Scaphoid fractures are easily missed in acute setting and are often diagnosed retrospectively. A common complication is AVN and non union.

1. Scaphoid fractures and Non
Union

2. Introduction
• Occur due to fall on outstretched arm or
forced dorsiflexion injury to the wrist.
• Undisplaced fractures can be mistaken for
sprains.
• Avascular necrosis occurs in estimated 13-50%
of fractures.

3. Blood supply
• Artery to the dorsal ridge of the scaphoid-
branch of radial artery.
• The branches of the artery enter the non
articular portion through foramina at dorsal
ridge at the waist.

4. • These vessels run proximally and volarly to
supply the proximal pole of scaphoid.
• The vascularity depends mainly on the
interosseous blood supply.
• Therefore time of healing is prolonged- 3-6
months

5. Clinical features

6. X rays
• PA view of wrist in slight ulnar deviation is
helpful.
• Repeat x rays after 2 weeks of immobilization
in suspected fractures.

7. X Rays

8. Imaging
Test Sensitivity Specificity
Bone scintigraphy 100% 98%
MRI 95-100% 100%
X Ray 65-70% 85%

9. MRI
• Determine preop vascularity in a diagnosed
scaphoid fracture.
• Acute fractures- Normal or decreased T1
intensity or increased T2 intensity.
• Low T1 and T2 marrow signal intensity
indicates poor vascularity.

10. Casting and X ray
• Safer approach.
• Less expensive.
• Unnecessary
immobilisation.
• Poor interobserver
agreement.
MRI
• Reduces time of
immobilisation
• Better interobserver
aggreability
• Find other causes of wrist
pain.
• Assesment of vascularity.
• Expensive.

11. • Obtain AP, Lateral and Oblique views.
• If a scaphoid fracture is identified, do a CT for
proper surgical planning.
• MRI wrist for negative or equivocal X rays.

12. Herbert classification

14. Non displaced, stable fractures
• Acute non displaced stable fractures through
the waist.
• Fractures through the distal pole.
• No other bony or ligamentous injury.
• Scaphoid injuries in children.

15. J Hand Surg Am. 2008 Jul-Aug; 33(6): 988–997.

16. Scaphoid cast
• Just below the elbow proximally to the base of
thumbnail and proximal palmar crease.
• Wrist in slight radial deviation and neutral
flexion.
• Thumb in functional position and MCP joints
free.
• 90-95% union in 10-12 weeks.
• Take regular X rays.

18. • Initial long arm thumb spica justified in case of
proximal fractures or those diagnosed later.
• 6 weeks.
• A clinical sign of union is the strength of the
pinch of the tip of the index finger to the
thumb.

19. Displaced, unstable fractures
• Fragments are offset more than 1mm in the
AP or oblique view.
• Lunocapitate angulation > 15 deg.
• Scapholunate angulation is > 45 deg.
• Lateral intrascaphoid angle >45 deg
• AP intrascaphoid ange <35 deg.
• Height to length ratio of 0.65 or more.

21. Methods of fixation
• K wires
• AO Cannulated screw
• Herbert diffferential pitch bone screw
• Acutrak screw
• Herbert- Whipple Screw

23. Approach
• Scaphoid tubercle and
FCR tendon.

25. • Extend the wrist in ulnar deviation, open the
capsule in longitudnal axis towards the ST
joint.
• Place k wires and joystick them to reduce the
fractures.
• Radially deviate the wrist and direct the k
wires dorsally.

26. • Entry point is at palmar
edge of ST joint.
• Angulate guidweire 45
deg dorsally, medially
and along the mid axis.

27. Dorsal approach

28. Percutaneous approach
• To visualise the axis the
PA view of the wrist is
obtained.

29. • Pronate the wrist so
that the scaphoid poles
are aligned and it
appears as a cylinder

30. • Wrist is flexed until the
scaphoid has a ring
appearance.
• 1.14 mm K wire to be
inserted at the proximal
pole of the scaphoid.

31. • Pass the wire along the
central axis of the
scaphoid, through the
distal pole into the
palmar surface.

33. • Determine dorsal or palar insertion of screw
based on fracture location.
• Select screw length 4mm shorter for allowing
countersinking.
• Advance the screw within 1-2 mm of the
opposite cortex.

35. Non union of scaphoid fractures
• Factors-
– Gross displacement
– Associated carpal injuries
– Impaired blood supply.
• Displaced fractures- 92% non union incidence.
• AVN-30-40 % most frequently in the proximal
third.
• Delayed treatment- 88%

36. • Treatment options- based on vascularity.
• If the blood supply to the proximal pole is
poor- vascularised bone graft is indicated.

38. Scaphoid Non union advanced collapse

39. Knoll and Trumble Algorithm

40. Operations for scaphoid non union
• Radial styloidectomy
• Excision of proximal/distal/ entire scaphoid.
• Proximal row carpectomy.
• Bone grafting
• Vascularised bone grafting
• Partial/total wrist arthrodesis.

41. Styloidectomy
• Indicated alongwith grafting or excision of ulnr
fragment when arthritic changes involve the
scaphoid fossa.
• Enough styloid should be resected to remove
entire articulation with scaphoid.
• Preserve palmar radiocarpal ligaments to
prevent ulnar translocation of carpus.

43. Excision
• Capitate migration should be addressed by
capitolunate or capito-lunate-triquetral- hamate
fusions.
• Indications of excision of proximal pole-
– Fragment is one fourth or less of scaphoid.
– Fragment is one fourth or less of scaphoid and is
sclerotic ,comminuted or severely displaced.
– Failed grafting
– Arthritic changes.

44. Proximal Row Carpectomy
• Post traumatic degenerative conditions of the
wrist.
• Healthy articular surfaces should be present
between the lunate fossa of the radius and
articular surface of capitate.
• Treatment of severe open carpal fracture
dislocations with disruption of bony
architecture and bony communition.

45. • Excision of lunate, triquetrum and entire
scaphoid.
• Distal pole with trapezium attachment can be
left for stable attachment of thumb.

47. Grafting operations
• First described by Matti and modified by
Russe.
• Union in 80-97%.
• Useful for non union without
shortening/angulation.

48. • Volar incision over FCR
tendon ending distally
over the saphoid
tuberosity.
• Opening made in volar
non articular cortex.
• Opposing cavities
excavated.
• Cancellous graft packed
+/- K wires.

49. Humpback deformity
• Resorption/communition
at fracture site.
• Extension of proximal pole
of scaphoid and lunate.
• Techniques-
– Fernandez et al
– Tomaino et al
– Stark et al

50. Fernandez bone grafting technique
• Volar approach similar to Matti Russe.
• Lamina spreader used to open volar site.
• Fracture site curreted.
• Corticocancellous bone graft harvested-
wedge shaped/ trapezoidal.
• Stabilise with 1mm K- wires; proximal to
distal.
• Interpositonal

51. • Calculate- amount of
resection, graft size,
angular deformity on
normal side.
• 1 mm drill holes in the
sclerotic bone.
• Correct the deformity
and shortening
alongwith the dorsal
rotation of lunate.

52. Tomaino technique

53. Vascularised bone grafts
• For non unions with avascular proximal pole
and previous failed surgeries for salvage.
• Pronator quadratus – pedicle bone
graft.(Yamamoto)

54. Zaidemberg
• Incision on the
dorsoradial side of the
wrist- centred on the
radiocarpal joint.
• First dorsal
compartment- identify
the ascending irrigating
branch of the radial
artery

56. Thank you