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Scaphoid - Tips to fix Scaphoid fractures & Non union management
1. Scaphoid Fixation
Dr Vaibhav BAGARIA
Orthopedic Surgeon
CARE hospital & ORIGYN Clinic
Nagpur, INDIA
www.drbagaria.com
E: drbagaria@gmail.com
2. 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
3. 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
7. 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
8. 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
9. 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
10. 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
12. 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
14. 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.
18. 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
19. 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
20. 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
39. 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.
