Percutaneous fixation of scaphoid fractures through the snuffbox: an anatomical study

The aim of the present anatomical study was to assess the dorso-radial approach for percutaneous fixation of scaphoid wist fractures. Through the anatomical snuffbox, cannulated screws or 1.2 mm K-wires were inserted into the scaphoids of 20 fresh-frozen cadavers. No tendon injuries were observed. There were two lesions of the radial artery, and three lesions of the sensory branches of the radial nerve. After dissection and three-dimensional CT reconstruction, the K-wire or screw position was described in relation to the scaphoid centroid and its longitudinal axis. The mean distance between the device and the scaphoid centroid was 2.8 mm (SD 1.4, range 0.6 to 6.1). The mean angle between the device and the scaphoid's longitudinal axis was 29° (SD 11, range 6.5 to 54). Rather than percutaneous fixation, an open approach with a modest incision might be safer for identifying and protecting both the radial artery and the sensory nerves. This approach would make perpendicular fixation possible for specific patterns of scaphoid fracture orientated approximately 60° from the longitudinal axis.

Advances in wrist arthroscopic surgery in Indonesia

Since the 1990s, new insights in wrist arthroscopy have led to the introduction of numerous treatment methods. Consequently, therapeutic procedures are no longer limited to resection as more specialized repair and functional reconstruction methods, involving tissue replacement and essential structural augmentation, have been shown to be beneficial. This article discusses the most prevalent reasons and uses for wrist arthroscopy, with an emphasis on Indonesia’s most recent and major advances in reconstructive arthroscopic surgery. Joint debridement, synovectomy, ganglionectomy, capsular release, and osteotomies are frequent resection operations. Ligament repair and arthroscopy-aided reduction and fixation for fractures and nonunion are all examples of reconstructive surgery.

Plate fixation in challenging traumatic carpal scaphoid lesions

BACKGROUND

Complex fractures of the carpal scaphoid with poles fragmentation, edges comminution, bone loss and non-union of fractures previously treated by screw fixation remain challenging for hand surgeons. The authors present the indications, advantages and results of scaphoid plating, underlining the importance of correct plate positioning well shaped onto the bone.

MATERIALS AND METHODS

The study includes 11 patients presenting acute fracture with distal pole fragmentation, acute fracture with comminution and non-union after prior failure of screw fixation. All patients were treated with volar locked plate fixation, adding a cortical bone graft in cases of non-union.

RESULTS

Bone consolidation was achieved in all cases; excellent outcomes in fracture healing and relevant improvement in symptoms and functions were obtained in non-union group that are consistent with the literature. Only one patient underwent early further surgery (first row carpectomy) with poor results.

CONCLUSION

The treatment of the selected scaphoid lesions with volar locked plate is a surely efficient technique. The plate can be easily adjusted to the shape of the scaphoid and can achieve an adequate correction of bone deformity and high degree of stability both in non-union and 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.

Robot-assisted double screw fixation of minimally displaced scaphoid waist fracture nonunions or delayed unions without bone graft

We retrospectively reviewed 12 minimally displaced fractures of the scaphoid waist in 12 patients who developed delayed or nonunions with or without conservative treatment. Mean time between injury and surgery was 6 months (range 3-12). The fractures were stabilized with double screws, which were percutaneously inserted with robot assistance, and without bone grafting. All fractures united at a mean of 8 weeks (range 6-10) after surgery. The patients were followed-up at 6 months and 1 year. The patients recovered good wrist function. No major postoperative complications were reported, and the patients returned to their usual level of activity. Robot assistance gave a high degree of accuracy when placing the cannulated screws since only two attempts were needed for correct placement of the guide wires. We explain the high union incidence by patient selection, good stabilization and not disturbing the vascular supply.Level of evidence: IV.

Acute Scaphoid Waist Fracture in the Athlete

Scaphoid fractures are the most common carpal fracture and the most challenging. Although appropriately managing acute scaphoid waist fractures is a priority, it also is of primary importance to make a diagnosis acutely. Scaphoid waist fractures can occur with low-energy trauma and lead to mild symptoms. A tendency to minimize symptoms and low level of initial disability lead to delay in diagnosis. Displaced scaphoid fractures require operative intervention uniformly. Although nondisplaced fractures can heal with nonoperative treatment, management of these injuries is affected by patient demands. In high-level athletes, operative treatment of nondisplaced injuries may lead to earlier return to sport.

Early scaphoid fractures are better diagnosed with ultrasonography than X-rays: A prospective study over 114 patients

PURPOSE

Wrist has a complex anatomy and undergoes complex injuries. Scaphoid fracture is one of such injuries. It is the most common fracture in carpal bone. Most of the scaphoid fractures are missed on initial X-rays. Magnetic resonance imaging (MRI) is considered as a gold standard for diagnosing scaphoid fractures. Ultrasonography (USG) is emerging as a good alternative to make an early diagnosis of scaphoid fractures. Our aim is to throw light upon the role of USG in detection of scaphoid fractures.

METHODS

The study was centered upon 114 patients in the age range 10-65 years, with traumatic wrist injury and were clinically suspected to have scaphoid fractures. Patient with non-traumatic history, bilateral wrist injury and late presentation were excluded. X-rays, USG using high frequency probe and MRI were done for all patients. MRI was considered to be the gold standard test. Patients were followed up at 6 weeks.

RESULTS

Of the 114 patients, X-ray could diagnose scaphoid fractures in 48 patients, 30 of which were confirmed by MRI. USG results were positive in 74 patients, of which MRI was positive in 67 patients. The accuracy of scaphoid fracture detection with USG was 98.04% in comparison to X-ray (20.58%), which was statistically significant.

CONCLUSION

USG provides a more accurate and reliable method of making an early diagnosis of scaphoid fracture than X-rays. It is non-invasive, non-expensive and allows better visualisation of cortical disruption.

The economic evidence for advanced imaging in the diagnosis of suspected scaphoid fractures: systematic review of evidence

Given the limitations of conventional radiography in the diagnosis of suspected scaphoid fractures on presentation, advanced imaging, particularly magnetic resonance imaging, is a useful additional investigation. We carried out a systematic review of the economic evidence for the use of advanced imaging in the management of suspected scaphoid fractures. Fifteen articles were included in the review. Owing to the heterogeneity of study designs, the type and timing of interventions and the economic analyses performed, direct comparisons between the 15 studies were difficult. From a health care perspective, little could be concluded regarding the economic implications of the use of advanced imaging in clinical practice. However, from a societal perspective, the evidence favours the use of advanced imaging in the management of suspected scaphoid fractures as it does appear to lead to overall cost-savings.

A Systematic Review and Meta-Analysis Examining the Differences Between Nonsurgical Management and Percutaneous Fixation of Minimally and Nondisplaced Scaphoid Fractures

PURPOSE

The optimal management of undisplaced scaphoid fractures remains controversial. A systematic review was conducted to assess the outcomes of acute, undisplaced scaphoid fractures managed with cast immobilization versus percutaneous or miniopen screw fixation in terms of time to return to work (RTW), time to union, and morbidity.

METHODS

PubMed MEDLINE, Ovid MEDLINE, EMBASE, SCOPUS, and Cochrane electronic databases were searched over the period 1974 to 2015. Key words included "scaphoid fracture," "navicular fracture," "hand," "immobilization," "cast," "conservative," "percutaneous," "screw fixation," "mini open," and "minimally invasive." A 2-step review process was done by 2 independent reviewers (H.A. and J.K.) using the following criteria: (1) acute undisplaced scaphoid fracture, (2) English language, (3) RTW duration objectively reported, (5) age older than 15 years, and (5) studies with more than 10 patients. Patient demographics, duration of immobilization, time to RTW, time to union, and complications were extracted. The methodological quality of each study included was assessed independently. Meta-analysis was performed for comparative trials.

RESULTS

Ten studies met the inclusion criteria: 6 comparative studies and 4 case series. Patients were divided into 2 groups: cast immobilization (group 1) and percutaneous fixation (group 2). Average time to RTW was 77 days for group 1 versus 46 days for group 2. Average time to radiographic union was 79 days for group 1 versus 44 days for group 2. There was no significant difference in complication rate between the groups (7% in group 1 vs 14% in group 2).

CONCLUSIONS

Percutaneous fixation of acute undisplaced scaphoid fractures has union rates comparable with those of nonsurgical cast immobilization but with faster RTW and time to union without a significant difference in complication rate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Return to Play After Hand and Wrist Fractures

Wrist and hand injuries are common among athletes, and can lead to considerable disability. Dislocations and soft tissue injuries are common and require prompt recognition and treatment. Accurate diagnosis and early immobilization are often key to getting players back to their sport early. Some injuries require surgery; operative intervention allows the player to return to their sport more quickly or with less long-term disability. This article discusses the spectrum of injury from distal radius fractures to mallet fingers, and offers some general guidelines for the surgeon in how to counsel and treat athletes with these problems.

The Palpable Scaphoid Surface Area in Various Wrist Positions

PURPOSE

To determine the theoretical amount of surface area available for palpation of the scaphoid in various wrist positions and to provide a guide depicting which wrist position will expose proximal pole, waist, and distal pole fractures.

METHODS

Using 3 fresh-frozen male cadaver wrists, we digitized palpable surface areas (dorsal, volar, and snuffbox) of the scaphoid in several wrist positions. The entire scaphoid was then excised and a digitized 3-dimensional reconstruction of the entire scaphoid was obtained. The 2 images were superimposed and the surface area was calculated

RESULTS

The maximum palpable area of the scaphoid was achieved with the wrist in neutral extension and maximum ulnar deviation and the wrist in maximum flexion and neutral deviation. Neutral wrist extension and ulnar deviation exposed all but the most proximal portion of the proximal pole and the distal pole, which made this the ideal position to detect tenderness from a scaphoid waist fracture and larger proximal pole fractures. Maximum wrist flexion with neutral wrist deviation exposed the entire proximal pole, which made this the ideal position to detect tenderness from a proximal pole scaphoid fracture.

CONCLUSIONS

Wrist position influences the amount of scaphoid surface area available for palpation and should be considered when examining a patient with a suspected scaphoid fracture.

CLINICAL RELEVANCE

The scaphoid should be palpated in 3 anatomic regions with the wrist placed in different positions to maximally expose the anatomical region being palpated.

Scaphoid fractures

Scaphoid fractures are the most common carpal bone fracture, usually occurring in young men, although the incidence in women has increased over the past decade. Snuffbox tenderness and/or pain with axial loading of the thumb should be treated as a scaphoid fracture until proved otherwise and the diagnosis confirmed with serial radiographs and/or advanced imaging. Nearly all displaced scaphoid fractures should undergo operative intervention to reduce the risk of nonunion. Nondisplaced fractures have high union rates with cast treatment, but require extended periods of immobilization. Consideration may be given to operative fixation of these fractures to allow early return to sport.

How we do it?

The scaphoid is the common carpal bone to be fractured. Proper clinical and radiological evaluation is required to establish it's diagnosis. The management of acute fractures includes conservative treatment with cast in minimally displaced to open reduction and internal fixation in case of displaced ones. The established nonunion requires open reduction, bone grafting and internal fixation.