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Fig. 1

Computed tomography (CT) scan is a very useful diagnostic tool in detection of scaphoid fracture. In a plain X-ray of the wrist, a scaphoid fracture is suspected (white arrow head). CT scan shows cortical breakage in the scaphoid volar aspect (white arrow) and an occult fracture in the hamate hook base (black arrow). In below line photos, the fractures of scaphoid and hamate are fixed with a headless compression screw and a 2 mm screw, respectively, using the dorsal percutaneous technique.

Fig. 2

Percutaneous headless compression screw fixation using a palmar approach. There are two techniques in percutaneous headless screw fixation using a volar approach; one is the central method which requires rongeuring the volar side of the trapezium for centralization of distal insertion screw (upper photo line), the other is the oblique method in which screw fixation starts obliquely in order to avoid injury to trapezium (lower photo line).

Fig. 3

Surgical procedures for 1,2 intercompartmental supraretinacular artery (1,2-ICSRA) pedicled bone graft (courtesy of Prof. Jong Woong Park). (A) Incision. (B) 1,2-ICSRA identification. (C) Identification of the fracture site. (D) Making a slot for the bone graft. (E) 1,2-ICSRA pedicled bone fragment harvesting. (F) Insertion of bone graft and fixation.

Fig. 4

1,2 intercompartmental supraretinacular artery (1,2-ICSRA) pedicled bone graft (courtesy of Prof. Seok Hwan Song). (A) Scaphoid nonunion with atrophic change of the proximal fragment. (B) Postoperative X-ray showing focal radiolucency on the distal radius by donor bone harvesting (arrow). (C) Last follow-up X-ray showing complete union of scaphoid.

Fig. 5

Surgical procedures for medial femoral condyle free vascularized bone graft (courtesy of Prof. Jong Woong Park). (A) Skin incision. (B) Identification of the descending genicular artery (in photo, m: muscle, a: artery). (C, D) Pedicled donor bone harvesting. (E) Recipient incision line. (F) Finding and dissecting radial artery and vein for anastomosis. (G) Finding nonunion site and curettage of fibrotic tissue. (H) Removing cystic and sclerotic portion of both ends with a saw. (I, J) Harvested donor bone trimming according to the defect and inserted into the gap. (K) Graft insetting and fixation with a headless screw. (L) End-to-side anastomosis with radial artery and end-to-end anastomosis with venae comitantes or cephalic vein.

Fig. 6

Medial femoral condyle free vascularized bone graft (courtesy of Prof. Jong Woong Park). (A) Scaphoid nonunion with failed 1,2 intercompartmental supraretinacular artery (1,2-ICSRA) vascularized bone graft. (B) Computed tomography (CT) scan showing cystic change, sclerosis and avascular necrosis suspected in the proximal fragment. (C) Wrist lateral view showing dorsal intercalated segmental instability. (D) CT scan showing scaphoid humpback deformity (arrow). (E, F) Postopreative 10 weeks, the X-ray showing successful scaphoid union with scaphoid length restored and humpback deformity corrected.

Table 1

Clinical Tests in Diagnosis of Scaphoid Fractures1112131415)

Clinical test	Sensitivity (%)	Specificity (%)
Effusion	50	91
Tenderness on scaphoid tubercle	87	57
Snuff box tenderness	90	40
Scaphoid compression test	94	92
Combined	100	74

Table 2

Next Evaluation in Case of the Highly Suspected Patient with a Negative Simple X-Ray

Item	Finding	Describing
Short arm thumb spica splint, after 2 weeks, rechecking simple Xrays16)	Bone resorption or early callus formation adjacent to the fracture site	Low cost, possible time wasting
High-resolution ultrasound17,18)	Cortical step-off, cortical interruption, radiocarpal effusion, scaphotrapeziotrapezoidal joint effusion	Sensitivity 78%, specificity 89%, relatively low cost, early detection
Bone scan19,20)	Hot uptake	Sensitivity 100%, specificity 90%, useful in multiple fracture-patient and unconsciousness patient
Computed tomography21,22)	The better diagnostic performance in reformations along the long axis of the scaphoid than the planes of the wrist	Very effective in detection for nondisplaced scaphoid fractures, useful in evaluation for scaphoid union or eformation or scaphoid nonunion status
Magnetic resonance imaging23,24)	Acute fracture, normal or decreased signal in T1 and increased signal in T2; nonunion or avascular necrosis, decreased signal in T1 and T2	Sensitivity 100%, specificity 90%, useful in detection for ligament injuries or other concomitant injuries

Table 3

Criteria for Unstable Scaphoid Fracture (by Cooney)

Item	Criteria
Displacement or step-off	>1 mm
Angular displacement	>10°
Comminuted fracture
Scapholunate angle	>60°
Radiolunate angle	>15°
Intra-scaphoid angle in wrist postero-anterior view	>40°
Intra-scaphoid angle in wrist lateral view	>30°

Data from the article of Haisman et al. (J Bone Joint Surg Am 2006;88:2750-2758).31)

Table 4

Comparison of Surgical Approach

Comparison point	Volar approach	Dorsal approach
Scaphoid circulation preserving	Superior	Inferior
Applicable fracture sites	Fractures in scaphoid waist and distal, humpback deformity correction	Fracture in scaphoid proximal
Screw fixation along scaphoid long axis center	Relatively difficult (partial removal of trapezium volar portion)	Easy
Radiocarpal ligament injury	Yes	No

Figure & Data

REFERENCES

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