SCAPHOID FRACTURES

AND ITS NON UNION

MODERATOR : DR. NAGAKUMAR JS SIR

PRESENTER: DR. MUTHUKUMAR R
INTRODUCTION

 The name scaphoid comes from the greek word “skaphos” meaning boat, a reference to the shape

of the bone.

 Acute scaphoid fractures were first described by cousin and destot in 1889, with subsequent

descriptions by mouchet and jeanne in 1919.

 Fractures of the scaphoid are common and account for about 50% to 80% of carpal injuries.

 Anatomically, the scaphoid is divided into proximal and distal poles, a tubercle, and a waist

 80% of the scaphoid is covered with articular cartilage

 Scaphoid articulates with five bones:

1. Radius proximally

2. Trapezoid bone and trapezium bone distally

3. Capitate and lunate medially

 It forms the radial border of the carpal tunnel.

 The scaphoid bone is the largest of the proximal row of wrist bones, its long

axis being from above downward, lateralward, and forward.

 The palmar surface of the scaphoid is concave, elevated and forming a

tubercle, giving attachment to the transverse carpal ligament.

 The proximal surface is triangular, smooth and convex, and articulates with
 The lateral surface is narrow and gives attachment to the radial collateral ligament.

 The medial surface has two facets, a flattened semi-lunar facet articulating with

the lunate bone, and an inferior concave facet, articulating with the head of the
capitate bone.

 The dorsal surface of the bone is narrow, with a groove running the length of the

bone and allowing ligaments to attach, and the surface facing the fingers
(anatomically inferior) is smooth and convex, also triangular
 BLOOD SUPPLY OF SCAPHOID
• The scaphoid is supplied by two groups of small vessels.
• Majority of its blood supply comes from dorsal vessels at or just distal to
waist area perfusing the proximal pole in a retrograde fashion.
• These are branches of radial artery that enter scaphoid through foraminae
along its dorsal ridge. It supplies 70–80% of bone, including the entire
proximal pole.
• The second group of vessels arises from palmar and superficial palmar
branches of radial artery and enters carpal scaphoid in region of its distal
tubercle. This perfuses distal 20–30 % of bone, including tuberosity.
• There is no anastomosis between the dorsal and palmar vessels
FUNCTIONS OF SCAPHOID

 The carpal bones provide a bony super structure for the hand.

 They provide the mobile bearing for the hand to move as an organ over forearm bones.

 The scaphoid along with the lunate, articulates with the radius and ulna to form the wrist joint.

 With all movements and stress bearing, the scaphoid bone takes part in wrist function.

 The scaphoid serves as a link between the two rows of carpal bones. The scaphoid flexes

during radial deviation and extends on ulnar deviation of wrist.

 LIGAMENTS OF SCAPHOID
Scaphotrapeziumtrapezoid - Distal pole of scaphoid
Proximal palmar aspect of trapezium/trapezoid Insertion on
trapezoid

Scaphocapitate - Distal pole of scaphoid

Radial volar body of the capitate

Scapholunate
Dorsal, Palmar, Proximal
Dorsal lateral horn Lunate
Ulnar-dorsal aspect proximal pole scaphoid
CLASSIFICATION'S

1. Russe classification

2. AO classification

3. Herbert and Fisher classification

4. Mayo classification
RUSSE CLASSIFICATION

Classification Based on fracture pattern

 Horizontal oblique

 Transverse

 Vertical oblique
 CLASSIFICATION OF SCAPHOID FRACTURE

Based on displacement
Based on location
 Stable: nondisplaced fractures with no step-off in any plane
• Proximal pole: 10% to 20%
 Unstable • Distal pole and tuberosity: 5%
• Waist: 80%
1. >1-mm displacement
• Horizontal oblique: 13% to 14%
2. >10 degrees angular angulation
• Vertical oblique: 8% to 9%
3. Fracture comminution • Transverse: 45% to 48%
• Proximal pole: 5% to 7%
4. Capitolunate or radiolunate lunate angle >15 degrees

5. Scapholunate angle >60 degrees

6. Intrascaphoid angle >35 degrees

MAYO CLASSIFICATION

 Type 1: Tuberosity

 Type 2: Distal articular surface

 Type 3: Distal third

 Type 4: Waist, middle third

 Type 5: Proximal pole

HERBERT AND
FISHER
CLASSIFICATION
 SCAPHOID SHIFT TEST

• Pressure is applied to the palmar aspect of

the scaphoid tubercle while moving the wrist
from an ulnar to radial deviation.
DIAGNOSIS

 The four standard views

1. Neutral posteroanterior (PA)

2. Lateral radiographs,

3. 45-degree radial oblique

4. 45-degree ulnar oblique views

 Additional extension and flexion views are advocated for detecting intercarpal ligament injury,

along with a clenched fist and stress views

 For the normal carpus with the wrist and hand in a neutral position, in the coronal (PA) plane a

line drawn through the axis of rotation parallel with the anatomic axis of the forearm will pass
through the head and base of the third metacarpal, the capitate, the radial aspect of the lunate,
and the center of the lunate fossa of the radius.

 Standard radiographs should demonstrate a constant space between the scaphoid, lunate, and

triquetrum throughout the range of wrist motion.

 GILULA LINES
 Arc 1 runs along the proximal articular surface of the proximal

carpal row

 Arc 2 runs along the distal articular surface of the proximal

carpal row

 Arc 3 runs along the proximal cortical margins of the capitate

and hamate

 Three carpal arcs that produce smooth curves when drawn, with

a broken arc diagnostic of a fracture and/or instability,

particularly perilunate fracture dislocations
 Intercarpal, carpometacarpal, and radiocarpal joint spaces (neutral PA view)

 Space is normally ≤2 mm, with ligament disruption suspected at >3 mm and often diagnostic

at >5 mm
 In the sagittal (lateral) plane with the wrist and hand in a neutral position, a line will pass

through the longitudinal axis of the index finger metacarpal, capitate, lunate, and the radius,
with the scaphoid lying on an axis at a 45-degree angle to this line.
 Scapholunate angle (normal 45 degrees, range

30 to 60)

 Angle created by the longitudinal axes of the

scaphoid and the lunate

 DISI pattern greater than 60 degrees, VISI

pattern when less than 30 degrees; greater

than 80 degrees is diagnostic of carpal
(scapholunate) instability
 Scaphoid fractures are generally classified as either undisplaced and stable or displaced and

unstable

 MRI to diagnose “occult” scaphoid fractures at an average of 2.8 days after injury

 MRI, especially with gadolinium enhancement, also is useful in assessing the vascularity of a

fractured scaphoid
NONDISPLACED, STABLE SCAPHOID FRACTURES

 Scaphoid waist and in the distal pole without other bony or ligamentous injury and for

scaphoid fractures in children, conservative management / non operative management is the

treatment option

 The prognosis is better if the fracture is diagnosed early.

 The ideal candidate for nonoperative treatment is one who can manage to continue working in

a below-elbow cast without thumb immobilization for 6 or more weeks or is unwilling to take
the risks of immediate surgery
 When a scaphoid fracture is identified, immediate immobilization is done to facilitate bone

healing.

 when a fracture identified as late as 4 to 6 weeks, it may be treated nonoperatively with below

elbow cast

 Most fractures involving the waist and distal scaphoid are essentially undisplaced and can be

treated nonoperatively regardless of patient age.

CONTRAINDICATION

 Transscaphoid perilunate dislocation.

 Comminution causing instability

 Multiple fractures such as a combined scaphoid and radial styloid fracture

 Any displacement or gap

 A forearm cast from just below the elbow proximally to the base of the thumbnail and the

proximal palmar crease distally (thumb spica) with the wrist in slight radial deviation and in
neutral flexion.

 The thumb is maintained in a functional position, and the fingers are free to move from the

metacarpophalangeal joints distally.

 Using nonoperative casting techniques, the expected rate of union is 90% to 95% within 10 to

12 weeks.

 During this time, the fracture is observed radiographically for healing.

 If collapse or angulation of the fractured fragments occurs, surgical treatment usually is required
 Operative techniques, including percutaneous fixation with cannulated screws

 Surgery may be considered if new healing activity is not evident and if union is not apparent

after a trial of cast immobilization for about 20 weeks

DISPLACED, UNSTABLE SCAPHOID FRACTURES

 A different course of treatment is required for a displaced, unstable fracture

1. Offset more than 1 mm in the anteroposterior or oblique view

2. Lunocapitate angulation is greater than 15 degrees

3. Scapholunate angulation is greater than 45 degrees in the lateral view (range 30 to 60

degrees).

4. A lateral intrascaphoid angle greater than 45 degrees,

5. An anteroposterior intrascaphoid angle less than 35 degrees

 Closed reduction can be attempted initially by longitudinal traction and percutaneous joystick

Kirschner wires.

 If the reduction attempt is successful, percutaneous fixation with a cannulated screw or pins

and application of a thumb spica cast to be done

 If not, requires open reduction and internal fixation

INDICATIONS

 Patients with a nondisplaced scaphoid waist fracture who wish to proceed with operative

treatment

 All displaced fractures require operative treatment

 Transscaphoid perilunate fracture-dislocation

 Concomitant distal radius fracture

 Delayed presentation (3 weeks) nondisplaced fracture with no prior treatment

CONTRAINDICATIONS

1. Active infection

2. Metal allergy

3. Osteopenia with poor bone quality

 The AO cannulated screw, the Herbert differential pitch bone screw, and headless screws have been used to

advantage in displaced and unstable scaphoid fractures

 Cannulated bone screws are useful because the screw can be placed accurately over a guide pin with

fluoroscopy

 Advantages of screw fixation

I. Reduces the time of external immobilization

II. Provides relatively strong internal fixation

III. Produces compression at the fracture site

 OPEN REDUCTION AND INTERNAL FIXATION FOR DISPLACED
SCAPHOID FRACTURE - DORSAL APPROACH

• Noncomminuted fractures in the proximal pole of the scaphoid,

exposure of the fracture site and placement of internal fixation
can be done through a dorsal approach.
• The forearm is pronated and a longitudinal skin incision 2 cm in
length is placed beginning at the proximal aspect of the lister
tubercle extending along the axis of the third metacarpal. .
• The guide wire is inserted at the membranous portion of the
scapholunate ligament and is aimed down the central axis of the
scaphoid toward the thumb perpendicular to the fracture
 If the fracture is displaced, expose the scaphocapitate articulation and the radial aspect of the

midcarpal joint

 The carpus is manually distracted with two k-wire “joysticks” are inserted perpendicularly into

the proximal and distal scaphoid fragments to facilitate reduction

 The accuracy of the reduction can be determined by assessing the fracture line at both the

radioscaphoid and scaphocapitate articulations

 The wire is advanced into the trapezium for enhanced stability

 The patient is immobilized in a short-arm plaster splint

 At 2 weeks, Wrist range-of-motion exercises are begun along with removable forearm-based

thumb-spica splint.

 The splint is discontinued at 6 weeks postoperatively.

 If the fracture involves the proximal pole, or if significant comminution was noted at surgery,

or if there is concern regarding stability of the fixation, short-arm cast immobilization is

indicated for 6 to 10 weeks.
OPEN REDUCTION AND INTERNAL FIXATION— VOLAR APPROACH
WITH ILIAC CREST BONE GRAFTING

 The best exposure for scaphoid fractures at and distal to the waist.

 Make a longitudinal skin incision over the palmar surface of the wrist, beginning 3 to 4 cm proximal

to the wrist flexion crease over the flexor carpi radialis

 If comminution is absent or minimal, reduction and fixation suffice.

 If comminution is extensive, especially on the palmar surface, with a tendency to flexion of the

scaphoid at the fracture, obtain an iliac crest bone graft.

 Reduce the fracture and fix it with Kirschner wires or a screw technique (e.g., cannulated screws)
 OPEN REDUCTION AND INTERNAL FIXATION FRACTURES OF THE
SCAPHOID— VOLAR APPROACH WITH DISTAL RADIAL AUTOGRAFT
 Make a straight incision in the distal forearm between the distal portion of the flexor carpi

radialis and the radial artery.

 Carry the incision across the distal wrist crease using a hockey-stick incision that angles

toward the base of the thumb

 Reduce the fracture with manipulation or joysticks and insert Kirschner wires for

provisional fixation

 If bone grafting is required for volar comminution or a subacute fracture, harvest grafts

from the volar radius beneath the pronator quadratus by extending the incision additional 2

to 3 cm proximally or make a separate incision dorsally and just proximal to Lister’s

tubercle
PERCUTANEOUS SCAPHOID FIXATION: VOLAR
TRACTION APPROACH

 Percutaneous fixation is alternative to cast immobilization and permits early rehabilitation

with minimal risks

 The volar (distal to proximal) approach is applicable to all waist fractures

INDICATIONS

 Nondisplaced and minimally displaced scaphoid waist fractures

 Distal pole fractures

 Undisplaced fibrous scaphoid waist nonunions without evidence of avascular necrosis

 Undisplaced proximal pole fractures without avascular necrosis are amenable to this technique

provided that the proximal fragment is large enough to allow capture by at least 5 mm of

screw threads.
CONTRAINDICATION

 Proximal pole fractures

 Humpback deformities or scaphoid collapse with a dorsal intercalated

segmental instability pattern (DISI) deformity

 The scaphoid tuberosity is easily palpable and is the key to the insertion point.

 The entry point is then located using a 12 gauge IV needle introduced on the

anterolateral aspect of the wrist just radial to and distal to the scaphoid tuberosity.

 The aim should be to have the guide wire exiting the proximal pole just radial to the

scapholunate junction.

 The guide wire should be advanced to stop just short of the articular surface and

should not breach

 The self-tapping screw is then advanced over the guide wire and the wire removed
NON UNION OF SCAPHOID FRACTURES

 Nonunion of scaphoid fractures is influenced by

1. Delayed diagnosis (40%)

2. Gross displacement (92%)

3. Associated injuries of the carpus

4. Impaired blood supply

 The incidence of osteonecrosis is approximately 30% to 40%, occurring most frequently in

fractures of the proximal third.

 Cystic changes in the scaphoid and the adjoining bones followed by osteonecrosis can occur

after untreated fractures

 Nonunion is expected more often if the scaphoid fracture is untreated for 4 or more weeks.

 Delayed treatment can result in a nonunion rate of 88%.

 Treatment options for nonunions of proximal pole fractures depend on the blood supply to the

proximal pole and the size of the fragments.

 Nonunions involving the proximal third or more can be treated with nonvascularized bone

grafts if circulation is satisfactory as determined by preoperative gadolinium-enhanced MRI

and by intraoperative assessment of bone bleeding.

 Vascularized bone grafts are indicated when circulation to the proximal pole is poor.

 For very small, avascular, ununited fragments, the proximal pole can be excised if the

scapholunate ligament integrity is still intact.

 Scaphoid nonunion advanced collapse pattern

include

1. Radio scaphoid narrowing

2. Capito lunate narrowing

3. Cyst formation

4. Pronounced dorsal intercalated segment

instability
 Jupiter et al. Observed that ununited fractures of the scaphoid fall into three groups, depending

on the extent of arthrosis:

1. Established nonunions without arthrosis

2. Nonunions with radiocarpal arthrosis

3. Nonunions with advanced radiocarpal and intercarpal arthrosis.

Knoll and trumble proposed a protocol for scaphoid nonunion treatment, including the consideration
of osteonecrosis
Treatment options for nonunions of the scaphoid:

1. Traditional bone grafting

2. Vascularized bone grafting

3. Excision of the proximal fragment, the distal fragment, and, occasionally, the entire scaphoid

4. Radial styloidectomy

5. Proximal row carpectomy

6. Partial or total arthrodesis of the wrist

STYLOIDECTOMY

 If arthritic changes involve only the scaphoid fossa of the radiocarpal joint, styloidectomy is

indicated in conjunction with any grafting of the scaphoid or excision of its ulnar fragment.

 In older patients in whom radioscaphoid arthritis predominates, and the proximal fragment is

not loose, styloidectomy alone can provide pain relief.

 Current recommendations are to resect no more than 4 mm of the styloid to preserve the

radioscaphocapitate ligament integrity.

EXCISION OF THE PROXIMAL FRAGMENT

 The indications for excising the proximal fragment of a scaphoid nonunion:

1. The fragment is one fourth or less of the scaphoid and is sclerotic, comminuted, or severely displaced.

The comminuted fragments usually should be excised early to prevent arthritic changes; a severely

displaced fragment also should be excised early if it cannot be accurately replaced by manipulation.

2. The fragment is one fourth or less of the scaphoid, and grafting has failed.

3. Arthritic changes are present in the region of the radial styloid. Styloidectomy is indicated in

conjunction with excision of the proximal fragment.

EXCISION OF DISTAL SCAPHOID

 Treatment of scaphoid nonunions with radioscaphoid arthritis treated with distal scaphoid

resection.

 If capitolunate arthritis is present, an additional procedure (e.G., Limited intercarpal

arthrodesis) should be added to distal scaphoid excision.

PROXIMAL ROW CARPECTOMY

 It is a reconstructive procedure for posttraumatic degenerative conditions in the wrist,

especially conditions involving the scaphoid and lunate.

 Alternative to arthrodesis.

 Primary proximal row carpectomy can be useful in treating severe open carpal fracture-

dislocations characterized by significant disruption of the bony architecture, comminuted

fractures of the scaphoid and lunate, and disruption of the blood supply to the lunate and
scaphoid.
 Excision of the triquetrum, lunate, and entire scaphoid usually is recommended.

 The distal pole of the scaphoid at its articulation with the trapezium can be left, to provide a

more stable base for the thumb.

 If the distal scaphoid pole is left, radial styloidectomy should be done to avoid impingement of

the distal scaphoid pole and trapezium on the radial styloid.

 Excision of the pisiform is unnecessary because of its location in the flexor carpi ulnaris

tendon as a sesamoid.
 GRAFTING TECHNIQUE
 Cancellous bone grafting for scaphoid nonunion, as first described by Matti and modified by Russe,

has proved to be a reliable procedure, producing bony union in 80% to 97% of patients

 MATTI-RUSSE TECHNIQUE

 Longitudinal incision 3 to 4 cm long on the volar aspect of the wrist

 Incise the wrist capsule

 Freshen the sclerotic bone ends with a small gouge and form a cavity that extends well into each

adjacent fragment. The cavity can be formed with a high-speed burr.

 From the iliac crest, obtain a piece of cancellous

bone and shaped to fit into the preformed cavity

and stabilize the two fragments

 Stability can be improved with a kirschner wire

inserted from distal to proximal across the fracture

MALPOSITIONED NONUNION OF SCAPHOID FRACTURES
(“HUMPBACK” DEFORMITY)

 Established nonunions of scaphoid fractures can be seen in preoperative radiographs to have

resorption or comminution, with resulting shortening and angulation, with its convexity dorsal
and radial (“humpback” deformity).

 The deformity includes

1. Extension of the proximal pole of the scaphoid, resulting extension of the lunate,

2. A form of dorsal intercalated instability pattern seen on lateral plain radiographs.

 FERNANDEZ TECHNIQUE
 Approach the scaphoid between the flexor carpi radialis and the radial artery according to the classic

russe procedure.

 Oscillating saw, carry out resection according to the preoperative plan.

 If signs of osteonecrosis of the proximal fragment are apparent, place multiple 1-mm drill holes within

the sclerotic cancellous bone.

 Correct the flexion deformity and shortening by distracting the osteotomy site on the palmar-radial

aspect with two small bone hooks or a spreader clamp.

 Shape the corticocancellous graft from the iliac crest to fit the defect with a saw, rongeur, or bone cutter.
 Fix the scaphoid with two or three (1.2-mm) kirschner wires, which are power driven

percutaneously into the palmar aspect of the distal fragment across the graft into the dorsal
aspect of the proximal fragment

 A palmar plaster splint that includes the thumb is applied for 2 week

 The wrist and thumb are immobilized in a short navicular cast for 6 weeks.

 Immobilization is discontinued after 8 weeks

 TOMAINO TECHNIQUE
 Palmar incision between flexor carpi radialis and the radial artery

 Correct lunate extension by maximally flexing the wrist joint to

derotate the extended lunate

 Fix the lunate in the flexed position by percutaneously passing a

(1.1-mm) kirschner wire through the radius from its lateral surface
into the lunate fossa

 Using a microsagittal saw or rongeur, resect the nonunion to viable

bleeding bone proximally and distally.

 Measure the gap in the scaphoid (length, width, and depth) to determine the dimensions of the

wedge graft.

 Obtain a tricortical corticocancellous graft from the iliac crest

 Gently impact the graft into place with the inner (cancellous) surface facing the capitate

 Pass a single (1.1-mm) kirschner wire eccentrically down the long scaphoid axis to hold the

scaphoid and graft in place.

 Place the guidewire for the herbert-whipple screw.

 STARK TECHNIQUE
 Straight or zigzag volar incision

 Remove a small, rectangular window of bone from the volar aspect of the

distal fragment immediately adjacent to the fracture.

 Through this opening, clear fragments of fibrous tissue and dead bone

using a low-speed power burr or curet

 Fashion a large cavity in the proximal and distal parts of the scaphoid

 Transfix the scaphoid with two (0.9-mm) kirschner wires by inserting

them through the distal fragment into the proximal one

 Pack cancellous bone from the ilium into the cavity

VASCULARIZED BONE GRAFTS

 Nonunions with an avascular proximal pole and those that have failed to heal after previous procedures

1. Pronator quadratus pedicle graft from the distal radius

2. Pedicle flaps from ulna and the metacarpals

3. Iliac crest free flap

4. Vascularized bone graft from the distal dorsolateral radius

5. Pedicle bone grafts based on the 1,2 intercompartmental supraretinacular artery

6. Medial femoral condyle osteochondral free flap

PRONATOR-BASED GRAFT

KAWAI AND YAMAMOTO

 volar zigzag incision over the scaphoid tuberosity and the distal radius

 Excise the sclerotic bone ends and freshen them with a power burr to form an oval cavity 10 to

20 mm long and parallel to the axis of the scaphoid.

 Identify the pronator quadratus and outline a block of bone graft 15 to 20 mm long at its distal

insertion on the distal radius close to the abductor pollicis longus tendon was resected
 Dissect the muscle toward the ulna to secure a pedicle 20 mm thick

 Fix the proximal and distal scaphoid segments and the graft with two

0.045-inch (1.16-mm) kirschner wires introduced at the scaphoid

tuberosity

 The arm is immobilized in a short arm cast until healing has occurred,

usually at 10 to 12 weeks.

 When stable bony union is certain, the kirschner wires are removed,

usually about 3 to 4 months after surgery

 VASCULARIZED BONE GRAFTS— 1,2
INTERCOMPARTMENTAL SUPRARETINACULAR ARTERY
GRAFT (1,2 ICSRA)
ZAIDEMBERG TECHNIQUE

 Make an oblique skin incision on the dorsoradial

side of the wrist, centered on the radiocarpal

joint

 Incise the extensor retinaculum of the first dorsal

extensor compartment.
• Expose the scaphoid nonunion and freshen the

sclerotic bone ends with curets or a power burr.

• Use narrow osteotomes or a small gouge to

harvest a bone graft from the distal radius,

beneath the periosteal vessel
 VASCULARIZED BONE GRAFTS— PROXIMAL
RADIOCARPAL ARTERY GRAFT (PRCA GRAFT)
SOMMERKAMP TECHNIQUE

 Approach the wrist volarly through the flexor carpi radialis approach

 The proximal radiocarpal artery (PRCA) pedicle can now be seen at the distal edge of the

pronator quadratus,

 Gently dissect the pronator from the PRCA pedicle along the ulnar side of the radius

 Complete the graft harvest with a radial osteotomy using 2-mm osteotomes on either side

of the pedicle

 Rotate the pedicle 30 to 40 degrees to inset into the scaphoid nonunion defect.

 Complete fixation with either Kirschner wires or a cannulated compression screw in a

ARTHRODESIS OF THE WRIST

 Fusion of the wrist is done most often for ununited or malunited fractures of the carpal

scaphoid with associated radiocarpal traumatic arthritis and for severely comminuted fractures
of the distal end of the radius

 It also is useful for rheumatoid arthritis, volkmann ischemic paralysis, poliomyelitis and

cerebral palsy of the spastic type, and for tuberculosis.

 Fused in a position that would not be fatiguing and that would allow maximal grasping

strength in the hand

 10 to 20 degrees of extension, with the long axis of the third metacarpal shaft aligned with the

long axis of the radial shaft

 In patients with arthritis limited to the radiocarpal joint, without midcarpal involvement,

proximal row fusion (radioscapholunate) was successful in relieving pain

 For patients with ulnar translation of the carpus resulting from rheumatoid arthritis,

radiolunate fusion has been found to be an effective method to prevent further translation
 HADDAD AND RIORDAN

 Begin a J-shaped skin incision 2.5 to 3.8 cm proximal to the radial styloid on

the midlateral aspect of the forearm, extend it distally across the styloid, and
curve it dorsally to end at the base of the second metacarpal.

 Using an oscillating saw and osteotomes, obtain from the inner table of the

iliac crest a graft about 3.8 cm long × 2.5 cm wide

 With the wrist in 15 degrees of dorsiflexion, cut a slot, using an oscillating

saw, in the distal end of the radius, the carpal bones, and the bases of the
second and third metacarpals.
 Place the graft in the prepared bed

 If the wrist is unstable, insert a smooth Kirschner wire obliquely or longitudinally to engage the

base of the second metacarpal and the distal radius;

 . A solid sugar-tong cast is applied and is worn for another 4 weeks;

COMPRESSION PLATE TECHNIQUE

 The compression plate technique has proved beneficial in providing excellent internal fixation

and eliminating the need for prolonged immobilization

 Between the third and fourth compartments, make a 10- to 15-cm longitudinal dorsal incision

centered over the radiocarpal joint

 Open the wrist capsule with an h-shaped incision to expose the radiocarpal and intercarpal

joints

 Place a 3.5-mm cortex lag screw through the radial styloid into the capitate to pull the carpus

against the radial styloid to avoid impingement of the DRUJ.

 Inlay a flat rectangular corticocancellous graft from the ilium

into a prepared bed between the metacarpal bases and the distal
radius.

 Place a seven-hole or eight-hole, 3.5-mm dynamic compression

plate over the graft

 Compress the radiocarpal joint with one screw in the capitate

and one screw proximal to the bone graft in the radius

 Attach the plate to the third metacarpal (or occasionally the

second metacarpal) with two or three screws and to the radius

with three or four screws
 WEISS AND HASTINGS TECHNIQUE
 Make a 10- to 15-cm dorsal longitudinal incision centered over the

radiocarpal joint

 Use an osteotome to remove lister tubercle from the distal radius and to

decorticate the dorsal fourth of the scaphoid, lunate, capitate, and long
finger carpometacarpal joint

 Use a large (6-mm cup) curet to obtain bone from the distal radius

slightly to the lateral (radial) side of lister tubercle

 Dynamic compression plate to stabilize the long finger metacarpal-

carpal-radius together
 After placement of the plate, secure the distal screws to the metacarpal first

 Pack the cancellous bone graft from the distal radius into the denuded bone surfaces

 Fix the plate to the distal radius, and use a cancellous screw to fix the plate to the capitate.

 ensure that the plate holds the wrist in 10 to 15 degrees of extension.

PREISER DISEASE
 Idiopathic avascular necrosis of the scaphoid bone

 The condition was originally described by preiser in 1910

 Injury to the nutrient artery through trauma or infarction could lead to ischemia throughout the scaphoid,

predisposing it to the development of osteonecrosis.

 Patients will typically present with complaints of radialsided wrist pain localizing to the anatomical snuff

box and dorsal wrist

 Examination may reveal synovitis and scaphoid tenderness over the anatomical snuff box. Restricted

range of motion and decreased grip strength may also be present.

 Mri with gadolinium contrast will help establish the diagnosis and the degree of scaphoid involvement
HERBERT AND LANZETTA CLASSIFICATION BASED ON
RADIOGRAPHIC APPEARANCE

 Type I disease describes patients that present with normal radiographs but an abnormal bone

scan or abnormalities within the scaphoid on MRI

 Stage II disease reveals increased proximal pole density with generalized osteopenia.

 Stage III disease shows fragmentation of the proximal pole with or without pathological

fracture.

 Stage IV disease shows evidence of carpal collapse and osteoarthritis

 Nonoperative approaches include immobilization, nonsteroidal antiinfl ammatory, and electrical stimulation.

 Operative approaches include scaphoid preservation and salvage procedures

 Scaphoid-preserving procedures include

1. Closing wedge osteotomy of the radius,

2. Curettage with or without bone grafting

3. Vascularized bone grafting

4. Arthroscopic drilling

5. Arthroscopic debridement
 Salvage procedures should be considered for cases of established radioscaphoid arthritis or

significant scaphoid fragmentation.

 Surgical options

1. Scaphoid excision have included silicone replacement

2. Scaphoid excision and four-corner fusion

3. Wrist arthroplasty

4. Wrist arthrodesis.
REFERENCE
THANK YOU