1. JJM MEDICAL COLLEGE
JOURNAL ON
First experience with a new adjustable plate for
Osteosynthesis of
SCAPHOID NONUNIONS.
MODERATORS: PRESENTED BY:
DR NAGBHUSHAN D M DR ROHIT KUMAR
PROFFESOR PG IN ORTHOPAEDICS
DR SRINATH S R DATED:19.01.12
ASSOCIATE PROFESSOR

2. INTRODUCTION
• Scaphoid is one of the smallest bone of human body.
• Its derived from greek word SKAPHOS meaning boat.
• It acts as a link between proximal and distal carpal
rows.
• Scaphoid fractures constitute 2.9% of all bone
fractures.
• Second only to the distal radius in frequency.

3. RULE OF 70’S FOR SCAPHOID
• 70% of all carpal fractures occur at scaphoid.
• 70% of blood supply is by the dorsal branch of the
radial artery.
• 70% of fractures occur at the waist of scaphoid.
• 70% of the scaphoid fractures unite .

4. VOLAR LIGAMENTS OF SCAPHOID

5. DORSAL LIGAMENT OF SCAPHOID

6. BLOOD SUPPLY OF SCAPHOID
30% 70%

7. HERBERT & FISHER CLASSIFICATION OF
SCAPHOID

8. TYPES OF NON UNION OF SCAPHOID
• TYPE NAME CHARACTER
• 1. SIMPLE NO DISPLACEMENT WITH
NO DEGENERATIVE CHANGE
• 2. UNSTABLE DIAPLACEMENT> 1mm OR
SL ANGLE >70 DEG
• 3. EARLY ARTHRITIS RADIO-SCAPHOID ARTHRITIS
• 4. S N A C WRIST III + MID CARPAL ARTHRITIS
• 5. S N A C PLUS ARTHRITIS THROUGHOUT
WRIST

9. NON UNION SCAPHOID
RADIOGRAPH MRI

10. VOLAR APPROACH

13. DORSI FLEX THE WRIST TO EXPOSE
SCAPHOID

14. DORSO-LATERAL APPROACH

15. BETWEEN EPL AND EPB

16. VISUALIZATION OF THE JOINT CAPSULE

17. ULNAR DEVIATE THE HAND TO EXPOSE THE
SCAPHOID

18. JOURNAL PROPER

19. • CONSERVATIVE and a number of surgical options are
availaible for treatment of scaphoid fractures.
• Nonunions of scaphoid fractures need surgical
management .
• In this investigation, all patients who underwent surgery
for fractures of scaphoid were treated with fixation of
HERBERT SCREWS .
• Nonunion of fractures were treated with iliac crest
bone grafting & implantation

20. • of HERBERT SCREW after resection of the bony parts
of the fracture .
• The cannulated self tapping headless bone screw
system permits easy implantation of the screw.
• Bony consolidation was achieved in a large number of
cases, only in few healing was not achieved after
primary treatment and also after treatment of
pseudoarthrosis.

21. • In past few years surgeons used titanium plate
osteo-synthesis in such cases which provide
fragment stability , particularly rotational stability ,
finally leads to consolidation of the fracture after
these second or third surgeries…

22. PATIENT AND METHODS
• Between JAN 2007 AND AUGUST 2009 , we treated 7
men and 4 women of mean age 37 years (22-53
years) by scaphoid plate osteosynthesis .
• Most of the cases were secondary referrals to our
hospital for treatment of nonunions.
• All the patient had #’s at the waist of the scaphoid
with established nonunion persisting for atleast 6
months after the causative injury , with wrist pain

23. weakness or both.
• Patients with severe degenerative changes in the
wrist were considered unsuitable and thus were
excluded .
• 6 patient had previous unsuccessful surgery with
herbert or AO screws in place before our plating .
(fig 1-4)
• 3 patients previously had bone grafting &
radiological apperance was classified according to
Herbert and Fisher classification before surgery.

24. PREVIOUS UNSUCCESSFUL SURGERY WITH HERBERT
SCREW
X RAY AP VIEW AFTER 3 MONTHS LATERAL VIEW AFTER 3 MONTHS

25. CT SCAN VIEW AFTER 13 MONTHS OF HERBERT SCREW
ANTERO POSTERIOR VIEW LATERAL VIEW

26. • Clinical assessment used a standard
proforma, which included range of movement ,grip
strength in Kilograms measured using a hydraulic
dynamometer.
• The results were graded as showing either full
function, allowing return to pre fracture activity
without any pain or as reduced function in which
there was a subjective feeling of stiffness or
weakness or objective return of range of
movement.

27. • In addition we used DASH score which ranges from
0-100 (0 being no limitation of movement and 100
as maximum).
• Radiological union was achieved when the
trabeculae traversed the graft from proximal to
distal pole on atleast 2 out of 4 standard scaphoid
views.
• In 4 patients CT was used to clear the doubt.

28. • The scaphoid is accessed by volar approach on the
radial side of flexor carpi radialis.
• The wrist capsule is opened and scaphoid is seen
,by the use of small Hohmann hooks , which are
introduced at the radial cortex surface , the
scaphoid can now be set .
• The pseudoarthrosis is scraped with a spherical
cutter at a rotation speed under adequate
irrigation ..(fig 5)

29. INTRAOPERATIVE SITUS AFTER SCRAPING OFF OF
PSEUDO-ARTHROSIS

30. • The two fragment are then brought in anatomical
position under control with two 1mm drill wires and
then a 3-d titanium plate was bent and fixed with at-
least 6 screws.

31. • Then the bone defect was filled with autogenous
spongy bone from the iliac crest .
• Because of the divergent position the screws
, stable fixation was achieved .
• The plate is small and adjust well to the shape of
the scaphoid that one may expect minimum
impingement of the adjacent radial lip .

32. • Finally drill wires were removed and wrist is
immobilized using a wooden spatula –FILMULIN
and PEHA adhesive dressing with thumb ring for 6
weeks .
• Heavy manual loads were to be avoided for a
period of 16 weeks ..

33. RESULTS
• All 11 patients had clinical and radiological follow
up for at least 6 months . The mean period was 13
months (6-23) .
• The range of wrist movements and grip strength
was recorded for all patients .
• All the fractures united at a median time of
operation for about 4 months .
• All patients reported improvement in their
symptoms and function.

34. • The mean DASH score was 28 points this value
indicate a good outcome .
• 4 patients had minor symptoms such as aching
wrist, cold intolerance, or scar tenderness. 8
patients had full function and 3 had reduced
function .
• 6 of the 8 patients with full function showed mild
to moderate degenerative changes on the pre
operative radiograph when compared with 3
patients with reduced function .

35. X RAY IMAGES- 2 MONTHS AFTER PLATING
ANTERO-POSTERIOR VIEW LATERAL VIEW

36. RANGE OF MOVEMENT AFTER 2 MONTHS
SUPINATION PRONATION

37. CONTD…
FLEXION EXTENSION

38. DISCUSSION
• The treatment of scaphoid fractures has a long
history.
• After massage and extirpation of fracture
scaphoid which was the treatment in last century.
• Lorenz bohler introduced immobilization with
padded plaster splint for 6 weeks for
uncomplicated transverse #’s.

39. • For complex #’s such as oblique ones , he
recommended a further immobilization for 6 weeks
.
• However treating pseudoarthrosis with a long
period of immobilization was futile and did not lead
to fracture healing .
• A reliable method of obtaining stable union of an
unhealed scaphoid was rendered possible only after
surgical dissection and stabilizing by spongy bone
repair .

40. • Although Matti suggested excavation of scaphoid
from the dorsal aspect and filling with autologous
spongy bone ,Russe performed a blockage by the
use of the volar chip plasty .
• He further introduced modification –Russe II which
is based on removal of the necrotic proximal
fragment and introduction of the mushroom
shaped bone chip from the iliac bone ..

41. • An alternate procedure for pseudo arthrosis was
given by Ender in 1977, using a scaphoid –beaked
plate .
• After iliac crest bone grafting , the plate is fixed in
the distal portion of the scaphoid with the screw
and in the proximal fragment with staved hook.
• The screw fixation of Mc Laughlin proved
advantageous for unstable #’s and shortened the
period of immobilization.

42. • Streli introduced cannulated drill compression
screw in 1970 through a previously introduced
k wire .
• Nevertheless , the majority of isolated scaphoid
was treated with conservative management until
few years ago.
• Only after introduction of Herbert screw in 1984
and its double threaded system , we had
commercially available implant which led to its
widespread use .

43. • The Herbert screw is suitable for the treatment of
recent #’s and in combination with bone chip plasty
for fracture pseudoarthrosis.
• This construction was adopted by many
manufacturers and subsequently modified .
• Its now available as cannulated screw and a mini
Herbert screw.

44. • The cannulated screw facilitates the technique of
osteosynthesis and permits minimally invasive
percutaneous osteosynthesis of scaphoid fractures.
• In rare cases, healing is delayed or does not occur at
all . This has been observed after screw
osteosynthesis, double screw osteosynthesis, or
alternative procedures even after folding a vessel
pedicle bone chip whether from pisiform bone or
radius .

45. CONCLUSION
• Assuming that the main reason for failed healing is
lack of stability, particularly rotational stability (apart
from poor vascularization of the proximal fragment ),
improving the osteosynthesis material seems to be
one of the most important factor for successful
healing .
• Thus, we consider stable scaphoid pseudoarthrosis,
which has been previously treated with screw
osteosynthesis and failed, as one of the main
indication for stable plate osteosynthesis with spongy
bone repair.

46. X RAY VIEW AFTER 8 MONTHS OF PLATING
LATERAL VIEW ANTERO POSTERIOR