Professor Joe Dias
University Hospitals of Leicester NHS Trust
United Kingdom
BOTA, Chester, 2015
Tuberosity (18%)
avulsion
unicondylar
bicondylar
Waist (77%)
transverse
vertical
horizontal
Proximal pole (4.5%)
•
500 fractures (442 Males: 58 Females)
•
Overall incidence of 15 per 100,000 per year
Predicted annual UK scaphoid fracture burden broken down by 5
year age and sex bands
Scaphoid fracture incidence for Leicestershire and Rutland broken down by 5 year
age/sex bands
• UK
• 12.4/100,000/year
• 7265/year
• Low socioeconomic group had double the rate
• Highest rate on Mondays
• Highest month June
Garala K, Taub N, Dias J. Epidemiology of scaphoid fractures: Analysis of social deprivation,
seasonality and predicting a national UK rate
Salvage
Failed
surgery
Nonunion
# scaphoid treatment
Is the scaphoid broken
Joe Dias
University of Leicester
United Kingdom
1. Mechanism of injury: sudden extension of
the wrist
2. ASB swelling and tenderness
3. Imaging
1. Radiographs
2. Bone Scan
3. CT
4. Treat as fracture and review
5. Shared decision making: Warn the patient
Dias JJ, Thompson J, Barton NJ, Gregg PJ. Suspected scaphoid fractures The value of radiographs. The Journal of bone and joint
surgery.British volume 1990;72(1):98-101.
Dias JJ. Scaphoid Fractures. In: Bulstrode C, Buckwalter J, Carr A, Marsh L, Fairbank J, Wilson-MacDonald J, et al., editors. Oxford
1. 1:10 non-operatively treated fractures do not heal
2. The union rate after fixation is NOT 100%
3. Benefits are soft and short lived
1. No cast
2. Possible early return to work
3. Lower non-union rate
4. Risks
1. Anaesthetic
2. Implant
(misplacement, fracture tuberosity, proud thread)
3. Surgery
Ibrahim T, Qureshi A, Sutton AJ, Dias JJ. Surgical versus nonsurgical treatment of acute minimally displaced and undisplaced
scaphoid waist fractures: pairwise and network meta-analyses of randomized controlled trials. J Hand Surg Am 2011;36(11):175968.e1.
United
# site seen
Not united
Review
Assess
Treat
Splint
Treat
Review
Dias JJ. Scaphoid Fractures. In: Bentley G, editor. European Instructional Lectures. London: Springer,
2011:107-32.
• Patient Occupation needs hands free
(surgeon)
• Time since fracture > 1 month
• Proximal fracture
• Displaced fracture
• Gap at fracture site
• Mobility
• as none, slight or marked with sclerosis
• Vascularity
• good bleeding from each surface,
• Sparse bleeding
• no bleeding
• Radioscaphoid joint
• degree and extent of damage or arthritis
• Scapholunate joint laxity
• Balance between screw position and cartilage sacrifice
• Palmar 1st Choice (percutaneous, open)
–
–
–
–
Large scaphoid
Large tuberosity
Waist fracture
Lax
• Dorsal if (percutaneous, mini-open)
–
–
–
–
Proximal pole
Small tuberosity
Twisted scaphoid
Stiff wrist
25
5
10
15
20
Rate per 100,000 population served
200000
400000
600000
Estimated population served
2008/09
800000
0
0
5
10
15
20
Rate per 100,000 population served
25
25
20
15
10
5
0
0
0
200000
400000
600000
Estimated population served
2009/10
800000
0
200000
400000
600000
Estimated population served
2010/11
800000
Chief Investigator: Prof Joe Dias (Leicester)
Trial Manager: Dr Stephen Brealey (University of York Trials Unit)
Collaborators: University of Leicester, University of Nottingham &
Trusts (South Tees, Bolton, Coventry)
Sponsor: University Hospitals of Leicester NHS Trust
Funding Body: NIHR Health Technology Assessment Programme
£ 2.3 million + 0.6 million NHS costs
ISRCTN: 67901257
16
• What is a displaced fracture?
– Gap
– Step
– Angle
• Humpback
• Torsion
L
H
Height to Length
Ratio
• What is the impact of displacement on union?
– Relative risk of non-union is 4.4
• What does malunion cause?
– ? Reduced movement
– ? symptoms
Singh HP, Taub N, Dias JJ. Management of displaced fractures of the waist of the scaphoid: meta-analyses of comparative studies.
Injury 2012;43(6):933-9.
• 5.8% (67/1147 acute scaphoid fractures)
• 34% do not unite if treated in a cast
y
Site%=100*(a-b)/b
• Relative risk of non-union is 7.5
a
• Stronger case for Fixation
b
– Union Rate after fixation unknown
x
• Define as Proximal 5th of scaphoid
– Definition in literature inconsistent
Eastley N, Singh H, Dias JJ, Taub N. Union rates after proximal scaphoid fractures; meta-analyses and review of available evidence.
J Hand Surg Eur 2012.
• Smoking
– Relative risk of failure of union 3.7
• Laxity
– Recognised association but evidence weak
– Consider de-functioning cast if hyperlax
Little CP, Burston BJ, Hopkinson-Woolley J, Burge P. Failure of surgery for scaphoid non-union is associated with smoking. J Hand
Surg Br 2006;31(3):252-55.
Monsivais JJ, Nitz PA, Scully TJ. The role of carpal instability in scaphoid nonunion: casual or causal? J Hand Surg Br
1986;11(2):201-06.
• Definition of union
Pain
– Continuous process 100
Tenderness
75
– Time to union flawed outcome
80
• Partial union
90
60
50
60
40
– CT scan and progressive
union
23
17
• Patterns of union
20
0
United
# seen
Not
united
12 weeks
Dias JJ. Definition of union after acute fracture and surgery for fracture nonunion of the scaphoid. J Hand Surg Br 2001;26(4):32125
Dias JJ, Brenkel IJ, Finlay DB. Patterns of union in fractures of the waist of the scaphoid. The Journal of bone and joint
surgery.British volume 1989;71(2):307-10.
Singh HP, Forward D, Davis TR, Dawson JS, Oni JA, Downing ND. Partial union of acute scaphoid fractures. J Hand Surg Br
2005;30(5):440-45.
1 Satisfactory
appearances
Scaphoid # has united. The interval before a definite state
should be 6 months
2 Impending union Some blurring of the fracture line but clinical assessment
satisfactory
3 Impending nonunion
The radiographic appearances suggest mobility at the
fracture site
4 Unsatisfactory
appearances
These suggest that the scaphoid fracture has not and will
not unite without further treatment
Type
Treatment aim
Method
Unite
Stabilise
I
Early
II
Stable
III a
Mobile
Graft
Cancellous
III b
Deformed
Reconstruct
Tri-cortical graft
III c
Avascular
Vascularise
Pedical grafts
IV
Radio-Scaphoid
OA
Control Pain
Nerve
Osteophytes
Fuse
Excise
V
Proximal Pole
Unite
Fix
Graft
Vascularise
Pedicle grafts
Compress
PERCUTANEOUS GRAFT- GODDARD
Allegiance 8G Jamshidi
Illiac crest
Cancellous pellets
Needle in drill hole
Introduce pellet
Impact and screw
Nicholas Goddard, Royal Free Hospital, London, United Kingdom
Cotrico-cancellous wedge graft
Cotrico-cancellous wedge graft
Wedge graft
Sculpted
Type
•
n
% United
I
Early
11
91
II
Stable
20
90
III a
Mobile
15
80
III b
Deformed
5
60
III c
Avascular
10
10
IV
Radio-Scaphoid
OA
V
Proximal Pole
16
32
A. Gupta, G. Risitano, R. J. Crawford and F. D. Burke. The ununited scaphoid: prognostic factors in delayed and nonunions of the scaphoid. Hand Surgery. 1999, 4:11-19
Type
1
Technical failure
Problem
Treatment
Length
Change Screw
Implant Misplaced
Graft Unstable
Only just loose
Proximal hole small enough
Shell but some bone
Thin shell
Resite
Add wire or bridge
2
Large Hole
Larger screw
Headed screw
K-wires
Russe graft
3
Infection
4
Avascular necrosis
Vascularise
5
Fragmented
Control Pain
Abandon
Vascularise
Excise Proximal
Scaphoid
6
OA
Pain
Salvage
Debride
antibiotics
Mack
Ruby
Year
1984
1985
n
47
55
Fu Years
5-53
1-40
% OA No Symptoms
100 15
97
Lindstrom
1992
33
10-17
100
10
Arthritis
Healed
Non-union
None
40
2
Mild
6 (12%)
2
Clear
1 (2%)
5
Opposite wrist mild OA 4/56 (7%)
H. Duppe, O. Johnell, G. Lundborg, et al. Long-term results of fracture of the scaphoid. A follow-up study of more than thirty
years. JBJSA. 1994, 76:249-52
•
•
•
•
•
Denervation
4CF
PRC
Fusion
Replacement
• PRC vs 4CF
95 % of untreated nonunion will develop OA
OA depends on site of fracture
Treatment depends on symptoms
PRC
4CF
ROM
66%
60%
Grip
80%
80%
Failure
5% need
fusion
5% Non Union
Question
Answer
1
Avoid missing Fracture
CT & Warn
2
Fix?
Not Proven, Surgeon Preference
3
Palmar or dorsal
Position vs Cartilage
4
Displacement
RR 4.4
5
Proximal pole
1/5th , RR 7.5
6a
Smoking
RR 3.7
6b
Laxity
Defunction
7
United?
CT, Partial Union
8
Non-Union decisions
Stabilise or Reconstruct or Vascularise
9
Failure
Technical vs Biology
10
Salvage
PRC better