SCAPHOID FRACTURE,

BENNETT’S FRACTURE,
METACARPELS , PHALANGES
FRACTURE
NORMAL ANATOMY/RADIOGRAPH
 RADIOLOGICAL SIGNS
• GILULA CARPEL ARCS:
Gilula three carpal arcs refer to the carpal
alignment described on posteroanterior or
anteroposterior wrist radiographs and are
used to assess normal alignment of
the carpus:
• first arc: is a smooth curve outlining the
proximal convexities of
the scaphoid,lunate and triquetrum
• second arc: traces the distal concave
surfaces of the same bones
• third arc: follows the main proximal
curvatures of the capitate and hamate
• SCAPHOLUNATE ANGLE:
The scapholunate angle is the angle between
the long axis of the scaphoid and the mid axis
of the lunate on the sagittal imaging of the
wrist. In a normal situation, it should be
between 30 and 60o in the resting (neutral)
position.
• CAPITOLUNATE ANGLE:
The capitolunate angle is the angle between the
long axis of the capitate and the mid axis of the
lunate on the sagittal imaging of the wrist. In a
normal situation it should be less than 30° in the
resting (neutral) position.
 SCAPHOID FRACTURE
• Scaphoid is derived from Greek word SKAPHOS
meaning boat
• It acts as a link between proximal and distal carpal
rows
• The scaphoid is the most commonly fractured
carpal bone.
• AGE: 10-70 yrs. most common in young (20-30 yrs.)
• Scaphoid fractures are uncommon in children
because the physis of distal radius fails first.
• M:F- 4:1
• About 5-12% of scaphoid fractures are associated
with other fractures
• 70-80% occur at the waist, 10-20% occurs at
proximal pole
• RULE OF 70’S FOR SCAPHOID
• - 70% of all carpal bone fractures.
• - 70% of blood supply is by the dorsal branch of
the radial artery.
• - 70% of fractures occur at the waist of scaphoid.
• - 70% of the scaphoid fractures unite .
 ANATOMY
• The scaphoid lies at the radial
border of the proximal carpal row,
but its elongated shape and
position allow bridging between
the 2 carpal rows because it acts as
a stabilizing rod.
• The scaphoid has 5 articulating
surfaces: – with the radius, lunate,
capitate, trapezoid, and trapezium.
• As a result, nearly the entire
surface is covered by hyaline
cartilage.
• Parts of scaphoid :
[Link]
• [Link] pole
• [Link]
• [Link] pole

• Articulation:
• with the radius,
• lunate,
• capitate,
• trapezoid,
• and trapezium.
 BLOOD SUPPLY
• Blood supply to the scaphoid is primarily through the radial artery.
• The branches of the artery enter the scaphoid through the foramina at
the dorsal ridge at the level of the waist of the scaphoid. ( 80% of blood
supply to scaphoid)
• Subsequently, these vessels divide and run proximally and palmarly to
supply blood to the proximal pole of the scaphoid.
• Other branches provide 20– 30% of the blood flow and appear from
the distal palmar area of the scaphoid, arising either directly from the
radial artery or from the superficial palmar branch.
• The proximal pole, All studies consistently demonstrated poor supply
to the proximal pole
• The proximal pole is an intra-articular structure completely covered by
hyaline cartilage with a single ligamentous attachment therefore, is
dependent entirely on intraosseous blood flow.
 MECHANISM OF INJURY
• It is caused by fall on the
outstretched hand, resulting in
severe hyperextension and slight
radial deviation of the wrist
• The scaphoid usually fractures in
tension with the wrist extended,
concentrating the load on the
radial-palmar side.
• The proximal pole locks in the
scaphoid fossa of the radius, and
the distal pole moves excessively
dorsal resulting in fracture.
 PATHOPHYSIOLOGY
• Essentially fractures of scaphoid have been explained as a
failure of bone caused by compressive or tension load
• Compression, as explained by Cobey and White, against
concave surface by head of capitate
• Position of radial and ulnar deviation thought to determine
where it breaks
• Fryman subjected cadaver wrists to loading and observed
that: –
extension of 35 degrees of less resulted in distal forearm
fractures – >90degrees resulted in carpal fractures
• Combination of radial deviation and wrist extension locks
scaphoid within the scaphoid fossa
 CLINICAL EXAMINATION
• SYMPTOMS:
• [Link] along the radial side of wrist
• [Link] or difficulty to move the
wrist
• SIGNS:
• [Link] present in anatomical
snuff box [Link] in
anatomical snuffbox [Link]
with axial compression of thumb
towards the snuff box
• [Link] & ulnar deviation results
in pain on radial side of wrist
 CLASSIFICATION
• RUSSE’S classification
• AO classification
• HERBERT’S classification
• MAYO classification
 MAYO’S CLASSIFICATION
• It divides scaphoid fractures
into three basic types
according to anatomic
location of the fracture line.
• [Link] third (10%)
• [Link] third (70%)
• [Link] third (20%)
• Fracture of the distal third
are further divided
according to involvement of
the distal articular surface
or the distal tubercle.
 IMAGING
1. XRAYS: 4 essential views
PA view
Lateral view
Supinated oblique
Pronated oblique
• SCAPHOID VIEW: is a PA radiograph with the wrist
extended 30° and deviated ulnarly 20°. This view helps to
stretch out the scaphoid and is also used for assessing the
degree of scaphoid fracture angulation
• A clenched-fist radiograph has also been useful for
visualization of the scaphoid waist.
2. CT SCAN
• CT permits accurate anatomic assessment of
the fracture.
• Bone contusions are not evaluated with CT,
but true fractures can be excluded
• Most sensitive and specific
• Multiplanar and 3D-reconstructions are
possible.
3. MRI
• T1-weighted images obtained
in a single plane (coronal) are
typically sufficient to
determine the presence of a
scaphoid fracture.
• 100% sensitivity and specificity
• In recent study Dorsay has
shown that immediate MRI
provides cost benefit when
compared to splintage and
repeat x-ray
 BONE SCAN
• Sensitive, but less specific
• Increased osteocyte activity due to trauma will show as
a focal hot spot.
• Fractures are seen in around 95% of non-osteoporotic
patients within 24 hrs.
• Negative bone scan excludes any scaphoid fracture.
• Teil-van studied cost effectiveness and concluded that
initial x-ray followed by bone scan at 2 weeks if patient
is still symptomatic is most effective management
option
TREATMENT
 SCAPHOID CAST
• Forearm cast below the elbow proximally to the base
of thumbnail and the proximal palmar crease distally.
• Wrist in slight radial deviation and in neutral flexion.
• Thumb is maintained in functional position and the
fingers are free to move from MCP joints distally.
• 90-95% union in 10-12 weeks . During this time
fracture is observed radiographically for healing.
• If collapse or angulation of fractured fragments
occurs, surgical treatment is required.
• Forearm cast below the elbow proximally to the
base of thumbnail and the proximal palmar crease
distally.
• Wrist in slight radial deviation and in neutral
flexion.
• Thumb is maintained in functional position and
the fingers are free to move from MCP joints
distally.
• 90-95% union in 10-12 weeks . During this time
fracture is observed radiographically for healing.
• If collapse or angulation of fractured fragments
occurs, surgical treatment is required.
 OPERATIVE TREATMENT
• INDICATIONS OF SURGERY:
• 1. Displaced unstable fractures
• 2. Scaphoid fracture associated with perilunate # or
dislocation
• 3. Ligamentous injury
• 4. Non displaced fractures of proximal pole
• 5. Non displaced fractures if the patient will not tolerate
prolonged immobilization ( athletes and manual laborers)
The choice of surgical procedure depends on surgeons
preference and experience, the type of fracture, pt’s age.
 COMPLICATIONS
• DELAYED UNION
• MALUNION
• NONUNION
• AVASCULAR NECROSIS
• OA OF RADIOCARPAL AND INTERCARPAL
JOINTS
 BENNETT’S FRACTURE
• The Bennett's fracture is named after Edward
Hallaran Bennett .
• Bennett said his fracture "passed obliquely
across the base of the bone, detaching the
greater part of the articular surface” , and "the
separated fragment was very large and the
deformity that resulted there-from seemed
more a dorsal subluxation of the first
metacarpal".
THUMB METACARPEL FRACTURE
CLASSIFICATION
 BENNETT’S FRACTURE
• Bennett's fracture is a fracture of the base of
the first metacarpal bone which extends into
the carpometacarpal (CMC) joint.
• Intra-articular fracture
• most common type of fracture of the thumb
• nearly always accompanied by some degree
of subluxation or frank dislocation of the
carpometacarpal joint.
 MECHANISM OF INJURY
• an axial force directed against the
partially flexed metacarpal.
• This type of compression along
the metacarpal bone is often
sustained when a person punches
a hard object, such as the skull or
tibia of an opponent, or a wall.
• It can also occur as a result of a
fall onto the thumb.
• Specifically:
• Tension from the abductor pollicus longus muscle (APL)
subluxates the fragment in a dorsal, radial, and proximal
direction .
• Tension from the APL rotates the fragment into supination .
• Tension from the adductor pollicus muscle (ADP) displaces the
metacarpal head into the palm
 CLINICAL EVALUATION
Characteristic signs include –
• Pain,
• Swelling
• Ecchymosis around the base of the thumb and
thenar eminence, and especially over the CMC
joint of the thumb .
• Instability of the CMC joint of the thumb,
accompanied by pain and weakness of the pinch
grasp.
 IMAGING
• Xray – posteroanterior
and Lateral radiograph
• Traction xrays are
advisable
• CT scan – rarely
indicated in case of
doubt
 TREATMENT
• [Link] treatment Indicated for undisplaced
fractures.
• [Link] reduction and internal fixation Indicated for
reducible fractures.
• [Link] reduction internal fixation (ORIF) Indicated for:
[Link] which are not reducible in a closed manner.
[Link] is also indicated in high-demand patients and those
who need immediate restoration of a full range of motion.
[Link], ORIF is possible only if the anterior marginal
fragment is large enough for internal fixation (>20% of the
articular surface).
CLOSED REDUCTION AND POP APPLICATION

• Reduction is performed by a
combination of:
1. longitudinal traction
2. pronation of the metacarpal
3. pressure at the thumb
metacarpal base.

• Confirm correct restoration of

the articular surface using
image intensification
 CLOSED REDUCTION AND INTERNAL
FIXATION
• The most common are:
1. Transfixion of the base
of the first metacarpal to
the trapezium
2. Transfixion of the
thumb base to the
second metacarpal
3. Combination of both
WAGNERS TECHNIQUE FOR CLOSED PINNING
 ROLANDO FRACTURE
• This is a complete articular, ‘T’
or‘Y’ shaped fracture of the first
metacarpal.
• Perfect reduction is not as
important as in Bennett’s fracture
dislocation.
• Treatment is by accurate reduction
and fixation with ‘K1 ’ wires and
immobilisation in a thumb spica
for 3 weeks.
 METACARPEL FRACTURE
• Fractures of the metacarpal shaft
are common at all ages. The
common causes are:
(i) a fall on the hand
(ii) a blow on the knuckles (as in
boxing) and
(iii) crushing of the hand under a
heavy object.
• Fracture of one or more
metacarpals may occur.
• The fracture may be classified, according to the
site, as follows:
• a) Fracture through the base of the metacarpal,
usually transverse and undisplaced.
• b) Fracture through the shaft – transverse or
oblique. These fractures are usually not much
displaced because of the splinting effect of the
interossei muscles and adjacent metacarpals.
When more than one metacarpal shafts are
fractured,this “auto-immobilisation” advantage is
lost. Such fractures are unstable and require
operative treatment.
• Fracture through the neck of the metacarpal –
It commonly affects the neck of the fifth
metacarpal. The distal fragment is tilted
forwards. It is usually sustained when a closed
fist hits against a hard object (Boxer's fracture).
 TREATMENT
• Conservative treatment is sufficient in most cases. It
consists of immobilisation of the hand in a light
dorsal slab for 3 weeks.
• A minimal displacement is acceptable, but in cases
with severe displacement or angulation, reduction is
necessary.
• This is achieved in most cases by closed reduction; in
some, particularly those with multiple metacarpal
fractures, internal fixation with K-wires or mini plates
may be required.
 FRACTURE OF PHALANGES
• These are common fractures, generally
sustained by fall of a heavy object on the
finger or crushing of fingers. The fractures can
have various patterns, and may be displaced
or undisplaced.
 TREATMENT
• [Link]:
Treatment is basically for the relief of pain. A
simple method of splintage is to strap the
injured finger to an adjacent finger for 2
weeks .After this, finger mobilisation is
started.
[Link] FRACTURE:
• An attempt should be made to reduce the fracture by
manipulation, and immobilised in a simple malleable
aluminium splint.
• Active exercises must be started not later than 3 weeks
after the injury.
• If displacement cannot be controlled by the above means,
a percutaneous fixation or open reduction and internal
fixation using K-wire, may be necessary.
• A comminuted fracture of the tip of the distal phalanx
does not need any special treatment, and attention
should be directed solely to treatment of any soft tissue
injury.
 MALLET FINGER (BASEBALL FINGER)
• It results from the sudden passive flexion of the
distal interphalangeal joint so that the extensor
tendon of the distal interphalangeal (DIP) joint is
avulsed from its insertion at the base of the distal
phalanx.
• Sometimes it takes a fragment of bone with it.
Clinically, distal phalanx is in slight flexion.
• Treatment :is by immobilising the DIP joint in
hyperextension with the help of an aluminium splint
or plaster cast.
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