2. Fracture Scaphoid
Introduction
Anatomy
Biomechanics
Mechanism of injury.
Classification
Clinical picture& Diagnosis
Management
Conclusion.

3. Fracture Scaphoid
1. It is also called Navicular,
2. It is a irregular shaped bone more likea twisted peanut than
boat
3. Common in young adults rare in children if occurs it is distal
1/3 Fr
4. The mechanism of injury is by fall on out stretched hand.
5. Hyper extension of wrist ,pronation, radial deviation.
6. Second commonest Fr in the wrist
7. Scaphoid is the key bone in maintaining the stability of carpal
articulation
8. Blood supply of scaphoid
9. Subtleness of presentation- wrist sprain
10. Complexity of choice of treatment.

4. Fracture Scaphoid
• Present on the radial side of
wrist spans between two rows of
carpal bones
• It connected with rest of the
carpal bones through various
ligaments of , volar ligaments are
more strong
• Distally articulates with
trapizium ina gliding movement
gives independent movement to
thumb
• On the ulnar side articulates with
capitate, proximally with Lunate
in a rotatory movement
• Proximally the convex surface
articulates with distal end of
radius

5. Fracture Scaphoid…Blood supply.
• The blood supply to the scaphoid is
similar to that of head of femur
• He articular surface cover the 80%of
scaphoid only small part on the
dorsum of the neck and very small
part in the distal part of the bone is
available for the blood vessels to
enter the bone.
• Major blood supply is form scaphoid
branches of Radial artery enters into
the distal ridge just distal to the waist
supplies 80% of the bone in
retrograde fashion.
• The second group is form the palmar
and superficial branches of the radial
artery, perfuses distal20-30% of distal
bone and the tuberosity.
• There is no anastomosis between the
voalr and dorsal vessels.
• 79% of the vessels enter through the
dorsal ridge.

6. Fracture Scaphoid……. Biomechanics
• The carpal bones -3 groups-
medial ,central, lateral.
• Medial –stability
• Central---flexion/ extension
• Lateral--- rotations
• Scaphoid flexes on
radialdeviation ,& palmar
flexion of the wrist, extends
on extension & on ulnar
deviation

7. Fracture Scaphoid… Biomechanics. Contd
• The stable Fr maintains
the normal orientation
for proximal and distal
rows
• Unstable Fr angulates
dorsally and produces –
Humpback deformity
• Results in DISI
• Grip weakness, late OA
OA

8. Fracture Scaphoid -Mechanism of injury
1. Fall on outstretched hand force absorbed on the radial side of the
Hand
2. Hyper extension of the wrist presses the scaphoid against the
dorsal rim of the radius
3. The strong volar scapho lunate, lig holds tha proximal half scaphoid
the distal half is carried up, results in TS Fr that starts volarlay and
proresses dorsally.
4. Compression injury- un displaced Fr
5. Hyperextension injury- displaced Fr

9. Fracture Scaphoid… Classification
RUSSE
HERBERT
ANATOMICAL

10. Fracture Scaphoid -Diagnosis
•A strong index of suspicion is the key to
early diagnosis otherwise the injury will
be dubbed as wrist sprain
•The diagnosis should be based on :
• History
• Clinical examination
• Radiographic evaluation

11. History
• Occurs after a fall on an
outstretched hand, athletic
injury, or MVA
• Usually happens in young adult
men
• Pain at the radial side of the wrist
• Associated injuries

12. Clinical Examination
• Should demonstrate tenderness in the anatomic snuff box
• Tenderness to palpation over scaphoid tuberosity and/or
proximal pole just distal to Lister's tubercle
•Tenderness with axial compression of thumb toward the
snuff box
• Tenderness as patient supinates forearm against
resistance
•Radial & ulnar deviation results in pain on radial side
of wrist
• Forced dorsiflexion usually elicits significant
tenderness
•There is usually pain at extremes of motion
•Limitation of wrist motion – but not dramatically
•Swelling – usually not present

13. Differential Diagnosis
It is the same DD of radial sided wrist pain
1. Lunate dislocation or fr
2. Sapholunate instability
3. Radial styloid fr
4. Trapezium fr
5. Rupture of FCR tendon
6. ECRB or ECRL avulsion

14. Radiological Diagnosis
The best method for determining the presence of a fracture
Many different views have been recommended
Initial views are : PA, lateral, scaphoid view ( PA with ulnar
deviation
Motion views of the wrist ( flexion-extension-radial & ulnar
deviation ) may demonstrate fracture displacement
If a diagnosis still can’t be confirmed with confidence on routine
films, further oblique views can be taken
If Uncertainty still exists after all these maneuvers , the patient
should be placed in a cast for 2 to 4 weeks and the clinical &
radiographic evaluation repeated

15. Radiological Diagnosis
If the second radiographic examination is still equivocal , a
technetium Bone scan, CT or MRI of the wrist is recommended
The bone scan is the most sensitive but the least specific of these
modalities, thus if the bone scan is negative , a scaphoid fx is
ruled out
If the bone scan is positive, more specific studies ( e.g. CT or
MRI) can be helpful

16. Clinical presentation
Time since injury
• Acute fracture - less than 3 weeks old
• Delayed union - 4 to 6 months old
• Nonunion - more than 6 months old
Amount of fracture displacement ( stability ) :
• Un displaced ---- stable
• Displaced ---- unstable

17. Scaphoid Fracture….
• The unstable fracture Negative prognostic factors are
(displaced) is defined
as :
- presence of a fracture • late diagnosis
gap > 1 mm on any • proximal location
radiographic projection • displacement
- scapho lunate angle > 60 • angulation
- radio lunate angle > 15 • obliquity of the fracture line
or intrascaphoid angle > • smoking
20
• carpal instability

18. Scaphoid Fracture…..Treatment
STABLE UNSTABLE
Is determined by:
• Location
• Degree of displacement
• Fresh vs old fracture
Non operative( cast immobilization )
3-main areas of disagreement
1- the position of the wrist in the cast
2- the need to include joints other than
the wrist in the cast
3- the duration of the immobilization
CONSERVATIVE SURGERY

19. Stable Fr Cast Immobilization.
• B/E or A/E Cast (Fore arm supinaton/Pronation)
Long arm cast is recommended for non displaced proximal pole fr
• Thumb or Three fingers
To maintain the alignment of the Scaphoid in unstable Fr
• Duration of Treatment ‘’ longer the immobilization better is healing”
• Consider changing the cast every 10-14 days for the first 6 weeks so that it
remains firm around forearm muscles and the wrist
• Time to healing by location :
– Distal third fr heals in 6-8 weeks
– Middle third fr 8-12 weeks
– Proximal third fr 12-24 weeks
• A 95 % union rate can be expected with this management
• undisplaced, stable fractures if diagnosed and immobilized early (95 % with x-ray
evidence of beginning consolidation at 6 weeks )

20. Stable Fr Cast Immobilization.
• Initial delay in treatment does not preclude casting
• If treatment is instituted within4weeks no effect on
healing time or rate of union has been shown
• Delay beyond 6 months invariably requires operative
treatment
• The difficulty lies in fractures between 6 weeks and 6
months.
---If no evidence of bony resorption exists, casting
may result in union.
---- If bony resorption or displacement, greater than 1 mm exists,
operative reduction and bone grafting will be needed

21. Stable Fr------ Surgical treatment
• Indications.
• Professionally high demand pt
• Pt who cannot tolerate prolonged immobilization
Percutaneous Screw fixation- volar /dorsal app
Technically demanding
Displacement of fragments can occur
* Pt need to be explained about the pros & cons, need for the
short term cast immobilization thoroughly*

22. Problem Fractures.
1. Displaced /angulated/ acute fracture
2. Acute Fr associated with carpal instability
3. Delayed union or nonunion when bone grafting
4. is insufficient to provide adequate internal fixation
5. S.Fr associated with a perilunate fr - dislocation
Ligamentous injury
4. Non displaced fr of proximal pole)

23. Unstable Fr- conservative Treatment
Poor risk Pt
Pt not willing for Surgical Tr
Closed manipulation&
cast Immobilization
-- 3 point fixation with dorsal
pressure on capitate & lunate
,volar pressure over the distal end
of scaphoid ( rotates the
lunate,proximal fragment into
flexion)- cast A/E ,slight dorsi
flexion radial deviation, thumb/ 3
finger cast

24. 1.
Unstable Fr- surgical Treatment
The choice of the surgical
procedure will vary with the
surgeon’s preference and
experience,
type of the fracture,
patient’s age,
periscaphoid arthrosis
1. The most important aspect of
the treatment is meticulous
technique and not the device or
equipment selected
2. Reduction of the fracture should
be anatomic
Volar approach -- is most of the time the
preferred approach to limit the injury to the
blood supply of the scaphoid
Dorsal approach – will be used to address
the fractures of the proximal approach
24

25. After treatment care
• After achieving a rigid fixation ,
there is a big controversy about
the need for immobilization
• Some authors recommend a
long arm cast after k-wire or
compression screw fixation for 2-
3 weeks
• New literature is in favor of early
mobilization

26. Treatment of middle third fr
• They are the commonest (65%)
• If fresh stable: short-arm thumb spica cast
• If fresh undisplaced but potentially unstable
(e.g. vertical oblique) and stable fx older than
3 wks : long-arm thumb spica cast
• If fresh displaced : ORIF (k-wires or screws)

27. Proximal Pole Fractures
• challenging
• Often difficult to heal
• Prolonged immobilization- snug , well molded long arm cast-
(sometimes exceeds 9 mos) has been necessary with conventional
casting
• Early incorporation of PES has been recommended
• Displaced Fr-
• Fragment small- K wire fixation
• Fragment is 1/3 of Scaphoid Screw fixation – Dorsal app
• Determination of bony union is not easy
• Tomography or CT is needed
• Multiple follow up films should be obtained for several
months after the assumed healing

28. Distal Pole Fractures
• These are often avulsion injuries of the
tuberosity and can be expected to heal
promptly with cast treatment
• Fresh and undisplaced should heal in 4-8 wks
in a cast
• Displaced fr needs ORIF

29. Complications of Scaphoid Fr
• Delayed union or Nonunion
• Malunion (Humpback deformity)
• SLAC wrist
• Osteonecrosis

30. Scaphoid Fracture-- Nonunion
• The incidence of scaphoid nonunion for undisplaced
fr is 5-10%
• The incidence increases up to 90% in displaced
proximal pole frs
• Risk factors :
– Proximal pole fr
– Displacement
– Late diagnosis
– Inadequate immobilization
– Associated ligamentous injuries

31. Scaphoid Fracture-- Nonunion
• Failure to heal after 6 months establishes the Dx
of nonunion
• Recent studies indicated that virtually that “all
unstable non unions lead to carpal collapse and
post traumatic arthritis,,
• All scaphoid nonunions even if asymptomatics
hould be treated aggresively.
• Thin cut CT scan show more details than
conventional tomograms
• Sagittal views are helpful in determining the
degree of carpal collapse and humpback
deformity

32. Sc Fr—Nonunion… Treatment
• Procedures available- 1.Bone grafting,2.Electrical stimulation
• 3. Proximal pole excision 4. Salvage procedures
• Look for the following……
• Comminution of Fr site/ gape with collapse.
• Avascularity of proximal pole
• Orientation of lunate , Scapho-lunate angle, Intra scaphoid
angulation
Procedures of choice ….OR+ bone grafting
No collapse- Inlay grafting- RUSSE
COLLAPSE + - interposion grafting-FERNANDASE
proximal pole avascularity- vascular pedicle grafting
1. pronator Quadratus based
2.Supra retinacular artery based

33. Russe procedure
•Volar app radial to FCR
•Double coartico cancellous grafts
facing on the cancellous surface
•The time to union with this
procedure is relatively long
,generally requiring cast
immobilization for 6-4 months
•Healing rates of 85-90 % have been
reported
•Satisfactory relief of symptoms has
been reported ; 78 % of painful wrist
became free of symptoms and 88 %
of patients were satisfied with the
results

34. Fernandez procedure
• angulated nonunions with
a dorsal humpback
deformity
• Interpositional grafting.
• Trapezoidal iliac graft to
correct the angulation
and carpal collapse
pattern.
• Fixation is achieved with
screws or k-wires
• volar approach is used,
and care must be taken to
preserve the vascularity
of the fragments

35. Avasularity of proximal pole
Braun procedure
Braun procedure
Procedure similar to Russe procedure
Block of radius 15-20x8-10mm raised along with
distal pronator qudratus
Bone grafting based on supra retinacular branch of
radial artery
Dorsal approach

36. Non-union… treatment
Electrical stimulation:
• Noninvasive treatment for scaphoid nonunion. Although
controversial, there appears to be some benefit (shorter
healing time)when electric stimulation is combined with bone
grafting procedures
• Proximal pole excision:
when a small proximal fragment is not amenable
to bone grafting ,proximal pole excision and fascial
hemiarthroplasty are recommended

37. Non-union… treatment
Salvage procedures :
• Are indicated when nonunion has lead to carpal
collapse and secondary degenerative changes
• Proximal row carpectomy,intercarpal arthrodesis, or
radiocarpal arthrodesis is recommended in patients
with chronic wrist pain and stiffness
• Radial styloidectomy and scaphoid interposition
arthroplasty may be combined with other procedures
or performed independently in the younger patient
with less severe symptoms
• Silicone implants have been used in the past but are
now avoided because of silicone synovitis

38. Malunion
• Malunion of the scaphoid may occur when a displaced or
angulated fracture is allowed to heal without anatomic
reduction
• In most of cases , there is a dorsal angulation resulting in a
fixed humpback deformity
• DISI pattern ensues ,resulting in pain ,loss of motion, and
decreased grip strength
• Treatment in a young patient includes osteotomy,volar
wedge bone graft, and internal fixation
• Once degenerative arthritis has begun ,treatment is limited
to a salvage procedure such as proximal row carpectomy,
intercarpal arthrodesis,or complete wrist fusion

39. conclusion
Scaphoid treatment should be planned based on…
1 stability of fr stable/ unstable
2. Anatomical Location of fr( p1/3, waist, Distal1/3)
3.Comminution at Fr site, avasclarity of proximal pole
4.Delayed or early presentation
5. Features of non union
6.Evidence of DISI( dorsal tilting of lunate)
In cast application stable Fr- thumb spica,A/E castfor unstable Frs
,Stable proximal pole fr, 3 finger/ fist cast- displaced Fr, Fr
associated with carpal instability.
Percuataneous fixation to be used with cation after pt is well
informed and surgeon had enough open reduction experience
Reduction always should be Anatomical