Scaphoid Fractures

eradiology.bidmc.harvard.edu

Scaphoid Fractures

Bill Schloss

Gillian Lieberman, MD January 2001

Scaphoid Fractures

Bill Schloss

Harvard Medical School, Year- Year IV

Gillian Lieberman, MD


Bill Schloss

Gillian Lieberman, MD

Mr. F

23 year-old year old man with

rollerblading injury

Fell backwards,

breaking fall with

outstretched hands

Presents with radial-

sided left wrist pain,

snuffbox tenderness

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Bill Schloss

Gillian Lieberman, MD

Clinical differential diagnosis

Scaphoid Fracture

Scapholunate

Instability

Lunate Dislocation or

Fracture

Rupture of Flexor

Carpi Radialis Tendon

Radial Styloid

Fracture

Trapezium Fracture

Extensor Carpi

Radialis Longus

Avulsion

Extensor Carpi

Radialis Brevis

Avulsion

Osteochondral

Fracture of Distal

Radius

DeQuervain’s

Tenosynovitis

Basilar Joint (CMC)

Arthrosis

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Bill Schloss

Gillian Lieberman, MD

Menu of tests available to image

traumatic wrist injuries

Routine plain films

Specialty plain film series (eg ( eg scaphoid view)

CT

MRI

Bone Scan

Ultrasound

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Our patient’s plain films, left wrist

Film

findings:

Subtle linear

lucency

across the

waist of the

scaphoid

suggesting

scaphoid

fracture

Bill Schloss

Gillian Lieberman, MD

Courtesy of BIDMC files

5


Our patient’s scaphoid views

Film findings:

? Subtle scaphoid

fracture

Bill Schloss

Gillian Lieberman, MD

Courtesy of BIDMC files

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7

Bill Schloss

Gillian Lieberman, MD

A closer look at

the AP view…

Film findings:

Highly suggestive of an

acute scaphoid fracture

Courtesy of BIDMC files


Bill Schloss

Gillian Lieberman, MD

Courtesy of BIDMC files

Our

patient’s

wrist CT

Film findings:

Lucent line through

scaphoid confirms

acute fracture

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Bill Schloss

Gillian Lieberman, MD

Our patient

was treated

with internal

fixation

Courtesy of BIDMC files

9


Bill Schloss

Gillian Lieberman, MD

For our discussion

We will first review the typical history,

anatomy, and physical findings associated

with scaphoid fractures

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Bill Schloss

Gillian Lieberman, MD

History

History of wrist dorsiflexion injury

95% males

Average age 25 years

Sporting injuries, motorcycle accidents

Previous trauma?: second injury may be trivial

but may convert asymptomatic fracture to a

symptomatic fracture

11


Ritchie, JV, Munter, DW. Emer Med Clin N Amer, 1999 Nov;

17(4): 823-42, vi

Dorsal landmarks

A, Radial styloid

B, Extensor pollicis

brevis tendon

C, Anatomic snuffbox

D, Extensor pollicis

longus tendon

E, Lister’s tubercle

F, Dorsal wrist

depression

G, Ulnar styloid

Bill Schloss

Gillian Lieberman, MD

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13

Bill Schloss

Gillian Lieberman, MD

Bone anatomy

D, Scaphoid

Proximal row:

scaphoid (D), lunate

(F), triquetrum (G),

pisiform (H)

Distal row: trapezium

(B), trapezoid (K),

capitate (I), hamate (J)

Ritchie, JV, Munter, DW. Emer Med Clin N Amer,

1999 Nov; 17(4): 823-42, vi


The scaphoid

has a precarious

blood supply

67% have arterial foramina

throughout length

13% supplied

predominantly by distal 1/3

20% supplied by middle

1/3

1/3 of fractures in proximal

third at risk for avascular

necrosis

Bill Schloss

Gillian Lieberman, MD

www.amirmd.com/Images/scaphoidfx3.gif

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Bill Schloss

Gillian Lieberman, MD

Physical examination

Tenderness on palpation of anatomic snuffbox

Minimal or gross swelling

Pain with dorsiflexion, dorsiflexion,

radial deviation

Pain with longitudinal compression/tension on

thumb metacarpal

Palpable deformity distal to radial styloid

Check for compartment syndrome

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Scaphoid fractures can be subtle and

therefore the imaging algorithm

may include some of the following:

Plain films

Bone scan

Ultrasound

CT

MRI

Bill Schloss

Gillian Lieberman, MD

16


Bill Schloss

Gillian Lieberman, MD

Plain 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

17


Bill Schloss

Gillian Lieberman, MD

fracture

Scaphoid view

Ulnar deviation

Distracts scaphoid, scaphoid,

enhances visualization

of fracture

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

18


Bill Schloss

Gillian Lieberman, MD

Bone scan

Increased tracer

uptake in region of

scaphoid may suggest

occult fracture

Eustace, S, et al., Rad Clin North Am, 1999 Sept;

37(5): 975-94, vi

Fingers

Left hand Right hand

Rockwood & Green’s Fractures in Adults, 4 th ed., 1996

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Ultrasound

Top: normal scaphoid

(small arrows), flexor

carpi radialis tendon

(curved arrow)

Bottom: scaphoid

waist fracture

(arrows), compared to

normal scaphoid

Jacobson, JA, Orthop Clin North Am, 1998 Jan; 29(1): 135-67 20

Bill Schloss

Gillian Lieberman, MD


Bill Schloss

Gillian Lieberman, MD

Computed

tomography

Focuses on plane

of scaphoid

Assessment of

displacement,

angulation

Scaphoid fracture

Radius

Growth plate

Rettig, ME, et al., Clin in Sports Med, 1998 Jul; 17(3): 469-89

21


Bill Schloss

Gillian Lieberman, MD

Plain film MRI

Fracture?

www.scar.rad.washington.edu/radcourse/wrist.html

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www.scar.rad.washington.edu/radcourse/wrist.html

MRI (cont)

Coronal

STIR MR

confirming

marrow

edema and

scaphoid

injury

Bill Schloss

Gillian Lieberman, MD

23


Bill Schloss

Gillian Lieberman, MD

Rockwood & Green’s Fractures in Adults, 4 th ed., 1996

Types of

scaphoid fracture

65% Waist

15% Proximal pole

10% Distal body

8% Tuberosity

2% Distal articular

surface

24


Bill Schloss

Gillian Lieberman, MD

Simple Anatomic

Classification

I: Proximal third

II: Middle third

III: Distal third

Classification

Herbert Classification

A: Acute, stable

– A1: Tubercle

A2: Nondisplaced crack in

waist

– A2:

B: Acute, unstable

– B1: Oblique, distal 1/3

B: Acute, unstable

– B2: Displaced or mobile, waist

– B3: Proximal pole

– B4: Fracture-dislocation

Fracture dislocation

– B5: Comminuted

C: Delayed Union

D: Established Nonunion

– D1: Fibrous

– D2: Sclerotic

25


Bill Schloss

Gillian Lieberman, MD

Unstable

fracture

Greater than 1 mm

stepoff

Lunocapitate

angulation > 15

degrees (lateral)

Scapholunate

angulation > 70

degrees (lateral)

Schreibman, KL, et al., Orthop Clin North Am, 1997

Oct; 28(4): 537-582

26


Bill Schloss

Gillian Lieberman, MD

Complications

Nonunion

Avascular necrosis

Scapholunate

advanced collapse

(SLAC)

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Bill Schloss

Gillian Lieberman, MD

Nonunion

www.medmedia.com/image5/i1/scphn1.jpg

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Bill Schloss

Gillian Lieberman, MD

Avascular necrosis

www.e-hand.com/jpg

Sclerotic on plain film Low signal on MRI

www.e-hand.com/jpg

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Lunate

Scaphoid

www.medmedia.com/image4/i1/slac1.jpg

Scapholunate

advanced

collapse

(SLAC)

Bill Schloss

Gillian Lieberman, MD

30


Bill Schloss

Gillian Lieberman, MD

Treatment

Undisplaced, Undisplaced,

stable

– Splint, short/long arm

thumb spica cast (6-12 (6 12

weeks)

Displaced, unstable

– Longitudinal traction

along thumb,

compression of carpus, carpus,

then splint and cast

– Surgery

» Closed reduction,

percutaneous pinning

» Open reduction, internal

fixation

Nonunion

– Excision of fragments

– Styloidectomy

– Radial graft

– Proximal row

carpectomy

– Partial/total arthrodesis

of wrist

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Rettig, ME, et al., Clin in Sports Med, 1998 Jul;

17(3): 469-89

Surgery

Displaced scaphoid

fracture treated by

ORIF, Herbert

screw fixation,

radial bone grafting

for comminution

Bill Schloss

Gillian Lieberman, MD

32


Four corner

fusion

Bill Schloss

Gillian Lieberman, MD

www.medmedia.com/image4/i1/scp4.jpg

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Bill Schloss

Gillian Lieberman, MD

A history and examination typical

for scaphoid fractures may result

from other injuries

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Bill Schloss

Gillian Lieberman, MD

www.scar.rad.washington.edu/radcourse/wrist.html

Distal radius

fracture

Coronal fast

spin echo

MR

Distal radius

fracture in

patient with

snuffbox

tenderness,

negative AP

film

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Ddx for clinical

presentation of

scaphoid

fracture:

Transscaphoid

perilunar dislocation

Trapezium fracture

Bennett fracture

Radial head fracture

Distal radius fracture

Lunate dislocation

Bill Schloss

Gillian Lieberman, MD

Perilunate

dislocation Lunate dislocation

Ritchie, JV, Munter, DW, Emer

Med Clin N Amer, 1999 Nov;

17(4): 823-42, vi

www.aafp.org/afp/980301ap/

shearman.html

36


Bill Schloss

Gillian Lieberman, MD

References

Biondetti, Biondetti,

PR, et al: Wrist: Coronal and transaxial CT scanning.

Radiology. 1987; 163(1): 149-151. 149 151.

Bush, CH, et al: High-resolution High resolution CT of the wrist: Initial experience

with scaphoid disorders and surgical fusions. AJR. AJR.

1987 Oct; 149:

757-760. 757 760.

Canale. Canale.

Campbell’s Operative Orthopaedics. Orthopaedics.

9 th ed, ed,

1998: 3455- 3455

3480.

Eustace, S, et al: Emergency MR imaging of orthopedic trauma.

Rad Clin N Amer. Amer.

1999 Sep; 37(5): 975-94, 975 94, vi.

Taleisnik, Taleisnik,

J: Fractures of the carpal bones. Operative Hand Surgery. Surgery.

2 nd ed, ed,

1988: 813-873. 813 873.

Herbert, TJ: The Fractured Scaphoid. Scaphoid.

St.Louis: St.Louis:

1990.

Hodgkinson, Hodgkinson,

DW: Scaphoid fracture: A new method of assessment.

Clin Radiol. Radiol.

1993 Dec; 48(6): 398-401. 398 401.

Hunter, JC, et al: MR imaging of clinically suspected scaphoid

fractures. AJR. AJR.

1997 May; 168: 1287-1293. 1287 1293.

Imaeda, Imaeda,

T, et al: Magnetic resonance imaging in scaphoid fractures.

J Hand Surg. Surg.

1992 Feb; 17B(1): 20-27. 20 27.

Jacobson, JA: Musculoskeletal ultrasonography.

ultrasonography.

Orth Clin N Amer. Amer.

1998 Jan; 29(1): 135-67. 135 67.

Lepisto, Lepisto,

J, et al: Low field MRI and scaphoid fracture. J Hand Surg. Surg.

1995 Aug; 20B(4): 539-542. 539 542.

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4583/pictures/spizer5.jpg

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halfpipe/4583/pictures/kruse2.jpg

Bill Schloss

Gillian Lieberman, MD

References

Matityahu, Matityahu,

A: Scaphoid fractures. www.amirmd.com/ortho-

info/scafoidfx.html

Peh, Peh,

WCG, et al: Detection of occult wrist fractures by magnetic

resonance imaging. Clin Radiol. Radiol.

1996, 51: 285-292. 285 292.

Rettig, Rettig,

ME, et al: Hand and wrist injuries. Clin in Sports Med. Med.

1998

Jul; 17(3): 469-89. 469 89.

Richardson, ML: Interpretation of radiographic images: Snuffbox

tenderness following trauma. 1997.

www.scar.rad.washington.edu/radcourse/wrist.html

Ritchie, JV, Munter, Munter,

DW: Orthopedic emergencies, emergency

department evaluation and treatment of wrist injuries. Emer Med Clin

N Amer. Amer.

1999 Nov; 17(4): 823-42. 823 42.

Rockwood & Green’s Fractures in Adults. Adults.

4 th ed, ed,

1996: 826-867. 826 867.

Schreibman, Schreibman,

KL, et al.: Imaging of the hand and wrist. Orth Clin N

Amer. Amer.

1997 Oct; 28(4): 537-582. 537 582.

Shearman, CM, El-Khoury El Khoury, , GY: Pitfalls in radiologic evaluation of

upper extremity trauma. www.aafp.org/afp/980301ap/shearman.html

Wheeless’ Wheeless’

Textbook of Orthopaedics.

Orthopaedics.

www.medmedia.com/orthoo/41.htm

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Acknowledgments

Daniel Saurborn

Beverlee Turner

Haldon Bryer

Larry Barbaras and

Ben Crandall our

webmasters

Bill Schloss

Gillian Lieberman, MD

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