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

2. 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

3. 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

4. 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

5. 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

6. 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 ?

7. 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

8. 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

9. 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

10. 18 month follow-up Upper Limb Surgery Department
Hospital for Traumatology & Orthopaedics - Ho Chi Minh city
18 month follow-up
18 -month follow-up

11. 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

12. 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

13. 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

14. 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

15. 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

16. Thank you

17. 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.

18. 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

19. Wrist in neutral position Wrist in extension

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

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

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