Книга_574_Библиотеки_им_академика_М_И_Перельмана

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POST-OPERATIVE CARE AND SCAPHOID HEALING

Immediate post-operative care includes abulky compressive hand dressing and avolar splint. The patient is encouraged to initiate early ﬁnger exercises to reduce swelling. The therapist fashions aremovable volar splintthatholds thewrist and hand in afunctional position at the ﬁrst post-operative visit. An immediate strengthening program is initiated to axially load the fracture site. This early motion also decreases swelling and permits an early return of hand function. Patients with ligament injuries or proximal pole fractures, are restricted from wrist motion until CT scan conﬁrms bridging bone at the fracture site at six weeks post-op. Post-operative radiographs are obtained with the ﬁrst post-operative visit and at six week intervals. CT scans with 1mmcuts and sagittal and coronal reconstructions are used to evaluate bridging bone at the fracturesite. CT scans areordered at sixweeks intervals until ﬁnal unionis established.

Standard radiographs at three months are unreliable in detecting scaphoid healing (6). Patients are often pain free, prior to CT evidence of healing. Contact sports and heavy labor are restricted, until fracturehealing is conﬁrmed by CT.Ifbridging bone is not identiﬁed by 12 weeks one must consider aggressive treatmentincluding percutaneous bone grafting. Delay in treatmentfor earlynonunions,delayshealing.Wedonot routinelycastour scaphoid fracturespost-operatively,but candidatesfor additionalprotection areevaluated on an individual basis.

SUMMARY

Scaphoid fracturesare common injuries that often require surgicaltreatment. Closedtreatment is complicatedby prolonged casting and associated stiffness. The advent of cannulatedheadlessscrewshas simpliﬁedthe treatmentofthese difﬁcult fractures. Percutaneous treatment of scaphoid fractures offers high healing rates with minimal soft-tissue trauma.

SUMMATION POINTS

Indications

Non and minimally displaced scaphoid fractures

Displaced fractures are amenable, but requireadditional joy stick K-wires and is more technically challenging.

Outcomes

High healing rates

Quicker return to activities and work

Less wound problems and scar tenderness.

Complications

Similar to open technique

Nonunions

Hardwareproblems (screw excessively long).

REFERENCES

1. Toby EB, Butler TE,McCormack TJ,Jayaraman G. Acomparison of ﬁxation screws for the scaphoid during application of cyclic bending loads. JBone Joint Surg1997; 79:1190–7.

2. McCallister WV,Knight J, Kaliappan R, Tr umble TE.Central placement of the screwinsimulated fractures of the scaphoid waist: abiomechanicalstudy.JBone Joint Surg 2003; 85A:72–7.

3. Geissler WB,Freeland AE, Savoie FH ,McIntyreLW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fractureofthe distal end of the radius. JBone Joint Surg Am 1996; 78(3):357–65.

4. Palmer AK. Tr iangular ﬁbrocartilage complex lesions: aclassiﬁcation. JHand Surg 1989; 14A:594–606.

5. Bond CD, Shin AY,McBride MT,etal. Percutaneous screw ﬁxation or cast immobilization for nondisplacedscaphoid fractures. JBone Joint SurgAm2001; 83-A(4):483–8.

6. Dias JJ. Deﬁnition of union after acute fractureand surgery for fracturenonunionofthe scaphoid. JHand Surg Br 2001; 26(4):321–5.

Slade and Merrell

Percutaneous Fixation of Acute Scaphoid Fractures

John T. Capo, Tosca Kinchelow,and Virak Tan

Department of Orthopedics, The New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, U.S.A.

INTRODUCTION

Fractures of the scaphoid are common injuries, representing 60–70% of carpal fractures (1,2). Inadequate treatment of these injuries can result in nonunion, osteonecrosis, carpal instability patterns, all of whichcan lead to impairedfunction, and arthrosis (3–5). Early results of cast immobilization of acute fractures were quite favorable, reporting union rates of 88–100% and good motion, grip strength, and function (6–9). However, subsequentserieshaveshown more discouraging results, particularly with fractures displaced more than 1mm (10,11). The ﬁrst factor in initiating appropriate treatment is the proper and timely diagnosis of these fractures. Once diagnosed, the fracture can be managed by closed, open, or percutaneous methods. Internalﬁxationhas the advantage of providing compression and astable construct whichcan allowearly range of motion (ROM) (12–17). However,anopen approach risks stripping of the critical blood supply to the scaphoid and also division of important carpal ligaments, such as the radioscaphocapitateligament (18).Percutaneous techniques have since been developed, providing the beneﬁts of ORIF with a smallerincision, preservation of thecarpalligaments and potentially fewer wound problems.

INDICATIONS

The ultimate goal in any scaphoid treatment is to obtain and maintain anatomic alignment while preserving vascularity until complete fracturehealing has occurred. Operative ﬁxation is suggested when acceptable alignment cannot be reached by closed treatment. In addition, with the documented success of percutaneous screwﬁxation(3,19–22),webelieve that this technique should be offered to all patients with acomplete scaphoid fracture, evenifminimallyornon-displaced.The patient should be educated about the two treatment options: long-arm followed by short-arm casting versus operative percutaneous screw ﬁxation. We explain the risks and advantages of operative treatment as well as the risks and details concerning the prolonged length of non-operative treatment. In our experience, approximately 50% of patients select operative ﬁxation.

Otherindicationsinclude themultiplyinjured patient either in the same or other extremities.Patients with ipsilateral distal radius fractures and elbow fractures, as well as those with lower extremity injuries that need to useassistiveaids to mobilize, are good candidates for operative treatment of minimally displaced scaphoid fractures.Fractures with asmall amount of displacement (2–3 mm) or angulation (208 intrascaphoid angle) and no comminution at the fracture site may also be treated with percutaneous means. Kirschner (K)-wires can be used as joysticks to manipulate the proximal and distal fragments beforeguide wireplacement.

Contraindications to percutaneousﬁxationinclude moderate or severefracturedisplacementrequiring open reduction, nonunion with signiﬁcant bone resorption requiring supplemental cancellous bone graft, avascular necrosis (AVN) requiring avascularized bone graft, and adisplaced nonunion with a“humpback” deformity requiring astructural bone graft to restore normal carpal alignment.

PREOPERATIVE PLANNING

Physical Examination

The ideal patient for this technique is ayoung healthy male laborer or athlete with amid-waist acute fracturewith minimal displacement. The mechanism of injury usually includes load to the dorsiﬂexed, radially deviated wrist. On physical exam, there is typically mild to moderate edema, painful, limited ROM, and tenderness of the scaphoid. The body of the scaphoid can be palpated in the interval between the ﬁrst and second dorsal compartmentsdorso-radially and becomesmoreprominent with ulnar deviation of the wrist. The scaphoid tuberosity can be palpated volarly at the wrist crease, just radial to the ﬂexor carpi radialistendon. Thescaphoidcompression test (23) is positive when axiallyloading the thumb metacarpal toward the wrist causes pain.The Distal radial–ulnar joint, ulnar side of the wrist, and elbow should be examined for tenderness and crepitus. Soft tissues need to be evaluated, including athorough neurovascular exam. For proper edema management, the patient should be instructed on ﬁnger motion exercises and elevation of the extremity,ineither deﬁnitive closedmanagement or for temporary immobilization beforeoperative treatment.

Imaging

Standard plainradiography is mandatory, including posteroanterior (PA), lateral, oblique, and PA ulnar deviation views. This last view is termed the “scaphoid view” and extends the scaphoid, thereby visualizing an elongated view of the entire bone (Fig. 1). Images of the contralateral side may be useful, particularly in assessing anydeformity. It is importantto evaluate radiographs for the presence of an acute or chronic fracture andscaphoiddeformity, sincethiswillinﬂuence whetherﬁxationcan be done percutaneously. Radiographic parameters for inadequate reductionare:displacement

O 1mm, ascapholunateangle O 608 ,radiolunate angle O 15–308 ,anintrascaphoid angle O 358 ,orascaphoid height- to-length ratio O 0.65 (7,24–27).

Advanced Imaging

When plain ﬁlms are equivocal for fracture and the patient has scaphoid tenderness, management is controversial. While

it has been proposed that any fracture not seen on radiographs is incomplete and does not requireimmobilization (8), the usual practiceistopresumethatacomplete fracture is present. Traditionally,the patient is immobilized for one to two weeks and then re-examined and re-imaged. By that time, bony resorptionatthe fracture may demonstrate lucency within thescaphoid, conﬁrmingafracture.Ifplain ﬁlms remain equivocal and/or the patient remains tender,another immobilization trial can be done (8) or advanced imaging

[bone scan or magnetic resonance imaging (MRI)] should be obtained (23).

Attentionhas been given to theinaccuracy of plain radiography in diagnosing occult scaphoid fractures initially and postinjury (8,28). Furthermore, advanced imaging has been showntobemuchmorereliable (29–31), with aquoted sensitivity of 100% and speciﬁcity 95–100% for MRI scanning. Dorsay (32) compared the reliability of plain ﬁlms and MRI in diagnosing occult scaphoid fractures and evaluated the costs associated with each. MRI was more sensitive, speciﬁc, and had ahigher interobserver reliability than plain ﬁlms. Additionally, thecost of an earlyscreening MRIinacase with clinical suspicionand negative radiographs wascomparabletothe cost of lost work time due to keeping apatient immobilized for one to two weeks. In our practice, if apatient has an injury mechanismand clinical exam consistentwith ascaphoid fracture with negative radiographs, we immobilize the wrist in ashort-arm thumb-spica cast. If these parameters are the same follow-up exam in one to two weeks, then an MRI study is ordered.

SURGICAL TECHNIQUE

Operating Room Setup and Equipment

The following equipmentisneeded: amini-ﬂuoroscopy machine, non-sterile arm tourniquet, small battery drive drill, K-wires, and acannulated, headless screw set (headed screws may also be used). While there are currently several commercially available screws that can be used, most instrumentation systems are similar and utilize some variation of the following: a guide wire, acannulated drill bit, reamer,tap and screwdriver,a countersink, and screws. Wire size and screwdriver/instrumentation gauge vary,but we have found that aguide wire of at least

0.035 inch is ideal, as it provides better control for accurate placement into the proximal pole.

General or regional anesthesia may be used. The patient is positioned supine with aradiolucent hand table. Some authors place the patient in ﬁngertraps, with traction and weights, as needed (3,11,20). This helps to ulnarly deviate the wrist, which uncovers the distal scaphoid from the radial styloid and allows free rotation of the hand (11,20). We prefer to place the hand over asmall towel role for wrist extension and apply only manual, intermittent traction to the ﬁngers (Fig. 2). However,in thecaseofadisplaced fracture, traction canaid in closed reduction (29).

Surgical Technique

Ultimately,the location of the skin incision will be directedby wire placement. This is usually on the distal volar–radial aspect of the scaphoid near the scaphotrapezial (ST) joint. Care should be taken to avoid the dorsal aspect of the ST joint because the dorsal branch of the radial artery is in this area. There exist key landmarks to aid in proper guide wirestarting hole placement. This location can be approximated by simply drawing bony structures with askin marker and noting the level of the ST joint and radial aspect of the scaphoid (Fig. 3). Alternatively,the location can be found at the intersection of two lines drawn in line with K-wires placed on the outside of the skin parallel to the long axis of the scaphoid on frontal and lateral views (22,33). Typically,the wire must start through the volar,proximal corner of the trapezium, thus allowing access to the center of the distal scaphoid pole. Therefore, the subsequent drilling removes this edge of trapezium and screw placement traverses the defect to be countersunk in the scaphoid. Alternatively,asmall piece of

(A)

(B)

FIGURE 1 ( A )PAview of the wrist with aquestionable scaphoid waist fracture. ( B )Ulnar deviation PA view clearly demonstrating complete scaphoid fracture. Abbreviation:PA, posteroanterior. Source:Courtesy of John T. Capo, MD.

Capo et al.

thetrapeziumcan be removedwith arongeur to allow unhindered placement of the guide wire, requiring alarger incisionand dissection to directlyvisualize the ST joint. Anotheralternative is to avoidviolating thetrapezium by using amore radial starting point (34).

The ﬁnal position of the wire (and subsequent screw) is the most critical part of the procedure and should be in the center of the proximal pole of the scaphoid in all radiographic views. In Tr umble’s (35) study of screw ﬁxation with bone graft in 34 patients with scaphoid nonunion, those with screws placed in the central one-third of the proximal pole had asigniﬁcantly faster time to union than those with peripherally placed screws. McCallister(36)supported theseresults in abiomechanical study, ﬁnding that acenter–center screwplacement in the proximal pole of the scaphoid provided aconstruct that was

signiﬁcantly stiffer (43%) and moreresistant to displacement (113%) than an eccentrically placed screw.

The guide wire must be within the scaphoid body in all

views, with enough clearance on each side for screw placement (Fig. 4). A45 8 pronated (oblique) view is helpful to assess the proximal pole wire placement, as wire penetration through the proximal scaphoid articular surface can be missed on standard PA and lateral views (22,33). Once the wire is in place, and its position conﬁrmed ﬂuoroscopically,consideration should be given to placing asecond, derotational wire, whichcan be helpful in more unstable fractures(22,24). We have not found this second, derotation wiretobenecessary in most cases.

Often, the guide wireonthe implant set is of asmall caliber and easily bent.Asanexample, theAcutrak (Acumed, Beaverton, Oregon,U.S.A) mini-sized screw is preferable as it

FIGURE 2 The wrist is extended over asmall towel roll. This allows guide wire access to the trapezium and distal scaphoid pole. Source:Courtesy of John T. Capo, MD.

FIGURE 3 Theoutlines of the trapezium an dscaphoid aredrawn on thevolar wrist.The guidewire is placed starting at the trapezial edge and advanced in aproximal ulnar and dorsal direction. Source:Courtesy of John T. Capo, MD.

Percutaneous Fixation of Acute Scaphoid Fractures

removes less bone and creates asmaller starting hole in the scaphoid, but its guide wire is 0.028 inch. This size wireis insufﬁciently rigidtoobtainaccurate placementand easily bends with even gentle wrist motion. Atechnique to avoid this is to use a0.035 inch wirefor ideal placement and to use an additional identical length wirefor measuring. Alternatively, the new Synthes (Synthes Corp., We st Chester,Pennsylvania, U.S.A.) scaphoid screw set has asufﬁciently large guide wire of

0.045 inch.

After appropriate guide wire placement, alongitudinal incision (approximately 5mm, just largeenough for the depth gauge and screw)iscentered on the wire (20). Blunt dissection is then used to obtain access to the distal scaphoid and trapezium. Screw length is determined by using the supplied depth gauge or by an additional wire of identical length to calculate the amount of guide wire buried in the bone. It should be veriﬁed radiographically that the depth gauge or wire is on the distal scaphoid edge and not the trapezium to ensure accurate screw

(A)

(B)

FIGURE4 ( A )The lateral ﬂuoroscopicview demonstratesthe proper starting point of the guide wire.The edgeofthe trapeziumistraversed to allow access to the center of the distal scaphoid pole. ( B )Final guide wire placement in the AP view. Thewirestartsatthe distal radial edge of the scaphoid andiscentered in theproximalpole. Abbreviation:AP, anteroposterior. Source : Courtesy of John T. Capo, MD.

Capo et al.

length (Fig. 5). The screw length selected should be 2–4 mm shorter than the wire measurement, depending on the position of the proximal end of the wire. In our hands, the most accurate method is to place the proximal tip of the wire at the scaphoid cortical edge and then subtract 4–5 mm.

Hand or power drilling is then done, followed by tapping

as needed (based on screw type, bone quality,and presence of

sclerosis). Drilling, tapping, and screw placement are done with ﬂuoroscopic guidance (Fig. 6). The screw is placed over the wireand inserted under ﬂuoroscopic control to ensure maintenance of the reduction (Fig. 7). If any rotation between the proximal and distal fragments is noted, aderotational wire should be placed (33). The ideal screw provides appropriate compression and is countersunk at least 2mmoneither

FIGURE 6 Cannul ated drill advancingoverthe guide wire under ﬂuoroscopiccontrol. Thedrill has removed the volaredgeofthe trapezium. Source :Courtesy of John T. Capo, MD.

FIGURE 5 Asecond guide wire of equal length is placed on the scaphoid cortical surfacetoobtain aproper length measurement. If the measuring sleeve is used, it should be ensured to rest at the same location. Source:Courtesy of John T. Capo, MD.

Percutaneous Fixation of Acute Scaphoid Fractures

end of the scaphoid (5,22). Final screw placement is veriﬁed with imaging to ensure it is countersunkand within the conﬁnes of the scaphoid bone (Fig. 8). If traction is being used,itshould be released before ﬁnal screw tightening, allowing for more compression (11). When using aconical screw system (like the Acutrak set), care must be taken not to over-drill the channel in length or insert the screw too far. Due to the conical nature of the screw this may cause screw loosening or fracutre of the scaphoid proximal pole.

The wound is irrigated and closed with two to three nylon

sutures(Fig. 9). Asplint is placed for comfort and active ﬁnger

ROM is allowed immediately.Ifthe fracture was rigidly ﬁxed, then we begin gentle wrist ROM once the wound is stable (usuallyatthe ﬁrst postoperative visit).However, this is controversial.Preferences for postoperative immobilization range from mandatory (24) to optional or unnecessary (20,22,33). In between ROM exercises, patients wear aremovablethumb-spicasplint(offthe shelformadebyan occupational therapist). Patients can return to sedentary work when they feel ready or when their ROM is 75% comparedto thecontralateral side (20).Manualorathleticwork canbe resumed at the time of bony union (20). If plain radiographs

(A)

(B)

FIGURE 7 ( A )Cannulatedscrew being placed through volar wound. ( B )Lateral ﬂuoroscopic view of screw being advanced into scaphoid body. Note that the guide wire has been further advanced out of the proximal pole to avoid loosening with drilling and screw placement. Source: Courtesy of John T. Capo, MD.

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Capo et al.

are inconclusive, acomputed tomography scan can be obtained to verify bony healing.

COMPLICATIONS AND THEIR MANAGEMENT

Overall,the complicationrate forthistechniqueislow. However,the most frequent complications reported include

nonunion, symptomatic hardware, residual pain, superﬁcial radialnerve irritation, and superﬁcial woundinfection. Nonunion has been reported at rates ranging from 0% (20–22) to 11%(11,36). Nonunion has been attributed to improper screw placement, proximal polefractures,and treatmentdelayed beyond fourweeks(11,37).Mildresidualpainhas been reported from 5% (21) to 29% (37) of patients and associated with ipsilateral distal radius fractures, scaphotrapeziotrapezoid injury,adhesions, and scar sensitivity.Symptomatic hardware has occurred in cases of both headless and headed screws at a rate up to 10% (22,37). Of these cases, 50% were successfully treatedwith hardware removal (22,37). Transient superﬁcial radialnerve irritationhas beenreported in 2–6%ofcases. Superﬁcial wound infection, occurring in up to 1% of patients, has been effectively managed with oral antibiotics.

Wozasek (2001) reportedtreatment of 146 scaphoid fractures with apercutaneously placed 4.8 mm cannulated, headed screw and detected mild trapezial erosions in one-thirdofhis patients. The majority of these patients had painless, full ROM and no signiﬁcant clinical consequences (11). He also reported oneloose screw thatrequired replacement andreﬂex sympathetic dystrophyintwo of these 46 patients.

OUTCOMES

Percutaneous ﬁxation of scaphoid fractureswas ﬁrst introduced in the German literature by Streli in 1970 (38). In 1986, Cosio (39) reported 77% unionfor percutaneous K-wire treatment of scaphoid nonunions. In 1991, Wozasak (11) reported results of percutaneous ﬁxation, with cannulated 4.8 mm screws,of acutefractures,delayed unions,nonunions,and sclerotic nonunions. Of the 146 acute fracturestreated, there was an 84% unionatanaverage of four months.One-third of the nonunions were attributed to technical errors, including screw protrusion through the proximal fragment, threads across the fracture site, and screw length too long to provideadequate compression. Ledoux (40), in the French literature, reported 23 cases, demonstrating 100% union rate and wrist ROM of 95% compared to the contralateral side.

In 1998, Haddad (20) publishedresults of 15 patients treatedwith percutaneous screws. He reported a100% union rate within two months and ROM and grip strength similar to theopposite side.Returntoworkaveragedfourdaysfor sedentary and ﬁveweeks formanualjobs. Brutus (37) reportedaretrospectivereviewof30patientstreated with percutaneously placed Herbert screws and followed forat least six months. His results included a90% union rate and a return to work at an average of 1.6 months for professional work and 1.8 months for sports. Yip(22) percutaneously treated 49 fractureswith cannulated 3.5 mm screws and followed them for an average of four years. There was a100% union rate at 12 weeks and no infection, AV N, nonunion, or arthrosis.

The percutaneous techniquehas alsobeendirectly compared to cast immobilization of non- andminimally displaced fracturesand has had favorable results. Adolfsson (3) reviewed 53 patients treated with immobilization in ashortarmthumb-spica cast versus percutaneousAcutrak screw ﬁxation. While rate andtimetounion werefoundtobe similar,the operative group had signiﬁcantly better ROM at 16 weeks. Inoue (21) comparedthe outcomes of 39 patients treatedwith ashort-arm thumb-spica cast and 40 treated with a freehandstandard Herbert screwplacedthrougha1cm incision.Thiswas aretrospective review and the typeof treatmentwas determined by thepatients, afterinformed discussion about each treatment method. The operative group

(A)

(B)

FIGURE 8 ( A )APand ( B )lateral views demonstrating ﬁnal placement of screw. Both proximal and distal aspects of the screw are countersunk well within thebone. Abbreviation:AP, anteroposterior. Source : Courtesy of John T. Capo, MD.

Percutaneous Fixation of Acute Scaphoid Fractures

101

had asigniﬁcantly faster time to union (6 vs. 9.7 weeks) and return to work (5.8 vs. 10 weeks). There was one nonunion in the cast group that was successfully treated with subsequent screw ﬁxation and bone graft. Twopatients in the operative grouphad mild pain,which wasthought to be relatedto ipsilateral distal radius fractures.

In alandmarkstudy in 2001, Bond (19) prospectively randomized 25 military personnel with non-displaced scaphoid fracturestocast immobilization or percutaneous screw ﬁxation. The onecomplicationinthe ﬁxation groupwas adistally prominentand symptomatic screw that needed to be removed. There werenocomplications in the cast immobilization group. The times until union and return to work were signiﬁcantly shorter for the percutaneous ﬁxation group: seven and eight weeks versus 12 and 15 weeks, respectively.However, at two years, there werenosigniﬁcant differences in function or satisfaction between groups.

SUMMARY

General Conclusions

Internal ﬁxation has the advantage of providing rigid stabilization that eliminates the need for above-elbow immobilization and permits early ROM. However,open ﬁxation involves larger incisions, soft tissue stripping, and possible vascular compromise. The percutaneous ﬁxation technique for selected scaphoid fracture and nonunions is asafe and effective treatment option, now yielding up to 100% union rates with minimal surgical complications and signiﬁcantly faster return to work and activities of daily living. As surgeon familiarity continues to improve, percutaneous techniques are being used to treat a wider variety of fractures, nonunions, and AV Ncases. The data justifying its use are compelling and suggest that percutaneous ﬁxation for non- and minimally displaced scaphoid fractures is an ideal treatment option for apatient who desires early return to function.

Future Direction

Many advances continue to be made in the application and utilityofthe percutaneous techniquefor treating scaphoid

injuries.Closedreduction maneuvers, e.g.,ulnar deviation, and percutaneously placed K-wires as joysticks can be used to reduce unstable anddisplaced fractures(5,26,41–43) and reductioncan be veriﬁedwitharthroscopic assistance (5,43–46). Early nonunions can be treated with screw ﬁxation alone if the cartilaginous shell is intact, there is no collapse, and cystic changes are mild (5). If the nonunions are more advanced with larger cyst formation, these can be debrided with percutaneously placed curettes and then injected with bone graft, followed by percutaneous screw placement (43). Select cases of AVNhavealsobeentreated percutaneouslybyproviding “vascularized” bone graft through retrograde reaming (43).

Hardware improvement should include larger guide wires which providemore controlduring guide wireplacement and avoid bending. Another implant advance that has recently been introduced is the development of self-drilling screws (Acutrak; Wright Medical Technology,Arlington, Tennessee, USA). These can save time and also allow further advancement of the screw to amore accurate ﬁnal location while minimizing the chance of fracture of the proximal pole. New methods of percutaneously placed grafts would also be beneﬁcial in difﬁcult nonunion cases.

SUMMATION POINTS

Indications

Acute minimally displaced scaphoid fracture in ahealthy patient requiringearly return to work/functionor unwilling to accept prolonged closed, cast treatment

Scaphoid nonunion with near-anatomicalignmentand minimal cystic degeneration

Relative:Displaced fractures and nonunions with signiﬁcant cystic changes (only if surgeon is experienced with percutaneous techniques and assistive arthroscopy)

Outcomes

Union rates O 98%

Less/minimally invasive

Allows earlierROM and return to work and regular activities

Lessens immobilization

Shorter operative time: (with experience)

FIGURE 9 Three nylon sutures are used to close the skin of the entry site. Source:Courtesy of John T. Capo, MD.

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Capo et al.

Complications

Residual pain (up to 29%)

Nonunion (0–11%)

Symptomatic hardware (5–29%)

Transient superﬁcial radial nerve irritation (2–6%)

Superﬁcial wound infection (up to 1%)

REFERENCES

1. Chan KW,McAdams TR.Central screwplacement in percutaneous screw scaphoid ﬁxation: acadaveric comparison of proximal and distal techniques. JHand Surg [Am] 2004; 29(1):74–9.

2. Simonian PT,Trumble TE.Scaphoid nonunion.JAm Acad Orthop Surg 1994; 2(4):185–91.

3. Adolfsson L, Lindau T, Arner M. Acutrak screw ﬁxation versus cast immobilisation for undisplaced scaphoid waist fractures. JHand Surg [Br] 2001; 26(3):192–5.

4. Duppe H, Johnell O, LundborgG,Karlsson M, Redlund-Johnell I. Long-term results of fractureofthe scaphoid. Afollow-up study of morethan thirty years. JBone Joint Surg Am 1994; 76(2):249–52.

5. Slade JF,III, Gutow AP,Geissler WB.Percutaneous internal ﬁxation of scaphoid fractures via an arthroscopically assisted dorsal approach. JBone Joint Surg Am 2002; 84-A(Suppl. 2):21–36.

6. Bohler L, Trojan E, Jahna H. The results of treatment of 734 fresh, simple fractures of the scaphoid. JHand Surg [Br] 2003; 28(4):319–31.

7. Cooney WP,Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management.Clin Orthop Relat Res 1980; 149:90–7.

8. Dias JJ, Thompson J, Barton NJ, Gregg PJ.Suspected scaphoid fractures. The value of radiographs. JBone Joint Surg Br 1990; 72(1):98–101.

9. Russe O. Fractureofthe carpal navicular.Diagnosis,non-operative treatment, and operative treatment. JBone Joint Surg Am 1960; 42-A:759–68.

10. Eddeland A, Eiken O, HellgrenE,Ohlsson NM. Fractures of the scaphoid. Scand JPlast Reconstr Surg 1975; 9(3):234–9.

11.Wozasek GE, Moser KD. Percutaneous screwﬁxation for fractures

of the scaphoid. JBone Joint Surg Br 1991; 73(1):138–42 (Erratumin: JBone Joint Surg [Br] 1991; 73(3):524).

12. Bunker TD,McNamee PB,Scott TD.The Herbert screwfor scaphoid fractures. Amulticentrestudy.JBone Joint Surg Br 1987; 69(4):631–4.

13. Filan SL, Herbert TJ.Herbert screwﬁxation of scaphoid fractures. JBone Joint Surg Br 1996; 78(4):519–29.

14. Herbert TJ,Fisher WE .Management of the fractured scaphoid using anew bone screw.JBone Joint Surg Br 1984; 66(1):114–23.

15. Herbert TJ,Fisher WE ,Leicester AW.The Herbert bone screw: a ten year perspective.JHand Surg [Br] 1992; 17(4):415–9.

16. O’Brien L, Herbert T. Internal ﬁxation of acute scaphoid fractures: a new approach to treatment. Aust NZJSurg 1985; 55(4):387–9.

17. Rettig AC, Kollias SC. Internal ﬁxation of acute stable scaphoid fractures in the athlete. Am JSports Med 1996; 24(2):182–6.

18. Garcia-Elias M, Vall A, Salo JM, Lluch AL. Carpal alignment after different surgical approaches to the scaphoid: acomparativestudy. JHand Surg [Am] 1988; 13(4):604–12.

19. Bond CD, Shin AY,McBride MT,Dao KD. Percutaneous screw ﬁxation or cast immobilization for nondisplacedscaphoid fractures. JBone Joint Surg Am 2001; 83-A(4):483–8.

20. Haddad FS,Goddard NJ. Acute percutaneous scaphoid ﬁxation. A pilot study.JBone Joint Surg Br 1998; 80(1):95–9.

21. Inoue G, ShionoyaK.Herbert screwﬁxation by limited access for acute fractures of the scaphoid. JBone Joint Surg Br 1997; 79(3):418–21.

22. YipHS, Wu WC,Chang RY,SoTY. Percutaneous cannulatedscrew ﬁxation of acute scaphoid waist fracture. JHand Surg [Br] 2002; 27(1):42–6.

23. Ring D, Jupiter JB, Herndon JH. Acute fractures of the scaphoid. JAmAcad Orthop Surg2000; 8(4):225–31.

24. Cooney WP,III. Scaphoid fractures: current treatments and techniques. Instr Course Lect 2003; 52:197–208 (Review).

25. Gelberman RH, Wo lock BS, Siegel DB. Fractures and non-unions of the carpal scaphoid. JBone Joint SurgAm1989; 71(10):1560–5 (Review; no abstract available).

26. Trumble TE,Gilbert M, Murray LW,Smith J, Raﬁjah G, McCallister WV.Displaced scaphoid fractures treated with open reduction and internal ﬁxation with acannulatedscrew.JBone Joint Surg Am 2000; 82(5):633–41.

27. Trumble TE,Salas P, Barthel T, Robert KQ, III. Management of scaphoid nonunions. JAmAcad Orthop Surg 2003; 11(6):380–91 (Erratumin: JAmAcad Orthop Surg 2004; 12(1):33A).

28. Low G, Raby N. Can follow-upradiography for acute scaphoid fracturestill be considered avalid investigation? Clin Radiol 2005; 60(10):1106–10.

29. Jorgensen TM ,Andresen JH, ThommesenP,Hansen HH. Scanning and radiology of the carpal scaphoid bone. Acta Orthop Scand 1979; 50(6 Pt 1):663–5.

30. King JB, Turnbell TJ.Anearly method of conﬁrmingscaphoid fractures. In proceedings and reports of universities, colleges, councils and associations. JBone Joint Surg Am 1981; 63-B(2):287.

31. Vichard P, Garbuio P, Lepage D, Tr opetY.Occult fractures of the carpal navicular.Detection by quantitative radioscintigraphy. Social and medico-legal repercussions. Bull Acad Natl Med 2001; 185(8):1399–413 (Discussion 1414–6. Article in French).

32. Dorsay TA,Major NM, Helms CA. Cost-effectiveness of immediate MR imaging versus traditional follow-upfor revealing radiographically occult scaphoid fractures. Am JRoentgenol 2001; 177(6):1257–63.

33. Wu WC.Percutaneous cannulated screw ﬁxation of acute scaphoid fractures. Hand Surg 2002; 7(2):271–8.

34. Levitz S, Ring D. Retrograde (volar) scaphoid screwinsertion-a quantitative computedtomographic analysis. JHand Surg [Am] 2005; 30(3):543–8.

35. Trumble TE,Clarke T, Kreder HJ. Non-union of the scaphoid. Treatment with cannulatedscrews compared with treatment with Herbert screws. JBone Joint Surg Am 1996; 78(12):1829–37.

36. McCallister WV,Knight J, KaliappanR,Trumble TE.Central placement of the screwinsimulated fractures of the scaphoid waist: abiomechanical study.JBone Joint Surg Am 2003; 85-A(1):72–7.

37. Brutus JP,Baeten Y, Chahidi N, Kinnen L, MoermansJP, Ledoux P. Percutaneous Herbert screwﬁxation for fractures of the scaphoid: review of 30 cases. Chir Main 2002; 21(6):350–4.

38. Streli R. Percutaneous screwing of the navicular bone of the hand with acompression drill screw (a new method). Zentralbl Chir 1970; 95(36):1060–78 (Article in German).

39. Cosio MQ, Camp RA. Percutaneous pinning of symptomatic scaphoid nonunions. JHand Surg [Am] 1986; 11(3):350–5.

40. Ledoux P, Chahidi N, Moermans JP,Kinnen L. Percutaneous Herbert screwosteosynthesis of the scaphoid bone. Acta Orthop Belg 1995; 61(1):43–7 (Article in French).

41. Chen AC, Chao EK, Hung SS, Lee MS, Ueng SW.Percutaneous screw ﬁxation for unstable scaphoid fractures. JTrauma 2005; 59(1):184–7.

42. Jeon IH, Oh CW,Park BC, Ihn JC, Kim PT.Minimal invasive percutaneous Herbert screwﬁxation in acute unstablescaphoid fracture. Hand Surg 2003; 8(2):213–8.

43. Slade JF,III, Geissler WB ,Gutow AP,Merrell GA. Percutaneous internal ﬁxation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach. JBone Joint SurgAm2003; 85-A(Suppl. 4):20–32.

44. Shih JT,Lee HM, Hou YT,Tan CM. Results of arthroscopic reduction and percutaneous ﬁxation for acute displacedscaphoid fractures. Arthroscopy 2005; 21(5):620–6.

45. TohS,Nagao A, Harata S. Severely displacedscaphoid fracture treated by arthroscopic assisted reduction and osteosynthesis. JOrthop Trauma 2000; 14(4):299–302.

46. Whipple TL.Stabilization of the fractured scaphoid under arthroscopic control. Orthop Clin North Am 1995; 26(4):749–54.

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