scaphoid fractures
TRANSCRIPT
NON UNIONOF FRACTURE
SCAPHOID
Dr. Abdul G.SuhailMBBS, D.Ortho, MS (Ortho)
Assistant Professor in Orthopaedics
PROBLEM•WHAT IS THE CAUSE OF THE PROBLEM?•WHAT IS THE INCIDENCE OF THIS PROBLEM?•HOW TO DIAGNOSE THIS PROBLEM?•WHAT ARE CONSEQUENCES OF THIS PROBLEM?•HOW TO MANAGE THIS PROBLEM
BLOOD SUPPLY
Proximal to the waist: 20%, no foramina 13%, single
foramina
INCIDENCE OF THIS PROBLEM Missed InjuriesAfter conservative treatment
LinScheild 1992 5%
Leslie 1981 5%
Cooney 1980 25%
Herbert 1984 50%
DIAGNOSIS OF THE PROBLEM
Clinical : Tenderness in the anatomical snuff box
X-ray : P.A., Lateral, Oblique & Ulnar Deviation view
Repeat X-ray 15 days after the injury
Technetium Bone ScanMRI
Nonunion scaphoid
TECHNETIUM BONE SCAN
What are the consequences
of this problem?
• Degenerative changes
• Avascular necrosis
MANAGEMENT OF THE PROBLEM
Before embarking on the management one needs to know whether the nonunion is stable or not
STABLE FRACTURE
No displacement of fragments
No carpal collapse
Mc Laughlin and Parkes (1954)• With intact cartilaginous shell
"Peanut fracture"• Partially broken cartilaginous shell
UNSTABLE FRACTURES
Those with fracture line more than 1mm
Offset of the fractured fragmentsScapho-lunate angle > 60 degreesLunatocapitate and radio-lunate angle > 15 degreesHump back deformity
MANAGEMENT
•NON OPERATIVE•OPERATIVE
Non Operative Treatment
Stable non union : Without carpal collapse and symptom free needs no treatment
Mazet R & Hohl 1961Leads to post-traumatic osteo-arthrosis with passage of time
Mack et al 1984
All these studies are flawed in that, they are retrospective studies and not population based Kerluke & McCabe 1993
Non operative treatment
Prolonged immobilization
Electrical stimulation
Prolonged immobilization
Stable undisplaced fractures go into union
Stewart MJ 1954
Electrical Stimulation
44 non-unions treated by pulsedelectromagnetic Field (PEMF) andimmobilization 80% healed in 43 months Frykman et al - 1986
Apprehensive about the same Adams et al - 1992
-.
Electrical stimulation
Indications for PEMF Problem non-unions : proximal segment is fragmented and avascular
Infective non unions
OPERATIVE TREATMENT
Most of the non-unions are treated by Surgical intervention
”No single method of treatment can be used for all types of disability caused by an ununited fracture of the carpal
navicular”
Pennsylvania Orthopaedic Society, 1962
OPERATIVE TREATMENT
Many types of procedures are described
Choice depends on:
• Surgeon's preference and experience
• Type of fracture
• Age of the patient
• Presence of Periscaphoid changes
OPERATIVE TREATMENT
• Osteosynthesis • Bone grafting• Salvage procedures
OSTEOSYNTHESIS
Indications •Trans-scaphoid perilunate
dislocation•Those with carpal instability•Displaced fracture
fragments
OSTEOSYNTHESIS
• K wires• Screws• Staples• Plates
K - WIRES
•Most versatile of all implants
•Important part of the tool kit for surgeons treating fracture non union
K - WIRES•Easy to insert•Does not require radial
styloidectomy and other extensive exposures
•Better fixation especially in the presence of small proximal fragment with AVN
K -WIRESDisadvantages•May not be a stable fixation
•If pins protrude through the skin, it may produce pin tract infection
Screws• Harrison Mc Laughlin was the first
one to use screw for fixation of fracture scaphoid in 1954
• Screw fixation when done must be precise and meticulous• Poor fixation itself may lead to delayed or non union Trumble
1996
ScrewsA.O Screws:•Scaphoid lag screws•Needs limited approach• Insertion under direct vision
Leyshon et al,1984 and Fernandez, 1990
reported successful results
Cancellous screw fixation
ScrewsTrumbel et al ,1996 •Advocated cannulated
screw•Permits central placement
under radiographic control
ScrewsLane et al 1997• Two piece
screws
Herbert screw
•Tim J.Herbert, Orthopaedic registrar at Rowley Bristow Hospital used a jig for inserting screw
•Later he along with Fisher, an engineer developed the double threaded screw
•Settled in Sydney and continued his work
Herbert screw•Screw is double threaded
•Smaller than A.O. Screw•Can be used in cases with smaller fragments
•Need not be removed
Herbert screw•No separate head•Both ends are buried•Need special instruments•Jig gives the precision and compression
Herbert screw
Herbert ScrewDisadvantages:•Cannot be used in cases with small fragments with AVN
•Technical dependence is high
•Wide exposure is required
STAPLES• It has been in use since 1980•Carpenter et al 1990 and Korkala
et al 1992•Technically demanding•Memory staples made of Nickel -
Titanium Alloys Cugola & Tesloni,
1997
PLATES•Ender's blade Plate Huene and Huene,1991
•Plate needs removal•Not popular
BONE GRAFT
•Adams , 1928•Matti , 1937 : Cancellous
chips (Dorsal)•Russe ,1960 : Pegs + Chips
(Volar)•Modified Russe ,1980 : Two
Corticocancellous grafts
BONE GRAFT
• Fisk,1970 :Volar wedge graft with Styloidectomy
•Fernandez,1980 :Trapezoidal graft•Maltese : Cross graft•Vascularized grafts
Russe's method Insertion of two cortico-
cancellous grafts into the cavity with additional cancellous chips
Russe's method
Indications•All symptomatic, established non unions•Symptomatic delayed union without OA and instabilities
Original Russe bone grafting
Russe's methodPoor results in
•Cases with AVN Green
1985•Collapsed non union with dorsal Carpal instability Carrozella et al
1989
Russe -Matti Method
Results
• Green 1975 75%
• Cooney 198888%
Fisk - Fernandez
method,1976 Realignment of scaphoid fragments and insertion of appropriate shaped grafts to maintain the alignmentFisk
(1976)
Fisk Fernandez technique
Fisk - Fernandez
Wedge & Trapezoidal shaped grafts after careful measurement
Fernandez,1984
Maltese Cross graft
Better graft especially in revision surgery
Healing Potential
•If no bleeding, 100% failure Green,1985
•Avascular proximal poles will heal with surgery Murray,1998
Vascularized grafts
•Braun ,1983 : Pronator pedicle graft
•Pechlaner et al, 1987:Vascularized iliac crest graft
•Fernandez and Eggli 1995:vascular bundle implantation
Pronator Pedicle graft
Braun 1983 ,100% result
SALVAGE PROCEDURES
•Radial styloidectomy•Bentzon's procedure•Proximal row carpectomy
•Partial arthrodesis
Radial Styloidectomy
•Remove less than 1cm of Radial styloid
•Presence of important Volar ligaments
•Can be used as a graft •Styloidectomy alone is an
unsatisfactory procedure Mezet & Hohl
1961
Bentzon's Procedure
Bentzon (1939) •Soft tissue flap on the
dorsoradial aspect of the wrist to produce
pseudarthrosis•Not popular outside Scandinavia
Proximal Row Carpectomy
• Indicated in the elderly patients with symptomatic nonunion . Avoids
prolonged immobilization Hill,
1970• Done even in younger patients
where demands of movements are more
Crabbe 1964, Inglis & Jone 1977
Partial arthrodesis
•Radio scapho lunate•Scapho capitate
Scaphoid replacement
Silicon prosthesis
•Silicon synovitis
Management in brief
Older thinking:• Closed reduction and plaster cast
for all fractures, continue even upto 6 months
• ORIF if reduction cannot be achieved and at the end of failed closed treatment
• Non union - bone grafting
Management in brief
Older thinking (con’t):• Second non union - bone grafting• Third non union - Vascularised
bone grafting• Avascular necrosis - Salvage
procedures• Arthritis - Wrist fusion
Management in Brief
Newer thinking:
• Closed method only if fracture is seen on bone scan & MRI
• For all visible fractures: closed minimally open fixations and early mobilization
• ORIF for comminuted fractures• Early vascularized graft for
fractures at risk
Our ApproachProximal third fractures:• Small fragment Pronator vascular pedicle graft &
'K' wire• Big fragment with no AVN/OA/
Collapse Herbert screw fixation/ Russe bone
grafting + 'K' wire/ Pronator vascular pedicle graft
Our Approach Proximal third fractures (cont):
• Fragmented + AVN Excision & limited fusion
• Non union with limited radio-carpal OA Radial styloidectomy & Pronator vascular
pedicle graft
• Severe OA Proximal Row Carpectomy or wrist
arthrodesis
Our ApproachMiddle third fractures:
• Stable & asymptomatic Further immobilisation or prophylactic
Russe Bone graft+ 'K' wire & AO screw
• Symptomatic, with no OA/AVN/ collapse Russe bone grafting + AO Screw
• With carpal collapse and no AVN/ OA Fisk & Fernandez graft,K-wire/Herbert
screw
Our ApproachMiddle third fractures (cont):
• Non union with limited OA, no AVN Radial styloidectomy + bone grafting or
Scaphoid excision + mid carpal fusion
• Non union +AVN Pronator Vascular Pedicle graft or Scaphoid
excision + mid carpal fusion
• Extensive arthrosis Proximal row Carpectomy or Wrist arthrodesis
Our ApproachDistal third : very rare•Symptomatic but stable Short thumb spica
•Non union with carpal collapse Open reduction, bone grafting+
AO screw
Thank You