Fixation with a Cannulated Screw Displaced Scaphoid Fractures ...

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$Immediate internal fixation of open ankle fractures. Report$

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DISPLACED SCAPHOID FRACTURES TREATED WITH OPEN REDUCTION AND INTERNAL FIXATION 635FIG. 2Illustration showing the technique for measuring scaphoid angulation in the lateral plane. Normal values average 24 degrees. (Reprintedwith permission of the Mayo Foundation.)agreement with the measurements in other reports 18,25 .Sixteen of the nineteen patients in Group 1 and thirteenof the sixteen patients in Group 2 had sagittal andcoronal computerized tomography scans to evaluate thedisplacement of the fracture preoperatively. Postoperativeradiographs were made at monthly follow-up examinations.Once trabecular bridging was suspected on thebasis of radiographs, computerized tomography scanswere made with 0.5-millimeter nonreconstructed cuts inthe sagittal and coronal planes.The placement of the screw was assessed on the finalfollow-up anteroposterior radiographs made with thewrist in the neutral position and ulnar deviation and onlateral and oblique radiographs made with the forearmin pronation and supination 2 . The proximal pole of thescaphoid was divided into three equal sections, with themiddle section representing the central one-third. Thescrew was considered to be centrally placed if it waslocated in the central one-third of the proximal pole ofthe scaphoid 25 (Figs. 5 and 6). If the screw extended outof the central one-third of the scaphoid on a single radiograph,it was considered to be peripherally placed.Radiographic measurements were made in a blindedfashion by four orthopaedic surgeons and one plasticsurgeryresident, and the final determination was arrivedat by consensus.The range of motion, grip strength, and pain werealso measured at the final follow-up evaluation. Twentysixpatients were interviewed by an examiner who wasblinded to the type of internal fixation that had beenused. Nine patients were examined by local therapistsand interviewed by one of us by telephone. The range ofmotion was reported as both an absolute measurementand as a percentage of that on the contralateral side.Flexion and extension of the wrist as well as radial andulnar deviation were measured on both the injured andthe contralateral side 10 . Maximum grip strength on theinjured side was measured with a Jamar dynamometer(J. P. Marsh, Skokie, Illinois) and was reported as apercentage of the maximum strength on the contralateralside. With the use of a questionnaire, pain was assessedpreoperatively and postoperatively as stage 0 (nopain), stage 1 (mild discomfort or pain that does notrestrict work or sports activities), or stage 2 (pain thatrestricts work or sports activities). The patients werefollowed monthly until the fracture had united and theyhad resumed full activity. They were then followed onan annual basis. All physical and radiographic measurementswere performed at the final follow-up evaluationfor the purposes of this study only.The final follow-up radiographs were examined tograde postoperative osteoarthritis as stage 0 (none),FIG. 3Illustration showing the technique for measuring scaphoid angulationin the anteroposterior plane. Normal values average 45 degrees.(Reprinted with permission of the Mayo Foundation.)VOL. 82-A, NO. 5, MAY 2000
636 T. E. TRUMBLE, MARY GILBERT, L. W. MURRAY, JEFFERY SMITH, GREG RAFIJAH, AND W. V. MCCALLISTERFIG. 4Computerized tomography scan showing the technique for measuringthe height-to-length ratio. A baseline is drawn along the volar aspectof the scaphoid. The length of the scaphoid along the baseline ismeasured, as is the height of the scaphoid perpendicular to the baseline.Normal values average 0.60.stage 1 (mild beaking of the radius without involvementof the radioscaphoid joint), stage 2 (narrowing of theradioscaphoid joint space), or stage 3 (loss of the radioscaphoidjoint space). The numbers of patients witheach stage were too small for us to make meaningfulcomparisons among stages; therefore, we combined thepatients who had stage-1, 2, or 3 osteoarthritis into onegroup.Avascular necrosis was evaluated at the time of thefinal follow-up on plain radiographs. Postoperative magneticresonance images were not made. Avascular necrosiswas graded as stage 0 (none), stage 1 (patchy areas ofradiodensity of the proximal pole), stage 2 (involvementof the entire proximal pole), or stage 3 (avascular necrosiswith carpal collapse) 25 . The tourniquet was notreleased intraoperatively for the purpose of assessingblood flow to the scaphoid fragments.Operative TechniqueA palmar approach 21 was used in all patients. Carewas taken not to divide the radioscaphoid capitate ligament.Preservation of the radioscaphoid ligament maintainedthe proximal pole of the scaphoid in a reducedposition in the fossa of the distal part of the radius.When the ligament is divided, the proximal pole cantranslate in a palmar direction during efforts to reducethe fracture. In addition, instability of the scaphoid andlunate ligament complex increases with widening of thescapholunate interval, and rotation of the scaphoid hasbeen demonstrated 14 . When the fracture was not seen toreduce under fluoroscopy with extension and ulnardeviation of the wrist, the fracture site was exposed byextending the capsular incision to the level of theradioscaphoid capitate ligament. One of the most importantlandmarks to guide the realignment of the fracturedscaphoid was the articular border of the scaphoidwith the capitate. Operative dental picks were used tomanipulate and rotate the fragments. The operativedental picks caused less damage to the fracture site thandid Kirschner wires inserted perpendicularly as socalledjoysticks. Corticocancellous bone graft obtainedfrom the distal aspect of the radius, the olecranon, or theiliac crest was morseled and packed into the fracturesite when comminution resulted in the loss of bone continuityfollowing reduction of the fracture. Ten patientsin Group 1 and seven patients in Group 2 received abone graft. When the fracture had minimal comminutionand the scaphoid reduced anatomically with manipulationunder fluoroscopy, the surgical approach wasnarrowed to a small longitudinal 1.5-centimeter incisionthat was centered over the scaphotrapezial joint. Radialand ulnar flaps were elevated to expose the scaphotrapezialjoint. A rongeur was used to remove the foot processof the trapezium that lies over the distal pole of thescaphoid; this was done to allow for the placement ofthe guide-wires or screw into the center of the scaphoid.This portion of the trapezium has no articular cartilage,and its removal causes no degenerative changes in theFIG. 5Anteroposterior radiograph showing a Herbert-Whipple screw positionedin the central third of the proximal pole of the scaphoid.THE JOURNAL OF BONE AND JOINT SURGERY
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Fixation with a Cannulated Screw Displaced Scaphoid Fractures ...

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