Scaphoid fracture

Dr. Ghadeer Hikmat

Fractured scaphoid

• Scaphoid fractures account for 70%

off all carpal fractures
• It is common because: the scaphoid
lies obliquely across the two row
bones, and is also in the line
between the thumb and forearm .
 Blood supply
• The blood supply of the scaphoid
diminishes proximally.
• This account for the fact that 1% of
distal third fractures.
• 20% of middle third fractures and 40%
of proximal fractures result in non-
union or avascular necrosis of the
proximal fragment.
• Most scaphoid fractures are stable:
• with unstable fractures the fragments
may become displaced which is called
hump-back deformity where the
scaphoid is folded into flexion.
CIinical features:

• Fullness in the anatomical snuff box;

precisely tenderness in the same
place is an important diagnostic sign.
• Proximal pressure along the axis of
the thumb may be painful.
 X-ray:
• AP/ Lat. / oblique views.
• CT scan sometimes for questionable
cases.
• Usually the fracture line is transverse,
and through the narrowest part of the
bone (waist), but it ay be more
proximally situated (proximal pole
fracture) and sometimes only the
tuberele of the scaphoid is fractured.
• Signs of displacement and instability
are;
• 1- oblique fracture,
• 2-opening of the fracture line
• 3-angulation of the distal fragment
• 4-foreshortening of the scaphoid
image.
• Recent X-ray sometimes -ve and we
treat patient according to the clinical
examination and repeat the X-ray after two
weeks when we will see the fracture line to
be more obvious
• If union delayed cavitation
appears on either side of the
break Old un-united fracture have
hard borders.
• making it seem as if there is an extra-
carpal bone.
• Relative sclerosis of the
proximal segment is
pathognomonic of vascular neerosis
 treatment
• 1. Undisplaced fracture: 90% should
heal We DO below elbow PoP to just
short of the metacarpophalangeal joint
of the fingers, but incorporating the
proximal phalanx of the thumb, The
wrist is held dorsiflexed and the thumb
forwards in the 'glass holding' position.
The plaster retained for 6 weeks
• After that we examine the patient
clinically and radiologically; and if:
• 1-The fracture healed: encourage activity.
• 2- Fracture not healed and still
painful and tender: recast for 6 weeks, if:
• a- Painful wrist but healed fracture:
the cast can be dislodged.
• b- X-ray shows signs of delayed
union: we do open reduction and
screw fixation with bone graft
TREATMENT
• 2. In displaced fracture: we do open
reduction and screw fixation
• 3.Scaphoid tuberele needs no
splintage and treated as wrist sprain;
crepe bandage is applied and
movement is encouraged.
 Complications:
• 1. Non-union after three months in
young we do:
• A- Corticocancellous grafting
and internal fixation.
• B- Scaphoidectomy with proximal
to distal bone row fusion.
• C- . Proximal row carpeciomy.
• In old patients it is better to left alone.
complication
• 2. Avascular necrosis:
• if the bone structure is intact
• We do bone graft but if not we excise
proximal the proximal row; or else to
remove the scaphoid and fuse the
proximal to the distal row.
complication
• 3.ostscoarthristis it is sequel to non-
union and avascular necrosis if it is :
•  A- Mild: left alone with
painkillers and reduction of activity
• B- Moderate: we do
styloidectomy (radial styloid).
• C- Severe: we do proximal row
carpectomy. 
Metacarpal fracture
• Site: base, shaft, & neck.
• Mechanism: direct & indirect.
• Deformity: the serious
deformity is rotational Deformity.
• When we clench the list, normally the
fingers converge across the palm to a
point above the thenar eminence.
• Malrotation of the metacarpal (or the
proximal phalanx) will cause the finger
to diverge and overlap one of its
neighbours.
• Angular deformity is usually not very
marked, and even if it should persist it
does not interfere much with function.
• In extended fingers the fingers" nails
are in the same plane if we look to the
tips of the extended fingers.
• If there malrotation there will be loss
of this alignment at the affected fingers.
• The 4th and 5th fingers are more mobile
than the 2 th and 3 th .and therefore are
better able to compensate for residual
angular deformity .
 Fracture of the metacarpal neck:
• Mechanism:
• - Direct: transverse fracture often with
associated skin damage
• - Indirect: spiral or oblique fracture (due to
• twisting or punching force).
• Clinical features: P.S.T.D.Lf .
• X-ray: AP & Lat.

• Treatment :
• -undisplaced :firm crepe bandage or slab for 2-3
weeks
• -displaced :it is with rotation and can not be
treated perfectly , so ORIF required
Fracture of the metacarpal neck:

• Usually a direct blow commonly affects

neck of the fifth metacarpal bone,
which is called "boxer's fracture".
• Clinical features: P.S.T.D
• X-ray: AP/Lat. Shows an impacted
transverse fracture with volar
angulation of the distal fragment.
 Treatment:
• Because the 4 th and 5 th fingers main function is
flexion (power grip); therefore a flexion
deformity of about 40 degree can be accepted.
And the function of die 2 th and 3 th fingers are
function mainly in extension, no more than 20
degree of flexion at the fracture
• Is accepted provided for all ,there should be no
rotation.
• For undisplaced fracture, back slap while
• The MPJ flexed and IPJ extended for 2-3
weeks.
• 
Fracture of the metacarpal base:

• Mechanism: direct or indirect.

• Clinical fracture: P.S.T.
• X-Ray:Ap/lat.
• Treatment: back slap for stable
fracture for(2-3_)weeks, and
surgical fixation by k-wire for the
unstable one
Lunate and perlunate dislocation
•  Mechanism:  Fall on outstretched hand
on dorsiflexion.
• The lunate is attached to the radius, so
the carpus will go backward and the
lunate stay in position leading to
perilunate dislocation.
• Some times the carpus will go forward to
its position and pushing and dislocating
the lunate forward leading to dislocation
of the lunate.
• Clinical features:
• 
• Pain, swelling, tenderness,
deformity with signs of carpal tunnel
syndrome due to compression of the
median nerve by the forwardly
displaced lunate with weak abduction
of the thumb.
• 
• x-ray: AP/lat
• Treatment:
• 
• Manipulation under anesthesia with
traction in dorsiflexion, then slowly
palmarflex the wrist, at the same time we
squeeze the lunate back with the thumb,
then we put pop with or without peri-
coetaneous wire for the unstable reduction.
• If it can not be reduced by closed method,
the we do open reduction
• and K-wire fixation.
 THE END

•Dr. Ghadeer Hikmat