Anatomy and Kinematics
Osseous and Ligamentous Anatomy
Mechanism of Injury
Clinical Assessment and Diagnosis
Diagnosis of Carpal Injuries: Pearls and Pitfalls
Epidemiology and Etiology
Classification and Associated Injuries
Authors’ Preferred Management—Imaging and Diagnosis of Displacement
Authors’ Preferred Management—Acute Scaphoid Fractures
Suspected Scaphoid Fractures
Scaphoid Tubercle Fractures
Nondisplaced Scaphoid Fractures
Unstable and/or Displaced Scaphoid Fractures
Proximal Pole Scaphoid Fractures
Complications: Scaphoid Malunion
Complications: Scaphoid Nonunion
Authors’ Preferred Management—Scaphoid Fracture Nonunion
Complications: Scaphoid AVN
Directions for Future Research
Scaphoid Fractures: Pearls and Pitfalls
Other Carpal Fractures
Authors’ Preferred Management—Other Carpal Fractures
Other Carpal Fractures: Pearls and Pitfalls
Carpal Ligament Injuries
Authors’ Preferred Management—SLD
Perilunate Dislocation and Fracture-dislocation
Authors’ Preferred Management—Perilunate Dislocation and Fracture-Dislocations
Carpal Ligament Injuries: Pearls and Pitfalls
Data from Duckworth AD, Ring D, McQueen MM. Assessment of the suspected fracture of the scaphoid. J Bone Joint Surg Br. 2011;93:713–719, reprinted with permission.
PPV, positive predictive value; NPV, negative predictive value; ASB, Anatomical snuffbox.
From Duckworth AD, Ring D, McQueen MM. Assessment of the suspected fracture of the scaphoid. J Bone Joint Surg Br. 2011;93-B(6):713–719.
From Duckworth AD, Ring D, McQueen MM. Assessment of the suspected fracture of the scaphoid. J Bone Joint Surg Br. 2011;93-B(6):713–719; with data from Yin ZG, Zhang JB, Kan SL, et al. Diagnosing suspected scaphoid fractures: A systematic review and meta-analysis. Clin Orthop Relat Res. 2010;468:723–734.
From: Dias JJ, Singh HP. Displaced fracture of the waist of the scaphoid. J Bone Joint Surg Br. 2011;93:1433–1439.
Given the low prevalence of displacement and instability, we feel comfortable relying on radiographs that demonstrate no gapping or translation at the fracture, and no dorsal tilting of the lunate, if the patient agrees that a very small risk of healing problems is preferable to the radiation and other downsides of CT. If there is any uncertainty, we order CT in the planes defined by the long axis of the scaphoid.
Patients with a suspected occult scaphoid fracture are re-evaluated after 1 to 2 weeks of immobilization in a forearm cast or splint. An examination by a specialist after the injury has become less painful substantially decreases the probability of a scaphoid fracture in most circumstances. If the probability of a fracture remains unacceptable (a decision shared with the patient) and new scaphoid specific radiographs are also normal, the patient can either continue with immobilization (6 weeks of splint immobilization with normal scaphoid radiographs is likely sufficient) or advanced imaging (typically CT or MRI) can be used to attempt to exclude a fracture and avoid additional immobilization and activity restrictions. The higher the pretest odds of a fracture, the more likely an imaging diagnosis of a fracture will correlate with a true fracture. The lower the pretest odds; for example, “rule out” rather than “confirm,” the less likely that a radiologic diagnosis of a fracture will correspond with a true fracture. Patients with more pressing needs to diagnose a fracture (some athletes and other occupations) can be considered for more sophisticated imaging early on, keeping in mind the limitations of this diagnostic strategy.
For tubercle fractures, we recommend 3 to 4 weeks in a splint followed by active mobilization.
We recommend as standard a below-elbow cast with the thumb free for nondisplaced stable scaphoid fractures. If there is any doubt about the presence of displacement, particularly if there is fragmentation at the fracture line, we would progress to a CT scan. Based more on tradition than data, the duration of immobilization is 8 to 10 weeks. Radiographs and clinical examination should not be used to determine duration of immobilization because they are unreliable for diagnosis of union. Return to sport and use of the hand with force is delayed until there is clear radiographic evidence of union or 4 to 6 months have passed. At this point it is reasonable to “put things to the test” no matter what the radiographs show since additional protection is unlikely to facilitate union.
We offer patients with nondisplaced or minimally displaced fractures the option of percutaneous screw fixation, including a balanced discussion on the risks and benefits of surgery based on the best available evidence. One of us prefers a volar approach to percutaneous fixation and the other uses either a dorsal or a volar approach. We feel the advantages of the volar approach are that the scaphoid tubercle is very superficial, the wrist can be maintained in neutral which makes imaging easier and decreases the chance of bending the guidewire, and there is no need to open the radiocarpal joint. On the other hand, care must be taken to ensure that an overhanging trapezium does not cause the surgeon to insert the screw too superficially (too volar) or too vertical. There may also be a risk of later scaphotrapezial arthrosis. Using this approach, the surgeon must be prepared to place the screw through the overhang of the trapezium which is usually extra-articular. If the screw is placed too vertically in the sagittal plane, the screw tip may penetrate the dorsal radial scaphoid cortex, which both endangers the radioscaphoid cartilage and usually provides inadequate fixation of the proximal fragment.
We feel the advantages of a dorsal approach include easier central placement in the proximal pole and body of the scaphoid. Disadvantages include the need to keep the wrist in a flexed position, greater risk of bending the guidewire, risk to digital extensor tendons, and creation of a hole in the scaphoid articular surface. The starting point of the wire can be identified arthroscopically and a large bore needle used as a guidewire or this can be done entirely with the image intensifier. The hand is placed on top of a stack of towels on the image intensifier to maintain the wrist in flexion to provide access to the starting point and limit the potential for bending the wire. The wrist is kept flexed and the images are perpendicular to the carpus. After determining the length of the screw, the wire is placed into the trapezium to prevent unintended extraction if predrilling is used.
Some surgeons allow patients to return to sports and forceful activity sooner after screw fixation than they would after cast treatment (sometimes within a few weeks of screw placement), but we do not recommend that approach. Postoperatively, a bandage is applied and usually a cast is not required. Noncontact sports are allowed immediately. Contact sports, heavy lifting, or axial loading of the wrist can commence progressively 6 weeks after surgery.
Arthroscopic-assisted fixation or ORIF of the scaphoid is recommended if there is any gapping or angulation in the scaphoid, even if the fracture appears stable and impacted, because our impression is that displaced fractures are unstable and should be managed operatively.543 If reduction can be achieved and monitored arthroscopically percutaneous fixation is possible, but we feel the standard treatment is open reduction and internal fixation. Reduction is facilitated by the use of K-wires used as joysticks in each fragment as well as other instruments used to push and guide the fragments into position. Bone grafting is considered in the face of comminution.
A splint is applied for comfort after operative fixation. In most cases the splint is maintained until suture removal about 2 weeks later. In unreliable patients or some very unstable or very proximal fractures a cast may be used for 4 to 8 weeks. Return to sports is risky until the fracture is healed (at least 2 to 3 months). Patients who wish to return sooner must agree to assume the associated risks.
For proximal pole fractures we recommend operative treatment using a small open dorsal approach to check alignment in case the fracture is unstable.442 We prefer a straight 3-to 4-cm incision centered over the dorsal aspect of the wrist after checking the level of the scapholunate junction with the fluoroscope. The extensor pollicis longus tendon can usually be left in place. The dorsal capsule is then incised and the scaphoid exposed. Care is taken to avoid injury to the dorsal ridge vasculature during the approach. For unstable fractures, bone grafting might be considered to stimulate union. A compression screw is applied over a guidewire, using a second wire to control rotation if the fragment is unstable. Our postoperative protocol is as for unstable/displaced fractures.
Adapted from: Doornberg JN, Buijze GA, Ham SJ, et al. Nonoperative treatment for acute scaphoid fractures: A systematic review and meta-analysis of randomized controlled trials. J Trauma. 2011;71:1073–1081.
For a stable scaphoid nonunion, we prefer an open palmar approach using a straight incision as opposed to the curved incision described by Russe.173,407 The incision is based over or radial to the FCR from the scaphoid tubercle to the distal radius. The sheath of the FCR tendon is incised and the tendon retracted ulnarly. Directly beneath the tendon lies the palmar capsule of the wrist, just above the scaphoid. The capsule should be incised longitudinally. The superficial palmar branch of the radial artery is distal at the end of incision and needs to be ligated in cases of wider exposure of the distal scaphoid. Stable scaphoid nonunions might not be visible macroscopically and often need sharp division with the knife. It is useful to check the site of a nonunion as fusion of the proximal pole of the scaphoid with the lunate or the scaphoid distal pole and trapezium have been undertaken assuming that this joint was the site of nonunion. It is important to prepare the nonunion surfaces by removing any fibrous tissue and sclerotic bone. We usually leave the dorsal cartilage in place. This provides a hinge and facilitates assessment of scaphoid length. In most cases of stable nonunion, cancellous bone graft from the distal radius usually provides sufficient volume as structural support is not required, although iliac crest bone graft can be used if necessary. Screw fixation of the scaphoid is then used. Immobilization in a cast or splint is not required postoperatively except in occasional cases for pain relief.173
For an unstable nonunion, we feel a volar approach is necessary to correct the humpback deformity. The nonunion gap is exposed and debrided, and the fracture fragments are mobilized. It is best to leave a cartilage hinge posteriorly to provide a fulcrum around which the fragments may be hinged open although this is often not possible in older, unstable scaphoid fractures. If the hinge is released in an effort to regain all of the scaphoid length, the fracture fragments will become extremely unstable and difficult to align. Furthermore, the gap between the two fragments may be too great for the scaphoid to revascularize the proximal pole.500 The wrist is extended and the two fragments gently distracted with small spreaders. This maneuver usually achieves adequate correction of the carpal deformity and a satisfactory improvement in wrist extension. Provided that reasonable correction is achieved and that the wrist extends to at least 45 degrees, most patients achieve satisfactory clinical results. The fracture surfaces are excised with a small osteotome, burr, or curette. We prefer a corticocancellous wedge graft from the iliac crest. This is an interposition graft, which is inserted on the palmar surface and serves to bridge the fracture gap and correct any displacement or angulation of the scaphoid that has occurred. Vascularized bone grafts from the distal radius (radial artery) or distal ulna (ulnar artery) have also been described, though we would prefer the pronator quadratus graft.460 To correct angular deformity and restore normal scaphoid length, the amount of resection and size of the graft can be calculated preoperatively by CT scans. The indications for interposition grafting include gross motion at the nonunion site, scaphoid resorption, and loss of carpal height. Most commonly, the operative procedure involves an anterior interposition bone graft, with the size based on comparative scaphoid views of the opposite wrist and intraoperative measurements. The width and depth of the defect is measured and a graft of the exact size is removed from the iliac crest with an osteotome. Oscillating saws should not be used, as thermal necrosis of the graft can occur. With the wedge graft in place and the scaphoid reduced and held with a K-wire, a compression screw is inserted. Internal fixation with K-wires alone is usually not successful as compression is required to achieve union. However, if the graft shows a tendency to rotate, additional fixation with a K-wire may be required. If there is a severe or longstanding DISI deformity with an RL angle greater than 20 degrees, additional pinning of the lunate to radius for 6 to 8 weeks is advised.155 It may be difficult to completely correct carpal instability in longstanding cases, and these patients may be better served by various salvage procedures. Finally, a partial radial styloidectomy can be performed in patients with radiologic signs of stage I radioscaphoid arthritis, this being arthritis that is limited to the scaphoid and radial styloid. This is undertaken to relieve pain arising from arthritic joints or osteophyte impingement. If there are no radiologic signs of arthritis, a styloidectomy should not be undertaken at the same time as a scaphoid reconstruction often relieves symptoms.173
With stable fixation, postoperative immobilization is usually not required but a Colles cast can be used if there is doubt about stability or if pins have been used across the radiocarpal joint.
For the vast majority of isolated, undisplaced or minimally displaced carpal fractures we prefer nonoperative management. We routinely use a standard Colles cast or wrist splint, depending on the requirements of the patient, for a period of approximately 4 weeks followed by routine mobilization. For simple avulsion fractures, immediate motion and a splint as required for discomfort is sufficient. For displaced fractures, which are routinely associated with other osseous or soft tissue injuries of the carpus, we prefer closed or open reduction, with internal fixation.
CL, capitolunate; RL, radiolunate; SL, scapholunate.
Adapted from: Kitay A, Wolfe SW. Scapholunate instability: Current concepts in diagnosis and management. J Hand Surg Am. 2012;37:2175–2196 and Kuo CE, Wolfe SW. Scapholunate instability: Current concepts in diagnosis and management. J Hand Surg Am. 2008;33:998–1013.
We recommend primary repair and pin fixation for acute SLD using a dorsal approach.173 The approach is centered over Lister tubercle, reflecting the dorsal wrist capsule to preserve the dorsal intercarpal and dorsal radiotriquetral ligaments, using a radial-based capsular flap. The radial capsule is reflected from the scaphoid to its waist. The open technique allows direct visualization of the injured ligament, reduction, and ligament repair. Most often, the SL ligament is torn off the scaphoid, but still attached to the lunate. In rare cases, avulsion from the lunate or an oblique tear will be seen. Reduction of the lunate and scaphoid is performed with K-wire joysticks inserted in a dorsal-to-palmar direction. The rim of the proximal scaphoid is freshened to subcortical bone with a fine rongeur to facilitate ligament healing. Ideally, high-speed burrs should be avoided as thermal necrosis may occur. When the ligament remains attached to the lunate, intraosseous anchors are inserted into the waist of the scaphoid. The anchors are placed in such a position that the suture lies in a slightly oblique direction in order to resist the rotational forces between scaphoid and lunate.51 The sutures attached to the anchors are placed in the SL ligament in a palmar to dorsal direction. If anchors are not available, drill holes in the scaphoid are required to allow direct attachment of the ligament onto the scaphoid. When the sutures are positioned, the scaphoid and lunate are reduced with joysticks and held in the reduced position with K-wires. One K-wire is placed from the scaphoid to the lunate and another from the scaphoid to the capitate. The sutures are tied and the capsule repaired. A below-elbow cast is applied and retained for 12 weeks, when the K-wires are removed.
We prefer the Blatt’s technique of capsule reconstruction, using dorsal capsulodesis for the treatment of chronic scapholunate instability.52,120,173 For the Blatt type of capsule reconstruction, a long rectangular flap, about 1.5 cm wide, based on the dorsal aspect of the distal radius, is used. The distal edge of capsule is sutured to the distal pole of the scaphoid once the scaphoid is placed in a reduced position. A K-wire can be passed into the dorsum of the lunate to be used as a joystick to reduce any DISI. The scaphoid is reduced by pressure on the scaphoid tubercle and then transfixed to the capitate by another K-wire. The dorsal surface of the scaphoid is roughened with a fine rongeur just distal to the center of rotation. The dorsal flap of wrist capsule is sutured under tension with intraosseous anchors distal to the scaphoid center of rotation so that it tethers the proximal pole in the scaphoid fossa. The flap is sutured to reinforce the local tissue of the SL interval. For a distally based flap, one can raise a rectangular capsular flap, leaving the distal end of the flap attached to the scaphoid. After SL ligament reconstruction, immobilization in a below-elbow cast is recommended for 8 weeks. The K-wires are removed at 8 weeks. Splint immobilization for an additional 4 weeks is suggested to allow for tissue healing with gradual stress loading. Supporting splints are best worn intermittently for 6 months to prevent sudden stress to the wrist and to allow further collagen maturation.
All patients with an acute perilunate injury should undergo immediate closed reduction. For those patients with a lesser-arc injury that is reducible closed, we prefer K-wire fixation over conservative treatment in cast. The role of percutaneous reduction and fixation is unclear and still experimental.
We prefer a dorsal midline approach to expose and realign the bones (Fig. 31-44), with an additional palmar approach for neurovascular problems. The surgery is similar to that for treatment of SLD, except that an extended carpal tunnel release is performed when required. The palmar capsule should be examined either along its attachments to the radial rim or through the frequently damaged space of Poirier. The dorsal capsule is usually opened along its origin from the dorsal radial rim, as well as longitudinally in the space between the second and fourth extensor compartments, and the proximal carpal row is examined.173
If a scaphoid fracture is present (greater-arc injury), it can be reduced through the dorsal approach, temporarily stabilized with K-wires, and fixed with a cannulated screw. Autogenous cancellous bone graft from the distal radius is sometimes placed in comminuted scaphoid fractures. If there is not a scaphoid fracture, the scaphoid is aligned to the lunate and a screw is placed from radial to ulnar percutaneously. The dorsal scapholunate ligament is reattached with a small suture anchor. The screw is removed between 2 and 6 months after injury. Once the scaphoid is reduced, the lunotriquetral joint usually lines up. We sometimes stabilize it with K-wires or a temporary screw, but have left it unsecure more recently.
Reduction and K-wire fixation should be centered on the lunate. The lunate must be aligned and pinned first to the distal radius to neutralize the radiolunate alignment. The lunotriquetral joint is then reduced and fixed by a second K-wire. Ligaments are repaired as needed. The capitolunate joint alignment is then evaluated and correct colinear alignment is assessed. Lastly, the scapholunate joint is reduced and held with K-wires. Many of the patients have an associated radial styloid fracture, which should be reduced anatomically and stabilized with K-wires or a compression screw.173