Narrow Results

Scaphoid fracture patterns can be divided into volar and dorsal type using three-dimensional computed tomography. Ninety-nine patients underwent this examination plus radiography to determine how often fracture pattern was identifiable by radiography including proximal fragment ratio (PFR) measurement. Oblique radiographs obtained at 45° of pronation demonstrated a volar displacement in 28 of 37 volar type fractures in three-dimensional computed tomography (76%), while as oblique view with 45° of supination could identify the dorsal type in ten of 18 (56%). PFR showed a significant difference, with means of 0.59 for volar type and 0.43 for dorsal type. Using oblique views in the two rotational directions together with the PFR, the two fracture patterns could be differentiated in 35 of 43 fractures (81%). No differences were evident between the two fracture patterns with respect to prevalence of dorsal intercalated segment instability deformity.

We have performed the surgical procedure on the patients with the fracture of the scaphoid using mini-acutrak screws (ACUMED, Inc.).

A 25-year-old man was injured in a fall. Surgical treatment for non-union of the scaphoid using a mini-acutrak screw was performed. However, this screw was broken, despite the absence of any obvious trauma mechanism. A structural examination was performed with a metal microscope and a hardness test was performed. A hardness evaluation was conducted on this broken screw and similar screws. Cannulated screws having diameters of 2.7 and 3.5 mm were also evaluated in the strength test as controls for comparison.

The breakage of screw occurred due to fatigue. The screw provides the strength equivalent to that of a 3.5 mm cannulated screw but the bending strength of the head end portion in which the breakage occurred was assumed to be the strength of about one-third that of the intermediate portion.

Fracture dislocation of the wrist is a rare injury in adolescents, and therefore it is easily ignored at the initial treatment. Once ignored, an alternative treatment such as proximal row carpectomy is indicated, but surgical outcome is not as good as that of an early reduction. We have experienced a chronic case of fracture dislocation in a 15-year-old, skeletally immature boy and treated it by scaphoid osteotomy, associated with bone grafting, screw fixation and ligament repair. The patient had no difficulties in daily activities nine years post-operatively, however the X-ray showed slight deformity of the scaphoid. Even for a chronic case, late reduction with ligamentous repair should be considered in adolescents.

This retrospective study evaluates the functional and radiological results of a series of acute trans-scaphoid dorsal perilunate fracture-dislocations treated operatively by minimally invasive technique. Twenty-one patients had surgery performed by one of three surgeons between 1994 and 2006, and all cases involved: (1) closed reduction of the carpus; (2) closed reduction and percutaneous screw fixation of the scaphoid fracture; and (3) closed reduction and multiple Kirschner wire stabilisation of the carpal dissociation. Seventeen males and four females with an average age of 29 years were evaluated. Ninety five per cent of internally fixed scaphoid healed at a mean time of 16 weeks. Radiographic alignment of the carpus was satisfactory in 17 cases. The average Mayo wrist score was 80 with three excellent and two poor results. There was one patient with asymptomatic DISI deformity. Two patients had radiographic evidence of mid-carpal arthritis. One patient with a scaphoid nonunion required surgical repair with bone grafting. The results of this study suggest that a minimally invasive technique for treating acute trans-scaphoid perilunate fracture-dislocations can be considered as an alternative to open approaches.

Although scaphoid fractures are relatively common encounters in orthopaedic and trauma surgery, the demographics of these injuries are not well studied. The classical teaching in the subject limits scaphoid fractures in the age between ten and 60 years (or 70 years in other sources). The incidence or the prevalence of scaphoid fractures in the elderly population is not focused on and not studied or explored.

We reviewed the literature for any available epidemiological studies of scaphoid fractures. We also sought the available data of scaphoid fractures in the elderly population in case series and case reports which have relevant data on the subject. Four epidemiological studies, two case series, and one case report are included. We discuss the available data in these articles and conclude that scaphoid fractures in the elderly, although rare, have been reported. However, there are not enough epidemiological studies to draw figures. Ignorance of this proportion of population could result in missed fractures in the elderly. Therefore, we encourage researchers to carry out epidemiological studies of scaphoid fractures with more focus on this population group.

Introduction: Untreated ununited scaphoid fractures will almost inevitably progress to radiographic and symptomatic osteoarthritis of the wrist. This may lead to subsequent morbidity and lifelong disability especially in young males in which the fracture scaphoid is more common. Patients and methods: Twenty-one patients presenting non-united fracture scaphoid were operated upon by using disto-proximal bone peg technique with average time between injury and operation as 11 months (6–18 months). All of them male with average age of 26 years (17–35 years). There were 17 patients with fracture waist (80.9%) and four patients with fracture proximal pole (19.1%). Results: Anatomy of the wrist was restored and radiological healing confirmed in 17/21, partial healing in 3/21 and non-union in 3/21 patients. Eighteen patients (85.7%) were graded as satisfactory, 5 patients (23.8%) were graded as excellent, ten patients (47.6%) were graded as good, and three patients (14.3%) were graded as fair. The remaining three patients (14.3%) were graded as unsatisfactory. Conclusion: We conclude that the disto-proximal bone peg technique of taking the graft from the ipsilateral ulna without using any metal work for fixing scaphoid non-union fracture is a reliable, easy, and inexpensive alternative method. However, we would not recommend it for the non-union of the scaphoid proximal pole fracture. Also we find the time lag before operation is one of the most important factors to achieve union in non-united fractures of the scaphoid. Level of evidence: Therapeutic case series, level 1V.

Coronal fracture of the scaphoid is a rare configuration of scaphoid fracture. Only three cases have been found to be reported in English literature. In our case, a 25-year-old man sustained right wrist injury after a fall with an outstretched hand, was suspected of suffering from a scaphoid fracture as shown on the pre-operative plain radiograph. Coronal fracture of the patient's scaphoid was found intra-operatively and was fixed with two headless compression screws in dorsal-to-volar direction. Post-operative outcome was clinically good as patient was symptom-free, and a computed tomography and radiograph showed complete healing of the fracture with no sign of avascular necrosis.

We present an unusual case of a closed perilunate dorsal-dislocation of the carpus, with an associated scaphoid fracture. In this extreme case, the proximal scaphoid pole was extruded volarly and proximally. After closed manipulation, the proximal pole of the scaphoid was further dislocated dorsally, a phenomenon not previously described in the literature. At open reduction this fragment was noted to have no soft tissue attachment but after reduction, distal radius bone graft and compression screw fixation the scaphoid went on to unite with a good functional result. This case highlights a rare but serious injury to the wrist with an unusual dislocation pattern not previously described. It demonstrates that early surgical intervention to fix such fractures with an avascular fragment can still achieve fracture union, despite the severity.

Radiocarpal dislocations are uncommon and occur after significant trauma. We describe a unique case of open radiocarpal fracture-dislocation presenting with progressive neurovascular compromise. Staged management was necessary. As a first stage, emergent provisional bedside reduction in the emergency room with manual pressure through the open wounds was performed. The second stage then involved formal open reduction and internal fixation as soon as operating room staff and resources became available.

Background: To identify acute un-displaced and minimally displaced scaphoid fractures which are unlikely to unite with non-operative treatment at six weeks with CT scan and stabilize them with percutaneous screw fixation with the aim of preventing non-union.

Methods: A scaphoid series radiographs of wrist were obtained for patients with undisplaced or minimally displaced fractures and were immobilized in a thumb spica cast for six weeks. At six weeks, CT scan was done for patients showing doubtful signs of clinical and radiographic union. Patients with a gap less than 2 mm were continued on cast for an additional two to four weeks. Those with gap more than 2 mm underwent percutaneous screw fixation. In both cases the immobilisation was discontinued when the fracture was considered to be united and mobilization was initiated.

Results: 21 out of 39 patients managed initially with cast for six weeks showed clinical and radiological evidence of union. 18 patients showed persistent tenderness of which eight showed a clear gap in radiographs and 10 patients had doubtful union. Eight of these 10 patients on CT scan showed fracture gap of more than 2 mm while two patients showed fracture gap of less than 2 mm. Hence, 16 patients underwent percutaneous fixation. Repeat radiographs showed progression to union at an average of 3.8 weeks from surgery. Remaining two eventually united on continuing the cast. All patients showed confirmed union at one year on follow up.

Conclusions: An objective measurement of fracture gap by CT scan at six weeks is useful in predicting cases with tendency for delayed union. Early percutaneous fixation of fractures would not further jeopardize the blood supply of fracture site. This aggressive conservative management also avoids unnecessary surgery in all acute scaphoid fractures.

Background: Literature provides little and controversial evidence regarding the influence of ulnar variance (UV) on the incidence of scaphoid fractures. The aim of this retrospective study was to assess UV in a large number of patients with acute scaphoid fracture in comparison to a control group of the same population.

Methods: During a two year period, 182 patients with acute scaphoid fractures (fracture group) and 182 ethnicity-, gender- and age-matched patients with wrist contusions (control group) were treated in three non-university hospitals. Using standardized digital wrist radiographs, UV values were measured by means of the method of perpendiculars by two independent examiners. The UV values of the fracture group were then compared to the UV values of the control group.

Results: Analyses of the agreement between the two raters resulted in a good to excellent inter-item correlation of 0.89, with a high intra-class coefficient of 0.93 (95% confidence interval: 0.87–0.95). Mean (SD) UV value was -0.82 mm (1.77) in the fracture group and 0.27 mm (1.44) in the control group. Paired sample t-test showed a significant difference between the two groups (p < 0.0001).

Conclusions: According to this study, patients with scaphoid fractures are significantly more likely to show a negative UV than matched patients with wrist contusions.

Volar plate fixation (VPF) of scaphoid fractures has received increased attention over the past decade. The purported benefits over headless screw fixation are increased rigidity, better purchase of small fragments, the ability to prevent extrusion of bone graft, and to act as a buttress against excessive scaphoid flexion. We report a case of symptomatic radioscaphoid impingement presenting two years after successful VPF for a non-united scaphoid fracture. We performed an arthoscopic evaluation, synovectomy and chondroplasty, followed by open radial styloidectomy and implant removal. This article highlights the pertinent clinical features, relevant imaging, and key intra-operative findings. We have analyzed the factors that led to this complication and have highlighted several technical tips to minimize radiocarpal impingement and ongoing chondral damage.

We report a dorsal trans-scaphoid perilunate fracture-dislocation associated with dorsal dislocation of the thumb carpometacarpal joint in a 25-year-old man. This is a rare injury and we discuss a possible mechanism for the injury.

Level of Evidence: Level V (Therapeutic)

Background: Three-dimensional (3D) printing technology is increasingly commercially viable for pre-surgical planning, intraoperative templating, jig creation and customised implant manufacture. The challenging nature of scaphoid fracture and nonunion surgery make it an obvious target. The aim of this review is to determine the use of 3D printed technologies in the treatment of scaphoid fractures.

Methods: This is a review of the Medline, Embase and Cochrane Library databases examining studies aimed at therapeutic use of 3D printing, also known as rapid prototyping or additive technology, in the treatment of scaphoid fractures. All studies published up to and including November 2020 were included in the search. Relevant data extracted included modality of use (as template/model/guide/prosthesis), operative time, accuracy of reduction, radiation exposure, follow-up duration, time to union, complications and study quality.

Results: A total of 649 articles were identified, of which 12 met the full inclusion criteria. Analysis of the articles showed that 3D printing techniques can be utilised in myriad ways to aid planning and delivery of scaphoid surgery. Percutaneous guides for Kirschner-wire (K-wire) fixation of non-displaced fractures can be created; custom guides can be printed to aid reduction of displaced or non-united fractures; patient-specific total prostheses may recreate near-normal carpal biomechanics and a simple model may help graft harvesting and positioning.

Conclusions: This review found that the use of 3D printed patient-specific models and templates in scaphoid surgery can improve accuracy and speed, and reduce radiation exposure. 3D printed prostheses may also restore near-normal carpal biomechanics without burning bridges for potential future procedures.

Level of Evidence: Level III (Therapeutic)