Case report: 10-year scaphoid waist nonunion Nguyen Thuc Boi Chau, MD Huynh Thi Linh Thu, MD Upper Limb Surgery Department HTO

History 31-year old man, right handed, office holder, ID:3828CT/05 Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city History 31-year old man, right handed, office holder, ID:3828CT/05 Fall on outstretch hand when playing football 10 years ago Chief complaints: Persistent pain on radial side of the left wrist, increasing with wrist motion and hard work Loss of grip strength Traditional treatment

Little swelling at the left wrist Pain/Tenderness at the snuffbox ROM: Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city Little swelling at the left wrist Pain/Tenderness at the snuffbox ROM: Flexion-extension : L: 60° - 0° - 50° R: 80° - 0° - 80° Radial deviation : L: 0° ; R: 10° Ulnar deviation : L: 20°; R: 30° Grip strength: L: 12kilos, R: 38kilos Fingers : no pain, no paresthesia, no limitation of motion

Imaging studies X ray: fracture of the scaphoid waist Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city Imaging studies X ray: fracture of the scaphoid waist

Imaging studies CT scan: nonunion of the left scaphoid Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city Imaging studies CT scan: nonunion of the left scaphoid

Diagnosis Diagnosis: Left scaphoid waist nonunion Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city Diagnosis Diagnosis: Left scaphoid waist nonunion Differential diagnosis: bipartite left scaphoid ?

Operative treatment Volar approach Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city Operative treatment Volar approach Fracture at the waist, necrosis at both fracture ends, tourniquet release→ no bleeding point at the proximal pole, two bleeding points at the distal pole

Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city Operative treatment Fixation by 2 Kwires (1.2mm)+ bone graft from iliac crest

Follow-up 18-month follow-up K wire removal: Dec 6th, 2006 Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city Follow-up 18-month follow-up No pain at the left snuffbox ROM: Flexion-extension : L: 80° - 0° - 70° R: 80° - 0° - 80° Radial deviation : L: 0° ; R: 30° Ulnar deviation : L: 20°; R: 30° Grip strength: L: 36 kilos; R: 38kilos K wire removal: Dec 6th, 2006

18 month follow-up Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city 18 month follow-up 18 -month follow-up

X ray 18-month follow-up After pin removal Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city X ray 18-month follow-up After pin removal

Discussion Surgical options: → ORIF + bone graft Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city Discussion Surgical options: Patients with 1 or 2-year scaphoid nonunion frequently using their hand for hard work often have the proximal pole fragmented or arthritic development on Xray. This is a case of 10-year scaphoid nonunion, without arthritic development → ORIF + bone graft

Discussion Surgical technique: Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city Discussion Surgical technique: Bone graft: vascularized bone graft or bone graft from iliac crest ? Zaidermberg: pedicle is not long enough to reach the scaphoid waist → Bone graft from iliac crest is chosen

Discussion Result → Removal of all the necrotic bone Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city Discussion Result bone healing improved range of motion → Removal of all the necrotic bone → Enough bone graft (cortico-cancellous bone graft) for restoring the scaphoid’s height

Upper Limb Surgery Department Hospital for Traumatology & Orthopaedics - Ho Chi Minh city Discussion Diagnosis: In the presence of tenderness over the anatomic snuffbox without deformity, a fracture of the scaphoid should always be presumed until radiographic examination proves negative beyond doubt. (Watson-Jones) →Early diagnosis → Early treatment → Best functional recovery

Thank you

Phöông phaùp moå: gheùp xöông coù cuoáng maïch Zaidemberg 1991( 1,2 ICSRA); 2,3 ICSRA: coù cuoáng khoâng ñuû daøi . gheùp xöông coù cuoáng töø ñoäng maïch maët löng xöông baøn I Bertelli 1992( first dorsal metacarpal artery), töø ñoäng maïch truï ( ulnar artery) Guimberteau – Panconi 1990 : cuoáng deã bò gaáp khuùc . => Choïn gheùp chaäu rôøi.

anatomy Scaphoid lies at 450 flexion and 200 radial deviation to long axis of the wrist.  Special projections needed to align the beam with the plane of fracture line

Wrist in neutral position Wrist in extension

scaphoid views ULNAR DEVIATION VIEWS The hand flat, finger in extension wrist in ulnar deviation

scaphoid views SCHRECK I VIEWS Ulnar deviation wrist in 900 pronation Making a pinch

scaphoid views SCHRECK II VIEWS Thumb and index in writing position Wrist wrist on ulnar side, in 45° pronation