1. Blood supply & Fracture of Scaphoid

2. Blood Supply of Wrist and Carpus Radial Ulnar Anterior interosseous arteries Deep palmar arch 3. Anastomotic network three dorsal & three palmar arches connected longitudinally at their medial and lateral borders by radial & ulnar arteries dorsal to palmar interconnections b/w dorsal and palmar branches of anterior interosseous artery 4. Intrinsic blood Supply The scaphoid, capitate & 20% of lunatesupplied by a single vessel - at risk for osteonecrosis. The trapezium, triquetrum, pisiform & 80% oflunate receive nutrient arteries through twononarticular surfaces consistent intraosseous anastomoses. ON israre. The trapezoid and hamate lack an intraosseousanastomosis and after fracture, can haveavascular fragments. 5. Scaphoid Anatomy skaphos (Greek) boat Cashew shaped within the wrist joint more than 80% of its surface(except tubercle) -covered by articular cartilage 6. Scaphoid - blood supply two major vascular pedicles1.Volar branch enters the scaphoid tubercle andsupplies its distal 20% to 30%2. Dorsal scaphoid branch of the radial artery.Enter through numerous small foramina alongthe spiral groove and dorsal ridge. (80% of theblood supply). 7. No vascular supply (13%) or only a single perforator (20%) proximal to the waist of scaphoid. Unusual retrograde vascular supply - high risk ofnonunion and ON after fracture. 8. Scaphoid Fracture Most commonly fractured carpal bone 68% of carpal fractures Fall on outstretched hand forced dorsiflexion ofhand &radial deviation 9. When fractured, proximal pole - extend with attached lunate distal pole - remains flexed, creating -hump-back deformity. 10. Classification Russe -1)Horizontal oblique - compressive forces acrossfracture site.2)Transverse combination of compressive & shearforces.3)Vertical oblique 5% , shear forces across fracturesite. 11. Russe 12. Herbert classification- stability and delayed & nonunion of fractures. Type A fractures- stableType A1- fracture of tubercleType A2 incomplete fractures through waist 13. Type B Acute and Unstable fractures Type B1- Distal oblique fractures Type B2- Complete fractures through waistType B3- Proximal pole fracturesType B4- Transscaphoid & Perilunate dislocations of carpusType B5-Comminuted 14. Type C fractures Delayed unions Type D fractures established Nonunions 15. Prosser classification Classification of Distal pole fractures Type 1 Tuberosity fracture. Type 2 - Distal intra-articular fracture. Type 3 Osteochondral fracture. 16. Prosser Classification 17. Diagnosis Wrist pain Tenderness & fullness in anatomic snuffbox. Axial compression of thumb elicits pain Forced ulnar deviation of pronated wrist alsoelicits pain 18. Even if initial radiographs ve, immobilise in wristsplint/shortarm thumb cast Rpt after 10- 14 days If still ve and suspecting #,take MRI/ CT Scan Fast,convenient, sensitive and specific. 19. Associated Injuries Fractures of the distal radius Perilunate dislocation and Transscaphoid perilunate fracture dislocations Joint and ligament damage that inevitablyaccompanies this injury (x-ray never reveals thetrue degree of injury) 20. Management Cast Immobilization Open: VolarDorsal Percutaneous stabilization Arthroscopy 21. Cast Immobilization Undisplaced Stable Fractures A1 - 4 weeks A2 - 8 to 12 weeks until radiographic union. decision for conservative Mx - CT scan showsno displacement. patient reviewed 6 weeks after cast removal forclinical and radiological examination and then every 3 months until the outcome is clear. Patients should be seen for a final check upafter 1 year. 22. Cast Immobilization Position of wrist has no affect over healing. No difference b/w longarm & short arm cast. Needs to be continued till fracture has healed. Proximal pole fractures-12 weeks or longer 23. Surgery - indication Displaced fracture Proximal pole fractures regardless of displacement Associated perilunate injuries Open fractures Polytrauma pts 24. Percutaneous Fixation Guidewire placed percutaneously along central axis of scaphoid to use cannulated screw system. Main key is to achieve most centrally placed screw while holding fracture in compression 25. Risk of open procedures can be Avoided. Healing time found to be same as castimmobilization Bond etal reported average healing time to be 7weeks in these pts,compared to 12 weeks Rx in cast No functional difference after 2 yrs 26. Volar percutaneous approach distal scaphoidused as entry point. Preferred for distal pole fractures. Use 16 gauge needle to find entry point ofguidewire. Proximal cartilaginous surface of scaphoidpreserved. 27. Dorsal percutaneous approach: Proximal pole is entry point Wrist in flexion & ulnar deviation 28. Arthroscopic Allows assessment of intraarticular injuries likeligamentous structures Many choices for percutaneous fixation-Herbert screw-Herbert-whipple screw-Acutrak screw 29. Open-Palmar Classic Russe approach For stable and unstable non union Advantages --Excellent visualization-Less risk of vascular injury 30. Disadvantages-potential for scarring-limitation of wrist extension-injury to volar radiocarpal ligament-inability to assess and address dorsal scapholunateligament. 31. Open - Dorsal Centered over Listers tubercle Transverse incision over prox.scaphoid Do not disturb dorsal ridge Excellent visualization of prox.pole,esp with in maximumflexion Prefered open approac for prox. Pole fracture. 32. Disadvantages of immobilization Frequent visits to check cast fit. Frequent radiographs to check alignment. Potential skin breakdown Prolonged immobilization till complete healing Stiffness of immobilized joints 33. Disadvantages of Surgery Potential for infection Wound complications Injury to nerves,ligaments or tendons Injury to vascular supply to scaphoid Hardware failure or need for its removal Associated aneasthesia complications. 34. Complications Non Union Malunion Osteonecrosis Preisers disease Management arthroscopic debridement and drilling of thelesion, rest, splintage, and electricalstimulation vascularized bone graft harvesting a pronator quadratus graft. 35. Pearls Occult scaphoid fractures are easily detected by MRI scans. Percutaneous stabilization of scaphoid fractures significantly reduces the rate of nonunion, as well as reducing the time lost from work and sports. Proximal pole fractures can also be stabilizedpercutaneously by a dorsal approach. 36. Pitfalls Scaphoid fractures are easily missed in children. This can result in nonunion and serious problems. Malalignment of scaphoid fractures is often undiagnosed. CT scans are helpful. Conservative treatment often ends in delayed healing. An aggressive operative approach is recommended.