Segmental fracture of the scaphoid: report of a rare fracture pattern

Introduction:To the best of our knowledge, there are no reports in the orthopaedic and trauma literature of true segmental fracture of the scaphoid bone. We present such a case with a brief discussion of the morphology and mechanisms of injury of scaphoid fractures and the problems they present, particularly in diagnosis. Case history: A 43-year-old male with polytrauma sustained in a motorcycle road traffic accident was treated at our hospital. His injuries included a fracture initially thought to involve the waist of the scaphoid. Because he had bilateral upper limb injuries, we elected to treat the fracture surgically to facilitate rehabilitation. At the time of surgery, the fracture was noted to be truly segmental, an unsuspected and rare finding. The fracture was internally fixed, with a satisfactory result. Discussion: Scaphoid fracture patterns are generally consistent and predictable, occurring most commonly through the waist of the bone. Mechanism for injury is thought to be hyperextension of the wrist. Comminution, with or without a butterfly fragment, is occasionally seen, as are simultaneous tuberosity fractures. We suggest that the mechanism in this case may have been multiple or secondary trauma, or an effect of loaded rotation. We highlight the need for careful imaging of the scaphoid bone prior to choosing treatment.     

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.     

孤立闭合性腕舟骨完全脱位1例

患者,男,40岁,因车祸撞伤左上肢致左前臂腕关节肿胀疼痛、活动受限2d入院。查体:左前臂处有擦痕,肿胀,压痛,左腕关节肿胀明显,掌侧可触及脱位舟骨,腕关节背侧有凹陷感,腕关节屈伸活动明显受限。左腕X线片示:左腕舟骨完全脱位至桡骨远端掌侧(图1a,1b),近极可见细小骨折线。急诊行闭合复位失败后入院,在臂丛麻醉下采用腕背侧入路,经鼻烟窝于腕背部做"S"形切口,切开皮肤、皮下组织,     

Patient-rating of long term results of silicone implant arthroplasty of the scaphoid

Thirty-two patients had silicone implant arthroplasty of the scaphoid in our unit between 1974-1988. Ten years later eight had had their implants removed because they had failed. Twenty-four of the 32 were reviewed at an intermediate clinical follow up examination between 1988-89 and 21 by patient rated wrist evaluation 10 years later. Grip strength compared to the non-injured hand varied between 38% and 136% (mean (SD) 78 (25)%). Nine of the 24 wrists showed no signs of bone cysts, while 15 had intraosseous cysts of various sizes. Patient-rated evaluation gave a median subjective long term overall wrist score of 25, a pain score of 27, and a function score of 22 on a scale from 0 (best) to 100 (worst). Nine out of 21 patients had little or no pain, and 13 out of 21 had total scores of under 25. Many of these patients reported good subjective benefit from silicone scaphoid arthroplasty.     

Technique for percutaneous fixation of displaced and nondisplaced acute scaphoid fractures and select nonunions

Percutaneous surgical intervention for scaphoid fractures and some nonunions is increasingly common. There is a considerable learning curve for these procedures. Here we review basic and advanced techniques for volar and dorsal fixation of acute nondisplaced and displaced fractures as well as nonunions with minimal resorption and no humpback deformity.     

Avulsion fractures of the scaphoid and triquetrum in a 15 year- old male

Avulsion fractures of the perilunate ligaments occur in isolation, and multiple fractures are typically not seen in the same carpus. We present a case of a 15-year-old male who injured his wrist during football practice. He presented without wrist dislocation or deformity. Radiographs demonstrated avulsion fractures to the proximal pole of the scaphoid and proximal radial aspect of the triquetrum. The patient was immobilized with an upper extremity thumb spica cast; however, there was persistent non-union of both fractured segments. Magnetic resonance imaging confirmed avulsions at the site of the scapholunate and lunotriquetral ligaments, with both ligaments relatively intact. At the last follow-up, one year after the initial injury, the patient had a normal clinical exam, with no pain and full wrist range of motion despite fracture non-union at both locations. This is a unique injury with an unclear mechanism and complicated management.     

Isolated scaphoid fracture with anterosuperior dislocation of the proximal fragment

Isolated fracture of the scaphoid with an associated anterosuperior dislocation of the proximal fragment is an extremely rare injury. We present two cases where open reduction and internal fixation through a palmar and dorsal approach was performed. No instances of non-union, necrosis of the proximal fragment of the scaphoid or scapholunate dissociation were noted during a mean follow-up period of 18 months. Clinical results (active motion, power grip, DASH) following such injury and intervention are presented. The aetiology of this rare injury is discussed.     

腕舟骨的腱球置换术

目的 分析舟骨部分切除后腱球置换的效果。方法 对2例舟骨骨不连和4例Preiser病的患者进行了近侧半舟骨切除、掌长肌腱腱球植入术。术后平均随访58个月。结果 3例腕关节疼痛完全缓解，3例在从事重体力劳动时偶有疼痛；所有患者的握力和关节活动范围都有明显好转。X线片示5例腕骨高度和桡骨角均有不同程度塌陷，1例未见明显改变。有限要素法力学分析证明腱球置换能承受一定的载荷，改善应力分布。结论 舟骨部分切除腱球置入术能够长期缓解疼痛，改善关节功能，但X线片示腕关节仍有退行性变。     

15-year experience with soft tissue expansion in total knee arthroplasty

Preoperative identification of a knee at risk for wound healing after total knee arthroplasty (TKA) allows the surgeon to apply a soft tissue expansion technique to expand the available tissue for closure and healing after TKA. A consecutive series of 64 soft tissue expansions were performed for 59 cases of conflicting incisions and 5 cases of severe angular deformity, with a mean of 3.5 previous surgeries. An average 2.1 expanders were used for a total volume of 359 mL. Expansion took a mean of 70 days during which 14 minor and 7 major complications occurred. There were 8 post-TKA complications, 5 of which required a return to the operating room. Soft tissue expansion is a safe, prophylactic technique that provides adequate coverage in this complex subset of patients.     

Return to sport following scaphoid fractures:A systematic review and meta-analysis

BACKGROUND Scaphoid fracture is the most commonly fractured carpal bone in the athletic patient, accounting for over 85% of all sport-related carpal bone fractures, and is particularly common in sports involving high impact injuries to the wrist. The management of such injuries comprises both conservative and surgical techniques, as guided by fracture location and type. Athletes demonstrate a unique challenge with regards to the management of scaphoid fractures due to their requirement to return to sport, as soon as able.AIM To review systemically all studies recording return to sport following scaphoid fractures, to collate information on return rates to sport(RRS) and mean return times(RTS) to sport and to determine differences in sporting outcome for the various treatment methods.METHODS A systematic search of MEDLINE, EMBASE, CINAHAL, Cochrane, Google Scholar, Physiotherapy Evidence Database, SPORTDiscus, Web of Science and Scopus was performed in August 2018 using the keywords "scaphoid","fracture", "acute", "carpal", "athletes", "sports", "non-operative","conservative", "operative" and "return to sport". All studies that recorded RRS and RTS following scaphoid fractures were included. RTS was recorded as the length of time from commencement of either primary conservative management or primary surgical procedure to return to sport.RESULTS Eleven studies were included: Two randomised controlled trials, six retrospective cohort studies and three case series. Seven studies reported on conservative management(n = 77), and eight studies reported on surgical management(n =83). For conservative management, RRS was 90%(69/77), and the mean RTS was9.6 wk. Three studies allowed to return to sport in cast [RRS 89%(25/28); RTS 1.9 wk], and four studies required completion of cast treatment prior to returning to sport [RRS 90%(44/49); RTS 13.9 wk]. Four studies recorded fracture union data:Union rate 85%(47/55); mean time to union 14.0 wk. For surgical management,RRS was 98%(81/83), and RTS was 7.3 wk. Three studies reported on Percutaneous Screw Fixation [RRS 97%(32/33); RTS 6.5 wk], and five studies reported on Open Reduction Internal Fixation [RRS 98%(49/50); RTS 7.9 wk]. Six studies recorded fracture union data: Union rate 97%(69/71); mean time to union9.8 wk. On meta-analysis, RRS(RR = 1.09; 95% confidence interval(CI): 1.00-1.18;P 0.045), RTS(MD 2.3 wk; 95%CI: 0.79-3.87; P 0.002), union rates(RR = 1.14;95%CI: 1.01-1.28; P 0.030) and mean times to union(MD 4.2 wk; 95%CI: 3.94-4.36; P 0.001) were all significantly better for the surgical cohort compared to the conservative cohort.CONCLUSION Surgical management of scaphoid fractures can provide significantly improved RRS and RTS to sport compared to conservative management. Both treatments,however, remain acceptable options, and athletes should be fully informed of the benefits and risks of both prior to deciding treatment plans. Immediate return to sport in a cast should be avoided due to the significant risk of non-union.     

Percutaneous screw fixation for scaphoid nonunion in skeletally immature patients: a report of two cases

Nonunion of the scaphoid waist in skeletally immature patients is rarely diagnosed. We report 2 cases of scaphoid nonunion in skeletally immature patients who underwent percutaneous screw fixation without bone graft. In stable nonunions with minimal sclerosis, percutaneous screw fixation without bone graft can be an alternative to the conventional open procedure in skeletally immature patients, with successful union and clinical outcome.     

Scaphoid fracture and scaphoid pseudarthrosis

Summary Careful diagnostic and early therapy are especially important in cases of scaphoid fractures. This is due to the patients being mostly young and the high number of non-unions of these carpal bones. Conservative and various operative treatments are therapeutical options. Out of the patients who underwent surgery from January 1993 to February 1999 42 patients with a scaphoid fracture and 88 patients with a scaphoid non-union were, in addition to standard X-ray examination, examined clinically and by MRI pre- and post-operatively. Fractures of the scaphoid were treated by Herbert screw fixtion. The operative treatment of non- unions of the scaphoid included the transplantation of an iliac crest graft and Herbert screw fixation. Post-operatively a cast-immobilisation was done. Subjective statements of the patients and clinical results were assessed. The classification of Herbert and Fisher (1984)/Filan and Herbert (1996) for X-rays was used. The signal intensities of the MRI in the fragments of the scaphoid were determined qualitatively and quantitatively by computer calculation, comparing the pre- and post-operative results with one another. Post-operative results of the scaphoid fractures were in most cases good and excellent. 67 patients with a scaphoid non-union and 11 with a scaphoid fracture showed a pre-operative diminishing of the signal in the proximal fragment. For these patients, the fusion rate was lower than in patients without pre-operative signal reduction. The examination shows that in most cases bony fusions with good clinical results could be achieved by Herbert screw fixation. The MRI seems to be able to complete the radiological classification of the fractures regarding a prognosis.      

Palmar-divergent dislocation of the scaphoid and the lunate

We describe a patient with palmar-divergent dislocation of the scaphoid and lunate. After successful closed reduction, the scapholunate and lunotriquetral ligaments were sutured through the dorsal approach, and the anterior capsule was sutured through the palmar approach. The scapholunate and lunotriquetral joints were fixed with Kirschner wires for 7 weeks. At the 1-year follow-up, magnetic resonance imaging showed no evidence of avascular necrosis of the scaphoid or lunate, and radiographs showed no evidence of the dorsal and volar intercalated segment instability patterns associated with carpal instability. However, flexion of the scaphoid and a break in Gilula’s line remained. To our knowledge, this is the first report showing treatment of palmar-divergent dislocation of the scaphoid and lunate by suturing the carpal interosseous ligaments.     

加压螺钉治疗舟骨骨折的临床疗效

目的　评价加压螺钉内固定治疗舟骨骨折的临床疗效。方法　对 46例 (4 7侧 )舟骨骨折采用切开复位加压螺钉内固定治疗的患者 ,术后进行随访。从术后疼痛程度、腕关节活动度、手部握力、影像学检查、Krimmer腕关节评分和DASH(DisabilityofArm Shoulder Hand)问卷调查表等进行随访和疗效评估。结果　术后腕关节疼痛程度静息时为 2 ,用力时为 13。腕关节屈伸活动度 12 4°(达健侧 92 % ) ,尺桡偏5 7°(达健侧 91% ) ,平均握力 47kg(达健侧 90 % )。X线片及CT检查 :6例螺钉穿透骨皮质 ,4例发生腕关节炎 ,1例舟骨骨折不愈合及 1例畸形愈合。Krimmer评分总体疗效 :优 3 9侧 ,良 5侧 ,满意 3侧。DASH值为8 3。DASH问卷调查表结果显示 ,术后腕关节功能良好 ,仅有轻微不适症状。结论　应用切开复位加压螺钉内固定治疗舟骨骨折手术操作简便、疗效可靠。     

The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions

PURPOSE: Over the past decade vascularized bone grafts that use a 1,2-intercompartmental supraretinacular artery (1,2-ICSRA) pedicle have gained popularity in the treatment of scaphoid nonunions. The purpose of this study was to evaluate critically the outcome, complications, and failures of 1,2-ICSRA-based vascularized bone grafting at our institution to understand better the appropriate indications, methods, and possible contraindications. METHODS: From January 1994 through July 2003, 50 scaphoid nonunions in 49 patients were treated with 1,2-ICSRA-based vascularized bone grafts. A retrospective review of the clinical and radiographic information was performed. Two patients were lost to follow-up study. Nine female and 38 male patients averaging 24 years of age were followed-up for an average of 7.8 months. RESULTS: Thirty-four scaphoid nonunions went on to union at an average of 15.6 weeks after surgery. Complications occurred in 8 patients and consisted of graft extrusion, superficial infection, deep infection, and failure of fixation. Univariate risk factors for failure included older age, proximal pole avascular necrosis, preoperative humpback deformity, nonscrew fixation, tobacco use, and female gender. CONCLUSIONS: Although previous researchers have concluded that vascularized bone grafts based on the 1,2-ICSRA are efficacious in the treatment of scaphoid nonunions, we determined that a successful outcome is not universal and depends on careful patient and fracture selection and appropriate surgical techniques. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

1，2伸肌室间支持带上动脉为蒂骨瓣移植治疗舟骨骨折不愈合

目的探讨1,2伸肌室间支持带上动脉（1,2 intracompartmental supraretinacular artery 1,2 ICSRA）的解剖特点及治疗舟骨骨折不愈合的临床疗效。方法2008年7月-2010年9月共收治确诊的舟骨骨折不愈合患者11例,均采用逆行的1,2ICSRA为蒂骨瓣植入术结合Herbert螺钉内固定进行治疗,观察患者的骨折愈合情况及并发症,并以DASH评分对腕关节功能进行评价。结果所有患者均获6～33个月随访,平均17个月。11例患者均获骨性愈合,骨折愈合时间为9～14周。平均12周。术后6个月DASH评分平均为6．5分,腕关节功能接近正常。结论慎重的选择适应证,熟悉相关解剖知识,仔细的手术操作,采用逆行的1,2ICSRA为蒂骨瓣植入术结合Herbeft螺钉内固定治疗舟骨骨折不愈合可取得满意的临床疗效。