FRACTURES OF SCAPHOID

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FRACTURES OF SCAPHOID
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• SCAPHOID IS THE MC ED CARPAL BONE
• CONTRIBUTES TO WRIST STABILITY
• PRINCIPAL BONY SUPPORT
• ATTACHED AT BOTH ENDS TO STRONG LIGAMENTS
• FLEXES C WRIST FLEXION , RADIAL DEVIATION
• EXTENDS C WRIST EXT ULNAR DEVIATION

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anatomy

• Scaphoid irregular shaped bone
• rest in plane 45 to long axis of wrist
• 80 articular cartilage
• prox pole attatched to lunate by inteross lig
• distal pole has vshaped scaphotrapezoid lig
  scapho capitate lig and dorsal capsule

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BLOOD SUPPLY

• CRITICAL IN REGARD TO LOCATION
• MAJOR BS --SCAPHOID BR OF RADIAL ARTERY ENTERING
  DORSAL RIDGE 70 -80 INCLUDING PROX
  POLE
• 2ND GROUP OF VESSELS ENTER SCAPHOID TUBERCLE
  --SUPPLY ONLY DISTAL 30
• PROX 1/3 MAINLY INTRA ARTICULAR
• COVERED BY HYALINE
  CARTILAGE
• NEGLIGIBLE BLOOD SUPPLY
• SO PROX 1/3 IS PRONE FOR OSTEONECROSIS

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DORSAL DISTAL LEVO VOLAR
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A/C SCAPHOID

• INJ OF YOUNG MEN AFTER A FALL
• MECHANISM
• 1 compression inj--result from impaction
• 
  cout displacement
• 2hyper ext /bending inj-- result from tensile
  forces along palmar surf
• with
  displacement

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Clinical features

• Present c pain wrist ?sprain
• O/E tendernes in anat snuff box distal to radial
  styloid
• same findings may be found in lig inj
• so a high index of suspicion needed
• c a distal s tends to flex prox s extends c
  prox carpal row---- ch HUMP BACK DEFORMITY
• failure to correct deformity ---mal alignment,non
  union,malunion,late carpal instability,post
  traumatic arthritis

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radiology

• AP
• LATERAL, , SCAPHOID
• MOTION VIEWS flex /ext,radial/ulnardeviation--demo
  nstrate displacement
• radiologic sigh in fresh inj is displact of
  NAVICULAR FAT PAD STRIPE TERY RAMIN
• REPEAT XRAY2--3wks
• if still in doubt TECH BONE SCAN/CT/MRI
• BONE SCINTIGRAPHY

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CLASSIFICATION

• LOCATION OF WITHIN BONE
• AMOUNT OF STABILITY

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• STABLE
• UNSTABLE
• stable-----un displaced
• intact cartilage
• caused by impaction
• no step off in xray
• un stable-----displacedgt1mm step off
• caused by bending stress

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DISPLACED

• gt 1MM STEP OFF
• gt60SCAPHOLUNATE
• gt15LUNATOCAPITATE
• STILL A ROLE FOR CMR AND THUMB SPICA

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CMR OF DISPLACED BY 3 POINT PRESSURE. UPWARD
PRESSURE ON DISTAL POLE OF SCAPHOID,DOWNWARD
PRESSURE DORSALLY ON CAPITATE LUNATE
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• If CMR not acceptable ORIF is indicated
• ORIF DONE WITH K WIRES
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  COMPRESSION SCREW FIXATION
• AO SCREW/HERBERT SCREW CAN BE USED
• SCREWS PROVIDE rigid fixation
• allow
  early wristmotion

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• DELAYED UNION
• said to be present if there is no evidence of
  healing after 3 months
• NON UNION said to be present if there is no
  evidence of healing 6 months after

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• STABLE NONUNION
• should an asympt pt c nonunion have surgical
  treatment?
• Studies do favour surgery to prevent late
  arthritis
• PRINCIPLES
• preservation of BS
• BONE APPOSITION BY AN INLAY GRAFT
• IF for stability
• correction of carpal instability

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Before IF

• WHAT S EFFECT OF SURGERY ON BS ?
• HOW SHOULD AVN BE CONFIRMED ?
• IS THERE A ROLE FOR ELECTRICAL STIMULATION ?
• IS IF NECESAARY WHEN NON UNION IS
  NOT DISPLACED

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• SURGERY SHOULD BE CONSIDERED ONLY IF THERE IS NO
  INDICATION OF NEW HEALING ACTIVITY AND NO
  INDICATION OF UNION AFTER A TRIAL OF CAST
  IMMOBILISATION FOR ABOUT 20 WKS

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BONE GRAFTING

• MATTI USED CANCELLOUS BG INTO SITE THRU DORSAL
  APPROACH
• RUSSE MODIFIED THIS BY A PALMAR APROACH
• USED 2 CORTICO CANCELLOUS GRAFTS INTO SITE C
  CANCELLOUS SIDE FACING EACH OTHER
• RUSSE TYPE IS ROC
• REPORTED EXCELLENT RESULTS

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• RADIAL STYLOID /METAPHYSEAL GRAFT CAN BE SELECTED
• ILIAC GRAFT IS STRONGER COMPACT TRABECULAR
  GRAFT,EASIER TO SCULPT FOR PROPER FIT

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METHODS FOR ASSESING AVN

• Bone scan
• tomography
• MRI
• ONLY DEFINITIVE TEST -- observation at surgery of
  presence/absence of bleeding from bone

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• IF PROX SEGMENT COMPELETELY AVASCULAR
• INTERCARPAL FUSION
• EXCISION OF PROX FRAGMENT
• INTERPOSITION ARTHROPLASTY
• PROX ROW CARPECTOMY
• SCAPHOID ALLOGRAFT
• VASCULARISED BG CONSIDERED

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ELECTRICAL STIMULATION

• Pulsed electromagneticstimulation--proposed for
  undisplaced scaphoid non union
• has a role for 3--6 m old
• controversy regarding its use is unsettled

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Unstable non unions

• Indications for inter positional BG
• gross motion at non union site
• scaphoid resorbtion
• loss of carpal ht

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DORSORADIAL APPROACH,NON UNION SITE
DEBRIDED SMALL GRAFT TAKEN FROM ILIAC CREST AND
HELD WITH K WIRES
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RADIAL STYLOIDECTOMY

• ARTHRITIC CHANGES INVOLVE ONLY SCAPHOID FOSSA
  INDICATED C BG OR EXCISION OF FRAGMENT
• IN OLD PTS -- WHEN --RADIO SCAPHOID ARTHRITIS
  PREDOMINATES PROX FRAGMENT IS NOT LOOSE--IT
  ALONE PROVIDES PAIN RELIEF

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Excision of prox fragment

• When fragment consists oflt1/4 of scaphoid
• sclerotic ,comminuted displaced
• grafting has failed
• arthritic changes are present in region of radial
  styloid

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PROX ROW CARPECTOMY

• MANUAL LABOURERS ARE BETTER CANDIDATES FOR WRIST
  ARTHRODESIS BUT THOSE PTS REQ WRIST MOBILITY AND
  ARE WILLING TO ACCEPT SOME WRIST PAIN ARE BETTER
  CANDIDATES

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Muscle pedicle bone graft

• Kawai yamamoto --- pedicle bone graft using
  pronator quadratus
• useful in difficult non unions

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GRAFT FILLS EXCAVATED SITE OF NONUNION FIXED C
KWIRES
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• ZAIDEMBERG USED VASCULARISED BG ----DISTAL
  DORSOLATERAL RADIUS

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ARTHRODESIS

• CONSIDERED AS A SALVAGE PROCEDURE FOR OLD
  UNUNITED/MALUNITED OF SCAPHOID C ASSOCIATED
  RADIOCARPAL TRAUMATIC ARTHRITIS

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