Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Scaphoid Fractures

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Scaphoid Fractures · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

• 0:00
  OK, let's start with a statistic that really
• 0:02
  drives home the stakes here. Scaphoid fractures.
• 0:05
  This small bone in your wrist, it's the most
• 0:08
  commonly fractured carpal bone, making up something
• 0:10
  like 60 % of all wrist bone breaks. That's right.
• 0:14
  A huge proportion. And you might think, all right,
• 0:16
  a simple wrist break after a fall. But here's
• 0:19
  the critical part, depending on where it breaks,
• 0:21
  how it's treated. Well, a significant percentage,
• 0:24
  potentially 15 to 50 percent overall, maybe even
• 0:27
  hitting 100 percent in those tricky proximal
• 0:29
  pole fractures if not handled correctly, can
• 0:31
  lead to a vascular necrosis. Essentially bone
• 0:34
  death. Exactly, bone death. That seemingly simple
• 0:37
  fall can just unravel into chronic pain, loss
• 0:40
  of function, maybe even a career -threatening
• 0:42
  problem for someone relying on their hands. And
• 0:44
  so much of that risk comes down to the scaphoids'
• 0:47
  peculiar structure, that sort of twisted peanut
• 0:49
  shape we talk about. Right. complex, almost awkward
• 0:53
  blood supply. Welcome to the Deep Dive. This
• 0:56
  is where we take complex information research
• 0:58
  papers, clinical guidelines, expert knowledge,
• 1:01
  and really extract the vital insights, giving
• 1:03
  you the shortcut to being truly well -informed.
• 1:05
  Today we are taking a profound look into scaphoid
• 1:08
  fractures, navigating the orthopedic knowledge
• 1:10
  and clinical practices necessary to understand
• 1:13
  and manage this, well, really challenging injury.
• 1:16
  And guiding us through this deep dive is Professor
• 1:19
  Mo Imam, a distinguished expert in musculoskeletal
• 1:23
  trauma and hand surgery. Professor Imam, it's
• 1:26
  a real privilege to have you join us. Thank you.
• 1:28
  It's a crucial topic and I'm glad to explore
• 1:30
  it. The scaphoid is, well, it's a small bone.
• 1:34
  that presents some very large clinical problems
• 1:36
  you've not understood properly. Absolutely. So
• 1:39
  to kick things off and maybe give you a roadmap
• 1:41
  of where we're heading, let's hit you with three
• 1:43
  quick high -impact questions. OK. First, just
• 1:46
  stepping back, what exactly is a scaphoid fracture?
• 1:49
  And fundamentally, why does it pose such unique
• 1:51
  problems compared to, say, a break in the radius
• 1:54
  or ulna? Well, what's critically important here
• 1:56
  is the scaphoid's unique anatomy and its vascularization.
• 1:59
  You see, it's the critical mechanical link between
• 2:02
  the two rows of wrist bones, absolutely essential
• 2:05
  for smooth motion. But unlike most bones that
• 2:08
  have multiple points of entry for blood vessels,
• 2:11
  the scaphoid gets the majority of its blood supply
• 2:14
  through quite a limited area, often distal to
• 2:17
  where the fracture occurs. Which means the blood
• 2:20
  has to flow retrograde backwards towards that
• 2:23
  vital proximal pole. This sets it apart entirely
• 2:27
  from breaks in the long bones of the forearm.
• 2:29
  That retrograde flow sounds like a, well, a built
• 2:32
  -in vulnerability, doesn't it? It absolutely
• 2:34
  is. Second question, then. Beyond just the initial
• 2:36
  break healing, what are the most significant,
• 2:39
  potentially devastating complications that professionals,
• 2:42
  especially those who use their hands intensely,
• 2:44
  must absolutely be aware of? Yes. This really
• 2:47
  raises the specter of long -term disability.
• 2:50
  The primary complications are non -union, meaning
• 2:52
  the fracture simply fails to heal, endovascular
• 2:55
  necrosis, or AVN, where the bone tissue actually
• 2:58
  dies due to that lack of blood supply. Okay.
• 3:00
  Either of these can lead to malunion, where it
• 3:02
  heals crookedly, progressive carpal collapse,
• 3:05
  and ultimately debilitating osteoarthritis of
• 3:08
  the wrist. These aren't minor setbacks. They
• 3:11
  really can be career -ending issues. Non -union
• 3:13
  and AVN, those are the big risks. Okay. Finally,
• 3:17
  if you had to boil it all down, Is there one
• 3:19
  single most critical factor in achieving a good
• 3:22
  outcome for a scaphoid fracture? That's a key
• 3:25
  question. If we distill all the evidence and,
• 3:28
  you know, clinical experience, the single most
• 3:31
  critical factor is probably an early accurate
• 3:34
  diagnosis. Right. Followed immediately by appropriate
• 3:38
  individualized management. And that management
• 3:40
  has to be based on a thorough assessment of the
• 3:43
  fracture characteristics. Hesitation or misdiagnosis
• 3:46
  significantly increases the risk of those complications
• 3:48
  we just mentioned. Early, accurate diagnosis
• 3:51
  and appropriate management. Sounds like a bit
• 3:53
  of a race against the clock and the anatomy itself.
• 3:55
  In many ways, yes. So let's start by understanding
• 3:57
  the star of our show, the scaphoid bone itself.
• 4:01
  We often hear it called boat -shaped from its
• 4:03
  Greek origin, but you prefer twisted peanut.
• 4:05
  Why is that shape significant? Indeed. Oskifodium
• 4:08
  does translate to boat shapes. And I suppose
• 4:10
  if you look at it from one angle, maybe it vaguely
• 4:11
  resembles a small boat. But the twisted peanut
• 4:14
  analogy, while less scientific, perhaps gives
• 4:17
  you a better sense of its complex 3D geometry
• 4:20
  and its angulation. It's not a simple straight
• 4:23
  bone. OK. This shape is crucial because it has
• 4:25
  two main articulating surfaces, fitting neatly
• 4:28
  into the proximal and distal carpal rows. And
• 4:31
  the vast majority of its surface, over 75%, is
• 4:34
  covered in smooth articular cartilage, which
• 4:36
  is essential for wrist movement. Right, for the
• 4:39
  gliding. Exactly. But this also means there's
• 4:41
  very little raw bone surface available for soft
• 4:44
  tissues, ligaments, or critically, blood vessels
• 4:46
  to attach and actually enter the bone. The main
• 4:50
  area where blood vessels can get in is a small,
• 4:52
  non -articular area known as the dorsal ridge.
• 4:55
  So the very structure designed for smooth movement
• 4:58
  actually limits where its lifeblood can get in.
• 5:00
  Precisely. It's a trade -off. Let's dive deeper
• 5:02
  into that critical, tricky blood supply, maybe
• 5:05
  drawing on that foundational research. What did
• 5:08
  the classic Gelberman and Menon study from 1980
• 5:11
  using those latex injections really reveal about
• 5:14
  the scaphoid's vascularity? Yes, that study published
• 5:17
  in the Journal of Hand Surgery was absolutely
• 5:20
  seminal. It meticulously mapped the scaphoid's
• 5:24
  blood supply. They identified two primary sources
• 5:26
  or vascular leashes, as they call them. OK. The
• 5:30
  dominant supply comes from the dorsal ridge artery.
• 5:32
  Now, this is a branch of the radial artery, and
• 5:34
  it's responsible for a significant majority,
• 5:37
  perhaps 70 to 80 percent, of the scaphoid's total
• 5:40
  blood flow. It enters the bone through that non
• 5:42
  -articular dorsal ridge we just discussed. The
• 5:45
  small entry point on the back. And this is where
• 5:46
  the retrograde flow comes in, correct? Precisely.
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  The blood vessels entering the dorsal ridge predominantly
• 5:52
  supply the distal and middle parts of the scaphoid
• 5:55
  first. OK. So to reach the crucial proximal pole
• 5:58
  that's the part closest to the forearm bones,
• 6:01
  the blood has to flow backwards or retrogradedly
• 6:04
  up the length of the bone. It's quite counterintuitive
• 6:07
  compared to how blood typically flows into most
• 6:10
  bones. So blood comes in effectively at one end
• 6:12
  and has to push upstream to reach the other end.
• 6:14
  That seems inherently risky. Exactly. Now there
• 6:18
  is a secondary minor supply from the palmar side
• 6:21
  via branches of the palmar and superficial palmar
• 6:24
  radial artery. These vessels enter near the distal
• 6:27
  tubercle and supply roughly the distal 20 to
• 6:30
  30 percent of the scaphoid. OK, so combining
• 6:33
  these, you've got the main supply coming in dorsally,
• 6:35
  flowing retrograde -ly, and a smaller supply
• 6:38
  coming in palmerly just to the distal bit. That
• 6:41
  specific setup creates a significant vulnerability.
• 6:45
  The area reliant on that retrograde flow, particularly
• 6:48
  the proximal pole, is effectively in a watershed
• 6:51
  zone. A watershed zone, right. So if a fracture
• 6:54
  occurs between where those dominant dorsal vessels
• 6:56
  enter and the proximal pole itself, that proximal
• 6:59
  fragment can be entirely cut off from his blood
• 7:02
  supply. Completely isolated. Yes. And the small
• 7:04
  palmar supply is usually insufficient to sustain
• 7:07
  it. This is the fundamental anatomical reason
• 7:09
  why proximal pole fractures are at such a high
• 7:12
  risk of vascular necrosis. The blood simply can't
• 7:14
  get there. That anatomical detail is just incredibly
• 7:17
  important for understanding the prognosis, isn't
• 7:19
  it? Absolutely fundamental. No. Turning to how
• 7:22
  and where these fractures typically happen, what
• 7:25
  does the epidemiology tell us? Who gets these,
• 7:27
  and why? Well, epidemiologically, scaphoid fractures
• 7:31
  are, as you mentioned right at the start, the
• 7:32
  most common carpal fracture. They make up about
• 7:35
  60 % of all carpal breaks and maybe 15 % of acute
• 7:39
  wrist injuries generally. OK. The highest incidence
• 7:42
  is in young, active men. particularly in their
• 7:45
  third decade of life. The male to female ratio
• 7:48
  is often cited around 2 .1. So it's often associated
• 7:51
  with activities then, sports, falls. Absolutely.
• 7:54
  The overwhelming etiology that causes a fall
• 7:57
  onto an outstretched hand, the classic foosh
• 7:59
  injury. This mechanism typically involves the
• 8:02
  wrist being forced into hyperdorsiflexion, often
• 8:05
  with an axial load pushing down some pronation
• 8:07
  and frequently concurrent ulnar deviation, the
• 8:10
  wrist bending towards the little finger side.
• 8:12
  That's the classic scenario, isn't it? Tripping,
• 8:14
  falling off a bike. Exactly. Sports, falls from
• 8:18
  height, or simply tripping on the pavement. It's
• 8:21
  worth noting, too, that this foosh with ulnar
• 8:24
  deviation can also simultaneously injure ligaments
• 8:27
  around the wrist. Sometimes it leads to what
• 8:29
  we call a dis -e deformity dorsal intercalated
• 8:33
  segmental instability. OK, what does that mean?
• 8:35
  It essentially means the middle row of carpal
• 8:37
  bones tilts backwards abnormally, which adds
• 8:40
  another layer of complexity to the injury. Right,
• 8:42
  so it's not just the scaphoid break, that makes
• 8:44
  sense. And where in this twisted peanut does
• 8:47
  it most commonly break? You mentioned the proximal
• 8:49
  pole is riskiest, but is it the most frequent?
• 8:52
  No, interestingly, while the proximal pole is
• 8:54
  the riskiest spot for complications, it's not
• 8:57
  the most frequent location for the fracture itself.
• 9:00
  The most common fracture location is the waist,
• 9:02
  the narrowest part of the bone. That counts for
• 9:05
  about 65 % of scaphoid fractures. The majority,
• 9:08
  then? Yes. Fractures in the proximal third are
• 9:10
  next most common at around 25 % and fractures
• 9:14
  of the distal third or the little tubercle at
• 9:16
  the end are the least common, making up perhaps
• 9:18
  10%. There used to be belief that distal fractures
• 9:21
  were more common in children. But more recent
• 9:24
  large series suggest that waste fractures are
• 9:27
  now actually the predominant site across most
• 9:29
  age groups. So the waste is the frequent flyer,
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  but the proximal third is the high -risk passenger.
• 9:34
  That's a good way to put it, yes. This brings
• 9:36
  us neatly to classification systems. Why is it
• 9:39
  so vital to classify a scaphoid fracture beyond
• 9:43
  just saying it's broken? Oh, classification is
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  absolutely paramount because it's really the
• 9:48
  foundation for clinical decision -making. It
• 9:51
  helps us assess the fracture stability. understand
• 9:53
  its likely prognosis, and ultimately dictates
• 9:56
  the most appropriate treatment strategy. Whether
• 9:58
  it's casting or surgery. Precisely. Whether that's
• 10:02
  casting or surgery and indeed what type of surgery
• 10:04
  might be needed. A proper classification guides
• 10:07
  us towards maximizing the chance of union healing
• 10:10
  and minimizing those complications we talked
• 10:12
  about. The Herbert classification is widely used,
• 10:15
  isn't it? It seems to be based specifically on
• 10:17
  stability and also the timing. Whether it's acute
• 10:20
  or older, could you walk us through the main
• 10:22
  types? Yes, the Herbert classification is very
• 10:25
  clinically relevant because it categorizes fractures
• 10:28
  based on factors that directly impact treatment
• 10:30
  and outcome. It divides fractures into four main
• 10:33
  types A, B, C, and D. Okay. Type A. represents
• 10:38
  stable acute fractures. These are generally lower
• 10:40
  risk and include A1, which is a fracture of that
• 10:43
  distal tubercle. The little end bit, yes. And
• 10:45
  A2, which is an incomplete waste fracture, meaning
• 10:48
  the crack doesn't go all the way across the bone.
• 10:50
  Right, so those are relatively safe bets for
• 10:52
  healing. Generally, yes, with appropriate immobilization.
• 10:55
  Then you have type B, which represents unstable
• 10:58
  acute fractures. Now these are the ones that
• 11:00
  often require surgery due to their inherent risk
• 11:02
  of not healing well or displacing. Okay, what's
• 11:05
  in type B? This category includes B1, a distal
• 11:08
  oblique fracture, which is prone to shear forces
• 11:10
  and slipping. B2, a complete waist fracture,
• 11:13
  which is considered unstable because it breaks
• 11:15
  the main structural support across the middle.
• 11:18
  B3, a proximal pull fracture, which we know is
• 11:21
  unstable due to that high AVN risk and the anatomical
• 11:24
  difficulty. The blood supply issue again? Exactly.
• 11:27
  And B4, which is a very significant injury, indeed
• 11:29
  a transcephoid -paralinate fracture dislocation.
• 11:32
  That involves major disruption of the ligaments
• 11:35
  around the lunate bone as well as the scaphoid
• 11:38
  brick itself. Wow. Okay. So type A is relatively
• 11:41
  stable. Type B is unstable and problematic. What
• 11:45
  about C and D? Type C is designated for delayed
• 11:48
  union. This is when the fracture hasn't healed
• 11:51
  within the expected time frame, say after several
• 11:53
  months of casting. But there's still thought
• 11:55
  to be some biological potential for it to heal,
• 11:58
  perhaps with further immobilization or maybe
• 12:00
  some intervention. So slow healing, but not given
• 12:03
  up yet. Precisely. And then type D is for established
• 12:06
  non -union. This means the bone has failed to
• 12:08
  heal, the healing process is effectively stopped,
• 12:11
  and it requires intervention to achieve union.
• 12:13
  And Herbert breaks down non -union further. Yes,
• 12:16
  Herbert further subdivides non -union. which
• 12:18
  is useful prognosically. D1 is a fibrous union
• 12:20
  where there's maybe some soft tissue connection,
• 12:22
  but no solid bone bridging the gap. D2 is a pseudothrosis,
• 12:26
  which literally means a false joint with instability
• 12:28
  and often early deformity starting to develop.
• 12:31
  Like it's moving where it shouldn't. Exactly.
• 12:33
  D3 is a sclerotic pseudothrosis. which is a more
• 12:37
  established false joint where the bone edges
• 12:39
  have become hardened and dense, often with significant
• 12:42
  deformity like that humpback shape. And finally,
• 12:45
  D4 indicates avian avascular necrosis associated
• 12:48
  with the non -union, often presenting as a fragmented
• 12:51
  or collapsed proximal pole. That progression
• 12:54
  to D4 sounds like the real end stage of that
• 12:57
  avian risk we discussed right at the start. It
• 12:59
  often is, yes. It represents significant biological
• 13:02
  failure. Are there other classification systems
• 13:04
  that clinicians use alongside Herbert? Yes, there
• 13:08
  are others that focus on slightly different aspects,
• 13:10
  which can be complementary. The Mayo classification
• 13:13
  is a simpler system based purely on the anatomical
• 13:15
  location. Type 1 is a distal tubercle. Type 2,
• 13:19
  the distal articular surface. 3, the distal third.
• 13:22
  4, the middle third or waist. And type V, the
• 13:24
  proximal third. So just location. Just location.
• 13:27
  And the Roast classification describes the fracture
• 13:28
  line pattern or its orientation. Horizontal oblique.
• 13:31
  transverse straight across, and vertical oblique.
• 13:34
  Why does the pattern matter? Well, a vertical
• 13:36
  oblique fracture pattern, for instance, is a
• 13:39
  known risk factor for instability and nonunion.
• 13:41
  Because the fracture line runs more vertically,
• 13:44
  it's much more prone to shearing forces when
• 13:46
  the wrist is loaded, making it harder to hold
• 13:48
  reduced and less likely to heal in a cast. I
• 13:52
  see. So Herbert gives you the stability and chronicity
• 13:55
  picture, Mayo gives location, and Russ adds the
• 13:58
  fracture pattern detail. And combining these
• 14:00
  helps make the treatment decision. Exactly. The
• 14:02
  classification, drawn on these different aspects,
• 14:05
  directly informs the management pathway. Stable,
• 14:08
  undisplaced fractures, typically Herbert type
• 14:09
  A or maybe non -displaced type B2 or B3, depending
• 14:13
  on surgeon preference and careful imaging, and
• 14:15
  often majoroos types without displacement or
• 14:17
  vertical patterns are usually candidates for
• 14:20
  non -operative management with casting. Whereas
• 14:22
  unstable, acute fractures, Herbert type B, vertical
• 14:25
  oblique patterns, any proximal pole fracture,
• 14:27
  really. Those with significant displacement or
• 14:30
  angulation seen on imaging almost always require
• 14:33
  operative intervention due to the high likelihood
• 14:35
  of non - union or malunion if you simply put
• 14:37
  them in a cast. Right, the classification is
• 14:40
  absolutely the roadmap to treatment. Now, let's
• 14:42
  talk about actually spotting this injury in the
• 14:44
  first place. Given there's often no dramatic
• 14:47
  deformity, how do clinicians typically diagnose
• 14:50
  a scaphoid fracture? What are the key clinical
• 14:53
  signs to look for? Clinically, the cardinal sign,
• 14:56
  the one everyone learns, is tenderness in the
• 14:58
  anatomical snuff box. That little hollow on the
• 15:00
  back of your wrist? Exactly, on the thumb side,
• 15:03
  formed when you extend your thumb out. Pressing
• 15:06
  firmly in that area after a foosh injury is highly
• 15:09
  suggestive. Its sensitivity for detecting a scaphoid
• 15:12
  fracture is reported to be high, maybe up to
• 15:15
  90%. That's quite high. It is, but it's crucial
• 15:18
  to remember that other injuries, like ligament
• 15:20
  sprains or fractures of the radial styloid, can
• 15:23
  also cause snuff box tenderness. So it's sensitive,
• 15:26
  but not perfectly specific. It doesn't absolutely
• 15:29
  confirm a scaphoid fracture on its own. Okay,
• 15:31
  so it's a strong clue, but not proof. What else?
• 15:34
  Other signs include general swelling around the
• 15:36
  radial side of the wrist, often some reduced
• 15:39
  range of motion, particularly wrist extension
• 15:41
  and radial deviation. Pain with forceful resisted
• 15:45
  pronation of the forearm can sometimes elicit
• 15:47
  pain. And there's a positive scaphoid compression
• 15:50
  test, where you push axially along the line of
• 15:53
  the thumb metacarpal towards the wrist, and that
• 15:56
  reproduces their specific pain. Right. But the
• 15:59
  key challenge, as you said, is that unlike, say,
• 16:01
  a broken forearm bone, there's usually no obvious
• 16:04
  deformity. The wrist might look a bit swollen,
• 16:07
  maybe bruised, but often not dramatically out
• 16:09
  of shape. This makes it really easy to mistake
• 16:12
  for a simple wrist sprain, especially in the
• 16:14
  heat of the moment, like on a sports field or
• 16:16
  in a busy A &E. So the take -home is, after a
• 16:19
  fall onto an outstretched hand, if there's snuff
• 16:21
  box tenderness, you really should have a high
• 16:23
  clinical suspicion. What's the crucial next step,
• 16:26
  then, in terms of imaging? The standard initial
• 16:29
  imaging is plain x -rays, but... And this is
• 16:31
  a really important point. You need the right
• 16:33
  views to maximize the chance of actually seeing
• 16:35
  the fracture, especially if it's subtle or undisplaced.
• 16:38
  But not just the standard two views. No, definitely
• 16:41
  not. Relying on just standard PA, postural interior,
• 16:45
  and lateral views is often insufficient. The
• 16:47
  sources consistently recommend a minimum of four
• 16:49
  or ideally five specific views. This includes
• 16:52
  the standard PA and a true lateral. OK. But crucially,
• 16:56
  also, PA view is taken in 45 degrees of oblique
• 16:59
  pronation and 45 degrees of oblique supination.
• 17:02
  And the PA view taken with the wrist in maximum
• 17:05
  ulnar deviation bending towards the little finger.
• 17:08
  Why the honored deviation view? That specific
• 17:11
  view helps to elongate the scaphoid, straightening
• 17:13
  out its natural curve on the x -ray image, which
• 17:16
  makes fractures across the waist much more visible
• 17:19
  than they might be in the standard neutral PA
• 17:21
  view. Right, it sort of uncoils it visually.
• 17:23
  Exactly. And beyond just looking for the fracture
• 17:25
  line itself, on the x -rays you also look for
• 17:27
  other radiographic signs, things like sclerosis,
• 17:30
  which is increased bone density along the fracture
• 17:32
  line, suggesting poor healing or maybe even early
• 17:35
  bone death. or looking for that humpback deformity
• 17:38
  on the lateral view, which is an increased intraskeifoid
• 17:40
  angle. How much of an angle is abnormal? Generally,
• 17:44
  an angle over 35 degrees suggests some deformity,
• 17:47
  and an angle greater than 45 degrees is strongly
• 17:50
  associated with poor outcomes and the likely
• 17:53
  development of that dizzy instability pattern
• 17:55
  we mentioned earlier. Okay. Now... There's the
• 17:58
  historical approach, the two -week delay, where
• 18:00
  initial x -rays are negative but your suspicion
• 18:02
  is high, you cast the wrist and repeat the x
• 18:05
  -rays two weeks later. What was the thinking
• 18:08
  behind this, and is it still the recommended
• 18:11
  practice today? This was a very common practice
• 18:13
  for many years based on the idea that bone resorption,
• 18:16
  a natural process occurring around a fracture
• 18:18
  line in the early healing phase, might make a
• 18:21
  previously invisible, occult, non -displaced
• 18:24
  fracture become visible on a follow -up x -ray
• 18:26
  after a period of immobilization. The line might
• 18:29
  become clearer. That was the theory. However,
• 18:33
  evidence such as that quite pivotal 1981 Leslie
• 18:36
  and Dixon study of the JBJS has really challenged
• 18:39
  the utility of this approach. They reviewed a
• 18:41
  large series of patients presenting with scaphoid
• 18:43
  fractures and found that a staggering 98 % of
• 18:47
  these fractures were actually visible on the
• 18:49
  initial radiographic series, provided that adequate
• 18:52
  views, those multiple views we just discussed,
• 18:55
  were obtained. 98 % were visible initially. Yes.
• 18:58
  Only a tiny 2 % became apparent only on the later
• 19:01
  X -rays. And these were typically only very minor
• 19:04
  incomplete fractures located on the concave side
• 19:07
  of the bone. So the vast majority are there to
• 19:09
  be seen if you look correctly the first time.
• 19:12
  What's the implication of that finding for the
• 19:14
  whole two -week delay strategy? Well, the implication
• 19:16
  is pretty profound, really. Waiting two weeks
• 19:19
  misses almost nothing that wasn't truly visible
• 19:21
  initially and only picks up a very small number
• 19:24
  of potentially insignificant incomplete fractures
• 19:27
  later on. But crucially, what it does do is it
• 19:30
  delays definitive diagnosis and potentially the
• 19:34
  appropriate treatment for a full 14 days. During
• 19:37
  that delay, a fracture that might have been minimally
• 19:40
  displaced could become more displaced within
• 19:42
  the cast, or the optimal window for early surgical
• 19:45
  fixation, if indicated, could be missed. This
• 19:47
  potentially increases the risk of non -union
• 19:50
  and AVN. So paradoxically, the two -week delay
• 19:53
  meant to avoid missing things could actually
• 19:56
  be detrimental by delaying definitive management.
• 19:59
  In many cases, yes, it delays certainty. So what
• 20:01
  are the modern preferred alternatives if clinical
• 20:04
  suspicion remains high despite negative initial
• 20:06
  x -rays? What should be done instead of waiting
• 20:09
  two weeks? The modern approach, which is supported
• 20:11
  by higher quality evidence and much better technology,
• 20:14
  is to move swiftly to advanced imaging if those
• 20:16
  initial x -rays are negative. But your clinical
• 20:19
  suspicion of a scaphoid fracture persists. Advanced
• 20:21
  imaging meaning CT or MRI. Exactly. The primary
• 20:25
  alternatives are CT or MRI. CT is widely available,
• 20:29
  relatively quick, and generally less expensive
• 20:31
  than MRI. It's excellent at definitively demonstrating
• 20:34
  the presence or absence of a fracture line, even
• 20:37
  subtle ones. And MRI. MRI is even more sensitive,
• 20:40
  particularly for detecting truly occult fractures,
• 20:43
  those not visible on x -ray, or even sometimes
• 20:45
  CT, especially in the very early stages after
• 20:47
  injury, say within the first 24 to 48 hours.
• 20:51
  Let's break down the utility of CT and MRI a
• 20:53
  bit further then. What specific information does
• 20:56
  a CT scan give you that plain x -rays perhaps
• 20:59
  can't? CT is invaluable for assessing the fracture
• 21:02
  in fine detail. It provides high resolution images,
• 21:05
  typically using very thin 1mm slices, which are
• 21:08
  often reconstructed in the sagittal plane along
• 21:10
  the scaphoid's long axis. This allows for really
• 21:13
  accurate assessment of the precise fracture location,
• 21:16
  the degree of angulation or deformity, and crucially
• 21:18
  the amount of displacement between the fragments.
• 21:21
  Displacement of greater than 1mm is widely accepted
• 21:23
  as a key indicator of instability and a strong
• 21:26
  predictor of poor outcome with non -operative
• 21:28
  treatment alone. So CT is best for measuring
• 21:30
  that gap. Yes, CT is far more effective than
• 21:33
  x -rays, bone scans, or even MRI for precisely
• 21:37
  measuring displacement. It's also excellent for
• 21:39
  monitoring fracture healing progress over time,
• 21:42
  or for assessing the characteristics of an established
• 21:44
  non -union before planning surgery. And MRI.
• 21:47
  You mentioned it's high sensitivity for occult
• 21:49
  fractures. What else does it offer? MRI is really
• 21:52
  the gold standard for diagnosing those subtle
• 21:54
  or occult fractures that just aren't visible
• 21:56
  on x -rays or sometimes even CT. It attacks bone
• 22:00
  bruising, and occult fracture is essentially
• 22:01
  a severe bone bruise very early on. It can also
• 22:04
  show early signs of AVN. The blood supply issue
• 22:07
  again. Exactly. AVN shows up as a characteristic
• 22:09
  low signal intensity on both T1 and T2 weighted
• 22:13
  images. MRI is also superior to CT for evaluating
• 22:16
  associated soft tissue injuries like ligament
• 22:18
  tears, particularly the scaphalunid ligament,
• 22:21
  which can contribute significantly to overall
• 22:23
  wrist instability. So if you have high suspicion
• 22:26
  and a negative x -ray, an MRI gives you a definitive
• 22:29
  answer about whether a fracture is present or
• 22:31
  not. In most cases, yes. It often prevents the
• 22:34
  need for prolonged unnecessary casting based
• 22:37
  on suspicion alone. which has implications for
• 22:40
  patient convenience and health care costs. What
• 22:42
  about bone scans? You mentioned CT is better
• 22:45
  for displacement. Are bone scans still part of
• 22:47
  the diagnostic algorithm at all? Bone scans,
• 22:50
  or scintigraphy, are highly sensitive for detecting
• 22:52
  increased metabolic activity associated with
• 22:55
  any bone injury, including fractures. They typically
• 22:58
  become positive about 72 hours after the injury.
• 23:01
  They have high specificity, around 98%, meaning
• 23:03
  if it's negative, you likely don't have a fracture.
• 23:05
  Yeah. But they can show increased uptake for
• 23:08
  There are other reasons besides the scaphoid
• 23:09
  fracture inflammation, arthritis, other injuries
• 23:12
  leading to a 5 -15 % incidence of false positives.
• 23:15
  OK. So while sensitive, MRI is generally considered
• 23:19
  more sensitive and more specific for diagnosing
• 23:21
  occult scaphoid fractures and, importantly, for
• 23:24
  identifying early AVN. This makes MRI the preferred
• 23:27
  advanced imaging modality in most cases where
• 23:29
  suspicion remains high despite negative x -rays.
• 23:32
  OK, that makes sense. So the modern approach
• 23:35
  is high clinical suspicion plus proper initial
• 23:38
  x -rays. And if those are negative, proceed quickly
• 23:41
  to CT for bony detail and displacement, or ideally
• 23:44
  MRI for occult fracture and ADN assessment, rather
• 23:47
  than relying on the old two -week delay. That's
• 23:50
  the current thinking, yes. Much more proactive.
• 23:53
  This diagnostic rigor is clearly aimed at identifying
• 23:56
  instability early on. Let's just consolidate
• 23:58
  the criteria for what defines an unstable scaphoid
• 24:01
  fracture, which, as you said, is absolutely key
• 24:04
  for treatment decisions. Absolutely. Identifying
• 24:06
  instability is paramount because it almost always
• 24:10
  mandates surgical intervention for a predictable
• 24:12
  outcome. Based on the literature and the classification
• 24:15
  systems we've discussed, the key criteria for
• 24:17
  instability include significant displacement
• 24:20
  of the fracture fragments, generally defined
• 24:21
  as greater than one millimeter displacement on
• 24:24
  any radiographic view, and CT is the best tool
• 24:26
  for assessing this accurately. One millimeter
• 24:29
  gap or step. Got it. An intrascape white angle
• 24:31
  greater than 35 degrees on the lateral x -ray
• 24:33
  indicating significant regulation and the potential
• 24:36
  for that humpback deformity. Approximal pole
• 24:38
  fracture, location, location, location, which,
• 24:41
  as we've hammered home, is anatomically vulnerable
• 24:44
  and often considered unstable due to the high
• 24:46
  blood supply risk, regardless of initial displacement
• 24:49
  sometimes. Right. Significant comminution, meaning
• 24:52
  the bone is breaking into multiple pieces rather
• 24:54
  than a clean break. Shattered almost. In fact,
• 24:57
  yes. Also, associated carpal instability, suggesting
• 25:01
  wider ligamentous injury. Signs of this include
• 25:04
  a scapholunar SL angle greater than 60 degrees
• 25:07
  or a radial lunet angle greater than 15 degrees
• 25:10
  on the lateral x -ray. Indicating the other wrist
• 25:12
  bones aren't aligned properly. Correct. And finally,
• 25:15
  of course, the most obvious instability pattern
• 25:18
  is a paralunet transscapoid fracture dislocation,
• 25:22
  the Herbert B4 type, which is a major wrist disruption.
• 25:25
  If any of these criteria are met, the fracture
• 25:27
  is deemed unstable. Got it. That's a clear list.
• 25:30
  High suspicion, thorough imaging, precise classification
• 25:33
  to identify instability. Now that we understand
• 25:35
  the injury and how to spot it properly, what
• 25:38
  does this all mean for getting the patient back
• 25:40
  to full function? How are these injuries actually
• 25:42
  managed? Well, the overarching goal of management,
• 25:45
  regardless of the method, is firstly to achieve
• 25:47
  bony union healing in an anatomical position.
• 25:51
  Secondly, to relieve pain. Thirdly, to maximize
• 25:54
  functional recovery. getting strength and movement
• 25:57
  back. And perhaps most importantly, in the long
• 25:59
  run, to prevent the development of those long
• 26:01
  -term complications like non -union, malunion,
• 26:04
  and post -traumatic arthritis. OK. And as we've
• 26:07
  established, the approach is broadly divided
• 26:09
  into non -operative and operative management.
• 26:11
  And the choice is driven primarily by the fracture
• 26:13
  classification, stable versus unstable, and also
• 26:17
  patient factors like age, activity level, and
• 26:20
  occupation. Let's start with non -operative management
• 26:22
  then. When is that the appropriate route? Who
• 26:24
  gets put in a cast? Non -operative management,
• 26:27
  essentially casting, is typically reserved for
• 26:29
  acute, undisplaced, stable scaphoid fractures.
• 26:32
  So the Herbert A types. Primarily, yes. This
• 26:35
  includes Herbert Type A fractures, those distal
• 26:38
  tubercle or incomplete waste fractures. It can
• 26:41
  also include certain complete waste fractures,
• 26:43
  Herbert B2, or even some proximal bowl fractures,
• 26:46
  Herbert B3, if they show absolutely no significant
• 26:49
  displacement, usually less than one millimeter,
• 26:51
  and no other signs of instability on detailed
• 26:54
  imaging like CT. Okay. It's also, logically,
• 26:58
  the initial approach when you have strong clinical
• 27:00
  suspicion but your NFL X -rays are negative while
• 27:03
  you're waiting for or arranging that definitive
• 27:05
  CT or MRI scan. You treat it as fractured until
• 27:09
  proven otherwise in that short interval. Makes
• 27:11
  sense. And what does non -operative management
• 27:14
  actually entail? Is it just a standard wrist
• 27:16
  cast? Yes. It involves immobilization in a cast,
• 27:19
  but specifically a scaphoid cast. The traditional
• 27:22
  description is a well -molded cast extending
• 27:24
  from below the elbow crease down to the hand
• 27:26
  and, crucially, including the thumb, often up
• 27:28
  to the interphalangeal joint. This is often called
• 27:30
  a thumb spike a cast. Why include the thumb?
• 27:33
  The rationale is to maximally stabilize the scaphoid
• 27:35
  bone by preventing thumb movement. as forces
• 27:38
  can be transmitted through the thumb metacarpal
• 27:40
  to the scaphoid. Although, it's fair to say there
• 27:43
  is some ongoing debate in the literature regarding
• 27:46
  the absolute necessity of including the thumb
• 27:48
  in the cast for all types. Some studies have
• 27:52
  suggested that a simple short arm cast, without
• 27:55
  the thumb included, may be sufficient for certain
• 27:57
  stable fracture types, particularly distal ones.
• 28:01
  But the traditional widely accepted approach
• 28:03
  for waist and proximal fractures involves the
• 28:06
  thumb spica component. Right. How long does someone
• 28:09
  typically need to be in this cast? It sounds
• 28:10
  like quite a commitment. It is, and the duration
• 28:13
  varies significantly based on the fractural location.
• 28:16
  This directly reflects the differing healing
• 28:18
  potential due to that blood supply issue we keep
• 28:20
  coming back to. So distal heals faster. Generally,
• 28:23
  yes, distal third or tuberosity fractures having
• 28:26
  a better blood supply might unite in as little
• 28:29
  as six weeks. Middle third or waist fractures,
• 28:32
  the most common type, typically require around
• 28:34
  8 to 12 weeks of immobilization. 8 to 12 weeks.
• 28:37
  Yes. And proximal third fractures with their
• 28:41
  precarious retrograde blood supply. often need
• 28:43
  10 to 12 weeks, sometimes even longer, maybe
• 28:46
  up to 14 weeks or more in some protocols. And
• 28:49
  even with diligent casting for that extended
• 28:51
  period, they still have a higher rate of non
• 28:54
  -union compared to waste fractures. Wow, that's
• 28:56
  a significant period of immobilization, especially
• 28:58
  for the proximal ones. What's the follow -up
• 29:01
  protocol while they're actually in the cast?
• 29:03
  Do you just wait until the end? No, regular follow
• 29:06
  -up is essential. Firstly, to ensure the fracture
• 29:08
  doesn't displace within the cast, sometimes called
• 29:11
  secondary displacement, and secondly, to monitor
• 29:14
  healing progress. Typically, an x -ray is taken
• 29:17
  around two weeks after the initial casting. Primarily
• 29:20
  confirm the fracture remains undisplaced. Check
• 29:22
  it hasn't shifted. Exactly. Further x -rays,
• 29:25
  sometimes CT scans later on if union is questionable,
• 29:28
  are taken when the cast is planned to be removed
• 29:30
  at that estimated healing time point, 6, 8, 10,
• 29:33
  12 weeks, etc. To assess for clinical signs of
• 29:36
  union, no tenderness, and radiographic evidence
• 29:39
  of bone bridging the fracture line. A final check,
• 29:42
  perhaps at 6 or 12 months post -injury, is often
• 29:45
  recommended just to ensure the union is stable
• 29:47
  and no leak complications are developing. If
• 29:50
  union is confirmed at cast removal, then gradual
• 29:53
  mobilization, physiotherapy, and return to activity
• 29:56
  follows. And what's the success rate for casting
• 30:00
  these stable fractures? With appropriate patient
• 30:02
  selection meaning truly stable, undisplaced fractures,
• 30:05
  and strict adherence to the casting protocol,
• 30:08
  the union rate for non -operative management
• 30:09
  is generally high, often quoted as exceeding
• 30:12
  95%. That's encouraging for the stable ones at
• 30:15
  least. But you mentioned operative management
• 30:17
  is needed for the unstable or higher risk fractures.
• 30:20
  What are the key indications for deciding on
• 30:22
  surgery instead of a cast? Right. Operative management
• 30:25
  is indicated when the risks of non -union, malunion,
• 30:28
  or simply a poor functional outcome with casting
• 30:30
  alone are considered unacceptably high. The primary
• 30:34
  indications are those instability criteria we
• 30:36
  defined earlier. The list we went through. Yes,
• 30:39
  greater than one millimeter displacement, that
• 30:41
  intrascaphoid angle over 35 degrees, significant
• 30:44
  comminution, or associated carpal instability
• 30:46
  like a high SL angle. Proxable pull fractures,
• 30:50
  again due to their high AVN and non -union risk
• 30:52
  and theoretical instability, are generally considered
• 30:56
  strong candidates for surgery, often requiring
• 30:58
  a specific surgical approach from the back. So
• 31:01
  location drives surgery too. Any other reasons?
• 31:05
  Yes. Another significant group is based on patient
• 31:07
  factors. Certain patient groups, like high -level
• 31:10
  athletes or heavy manual workers, even if they
• 31:13
  have a minimally displaced or seemingly stable
• 31:15
  fracture, might be offered surgery. Why is that?
• 31:18
  Because surgical fixation particularly percutaneous
• 31:21
  screw fixation, can potentially allow for quicker
• 31:24
  union and a significantly earlier, safer return
• 31:27
  to demanding activities compared to the prolonged
• 31:29
  casting period, which might be unacceptable for
• 31:32
  their career or sport. Get them back faster.
• 31:34
  Essentially, yes. And finally, a delayed diagnosis
• 31:36
  if a fracture is picked up weeks or months late
• 31:38
  and it shows signs of instability or early non
• 31:41
  -union changes. That's also a clear indication
• 31:44
  for surgical intervention, usually involving
• 31:46
  bone grafting as well. Okay, so surgery is chosen
• 31:49
  for stability, anatomical risk, proximal pull,
• 31:53
  patient functional demands, or delayed presentation.
• 31:56
  Let's dive into the surgical techniques themselves.
• 31:59
  What are the main ways surgeons fix these fractures
• 32:02
  operatively? The two primary surgical techniques
• 32:04
  employed are open reduction internal fixation,
• 32:07
  commonly known as ORIF and percutaneous screw
• 32:10
  fixation. ORIF first, when is that needed? ORIF
• 32:13
  is generally necessary for displaced fractures,
• 32:17
  significantly angulated fractures, or complex
• 32:19
  patterns where the surgeon needs direct visual
• 32:21
  access to the fracture site to clean it out,
• 32:23
  manipulate the fragments back into perfect alignment,
• 32:26
  that's the open reduction part, and then hold
• 32:28
  them there rigidly with internal fixation, usually
• 32:30
  a screw. Okay, makes sense. Are there different
• 32:32
  ways to approach the scaphoid for ORIF? Yes,
• 32:35
  there are two main surgical approaches used for
• 32:37
  ORIF, depending primarily on the fracture location.
• 32:41
  The volar approach, meaning coming in from the
• 32:44
  palm side of the wrist, is the real workhorse
• 32:46
  for waist fractures. It's generally preferred
• 32:49
  for these because it allows good access to the
• 32:51
  waist and distal pole, and importantly, it helps
• 32:54
  preserve that critical dorsal blood supply entering
• 32:57
  the back of the bone. Protect the plumbing. Precisely.
• 33:01
  The other main approach is the dorsal approach,
• 33:03
  coming in from the back of the wrist. This is
• 33:06
  usually necessary for proximal third fractures,
• 33:09
  as it provides much better direct access to that
• 33:11
  proximal fragment, which is hard to reach reliably
• 33:14
  from the front. Right. Could you maybe walk us
• 33:16
  through the VOLAR approach for an ORRF of a typical
• 33:19
  waist fracture? What does that involve? Certainly.
• 33:22
  The procedure is typically performed with the
• 33:24
  patient lying supine, usually with the arm out
• 33:27
  on an arm table, and almost always under tourniquet
• 33:30
  control on the upper arm to provide a bloodless
• 33:33
  surgical field. The incision is commonly made
• 33:35
  longitudinally along the line of the flexor carpe
• 33:38
  radialis or FCR tendon, which is easily palpable
• 33:41
  on the front of the wrist. You carefully dissect
• 33:44
  down through the layers, protecting vital structures
• 33:46
  like branches of the radial artery and sensory
• 33:49
  nerves, and retracting the thenar muscles, the
• 33:52
  muscles at the base of the thumb, outwards. The
• 33:55
  capsule of the wrist joint is then opened, often
• 33:57
  along the FCR tendon sheath, to expose the scaphoid
• 34:01
  waste. The fracture site is identified, cleaned
• 34:04
  of any interposed soft tissue or blood clot,
• 34:07
  and the fragments are carefully manipulated back
• 34:08
  into their correct anatomical position. This
• 34:11
  reduction is often achieved and held temporarily
• 34:13
  using fine K -wires, sometimes used like little
• 34:17
  joysticks. Once a surgeon is happy with the reduction,
• 34:20
  confirmed perhaps with intraoperative x -rays
• 34:22
  or fluoroscopy, a cannulated headless compression
• 34:25
  screw is inserted. cannulated means it has a
• 34:28
  hollow core, so you can be inserted over a pre
• 34:31
  -placed guide wire. This guide wire is carefully
• 34:33
  drilled down the central axis of the scaphoid,
• 34:36
  ideally starting near the distal pole and aiming
• 34:38
  proximally across the fracture line. Headless
• 34:40
  screw. Yes. Headless means the screw doesn't
• 34:43
  have a traditional bulky head. It's designed
• 34:45
  so the entire screw can be buried just below
• 34:47
  the level of the articular cartilage surface.
• 34:50
  This is crucial to avoid the screw head impinging
• 34:53
  on joint movement or damaging the opposing cartilage
• 34:56
  surfaces later on. The screw is also designed
• 34:59
  with differential pitch threads to actively compress
• 35:03
  the fracture fragments together as it's tightened.
• 35:05
  Clutter design? Very. Longer screws generally
• 35:08
  provide better fixation stability across the
• 35:11
  fracture. Now, if the fracture was significantly
• 35:14
  comminuted, meaning broken into several pieces,
• 35:17
  or if there was a pre -existing deformity like
• 35:20
  a humpback that needed correcting during the
• 35:22
  reduction, then bone grafting might be necessary
• 35:24
  at this stage. Where does the bone graft come
• 35:27
  from? Small amounts can often be harvested locally
• 35:29
  from the distal radius bone near the wrist incision.
• 35:33
  If a larger volume of graft is needed, it's typically
• 35:35
  harvested from the patient's iliac crest, the
• 35:37
  pelvic bone, through a separate small incision.
• 35:40
  After the screw fixation and any necessary grafting,
• 35:44
  the joint capsule and any important ligaments
• 35:46
  that were incised, like the radioscapia capitate
• 35:48
  ligament, are carefully repaired. Then the soft
• 35:51
  tissues and skin are closed in layers. And what
• 35:54
  happens postoperatively? Still a cast? Yes. Despite
• 35:57
  the internal fixation, a period of immobilization
• 36:01
  in a cast, usually a thumb spica, is still typically
• 36:04
  required while the bone heals around the screw.
• 36:06
  This is often for around six to eight weeks,
• 36:09
  after which union is assessed radiographically,
• 36:11
  usually with x -rays or maybe a CT scan, before
• 36:14
  starting mobilization. That sounds like quite
• 36:16
  a meticulous procedure. And the dorsal approach
• 36:18
  for those challenging proximal pole fractures,
• 36:20
  how does that differ? The dorsal approach is
• 36:22
  quite different in terms of the structures you
• 36:24
  encounter. It's typically performed via what's
• 36:27
  called a 3 -4 approach, navigating between the
• 36:29
  third and fourth extensor tendon compartments
• 36:31
  on the back of the wrist. A midline incision
• 36:34
  is usually made over the back of the wrist. The
• 36:37
  sheath containing the extensor poleza longus,
• 36:39
  EPL tendon, the long thumb extensor is opened,
• 36:42
  and the EPL tendon is retracted radially towards
• 36:45
  the thumb side. The main finger extensor tendons,
• 36:49
  the extensor digitorum communus, EDC, are then
• 36:52
  retracted a little gnarly towards the little
• 36:53
  finger side. Okay, moving tendons out of the
• 36:55
  way. Exactly. This exposes the dorsal wrist capsule,
• 36:59
  which is then open, often over the scaffolding
• 37:01
  joint interval. The wrist is often flexed significantly
• 37:05
  downwards to bring the proximal pole of the scaphoid
• 37:07
  into better view. A K -wire is then inserted,
• 37:10
  usually starting just radial to the scaffolding
• 37:12
  ligament itself, aiming from the small proximal
• 37:15
  pole fragment down into the larger distal fragment,
• 37:18
  sometimes provisionally driving it into the trapezium
• 37:20
  bone distally for extra stability during screw
• 37:23
  insertion. So coming from the top down, essentially.
• 37:26
  Yes, aiming proximal to distal. Multiple fluoroscopic
• 37:30
  views, AP, lateral obliques are absolutely essential
• 37:33
  throughout this dorsal approach to confirm accurate
• 37:36
  guide wire placement before drilling and inserting
• 37:38
  the cannulated screw. It's technically demanding
• 37:41
  because the proximal pole fragment can be quite
• 37:43
  small and rotated. This approach is necessary
• 37:46
  for most proximal pole fractures simply due to
• 37:48
  their location and the need to access that specific
• 37:51
  fragment directly for reduction and fixation.
• 37:53
  Right. What are the union rates like for these
• 37:56
  ORIF procedures, especially when used for those
• 37:58
  unstable Herbert Type B fractures? For Herbert
• 38:01
  Type B unstable fractures treated with ORIF,
• 38:03
  the reported union rates are generally good,
• 38:05
  certainly much better than casting alone for
• 38:07
  these types, but they do vary slightly by the
• 38:09
  specific subtype, reflecting those inherent biological
• 38:12
  and mechanical challenges. Based on studies specifically
• 38:15
  using the Herbert classification, union rates
• 38:17
  for ORIF are often reported around 90 % for B1
• 38:20
  distal oblique fractures. OK. Maybe 88 % for
• 38:23
  B2 complete waste fractures, and slightly lower,
• 38:26
  perhaps around 85%, for B3 proximal pole fractures.
• 38:30
  Still. 85 % for the proximal pole with surgery
• 38:33
  is pretty good, but it highlights the challenge.
• 38:35
  It does. It highlights that even with optimal
• 38:38
  surgical technique, proximal pole fractures remain
• 38:41
  biologically more challenging to heal compared
• 38:44
  to waist fractures, purely due to that vascular
• 38:46
  issue. Now let's talk about the other main surgical
• 38:49
  technique, percutaneous screw fixation. That
• 38:53
  sounds less invasive than opening the wrist up
• 38:55
  fully. It is, yes. And it's become increasingly
• 38:58
  popular over the last couple of decades, particularly
• 39:00
  for specific indications. Percutaneous screw
• 39:03
  fixation involves inserting the fixation screw
• 39:06
  through very small stab incisions, typically
• 39:09
  just one or two, without formally opening the
• 39:11
  joint capsule widely. What are the main advantages
• 39:14
  of doing it that way? The key potential advantages
• 39:16
  are even faster union rates, with some studies
• 39:18
  reporting rates approaching 100 % in carefully
• 39:21
  selected ideal cases. Also, potentially less
• 39:24
  time required in a cast postoperatively compared
• 39:26
  to ORF and consequently an earlier return to
• 39:28
  activities including work and sport, which is
• 39:31
  a major driver for certain patients. When is
• 39:33
  percutaneous fixation indicated then? Is it suitable
• 39:36
  for all types? No, it's primarily indicated for
• 39:39
  acute minimally displaced scaphoid fractures,
• 39:42
  usually waist fractures, where an anatomical
• 39:45
  reduction can be achieved closed just by manipulating
• 39:48
  the wrist and thumb, and crucially where this
• 39:51
  position can be confirmed with high quality intraoperative
• 39:54
  imaging. So not for badly displaced ones. Generally
• 39:58
  not, as you can't directly see and manipulate
• 40:00
  the fragments. It's especially appealing for
• 40:02
  patients like manual workers or athletes who
• 40:05
  have a strong need to minimize their time in
• 40:07
  a cast and return to function as quickly as possible,
• 40:10
  provided their fracture pattern is suitable.
• 40:12
  Typically that minimally displaced waste fracture,
• 40:14
  which is already in good alignment or can be
• 40:16
  easily reduced closed. How is that technique
• 40:18
  actually performed? If you're not opening it
• 40:20
  up, how do you get the screw in the right place?
• 40:22
  The patient setup is similar. supine arm table
• 40:25
  tourniquet, but absolutely critical for percutaneous
• 40:27
  fixation is the use of high -quality image intensification
• 40:31
  fluoroscopy or live x -ray throughout the procedure
• 40:34
  for precise guidance. Continuous x -ray vision.
• 40:37
  Essentially, yes. Traction is often applied to
• 40:39
  the thumb, sometimes using a finger trap device
• 40:42
  to help distract the fracture fragments slightly
• 40:44
  and align the scaphoid along its long axis. The
• 40:48
  wrist is positioned carefully, often in ulna
• 40:50
  deviation, and flexed over a bolster or roll,
• 40:53
  again to bring the scaphoid into a straight orientation
• 40:55
  relative to the fluoroscopy beam. Okay. A small,
• 40:59
  volar, palm -side stab incision, maybe only five
• 41:02
  millimeters long, is made over the palpable scaphoid
• 41:05
  tuberosity distally. Through this tiny incision,
• 41:08
  a guide wire is then very carefully inserted,
• 41:10
  aiming along the central axis of the scaphoid
• 41:12
  towards the proximal pole. This sounds like the
• 41:14
  tricky part. It is the crucial step. Multineural
• 41:17
  fluoroscopic views AP, lateral, and those 45
• 41:19
  degrees obliques are used repeatedly and meticulously
• 41:22
  to ensure the wire is perfectly positioned down
• 41:25
  the central third of the bone on all views and
• 41:27
  critically that it's not penetrating out through
• 41:29
  the joint surfaces anywhere along its path. Once
• 41:33
  the surgeon is completely satisfied with the
• 41:34
  guide wire position, a cannulated drill is passed
• 41:37
  over the wire to create the channel and then
• 41:40
  the cannulated headless compression screw is
• 41:42
  inserted over the wire. Often, a slightly shorter
• 41:45
  screw length is chosen compared to the measured
• 41:47
  length to ensure good compression is achieved
• 41:49
  across the fracture site as the screw tightens.
• 41:52
  Typically, screws around 24mm or 26mm are used
• 41:56
  for the waist. In some cases, particularly for
• 41:59
  longer oblique fracture patterns which might
• 42:01
  have some rotational instability, a second, parallel
• 42:04
  K -wire might be inserted percutaneously alongside
• 42:08
  the screw guide wire just to provide some anti
• 42:10
  -rotation stability. It sounds like navigating
• 42:13
  that guide wire and screw perfectly within that
• 42:15
  small awkwardly shaped bone purely using fluoroscopy
• 42:18
  is the real art and challenge here, especially
• 42:20
  avoiding poking out into the joint. Absolutely.
• 42:23
  Accurate 3D placement based on 2D imaging is
• 42:26
  paramount. The risk of unrecognized screw penetration
• 42:29
  into the joint cartilage is a potential complication.
• 42:31
  particularly if using many open techniques where
• 42:34
  direct visualization is limited or perhaps with
• 42:36
  less precise fluoroscopy. However, with modern
• 42:39
  high -resolution fluoroscopy units and surgeon
• 42:42
  experience, this risk is significantly reduced
• 42:45
  compared to the earlier days of the technique.
• 42:47
  Right. You mentioned earlier that bone grafting
• 42:50
  is sometimes necessary, especially in ORF for
• 42:53
  comminuted fractures or to correct deformity
• 42:55
  like a humpback. Can we talk a bit more about
• 42:58
  the role of bone grafting? Yes, bone grafting
• 43:00
  plays a crucial role in several scenarios. It's
• 43:03
  needed when there's actual bone loss at the fracture
• 43:05
  site due to the injury mechanism or significant
• 43:08
  comminution that creates a defect or gap after
• 43:10
  you've reduced the main fragments. It's also
• 43:13
  essential when treating an established non -union
• 43:15
  where you need to bridge the gap and stimulate
• 43:17
  healing. And as you mentioned, it's vital when
• 43:19
  you need to correct a malunion deformity, like
• 43:21
  surgically opening up a healed humpback. The
• 43:23
  graft fills the wedge created by the corrective
• 43:26
  osteotomy. What does the graft actually do? The
• 43:29
  graft serves multiple purposes. Firstly, it acts
• 43:31
  as a scaffold. providing structural support across
• 43:33
  the defect. Secondly, and importantly, it introduces
• 43:36
  osteoconductive properties, meaning it provides
• 43:39
  a physical framework or trellis for the patient's
• 43:42
  own new bone cells to grow across the gap. And
• 43:45
  depending on the type of graft, it might also
• 43:47
  provide some osteoinductive properties, meaning
• 43:50
  it contains signaling molecules that actively
• 43:53
  stimulate undifferentiated cells to become bone
• 43:56
  -forming cells. osteoblasts. Some grafts even
• 44:00
  provide osteogenic cells themselves. So structure
• 44:02
  and stimulus. What types of bone grafts are typically
• 44:05
  used for scaphoid surgery? We broadly divide
• 44:07
  them into non -vascularized and vascularized
• 44:10
  bone grafts. Non -vascularized grafts are simpler
• 44:12
  in concept. You harvest bone from one site, the
• 44:15
  donor site, and simply transfer it to the scaphoid,
• 44:18
  the recipient site, without maintaining its original
• 44:20
  blood supply. Okay, standard bone graft. Examples.
• 44:24
  Common examples include the Rus -type inlay graft.
• 44:27
  This is typically used for waist non -unions
• 44:29
  approached via a volar incision, using struts
• 44:32
  of corticocancelous bone, bone with both a hard
• 44:35
  outer cortex and spongy, inner cancels part,
• 44:38
  placed longitudinally across the non -union site.
• 44:40
  This technique generally yields good union rates,
• 44:43
  perhaps 85 -95 % for waist non -unions. Another
• 44:46
  well -described non -vascularized graft is the
• 44:49
  Fisk wedge graft, or sometimes called the Matty
• 44:52
  -Roose technique. This often involves harvesting
• 44:55
  a specifically shaped trapezoidal or triangular
• 44:57
  wedge of bone, usually from the iliac crest,
• 45:00
  which is then inserted into a surgically created
• 45:02
  gap on the volar side of a malunited or non -united
• 45:05
  scaphoid to correct a humpback deformity and
• 45:08
  restore the scaphoid's normal length and alignment.
• 45:10
  When this is combined with rigid internal fixation
• 45:13
  like a screw, it can achieve very high union
• 45:15
  rates, sometimes reported as 95 -100%. How is
• 45:19
  a waste non -union managed specifically with
• 45:21
  one of these non -vascularized grafts, say, using
• 45:23
  the FIST technique to correct a humpback? Right,
• 45:25
  so for a waste non -union, often with some humpback
• 45:28
  deformity, a volar approach is usually preferred.
• 45:32
  The non -union site itself is meticulously debrided.
• 45:36
  That means all the fiber scar tissue and any
• 45:39
  unhealthy sclerotic bone edges are removed using
• 45:42
  sharp osteotomes or fine burrs, taking great
• 45:44
  care not to damage the intact healthy dorsal
• 45:47
  cortex if possible. Cleaning it out. Exactly,
• 45:50
  preparing a healthy bed. During this debridement,
• 45:53
  the surgeon carefully assesses the viability
• 45:55
  of the bone fragments, particularly looking for
• 45:57
  punctate bleeding from the proximal fragment,
• 46:00
  tiny spots of blood welling up. which is a good
• 46:02
  sign that it still has some blood supply remaining.
• 46:04
  The paprika sign. Sometimes call that, yes. If
• 46:07
  there's a humpback deformity, an osteotomy, a
• 46:10
  controlled surgical cut, is made through the
• 46:11
  milunian site, usually on the volar side, and
• 46:14
  the defect is carefully opened up like a book,
• 46:16
  correcting the angulation. The bone graft, harvested
• 46:20
  maybe from the distal radius or iliac crest,
• 46:23
  is then shaped precisely to fit the defect created
• 46:25
  or to act as the wedge maintaining the correction.
• 46:27
  It's then carefully inserted, ensuring good press
• 46:30
  -fit contact with the healthy host bone on either
• 46:33
  side. Provisional fixation is often achieved
• 46:36
  with temporary K -wires, while the definitive
• 46:39
  fixation, usually a cannulated headless screw,
• 46:42
  is inserted across the graft and fracture site.
• 46:45
  And the outcomes for non -union surgery like
• 46:47
  this? While the union rates are generally good,
• 46:50
  often around 90 % for waste non -unions treated
• 46:53
  this way, It's important to note that patients
• 46:55
  often have some residual loss of wrist range
• 46:58
  of motion and perhaps some reduction in grip
• 47:00
  strength compared to their uninjured side, even
• 47:03
  after successful union. Treating an established
• 47:05
  nonunion is always more complex than fixing an
• 47:07
  acute fracture. You mentioned earlier that proximal
• 47:10
  pole nonunions are even more challenging, even
• 47:12
  with grafting. They are, unfortunately. Proximal
• 47:15
  pole non -unions, which are typically approached
• 47:17
  dorsally due to access, have historically had
• 47:20
  significantly lower union rates when treated
• 47:22
  with standard non -vascularized grafts alone.
• 47:25
  Union rates are often cited in the literature
• 47:26
  as being only around 67%, maybe 70 % at best.
• 47:30
  That's quite a drop from the waste non -union
• 47:32
  rates. It is. And this is where the concept of
• 47:35
  using a vascularized bone graft, or VVG, becomes
• 47:39
  particularly relevant and often necessary. Vascularized
• 47:42
  bone grafting, right? This is where you transfer
• 47:44
  the bone along with its attached blood vessel,
• 47:46
  keeping it alive, correct? When is that specifically
• 47:48
  indicated over a standard non -vascularized graft?
• 47:52
  Precisely. A VBG is indicated in situations where
• 47:55
  a standard non -vascularized graft is considered
• 47:57
  less likely to succeed. This primarily means
• 48:00
  proximal pulmon unions, and especially when there's
• 48:03
  definite suspicion or clear confirmation of a
• 48:05
  vascular necrothus, AVN, of that proximal fragment
• 48:08
  on preoperative imaging like MRI. Because the
• 48:11
  fragment is already dead or dying. Exactly. The
• 48:14
  fundamental idea is to bring a new living blood
• 48:16
  supply directly into the compromised vascular
• 48:19
  bone fragment alongside providing the structural
• 48:21
  bone graft itself. This aims to revitalize the
• 48:24
  fragment and promote healing where a nonvascularized
• 48:27
  graft might simply fail or become incorporated
• 48:29
  very slowly, if at all. Does the evidence support
• 48:31
  using VBG in these cases? Yes, quite strongly.
• 48:35
  There was a key meta -analysis by Merrill published
• 48:37
  in the Journal of Hand Surgery American Volume
• 48:39
  back in 2002. which directly compared outcomes.
• 48:43
  It demonstrated a significantly higher union
• 48:46
  rate for proximal pole non -unions with AVN when
• 48:49
  they were treated with a vascularized bone graft
• 48:51
  around 88 % union compared to those treated with
• 48:53
  non -vascularized bone graft, which only achieved
• 48:56
  about 50 % union in that analysis. 88 % versus
• 48:59
  50%. That is a compelling difference, isn't it?
• 49:02
  It's a dramatic difference, yes. It really highlights
• 49:04
  the biological power of bringing a dedicated
• 49:07
  blood supply to a dying bone fragment. What are
• 49:10
  the types of vascularized grafts that are commonly
• 49:12
  used for the scaphoid? Where do they come from?
• 49:15
  Several different techniques and donor sites
• 49:16
  have been described over the years, but some
• 49:18
  are definitely more common and widely used now.
• 49:21
  A graft based on the pronator quadratus muscle
• 49:23
  pedicle in the forearm used to be quite popular,
• 49:26
  but seems to be used less frequently today, perhaps
• 49:29
  due to variability in the vessel or technical
• 49:31
  difficulty. Probably the most common vascularized
• 49:33
  graft used currently for scaphoid non -union,
• 49:37
  particularly for proximal pole issues or when
• 49:39
  AVN is present, is a vascularized discal radius
• 49:42
  graft. This is often based on the technique described
• 49:45
  by Zeitemberg. Another very common and reliable
• 49:48
  option, particularly popular in some centers,
• 49:50
  is a vascularized graft harvested from the base
• 49:53
  of the second metacarpal bone in the hand. Could
• 49:56
  you briefly describe the Zeitemberg technique?
• 49:59
  taking the graft from the distal radius, that
• 50:01
  sounds quite accessible. Yes, it's an elegant
• 50:03
  technique. This graft is based on a specific
• 50:06
  small artery that runs on the back dorsal aspect
• 50:09
  of the wrist. It's usually the 12 -2 intercompartmental
• 50:12
  supranacular artery, a small branch of the radial
• 50:15
  artery, or sometimes a 2S3 branch if the 12 -2
• 50:18
  is very small or absent. This vessel travels
• 50:20
  in the tissues just superficial to the extensor
• 50:22
  compartments between the first and second, or
• 50:25
  second and third compartments. A dorsal radial
• 50:27
  surgical approach is used to carefully identify
• 50:30
  and dissect out this small artery in its accompanying
• 50:32
  veins, the vascular pedicle. You follow the pedicle
• 50:35
  proximally down towards the distal radius bone,
• 50:38
  where it can be seen to supply a patch of the
• 50:41
  periosteum and underlying bone. Using a fine
• 50:44
  osteotome, or saw, a small block or section of
• 50:47
  cortico -canceled bone is then very carefully
• 50:50
  harvested from the distal radius, ensuring that
• 50:53
  the vascular pedicle remains attached and intact,
• 50:56
  feeding into this piece of bone. Great care is
• 50:58
  taken not to damage this delicate pedicle. The
• 51:02
  scaphoid non -union site is then approached,
• 51:04
  usually dorsally as we discussed. The non -union
• 51:06
  is thoroughly cleaned out and prepared to receive
• 51:08
  the graft. The vascularized bone graft, still
• 51:12
  attached to its artery and vein, is then gently
• 51:14
  transferred and rotated into the scaphoid non
• 51:16
  -union site. You have to make sure the pedicle
• 51:18
  isn't kinked, stretched, or compressed during
• 51:20
  this transfer. So you're essentially bringing
• 51:23
  a small living piece of radius bone with its
• 51:25
  own blood supply and plumbing it into the scaphoid
• 51:28
  defect. That's exactly the principle. It brings
• 51:31
  its own perfusion. Fixation of the scaphoid fraction
• 51:35
  on union site, usually with a compression screw,
• 51:38
  is then performed to secure the graft firmly
• 51:41
  in place and stabilize the construct. That's
• 51:43
  fascinating surgery essentially replanting a
• 51:46
  piece of bone with its plumbing intact. It's
• 51:48
  clear that managing these established non -unions,
• 51:51
  especially when AVM is involved, requires complex,
• 51:54
  reconstructive surgical skills. We've touched
• 51:57
  on them throughout our discussion, but let's
• 51:59
  just consolidate the conversation specifically
• 52:01
  on complications. What are the most serious issues
• 52:04
  that can arise from a staphoid fracture, particularly
• 52:06
  if it's missed or not managed correctly initially?
• 52:09
  Yes. The serious complications are essentially
• 52:12
  the consequences of failure to achieve timely
• 52:14
  anatomical bony union. The most significant ones
• 52:17
  we worry about are non -union itself, AVN, malunion,
• 52:22
  and ultimately the development of post -traumatic
• 52:24
  arthritis, often in the specific pattern known
• 52:27
  as SNAC wrist. Let's take non -union first. How
• 52:29
  common is it? Non -union, where the bone simply
• 52:32
  fails to heal, unfortunately occurs in a proportion
• 52:35
  of cases even with appropriate management. perhaps
• 52:37
  5 -10 % overall for all scaphoid fractures treated.
• 52:41
  But the rate is significantly higher for fractures
• 52:44
  that were unstable to begin with, significantly
• 52:46
  displaced, or located in the proximal pole, especially
• 52:49
  if treatment was delayed or inappropriate, like
• 52:52
  inadequate casting for an unstable fracture.
• 52:55
  Are there other risk factors for non -union?
• 52:57
  Yes, key risk factors beyond displacement and
• 53:00
  location include certain fracture patterns, like
• 53:03
  that vertical oblique pattern we mentioned, which
• 53:05
  is prone to shear. Increasing patient age is
• 53:07
  also a factor. And crucially, smoking or any
• 53:11
  nicotine use is a major negative factor, as nicotine
• 53:13
  is a potent vasoconstrictor and significantly
• 53:16
  impairs bone healing potential. Treatment for
• 53:19
  established non -union involves the surgical
• 53:20
  strategies we've just discussed, primarily bone
• 53:23
  grafting, often vascularized for the proximal
• 53:25
  pole or if AVN is present. and AVN, the risk
• 53:29
  we flagged right at the very beginning. How often
• 53:30
  does that actually happen? Avascular necrosis,
• 53:33
  or AVN, remains a major concern precisely because
• 53:36
  of that vulnerable retrograde blood supply to
• 53:39
  the proximal pole. The reporting incidence varies
• 53:42
  quite widely in the literature, perhaps from
• 53:44
  13 % up to 50 % overall, depending on the study
• 53:47
  population and fracture types included. But particularly
• 53:50
  high figures, up to 50 % are often quoted specifically
• 53:54
  for proximal pole fractures. And the risk increases
• 53:57
  dramatically with the amount of initial displacement.
• 53:59
  OK. As cited in the source material, it can even
• 54:02
  approach 100 % in fractures involving the most
• 54:05
  proximal fifth of the scaphoid if they are treated
• 54:08
  with immobilization alone. without surgical fixation
• 54:11
  to restore stability and potentially improve
• 54:13
  perfusion. And it's sneaky, isn't it? It doesn't
• 54:16
  show up immediately. That's the insidious nature
• 54:18
  of AVN. It often doesn't become apparent on standard
• 54:21
  x -rays until months after the initial injury.
• 54:24
  This is because it takes time for the bone to
• 54:26
  slowly lose its viability, die, and then either
• 54:29
  collapse or become relatively denser. sclerotic
• 54:32
  compared to the surrounding living bone which
• 54:34
  undergoes normal disuse osteoporosis in a cast.
• 54:37
  This delay in radiographic appearance really
• 54:40
  underscores why early accurate diagnosis of the
• 54:42
  fracture type and risk factors, followed by appropriate
• 54:45
  initial management, often surgery for proximal
• 54:47
  pole fractures, is absolutely critical for trying
• 54:51
  to prevent this devastating complication in the
• 54:53
  first place. Once AVN is established, managing
• 54:56
  it adds significant complexity and uncertainty
• 54:59
  to the treatment. What about malunion when it
• 55:01
  does heal but heals in the wrong position? Malunion,
• 55:04
  which most commonly presents as that humpback
• 55:06
  deformity with excessive flexion at the fracture
• 55:09
  site, giving an intrascaphoid angle greater than
• 55:11
  35 degrees on the lateral view, typically occurs
• 55:14
  when an unstable or displaced fracture is treated
• 55:17
  non -operatively. or perhaps when the reduction
• 55:20
  achieved initially is lost within the cast and
• 55:23
  the bone then heals in that abnormal flexed position.
• 55:25
  What's the consequence of it healing bent like
• 55:27
  that? The natural history, the long -term consequence
• 55:30
  of this scaphoid malignant, is progressive carpal
• 55:34
  instability. Specifically, it tends to lead to
• 55:37
  that dizzy deformity pattern we mentioned, where
• 55:39
  the lunate bone tilts backwards. This abnormal
• 55:43
  alignment is followed by altered joint mechanics,
• 55:46
  carpal collapse over time, increasing wrist pain,
• 55:49
  reduced range of motion, especially extension,
• 55:51
  decreased grip strength, and inevitably the development
• 55:54
  of post -traumatic osteoarthritis. And the final
• 55:57
  stage of that... It typically starts between
• 55:58
  the tip of the radial styloid and the scaphoid
• 56:01
  itself, then progresses to involve the scaphocapitate
• 56:05
  joint. between the scaphoid and the large capitate
• 56:08
  bone in the middle of the wrist, and finally
• 56:10
  involves the capital lunate joint. By the time
• 56:13
  a SNAC wrist pattern is fully established, the
• 56:16
  joint surfaces are significantly damaged. At
• 56:19
  this point, surgery aimed at achieving scaphoid
• 56:21
  union is often no longer appropriate or even
• 56:24
  possible, and treatment usually shifts towards
• 56:27
  salvage procedures like wrist fusions or proximal
• 56:30
  row carbectomy. It really represents the failure
• 56:33
  to prevent the long -term consequences of the
• 56:35
  initial scaphoid problem. A sobering endpoint.
• 56:38
  Are there other complications to be aware of,
• 56:40
  perhaps arising from the treatment itself? Yes,
• 56:42
  certainly. Other potential complications include
• 56:45
  delayed union, which is distinct from non -union.
• 56:48
  This is where healing takes significantly longer
• 56:50
  than expected, but is still biologically occurring.
• 56:53
  Sometimes interventions like bone stimulators
• 56:55
  using pulsed electromagnetic fields are tried
• 56:57
  in these cases, although the evidence for their
• 56:59
  effectiveness is somewhat limited and not universally
• 57:01
  accepted. Hardware -related issues are possible
• 57:04
  with surgery, such as irritation from a prominent
• 57:06
  screw, or more seriously, subchondral bone penetration
• 57:09
  by the screw tip, which can lead to cartilage
• 57:12
  damage on the opposing joint surface and subsequent
• 57:14
  arthrosis. While less common with modern screw
• 57:18
  designs and careful fluoroscopic guidance, it
• 57:21
  can occur and might require revision surgery
• 57:23
  or implant removal. Infection is always a potential
• 57:27
  risk with any surgical procedure, though thankfully
• 57:29
  it's relatively infrequent after scaphoid surgery.
• 57:32
  And despite achieving successful bony unions,
• 57:34
  some patients may unfortunately experience persistent
• 57:37
  symptoms like chronic pain, residual stiffness,
• 57:40
  limiting function, or reduced grip strength compared
• 57:42
  to their pre -injury state. It's worth noting,
• 57:44
  once some A summary cited in the provided material
• 57:47
  mentioned overall serious complication rates
• 57:49
  being perhaps around 14 % in patients managed
• 57:52
  operatively versus 18 % reporting cast -related
• 57:55
  complications like stiffness, skin issues, nerve
• 57:58
  compression in the non -operative treatment group.
• 58:01
  This suggests risks exist down both pathways,
• 58:05
  but importantly, the nature of the potential
• 58:07
  complications differs significantly. Operative
• 58:10
  intervention is often chosen specifically to
• 58:12
  mitigate the higher risks of non -union and AVN
• 58:15
  inherent to the unstable fracture types, even
• 58:18
  though surgery carries its own set of potential.
• 58:20
  all be different risks. That paints a very clear
• 58:22
  picture of why prevention, early diagnosis, and
• 58:25
  diligent appropriate management are so incredibly
• 58:27
  crucial to avoid these serious, potentially life
• 58:30
  -altering long -term issues. So, turning towards
• 58:32
  the positive, what's the general prognosis and
• 58:35
  recovery outlook for a scaphoid fracture that
• 58:37
  is treated appropriately and in a timely manner?
• 58:39
  Well, with timely and appropriate management
• 58:41
  tailored to the specific fracture type, the prognosis
• 58:44
  for most scaphoid fractures is generally good,
• 58:47
  particularly for those stable undisplaced fractures
• 58:51
  treated effectively with casting. What influences
• 58:53
  the outcome? Key factors influencing the final
• 58:56
  outcome include, naturally, the initial fracture
• 58:59
  type and its location, proximal pole always being
• 59:02
  less favorable, the presence and degree of displacement
• 59:06
  or comminution, the presence of any associated
• 59:08
  ligament injury causing carpal instability, the
• 59:11
  chosen treatment method, cast versus surgery,
• 59:14
  and importantly, patient factors like age, general
• 59:17
  health, adherence to treatment, or particularly
• 59:19
  their smoking status. You mentioned surgery might
• 59:22
  get people back quicker. Yes. Surgical treatment,
• 59:25
  when indicated and performed successfully, has
• 59:27
  been shown in several meta -analyses to be associated
• 59:30
  with a more rapid return to work and sorting
• 59:32
  activities, compared to prolonged non -surgical
• 59:35
  management in a cast, even for some fractures
• 59:37
  that might otherwise have healed in a cast eventually.
• 59:39
  That faster return is often a key factor in the
• 59:42
  decision -making for athletes or manual laborers.
• 59:44
  What's a typical recovery timeline look like?
• 59:47
  The bone healing time itself Achieving solid
• 59:49
  union typically ranges from 6 to 12 weeks, sometimes
• 59:53
  longer for proximal pole fractures, depending
• 59:55
  on the location and the type of treatment. However,
• 59:59
  achieving full functional recovery, regaining
• 1:00:01
  wrist range of motion, grip strength, and confidence
• 1:00:04
  for demanding activities usually takes significantly
• 1:00:06
  longer, often several months of dedicated rehabilitation
• 1:00:09
  after the cast is removed or after surgery. So
• 1:00:12
  patience is needed. Definitely. Follow -up with
• 1:00:14
  periodic x -rays or sometimes CT scans is needed
• 1:00:17
  to monitor the union progress until it's confirmed
• 1:00:19
  solid. While some patients may experience some
• 1:00:22
  minor residual stiffness or perhaps aching in
• 1:00:25
  the wrist, especially in cold weather or after
• 1:00:27
  heavy use, with successful union and appropriate
• 1:00:29
  physiotherapy, chronic disabling pain and major
• 1:00:32
  functional limitations are thankfully infrequent.
• 1:00:35
  So, while it's undoubtedly a challenging fracture,
• 1:00:38
  good outcomes are very much achievable with the
• 1:00:41
  right approach. Finally, let's think about prevention.
• 1:00:44
  Are there practical steps people can take to
• 1:00:47
  reduce their risk of getting this injury in the
• 1:00:49
  first place, or perhaps reduce the risk of complications
• 1:00:52
  if they do sustain one? Yes, there are certainly
• 1:00:55
  steps one can consider at different stages. Prevention
• 1:00:58
  of the initial injury starts with basic safety
• 1:01:00
  precautions, especially in activities known to
• 1:01:03
  have a high risk of falls onto an outstretched
• 1:01:05
  hand. Things like snowboarding, skateboarding,
• 1:01:08
  rollerblading, or certain contact sports come
• 1:01:11
  to mind. Wrist guards. Exactly. Wearing well
• 1:01:14
  -fitting wrist guards during these activities
• 1:01:15
  can significantly absorb the impact force and,
• 1:01:18
  crucially, limit the degree of wrist hyperextension
• 1:01:21
  during a fall, which can potentially prevent
• 1:01:23
  the fracture from occurring. Also, just using
• 1:01:26
  appropriate safety equipment generally and ensuring
• 1:01:29
  safe environments during these activities is
• 1:01:30
  key. What about people who are already involved
• 1:01:33
  in sports or have had previous risk issues? For
• 1:01:36
  individuals involved heavily in sports or demanding
• 1:01:38
  manual labor, especially if they have a history
• 1:01:41
  of previous risk pain or perhaps minor injuries,
• 1:01:45
  tailored training and rehabilitation programs
• 1:01:46
  can be beneficial. This might include exercises
• 1:01:49
  to improve risk proprioception, your sense of
• 1:01:52
  joint position, strengthening the muscles of
• 1:01:54
  the forearm and thumb that support the wrist,
• 1:01:56
  and maintaining good flexibility. And falling
• 1:01:58
  technique. Yes, somewhat counter -intuitively.
• 1:02:02
  Educating athletes and others at risk on techniques
• 1:02:05
  to fall more safely learning how to tuck and
• 1:02:07
  roll, for instance, to absorb the impact over
• 1:02:10
  a larger body area rather than landing directly
• 1:02:13
  onto a single outstretched hand can be a very
• 1:02:16
  valuable preventative measure. Avoiding activities
• 1:02:18
  that cause pain or strain seems pretty sensible,
• 1:02:21
  too. Absolutely. If you start experiencing persistent
• 1:02:24
  wrist pain or discomfort, particularly after
• 1:02:26
  a fall or even just a minor incident, it's wise
• 1:02:29
  to avoid activities that clearly exacerbate it.
• 1:02:33
  Potentially using a supportive wrist splint temporarily
• 1:02:36
  might help settle things down to prevent a minor
• 1:02:38
  issue from becoming a more significant injury.
• 1:02:40
  And seeking help if it persists. Crucially, yes.
• 1:02:43
  After any wrist injury, Even if it is initially
• 1:02:46
  dismissed as just a sprain, paying close attention
• 1:02:49
  to persistent symptoms, especially that tenderness
• 1:02:51
  in the anatomical snuff box, and seeking PROMP's
• 1:02:54
  further medical evaluation and appropriate imaging
• 1:02:56
  if it doesn't settle quickly is paramount to
• 1:02:58
  avoid a missed or delayed diagnosis. And of course,
• 1:03:02
  diligent follow -up care and maintaining open
• 1:03:04
  communication with your health care provider
• 1:03:06
  throughout the treatment and recovery process
• 1:03:08
  are essential to catch any potential non -unions
• 1:03:11
  or other complications early before they become
• 1:03:13
  major harder to fix problems. Those are really
• 1:03:17
  concrete, actionable steps listeners can consider.
• 1:03:20
  We've covered a huge landscape today, haven't
• 1:03:22
  we? From the spaphoid's really tricky anatomy
• 1:03:24
  and blood supply, through all the nuances of
• 1:03:27
  diagnosis, classification, the different surgical
• 1:03:29
  techniques, including complex vascularized grafting,
• 1:03:33
  and exploring those potentially devastating complications.
• 1:03:36
  Let's try and boil this all down to the absolute
• 1:03:38
  most crucial takeaways that you should remember
• 1:03:40
  from this deep dive. Right. Let's try and crystallize
• 1:03:43
  it. First, after any fall into an outstretched
• 1:03:45
  hand, you must always suspect a scaphoid fracture
• 1:03:48
  if there's tenderness in the anatomical snuff
• 1:03:50
  box, period. Regardless of what the initial x
• 1:03:53
  -rays might show or fail to show, high suspicion
• 1:03:56
  is the very first step to avoiding disaster down
• 1:03:58
  the line. OK, suspicion first. Second key takeaway.
• 1:04:02
  Second, don't rely solely on standard basic x
• 1:04:05
  -rays if your clinical suspicion remains high.
• 1:04:07
  Be prepared to utilize advanced imaging promptly.
• 1:04:10
  Use CT scanning for accurately assessing displacement,
• 1:04:13
  combination, and monitoring union, and especially
• 1:04:16
  use MRI for definitively diagnosing those occult
• 1:04:19
  fractures or assessing for AVN when initial x
• 1:04:22
  -rays are negative. Don't fall back on the two
• 1:04:24
  -week wait. Right. Image appropriately. Third.
• 1:04:26
  Third. Classification matters deeply because
• 1:04:29
  it guides treatment. Understand that unstable
• 1:04:31
  fractures, displaced 1 millimeter, angulated
• 1:04:34
  35 degrees, comminuted vertically oblique patterns,
• 1:04:37
  and particularly all proximal pole fractures,
• 1:04:39
  carry a significantly high risk of non -union
• 1:04:41
  and AVN. These types generally require surgical
• 1:04:44
  fixation for the best, most predictable outcome.
• 1:04:47
  Stable versus unstable, location, location, location.
• 1:04:50
  Fourth, complications like non -union, AVN, malunion,
• 1:04:55
  and the end -stage SNSC risk are serious life
• 1:04:58
  -changing problems, but they're often preventable.
• 1:05:01
  Timely, accurate diagnosis followed immediately
• 1:05:03
  by appropriate evidence -based management casting
• 1:05:06
  for the truly stable, surgery for the unstable
• 1:05:09
  or high risk is the absolute key to mitigating
• 1:05:12
  these long -term risks. Okay, prevention is key.
• 1:05:14
  And finally, perhaps linking back to the start.
• 1:05:17
  Prevention, where possible, through protective
• 1:05:19
  measures like wrist guards and high -risk activities
• 1:05:22
  and learning safer falling techniques, combined
• 1:05:25
  with diligent follow -up care and simply listening
• 1:05:27
  to your body after any wrist injury, plays a
• 1:05:29
  vital role in maintaining long -term wrist health
• 1:05:31
  and function. Don't ignore persistent wrist pain
• 1:05:34
  after a fall. Excellent summary. That gives you
• 1:05:38
  a really clear, deep understanding of why the
• 1:05:41
  scaphoid fracture is absolutely not just a simple
• 1:05:43
  break and what really needs to be done to manage
• 1:05:46
  it effectively. If you found this deep dive valuable,
• 1:05:49
  please do consider sharing it with your colleagues
• 1:05:52
  on platforms like LinkedIn or X and perhaps leaving
• 1:05:55
  us a rating. It genuinely helps us reach more
• 1:05:57
  professionals who could benefit from this information.
• 1:06:00
  And a huge thank you again to Professor Moimam
• 1:06:03
  for sharing your incredible expertise and guiding
• 1:06:06
  us through this very complex topic with such
• 1:06:08
  remarkable clarity. It's been my pleasure. Important
• 1:06:10
  topic. So as we wrap up, and considering all
• 1:06:13
  the hidden dangers and potentially severe long
• 1:06:16
  -term consequences we've discussed today for
• 1:06:17
  this seemingly quite minor coin, perhaps the
• 1:06:20
  final thought to leave you with is this. In the
• 1:06:22
  face of such significant potential functional
• 1:06:24
  loss down the line, are we consistently in our
• 1:06:27
  clinics, on our sports fields, or perhaps in
• 1:06:29
  our workplaces, giving every single wrist injury
• 1:06:32
  the level of initial attention, diagnostic rigor,
• 1:06:34
  and timely follow -through that the humble yet
• 1:06:37
  absolutely critical scaphoid bone truly demands?