Comparison of Fracture Location and Extent of Comminution in Isolated Scaphoid Fractures Versus Transscaphoid Fracture-Dislocations

Background: Isolated scaphoid fractures (ISFs) are common, whereas transscaphoid fracture-dislocations (TSFDs) are not. Scaphoid fracture location and the extent of comminution are factors that affect treatment and outcome. The purpose of this study is to compare the radiographic characteristics of ISFs with TSFDs associated with greater arc injury. Methods: This study is a retrospective review of all ISFs and TSFDs that presented to our institution during a 5-year period. Fracture location (along the long axis of the scaphoid) was calculated by dividing the distance from the proximal pole to the fracture by the entire length of the scaphoid. The extent of comminution was measured in millimeters along the mid-axis of the scaphoid and divided by the entire length of the scaphoid. Results: One-hundred thirty-eight scaphoid fractures in 137 patients were identified. One-hundred twelve fractures (81%) were ISFs, and 26 (19%) were associated with a TSFD. The mean fracture location was more proximal in TSFDs than in ISFs. However, fractures occurred in the distal third of the scaphoid in 12% of ISFs compared with 0% of TSFDs. Nine percent of ISFs demonstrated comminution as compared with 12% of TSFDs. Extent of comminution was 16% and 28% for ISFs and TSFDs, respectively. Conclusion: Scaphoid fractures associated with greater arc injuries are located more proximally and are more comminuted than ISFs, and distal pole fractures rarely occur in the setting of TSFDs. The increased incidence and extent of comminution in TSFDs may be suggestive of a higher energy injury mechanism.

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Outcomes of Local Bone Graft and Fixation of Proximal Pole Scaphoid Nascent Nonunions and Nonunions

Journal of Wrist Surgery ◽

10.1055/s-0040-1701512 ◽

2020 ◽

Vol 09 (03) ◽

pp. 203-208

Author(s):

Kristin E. Shoji ◽

F. Joseph Simeone ◽

Sezai Ozkan ◽

Chaitanya S. Mudgal

Keyword(s):

Bone Graft ◽

Common Mechanism ◽

Study Cohort ◽

Proximal Pole ◽

Scaphoid Fractures ◽

Local Bone ◽

Case Series Study ◽

Increased Risk ◽

Surgical Fixation ◽

The Mean

Abstract Background Fractures of the proximal pole of the scaphoid have an increased risk of nonunion due to its tenuous blood supply. The optimal treatment of proximal pole scaphoid nonunions remains controversial. Objectives To review a single surgeon's experience with proximal pole scaphoid nascent nonunions (delayed unions) and nonunions that underwent surgical fixation with a cannulated headless compression screw and local autologous bone graft from the distal radius. Patients and Methods After obtaining Institutional Review Board approval, the electronic medical record of one tertiary care center was queried for patients with the diagnosis of “proximal pole scaphoid fractures” who underwent surgical fixation by a single surgeon over an 11-year period (2006–2017). Fifteen patients met initial query criteria; upon review of records, four patients were excluded due to the acute nature of the fracture, and one was excluded as surgical fixation included a vascularized bone graft. Results The final study cohort consisted of 10 patients with a total of 10 proximal pole scaphoid nonunions. Almost all of the patients in this study were male (9/10 [90%]), and sporting activities were the most common mechanism of injury (8/10 [80%]). Volumetric measurements of the scaphoid fractures on computed tomography (CT) revealed that the mean total volume of the scaphoid was 2.4 ± 0.48 cm3 and the mean volume of the proximal pole fragment was 0.38 ± 0.15 cm3. Postoperative CT scans were performed at a mean of 12.4 weeks (range: 8–16 weeks), with seven (7/10 [70%]) showing signs of complete union and three (3/10 [30%]) demonstrating partial union. None of the patients required additional procedures and there were no complications. Conclusions Our results suggest that proximal pole scaphoid fractures with delayed union and nonunion treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. The volume of the proximal pole fragment did not correlate with increased risk of ongoing nonunion after the index procedure. Level of Evidence This is a Level IV, case series study.

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Factors Associated with Scaphoid Nonunion following Early Open Reduction and Internal Fixation

Journal of Wrist Surgery ◽

10.1055/s-0039-3402769 ◽

2020 ◽

Vol 09 (02) ◽

pp. 141-149

Author(s):

Pooja Prabhakar ◽

Lauren Wessel ◽

Joseph Nguyen ◽

Jeffrey Stepan ◽

Michelle Carlson ◽

...

Keyword(s):

Internal Fixation ◽

Open Reduction ◽

Scaphoid Fracture ◽

Receiver Operating Curve ◽

Scaphoid Nonunion ◽

Retrospective Case ◽

Level Of Evidence ◽

Fracture Location ◽

Scaphoid Fractures ◽

Time From Injury

Abstract Background Nonunion after open reduction and internal fixation (ORIF) of scaphoid fractures is reported in 5 to 30% of cases; however, predictors of nonunion are not clearly defined. Objective The purpose of this study is to determine fracture characteristics and surgical factors which may influence progression to nonunion after scaphoid fracture ORIF. Patients and Methods We performed a retrospective case–control study of scaphoid fractures treated by early ORIF between 2003 and 2017. Inclusion criteria were surgical fixation within 6 months from date of injury and postoperative CT with minimum clinical follow-up of 6 months to evaluate healing. Forty-eight patients were included in this study. Nonunion cases were matched by age, sex, and fracture location to patients who progressed to fracture union in the 1:2 ratio. Results This series of 48 patients matched 16 nonunion cases with 32 cases that progressed to union. Fracture location was proximal pole in 15% (7/48) and waist in 85% (41/48). Multivariate regression demonstrated that shorter length of time from injury to initial ORIF and smaller percent of proximal fracture fragment volume were significantly associated with scaphoid nonunion after ORIF (63 vs. 27 days and 34 vs. 40%, respectively). Receiver operating curve analysis revealed that fracture volume below 38% and time from injury to surgery greater than 31 days were associated with nonunion. Conclusion Increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury and when fracture volume was less than 38% of the entire scaphoid. Level of Evidence This is a Level III, therapeutic study.

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Association of Lunate Morphology With Progression to Scaphoid Fracture Nonunion

Hand ◽

10.1177/1558944720937368 ◽

2020 ◽

pp. 155894472093736

Author(s):

Rachel E. Hein ◽

Amanda N. Fletcher ◽

Rose T. Tillis ◽

Eric Q. Pang ◽

David S. Ruch ◽

...

Keyword(s):

Scaphoid Fracture ◽

Significant Risk ◽

Significant Risk Factor ◽

Delayed Union ◽

Type I ◽

Type Ii ◽

Fracture Location ◽

Scaphoid Fractures ◽

Fracture Nonunion ◽

N 93

Background: The purpose of our study was to review a series of patients with scaphoid fractures to determine whether there was an association between lunate morphology and progression to delayed union or nonunion when treated operatively or nonoperatively. Secondary aims included evaluation of the relationship between lunate morphology and scaphoid fracture location. Methods: A retrospective review of all patients with a diagnosis of scaphoid fracture was performed at our institution between 2014 and 2017. Medical records and radiographs were evaluated to determine lunate morphology, scaphoid fracture location, treatment, and time to union. Differences between groups were determined using χ2 analysis with significance set at P <.05. Multiple logistic regression analyses were used to evaluate scaphoid union in the setting of lunate morphology when controlling for confounders. Results: A total of 169 patients were included; 45.0% (n = 76) of patients had type I lunate morphology, and 55.0% (n = 93) had type II. In all, 64.5% (n = 49) of patients with type I lunate and 68.8% (n = 64) with type II lunate had a fracture at the scaphoid waist. Among all patients with a scaphoid fracture, type II lunates were more likely than type I lunates to progress to nonunion when treated both operatively and nonoperatively (18.3% vs 4.0%, P = .0042). Lunate facet size was not shown to be a significant risk factor for nonunion among patients with a type II lunate ( P = .4221). Conclusions: Patients with a scaphoid fracture and type II lunate morphology were more likely to progress to nonunion than patients with a type I lunate.

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Treatment of Type II Scaphoid Nonunion Advanced Collapse Lesions by Scaphoid Distal Pole Resection and Proximal Tenodesis of Extensor Brevis Carpi Radialis: Technique Description and Case Series

Revista Iberoamericana de Cirugía de la Mano ◽

10.1055/s-0039-1695763 ◽

2019 ◽

Vol 47 (02) ◽

pp. 084-090

Author(s):

Niceas da Silva Gusmão Filho ◽

Ricardo Kaempf de Oliveira

Keyword(s):

Scaphoid Fracture ◽

Case Series ◽

Good Alternative ◽

Definitive Treatment ◽

Type Ii ◽

Scaphoid Nonunion ◽

Wrist Flexion ◽

Proximal Pole ◽

Included Patient ◽

The Mean

Abstract Objective To describe a new surgical technique and treatment outcomes of type II scaphoid nonunion advanced collapse (SNAC) lesions by scaphoid distal resection associated to the tenodesis of the remaining proximal pole with the extensor brevis carpi radialis tendon. Material and Methods This is a retrospective, observational study in which six patients were enrolled and submitted to this original technique, from February 2016 to March 2018. Only those patients with a comprehensive assessment and minimum 6 months postoperative evolution were included. Patient data, such as age, gender, and dominance, along with injury characteristics, previous therapies, complaints, and time span between appearance of the lesion and surgery were all analyzed. Results Among the six patients assessed, four were male, with ages ranging from 28 and 46 years (mean, 38.1 years). The elapsed time between nonunion diagnosis or scaphoid fracture and definitive treatment ranged from 34 to 72 months, with an average of 48.0 months. The mean follow-up time between the surgery and final results assessment was 15.3 months, ranging from 8 to 22 months. Preoperative measured mean pain was 8.8, ranging from 8 to 10. At 6 months postoperatively, mean pain assessment was 1.5, ranging from 0 to 5. We added wrist flexion and extension to assess joint range of motion. Preoperatively, the mean measure was 76.6°, ranging from 55° to 90°. Postoperatively, the mean was 127.1°, ranging from 110° to 140°. One patient had proximal scaphoid necrosis at 8 months postoperatively as a complication. The patient was treated with proximal carpectomy, with good clinical outcome; however, he did not return to his original job activities. The other five patients did return to their previous labor activities. Conclusions Treatment of type II SNAC lesions by resection of the distal scaphoid associated to tenodesis of the remaining proximal pole with a portion of the extensor brevis carpi radialis tendon has proved to be a useful, safe technique. Having low morbidity and few complications, the treatment represents a good alternative to previously described techniques.

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Interobserver Variability of the Diagnosis of Scaphoid Proximal Pole Fractures

Journal of Wrist Surgery ◽

10.1055/s-0038-1641716 ◽

2018 ◽

Vol 07 (04) ◽

pp. 350-354

Author(s):

Reinier Beks ◽

Tessa Drijkoningen ◽

Femke Claessen ◽

Thierry Guitton ◽

David Ring ◽

...

Keyword(s):

Interobserver Reliability ◽

Tertiary Hospital ◽

Adverse Outcomes ◽

Consecutive Series ◽

Proximal Pole ◽

Level Of Evidence ◽

Fracture Location ◽

Scaphoid Fractures ◽

Improve Reliability ◽

Control Study

Purpose Fractures of the proximal pole of the scaphoid are prone to adverse outcomes such as nonunion and avascular necrosis. Distinction of scaphoid proximal pole fractures from waist fractures is important for management but it is unclear if the distinction is reliable. Methods A consecutive series of 29 scaphoid fractures from one tertiary hospital was collected consisting of 5 scaphoid proximal pole and 24 scaphoid waist fractures. Fifty-seven members of the Science of Variation Group (SOVG) were randomized to diagnose fracture location and displacement by using radiographs alone or radiographs and a computed tomography (CT) scan. Results Observers reviewing radiographs alone and observers reviewing radiographs and CT scans both had substantial agreement on fracture location (κ = 0.82 and κ = 0.80, respectively; p = 0.54). Both groups had only fair agreement on fracture displacement (κ = 0.28 and κ = 0.35, respectively; p = 0.029). Conclusion Proximal pole fractures are sufficiently distinct from proximal waist fractures that CT does not improve reliability of diagnosis. Level of Evidence Level IV interobserver reliability case-control study.

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Gadolinium Enhanced Mr Assessment of Proximal Fragment Vascularity in Nonunions after Scaphoid Fracture: Does It Predict the Outcome of Reconstructive Surgery?

Journal of Hand Surgery (European Volume) ◽

10.1016/j.jhsb.2004.03.012 ◽

2004 ◽

Vol 29 (5) ◽

pp. 444-448 ◽

Cited By ~ 41

Author(s):

A.K. SINGH ◽

T.R.C. DAVIS ◽

J.S. DAWSON ◽

J.A. ONI ◽

N.D. DOWNING

Keyword(s):

Internal Fixation ◽

Reconstructive Surgery ◽

Scaphoid Fracture ◽

Proximal Fragment ◽

Proximal Pole ◽

Scaphoid Fractures ◽

Fracture Nonunion ◽

Fracture Nonunions ◽

Outcome Of Surgery ◽

Mr Scanning

This study investigated whether the outcome of bone graft and internal fixation surgery for nonunion of scaphoid fractures could be predicted by gadolinium-enhanced MR assessments of proximal fragment vascularity. Sixteen established scaphoid fracture nonunions underwent gadolinium-enhanced MR scanning before surgical treatment with bone grafting and internal fixation. No relationship was found between MR enhancement and the outcome of surgery. Union was achieved in eight of the 12 nonunions with more than 50% enhancement, and three of the four with less than 50% enhancement, of the proximal pole. Furthermore, union was achieved in both of the nonunions which had less than 25% enhancement of the proximal pole. We conclude that enhanced MR assessments of the vascularity of the proximal fragment of a scaphoid fracture nonunion do not accurately predict the outcome of reconstructive surgery.

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Scaphoid Fracture Patterns—Part Two: Reproducibility and Demographics of a Simplified Scaphoid Fracture Classification

Journal of Wrist Surgery ◽

10.1055/s-0039-1692470 ◽

2019 ◽

Vol 08 (06) ◽

pp. 446-451

Author(s):

Tessa Drijkoningen ◽

Amin Mohamadi ◽

Wouter F. van Leeuwen ◽

Yonatan Schwarcz ◽

David Ring ◽

...

Keyword(s):

Electronic Medical Records ◽

Medical Records ◽

Interobserver Reliability ◽

Scaphoid Fracture ◽

Fracture Classification ◽

Proximal Pole ◽

Level Of Evidence ◽

Related Factors ◽

Scaphoid Fractures ◽

Fracture Patterns

Abstract Objective To analyze the reproducibility, reliability, and demographics of a simplified anatomical scaphoid fracture classification based on posteroanterior radiographs using a large database of scaphoid fractures. Methods The study consisted of a retrospective review of electronic medical records of 871 consecutive patients. All patients presented between 2003 and 2014 at two centers. Patient- and surgeon-related factors were analyzed. Additionally, interobserver reliability of the Herbert and simplified scaphoid fracture classifications were tested. Results Proximal pole fractures were defined as fractures in which the center of the fracture line was proximal to the distal scapholunate interval (n = 30), waist fractures (n = 802) were defined as fractures involving the scaphocapitate interval, and distal tubercle fractures (n = 39) were defined as fractures involving the scaphotrapeziotrapezoid (STT) interval. The interobserver reliability of the simplified classification was fair (κ = 0.37) as for the Herbert classification (κ = 0.31). The average doubt of the answers of the observers was 2.1 on a scale from 0 to 10 for the simplified classification and 3.6 for the Herbert classification (P < 0.05). Conclusions All complete fractures across the entire scaphoid distal to the scapholunate articulation and proximal to the STT joint can be classified as waist fractures; nonwaist scaphoid fractures are uncommon (6%) and have somewhat different presentations compared to waist fractures. Simplifying the fracture classification slightly improves interobserver reliability, although remaining fair, and significantly reduces doubt. Level of Evidence This is a Level III, prognostic study.

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Imaging the Position of a Screw within the Scaphoid

Journal of Hand Surgery (European Volume) ◽

10.1016/0266-7681(93)90230-d ◽

1993 ◽

Vol 18 (6) ◽

pp. 716-724 ◽

Cited By ~ 14

Author(s):

J. P. COMPSON ◽

F. W. HEATLEY

Keyword(s):

Proximal Pole ◽

Radiological Study ◽

Bone Screw ◽

Non Union ◽

Scaphoid Fractures ◽

Distal Pole ◽

Screw Position

In an audit of 68 scaphoid fractures with delayed and non-union that had been internally fixed using the Herbert bone screw, it was found that 39 had a significant fault in screw position. Poor intra-operatrve imaging was a major contributing factor. An anatomical and radiological study was therefore performed to evaluate which views were necessary in order to be confident about screw position. We recommend a minimum of four views. To display the proximal pole, an ulnar deviated postero-anterior (PA) view and true lateral; and to display the distal pole, a semi-pronated and semi-supinated view.

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Effect of Screw Length and Geometry on Interfragmentary Compression in a Simulated Proximal Pole Scaphoid Fracture Model

Hand ◽

10.1177/1558944718795281 ◽

2018 ◽

Vol 15 (3) ◽

pp. 378-383

Author(s):

Samik Patel ◽

Juan M. Giugale ◽

Richard E. Debski ◽

John R. Fowler

Keyword(s):

Analysis Of Variance ◽

Scaphoid Fracture ◽

Fracture Site ◽

Proximal Pole ◽

Scaphoid Fractures ◽

Screw Length ◽

Significant Difference ◽

Headless Compression Screws ◽

With Screws ◽

Interfragmentary Compression

Background: The objective of this study was to determine interfragmentary compression forces based on screw length and geometry for simulated proximal scaphoid fractures. Methods: Sixty-four foam model simulated fractures were stabilized with screws of various length (10 mm, 18 mm, 20 mm, or 24 mm) and geometry (central threadless or fully threaded) across a proximal fracture. Interfragmentary compression was measured at the simulated fracture site upon fixation. An independent sample t test and 1-way analysis of variance were performed to assess differences in interfragmentary compression. Results: Fixation utilizing a 10-mm screw generated significantly less interfragmentary compression than fixation utilizing a 20-mm or 24-mm screw. When accounting for both screw length and geometry, an 18-mm central threadless screw generated greater interfragmentary compression than a 20-mm and 24-mm fully threaded screw; there was no significant difference in compression between an 18-mm and 24-mm central threadless screw. Conclusions: The design of headless compression screws allows for maximal interfragmentary compression at the screw midpoint; we questioned whether a short screw centered on the fracture site resulted in superior compression to a longer, noncentered screw. Our data suggest that centering a small screw (10 mm) along a proximal fracture generates significantly less interfragmentary compression than a longer, noncentered screw. Our results demonstrate that balance between maximizing screw length and centering the screw on the fracture is vital toward maximizing interfragmentary compression for the fixation of proximal third scaphoid fractures.

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Importance of Computed Tomography in Determining Displacement in Scaphoid Fractures

Journal of Wrist Surgery ◽

10.1055/s-0037-1604136 ◽

2017 ◽

Vol 07 (01) ◽

pp. 038-042 ◽

Cited By ~ 1

Author(s):

Emily Gilley ◽

Sameer Puri ◽

Krystle Hearns ◽

Andrew Weiland ◽

Michelle Carlson

Keyword(s):

Computed Tomography ◽

Ct Scan ◽

Interobserver Reliability ◽

Scaphoid Fracture ◽

High Rate ◽

Radiographic Evaluation ◽

Angular Deformity ◽

Level Of Evidence ◽

Scaphoid Fractures ◽

The Mean

Background Displaced scaphoid fractures have a relatively high rate of nonunion. Detection of displacement is vital in limiting the risk of nonunion when treating scaphoid fractures. Questions/Purpose We evaluated the ability to diagnose displacement on radiographs and computed tomography (CT), hypothesizing that displacement is underestimated in assessing scaphoid fracture by radiograph compared with CT. Materials and Methods Thirty-five preoperative radiographs and CT scans of acute scaphoid fractures were evaluated by two blinded observers. Displacement and angular deformity were measured, and the fracture was judged as displaced or nondisplaced. Scapholunate, radiolunate, and intrascaphoid angles were measured. Radiograph and CT measurements between nondisplaced and displaced fractures were compared. Intraobserver reliability was measured. Results Reader 1 identified 12 fractures as nondisplaced on radiograph, but displaced on CT (34%). Reader 2 identified 9 fractures as nondisplaced on radiograph, but displaced on CT (26%). For displaced fractures, the mean intrascaphoid angle was over three times greater when measured on CT than on radiograph (56 vs. 16 degrees). Scapholunate angle >65 degrees and radiolunate angle >16 degrees were significantly associated with displacement on CT. Interobserver reliability for diagnosing displacement was perfect on CT but less reliable on radiograph. Conclusion Scaphoid fracture displacement on CT was identified in 26 to 34% of fractures that were nondisplaced on radiograph, confirming that radiographic evaluation alone underestimates displacement. These results underscore the importance of CT scan in determining displacement and angular deformity when evaluating scaphoid fractures, as it may alter the decision on treatment and surgical approach to the fracture. We recommend considering CT scan to evaluate all scaphoid fractures. Level of Evidence Level III.

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