Scaphoid Waist Research Articles

Autologous iliac bone flap graft with cross Kirschner wire fixation for treatment of scaphoid waist fracture nonunion in young adults

Objective To explore the autologous iliac flap graft without blood flow combined with cross Kirschner wire and splint fixation in the treatment of scaphoid waist fracture nonunion in young adults. Methods From January 2010 and August 2015, 18 cases of scaphoid waist fracture nonunion were treated in our department. According to preoperative MRI evaluation, ischemic necrosis of proximal or distal pole scaphoid was not seen. The incision was made at dorsal radial wrist. Autologous iliac flap grafting and packing combined with cross Kirschner wire and splint fixation were conducted after cleaning up the dead bone of scaphoid nonunion. Postoperatively, injured limb was continuously fixed by splint for 6 weeks. Removal of Kirschner wire was conducted when fracture line blurred showed by wrist X-ray photograph. The patients were guided to gradually strengthen the wrist joint function exercise. Results Postoperative follow-up ranged from 6 to 24 months, with an average of 13 months. All the cases of scaphoid waist fracture nonunion were healed with 2 cases of delayed union. No scaphoid necrosis occurred. Wrist joint stability was achieved. Wrist joint pain disappeared in 16 cases. Two cases still had slightly pain and significantly alleviated compared with preoperative condition. Postoperatively the angle of wrist extension was 38° to 60° (average, 52°), of wrist flexion 36° to 60° (average, 48°). The wrist range of motion obviously improved. Hand grip strength was 42.5 to 55.5 kg (average, 50.6 kg) for male patients and 28.5 to 35.4 kg (average, 32.6 kg) for female patients. Grip strength increased postoperatively and the patients returned to original work. Conclusion Autologous iliac flap graft without blood flow combined with cross Kirschner wire and splint fixation is a good method for treating scaphoid waist fracture nonunion in young adults, because of the simple technique, minor local injuries of wrist, and satisfactory curative effects. Key words: Scaphoid bone; Fractures,bone; Nonunion; Iliac bone flap

Vascularized Bone Grafts for the Treatment of Scaphoid Nonunion

Scaphoid nonunion without treatment can progress to carpal collapse and a predictable pattern of radiocarpal arthrosis. Surgical intervention is indicated to prevent progressive carpal instability and arthritis. In proximal pole nonunion and occasionally in scaphoid waist fracture with osteonecrosis, or when traditional bone grafting has failed to achieve union, vascularized bone grafts are used because they improve the biology of bone healing. This review describes the most common vascularized bone grafts used to treat scaphoid nonunion, either pedicled or free.

Traumatic Bilateral Scaphoid Fracture-A Case Report

Introduction: The largest carpal bone, the scaphoid, is the most commonly injured bone in the wrist joint. While unilateral scaphoid fractures are quite common, bilateral ones are rarely encountered. Existing literature on traumatic bilateral scaphoid fractures is very limited. Case report: We came across a young biker, who sustained bilateral, undisplaced, scaphoid waist fractures following a road traffic accident. He was treated conservatively with bilateral thumb spica casts, and recovered fully in about 12 weeks after the injury. Conclusion: Comprehensive imaging should be done in case of suspected scaphoid fractures, as failure to do so may lead to missed fracture. Although internal fixation reduces healing time, conservative management with thumb spica casts can also successfully treat undisplaced bilateral scaphoid fractures, and the patient can attain full range of motion within a comparable time frame. Surgical management should be favored more in case of displaced/ unstable fractures.

HOW SCAPHOID FRACTURES ARE TREATED IN BRAZIL.

ABSTRACTObjectiveTo verify how hand surgeons manage scaphoid fractures and their complications.MethodsTwo hundred questionnaires were distributed during the 36th Brazilian Hand Surgery Congress (2016).ResultsOn suspicion of fracture without radiographic confirmation, 57% of surgeons request a CT or MRI scan, while 43% opt for immobilization and consecutive radiographs. In stable fractures the preference was for treatment with plaster cast. In fractures with no scaphoid waist displacement, 33% opt for percutaneous fixation. In displaced waist or proximal pole fractures, 66% and 99.4%, respectively, opted for surgical treatment. Most surgeons treat waist nonunion with a nonvascularized bone graft. When absorption at the site of nonunion is greater than 4 mm, 50% prefer to use iliac graft and screw fixation. In proximal pole nonunion, the Zaidemberg technique is preferred by 64%. More experienced surgeons are more likely to request tests in occult fractures (63.9% versus 47.6%; p=0.04), and tend to recommend surgery for distal third fractures more frequently (16.4% versus 4.7%; p=0.02).ConclusionsWe have provided an overview of treatment preferences for scaphoid fractures. It should be noted that more experienced surgeons are more likely to request additional tests for occult fractures and to recommend surgical treatment of distal third fractures. Level of Evidence IV, Cross-sectional survey.

Results of percutaneous fixation and distal radius core decompression in scaphoid waist non-unions treated without grafting

Scaphoid non-union management is still a challenge in clinical practice for orthopaedic surgeons. Though several treatment methods have been described, there is an ongoing debate about optimum management. Based on new concepts about avascular conditions, promising results were reported with metaphyseal decompression of the distal radius by increasing the vascularization of the radial column of the carpus. We aimed to evaluate the clinical, radiological, and functional outcomes of distal radius core decompression and fixation with palmar percutaneous cannulated compression screws without grafting in patients with scaphoid waist fracture non-union. Twenty-nine patients with scaphoid non-union were included in this prospective study. There were 27 male and 2 female patients with an average age of 29 years (range 18–45 years). Mean time from the injury to surgery was 18.3 months. The Slade and Geissler classification was used to classify the non-unions. Wrist range of motion (ROM), pain based on a visual analog scale (VAS), and the Mayo wrist score were used to assess the clinical outcomes. Postoperative radiographs and CT-scans were reviewed to assess fracture union, carpal alignment and screw position. The average clinical follow-up was 76 weeks (range: 74–87 weeks) postoperatively. Mean time to union was 11 weeks (range: 7–18 weeks). There was no humpback/no DISI in any of the cases. Twenty-six patients healed successfully with no additional procedures. Three patients with failed union underwent revision surgery with grafting. At the final follow-up, average wrist ROM was 61° (range: 30–80) in extension and 61° (range: 35–80) in flexion, the average Mayo wrist score was 66±20 (range: 20–90), and the mean VAS was 2±2 (range: 0–7). Percutaneous fixation without grafting associated with distal radius core decompression can provide satisfactory outcomes in surgical management of scaphoid non-unions. Level of evidenceII.

Fracturas de escafoides tratadas con técnica percutánea volar. Análisis y resultados de 92 casos

ObjectiveHerbert type B1 and B2 scaphoid fractures can be treated by orthopaedic treatment or surgery. The aim of this study is to analyse results and complications of scaphoid waist fractures treated using the percutaneous volar approach. Material and methodWe present a retrospective study of 92 patients, treated in our institution from 2006 to 2016 using a volar percutaneous fixation. Mean Follow-up was 16 months (range 12-48). Injuries were classified using Hebert's classification, including B1 and B2 fracture types; the other fracture types following this classification system were excluded. Politrauma patients, dorsal approach, fractures associated with distal radius injuries, patients treated using another surgical technique and patients with non follow-up were also excluded. Functional results were evaluated using the DASH questionnaire. Consolidation was established as the presence of bony bridges crossing the fracture site on x-rays, associated with absence of pain. ResultsThe average time to fracture healing was 6.6 weeks (range 5-11). After 12 months of follow-up, the average wrist range of motion was 70° of extension (range 58-75) and 70° of flexion (range 62-80). Regarding functional evaluation, the average DASH questionnaire score was 42. The most frequent complication was non-union in 4 cases (4.44%). Average surgical time was 25min. ConclusionsVolar percutaneous fixation is a simple and quick technique for a specialist surgeon, characterised by low morbidity and complication rates compared to ORIF and orthopaedic treatment, which accelerates the patient's functional recovery.

Lessons learned from volar plate fixation of scaphoid fracture nonunions.

IV.

Scaphoid Healing Required for Unrestricted Activity: A Biomechanical Cadaver Model.

To determine if scaphoid fractures with bridging bone of 50% of their width treated with a centrally placed screw will restore biomechanical integrity equivalent to that of the intact scaphoid. Twenty-four fresh cadaver scaphoids were used. Six were left intact to serve as the control group. Six were osteotomized 50% of their width and made up the osteotomy without screw group. Six were included in the 50% osteotomy plus compression screw group. The remaining 6 were to be treated with an osteotomy of 25% or 75% with a screw, based upon the results of the 50% osteotomy with screw group. Biomechanical testing was performed using an Instron testing machine, with a load applied to the scaphoid's distal pole. Load to failure and stiffness were measured. Intact scaphoids had an average load to failure of 610.0 N. The average load to failure of the 50% osteotomy group without a screw was 272.0 N and with a screw was 666.3 N. There was no significant difference in load to failure between the 50% osteotomy plus screw and the intact scaphoid. The 75% osteotomy plus screw was found to have a load to failure of 174.0 N, significantly lower than the intact scaphoid. The 50% osteotomy plus screw had a significantly higher stiffness than the intact scaphoid control. A 50% intact scaphoid with a centrally placed screw showed similar load to failure and significantly higher stiffness than the intact scaphoid when tested in cantilever bending. This study demonstrates that patients with scaphoid waist fractures who undergo surgery with a compression screw may be able to return to unrestricted activity with 50% partial healing.

Treatment of the scaphoid humpback deformity – is correction of the dorsal intercalated segment instability deformity critical?

Treatment of scaphoid fractures has been focused mainly on achieving union, with less attention to restoring normal scaphoid shape and orientation. Malalignment of one carpal bone will disrupt the kinetics of the entire wrist. The dorsal intercalated segment instability deformity associated with scaphoid waist nonunion is a nondissociative form of carpal instability. It has to be reduced in the treatment of scaphoid waist nonunions to avoid kinetic problems that will lead to arthritic changes. Computerized tomography scanning has become indispensable to visualize the humpback deformity clearly. Different techniques may be used to restore the normal anatomy of scaphoid, from non-vascularized graft to arthroscopic bone grafting, and also the option of vascularized bone grafting.

Outcomes of Scaphoid Nonunion with Segmental Defect Treated with Plate Fixation and Autogenous Cancellous Graft: First Clinical Report

There is no financial information to disclose. Treatment of scaphoid nonunion with segmental defect presents a challenging clinical problem. Various techniques have been proposed, usually involving vascularized bone grafting with or without structural bone. Outcomes of these complex procedures have been inconsistent in the medical literature. The authors hypothesize that similar or perhaps better clinical and radiographic outcomes are possible with a relatively simplified technique of volar plate fixation augmented with autogenous pure cancellous graft. The authors performed a retrospective chart review of 49 consecutive patients with scaphoid nonunion with segmental defect treated with plate fixation and pure cancellous bone grafting. Surgical management included a single volar incision, reduction, insertion of bone graft from ipsilateral olecranon and/or distal radius, and application of a volar locking plate. Post-operative outcome measures included time to union based on computerized tomography (CT), return to work, patient-reported pain and disability scores, grip strength, and range of motion (ROM). The average patient was 31 years old and treated an average of 28 months after initial injury. Twenty-nine patients (59.0%) were treated for nonunion at the scaphoid waist, 19 (38.8%) at the proximal pole, and 1 (2.0%) at the distal pole. 13 patients (26.5%) were treated specifically for avascular necrosis confirmed with magnetic resonance imaging (MRI). Mean follow-up was 18.9 months (range, 12-34). Union was achieved in all patients and average time to union was 78 +/- 18.4 days post-operatively. Complications included symptomatic hardware that required plate removal for 1 patient. Mean DASH score improved from 13.4 +/- 0.5 pre-operatively to 41.4 +/- 3.7 post-operatively. Mean visual analogue scale (VAS) improved from 7.0 +/- 0.7 pre-operatively to 2.1 +/- 0.7 post-operatively. All employed patients returned to work, although 5 (13.9%) did not return to full capacity. Grip strength improved from 79.9% of the non-operative side pre-operatively, to 93.5% post-operatively. At final follow-up, ROM including wrist flexion, extension, ulnar deviation, and radial deviation improved 128%, 173%, 112%, and 164%, respectively, compared to pre-operative ROM. •The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunions with segmental defects yields reliable union rates and good patient outcomes.•Autogenous cancellous bone grafting is a reliable alternative to more technically demanding or morbid grafting procedures for the treatment of scaphoid nonunions with segmental bone defects.•In cases of avascular necrosis, outcomes of volar locked plating with pure cancellous grafting appear to be similar, if not superior, to those reported for vascularized bone grafting techniques.

Biomechanical Strength of Scaphoid Partial Unions

Grant received from: VICTR Consulting Fee: Biomet (Lee) It is not known how much force a partially united scaphoid can sustain without refracturing. This is critically important in determining when to discontinue immobilization in laborers or active individuals and when considering return to play in athletes. The purpose of this study was to test the biomechanical strength of simulated partially united scaphoids using a validated testing model for scaphoid fractures. We hypothesized that there would be no difference in the strength of scaphoids with 50% or greater bone at the waist compared to intact scaphoids. Forty-one lightly embalmed cadaver scaphoids were divided into 4 groups, 3 experimental osteotomy groups (25%, 50% and 75% of the scaphoid waist) and 1 control group (intact). Each specimen was potted and tested using a validated protocol. Using a materials testing machine (MTS), each scaphoid was subjected to a dorsal to volar cantilever force of 80 N to 120 N for 4,000 cycles, representing a sub-failure physiological load, followed by load-to-failure. Permanent deformation was measured during the physiologic load phase and stiffness, max force, work to failure and mechanism of failure were recorded during load-to-failure testing. Analysis of variance between groups was determined using the Kruskal-Wallis test. All scaphoids survived the sub-failure conditioning with no significant difference in permanent deformation (P = 0.34) (Table 57-1). Intact scaphoids endured an average maximum load of 333N prior to failure, compared to 321N for the 25% group, 297N for the 50% group and 324N for the 75% group, with no statistically significant variance (P = 0.86) (Fig. 57-1). There were also no statistically significant differences in stiffness (P = 0.15) or work to failure (P = 0.93) between the intact, 25%, 50% and 75% groups. One specimen from each osteotomy group failed by fracturing through the osteotomy site; all others failed by fracturing at the distal pole near the loading site. This is consistent with previous reports in the literature. •Scaphoids with at least 25% of intact cortical bone at the waist can withstand normal physiologic loads.•The data provide valuable information regarding partial scaphoid union and supports return to play or mobilization once the scaphoid has reached 25% union across the fracture site.Table 57-1Average Values During Physiologic Sub-failure Conditioning and Load-to-failure TestingNPermanent Deformation (mm)Stiffness (N/mm)Max Force to Failure (N)Work to Failure (N ∙ mm)Intact101.4226333478125%112.1327132172050%102.4219429765575%101.82168343703 Open table in a new tab

Treatment of Scaphoid Waist Non-Union with A Modified Matti-Russe Technique: Our Experience Giuseppe

Amongst the different techniques for scaphoid non-union, the Matti-Russe procedure is a simple method where a cortico-cancellous bone graft from the iliac crest is packed in the scaphoid...

Acute scaphoid fractures and non-unions

The diagnosis of scaphoid fractures requires a high index of suspicion, with a focus on the mechanism of injury and careful clinical examination. A scaphoid series of radiographs is required but if negative does not rule out a fracture. If there is clinical suspicion for fracture, one should obtain an MRI scan, which has the highest sensitivity and specificity for diagnosis. The management of acute scaphoid fractures is dependent largely on fracture location and displacement, although there are other factors to consider. On the whole, distal pole fractures can be managed conservatively and proximal pole fractures surgically, as the latter have poorer healing potential with a risk of avascular necrosis, due to a retrograde blood supply. The controversy lies with scaphoid waist fractures. One should consider surgical management for displaced waist fractures. The surgical approach is dependent on the fracture location and the surgeon's individual preference. Scaphoid non-union predictably leads to arthritis of the wrist, and therefore should be managed upon diagnosis. Reconstructive surgery provides the best outcomes, and more research is required into conservative treatments. Recent times have seen an increase in the use of vascularized bone grafts. In cases where there is established arthritis, salvage options include scaphoidectomy with four-corner fusion, proximal row carpectomy, total wrist arthroplasty and arthrodesis.

Percutaneous Screw Fixation for Scaphoid Fractures.

Treatment of nondisplaced scaphoid waist fractures has evolved from conventional cast immobilization to percutaneous screw insertion. This study assessed clinical and radiologic outcomes of volar percutaneous screw fixation for 15 type B2 scaphoid fractures (according to the Herbert and Fisher classification). All patients were followed for an average of 33 months (range, 6-50 months). All fractures achieved radiographic union at an average of 57 days (range, 35-70 days), requiring no additional procedures. None of the patients showed radiographic signs of osteoarthritis, osteonecrosis of the scaphoid, or hardware-related complications. For scaphoid waist fractures without collapse, percutaneous screw fixation provided satisfactory results with a high rate of union, early return of function, and minimal complications. [Orthopedics. 2017; 40(4):e729-e734.].

Wrist Injuries in Youth Athletes

To identify new evidence-based medicine regarding wrist injuries in youth athletes. Worthy studies identified include reports on changing wrist injury epidemiology, increasing recognition of stress fractures, evolving pathology in scaphoid fractures, risk factors for youth overuse injuries, comparison of immobilization techniques following distal radial fractures, and benefits and risks of MRI imaging, among others. Changes in epidemiology are seen in American football, basketball, and soccer. These changes, and the potential rise of scaphoid waist fractures, are reported with theorized factors being the increasing body mass index (BMI) of today’s youth, use of synthetic turf, and changing popularity of various sports. A new study identifying overuse injury risk associated with sport specialization is discussed. Finally, MRI imaging is discussed, specifically, its reported 100% negative predictive value for scaphoid fractures, but also the potential to lead to overdiagnosis of wrist pathology.

In Vivo Scaphoid Motion During Thumb and Forearm Motion in Casts for Scaphoid Fractures

In nonsurgical treatment for acute undisplaced or minimally displaced scaphoid waist fractures, immobilization of both wrist and thumb can be an option. However, invivo scaphoid motion during forearm and thumb motion with the wrist immobilized in a cast has not been measured. Therefore, we examined the invivo kinematics of the scaphoid during forearm and thumb motion with cast immobilization. Ten healthy right wrists of 10 male volunteers were included. These wrists were immobilized in a short-arm spica cast with the thumb in a position of volar abduction and then were scanned with the forearm in supination, neutral rotation, and pronation using computed tomography. Next, these wrists were scanned with a forearm gauntlet cast in place with the thumb abducted radially and opposed with the forearm positioned in neutral rotation. From these data, the 3-dimensional position of the third metacarpal and scaphoid was analyzed. From forearm supination to pronation, the scaphoid showed 0.2° radial deviation, 0.4° pronation, and 8.3° extension. The third metacarpal showed 14.6° ulnar deviation, 6.5° pronation, and 1.6° flexion. During thumb opposition from radial abduction, the scaphoid showed 2.9° radial deviation, 0.4° supination, and 7.2° extension and the third metacarpal showed 4.5° ulnar deviation, 2.8° pronation, and 5.5° extension. The scaphoid was not completely immobilized by either cast. However, the scaphoid motion during forearm and thumb motion was not significant. Several high-quality studies have shown that undisplaced or minimally displaced scaphoid waist fractures can be successfully treated with casts. Movement of scaphoid and wrist during forearm rotation or thumb motion with a cast may not be sufficient to have a negative impact on the outcome of scaphoid fracture using a cast.

Three-dimensional comparison of alternative screw positions versus actual fixation of scaphoid fractures

PurposeThe recommended technique for the fixation of a scaphoid waist fracture involves a headless compression screw placed in the proximal fragment center. This is usually accomplished by placing a longitudinal axis screw as visualized by fluoroscopy. The screw length has been shown to have a biomechanical advantage. An alternative to these options, which has been debated in the literature, is a screw placed perpendicular to the fracture plane and in its center. The perpendicular screw may have a biomechanical advantage despite the fact that it may be shorter. This study examined the differences in location and length in actual patients between a screw in the center of the proximal fragment with a longitudinal axis screw, and the actual fixating screw. These were then compared to a perpendicular axis screw. MethodsPre- and post-operative CT scans of 10 patients with scaphoid waist fractures were evaluated using a 3D computer model. Comparisons were made between the length, location and angle of actual and virtual screw alternatives; namely, a screw along the central third of the proximal fragment (central screw axis) where the scaphoid longitudinal axis was calculated mathematically (longitudinal screw axis) and a screw placed at 90° to the fracture plane and in its center (perpendicular screw axis). ResultsThe longitudinal axis screw was found to be significantly longer than the other axes (28.3mm). There was a significant difference between the perpendicular axis screw and the location and angle of the other screw axis, but it was only shorter than the longitudinal screw (23.6mm versus 25.5mm for the actual screw; ns.). ConclusionsA computed longitudinal axis screw is longer than a central or actual screw placed longitudinally by visual inspection by the surgeon. Although it needs to be placed using computer assisted (CAS) techniques, it may have the biomechanical advantages of a longer screw in a similar trajectory. The perpendicular screw was found to be significantly different in position and angle but not shorter than the actually placed screw. It has biomechanical advantages and does not require visualization with CAS methods, making it the more attractive alternative.

Greffe spongieuse et fixation par vis de compression sans tête dans les pseudarthroses du scaphoïde carpien

PurposeScaphoid fracture commonly occurs around the mid-third of the scaphoid, and nonunion of this fracture has several treatment options. The authors performed autologous cancellous bone graft from the iliac crest and headless compression screw fixation for the treatment of Mack–Lichtman type II scaphoid waist nonunion. The purpose of this study was to determine whether this procedure was effective in achieving bony union and restoration of alignment. MethodsMedical records and radiographs of 30 patients who underwent cancellous bone graft and headless compression screw fixation for nonunion of scaphoid waist fracture were retrospectively reviewed. There were 28 men and 2 women, with a mean age of 32.8 years (range, 21–63). The mean time to surgery was 10 months (range, 3–25) and mean follow-up was 37.5 months (range, 15–52). The authors analyzed bony union, lateral intrascaphoid angle, scapholunate angle, radiolunate angle and scaphoid length on radiographs and evaluated the modified mayo wrist score (MMWS) as a functional outcome. ResultsBony union was achieved in all cases. The lateral intrascaphoid angle improved from 40° to 32° (P<0.001). The scapholunate angle also improved from 61° to 56° (P=0.009). The radiolunate angle decreased from 8° to 4° (P=0.048) and scaphoid length increased from 22mm to 26mm (P<0.001) postoperatively. Wrist motion and MMWS improved significantly at last follow-up. However, there were no significant differences between scaphoid deformity correction angle and pre to postoperative difference in MMWS. ConclusionsNonstructural autologous cancellous bone graft from the iliac crest and headless screw fixation provided reliable results and can be one of the effective treatment options for patients with symptomatic Mack–Lichtman type II nonunion in the mid-third of the scaphoid. Level of evidenceLevel III.

Three-Dimensional Analysis of Acute Scaphoid Fracture Displacement: Proximal Extension Deformity of the Scaphoid.

Our goal was to analyze the movement of acute scaphoid waist fracture fragments and adjacent bones in a common coordinate system. Our hypothesis was that the distal scaphoid fragment flexes and pronates and the proximal fragment extends. Computed tomography (CT) scans of patients diagnosed with an acute scaphoid waist fracture were evaluated using a 3-dimensional (3D) model. The scans of 57 nondisplaced and 23 displaced fractures were compared with a control group of 27 scans showing no pathological involvement of the wrist. Three anatomical landmarks were labeled on the distal and proximal fragments of the scaphoid, the lunate, and the trapezium. Each set of labels formed a triangle representing the bone or fragment. Four landmarks were labeled on the distal radial articular surface and used to create a common coordinate system. The position of each bone or fragment was calculated in reference to these coordinates. The displaced fracture group showed significant extension, supination, and volar translation of the proximal scaphoid fragment when compared with the other groups. The lunate tended toward a supinated position, which was not statistically significant. The distal scaphoid fragment and the trapezium showed no movement. In acute displaced scaphoid fractures, it is the proximal fragment that displaces and should be reduced. The typical "humpback" deformity is actually a "proximal extension" deformity, the consequence of displacement of the proximal fragment of the scaphoid (with the lunate). Manipulating only the proximal fragment (with the lunate) may be technically easier and more effective than manipulating both fragments.

The Result of Percutaneous Screw Fixation without Bone Grafting for Scaphoid Waist Nonunion under Local Anesthesia

The Result of Percutaneous Screw Fixation without Bone Grafting for Scaphoid Waist Nonunion under Local Anesthesia