WEBVTT

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OK, let's start with a statistic that really

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drives home the stakes here. Scaphoid fractures.

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This small bone in your wrist, it's the most

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commonly fractured carpal bone, making up something

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like 60 % of all wrist bone breaks. That's right.

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A huge proportion. And you might think, all right,

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a simple wrist break after a fall. But here's

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the critical part, depending on where it breaks,

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how it's treated. Well, a significant percentage,

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potentially 15 to 50 percent overall, maybe even

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hitting 100 percent in those tricky proximal

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pole fractures if not handled correctly, can

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lead to a vascular necrosis. Essentially bone

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death. Exactly, bone death. That seemingly simple

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fall can just unravel into chronic pain, loss

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of function, maybe even a career -threatening

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problem for someone relying on their hands. And

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so much of that risk comes down to the scaphoids'

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peculiar structure, that sort of twisted peanut

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shape we talk about. Right. complex, almost awkward

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blood supply. Welcome to the Deep Dive. This

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is where we take complex information research

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papers, clinical guidelines, expert knowledge,

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and really extract the vital insights, giving

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you the shortcut to being truly well -informed.

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Today we are taking a profound look into scaphoid

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fractures, navigating the orthopedic knowledge

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and clinical practices necessary to understand

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and manage this, well, really challenging injury.

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And guiding us through this deep dive is Professor

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Mo Imam, a distinguished expert in musculoskeletal

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trauma and hand surgery. Professor Imam, it's

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a real privilege to have you join us. Thank you.

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It's a crucial topic and I'm glad to explore

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it. The scaphoid is, well, it's a small bone.

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that presents some very large clinical problems

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you've not understood properly. Absolutely. So

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to kick things off and maybe give you a roadmap

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of where we're heading, let's hit you with three

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quick high -impact questions. OK. First, just

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stepping back, what exactly is a scaphoid fracture?

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And fundamentally, why does it pose such unique

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problems compared to, say, a break in the radius

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or ulna? Well, what's critically important here

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is the scaphoid's unique anatomy and its vascularization.

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You see, it's the critical mechanical link between

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the two rows of wrist bones, absolutely essential

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for smooth motion. But unlike most bones that

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have multiple points of entry for blood vessels,

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the scaphoid gets the majority of its blood supply

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through quite a limited area, often distal to

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where the fracture occurs. Which means the blood

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has to flow retrograde backwards towards that

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vital proximal pole. This sets it apart entirely

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from breaks in the long bones of the forearm.

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That retrograde flow sounds like a, well, a built

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-in vulnerability, doesn't it? It absolutely

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is. Second question, then. Beyond just the initial

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break healing, what are the most significant,

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potentially devastating complications that professionals,

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especially those who use their hands intensely,

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must absolutely be aware of? Yes. This really

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raises the specter of long -term disability.

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The primary complications are non -union, meaning

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the fracture simply fails to heal, endovascular

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necrosis, or AVN, where the bone tissue actually

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dies due to that lack of blood supply. Okay.

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Either of these can lead to malunion, where it

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heals crookedly, progressive carpal collapse,

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and ultimately debilitating osteoarthritis of

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the wrist. These aren't minor setbacks. They

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really can be career -ending issues. Non -union

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and AVN, those are the big risks. Okay. Finally,

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if you had to boil it all down, Is there one

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single most critical factor in achieving a good

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outcome for a scaphoid fracture? That's a key

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question. If we distill all the evidence and,

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you know, clinical experience, the single most

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critical factor is probably an early accurate

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diagnosis. Right. Followed immediately by appropriate

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individualized management. And that management

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has to be based on a thorough assessment of the

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fracture characteristics. Hesitation or misdiagnosis

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significantly increases the risk of those complications

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we just mentioned. Early, accurate diagnosis

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and appropriate management. Sounds like a bit

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of a race against the clock and the anatomy itself.

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In many ways, yes. So let's start by understanding

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the star of our show, the scaphoid bone itself.

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We often hear it called boat -shaped from its

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Greek origin, but you prefer twisted peanut.

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Why is that shape significant? Indeed. Oskifodium

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does translate to boat shapes. And I suppose

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if you look at it from one angle, maybe it vaguely

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resembles a small boat. But the twisted peanut

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analogy, while less scientific, perhaps gives

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you a better sense of its complex 3D geometry

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and its angulation. It's not a simple straight

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bone. OK. This shape is crucial because it has

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two main articulating surfaces, fitting neatly

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into the proximal and distal carpal rows. And

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the vast majority of its surface, over 75%, is

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covered in smooth articular cartilage, which

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is essential for wrist movement. Right, for the

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gliding. Exactly. But this also means there's

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very little raw bone surface available for soft

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tissues, ligaments, or critically, blood vessels

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to attach and actually enter the bone. The main

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area where blood vessels can get in is a small,

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non -articular area known as the dorsal ridge.

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So the very structure designed for smooth movement

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actually limits where its lifeblood can get in.

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Precisely. It's a trade -off. Let's dive deeper

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into that critical, tricky blood supply, maybe

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drawing on that foundational research. What did

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the classic Gelberman and Menon study from 1980

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using those latex injections really reveal about

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the scaphoid's vascularity? Yes, that study published

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in the Journal of Hand Surgery was absolutely

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seminal. It meticulously mapped the scaphoid's

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blood supply. They identified two primary sources

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or vascular leashes, as they call them. OK. The

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dominant supply comes from the dorsal ridge artery.

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Now, this is a branch of the radial artery, and

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it's responsible for a significant majority,

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perhaps 70 to 80 percent, of the scaphoid's total

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blood flow. It enters the bone through that non

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-articular dorsal ridge we just discussed. The

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small entry point on the back. And this is where

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the retrograde flow comes in, correct? Precisely.

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The blood vessels entering the dorsal ridge predominantly

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supply the distal and middle parts of the scaphoid

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first. OK. So to reach the crucial proximal pole

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that's the part closest to the forearm bones,

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the blood has to flow backwards or retrogradedly

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up the length of the bone. It's quite counterintuitive

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compared to how blood typically flows into most

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bones. So blood comes in effectively at one end

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and has to push upstream to reach the other end.

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That seems inherently risky. Exactly. Now there

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is a secondary minor supply from the palmar side

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via branches of the palmar and superficial palmar

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radial artery. These vessels enter near the distal

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tubercle and supply roughly the distal 20 to

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30 percent of the scaphoid. OK, so combining

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these, you've got the main supply coming in dorsally,

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flowing retrograde -ly, and a smaller supply

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coming in palmerly just to the distal bit. That

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specific setup creates a significant vulnerability.

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The area reliant on that retrograde flow, particularly

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the proximal pole, is effectively in a watershed

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zone. A watershed zone, right. So if a fracture

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occurs between where those dominant dorsal vessels

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enter and the proximal pole itself, that proximal

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fragment can be entirely cut off from his blood

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supply. Completely isolated. Yes. And the small

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palmar supply is usually insufficient to sustain

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it. This is the fundamental anatomical reason

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why proximal pole fractures are at such a high

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risk of vascular necrosis. The blood simply can't

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get there. That anatomical detail is just incredibly

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important for understanding the prognosis, isn't

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it? Absolutely fundamental. No. Turning to how

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and where these fractures typically happen, what

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does the epidemiology tell us? Who gets these,

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and why? Well, epidemiologically, scaphoid fractures

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are, as you mentioned right at the start, the

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most common carpal fracture. They make up about

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60 % of all carpal breaks and maybe 15 % of acute

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wrist injuries generally. OK. The highest incidence

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is in young, active men. particularly in their

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third decade of life. The male to female ratio

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is often cited around 2 .1. So it's often associated

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with activities then, sports, falls. Absolutely.

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The overwhelming etiology that causes a fall

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onto an outstretched hand, the classic foosh

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injury. This mechanism typically involves the

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wrist being forced into hyperdorsiflexion, often

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with an axial load pushing down some pronation

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and frequently concurrent ulnar deviation, the

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wrist bending towards the little finger side.

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That's the classic scenario, isn't it? Tripping,

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falling off a bike. Exactly. Sports, falls from

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height, or simply tripping on the pavement. It's

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worth noting, too, that this foosh with ulnar

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deviation can also simultaneously injure ligaments

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around the wrist. Sometimes it leads to what

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we call a dis -e deformity dorsal intercalated

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segmental instability. OK, what does that mean?

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It essentially means the middle row of carpal

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bones tilts backwards abnormally, which adds

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another layer of complexity to the injury. Right,

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so it's not just the scaphoid break, that makes

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sense. And where in this twisted peanut does

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it most commonly break? You mentioned the proximal

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pole is riskiest, but is it the most frequent?

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No, interestingly, while the proximal pole is

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the riskiest spot for complications, it's not

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the most frequent location for the fracture itself.

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The most common fracture location is the waist,

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the narrowest part of the bone. That counts for

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about 65 % of scaphoid fractures. The majority,

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then? Yes. Fractures in the proximal third are

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next most common at around 25 % and fractures

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of the distal third or the little tubercle at

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the end are the least common, making up perhaps

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10%. There used to be belief that distal fractures

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were more common in children. But more recent

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large series suggest that waste fractures are

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now actually the predominant site across most

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age groups. So the waste is the frequent flyer,

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but the proximal third is the high -risk passenger.

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That's a good way to put it, yes. This brings

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us neatly to classification systems. Why is it

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so vital to classify a scaphoid fracture beyond

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just saying it's broken? Oh, classification is

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absolutely paramount because it's really the

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foundation for clinical decision -making. It

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helps us assess the fracture stability. understand

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its likely prognosis, and ultimately dictates

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the most appropriate treatment strategy. Whether

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it's casting or surgery. Precisely. Whether that's

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casting or surgery and indeed what type of surgery

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might be needed. A proper classification guides

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us towards maximizing the chance of union healing

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and minimizing those complications we talked

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about. The Herbert classification is widely used,

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isn't it? It seems to be based specifically on

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stability and also the timing. Whether it's acute

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or older, could you walk us through the main

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types? Yes, the Herbert classification is very

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clinically relevant because it categorizes fractures

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based on factors that directly impact treatment

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and outcome. It divides fractures into four main

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types A, B, C, and D. Okay. Type A. represents

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stable acute fractures. These are generally lower

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risk and include A1, which is a fracture of that

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distal tubercle. The little end bit, yes. And

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A2, which is an incomplete waste fracture, meaning

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the crack doesn't go all the way across the bone.

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Right, so those are relatively safe bets for

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healing. Generally, yes, with appropriate immobilization.

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Then you have type B, which represents unstable

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acute fractures. Now these are the ones that

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often require surgery due to their inherent risk

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of not healing well or displacing. Okay, what's

00:11:05.230 --> 00:11:08.740
in type B? This category includes B1, a distal

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oblique fracture, which is prone to shear forces

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and slipping. B2, a complete waist fracture,

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which is considered unstable because it breaks

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the main structural support across the middle.

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B3, a proximal pull fracture, which we know is

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unstable due to that high AVN risk and the anatomical

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difficulty. The blood supply issue again? Exactly.

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And B4, which is a very significant injury, indeed

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a transcephoid -paralinate fracture dislocation.

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That involves major disruption of the ligaments

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around the lunate bone as well as the scaphoid

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brick itself. Wow. Okay. So type A is relatively

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stable. Type B is unstable and problematic. What

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about C and D? Type C is designated for delayed

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union. This is when the fracture hasn't healed

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within the expected time frame, say after several

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months of casting. But there's still thought

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to be some biological potential for it to heal,

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perhaps with further immobilization or maybe

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some intervention. So slow healing, but not given

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up yet. Precisely. And then type D is for established

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non -union. This means the bone has failed to

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heal, the healing process is effectively stopped,

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and it requires intervention to achieve union.

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And Herbert breaks down non -union further. Yes,

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Herbert further subdivides non -union. which

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is useful prognosically. D1 is a fibrous union

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where there's maybe some soft tissue connection,

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but no solid bone bridging the gap. D2 is a pseudothrosis,

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which literally means a false joint with instability

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and often early deformity starting to develop.

00:12:31.269 --> 00:12:33.149
Like it's moving where it shouldn't. Exactly.

00:12:33.570 --> 00:12:37.250
D3 is a sclerotic pseudothrosis. which is a more

00:12:37.250 --> 00:12:39.470
established false joint where the bone edges

00:12:39.470 --> 00:12:42.409
have become hardened and dense, often with significant

00:12:42.409 --> 00:12:44.889
deformity like that humpback shape. And finally,

00:12:45.110 --> 00:12:48.769
D4 indicates avian avascular necrosis associated

00:12:48.769 --> 00:12:51.929
with the non -union, often presenting as a fragmented

00:12:51.929 --> 00:12:54.610
or collapsed proximal pole. That progression

00:12:54.610 --> 00:12:57.710
to D4 sounds like the real end stage of that

00:12:57.710 --> 00:12:59.769
avian risk we discussed right at the start. It

00:12:59.769 --> 00:13:02.590
often is, yes. It represents significant biological

00:13:02.590 --> 00:13:04.980
failure. Are there other classification systems

00:13:04.980 --> 00:13:08.299
that clinicians use alongside Herbert? Yes, there

00:13:08.299 --> 00:13:10.559
are others that focus on slightly different aspects,

00:13:10.820 --> 00:13:13.240
which can be complementary. The Mayo classification

00:13:13.240 --> 00:13:15.679
is a simpler system based purely on the anatomical

00:13:15.679 --> 00:13:19.059
location. Type 1 is a distal tubercle. Type 2,

00:13:19.159 --> 00:13:22.019
the distal articular surface. 3, the distal third.

00:13:22.139 --> 00:13:24.659
4, the middle third or waist. And type V, the

00:13:24.659 --> 00:13:26.820
proximal third. So just location. Just location.

00:13:27.039 --> 00:13:28.940
And the Roast classification describes the fracture

00:13:28.940 --> 00:13:31.500
line pattern or its orientation. Horizontal oblique.

00:13:31.629 --> 00:13:34.169
transverse straight across, and vertical oblique.

00:13:34.289 --> 00:13:36.610
Why does the pattern matter? Well, a vertical

00:13:36.610 --> 00:13:39.090
oblique fracture pattern, for instance, is a

00:13:39.090 --> 00:13:41.389
known risk factor for instability and nonunion.

00:13:41.929 --> 00:13:43.769
Because the fracture line runs more vertically,

00:13:44.309 --> 00:13:46.230
it's much more prone to shearing forces when

00:13:46.230 --> 00:13:48.690
the wrist is loaded, making it harder to hold

00:13:48.690 --> 00:13:52.029
reduced and less likely to heal in a cast. I

00:13:52.029 --> 00:13:55.000
see. So Herbert gives you the stability and chronicity

00:13:55.000 --> 00:13:58.600
picture, Mayo gives location, and Russ adds the

00:13:58.600 --> 00:14:00.360
fracture pattern detail. And combining these

00:14:00.360 --> 00:14:02.759
helps make the treatment decision. Exactly. The

00:14:02.759 --> 00:14:04.659
classification, drawn on these different aspects,

00:14:05.100 --> 00:14:07.789
directly informs the management pathway. Stable,

00:14:08.049 --> 00:14:09.970
undisplaced fractures, typically Herbert type

00:14:09.970 --> 00:14:13.289
A or maybe non -displaced type B2 or B3, depending

00:14:13.289 --> 00:14:15.750
on surgeon preference and careful imaging, and

00:14:15.750 --> 00:14:17.929
often majoroos types without displacement or

00:14:17.929 --> 00:14:20.129
vertical patterns are usually candidates for

00:14:20.129 --> 00:14:22.730
non -operative management with casting. Whereas

00:14:22.730 --> 00:14:25.590
unstable, acute fractures, Herbert type B, vertical

00:14:25.590 --> 00:14:27.669
oblique patterns, any proximal pole fracture,

00:14:27.769 --> 00:14:30.529
really. Those with significant displacement or

00:14:30.529 --> 00:14:33.570
angulation seen on imaging almost always require

00:14:33.570 --> 00:14:35.629
operative intervention due to the high likelihood

00:14:35.629 --> 00:14:37.730
of non - union or malunion if you simply put

00:14:37.730 --> 00:14:40.070
them in a cast. Right, the classification is

00:14:40.070 --> 00:14:42.789
absolutely the roadmap to treatment. Now, let's

00:14:42.789 --> 00:14:44.809
talk about actually spotting this injury in the

00:14:44.809 --> 00:14:47.490
first place. Given there's often no dramatic

00:14:47.490 --> 00:14:50.549
deformity, how do clinicians typically diagnose

00:14:50.549 --> 00:14:53.309
a scaphoid fracture? What are the key clinical

00:14:53.309 --> 00:14:56.070
signs to look for? Clinically, the cardinal sign,

00:14:56.149 --> 00:14:58.470
the one everyone learns, is tenderness in the

00:14:58.470 --> 00:15:00.929
anatomical snuff box. That little hollow on the

00:15:00.929 --> 00:15:02.950
back of your wrist? Exactly, on the thumb side,

00:15:03.370 --> 00:15:06.049
formed when you extend your thumb out. Pressing

00:15:06.049 --> 00:15:09.210
firmly in that area after a foosh injury is highly

00:15:09.210 --> 00:15:12.590
suggestive. Its sensitivity for detecting a scaphoid

00:15:12.590 --> 00:15:15.049
fracture is reported to be high, maybe up to

00:15:15.049 --> 00:15:18.389
90%. That's quite high. It is, but it's crucial

00:15:18.389 --> 00:15:20.889
to remember that other injuries, like ligament

00:15:20.889 --> 00:15:23.629
sprains or fractures of the radial styloid, can

00:15:23.629 --> 00:15:26.850
also cause snuff box tenderness. So it's sensitive,

00:15:26.950 --> 00:15:29.210
but not perfectly specific. It doesn't absolutely

00:15:29.210 --> 00:15:31.470
confirm a scaphoid fracture on its own. Okay,

00:15:31.470 --> 00:15:34.409
so it's a strong clue, but not proof. What else?

00:15:34.570 --> 00:15:36.909
Other signs include general swelling around the

00:15:36.909 --> 00:15:39.210
radial side of the wrist, often some reduced

00:15:39.210 --> 00:15:41.470
range of motion, particularly wrist extension

00:15:41.470 --> 00:15:45.080
and radial deviation. Pain with forceful resisted

00:15:45.080 --> 00:15:47.320
pronation of the forearm can sometimes elicit

00:15:47.320 --> 00:15:50.500
pain. And there's a positive scaphoid compression

00:15:50.500 --> 00:15:53.500
test, where you push axially along the line of

00:15:53.500 --> 00:15:56.320
the thumb metacarpal towards the wrist, and that

00:15:56.320 --> 00:15:59.100
reproduces their specific pain. Right. But the

00:15:59.100 --> 00:16:01.820
key challenge, as you said, is that unlike, say,

00:16:01.919 --> 00:16:04.639
a broken forearm bone, there's usually no obvious

00:16:04.639 --> 00:16:06.940
deformity. The wrist might look a bit swollen,

00:16:07.080 --> 00:16:09.720
maybe bruised, but often not dramatically out

00:16:09.720 --> 00:16:12.120
of shape. This makes it really easy to mistake

00:16:12.120 --> 00:16:14.179
for a simple wrist sprain, especially in the

00:16:14.179 --> 00:16:16.159
heat of the moment, like on a sports field or

00:16:16.159 --> 00:16:19.360
in a busy A &E. So the take -home is, after a

00:16:19.360 --> 00:16:21.659
fall onto an outstretched hand, if there's snuff

00:16:21.659 --> 00:16:23.580
box tenderness, you really should have a high

00:16:23.580 --> 00:16:26.320
clinical suspicion. What's the crucial next step,

00:16:26.600 --> 00:16:29.059
then, in terms of imaging? The standard initial

00:16:29.059 --> 00:16:31.840
imaging is plain x -rays, but... And this is

00:16:31.840 --> 00:16:33.740
a really important point. You need the right

00:16:33.740 --> 00:16:35.779
views to maximize the chance of actually seeing

00:16:35.779 --> 00:16:38.500
the fracture, especially if it's subtle or undisplaced.

00:16:38.700 --> 00:16:41.460
But not just the standard two views. No, definitely

00:16:41.460 --> 00:16:44.919
not. Relying on just standard PA, postural interior,

00:16:45.000 --> 00:16:47.539
and lateral views is often insufficient. The

00:16:47.539 --> 00:16:49.759
sources consistently recommend a minimum of four

00:16:49.759 --> 00:16:52.639
or ideally five specific views. This includes

00:16:52.639 --> 00:16:56.299
the standard PA and a true lateral. OK. But crucially,

00:16:56.740 --> 00:16:59.200
also, PA view is taken in 45 degrees of oblique

00:16:59.200 --> 00:17:02.080
pronation and 45 degrees of oblique supination.

00:17:02.980 --> 00:17:05.680
And the PA view taken with the wrist in maximum

00:17:05.680 --> 00:17:08.309
ulnar deviation bending towards the little finger.

00:17:08.609 --> 00:17:11.450
Why the honored deviation view? That specific

00:17:11.450 --> 00:17:13.970
view helps to elongate the scaphoid, straightening

00:17:13.970 --> 00:17:16.569
out its natural curve on the x -ray image, which

00:17:16.569 --> 00:17:19.170
makes fractures across the waist much more visible

00:17:19.170 --> 00:17:21.170
than they might be in the standard neutral PA

00:17:21.170 --> 00:17:23.349
view. Right, it sort of uncoils it visually.

00:17:23.630 --> 00:17:25.670
Exactly. And beyond just looking for the fracture

00:17:25.670 --> 00:17:27.930
line itself, on the x -rays you also look for

00:17:27.930 --> 00:17:30.329
other radiographic signs, things like sclerosis,

00:17:30.390 --> 00:17:32.769
which is increased bone density along the fracture

00:17:32.769 --> 00:17:35.289
line, suggesting poor healing or maybe even early

00:17:35.289 --> 00:17:38.400
bone death. or looking for that humpback deformity

00:17:38.400 --> 00:17:40.859
on the lateral view, which is an increased intraskeifoid

00:17:40.859 --> 00:17:43.799
angle. How much of an angle is abnormal? Generally,

00:17:44.000 --> 00:17:47.059
an angle over 35 degrees suggests some deformity,

00:17:47.500 --> 00:17:50.220
and an angle greater than 45 degrees is strongly

00:17:50.220 --> 00:17:53.180
associated with poor outcomes and the likely

00:17:53.180 --> 00:17:55.400
development of that dizzy instability pattern

00:17:55.400 --> 00:17:58.339
we mentioned earlier. Okay. Now... There's the

00:17:58.339 --> 00:18:00.819
historical approach, the two -week delay, where

00:18:00.819 --> 00:18:02.900
initial x -rays are negative but your suspicion

00:18:02.900 --> 00:18:05.480
is high, you cast the wrist and repeat the x

00:18:05.480 --> 00:18:08.420
-rays two weeks later. What was the thinking

00:18:08.420 --> 00:18:11.019
behind this, and is it still the recommended

00:18:11.019 --> 00:18:13.759
practice today? This was a very common practice

00:18:13.759 --> 00:18:16.660
for many years based on the idea that bone resorption,

00:18:16.799 --> 00:18:18.740
a natural process occurring around a fracture

00:18:18.740 --> 00:18:21.759
line in the early healing phase, might make a

00:18:21.759 --> 00:18:24.180
previously invisible, occult, non -displaced

00:18:24.180 --> 00:18:26.799
fracture become visible on a follow -up x -ray

00:18:26.799 --> 00:18:29.519
after a period of immobilization. The line might

00:18:29.519 --> 00:18:32.380
become clearer. That was the theory. However,

00:18:33.180 --> 00:18:36.220
evidence such as that quite pivotal 1981 Leslie

00:18:36.220 --> 00:18:39.299
and Dixon study of the JBJS has really challenged

00:18:39.299 --> 00:18:41.579
the utility of this approach. They reviewed a

00:18:41.579 --> 00:18:43.779
large series of patients presenting with scaphoid

00:18:43.779 --> 00:18:47.079
fractures and found that a staggering 98 % of

00:18:47.079 --> 00:18:49.299
these fractures were actually visible on the

00:18:49.299 --> 00:18:52.420
initial radiographic series, provided that adequate

00:18:52.420 --> 00:18:54.900
views, those multiple views we just discussed,

00:18:55.279 --> 00:18:58.420
were obtained. 98 % were visible initially. Yes.

00:18:58.660 --> 00:19:01.480
Only a tiny 2 % became apparent only on the later

00:19:01.480 --> 00:19:04.339
X -rays. And these were typically only very minor

00:19:04.339 --> 00:19:07.059
incomplete fractures located on the concave side

00:19:07.059 --> 00:19:09.799
of the bone. So the vast majority are there to

00:19:09.799 --> 00:19:11.720
be seen if you look correctly the first time.

00:19:12.180 --> 00:19:14.160
What's the implication of that finding for the

00:19:14.160 --> 00:19:16.819
whole two -week delay strategy? Well, the implication

00:19:16.819 --> 00:19:19.000
is pretty profound, really. Waiting two weeks

00:19:19.000 --> 00:19:21.440
misses almost nothing that wasn't truly visible

00:19:21.440 --> 00:19:24.059
initially and only picks up a very small number

00:19:24.059 --> 00:19:27.200
of potentially insignificant incomplete fractures

00:19:27.200 --> 00:19:30.869
later on. But crucially, what it does do is it

00:19:30.869 --> 00:19:34.069
delays definitive diagnosis and potentially the

00:19:34.069 --> 00:19:37.309
appropriate treatment for a full 14 days. During

00:19:37.309 --> 00:19:40.009
that delay, a fracture that might have been minimally

00:19:40.009 --> 00:19:42.069
displaced could become more displaced within

00:19:42.069 --> 00:19:45.049
the cast, or the optimal window for early surgical

00:19:45.049 --> 00:19:47.950
fixation, if indicated, could be missed. This

00:19:47.950 --> 00:19:50.349
potentially increases the risk of non -union

00:19:50.349 --> 00:19:53.720
and AVN. So paradoxically, the two -week delay

00:19:53.720 --> 00:19:56.359
meant to avoid missing things could actually

00:19:56.359 --> 00:19:58.720
be detrimental by delaying definitive management.

00:19:59.019 --> 00:20:01.880
In many cases, yes, it delays certainty. So what

00:20:01.880 --> 00:20:04.240
are the modern preferred alternatives if clinical

00:20:04.240 --> 00:20:06.720
suspicion remains high despite negative initial

00:20:06.720 --> 00:20:09.119
x -rays? What should be done instead of waiting

00:20:09.119 --> 00:20:11.519
two weeks? The modern approach, which is supported

00:20:11.519 --> 00:20:14.019
by higher quality evidence and much better technology,

00:20:14.440 --> 00:20:16.880
is to move swiftly to advanced imaging if those

00:20:16.880 --> 00:20:19.220
initial x -rays are negative. But your clinical

00:20:19.220 --> 00:20:21.819
suspicion of a scaphoid fracture persists. Advanced

00:20:21.819 --> 00:20:25.200
imaging meaning CT or MRI. Exactly. The primary

00:20:25.200 --> 00:20:29.240
alternatives are CT or MRI. CT is widely available,

00:20:29.440 --> 00:20:31.680
relatively quick, and generally less expensive

00:20:31.680 --> 00:20:34.740
than MRI. It's excellent at definitively demonstrating

00:20:34.740 --> 00:20:37.339
the presence or absence of a fracture line, even

00:20:37.339 --> 00:20:40.289
subtle ones. And MRI. MRI is even more sensitive,

00:20:40.490 --> 00:20:42.910
particularly for detecting truly occult fractures,

00:20:43.210 --> 00:20:45.890
those not visible on x -ray, or even sometimes

00:20:45.890 --> 00:20:47.990
CT, especially in the very early stages after

00:20:47.990 --> 00:20:51.210
injury, say within the first 24 to 48 hours.

00:20:51.390 --> 00:20:53.930
Let's break down the utility of CT and MRI a

00:20:53.930 --> 00:20:56.490
bit further then. What specific information does

00:20:56.490 --> 00:20:59.109
a CT scan give you that plain x -rays perhaps

00:20:59.109 --> 00:21:02.289
can't? CT is invaluable for assessing the fracture

00:21:02.289 --> 00:21:05.160
in fine detail. It provides high resolution images,

00:21:05.299 --> 00:21:08.359
typically using very thin 1mm slices, which are

00:21:08.359 --> 00:21:10.359
often reconstructed in the sagittal plane along

00:21:10.359 --> 00:21:13.259
the scaphoid's long axis. This allows for really

00:21:13.259 --> 00:21:15.539
accurate assessment of the precise fracture location,

00:21:16.000 --> 00:21:18.480
the degree of angulation or deformity, and crucially

00:21:18.480 --> 00:21:20.279
the amount of displacement between the fragments.

00:21:21.039 --> 00:21:23.579
Displacement of greater than 1mm is widely accepted

00:21:23.579 --> 00:21:26.220
as a key indicator of instability and a strong

00:21:26.220 --> 00:21:28.200
predictor of poor outcome with non -operative

00:21:28.200 --> 00:21:30.660
treatment alone. So CT is best for measuring

00:21:30.660 --> 00:21:33.799
that gap. Yes, CT is far more effective than

00:21:33.799 --> 00:21:37.039
x -rays, bone scans, or even MRI for precisely

00:21:37.039 --> 00:21:39.839
measuring displacement. It's also excellent for

00:21:39.839 --> 00:21:42.259
monitoring fracture healing progress over time,

00:21:42.660 --> 00:21:44.819
or for assessing the characteristics of an established

00:21:44.819 --> 00:21:47.640
non -union before planning surgery. And MRI.

00:21:47.940 --> 00:21:49.900
You mentioned it's high sensitivity for occult

00:21:49.900 --> 00:21:52.559
fractures. What else does it offer? MRI is really

00:21:52.559 --> 00:21:54.539
the gold standard for diagnosing those subtle

00:21:54.539 --> 00:21:56.839
or occult fractures that just aren't visible

00:21:56.839 --> 00:22:00.099
on x -rays or sometimes even CT. It attacks bone

00:22:00.099 --> 00:22:01.759
bruising, and occult fracture is essentially

00:22:01.759 --> 00:22:04.400
a severe bone bruise very early on. It can also

00:22:04.400 --> 00:22:07.039
show early signs of AVN. The blood supply issue

00:22:07.039 --> 00:22:09.740
again. Exactly. AVN shows up as a characteristic

00:22:09.740 --> 00:22:13.000
low signal intensity on both T1 and T2 weighted

00:22:13.000 --> 00:22:16.339
images. MRI is also superior to CT for evaluating

00:22:16.339 --> 00:22:18.859
associated soft tissue injuries like ligament

00:22:18.859 --> 00:22:21.039
tears, particularly the scaphalunid ligament,

00:22:21.380 --> 00:22:23.700
which can contribute significantly to overall

00:22:23.700 --> 00:22:26.339
wrist instability. So if you have high suspicion

00:22:26.339 --> 00:22:29.180
and a negative x -ray, an MRI gives you a definitive

00:22:29.180 --> 00:22:31.200
answer about whether a fracture is present or

00:22:31.200 --> 00:22:34.460
not. In most cases, yes. It often prevents the

00:22:34.460 --> 00:22:37.480
need for prolonged unnecessary casting based

00:22:37.480 --> 00:22:40.380
on suspicion alone. which has implications for

00:22:40.380 --> 00:22:42.599
patient convenience and health care costs. What

00:22:42.599 --> 00:22:45.119
about bone scans? You mentioned CT is better

00:22:45.119 --> 00:22:47.740
for displacement. Are bone scans still part of

00:22:47.740 --> 00:22:50.119
the diagnostic algorithm at all? Bone scans,

00:22:50.259 --> 00:22:52.779
or scintigraphy, are highly sensitive for detecting

00:22:52.779 --> 00:22:55.259
increased metabolic activity associated with

00:22:55.259 --> 00:22:58.240
any bone injury, including fractures. They typically

00:22:58.240 --> 00:23:00.859
become positive about 72 hours after the injury.

00:23:01.039 --> 00:23:03.480
They have high specificity, around 98%, meaning

00:23:03.480 --> 00:23:05.619
if it's negative, you likely don't have a fracture.

00:23:05.660 --> 00:23:08.019
Yeah. But they can show increased uptake for

00:23:08.009 --> 00:23:09.470
There are other reasons besides the scaphoid

00:23:09.470 --> 00:23:12.170
fracture inflammation, arthritis, other injuries

00:23:12.170 --> 00:23:15.710
leading to a 5 -15 % incidence of false positives.

00:23:15.789 --> 00:23:19.150
OK. So while sensitive, MRI is generally considered

00:23:19.150 --> 00:23:21.430
more sensitive and more specific for diagnosing

00:23:21.430 --> 00:23:24.450
occult scaphoid fractures and, importantly, for

00:23:24.450 --> 00:23:27.690
identifying early AVN. This makes MRI the preferred

00:23:27.690 --> 00:23:29.950
advanced imaging modality in most cases where

00:23:29.950 --> 00:23:32.150
suspicion remains high despite negative x -rays.

00:23:32.359 --> 00:23:35.019
OK, that makes sense. So the modern approach

00:23:35.019 --> 00:23:38.440
is high clinical suspicion plus proper initial

00:23:38.440 --> 00:23:41.079
x -rays. And if those are negative, proceed quickly

00:23:41.079 --> 00:23:44.740
to CT for bony detail and displacement, or ideally

00:23:44.740 --> 00:23:47.940
MRI for occult fracture and ADN assessment, rather

00:23:47.940 --> 00:23:50.299
than relying on the old two -week delay. That's

00:23:50.299 --> 00:23:52.839
the current thinking, yes. Much more proactive.

00:23:53.099 --> 00:23:56.200
This diagnostic rigor is clearly aimed at identifying

00:23:56.200 --> 00:23:58.960
instability early on. Let's just consolidate

00:23:58.960 --> 00:24:01.700
the criteria for what defines an unstable scaphoid

00:24:01.700 --> 00:24:04.200
fracture, which, as you said, is absolutely key

00:24:04.200 --> 00:24:06.960
for treatment decisions. Absolutely. Identifying

00:24:06.960 --> 00:24:10.019
instability is paramount because it almost always

00:24:10.019 --> 00:24:12.220
mandates surgical intervention for a predictable

00:24:12.220 --> 00:24:15.220
outcome. Based on the literature and the classification

00:24:15.220 --> 00:24:17.680
systems we've discussed, the key criteria for

00:24:17.680 --> 00:24:20.019
instability include significant displacement

00:24:20.019 --> 00:24:21.980
of the fracture fragments, generally defined

00:24:21.980 --> 00:24:24.079
as greater than one millimeter displacement on

00:24:24.079 --> 00:24:26.839
any radiographic view, and CT is the best tool

00:24:26.839 --> 00:24:29.119
for assessing this accurately. One millimeter

00:24:29.119 --> 00:24:31.579
gap or step. Got it. An intrascape white angle

00:24:31.579 --> 00:24:33.799
greater than 35 degrees on the lateral x -ray

00:24:33.799 --> 00:24:36.460
indicating significant regulation and the potential

00:24:36.460 --> 00:24:38.880
for that humpback deformity. Approximal pole

00:24:38.880 --> 00:24:41.319
fracture, location, location, location, which,

00:24:41.680 --> 00:24:44.160
as we've hammered home, is anatomically vulnerable

00:24:44.160 --> 00:24:46.500
and often considered unstable due to the high

00:24:46.500 --> 00:24:49.099
blood supply risk, regardless of initial displacement

00:24:49.099 --> 00:24:52.380
sometimes. Right. Significant comminution, meaning

00:24:52.380 --> 00:24:54.559
the bone is breaking into multiple pieces rather

00:24:54.559 --> 00:24:57.579
than a clean break. Shattered almost. In fact,

00:24:57.740 --> 00:25:01.359
yes. Also, associated carpal instability, suggesting

00:25:01.359 --> 00:25:04.210
wider ligamentous injury. Signs of this include

00:25:04.210 --> 00:25:07.029
a scapholunar SL angle greater than 60 degrees

00:25:07.029 --> 00:25:10.009
or a radial lunet angle greater than 15 degrees

00:25:10.009 --> 00:25:12.789
on the lateral x -ray. Indicating the other wrist

00:25:12.789 --> 00:25:15.630
bones aren't aligned properly. Correct. And finally,

00:25:15.650 --> 00:25:18.009
of course, the most obvious instability pattern

00:25:18.009 --> 00:25:21.869
is a paralunet transscapoid fracture dislocation,

00:25:22.130 --> 00:25:24.710
the Herbert B4 type, which is a major wrist disruption.

00:25:25.130 --> 00:25:27.410
If any of these criteria are met, the fracture

00:25:27.410 --> 00:25:29.880
is deemed unstable. Got it. That's a clear list.

00:25:30.279 --> 00:25:33.079
High suspicion, thorough imaging, precise classification

00:25:33.079 --> 00:25:35.900
to identify instability. Now that we understand

00:25:35.900 --> 00:25:38.140
the injury and how to spot it properly, what

00:25:38.140 --> 00:25:40.099
does this all mean for getting the patient back

00:25:40.099 --> 00:25:42.619
to full function? How are these injuries actually

00:25:42.619 --> 00:25:45.579
managed? Well, the overarching goal of management,

00:25:45.900 --> 00:25:47.980
regardless of the method, is firstly to achieve

00:25:47.980 --> 00:25:50.400
bony union healing in an anatomical position.

00:25:51.000 --> 00:25:54.579
Secondly, to relieve pain. Thirdly, to maximize

00:25:54.579 --> 00:25:57.069
functional recovery. getting strength and movement

00:25:57.069 --> 00:25:59.569
back. And perhaps most importantly, in the long

00:25:59.569 --> 00:26:01.910
run, to prevent the development of those long

00:26:01.910 --> 00:26:04.329
-term complications like non -union, malunion,

00:26:04.490 --> 00:26:07.069
and post -traumatic arthritis. OK. And as we've

00:26:07.069 --> 00:26:09.089
established, the approach is broadly divided

00:26:09.089 --> 00:26:11.470
into non -operative and operative management.

00:26:11.730 --> 00:26:13.809
And the choice is driven primarily by the fracture

00:26:13.809 --> 00:26:17.029
classification, stable versus unstable, and also

00:26:17.029 --> 00:26:20.039
patient factors like age, activity level, and

00:26:20.039 --> 00:26:22.400
occupation. Let's start with non -operative management

00:26:22.400 --> 00:26:24.680
then. When is that the appropriate route? Who

00:26:24.680 --> 00:26:27.000
gets put in a cast? Non -operative management,

00:26:27.200 --> 00:26:29.039
essentially casting, is typically reserved for

00:26:29.039 --> 00:26:31.880
acute, undisplaced, stable scaphoid fractures.

00:26:32.000 --> 00:26:35.319
So the Herbert A types. Primarily, yes. This

00:26:35.319 --> 00:26:38.259
includes Herbert Type A fractures, those distal

00:26:38.259 --> 00:26:41.259
tubercle or incomplete waste fractures. It can

00:26:41.259 --> 00:26:43.279
also include certain complete waste fractures,

00:26:43.440 --> 00:26:45.920
Herbert B2, or even some proximal bowl fractures,

00:26:46.019 --> 00:26:49.359
Herbert B3, if they show absolutely no significant

00:26:49.359 --> 00:26:51.339
displacement, usually less than one millimeter,

00:26:51.539 --> 00:26:54.220
and no other signs of instability on detailed

00:26:54.220 --> 00:26:57.529
imaging like CT. Okay. It's also, logically,

00:26:58.069 --> 00:27:00.109
the initial approach when you have strong clinical

00:27:00.109 --> 00:27:03.089
suspicion but your NFL X -rays are negative while

00:27:03.089 --> 00:27:05.789
you're waiting for or arranging that definitive

00:27:05.789 --> 00:27:09.069
CT or MRI scan. You treat it as fractured until

00:27:09.069 --> 00:27:11.859
proven otherwise in that short interval. Makes

00:27:11.859 --> 00:27:14.200
sense. And what does non -operative management

00:27:14.200 --> 00:27:16.460
actually entail? Is it just a standard wrist

00:27:16.460 --> 00:27:19.480
cast? Yes. It involves immobilization in a cast,

00:27:19.640 --> 00:27:22.220
but specifically a scaphoid cast. The traditional

00:27:22.220 --> 00:27:24.220
description is a well -molded cast extending

00:27:24.220 --> 00:27:26.220
from below the elbow crease down to the hand

00:27:26.220 --> 00:27:28.680
and, crucially, including the thumb, often up

00:27:28.680 --> 00:27:30.700
to the interphalangeal joint. This is often called

00:27:30.700 --> 00:27:32.799
a thumb spike a cast. Why include the thumb?

00:27:33.140 --> 00:27:35.819
The rationale is to maximally stabilize the scaphoid

00:27:35.819 --> 00:27:38.500
bone by preventing thumb movement. as forces

00:27:38.500 --> 00:27:40.720
can be transmitted through the thumb metacarpal

00:27:40.720 --> 00:27:43.799
to the scaphoid. Although, it's fair to say there

00:27:43.799 --> 00:27:46.480
is some ongoing debate in the literature regarding

00:27:46.480 --> 00:27:48.619
the absolute necessity of including the thumb

00:27:48.619 --> 00:27:52.119
in the cast for all types. Some studies have

00:27:52.119 --> 00:27:55.140
suggested that a simple short arm cast, without

00:27:55.140 --> 00:27:57.819
the thumb included, may be sufficient for certain

00:27:57.819 --> 00:28:00.859
stable fracture types, particularly distal ones.

00:28:01.579 --> 00:28:03.720
But the traditional widely accepted approach

00:28:03.720 --> 00:28:06.500
for waist and proximal fractures involves the

00:28:06.500 --> 00:28:09.019
thumb spica component. Right. How long does someone

00:28:09.019 --> 00:28:10.980
typically need to be in this cast? It sounds

00:28:10.980 --> 00:28:13.160
like quite a commitment. It is, and the duration

00:28:13.160 --> 00:28:15.619
varies significantly based on the fractural location.

00:28:16.240 --> 00:28:18.079
This directly reflects the differing healing

00:28:18.079 --> 00:28:20.339
potential due to that blood supply issue we keep

00:28:20.339 --> 00:28:23.390
coming back to. So distal heals faster. Generally,

00:28:23.730 --> 00:28:26.970
yes, distal third or tuberosity fractures having

00:28:26.970 --> 00:28:29.470
a better blood supply might unite in as little

00:28:29.470 --> 00:28:32.430
as six weeks. Middle third or waist fractures,

00:28:32.470 --> 00:28:34.650
the most common type, typically require around

00:28:34.650 --> 00:28:37.549
8 to 12 weeks of immobilization. 8 to 12 weeks.

00:28:37.970 --> 00:28:41.150
Yes. And proximal third fractures with their

00:28:41.150 --> 00:28:43.980
precarious retrograde blood supply. often need

00:28:43.980 --> 00:28:46.480
10 to 12 weeks, sometimes even longer, maybe

00:28:46.480 --> 00:28:49.240
up to 14 weeks or more in some protocols. And

00:28:49.240 --> 00:28:51.519
even with diligent casting for that extended

00:28:51.519 --> 00:28:54.119
period, they still have a higher rate of non

00:28:54.119 --> 00:28:56.359
-union compared to waste fractures. Wow, that's

00:28:56.359 --> 00:28:58.779
a significant period of immobilization, especially

00:28:58.779 --> 00:29:01.180
for the proximal ones. What's the follow -up

00:29:01.180 --> 00:29:03.319
protocol while they're actually in the cast?

00:29:03.519 --> 00:29:06.420
Do you just wait until the end? No, regular follow

00:29:06.420 --> 00:29:08.970
-up is essential. Firstly, to ensure the fracture

00:29:08.970 --> 00:29:11.650
doesn't displace within the cast, sometimes called

00:29:11.650 --> 00:29:14.269
secondary displacement, and secondly, to monitor

00:29:14.269 --> 00:29:17.170
healing progress. Typically, an x -ray is taken

00:29:17.170 --> 00:29:20.390
around two weeks after the initial casting. Primarily

00:29:20.390 --> 00:29:22.930
confirm the fracture remains undisplaced. Check

00:29:22.930 --> 00:29:25.289
it hasn't shifted. Exactly. Further x -rays,

00:29:25.470 --> 00:29:28.049
sometimes CT scans later on if union is questionable,

00:29:28.529 --> 00:29:30.490
are taken when the cast is planned to be removed

00:29:30.490 --> 00:29:33.650
at that estimated healing time point, 6, 8, 10,

00:29:33.650 --> 00:29:36.329
12 weeks, etc. To assess for clinical signs of

00:29:36.329 --> 00:29:39.460
union, no tenderness, and radiographic evidence

00:29:39.460 --> 00:29:41.960
of bone bridging the fracture line. A final check,

00:29:42.119 --> 00:29:45.039
perhaps at 6 or 12 months post -injury, is often

00:29:45.039 --> 00:29:47.460
recommended just to ensure the union is stable

00:29:47.460 --> 00:29:50.740
and no leak complications are developing. If

00:29:50.740 --> 00:29:53.579
union is confirmed at cast removal, then gradual

00:29:53.579 --> 00:29:56.920
mobilization, physiotherapy, and return to activity

00:29:56.920 --> 00:30:00.140
follows. And what's the success rate for casting

00:30:00.140 --> 00:30:02.730
these stable fractures? With appropriate patient

00:30:02.730 --> 00:30:05.349
selection meaning truly stable, undisplaced fractures,

00:30:05.730 --> 00:30:07.529
and strict adherence to the casting protocol,

00:30:08.109 --> 00:30:09.730
the union rate for non -operative management

00:30:09.730 --> 00:30:12.190
is generally high, often quoted as exceeding

00:30:12.190 --> 00:30:15.059
95%. That's encouraging for the stable ones at

00:30:15.059 --> 00:30:17.680
least. But you mentioned operative management

00:30:17.680 --> 00:30:20.500
is needed for the unstable or higher risk fractures.

00:30:20.900 --> 00:30:22.980
What are the key indications for deciding on

00:30:22.980 --> 00:30:25.859
surgery instead of a cast? Right. Operative management

00:30:25.859 --> 00:30:28.480
is indicated when the risks of non -union, malunion,

00:30:28.579 --> 00:30:30.940
or simply a poor functional outcome with casting

00:30:30.940 --> 00:30:34.329
alone are considered unacceptably high. The primary

00:30:34.329 --> 00:30:36.769
indications are those instability criteria we

00:30:36.769 --> 00:30:38.910
defined earlier. The list we went through. Yes,

00:30:39.130 --> 00:30:41.190
greater than one millimeter displacement, that

00:30:41.190 --> 00:30:44.369
intrascaphoid angle over 35 degrees, significant

00:30:44.369 --> 00:30:46.869
comminution, or associated carpal instability

00:30:46.869 --> 00:30:50.049
like a high SL angle. Proxable pull fractures,

00:30:50.369 --> 00:30:52.990
again due to their high AVN and non -union risk

00:30:52.990 --> 00:30:56.130
and theoretical instability, are generally considered

00:30:56.130 --> 00:30:58.829
strong candidates for surgery, often requiring

00:30:58.829 --> 00:31:01.720
a specific surgical approach from the back. So

00:31:01.720 --> 00:31:04.759
location drives surgery too. Any other reasons?

00:31:05.099 --> 00:31:07.420
Yes. Another significant group is based on patient

00:31:07.420 --> 00:31:10.279
factors. Certain patient groups, like high -level

00:31:10.279 --> 00:31:13.039
athletes or heavy manual workers, even if they

00:31:13.039 --> 00:31:15.220
have a minimally displaced or seemingly stable

00:31:15.220 --> 00:31:18.200
fracture, might be offered surgery. Why is that?

00:31:18.640 --> 00:31:21.430
Because surgical fixation particularly percutaneous

00:31:21.430 --> 00:31:24.130
screw fixation, can potentially allow for quicker

00:31:24.130 --> 00:31:27.470
union and a significantly earlier, safer return

00:31:27.470 --> 00:31:29.930
to demanding activities compared to the prolonged

00:31:29.930 --> 00:31:32.490
casting period, which might be unacceptable for

00:31:32.490 --> 00:31:34.410
their career or sport. Get them back faster.

00:31:34.809 --> 00:31:36.930
Essentially, yes. And finally, a delayed diagnosis

00:31:36.930 --> 00:31:38.990
if a fracture is picked up weeks or months late

00:31:38.990 --> 00:31:41.730
and it shows signs of instability or early non

00:31:41.730 --> 00:31:44.150
-union changes. That's also a clear indication

00:31:44.150 --> 00:31:46.430
for surgical intervention, usually involving

00:31:46.430 --> 00:31:49.279
bone grafting as well. Okay, so surgery is chosen

00:31:49.279 --> 00:31:52.579
for stability, anatomical risk, proximal pull,

00:31:53.180 --> 00:31:55.779
patient functional demands, or delayed presentation.

00:31:56.519 --> 00:31:58.680
Let's dive into the surgical techniques themselves.

00:31:59.519 --> 00:32:02.019
What are the main ways surgeons fix these fractures

00:32:02.019 --> 00:32:04.579
operatively? The two primary surgical techniques

00:32:04.579 --> 00:32:07.380
employed are open reduction internal fixation,

00:32:07.660 --> 00:32:10.420
commonly known as ORIF and percutaneous screw

00:32:10.420 --> 00:32:13.940
fixation. ORIF first, when is that needed? ORIF

00:32:13.940 --> 00:32:16.599
is generally necessary for displaced fractures,

00:32:17.119 --> 00:32:19.519
significantly angulated fractures, or complex

00:32:19.519 --> 00:32:21.460
patterns where the surgeon needs direct visual

00:32:21.460 --> 00:32:23.660
access to the fracture site to clean it out,

00:32:23.940 --> 00:32:26.220
manipulate the fragments back into perfect alignment,

00:32:26.259 --> 00:32:28.380
that's the open reduction part, and then hold

00:32:28.380 --> 00:32:30.519
them there rigidly with internal fixation, usually

00:32:30.519 --> 00:32:32.700
a screw. Okay, makes sense. Are there different

00:32:32.700 --> 00:32:35.500
ways to approach the scaphoid for ORIF? Yes,

00:32:35.500 --> 00:32:37.980
there are two main surgical approaches used for

00:32:37.980 --> 00:32:40.660
ORIF, depending primarily on the fracture location.

00:32:41.230 --> 00:32:44.089
The volar approach, meaning coming in from the

00:32:44.089 --> 00:32:46.849
palm side of the wrist, is the real workhorse

00:32:46.849 --> 00:32:49.730
for waist fractures. It's generally preferred

00:32:49.730 --> 00:32:51.930
for these because it allows good access to the

00:32:51.930 --> 00:32:54.809
waist and distal pole, and importantly, it helps

00:32:54.809 --> 00:32:57.750
preserve that critical dorsal blood supply entering

00:32:57.750 --> 00:33:00.710
the back of the bone. Protect the plumbing. Precisely.

00:33:01.170 --> 00:33:03.230
The other main approach is the dorsal approach,

00:33:03.609 --> 00:33:06.150
coming in from the back of the wrist. This is

00:33:06.150 --> 00:33:08.849
usually necessary for proximal third fractures,

00:33:09.049 --> 00:33:11.690
as it provides much better direct access to that

00:33:11.690 --> 00:33:14.210
proximal fragment, which is hard to reach reliably

00:33:14.210 --> 00:33:16.829
from the front. Right. Could you maybe walk us

00:33:16.829 --> 00:33:19.730
through the VOLAR approach for an ORRF of a typical

00:33:19.730 --> 00:33:21.990
waist fracture? What does that involve? Certainly.

00:33:22.710 --> 00:33:24.769
The procedure is typically performed with the

00:33:24.769 --> 00:33:27.430
patient lying supine, usually with the arm out

00:33:27.430 --> 00:33:30.569
on an arm table, and almost always under tourniquet

00:33:30.569 --> 00:33:33.269
control on the upper arm to provide a bloodless

00:33:33.269 --> 00:33:35.660
surgical field. The incision is commonly made

00:33:35.660 --> 00:33:38.160
longitudinally along the line of the flexor carpe

00:33:38.160 --> 00:33:41.859
radialis or FCR tendon, which is easily palpable

00:33:41.859 --> 00:33:44.400
on the front of the wrist. You carefully dissect

00:33:44.400 --> 00:33:46.839
down through the layers, protecting vital structures

00:33:46.839 --> 00:33:49.279
like branches of the radial artery and sensory

00:33:49.279 --> 00:33:52.380
nerves, and retracting the thenar muscles, the

00:33:52.380 --> 00:33:55.180
muscles at the base of the thumb, outwards. The

00:33:55.180 --> 00:33:57.660
capsule of the wrist joint is then opened, often

00:33:57.660 --> 00:34:01.160
along the FCR tendon sheath, to expose the scaphoid

00:34:01.160 --> 00:34:04.200
waste. The fracture site is identified, cleaned

00:34:04.200 --> 00:34:06.420
of any interposed soft tissue or blood clot,

00:34:07.019 --> 00:34:08.940
and the fragments are carefully manipulated back

00:34:08.940 --> 00:34:11.619
into their correct anatomical position. This

00:34:11.619 --> 00:34:13.860
reduction is often achieved and held temporarily

00:34:13.860 --> 00:34:17.000
using fine K -wires, sometimes used like little

00:34:17.000 --> 00:34:20.239
joysticks. Once a surgeon is happy with the reduction,

00:34:20.760 --> 00:34:22.719
confirmed perhaps with intraoperative x -rays

00:34:22.719 --> 00:34:25.719
or fluoroscopy, a cannulated headless compression

00:34:25.719 --> 00:34:28.570
screw is inserted. cannulated means it has a

00:34:28.570 --> 00:34:31.070
hollow core, so you can be inserted over a pre

00:34:31.070 --> 00:34:33.510
-placed guide wire. This guide wire is carefully

00:34:33.510 --> 00:34:35.809
drilled down the central axis of the scaphoid,

00:34:36.130 --> 00:34:38.449
ideally starting near the distal pole and aiming

00:34:38.449 --> 00:34:40.510
proximally across the fracture line. Headless

00:34:40.510 --> 00:34:43.090
screw. Yes. Headless means the screw doesn't

00:34:43.090 --> 00:34:45.570
have a traditional bulky head. It's designed

00:34:45.570 --> 00:34:47.929
so the entire screw can be buried just below

00:34:47.929 --> 00:34:50.289
the level of the articular cartilage surface.

00:34:50.539 --> 00:34:53.900
This is crucial to avoid the screw head impinging

00:34:53.900 --> 00:34:56.679
on joint movement or damaging the opposing cartilage

00:34:56.679 --> 00:34:59.940
surfaces later on. The screw is also designed

00:34:59.940 --> 00:35:03.099
with differential pitch threads to actively compress

00:35:03.099 --> 00:35:05.420
the fracture fragments together as it's tightened.

00:35:05.760 --> 00:35:08.780
Clutter design? Very. Longer screws generally

00:35:08.780 --> 00:35:11.559
provide better fixation stability across the

00:35:11.559 --> 00:35:14.940
fracture. Now, if the fracture was significantly

00:35:14.940 --> 00:35:17.389
comminuted, meaning broken into several pieces,

00:35:17.829 --> 00:35:20.110
or if there was a pre -existing deformity like

00:35:20.110 --> 00:35:22.309
a humpback that needed correcting during the

00:35:22.309 --> 00:35:24.730
reduction, then bone grafting might be necessary

00:35:24.730 --> 00:35:27.150
at this stage. Where does the bone graft come

00:35:27.150 --> 00:35:29.670
from? Small amounts can often be harvested locally

00:35:29.670 --> 00:35:32.409
from the distal radius bone near the wrist incision.

00:35:33.230 --> 00:35:35.809
If a larger volume of graft is needed, it's typically

00:35:35.809 --> 00:35:37.989
harvested from the patient's iliac crest, the

00:35:37.989 --> 00:35:40.329
pelvic bone, through a separate small incision.

00:35:40.480 --> 00:35:43.659
After the screw fixation and any necessary grafting,

00:35:44.139 --> 00:35:46.099
the joint capsule and any important ligaments

00:35:46.099 --> 00:35:48.619
that were incised, like the radioscapia capitate

00:35:48.619 --> 00:35:51.400
ligament, are carefully repaired. Then the soft

00:35:51.400 --> 00:35:54.139
tissues and skin are closed in layers. And what

00:35:54.139 --> 00:35:57.719
happens postoperatively? Still a cast? Yes. Despite

00:35:57.719 --> 00:36:01.079
the internal fixation, a period of immobilization

00:36:01.079 --> 00:36:04.119
in a cast, usually a thumb spica, is still typically

00:36:04.119 --> 00:36:06.199
required while the bone heals around the screw.

00:36:06.360 --> 00:36:08.940
This is often for around six to eight weeks,

00:36:09.320 --> 00:36:11.539
after which union is assessed radiographically,

00:36:11.599 --> 00:36:14.440
usually with x -rays or maybe a CT scan, before

00:36:14.440 --> 00:36:16.360
starting mobilization. That sounds like quite

00:36:16.360 --> 00:36:18.340
a meticulous procedure. And the dorsal approach

00:36:18.340 --> 00:36:20.639
for those challenging proximal pole fractures,

00:36:20.699 --> 00:36:22.679
how does that differ? The dorsal approach is

00:36:22.679 --> 00:36:24.460
quite different in terms of the structures you

00:36:24.460 --> 00:36:27.159
encounter. It's typically performed via what's

00:36:27.159 --> 00:36:29.820
called a 3 -4 approach, navigating between the

00:36:29.820 --> 00:36:31.840
third and fourth extensor tendon compartments

00:36:31.840 --> 00:36:34.559
on the back of the wrist. A midline incision

00:36:34.559 --> 00:36:37.159
is usually made over the back of the wrist. The

00:36:37.159 --> 00:36:39.639
sheath containing the extensor poleza longus,

00:36:39.840 --> 00:36:42.519
EPL tendon, the long thumb extensor is opened,

00:36:42.820 --> 00:36:45.639
and the EPL tendon is retracted radially towards

00:36:45.639 --> 00:36:48.820
the thumb side. The main finger extensor tendons,

00:36:49.119 --> 00:36:52.059
the extensor digitorum communus, EDC, are then

00:36:52.059 --> 00:36:53.699
retracted a little gnarly towards the little

00:36:53.699 --> 00:36:55.900
finger side. Okay, moving tendons out of the

00:36:55.900 --> 00:36:59.179
way. Exactly. This exposes the dorsal wrist capsule,

00:36:59.420 --> 00:37:01.659
which is then open, often over the scaffolding

00:37:01.659 --> 00:37:05.179
joint interval. The wrist is often flexed significantly

00:37:05.179 --> 00:37:07.440
downwards to bring the proximal pole of the scaphoid

00:37:07.440 --> 00:37:10.000
into better view. A K -wire is then inserted,

00:37:10.320 --> 00:37:12.360
usually starting just radial to the scaffolding

00:37:12.360 --> 00:37:15.219
ligament itself, aiming from the small proximal

00:37:15.219 --> 00:37:17.820
pole fragment down into the larger distal fragment,

00:37:18.380 --> 00:37:20.679
sometimes provisionally driving it into the trapezium

00:37:20.679 --> 00:37:23.139
bone distally for extra stability during screw

00:37:23.139 --> 00:37:26.360
insertion. So coming from the top down, essentially.

00:37:26.679 --> 00:37:30.320
Yes, aiming proximal to distal. Multiple fluoroscopic

00:37:30.320 --> 00:37:33.119
views, AP, lateral obliques are absolutely essential

00:37:33.119 --> 00:37:36.019
throughout this dorsal approach to confirm accurate

00:37:36.019 --> 00:37:38.500
guide wire placement before drilling and inserting

00:37:38.500 --> 00:37:41.500
the cannulated screw. It's technically demanding

00:37:41.500 --> 00:37:43.500
because the proximal pole fragment can be quite

00:37:43.500 --> 00:37:46.519
small and rotated. This approach is necessary

00:37:46.519 --> 00:37:48.880
for most proximal pole fractures simply due to

00:37:48.880 --> 00:37:51.420
their location and the need to access that specific

00:37:51.420 --> 00:37:53.480
fragment directly for reduction and fixation.

00:37:53.840 --> 00:37:56.559
Right. What are the union rates like for these

00:37:56.559 --> 00:37:58.719
ORIF procedures, especially when used for those

00:37:58.719 --> 00:38:01.659
unstable Herbert Type B fractures? For Herbert

00:38:01.659 --> 00:38:03.880
Type B unstable fractures treated with ORIF,

00:38:03.980 --> 00:38:05.659
the reported union rates are generally good,

00:38:05.920 --> 00:38:07.500
certainly much better than casting alone for

00:38:07.500 --> 00:38:09.880
these types, but they do vary slightly by the

00:38:09.880 --> 00:38:12.340
specific subtype, reflecting those inherent biological

00:38:12.340 --> 00:38:15.030
and mechanical challenges. Based on studies specifically

00:38:15.030 --> 00:38:17.150
using the Herbert classification, union rates

00:38:17.150 --> 00:38:20.269
for ORIF are often reported around 90 % for B1

00:38:20.269 --> 00:38:23.070
distal oblique fractures. OK. Maybe 88 % for

00:38:23.070 --> 00:38:25.949
B2 complete waste fractures, and slightly lower,

00:38:26.090 --> 00:38:29.670
perhaps around 85%, for B3 proximal pole fractures.

00:38:30.110 --> 00:38:33.110
Still. 85 % for the proximal pole with surgery

00:38:33.110 --> 00:38:35.349
is pretty good, but it highlights the challenge.

00:38:35.530 --> 00:38:38.050
It does. It highlights that even with optimal

00:38:38.050 --> 00:38:41.409
surgical technique, proximal pole fractures remain

00:38:41.409 --> 00:38:44.150
biologically more challenging to heal compared

00:38:44.150 --> 00:38:46.869
to waist fractures, purely due to that vascular

00:38:46.869 --> 00:38:49.610
issue. Now let's talk about the other main surgical

00:38:49.610 --> 00:38:53.380
technique, percutaneous screw fixation. That

00:38:53.380 --> 00:38:55.559
sounds less invasive than opening the wrist up

00:38:55.559 --> 00:38:58.400
fully. It is, yes. And it's become increasingly

00:38:58.400 --> 00:39:00.780
popular over the last couple of decades, particularly

00:39:00.780 --> 00:39:03.800
for specific indications. Percutaneous screw

00:39:03.800 --> 00:39:06.460
fixation involves inserting the fixation screw

00:39:06.460 --> 00:39:09.380
through very small stab incisions, typically

00:39:09.380 --> 00:39:11.659
just one or two, without formally opening the

00:39:11.659 --> 00:39:14.139
joint capsule widely. What are the main advantages

00:39:14.139 --> 00:39:16.380
of doing it that way? The key potential advantages

00:39:16.380 --> 00:39:18.860
are even faster union rates, with some studies

00:39:18.860 --> 00:39:21.059
reporting rates approaching 100 % in carefully

00:39:21.059 --> 00:39:24.110
selected ideal cases. Also, potentially less

00:39:24.110 --> 00:39:26.469
time required in a cast postoperatively compared

00:39:26.469 --> 00:39:28.969
to ORF and consequently an earlier return to

00:39:28.969 --> 00:39:31.269
activities including work and sport, which is

00:39:31.269 --> 00:39:33.349
a major driver for certain patients. When is

00:39:33.349 --> 00:39:36.130
percutaneous fixation indicated then? Is it suitable

00:39:36.130 --> 00:39:39.150
for all types? No, it's primarily indicated for

00:39:39.150 --> 00:39:42.389
acute minimally displaced scaphoid fractures,

00:39:42.690 --> 00:39:45.230
usually waist fractures, where an anatomical

00:39:45.230 --> 00:39:48.650
reduction can be achieved closed just by manipulating

00:39:48.650 --> 00:39:51.449
the wrist and thumb, and crucially where this

00:39:51.449 --> 00:39:54.869
position can be confirmed with high quality intraoperative

00:39:54.869 --> 00:39:58.519
imaging. So not for badly displaced ones. Generally

00:39:58.519 --> 00:40:00.699
not, as you can't directly see and manipulate

00:40:00.699 --> 00:40:02.860
the fragments. It's especially appealing for

00:40:02.860 --> 00:40:05.420
patients like manual workers or athletes who

00:40:05.420 --> 00:40:07.420
have a strong need to minimize their time in

00:40:07.420 --> 00:40:10.420
a cast and return to function as quickly as possible,

00:40:10.760 --> 00:40:12.320
provided their fracture pattern is suitable.

00:40:12.400 --> 00:40:14.519
Typically that minimally displaced waste fracture,

00:40:14.900 --> 00:40:16.659
which is already in good alignment or can be

00:40:16.659 --> 00:40:18.840
easily reduced closed. How is that technique

00:40:18.840 --> 00:40:20.719
actually performed? If you're not opening it

00:40:20.719 --> 00:40:22.440
up, how do you get the screw in the right place?

00:40:22.539 --> 00:40:25.329
The patient setup is similar. supine arm table

00:40:25.329 --> 00:40:27.889
tourniquet, but absolutely critical for percutaneous

00:40:27.889 --> 00:40:31.389
fixation is the use of high -quality image intensification

00:40:31.389 --> 00:40:34.409
fluoroscopy or live x -ray throughout the procedure

00:40:34.409 --> 00:40:37.130
for precise guidance. Continuous x -ray vision.

00:40:37.530 --> 00:40:39.710
Essentially, yes. Traction is often applied to

00:40:39.710 --> 00:40:42.010
the thumb, sometimes using a finger trap device

00:40:42.010 --> 00:40:44.530
to help distract the fracture fragments slightly

00:40:44.530 --> 00:40:48.010
and align the scaphoid along its long axis. The

00:40:48.010 --> 00:40:50.389
wrist is positioned carefully, often in ulna

00:40:50.389 --> 00:40:52.889
deviation, and flexed over a bolster or roll,

00:40:53.269 --> 00:40:55.510
again to bring the scaphoid into a straight orientation

00:40:55.510 --> 00:40:58.969
relative to the fluoroscopy beam. Okay. A small,

00:40:59.170 --> 00:41:02.309
volar, palm -side stab incision, maybe only five

00:41:02.309 --> 00:41:05.030
millimeters long, is made over the palpable scaphoid

00:41:05.030 --> 00:41:08.170
tuberosity distally. Through this tiny incision,

00:41:08.269 --> 00:41:10.250
a guide wire is then very carefully inserted,

00:41:10.750 --> 00:41:12.829
aiming along the central axis of the scaphoid

00:41:12.829 --> 00:41:14.909
towards the proximal pole. This sounds like the

00:41:14.909 --> 00:41:17.440
tricky part. It is the crucial step. Multineural

00:41:17.440 --> 00:41:19.940
fluoroscopic views AP, lateral, and those 45

00:41:19.940 --> 00:41:22.639
degrees obliques are used repeatedly and meticulously

00:41:22.639 --> 00:41:25.000
to ensure the wire is perfectly positioned down

00:41:25.000 --> 00:41:27.500
the central third of the bone on all views and

00:41:27.500 --> 00:41:29.900
critically that it's not penetrating out through

00:41:29.900 --> 00:41:33.059
the joint surfaces anywhere along its path. Once

00:41:33.059 --> 00:41:34.900
the surgeon is completely satisfied with the

00:41:34.900 --> 00:41:37.780
guide wire position, a cannulated drill is passed

00:41:37.780 --> 00:41:40.039
over the wire to create the channel and then

00:41:40.039 --> 00:41:42.260
the cannulated headless compression screw is

00:41:42.260 --> 00:41:45.239
inserted over the wire. Often, a slightly shorter

00:41:45.239 --> 00:41:47.260
screw length is chosen compared to the measured

00:41:47.260 --> 00:41:49.659
length to ensure good compression is achieved

00:41:49.659 --> 00:41:52.480
across the fracture site as the screw tightens.

00:41:52.920 --> 00:41:56.340
Typically, screws around 24mm or 26mm are used

00:41:56.340 --> 00:41:59.579
for the waist. In some cases, particularly for

00:41:59.579 --> 00:42:01.579
longer oblique fracture patterns which might

00:42:01.579 --> 00:42:04.880
have some rotational instability, a second, parallel

00:42:04.880 --> 00:42:08.380
K -wire might be inserted percutaneously alongside

00:42:08.380 --> 00:42:10.840
the screw guide wire just to provide some anti

00:42:10.840 --> 00:42:13.250
-rotation stability. It sounds like navigating

00:42:13.250 --> 00:42:15.610
that guide wire and screw perfectly within that

00:42:15.610 --> 00:42:18.550
small awkwardly shaped bone purely using fluoroscopy

00:42:18.550 --> 00:42:20.449
is the real art and challenge here, especially

00:42:20.449 --> 00:42:22.889
avoiding poking out into the joint. Absolutely.

00:42:23.590 --> 00:42:26.190
Accurate 3D placement based on 2D imaging is

00:42:26.190 --> 00:42:29.070
paramount. The risk of unrecognized screw penetration

00:42:29.070 --> 00:42:31.469
into the joint cartilage is a potential complication.

00:42:31.710 --> 00:42:34.210
particularly if using many open techniques where

00:42:34.210 --> 00:42:36.889
direct visualization is limited or perhaps with

00:42:36.889 --> 00:42:39.869
less precise fluoroscopy. However, with modern

00:42:39.869 --> 00:42:42.150
high -resolution fluoroscopy units and surgeon

00:42:42.150 --> 00:42:45.130
experience, this risk is significantly reduced

00:42:45.130 --> 00:42:47.110
compared to the earlier days of the technique.

00:42:47.659 --> 00:42:50.159
Right. You mentioned earlier that bone grafting

00:42:50.159 --> 00:42:53.340
is sometimes necessary, especially in ORF for

00:42:53.340 --> 00:42:55.780
comminuted fractures or to correct deformity

00:42:55.780 --> 00:42:58.119
like a humpback. Can we talk a bit more about

00:42:58.119 --> 00:43:00.380
the role of bone grafting? Yes, bone grafting

00:43:00.380 --> 00:43:03.139
plays a crucial role in several scenarios. It's

00:43:03.139 --> 00:43:05.519
needed when there's actual bone loss at the fracture

00:43:05.519 --> 00:43:08.239
site due to the injury mechanism or significant

00:43:08.239 --> 00:43:10.800
comminution that creates a defect or gap after

00:43:10.800 --> 00:43:13.059
you've reduced the main fragments. It's also

00:43:13.059 --> 00:43:15.179
essential when treating an established non -union

00:43:15.179 --> 00:43:17.139
where you need to bridge the gap and stimulate

00:43:17.139 --> 00:43:19.199
healing. And as you mentioned, it's vital when

00:43:19.199 --> 00:43:21.480
you need to correct a malunion deformity, like

00:43:21.480 --> 00:43:23.820
surgically opening up a healed humpback. The

00:43:23.820 --> 00:43:26.019
graft fills the wedge created by the corrective

00:43:26.019 --> 00:43:29.159
osteotomy. What does the graft actually do? The

00:43:29.159 --> 00:43:31.199
graft serves multiple purposes. Firstly, it acts

00:43:31.199 --> 00:43:33.599
as a scaffold. providing structural support across

00:43:33.599 --> 00:43:36.960
the defect. Secondly, and importantly, it introduces

00:43:36.960 --> 00:43:39.539
osteoconductive properties, meaning it provides

00:43:39.539 --> 00:43:42.260
a physical framework or trellis for the patient's

00:43:42.260 --> 00:43:45.500
own new bone cells to grow across the gap. And

00:43:45.500 --> 00:43:47.760
depending on the type of graft, it might also

00:43:47.760 --> 00:43:50.360
provide some osteoinductive properties, meaning

00:43:50.360 --> 00:43:53.079
it contains signaling molecules that actively

00:43:53.079 --> 00:43:56.500
stimulate undifferentiated cells to become bone

00:43:56.500 --> 00:44:00.099
-forming cells. osteoblasts. Some grafts even

00:44:00.099 --> 00:44:02.800
provide osteogenic cells themselves. So structure

00:44:02.800 --> 00:44:05.539
and stimulus. What types of bone grafts are typically

00:44:05.539 --> 00:44:07.880
used for scaphoid surgery? We broadly divide

00:44:07.880 --> 00:44:10.539
them into non -vascularized and vascularized

00:44:10.539 --> 00:44:12.960
bone grafts. Non -vascularized grafts are simpler

00:44:12.960 --> 00:44:15.800
in concept. You harvest bone from one site, the

00:44:15.800 --> 00:44:18.539
donor site, and simply transfer it to the scaphoid,

00:44:18.579 --> 00:44:20.860
the recipient site, without maintaining its original

00:44:20.860 --> 00:44:23.800
blood supply. Okay, standard bone graft. Examples.

00:44:24.340 --> 00:44:26.940
Common examples include the Rus -type inlay graft.

00:44:27.289 --> 00:44:29.610
This is typically used for waist non -unions

00:44:29.610 --> 00:44:32.510
approached via a volar incision, using struts

00:44:32.510 --> 00:44:35.289
of corticocancelous bone, bone with both a hard

00:44:35.289 --> 00:44:37.789
outer cortex and spongy, inner cancels part,

00:44:38.250 --> 00:44:40.349
placed longitudinally across the non -union site.

00:44:40.829 --> 00:44:43.030
This technique generally yields good union rates,

00:44:43.090 --> 00:44:46.909
perhaps 85 -95 % for waist non -unions. Another

00:44:46.909 --> 00:44:49.650
well -described non -vascularized graft is the

00:44:49.650 --> 00:44:52.309
Fisk wedge graft, or sometimes called the Matty

00:44:52.309 --> 00:44:55.010
-Roose technique. This often involves harvesting

00:44:55.010 --> 00:44:57.550
a specifically shaped trapezoidal or triangular

00:44:57.550 --> 00:45:00.190
wedge of bone, usually from the iliac crest,

00:45:00.590 --> 00:45:02.510
which is then inserted into a surgically created

00:45:02.510 --> 00:45:05.550
gap on the volar side of a malunited or non -united

00:45:05.550 --> 00:45:08.130
scaphoid to correct a humpback deformity and

00:45:08.130 --> 00:45:10.329
restore the scaphoid's normal length and alignment.

00:45:10.869 --> 00:45:13.230
When this is combined with rigid internal fixation

00:45:13.230 --> 00:45:15.409
like a screw, it can achieve very high union

00:45:15.409 --> 00:45:19.019
rates, sometimes reported as 95 -100%. How is

00:45:19.019 --> 00:45:21.360
a waste non -union managed specifically with

00:45:21.360 --> 00:45:23.480
one of these non -vascularized grafts, say, using

00:45:23.480 --> 00:45:25.659
the FIST technique to correct a humpback? Right,

00:45:25.739 --> 00:45:28.880
so for a waste non -union, often with some humpback

00:45:28.880 --> 00:45:31.920
deformity, a volar approach is usually preferred.

00:45:32.840 --> 00:45:35.880
The non -union site itself is meticulously debrided.

00:45:36.030 --> 00:45:39.090
That means all the fiber scar tissue and any

00:45:39.090 --> 00:45:42.070
unhealthy sclerotic bone edges are removed using

00:45:42.070 --> 00:45:44.929
sharp osteotomes or fine burrs, taking great

00:45:44.929 --> 00:45:47.690
care not to damage the intact healthy dorsal

00:45:47.690 --> 00:45:50.230
cortex if possible. Cleaning it out. Exactly,

00:45:50.429 --> 00:45:53.230
preparing a healthy bed. During this debridement,

00:45:53.369 --> 00:45:55.329
the surgeon carefully assesses the viability

00:45:55.329 --> 00:45:57.590
of the bone fragments, particularly looking for

00:45:57.590 --> 00:45:59.670
punctate bleeding from the proximal fragment,

00:46:00.230 --> 00:46:02.829
tiny spots of blood welling up. which is a good

00:46:02.829 --> 00:46:04.690
sign that it still has some blood supply remaining.

00:46:04.849 --> 00:46:07.690
The paprika sign. Sometimes call that, yes. If

00:46:07.690 --> 00:46:10.250
there's a humpback deformity, an osteotomy, a

00:46:10.250 --> 00:46:11.889
controlled surgical cut, is made through the

00:46:11.889 --> 00:46:14.250
milunian site, usually on the volar side, and

00:46:14.250 --> 00:46:16.409
the defect is carefully opened up like a book,

00:46:16.949 --> 00:46:20.110
correcting the angulation. The bone graft, harvested

00:46:20.110 --> 00:46:22.570
maybe from the distal radius or iliac crest,

00:46:23.090 --> 00:46:25.409
is then shaped precisely to fit the defect created

00:46:25.409 --> 00:46:27.630
or to act as the wedge maintaining the correction.

00:46:27.849 --> 00:46:30.750
It's then carefully inserted, ensuring good press

00:46:30.750 --> 00:46:33.449
-fit contact with the healthy host bone on either

00:46:33.449 --> 00:46:36.590
side. Provisional fixation is often achieved

00:46:36.590 --> 00:46:39.329
with temporary K -wires, while the definitive

00:46:39.329 --> 00:46:41.849
fixation, usually a cannulated headless screw,

00:46:42.250 --> 00:46:44.769
is inserted across the graft and fracture site.

00:46:45.050 --> 00:46:47.610
And the outcomes for non -union surgery like

00:46:47.610 --> 00:46:50.230
this? While the union rates are generally good,

00:46:50.650 --> 00:46:53.289
often around 90 % for waste non -unions treated

00:46:53.289 --> 00:46:55.699
this way, It's important to note that patients

00:46:55.699 --> 00:46:58.000
often have some residual loss of wrist range

00:46:58.000 --> 00:47:00.239
of motion and perhaps some reduction in grip

00:47:00.239 --> 00:47:03.039
strength compared to their uninjured side, even

00:47:03.039 --> 00:47:05.539
after successful union. Treating an established

00:47:05.539 --> 00:47:07.880
nonunion is always more complex than fixing an

00:47:07.880 --> 00:47:10.659
acute fracture. You mentioned earlier that proximal

00:47:10.659 --> 00:47:12.880
pole nonunions are even more challenging, even

00:47:12.880 --> 00:47:15.679
with grafting. They are, unfortunately. Proximal

00:47:15.679 --> 00:47:17.539
pole non -unions, which are typically approached

00:47:17.539 --> 00:47:20.019
dorsally due to access, have historically had

00:47:20.019 --> 00:47:22.360
significantly lower union rates when treated

00:47:22.360 --> 00:47:24.619
with standard non -vascularized grafts alone.

00:47:25.139 --> 00:47:26.840
Union rates are often cited in the literature

00:47:26.840 --> 00:47:30.380
as being only around 67%, maybe 70 % at best.

00:47:30.539 --> 00:47:32.440
That's quite a drop from the waste non -union

00:47:32.440 --> 00:47:35.480
rates. It is. And this is where the concept of

00:47:35.480 --> 00:47:39.139
using a vascularized bone graft, or VVG, becomes

00:47:39.139 --> 00:47:42.090
particularly relevant and often necessary. Vascularized

00:47:42.090 --> 00:47:44.070
bone grafting, right? This is where you transfer

00:47:44.070 --> 00:47:46.030
the bone along with its attached blood vessel,

00:47:46.030 --> 00:47:48.909
keeping it alive, correct? When is that specifically

00:47:48.909 --> 00:47:51.769
indicated over a standard non -vascularized graft?

00:47:52.050 --> 00:47:55.070
Precisely. A VBG is indicated in situations where

00:47:55.070 --> 00:47:57.969
a standard non -vascularized graft is considered

00:47:57.969 --> 00:48:00.489
less likely to succeed. This primarily means

00:48:00.489 --> 00:48:03.309
proximal pulmon unions, and especially when there's

00:48:03.309 --> 00:48:05.989
definite suspicion or clear confirmation of a

00:48:05.989 --> 00:48:08.949
vascular necrothus, AVN, of that proximal fragment

00:48:08.949 --> 00:48:11.690
on preoperative imaging like MRI. Because the

00:48:11.690 --> 00:48:14.730
fragment is already dead or dying. Exactly. The

00:48:14.730 --> 00:48:16.909
fundamental idea is to bring a new living blood

00:48:16.909 --> 00:48:19.309
supply directly into the compromised vascular

00:48:19.309 --> 00:48:21.869
bone fragment alongside providing the structural

00:48:21.869 --> 00:48:24.590
bone graft itself. This aims to revitalize the

00:48:24.590 --> 00:48:27.050
fragment and promote healing where a nonvascularized

00:48:27.050 --> 00:48:29.570
graft might simply fail or become incorporated

00:48:29.570 --> 00:48:31.929
very slowly, if at all. Does the evidence support

00:48:31.929 --> 00:48:34.710
using VBG in these cases? Yes, quite strongly.

00:48:35.110 --> 00:48:37.650
There was a key meta -analysis by Merrill published

00:48:37.650 --> 00:48:39.690
in the Journal of Hand Surgery American Volume

00:48:39.690 --> 00:48:42.739
back in 2002. which directly compared outcomes.

00:48:43.920 --> 00:48:46.000
It demonstrated a significantly higher union

00:48:46.000 --> 00:48:49.179
rate for proximal pole non -unions with AVN when

00:48:49.179 --> 00:48:51.260
they were treated with a vascularized bone graft

00:48:51.260 --> 00:48:53.900
around 88 % union compared to those treated with

00:48:53.900 --> 00:48:56.099
non -vascularized bone graft, which only achieved

00:48:56.099 --> 00:48:59.599
about 50 % union in that analysis. 88 % versus

00:48:59.599 --> 00:49:01.980
50%. That is a compelling difference, isn't it?

00:49:02.039 --> 00:49:04.800
It's a dramatic difference, yes. It really highlights

00:49:04.800 --> 00:49:07.519
the biological power of bringing a dedicated

00:49:07.519 --> 00:49:10.139
blood supply to a dying bone fragment. What are

00:49:10.139 --> 00:49:12.840
the types of vascularized grafts that are commonly

00:49:12.840 --> 00:49:14.679
used for the scaphoid? Where do they come from?

00:49:15.000 --> 00:49:16.619
Several different techniques and donor sites

00:49:16.619 --> 00:49:18.440
have been described over the years, but some

00:49:18.440 --> 00:49:20.619
are definitely more common and widely used now.

00:49:21.159 --> 00:49:23.380
A graft based on the pronator quadratus muscle

00:49:23.380 --> 00:49:25.699
pedicle in the forearm used to be quite popular,

00:49:26.179 --> 00:49:29.059
but seems to be used less frequently today, perhaps

00:49:29.059 --> 00:49:31.179
due to variability in the vessel or technical

00:49:31.179 --> 00:49:33.880
difficulty. Probably the most common vascularized

00:49:33.880 --> 00:49:36.800
graft used currently for scaphoid non -union,

00:49:37.119 --> 00:49:39.119
particularly for proximal pole issues or when

00:49:39.119 --> 00:49:42.139
AVN is present, is a vascularized discal radius

00:49:42.139 --> 00:49:45.039
graft. This is often based on the technique described

00:49:45.039 --> 00:49:48.139
by Zeitemberg. Another very common and reliable

00:49:48.139 --> 00:49:50.360
option, particularly popular in some centers,

00:49:50.780 --> 00:49:53.880
is a vascularized graft harvested from the base

00:49:53.880 --> 00:49:56.579
of the second metacarpal bone in the hand. Could

00:49:56.579 --> 00:49:59.460
you briefly describe the Zeitemberg technique?

00:49:59.710 --> 00:50:01.789
taking the graft from the distal radius, that

00:50:01.789 --> 00:50:03.909
sounds quite accessible. Yes, it's an elegant

00:50:03.909 --> 00:50:06.610
technique. This graft is based on a specific

00:50:06.610 --> 00:50:09.610
small artery that runs on the back dorsal aspect

00:50:09.610 --> 00:50:12.949
of the wrist. It's usually the 12 -2 intercompartmental

00:50:12.949 --> 00:50:15.269
supranacular artery, a small branch of the radial

00:50:15.269 --> 00:50:18.010
artery, or sometimes a 2S3 branch if the 12 -2

00:50:18.010 --> 00:50:20.610
is very small or absent. This vessel travels

00:50:20.610 --> 00:50:22.909
in the tissues just superficial to the extensor

00:50:22.909 --> 00:50:25.489
compartments between the first and second, or

00:50:25.489 --> 00:50:27.630
second and third compartments. A dorsal radial

00:50:27.630 --> 00:50:30.130
surgical approach is used to carefully identify

00:50:30.130 --> 00:50:32.929
and dissect out this small artery in its accompanying

00:50:32.929 --> 00:50:35.989
veins, the vascular pedicle. You follow the pedicle

00:50:35.989 --> 00:50:38.409
proximally down towards the distal radius bone,

00:50:38.869 --> 00:50:41.110
where it can be seen to supply a patch of the

00:50:41.110 --> 00:50:44.230
periosteum and underlying bone. Using a fine

00:50:44.230 --> 00:50:47.750
osteotome, or saw, a small block or section of

00:50:47.750 --> 00:50:50.539
cortico -canceled bone is then very carefully

00:50:50.539 --> 00:50:53.360
harvested from the distal radius, ensuring that

00:50:53.360 --> 00:50:56.099
the vascular pedicle remains attached and intact,

00:50:56.579 --> 00:50:58.980
feeding into this piece of bone. Great care is

00:50:58.980 --> 00:51:02.099
taken not to damage this delicate pedicle. The

00:51:02.099 --> 00:51:04.039
scaphoid non -union site is then approached,

00:51:04.199 --> 00:51:06.579
usually dorsally as we discussed. The non -union

00:51:06.579 --> 00:51:08.980
is thoroughly cleaned out and prepared to receive

00:51:08.980 --> 00:51:12.039
the graft. The vascularized bone graft, still

00:51:12.039 --> 00:51:14.139
attached to its artery and vein, is then gently

00:51:14.139 --> 00:51:16.880
transferred and rotated into the scaphoid non

00:51:16.880 --> 00:51:18.579
-union site. You have to make sure the pedicle

00:51:18.579 --> 00:51:20.920
isn't kinked, stretched, or compressed during

00:51:20.920 --> 00:51:23.099
this transfer. So you're essentially bringing

00:51:23.099 --> 00:51:25.659
a small living piece of radius bone with its

00:51:25.659 --> 00:51:28.719
own blood supply and plumbing it into the scaphoid

00:51:28.719 --> 00:51:31.639
defect. That's exactly the principle. It brings

00:51:31.639 --> 00:51:35.260
its own perfusion. Fixation of the scaphoid fraction

00:51:35.260 --> 00:51:37.900
on union site, usually with a compression screw,

00:51:38.400 --> 00:51:41.099
is then performed to secure the graft firmly

00:51:41.099 --> 00:51:43.900
in place and stabilize the construct. That's

00:51:43.900 --> 00:51:46.079
fascinating surgery essentially replanting a

00:51:46.079 --> 00:51:48.559
piece of bone with its plumbing intact. It's

00:51:48.559 --> 00:51:51.059
clear that managing these established non -unions,

00:51:51.420 --> 00:51:54.500
especially when AVM is involved, requires complex,

00:51:54.519 --> 00:51:57.219
reconstructive surgical skills. We've touched

00:51:57.219 --> 00:51:59.159
on them throughout our discussion, but let's

00:51:59.159 --> 00:52:01.260
just consolidate the conversation specifically

00:52:01.260 --> 00:52:04.219
on complications. What are the most serious issues

00:52:04.219 --> 00:52:06.320
that can arise from a staphoid fracture, particularly

00:52:06.320 --> 00:52:09.159
if it's missed or not managed correctly initially?

00:52:09.449 --> 00:52:12.050
Yes. The serious complications are essentially

00:52:12.050 --> 00:52:14.750
the consequences of failure to achieve timely

00:52:14.750 --> 00:52:17.869
anatomical bony union. The most significant ones

00:52:17.869 --> 00:52:21.989
we worry about are non -union itself, AVN, malunion,

00:52:22.570 --> 00:52:24.570
and ultimately the development of post -traumatic

00:52:24.570 --> 00:52:27.050
arthritis, often in the specific pattern known

00:52:27.050 --> 00:52:29.769
as SNAC wrist. Let's take non -union first. How

00:52:29.769 --> 00:52:32.469
common is it? Non -union, where the bone simply

00:52:32.469 --> 00:52:35.110
fails to heal, unfortunately occurs in a proportion

00:52:35.110 --> 00:52:37.760
of cases even with appropriate management. perhaps

00:52:37.760 --> 00:52:41.039
5 -10 % overall for all scaphoid fractures treated.

00:52:41.840 --> 00:52:44.019
But the rate is significantly higher for fractures

00:52:44.019 --> 00:52:46.460
that were unstable to begin with, significantly

00:52:46.460 --> 00:52:49.820
displaced, or located in the proximal pole, especially

00:52:49.820 --> 00:52:52.639
if treatment was delayed or inappropriate, like

00:52:52.639 --> 00:52:54.780
inadequate casting for an unstable fracture.

00:52:55.300 --> 00:52:57.559
Are there other risk factors for non -union?

00:52:57.920 --> 00:53:00.920
Yes, key risk factors beyond displacement and

00:53:00.920 --> 00:53:03.099
location include certain fracture patterns, like

00:53:03.099 --> 00:53:05.019
that vertical oblique pattern we mentioned, which

00:53:05.019 --> 00:53:07.900
is prone to shear. Increasing patient age is

00:53:07.900 --> 00:53:11.000
also a factor. And crucially, smoking or any

00:53:11.000 --> 00:53:13.920
nicotine use is a major negative factor, as nicotine

00:53:13.920 --> 00:53:16.199
is a potent vasoconstrictor and significantly

00:53:16.199 --> 00:53:19.000
impairs bone healing potential. Treatment for

00:53:19.000 --> 00:53:20.860
established non -union involves the surgical

00:53:20.860 --> 00:53:23.219
strategies we've just discussed, primarily bone

00:53:23.219 --> 00:53:25.760
grafting, often vascularized for the proximal

00:53:25.760 --> 00:53:29.269
pole or if AVN is present. and AVN, the risk

00:53:29.269 --> 00:53:30.989
we flagged right at the very beginning. How often

00:53:30.989 --> 00:53:33.489
does that actually happen? Avascular necrosis,

00:53:33.510 --> 00:53:36.789
or AVN, remains a major concern precisely because

00:53:36.789 --> 00:53:39.710
of that vulnerable retrograde blood supply to

00:53:39.710 --> 00:53:42.530
the proximal pole. The reporting incidence varies

00:53:42.530 --> 00:53:44.869
quite widely in the literature, perhaps from

00:53:44.869 --> 00:53:47.769
13 % up to 50 % overall, depending on the study

00:53:47.769 --> 00:53:50.869
population and fracture types included. But particularly

00:53:50.869 --> 00:53:54.250
high figures, up to 50 % are often quoted specifically

00:53:54.250 --> 00:53:57.090
for proximal pole fractures. And the risk increases

00:53:57.090 --> 00:53:59.090
dramatically with the amount of initial displacement.

00:53:59.489 --> 00:54:02.769
OK. As cited in the source material, it can even

00:54:02.769 --> 00:54:05.750
approach 100 % in fractures involving the most

00:54:05.750 --> 00:54:08.510
proximal fifth of the scaphoid if they are treated

00:54:08.510 --> 00:54:11.539
with immobilization alone. without surgical fixation

00:54:11.539 --> 00:54:13.619
to restore stability and potentially improve

00:54:13.619 --> 00:54:16.059
perfusion. And it's sneaky, isn't it? It doesn't

00:54:16.059 --> 00:54:18.500
show up immediately. That's the insidious nature

00:54:18.500 --> 00:54:21.260
of AVN. It often doesn't become apparent on standard

00:54:21.260 --> 00:54:23.599
x -rays until months after the initial injury.

00:54:24.420 --> 00:54:26.400
This is because it takes time for the bone to

00:54:26.400 --> 00:54:29.300
slowly lose its viability, die, and then either

00:54:29.300 --> 00:54:32.199
collapse or become relatively denser. sclerotic

00:54:32.199 --> 00:54:34.079
compared to the surrounding living bone which

00:54:34.079 --> 00:54:37.139
undergoes normal disuse osteoporosis in a cast.

00:54:37.480 --> 00:54:40.019
This delay in radiographic appearance really

00:54:40.019 --> 00:54:42.900
underscores why early accurate diagnosis of the

00:54:42.900 --> 00:54:45.659
fracture type and risk factors, followed by appropriate

00:54:45.659 --> 00:54:47.960
initial management, often surgery for proximal

00:54:47.960 --> 00:54:51.039
pole fractures, is absolutely critical for trying

00:54:51.039 --> 00:54:53.139
to prevent this devastating complication in the

00:54:53.139 --> 00:54:56.610
first place. Once AVN is established, managing

00:54:56.610 --> 00:54:59.170
it adds significant complexity and uncertainty

00:54:59.170 --> 00:55:01.130
to the treatment. What about malunion when it

00:55:01.130 --> 00:55:03.949
does heal but heals in the wrong position? Malunion,

00:55:04.230 --> 00:55:06.429
which most commonly presents as that humpback

00:55:06.429 --> 00:55:09.190
deformity with excessive flexion at the fracture

00:55:09.190 --> 00:55:11.949
site, giving an intrascaphoid angle greater than

00:55:11.949 --> 00:55:14.670
35 degrees on the lateral view, typically occurs

00:55:14.670 --> 00:55:17.349
when an unstable or displaced fracture is treated

00:55:17.349 --> 00:55:20.179
non -operatively. or perhaps when the reduction

00:55:20.179 --> 00:55:23.000
achieved initially is lost within the cast and

00:55:23.000 --> 00:55:25.659
the bone then heals in that abnormal flexed position.

00:55:25.880 --> 00:55:27.840
What's the consequence of it healing bent like

00:55:27.840 --> 00:55:30.599
that? The natural history, the long -term consequence

00:55:30.599 --> 00:55:34.059
of this scaphoid malignant, is progressive carpal

00:55:34.059 --> 00:55:37.219
instability. Specifically, it tends to lead to

00:55:37.219 --> 00:55:39.800
that dizzy deformity pattern we mentioned, where

00:55:39.800 --> 00:55:43.429
the lunate bone tilts backwards. This abnormal

00:55:43.429 --> 00:55:45.849
alignment is followed by altered joint mechanics,

00:55:46.269 --> 00:55:48.809
carpal collapse over time, increasing wrist pain,

00:55:49.050 --> 00:55:51.050
reduced range of motion, especially extension,

00:55:51.710 --> 00:55:54.289
decreased grip strength, and inevitably the development

00:55:54.289 --> 00:55:57.250
of post -traumatic osteoarthritis. And the final

00:55:57.250 --> 00:55:58.909
stage of that... It typically starts between

00:55:58.909 --> 00:56:01.389
the tip of the radial styloid and the scaphoid

00:56:01.389 --> 00:56:05.269
itself, then progresses to involve the scaphocapitate

00:56:05.269 --> 00:56:08.000
joint. between the scaphoid and the large capitate

00:56:08.000 --> 00:56:10.199
bone in the middle of the wrist, and finally

00:56:10.199 --> 00:56:13.659
involves the capital lunate joint. By the time

00:56:13.659 --> 00:56:16.519
a SNAC wrist pattern is fully established, the

00:56:16.519 --> 00:56:19.260
joint surfaces are significantly damaged. At

00:56:19.260 --> 00:56:21.900
this point, surgery aimed at achieving scaphoid

00:56:21.900 --> 00:56:24.780
union is often no longer appropriate or even

00:56:24.780 --> 00:56:27.300
possible, and treatment usually shifts towards

00:56:27.300 --> 00:56:30.440
salvage procedures like wrist fusions or proximal

00:56:30.440 --> 00:56:33.190
row carbectomy. It really represents the failure

00:56:33.190 --> 00:56:35.769
to prevent the long -term consequences of the

00:56:35.769 --> 00:56:38.329
initial scaphoid problem. A sobering endpoint.

00:56:38.769 --> 00:56:40.710
Are there other complications to be aware of,

00:56:40.849 --> 00:56:42.909
perhaps arising from the treatment itself? Yes,

00:56:42.969 --> 00:56:45.480
certainly. Other potential complications include

00:56:45.480 --> 00:56:47.699
delayed union, which is distinct from non -union.

00:56:48.420 --> 00:56:50.440
This is where healing takes significantly longer

00:56:50.440 --> 00:56:52.659
than expected, but is still biologically occurring.

00:56:53.320 --> 00:56:55.139
Sometimes interventions like bone stimulators

00:56:55.139 --> 00:56:57.239
using pulsed electromagnetic fields are tried

00:56:57.239 --> 00:56:59.539
in these cases, although the evidence for their

00:56:59.539 --> 00:57:01.739
effectiveness is somewhat limited and not universally

00:57:01.739 --> 00:57:04.019
accepted. Hardware -related issues are possible

00:57:04.019 --> 00:57:06.860
with surgery, such as irritation from a prominent

00:57:06.860 --> 00:57:09.940
screw, or more seriously, subchondral bone penetration

00:57:09.940 --> 00:57:12.300
by the screw tip, which can lead to cartilage

00:57:12.300 --> 00:57:14.800
damage on the opposing joint surface and subsequent

00:57:14.800 --> 00:57:18.280
arthrosis. While less common with modern screw

00:57:18.280 --> 00:57:21.199
designs and careful fluoroscopic guidance, it

00:57:21.199 --> 00:57:23.780
can occur and might require revision surgery

00:57:23.780 --> 00:57:27.179
or implant removal. Infection is always a potential

00:57:27.179 --> 00:57:29.699
risk with any surgical procedure, though thankfully

00:57:29.699 --> 00:57:32.059
it's relatively infrequent after scaphoid surgery.

00:57:32.800 --> 00:57:34.739
And despite achieving successful bony unions,

00:57:34.840 --> 00:57:37.119
some patients may unfortunately experience persistent

00:57:37.119 --> 00:57:39.780
symptoms like chronic pain, residual stiffness,

00:57:40.079 --> 00:57:42.420
limiting function, or reduced grip strength compared

00:57:42.420 --> 00:57:44.719
to their pre -injury state. It's worth noting,

00:57:44.980 --> 00:57:47.070
once some A summary cited in the provided material

00:57:47.070 --> 00:57:49.429
mentioned overall serious complication rates

00:57:49.429 --> 00:57:52.690
being perhaps around 14 % in patients managed

00:57:52.690 --> 00:57:55.929
operatively versus 18 % reporting cast -related

00:57:55.929 --> 00:57:58.650
complications like stiffness, skin issues, nerve

00:57:58.650 --> 00:58:00.909
compression in the non -operative treatment group.

00:58:01.670 --> 00:58:04.489
This suggests risks exist down both pathways,

00:58:05.010 --> 00:58:07.050
but importantly, the nature of the potential

00:58:07.050 --> 00:58:10.320
complications differs significantly. Operative

00:58:10.320 --> 00:58:12.239
intervention is often chosen specifically to

00:58:12.239 --> 00:58:15.420
mitigate the higher risks of non -union and AVN

00:58:15.420 --> 00:58:18.000
inherent to the unstable fracture types, even

00:58:18.000 --> 00:58:19.960
though surgery carries its own set of potential.

00:58:20.190 --> 00:58:22.789
all be different risks. That paints a very clear

00:58:22.789 --> 00:58:25.389
picture of why prevention, early diagnosis, and

00:58:25.389 --> 00:58:27.710
diligent appropriate management are so incredibly

00:58:27.710 --> 00:58:30.170
crucial to avoid these serious, potentially life

00:58:30.170 --> 00:58:32.949
-altering long -term issues. So, turning towards

00:58:32.949 --> 00:58:35.429
the positive, what's the general prognosis and

00:58:35.429 --> 00:58:37.389
recovery outlook for a scaphoid fracture that

00:58:37.389 --> 00:58:39.369
is treated appropriately and in a timely manner?

00:58:39.650 --> 00:58:41.670
Well, with timely and appropriate management

00:58:41.670 --> 00:58:44.929
tailored to the specific fracture type, the prognosis

00:58:44.929 --> 00:58:47.710
for most scaphoid fractures is generally good,

00:58:47.989 --> 00:58:51.139
particularly for those stable undisplaced fractures

00:58:51.139 --> 00:58:53.900
treated effectively with casting. What influences

00:58:53.900 --> 00:58:56.699
the outcome? Key factors influencing the final

00:58:56.699 --> 00:58:59.440
outcome include, naturally, the initial fracture

00:58:59.440 --> 00:59:02.949
type and its location, proximal pole always being

00:59:02.949 --> 00:59:06.010
less favorable, the presence and degree of displacement

00:59:06.010 --> 00:59:08.769
or comminution, the presence of any associated

00:59:08.769 --> 00:59:11.409
ligament injury causing carpal instability, the

00:59:11.409 --> 00:59:13.809
chosen treatment method, cast versus surgery,

00:59:14.329 --> 00:59:17.110
and importantly, patient factors like age, general

00:59:17.110 --> 00:59:19.769
health, adherence to treatment, or particularly

00:59:19.769 --> 00:59:22.760
their smoking status. You mentioned surgery might

00:59:22.760 --> 00:59:25.360
get people back quicker. Yes. Surgical treatment,

00:59:25.579 --> 00:59:27.800
when indicated and performed successfully, has

00:59:27.800 --> 00:59:30.360
been shown in several meta -analyses to be associated

00:59:30.360 --> 00:59:32.320
with a more rapid return to work and sorting

00:59:32.320 --> 00:59:35.139
activities, compared to prolonged non -surgical

00:59:35.139 --> 00:59:37.280
management in a cast, even for some fractures

00:59:37.280 --> 00:59:39.380
that might otherwise have healed in a cast eventually.

00:59:39.840 --> 00:59:42.199
That faster return is often a key factor in the

00:59:42.199 --> 00:59:44.300
decision -making for athletes or manual laborers.

00:59:44.500 --> 00:59:46.860
What's a typical recovery timeline look like?

00:59:47.179 --> 00:59:49.860
The bone healing time itself Achieving solid

00:59:49.860 --> 00:59:53.480
union typically ranges from 6 to 12 weeks, sometimes

00:59:53.480 --> 00:59:55.820
longer for proximal pole fractures, depending

00:59:55.820 --> 00:59:58.719
on the location and the type of treatment. However,

00:59:59.079 --> 01:00:01.199
achieving full functional recovery, regaining

01:00:01.199 --> 01:00:04.260
wrist range of motion, grip strength, and confidence

01:00:04.260 --> 01:00:06.500
for demanding activities usually takes significantly

01:00:06.500 --> 01:00:09.380
longer, often several months of dedicated rehabilitation

01:00:09.380 --> 01:00:12.019
after the cast is removed or after surgery. So

01:00:12.019 --> 01:00:14.789
patience is needed. Definitely. Follow -up with

01:00:14.789 --> 01:00:17.349
periodic x -rays or sometimes CT scans is needed

01:00:17.349 --> 01:00:19.889
to monitor the union progress until it's confirmed

01:00:19.889 --> 01:00:22.670
solid. While some patients may experience some

01:00:22.670 --> 01:00:25.090
minor residual stiffness or perhaps aching in

01:00:25.090 --> 01:00:27.250
the wrist, especially in cold weather or after

01:00:27.250 --> 01:00:29.809
heavy use, with successful union and appropriate

01:00:29.809 --> 01:00:32.909
physiotherapy, chronic disabling pain and major

01:00:32.909 --> 01:00:34.929
functional limitations are thankfully infrequent.

01:00:35.170 --> 01:00:38.190
So, while it's undoubtedly a challenging fracture,

01:00:38.750 --> 01:00:41.090
good outcomes are very much achievable with the

01:00:41.090 --> 01:00:44.320
right approach. Finally, let's think about prevention.

01:00:44.940 --> 01:00:47.099
Are there practical steps people can take to

01:00:47.099 --> 01:00:49.239
reduce their risk of getting this injury in the

01:00:49.239 --> 01:00:52.719
first place, or perhaps reduce the risk of complications

01:00:52.719 --> 01:00:55.340
if they do sustain one? Yes, there are certainly

01:00:55.340 --> 01:00:58.239
steps one can consider at different stages. Prevention

01:00:58.239 --> 01:01:00.480
of the initial injury starts with basic safety

01:01:00.480 --> 01:01:03.340
precautions, especially in activities known to

01:01:03.340 --> 01:01:05.400
have a high risk of falls onto an outstretched

01:01:05.400 --> 01:01:08.420
hand. Things like snowboarding, skateboarding,

01:01:08.559 --> 01:01:11.139
rollerblading, or certain contact sports come

01:01:11.139 --> 01:01:14.260
to mind. Wrist guards. Exactly. Wearing well

01:01:14.260 --> 01:01:15.820
-fitting wrist guards during these activities

01:01:15.820 --> 01:01:18.659
can significantly absorb the impact force and,

01:01:18.820 --> 01:01:21.559
crucially, limit the degree of wrist hyperextension

01:01:21.559 --> 01:01:23.960
during a fall, which can potentially prevent

01:01:23.960 --> 01:01:26.530
the fracture from occurring. Also, just using

01:01:26.530 --> 01:01:29.070
appropriate safety equipment generally and ensuring

01:01:29.070 --> 01:01:30.889
safe environments during these activities is

01:01:30.889 --> 01:01:33.550
key. What about people who are already involved

01:01:33.550 --> 01:01:36.110
in sports or have had previous risk issues? For

01:01:36.110 --> 01:01:38.829
individuals involved heavily in sports or demanding

01:01:38.829 --> 01:01:41.389
manual labor, especially if they have a history

01:01:41.389 --> 01:01:44.389
of previous risk pain or perhaps minor injuries,

01:01:45.150 --> 01:01:46.889
tailored training and rehabilitation programs

01:01:46.889 --> 01:01:49.769
can be beneficial. This might include exercises

01:01:49.769 --> 01:01:52.349
to improve risk proprioception, your sense of

01:01:52.349 --> 01:01:54.570
joint position, strengthening the muscles of

01:01:54.570 --> 01:01:56.409
the forearm and thumb that support the wrist,

01:01:56.929 --> 01:01:58.969
and maintaining good flexibility. And falling

01:01:58.969 --> 01:02:02.250
technique. Yes, somewhat counter -intuitively.

01:02:02.610 --> 01:02:05.409
Educating athletes and others at risk on techniques

01:02:05.409 --> 01:02:07.969
to fall more safely learning how to tuck and

01:02:07.969 --> 01:02:10.610
roll, for instance, to absorb the impact over

01:02:10.610 --> 01:02:13.389
a larger body area rather than landing directly

01:02:13.389 --> 01:02:16.309
onto a single outstretched hand can be a very

01:02:16.309 --> 01:02:18.900
valuable preventative measure. Avoiding activities

01:02:18.900 --> 01:02:21.139
that cause pain or strain seems pretty sensible,

01:02:21.500 --> 01:02:24.380
too. Absolutely. If you start experiencing persistent

01:02:24.380 --> 01:02:26.960
wrist pain or discomfort, particularly after

01:02:26.960 --> 01:02:29.980
a fall or even just a minor incident, it's wise

01:02:29.980 --> 01:02:32.800
to avoid activities that clearly exacerbate it.

01:02:33.260 --> 01:02:36.019
Potentially using a supportive wrist splint temporarily

01:02:36.019 --> 01:02:38.000
might help settle things down to prevent a minor

01:02:38.000 --> 01:02:40.019
issue from becoming a more significant injury.

01:02:40.199 --> 01:02:43.280
And seeking help if it persists. Crucially, yes.

01:02:43.659 --> 01:02:46.059
After any wrist injury, Even if it is initially

01:02:46.059 --> 01:02:49.079
dismissed as just a sprain, paying close attention

01:02:49.079 --> 01:02:51.340
to persistent symptoms, especially that tenderness

01:02:51.340 --> 01:02:54.179
in the anatomical snuff box, and seeking PROMP's

01:02:54.179 --> 01:02:56.300
further medical evaluation and appropriate imaging

01:02:56.300 --> 01:02:58.860
if it doesn't settle quickly is paramount to

01:02:58.860 --> 01:03:02.380
avoid a missed or delayed diagnosis. And of course,

01:03:02.679 --> 01:03:04.880
diligent follow -up care and maintaining open

01:03:04.880 --> 01:03:06.460
communication with your health care provider

01:03:06.460 --> 01:03:08.400
throughout the treatment and recovery process

01:03:08.400 --> 01:03:11.099
are essential to catch any potential non -unions

01:03:11.099 --> 01:03:13.980
or other complications early before they become

01:03:13.980 --> 01:03:17.050
major harder to fix problems. Those are really

01:03:17.050 --> 01:03:19.469
concrete, actionable steps listeners can consider.

01:03:20.110 --> 01:03:22.210
We've covered a huge landscape today, haven't

01:03:22.210 --> 01:03:24.690
we? From the spaphoid's really tricky anatomy

01:03:24.690 --> 01:03:27.389
and blood supply, through all the nuances of

01:03:27.389 --> 01:03:29.909
diagnosis, classification, the different surgical

01:03:29.909 --> 01:03:33.030
techniques, including complex vascularized grafting,

01:03:33.610 --> 01:03:36.250
and exploring those potentially devastating complications.

01:03:36.809 --> 01:03:38.730
Let's try and boil this all down to the absolute

01:03:38.730 --> 01:03:40.489
most crucial takeaways that you should remember

01:03:40.489 --> 01:03:43.179
from this deep dive. Right. Let's try and crystallize

01:03:43.179 --> 01:03:45.940
it. First, after any fall into an outstretched

01:03:45.940 --> 01:03:48.860
hand, you must always suspect a scaphoid fracture

01:03:48.860 --> 01:03:50.579
if there's tenderness in the anatomical snuff

01:03:50.579 --> 01:03:53.199
box, period. Regardless of what the initial x

01:03:53.199 --> 01:03:56.239
-rays might show or fail to show, high suspicion

01:03:56.239 --> 01:03:58.739
is the very first step to avoiding disaster down

01:03:58.739 --> 01:04:01.619
the line. OK, suspicion first. Second key takeaway.

01:04:02.019 --> 01:04:05.239
Second, don't rely solely on standard basic x

01:04:05.239 --> 01:04:07.360
-rays if your clinical suspicion remains high.

01:04:07.550 --> 01:04:10.309
Be prepared to utilize advanced imaging promptly.

01:04:10.849 --> 01:04:13.489
Use CT scanning for accurately assessing displacement,

01:04:13.909 --> 01:04:16.610
combination, and monitoring union, and especially

01:04:16.610 --> 01:04:19.489
use MRI for definitively diagnosing those occult

01:04:19.489 --> 01:04:22.329
fractures or assessing for AVN when initial x

01:04:22.329 --> 01:04:24.349
-rays are negative. Don't fall back on the two

01:04:24.349 --> 01:04:26.449
-week wait. Right. Image appropriately. Third.

01:04:26.610 --> 01:04:29.230
Third. Classification matters deeply because

01:04:29.230 --> 01:04:31.869
it guides treatment. Understand that unstable

01:04:31.869 --> 01:04:34.110
fractures, displaced 1 millimeter, angulated

01:04:34.110 --> 01:04:37.090
35 degrees, comminuted vertically oblique patterns,

01:04:37.309 --> 01:04:39.269
and particularly all proximal pole fractures,

01:04:39.510 --> 01:04:41.610
carry a significantly high risk of non -union

01:04:41.610 --> 01:04:44.590
and AVN. These types generally require surgical

01:04:44.590 --> 01:04:46.750
fixation for the best, most predictable outcome.

01:04:47.130 --> 01:04:50.170
Stable versus unstable, location, location, location.

01:04:50.559 --> 01:04:54.760
Fourth, complications like non -union, AVN, malunion,

01:04:55.139 --> 01:04:58.360
and the end -stage SNSC risk are serious life

01:04:58.360 --> 01:05:00.820
-changing problems, but they're often preventable.

01:05:01.340 --> 01:05:03.639
Timely, accurate diagnosis followed immediately

01:05:03.639 --> 01:05:06.500
by appropriate evidence -based management casting

01:05:06.500 --> 01:05:09.159
for the truly stable, surgery for the unstable

01:05:09.159 --> 01:05:12.039
or high risk is the absolute key to mitigating

01:05:12.039 --> 01:05:14.400
these long -term risks. Okay, prevention is key.

01:05:14.619 --> 01:05:17.480
And finally, perhaps linking back to the start.

01:05:17.559 --> 01:05:19.980
Prevention, where possible, through protective

01:05:19.980 --> 01:05:22.159
measures like wrist guards and high -risk activities

01:05:22.159 --> 01:05:25.000
and learning safer falling techniques, combined

01:05:25.000 --> 01:05:27.239
with diligent follow -up care and simply listening

01:05:27.239 --> 01:05:29.679
to your body after any wrist injury, plays a

01:05:29.679 --> 01:05:31.900
vital role in maintaining long -term wrist health

01:05:31.900 --> 01:05:34.980
and function. Don't ignore persistent wrist pain

01:05:34.980 --> 01:05:38.050
after a fall. Excellent summary. That gives you

01:05:38.050 --> 01:05:41.050
a really clear, deep understanding of why the

01:05:41.050 --> 01:05:43.929
scaphoid fracture is absolutely not just a simple

01:05:43.929 --> 01:05:46.210
break and what really needs to be done to manage

01:05:46.210 --> 01:05:49.570
it effectively. If you found this deep dive valuable,

01:05:49.829 --> 01:05:52.030
please do consider sharing it with your colleagues

01:05:52.030 --> 01:05:55.170
on platforms like LinkedIn or X and perhaps leaving

01:05:55.170 --> 01:05:57.869
us a rating. It genuinely helps us reach more

01:05:57.869 --> 01:06:00.010
professionals who could benefit from this information.

01:06:00.550 --> 01:06:03.070
And a huge thank you again to Professor Moimam

01:06:03.070 --> 01:06:06.179
for sharing your incredible expertise and guiding

01:06:06.179 --> 01:06:08.400
us through this very complex topic with such

01:06:08.400 --> 01:06:10.900
remarkable clarity. It's been my pleasure. Important

01:06:10.900 --> 01:06:13.760
topic. So as we wrap up, and considering all

01:06:13.760 --> 01:06:16.019
the hidden dangers and potentially severe long

01:06:16.019 --> 01:06:17.920
-term consequences we've discussed today for

01:06:17.920 --> 01:06:20.340
this seemingly quite minor coin, perhaps the

01:06:20.340 --> 01:06:22.679
final thought to leave you with is this. In the

01:06:22.679 --> 01:06:24.739
face of such significant potential functional

01:06:24.739 --> 01:06:27.219
loss down the line, are we consistently in our

01:06:27.219 --> 01:06:29.159
clinics, on our sports fields, or perhaps in

01:06:29.159 --> 01:06:32.000
our workplaces, giving every single wrist injury

01:06:32.000 --> 01:06:34.719
the level of initial attention, diagnostic rigor,

01:06:34.920 --> 01:06:37.440
and timely follow -through that the humble yet

01:06:37.440 --> 01:06:40.039
absolutely critical scaphoid bone truly demands?