ScaphoidScaphoid FracturesFractures
Bill Bill SchlossSchloss
Harvard Medical School, YearHarvard Medical School, Year-- IVIV
Gillian Lieberman, MDGillian Lieberman, MD
Bill Schloss
Gillian Lieberman, MD January 2001
Mr. FMr. F
23 year23 year--old man with old man with
rollerblading injuryrollerblading injury
Fell backwards, Fell backwards,
breaking fall with breaking fall with
outstretched handsoutstretched hands
Presents with radialPresents with radial--
sided left wrist pain, sided left wrist pain,
snuffbox tendernesssnuffbox tenderness
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Bill Schloss
Gillian Lieberman, MD
Clinical differential diagnosisClinical differential diagnosis
ScaphoidScaphoid FractureFracture
ScapholunateScapholunate
InstabilityInstability
LunateLunate Dislocation or Dislocation or
FractureFracture
Rupture of Flexor Rupture of Flexor
Carpi Carpi RadialisRadialis TendonTendon
Radial Radial StyloidStyloid
FractureFracture
Trapezium FractureTrapezium Fracture
Extensor Carpi Extensor Carpi
RadialisRadialis LongusLongus
AvulsionAvulsion
Extensor Carpi Extensor Carpi
RadialisRadialis BrevisBrevis
AvulsionAvulsion
OsteochondralOsteochondral
Fracture of Distal Fracture of Distal
RadiusRadius
DeQuervain’sDeQuervain’s
TenosynovitisTenosynovitis
Basilar Joint (CMC) Basilar Joint (CMC)
ArthrosisArthrosis 3
Bill Schloss
Gillian Lieberman, MD
Menu of tests available to image Menu of tests available to image
traumatic wrist injuriestraumatic wrist injuries
Routine plain filmsRoutine plain films
Specialty plain film series (Specialty plain film series (egeg scaphoidscaphoid view)view)
CTCT
MRIMRI
Bone ScanBone Scan
UltrasoundUltrasound
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Bill Schloss
Gillian Lieberman, MD
Our patient’s plain films, left wristOur patient’s plain films, left wrist
5
Film Film
findings:findings:
Subtle linear Subtle linear
lucencylucency
across the across the
waist of the waist of the
scaphoidscaphoid
suggesting suggesting
scaphoidscaphoid
fracturefracture
Courtesy of BIDMC files
Bill Schloss
Gillian Lieberman, MD
6
Courtesy of BIDMC files
Our patient’s Our patient’s scaphoidscaphoid viewsviews
Film findings:Film findings:
?? Subtle Subtle scaphoidscaphoid
fracturefracture
Bill Schloss
Gillian Lieberman, MD
A closer look at A closer look at
the AP view…the AP view…
7
Film findings:Film findings:
Highly suggestive of an Highly suggestive of an
acute acute scaphoidscaphoid fracturefracture
Courtesy of BIDMC files
Bill Schloss
Gillian Lieberman, MD
Our Our
patient’s patient’s
wrist CTwrist CT
8Courtesy of BIDMC files
Film findings:Film findings:
Lucent line through Lucent line through
scaphoidscaphoid confirms confirms
acute fractureacute fracture
Bill Schloss
Gillian Lieberman, MD
Our patient Our patient
was treated was treated
with internal with internal
fixationfixation
9
Courtesy of BIDMC files
Bill Schloss
Gillian Lieberman, MD
For our discussionFor our discussion
We will first review the typical history, We will first review the typical history,
anatomy, and physical findings associated anatomy, and physical findings associated
with with scaphoidscaphoid fracturesfractures
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Bill Schloss
Gillian Lieberman, MD
HistoryHistory
History of wrist History of wrist dorsiflexiondorsiflexion injuryinjury
95% males95% males
Average age 25 yearsAverage age 25 years
Sporting injuries, motorcycle accidentsSporting injuries, motorcycle accidents
Previous trauma?: second injury may be trivial Previous trauma?: second injury may be trivial
but may convert asymptomatic fracture to a but may convert asymptomatic fracture to a
symptomatic fracturesymptomatic fracture
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Bill Schloss
Gillian Lieberman, MD
Dorsal landmarksDorsal landmarks
A, Radial A, Radial styloidstyloid
B, Extensor B, Extensor pollicispollicis
brevisbrevis tendontendon
C, Anatomic snuffboxC, Anatomic snuffbox
D, Extensor D, Extensor pollicispollicis
longuslongus tendontendon
E, Lister’s tubercleE, Lister’s tubercle
F, Dorsal wrist F, Dorsal wrist
depressiondepression
G, G, UlnarUlnar styloidstyloid
Ritchie, JV, Munter, DW. Emer Med Clin N Amer, 1999 Nov;
17(4): 823-42, vi
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Bill Schloss
Gillian Lieberman, MD
Bone anatomyBone anatomy
D, D, ScaphoidScaphoid
Proximal row: Proximal row:
scaphoidscaphoid (D), (D), lunatelunate
(F), (F), triquetrumtriquetrum (G), (G),
pisiformpisiform (H)(H)
Distal row: trapezium Distal row: trapezium
(B), trapezoid (K), (B), trapezoid (K),
capitatecapitate (I), (I), hamatehamate (J)(J)
Ritchie, JV, Munter, DW. Emer Med Clin N Amer,
1999 Nov; 17(4): 823-42, vi
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Bill Schloss
Gillian Lieberman, MD
The The scaphoidscaphoid
has a precarious has a precarious
blood supplyblood supply
67% have arterial foramina 67% have arterial foramina
throughout lengththroughout length
13% supplied 13% supplied
predominantly by distal 1/3predominantly by distal 1/3
20% supplied by middle 20% supplied by middle
1/31/3
1/3 of fractures in proximal 1/3 of fractures in proximal
third at risk for third at risk for avascularavascular
necrosisnecrosis
www.amirmd.com/Images/scaphoidfx3.gif
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Bill Schloss
Gillian Lieberman, MD
Physical examinationPhysical examination
Tenderness on palpation of anatomic snuffboxTenderness on palpation of anatomic snuffbox
Minimal or gross swelling Minimal or gross swelling
Pain with Pain with dorsiflexiondorsiflexion, radial deviation, radial deviation
Pain with longitudinal compression/tension on Pain with longitudinal compression/tension on
thumb metacarpalthumb metacarpal
Palpable deformity distal to radial Palpable deformity distal to radial styloidstyloid
Check for compartment syndromeCheck for compartment syndrome
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Bill Schloss
Gillian Lieberman, MD
ScaphoidScaphoid fractures can be subtle and fractures can be subtle and
therefore the imaging algorithm therefore the imaging algorithm
may include some of the following:may include some of the following:
Plain filmsPlain films
Bone scanBone scan
UltrasoundUltrasound
CTCT
MRIMRI
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Bill Schloss
Gillian Lieberman, MD
Plain film evaluationPlain film evaluation
AP Lateral Pronated
oblique
Scaphoid
view
Schreibman, KL, et al, Orth Clin North Am, 1997 Oct; 28(4): 537-582;
Ritchie, HV, Munter, DW, Emer Med Clin N Amer, 1999 Nov; 17(4): 823-42, vi
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Bill Schloss
Gillian Lieberman, MD
ScaphoidScaphoid viewview
UlnarUlnar deviationdeviation
Distracts Distracts scaphoidscaphoid, ,
enhances visualization enhances visualization
of fractureof fracture
Rettig, ME, et al, Clin in Sports Med, 1998 Jul; 17(3): 469-89 Ritchie, JV, Munter, DW, Emer Med Clin
N Amer, 1999 Nov; 17(4); 823-42, vi
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fracture
fracture
Bill Schloss
Gillian Lieberman, MD
Bone scanBone scan
Increased tracer Increased tracer
uptake in region of uptake in region of
scaphoidscaphoid may suggest may suggest
occult fractureoccult fracture
Rockwood & Green’s Fractures in Adults, 4th ed., 1996Eustace, S, et al., Rad Clin North Am, 1999 Sept;
37(5): 975-94, vi
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Left hand Right hand
Fingers
Bill Schloss
Gillian Lieberman, MD
UltrasoundUltrasound
Top: normal Top: normal scaphoidscaphoid
(small arrows), flexor (small arrows), flexor
carpicarpi radialisradialis tendon tendon
(curved arrow)(curved arrow)
Bottom: Bottom: scaphoidscaphoid
waist fracture waist fracture
(arrows), compared to (arrows), compared to
normal normal scaphoidscaphoid
Jacobson, JA, Orthop Clin North Am, 1998 Jan; 29(1): 135-67 20
Bill Schloss
Gillian Lieberman, MD
Computed Computed
tomographytomography
Focuses on plane Focuses on plane
of of scaphoidscaphoid
Assessment of Assessment of
displacement, displacement,
angulationangulation
Rettig, ME, et al., Clin in Sports Med, 1998 Jul; 17(3): 469-89
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Scaphoid fracture
Growth plate
Radius
Bill Schloss
Gillian Lieberman, MD
Plain film MRIPlain film MRI
www.scar.rad.washington.edu/radcourse/wrist.html
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Fracture?
Bill Schloss
Gillian Lieberman, MD
MRI (cont)MRI (cont)
Coronal Coronal
STIR MR STIR MR
confirming confirming
marrow marrow
edema and edema and
scaphoidscaphoid
injury injury
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Bill Schloss
Gillian Lieberman, MD
Types of Types of
scaphoidscaphoid fracturefracture
65% Waist65% Waist
15% Proximal pole15% Proximal pole
10% Distal body10% Distal body
8% 8% TuberosityTuberosity
2% Distal 2% Distal articulararticular
surfacesurface
Rockwood & Green’s Fractures in Adults, 4th ed., 1996
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Bill Schloss
Gillian Lieberman, MD
ClassificationClassification
Herbert ClassificationHerbert Classification
A: Acute, stableA: Acute, stable
–– A1: TubercleA1: Tubercle
–– A2: A2: NondisplacedNondisplaced crack in crack in
waistwaist
B: Acute, unstableB: Acute, unstable
–– B1: Oblique, distal 1/3B1: Oblique, distal 1/3
–– B2: Displaced or mobile, waistB2: Displaced or mobile, waist
–– B3: Proximal poleB3: Proximal pole
–– B4: FractureB4: Fracture--dislocationdislocation
–– B5: ComminutedB5: Comminuted
C: Delayed UnionC: Delayed Union
D: Established NonunionD: Established Nonunion
–– D1: FibrousD1: Fibrous
–– D2: ScleroticD2: Sclerotic
Simple Anatomic Simple Anatomic
ClassificationClassification
I: Proximal thirdI: Proximal third
II: Middle thirdII: Middle third
III: Distal thirdIII: Distal third
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Bill Schloss
Gillian Lieberman, MD
Unstable Unstable
fracturefracture
Greater than 1 mm Greater than 1 mm
stepoffstepoff
LunocapitateLunocapitate
angulationangulation > 15 > 15
degrees (lateral)degrees (lateral)
ScapholunateScapholunate
angulationangulation > 70 > 70
degrees (lateral)degrees (lateral)
Schreibman, KL, et al., Orthop Clin North Am, 1997
Oct; 28(4): 537-582
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Bill Schloss
Gillian Lieberman, MD
ComplicationsComplications
NonunionNonunion
AvascularAvascular necrosisnecrosis
ScapholunateScapholunate
advanced collapse advanced collapse
(SLAC)(SLAC)
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Bill Schloss
Gillian Lieberman, MD
NonunionNonunion
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Bill Schloss
Gillian Lieberman, MD
AvascularAvascular necrosisnecrosis
www.e-hand.com/jpgwww.e-hand.com/jpg
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Sclerotic on plain filmSclerotic on plain film Low signal on MRILow signal on MRI
Bill Schloss
Gillian Lieberman, MD
ScapholunateScapholunate
advanced advanced
collapse collapse
(SLAC)(SLAC)
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Lunate
Scaphoid
Bill Schloss
Gillian Lieberman, MD
TreatmentTreatment
UndisplacedUndisplaced, stable, stable
–– Splint, short/long arm Splint, short/long arm
thumb thumb spicaspica cast (6cast (6--12 12
weeks)weeks)
Displaced, unstableDisplaced, unstable
–– Longitudinal traction Longitudinal traction
along thumb, along thumb,
compression of compression of carpuscarpus, ,
then splint and castthen splint and cast
–– SurgerySurgery
»» Closed reduction, Closed reduction,
percutaneouspercutaneous pinningpinning
»» Open reduction, internal Open reduction, internal
fixationfixation
NonunionNonunion
–– Excision of fragmentsExcision of fragments
–– StyloidectomyStyloidectomy
–– Radial graftRadial graft
–– Proximal row Proximal row
carpectomycarpectomy
–– Partial/total Partial/total arthrodesisarthrodesis
of wristof wrist
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Bill Schloss
Gillian Lieberman, MD
SurgerySurgery
Displaced Displaced scaphoidscaphoid
fracture treated by fracture treated by
ORIF, Herbert ORIF, Herbert
screw fixation, screw fixation,
radial bone grafting radial bone grafting
for for comminutioncomminution
Rettig, ME, et al., Clin in Sports Med, 1998 Jul;
17(3): 469-89
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Bill Schloss
Gillian Lieberman, MD
Four corner Four corner
fusionfusion
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Bill Schloss
Gillian Lieberman, MD
A history and examination typical A history and examination typical
for for scaphoidscaphoid fractures may result fractures may result
from other injuriesfrom other injuries
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Bill Schloss
Gillian Lieberman, MD
Distal radius Distal radius
fracturefracture
Coronal fast Coronal fast
spin echo spin echo
MRMR
Distal radius Distal radius
fracture in fracture in
patient with patient with
snuffbox snuffbox
tenderness, tenderness,
negative AP negative AP
filmfilm
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Gillian Lieberman, MD
DdxDdx for clinical for clinical
presentation of presentation of
scaphoidscaphoid
fracture:fracture:
TransscaphoidTransscaphoid
perilunarperilunar dislocationdislocation
Trapezium fractureTrapezium fracture
Bennett fractureBennett fracture
Radial head fractureRadial head fracture
Distal radius fractureDistal radius fracture
LunateLunate dislocationdislocation Ritchie, JV, Munter, DW, EmerMed Clin N Amer, 1999 Nov;
17(4): 823-42, vi
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shearman.html
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PerilunatePerilunate
dislocationdislocation LunateLunate dislocationdislocation
Bill Schloss
Gillian Lieberman, MD
ReferencesReferences
BiondettiBiondetti, PR, et al: Wrist: Coronal and , PR, et al: Wrist: Coronal and transaxialtransaxial CT scanning. CT scanning.
Radiology. 1987; 163(1): 149Radiology. 1987; 163(1): 149--151.151.
Bush, CH, et al: HighBush, CH, et al: High--resolution CT of the wrist: Initial experience resolution CT of the wrist: Initial experience
with with scaphoidscaphoid disorders and surgical fusions. disorders and surgical fusions. AJRAJR. 1987 Oct; 149: . 1987 Oct; 149:
757757--760.760.
CanaleCanale. . Campbell’s Operative Campbell’s Operative OrthopaedicsOrthopaedics. 9. 9thth eded, 1998: 3455, 1998: 3455--
3480.3480.
Eustace, S, et al: Emergency MR imaging of orthopedic trauma. Eustace, S, et al: Emergency MR imaging of orthopedic trauma.
RadRad ClinClin N AmerN Amer. 1999 Sep; 37(5): 975. 1999 Sep; 37(5): 975--94, vi.94, vi.
TaleisnikTaleisnik, J: Fractures of the carpal bones. , J: Fractures of the carpal bones. Operative Hand SurgeryOperative Hand Surgery. .
22ndnd eded, 1988: 813, 1988: 813--873.873.
Herbert, TJ: Herbert, TJ: The Fractured The Fractured ScaphoidScaphoid. . St.LouisSt.Louis: 1990. : 1990.
HodgkinsonHodgkinson, DW: , DW: ScaphoidScaphoid fracture: A new method of assessment. fracture: A new method of assessment.
ClinClin RadiolRadiol. 1993 Dec; 48(6): 398. 1993 Dec; 48(6): 398--401.401.
Hunter, JC, et al: MR imaging of clinically suspected Hunter, JC, et al: MR imaging of clinically suspected scaphoidscaphoid
fractures. fractures. AJRAJR. 1997 May; 168: 1287. 1997 May; 168: 1287--1293.1293.
ImaedaImaeda, T, et al: Magnetic resonance imaging in , T, et al: Magnetic resonance imaging in scaphoidscaphoid fractures. fractures.
J Hand SurgJ Hand Surg. 1992 Feb; 17B(1): 20. 1992 Feb; 17B(1): 20--27.27.
Jacobson, JA: Musculoskeletal Jacobson, JA: Musculoskeletal ultrasonographyultrasonography. . OrthOrth ClinClin N AmerN Amer. .
1998 Jan; 29(1): 1351998 Jan; 29(1): 135--67.67.
LepistoLepisto, J, et al: Low field MRI and , J, et al: Low field MRI and scaphoidscaphoid fracture. fracture. J Hand SurgJ Hand Surg. .
1995 Aug; 20B(4): 5391995 Aug; 20B(4): 539--542.542.
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4583/pictures/spizer5.jpg
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Bill Schloss
Gillian Lieberman, MD
ReferencesReferences
MatityahuMatityahu, A: , A: ScaphoidScaphoid fractures. fractures. www.amirmd.com/orthowww.amirmd.com/ortho--
info/scafoidfx.htmlinfo/scafoidfx.html
PehPeh, WCG, et al: Detection of occult wrist fractures by magnetic , WCG, et al: Detection of occult wrist fractures by magnetic
resonance imaging. resonance imaging. ClinClin RadiolRadiol. 1996, 51: 285. 1996, 51: 285--292.292.
RettigRettig, ME, et al: Hand and wrist injuries. , ME, et al: Hand and wrist injuries. ClinClin in Sports Medin Sports Med. 1998 . 1998
Jul; 17(3): 469Jul; 17(3): 469--89.89.
Richardson, ML: Interpretation of radiographic images: Snuffbox Richardson, ML: Interpretation of radiographic images: Snuffbox
tenderness following trauma. 1997. tenderness following trauma. 1997.
www.scar.rad.washington.edu/radcourse/wrist.htmlwww.scar.rad.washington.edu/radcourse/wrist.html
Ritchie, JV, Ritchie, JV, MunterMunter, DW: Orthopedic emergencies, emergency , DW: Orthopedic emergencies, emergency
department evaluation and treatment of wrist injuries. department evaluation and treatment of wrist injuries. EmerEmer Med Med ClinClin
N AmerN Amer. 1999 Nov; 17(4): 823. 1999 Nov; 17(4): 823--42.42.
Rockwood & Green’s Fractures in AdultsRockwood & Green’s Fractures in Adults. 4. 4thth eded, 1996: 826, 1996: 826--867.867.
SchreibmanSchreibman, KL, et al.: Imaging of the hand and wrist. , KL, et al.: Imaging of the hand and wrist. OrthOrth ClinClin N N
AmerAmer. 1997 Oct; 28(4): 537. 1997 Oct; 28(4): 537--582.582.
Shearman, CM, ElShearman, CM, El--KhouryKhoury, GY: Pitfalls in radiologic evaluation of , GY: Pitfalls in radiologic evaluation of
upper extremity trauma. www.aafp.org/afp/980301ap/shearman.htmlupper extremity trauma. www.aafp.org/afp/980301ap/shearman.html
WheelessWheeless’ Textbook of ’ Textbook of OrthopaedicsOrthopaedics. .
www.medmedia.com/orthoo/41.htmwww.medmedia.com/orthoo/41.htm
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38Bill Schloss
Gillian Lieberman, MD
AcknowledgmentsAcknowledgments
Daniel Daniel SaurbornSaurborn
BeverleeBeverlee TurnerTurner
HaldonHaldon BryerBryer
Larry Barbaras and Larry Barbaras and
Ben Crandall our Ben Crandall our
webmasterswebmasters
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Bill Schloss
Gillian Lieberman, MD
Scaphoid Fractures
Mr. F
Clinical differential diagnosis
Menu of tests available to image traumatic wrist injuries
Our patient’s plain films, left wrist
Slide Number 6
A closer look at the AP view…
Our patient’s wrist CT
Our patient was treated with internal fixation
For our discussion
History
Dorsal landmarks
Bone anatomy
The scaphoid has a precarious blood supply
Physical examination
Scaphoid fractures can be subtle and therefore the imaging algorithm may include some of the following:
Plain film evaluation
Scaphoid view
Bone scan
Ultrasound
Computed �tomography
Plain film MRI
MRI (cont)
Types of �scaphoid fracture
Classification
Unstable fracture
Complications
Nonunion
Avascular necrosis
Scapholunate advanced collapse (SLAC)
Treatment
Surgery
Four corner fusion
A history and examination typical for scaphoid fractures may result from other injuries
Distal radius fracture
Ddx for clinical presentation of scaphoid fracture:
References
References
Acknowledgments