Management of Scaphoid Fractures. Plast Reconstr Surg. 2017;140:333e-346e. [PMID: 28746289 DOI: 10.1097/prs.0000000000003558]

Improved Outcomes in Operative Management of Concomitant Distal Radius and Scaphoid Fractures

BACKGROUND

This study aims to investigate the characteristics of concomitant distal radius and scaphoid fractures and determine outcome differences of operative and nonoperative management.

METHODS

A retrospective search of a level-1 trauma center's database over a 15-year period (2007-2022) for concomitant distal radius and scaphoid fractures in adult patients was completed. In all, 31 cases were reviewed for mechanism of injury, method of fracture management, distal radius fracture AO Foundation/Orthopaedic Trauma Association classification, scaphoid fracture classification, time to radiographic scaphoid union, time to motion, and other demographics. A multivariate statistical analysis was completed comparing outcomes in operative versus conservative management of the scaphoid fracture in these patients. Outcomes were defined as time to radiographic union and time to motion.

RESULTS

In all, 22 cases of operative fixation of the scaphoid and 9 cases of nonoperative management of the scaphoid were reviewed. One case of nonunion was identified in the operative group. Operative management of scaphoid fractures resulted in a statistically significant reduction in time to motion (2-week reduction) and time to radiographic union (8-week reduction).

CONCLUSIONS

This study demonstrates that operative management of scaphoid fractures in the setting of a concomitant distal radius fracture reduces the time to radiographic union and time to clinical motion. This suggests that operative management is ideal in patients who are good candidates for surgery and desire earlier return of motion. However, conservative management should be considered, as nonoperative care showed no statistical difference regarding union rates of scaphoid or distal radius fractures.

Proximal Hamate Reconstruction of Proximal Pole Scaphoid Nonunion: A Case Series and Analysis of Clinical Outcomes

BACKGROUND

Small proximal pole scaphoid nonunions present a clinical challenge influenced by fragment size, vascular compromise, deforming forces exerted through the scapholunate interosseous ligament (SLIL), and potential articular fragmentation. Osteochondral autograft options for proximal pole reconstruction include the medial femoral trochlea, costochondral rib, or proximal hamate. This study reports the clinical outcomes of patients treated with proximal hamate osteochondral autograft reconstruction.

METHODS

A retrospective review identified patients treated with this surgery from 2 institutions with a minimum 6-month follow-up. Clinical outcomes included the Visual Analog Dcale pain score, 12-item Short-Form survey, abbreviated Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, wrist and forearm range of motion (ROM), radiographic assessment, and complications. We reviewed and compared these outcomes with those of the current published literature.

RESULTS

Four patients (mean age: 24 years, 75% men) with a 12.8-month average follow-up (range: 6-20 months) were included. Radiographic union was identified in all cases by 12 weeks (range, 10-12). The average wrist ROM was 67.5% flexion/extension and 100% pronation/supination compared with the contralateral side at the final follow-up. The mean QuickDASH score was 17.6 (SD, 13). No complications were identified.

CONCLUSIONS

Proximal pole scaphoid nonunion reconstruction using autologous proximal hamate osteochondral graft demonstrated encouraging clinical and radiographic outcomes. Proximal hamate harvest involves minimal donor site morbidity without a distant operative site, uses an osteochondral graft with similar morphology to the proximal scaphoid, requires no microsurgical technique, and permits reconstruction of the SLIL using the volar capitohamate ligament.

Nonunion scaphoid bone shape prediction using iterative kernel principal polynomial shape analysis

BACKGROUND

The scaphoid is an important mechanical stabilizer for both the proximal and distal carpal columns. The precise estimation of the complete scaphoid bone based on partial bone geometric information is a crucial factor in the effective management of scaphoid nonunion. Statistical shape model (SSM) could be utilized to predict the complete scaphoid shape based on the defective scaphoid. However, traditional principal component analysis (PCA) based SSM is limited by its linearity and the inability to adjust the number of modes used for prediction.

PURPOSE

This study proposes an iterative kernel principal polynomial shape analysis (iKPPSA)-based SSM to predict the pre-morbid shape of the scaphoid, aiming at enhancing the accuracy as well as the robustness of the model.

METHODS

Sixty-five sets of scaphoid images were used to train SSM and nine sets of scaphoid images were used for validation. For each validation image set, three defect types (tubercle, proximal pole, and avascular necrosis) were virtually created. The predicted shapes of the scaphoid by PCA, PPSA, KPCA, and iKPPSA-based SSM were evaluated against the original shape in terms of mean error, Hausdorff distance error, and Dice coefficient.

RESULTS

The proposed iKPPSA-based scaphoid SSM demonstrates significant robustness, with a generality of 0.264 mm and a specificity of 0.260 mm. It accounts for 99% of variability with the first seven principal modes of variation. Compared to the traditional PCA-based model, the iKPPSA-based scaphoid model prediction demonstrated superior performance for the proximal pole type fracture, with significant reductions of 25.2%, 24.7%, and 24.6% in mean error, Hausdorff distance, and root mean square error (RMSE), respectively, and a 0.35% improvement in Dice coefficient.

CONCLUSION

This study showed that the iKPPSA-based SSM exploits the nonlinearity of data features and delivers high reconstruction accuracy. It can be effectively integrated into preoperative planning for scaphoid fracture management or morphology-based biomechanical modeling of the scaphoid.

The Impact of Wrist Fractures on Long-Term Basketball Performance

Background

Wrist joint fractures may present challenging obstacles for the rehabilitating athlete upon return to play. Although current literature has examined the effects of specific injuries to the upper extremity for basketball athletes, little is known about long-term performance outcomes following wrist joint fractures.

Methods

Review of all National Basketball Association players who sustained wrist joint fractures was conducted. Player characteristics, preinjury and postinjury performance, and overall efficiency were analyzed.

Results

A total of 31 players were deemed appropriate for inclusion, with an average age of 26.2 ± 4.3 years and a mean of 5.2 ± 3.6 years played before injury and 4.1 ± 3.1 years played upon return. Operative management was pursued in 48.4% of players. Players demonstrated a significant decrease in win shares before injury (mean: 24.3 ± 31.5) compared to after return from injury (mean: 9.6 ± 19.6) (p < 0.032). Multivariate regression demonstrated that increased points per game before injury (standardized β: 0.71; 95% confidence interval [CI]: 1.2-8.5, p < 0.011) and increased win shares before injury (β: 1.0; 95% CI: 1.4-9.5, p < 0.001) were both independently predictive with increased win shares after return to play. Player position, age, management type, and all other statistics were not significantly associated with any other findings upon return.

Conclusion

Overall efficiency following return to play in the setting of basketball-associated wrist joint fractures appears to be decreased in athletes. However, preinjury performance as captured through win share efficiency and points per game appears to be predictive of increased productivity after successful return.

Resource Utilization and the Use of Bone Stimulators among Operatively and Nonoperatively Managed Scaphoid Nonunion Patients

The prevalence of bone stimulator use among nonoperatively and operatively managed scaphoid nonunion patients is unknown. We hypothesize that bone stimulators are a relatively underutilized treatment for scaphoid nonunion patients.

Methods

We used the 2009-2017 Truven Marketscan Research Databases to identify patients with closed scaphoid fractures and performed an analysis of variance test to determine resource utilization and bone stimulator use among these patients.

Results

A total of 36,611 patients with scaphoid fractures were identified: 30,143 were managed nonoperatively and 6468 were managed operatively. Nonunion was diagnosed in 500 (1.66%) nonoperatively and in 1211 (19%) operatively managed patients. Bone stimulators were used in less than 2% of nonoperatively and operatively managed scaphoid nonunion patients.

Conclusion

Lack of trust in the technology and heterogenous (and occasionally burdensome) requirements for insurance approval are barriers to bone stimulator use; however, surgeons should examine how this technology may fit into the treatment algorithm for these difficult cases.

The progress in the classification and treatment of scaphoid nonunion

Scaphoid fracture is the most common carpal fracture, accounting for 50%-80% of all carpal fractures in the Youngers and manual workers. The nonunion rate of scaphoid fractures was approximately 10-15%. Scaphoid nonunion can lead to wrist deformity, wrist collapse, ischemic necrosis, and traumatic osteoarthritis resulting in the loss of wrist function and seriously influence the patients' lives. Achieving bony union is essential for the treatment of scaphoid nonunion. Although many surgical procedures including various forms of bone grafting have been developed to improve bony union, there is no conclusion about which method is the most effective and optimal. In this review, we provide an overview of the diagnostic, classification and progress in the treatments of scaphoid nonunion fractures.

Value of the 45-degree reverse oblique view of the carpal palm in diagnosing scaphoid waist fractures

OBJECTIVES

To investigate the value of 45° reverse oblique view of the carpal palm in diagnosing scaphoid waist fracture and displacement.

METHODS

Eighty-four patients with wrist injury and plain radiography including posteroanterior, lateral, Stecher, and 45° reverse oblique view of the wrist were analyzed for the detection rate in diagnosing scaphoid fractures and displacement. The degree of difficulty in the four views for detecting the scaphoid waist fracture and displacement was rated on a five-grade Likert scale.

RESULTS

Among 84 patients, scaphoid waist fractures occurred in 43, and fracture displacement in 32. A significantly (P<0.01) greater rate of detecting the scaphoid waist fracture was found in the Stecher, and 45° reverse oblique view than in the posteroanterior and lateral views. The rate of detecting fracture displacement was significantly (P<0.01) greater in the Stecher and 45° reverse oblique view than in the posteroanterior and lateral views. The Stecher view had a significantly (P = 0.006) lower rate of detecting fracture displacement than the 45° reverse oblique view. It was significantly (P<0.001) easier to identify the scaphoid waist fracture and displacement with the 45° reverse oblique view and the Stecher view than with the posteroanterior and lateral view. The 45° reverse oblique view had the easiest degree to identify the scaphoid waist fracture displacement, followed by the Stecher view, the posteroanterior and the lateral view (P<0.001).

CONCLUSIONS

The 45° reverse oblique view clearly shows the scaphoid oblique view in the long axis for better observation of the scaphoid waist fracture and displacement.

How to manage scaphoid waist fractures? Introduction of pragmatic imaging efficient pathway and literature review of the recent evidence

INTRODUCTION AND OBJECTIVE

The scaphoid bone sustains about 90 % of carpal bone fractures and is the second-highest bone at risk of post-traumatic osteonecrosis. Delayed diagnosis and treatment could lead to non-union and advanced carpal bones collapse. This study aimed to introduce an imaging efficient and practical scaphoid waist fracture management pathway (SWFMP) and measure its efficacy in clinical practice.

MATERIALS AND METHODS

The SWFMP was introduced in January 2020. Suspected occult fractures were approached by early orthopaedic clinical assessment and subsequent urgent MRI scan without repeating scaphoid X-rays. Scaphoid waist fractures displaced < 2 mm were treated with 8 weeks below elbow cast immobilization followed by CT scan if delayed union was suspected. Waist fractures displaced > 2 mm were managed with surgical fixation. Adult patients referred from the emergency department (ED) to the Virtual Fracture Clinic (VFC) with acute scaphoid injury from January 2019 to October 2019 (Pre SWFMP, n = 29), were identified and compared to those managed from January 2020 to October 2020 (Post SWFMP, n = 33).

RESULTS

Mean age was 37.9 (SD = 20.61) and 36.2 (SD = 17.06) years in the pre-SWFMP and post-SWFMP cohorts respectively. Fiften patients (51.7%) had the right side affected in the pre-SWFMP cohort and twenty-three patients (69.7%) in the post-SWFMP cohort. Scaphoid X-rays requested by ED have increased from 19 (65.5%) to 31 (94%) and repeated X-rays reduced from 17 (58.6%) to 10 (30.3%) after the introduction of the SWFMP. Mean wrist cast immobilization for patients without scaphoid fractures dropped from 16.9 days (SD = 5.57) to 3.6 days (SD = 6.24) after the SWFMP (p = 0.001). In the pre-SWFMP cohort, 24 patients had no fracture, 4 achieved full healing and 1 developed non-union. In the post-SWFMP cohort, 29 patients had no fracture, 1 achieved full union and delayed union was detected in 3 patients at 8 weeks.

CONCLUSIONS

The SWFMP has improved the clinical practice by reducing unnecessary ionizing radiation, unnecessary cast immobilization, and by using a timely fracture fixation intervention.

Incremental diagnostic value of color-coded virtual non-calcium dual-energy CT for the assessment of traumatic bone marrow edema of the scaphoid

OBJECTIVES

To investigate the diagnostic accuracy of color-coded dual-energy CT virtual non-calcium (VNCa) reconstructions for the assessment of bone marrow edema (BME) of the scaphoid in patients with acute wrist trauma.

METHODS

Our retrospective study included data from 141 patients (67 women, 74 men; mean age 43 years, range 19-80 years) with acute wrist trauma who had undergone third-generation dual-source dual-energy CT and 3-T MRI within 7 days. Eight weeks after assessment of conventional grayscale dual-energy CT scans for the presence of fractures, corresponding color-coded VNCa reconstructions were independently analyzed by the same six radiologists for the presence of BME. CT numbers on VNCa reconstructions were evaluated by a seventh radiologist. Consensus reading of MRI series by two additional radiologists served as the reference standard.

RESULTS

MRI depicted 103 scaphoideal zones with BME in 76 patients. On qualitative analysis, VNCa images yielded high overall sensitivity (580/618 [94%]), specificity (1880/1920 [98%]), and accuracy (2460/2538 [97%]) for assessing BME as compared with MRI as reference standard. The interobserver agreement was excellent (κ = 0.98). CT numbers derived from VNCa images were significantly different in zones with and without edema (p < 0.001). A cutoff value of - 46 Hounsfield units provided a sensitivity of 91% and specificity of 97% for differentiating edematous scaphoid lesions. Receiver operating characteristic curve analysis revealed an overall area under the curve of 0.98.

CONCLUSIONS

Qualitative and quantitative analyses showed excellent diagnostic accuracy of color-coded VNCa reconstructions for assessing traumatic BME of the scaphoid compared to MRI.

KEY POINTS

• Color-coded virtual non-calcium (VNCa) reconstructions yield excellent diagnostic accuracy in assessing bone marrow edema of the scaphoid. • VNCa imaging enables detection of non-displaced fractures that are occult on standard grayscale CT. • Diagnostic confidence is comparable between VNCa imaging and MRI.

Nuanced Trans-scaphoid, Perilunate Fracture Dislocations With Complete Scapholunate Dissociation: Two Cases With Proximal Row Preservation

We offer two reports of trans-scaphoid perilunate fracture dislocations, both involving complete dissociations and loss of vascular supply to the proximal scaphoid poles. Case 1 involves a 25-year-old man who fell on an outstretched hand and suffered a trans-styloid, trans-scaphoid, perilunate fracture dislocation. The patient underwent open reduction and screw fixation of the scaphoid using a dorsal approach. Kirchner wire fixation and suture anchor ligamentous repairs were used to reduce the scapholunate, lunar-triquetral, and radioscaphocapitate intervals. At 6 months, the patient was released to work without restrictions. Case 2 is a 66-year-old man who suffered a trans-scaphoid, perilunate fracture dislocation after a fall from a horse. A portion of the completely torn scapholunate ligament remained intact to the proximal pole, but no soft-tissue attachment to the rest of the carpus remained. The patient underwent open reduction of the scaphoid with compression screw and Kirschner wire fixation to repair the scapholunate and lunar-triquetral ligaments. At 1-year, the patient was released to full activity. Intraoperatively, the proximal scaphoid poles were completely devoid of any uninterrupted soft-tissue attachments, elevating concern for osteonecrosis. Although both patients showed radiographic signs of transient ischemia, neither patient displayed osteonecrosis or proximal pole collapse at their terminal visits.

Radiographic evaluation of vascularity in scaphoid nonunions: A review

Scaphoid fractures, particularly those that occur more proximally, are unreliable in achieving union due to the retrograde blood supply of the scaphoid bone. Vascular compromise is associated with the development of nonunions and avascular necrosis of the proximal pole. Due to the tenuous blood supply of the scaphoid, it is imperative that the vascularity be assessed when creating diagnostic and treatment strategies. Early detection of vascular compromise via imaging may signal impending nonunion and allow clinicians to perform interventions that aid in restoring perfusion to the scaphoid. Vascular compromise in the scaphoid presents a diagnostic challenge, in part due to the non-specific findings on plain radiographs and computed tomography. Magnetic resonance imaging techniques have dramatically improved our ability to assess the blood supply to the scaphoid and improve time to intervention. This review aims to summarize these advances and highlights the importance of imaging in assessing vascular compromise in scaphoid nonunion and in reperfusion following surgical intervention.

Conservatively Managed, Displaced Scaphoid Fracture in a Young, Female Collegiate Basketball Player

Fractures of the scaphoid bone occur in 60-70% of wrist bone fractures. It most often occurs after a fall onto outstretched hand injury. Many times, the diagnosis of a scaphoid fracture is missed due to the unique anatomy and positioning of this carpal bone. Treatment options vary depending on the type of fracture and degree of displacement. We present the case of a 19-year-old female patient. She reported to the urgent care facility after a fall on an outstretched hand while playing basketball. She was diagnosed with a wrist sprain. After having continued pain she sought care at the sports medicine clinic where she was diagnosed with a displaced scaphoid fracture. She was managed conservatively with thumb-spica casting and later adjuvant therapy treatments with low-intensity pulsed ultrasound (LIPUS) technology.

The Use of Nitinol Compression Staple Fixation and Bone Graft for Scaphoid Waist Fractures and Nonunion: A Surgical Technique

In the management of scaphoid fractures, nonunion is an important complication that can lead to carpal instability and early-onset arthritis. Various techniques have been described to treat scaphoid nonunions, yet a clear consensus on the superiority of one method is not yet established. The use of compression staple fixation has been described in the literature and may be a viable alternative to other fixation techniques. Volar Nitinol staple fixation avoids damage to the trapezium during retrograde fixation with a screw. It also avoids damage to the proximal dorsal cartilage, which occurs during anterograde screw fixation. Because of its shape and position on the volar aspect of the scaphoid, staple fixation provides compression, prevents graft extrusion, and avoids taking up space in the medullary canal of the scaphoid. Moreover, it may be technically easier than screw fixation. Despite these advantages, this technique has not been widely adopted. We describe the technique for utilizing Nitinol compression staples and bone grafting in the treatment of scaphoid nonunion.

Outcomes of Local Bone Graft and Fixation of Proximal Pole Scaphoid Nascent Nonunions and Nonunions

Background  Fractures of the proximal pole of the scaphoid have an increased risk of nonunion due to its tenuous blood supply. The optimal treatment of proximal pole scaphoid nonunions remains controversial. Objectives  To review a single surgeon's experience with proximal pole scaphoid nascent nonunions (delayed unions) and nonunions that underwent surgical fixation with a cannulated headless compression screw and local autologous bone graft from the distal radius. Patients and Methods  After obtaining Institutional Review Board approval, the electronic medical record of one tertiary care center was queried for patients with the diagnosis of "proximal pole scaphoid fractures" who underwent surgical fixation by a single surgeon over an 11-year period (2006-2017). Fifteen patients met initial query criteria; upon review of records, four patients were excluded due to the acute nature of the fracture, and one was excluded as surgical fixation included a vascularized bone graft. Results  The final study cohort consisted of 10 patients with a total of 10 proximal pole scaphoid nonunions. Almost all of the patients in this study were male (9/10 [90%]), and sporting activities were the most common mechanism of injury (8/10 [80%]). Volumetric measurements of the scaphoid fractures on computed tomography (CT) revealed that the mean total volume of the scaphoid was 2.4 ± 0.48 cm ³ and the mean volume of the proximal pole fragment was 0.38 ± 0.15 cm ³ . Postoperative CT scans were performed at a mean of 12.4 weeks (range: 8-16 weeks), with seven (7/10 [70%]) showing signs of complete union and three (3/10 [30%]) demonstrating partial union. None of the patients required additional procedures and there were no complications. Conclusions  Our results suggest that proximal pole scaphoid fractures with delayed union and nonunion treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. The volume of the proximal pole fragment did not correlate with increased risk of ongoing nonunion after the index procedure. Level of Evidence  This is a Level IV, case series study.

Revision surgery after vascularized or non-vascularized scaphoid nonunion repair: A national population study

HYPOTHESIS

We aimed (1) to discover the prevalence of vascularized bone grafting in the treatment of scaphoid nonunion and (2) to compare healing using vascularized bone grafting versus standard non-vascularized techniques. Secondarily, we sought to compare resource utilization between procedures and identify factors that may be associated with nonunion repair failure. We hypothesized that, despite being less common, vascularized bone grafts have greater success than non-vascularized bone grafting surgeries.

METHODS

We performed a large population analysis using the Truven MarketScan databases to identify patients from 2009 to 2017 with a diagnosis of a scaphoid nonunion undergoing repair surgery with and without the insertion of a pedicled or free vascularized bone graft. We defined any subsequent scaphoid or wrist surgery within 12 months after surgery as surgery failure. We compared success rates and post-operative resource utilization using Chi-squared tests.

RESULTS

Of 4177 eligible patients, 358 underwent nonunion repair with vascularized bone graft and 3819 patients received non-vascularized bone grafting. The failure rate requiring revision surgery was 5.0% in vascularized repair, versus 6.1% for non-vascularized surgery. Age and comorbidities did not affect bone graft type. Areas with higher median household incomes had more vascularized repairs. Vascularized bone graft patients received significantly more therapy and imaging after surgery.

CONCLUSIONS

Most scaphoid nonunion repairs are performed without vascularize bone grafting. Typical nonunions may not justify the increased time and technical demands of vascularized bone grafting, and traditional repair should remain first line treatment for scaphoid nonunions without additional risk factors. Further studies to elucidate which fractures benefit most from vascularized grafting are needed.