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Fractures of the scaphoid, diagnosis and management--a review

Article  in  Acta chirurgica iugoslavica · December 2013

DOI: 10.2298/ACI1302099A · Source: PubMed

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/STRU^NI RAD
Fractures of the scaphoid, diagnosis and management-
a review
........
.................................
Sladjana Z. Andjelkovi}1,2, ^edo D. Vu~kovi}1, Aleksandar R. Leši}1,2,
Goran C. Tuli}1,2, Suzana M. Milutinovi}1, Tomislav D. Palibrk1,
Slaviša G. Zagorac1, Marko @. Bumbaširevi}1,2
1
Clinic of orthopedic surgery and traumatology, Clinical center of Serbia,
Belgrade
2
School of medicine, University of Belgrade Serbia, Belgrade
rezime
The scaphoid is vitally important for the proper
mechanics of wrist function. Fracture of the sca-
phoid bone is the most common carpal fracture.
Among all wrist injuries the incidence of scaphoid
fracture is second only to fractures of the distal
radius. Scaphoid fractures are significant because
a delay in diagnosis can lead to a variety of ad-
verse outcomes that include nonunion, delayed union,
decreased grips strength, range of motion and osteo-
arthritis of the radiocarpal joint. To avoid missing this
diagnosis, a high index of suspicion and a through his-
tory and physical examination are necessary, because
initial radiographs are often negative. Regardless of
the technique of bone grafting, there will almost al-
ways be some loss of motion even if the fracture unites.
Key words: scaphoid fractures, occult scaphoid
fracture, pedicle vascularized bone graft
INTRODUCTION
T he scaphoid is vitally important for the proper me-
chanics of wrist function. Fracture of the scaphoid
bone is the most common carpal fracture. Among all
wrist injuries the incidence of scaphoid fracture is sec-
ond only to fractures of the distal radius. Besides that,
they are the most frequent fractures among the carpal
bones (60-70%) and among the upper limb in general.
These fractures usually appear in the case of young males
and are localized in the middle third of the scaphoid1. The
case-history usually shows that the patient fell on the wri-
st, when it was placed in dorsiflextion. In 17% of cases
these fractures are associated to fractures and/or disloca-
tions of the rest of the carpal bones or to fractures of the
radius or the head of the radius. Scaphoid fractures are
significant because a delay in diagnosis can lead to a va-
riety of adverse outcomes that include nonunion, delayed
union, decreased grips strength, range of motion and
osteoarthritis of the radiocarpal joint2.
UDK 616.717.7-001.5-089
DOI 10.2298/ACI1302099A
The scaphoid is vitally important for the proper me-
chanics of wrist function. Its unique morphology from its
shape to its blood supply can present challenge in the trea-
tment of the fracture. Taleisnik introduces again the term
"vertical columns", which was introduced first by Navarro
back in 19193. The name "scaphoid" comes from the
Greek word "skaphos", which means "boat" or "canoe".
When a fracture of the scaphoid bone occurs, its anatomy
explains why we should expect a slow healing or even the
lack of healing. First, two thirds of its surface is covered
by cartilage that has no ligament attachment or blood ve-
ssels. Second, the circulation of this bone is very specific.
Obletz and Halbstein discovered that in 67% of the sca-
phoid bones there are openings for blood vessels and nu-
trient supply all along its length. In 13% of the scaphoid
bones the blood vessels are located only in the distal third
of the bone, while in 20% of cases most blood vessels are
located in the middle part or "waist". No case has been fo-
und in which openings are located exclusively in the pro-
ximal third of the bone4. This explains why in one third of
the fractures of the proximal half, the bone remains with
no suitable vascularization and why avascular necrosis is
more frequent in 35% of the fractures at this level5.
DIAGNOSIS
We should expect a scaphoid fracture, if in front of us
there is a young person that fell on the palm of his hand,
with the wrist placed in dorsiflextion, and who has pain in
the region of the anatomic snuffbox or volarly, above the
scaphoid bone. The initial radiography is often negative
and a very common mistake is to declare that injury as a
distortion of the wrist. The other diagnose methods used
in the early detection of scaphoid fractures are the bone
scintigraphy and the magnetic resonance (MRI). Some re-
searches try to establish whether one method is better than
the other, as well as the economic advantages of the MRI
diagnose, compared to carrying an immobilization device
and not being able to work6,7. It is considered that MRI is
100 S. Z. Andjelkovi} et al. ACI Vol. LX

an excellent method to detect hidden fractures of the

scaphoid, as well as associated injuries in the wrist area.
Thanks to this method, it was established that the inci-
dence of occult scaphoid fractures amounts to 19%8. It
was also established that scintigraphy is a sensitive
method, but due to its bad specificity, it produces false
positive results in 25% of cases. In the same research it
was established that computerized tomography (CT) has a
low sensitivity in these cases and cannot identify fractures
in 21% of cases8.
CLASSIFICATION OF FRACTURES
Fractures are most frequently classified according to the
anatomic location of the fracture line, which usually has
an influence on the healing rate and on the prognosis.
They can be divided into:
1. Tuberosistas fracture, where the expected time for the PICTURE 1:
fusion of the bones is four weeks FIXATION OF THE SCAPHOID BONE WITH
2. osteochondral fractures of the distal articular surface KIRSCHNER WIRES
3. fractures of the distal part of the bone, also with good
prognosis
4. fractures in the middle of the bone or "waist" frac-
tures, in which there can be fusion problems in a third of
cases
5. fracture of the proximal pole, in which healing prob-
lems can appear almost in 100% of cases, according to so-
me authors.
NON-SURGICAL TREATMENT
Non-surgical treatment is indicated in those cases, in
which the fracture gap is not greater than 1 mm in the an-
teroposterior and oblique images, the lunate-capitate angle
not greater than 15º and the scaphoid-lunate angle is not
greater than 45º in the lateral image. There are different
opinions regarding the type of immobilization: above-the-
elbow or below-the-elbow, with incorporating the thumb
or without. In the works of Gellman and his collaborators,
there were not observed healing delays or unhealed frac-
tures, in the case of non-dislocated fractures, when above- PICTURE 2 :
elbow devices were used, while there were two cases of FIXATION OF THE SCAPHOID BONE WITH HERBERT
unhealed fractures and six cases of healing delay, when SCREW
below-the-elbow plaster splints with thumb inclusion shorter in the group of patients that were treated by means
were used. Their conclusion is that in the case of fractures of percutaneous fixation with cannulated screws 11. Surgi-
of the proximal and middle third of the scaphoid bone, cal treatment of non-dislocated fractures of the scaphoid
one should use long thumb spica cast, but that fractures of bone is indicated also by Ring and collaborators, because
the distal third of the scaphoid bone heal well, no matter it shortens the period of immobilization and fastens the re-
what kind of immobilization is used9. Conventionally, in turn to sports12.
the case of scaphoid fractures, there are applied plaster
immobilization devices, which incorporate the thumb. In SURGICAL TREATMENT
the work of Clay and collaborators, two kinds of immobi-
lization devices are applied in 392 cases of scaphoid frac- All angulated fractures or fractures with dislocation, in
ture: the first one is an immobilization device that in- which an adequate position cannot be obtained by manual
cludes the thumb, while the second one is similar to the reposition and the use of a splint, shall be treated surgi-
immobilization device used in the Colles fractures of the cally, by applying Kirschner wires (K) or screws (Picture
distal radius. The incidence of non-healed fractures did 1, Picture 2). If there is no comminution, bone grafting is
not depend on the kind of plaster cast used10. Bond and not absolutely necessary in these cases. Surgical treatment
collaborators compared the non-surgical treat-ment with is also indicated in the case of slow healing or when there
the percutaneous fixation of non-dislocated fra-ctures of is no healing at all. The procedure of choice depends on
the scaphoid bone with Acutrack screws. It was estab- the experience of the surgeon, the type of fracture, the age
lished that healing was faster and absence from work was
Br. 2 Fractures of the scaphoid - diagnosis and management
PICTURE 3:
TYPES OF SCREWS
PICTURE 4:
VASCULARIZED BONE GRAFT TAKEN FROM THE
DISTAL RADIUS
of the patient and the presence or absence of arthrosis.
The following are some of the most usual techniques.
Techniques with bone graft
Back in 1937 Matti demonstrated that healing can be
obtained by using cancellous bone with dorsal approach.
This technique was modified by Russe, who used volar
access13. Fisk proposed lateral approach for this opera-
tion, with radial styloidectomy14. Fernandez modified
Fisk’s technique by using a precisely measured iliac cor-
tical bone graft, with palmar access and internal fixa-
tion15. However, these procedures can hardly be efficient
in case of a completely avascular proximal pole. The oss-
ification material used in these procedures can be K wires,
Herbert’s screws, Acutrack screws, interfering screws etc.
101
Immobilization devices can be used for a period between
10 and 12 weeks (Picture 3).
Radial styloidectomy
This procedure can be carried out subperiosteally,
through the snuffbox, paying special attention to the sen-
sitive branch of the radial nerve. It is rarely used isolated,
but it is indicated in cases of arthrosis between the sca-
phoid and the styloid of the radius.
Proximal row carpectomy
According to Hill, this operation is indicated for the tre-
atment of pseudoarthrosis of the scaphoid bone, in the ca-
se of patients that have symptomatic pseudoarthrosis, do
not wish to be submitted to long period of immobilization,
do not suffer from a pronounced radiocarpal arthrosis and
do not carry out heavy physical activities16. In this pro-
cedure the lunate bone and the triquetral bone are remo-
ved, while the scaphoid can be completely excided or its
distal part can be left, which is joined to the trapezium and
the trapezoid. The proximal pole of the capitate bone is
placed in the lunate fossa on the articular surface of the
radius.
Partial fusions of the carpus
This procedure is used when there are changes in small
individual joints inside the carpus, when there are changes
in the capitate and/or lunate bone or after the failure of
previous operations, in order to prevent the midcarpal co-
llapse. The most usual indication is related to the existen-
ce of a SLAC deformity (Scapholunate Advanced Colla-
pse)17, triscaphe degenerative modifications (arthritic
changes between the trapezium, the trapezoid and the dis-
tal scaphoid) or the combination of them. Usually it is ne-
cessary to carry out the fusion of the capitate and the lu-
nate, but it may also be necessary to carry out the fusion
between the hamate and the triquetral bone (four corner
arthrodesis). Sometimes, this procedure can be combined
with the excision of the scaphoid and the implantation of a
silicon prosthesis in its place. One of the options of partial
fusions is the triscaphe arthrodesis, i.e. the arthrodesis be-
tween the scaphoid, the trapezium and the trapezoid. The
complete arthrodesis of the wrist is carried out only in
case of advanced destruction of the radiocarpal articula-
tion, in the dominant hand of young people, who make
heavy physical work.
Vascularized bone grafts
These pedicle grafts are used in the case of pseudo-
arthrosis of the scaphoid bones with osteonecrosis of the
proximal pole and/or after an unsuccessful osteoplastic
procedure. The choice of the adequate graft depends on
the characteristics of the pseudoarthrosis and the presence
or absence of deformities, which will also determine the
surgical approach18. Mund and Larsen said that, after ap-
plying vascularized grafts, the obtained a 91% fusion in
the case of patients that had been unsuccessfully treated
with conventional grafts and/or suffered from necrosis of
the proximal pole. These results are significant if we com-
102 S. Z. Andjelkovi} et al. ACI Vol. LX

pare then to the 64% fusion achieved by using non-vascu-
larized grafts19. Numerous pedicle and free vascula-rized
grafts have been described with variable, but gene-rally
favorable, outcomes. Understanding the indications for
different grafts is critical to the successful application to
these techniques20 (Picture 4).
SUMMARY
PRELOMI SKAFOIDNE KOSTI - DIJAGNOSTIKA I
LE^ENJE
Skafoid je od vitalnog zna~aja za pravilno funkcionisa-
nje ru~nog zgloba. Od svih preloma karpalnih kostiju naj-
~eš}i su prelomi skafoidne kosti. Kod povreda ru~nog
zgloba, po u~estalosti dolaze odmah nakon preloma dis-
talnog radijusa. Ovi prelomi su va‘ni jer kašnjenje u dija-
gnozi vodi velikom broju komplikacija, kao što su nesra-
stanje, usporeno srastanje, smanjenje snage stiska i opsega
pokreta, kao i razvoja osteoartritisa ru~nog zgloba. Da se
dijagnoza ne bi propustila, potrebno je sumnjati na ovu
povredu, uzimaju}i u obzir anamnezu i klini~ki pregled,
jer su inicijalne radiografije ~esto negativne. Bez obzira
na operativnu tehniku, skoro uvek se mo‘e o~ekivati neki
stepen ograni~enja pokreta i u slu~ajevima kada se fuzija
postigne.
Klju~ne re~i: prelomi skafoida, okultni prelomi
skafoida, vaskularizovani peteljkasti
graftovi
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