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Abstract
Fracture of scaphoid is relatively common, and accurate and prompt diagnosis leads to bony union with good clinical outcome. However, it can be easily missed due to vague symptomatic complaints by patients, which in turn leads to negligence of a doctor in making the diagnosis or anatomical shape of scaphoid that causes minute fracture to be ignored while viewing simple radiography. When missed, nonunion of scaphoid gradually progresses to arthritic change in the wrist. Thus when fracture of the scaphoid is suspected, further evaluation should be initiated with care, and if the diagnosis is confirmed, a proper treatment plan must be set with assessment of stability of the fracture fragment. Internal fixation is usually proposed since solid fixation of the fracture provides early return to daily activity. When nonunion of the scaphoid is present, most patients can achieve bony union with avascular bone graft and internal fixation. However, if there is sclerotic change, large bone cyst or avascular necrosis of the fracture fragment, internal fixation with bone graft that includes vascular supply should be introduced in order to achieve bony union.
Figures and Tables
Fig. 1
Computed tomography (CT) scan is a very useful diagnostic tool in detection of scaphoid fracture. In a plain X-ray of the wrist, a scaphoid fracture is suspected (white arrow head). CT scan shows cortical breakage in the scaphoid volar aspect (white arrow) and an occult fracture in the hamate hook base (black arrow). In below line photos, the fractures of scaphoid and hamate are fixed with a headless compression screw and a 2 mm screw, respectively, using the dorsal percutaneous technique.
Fig. 2
Percutaneous headless compression screw fixation using a palmar approach. There are two techniques in percutaneous headless screw fixation using a volar approach; one is the central method which requires rongeuring the volar side of the trapezium for centralization of distal insertion screw (upper photo line), the other is the oblique method in which screw fixation starts obliquely in order to avoid injury to trapezium (lower photo line).
Fig. 3
Surgical procedures for 1,2 intercompartmental supraretinacular artery (1,2-ICSRA) pedicled bone graft (courtesy of Prof. Jong Woong Park). (A) Incision. (B) 1,2-ICSRA identification. (C) Identification of the fracture site. (D) Making a slot for the bone graft. (E) 1,2-ICSRA pedicled bone fragment harvesting. (F) Insertion of bone graft and fixation.
Fig. 4
1,2 intercompartmental supraretinacular artery (1,2-ICSRA) pedicled bone graft (courtesy of Prof. Seok Hwan Song). (A) Scaphoid nonunion with atrophic change of the proximal fragment. (B) Postoperative X-ray showing focal radiolucency on the distal radius by donor bone harvesting (arrow). (C) Last follow-up X-ray showing complete union of scaphoid.
Fig. 5
Surgical procedures for medial femoral condyle free vascularized bone graft (courtesy of Prof. Jong Woong Park). (A) Skin incision. (B) Identification of the descending genicular artery (in photo, m: muscle, a: artery). (C, D) Pedicled donor bone harvesting. (E) Recipient incision line. (F) Finding and dissecting radial artery and vein for anastomosis. (G) Finding nonunion site and curettage of fibrotic tissue. (H) Removing cystic and sclerotic portion of both ends with a saw. (I, J) Harvested donor bone trimming according to the defect and inserted into the gap. (K) Graft insetting and fixation with a headless screw. (L) End-to-side anastomosis with radial artery and end-to-end anastomosis with venae comitantes or cephalic vein.
Fig. 6
Medial femoral condyle free vascularized bone graft (courtesy of Prof. Jong Woong Park). (A) Scaphoid nonunion with failed 1,2 intercompartmental supraretinacular artery (1,2-ICSRA) vascularized bone graft. (B) Computed tomography (CT) scan showing cystic change, sclerosis and avascular necrosis suspected in the proximal fragment. (C) Wrist lateral view showing dorsal intercalated segmental instability. (D) CT scan showing scaphoid humpback deformity (arrow). (E, F) Postopreative 10 weeks, the X-ray showing successful scaphoid union with scaphoid length restored and humpback deformity corrected.
Table 1
| Clinical test | Sensitivity (%) | Specificity (%) |
|---|---|---|
| Effusion | 50 | 91 |
| Tenderness on scaphoid tubercle | 87 | 57 |
| Snuff box tenderness | 90 | 40 |
| Scaphoid compression test | 94 | 92 |
| Combined | 100 | 74 |
Table 2
Next Evaluation in Case of the Highly Suspected Patient with a Negative Simple X-Ray
| Item | Finding | Describing |
|---|---|---|
| Short arm thumb spica splint, after 2 weeks, rechecking simple Xrays16) | Bone resorption or early callus formation adjacent to the fracture site | Low cost, possible time wasting |
| High-resolution ultrasound17,18) | Cortical step-off, cortical interruption, radiocarpal effusion, scaphotrapeziotrapezoidal joint effusion | Sensitivity 78%, specificity 89%, relatively low cost, early detection |
| Bone scan19,20) | Hot uptake | Sensitivity 100%, specificity 90%, useful in multiple fracture-patient and unconsciousness patient |
| Computed tomography21,22) | The better diagnostic performance in reformations along the long axis of the scaphoid than the planes of the wrist | Very effective in detection for nondisplaced scaphoid fractures, useful in evaluation for scaphoid union or eformation or scaphoid nonunion status |
| Magnetic resonance imaging23,24) | Acute fracture, normal or decreased signal in T1 and increased signal in T2; nonunion or avascular necrosis, decreased signal in T1 and T2 | Sensitivity 100%, specificity 90%, useful in detection for ligament injuries or other concomitant injuries |
Table 3
Criteria for Unstable Scaphoid Fracture (by Cooney)
Data from the article of Haisman et al. (J Bone Joint Surg Am 2006;88:2750-2758).31)
Table 4
Comparison of Surgical Approach
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