scaphoid fracture gaju
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S
Blood Supply -Scaphoid And Its
Clinical Importance
Dr Gajendra Mani ShahMS-OrthoResident
1st year NAMS
Moderator Maj.Dr Bishnu B. Thapa
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General features
Forms radial part of the carpus.
Lies obliquely 45 degree to longitudinal axes to 2 rows.
Articulates with 5 bones…..
Since it crosses two rows of carpus, it is more susceptible to fracture.
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Obletz & halbestin’s
1. 67% of scaphoid have arterial foramina throughout their length
2. 13%have blood supply predominately in the distal third.
3. 20 %have most foramina in the waist and one foramina near the proximal pole.
Blood Supply
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Talesnic & kelly
1. Lateral volar group
2. Dorsal group
3. Distal group
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Gelberman & Menon
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Mechanism of Injury
a. Fall onto outstretched hand
b. Forced dorsiflexion (usually beyond 95 degrees extension), radially deviated wrist with intercarpal supination.
c. Palmar flexion in 3 % of cases (Leslie & Dickenson; Clay et al)
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Clinical evaluation (high diagnostic sensitivity, specificity approaches 74-80 %)
a. Wrist pain
b. Swelling and fullness off anatomical snuffbox - indicates effusion
c. Tender palpation of Scaphoid tubercle and anatomical snuffbox
d. Pronation followed by ulnar deviation cause pain
e. Slight reduction in range of motion
f. Reduced grip strength
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Anatomical Snuffbox
Scaphoid tubercle palpation tenderness has a sensitivity of 87% and a specificity of 57% as an indicator of a scaphoid fracture
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g. Provocative tests
Scaphoid lift test: painful dorsal and volar ballottement.
Watson test: painful dorsal Scaphoid displacement as the wrist is moved from ulnar to radial deviation with compression of the tuberosity.
Scaphoid compression test: longitudinal force along 1 metacarpal elicits pain.
Resisted pronation causes pain.
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Scaphoid compression test: The sensitivity 70.5% but the specificity is only 21.8%
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Radiographic evaluation (70 % sensitivity)
a. Standard PA
b. Lateral (wrist neutral)
c. 45 degree pronated oblique (STTJ)
d. 45 degree supinated oblique (Radio-scaphoid joint)
e. Scaphoid view (PA with ulnar deviation)
f. Others:
PA with wrist in slight extension (Ziter view)
AP with clenched fist to detect a ligamentous injury
Initial films non-diagnostic in 15-25 % of cases.
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Other special investigations
a. Technetium bone scan (92-95 % sensitivity; 60-95 % specificity)
b. MRI (90-100 % sensitivity; 90% specificity - false positives because of bone bruises)
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c. CT
i. Less costly and readily available
ii. Clearer visualization of fracture displacement
d. Ultrasound evaluation
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Classification
Russe classification -Fracture pattern based
Horizontal oblique (HO) 35 %, Transverse (T) 60 %, Vertical oblique (VO) 5 %
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Herbert classification of Scaphoid fractures
Displacement based (stable or unstable)
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a. Tuberosity : 17-20 %
b. Distal pole : 10-12 %
c. Waist : 66-70 %
i. Horisontal oblique: 13-14 %
ii. Vertical oblique: 8-9 %
iii. Transverse: 45-48 %
d. Proximal pole 5-7 %
Based on location
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Avascular Necrosis
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Management
a. Non-operative treatment
i. Indications:
1. Non-displaced distal third fractures
2. Tuberosity fractures
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Expected time to union
1. Distal third 6-8 weeks
2. Middle third 8-12 weeks
3. Proximal third 12-24 weeks
Healing rate and prognosis
1. Tuberosity and distal third - 100 %
2. Waist - 80-90 %
3. Proximal pole - 60-70 %
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b. Operative treatment
1. Fracture displacement > 1 mm
2. Trans-Scaphoid peri-lunar dislocation
3. Unstable fractures (Herbert classification)
4. Fractures known for AVN
• Proximal pole
• Vertical oblique
• Comminuted
• Diagnosed late (after 4/52)
5. Scapholunate angle > 60 degrees
6. Humpback deformity
7. Non-union
Indications:
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References
1. Apley`s System of Orthopaedics and Fractures
2. Miller`s Review of Orthopaedics
3. Campbell`s Operative Orthopaedics
4. Chapman`s Orthopaedic surgery
5. Internet