Plating as a modality of treatment.
Kirschner wire as a modality of treatment.
Hand is reflexly stretched out in the act of a falls. The major impact is borne by the wrist. Among several injuries that may be sustained by the wrist, one of them may be fracture of the scaphoid bone. For the injury to occur, the fall may be from a standing height or off a two-wheeler or while running on a playground.
Put simply, the scaphoid is a bone at the base of the bulkiest part of the thumb, somewhere near the location, where the doctor checks your pulse.
Symptoms. Following a fall on the outstretched hand, the person will develop a swelling, though insignificant, at the base of the thumb. Pain may often not be much. The insignificant swelling and pain may be presumed to be a sprain and but is not so and should not be neglected.
Signs. There will be tenderness in the snuff box. There may be tenderness over the front of the wrist, what is called a scaphoid tubercle.
Investigation. X- rays are needed to confirm the diagnosis.
Are x rays done differently for fracture scaphoid?
Routine x-ray views are called AP(Antero-posterior)and lateral. These views may be misleading as they may not reveal the fracture. For fracture of the scaphoid, the wrist is placed at different angles. The x- ray machine is angled in such a way to pick up a subtle fracture lines. These are called scaphoid views, tube tilt views , pencil holding view or billiard view.
These are x-ray pictures of the wrist of the same patient taken at the same time but in different positions of the wrist and the x ray machine. Focus on the content within the yellow circle. This is the scaphoid bone. In the first x ray view the fracture is not seen . In the second and the third view, the fracture is clearly shown by the arrow within the circle.
Can the fracture be still missed?Inspite of the best efforts, the fracture can still be visible and not visualized on this first x ray.
Are there any other tests available to ascertain the fracture scaphoid?
Yes. MRI or CT scan can be done.
Shall I ignore my wrist pain if the initial xrays is normal?
On the xray several things are noted.
*Location of fracture. Whether in the centre of the scaphoid bone or at its ends.
*Whether the fracture is displaced or not.
*Whether the fracture is into 2 pieces or more.
*Whether other bones of the wrist are also affected.
* Whether bones of the forearm are also affected.
*Whether one or both hands are affected.
There are two methods of treatment :
A.Non surgical. The hand is immobilized and rested in a plaster for about 6to 8 weeks or more. Almost 85% of patients are treated this way.
How big is the plaster?
It covers 2/3 of the forearm and the hand. The fingers and the thumb are free. It may be replaced with another material which is fiberglass.
Who are the patients, who need surgery for fracture scaphoid?
The decision is largely based on the x ray finding. But there are other factors like social aspect and delay in diagnosis, which may influence the plan of treatment.
1.Scaphoid fragments are displaced.
2.Scaphoid is in multiple pieces, called a comminuted fracture.
3.There are associated fractures of the adjacent bones like the radius and other carpal bones.
4.The fracture of the scaphoid is associated with displacement of adjacent bones of the wrist. This in medical parlance is called trans scaphoid Perilunate dislocation
5. Proximal pole fracture.Scaphoid bone has been designed in such away by nature that at one end there is rich blood supply and at the end closer to forearm the blood supply is scanty.This poor blood supply may jeopardize the healing of the fracture.Such a fracture which is near the forearm end of the scaphoid boner is called proximal pole fracture and necessitate surgery
6.Fracture both hands. Placing both hands in a plaster cast may make life difficult as far as personal care and eating is concerned . This may again make surgery necessary.
7.Exam next week ?. If one cannot get a writer and it is mandatory to use the hand, surgery is an option .
9.Non union. This is one of those unfortunate situations, where the bone will just not unite. This will again require surgery.
Can I have plaster cast for just about 2 weeks?
Inadequate immobilization is an important cause of delayed union and non union of scaphoid.
The immobilization has to be for adequate time till tenderness disappears which may be 6 to 8 weeks or more.
Can I go to work after surgery?
Yes , the patient is encouraged to use the hand after surgery. Just be careful and do not fall again!
What do you do in Surgery?
There are several options available. Very thin medical grade straight stainless steel wires or needles which are called Kirschner wires, are introduced, which hold the fracture together. Then , there are tiny screws about 20mm long and 2 to3 mm thick which clamp the fracture together. These are made of a special material called titanium. Majority of patients are fixed with Titanium screws. They are both Indian and imported screws available in our country.
Will I require any supplementary surgery?
Yes you may require bone graft. The bone graft is needed if the scaphoid bone is crushed or the diagnosis is delayed or there is non-union. The bone graft may be harvested from the wrist itself or from the hip region, where you tie your undergarment. It does not harm you in any way.
Are there other types of bone grafts?
Yes, there are bone grafts whish are scooped out from one place and grafted at other place . While there are other grafts which are delivered with their blood supply .These are called vascularized bone graft .
What kind of special aids are needed during surgery?
Xray control or image intensifier or C arm as it is popularly called and magnification.
All steps of surgery are precise and at each step , the position of screw placement is accurately determined.
What kind of anesthesia is administered?
It is done under local anesthesia . We call it regional anesthesia .An injection is given in the armpit and the arm goes to sleep for several hours. If you want general anesthesia, it can be given or avoided based on the wishes of the patient. This is discussed with the patient and then only we proceed.
Does it require prolonged hospitalization?
It can be done on outpatient basis or one day hospitalization.
Do we have all the facility in our country?
Of course . Our results match any other country. Sheer work load in our country with a huge population make us pretty experienced.
What if the bone does not unite?
Scaphoid nonunion may be painless to start with. But slowly it is going to damage all the adjacent bones of the wrist in 5 to 7 years and lead to irreversible arthritis. So even if it is painless to start with, It should be treated to make it unite and avoid arthritis.
Treatment of scaphoid nonunion
The fracture may have led to deformity in the shape of the bone already. This is corrected with bone graft. The correct alignment is held steady with a screw. If there is early arthritis, this is corrected by excising new bone growth called styloidectomy or bump excision.
What if arthritis has set in following scaphoid non union?
The aim is to provide painless movement to the wrist. Various options are available. One such option involves reconstruction of a new joint by removing a row of bones .This procedure is called proximal row carpectomy.
The scaphoid can fracture at various levels. it can be considered as distal third, middle third and proximal third fractures. Among these fractures, in the proximal third, there is a poor blood supply. They are notorious for playing truants and not uniting. They require bone grafting and fixation and additional immobilisation for union.
Arrow points at the fracture.
Wires holding the fractures.
Wire removal and healing of the fracture.
Not a very common condition. The patient presents with pain in a small focal area on the palmar aspect of the hand, just distal to the wrist crease but in line with the ring finger. X-ray called carpal tunnel view may at times pick up the fracture. If this does not help, one may require a CT scan to diagnose the fracture. The fracture may irritate the ulnar nerve(Ulnar nerve neuropathy) and cause tingling in the small finger. The fracture may require surgery. Either fixation or excision of part of the bone (HAMATE) alleviates the symptoms.
There is pain in the center of the wrist at the level of wrist joint. In this picture, the broken piece of bone called the Hook of the Hamate is dissected out.
This injury occurs after a major fall, heavy fall from a height or in a high velocity road accident. Sustained a wrist injury. X-ray showed a Perilunate injury and median nerve injury. The surgery was done, median nerve was decompressed. The architecture of the wrist bones was restored.
The bony configuration is altered and the lunate bone has popped out of alignment.
Wire holding the bones in proper alignment. They are removed after 8 to 10 weeks.
Final result after wire removal.
This patient had a massive fall leading to a terrible wrist injury. X-rays showed a trans scaphoid Perilunate injury.
This consisted of a fracture of the scaphoid bone and tear of multiple ligaments.
He visited several hospitals and ended up loosing some precious MONTHS!
We opted to create a new joint by a salvage procedure called Proximal row Carpectomy. This gave him a painless mobile wrist.
The delay in seeking treatment causes damage to the cartilage. Hence, a new joint is created by a procedure called Proximal Row Carpectomy, wherein a new articulation is created between capitate and radius.
This young man sustained a open fracture of the finger. There was a large wound in the front of the finger. All the principles of wound and fracture management were followed. Wound cleaning. To convert a contaminated wound into a clean wound. Primary fixation of the fracture with fixation device. Our fixation method allows early finger movements. Immediate wound closure. The gentleman made a full recovery.
Diagnosis. An x-ray reveals loss of alignment of the bones. Interpreting the x ray properly helps avoid missing the diagnosis. At times, the report accompanying the x- ray film may be erroneous and delays establishing the correct diagnosis. A good quality x-ray image with appropriate position of the finger and magnification will show loss of concentric bones. Once the loss of alignment is established, the next step, is to assess the extent of joint affection and whether the fracture has resulted in gross multiple pieces (comminution).
Treatment. The aim of treatment is restoration of movement of the finger. While there are a significant number who do not require surgery, a few who underwent surgery are presented. Almost 10 methods of treatment are available. The common methods of treatment include:
Fracture dislocation of proximal interphalangeal joint 2.
Diagnosis. An x ray reveals loss of alignment of the bones. Interpreting the x ray properly helps avoid missing the diagnosis. At times, the report accompanying the x ray film may be erroneous and delays establishing the correct diagnosis. A good quality x ray image with appropriate position of the finger and magnification will show loss of concentric bones. Once the loss of alignment is established, the next step, is to assess the extent of joint affection and whether the fracture has resulted in gross multiple pieces (comminution).
TREATMENT. Based on certain parameters, we opted to fix the fracture with wires. The fracture was held together with wires. An additional wire was inserted in the proximal bone while the fracture was healing. These wires are all removed after a few weeks.
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