Scaphoid - Tips to fix Scaphoid fractures & Non union management

Scaphoid FixationDr Vaibhav BAGARIA

Orthopedic Surgeon

CARE hospital & ORIGYN Clinic

Nagpur, INDIA

www.drbagaria.com

E: drbagaria@gmail.com

Background

First described By French surgeon Destot in 1905

2 – 7% of all fractures in young adults

5 – 15% non union rates

Derived from Greek word skaphos which means boat.

Term based on its unique shape and articulations

Scaphoid Anatomy

Articulates with five bones: Distal radius, capitate, lunate trapezium and trapezoid

80% scaphoid is covered by articular cartilage leaving little space for the nutrient artery

Main blood supply is through retrograde branches of the radial artery

80% through the foraminal artery which is part of dorsal branch of radial artery

Palmar branch reaches through dorsal tubercle

Scaphoid Anatomy

Scaphoid Anatomy

Scaphoid Vascular Supply

Scaphoid Anatomy

Distal part has independent blood supply

In contrast the proximal part depends on the distal part for supply through the intra osseous part

This leaves proximal part vulnerable in case of fractures of the proximal pole which is dependent on distal part for this.

Healing is thus difficult for proximal pole which often goes into AVN

Clinical Presentation

Fall on the out-stretched hand with wrist in radial deviation

Proximal pole fractures occurs when the wrist in Abduction

The same trauma mechanism causes supracondylar fracture in kids and distal radius fractures in elderly

Imaging for Scaphoid fractures

X ray

CT scan

MRI

Scintigram

Sonography

Each has its own advantage and disadvantage and are applied at different stage of the management

Radiographs

Initial X Ray may miss up to 30% of scaphoid fractures

Apart from standard AP and Lat X Rays, two additional views are required

Some people recommend routine screening 10 -1 2 day post trauma in case of high degree of suspicion and initial negative x ray – a lucency/ sclerosis may provide clue

AP Lat and Oblique views

Diagnosis

Scintigraphy has close to 100% sensitivity

MRI has less initial sensitivity but high degree of sensitivity at later stage, good for delayed presentation & to r/o AVN

CT Scan helps in preoperative planning and assessing cortical and trabecular pattern

Scaphoid Imaging: MRI, CT, Scinti

Scaphoid Fracture Classification

Herbert’s, Russe and Mayo classification is commonly used

Herbert’s is based on the stability & russe is based on the predictability of healing depending on the fracture line

As per Herbert unstable fractures are: displacement greater than 1 mm or angulation greater than 15 degree. Additional fractures ,trans-scaphoid-perilunate dislocations, multi- fragment fractures and proximal pole fractures are also classified as unstable.

Mayo’s Classification

Modified Staging System

Herbert’s Classification

Treatment Approaches

The aim of the treatment is to achieve fracture consolidation and functional recovery whilst avoiding complications such as non- or mal-union

Direct Functional treatment

Cast Immobilization

Fixation: Open/ Percutaneous

Managing complication & delayed presentation

TREATMENT

Functional treatment involves bandaging or orthosis and is used only occasionally and in suspected fractures before immobilisation in cast is done.

Casting is indicated for undisplaced fractures only

Prolonged period of casting upto 12 weeks is required.

Casting has inherent disadvantages of stiffness, probability of non union, chances of developing CRPS

Operative Treatment

All Proximal pole and displaced scaphoid fractures should be treated operatively.

Percutaneous fixation using careful dorsal approach is the preferred method.

In case of proximal pole fracture a reverse approach may be required

Surface Anatomy

Per cut Fixation steps: Reduction

Skin Incision - Landmarks

Guide wire trajectory

Guide wire insertion

Confirm under II ( C ARM)

Correct Placement

Post Fixation radiographs

Approach to Non Union /AVN

Bone Grafting & Fixation

Vascularized Bone grafting – Pronator Quadratus/ Dorsal

Bone Graft fixation

Approach To Vascular BG

Planes

Vascular anatomy in Cadaver

Vascular pedicle BG

Temporary Fixation with BG

Pre & Post Vascular Graft

Take Home!

Do not miss the fracture on initial X rays

Prolonged immobilization is often required

Percut fixation is preferred management in majority cases

Non unions and AVN are common and need bone graft and fixation.

Pronator quadratus vascularized Bone grafting is often an excellent method for fixing Non unions with AVN.

Thank You!

ORIGYN Healthcare Nagpur & Indrapuram

Dr Vaibhav BAGARIA