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Scaphoid Fixation

Percutaneous and open compression-screw fixation of scaphoid fractures.

Overview

Fractures of the carpus other than the scaphoid are frequently missed on initial presentation and require a high index of suspicion with tailored imaging for diagnosis [1]. In a series of patients with acute scaphoid fractures, 15 of 24 presented with associated ligamentous and/or chondral/osteochondral injuries [5]. The complex scaphoid anatomy with its waist might alter the strategy of fracture fixation, education and research [4].

The specific indications for and the risks and benefits of percutaneous screw fixation of nondisplaced scaphoid fractures must be determined in larger randomized, prospective studies [2].

Anatomy & Pathophysiology

Osseous Morphology and Articulation

The scaphoid is a small, irregular S-shaped tubular bone located in the proximal carpal row on the radial aspect of the wrist, lying entirely within the wrist joint at a 45-degree plane to the longitudinal and horizontal axis [18]. It articulates with the trapezium and trapezoid on its distal surface, the radius on its proximal/lateral surface, and the capitate and lunate on its medial surface [18]. The proximal articular surface is convex and articulates with the radius, while the capitate head articulates with a sulcus on the scaphoid across the radial articular surface, providing a socket-like fit [18]. Two distinct articular facets for the trapezium and trapezoid are present at the distal articular surface, forming the scaphotrapeziotrapezoid (STT) joint [18]. Over 80% of the scaphoid surface is covered with articular cartilage, resulting in a reduced capacity for periosteal healing and an increased tendency for delayed union and nonunion [18]. The bone is ridged across its nonarticular dorsoradial surface, along which critical dorsal ridge vessels traverse, and serves as the insertion point for both the dorsal component of the scapholunate and intercarpal ligaments [18]. Ligamentous attachments are predominantly found on this nonarticular dorsoradial surface, while short intrinsic ligaments provide stability through attachments to other carpal bones, particularly the lunate, merging with extrinsic ligaments and the wrist capsule [18]. The radioscapocapitate ligament does not attach to the scaphoid bone itself but crosses the waist, acting as a sling allowing rotation, and there are no tendon attachments to the scaphoid [18]. The scaphoid acts as a midcarpal joint "bridge" linking and synchronizing the motions of the proximal and distal carpal rows, rotating proximally and gliding distally while providing stability to the midcarpal joint [18]. Scaphoid fractures account for almost 75% of all carpal fractures but are rare in children and in the elderly [13].

Vascular Supply and Pathophysiology

The blood supply of the scaphoid arises from the dorsal distal pole, resulting in a poor blood supply to the proximal pole [13]. The scaphoid blood supply originates from two vascular pedicles: the dorsal branch and the volar branch [18]. The dorsal branch enters via small foramina along the spiral groove and dorsal ridge of the scaphoid and supplies 70% to 80% of the scaphoid proximally, including the proximal pole [18]. The volar branch enters via the scaphoid tubercle and supplies the remaining 20% to 30% of the distal scaphoid [18]. Vessels enter the scaphoid from the radial artery laterovolarly, dorsally, and distally, with the laterovolar and dorsal systems sharing in the blood supply to the proximal two thirds of the scaphoid [23]. Vascularity of the proximal pole and 70% to 80% of the interosseous circulation are provided through branches of the radial artery entering through the dorsal ridge, while in the distal tuberosity region, 20% to 30% of the bone receives its blood supply from volar branches of the radial artery [23]. The waist of the scaphoid has minimal or no perforating vasculature, and no vessels perforate the proximal dorsal cartilaginous area or through the scapholunate ligament [18]. Only 67% of scaphoid bones have arterial foramina throughout their length, including the distal, middle, and proximal thirds; in 13% of scaphoid bones, blood supply is predominantly in the distal third, and in 20% of scaphoid bones, most arterial foramina are in the waist area with no more than a single foramen near the proximal third [23]. Proximal fractures are associated with at least temporary disruption of the interosseous blood supply to the proximal pole [18]. One third of scaphoid fractures occurring in the proximal third may be without adequate blood supply, and the prevalence of osteonecrosis can be 35% in fractures at the proximal pole level [23]. The proximal pole has a poor blood supply, is less likely to heal than the distal pole, and may undergo avascular necrosis [13]. Fractures in the proximal pole take longer to heal and usually have higher rates of nonunion [23].

Mechanism of Injury and Fracture Patterns

The usual mechanism of scaphoid fracture is forced hyperextension of the wrist, caused by a fall on the outstretched palm resulting in severe hyperextension and slight radial deviation of the wrist [13]. Hyperextension past 95 degrees is the usual position of injury for scaphoid fractures, though other mechanisms postulated to produce scaphoid fractures include axial loading and hyperflexion of the wrist [29]. During injury, the proximal pole locks in the scaphoid fossa of the radius while the distal pole moves excessively dorsal [23]. With the hyperextension mechanism, a fracture of the scaphoid usually begins at the volar waist with tensile failure, and forces in hyperextension fractures propagate to the dorsal surface with compression loading until failure occurs [29]. In cadaveric studies, wrists placed in extreme dorsiflexion and ulnar deviation produced fractures through the scaphoid waist as the scaphoid impinged on the dorsal rim of the radius [29]. Proximal scaphoid fractures resulted from dorsal subluxation during forced hyperextension [29]. The scaphoid usually fractures on tension at the radial-palmar side [23]. Fractures occur in three anatomical locations: distal tubercle, waist, and proximal pole [13]. Sixty percent to 80% of scaphoid fractures occur at the scaphoid waist or midportion, with 70% of scaphoid fractures being waist fractures [23], [12]. The second most common type of scaphoid fracture is a proximal pole fracture, at 20%, and the least common type of scaphoid fracture is a distal pole fracture, at 10% [12]. Fractures tend to occur at the waist partly because the radioscapocapitate (RSC) ligament acts as a fulcrum over which the scaphoid waist fractures [12].

Complications and Progression

Some fractures, especially distal oblique and waist fractures, are unstable, predisposing to nonunion or malunion [13]. Nonunion occurs in 10% to 15% of all scaphoid fractures [29]. The risk of nonunion increases with a delay of treatment for more than 4 weeks, proximal pole fractures, fracture displacement greater than 1 mm, osteonecrosis, tobacco use, and associated carpal instability [29]. Associated carpal instability specifically includes dorsal intercalated segmental instability (DISI) with a scapholunate angle greater than 60 degrees and a capitolunate angle greater than 15 degrees [29]. DISI is associated with a humpback deformity where the intrascaphoid angle is greater than 45 degrees, compared to a normal intrascaphoid angle of 24 degrees [29]. For nondisplaced waist fractures treated with casting, nonunion rates are 5% to 12%, whereas nonunion rates for displaced scaphoid fractures treated nonoperatively reach 50% [29]. Untreated displaced fractures of the waist will usually angulate as the volar bone is reabsorbed, yielding a "humpback" flexion deformity of the scaphoid [29]. The resultant radial column shortening and extension of the proximal scaphoid pole releases the lunate to rotate into DISI under the influence of the attached triquetrum [29]. Untreated scaphoid nonunion will predictably progress to arthritic change, termed scaphoid nonunion advanced collapse (SNAC) [29]. In SNAC, arthritic change arises at the radial styloid articulation with the distal scaphoid pole (stage I), degeneration of the scaphocapitate joint follows stage I (stage II), and degeneration of the midcarpal joint occurs ultimately (stage III) [29]. Arthritic changes have been found in 97% of patients assessed at least 5 years after injury, and the degree of arthritic changes is proportionate to the duration of nonunion [29]. Patients with untreated scaphoid nonunion generally present with escalating mechanical pain and limitations in range of motion [29]. In a review of 30-year follow-up results, 10% of patients developed nonunion after scaphoid fractures treated with thumb spica short-arm casts; of those who developed nonunion, 60% demonstrated radiographic evidence of radiocarpal osteoarthritis, while only 2% of the healed group demonstrated degenerative change [29].

Associated Injuries and Clinical Presentation

Seventeen percent of patients with scaphoid fractures have other fractures of the carpus and forearm [23]. Associated injuries include transscaphoid perilunar dislocations, fractures of the trapezium, Bennett fractures, fractures of the radial head, dislocations of the lunate, and fractures at the distal end of the radius [23]. Fractures of the carpus other than the scaphoid are frequently missed on initial presentation and require a high index of suspicion with tailored imaging for diagnosis [1]. In a series of 24 patients with acute scaphoid fractures, 15 presented with associated ligamentous and/or chondral/osteochondral injuries [5]. The patient usually presents with pain on the radial side of the wrist, which may be accompanied by swelling on the radial side [12]. There is usually a history of trauma, such as falling on an outstretched hand, collision of the wrist against a person or heavy obstacle, or a direct blow against an object [12]. There may be limited range of motion and pain when applying extended wrist loading or positioning the wrist in extreme positions of flexion or extension [12]. Wrists with acute fractures may have swelling and bruising in the radial aspect of the wrist, while wrists with chronic injury may have swelling in the dorsoradial wrist [12]. "Snuffbox tenderness" applies predominantly to waist fractures [12]. To palpate the anatomic snuffbox for the waist examination, palpate just distal to the radial styloid in the "soft spot" [12]. The distal pole should be palpated at the scaphoid tubercle on the palmar aspect of the wrist, and the proximal pole is palpated dorsally in line with the second ray just distal to the dorsal radius lip [12]. The scapholunate ligament is in line between the second and third rays just distal to the dorsal radius lip and corresponds to the 3-4 wrist arthroscopy portal, with the proximal pole just radial to this area [12]. Pain on longitudinal compression of the thumb (scaphoid axial compression test) is a sign of scaphoid fracture [12]. If all three tests of anatomic snuffbox tenderness, scaphoid tubercle tenderness, and scaphoid axial compression test are positive, there is 87% to 100% sensitivity and 74% specificity for scaphoid fracture [12]. There may be slight fullness in the anatomical snuffbox, and precisely localized tenderness in the anatomical snuffbox is an important diagnostic sign [13]. Examination must also include pressure backwards over the scaphoid tubercle, palpation over the proximal pole, and telescoping of the thumb base [13]. If any of these specific examination findings are positive, the suspicion for a scaphoid fracture should be high [13].

Classification

Other Considerations: Fractures of the carpus other than the scaphoid are frequently missed on initial presentation [1]. Diagnosis of these injuries requires a high index of suspicion with tailored imaging [1]. In a series of acute scaphoid fractures, 15 of 24 patients presented with associated ligamentous and/or chondral/osteochondral injuries [5]. The complex scaphoid anatomy with its waist might alter the strategy of fracture fixation [4], education [4], and research [4]. The specific indications for percutaneous screw fixation of nondisplaced scaphoid fractures must be determined in larger randomized, prospective studies [2]. The risks and benefits of percutaneous screw fixation of nondisplaced scaphoid fractures must be determined in larger randomized, prospective studies [2].

Clinical Presentation

Scaphoid fractures account for nearly 75% of all carpal fractures but remain rare in children and the elderly [13]. In the pediatric population, they are the most common carpal injury, representing approximately 3% of hand and carpal fractures and 0.34% of all fractures in children [34]. The typical mechanism involves forced hyperextension of the wrist, often following a fall onto an outstretched hand, with almost 90% of patients recalling such an injury [13, 31]. Patients classically present with radial-sided wrist pain and swelling following trauma [12]. Chronic injuries may present with dorsoradial swelling, limited range of motion, and pain during extended wrist loading or extreme flexion/extension [12].

Fractures occur in three anatomical locations: the distal tubercle, waist, and proximal pole [13]. Waist fractures represent 70% of cases, proximal pole fractures 20%, and distal pole fractures 10% [12]. The waist is a common fracture site because the radial scaphocapitate (RSC) ligament acts as a fulcrum [12]. The blood supply arises from the dorsal distal pole; consequently, the proximal pole has poor vascularity, is less likely to heal, and carries a risk of avascular necrosis [13]. Unstable fractures, particularly distal oblique and waist types, predispose patients to non-union or malunion [13].

Physical examination requires precise localization of tenderness. Slight fullness in the anatomical snuffbox may be present, but precisely localized tenderness is a critical diagnostic sign [13]. To examine the waist, palpate just distal to the radial styloid in the "soft spot" [12]. The distal pole is palpated at the scaphoid tubercle on the palmar aspect; with radial deviation, this prominence moves palmarly toward the examiner's thumb [12]. The proximal pole is palpated dorsally in line with the second ray, just distal to the dorsal radius lip and radial to the scapholunate ligament/3-4 portal area [12]. Examination must also include pressure backwards over the scaphoid tubercle, palpation of the proximal pole, and telescoping of the thumb base [13].

Special Tests: * Scaphoid Axial Compression: Pain on longitudinal compression of the thumb is a sign of fracture [12]. * Combined Sensitivity: If anatomical snuffbox tenderness, scaphoid tubercle tenderness, and scaphoid axial compression are all positive, sensitivity ranges from 87% to 100% with 74% specificity [12]. * Individual Test Metrics: Anatomical snuffbox tenderness has a sensitivity of 87–100% and specificity of 3–98% [31]. Scaphoid tubercle tenderness has a sensitivity of 82–100% and specificity of 17–57% [31]. Axial compression of the thumb has a sensitivity of 48–100% and specificity of 22–97% [31]. Pain on ulnar deviation has a sensitivity of 67–100% and specificity of 17–60% [31]. Pain on radial deviation has a sensitivity of 67–90% and specificity of 31–42% [31]. Reduced thumb range of movement has a sensitivity of 65–66% and specificity of 38–59% [31]. Thumb–index finger pinch has a sensitivity of 75–79% and specificity of 44–76% [31]. * Predictive Value: No single sign is adequately sensitive or specific [31]. In a study of 246 patients, snuffbox tenderness had 90% sensitivity and 40% specificity, while tubercle tenderness had 87% sensitivity and 57% specificity [31]. A combination of snuffbox tenderness, tubercle tenderness, and axial compression generated 100% sensitivity and 74% specificity within the first 24 hours [31]. Pain on thumb–index finger pinch and snuffbox pain on forearm pronation were most suggestive of true fracture [31]. Absence of ulnar deviation pain and presence of pinch pain were the best predictors within 72 hours [31]. Tubercle tenderness was most predictive at week 2 [31]. * Clinical Scaphoid Score (CSS): Using snuffbox tenderness in ulnar deviation (3 points), tubercle tenderness (2 points), and axial compression pain (1 point), a score of 4 or higher indicates the need for MRI [31].

Imaging and Occult Fractures: Up to 30% to 40% of fractures are missed on initial standard four-view radiographs [31]. Radiographs are often negative at presentation in approximately 25% of cases [35]. Two weeks later, fractures are usually clearer due to bone resorption and slight displacement [13]. A CT scan is more sensitive than X-rays and is useful for confirming fragment alignment or union [13]. MRI is the definitive method to confirm or exclude a diagnosis if available [13]. Ultrasonography can diagnose fractures if radiographs are equivocal [34]. If radiographs are negative but clinical suspicion is high, the patient should be splinted in a short arm-thumb spica and an MRI obtained [35].

Associated Injuries: In a series of 24 patients, 15 presented with associated ligamentous or chondral/osteochondral injuries [5]. Associated injuries, including distal radius fracture, transscaphoid perilunate dislocations, ulnar styloid fractures, capitate fractures, and bilateral injuries, can be present in up to 10% of patients [34].

Management and Outcomes: Nondisplaced waist fractures in football linemen can be treated with thumb spica casting and frequent follow-up radiographs [35]. Percutaneous compression screw fixation is strongly considered for skilled position players with nondisplaced waist fractures [35]. Casting is generally required for 9 to 12 weeks, though union may take up to 6 months, especially for proximal pole fractures [35]. Union is confirmed on CT scan [35]. Displaced waist fractures are managed with open reduction and internal fixation (ORIF) using a compression screw [35]. Proximal pole fractures are almost always treated with ORIF and compression screw fixation regardless of displacement due to high rates of osteonecrosis and nonunion [35]. Surgical indications include a 15° humpback deformity, comminuted fractures, and displacement greater than 1 mm [35]. Fractures treated within 28 days have a 5% nonunion rate, whereas delayed treatment increases this to 28% [35]. Chronic fractures and osteonecrosis predict worse functional outcomes in pediatric and adolescent patients [34]. However, 95% of pediatric and adolescent patients report functional status equal to or better than the general population per median DASH score [34]. The median Modified Mayo Wrist Score (MMWS) for both surgical and nonsurgical pediatric patients represents excellent outcomes with no difference between groups [34]. Surgical treatment for pediatric nonunions yields union rates greater than 94% with no difference between grafted and nongrafted techniques [34]. Athletes cannot return to unprotected play until radiographic union is confirmed [35]. Healing is assessed by tenderness, radiographs, and CT scans, with CT being the most reliable study for union [35]. Arthroscopically assisted reduction and fixation has been performed in athletes but requires substantial fluoroscopy [35].

Investigations

Plain radiography: Scaphoid fractures account for almost 75% of all carpal fractures [13], yet plain radiography is approximately 50% sensitive for their detection and less than 50% sensitive for other carpal bones [26]. The usual mechanism is forced hyperextension of the wrist, often following trauma such as a fall on an outstretched hand or a direct blow [12, 13]. Patients typically present with radial-sided pain, swelling, and bruising, with limited range of motion and pain on extended wrist loading or extreme flexion/extension [12]. Examination must include palpation of the anatomic snuffbox (just distal to the radial styloid), the scaphoid tubercle on the palmar aspect, and the proximal pole dorsally in line with the second ray [12]. Pain on longitudinal compression of the thumb (scaphoid axial compression test) is also a sign of fracture [12]. If all three tests—snuffbox tenderness, scaphoid tubercle tenderness, and axial compression—are positive, sensitivity ranges from 87% to 100% with 74% specificity [12]. Radiographs should include AP, lateral, and two oblique views [13]. Fractures may not be visible in the first few days; however, two weeks later, the fracture is usually much clearer due to bone resorption and slight displacement [13]. The crack is usually transverse through the waist, though it may be more proximal or distal [13]. One must always look for signs of associated carpal displacement [13]. If a fracture is suggested but radiographs are negative, the wrist should be immobilized and reevaluated in 2 weeks because up to 30% of patients may have positive follow-up radiographs [26].

MRI: MRI is the definitive way to confirm or exclude a diagnosis of scaphoid fracture if the technique is available [13]. It is more sensitive than CT for making the diagnosis [26]. A normal MRI study as early as 2 days after injury has a negative predictive value of 100% [26].

CT: A CT scan is more sensitive for diagnosing a scaphoid fracture than X-ray [13]. It is particularly useful in confirming the alignment of bone fragments if surgery is planned [13] and to confirm whether the fracture has united [13]. Computed tomography can also be helpful as an adjunct to standard x-rays to evaluate the cartilage of the radiolunate joint and confirm the SLAC stage [27]. Optimization of post-processing algorithms, rather than modifications of image acquisition, may increase image quality for assessing implant positioning [37]. However, limitations in evaluating fracture reduction quality still exist with intraoperative three-dimensional fluoroscopy [37].

Other Considerations: Fractures occur in three anatomical locations: distal tubercle, waist, and proximal pole [13]. Waist fractures represent 70% of scaphoid fractures, proximal pole fractures 20%, and distal pole fractures 10% [12]. Fractures tend to occur at the waist partly because the RSC ligament acts as a fulcrum [12]. The blood supply arises from the dorsal distal pole; consequently, the proximal pole has a poor blood supply, is less likely to heal, and may undergo avascular necrosis [13]. Some fractures, especially distal oblique and waist fractures, are unstable, predisposing to non-union or malunion [13]. Scaphoid fractures are rare in children and the elderly [13]. While "snuffbox tenderness" applies predominantly to waist fractures [12], slight fullness in the anatomical snuffbox may be present [13], and precisely localized tenderness is an important diagnostic sign [13]. Examination must also include pressure backwards over the scaphoid tubercle, palpation over the proximal pole, and telescoping of the thumb base [13].

Treatment

Operative

Indications: While specific indications and risk-benefit profiles for percutaneous screw fixation of nondisplaced scaphoid fractures require validation in larger randomized, prospective studies [2], surgical intervention is often necessitated by complex anatomy or associated injuries. The complex scaphoid anatomy with its waist might alter the strategy of fracture fixation, education and research [4]. In acute scaphoid fractures, a high index of suspicion is required as 15 of 24 patients presented with associated ligamentous and/or chondral/osteochondral injuries [5].

Surgical Approach / Technique: Arthroscopic treatment allows accurate reconstruction of the weight bearing surface of the joint and secure internal fixation of the fracture [6]. Although the evidence base for carpal fractures other than the scaphoid notes they are frequently missed on initial presentation requiring tailored imaging [1], specific operative strategies for these injuries are not detailed in the current evidence set.

Implant Selection: Construct stability varies by hardware; constructs with locking and nonlocking screws demonstrated equivalent loads at failure and were superior in load at failure compared with cables [10]. In specific pathologies such as osteogenesis imperfecta, unicortical locking plate fixation effectively supplements intramedullary rod fixation [9]. For floating pubic symphysis, subcutaneous fixation offers satisfactory outcomes, with sub-rod offering good anti-compression and sub-plate providing favorable anti-rotational capacity [11].

Other Considerations: Surgeons must account for hardware-related risks, as the presence of protruding metal prominences, even smooth ones like a plate corner or screw head, might endanger the bladder [8]. While posterior ring reduction and stabilization is crucial for anterior pelvic ring injuries regardless of fixation strategy [7], this principle does not directly translate to scaphoid management without further evidence.

Complications

Other Considerations: Fractures of the carpus other than the scaphoid are frequently missed on initial presentation [1]. In a series of 24 patients with acute scaphoid fractures, 15 presented with associated ligamentous and/or chondral/osteochondral injuries [5]. The presence of protruding metal prominences, even smooth ones like a plate corner or screw head, might endanger the bladder [8]. Surgical dislocation for femoral head fractures presents a higher risk of heterotopic ossification compared to common approaches [15].

Recovery

Light activity (weeks): Evidence regarding early mobilisation following scaphoid fixation is limited to percutaneous screw fixation of nondisplaced fractures, which may allow for early mobilisation, though specific indications, risks, and benefits require determination in larger randomized, prospective studies [2]. While anatomical reduction and rigid fixation of coronal plane partial articular fractures of the distal femoral condyle are aimed at allowing early mobilisation and restoration of function, no specific week range is provided for scaphoid fractures in the available evidence [3].

Full activity (months): No specific month ranges for manual work, sport, or full range of motion return are defined in the provided evidence base for scaphoid fixation.

Complete recovery / outcome plateau (months): No specific month ranges for the stabilization of pain, strength, or final functional outcomes are defined in the provided evidence base for scaphoid fixation.

Rehabilitation protocol: Arthroscopic treatment allows accurate reconstruction of the weight-bearing surface of the joint and secure internal fixation of fractures, supporting the strategy for fixation in complex anatomical scenarios [6]. The complex anatomy of the scaphoid waist may alter the strategy of fracture fixation, education, and research [4]. Associated ligamentous and/or chondral/osteochondral injuries were present in 15 of 24 patients with acute scaphoid fractures undergoing arthroscopically assisted reduction and percutaneous fixation, necessitating consideration of these concomitant pathologies during the recovery phase [5].

Functional milestones: No validated PROM trajectories or outcome-measure benchmarks (e.g., Constant, ASES, WOMAC) are reported in the provided evidence for scaphoid fixation.

Other Considerations: While protruding metal prominences, including smooth plate corners or screw heads, may endanger the bladder following pelvic ring fixation, and unicortical locking plate fixation effectively supplements intramedullary rod fixation in selected cases of osteogenesis imperfecta, these findings do not directly apply to standard scaphoid recovery protocols [8, 9].

Key Evidence

  • [L5] Fractures of the carpus other than the scaphoid are frequently missed on initial presentation and require a high index of suspicion with tailored imaging for diagnosis. (10.5435/jaaos-d-20-00062)
  • [L1] The specific indications for and the risks and benefits of percutaneous screw fixation of such fractures must be determined in larger randomized, prospective studies. (10.2106/00004623-200104000-00001)
  • [L4] The aim of treatment is to obtain anatomical reduction and rigid fixation in order to allow early mobilisation and restoration of function. (10.1302/0301-620x.95b9.30656)
  • [L4] The complex scaphoid anatomy with its waist might alter the strategy of fracture fixation, education and research. (10.1186/s13018-021-02330-8)
  • [L4] In this series, 15 of 24 patients with acute scaphoid fractures presented with associated ligamentous and/or chondral/osteochondral injuries. (10.1016/j.arthro.2008.01.003)
  • [L4] The procedure is technically feasible, allows accurate reconstruction of the weight bearing surface of the joint and secure internal fixation of the fracture. (10.1007/s00167-006-0234-3)
  • [L4] Regardless of fixation strategy, posterior ring reduction and stabilization is crucial. (10.5435/jaaos-d-17-00839)
  • [Case_report] The presence of protruding metal prominences, even smooth ones like a plate corner or screw head, might endanger the bladder. (10.1186/s12891-015-0581-7)
  • [L4] Unicortical locking plate fixation effectively supplements intramedullary rod fixation in selected cases of osteogenesis imperfecta. (10.2106/jbjs.n.01185)
  • [L5] Constructs with locking and nonlocking screws demonstrated equivalent loads at failure and were superior in load at failure compared with cables. (10.1016/j.arth.2011.08.019)
  • [L5] Subcutaneous fixation had satisfactory outcomes, with sub-rod offering good anti-compression and sub-plate providing favorable anti-rotational capacity. (10.1186/s13018-017-0541-z)
  • [L4] Our experience with surgical dislocation shows clinical results comparable to previously reported outcomes in femoral head fractures treated with common approaches; we also present a similar rate of AVN and a lower rate of posttraumatic arthritis, but a higher risk of heterotopic ossification. (10.1007/s11999-015-4352-4)
  • [L4] Optimization of post-processing algorithms, rather than modifications of image acquisition, may increase the image quality for assessing implant positioning, but limitations in evaluating fracture reduction quality still exist. (10.1177/1753193419848963)

See Also

References

[1] Evaluation and Management of Carpal Fractures Other Than the Scaphoid. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-20-00062

[2] Percutaneous Screw Fixation or Cast Immobilization for Nondisplaced Scaphoid Fractures. The Journal of Bone and Joint Surgery-American Volume. 2001. DOI: 10.2106/00004623-200104000-00001

[3] Coronal plane partial articular fractures of the distal femoral condyle. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b9.30656

[4] 3D computational anatomy of the scaphoid and its waist for use in fracture treatment. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02330-8

[5] Incidence of Ligamentous and Other Injuries Associated With Scaphoid Fractures During Arthroscopically Assisted Reduction and Percutaneous Fixation. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.01.003

[6] Arthroscopic treatment of a juvenile tillaux fracture. Knee Surgery, Sports Traumatology, Arthroscopy. 2006. DOI: 10.1007/s00167-006-0234-3

[7] Fixation of Anterior Pelvic Ring Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00839

[8] Recurrent episodes of micturition with expulsion of symphyseal plate screws following pelvic ring fixation: case report. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0581-7

[9] Locking Plate Placement with Unicortical Screw Fixation Adjunctive to Intramedullary Rodding in Long Bones of Patients with Osteogenesis Imperfecta. The Journal of Bone and Joint Surgery-American Volume. 2015. DOI: 10.2106/jbjs.n.01185

[10] A Biomechanical Comparison of Periprosthetic Femoral Fracture Fixation in Normal and Osteoporotic Cadaveric Bone. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2011.08.019

[11] Biomechanical characteristics of fixation methods for floating pubic symphysis. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0541-z

[12] Green S Operative Hand Surgery. Examination and Imaging of the Scaphoid.

[13] Apley And Solomon S Concise System Of Orthopaedics And Trauma. FRACTURES OF THE DISTAL RADIUS IN CHILDREN > FRACTURE OF THE SCAPHOID.

[15] Surgical Hip Dislocation Is a Reliable Approach for Treatment of Femoral Head Fractures. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-015-4352-4

[18] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Pathoanatomy and Applied Anatomy Related to Scaphoid Fractures.

[23] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > FRACTURES OF THE SCAPHOID.

[26] Campbell S Operative Orthopaedics 4 Volume Set. OVERCORRECTION OSTEOTOMY AND LIGAMENTOUS REPAIR OR RECONSTRUCTION > SCAPHOID AND CARPAL FRACTURES.

[27] Green S Operative Hand Surgery. Scaphoid Excision and Four-Corner Fusion.

[29] Green S Operative Hand Surgery. Biomechanics of Scaphoid Fractures and Implications of Nonunion.

[31] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Signs and Symptoms of Scaphoid Fractures.

[34] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Pediatric Forearm, Wrist, and Hand Trauma > Scaphoid Fractures.

[35] Orthopaedic Knowledge Update Sports Medicine 6. Hand and Wrist Injuries > Hand Injuries > Scaphoid Fractures.

[37] Effect of different multiplanar reformation algorithms on image quality of intraoperative three-dimensional fluoroscopy. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419848963

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Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.