ScaPHOID #

FRACTURE CONTROVERSIES.

1. SCAPHOID FRACTURES

2. S caphoid comes from the Greek word “ skaphos ” meaning boat, a reference to the shape of the bone. The position of the scaphoid on the radial side of the wrist, as the proximal extension of the thumb ray, makes it vulnerable to injury.

3. ANATOMY It is located at a 45-degree plane to the longitudinal and horizontal axes of the wrist. It has a reduced capacity for periosteal healing and an increased tendency for delayed union and nonunion because just over 80% of its surface is articular cartilage . There are no tendon attachments to the scaphoid. The scaphoid is ridged across its nonarticular dorsoradial surface , along which the critical dorsal ridge vessels traverse.

4. BLOOD SUPPLY L argely retrograde blood supply. Dorsal branch: Enters via the small foramina along the spiralgroove and dorsal ridge of the scaphoid and supplies 70% to80 % of the scaphoid proximally, including the proximal pole. Volar branch: Enters via the scaphoid tubercle and supplies the remaining 20% to 30% of distal scaphoid

5. M ale predominance is seen with a male-to-female ratio of approximately 2.5:1. 90 % recalling a hyperextension injury . 30% to 40% of SUSPECTED scaphoid fractures are not identified on initial assessment and investigation with standard four-view radiographs. O ccult fractures of the scaphoid detected 10-14 days of injury.

6. INCIDENCE 2 to 7% of all fractures . 70 to 80% of carpal fractures. W aist (70%) are the commonest type in adults. D istal pole fractures (10-20 %). Proximal pole fractures (5-10 %). Tubercle fractures (5 %).

7. CLINICAL DIAGNOSIS. Acute scaphoid fractures can be difficult to diagnose. Combination of ASB tenderness , scaphoid tubercle tenderness, and ASB pain on longitudinal compression of the thumb generated a sensitivity of 100 % and a specificity of 74%. However, only valid for the first 24 hours. S pecificity of ASB pain on ulnar deviation of the pronated wrist, had a negative predictiveb value (NPV) of 100% ,negative test patients could be safely discharged.

8. SCAPHOID SERIES

9. ZITER VIEW/BANANA VIEW

10. FRACTURE MIMICKING D ark line that represents the dorsal lip of the radius, and the dorsal ridge can seem like a fracture in a semisupinated view. Mach effect (a dark line that represents the dorsal lip of the radius) (black arrow), a white line that represents the proximal side of the scaphoid tuberosity (white arrow ).

11. ULTRASOUND U se of high–spatial-resolution sonography for detecting the suspected scaphoid fracture, with the sensitivity rising up to 100% and the specificity as high as 91 %. MRI is argued to be the best investigation, it was found that the sensitivity and specificity of MRI were 100 %.

12. MRI

13. BONE SCAN S ensitive for the diagnosis of the occult scaphoid fracture . T o exclude a fracture and remove the unnecessary cast.

14. CLASSIFICATIONS Russe classification AO classification Herbert and Fisher classification Mayo classification

15. HERBERT & FISCHER

16. CRITERIA OF INSTABILITY >1 mm of fracture displacement. A lateral intrascaphoid angle of >35 degrees . Bone loss or comminution . Fracture malalignment . Proximal pole fractures. DISI deformity. Perilunate fracture-dislocation. A scapholunate angle more than 60° or a lunocapitate angle more than 15° also make the fracture unstable.

17. Associated injuries in 10 % of all scaphoid fractures , following a high-energy mode of injury. P roximal radial fractures are most frequently seen. C oncomitant fracture of the distal radius can be indicative of more serious ligamentous disruption and carpal instability.

18. Suspected Scaphoid Fractures Patients with a suspected occult scaphoid fracture are reevaluated after 1 to 2 weeks of immobilization . Posfracture CT/X ray. F urther 6 weeks of immobilisation before offering operative fixation if at 6 weeks the CT shows an unhealed fracture. Scaphoid Tubercle Fractures Avulsion injuries. For tubercle fractures, we recommend 3 to 4 weeks in a splint followed by active mobilization.

19. Nondisplaced Scaphoid Fractures S tandard a below-elbow cast with the thumb free for nondisplaced stable scaphoid fractures. O ffer patients with nondisplaced or minimally displaced fractures the option of percutaneous screw fixation, including a balanced discussion on the risks and benefits of surgery.

20. Unstable and/or Displaced Scaphoid Fractures Arthroscopic-assisted fixation or ORIF of the scaphoid is recommended if there is any gapping or angulation in the scaphoid, even if the fracture appears stable and impacted, because our impression is that displaced fractures are unstable.

21. Proximal Pole Scaphoid Fractures Relative risk of nonunion for proximal pole fractures (Herbert B3) was 7.5 times more when compared with more distal fractures when all were managed nonoperatively . For proximal pole fractures we recommend operative treatment using a small open dorsal approach to check alignment in case the fracture is unstable.

22. Nonoperative Versus Operative Management. Controversy exists regarding the management techniques for nondisplaced or minimally displaced waist fractures ( Herbert A2 , B1, and B2 ). There is an increasing body of evidence to support early percutaneous screw fixation of these fractures.

23. NON OPERATIVE OPERATIVE(ORIF) EARLY REHABILITATION LATE REHABILITATION DELAY RETURN TO WORK EARLY RETURN TO WORK LOW COMPLICATIONS` HIGH COMPLICATIONS RELATIVELY - SCAPHOTRAPEZOIDAL RTHRITIS? HIGH CHANCE OF DELAYED & NONUNION LESS CHANCE 3-20% CHANCE OF DISPLACEMENT IN CAST RIGID FIXATION ,Good compression 90-95% UNION O n current evidence neither method is clearly superior, not only with surgical management associated with improved functional outcome, a more rapid return to function/sports/work and superior union rates, but also with a significantly increased rate of complications. MORE TIME EXTERNAL IMMOBILAZTION LESS TIME EXTERNAL IMMOMOBILIZATION

24. PERCUTANEOS SCREW FIXATION S imple hyperextension of the wrist can achieve good reduction. Minimally invasive technique. Low complication rate. Lesser,faster time for union. Rapid return to function. Reduced scar & CRPS.

25. CONSERVATIVE APPROACHES. Above elbow cast. Colles cast. Scaphoid cast. Above-elbow casting, casting with or without the thumb included , and casting with the wrist in 20 degrees of flexion to 20 degrees of extension found no significant differences in union rate, pain, grip strength, time to union, or osteonecrosis .

26. L ong-arm casting is recommended. Immobilisation in a Colles ’ cast with the wrist in 20- degree extension is therefore recommended. Immobilisation of the thumb did not influence union rates scaphoid cast, leaving the interphalangeal joint of the thumb free.

27. DISADVANTAGES Immobilisation . S tiffness , D iminished grip strength , and D elayed return to work. Pseudoarthrosis ensues in approximately 4% of patients who only have casting, and is usually associated with vertical oblique fracture patterns (due to tilting and shearing forces ) and diastasis between bone fragments.

28. Trend toward earlier operative fixation of nondisplaced fractures TO REDUCE IMMOBILISATION period. Surgery may be considered if new healing activity is not evident and if union is not apparent after a trial of cast immobilization for about 20 weeks.

29. IF LEFT UNTREATED? N eglected scaphoid fractures , 100 % of patients developed radiographic osteoarthritis, mostly of the radiocarpal joint.