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Scaphoid Fracture
Posted: Jul 6 2020 #(C101517)
A

Proximal Pole Scaphoid Fracture in 21M

HPI

A 21-year-old male, a recreational soccer player, sustained a fall onto an outstretched left hand 6 weeks prior and was diagnosed with a wrist sprain at an outside emergency department. The patient failed to improve with a removable wrist splint and was referred for orthopedic evaluation. He denies any numbness or tingling of the hand. He is right-hand-dominant.

PMH

None

PE

A focused examination of the left wrist demonstrates moderate swelling over the dorsal and volar aspects of the wrist. There is no ecchymosis present. Range of motion is limited to 40 degrees of wrist extension and 50 degrees of wrist flexion due to pain. There is tenderness to palpation over the anatomic snuffbox. Sensation is otherwise intact to light touch in the median, ulnar, and radial nerve distributions. Motor function is intact in the anterior interosseous nerve, posterior interosseous nerve, and ulnar nerve.

Poll
1 of 10
1. In addition to the current plain radiographs, would you obtain additional imaging studies to guide treatment?
No - Current radiographs are sufficient
22%
130/581
Yes - additional radiographic views (aXR)
1%
11/581
Yes - CT scan of the wrist (CT)
54%
317/581
Yes - MRI scan of the wrist (MRI)
9%
57/581
Yes - aXR + CT
4%
26/581
Yes - aXR + MRI
0%
4/581
Yes - CT + MRI
2%
16/581
Yes - aXR + CT + MRI
1%
11/581
Outside my area of expertise - best if I don't vote
1%
9/581
2. How would you manage this patient?
Nonoperative
7%
41/567
Operative
90%
512/567
Outside my area of expertise - best if I don't vote
2%
14/567
3. If you choose Nonoperative Management, what technique would you use?
I would not choose Nonoperative Management
69%
372/538
Short arm cast - thumb Free
4%
26/538
Short arm cast - thumb Immobilized (spica)
18%
100/538
Long arm cast - thumb Free
0%
2/538
Long arm cast - thumb Immobilized (spica)
5%
31/538
Other
0%
0/538
Outside my area of expertise - best if I don't vote
1%
7/538
4. If you choose Operative management, and the patient presented to the ER at 2 PM on a Saturday on the day of injury, last meal at 9 am, what would be your time frame to take him to surgery and where would you do it?
I would not choose Operative Management
2%
13/543
Admit to hospital - perform surgery Same day
10%
58/543
Admit to hospital - perform surgery Next day
10%
56/543
Discharge - operate at Hospital - within 5 days
26%
145/543
Discharge - operate at Hospital - within 10 days
9%
54/543
Discharge - operate at Hospital - no time limit
2%
14/543
Discharge - operate at Surgery Center - within 5 days
16%
92/543
Discharge - operate at Surgery Center - within 10 days
14%
78/543
Discharge - operate at Surgery Center - no time limit
3%
20/543
Other
0%
1/543
Outside my area of expertise - best if I don't vote
2%
12/543
5. If you choose Operative Management, what surgery and approach would you perform?
I would not choose Operative Management
0%
4/534
ORIF - Volar - Screw/s
24%
131/534
ORIF - Volar - Plate
1%
8/534
ORIF - Volar - K-wire/s
0%
5/534
ORIF - Dorsal - Screw/s
35%
191/534
ORIF - Dorsal - Plate
0%
3/534
ORIF - Dorsal - K-wire/s
0%
4/534
Percutaneous - Volar - Screw/s
13%
73/534
Percutaneous - Volar - K-wire/s
0%
3/534
Percutaneous - Dorsal - Screw/s
16%
86/534
Percutaneous - Dorsal - K-wire/s
0%
1/534
Other
0%
2/534
Outside my area of expertise - best if I don't vote
4%
23/534
6. If you choose ORIF - Dorsal - Screw fixation, what screw configuration would you choose?
I would not choose ORIF - Dorsal - Screw fixation
6%
30/493
One Screw - Non Cannulated - Fully Threaded
2%
11/493
One Screw - Non Cannulated - Partially Threaded
2%
13/493
One Screw - Cannulated - Fully Threaded
26%
132/493
One Screw - Cannulated - Partially Threaded
46%
228/493
Two Screws - Non Cannulated - Fully Threaded
0%
2/493
Two Screws - Non Cannulated - Partially Threaded
0%
4/493
Two Screws - Cannulated - Fully Threaded
2%
11/493
Two Screws - Cannulated - Partially Threaded
7%
35/493
Other Screw Configuration
1%
8/493
Outside my area of expertise - best if I don't vote
3%
19/493
7. If you choose ORIF - Volar - Screw fixation, what screw configuration would you choose?
I would not choose ORIF - Volar - Screw fixation
32%
144/450
One Screw - Non Cannulated - Fully Threaded
0%
4/450
One Screw - Non Cannulated - Partially Threaded
2%
9/450
One Screw - Cannulated - Fully Threaded
14%
66/450
One Screw - Cannulated - Partially Threaded
41%
188/450
Two Screws - Non Cannulated - Fully Threaded
0%
1/450
Two Screws - Cannulated - Fully Threaded
0%
1/450
Two Screws - Cannulated - Fully Threaded
0%
1/450
Two Screws - Cannulated - Partially Threaded
2%
13/450
Other Screw Configuration
0%
4/450
Outside my area of expertise - best if I don't vote
4%
19/450
8. If you choose ORIF - Dorsal - Screw fixation, would you use bone grafting or biologics?
I would not choose ORIF - Dorsal - Screw fixation
7%
37/463
No - I would not use bone grafting or biologics
44%
207/463
Yes - Autograft - Distal Radius - Non Vascularized
28%
131/463
Yes - Autograft - Distal Radius - Vascularized
7%
33/463
Yes - Autograft - Iliac Crest
4%
21/463
Yes - Autograft - Medial Femoral - Vascularized
0%
1/463
Yes - Autograft - Other
0%
1/463
Yes - BMP
1%
6/463
Yes - Other Biologic
1%
7/463
Outside my area of expertise - best if I don't vote
4%
19/463
9. If you choose ORIF - Dorsal - Screw fixation, and obtained the construct shown below, how long do you immobilize post-operatively?
I would not choose ORIF - Dorsal - Screw fixation
3%
15/444
No immobilization
3%
16/444
1-2 weeks (1-14 days)
10%
45/444
3-4 weeks (15-28 days)
20%
90/444
5-6 weeks (29-42 days)
43%
192/444
7-8 weeks (43-56 days)
14%
65/444
9 or more weeks (> 57 days)
2%
9/444
Outside of my area of expertise - best if I don't vote
2%
12/444
10. If you choose ORIF - Dorsal - Screw fixation, and obtained the construct shown below, when would you allow full return to athletic activity?
I would not choose ORIF - Dorsal - Screw fixation
4%
20/434
Immediately - in cast - before radiographic confirmation of union
0%
2/434
2 -3 weeks - in cast - before radiographic confirmation of union
1%
5/434
4 - 6 weeks - in cast - before radiographic confirmation of union
7%
34/434
After confirmation of union by Xray - in Cast
4%
19/434
After confirmation of union by Xray - without Cast
34%
150/434
After confirmation of union by CT - in Cast
7%
31/434
After confirmation of union by CT - without Cast
35%
156/434
Other
0%
3/434
Outside my area of expertise - best if I don't vote
3%
14/434
PROCEDURE #1

Open reduction and internal fixation of scaphoid fracture (dorsal approach)

POLL#
Surgeon's Choices
1
In addition to the current plain radiographs, would you obtain additional imaging studies to guide treatment?
No - Current radiographs are sufficient
2
How would you manage this patient?
Operative
3
If you choose Nonoperative Management, what technique would you use?
I would not choose Nonoperative Management
4
If you choose Operative management, and the patient presented to the ER at 2 PM on a Saturday on the day of injury, last meal at 9 am, what would be your time frame to take him to surgery and where would you do it?
Discharge - operate at Surgery Center - within 5 days
5
If you choose Operative Management, what surgery and approach would you perform?
ORIF - Dorsal - Screw/s
6
If you choose ORIF - Dorsal - Screw fixation, what screw configuration would you choose?
Two Screws - Cannulated - Partially Threaded
7
If you choose ORIF - Volar - Screw fixation, what screw configuration would you choose?
I would not choose ORIF - Volar - Screw fixation
8
If you choose ORIF - Dorsal - Screw fixation, would you use bone grafting or biologics?
Yes - Autograft - Distal Radius - Non Vascularized
9
If you choose ORIF - Dorsal - Screw fixation, and obtained the construct shown below, how long do you immobilize post-operatively?
5-6 weeks (29-42 days)
10
If you choose ORIF - Dorsal - Screw fixation, and obtained the construct shown below, when would you allow full return to athletic activity?
After confirmation of union by CT - without Cast
Intra-procedure P1
icon
OUTCOMES
Post-procedure P1
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