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 Associated conditions SNAC (Scaphoid Nonunion Advanced Collapse) 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 indications most sensitive for diagnosis occult fractures < 24 hours immediate identification of fractures / ligamentous injuries assessment of vascular status of bone (vascularity of proximal pole) proximal pole AVN best determined on T1 sequences 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 electromagnetic 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 Scaphoid Nonunion treatment inlay (Russe) bone graft indications if minimal deformity and there is no adjacent carpal collapse or excessive flexion deformity (humpback scaphoid) outcomes 92% union rate interposition (Fisk) bone graft indications if there is adjacent carpal collapse and excessive flexion deformity (humpback scaphoid) technique an opening wedge graft that is designed to restore scaphoid length and angulation outcomes results show 72-95% union rates vascular bone graft from radius indications gaining popularity and a good option for proximal pole fractures with osteonecrosis confirmed by MRI technique 1-2 intercompartmental supraretinacular artery (branch of radial artery) is harvested to provide vascularized graft from dorsal aspect of distal radius vascular bone graft from medial femoral condyle corticoperiosteal flap that provides highly osteogenic periosteum indications proximal pole fractures with osteonecrosis lack of pancarpal arthritis and collapse technique utilize the descending genicular artery pedicle (from the superficial femoral artery) if DGA is too small, use superomedial genicular artery (from popliteal artery) identify and protect MCL (distal to flap) SNAC wrist (scaphoid nonunion advanced collapse)
QUESTIONS 1 of 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Previous Next (OBQ09.234) Which of the following statements is TRUE about force transmission based on wrist position? Review Topic QID: 3047 1 neutral wrist position decreases force through the lunate fossa 4% (104/2382) 2 extended wrist position increases force through the lunate fossa 25% (592/2382) 3 neutral wrist position increases force through the scaphoid fossa 4% (84/2382) 4 extended wrist position increases force through the scaphoid fossa 62% (1487/2382) 5 wrist position has no effect on force transmission 4% (95/2382) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic QID: 1016 FIGURES: A B 1 Rest, ice, elevation 0% (6/2008) 2 Removable splint for comfort 0% (5/2008) 3 Thumb spica cast 4% (88/2008) 4 Open reduction, internal fixation 94% (1895/2008) 5 Vascularized bone grafting 0% (5/2008) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 27 FIGURES: A 1 Cock-up wrist splint and immediate return to sport as tolerated by pain 3% (54/1983) 2 Steroid injection of the snuffbox, taping of the wrist and return to sport 1% (18/1983) 3 Wrist MRI 87% (1724/1983) 4 Percutaneous screw fixation of the nondisplaced fracture 8% (165/1983) 5 Scapholunate ligament repair and percutaneous pin fixation 0% (8/1983) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (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? Review Topic QID: 788 FIGURES: A 1 four corner fusion 2% (53/3056) 2 long arm thumb spica cast 1% (29/3056) 3 wrist arthroscopy to evaluate intercarpal ligaments 1% (37/3056) 4 open reduction internal fixation with autologous bone graft 95% (2918/3056) 5 wrist arthrodesis 0% (9/3056) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 2849 FIGURES: A 1 Using a longer screw placed in the central axis of the scaphoid 67% (1917/2868) 2 Using a supplementary K-wire transfixing the distal pole of the scaphoid to the capitate 15% (428/2868) 3 Using a longer screw placed in the dorsal axis of the scaphoid 4% (106/2868) 4 Using a larger diameter screw placed in the dorsal axis of the scaphoid 10% (274/2868) 5 Using a larger diameter screw placed in the volar axis of the scaphoid 4% (124/2868) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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? Review Topic QID: 497 1 Increased direct and indirect cost 10% (264/2597) 2 Slower return to work 1% (20/2597) 3 Higher union rates 22% (574/2597) 4 Reduced time to fracture union 65% (1693/2597) 5 Improved motion and grip strength after 2 years 1% (36/2597) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ09.56) An open dorsal approach for antegrade screw fixation of a nondisplaced scaphoid waist fracture differs in which of the following ways compared to a percutaneous dorsal approach? Review Topic QID: 2869 1 Decreased risk of proximal pole AVN 6% (180/2932) 2 Increased risk of posterior interosseous nerve injury 5% (140/2932) 3 Decreased risk of injury to the APL tendon 12% (358/2932) 4 Increased risk of injury to the EPL tendon 6% (183/2932) 5 Decreased risk of screw prominence above subchondral bone 70% (2054/2932) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Login to View Community Videos Login to View Community Videos California Orthopaedic Association Annual Meeting - 2018 Scaphoid Fractures- Tips and Tricks - Jeffrey Yao, MD (COA 2018, 9.2) Jeffrey Yao Hand - Scaphoid Fracture 8/30/2018 904 views
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