3. Blood Supply of Wrist and Carpus
Radial
Ulnar
Anterior interosseous arteries
Deep palmar arch
4. Anastomotic network
three dorsal & three palmar arches connected
longitudinally at their
medial and lateral borders by
radial & ulnar arteries
dorsal to palmar interconnections b/w
dorsal and palmar branches of
anterior interosseous artery
5.
6. Intrinsic blood Supply
The scaphoid, capitate & 20% of lunate
supplied by a single vessel - at risk for
osteonecrosis.
The trapezium, triquetrum, pisiform & 80% of
lunate receive nutrient arteries through two
nonarticular surfaces
consistent intraosseous anastomoses. ON is
rare.
The trapezoid and hamate lack an intraosseous
anastomosis and after fracture, can have
avascular fragments.
7. Scaphoid Anatomy
skaphos (Greek) – boat
Cashew shaped
within the wrist joint
more than 80% of its surface(except tubercle) -
covered by articular cartilage
8.
9. Scaphoid - blood supply
two major vascular pedicles
1.Volar branch enters the scaphoid tubercle and
supplies its distal 20% to 30%
2. Dorsal scaphoid branch of the radial artery.
Enter through numerous small foramina along
the spiral groove and dorsal ridge. (80% of the
blood supply).
10.
11. No vascular supply (13%) or
only a single perforator (20%) proximal to the waist
of scaphoid.
Unusual retrograde vascular supply - high risk of
nonunion and
ON after fracture.
12. Scaphoid Fracture
Most commonly fractured carpal bone
68% of carpal fractures
Fall on outstretched hand – forced dorsiflexion of
hand &
radial deviation
13. When fractured,
proximal pole - extend with attached lunate
distal pole - remains flexed, creating -hump-back
deformity.
14.
15. Classification
Russe -
1)Horizontal oblique - compressive forces across
fracture site.
2)Transverse –combination of compressive & shear
forces.
3)Vertical oblique – 5% , shear forces across fracture
site.
18. Herbert classification-
stability and delayed & nonunion of fractures.
Type A fractures- stable
Type A1- fracture of tubercle
Type A2 – incomplete fractures through waist
19. Type B –Acute and Unstable fractures
Type B1- Distal oblique fractures
Type B2- Complete fractures through waist
Type B3- Proximal pole fractures
Type B4- Transscaphoid & Perilunate
dislocations of carpus
Type B5-Comminuted
20. Type C fractures – Delayed unions
Type D fractures – established Nonunions
21.
22. Prosser classification
Classification of Distal pole fractures
Type 1 – Tuberosity fracture.
Type 2 - Distal intra-articular fracture.
Type 3 – Osteochondral fracture.
24. Diagnosis
Wrist pain
Tenderness & fullness in anatomic snuffbox.
Axial compression of thumb elicits pain
Forced ulnar deviation of pronated wrist also
elicits pain
25.
26.
27.
28. Even if initial radiographs –ve, immobilise in wrist
splint/shortarm thumb cast
Rpt after 10- 14 days
If still –ve and suspecting #,take MRI/ CT Scan
Fast,convenient, sensitive and specific.
29. Associated Injuries
Fractures of the distal radius
Perilunate dislocation and
Transscaphoid perilunate fracture dislocations
Joint and ligament damage that inevitably
accompanies this injury (x-ray never reveals the
true degree of injury)
31. Cast Immobilization
Undisplaced Stable Fractures
A1 - 4 weeks
A2 - 8 to 12 weeks until radiographic union.
decision for conservative Mx - CT scan shows
no displacement.
patient reviewed 6 weeks after cast removal for
clinical and radiological examination and
then every 3 months until the outcome is clear.
Patients should be seen for a final check up
after 1 year.
32. Cast Immobilization
Position of wrist has no affect over healing.
No difference b/w longarm & short arm cast.
Needs to be continued till fracture has healed.
Proximal pole fractures-12 weeks or longer
33. Surgery - indication
Displaced fracture
Proximal pole fractures regardless of displacement
Associated perilunate injuries
Open fractures
Polytrauma pts
34. Percutaneous Fixation
Guidewire placed percutaneously
along central axis of scaphoid to use cannulated screw
system.
Main key is to achieve most centrally placed screw
while holding fracture in compression
35. Risk of open procedures can be Avoided.
Healing time found to be same as cast
immobilization
Bond etal reported average healing time to be 7
weeks in these pts,compared to 12 weeks Rx in cast
No functional difference after 2 yrs
36. Volar percutaneous approach – distal scaphoid
used as entry point.
Preferred for distal pole fractures.
Use 16 gauge needle to find entry point of
guidewire.
Proximal cartilaginous surface of scaphoid
preserved.
37. Dorsal percutaneous approach:
Proximal pole is entry point
Wrist in flexion & ulnar deviation
38. Arthroscopic
Allows assessment of intraarticular injuries like
ligamentous structures
Many choices for percutaneous fixation
-Herbert screw
-Herbert-whipple screw
-Acutrak screw
39.
40.
41.
42. Open-Palmar
Classic Russe approach
For stable and unstable non union
Advantages
-
-Excellent visualization
-Less risk of vascular injury
43. Disadvantages
-potential for scarring
-limitation of wrist extension
-injury to volar radiocarpal ligament
-inability to assess and address dorsal scapholunate
ligament.
44. Open - Dorsal
Centered over Lister’s tubercle
Transverse incision over prox.scaphoid
Do not disturb dorsal ridge
Excellent visualization of prox.pole,esp with in maximum
flexion
Prefered open approac for prox. Pole fracture.
45. Disadvantages of immobilization
Frequent visits to check cast fit.
Frequent radiographs to check alignment.
Potential skin breakdown
Prolonged immobilization till complete healing
Stiffness of immobilized joints
46. Disadvantages of Surgery
Potential for infection
Wound complications
Injury to nerves,ligaments or tendons
Injury to vascular supply to scaphoid
Hardware failure or need for its removal
Associated aneasthesia complications.
47. Complications
Non Union
Malunion
Osteonecrosis – Preiser’s disease
Management –
arthroscopic debridement and drilling of the
lesion, rest, splintage, and electrical
stimulation
vascularized bone graft
harvesting a pronator quadratus graft.
48. Pearls
Occult scaphoid fractures are easily detected by
MRI scans.
Percutaneous stabilization of scaphoid
fractures significantly reduces the rate of
nonunion, as well as reducing the time lost
from work and sports.
Proximal pole fractures can also be stabilized
percutaneously by a dorsal approach.
49. Pitfalls
Scaphoid fractures are easily missed in children.
This can result in nonunion and serious problems.
Malalignment of scaphoid fractures is often
undiagnosed. CT scans are helpful.
Conservative treatment often ends in delayed
healing. An aggressive operative approach is
recommended.