Fractura de Escafoides

FRACTURA DE
ESCAFOIDES
Dr Rene Jorquera A
Equipo de Mano y Microciruga
Clnica Indisa
ANATOMA
1930
1932
1928
FIGURE 2: Study flow-diagram of the systematic review.
ANATOMY
OF THE
THE SCAPHOID
SCAPHOID
BONE AND
AND LIGAMENTS
LIGAMENTS
ANATOMY
OF
BONE
ANATOMY
OF THE SCAPHOID
BONE
AND LIGAMENTS
FIGURE 3: Radial A, dorsal B, ulnar C, and volar D views of the scaphoid and its articular surfaces color coded for contact with
FIGURE 5: A Dorsal carpal ligaments according to Berger. (Reprinted with permission from William P. Cooney, ed. The wrist.
the distal radius (green), trapezium (yellow), trapezoid (orange), capitate (blue), and lunate (red). The bottom of each image
Diagnosis and operative treatment. Vol. 1, Ligament anatomy. Elsevier Mosby-Year Book, 1998:88.) B Dorsal carpal ligaments
represents proximal and the top represents distal. Note the vascular foramina in the regions of the radiodorsal ridge and the
according to Taleisnik.24 Note the presence of the dorsal radioscaphoid ligament (see RS). (Illustration by Elizabeth Martin,
tubercle.
1985. Reprinted with permission from Taleisnik J, ed. The wrist. New York: Churchill Livingstone, 1985.)
FIGURE 4: A Volar carpal ligaments, according to Berger. (Reprinted with permission from William P. Cooney, ed. The wrist.
4
FIGURE
1: Aand
Volar
carpal ligaments
by Weitbrecht
in 1742. c,
os carpi St.
primum
(scaphoid);
e, os carpi
quinti (trapezium);
Diagnosis
operative
treatment.
Vol. 1. Ligament
anatomy.
Louis,
MO: Elsevier
Mosby-Year
Book,q,1998:79.) B Volar
lacertus membranae communis proprius, obliquus
24 superior (radiolunate bundle or LRL ligament); r, lacertus membranae communis
carpal
ligaments
according
to Taleisnik.
Notescaphoid
the presence
of a radial
collateral
ligamentmainly,
(see RCL).
(Illustration bytriquetroElizabeth
its
origin,
it
passes
ulnarly
toward
the
and
rounding
ligaments:
the ulnocapitate,
across
the
scaphoid,
The obliquus
most proximal
portionbundle
is grossly
anisotropic
proprius,
inferior (radiocapitate
or RSC ligament).
B Dorsal the
carpalligament
ligaments. run
i, ligamentum
rhomboides
(dorsalproviding some
Martin, with
1985. bundles
Reprinted
with
permission
fromin
Taleisnik
J, ed.
The
wrist.
New
Churchill
Livingstone,
1985.)33,34,41
capitate,
of
fibers
inserting
the
radial
capitate,
andYork:
volar
scaphotriquetral
ligaments.
ThisOwinradiocarpal ligament);
l, lacertus
obliquus
ligament).
(Reprinted
from stability
Weitbrecht
J. Syndesmologia
sive historia
dorsal
without
inserting
onto
it.
(composed
of fibrocartilage
with(dorsal
few intercarpal
collagen
bundles
ligamentorum
corporis
humani,waist,
quam secundum
observationes
concinnavit,
et figuris
objecta recentia
aspect
ofneurovascular
the
scaphoid
the Itproximal
edgeanatomicas
of the
terdigitation
isand
referred
to asadumbratis
the
arcuatedescriptions,
ligament,
ing
to
the
high
variation
found
in
different
without
bundles).
is
approximately
1
illustravit. Petropoli:
Academy
of Sciences;
1742.)
scaphoid
tubercle,
and the
volar surface
of the
deltoid ligament, palmar distal V ligament, or Weit44 capitate
classification systems were

generated that allow for charmm thick, 4 mm long, and 11 mm wide. It is the
4,32,37
head.
Fibers
from
this
ligament
interdigitate
with
surbrecht
oblique
ligament.
54
There
severalportion
controversies
regarding
the RSC acterization
other study,ofitthe
should
be considered
a separate
widest
andareweakest
of the SLIO
ligament.
different
DRC ligament
insertionentity
patBuijze GA, Lozano-Calderon SA, Strackee SD, Blankevoort L, Jupiter JB. Osseous and Ligamentous Scaphoid Anatomy: Part I. A Systematic Literature Review Highlighting Controversies. YJHSU. Elsevier Inc; 33,41
2011 Dec 1;36(12):192635.
12
(Table
1).articulates
Although
most
authors
concur
regarding
because
its
presence
wascited
documented
eachYJHSU.
of the
15Inc; 2011 Dec 1;36(12):193643.
Buijze GA, Dvinskikh NA, Strackee
SD,
Streekstra
GJ,
Blankevoort
L.
Osseous
and
Ligamentous
Scaphoid
Anatomy:
Part
II. Evaluation
of Ligament
Morphology
Three-Dimensional
Anatomical
Elsevier
The
volar
portion
courses
obliquely
and
distally
beterns
thatTaleisnik
can
be Using
present
in
the
population.
lunar
area
with
the lunate;
distally,
a large,
(1976,
180general
times),inImaging.
following
authors:
ADAMS
J,
STEINMANN
S.
Acute
Scaphoid
Fractures.
Orthopedic
Clinics
of
North
America.
2007
Apr;38(2):22935.
13
interdigitation
the ligament
specimens
wasBerger
visible
cited 133and
times),
andon MRI in some
concave
surface of
articulates
with thewith
radial,surrounding
proximal ligaMayfield dissected
et al (1976,
EIDEMIOLOGA
Dinamarca: 26/100,000
Islandia: 29/100,000
EEUU: 1,47/100,000
personas/ao
hombres/ao
personas/ao
2,4%
de todas las fracturas alrededor de la mueca
60%
de fracturas del carpo
11%
de fracturas de la mano
75%
en la cintura y 20% en el polo proximal

Van Tassel DC, Owens BD, Wolf JM. Incidence Estimates and Demographics of Scaphoid Fracture in the U.S. Population. YJHSU. Elsevier Inc; 2010 Aug 1;35(8):12425.
Haisman J, Rohde R. Acute fractures of the scaphoid. The Journal of bone and . 2006.
EPIDEMIOLOGA
FRACTURE1244
EPIDEMIOLOGY
FRACTURE EPIDEMIOLOGY
udy
n the
ataated
U.S.
udes
omcare
care
g to
.ient
tion
SCAPHOID FRACTURE
EPIDEMIOLOGY
1243
FIGURE 3
FIGURE
Scaphoid
fracture
incidence
by
FIGURE
2: 1:
Scaphoid
fracture
incidence
agegender.
decade.
FIGURE
3: Scaphoid
fractures
by by
sport.
Van Tassel DC, Owens BD, Wolf JM. Incidence Estimates and Demographics of Scaphoid Fracture in the U.S. Population. YJHSU. Elsevier Inc; 2010 Aug 1;35(8):12425.
the current study s
MECANISMO DE LESIN
Cada
radial
con mano en extensin y desviacin
Compresin
Weber
v/s tensin?
- Chao:
Fracturas
con 95-100 de dorsiflexin
WB G, JE A, RR B, WD L, DJ S. Scaphoid Fractures: Whats Hot, Whats Not. 2011 Dec 23;:114.
DIAGNSTICO
Clnica
Dolor
en tabaquera anatmica
Dolor
en tubrculo de escafoides
Dolor
a compresin axial de pulgar
Dolor
con cubitalizacin de mueca

A total of 10 physical examination tests of the wrist w

performed. The following manoeuvres were performed in
sequential order and pain was elicited by these manoeuvres
the anatomical snuffbox, scaphoid tubercle and radio-scaph
joints. ASSESSMENT OF THE SUSPECTED FRACTUREK.OFUnay
al. / Injury, Int. J. Care Injured 40 (2009) 126
THEet
SCAPHOID
DIAGNSTICO
Table I.1 The sensitivity, specificity, positive predictive value and negative predictive value of
Table
mandatory. Unl
clinical
signs
of
a
fracture
of
the
scaphoid.
(Reproduced
from
Gaebler
C,
McQueen
MM.
Carpus
Sensitivity, specificity, positive predictive value, negative predictive value,
fractures and dislocations. In: Buchholz RW, Court-Brown CM, Heckman JD, Tornetta P, eds. assume that pa
accuracy,
ratio ofinthe
physical
examination
tests evaluated
the
Rockwood and
and likelihood
Greens fractures
adults.
Seventh
ed. Philadelphia:
Lippincotton
Williams
&
fractures have s
basis
of 2010).
MRI scans.
Wilkins,
1. Abduction of the thumb;

2. Radial deviation of the wrist;
(%)
Specificity
NPV
Sensitivity
PPV Accuracy
3. Axial Sensitivity
loadingSpecificity
of the
thumb;
Examination
PPV (%)NPV
LR(+) (%)LR(!)
ASB tenderness
100
30
19
100
wrist;
E14. Flexion
0.73 of the
0.50
0.86 0.31 0.68
1.45
0.55
Scaphoid tubercle tenderness
100
34
30
100
E2
0.68
0.33
0.93 0.08 0.66
1.03
0.95
Longitudinal
thumb compression
100
40
48
100
5.
Extension
of
the
wrist;
E3
0.71
0.35
0.54 0.54 0.54
1.10
0.82
Reduced thumb movement
66
41
66
85
E46. Power
0.71
0.50
0.89
0.23
0.68
1.43
0.57
grip of the 61hand; 50
ASB swelling
52
58
E5
0.72
0.60
0.93 0.23 0.71
1.81
0.46
ASB pain in ulnar deviation/pronation 83
44
17
56
deviation
E67. Ulnar0.67
0.20 of the
0.86wrist;
0.08 0.61
0.83
1.67
ASB in radial deviation/pronation
70
45
31
56
E7
0.70
0.36
0.75 0.31 0.61
1.10
0.83
Pain
thumb/index pinchof the forearm;
48
44
31
41
8.onPronation
E8
0.79
0.58
0.82 0.54 0.73
1.90
0.35
Scaphoid shift test
66
49
31
69
E99. Supination
0.76
0.50
0.79
0.46
0.68
1.52
0.48
of the forearm;
* PPV, positive predictive value
E10
0.73
0.75
0.96 0.23 0.73
2.92
0.36
NPV, negative predictive value
10.
Thumb-index finger pinch.
ASB, anatomical snuffbox
approach incre
(%)
productivity.5 I
cannot be cons
daily activities a
detect patients
having scaphoid
These patients m
after simple tre
An MRI has a
modalities to de
clinically suspec
PPV: positive predictive value; NPV: negative predictive value; LR: likelihood ratio.
by an experien
valuable in the d
Duckworth A, Ring D, McQueen M. Assessment of the suspected fracture of the scaphoid. Journal of Bone and Joint Surgery-British Volume. JBJS (Br); 2011;93(6):713.
Unay K, Gokcen B, Ozkan K, Poyanli O, Eceviz E. Examination tests predictive of bone injury in patients with clinically suspected occult scaphoid fracture. Injury. Elsevier; 2009;40(12):12658.
The
results of
these examinations
were
recordedMRI
as being
eit
The
sensitivity,
specificity,
positive & negative
predictive
varies acros
*
DIAGNSTICO
Imgenes
Radiografas
30
a 40% de fracturas no se identifican inicialmente
Repeticin
de radiografa identifica 50% de fracturas ocultas
TAC
Cintigrafa
sea
RNM
Duckworth A, Ring D, McQueen M. Assessment of the suspected fracture of the scaphoid. Journal of Bone and Joint Surgery-British Volume. JBJS (Br); 2011;93(6):713.
DIAGNSTICO
Radiografas
PA
standard
PA
con desviacin cubital
Lateral
PA
verdadera
con 45 supinacin-pronacin
DIAGNSTICO
ASSESSMENT OF THE SUSPECTED FRACTURE
Table II. The sensitivity, specificity, accuracy and avera
ASSESSMENT OF THE SUSPECTED

FRACTURE
OF THE
predictive
value (PPV)
andSCAPHOID
negative predictive value (NPV
as determined by Ring and Lozano-Caldern21 for a suspe
Table II. The sensitivity, specificity, accuracy and average prevalence-adjusted positive
Imagingvalue
modality
predictive value (PPV) and negative predictive
(NPV) for various imaging modalities
21
(numberfor
of astudies
assessed)
(%) Specificity
suspected
fracture Sensitivity
of the scaphoid
as determined by Ring and Lozano-Caldern
Imgenes
Ultrasound (n = 4)
93
Imaging modality
(number of studies assessed) Sensitivity
(%)
Specificity (%)
Bone
scintigraphy
(n = Accuracy
18)
96(%)
Radiografas
Ultrasound (n = 4)
Bone scintigraphy (n = 18)
CT (n = 8)
MRI (n = 22)
TAC
93
96
94
98
CT (n = 8)
89
MRI (n =89
22)
96
99
92
93
98
96
94
98
PPV
0.38
0.39
0.75
0.88
Table III. The sensitivity and specificity as determined by Yin et

al37 of different imaging techniques in the diagnosis of occult
Table III. The sensitivity and specificity
as determined
by Yin et
fractures
to the scaphoid
abnormalities diagnosed as
0.99
1.00
abnorma
radiolog
fractures
by
37
al of different imaging techniques in the diagnosis of occult
Recen
radiologists.
fractures to the scaphoid
Imaging modality (number of
37
studies assessed)
Sensitivity
(%) Yin
Specificity
26 studie
Recently,
et al(%)
performed
a m
Imaging modality (number of
accuracy
studies assessed)
Sensitivity
(%) Specificity
Bone scintigraphy
(n = (%)
15)
97
26 studies to89assess the prevalence-adju
93
99 scintigraphy, CT
fractures
accuracy of bone
and M
Bone scintigraphy (n = 15)
97 CT (n = 6) 89
96
99 scaphoid. Nine studies
CT (n = 6)
93 MRI (n = 10) 99
fractures of the
used
logical
fo
MRI (n = 10)
96
99
logical follow-up as their reference
standa
raphy
a
raphy
and
MRI were shown tosensitivit
have c
Duckworth A, Ring D, McQueen M. Assessment of the suspected fracture of the scaphoid. Journal of Bone and Joint Surgery-British
Volume. JBJS
(Br); 2011;93(6):713.
Cintigrafa
RNM
89
NPV
89
96
0.99
99
0.99
sea
or their relatives with authority to consent on their behalf, and

they were included in the study. Due to problems with obtaining
informed consent or concerns about the social security of the
patients, only 67 of the 98 patients were available for MRI scans.
The findings of the MRIs and physical examination tests of these
patients were recorded.
NEX2; FOV220 ! 165; axial conventional spin echo T1 ! TR/

TE640/14 and slice thickness4 mm; fast-spin echo fat-saturation T2 ! TR/TE1590/22 and slice thickness4 mm; FA908;
matrix256 ! 156; NEX2; FOV220 ! 165.
After data collection from all the patients was completed, the
radiographs of 67 patients were reviewed by three orthopaedic
surgeons who had a minimum of 10 years of clinical experience
in treating trauma; they were provided with the trauma history
and
the clinical presentation of each patient as well
as the
K. Unay
et results
al. / Injury, Int. J. Care Inju
1266
of the above-mentioned physical examination tests. A patient
was included in the study only if all three orthopaedic surgeons
stated that there was no fracture of the scaphoid or other wrist
pe
bones. Thus, we included 41 patients in the study who were
se
confirmed by these three surgeons to have no evidence of
th
fracture at the scaphoid or other wrist bones. The study
jo
population comprised 12 females and 29 males with a mean
age of 28.9 years (range: 950).
Statistical analysis
We calculated the percentage distribution of the various MRIconfirmed conditions. Further, we also evaluated the sensitivity,
specificity, positive and negative predictive values, accuracy and
likelihood ratio of each physical examination in relation to the MRI
results. A statistical analysis of the findings of this study was
performed using the NCSS 2007 software (329 North 1000 East
Kaysville, UT, USA).
1
2
3
4
5
6
7
8
9
10
Results
Fig. 2. Scaphoid view of wrist in same patients (Fig. 1) with suspected occult
scaphoid fracture.
The incidence of each MRI-confirmed condition was as follows:

13Fig.
cases
of no
bone involvement;
12occult
casesscaphoid
of scaphoid
fracture;
9 fracture
1. MRI
of patients
with suspected
fracture.
Scaphoid
cases
ofindicated
fractureby
at the
thewhite
distal
end of the radius; 6 cases of boneline is
arrow.
bruise (four distal radius and two scaphoid) and one case of
triquetral fracture.
emergency department fulfilled the above-mentioned criteria.

These patients were initially evaluated by radiography of the wrist
in four views (antero-posterior, lateral, oblique and scaphoid)
(Fig. 2). The radiographs obtained were evaluated by the on-duty
orthopaedic surgeon in the emergency department. From the total
187with
patients,
89 had
fractures
the
scaphoid
or other bones and
Unay K, Gokcen B, Ozkan K, Poyanli O, Eceviz E. Examination tests predictive of bone injury inof
patients
clinically suspected
occult scaphoid
fracture. of
Injury.
Elsevier;
2009;40(12):12658.
98 had no evidence of a fracture at the wrist region, including the
ne
ex
sa
m
G
co
64
ec
2.
an
2;
RELEVANCIA
12%
de no-unin en fracturas ocultas no tratadas
Algunos
autores recomiendan estrategia altamente conservadora
Costo
de control-reposo > costo TAC-RNM
Costo
por da de inmovilizacin innecesaria llega a USD$ 44
Tasa
de inmovilizacin innecesaria llega al 80%
Consecuencias
mdicas de inmovilizacin innecesaria

ADAMS J, STEINMANN S. Acute Scaphoid Fractures. Orthopedic Clinics of North America. 2007 Apr;38(2):22935.
232
CLASIFICACIN
ADAMS & STEINMANN
Fig. 1. Herbert classification of scaphoid fractures. (From Herbert TJ. The fractured scaphoid. St. Louis (MO): Quality
Medical Publishing;1990; with permission.)
ADAMS J, STEINMANN S. Acute Scaphoid Fractures. Orthopedic Clinics of North America. 2007 Apr;38(2):22935.
TRATAMIENTO
1. Fractura descartada
Inmovilizacin
2.Fracturas agudas
Ortopdico
A. Fractura oculta
B. Fractura estable
C. Fractura inestable
3. Retraso consolidacin /
no-unin
Yeso
y control
BP v/s ABP
Pulgar?
Quirrgico
Percutneo
v/s abierto
FX ESTABLE V/S INESTABLE

Table 2
Mayo Classification of Acute
Scaphoid Fractures
Stable
Displacement <1 mm
Normal intercarpal alignment
Distal pole fractures
Unstable
Displacement >1 mm
Lateral intrascaphoid angle >35
Bone loss or comminution
Perilunate fracture dislocation
Dorsal intercalated segmental
instability (DISI) alignment
Proximal pole fractures
Adapted with permission from Cooney
WP III: Scaphoid fractures: Current
treatments and techniques. Instr Course
Lect 2003;52:197-208.
Gutow A. Percutaneous fixation of scaphoid fractures. Journal of the American Academy of Orthopaedic . 2007.
TTO. ORTOPDICO
BP v/s ABP?
Controversial
ABP
no prevendra rotaciones, BP trasladara rotacin al carpo
Tasas
BP
similares de consolidacin
con mayor rigidez

Rockwood And Green's Fractures In Adults, 7th Edition; Copyright 2010 Lippincott Williams & Wilkins
TTO. ORTOPDICO
Pulgar?
Sin
diferencias en desplazamiento (Schramm et al. HAND 2008)
Sin
diferencia en tasas de consolidacin (Clay et al. J Bone Joint Surg 1991)
Posicin
del pulgar no influye si mueca no est en extensin ni

cubitalizacin (Yanni et al. J Bone Joint Surg 1991)
Schramm JM, Nguyen M, Wongworawat MD, Kjellin I. Does thumb immobilization contribute to scaphoid fracture stability? Hand (N Y). Springer; 2008;3(1):413.
Rockwood And Green's Fractures In Adults, 7th Edition; Copyright 2010 Lippincott Williams & Wilkins
Fig. 4
TTO. QUIRRGICO
Volar (distal) percutaneous technique. A and B: Posteroanterior and lateral views of the guidewire. C and D: Hand-drilling over the guidewire. The
derotational wire has been placed. E and F: Posteroanterior and lateral views of Acutrak Mini screw fixation.
Tornillo
Mayor
immobilization alone unite33,42,43. The

patient to perform gentle range-ofated risks such as anesthesia complidifficulty is determining which fracmotion exercises. Additional advancations. Percutaneous stabilization of
tures are nondisplaced. A computed
tages of surgical intervention are that
nondisplaced waist fractures has betomography scan along the long axis
the fracture is substantially less likely
come popular. The techniques have
of the scaphoid enables one to assess
to lose its alignment and ideally is fixed
evolved such that the benefits outweigh
20,44
displacement . Determining union is
with compression, which has been rethe risks, as discussed later.
46
also difficult. Dias et al. reported that
ported to shorten the time to healing .
Displaced Waist Fractures
The reduction should be anatomic,
critical examination of radiographs at
Scaphoid fractures with 1 mm of disand the fixation should be stable. The
one year revealed that the nonunion
placement are considered unstable.
disadvantages of surgery include the
rate was higher (12.3%) than they had
45
Cooney et al.35 defined displacement as
potential for infection; wound compliinitially suspected . A radiographic assessment of healing at twelve weeks is
a fracture gap of 1 mm seen on any plain
cations; injury to nerves, ligaments, or
probably not very reliable. Thus, some
radiographic projection, a scapholunate
tendons; injury to the vascular supply
scaphoid fractures that are classified as
angle of >60, or a radiolunate angle
to the scaphoid; hardware failure or the
nondisplaced actually might be disof >15. It has also been shown20 that
need for its removal; and other associplaced, and some that are considered to
have healed can actually be nonunions.
The treatment options for a nonFig. 8
displaced waist fracture must be disFixation screws for the scaphoid. From left: Herbert screw, AO 3.5-mm cannulated s
cussed thoroughly with the patient.
bert-Whipple screw, Acutrak cannulated screw, and Universal Compression screw. (R
The patients lifestyle, expectations,
from: Toby EB, Butler TE, McCormack TJ, Jayaraman G. A comparison of fixation scr
compliance, and demands (for return
scaphoid during application of cyclical bending loads. J Bone Joint Surg Am. 1997;7
to work or sports) must all be considered. Although the fracture will most
likely heal with cast immobilization,
This yields excellent visualiza
For proximal pole fractures, this can
28
the patient must know the risks, beneless risk of injury to the main
take twelve weeks or longer . Although
fits, and alternatives.
we are not aware of any data suggestsupply, which is on the dorsa
The main disadvantages of iming the superiority of long arm thumbexposure is required if an alig
mobilization, compared with surgery,
spica casts over short arm thumb-spica
strument such as the Huene j
are more frequent office visits to check
casts, we initially immobilize proximal
with a Herbert screw. A long
that the cast fits properly, more frefractures as well as severely commiincision is made just radial to
quent radiographs to check fracture
nuted or unstable fractures in a long
carpi radialis tendon, which i
alignment, potential skin breakdown,
arm thumb-spica cast.
to the ulnar side. Distally, the
prolonged immobilization until comProlonged cast immobilization
carried over the tubercle of th
plete healing has occurred, stiffness of
is becoming less well tolerated, espeforming a hockey-stick incisi
immobilized joints, and even perhaps a
46
longer time to healing . The immobilicially by younger patients who want to
gitudinal incision then is ma
zation period after
surgery
is shorter
Fig. 5
to .
work
volar wrist capsule, with care
Haisman
J, Rohde R. Acute fractures of the scaphoid. The Journalreturn
of bone and
2006.and sports as soon as
46-48
Dorsal
percutaneous
technique.
The
Acutrak
Mini
2
screw
is
self-drilling
and
.
If
the
fracture
or even unnecessary
Rockwood And Green's Fractures In Adults, 7th Edition; Copyright 2010
Lippincott Williams
& Wilkins
possible.
Patient
expectations are now
totapping
injureover
the aradioscaphocap
Gutow
A.
Percutaneous
fixation
of
scaphoid
fractures.
Journal
of
the
American
Academy
of
Orthopaedic
.
2007.
has been rigidly fixed, it is safe for the
0.045-in (1.143-mm)
guidewire.
pushing
the trend to fix even nondisment. The nonarticular port
canulado en eje central de escafoides
tasa de consolidacin
v/s 12 semanas para consolidacin
v/s 15 semanas para retorno laboral
>
tasa de complicaciones que yeso
Menor
costo?
TTO. QUIRRGICO
Abierto
Abordaje
volar o dorsal
Fracturas
que no pueden ser reducidas

de manera cerrada
Costo
US$D 7,000 v/s 14,000 con yeso

Davis EN, Chung KC, Kotsis SV, Lau FH, Vijan S. A cost/utility analysis of open reduction and internal fixation versus cast immobilization for acute nondisplaced mid-waist scaphoid fractures. Plast Re- constr Surg. 2006;117:1223-35.
Weiland_ICL.fm Page 2753 Monday, November 6, 2006 2:29 PM
TTO. QUIRRGICO
2753
THE JOURNAL OF BONE & JOINT SURGER Y JBJS.ORG

VO L U M E 88-A N U M B E R 12 D E C E M B E R 2006
AC U
Percutnea
d_ICL.fm Page 2753 Monday, November 6, 2006 2:29 PM
Fx
no desplazadas o reducibles
cerrado o artroscpico
2753
THE JOURNAL OF BONE & JOINT SURGER Y JBJS.ORG

VO L U M E 88-A N U M B E R 12 D E C E M B E R 2006
Punto
7
AC U T E FR A C T U R E S
OF THE
SCAPHOID
de entrada volar o dorsal
v/s 12 semanas para consolidacin
Fig. 4
Volar (distal) percutaneous technique. A and B: Posteroanterior and lateral views
derotational wire has been placed. E and F: Posteroanterior and lateral views of
v/s 15 semanas para retorno laboral
immobilization alone unite33,42,43. The

patient to perform gentle
difficulty is determining which fracmotion exercises. Additio
Sin diferencia funcional a 2 aos
tures are nondisplaced. A computed
tages of surgical intervent
tomography scan along the long axis
the fracture is substantial
of the scaphoid enables one to assess
to lose its alignment and i
20,44
> tasa de complicaciones que yeso
displacement . Determining union is
with compression, which
also difficult. Dias et al. reported that
ported to shorten the tim
Fig. 4
The reduction should be
critical examination of radiographs at
Volar (distal) percutaneous technique. A and B:
Posteroanterior
and
lateral
views
of the
guidewire.
D: Hand-drilling over
thethe
guidewire.
and
fixationThe
should b
one
year
revealed
thatCthe
nonunion
Rockwood
And Green's Fractures
In Adults,
7th Edition;
Copyright
2010
Lippincott Williams
&and
Wilkins
Gutow A. Percutaneous fixation of scaphoid fractures. Journal of the American Academy of Orthopaedic . 2007.
disadvantages of surgery i
rate
was higher
than they had
derotational wire has been placed. E and F: Posteroanterior and lateral views
of Acutrak
Mini(12.3%)
screw fixation.
TTO. QUIRRGICO
173
TH E JO U R NA L O F B ON E & JOI NT SU RG E RY J B J S . ORG
V O L U M E 94-A N U M B E R 2 J A N UA R Y 18, 2 012
d
SC
Artroscopa
Permite
ver superficie articular
Permite
ver punto de entrada
No
daa ligamentos
Fig. 1
Fig
Fig. 1 The hand is suspended in 10 lb of traction in a traction tower, with the wrist in
Tratamiento
and a probe is inserted into the 3-4 portal to palpate the scapholunate interosseo
Arthroscopic view of a 14-gauge needle inserted through the 3-4 portal as it impa
de posibles lesiones asociadas
point of the guidewire and initial screw placement can be directly visualized arth
thumb under fluoroscopy, and a guidewire is advanced through the needle and
The reduction of t
evaluated with the arthr
FX DE POLO DISTAL
Fig. 2
Herbert classification of scaphoid fractures.
changes. In a study of fifty-six untreated

nonunions, Ruby et al. reported that
degeneration was present in thirty-one
of thirty-two patients who had been injured at least five years earlier40. Thus,
scaphoid nonunion is not an innocuous
condition.
Buena
Altas
Distal Pole Fractures

Fractures of the distal pole of the scaphoid
tend to heal well. Most can be treated
closed (with four to eight weeks of immobilizaton) and, probably because of
the rich vascularization of the distal
pole, union is the rule30,41. However,
displaced intra-articular fractures
(Prosser type II) are generally thought
to require surgical management to minimize the risk of degenerative arthritis.
vascularizacin
tasas de consolidacin
Yeso ABP
6-8 semanas
Waist Fractures
Fractures of the scaphoid waist can be
difficult to manage. Some can be treated
closed whereas others should be internally stabilized.
Fig. 3
Nondisplaced Waist Fractures
Prosser classification of distal pole scaphoid fractures. (Reprinted, with permission from
It has been reported that >90% of nondisplaced waist fractures treated with
the British Society for Surgery of the Hand, from: Prosser AJ, Brenkel IJ, Irvine GB. Articular fractures of the distal scaphoid. J Hand Surg [Br]. 1988;13:87-91.)
Wolfe: Green's Operative Hand Surgery, 6th ed.; Copyright 2010 Churchill Livingstone, An Imprint of Elsevier
FX DE CINTURA
Estables
Yeso ABP 6-12 semanas
Tasa
de consolidacin 85-95%
80%
a las 6 semanas, resto a las 12 semanas
Mnima
tasa de complicaciones
Ciruga
en pacientes de alta demanda?

FX DE CINTURA
Inestables
Fijacin quirrgica
Tcnica
y abordaje de acuerdo a rasgo de fractura y

desplazamiento
Mayor
tasa de complicaciones que tratamiento no quirrgico
Disminuye
riesgo de no unin
FX DE POLO PROXIMAL
Consideradas inestables
Gran brazo de palanca
Pequeos fragmentos
Lquido sinovial puede bloquear consolidacin
Mala vascularizacin
Riesgo de necrosis avascular
100% de consolidacin con tratamiento quirrgico agudo
(Rettig et al. J Hand Surg Am. 1999)
171
d
S C A P H O I D F R A C T U R E S : W H AT s H O T , W H AT s N
TABLE II Algorithm for Management of Acute Scaphoid Fractures

Acute Scaphoid Fracture Type
Stable fractures, nondisplaced
Tubercle fracture
Distal third fracture and/or
incomplete fracture
Waist fracture
Treatment
Short arm cast for 6 to 8 weeks
Short arm cast for 6 to 8 weeks
Long arm thumb spica cast for 6 weeks,
short arm cast for 6 weeks or until CT
confirms healing, especially for pediatric
patients, sedentary or low-demand
patients, or patients with a preference
for nonoperative treatment
Percutaneous or open internal fixation,
especially for active and young manual
worker, athlete, patient with high-demand
occupation, or patient with a preference
for early range of motion
Proximal pole fracture,

nondisplaced
Unstable Fractures
Displacement >1 mm
Lateral intrascaphoid
angle >35!
Bone loss or comminution
Perilunate fracture-dislocation
Percutaneous or open internal fixation
Dorsal percutaneous or open screw fixation

Dorsal intercalated segmental instability alignment
made six to twelve months after injury

reliable modality to diagnose acute and
G, JE A,lower
RR B, WD L,rates
DJ S. Scaphoid
Hot, Whats
Not. 2011 Dec
23;:114.
or CT evaluation WB
show
of Fractures: Whats
occult
fractures
and
is able to diagnose
Davis et al. con

analysis to compare o
cast immobilization
acute nondisplaced m
fractures11. A mathem
developed to calculat
cost of open reductio
cast immobilization
estimated Medicare r
rates and the cost of
estimated by average
from the United Stat
and Statistics. They f
reduction with intern
greater quality-adjus
did casting. Open red
fixation was less cost
($7,940 versus $13,8
respectively) because
riod of lost producti
There is strong
literature that nonun
should be treated ope
Management of scap
depends on the scap
bone loss, presence o
deformity, carpal col
necrosis. Nonunion
leads to a predictable
COMPLICACIONES
No-unin
5-25%
de fracturas
Lleva
a patrn predecible de artrosis, acelerado por mal

alineamiento (Mack et al.)

d
S C A P H O I D F R A C T U R E S : W H AT s H O T , W H AT s N O T
TABLE I Radiographic Classification System of Geissler and Slade for Scaphoid Nonunion
Classification
Description
Class I
Scaphoid fractures with a 4 to 12-wk delayed

presentation for treatment
Class II
Fibrous union: minimal fracture line at nonunion

interface, no cyst or sclerosis
Class III
Minimal sclerosis: 1 mm of bone resorption

at nonunion interface
Class IV
Cystic formation and sclerosis: bone resorption

of >1 mm but <5 mm at nonunion interface; cyst;
no deformity visible on lateral radiograph
Class V
Deformity and/or pseudarthrosis: 5 mm of bone

resorption at nonunion interface; cyst; fragment
motion; deformity visible on lateral radiograph
Class VI
Wrist arthrosis: scaphoid nonunion with

radiocarpal and/or midcarpal arthrosis
Special circumstances
Proximal pole nonunion. The proximal pole of the

scaphoid has a tenuous blood supply and a
mechanical disadvantage, which places it at greater
risk of delayed or failed union. Because of these
difficulties, this injury requires aggressive treatment
to ensure successful healing.
Osteonecrosis. Scaphoid nonunion with osteonecrosis
is suggested by MRI, demonstrating a decrease or
absence of vascularity of one or both poles. Bone
biopsy can confirm necrosis. Intraoperative
inspection of the scaphoid for punctate bleeding is
considered definitive.
Ligament injury. Ligament injury is suggested by static and
dynamic imaging of the carpal bones. Arthroscopy is the
most sensitive tool for detecting carpal ligament injury.
scaphoid were the result of dorsal subconsidered stable and included incom2
luxation during forced hyperextension .
plete fractures or fractures of the scaphWB G, JE A, RR B, WD L, DJ S. Scaphoid Fractures: Whats Hot, Whats Not. 2011 Dec 23;:114.
Heinzelmann
et al., using microcomputed
oid tubercle. Type-B fractures were
Geissler and Slade

radiographic classificatio
nonunions (Table I)6.
Management of Acute
Scaphoid Fractures
Distal Pole Fractures
Distal pole fractures of
are generally treated no
The distal pole of the s
vascularized, and distal p
the scaphoid have a high
six to eight weeks of imm
short arm cast. Distal po
generally fall into two g
avulsion fractures from
mar lip of the scaphoid
Group II, impaction fra
radial half of the distal s
ular surface. If displaced
fractures may need to b
stabilized.
Proximal Pole Fracture

Both displaced and non
tures of the proximal po
ered unstable and canno
treated nonoperatively b
small fracture fragmen
uous blood supply. Bec
intra-articular location
can block fracture-hea
proximal location of th
to large lever-arm stre
fracture site. Rettig an
a 100% healing rate of
172
d
S C A P H O I D F R A C T U R E S : W H AT s H O T
TABLE III Algorithm for Management of Scaphoid Fracture Nonunion

Type of Fracture
I
II
III IV V
Treatment
Delayed union
Percutaneous or open rigid fixation with a headless

compression screw
Established nonunion
Open repair and bone-grafting
Fibrous nonunion, waist
Dorsal for proximal pole fracture, volar for waist

fracture
Sclerotic nonunion, waist
Dorsal for proximal pole fracture, volar for waist

fracture
Humpback nonunion, waist
Volar approach and corticocancellous wedge graft
Proximal pole nonunion,

nonischemic
Dorsal approach; percutaneous or open bone-grafting

and fixation with headless screw; lock midcarpal joint
with mini-screw or sandwich proximal fragment
between lunate and scaphoid waist with headless
screw
Vascular nonunion, waist or

proximal pole
Vascularized bone graft: dorsal or palmar approach
management in a patient with a fracture

equipment. The disadvantage is that
of the scaphoid, and furthermore, when
the screw may be placed slightly oblique
operative fixation
isOperative
indicated,
to6th define
to a Livingstone,
fracture
lineof in
the mid-waist portion
Wolfe: Green's
Hand Surgery,
ed.; Copyright 2010 Churchill
An Imprint
Elsevier
whether an arthroscopic or open techof the scaphoid.
and to resi
forces.
The
advanced v
proximal p
and the wr
The
spaces are
any associa
arthroscop
space to ev
and may b
flexed and
dorsally, ex
guidewire i
and dorsal
wire breaka
tinued arou
minimize t
the extenso
reamed an
The
proach is t
down the c
COMPLICACIONES
Necrosis avascular
En
polo proximal principalmente
Hasta
un 13% de fracturas proximales
Diagnstico
Necesidad
con RNM
de injerto vascularizado
Fascio-osteal, metacarpiano, pisiforme, pronador
dorsal-volar, capsular, cndilo femoral medial

cuadrado, radio
Mathoulin C. Technique: vascularized bone grafts from the volar distal radius to treat scaphoid nonunion. Journal of the American Society for Surgery of the Hand. 2004 Feb;4(1):410.
RESULTADOS
No-unin
Injerto
+ tornillo: 94% consolidacin
Injerto
+ Agujas: 77% consolidacin
Necrosis
avascular
Injerto
vascularizado: 88% consolidacin
Injerto
+ tornillo: 47% consolidacin

COMPLICACIONES
SNAC (Scaphoid Necrosis Advanced Collapse)
Resultado
final de no-unin sin tratamiento
Etapa
1: Estiloidectoma + OTS +/denervacin
Etapa
II: Carpectoma proximal + artrodesis

parcial
Etapa
III: Excisin escafoide + artrodesis

parcial
Etapa
IV: Artrodesis total de mueca

REHABILITATION
A small dorsal splint is placed across the wrist joint at the time
of surgery. Active range of motion of the digits is encouraged
to preserve motion and decrease postoperative edema. The
patient typically was followed up from 10 to 14 days, at which
follow-up beyond their 2 weeks visit to have their sutures

removed. Two patients were women and 19 patients were men.
Patient ages were between 32 and 67 years, and most worked
heavily with their hands. Many recalled an old wrist sprain
or injury. Four of the 21 patients were noted to have bilateral
injuries.
R.S. Leak, R.W. Culp / Atlas Hand Clin 8 (2003) 185189
FIGURE 8. Postoperative radiographs (A) anterior/posterior view (B) lateral view.
102 | www.techhandsurg.com
Fig. 1. Early carpal collapse in chronic scaphoid nonunion pattern.
xtensor compartment is identified and opened. The extensor pollicis longus is

lly, and the fourth compartment is elevated o the distal radius and capsule in an
n, exposing the wrist capsule. Alternatively the wrist capsule can be exposed
gitudinal incision through the fourth compartment with retraction of the extensor
2011 Lippincott Williams & Wilkins

Fractura de Escafoides

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FRACTURA DE

FIGURE 2: Study flow-diagram of the systematic review.

classification systems were

de todas las fracturas alrededor de la mueca

de fracturas del carpo

en la cintura y 20% en el polo proximal

the current study s

con mano en extensin y desviacin

con 95-100 de dorsiflexin

WB G, JE A, RR B, WD L, DJ S. Scaphoid Fractures: Whats Hot, Whats Not. 2011 Dec 23;:114.

a compresin axial de pulgar

con cubitalizacin de mueca

A total of 10 physical examination tests of the wrist w

1. Abduction of the thumb;

a 40% de fracturas no se identifican inicialmente

de radiografa identifica 50% de fracturas ocultas

con desviacin cubital

ASSESSMENT OF THE SUSPECTED FRACTURE

Table II. The sensitivity, specificity, accuracy and avera

ASSESSMENT OF THE SUSPECTED

as determined by Ring and Lozano-Caldern21 for a suspe

Table III. The sensitivity and specificity as determined by Yin et

or their relatives with authority to consent on their behalf, and

NEX2; FOV220 ! 165; axial conventional spin echo T1 ! TR/

The incidence of each MRI-confirmed condition was as follows:

emergency department fulfilled the above-mentioned criteria.

de no-unin en fracturas ocultas no tratadas

autores recomiendan estrategia altamente conservadora

de control-reposo > costo TAC-RNM

por da de inmovilizacin innecesaria llega a USD$ 44

de inmovilizacin innecesaria llega al 80%

mdicas de inmovilizacin innecesaria

FX ESTABLE V/S INESTABLE

no prevendra rotaciones, BP trasladara rotacin al carpo

con mayor rigidez

diferencias en desplazamiento (Schramm et al. HAND 2008)

diferencia en tasas de consolidacin (Clay et al. J Bone Joint Surg 1991)

del pulgar no influye si mueca no est en extensin ni

immobilization alone unite33,42,43. The

canulado en eje central de escafoides

v/s 12 semanas para consolidacin

v/s 15 semanas para retorno laboral

tasa de complicaciones que yeso

que no pueden ser reducidas

US$D 7,000 v/s 14,000 con yeso

WB G, JE A, RR B, WD L, DJ S. Scaphoid Fractures: Whats Hot, Whats Not. 2011 Dec 23;:114.

Weiland_ICL.fm Page 2753 Monday, November 6, 2006 2:29 PM

THE JOURNAL OF BONE & JOINT SURGER Y JBJS.ORG

d_ICL.fm Page 2753 Monday, November 6, 2006 2:29 PM

THE JOURNAL OF BONE & JOINT SURGER Y JBJS.ORG

de entrada volar o dorsal

v/s 12 semanas para consolidacin

Volar (distal) percutaneous technique. A and B: Posteroanterior and lateral views

v/s 15 semanas para retorno laboral

immobilization alone unite33,42,43. The

ver superficie articular

ver punto de entrada

de posibles lesiones asociadas

WB G, JE A, RR B, WD L, DJ S. Scaphoid Fractures: Whats Hot, Whats Not. 2011 Dec 23;:114.