Extract
The scaphoid is the most commonly fractured carpal bone, accounting for
approximately 60% of carpal fractures and 11% of all hand
fractures1,2.
Often misdiagnosed as a simple wrist sprain, scaphoid fractures may go on to
malunion or nonunion. Patients with one of these problems will almost always
present later because of persistent wrist pain. Malunions and nonunions are
especially challenging conditions to treat successfully and, if untreated,
they usually produce abnormal carpal kinematics that can lead to wrist
arthrosis3,4.
Thus, early diagnosis and vigilant care of an acute scaphoid fracture are
warranted5,6.
The scaphoid is the most commonly fractured carpal bone, accounting for
approximately 60% of carpal fractures and 11% of all hand
fractures1,2.
Often misdiagnosed as a simple wrist sprain, scaphoid fractures may go on to
malunion or nonunion. Patients with one of these problems will almost always
present later because of persistent wrist pain. Malunions and nonunions are
especially challenging conditions to treat successfully and, if untreated,
they usually produce abnormal carpal kinematics that can lead to wrist
arthrosis3,4.
Thus, early diagnosis and vigilant care of an acute scaphoid fracture are
warranted5,6.
Scaphoid fractures usually result from a fall. Most commonly, the patient
lands on the hand with the wrist in extension and radial
deviation7-9.
Other mechanisms of injury can cause a scaphoid
fracture9,10.
The exact mechanism of failure is a subject of debate. Some have suggested
that the scaphoid fails secondary to excessive compression along its concave
medial articulation with the capitate, whereas others believe that the
scaphoid fails secondary to excessive
tension10-12.
Look for this and other related articles in Instructional Course
Lectures, Volume 56, which will be published by the American Academy of
Orthopaedic Surgeons in February 2007:• "Posttraumatic Reconstruction in the Hand," by Jesse
B. Jupiter, MD, Charles A. Goldfarb, MD, Ladislav Nagy, MD, and Martin I.
Boyer, MD
Look for this and other related articles in Instructional Course
Lectures, Volume 56, which will be published by the American Academy of
Orthopaedic Surgeons in February 2007:
• "Posttraumatic Reconstruction in the Hand," by Jesse
B. Jupiter, MD, Charles A. Goldfarb, MD, Ladislav Nagy, MD, and Martin I.
Boyer, MD
Weber and Chao created scaphoid fractures in cadavers with the wrist in
only 95° to 100° of dorsiflexion and a load applied to the radial
portion of the
palm8. The force was
magnified four times at the radioscaphoid joint, and the proximal pole
appeared to be caught between the radius and capitate.
Patients with a scaphoid fracture most often present with "wrist
pain." They almost always have tenderness and a fullness in the anatomic
snuffbox. Axial compression of the thumb, which compresses the scaphoid,
usually elicits pain. Sometimes there is discomfort just with percussion of
the tip of an abducted thumb. Forced ulnar deviation of a pronated wrist can
also elicit
pain13.
Pain and tenderness in the anatomic snuffbox should warrant studies to rule
out a scaphoid fracture. Even if initial radiographs reveal negative findings,
the wrist should be immobilized in a wrist splint or short arm thumb-spica
cast and the radiographs should be repeated in one to two
weeks14. If a
fracture is not seen on the repeat radiographs and a scaphoid fracture is
still suspected, a computed tomography scan, a magnetic resonance imaging
scan, or a bone scan should be
done15-18.
Computed tomography scanning is fast, convenient, and the most sensitive and
specific of the studies; bone-scanning is the least sensitive and
specific19,20.
When the patient has sustained multiple injuries and a scaphoid fracture is
suspected, computed tomography or magnetic resonance imaging should be
performed as soon as medically safe and possible. When immobilization will
result in a great loss of patient productivity, these additional imaging
modalities may be performed at the time of the initial presentation if the
plain radiographs reveal negative findings. Associated injuries, including
ligamentous injuries, should be considered and looked for, but that is beyond
the scope of this review.
Derived from the Greek word skaphe, meaning skiff or boat,
the scaphoid is named for its likeness to a boat. This is a great
simplification; it is shaped more like a banana with a twist. The scaphoid
serves a complex role, as is reflected in its osseous anatomy. The entire
proximal, distal, and medial surfaces as well as half of the lateral side are
covered with articular cartilage.
The main blood supply to the scaphoid is from the radial
artery21. A dorsal
ridge serves as the attachment point for the dorsal joint capsule, and
perforating branches from the radial artery supply approximately 75% of the
intraosseous blood. Through retrograde flow, the dorsal branches also supply
all of the proximal pole. The distal pole appears to have its own abundant
blood supply from volar branches of the radial artery. There is a less
consistent blood supply through the scapholunate ligament as well.
Obletz and Halbstein examined 297 scaphoids and found that 13% had no
foramina proximal to the waist, 20% had only one small foramen proximal to the
waist, and 67% had two or more foramina proximal to the
waist22. Thus, the
blood supply to the proximal pole is the most tenuous.
Although the scaphoid is mostly covered with articular cartilage, there are
important sites of ligamentous attachment. Along the ulnar aspect of the
proximal pole, the scapholunate interosseous ligament, composed of the dorsal,
proximal, and palmar regions, links the scaphoid to the
lunate23,24.
When a scaphoid fractures, the proximal fragment tends to extend with the
attached lunate, and the distal fragment remains flexed, creating a
"humpback"
deformity3.
Attaching directly on the scapholunate interosseous ligament is the
radioscapholunate ligament, which acts as a neurovascular conduit. The
radioscapholunate ligament is flanked on the radial side by the long
radiolunate ligament, which passes along the palmar aspect of the proximal
part of the scaphoid as it inserts on the lunate. Even more radial is the
radioscaphocapitate ligament, which has substantial insertions on the waist of
the scaphoid24.
At the distal articulation of the scaphoid is the v-shaped scaphotrapezial
ligament25. Just
proximal to this attachment along the dorsum is the attachment for the dorsal
intercarpal
ligament26. The
scaphocapitate ligament is found almost confluent with the fibroosseous tunnel
of the flexor carpi radialis tendon, which runs directly palmar to the distal
pole of the scaphoid as it heads toward the
trapezium27.
Russe classified scaphoid fractures as horizontal oblique, transverse, or
vertical oblique28
(Fig. 1). The vertical oblique
type accounts for only 5% of fractures. This fracture pattern results in the
most shear forces across the fracture site, thus making it the most unstable
type. Horizontal oblique types have the most compressive forces across the
fracture site, whereas transverse fractures have a combination of compressive
and shear forces.
We prefer to use the classification system devised by Herbert, which
incorporates the stability of the fracture as well as delayed unions and
nonunions29
(Fig. 2). Type-A fractures
include fractures of the tubercle (A1) and incomplete fractures through the
waist (A2), which are inherently stable patterns. Type-B fractures are acute
and unstable; they include distal oblique fractures (B1), complete fractures
through the waist (B2), proximal pole fractures (B3), and transscaphoid
perilunate fracture-dislocations of the carpus (B4). Type-C fractures are
delayed unions, and type-D fractures are established nonunions.
Prosser et al. expanded the classification of distal pole fractures
(Fig.
3)30.
Type I indicates a tuberosity fracture; type II, a distal intra-articular
fracture; and type III, an osteochondral fracture.
The majority of scaphoid fractures (approximately 75%) occur at the waist,
whereas only about 20% occur in the proximal
third10,28.
The least common location is the distal third of the scaphoid, and fractures
in that location are more common in children than in
adults31.
The true incidence and natural history of scaphoid fractures and the
consequences of malunions and nonunions are not known because not all
individuals with a scaphoid fracture present for medical attention. This
selection bias should be kept in mind when specific studies are used to
justify management choices.
The reported nonunion rates of scaphoid fractures range from 5% to
25%28,32-34.
The factors associated with nonunion include fracture displacement of >1
mm, proximal fracture, osteonecrosis, vertical oblique fracture, and
smoking35-38.
Mack et al. found that wrist arthritis developed in patients with scaphoid
nonunion39. In the
first ten years following a scaphoid fracture, the changes were seen only in
the scaphoid. In the second decade, there was radioscaphoid arthritis.
Pancarpal arthritis ensued after twenty to thirty years. This process was
accelerated by displacement or dorsal intercalary segment instability
patterns. Mack et al. also found that the fracture location and configuration
did not correlate with degenerative changes. In a study of fifty-six untreated
nonunions, Ruby et al. reported that degeneration was present in thirty-one of
thirty-two patients who had been injured at least five years
earlier40. Thus,
scaphoid nonunion is not an innocuous condition.
Distal Pole Fractures
Fractures of the distal pole of the scaphoid tend to heal well. Most can be
treated closed (with four to eight weeks of immobilizaton) and, probably
because of the rich vascularization of the distal pole, union is the
rule30,41.
However, displaced intra-articular fractures (Prosser type II) are generally
thought to require surgical management to minimize the risk of degenerative
arthritis.
Waist Fractures
Fractures of the scaphoid waist can be difficult to manage. Some can be
treated closed whereas others should be internally stabilized.
Nondisplaced Waist Fractures
It has been reported that >90% of nondisplaced waist fractures treated
with immobilization alone
unite33,42,43.
The difficulty is determining which fractures are nondisplaced. A computed
tomography scan along the long axis of the scaphoid enables one to assess
displacement20,44.
Determining union is also difficult. Dias et al. reported that critical
examination of radiographs at one year revealed that the nonunion rate was
higher (12.3%) than they had initially
suspected45. A
radiographic assessment of healing at twelve weeks is probably not very
reliable. Thus, some scaphoid fractures that are classified as nondisplaced
actually might be displaced, and some that are considered to have healed can
actually be nonunions.
The treatment options for a nondisplaced waist fracture must be discussed
thoroughly with the patient. The patient's lifestyle, expectations,
compliance, and demands (for return to work or sports) must all be considered.
Although the fracture will most likely heal with cast immobilization, the
patient must know the risks, benefits, and alternatives.
The main disadvantages of immobilization, compared with surgery, are more
frequent office visits to check that the cast fits properly, more frequent
radiographs to check fracture alignment, potential skin breakdown, prolonged
immobilization until complete healing has occurred, stiffness of immobilized
joints, and even perhaps a longer time to
healing46. The
immobilization period after surgery is shorter or even
unnecessary46-48.
If the fracture has been rigidly fixed, it is safe for the patient to perform
gentle range-of-motion exercises. Additional advantages of surgical
intervention are that the fracture is substantially less likely to lose its
alignment and ideally is fixed with compression, which has been reported to
shorten the time to
healing46. The
reduction should be anatomic, and the fixation should be stable. The
disadvantages of surgery include the potential for infection; wound
complications; injury to nerves, ligaments, or tendons; injury to the vascular
supply to the scaphoid; hardware failure or the need for its removal; and
other associated risks such as anesthesia complications. Percutaneous
stabilization of nondisplaced waist fractures has become popular. The
techniques have evolved such that the benefits outweigh the risks, as
discussed later.
Displaced Waist Fractures
Scaphoid fractures with =1 mm of displacement are considered unstable.
Cooney et al.35
defined displacement as a fracture gap of 1 mm seen on any plain radiographic
projection, a scapholunate angle of >60°, or a radiolunate angle of
>15°. It has also been
shown20 that a
displaced fracture tends to have an intrascaphoid angle of >35°. The
displaced scaphoid fracture should be reduced and stabilized surgically
(unless there are other conditions that contraindicate surgery) because the
risk of malunion or nonunion of such a fracture is unacceptable.
Proximal Pole Fractures
Unless surgery is contraindicated or the patient refuses it, acute
fractures of the proximal pole of the scaphoid should be treated surgically.
The proximal pole has the most tenuous blood supply, which is thought to
explain the higher rates of nonunion compared with those of fractures at the
distal pole or the
waist21. Despite
the lack of data, it is believed that internal fixation reduces the risk of
nonunion and perhaps decreases the chances of proximal fragment collapse due
to osteonecrosis.
The choice of fixation depends on the size of the proximal fragment. If the
fragment is large enough, a headless compression screw can be used. The type
of screw is not as important as the starting point, which should be proximal
and dorsal. It is critical to obtain good, preferably central, purchase on the
proximal fragment, and ideally the screw should be placed orthogonal to the
line of the fracture. If the fragment is too small to accept such a screw,
then temporary Kirschner wires can be used to hold the fracture reduced.
Cast Immobilization
The best method of cast immobilization is controversial. The position of
the wrist has not been definitively shown to affect
healing49. There
have been conflicting results associated with immobilization of the elbow and
thumb50,51.
Studies have shown that short arm thumb-spica casts provide adequate
immobilization of scaphoid fractures; thus, they are used by us and are
accepted widely as a treatment
option42,52,53.
If cast immobilization is the only treatment chosen, then it should be
continued until the fracture has healed. For proximal pole fractures, this can
take twelve weeks or
longer28. Although
we are not aware of any data suggesting the superiority of long arm
thumb-spica casts over short arm thumb-spica casts, we initially immobilize
proximal fractures as well as severely comminuted or unstable fractures in a
long arm thumb-spica cast.
Prolonged cast immobilization is becoming less well tolerated, especially
by younger patients who want to return to work and sports as soon as possible.
Patient expectations are now pushing the trend to fix even nondisplaced
scaphoid fractures, although long-term outcomes do not seem to differ between
open and closed treatment of such
fractures54.
Patients are more satisfied with early
mobilization48,55.
Open Techniques
Volar Approach
The classic Russe approach to the scaphoid is through a volar
exposure28. This
yields excellent visualization with less risk of injury to the main blood
supply, which is on the dorsal side. This exposure is required if an alignment
instrument such as the Huene jig is used with a Herbert screw. A longitudinal
incision is made just radial to the flexor carpi radialis tendon, which is
retracted to the ulnar side. Distally, the incision is carried over the
tubercle of the scaphoid, forming a hockey-stick incision. A longitudinal
incision then is made in the volar wrist capsule, with care taken not to
injure the radioscaphocapitate ligament. The nonarticular portion of the
proximal part of the trapezium may need to be resected in order to gain
central access to the distal part of the scaphoid; the capsule here may be
incised horizontally to gain access to the scaphotrapezial joint. The fracture
is reduced with use of a dental pick or Kirschner wire
"joysticks." Anatomic reduction should be achieved prior to
fixation.
This exposure is especially good for inspecting the entire volar surface of
the scaphoid. The disadvantages of this approach are the potential for
scarring, which could limit wrist extension; a risk of injury to the volar
radiocarpal ligaments; and the inability to assess and address the dorsal
scapholunate ligament.
With an open volar approach, fixation options are numerous. If the approach
was used mainly for reduction purposes, Kirschner wires may be employed to
stabilize the fracture. A reduction/alignment guide can be used in preparation
for a Herbert screw. Alternatively, a guidewire can be passed under
fluoroscopic guidance starting at the distal or proximal aspect of the
scaphoid in preparation for a cannulated screw system, as will be elaborated
on later in this article.
Dorsal Approach
The dorsal approach to the scaphoid is centered over Lister's tubercle. A
transverse skin incision is made over the proximal pole of the scaphoid. The
extensor retinaculum is longitudinally incised in order to retract the tendons
of the second and third dorsal compartments. Care must be taken not to disturb
the dorsal ridge, in which the main blood supply to the scaphoid is found. The
wrist capsule is incised longitudinally, without injuring the deeper
scapholunate ligament. This approach provides excellent visualization of the
proximal portion of the scaphoid, especially with the wrist in maximum
flexion. This is the preferred open approach to proximal pole fractures. A
guidewire can be placed for use with a cannulated screw system or a Herbert
screw can be placed freehand.
Percutaneous Techniques
Percutaneous scaphoid fixation is becoming increasingly popular as it
becomes more apparent that many of the risks of the open techniques can be
avoided with use of this
method48. The
healing time is at least the same as that associated with cast
immobilization56.
Bond et al. reported that the average time to healing was seven weeks for
patients treated with percutaneous screw fixation compared with twelve weeks
for those treated with a
cast46. In their
study, the surgical group was able to return to work after only eight weeks
compared with fifteen weeks for the cast immobilization group; there was no
functional difference after two years.
The basic concept is to place a guidewire percutaneously along the central
axis of the scaphoid and then use a cannulated screw system for definitive
internal fixation. This approach should be reserved for fractures that are not
displaced or that can be anatomically reduced by closed or arthroscopic means.
A surgeon must be comfortable using both distal and proximal starting points
for the percutaneous techniques.
The key to the procedure is to achieve the most centrally placed screw
possible while holding the fracture in
compression57.
Slade and Moore reported that the central axis of the scaphoid can be found
with fluoroscopic guidance by pronating and flexing the wrist so as to align
the distal and proximal poles of the scaphoid in the radiographic
beam58. The center
of the circle formed by the scaphoid on this view is the central axis, and
this is where the screw is ideally placed.
The setup for the percutaneous technique requires the use of palpable
osseous landmarks as well as a minifluoroscopy unit covered with a sterile
drape. The patient is placed supine with the arm supported on a hand-table.
With the volar percutaneous approach, the distal aspect of the scaphoid is
used as the entry point for fixation (Fig.
4). Again, this is preferred for distal pole fractures that
warrant fixation. The guidewire is started palmar at the tubercle, and the
trajectory is toward the dorsum of the wrist. Achievement of a good starting
point is sometimes aided by removal of overhanging trapezial bone in the area
of the scaphotrapezial joint through a limited skin incision. Slade and Moore
even advocated starting the guidewire in the trapezium in order to obtain a
central position in the
scaphoid58.
We prefer to use a 16-gauge needle to find the starting point for the
guidewire. It is less likely to perforate the surgeon's gloves or the sterile
drape of the mini-fluoroscopy unit than is direct manipulation of the
double-cut guidewire. Once proper orientation is confirmed with fluoroscopy,
the cannulated screw system of choice is used. Unlike the dorsal approach,
this volar approach does not violate the proximal cartilaginous surface of the
scaphoid, although studies have shown that this defect subsequently
heals59,60.
With the dorsal percutaneous approach
(Fig. 5), the proximal pole of
the scaphoid is used as the entry point for fixation. With the wrist in
maximum flexion and slight ulnar deviation, the proximal pole of the scaphoid
is presented for introduction of the 16-gauge needle through the skin of the
dorsal aspecof the wrist. Once the position of-the needle is confirmed
radiographically, the guidewire can be driven through the needle. The surgeon
can hold the needle and stabilize the wrist, making sure of the correct
orientation, while the assistant drives the guidewire into the scaphoid. This
approach was found to result in the most central screw placement in the distal
pole in a cadaver study; however, whether this makes a difference clinically
is still to be
seen61.
Arthroscopy also has been used in conjunction with the percutaneous
approach to provide visualization of the fracture site without violation of
important structures as can occur with the open technique
(Fig. 6). If fracture reduction
is required, it can be done with fluoroscopic guidance alone or with the aid
of arthroscopic visualization and manipulation. A joystick technique can be
used to manipulate the fractured ends of the scaphoid, with use of 0.062-in
(1.574-mm) Kirschner wires (preferred) or 0.045-in (1.143-mm) Kirschner wires
(Fig. 7). If the fracture is
not reducible by closed means or with arthroscopic assistance, then an open
approach is recommended in lieu of the percutaneous approach. The arthroscopic
technique also allows assessment for other associated intra-articular injuries
such as ligamentous structures.
There are many choices for fixation with the percutaneous technique
(Fig. 8). AO screws with
prominent heads have been replaced in popularity by headless compression
screws. The Herbert screw (Zimmer, Warsaw, Indiana) was the original headless
compression screw introduced for use in the scaphoid, but it is not cannulated
and it is practical only for use with the open technique. The Herbert-Whipple
screw (Zimmer) (Fig. 9) and the
Acutrak screw (Acumed, Hillsboro, Oregon) are cannulated. Biomechanical
studies have shown that wider screws provide better resistance to lateral
displacement forces, as their resistance is proportional to the radius of the
screw to the fourth
power62. In a
comparison of the screws loaded cyclically, the Acutrak screw was found to be
the strongest, was the least likely to fail catastrophically, and produced the
most
compression62,63.
The Acutrak Standard screw (used with a 0.045-in [1.143-mm] guidewire, 2-mm
hex size) and the Acutrak Mini screw (used with a 0.035-in [0.889-mm]
guidewire, 1.5-mm hex size) are not self-drilling. The new Acutrak Mini 2
screw (1.5-mm hex size) is self-drilling and self-tapping, which makes it
convenient to advance over a 0.045-in (1.143-mm) guidewire. We prefer to use
the Acutrak Mini 2 screw because of the smaller defect that is created in the
surface of the scaphoid, the larger guidewire (less risk of breakage), and the
ease of placement without having to predrill or tap.
The chosen implant should be buried below the level of the cartilage on
both ends of the scaphoid to prevent the development of radioscaphoid or
scaphotrapezial arthritis. When measuring the length of the screw according to
the manufacturer's directions, one must consider that the screw length is
often about 4 mm shorter than the measured guidewire, which will render it
approximately 2 mm countersunk at each end. If arthroscopy is used, screw
placement can be confirmed to be deep to the articular surface of the
scaphoid.
We consider surgery to be indicated for all displaced scaphoid fractures,
proximal pole fractures regardless of displacement, fractures associated with
perilunate injuries, open fractures, and fractures in multiply injured
patients. Other decision-making factors are whether there is a great potential
for morbidity from prolonged immobilization, the occupation of the patient,
and a lack of evidence of healing after three to four months of conservative
treatment of the fracture.
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