SCAPHOID FRACTURES
Why I think that many of them need to be managed with surgery

T. HERBERT

Mons - France

Introduction

Fig. 1 : Scaphoid fractures are common injuries, which may lead to complications such as malunion, osteonecrosis, non-union, and post-traumatic OA, to say nothing of iatrogenic complications.

 

Fig. 2

Fig. 3

Fig. 4 The textbooks teach that 95% of these fractures will unite with proper conservative management. However, there is no agreement on the form that this non-operative management should take, and the evidence from experimental and clinical studies is conflicting. There are questions such as whether the thumb and/or the elbow should be included in the cast. Also, the healing rates quoted in the literature range from 98% to a mere 50%; times to union, from 2 to 18 months; and complication rates from 2% to 50%.

Stable and unstable fractures

Fig. 5a: Tubercle fracture Fig. 5 Fig. 6a : Incomplete fracture through waist Fig. 6

I think it is important to differentiate between stable and unstable fractures. - Stable (Type A) fractures are of two types: Type A1, which is a fracture of the tubercle - Type A2, which is an incomplete fracture through the waist.

Fig. 7a: Distal oblique fracture B1: Distal oblique fracture	Fig. 7
Fig. 8	Fig. 9
The unstable (Type 2) fracture patterns, which are likely to displace even if treated conservatively, are subdivided into distal oblique fractures (Type B1)

Fig. 10a: Complete fracture of waist Fig. 10 Fig. 11

Complete fractures of the waist (Type B2).

Fig. 12a: Proximal pole fracture Fig. 12 Fig. 13

Proximal pole fractures (Type B3)

Fig. 14a: Transscaphoid-perilunate fracture dislocation of the carpus B4: Transscaphoid-perilunate fracture dislocation of the carpus Fig. 14 Fig. 15

and transscaphoid-perilunate fracture dislocations of the carpus (Type B4).

Treatment

Fig. 19a : The stable patterns (A1 and A2) will not displace secondarily, and may be managed non-operatively.

Fig. 20a : The unstable patterns (Type B), on the other hand, must be operated on.

Fig. 16	Fig. 17
However, surgery may be difficult (and not only for the surgeon)..
Fig. 18	Fig. 19
...while a cast appears to be straightforward, to the point that it may be displayed in public by all and sundry.

Fig. 20	However, this treatment may be uncomfortable and lengthy, and the outcome may be unpredictable.
Fig. 21	Fig. 22
Fig. 23	Fig. 24

Fig. 25

Fig. 26

This patient, who needed secondary surgery, is a case in point. In this case, an undisplaced fracture that had been treated conservatively from the outset had become completely displaced after six weeks' immobilization. There is no certainty that an undisplaced fracture will remain stable in a cast.

Fig. 27 : It follows that all fractures should be considered to be unstable; radiographs should be viewed with a high index of suspicion;	Fig. 28 : and, if need be, CT should be performed.
Fig. 29	Fig. 30
If there is the slightest doubt, the fracture should be operated upon.

 

Witch technique for unstable fracture

Fig. 28a : As regards technique, all fractures may be managed with open reduction and internal fixation, through a dorsal, a volar, or a combined approach.

Fig. 29a: Incomplete fracture through waist

Fig. 30a: B2: Complete fracture of waist B3: Proximal pole fracture

Incomplete and complete waist fractures, and, possibly, some proximal pole fractures, may also be treated percutaneously.

Fig. 31a	Fig. 32b
Fig. 33c	Fig. 34d
Fig. 35e	Fig. 36f
Various types of internal fixation have been advocated, ranging from K-wires (a), through plates (b), and conventional screws (c), to headless screws (d), which may be cannulated (e and f).

 

Percutaneous screw

Fig. 37a	Fig. 38b
Fig. 39c	Fig. 40d
Fig. 41e
Fig. 42f
Fig. 43g
Fig. 44h	Fig. 45i
Whenever possible, the screw should be inserted percutaneously, over a guide pin (a). This is minimal-access surgery (b). Following a check on the image intensifier (c), the screw may be safely inserted (d), and the clinical outcome (e, f, g) and radiographic results (h, i) will be excellent, within a short period. This is a simple technique that will produce a predictable outcome in a short time.

 

Open suregery

 

 

Fig. 47
Fig. 48
Fig. 49
Fig. 50
Fig. 46	Fig. 51
However, not all fractures lend themselves to percutaneous fixation. Type B3 fractures require open surgery, usually through a dorsal incision. The fracture site is not easy to see, but with fixation the fracture should heal, and grafting will rarely be required.

Fig. 52	Fig. 53
Fig. 54
Fig. 55
Fig. 56	Fig. 57
The same goes for Type B4 lesions (in which a scaphoid fracture is associated with midcarpal dislocation). Internal fixation is performed through a volar approach.

Fig. 58

Fig. 59

Scaphoid surgery means anatomical reduction, rigid fixation, and early mobilization - i.e. no immobilization in a cast. A headless compression screw allows these goals to be attained. It should always be remembered that scaphoid fractures are intra-articular fractures (b) which are potentially unstable and tend to have a high incidence of complications. Correct primary management is, therefore, of the utmost importance...

Fig. 60a	Fig. 61b
Fig. 62c	Fig. 63d
...to prevent the sort of disaster that may be seen otherwise - as in this 20-year-old student, whose apparently simple fracture (a) had not healed after five months of conservative treatment (b), and was still not united after 14 weeks of treatment plus two bone grafts (d). In this instance, what had looked like a simple fracture had ended up as a complete disaster, since, after nine years, there was evidence of radiocarpal OA (d).

Maîtrise Orthopédique n°105 - June-July 2001