Open reduction and internal fixation of acute displaced scaphoid waist fractures

Fourteen consecutive patients with acute displaced scaphoid waist fractures were treated with open reduction and internal fixation. The operative technique consisted of anatomic reduction of the displaced scaphoid waist fracture, correction of carpal instability, radial bone grafting for comminution, and internal fixation with K-wires or Herbert screw. The patients were evaluated an average of 26 months (range, 4-48 months) after surgery. Thirteen of the 14 (93%) fractures united. The average time to union was 11.5 weeks (range, 8-20 weeks). Fracture union was confirmed with trispiral tomography. Final radiographic assessment consistently revealed a healed scaphoid fracture, restored intrascaphoid alignment, and no evidence of carpal instability. All patients regained functional wrist range of motion (wrist extension, 57 degrees; wrist flexion, 52 degrees ) and grip strength. Open reduction and internal fixation of acute displaced scaphoid waist fractures restores scaphoid alignment and leads to predictable union. Early operative intervention avoids malunion and carpal instability that often occurs with closed management of these complex fractures.     

Minimally invasive management of scaphoid fractures

Percutaneous internal fixation of scaphoid fractures allows for more predictable union and less morbidity than cast treatment or open internal fixation. This technique is appropriate for both acute scaphoid waist and proximal pole fractures, as well as selected nonunions. A headless cannulated compression screw (standard Acutrak) is implanted via a dorsal percutaneous approach using fluoroscopy and arthroscopy to confirm position and reduction. The details of this technique are reviewed. In a consecutive series of 27 fractures treated with arthroscopic assisted dorsal percutaneous fixation, eighteen fractures were treated acutely and 9 were treated more than 1 month after injury. CT scan confirmed 100% union rate at an average of 12 weeks with no complications.     

Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach

Percutaneous internal fixation of scaphoid fractures allows for more predictable union and less morbidity than cast treatment or open internal fixation. A headless cannulated compression screw (standard Acutrak) is implanted by way of a dorsal percutaneous approach with the aid of fluoroscopy and arthroscopy to confirm screw position and fracture reduction. This technique is indicated in the correction of acute proximal pole fractures, acute waist fractures, and delayed unions that are not associated with avascular necrosis or collapse. The details of this technique are reviewed. In a consecutive series of twenty-seven fractures (seventeen waist fractures and ten proximal pole fractures) treated with arthroscopically assisted dorsal percutaneous fixation, computed tomographic scanning confirmed 100% union at an average of twelve weeks. Eighteen fractures were treated within one month after the injury, and nine were treated more than one month after the injury. In this series, the fractures that were treated early (less than one month after the injury) healed more quickly than those treated later.     

Avascular necrosis after scaphoid fracture: a correlation of magnetic resonance imaging and histology

In this study 12 male patients with fractures of the middle third of the scaphoid had an magnetic resonance imaging study before open reduction and internal fixation in conjunction with bone grafting of the scaphoid. The patients' average age was 27 years (range, 17 to 37 years). At the time of surgery biopsy specimens were obtained from both the proximal and distal poles of the scaphoid. The length of time before surgery ranged from a minimum of 1 1/2 months in recently displaced fractures to a maximum of 10 years in established nonunions. Results of the biopsy showed that six patients had avascular necrosis noted in the proximal pole fragment. In three of these six patients avascular necrosis was confirmed by the absence of tetracycline labeling despite positive uptake noted in biopsy specimens from the bone graft site; the other three patients did not receive tetracycline labeling. Magnetic resonance imaging showed that all six of the patients with biopsy specimens of the proximal poles showing avascular necrosis demonstrated decreased signal intensity in the proximal pole fragment, whereas the plain radiographs demonstrated changes in the proximal pole in only three of the six patients. A decreased signal intensity from the proximal pole of the scaphoid may indicate a poor prognosis inasmuch as only three of the six patients had healing of the fracture even with bone grafting and internal fixation.     

Percutaneous fixation of scaphoid fractures.

The scaphoid proximal pole and waist fractures presented here were treated by a novel dorsal percutaneous technique with arthroscopic assistance. All fractures healed, with good final functional results and no complications. The advantages of the dorsal percutaneous approach to scaphoid fixation are: (1) the proximal-to-distal placement of the guide pin and screw allow for more precise placement along the central axis of the scaphoid, which decreases healing time and reduces risk of screw thread exposure. (2) The dorsal approach avoids injuring the vulnerable volar ligament anatomy. And (3) the insertion of the screw from the proximal to distal direction allows the more rigid fixation of proximal scaphoid fractures. Arthroscopy allows confirmation of fracture reduction and screw implantation as well as evaluation of concurrent ligament injuries not detected with standard imaging. Percutaneous K-wires act as joysticks to reduce and compress fracture fragments prior to fixation. The presented technique allows for early, rigid internal fixation with minimal associated morbidity. Patients successfully treated with this technique include those with stable and unstable acute fractures of the scaphoid at all locations, including the proximal pole. Nondisplaced fractures that present with delayed or fibrous union without evidence of avascular necrosis, cyst formation, or bony sclerosis may also be treated with this technique. This technique allows for faster rehabilitation and an earlier return to work or avocation without restriction once CT scan confirms a solid union. Some articles document extraordinary rapid healing by standard radiographs; however, we caution that scaphoid bone healing cannot accurately be determined without CT scan. Percutaneous, arthroscopically assisted internal fixation by a dorsal approach may be considered in all acute scaphoid fractures selected for surgical fixation. The dorsal guidewire permits dorsal and volar implantation of a cannulated screw along the central axis of the scaphoid. This technique permits the reduction of displaced fractures and the stable repair of fractures of the proximal pole. In addition, selected scaphoid fibrous union or delayed union may also be repaired, with realistic expectations of healing. The proven benefits of the percutaneous technique include decreased soft tissue trauma; arthroscopic visualization of the fracture, ensuring anatomic reduction; and stable fixation, allowing early physical rehabilitation. The theoretical benefits of the technique include decreased risk of interruption of the tenuous scaphoid blood supply. Percutaneous internal fixation of scaphoid fractures provides faster rehabilitation, earlier return to work, and quicker bony union in most patients.     

Scaphoid nonunions. Pitfalls and pearls.

Our ability to treat scaphoid nonunions has improved dramatically. The degree of collapse and bone loss can be accurately assessed in waist fractures using sagittal images on CT scans. These nonunions require reduction and bone grafting to re-establish the normal geometry of the scaphoid. Magnetic resonance imaging helps evaluate whether or not avascular necrosis is present in the proximal pole. Because of the poor prognosis of conventional bone grafts, a vascularized bone graft is recommended as the primary treatment when AVN is present. The volar collapse of the humpback deformity is best corrected with a volar approach and the proximal pole nonunion is best approached using a dorsal approach. Nearly all proximal pole nonunions require a vascularized bone graft and all acute proximal pole fractures require open reduction and internal fixation. Using specially designed cannulated screws, the nonunions can be stabilized accurately to decrease the time to resolution of the nonunion and minimize the amount of time in a cast. Stable fixation requires that the screw fixation target the central portion of the scaphoid regardless of the type of screw design used. Using these techniques, the hand surgeon should be able to provide a reasonable prognosis for patients presenting with a scaphoid nonunion, and the treatment should result in functional range of motion, grip strength, and relief of pain.     

Proximal pole scaphoid fractures and nonunion

Proximal pole fractures and nonunions of the scaphoid present an extremely challenging treatment problem. Untreated, proximal pole fractures have a high rate of developing a nonunion that may lead to painful arthritis. Cast immobilization is not adequate, and surgery is recommended for the treatment of acute fractures and nonunions. The fractures are difficult to treat through a conventional volar approach, and the preferred treatment is open reduction and internal fixation using a dorsal approach with a screw that is specially designed for the scaphoid. The type of fixation implant used is important, because the end of the screw must be buried beneath the articular cartilage when the dorsal approach is used. The main blood supply of the scaphoid enters through the dorsoradial ridge of the scaphoid. By definition, proximal pole nonunions have partial ischemia or complete avascular necrosis, because the fracture line isolates the proximal pole from the perforating vessels. The definitive treatment for these fractures is a standard or vascularized bone graft, depending on the vascularity of the proximal pole of the scaphoid in addition to internal fixation via a dorsal approach. Using this treatment algorithm, the surgeon can optimize the success rate of achieving a successful scaphoid union in the shortest possible time of immobilization. Copyright © 2001 by the American Society for Surgery of the Hand     

Internal fixation of acute scaphoid fractures: a new approach to treatment

Thirty-five patients with acute, unstable fractures of the scaphoid were treated by primary internal fixation using the Herbert Bone Screw System. The use of plaster was avoided whenever possible, and operation was carried out as soon as practicable after injury. The average time for return to work after operation was 3.7 weeks. Only one fracture failed to unite, and this was due to avascular necrosis of the proximal fragment of the scaphoid. Internal fixation of the acute scaphoid fracture successfully avoids the morbidity associated with standard methods of treatment in plaster.     

背侧入路经皮加压螺钉内固定治疗舟骨骨折的临床研究

目的介绍背侧入路经皮加压螺钉内固定治疗舟骨骨折的适应证、手术方法和疗效。方法2009年4~10月,采用背侧入路经皮加压螺钉固定小切口空心钉技术治疗6例急性舟骨骨折的患者,骨折分型为HerbertB2,B3型。术中以Lister结节为标志,于其远端0·5~1cm处触及舟骨近极,在导针引导、C型臂监视下、沿舟骨轴线打入合适长度的加压螺钉。结果6例患者均有初步随访资料,随访时间为4至6个月,平均5个月。B2型骨折平均愈合时间为8周,B3型骨折平均愈合时间为12周;恢复工作时间平均为14d;活动度达到健侧90%以上;无疼痛等不适感觉。没有并发症。结论背侧入路经皮加压螺钉技术治疗急性舟骨骨折创伤小,根据骨折类型不需外固定或外固定时间较保守治疗缩短,愈合率高,治疗结果满意。     

Cannulated variable pitch compression screw fixation of scaphoid fractures using a limited dorsal approach

Scaphoid fractures are common in the young, active patient. Treatment is challenging because of the complex three-dimensional anatomy of the scaphoid and the tenuous blood supply. Traditionally, cast immobilization has been used for the management of non-displaced fractures with satisfactory outcomes reported in the literature. However, non-surgical treatment may result in a delayed union or nonunion particularly if the fracture is unstable, displaced, or involves the proximal pole. Recently there has been increased interest in the fixation of non-displaced scaphoid fractures. The proposed advantages for operative treatment include avoiding the morbidity and inconvenience of prolonged cast immobilization and a lower incidence of delayed union or nonunion. A variety of surgical approaches for fixation of an acute scaphoid fracture have been described. The most common techniques include percutaneous fixation, arthroscopically assisted reduction and fixation, or open reduction and internal fixation via a volar approach. The senior author favors a limited dorsal approach with compression screw fixation of all proximal pole fractures as well as displaced and non-displaced fractures of the waist region. The technique is simple permitting accurate screw placement in the central axis of the scaphoid, which is biomechanically advantageous and important for achieving union.     

Late treatment of unreduced perilunate dislocations.

Twenty-eight patients with perilunate dislocations that had been untreated for a minimum of 6 weeks after injury were assessed at a mean of 6.8 years after subsequent treatment. Treatment consisted of open reduction with or without internal fixation of the scaphoid in six patients, proximal row carpectomy in 16, total excision of the lunate in four, and carpal tunnel release and partial excision of the lunate in two. Open reduction yielded satisfactory results in cases of less than 2 months standing. We believe that proximal row carpectomy should be considered in the treatment of chronic perilunate dislocations in patients who are seen later than 2 months after injury, if the cartilage of the proximal pole of the capitate is well preserved. The results of lunate excision were less favourable.     

Management of acute scaphoid fractures

Scaphoid fractures in the athlete present a dilemma to the treating clinician. Diagnosis of scaphoid fractures should be suspected in any athlete, especially those participating in contact sports, presenting with radial wrist pain. Appropriate imaging studies should be obtained to make a timely and complete diagnosis. Treatment alternatives for acute scaphoid fractures in the athlete include casting and staying out of sports, casting with use of a playing cast, and internal fixation. Displaced unstable fractures and proximal pole fractures should be treated by open reduction and internal fixation. Nondisplaced mid-third fractures are the most common type seen in the athlete. Alternatives of treatment should be carefully explained to the patients and family and the most appropriate treatment employed.     

Vascularised bone graft for the treatment of non-union of the scaphoid.

A 4/5 compartment pedicled vascularised bone graft from the distal radius combined with internal fixation with a Herbert type cannulated screw was used to treat non-union fractures of the proximal pole of the scaphoid in 13 patients. Non-union was identified on plain radiographs alone. Uneventful clinical and radiological healing was achieved in 11 patients. One patient had progressive signs of failure of the fixation of the screw at the proximal pole; the screw was changed and the fracture was stable at reoperation. One patient had a fall postoperatively, radiographs taken at follow-ups showed only partial healing, and he had a bone graft 12 months later. Twelve patients had clinical and radiological union of the fracture, and one patient fibrous healing alone. The technique may improve healing of non-union of fractures of the proximal pole of the scaphoid, but it is still a technical challenge.     

股骨近端解剖钢板内固定治疗老年股骨粗隆间骨折

目的探讨老年人股骨粗隆间骨折的手术方法及治疗原则。方法采用闭合复位、股骨近端解剖钢板内固定治疗老年股骨粗隆间骨折26例。结果26例均手术成功,所有26例患者均获4～18个月的随访,平均为12.4个月。所有患者均在术后3个月内达到骨性愈合,关节功能评定:优13例,良11例,可2例,优良率92.3%。结论股骨近端解剖钢板内固定是治疗老年人股骨粗隆间骨折的较好方法。     

经皮腕背入路DTJ空心螺钉内固定治疗舟骨骨折

目的 总结经皮腕背人路DTJ空心螺钉内固定治疗舟骨骨折的经验.方法 利用经皮腕背人路DTJ空心螺钉内固定治疗舟骨骨折患者12例,男10例,女2例;年龄16~39岁,平均25岁.根据改良Herbert舟骨骨折分型:A2型3例,82型5例,83型2例,D1型2例.10例新鲜骨折患者自受伤至就诊时间为1~12d,平均3.5d;2例纤维愈合患者自受伤至就诊时间分别为76d和68d.结果 骨愈合时间为术后6.5~9.5周,平均8.5周.除1例患者行体力劳动后自觉有轻度腕痛外,其余11例患者术后疼痛均消失.患者均获得随访,随访时间6~26个月,平均14个月.12例患者术后患手握力恢复至健侧的平均86.4%(82%~93%),患侧腕关节屈伸活动度恢复至健侧的平均87.5%(83%~100%).除1例患者体力劳动后自觉有轻度腕痛改变原工作外,6例患者于术后平均5.5周(4.5~8周)返回原工作岗位,5例学生患者于术后平均4.5个月(3~6个月)恢复体育运动.所有患者腕背小切口均一期愈合,无感染等并发症发生.结论 经皮腕背入路DTJ空心螺钉内固定是一种微创、骨折愈合率高、并发症相对较少的舟骨骨折的有效治疗方法.     

The relationship between proximal pole blood flow and the subjective assessment of increased density of the proximal pole in acute scaphoid fractures

The cause and importance of increased density of the proximal pole of the scaphoid seen in radiographs after an acute fracture were investigated. Blood flow to the proximal poles of 32 nonsurgically treated scaphoid fractures were assessed 1 to 2 weeks after injury by measuring their uptake of gadopentetate dimeglumine with dynamic magnetic resonance imaging and calculating its steepest slope and percentage of enhancement values. Initial (week 0) and week 8 scaphoid series radiographs were independently assessed by 2 observers for increased proximal pole density; both agreed that the density had increased during treatment in 9 fractures. All 9 fractures united, suggesting that increased proximal pole density is not a major determinant of fracture outcome. Increased density of the proximal pole was associated with low proximal pole blood flow, but this relationship was not absolute, suggesting that other factors contribute to the appearance of increased density.     

可吸收棒内固定治疗陈旧性腕舟骨骨折

目的探讨可吸收棒治疗陈旧性腕舟骨骨折的手术疗效。方法对17例陈旧性腕舟骨骨折,按Herbert分类:D1型4例,D2型11例,D3型2例,采用骨折切开复位自体松质骨植骨,可吸收棒内固定术。结果17例获得4~26个月随访,平均9个月。术后伤口均Ⅰ期愈合,骨折愈合时间8~19周,平均13周。腕关节活动范围掌屈[(49.5±8.5)°,x-±s,下同],(达健侧78.3%);背伸(41.5±4.5)°,(达健侧70.5%);桡偏(16.5±2.5)°,(达健侧57.1%);尺偏(24.5±5.5)°,(达健侧60.3%)。15例腕关节活动时无疼痛。2例有疼痛。腕部握力(24.7±3.1)kg,(达健侧83.2%)。术后X线片示17例均未发生腕骨性关节炎及舟骨缺血性坏死。结论可吸收棒治疗陈旧性舟骨骨折手术操作简单,固定牢靠,可缩短骨折愈合时间及提高骨折愈合率,是治疗陈旧性舟骨骨折的一种有效的手术方法。     

Treatment of scaphoid fractures and nonunions

Scaphoid fractures are common but present unique challenges because of the particular geometry of the fractures and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures can lead to nonunions and subsequent degenerative wrist arthritis. Improvements in diagnosis, surgical treatment, and implant materials have encouraged a trend toward early internal fixation, even for nondisplaced scaphoid fractures that could potentially be treated nonoperatively. Despite the advent of newly developed fixation techniques, including open and percutaneous fixation, the nonunion rate for scaphoid fractures remains as high as 10% after surgical treatment. Scaphoid nonunions can present with or without avascular necrosis of the proximal pole and may show a humpback deformity on the radiograph. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis. Surgical treatment is directed at correcting the deformity with open reduction and internal fixation with bone grafting. Recently, vascularized bone grafts have gained popularity in the treatment of scaphoid nonunions, particularly in cases with avascular necrosis. This article reviews current concepts regarding the treatment of scaphoid fractures and nonunions.     

Posttraumatic osteonecrosis and nonunion of distal pole of scaphoid

Posttraumatic osteonecrosis of distal pole of scaphoid is an extremely rare with only two reported cases so far. We present a case of a 30-year-old male with a 2-year-old posttraumatic osteonecrosis and nonunion of distal pole of scaphoid left wrist. He presented with complaints of pain and restriction of movements. There was no evidence of radiocarpal arthritis. He was managed with open reduction and internal fixation with k-wires, supplemented by a pronator quadratus based muscle pedicle bone graft. The fracture union was achieved at 6 months. After 2 years, he had almost complete range of wrist motion and had returned to his preinjury level of functional activity. His MRI (magnetic resonance imaging) scans showed evidence of revascularization suggesting successful incorporation of bone graft.     

Acute percutaneous scaphoid fixation using a cannulated screw

Fractures of the scaphoid are most commonly seen in young males where immobilisation in a cast will lead to a prolonged period away from work and from athletic activities. Early rigid fixation has recently been advocated to promote a rapid functional recovery. Open reduction and internal fixation of the scaphoid is however technically demanding, damages the anterior radiocarpal ligaments, violates the scapho trapezial joint, further endangers the already compromised blood supply of the scaphoid and not infrequently leads to troublesome hypertrophic scars. These problems can be overcome in minimally displaced or undisplaced fractures by percutaneous fixation. We present the first 50 cases from our ongoing study of patients treated acutely in this way. No cast immobilisation was used and the patients were allowed to mobilise immediately postoperatively. Union was obtained in all cases after an average of 55 days (37-79). Range of movement at the time of fracture union was equal to that of the contralateral limb at three months and grip strength was 98% of the contralateral side at three months. Patients returned to sedentary work within 4 days and to manual work/sports within 5 weeks. We have found percutaneous scaphoid fixation for acute fractures a rapid and very satisfactory intervention which leads to a rapid functional recovery.