4/23/18 Shameless Plug… How I Manage Acute Scaphoid Fractures Jeffrey Yao, MD Associate Professor Department of Orthopaedic Surgery Stanford University Medical Center Scaphoid Fractures Epidemiology • Most frequent in young adult males • The classic controversies: – 2nd/3rd decade – Cast versus surgery? – Most common: waist of the scaphoid • Requires twice the force needed to cause a distal radius – Cast: Long or short arm? fracture – Cast: Include thumb or not? – Recent increase in females – Athletes? • Sports – Surgery: Volar versus dorsal approach? • Rare in children – 0.34% of all patients less than 15 y/o – Surgery: One screw? 2 screws? Plate and – Increasing incidence (sports, BMI?) screws? – Most common: distal pole of the scaphoid – Cast immobilization is standard; nonunion rare Examination Imaging • Non-displaced fractures • Wrist swelling frequently missed on • Tender snuff box initial radiographs • Tender dorsal scaphoid • Scaphoid normally rests in 45o of flexion relative • Tender scaphoid tubercle to the radius • Pain with radial deviation • A fracture may not be • Pain with pinch and visible if it rests in a pronation most predictive plane oblique to beam – Unay, Injury 2009 of radiograph Courtesy of Mark E. Baratz, MD • Diagnosis confirmed by radiographic examination Courtesy of Mark E. Baratz, MD 1 4/23/18 “Occult” scaphoid fracture Scaphoid Oblique Radiograph • Posteroanterior (PA) view with wrist in ulnar deviation and the beam angled 20o distal to proximal • Will often show fractures not seen on PA or lateral view Courtesy of Mark E. Baratz, MD PA view Scaphoid Oblique • If initial films are unremarkable, Other imaging modalities the wrist should be immobilized and reexamined in 2-3 weeks • Bone scan – Thumb spica splint/cast – Sensitive (96%), not specific (89%) • CT scan – Repeat radiographs – Take in plane of scaphoid – Ultrasound – Sensitive, defines comminution and – Tomogram angulation of the fractured scaphoid – CT – Excellent to assess healing – MRI • MRI – Only 7% of suspected fractures – Sensitive (98%), specific (99%) are true fractures • Ring, et al (Arthroscopy, 2008) – defines vascularity of proximal pole • Van Tessel, JHS 2010 Cast Immobilization Treatment Options • Include the Elbow? – First suggested by Verdan in 1954 – Eliminate the action of the volar • Cast Immobilization radiocarpal ligaments on the scaphoid • Surgery during supination and pronation – Gellman (JBJS, 1989) • significant reduction in time to healing when LAC was used – Dickson (JBJS, 1981) • 95% union rate in fractures treated with short arm, thumb spica cast – McAdams and Ladd (CORR, 2003) • minimal motion at the fracture site during rotation in a below-elbow cast 2 4/23/18 Consider long arm cast for 6 weeks followed Cast Immobilization by short arm cast until healed for: • Why include the thumb? • Patient – include the thumb in a • Smoker position of opposition • Poor compliance • Eliminates disruptive action • Fracture from the APL, APB, EPL, EPB • All proximal pole – Bohler, Herbert, Clay: • Waist fracture “at risk” • nonunion risk increased with • Comminution below elbow casting and the • Oblique/vertical thumb left free • Fracture displacement – Recent metanalysis suggests no difference • Doornberg et al (JOT 2011) Percutaneous fixation of scaphoid Duration of immobilization fractures versus casting • Bond et al. JBJS 2001 • Distal pole: 4 weeks – Union rates (time to healing) • Waist fracture: 6 to 8 • 7 weeks for surgery vs 12 weeks weeks for cast • Proximal pole: 6 weeks – Return to work to ??? months (CT Scan) • 8 weeks vs 15 weeks – Motion & strength • No difference @ 2 years Cast Versus Surgery, What’s Cast Versus Surgery, What’s the Evidence? the Evidence? • Bond, et al (JBJS, 2001) • Buijze, et al (JBJS 2010) – Benefit of surgical fixation for early return to – Meta-analysis of 419 patients in 8 randomized ADLs controlled trials • Arora, et al (Arch Orthop Trauma, 2007) – Surgery: higher patient satisfaction, grip – Benefit of surgical fixation for early return to strength, shorter time to union and RTW ADLs • Ibrahim, et al (JHS 2011) • Dias, et al (JBJS, 2008) – Meta-analysis of 363 patients in 6 controlled – 93 month f/u: no difference between cast and trials screw fixation • Vinnars, et al (JBJS 2008) – Non-significant improvement in union, but higher complication rates – No long term benefit of ORIF; ? complications 3 4/23/18 Scaphoid Fractures in Athletes Surgical Indications • Distal Pole: • Absolute indications for ORIF • Safest fracture to consider allowing athlete to – Displaced > 1 mm compete in splint and cast when not competing – Proximal pole fractures • Waist: – Comminution • Sport/position dependent – Trans-scaphoid perilunate • Cast until heals vs. early surgical treatment fracture/dislocations • Proximal Pole: – Lateral intrascaphoid angle > • Surgical treatment, and no competition until 35 degrees (“humpback”) fracture healed on CT scan • Fractures with associated DISI • Old fracture: – Athletes? • No urgency, can finish season in splint Principles of Fixation Techniques • Accurate reduction • Arthroscopic Assisted • Screws better than pins • Percutaneous or limited • Central third placement of open screw • Open reduction & fixation – McCallister, Trumble JBJS – Kirschner wires 2003 – Headless compression – Dodds and Slade JHS 2006 screws • Full thread stronger than smooth shank thread (Grewal, JOSR, 2011) Arthroscopic-assisted percutaneous Open Approaches fixation of scaphoid fractures • Dorsal • Slade, Gutow, Geissler – Indicated when have an associated carpal (JBJS 2002) dislocation (perilunate) – Acute proximal pole & – Indicated for proximal pole fractures waist fractures; no AVN – Easier to place screw down central axis or collapse • 100% union • Palmar Scaphoid • Average time to union: Fracture – Indicated for distal pole fractures 12 weeks – Humpback deformity • May identify concomitant – Easier starting location, but difficult to obtain ligamentous injuries (20-30%) central axis without violating the STT joint • Technofest 4 4/23/18 Pre-Op Radiographs Dorsal Percutaneous Approach Naranje, et al SICOT 2010 Dorsal Percutaneous Approach Extensor tendons penetrated in 2/12 specimens Adamany, et al., JHS 2008 Gutow (JAAOS, 2007) Dorsal Open Approach 2 Weeks Post-Op Kawamura and Chung JHS 2008 5 4/23/18 Tips for Volar Approach Positioning Locating Entry Point Use of 14G Angiocath Place Guidewire Down Central Place Screw Axis (Lever Against Trapezium) 6 4/23/18 CT Scan @ 6 weeks Post-Operative Regimen • 1-2 weeks: Splint immobilization • 2-6 weeks: ROM exercises • > 6 weeks: Strengthening exercises • 12 weeks: Weight-lifting, pushups • 4-5 mos: Contact sports • Regimen accelerated for athletes More Controversial Topics 1 versus 2 Screws? • Jurkowitsch, et al. Arch Orthop Trauma Surg . 2016 – Biomechanically improved rotational stability of 2 headless compression screws vs 1 • Quadlbauer, et al. Arch Orthop Trauma Surg . 2017 – 10/10 union unstable fxs with 2 x 2.2 mm HCS – 19/22 union unstable fxs with 1 x 3.0 mm HCS – Similar functional outcome and complications Scaphoid Plating? Scaphoid Plating? • Ender, H. (Unfallheilkunde. 1977) • Supplanted by the Herbert screw (introduced in 1984) • For Nonunions: – Leixnering, et al. (JOT 2011) • 11 patients • Median healing: 4 mos • DASH: 28 – Ghonheim A (JHS 2011) • 13/14 patients healed at mean 3.8 months THUES 2014 7 4/23/18 Scaphoid Plating? How Do I Treat Acute Scaphoid Fractures? • Non-Displaced Fractures – Distal Pole • Short Arm Cast immobilization (no thumb) – Waist Fractures • Sedentary patient: Cast • Active patient: ORIF (1-2 weeks to ROM) – Proximal Pole • ORIF (2-4 weeks prior to ROM) • Any displaced, unstable fractures : ORIF • Athletes: ORIF Thank You! 8 .