotrapezoidal
lig
2. Trapeziocapitate
3. Capitohamate lig
Palmar midcarpal
1. Scaphotrapeziotrapezo
id
2. Scaphocapitate
3. triquetralcapitate

Blood Supply to the Scaphoid
Primarily through the radial
artery.
The branches of the artery enter
the scaphoid through the foramina
at the dorsal ridge at the level of
the waist of the scaphoid. (80% of
blood supply to scaphoid)
Subsequently, these vessels divide
and run proximally and palmarly
to supply blood to the proximal
pole of the scaphoid.

Other branches provide 20-30%
of the blood flow and appear
from the distal palmar area of the
scaphoid, arising either directly
from the radial artery or from the
superficial palmar branch.
The proximal pole, therefore, is
dependent entirely on
intraosseous blood flow

Mechanism of Injury
Fall on the outstretched hand, resulting in
severe hyperextension (95 degrees) and
slight radial deviation of the wrist
Usually begins at the volar waist with a
tensile failure; the forces propagate to the
dorsal surface with compression loading,
until failure occurs
Proximal scaphoid fractures – from dorsal
subluxation during forced hyperextension.
Carpal dislocations and scapholunate
ligament tears were reproduced with wrist
extension and ulnar deviation, combined
with intercarpal supination.

Nonunion occurs on 10-15% of all scaphoid fractures.
The risk of nonunion increases with:
1. Delay of treatment for > 4 weeks
2. Proximal pole fractures
3. Fracture displacement > 1 mm
4. Osteonecrosis
5. Tobacco use
6. Associated carpal instability (DISI with a scapholunate
angle > 60 degrees and a capitolunate angle > 15
degrees) secondary to humpback (flexed with
intrascaphoid angle > 45 degrees; normal – 24 degrees)
scaphoid positioning
Pathophysiology
Essentially fraactures of scaphoid have been explained as
a failure of bone caused by compressive or tension load
Compression, as explained by Cobey and White, against
concave surface by head of capitate
Position of radial and ulnar deviation though to
determine where it breaks
Fryman subjected cadaver wrists to loading and observed
that:
Extension of 35 degrees of less resulted in distal forearm
fractures
>90 degrees resulted in carpal fractures

Clinical Presentation
Low energy injuries low grade wrist pain
High energy injury suspicious of concomitant other
carpal bone injury
Swelling on the radial side of the wrist
Limited range of movement
Tenderness in the anatomical snuffbox
Pain on axial loading along the thumb
Pain on pronation of hand

Tests
Tapping the scaphoid: by palcing one thumb in snuff
box and other on distal tubercle produces pain or
crepitus
Scaphoid lift test: reproduction of pain by dorsal and

volar shifting of scaphoid
Watson test: painful dorsal scaphoid displacement as

the wrist is moved from ulnar to radial deviation with
compression of tuberosity

Herbert and Fisher Classification

Russe Classification
According to direction of fracture

Type A – Horizontal oblique fracture
Type B – Transverse fracture
Type C – Vertical oblique fracture (unstable)

Mayo’s Classification
According to anatomical location of the fracture line
Type 1 – Distal tubercle fracture
Type 2 – Distal articular surface fracture
Type 3 – Distal third fracture
Type 4 – Middle third fracture
Type 5 – Proximal third fracture

AO Classification

Imaging
X-ray
Preferred modes of diagnostic imaging
5 views: wrist posteroanterior (PA), lateral (SPC),
oblique, scaphoid view and clenched pencil views
Scaphoid view – a full view of the scaphoid bone with
minimal overlap from neighboring bones
Clenched pencil view – the best view to assess
associated dynamic scapholunate widening
Scaphoid healing cannot be reliably determined by
standard radiographs at 3 months

Scaphoid view

Clenched pencil views

Ziter View/ Banana View

Scaphoid axis
The true axis of the scaphoid is the line through the midpoints
of its proximal and distal poles. Since the midpoint of the
proximal pole is often difficult to appreciate, an almost
parallel line can be used that is traced along the most ventral
points of the proximal and distal poles of the bone.

The scapholunate angle is the angle between the long
axis of the scaphoid and the mid axis of the lunate on the
sagittal imaging of the wrist. In a normal situation it
should be between 30 degrees and 60 degrees in the
resting (neutral) position.

The capitate axis joins the midportion of the proximal
convexity of the third metacarpal and that of the proximal
surface of the capitate.
Capitolunate angle
Normal: 0-30 degrees
Abnormal: > 30degrees – indicates instability of the wrist
DISI or dorsiflexion instability
The term ‘intercalated segment’ refers to the part in
between the proximal segment, represented by the
distal carpal row and the metacarpals.
So all this means is that in DISI or dorsiflexion
instability the lunate is angulated dorsally.

VISI or palmar flexion instability
Occurs when the lunate is tilted palmarly too much.
While most DISI is abnormal, in many cases VISI is a
normal varient, especially if the wrist is very lax.

MRI -100% sensitivity and specifity for occult
scaphoid fracture within average 2.8days
-can assess the vascularity of scaphoid bone

CT scan
Give accurate anatomic assessment of the fracture
True fracture can be excluded

Radionucleotide Scan
Typically performed 3-7 days after initial surgery
if the X rays is still normal
Best at 48 hours
Identify the focal tracer accumulation

Treatment
Treatment of scaphoid fractures are determined by
displacement and stability of fracture
ACUTE SCAPHOID FRACTURES
Nondisplaced, stable fractures Displaced, unstable fractures
Non operative treatment Operative treatment

Scaphoid Cast
Forearm cast below the elbow proximally to the base
of thumbnail and the proximal palmar crease distally.
Wrist in slight radial deviation and in neutral flexion.
Thumb is maintained in functional position and the
fingers are free to move from MCP joints distally.
90-95% union in 10-20 weeks. During this time
fracture is observed radiographically for healing.
If collapse or angulation of fractured fragments occurs,
surgical treatment is required.

Management of waist fracture
Most common type of fracture
Operative vs non-operative: controversial
High rate of delayed and nonunion
Most stable fractures – with below elbow thumb spica cast.
Unstable fractures best treated with compression screw fixation
>1mm displacement
Fragment angulation
Abnormal carpal alignment
With advent of percutaneous techniques of cannulated screws
under fluroscopic control trend towards operative management

Management of distal pole fracture
Distal pole
Are infrequent
Usually
extraarticular with
good blood supply
Best treated with
short arm thumb
spica for 3-6 weeks

Management of proximal pole fractures
Fracture at and distal to the scaphoid waist heal sooner
than the fractures in proximal pole
Immobilization for 6 weeks by using long arm thumb

spica cast is justified in case of proximal third fractures
or those in which diagnosis is delayed
Healing occurs by creeping substitution

Displaced, unstable fractures
Following are the criteria to label it as unstable
1. Fragments are offset more than 1 mm in the AP or
Oblique view
2. Lunocapitate angulation >15 deg
3. Scapholunate angulation >45 deg in lateral view
Other criteria for evaluating displacement include:
1. Lateral intrascaphoid angle >45 deg
2. AP intrascaphoid angle <35 deg
3. Height to length ratio of 0.65 or more

Operative Treatment
Indications
1. Displaced unstable fractures
2. Scaphoid fracture associated with perilunate fracture
or dislocation
3. Ligamentous injury
4. Non displaced fracture of proximal pole
5. Non displaced fracture if the patient will not tolerate
prolonged immobilization (athletes and manual
laborers)
The choice of surgical procedure depends on surgeons
preference and experience, the type of fracture,
Green, Campbell and Rockwood & Green
43
patient’s age 07/28/2023
Methods of fixation
Operative Procedures
K-wire 1. Percutaneous fixation
The AO cannulated 2. ORIF with volar/
screw dorsal approach
The Herbert differential
pitch bone screw
The Acutrak screw
Herbert-Whipple screw

Surgical Approaches
VOLAR APPROACH:
Indications
Best exposure for
scaphoid fractures at and
distal to the waist.
Comminuted fractures
ORIF of fractures
Bone grafting for
nonunion scaphoid

Angled skin incision
The landmarks for this
incision are:
1. The scaphoid tubercle
2. The flexor carpi
radialis (FCR) tendon
Incision: The incision line
can be marked on the skin,
in line with the FCR
tendon, starting at the
scaphoid tubercle, and
running proximally for
about 2 cm. Distal of the
scaphoid tubercle, the
incision angles towards the
base of the thumb, over
the scaphotrapezial joint.
Ligate superficial palmar
branch of radial artery
Open the FCR sheath

Exposure the wrist capsule
The capsule is then incised obliquely from the tubercle
distally towards the palmar rim of the radius
proximally.

Expose the scaphoid
Retract the divided
radioscaphocapitate
ligament to expose the
scaphoid.
If it is necessary to
expose the proximal part
of the scaphoid, divide
the long radiolunate
ligament, proximally as
far as the palmar rim of
the radius.

Exposure of the scaphotrapezial
joint
The scaphotrapezial joint must
be exposed to allow optimal
positioning of a screw.

Wound Closure:
The divided palmar
ligaments must be
repaired with fine
interrupted sutures in
order to prevent
secondary carpal
instability.

Dorsal Approach
Indications
This approach is used for
the following injuries:
ORIF of proximal pole
fractures
Excision of the
proximal fragment of a
nonunion scaphoid
Bone grafting for
nonunion

Straight skin incision
Make a straight dorsal skin incision starting over Lister’s
tubercle and extending for about 4 cm distally.
Identify the radial nerve
-which runs in the radial
skin flap of the wound.

Incise the retinaculum
Incise the extensor
retinaculum over the extensor
pollicis longus (EPL) tendon
opening the distal part of the
third extensor compartment.

Retraction of the tendons
The EPL tendon is then retracted
radially together with the tendons
of the second extensor
compartment.
The fourth extensor compartment,

containing the extensor digitorum
and extensor indicis, is located on
the ulnar side.

Opening the capsule
Make a longitudinal, or inverted T-shaped incision,
starting at the dorsal rim of the distal radius, extending to
the dorsal intercarpal ligament.

Take care to preserve the vessels to the dorsal ridge of
the scaphoid. The capsule is not stripped from this area.

Expose the scaphoid
To expose the proximal pole of the scaphoid, it is necessary to flex the wrist.
The scaphoid now comes into view. Identify the SL ligament.

Wound Closure
Close the capsule with interrupted
sutures.
Close the third extensor compartment,

avoiding any tension over the EPL
tendon, which must glide smoothly. If
this is not possible, the EPL tendon is
the best left superficial to the
retinaculum, in the subcutaneous
tissue.

Complications
Delayed union
Malunion
Nonunion
Avascular necrosis
OA of radiocarpal and intercarpal joints

Goals of Management
1. Relieve symptoms
2. Correct the carpal deformity
3. Achieve union
4. Delay the onset of wrist arthrodesis

Vascularized Bone Grafts

Proximal Row Carpectomy

After proximal carpectomy

Arthroscopic Proximal Row Carpectomy by
WEISS et.al

References
1. Campbell’s Operative Orthopaedics-14th EDT
2. Rockwood and Green’s Fracture in Adult-8th EDT
3. Green’s Operative Hand Surgery
4. Surgical Exposure in Orthopaedics
5. Journal: AAOS

Thank You !

Scaphoid Fracture (YHT)

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Scaphoid Fracture (YHT)

Uploaded by

Copyright:

Available Formats

Scaphoid Fracture

Capt Ye Htut Thu

2 Green, Campbell and Rockwood & Green 07/28/2023

3 Green, Campbell and Rockwood & Green 07/28/2023

6 Green, Campbell and Rockwood & Green 07/28/2023

7 Green, Campbell and Rockwood & Green 07/28/2023

8 Green, Campbell and Rockwood & Green 07/28/2023

9 Green, Campbell and Rockwood & Green 07/28/2023

10 Green, Campbell and Rockwood & Green 07/28/2023

11 Green, Campbell and Rockwood & Green 07/28/2023

12 Green, Campbell and Rockwood & Green 07/28/2023

13 Green, Campbell and Rockwood & Green 07/28/2023

15 Green, Campbell and Rockwood & Green 07/28/2023

16 Green, Campbell and Rockwood & Green 07/28/2023

Scaphoid lift test: reproduction of pain by dorsal and

Watson test: painful dorsal scaphoid displacement as

17 Green, Campbell and Rockwood & Green 07/28/2023

18 Green, Campbell and Rockwood & Green 07/28/2023

According to direction of fracture

19 Green, Campbell and Rockwood & Green 07/28/2023

20 Green, Campbell and Rockwood & Green 07/28/2023

21 Green, Campbell and Rockwood & Green 07/28/2023

22 Green, Campbell and Rockwood & Green 07/28/2023

23 Green, Campbell and Rockwood & Green 07/28/2023

24 Green, Campbell and Rockwood & Green 07/28/2023

25 Green, Campbell and Rockwood & Green 07/28/2023

26 Green, Campbell and Rockwood & Green 07/28/2023

27 Green, Campbell and Rockwood & Green 07/28/2023

29 Green, Campbell and Rockwood & Green 07/28/2023

30 Green, Campbell and Rockwood & Green 07/28/2023

31 Green, Campbell and Rockwood & Green 07/28/2023

32 Green, Campbell and Rockwood & Green 07/28/2023

33 Green, Campbell and Rockwood & Green 07/28/2023

ACUTE SCAPHOID FRACTURES

Nondisplaced, stable fractures Displaced, unstable fractures

Non operative treatment Operative treatment

34 Green, Campbell and Rockwood & Green 07/28/2023

35 Green, Campbell and Rockwood & Green 07/28/2023

38 Green, Campbell and Rockwood & Green 07/28/2023

39 Green, Campbell and Rockwood & Green 07/28/2023

Immobilization for 6 weeks by using long arm thumb

Healing occurs by creeping substitution

40 Green, Campbell and Rockwood & Green 07/28/2023

41 Green, Campbell and Rockwood & Green 07/28/2023

44 Green, Campbell and Rockwood & Green 07/28/2023

45 Green, Campbell and Rockwood & Green 07/28/2023

48 Green, Campbell and Rockwood & Green 07/28/2023

49 Green, Campbell and Rockwood & Green 07/28/2023

50 Green, Campbell and Rockwood & Green 07/28/2023

51 Green, Campbell and Rockwood & Green 07/28/2023

52 Green, Campbell and Rockwood & Green 07/28/2023

53 Green, Campbell and Rockwood & Green 07/28/2023

55 Green, Campbell and Rockwood & Green 07/28/2023

56 Green, Campbell and Rockwood & Green 07/28/2023

The fourth extensor compartment,

57 Green, Campbell and Rockwood & Green 07/28/2023

58 Green, Campbell and Rockwood & Green 07/28/2023

59 Green, Campbell and Rockwood & Green 07/28/2023

60 Green, Campbell and Rockwood & Green 07/28/2023

Close the third extensor compartment,

61 Green, Campbell and Rockwood & Green 07/28/2023

62 Green, Campbell and Rockwood & Green 07/28/2023

71 Green, Campbell and Rockwood & Green 07/28/2023

83 Green, Campbell and Rockwood & Green 07/28/2023