NON UNIONOF FRACTURE

SCAPHOID

Dr. Abdul G.SuhailMBBS, D.Ortho, MS (Ortho)

Assistant Professor in Orthopaedics

PROBLEM•WHAT IS THE CAUSE OF THE PROBLEM?•WHAT IS THE INCIDENCE OF THIS PROBLEM?•HOW TO DIAGNOSE THIS PROBLEM?•WHAT ARE CONSEQUENCES OF THIS PROBLEM?•HOW TO MANAGE THIS PROBLEM

BLOOD SUPPLY

Proximal to the waist: 20%, no foramina 13%, single

foramina

INCIDENCE OF THIS PROBLEM Missed InjuriesAfter conservative treatment

LinScheild 1992 5%

Leslie 1981 5%

Cooney 1980 25%

Herbert 1984 50%

DIAGNOSIS OF THE PROBLEM

Clinical : Tenderness in the anatomical snuff box

X-ray : P.A., Lateral, Oblique & Ulnar Deviation view

Repeat X-ray 15 days after the injury

Technetium Bone ScanMRI

Nonunion scaphoid

TECHNETIUM BONE SCAN

What are the consequences

of this problem?

• Degenerative changes

• Avascular necrosis

MANAGEMENT OF THE PROBLEM

Before embarking on the management one needs to know whether the nonunion is stable or not

STABLE FRACTURE

No displacement of fragments

No carpal collapse

Mc Laughlin and Parkes (1954)• With intact cartilaginous shell

"Peanut fracture"• Partially broken cartilaginous shell

UNSTABLE FRACTURES

Those with fracture line more than 1mm

Offset of the fractured fragmentsScapho-lunate angle > 60 degreesLunatocapitate and radio-lunate angle > 15 degreesHump back deformity

MANAGEMENT

•NON OPERATIVE•OPERATIVE

Non Operative Treatment

Stable non union : Without carpal collapse and symptom free needs no treatment

Mazet R & Hohl 1961Leads to post-traumatic osteo-arthrosis with passage of time

Mack et al 1984

All these studies are flawed in that, they are retrospective studies and not population based Kerluke & McCabe 1993

Non operative treatment

Prolonged immobilization

Electrical stimulation

Prolonged immobilization

Stable undisplaced fractures go into union

Stewart MJ 1954

Electrical Stimulation

44 non-unions treated by pulsedelectromagnetic Field (PEMF) andimmobilization 80% healed in 43 months Frykman et al - 1986

Apprehensive about the same Adams et al - 1992

-.

Electrical stimulation

Indications for PEMF Problem non-unions : proximal segment is fragmented and avascular

Infective non unions

OPERATIVE TREATMENT

Most of the non-unions are treated by Surgical intervention

”No single method of treatment can be used for all types of disability caused by an ununited fracture of the carpal

navicular”

Pennsylvania Orthopaedic Society, 1962

OPERATIVE TREATMENT

Many types of procedures are described

Choice depends on:

• Surgeon's preference and experience

• Type of fracture

• Age of the patient

• Presence of Periscaphoid changes

OPERATIVE TREATMENT

• Osteosynthesis • Bone grafting• Salvage procedures

OSTEOSYNTHESIS

Indications •Trans-scaphoid perilunate

dislocation•Those with carpal instability•Displaced fracture

fragments

OSTEOSYNTHESIS

• K wires• Screws• Staples• Plates

K - WIRES

•Most versatile of all implants

•Important part of the tool kit for surgeons treating fracture non union

K - WIRES•Easy to insert•Does not require radial

styloidectomy and other extensive exposures

•Better fixation especially in the presence of small proximal fragment with AVN

K -WIRESDisadvantages•May not be a stable fixation

•If pins protrude through the skin, it may produce pin tract infection

Screws• Harrison Mc Laughlin was the first

one to use screw for fixation of fracture scaphoid in 1954

• Screw fixation when done must be precise and meticulous• Poor fixation itself may lead to delayed or non union Trumble

1996

ScrewsA.O Screws:•Scaphoid lag screws•Needs limited approach• Insertion under direct vision

Leyshon et al,1984 and Fernandez, 1990

reported successful results

Cancellous screw fixation

ScrewsTrumbel et al ,1996 •Advocated cannulated

screw•Permits central placement

under radiographic control

ScrewsLane et al 1997• Two piece

screws

Herbert screw

•Tim J.Herbert, Orthopaedic registrar at Rowley Bristow Hospital used a jig for inserting screw

•Later he along with Fisher, an engineer developed the double threaded screw

•Settled in Sydney and continued his work

Herbert screw•Screw is double threaded

•Smaller than A.O. Screw•Can be used in cases with smaller fragments

•Need not be removed

Herbert screw•No separate head•Both ends are buried•Need special instruments•Jig gives the precision and compression

Herbert screw

Herbert ScrewDisadvantages:•Cannot be used in cases with small fragments with AVN

•Technical dependence is high

•Wide exposure is required

STAPLES• It has been in use since 1980•Carpenter et al 1990 and Korkala

et al 1992•Technically demanding•Memory staples made of Nickel -

Titanium Alloys Cugola & Tesloni,

1997

PLATES•Ender's blade Plate Huene and Huene,1991

•Plate needs removal•Not popular

BONE GRAFT

•Adams , 1928•Matti , 1937 : Cancellous

chips (Dorsal)•Russe ,1960 : Pegs + Chips

(Volar)•Modified Russe ,1980 : Two

Corticocancellous grafts

BONE GRAFT

• Fisk,1970 :Volar wedge graft with Styloidectomy

•Fernandez,1980 :Trapezoidal graft•Maltese : Cross graft•Vascularized grafts

Russe's method Insertion of two cortico-

cancellous grafts into the cavity with additional cancellous chips

Russe's method

Indications•All symptomatic, established non unions•Symptomatic delayed union without OA and instabilities

Original Russe bone grafting

Russe's methodPoor results in

•Cases with AVN Green

1985•Collapsed non union with dorsal Carpal instability Carrozella et al

1989

Russe -Matti Method

Results

• Green 1975 75%

• Cooney 198888%

Fisk - Fernandez

method,1976 Realignment of scaphoid fragments and insertion of appropriate shaped grafts to maintain the alignmentFisk

(1976)

Fisk Fernandez technique

Fisk - Fernandez

Wedge & Trapezoidal shaped grafts after careful measurement

Fernandez,1984

Maltese Cross graft

Better graft especially in revision surgery

Healing Potential

•If no bleeding, 100% failure Green,1985

•Avascular proximal poles will heal with surgery Murray,1998

Vascularized grafts

•Braun ,1983 : Pronator pedicle graft

•Pechlaner et al, 1987:Vascularized iliac crest graft

•Fernandez and Eggli 1995:vascular bundle implantation

Pronator Pedicle graft

Braun 1983 ,100% result

SALVAGE PROCEDURES

•Radial styloidectomy•Bentzon's procedure•Proximal row carpectomy

•Partial arthrodesis

Radial Styloidectomy

•Remove less than 1cm of Radial styloid

•Presence of important Volar ligaments

•Can be used as a graft •Styloidectomy alone is an

unsatisfactory procedure Mezet & Hohl

1961

Bentzon's Procedure

Bentzon (1939) •Soft tissue flap on the

dorsoradial aspect of the wrist to produce

pseudarthrosis•Not popular outside Scandinavia

Proximal Row Carpectomy

• Indicated in the elderly patients with symptomatic nonunion . Avoids

prolonged immobilization Hill,

1970• Done even in younger patients

where demands of movements are more

Crabbe 1964, Inglis & Jone 1977

Partial arthrodesis

•Radio scapho lunate•Scapho capitate

Scaphoid replacement

Silicon prosthesis

•Silicon synovitis

Management in brief

Older thinking:• Closed reduction and plaster cast

for all fractures, continue even upto 6 months

• ORIF if reduction cannot be achieved and at the end of failed closed treatment

• Non union - bone grafting

Management in brief

Older thinking (con’t):• Second non union - bone grafting• Third non union - Vascularised

bone grafting• Avascular necrosis - Salvage

procedures• Arthritis - Wrist fusion

Management in Brief

Newer thinking:

• Closed method only if fracture is seen on bone scan & MRI

• For all visible fractures: closed minimally open fixations and early mobilization

• ORIF for comminuted fractures• Early vascularized graft for

fractures at risk

Our ApproachProximal third fractures:• Small fragment Pronator vascular pedicle graft &

'K' wire• Big fragment with no AVN/OA/

Collapse Herbert screw fixation/ Russe bone

grafting + 'K' wire/ Pronator vascular pedicle graft

Our Approach Proximal third fractures (cont):

• Fragmented + AVN Excision & limited fusion

• Non union with limited radio-carpal OA Radial styloidectomy & Pronator vascular

pedicle graft

• Severe OA Proximal Row Carpectomy or wrist

arthrodesis

Our ApproachMiddle third fractures:

• Stable & asymptomatic Further immobilisation or prophylactic

Russe Bone graft+ 'K' wire & AO screw

• Symptomatic, with no OA/AVN/ collapse Russe bone grafting + AO Screw

• With carpal collapse and no AVN/ OA Fisk & Fernandez graft,K-wire/Herbert

screw

Our ApproachMiddle third fractures (cont):

• Non union with limited OA, no AVN Radial styloidectomy + bone grafting or

Scaphoid excision + mid carpal fusion

• Non union +AVN Pronator Vascular Pedicle graft or Scaphoid

excision + mid carpal fusion

• Extensive arthrosis Proximal row Carpectomy or Wrist arthrodesis

Our ApproachDistal third : very rare•Symptomatic but stable Short thumb spica

•Non union with carpal collapse Open reduction, bone grafting+

AO screw

Thank You