Hand and Wrist Surgery - part 7 pot

frac-Differential Diagnosis Scaphoid fractureDistal radius fractureRadioulnar joint injuryPerilunate ligament disruptionInjury of the extensor carpi radialis brevis and longus or flexor

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In the event of failure of obtaining a successful closed reduction, an open tion should be performed The joints can be approached via a transverse incisionalong Langer’s lines at the level of the carpometacarpal joint Reduction of the thirdcarpometacarpal joint is the key to the reduction of the remaining joints as this jointfunctions as the keystone of the transverse and longitudinal arches of the hand.K-wire fixation of the reduced joints produces a joint that will remain stable duringthe course of immobilization Internal fixation with pins, screws, or plates can beperformed to maintain stability High-energy injuries often require internal fixation

reduc-as they are often reduc-associated with fractures

In the event of multiple dislocations, K-wire fixation of all dislocated joints neednot be performed The second and third carpometacarpal joints should be stabilized,

as they are the keystones of the hand, and the fifth carpometacarpal joint should

be stabilized to avoid subluxation and ulnar deviation The fourth carpometacarpaljoint need not be pinned if its adjacent joints have been pinned, as the strong inter-metacarpal ligaments are not disrupted and will contribute to stability

After reduction and pinning of the carpometacarpal dislocation, the hand should

be splinted for pain management and soft tissue rest After a week, gentle activeand passive range-of-motion exercises of the fingers and wrist can be performed.The K wires can be removed after 6 to 12 weeks Patients with concomitant frac-tures require the longer length of time before K-wire removal After removal of the

K wires, progressive active and passive range-of-motion and strengthening exerciseshould be performed

Complications

Percutaneous pinning has seen rare complications Post-operative stiffness may bepresent but early and appropriate hand therapy can often eliminate this complica-tion Fluroscopic guidance may aid in the accurate placement of the K wire

Suggested Readings

Ahmad S, Plancher KP Carpometacarpal dislocation of the fingers Op Tech Sports

Med 1996;4:256–267.

Fisher MR, Rogers LF, Hendrix RW Systematic approach to identifying fourth and

fifth carpometacarpal joint dislocation AJR 1986;140:319–324.

Gurland M Carpometacarpal joint injuries of the fingers Hand Clin 1992;8:

733–744

Jebson PJ, Engber WD, Lange RH Dislocation and fracture dislocation of the

car-pomteacarpal joints Orthop Rev 1994;23:19–28.

Lawlis JF, Gunther SF Carpometacarpal dislocation: Long-term followup J Bone Joint

Surg [Am] 1991;73A:52–59.

Van Der Lei B, Kalsen HJ Dorsal carpometacarpal dislocation of the index

fin-ger: a report of three cases and a review of the English language literature J Trauma

1992;32:789–793

Section IX

Fractures and Dislocations

of the Wrist

A Wrist Fractures and Dislocations Scaphoid Fractures: “Classic” Volar Approach

Kevin D Plancher

Percutaneous Treatment of Proximal Pole Scaphoid Fractures

Joseph F Slade III and John D Mahoney

Scaphoid Nonunion

James W Vahey and Kevin D Plancher

B Fractures of the Distal Radius Radial Styloid Fractures

James H Calandruccio

Extraarticular Distal Radius Fractures

Kydee K Sheetz and Matthew D Putman

Intraarticular Distal Radius Fractures: Volar Approach, Dorsal Approach, and Arthroscopic Reduction

Kevin D Plancher

History and Clinical Presentation

A 17-year-old boy presented to the emergency room with a dull, deep pain in thewrist after a fall, while he was rock climbing, on an outstretched hand The patientremembers that his wrist was radially deviated when he fell The patient reports dis-comfort in the wrist on the thumb side with mild swelling and ecchymosis

Physical Examination

The major structures of the wrist are palpated Pain with axial compression of thethumb is suggestive of a scaphoid fracture The patient also has pain in the anatomicsnuffbox between the first and third dorsal compartments (Fig 56–1)

Diagnostic Studies

Initial imaging of the patient should include a zero posteroanterior (PA) x-ray of thewrist (Fig 56–2) If the fracture is not seen, the patient should have PA x-rays ofthe wrist in radial and ulnar deviation (scaphoid and longitudinal profile with theelbow flexed at 90 degrees) These views are used to better define the anatomy ofthe scaphoid and allow visualization of its margins A clenched fist with radial andulnar deviation views may also diagnose a scapholunate ligament tear as the cause

of the patient’s pain If all x-rays are negative, further imaging to diagnose an occultscaphoid fracture that is not seen on plain films may be done with a bone scan A

Figure 56–2 Radiograph, zero posteroanterior (PA), of the wrist demonstrating a scaphoid fracture.

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Figure 56–3 The vasculature of the scaphoid (volar and dorsal).

negative bone scan 3 to 5 days following an injury rules out a scaphoid fracture Weroutinely use computed tomography (CT) evaluation of the scaphoid when there

is evidence of a fracture This test gives the best definition of cortical integrity, ture pattern and the ability to evaluate a humpback deformity or dorsal intercalatedsegment instability (DISI) pattern Magnetic resonance imaging (MRI) is quicklyreplacing CT evaluation and it demonstrates more anatomy, which allows for visu-alization of the fracture and ligament disruptions

frac-Differential Diagnosis

Scaphoid fractureDistal radius fractureRadioulnar joint injuryPerilunate ligament disruptionInjury of the extensor carpi radialis (brevis and longus) or flexor carpi radialis tendonsWrist sprain

Diagnosis

Scaphoid Fracture

The scaphoid is the most frequently injured carpal bone Scaphoid injuries are mostcommonly seen in young men, are often misdiagnosed as sprained wrists, and arerarely seen in children because the distal radial physis usually fails first

Fractures are localized within the proximal, middle (waist), or distal third of thebone The incidence of avascular necrosis increases as fractures are located more prox-imally in poorly vascularized areas (Fig 56–3) Most scaphoid fractures occur at thewaist, followed by the proximal pole and then the distal pole Orientation of the frac-ture is a clue to its stability (Fig 56–4) The most stable fracture orientation is thehorizontal oblique, wherein the axis of the load is perpendicular to the fracture line.Transverse fractures may be unstable The most unstable fracture has a vertical obliqueorientation; fragments are vulnerable to longitudinal shearing forces from the radius

PEARLS

• Plain radiograph initially should

be a zero PA

• Correlate clinical exam with

diagnostic studies and utilize

CT or MRI when necessary

• If closed treatment is decided,

need to follow guidelines of

6 weeks in a long-arm cast

• Avoid damaging underlying

articular cartilage during

inter-nal stabilization

• Avoid damaging the

vascula-ture by keeping the volar

inci-sion into the joint capsule not

too deep or too proximal

PITFALLS

• Misdiagnosis and failure to

diagnose

• Failure to follow-up clinically

with a painful snuffbox on

phys-ical examination and negative

plain x-rays

• Treating a proximal pole

frac-ture of the scaphoid as if it

were a distal pole fracture

• Poor screw placement and

not verifying placement

intraoperatively

non-is suggested Wanon-ist fractures should be considered for open reduction; however,nondisplaced, horizontal oblique fractures of the waist have the best chance ofsuccessful nonsurgical treatment Though closed treatment has less surgical risk,prolonged immobilization and nonunion are other risks to consider Closed treat-ment consists of 6 weeks in a long-arm cast, followed by a short-arm cast wornuntil healing is seen on radiographs Waist fractures require a total of 8 to 12weeks of immobilization Vertical oblique fractures of the waist should be referred

to an orthopedist

Closed treatment of stable, nondisplaced fractures on the proximal pole can be tempted; however, orthopedic referral is suggested because open treatment is prefer-able Proximal pole fractures require 12 to 24 weeks of immobilization for closedtreatment

at-Surgical Management

An incision is made over the center of the tubercle of the scaphoid This can beeasily palpated with the wrist in full radial deviation The incision is curved towardthe thumb at the distal end The proximal end of the incision extends along theradial border of the flexor carpi radialis tendon An incision is made in the sheath

of the flexor carpi radialis tendon and the tendon is retracted to expose the anteriorcapsule over the scaphoid bone The capsule is incised from the tubercle to the tip

of the radius Care should be taken to avoid the underlying articular cartilage of thescaphoid The radiolunate ligament is divided to provide adequate exposure of theproximal pole of the scaphoid (Fig 56–5)

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Figure 56–5 The surgical exposure of the scaphoid fracture.

Figure 56–6 The jig, and the drilling, tapping, and placement of the screw.

After the joint between the scaphoid and trapezium is identified, an incision ismade in the joint capsule around the tubercle of the scaphoid To avoid damage tothe blood vessels entering the scaphoid, the incision should not be too deep or tooproximal

The hemarthrosis is suctioned, and soft tissue that is attached to the fracture site

is removed Loose bone fragments are removed The wrist is manipulated to assess

With proper technique, most complications can be avoided However, adhesionscan cause stiffness in the joint, and volar scar tenderness has been seen Nerve dam-age during surgery is a risk as well as the development of a neuroma at the surgicalsite Poor screw placement or other technique problems can cause a nonunion of thefracture

Gellman H, Caputo RJ, Carter V, et al Comparison of short and long thumb-spica

casts for nondisplaced fractures of the carpal scaphoid J Bone Joint Surg [Am] 1989;

71A:354–357

Hebert TJ Open volar repair of acute scaphoid fractures Hand Clin 2001;17:

589–599

Herndon JH Scaphoid Fractures and Complications Rosemont, IL: American

Acad-emy of Orthopaedic Surgeons; 1994

Krimmer H Management of acute fractures and nonunions of the proximal pole of

the scaphoid J Hand Surg [Br] 2002;27B:245–248.

Plancher KD Methods of imaging the scaphoid Hand Clin 2001;17:703–721.

Polsky MB, Kozin SH, Porter ST, Thoder JJ Scaphoid fractures: dorsal versus volar

approach Orthropedics 2002;25:817–819.

Powell JM, Lloyd GJ, Rintoul RF New clinical test for fracture of the scaphoid

Can J Surg 1988;31:237–238.

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Raskin KB, Parisi D, Baker J, Rettig ME Dorsal open repair of proximal pole scaphoid

fractures Hand Clin 2001;17:601–610.

Taleisnik J Fracture of the carpal bones In: Green DP, ed Operative Hand Surgery,

2nd ed New York: Churchill Livingstone; 1988

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PEARLS

• The plain radiographic

ap-pearance of a scaphoid

frac-ture is often a poor predictor

of operative findings Green

suggested the best indicator

of proximal viability is

punc-tate bleeding in the

operat-ing room The postoperative

management of scaphoid

fractures should include serial

CT scans to confirm reduction

and identify bridging callus of

a healing fracture.

• Stable fixation with a minimally

invasive procedure will allow

earlier return of function and

better long-term outcome

• Relative ischemia of the

proximal pole is not a

con-traindication to internal

fixa-tion Stable union will permit

revascularization

PITFALLS

• Interval radiographs of less

than 6 months should not be

used for analysis of union.

57

Percutaneous Treatment of Proximal

Pole Scaphoid Fractures

Joseph F Slade III and John D Mahoney

History and Clinical Presentation

A 20-year-old male college football player sustained a hyperextension injury to hiswrist after a fall during practice He initially had radiographs taken, and his injurywas diagnosed as a sprain and was splinted for 2 weeks He was referred to the handclinic for evaluation and treatment

Physical Examination

The patient complains of pain at the base of his thumb, and locates pain to the gion of the snuffbox There is minimal swelling noted, and range of motion is de-creased when compared with the opposite wrist There is point tenderness over theproximal pole of the scaphoid There is no carpal or wrist instability (Shuck testevaluating lunate-triquetrum, scaphoid shift test for scapholunate instability, andballottement test for distal radioulnar joint are all negative)

re-Diagnostic Studies

Initial radiographs included three standard films of the wrist: a posteroanterior (PA)view of the wrist with the forearm in a neutral position, a lateral projection of thewrist, and an oblique view with the forearm in 35 degrees of supination These filmswere negative Follow-up serial films at 4 weeks demonstrated a fracture of the prox-imal pole of the scaphoid (Fig 57–1)

Figure 57–1 Posteroranterior view of the hand showing acute proximal pole scaphoid fracture.

The diagnosis of scaphoid fracture is often not straightforward We have developed

an algorithm for the radiographic evaluation of radial wrist pain (Fig 57–2) Initialevaluation includes the standard set of radiographs Follow-up of initial studies is de-manded for persistent pain Resorption of bone at follow-up will aid in fracture de-tection A bone scan taken 2 to 3 weeks after injury is highly sensitive for fracture orligamentous injury A negative scan excludes a fracture Computed tomography (CT)and magnetic resonance imaging (MRI) are highly specific and sensitive for detection

Lunate-triquetral ligament tear Clenched fist radiographs, arthrogram,

cineradiography, bone scanAvascular necrosis of the lunate MRI

or scaphoidOther carpal bone fractures Radiographs, CT scan, and bone scanCombination of above injuries Appropriate combination of studies, as above

Figure 57–2 Evaluation of acute radial-sided wrist pain.

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Diagnosis

Fracture of the Proximal Pole of the Scaphoid (Herbert B3)

Scaphoid fractures are the most common fracture of the carpus (80% of total),and of the wrist, the second most common after fractures of the distal radius Thetypical patient is a young man injured after a fall on an extended wrist Diagnosis

of fracture is suggested by the patient’s age, mechanism of injury, and symptoms.Radiographs are required to confirm diagnosis

The scaphoid bone is anatomically unique First, its blood supply from the cial palmar branch of the radial artery and the dorsal carpal branch of the radial arteryruns from distal to proximal, with the proximal pole receiving the most tenuousblood supply Thus, the proximal pole is particularly susceptible to avascular necrosis

superfi-as a complication of fracture Second, its irregular three-dimensional shape presentsspecial problems in diagnosis of acute fractures and their treatment It is an intraartic-ular bone, with 80% of its surface covered with articular cartilage Displaced fracturesresult in early degenerative arthritis, and malunions can lead to carpal collapse.The scaphoid is most commonly fractured across its middle third, with 70% of frac-tures across the “waist.” Ten percent are distal third fractures, and 20% are proximalthird fractures All proximal pole fractures should be considered unstable regardless

of radiographic appearance Russe classified scaphoid fractures into three categoriesbased on the fracture axis: horizontal oblique, transverse, and vertical oblique Hori-zontal oblique and transverse fractures together comprise ~95% of fractures, and re-spond equally well to therapy Vertical oblique fractures comprise the remaining 5%,and they tend to have a slower progress to union and a higher rate of nonunion.Optimum treatment depends on diagnosing a fracture acutely and the correctclassification of the injury CT scans greatly assist in classifying these injuries and

in assessing displacement and angulation CT scans are most useful for ing fracture union The Herbert classification scheme for scaphoid fractures usesradiographic appearance to determine surgical versus nonsurgical management(Table 57–2) Nonsurgical management is reserved for Herbert type A fractures

determin-Surgical Management

A contralateral radiograph of the normal scaphoid was taken to determine screw length

A CT scan confirmed proximal pole fracture, nondisplaced Seven weeks after the initial

Table 57–2 The Herbert Classification Scheme Type Description

Type A Acute, stable fractures; conservative management possible

A1 Fracture of tubercle

A2 Incomplete fracture through waist

Type B Acute, unstable fractures; surgical management required

B1 Distal pole oblique fracture

B2 Complete fracture of waist

B3 Proximal pole fracture

B4 Transscaphoid-perilunate fracture-dislocation of the carpus

Type C Classification no longer used; included delayed union; now part of type DType D All nonunions older than 6 weeks

injury, the patient was taken to the operating room for definitive management Thewrist was flexed to 90 degrees with the forearm pronated until the scaphoid was vieweddown its long axis as a ring of cortical bone (Fig 57–3) In the center of the ring, a0.045-inch Kirschner wire (K wire) was driven from proximal to distal (dorsal wrist),exiting at the base of the thumb From the base of the thumb (distal), the wire waswithdrawn to the point that the wrist can again be extended to a neutral position Thehand and forearm were exsanguinated, and a tourniquet was used to maintain a blood-less field The fingers are placed in finger traps, and longitudinal traction is applied(12 to 15 lb).

The scaphoid fracture was visualized arthroscopically through the midcarpal row

A minifluoroscopy unit placed in the horizontal plane and around the wrist was

A 2.8-mm cannula with a blunt trocar was used to enter the joint The trocarwas removed and a 2.3-mm, 30-degree angled arthroscope was placed through thecannula The inflow was then hooked up to the arthroscope cannula A second por-tal was established in the same manner using the second 19-gauge needle as a guide.The second portal was used for instrument placement.

The fracture was then visualized Both the arthroscope and traction were moved, and the wrist was flexed to 90 degrees Minifluoroscopy confirmed that thescaphoid was reduced The minifluoroscopy unit was used to confirm the position

re-of the guidewire and the architectural alignment re-of the scaphoid The arthroscopewas reinserted to confirm articular fracture alignment If the fracture were still dis-placed, we would have withdrawn the guidewire into the distal pole of the scaphoidand inserted two 0.062-inch K wires placed percutaneously to be used as joysticks

to reduce the fracture The guidewire was then driven back to secure both fracturefragments Reduction was confirmed arthroscopically

The wrist was removed from traction and flexed to 90 degrees, and the K wire wasdriven proximally The scaphoid was prepared for screw placement using a cannu-lated hand tap dorsally The cannulated screw was placed dorsally with a cannulateddriver (Fig 57–4) Skin incisions were closed with nylon sutures

Postoperative Management

Postoperatively, proximal pole fractures are managed differently from waist tures, because of the possible difficulty in maintaining fixation of small fracturefragments A protective thumb-spica splint is applied for 4 weeks Rehabilitation

frac-Figure 57–4 Intraoperative fluoroscopic view of cannu- lated Acutrak screw.

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Figure 57–5 Two-week postoperative radiograph, showing stable fixation.

begins at 4 weeks Serial radiographs (Fig 57–5) and CT scans beginning at 6 weeksevaluate the course of healing and the fracture alignment Splinting was discontin-ued when the patient was pain free and nontender, and the CT documented bridg-ing bone across the fracture site

Alternative Methods of Management

Alternative methods of management are summarized in Table 57–3 In stable type Afractures, nonsurgical management may still be appropriate Six weeks of immobiliza-tion in a Colles-type cast is often sufficient It is not necessary to incorporate the base

of the thumb There is no consensus on the position of the wrist in regard to flexion/extension or ulnar/radial deviation However, many authors report success with slightwrist extension and slight radial deviation As stated above, the initial radiographs arenot to be trusted Follow-up examination and radiographs of all conservatively treatedfractures should be done at 4 to 6 weeks to look for signs of healing versus fracture in-stability Six weeks of immobilization followed by 6 weeks of restricted activity is suffi-cient for fractures that appear to be healing with no signs of instability (i.e., evidence oftype B fracture) However, many fractures treated conservatively will develop instability

as seen on follow-up radiographs, and then will require surgical management All casesmanaged conservatively require follow-up at 6 months at the earliest, because earlier ra-diographs have an unacceptably low sensitivity for nonunion

Nonsurgical management was formerly the standard of care for all acute scaphoidfractures, with surgical management reserved for failures of conservative therapy.Most authors report a greater than 90% union rate of conservatively treated scaphoidfractures However, long-term follow-up has put the union rate at closer to 60% for

Requires high level of cal skill; potential for blindinjury (for volar approach)

techni-Higher likelihood of nonunion;

possible avascular necrosis;

osteoarthritisGreater operative exposurethan percutaneous methods;

screw provides little pression; requires greatertechnical skill; greateroperative time required;

com-application of jig maydamage articular cartilageScrew head interferes withmotion and may requiresubsequent removal; greateroperative exposure

Not stable fixation when usedalone

Greater operative exposure

With experience, the operativetime should be less thanopen techniques; recom-mended for all type B frac-tures; may be appropriatefor type A and D fractures

in an active, young patientfor whom prolonged immo-bilization would not beacceptable

Best reserved for stable type Afractures that are not surgi-cal candidates

Prior cadaveric experiencerecommended; carefultechnique will minimizelikelihood of nerve orvascular injury

Used in combination withother fixation techniquesMay be useful for delayedpresentation

simple fractures of the waist The goal of surgical management is to establish early,stable reduction to allow early return of function

Herbert Screw

Specially designed for scaphoid fractures, Herbert screws are distinguished by theirheadless design, calibrated insertion jig, and threads at both ends of the screw Thethreads engage both fracture fragments and allow for compression by the fact thatthe threads are of different pitch However, the most common complaints are of dif-ficulty in use (particularly in applying the jig properly), poor compression provided

by the screw, and difficult placement in proximal pole fractures

For fractures of the distal two thirds of the scaphoid, a volar approach is used withplacement of the screw aided by the specially designed jig For fractures of the proximalthird, a dorsal approach is best, with retrograde placement of the screw in a free-handfashion Verification of jig placement with the image intensifier before screw insertionprevents malplacement Prolonged postoperative immobilization is not necessary Use

a firm, padded bandage to provide wrist support and protection for the first 2 weeks

At this time, remove the sutures and begin a program of active motion rehabilitation

Bone Graft

Bone grafts are generally reserved for established nonunions However, they alsomay be appropriate for primary treatment of a delayed presentation of a scaphoidfracture The usual site of the graft is the iliac crest, with the graft shaped appropri-ately to fill the defect in the scaphoid In the case of a still unstable fracture, Herbertscrews or K wires maintain reduction of the fracture

Complications

We have experienced no complications in our patients treated with arthroscopicallyassisted reduction and percutaneous fixation Careful blunt dissection is essentialfor avoidance of neurologic, vascular, or other soft tissue injury For all techniques,the risk of avascular necrosis to the proximal pole is well known Early stable fixa-tion probably reduces the risk of avascular necrosis, but this has not been proven.For the Herbert screw, errors in screw placement secondary to difficulty usingthe jig are not uncommon For immobilization, the most common complication

is nonunion, which generally responds favorably to surgical management Whetherthese nonunions actually represent unstable fractures, incorrectly diagnosed as sta-ble fractures initially, is a matter of debate

Suggested Readings

Dias JJ, Brenkel IJ, Finlay DBL Patterns of union in fractures of the waist of the

scaphoid J Bone Joint Surg [Br] 1989;71B:307–310.

Dias JJ, Taylor M, et al Radiological signs of scaphoid fractures: an analysis of

inter-observer agreement and reproducibility J Bone Joint Surg [Br] 1988;70B:299–301 Haddad FS, Goddard NJ Acute percutaneous scaphoid fixation A pilot study J Bone

Joint Surg [Br] 1998;80B:95–99.

Herbert TJ The Fractured Scaphoid St Louis: Quality Medical Publishing; 1990.

Russe O Fracture of the carpal navicular: diagnosis, non-operative treatment, and

operative treatment J Bone Joint Surg [Am] 1960;42A:759–768.

Stewart M Fractures of the carpal navicular: A report of 436 cases J Bone Joint

Surg [Am] 1954;36A:998–1007.

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PEARLS

• A high index of suspicion of a

scaphoid fracture is warranted

when a patient presents with

the history of wrist pain

follow-ing a fall on an outstretched

hand even, if the radiographs

initially appear negative Very

commonly, a patient with a

scaphoid nonunion

experi-ences an asymptomatic

pe-riod (sometimes quite a long

period) following his initial

re-covery from the acute trauma

The patient can present later

with the history of the insidious

onset of wrist symptoms

Alter-natively, the patient can

pre-sent after another traumatic

event (often not even

associ-ated with high energy) with

the onset of wrist symptoms

• Useful techniques for

identify-ing the nonunion site include

identifying the position of the

fracture along the longitudinal

axis of the scaphoid from the

preoperative radiograph, CT

scan, or MRI, and scrutinizing

the cartilage for the presence

of wrinkling, buckling, or fibrous

tissue If the nonunion site

can-not be reliably identified by

any of these techniques,

intra-operative fluoroscopy can be

used to identify the location

and a 25-gauge needle can

be used to mark the location

of the nonunion

58

Scaphoid Nonunion

James W Vahey and Kevin D Plancher

History and Clinical Presentation

A 38-year-old police officer presents with the chief complaint of progressively ening pain and decreased range of motion in his dominant right wrist He notes ahistory of a wrist injury from a fall 5 years ago when playing basketball His evalua-tion at that time included radiographs that were interpreted as normal He was di-agnosed with a wrist sprain His pain gradually subsided and became asymptomaticafter an unknown amount of time However, over the last 2 years he has noticedwrist stiffness, mild and occasional pain, and mild decreased wrist motion

wors-Physical Examination

The right wrist has no swelling There is mild tenderness on palpation and mild derness with Watson shift testing; however, there is no subluxation The right wristrange of motion is extension/flexion of +40/45, radial/ulnar deviation of 5/15, andpronation/supination of 85/85 The left, asymptomatic wrist range of motion is ex-tension/flexion of +60/65, radial/ulnar deviation of 10/15, and pronation/supina-tion of 85/85

ten-Diagnostic Studies

Posteroanterior, lateral, and scaphoid radiographs of the right wrist may strate an established nonunion of the proximal pole of the scaphoid (Fig 58–1).The sclerotic appearance of the proximal pole was consistent with avascular nec-rosis There was no evidence of carpal malalignment or instability, including sca-pholunate and capitolunate angles within normal limits No significant arthriticchanges were present

demon-Magnetic resonance imaging (MRI) confirmed the diagnosis of avascularnecrosis of the proximal pole of the scaphoid (Fig 58–2) To obtain sagittalviews of the scaphoid, MRI images were performed in the oblique plane oriented

in line with the longitudinal axis of the scaphoid These images demonstratedthe fracture well and also confirmed that a “humpback” deformity was not pre-sent (Fig 58–3)

frac-A B

Figure 58–2 Posteroanterior (PA) (A) and lateral (B) mag- netic resonance imaging (MRI) of a wrist at stage D5 scaphoid nonunion.

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PITFALLS

• A humpback deformity of the

scaphoid is a relative

contra-indication for a vascularized,

pedicled bone graft because

correction of the deformity is

very difficult when performing

the graft Adequate correction

of the deformity is more reliably

accomplished from a palmar

(Russe) approach with

conven-tional trapezoidal

corticocan-cellous bone grafting and

Herbert screw fixation.

• The scaphoid nonunion may

not be readily identifiable

be-cause the cartilage may be

partially intact or fibrous tissue

in-Figure 58–3 Computed tomography (CT) scan of a patient with a non- union and humpback deformity.

Figure 58–4 Herbert’s five stages of scaphoid nonunions.

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not have a humpback deformity, a vascularized, pedicled distal radius bone graft can

be considered Some authors recommend vascularized grafts for patients with stageD5 who have humpback deformities However, correction of the carpal malalign-ment pattern is difficult, and the likelihood of success is less than for patients with-out a humpback deformity

Surgical Management

The patient was provided with a “clam-shell” anteroposterior thumb-spica splintthat was custom fabricated by an occupational hand therapist For the interval be-tween the office evaluation and surgery, the patient was instructed to wear the splint

at all times except to shower Unlike a cast, a removable splint is less likely to causeskin problems prior to surgery, and the splint can be reused during the postopera-tive course

Nonsurgical options included no treatment, immobilization in a cast or splint,and/or electrical stimulation The surgical options included an anterior (palmar)Russe versus dorsal approach (Fig 58–5), conventional nonvascularized bone graft(cancellous or corticocancellous) (Fig 58–6) versus vascularized, pedicled bonegraft from the distal radius, and fixation options including no fixation, Kirschnerwires (K wires), or screw fixation A vascularized distal radius corticocancellous

A

B

Figure 58–5 (A) Classic Russe volar bone graft tech- nique (B) Graft inset for the Russe graft.

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the radial nerve and lateral antebrachial cutaneous nerve were identified, mobilized

as necessary, and protected throughout the case The 1,2 ICSRA was identified perficial to the retinaculum between the first and second dorsal compartments Thefirst and second dorsal compartments were released The vascular pedicle was dis-sected distally from the level of the radioscaphoid joint toward the radial arteryanastomosis The dissection was performed distally to an extent that would enable atransverse capsulotomy to be performed to expose the scaphoid nonunion Also, thedissection was performed distally to an extent that allowed adequate mobilization ofthe pedicle such that the graft could be placed in the scaphoid defect without unduetension or kinking of the pedicle

su-The proximal pole nonunion was readily identifiable through the transverse sulotomy Wrist flexion over a rolled towel facilitated the exposure of the nonunionsite The nonunion site was taken down and fresh cancellous surfaces were preparedfor bone grafting A No 69 Beaver blade was used to remove fibrous tissue and scle-rotic bone Other useful instruments are small curettes, small rongeurs including

cap-a synovicap-al rongeur, cap-a smcap-all mosquito clcap-amp, cap-and cap-a power bur cap-at low speed cap-and withirrigation to prevent thermal necrosis The bony surfaces were debrided until freshcancellous bone was present both proximally and distally Adequate preparation

of the proximal fragment involved removal of most of the cancellous bone to thelevel of the subchondral bone A trough transverse to the longitudinal axis of thescaphoid was created for placement of the corticocancellous vascularized distal ra-dius bone graft Care was taken to ensure maintenance of the integrity of the sub-chondral bone and cartilaginous surfaces of both fragments

The bone graft harvest site was planned so that the distal aspect of the graftwas ~1.5 cm proximal to the distal end of the radius The size of the bone graft wasplanned so that the graft was slightly larger than the void present in the scaphoidfollowing its preparation Small osteotomes were used to harvest the graft Themore dependent cuts were made first so that blood from the bone would not ob-scure visualization during subsequent cuts Prior to performing the proximal limb

of the osteotomy, the 1,2 ICSRA was ligated proximally The last cut was at the tal aspect of the graft The pedicle was mobilized dorsally to cut the palmar portion

dis-of the distal cut and then palmarly to cut the dorsal portion dis-of the distal cut A tal pick was inserted in the cut created with the osteotome, and the dental pick wasrotated to osteotomize the deep cancellous bone Then a small osteotome was used

den-as a lever at the proximal osteotomy site to deliver the bone graft Additional lous bone graft was harvested from the distal radius

cancel-A strip of retinaculum containing the 1,2 ICSRcancel-A was elevated in a subperiostealfashion from proximal (the site of the bone graft harvest) to distal Adequate dissec-tion of the distal aspect of the pedicle was performed so that the graft could easily berotated dorsally to the scaphoid fracture site A rongeur was used to trim the graft tofit the scaphoid defect The graft was placed beneath the contents of the first dorsalcompartment

The wound was irrigated thoroughly to remove any blood, exposure to thescaphoid was achieved, and the tourniquet was released The proximal and distalscaphoid fragments were monitored to determine their vascular status Punctatebleeding was present on the distal fragment, but the proximal pole fragment did nothave any punctate bleeding Bleeding was visible along the periosteal edges of thebone graft, and punctate bleeding was visible from the cancellous bone of the graft

A vascularized, pedicled bone graft from the distal radius is not necessary and notappropriate for all scaphoid nonunions

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The limb was reexsanguinated by elevation, and the tourniquet was re-inflated.All wounds were irrigated thoroughly A small amount of cancellous bone graft waspacked into the proximal pole and onto the surface of the distal fragment so that allinterstices would be filled Then the vascularized bone graft was placed into thescaphoid defect and trough Care was taken to exert pressure only at the perimeter

of the graft to prevent any injury to the pedicle

Two nonparallel K wires were placed in a retrograde fashion under direct vision tostabilize the two scaphoid fragments and the bone graft Intraoperative fluoroscopywas used to confirm adequate positioning of the bone graft and the internal fixation.The capsulotomy was not closed Marcaine (0.05%) without epinephrine wasplaced, and the wound was closed A noncompressive dressing was applied, and asingle sugar-tong, thumb spica splint was applied with the elbow at 90 degrees,forearm in neutral rotation, wrist in neutral position, and thumb in the opposedposition

Postoperative Management

The postoperative splint was removed after 2 weeks The patient was placed into along-arm thumb spica cast for 4 additional weeks He was then placed in a short-arm thumb spica cast until there was radiographic evidence of scaphoid union at

16 weeks postoperatively The patient then began wearing a “clam shell” terior thumb spica splint and performing range-of-motion exercises The K wireswere removed 6 weeks later when the wrist stiffness had improved An MRI wasperformed to confirm vascularity throughout the scaphoid, including the graft andproximal pole, and to confirm healing at the two osteosynthesis sites At this timethe postoperative splint was discontinued, and the patient proceeded with contin-ued range of motion and began strengthening exercises

anteropos-Alternative Methods of Management

Alternative options for patients with stage D5 who do not have significant teoarthritis but do have a humpback deformity include a palmar trapezoidal non-vascularized bone graft, a palmarly placed corticocancellous vascularized graft, and

os-a sos-alvos-age procedure Sos-alvos-age procedures include ros-adios-al styloidectomy, scos-aphoid sion and midcarpal fusion, and radiocarpal arthrodesis

exci-A dorsal or palmar approach can be used exci-A palmar approach offers the tages of excellent visualization, easier correction of a humpback deformity, and abil-ity to compress the fracture fragments with a compression jig such as the Herbertjig The palmar approach is applicable for most nonunion patterns except for frac-tures with small proximal pole fragments that would be difficult to engage with theend of the fixation used The dorsal approach is better reserved for the cases of smallproximal pole fragments or when other procedures such as vascularized bone graft-ing dictate a dorsal approach

advan-A complete range of fixation options exists Options include no fixation, K-wirefixation, and compression-screw fixation with or without K-wire augmentation In-lay bone grafting without internal fixation is appropriate when the fracture is stable,

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but without internal fixation early range of motion will not be possible K wires areeasily placed, inexpensive, and can be removed for postoperative imaging; however,they do not create compression at the fracture site

Compression screws all provide security for earlier range of motion Also, theyallow compression with screw placement, but necessarily have the associated risk offlexing the fracture if the screw is placed poorly or there is inadequate palmar sup-port Additionally, compression screws have added expense and require additionaltechnical skills

When applicable, the conventional noncannulated Herbert screw offers manyadvantages Rigid internal fixation is possible, thus providing added security forearlier range of motion or a longer period of implant integrity for slow healing sit-uations The Herbert jig allows for compression across the osteosynthesis site prior

to screw placement, and it is more easily placed than the more bulky jig for theHerbert-Whipple cannulated screw Because the core area at the osteosynthesis site

is smaller than that of the Herbert-Whipple screw, more bone contact area remainsfor osteosynthesis In contrast to an Acutrak screw, the threads on each end of aHerbert or Herbert-Whipple screw are uniform (i.e., constant pitch) Thus, there

is minimal resistance during advancement of the screw through the “upstream”fragment (proximal relative to the screw) during the screw insertion With mini-mal resistance, the screw imparts minimal torsional force to the “upstream” frag-ment, and subsequently there is less tendency for rotation at the osteosynthesisduring insertion than with the placement of an Acutrak screw Situations where aHerbert screw is not optimal include fixation of a very small proximal pole frag-ment and when postoperative imaging is anticipated such as with a vascularizedbone graft

Complications

Treatment of scaphoid nonunion is more difficult and more technically ing than the treatment of primary scaphoid fractures The complexity increasesand the likelihood of persistent nonunion increases with the number of opera-tive interventions Complications include inadequate restoration of the scaphoidanatomy and the persistence of carpal instability Meticulous attention to detailincluding direct observation of the scaphoid and intraoperative fluoroscopic ex-amination is essential Fluoroscopic images in multiple planes and real-time flu-oroscopy with rotation of the wrist are helpful for ensuring restoration of thescaphoid anatomy and carpal alignment Persistence of the nonunion can occurand is more likely in the presence of an avascular necrosis, large amounts of bonyresorption, excessive soft tissue and blood supply disruption, and poor fixation.Superficial branch of radial nerve injuries are possible with dorsal and dorsoradialapproaches to the scaphoid During a palmar approach, palmar cutaneous nerveinjuries are possible but less likely Pin tract infections can occur if K wires are per-cutaneous Cutting the K wires beneath the skin prevents pin tract infections, butrequires that another procedure be performed for removal With prolonged periods

demand-of internal fixation with K wires, especially when range-demand-of-motion exercises are ing performed, there is an increased likelihood of K-wire breakage from motionimparted by overlying tendons and other soft tissue Some degree of wrist stiffness

be-F R A C T U R E S A N D D I S L O C A T I O N S O be-F T H E W R I S T

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Figure 58–8 Range-of-motion check in a patient at 1-year follow-up showing slight decrease

in the operation side The patient reported no pain.

should be anticipated (Fig 58–8) Minimizing the operative exposure, attention tosoft tissue technique, and earlier range of motion can optimize postoperative wristmotion

Suggested Readings

Barton NJ Experience with scaphoid grafting J Hand Surg [Br] 1997;22B:2:153–160 Cooney WP Bone-grafting techniques for scaphoid nonunion Tech Hand Upper

Extrem Surg 1997;1:148–167.

Green DP The effect of avascular necrosis on Russe bone grafting for scaphoid

nonunion J Hand Surg [Am] 1985;10A:597–605.

Hastings H, Zaidenberg CR, Mih AD Vascularity of the distal radius: clinical

impli-cations for harvesting bone grafts Current Trends Hand Surg 1995;167–175.

Herbert TJ Treatment of established nonunion In: Herbert TJ, ed The Fractured

Scaphoid St Louis: Quality Medical Publishing; 1990:91–120.

Ruby LK, Stinson J, Belsky MR The natural history of scaphoid nonunion A review

of fifty cases J Bone Joint Surg [Am] 1985;67A:428–432.

Shin AY, Bishop AT, Berger RA Vascularized pedicle bone grafts for disorders of the

carpus Tech Hand Upper Extrem Surg 1998;2:94–109.

the scapholunate ligament in

addition to other carpal

frac-tures besides the scaphoid.

• Rigid carpal fracture fixation

and anatomic restoration of

the distal radial articular

sur-face and intercarpal

relation-ships are prerequisites for

satisfactory wrist function

PITFALLS

• Biplanar roentgenograms of

radial styloid fractures may not

represent concomitant

inter-carpal ligamentous injury Figure 59–1 Posteroanterior (A), oblique (B), and lateral (C) roentgenograms of wrist with radial

styloid and scaphoid fractures with concomitant scapholunate dissociation.

59

Radial Styloid Fractures

James H Calandruccio

History and Clinical Presentation

A 40-year-old man lost control of his four-wheeler and landed on his dominantwrist He was initially examined at a local emergency room where a closed defor-mity about the wrist level was observed A thumb-spica splint was applied, and hewas referred to an orthopedic surgeon whom, he saw 5 days after his original injury

Physical Examination

There is moderate swelling of the hand to the metacarpophalangeal joint level, withsensation diffusely diminished in the hand, most predominantly in the mediannerve distribution

Diagnostic Studies

Posteroanterior and lateral radiographs revealed a radial styloid fracture associatedwith a displaced fracture of the waist of the scaphoid (Fig 59–1) No other abnor-malities were noted on films of the hand, forearm, or elbow

Radial styloid fractures without obvious intercarpal malalignment in patientswho have suspected intercarpal ligament injuries may benefit from adjunctive wristarthroscopic management, but it is the author’s opinion that surgical management

of acute partial scapholunate ligament tears associated with distal radial fractures isprobably rarely warranted

Surgical Management

During the 7 days before surgery, a splint was applied and the upper extremity mally elevated to reduce swelling Operative procedures included open reduction andinternal fixation of the scaphoid with an antegrade screw and 0.054-inch Kirschnerwire, closed reduction and pinning of the distal radial fracture with Kirschner wires,repair of the scapholunate interosseous ligament, intercarpal pin stabilization, andopen carpal tunnel release (Fig 59–2)

maxi-The scaphoid was exposed through a longitudinal dorsal incision maxi-The proximal pole

of the scaphoid was found to be completely detached from the scapholunate osseous ligament Secure fixation of the scaphoid fracture was accomplished with anantegrade Herbert screw Direct visualization of the intraarticular radial styloid frac-ture assisted reduction before percutaneous Kirschner pin fixation Maintenance of theproper capitolunate orientation was achieved with a retrograde Kirschner wire from thecapitate to the lunate (Fig 59–3) The scapholunate joint was then reduced and two0.054-inch Kirschner wires were used to maintain the normal scapholunate relationship