Scaphoid Fracture

Author: David Abbasi

Topic updated on 03/17/13 5:26pm

Introduction

Scaphoid is most frequently fractured carpal bone
Epidemiology
- incidence
  - accounts for up to 15% of acute wrist injuries
- location
  - incidence of fracture by location
    - waist -65%
    - proximal third - 25%
    - distal third - 10%
      - distal pole is most common location in kids due to ossification sequence
Pathoanatomy
- most common mechanism of injury is axial load across hyper-extended and radially deviated wrist
  - common in contact sports
- transverse fracture patterns are considered more stable than vertical or oblique oriented fractures
Prognosis
- incidence of AVN with fracture location
  - proximal 5th AVN rate of 100%
  - proximal 3rd AVN rate of 33%

Anatomy

Articular surface
- > 75% of scaphoid bone is covered by articular cartilage
Blood supply
- major blood supply is dorsal carpal branch (branch of the radial artery)
  - enters scaphoid in a nonarticular ridge on the dorsal surface and supplies proximal 80% of scaphoid via retrograde blood flow
- minor blood supply from superficial palmar arch (branch of volar radial artery)
  - enters distal tubercle and supplies distal 20% of scaphoid
Motion
- both intrinsic and extrinsic ligaments attach and surround the scaphoid
- the scaphoid flexes with wrist flexion and radial deviation and it extends during wrist extension and ulnar deviation (same as proximal row)
Also see Wrist Ligaments and Biomechanics for more detail

Presentation

Physical exam
- anatomic snuffbox tenderness dorsally
- scaphoid tubercle tenderness volarly
- pain with resisted pronation

Imaging

Radiographs
- recommended views
  - AP and lateral
  - scaphoid view
    - 30 degree wrist extension, 20 degree ulnar deviation
  - 45° pronation view
- findings
  - if radiographs are negative and there is a high clinical suspicion
    - should repeat radiographs in 14-21 days
Bone scan
- effective to diagnose occult fractures at 72 hours
  - specificity of 98%, and sensitivity of 100%, PPV 85% to 93% when done at 72 hours
MRI
- most sensitive method to diagnose of occult fractures within 24 hours
- allows immediate identification of fractures and ligamentous injuries in addition to assessment of vascular status of bone (vascularity of proximal pole)
CT scan with 1mm cuts
- less effective than bone scan and MRI to diagnose occult fracture
- can be used to evaluate location of fracture, size of fragments, extent of collapse, and progression of nonunion or union after surgery

Treatment

Nonoperative
- thumb spica cast immobilization
  - indications
    - stable nondisplaced fracture (majority of fractures)
    - if patient has normal xrays but there is a high level of suspicion can immobilize in thumb spica and reevaluate in 12 to 21 days
  - technique
    - start immobilization early (nonunion rates increase with delayed immobilization of > 4 weeks after injury)
    - long arm spica vs short arm casting is controversial
      - with no consensus
    - duration of casting depends on location of fracture
      - distal-waist for 3 months
      - mid-waist for 4 months
      - proximal third for 5 months
      - athletes should not return to play until imaging shows a healed fracture
    - may opt to augment with pulsed electomagnetic field (studies show beneficial in delayed union)
  - outcomes
    - scaphoid fractures with <1mm displacement have union rate of 90%
Operative
- ORIF vs percutaneous screw fixation
  - indications
    - in unstable fractures as shown by
      - proximal pole fractures
      - displacement > 1 mm
      - 15° scaphoid humpback deformity
      - radiolunate angle > 15° (DISI)
      - intrascaphoid angle of > 35°
      - scaphoid fractures associated with perilunate dislocation
      - comminuted fractures
      - unstable vertical or oblique fractures
    - in non-displaced waist fractures
      - to allow decreased time to union, faster return to work/sport, similar total costs compared to casting
  - outcomes
    - union rates of 90-95% with operative treatment of scaphoid fractures
      - CT scan is helpful for evaluation of union

Technique

ORIF vs percutaneous screw fixation
- approach
  - dorsal approach
    - indicated in proximal pole fractures
    - care must be taken to preserve the blood supply when entering the dorsal ridge by limiting exposure to the proximal half of the scaphoid
    - percutaneous has higher risk of unrecognized screw penetration of subchondral bone
  - volar approach
    - indicated in waist and distal pole fractures and fractures with humpback flexion deformities
    - allows exposure of the entire scaphoid
    - uses the interval between the FCR and the radial artery
  - arthroscopic assisted approach
    - has also been described
- fixation
  - rigidity is optimized by long screw placed down the central axis of the scaphoid
- radial styloidectomy
  - should be performed if there is evidence of impaction osteoarthritis between radial styloid and scaphoid

Complications

Nonunion
- SNAC wrist (scaphoid nonunion advanced collapse)
  - see below

Scaphoid Nonunion and Scaphoid Nonunion Advanced Collapse (SNAC wrist)

Introduction
- nonion can lead to advanced collapse and progressive arthritis
  - Scaphoid Nonunion Advanced Collapse (SNAC)
    - natural history of degenerative changes first occurs at the radioscaphoid area followed by pancarpal / midcarpal arthritis
Treatment
- inlay (Russe) bone graft
  - indicated if minimal deformity and there is no adjacent carpal collapse or excessive flexion deformity (humpback scaphoid)
  - 92% union rate
- interposition (Fisk) bone graft
  - an opening wedge graft that is designed to restore scaphoid length and angulation
  - indicated if there is adjacent carpal collapse and excessive flexion deformity (humpback scaphoid)
  - results show 72-95% union rates
- vascular bone graft from radius
  - gaining popularity and a good option for proximal pole fractures with osteonecrosis confirmed by MRI
  - 1-2 intercompartmental supraretinacular artery (branch of radial artery) is harvested to provide vascularized graft from dorsal aspect of distal radius
Outcomes
- patients with scaphoid nonunions of > 5 years duration or proximal pole necrosis have less favorable outcomes
- punctate bleeding of bone during surgery is a good prognostic indicator of union
  - 92% union with obvious bleeding, 71% with questionable bleeding, 0% with no bleeding
  - results show decreased rate of arthritis (down to 40-50%)

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Qbank (8 Questions)

TAG

(OBQ09.36) A 22-year-old male snowboarder falls on an outstretched hand and presents with the radiograph shown in Figure A. Which of the following techniques is MOST important in optimizing biomechanical fixation? Topic

Review Topic

FIGURES: A

1. Using a longer screw placed in the central axis of the scaphoid
2. Using a larger diameter screw placed in the central axis of the scaphoid
3. Using a longer screw placed in the dorsal axis of the scaphoid
4. Using a larger diameter screw placed in the dorsal axis of the scaphoid
5. Using a larger diameter screw placed in the volar axis of the scaphoid

PREFERRED RESPONSE ▶

DISCUSSION: Several studies have shown a longer screw placed in the central axis of the scaphoid optimizes biomechanical fixation of scaphoid waist fractures. The first reference by McCallister et al is a cadaveric, biomechanical study that demonstrated a centrally placed screw had 43% more stiffness than an eccentrically placed screw. They recommend using surgical techniques that optimize central placement and screw length, such as using a cannulated screw. The study by Dodds et al supported these findings and added that a longer screw with 2mm of bone coverage provided greater stability than a shorter screw. A more centrally placed screw is generally longer and has more length of screw on each side of the fracture than does a peripherally placed screw due to the anatomic dimensions of the scaphoid. Many studies have discussed the amount of compression generated by various internal fixation screws (e.g headless vs. headed, variable pitch, partially vs. fully threaded, cannulated vs. noncannulated), but it is believed that rigidity of fixation is probably the most important factor in promoting healing of scaphoid fractures.

REFERENCES:

1. McCallister WV, Knight J, Kaliappan R, Trumble TE. Central placement of the screw in simulated fractures of the scaphoid waist: a biomechanical study. J Bone Joint Surg Am. 2003 Jan;85-A(1):72-7. PMID:12533575 (Link to Abstract)

2. Dodds SD, Panjabi MM, Slade JF 3rd. Screw fixation of scaphoid fractures: a biomechanical assessment of screw length and screw augmentation. J Hand Surg Am. 2006 Mar;31(3):405-13 PMID:16516734 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD,

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(OBQ09.56) An open dorsal approach for antegrade screw fixation of a nondisplaced scaphoid waist fracture has which of the following advantages over a percutaneous dorsal approach? Topic

Review Topic

1. Decreased risk of proximal pole AVN
2. Increased risk of posterior interosseous nerve injury
3. Decreased risk of injury to the APL tendon
4. Increased risk of injury to the EPL tendon
5. Decreased risk of screw prominence above subchondral bone

PREFERRED RESPONSE ▶

DISCUSSION: Scaphoid screw fixation should be just below the subchondral bone; this is best judged by direct visualization.

Adamany et al in an anatomic study using fluoroscopy to insert a scaphoid screw via a percutaneous approach found that the scaphoid screw "was prominent (above the subchondral bone) in 2 of 12 specimens and flush with or buried in the remaining 10 specimens." As a result, they recommend using a limited dorsal incision to verify full seating of the screw. In addition, they found the percutaneous approach was within 2.2-3.1 mm of the PIN, EDC, and EIP. Thus, all of these structures are at increased risk of injury in a percutaneous approach. The APL tendon is not in the surgical field. Illustration A shows the AIN(arrowhead) is deep in relation to pronator quadratus. Sensory remnant of posterior interosseous nerve (straight thick arrow) is adjacent to interosseous membrane. White arrow is median nerve. Shaded open arrow is ulnar nerve, and long thin arrow is superficial radial nerve.

Tumilty et al inserted a Herbert screw through a dorsal approach in 12 cadaveric wrists. They then imaged them with AP/Lateral xrays, and 360 degree fluoroscopic views. The wrists were then dissected to evaluated for subchondral penetration, and plain x-ray films were accurate in 5 of 6 specimens. Fluoroscopy was accurate in all 6. They concluded that fluoroscopy during placement of the Herbert screw may decrease the rate of subchondral penetration.

Illustrations: A

REFERENCES:

1. Adamany DC, Mikola EA, Fraser BJ. Percutaneous fixation of the scaphoid through a dorsal approach: an anatomic study. J Hand Surg Am. 2008 Mar;33(3):327-31. PMID:18343286 (Link to Abstract)

2. Tumilty JA, Squire DS. Unrecognized chondral penetration by a Herbert screw in the scaphoid. J Hand Surg Am. 1996 Jan;21(1):66-8. PMID:8775197 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Derek Moore, Patrick McCulloch MD,

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TAG

(OBQ09.234) Which of the following statements is true about force transmission based on wrist position? Topic

Review Topic

1. neutral wrist position decreases force through the lunate fossa
2. extended wrist position increases force through the lunate fossa
3. neutral wrist position increases force through the scaphoid fossa
4. extended wrist position increases force through the scaphoid fossa
5. wrist position has no effect on force transmission

PREFERRED RESPONSE ▶

DISCUSSION: Majima et al tested force transmission through the wrist in different positions in a cadaveric model. They found that force through the scaphoid fossa is less in neutral and more in extension, while the force through the lunate fossa is more in neutral and less in extension. The authors hypothesize that this may explain scaphoid fractures and intra-articular distal radius fractures as the result of a fall onto an extended wrist.

REFERENCES:

1. Majima M, Horii E, Matsuki H, et al: Load transmission through the wrist in the extended position. J Hand Surg Am 2008;33:182-188 PMID:18294538 (Link to Abstract)

2. Weber ER, Chao EY: An experimental approach to the mechanism of scaphoid waist fractures. J Hand Surg Am 1978;3:142-148 PMID:556476 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore,

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(OBQ08.111) Percutaneous screw fixation for non-displaced scaphoid waist fractures has been shown to have which of the following differences compared to closed treatment? Topic

Review Topic

1. Increased direct and indirect cost
2. Slower return to work
3. Higher union rates
4. Reduced time to fracture union
5. Improved motion and grip strength after 2 years

PREFERRED RESPONSE ▶

DISCUSSION: Fixation of non-displaced scaphoid fractures with a percutaneous screw has resulted in a shorter time to union (6-7 weeks verses 10-12 weeks) and faster return to work or sports.

Arora et al found the indirect cost reduction by a quicker return to work was shown to offset the direct costs of surgical intervention.

Bond et al found in active military personnel there was faster healing but no difference in ultimate union rates or final grip strength or range of motion between percutanous screw fixation and non-operative groups.

REFERENCES:

1. Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M. Fixation of nondisplaced scaphoid fractures: making treatment cost effective. Prospective controlled trial. Arch Orthop Trauma Surg. 2007 Jan;127(1):39-46. PMID:17004075 (Link to Abstract)

2. Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001 Apr;83-A(4):483-8. PMID:11315775 (Link to Abstract)

Question Authors:

Charles Jobin MD, Michael Hughes MD,

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TAG

(OBQ07.78) A 30-year-old female reports 5 months of wrist pain after a fall onto her wrist. A radiograph is shown in Figure A. If untreated, all of the following degenerative changes may be observed EXCEPT? Topic

Review Topic

FIGURES: A

1. radial styloid osteophyte
2. radioscaphoid arthritis
3. midcarpal arthritis
4. pancarpal arthritis
5. radiolunate arthritis

PREFERRED RESPONSE ▶

DISCUSSION: Radiographs show a scaphoid non-union which can lead to Scaphoid Nonunion Advanced Collapse (SNAC wrist) and progressive arthritis. The natural history of degenerative changes first occurs at the radioscaphoid area and progresses to pancarpal arthritis. All of the answers above are features of a SNAC wrist except radiolunate arthritis.

In the cited reference by Schuind et al, they found that professional heavy work, age of the nonunion of over 5 years, associated radial styloidectomy, and duration of postoperative immobilization were associated with a significantly decreased likelihood of healing of the scaphoid nonunion with operative treatment.

The study by Soejima et al found that distal scaphoid resection produces a satisfactory clinical outcome and should be considered one of the surgical options for patients with long-standing scaphoid nonunion with either radioscaphoid or intercarpal degenerative arthritis.

REFERENCES:

1. Schuind F, Haentjens P, Van Innis F, et al: Prognostic factors in the treatment of carpal scaphoid nonunions. J Hand Surg Am 1999;24:761-776 PMID:10447168 (Link to Abstract)

2. Soejima O, Iida H, Hanamura T, et al: Resection of the distal pole of the scaphoid for scaphoid nonunion with radioscaphoid and intercarpal arthritis. J Hand Surg Am 2003; 28:591-596. PMID:12877845 (Link to Abstract)

Question Authors:

Ben Taylor MD, Ben Taylor MD, John Badylak MD,

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(OBQ07.127) A 20-year-old skateboarder fell 6 months ago and has had radial-sided wrist pain since. His radiograph upon presentation to your office is shown in figure A. What is the most appropriate treatment at this time? Topic

Review Topic

FIGURES: A

1. short arm thumb spica cast
2. long arm thumb spica cast
3. wrist arthroscopy to evaluate intercarpal ligaments
4. open reduction internal fixation with autologous bone graft
5. wrist arthrodesis

PREFERRED RESPONSE ▶

DISCUSSION: This patient has a scaphoid waist fracture nonunion. Several studies indicate that scaphoid nonunions left untreated have a determined course of collapse and progressive arthritis (scaphoid nonunion advanced collapse - SNAC). Per Markiewitz et al, the standard treatment of scaphoid nonunions is open reduction internal fixation with bone graft; non-operative treatment is not appropriate. Proximal row carpectomy and wrist fusion are salvage procedures reserved for patient that has an advanced scaphoid nonunion, collapse and wrist arthritis.

REFERENCES:

1. Markiewitz, AD, Stern PJ: Current perspectives in the management of scaphoid nonunions. Instr Course Lect 2005; 54: 99-113 PMID:15948438 (Link to Abstract)

Question Authors:

Greg Galano MD,

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TAG

(OBQ06.16) A 27-year-old professional cowboy is thrown from a bull during the rodeo and lands on his hand. No deformity is identified and the hand is completely neurovascularly intact. Pain is present upon palpation of the anatomic snuffbox. A radiograph is provided in Figure A. The cowboy wants to return to competitive riding tomorrow. Which of the following is the best next step in management? Topic

Review Topic

FIGURES: A

1. Cock-up wrist splint and immediate return to sport as tolerated by pain
2. Steroid injection of the snuffbox, taping of the wrist and return to sport
3. Wrist MRI
4. Percutaneous screw fixation of the nondisplaced fracture
5. Scapholunate ligament repair and percutaneous pin fixation

PREFERRED RESPONSE ▶

DISCUSSION: Tenderness with palpation of the anatomic snuffbox should raise suspicion of a scaphoid fracture. The radiograph does not show any findings, but scaphoid fractures are often not initially visualized on plain radiographs. Appropriate treatment for any patient with snuffbox tenderness entails cast immobilization with repeat radiographs at 2-3 weeks or advanced imaging with MRI to evaluate for a fracture that is not identified with plain radiographs. The MRI that correlates with this patient's radiograph is provided in Illustration A and demonstrates a nondisplaced scaphoid fracture. Gaebler et al performed an MRI study of 32 consecutive patients who were clinically suspicious for a scaphoid fracture, but no fracture could be indentified on wrist radiographs. The MRI was 100% sensitive and specific in diagnosing scaphoid fracture. Treatment for this patient following the MRI would be debatable. Cast immobilization would be appropriate, but screw fixation may allow earlier return to sport. A percutaneous compression screw would be an appropriate technique for this scaphoid fracture.

Illustrations: A

REFERENCES:

1. Gaebler C, Kukla C, Breitenseher M, Trattnig S, Mittlboeck M, Vécsei V.Magnetic resonance imaging of occult scaphoid fractures. J Trauma. 1996Jul;41(1):73-6. PMID:8676426 (Link to Abstract)

Question Authors:

John Badylak MD,

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(OBQ05.130) A 35-year-old woman reports wrist pain after a fall onto an outstretched hand. On exam, she has focal tenderness over the wrist snuffbox. A radiograph and CT image are shown in Figures A and B. What is the proper treatment of her injury? Topic

Review Topic

FIGURES: A

1. Rest, ice, elevation
2. Removable splint for comfort
3. Thumb spica cast
4. Open reduction, internal fixation
5. Vascularized bone grafting

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph and CT scan show a displaced scaphoid waist fracture. Optimal treatment is ORIF with screw fixation.

The usual mechanism of injury to the scaphoid is axial load across a hyperextended wrist. Pain with resisted pronation, snuffbox tenderness and scaphoid tuberosity tenderness should all raise suspicion for a scaphoid fracture. AP and lateral X-rays, as well as PA view with the hand in ulnar deviation and an oblique 45 degree view with the hand in pronation can help to identify the fracture. Bone scan, CT and MRI can also be used to make the diagnosis if radiographs are indeterminate. ORIF is recommended for any fracture displaced more than 1mm, with a radiolunate angle greater than 15 degrees, with intrascaphoid angle greater than 35 degrees, associated with perilunate dislocation or with a proximal pole fracture. Optimal treatment is ORIF with screw fixation. For minimally displaced fractures, percutaneous or mini-open fixation allows minimal dissection and preservation of extrinsic ligaments.

Incorrect Answers:
Answer 1,2,3: Nonoperative management is not indicated in displaced scaphoid fractures
Answer 5: Vascularized bone grafting is reserved for cases of scaphoid nonunion.

REFERENCES:

1. Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow and Shoulder. Rosemont, IL, American Society for Surgery of the hand, 2003, pp 161-73.

Question Authors:

Doug Nowak MD, Derek Moore, Ben Taylor MD,

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Posts

Percutaneous Fixation of the Scaphoid Through a Dorsal approach: An Anatomic Study. Includes Poll

Adamany DC, Mikola EA, Fraser BJ
J Hand Surg Am. 2008 Mar;33(3):327-31. PMID: 18343286 (Link to Pubmed)

Hand - Journal Club - Scaphoid Fracture

2 weeks ago

13 responses

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ABOS II: Scaphoid Fracture

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001 Apr;83-A(4):483-8. PMID:11315775 (Link to Abstract)

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M. Fixation of nondisplaced scaphoid fractures: making treatment cost effective. Prospective controlled trial. Arch Orthop Trauma Surg. 2007 Jan;127(1):39-46. PMID:17004075 (Link to Abstract)

Level of Evidence 4 (Case Series)

Tumilty JA, Squire DS. Unrecognized chondral penetration by a Herbert screw in the scaphoid. J Hand Surg Am. 1996 Jan;21(1):66-8. PMID:8775197 (Link to Abstract)
Gaebler C, Kukla C, Breitenseher M, Trattnig S, Mittlboeck M, Vécsei V.Magnetic resonance imaging of occult scaphoid fractures. J Trauma. 1996Jul;41(1):73-6. PMID:8676426 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Adamany DC, Mikola EA, Fraser BJ. Percutaneous fixation of the scaphoid through a dorsal approach: an anatomic study. J Hand Surg Am. 2008 Mar;33(3):327-31. PMID:18343286 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

McCallister WV, Knight J, Kaliappan R, Trumble TE. Central placement of the screw in simulated fractures of the scaphoid waist: a biomechanical study. J Bone Joint Surg Am. 2003 Jan;85-A(1):72-7. PMID:12533575 (Link to Abstract)
Dodds SD, Panjabi MM, Slade JF 3rd. Screw fixation of scaphoid fractures: a biomechanical assessment of screw length and screw augmentation. J Hand Surg Am. 2006 Mar;31(3):405-13 PMID:16516734 (Link to Abstract)
Majima M, Horii E, Matsuki H, et al: Load transmission through the wrist in the extended position. J Hand Surg Am 2008;33:182-188 PMID:18294538 (Link to Abstract)
Weber ER, Chao EY: An experimental approach to the mechanism of scaphoid waist fractures. J Hand Surg Am 1978;3:142-148 PMID:556476 (Link to Abstract)
Schuind F, Haentjens P, Van Innis F, et al: Prognostic factors in the treatment of carpal scaphoid nonunions. J Hand Surg Am 1999;24:761-776 PMID:10447168 (Link to Abstract)
Soejima O, Iida H, Hanamura T, et al: Resection of the distal pole of the scaphoid for scaphoid nonunion with radioscaphoid and intercarpal arthritis. J Hand Surg Am 2003; 28:591-596. PMID:12877845 (Link to Abstract)
Markiewitz, AD, Stern PJ: Current perspectives in the management of scaphoid nonunions. Instr Course Lect 2005; 54: 99-113 PMID:15948438 (Link to Abstract)
Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow and Shoulder. Rosemont, IL, American Society for Surgery of the hand, 2003, pp 161-73.

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Scaphoid Fracture

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