Updated: 9/18/2018

Scaphoid Fracture

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https://upload.orthobullets.com/topic/6034/images/snuffbox.jpg
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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) 
 

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Questions (18)
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(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%

(101/2299)

2

extended wrist position increases force through the lunate fossa

25%

(579/2299)

3

neutral wrist position increases force through the scaphoid fossa

4%

(83/2299)

4

extended wrist position increases force through the scaphoid fossa

62%

(1425/2299)

5

wrist position has no effect on force transmission

4%

(91/2299)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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:
1

Rest, ice, elevation

0%

(6/1952)

2

Removable splint for comfort

0%

(5/1952)

3

Thumb spica cast

4%

(86/1952)

4

Open reduction, internal fixation

94%

(1841/1952)

5

Vascularized bone grafting

0%

(5/1952)

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:
1

Cock-up wrist splint and immediate return to sport as tolerated by pain

3%

(54/1916)

2

Steroid injection of the snuffbox, taping of the wrist and return to sport

1%

(13/1916)

3

Wrist MRI

87%

(1667/1916)

4

Percutaneous screw fixation of the nondisplaced fracture

8%

(160/1916)

5

Scapholunate ligament repair and percutaneous pin fixation

0%

(8/1916)

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:
1

four corner fusion

2%

(52/2970)

2

long arm thumb spica cast

1%

(28/2970)

3

wrist arthroscopy to evaluate intercarpal ligaments

1%

(35/2970)

4

open reduction internal fixation with autologous bone graft

95%

(2836/2970)

5

wrist arthrodesis

0%

(9/2970)

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:
1

Using a longer screw placed in the central axis of the scaphoid

66%

(1836/2765)

2

Using a supplementary K-wire transfixing the distal pole of the scaphoid to the capitate

15%

(426/2765)

3

Using a longer screw placed in the dorsal axis of the scaphoid

4%

(102/2765)

4

Using a larger diameter screw placed in the dorsal axis of the scaphoid

10%

(264/2765)

5

Using a larger diameter screw placed in the volar axis of the scaphoid

4%

(118/2765)

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%

(257/2511)

2

Slower return to work

1%

(20/2511)

3

Higher union rates

22%

(540/2511)

4

Reduced time to fracture union

66%

(1654/2511)

5

Improved motion and grip strength after 2 years

1%

(30/2511)

ML 3

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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%

(175/2856)

2

Increased risk of posterior interosseous nerve injury

5%

(138/2856)

3

Decreased risk of injury to the APL tendon

12%

(348/2856)

4

Increased risk of injury to the EPL tendon

6%

(176/2856)

5

Decreased risk of screw prominence above subchondral bone

70%

(2002/2856)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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