Scaphoid Fracture

The scaphoid bridges the proximal and distal carpal rows and plays a major role in carpal stability.

Approximately 80% of its blood supply enters dorsally and travels in a predominantly retrograde direction toward the proximal pole.

This explains why proximal pole fractures have:

Slower union
Greater nonunion risk
Greater osteonecrosis risk

Most fractures occur through the waist.

Classification by location

Distal tubercle
Distal pole
Waist
Proximal pole

Approximately 65% to 80% occur through the waist.

Herbert and Fisher classification

Type A: Stable acute fracture

Tubercle fracture.

Incomplete waist fracture.

Type B: Unstable acute fracture

Distal oblique fracture.

Complete waist fracture.

Proximal pole fracture.

Transscaphoid perilunate fracture dislocation.

Comminuted fracture.

Type C

Delayed union with widening or cystic change.

Type D

Established nonunion.

Fibrous union.

Pseudoarthrosis or mobile nonunion.

Russe classification

Based on fracture orientation.

Horizontal oblique

More compressive and generally stable.

Transverse

Intermediate.

Vertical oblique

Shear dominant and mechanically unstable, with greater nonunion risk.

SNAC wrist

Untreated scaphoid nonunion can progress to scaphoid nonunion advanced collapse.

Degenerative progression broadly begins at the radial styloid and distal scaphoid, progresses across the radioscaphoid articulation, and ultimately involves midcarpal joints while the radiolunate articulation is relatively preserved until late disease.

Obtain scaphoid radiographic series:

PA
Lateral
Oblique
Dedicated scaphoid view with ulnar deviation

Initial radiographs can be normal.

If clinical suspicion remains high despite normal radiographs:

MRI provides the most sensitive early diagnosis.

An alternative is immediate immobilisation and repeat imaging, but MRI avoids unnecessary prolonged immobilisation in patients without fracture.

CT: best for:

Fracture displacement
Humpback deformity
Surgical planning
Assessing union

MRI can assess proximal pole vascularity when osteonecrosis is suspected.

Stable distal fracture

Distal tubercle and stable distal pole injuries generally heal reliably with cast immobilisation because blood supply is excellent.

Stable nondisplaced waist fracture

Treat with below elbow cast immobilisation.

A truly stable waist fracture with displacement below approximately 1 mm has a high union rate with cast treatment.

Thumb immobilisation is not necessarily required for every stable waist fracture, although many surgeons still use a thumb spica initially.

Follow union clinically and, where uncertain, with CT.

Operative indications

Strong indications include:

Displacement greater than approximately 1 mm
Proximal pole fracture
Vertical oblique fracture
Humpback deformity
Comminution
Perilunate associated injury
Established nonunion
Failure of conservative treatment

Internal fixation may also be selected in high demand athletes or manual workers to accelerate predictable union and return to function.

Screw fixation

Use a headless compression screw placed along the central axis of the scaphoid.

Long central screw placement maximises fixation strength.

Use fluoroscopy to ensure:

No joint penetration
Appropriate screw length
Central position
Restoration of scaphoid alignment

Proximal pole

Proximal pole fractures generally warrant fixation because:

Blood supply is tenuous
Fragment is small
Nonunion risk is high

A dorsal approach often provides the most direct trajectory for central screw placement.

Nonunion

Assess:

Fracture location
Deformity
Carpal collapse
Proximal pole vascularity
Presence of arthritis

A mobile nonunion without advanced arthritis generally requires:

Debridement of nonunion
Restoration of scaphoid length and alignment
Internal fixation
Bone grafting

Use vascularised bone graft when proximal pole vascularity is poor or previous conventional grafting has failed.

Persistent scaphoid nonunion can produce humpback deformity and DISI carpal alignment.

Advanced SNAC

Once advanced degenerative collapse is established, simple scaphoid union may no longer solve the patient\'s pain.

Salvage options include:

Radial styloidectomy in very limited early disease
Proximal row carpectomy
Four corner fusion with scaphoid excision
Total wrist arthrodesis in advanced destructive disease

Major complications include:

Nonunion
Osteonecrosis
Humpback deformity
DISI
SNAC wrist
Wrist stiffness
Hardware penetration

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Distal Femur Fracture

Distal femur fractures involve the distal metaphysis and femoral condyles above the knee.

They occur in two major populations:

Young patients after high energy trauma
Older osteoporotic patients after low energy falls

These fractures are challenging because of:

Metaphyseal comminution
Short distal fragments
Osteoporotic bone
Articular involvement
Coronal plane Hoffa fragments
Strong deforming forces

The gastrocnemius pulls the distal fragment posteriorly, creating an apex posterior deformity. Adductor forces can contribute to varus or shortening.

AO/OTA classification

Distal femur = 33

33A: Extraarticular

The articular surface is intact.

A1 simple
A2 metaphyseal wedge
A3 metaphyseal multifragmentary

33B: Partial articular

Part of the articular surface remains attached to the shaft.

B1 lateral condyle sagittal fracture
B2 medial condyle sagittal fracture
B3 coronal plane fracture, commonly called a Hoffa fracture

33C: Complete articular

The entire articular block is separated from the shaft.

C1 simple articular and simple metaphyseal component
C2 simple articular component with metaphyseal comminution
C3 multifragmentary articular fracture.

Patients present with severe distal thigh or knee pain and inability to bear weight.

Look for:

Deformity
Extensive swelling
Knee haemarthrosis
Open wounds
Skin tenting
Associated patellar injury

Because of proximity to the popliteal artery, document:

Distal pulses
Capillary refill
Motor function
Sensation

Repeat vascular examination after reduction.

High energy fractures may accompany knee ligament injuries that are not immediately obvious.

Nonoperative treatment

Nonoperative treatment has a limited role.

Consider a hinged knee brace for:

Stable nondisplaced fracture
Nonambulatory patient
Patient whose operative risk is prohibitive.

Prolonged immobilisation produces stiffness, muscle loss and complications of immobility and should be avoided where possible.

Temporary external fixation

Use spanning external fixation when:

The patient is physiologically unstable
Severe swelling or soft tissue injury prevents definitive internal fixation
Open contamination requires repeated debridement
Temporary restoration of length and alignment is required.

Operative principles

The sequence in an articular fracture is:

Reconstruct the joint surface
Restore the condylar block
Restore femoral length, alignment and rotation
Connect the reconstructed articular segment to the shaft

Avoid varus alignment.

Lateral locking plate

A precontoured lateral locking plate is useful for:

Metaphyseal comminution
Osteoporotic bone
Intra articular fractures
Very distal fractures

The construct should provide adequate working length and avoid unnecessarily dense locking screw placement that creates an excessively stiff construct and contributes to nonunion.

Medial comminution with poor cortical support can require additional medial fixation.

Retrograde intramedullary nail

Useful for:

Extraarticular fractures
Simple articular fractures after independent fixation of the joint split
Selected periprosthetic fractures with an open femoral component box

The distal segment must be large enough to accept sufficient locking fixation.

Hoffa fracture

A coronal plane femoral condyle fracture is inherently unstable and should usually undergo anatomical reduction and screw fixation, often supplemented with a buttress plate in large or unstable fragments.

Nonoperative management of a displaced Hoffa fracture produces poor articular results.

Severe osteoporotic fracture

In an elderly patient with extreme comminution, severe bone loss or a nonreconstructible articular surface, distal femoral replacement may permit immediate stable reconstruction and early weight bearing.

It is a major arthroplasty procedure and should not replace reconstructive fixation when satisfactory osteosynthesis is achievable.

Rehabilitation

Stable fixation should permit early knee motion.

Prolonged knee immobilisation leads rapidly to arthrofibrosis.

Weight bearing depends on construct stability, fracture morphology and bone quality. Increasingly robust constructs can permit early weight bearing in selected patients.

Complications

Major complications are:

Nonunion
Varus collapse
Implant failure
Infection
Knee stiffness
Post traumatic osteoarthritis
Malalignment

Scaphoid Fracture

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management