Scaphoid Fractures

Courtesy:Dr Sudhir Warrier, President Bombay Orthopaedic Society

SCAPHOID FRACTURE

BLOOD SUPPLY

• Comes from distal to proximal
• Dorsal vessels >volar vessels
• Any fracture at waist/proximal to waist is at great danger of avascular necrosis of the proximal pole of the scaphoid

CLASSIFICATION

HERBERT’S CLASSIFICATION
1. Type A
A1 fracture of the tubercle
A2 incomplete fractures of the waist

2. Type B
B1 Distal oblique fractures
B2 complete fracture of the waist
B3 proximal pole fracture
B4 fracture dislocations (associated with peri lunate dissociation)
3. Type C
Delayed union
4. Type D
Non-union

• IMAGING
Best view of the scaphoid PA view, wrist in ulnar deviation, beam tilted by 30*

TREATMENT

• Scaphoid cast – BE cast with the forearm in the neutral position, wrist in 15-20* dorsiflexion, thumb in glass holding position with POP extending up to proximal phalanx leaving IP joint free
• Serial X-rays have to be taken Between 6-12 weeks for assessment of the healing

A If the fracture is uniting/no displacement -continue cast/change into splint -apply for another 6 weeks

B If the fracture is displaced /or developed a cyst/or developed humpback deformity surgery is required

B1 Rigid fibrous non union
Compression screw fixation without additional bone graft

B2 Lax-crepitant displaced non union

Bone grafting and fixation
1 Matti technique/ cancellous bone, dorsal approach
2 Russe technique/cortico cancellous grafts, volar approach
3 Fisk-Fernandez /tri cortical wedge of iliac crest

SCREWS
1 Herbert’s screw[3.5-3.9 mm]
2 AO headless screw[2.4mm]
3 Accutrac screw

Screw placement -central position
1 ANTEGRADE /proximal to distal for waist and distal # proximal pole #
2 RETROGRADE/distal to proximal for #close to tuberosity

BONE GRAFTS
If avascularity develops vascularised bone grafts required
A PEDICLED

• Zaidemberg 1.2 ICSRA Graft
• Pronator Quadratus

B MICROVASCULAR

• Free tissue transfer
• Medial femoral condyle graft

SNAC Wrist

• Scaphoid non union with advanced collapse
• Degenerative changes of the wrist following un-united scaphoid fractures

SNAC Wrist stages and treatment

1 involves only radial styloid———styloidectomy
2 radio carpal involvement———-4 corner fusion, radiocarpal fusion, proximal row carpectomy
3 mid carpal involvement———–wrist fusion
4 global wrist involvement——-wrist fusion