Which of the following is the most appropriate next step in management?

(A) Further immobilization
(B) Cancellous grafting
(C) Corticocancellous grafting
(D) Reconstruction with a bone pedicle flap
(E) Bone autotransplantation

The correct response is Option D.

Approximately two-thirds of carpal fractures involve the scaphoid, and more than 90% of nondisplaced scaphoid fractures treated by cast immobilization result in bony union. However, fracture displacement disrupts the retrograde endosteal blood supply of the scaphoid. In patients with scaphoid fractures that are displaced more than 1 mm treated with cast immobilization, approximately 55% have nonunion, and 50% ultimately develop avascular necrosis. Fractures of the proximal pole of the scaphoid are associated with an incidence of avascular necrosis approaching 100%.

Appropriate management of a displaced fracture of the scaphoid bone involves reduction and compressive, rigid fixation. Pedicled bone flaps can be used to revascularize the nonhealing scaphoid bone. These flaps are based on septal perforators from the adjacent extensor compartments. A bone flap based on the septum between the first and second extensor compartments is used most commonly. Bone flaps from the distal radius have been shown to improve the rate of bone healing in patients who have nonunion of the scaphoid. According to one study of ten patients who underwent reconstruction with a pedicled bone flap for long-term nonunion of fractures of the proximal pole of the scaphoid, approximately 100% demonstrated union, at an average of twelve weeks after surgery. In addition, in those patients who have Kienbšck disease (avascular necrosis of the lunate), successful revascularization of the lunate has been shown to occur.

Although bone grafts from the distal radius have been used in the past, they do not provide vascularized bone for grafting at the avascular site of the fracture.

References
1. Doi K, Oda T, Soo-Heong T, et al. Free vascularized bone graft for nonunion of the scaphoid. J Hand Surg. 2000;25A:507-519.
2. Steinmann SP, Bishop AT, Berger RA. Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg. 2002;27A:391-401.

A 35-year-old man sustained a dorsal perilunate dislocation of the left wrist when he jumped from a moving truck. Following closed reduction in the emergency department, anteroposterior radiographs show a scapholunate interval of 10 mm. Lateral radiographs show a dorsal intercalated segment instability (DISI) pattern (scapholunate angle of 90 degrees). There are no fractures.

Which of the following is the most appropriate management?

(A) Application of a long arm cast for 12 weeks
(B) Percutaneous pin fixation followed by application of a cast for six weeks
(C) Operative repair through a dorsal incision
(D) Proximal row carpectomy
(E) Scapholunate arthrodesis

The correct response is Option C.

In this patient who has an acute scapholunate ligament tear, the most appropriate management is operative repair through a dorsal incision. Surgery should be expedited in patients who have acute scapholunate ligament tears associated with carpal instability because degenerative wrist arthritis is likely to occur if the diastasis and carpal collapse are not corrected. The tear is repaired through a dorsal approach, and the carpal collapse is reduced with Kirschner wires. Pin fixation of the reduced scapholunate joint is performed under fluoroscopic control. The scapholunate ligament is repaired either directly or with suture anchors if necessary. Dorsal (ie, Blatt) capsulodesis will augment the repair and further stabilize the rotary subluxation of the scaphoid.

According to Mayfield's classification of progressive perilunate instability patterns, the stage of injury correlates directly with the progression of ligamentous injury around the lunate. Stage I involves instability of the scapholunate joint, or tearing of the scapholunate and volar radioscaphoid ligaments. Stage II is dislocation of the capitate. Separation of the lunate and triquetrum is seen in stage III. Lunate dislocation is classified as stage IV.

Greater and lesser arc injuries are also associated with perilunate dislocations. Greater arc injuries can include fractures of the radial styloid, scaphoid, capitate, triquetrum, and ulnar styloid. Lesser arc injuries are classified according to the stages of Mayfield's progressive perilunate instability.

Application of a long arm cast without operative repair does not address the injury and is likely to result in degenerative wrist arthritis.

Percutaneous pin fixation is appropriate only in patients who have diastasis of the scapholunate joint that can be corrected with this technique. Pin fixation is difficult in a patient who has a carpal collapse pattern and would most likely be ineffective.

Proximal row carpectomy and scapholunate arthrodesis are contraindicated in patients with acute injuries and are instead reserved for management of certain types of late degenerative wrist arthritis.

References
1. Garcia-Elias M. Carpal instabilities and dislocations. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:865-920.
2. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations, pathomechanics and progressive perilunate instability. J Hand Surg. 1980;5A:226.
3. Szabo RM, Sutherland TB. Acute carpal fractures and dislocations. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996:711.

A 40-year-old man sustains the fracture shown in the radiograph above when he falls on his outstretched hand. Which of the following is the most appropriate management?

(A) Immobilization in a thumb spica cast for six weeks
(B) Immobilization in a long arm cast for six weeks
(C) Open reduction and compression screw fixation
(D) Open reduction and Kirschner wire fixation
(E) Scaphoidectomy
The correct response is Option C.

In this patient who has a displaced fracture of the scaphoid waist, the most appropriate management is open reduction and compression screw fixation. This can be accomplished using a Herbert, Herbert-Whipple, or Accutrak screw; the Herbert-Whipple and Accutrak screws are cannulated to allow for guided pin placement. Compression screw fixation allows reduction of the fracture and compression across the fracture site, decreasing the risk for nonunion and the time required for immobilization. Although some surgeons suggest that adequate screw fixation allows early protected range of motion and eliminates the need for cast application, most physicians still recommend postoperative cast immobilization for three to six weeks. This shortened period of immobilization decreases the potential for muscle atrophy and joint stiffness and allows the patient to return to work sooner.

Previously recommended techniques for management of displaced fractures of the scaphoid waist, including prolonged immobilization in a long arm cast for three months or longer, have been associated with nonunion or malunion rates ranging from 30% to 40%.

Kirschner wire fixation is considered an acceptable fixation method, but is associated with higher rates of nonunion than compression screw fixation. In addition, Kirschner wires are typically buried for an extended fixation time to allow bony union and require an additional operative procedure for removal.

Scaphoidectomy is appropriate for management of patients with malunion or nonunion who develop scaphoid nonunion advanced collapse (SNAC wrist), which is a progressive, patterned arthritis of the wrist that may develop in a patient with nonunion. This procedure can be performed adjuvantly with proximal row carpectomy or four-corner arthrodesis, depending on the pattern of arthritis seen in the patient. It is not appropriate in patients with acute injuries.

References
1. Amadio PC, Taleisnik J. Fractures of the carpal bones. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:817.
2. Hebert TJ. Open volar repair of acute scaphoid fractures. Hand Clin. 2001;17:589-599.
3. Rettig A. Management of acute scaphoid fractures. Hand Clin. 2000;16:381-394.

PHOTO

A 15-year-old boy sustains the fracture shown in the radiograph above when he falls on his outstretched hand during a football game. The most appropriate management is immobilization in a thumb spica cast for how many weeks?

(A) 2 to 4
(B) 5 to 6
(C) 7 to 8
(D) 10 to 14
(E) 16 to 20

The correct response is Option D.

In this patient who has a nondisplaced transverse fracture of the scaphoid waist, the wrist should be immobilized in a thumb spica cast for 10 to 14 weeks. Most surgeons agree that acute nondisplaced scaphoid fractures will generally heal if the wrist is immobilized adequately for two to three months. Some surgeons recommend immobilization in a long arm cast for the first several weeks and replacement with a short arm cast for the duration of the healing period.

Open reduction and internal fixation are indicated in patients who have scaphoid fractures with displacement of more than 1 mm because the blood supply to the bone is likely to be disrupted. Because this blood supply enters the scaphoid distally and proceeds proximally, fractures of the tubercle and distal third of the scaphoid exhibit a more rapid
healing process. Therefore, casting for no more than four to six weeks is recommended in patients with fractures of the distal third of the scaphoid if there is no displacement. In contrast, the proximal pole of the scaphoid receives the poorest blood supply, and nondisplaced fractures of the proximal pole of the scaphoid would typically be immobilized for four to six months to allow for bony union. Instead, open reduction and internal fixation can be performed even if the fracture is nondisplaced. Electrical stimulation or ultrasound can be used adjunctively to treat delayed bony union.

Because fracture healing is variable, frequent follow-up examination and radiographs are indicated. CT scans show fracture callus and bridging trabeculae in healing scaphoid fractures.

References
1. Amadio PC, Taleisnik J. Fractures of the carpal bones. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1817.
2. Burge P. Closed cast treatment of scaphoid fractures. Hand Clin. 2001;17:541-551.
3. Rettig A. Management of acute scaphoid fractures. Hand Clin. 2000;16:385.

A 65-year-old woman has had worsening pain in the dominant right thumb for the past four years. She has difficulty buttoning her shirt and opening jars. Conservative management has not been effective. A radiograph is shown on page 162.

Which of the following is the most appropriate management?

(A) Metacarpal dorsal opening wedge osteotomy
(B) Trapeziectomy and tendon interposition arthroplasty
(C) Trapeziectomy and implant interposition arthroplasty
(D) Carpometacarpal joint arthrodesis
(E) Scaphotrapeziotrapezoid arthrodesis

The correct response is Option B.

This patient has pantrapezial osteoarthritis of the basal joint of the thumb, as shown in the radiograph. Degenerative arthritis of the basal joint of the thumb can affect the carpometacarpal, scaphotrapeziotrapezoid, and radiocarpal joints. This condition is common in laborers or other persons with occupations that require extensive hand functions.

Pantrapezial arthritis manifests as pain at the base of the thumb that is exacerbated with pinch, grasp, lifting, or twisting functions. Failure of the volar beak ligament is the most common initial finding. Patients typically have trouble opening jars and buttoning their clothes. Tenderness that is increased with direct compression and axial loading on physical examination will isolate the osteoarticular level of the thumb. Progressive dorsal subluxation of the basilar joint of the thumb may result in hyperextension of the metacarpophalangeal joint. Posteroanterior, oblique, lateral, and Robert's view radiographs of the thumb should be obtained.

The treatment of pantrapezial osteoarthritis depends on the stage of the disease. In patients in the early stages of arthritis, joint protection, modification of activity, and administration of nonsteroidal anti-inflammatory drugs are recommended. A splint can be based at either the hand or forearm. Injection of a corticosteroid may be considered in those patients who have significant pain.

If conservative management is unsuccessful, surgery is an option. The goals of surgery include stability and functional positioning of the thumb. In this patient, trapeziectomy, reconstruction of the volar beak ligament, and tendon interposition arthroplasty are indicated.

Dorsal opening wedge osteotomy of the thumb metacarpal is more appropriate for patients in the earlier stages of arthritis.

Although silicone and metal implants have been used in the past, the trapezium would only be partially resected to fit the implant; therefore, this patient's pain would not be relieved completely.

Arthrodesis of the carpometacarpal joint is indicated in patients who have high work demand, and is associated with nonunion. Patients who undergo this procedure are unable to flatten the palm.

Scaphotrapeziotrapezoid arthrodesis would not treat the involved joint.

References
1. Pellegrini VD Jr. The basal articulations of the thumb: pain, instability and osteoarthritis. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996:1019-1042.
2. Tomaino MM, Herndon JH. Arthroplasty. In: Herndon JH, ed. Surgical Reconstruction of the Upper Extremity. Stamford, Conn: Appleton & Lange; 1999:963-995.