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Imaging and Treatment of Scaphoid Fractures and Their Complications 159 Imaging and Treatment of Scaphoid Fractures and Their Complications Mihra S. Taljanovic, M.D., M.Sc., F.A.C.R. 1 Apostolos Karantanas, M.D., Ph.D. 2, 3 James F. Griffith, M.D. 4 Gregory L. DeSilva, M.D. 5 Joshua D. Rieke, M.D. 1 Joseph E. Sheppard, M.D. 5 1 Department of Medical Imaging, The University of Arizona Health Address for correspondence and reprint requests Mihra S. Taljanovic, Network, Tucson, Arizona. M.D., M.Sc., Department of Medical Imaging, The University of Arizona 2 Department of Radiology, University of Crete, Heraklion, Greece. Health Network, 1501 N. Campbell Ave., Tucson, AZ 85724-5067 3 Department of Medical Imaging, University Hospital, Heraklion, (e-mail: [email protected]). Greece. 4 Department of Imaging and Interventional Radiology, Prince of Wales Hospital, Shatin, New Territories, Hong Kong. 5 Department of Orthopaedic Surgery, The University of Arizona Health Network, Tucson, Arizona. Semin Musculoskelet Radiol 2012;16:159–174. Abstract The scaphoid is the most commonly fractured carpal bone, with frequent complications that are predisposed by its anatomical location, anatomical configuration (shape and length), and vascular supply. The most common mechanism of injury is a fall onto an outstretched hand. Imaging plays a significant role in the initial evaluation and treatment of scaphoid fractures and their complications. Radiography should be the first imaging modality in the initial evaluation and follow-up of scaphoid fractures. Computed tomography with its superb spatial resolution enables better visualization and charac- terization of the fracture line, and the amount of displacement and angulation of the fracture fragments. Using the metal reduction artifact with computed tomography allows good follow-up of scaphoid fractures despite surgical hardware. Magnetic Keywords resonance imaging without contrast is the imaging modality of choice for depiction ► scaphoid of radiographically occult scaphoid fracture, bone contusion, and associated soft tissue ► fracture injury; contrast-enhanced imaging aids assessment of scaphoid fracture nonunion, ► nonunion osteonecrosis, fracture healing after bone grafting, and revitalization of the necrotic ► osteonecrosis bone after bone grafting. Proper identification and classification of scaphoid fracture and ► radiography its complications is necessary for appropriate treatment. This article describes the ► fi MRI normal anatomy, mechanism of injury, and classi cation of stable and unstable fractures, Downloaded by: University of Colorado Denver. Copyrighted material. ► CT together with the imaging and treatment algorithm of scaphoid fractures and their ► treatment complications with an emphasis on magnetic resonance imaging. The scaphoid is the most frequently injured carpal bone. Often misdiagnosed as a simple wrist sprain, scaphoid frac- Scaphoid fractures account for 60 to 70% of all carpal frac- tures are prone to complication.3 Early diagnosis of scaphoid tures1 (►Figs. 1 and 2). Young active adults are most com- fractures (►Fig. 3) is of great importance to minimize these monly affected with a male predominance.1,2 Patients with potential complications such as nonunion (►Figs. 4–7), os- scaphoid fractures most often present with wrist pain and teonecrosis (►Figs. 8 and 9), carpal instability, and osteoar- with tenderness and fullness in the anatomical snuffbox. thritis (►Fig. 10).4 Issue Theme Hand and Wrist Imaging; Copyright © 2012 by Thieme Medical DOI http://dx.doi.org/ Guest Editor, Andrea S. Klauser, M.D. Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0032-1311767. New York, NY 10001, USA. ISSN 1089-7860. Tel: +1(212) 584-4662. 160 Scaphoid Fractures Taljanovic et al. Figure 1 (A–D) An 18-year-old male patient with an acute scaphoid waist fracture. (A) Posteroanterior (PA), (B) PA oblique, (C) lateral, and (D) PA ulnar deviation radiographs of the left wrist show a minimally displaced scaphoid waist fracture (arrows) that is best seen in the PA ulnar deviation projection. Normal Anatomy and Mechanism of Injury the lunate and capitate, and distally with the trapezium and trapezoid bones. The normal anatomy of the scaphoid bone The scaphoid is the most radially positioned bone of the includes the distal pole, the volar tubercle located at the distal proximal carpal row, and it articulates proximally with the pole immediately proximal to the trapezium, the waist, and Downloaded by: University of Colorado Denver. Copyrighted material. radial styloid at the scaphoid fossa, at the ulnar side with the proximal pole. All of these structures may be identified on radiographs.5 The scaphoid receives its blood supply from the branches of the radial artery in a retrograde fashion (►Fig. 11).6 The proximal pole of the scaphoid is fixed in place volarly by the strong extrinsic radioscaphocapitate and long radiolunate ligaments and the intrinsic capsular palmar scaphotriquetral ligament. The intrinsic interosseous liga- ments (scapholunate, scaphocapitate, and scaphotrapeziotra- pezoid) connect the scaphoid to the neighboring bones. At the dorsal side of the carpus, the intrinsic capsular dorsal inter- carpal ligament attaches via its proximal band to the scaphoid bone waist. The less important radial collateral ligament extends from the radial styloid to the scaphoid waist.7,8 Figure 2 (A, B) Comminuted right scaphoid distal pole fracture in a Most carpal bone fractures occur along the zone of vul- 20-year-old male patient who was treated conservatively with a spica nerability (►Fig. 12), which follows the direction of the major cast. (A) Posteroanterior (PA) ulnar deviation radiograph of the right volar wrist ligaments starting at the radial styloid, traversing wrist shows a comminuted fracture of the distal scaphoid pole (arrow). the waist and proximal pole of the scaphoid and the body of (B) PA radiograph of the right wrist obtained 8 weeks later shows that the fracture is healed (arrow). Note generalized osteopenia secondary the capitate before turning ulnarly to include the base of the 9 to disuse. hamate and the ulnar styloid. The mechanism of injury is Seminars in Musculoskeletal Radiology Vol. 16 No. 2/2012 Scaphoid Fractures Taljanovic et al. 161 Figure 3 (A–D) A 16-year-old male patient with a nondisplaced fracture of the proximal pole of the right scaphoid treated with open reduction and internal fixation (ORIF). (A) Posteroanterior (PA) radiograph of the right wrist shows a subtle fracture of the proximal scaphoid pole (arrow). The fracture line is better seen on (B) the coronal T1-weighted and (C) short tau inversion recovery magnetic resonance images (arrows). Note bone marrow edema of intermediate signal intensity in (B) and high signal intensity in (C) involving the near entire scaphoid bone. (D) PA radiograph of the radial side of the right wrist obtained 8 weeks after ORIF shows a dorsally placed variable pitch cannulated fixation screw transfixingahealedscaphoidfracture. most often due to hyperextension of the wrist, but it can also scaphoid injury.1,5 Perilunate fracture dislocations are rela- result from a pure compressive force. A fall on an outstretched tively uncommon but may be associated with scaphoid Downloaded by: University of Colorado Denver. Copyrighted material. hand causes palmar tensile and dorsal compressive force on fracture (►Fig. 13) and occur as a result of high-energy the scaphoid, and it is the most common mechanism of trauma10 with notable disruption of the carpal arcs.11 The scaphoid is a critical link in the biomechanics of the carpus and participates in the movement of both proximal and distal rows. Because of its offset articular surfaces both proximally and distally, the scaphoid has a natural tendency to palmar-flex with longitudinal loading. Therefore, scaphoid extension places progressively increasing tension on the palmar cortex of its curved waist. Excessive extension or ulnar deviation of the wrist, associated with excessive load- ing, predisposes the scaphoid to fracture. This is especially true if the strong ligaments attached to the scaphoid retain their integrity. When a fracture occurs proximal to the scaphoid waist, it is predisposed to displacement because of the opposing forces acting on the proximal and distal fragments as well as the distribution of ligament attach- Figure 4 Nonunited displaced scaphoid fracture in a 30-year-old male ments. The distal entry point of nutrient vessels and a patient. Posteroanterior radiograph of the left wrist shows a displaced nonunited scaphoid fracture at the junction of the waist and proximal retrograde intraosseous blood supply also predispose the pole (arrow). proximal pole to ischemic conditions.12 Seminars in Musculoskeletal Radiology Vol. 16 No. 2/2012 162 Scaphoid Fractures Taljanovic et al. Figure 5 (A–D) Nonunited scaphoid waist fracture in a 44-year-old male patient 13 years after trauma. (A) Posteroanterior radiograph of the left wrist shows a nonunited scaphoid waist fracture (arrow). (B) Coronal reformatted and (C) sagittal oblique reformatted computed tomography (CT) images of the left wrist better demonstrate sclerosis and cystic changes about the fracture line (arrows). (D) On the sagittal oblique reformatted CT image, note humpback deformity at the dorsal aspect of the scaphoid (arrow) and measurements of the scaphoid height (double- headed black arrow) and length (double-headed white arrow). Distribution and Classification Several classification systems of scaphoid fractures have of Scaphoid Fractures been proposed in the literature.
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