This document provides information on scaphoid fractures and perilunate dislocations of the wrist. It begins with an introduction to scaphoid fractures, including their incidence and location. It then describes the anatomy of the scaphoid bone and its articulations. Mechanisms of injury are explained as hyperextension injuries. Classification systems for scaphoid fractures and perilunate dislocations are outlined. Clinical assessment, investigations including imaging, complications, and types of perilunate dislocations are summarized.

1. SCAPHOID FRACTURE &
PERILUNATE DISLOCATION

2. INTRODUCTION
➢ First described by Cousin & Destot in 1889
-Position of the scaphoid on the radial side of the wrist,
as the proximal extension of the thumb ray, makes it vulnerable
to injury.
Incidence:
➢ 10-15% of the hand and wrist fractures.
➢ It’s the most frequently fractured carpal bone around 70%
➢ Of these 70% occurs in waist.

3. ANATOMY

4. ◈ Derived from greek word “skaphos” meaning boat
◈ Boat or cashew shaped bone
◈ Parts of the scaphoid:
proximal pole
waist
distal pole
tubercle

5. ◈ Small irregular S shaped tubular bone, located at
a 45degree plane to the longitudinal &
horizontal axes of the wrist.
◈ Since its 80% of its surface is articular cartilage,
reduced capacity for periosteal reaction &
increased tendency for delayed & non union.
◈ Distal pole is pronated, flexed & ulnarly
angulated with respect to the proximal pole.

6. ◈ ARTICULATIONS: with 5 bones
Proximal surface- radius
Distal surface- split into two separate articular surfaces by a
bony ridge & laterally with trapezoid & trapezium, medially with
capitate
Ulnar surface- lunate

7. ◈ ATTACHMENTS:
- No musculotendinous attachments
Ligamentous
Extrinsic ligaments are
-radioscaphocapitate
-radioscapholunate
-radial collateral ligament
Intrinsic ligaments are
-scaphotrapezium-trapezoid
-scaphocapitate ligament
-scapholunate ligament

8. Blood supply
✓ Retrograde blood supply via two vascular pedicles
✓ Originating from the scaphoid branches of the
radial artery
✓ Dorsal branch
-70 to 80% (proximal part)
-enters via small foramina present along the
spiral groove & dorsal ridge
✓ Volar branch
-20 to 30% (distal scaphoid)
-enters via the scaphoid tubercle
Note-minimal or no perforating vasculature at waist

9. MECHANISM OF INJURY

10. Hyperextension injury
Fall on outstretched hand
Wrist is dorsiflexed to>95degrees
& radially deviated to >10
degrees
Compression occurs dorsally and
tension on palmar surface of
wrist
Bending forces applied to waist and distal pole of
scaphoid as proximal pole is tightly held between
the capitate, dorsal lip of radius and taut palmar
capsule
Leads to fracture
scaphoid most
commonly waist

11. ➢ Degree of force and position of the wrist at the time of injury –
determines the type & severity
➢ Herbert suggested that wrist deviation may predict the location of
the fracture as the line of midcarpal joint crosses the
proximal pole -in radial deviation
distal pole -in ulnar deviation
➢ Waist # -usually due to shear forces
➢ Tubercle # - either compression or avulsion
➢ Waist -60-70%
➢ Proximal 3rd
-25%
➢ Distal 3rd
-10%

12. CLASSIFICATION

13. Herbert & fisher
classification

14. AO classification- based on anatomic location
Scaphoid(72)
Non comminuted(72.A) Comminuted(72.B)
proximal pole(72.A1) 72.B1
waist (72.A2) 72.B2
distal pole(72.A3) 72.B3
Russe classification-based on inclination of the fracture line
Horizontal
oblique
Vertical(unstable)

15. Mayo classification (based on location & stability)
based on location-5 types
Unstable fracture:
o >1mm of # displacement
o Lateral intrascaphoid angle>35 degrees
o Bone loss or comminution
o Fracture malalignment
o Proximal pole #
o perilunate # dislocation

16. CLINICAL ASSESSMENT

17. ➢ Diagnosis made by combination of clinical history,
examination & radiographic assessment.
➢ History of hyperextension to wrist following a fall,
sports ,RTA or punch injury
Clinical Symptoms:
Radial sided wrist pain following a fall onto
the outstretched hand, with almost 90% recalling the
hyperextension injury
Swelling
ecchymosis(rarely)

18. Clinical Signs:
Anatomical snuff box tenderness
Scaphoid tubercle tenderness
Adding longitudinal thumb compression( scaphoid
compression test) : specificity reaches 75%
100%
sensitive
20% specific

19. Scaphoid shift test( Watson test)
◈ Pressure applied over the
tubercle & wrist moving
from radial to ulnar
deviation
◈ Positive test- if there is a
“clunk” as the scaphoid
subluxes dorsally out of
the scaphoid fossa
◈ Inference –
scapholunate disruption

20. ◈ Reduced thumb
movement
◈ Anatomical snuff box
swelling
◈ Anatomical snuff box
pain in ulnar deviation
◈ Pain on thumb/index
pinch

21. Clinical prediction rules-for suspected fracture

22. INVESTIGATIONS

23. X-ray
➢ Neutral PA and lateral view:
-to assess the carpal alignment & determining the clear #
-often poor for scaphoid # detection due to tubercle overhang
on PA view and overlap on the lateral view
Ulnar deviated PA view: (scaphoid view)
-to detect the proximal pole fractures
-scaphoid fat pad is best visualized
-ulnar deviation rotates the scaphoid
parallel to the long axis of the foream and to
achieve an en face image

24. 45 degree ulnar oblique view:
-in semipronated position
-to detect tubercle fracture,Oblique sulcus
and waist(displaced)
45 degree radial oblique view:
-in semisupinated position
-to detect proximal pole #, humpback
deformity and avulsion fracture
Note-30 to 40% scaphoid # not visualised on initial
assessment & investigation with four view
radiographs

25. Ziter view:
-PA view of the wrist in ulnar deviation with 20 degree
tube angulation to the elbow
-To detect waist fracture as beam at right angles to long
axis
Soft tissue signs:
@Scaphoid fat pad sign-distortion or loss of
adjacent fat stripes over the radial aspect of the
scaphoid on the PA view
@Pronator fat pad sign- a prominent pronator
quadratus fat pad over the volar aspect of the wrist
on the lateral view

26. ➢ Barton suggested 3 possible reasons why
standard scaphoid radiographs are often
misinterpreted
- Dark line may be formed by the dorsal lip of
the radius overlapping the scaphoid
- White line formed by the proximal end of
the scaphoid tuberosity
- Dorsal ridge of the scaphoid may appear
bent on the semisupinated view
➢ Contralateral wrist views - because of the wide range of
normal alignment

27. Bone
scan-scintigraphy-Fast and reliable diagnostic tool
-100% sensitivity
Demerits-
Lacks specificity
Little information regarding location
Ultrasound:
-Inter observer variability
-Useful in patients with cortical irregularity and
hemarthrosis
-Little information on structural integrity of
scaphoid

28. CT SCAN & MRI
◈ For surgical planning & assessment of healing
◈ To diagnose additional bony & ligament injuries
Fracture displacement
step>1mm at dorsal cortices
gap > 1mm in sagittal or coronal views
◈ To measure the scaphoid fracture displacement-3 angles
-Lateral intrascaphoid angle measurement
-Normal 30+/-5degrees,saggital view
>35* -cut off for displacement.
-angle created by lines drawn perpendicular
to the proximal & distal articular surfaces/poles

29. ◈ Dorsal cortical angle (sagittal view)
-Normal-140 degrees;
-Abnormal >160*
-Angle created by tangential lines drawn along the dorsal
cortices of
proximal & distal scaphoid fragments
Scaphoid height to length ratio (sagittal view)
-normal 0.60, abnormal->0.65
-length is determined by a palmar line drawn from the most
proximal to
the most distal edge
-height is the maximal point with a line perpendicular to the
length line

30. COMPLICATIONS

31. Malunion
-Humpback deformity (proximal scaphoid rotates dorsally into
extension & distal part faces downward in flexion)
-Wrist pain, reduced wrist extension &diminished grip strength
-Loss of extension is proportional to the angular deformity, which is
best calculated by lateral intrascaphoid angle & height to length ratio
Humpback
deformity

32. Non union
• Leads to specific type of post traumatic wrist arthrosis
called Scaphoid nonunion advance collapse(SNAC)
• Non union rate –undisplaced waist #-10%
• Displaced waist-50%
• Risk factors: delayed diagnosis & treatment
• Leads to radiocarpal arthritis & secondary mid carpal
arthritis
• Types fibrous nonunion-seen in stable #
sclerotic nonunion-unstable #
• Two patterns of nonunion displacement
-based on fracture line relative to the dorsal apex of
scaphoid ridge
Dorsal displacement-in proximal waist#
Volar displacement-in distal waist #

33. AVN
◈ Late complication of scaphoid fracture especially those
involving proximal pole fracture
◈ Preiser disease:
Scaphoid avn without a fracture either SL ligament
injury or idiopathic
-Increasing pain and stiffness of the wrist
-Small, deformed proximal pole fragment with cystic changes
& areas of sclerosis
-MRI is useful

34. Perilunate dislocation

35. Perilunate dislocation & fracture
dislocation
◈ Introduction:
◈ Most common form of wrist dislocation
◈ Spectrum of injury which include both ligamentous and
osseous disruption
◈ Prefix trans –refer to associated fracture
◈ Prefix peri – dislocation
◈ Usually traumatic, high energy
◈ Occurs when wrist extended and ulnarly deviated lead to
intercarpal supination
◈ Commonly missed ~25% on initial presentation.

36. Types
◈ Greater arc injury: (perilunate fracture
dislocation)
Ligamentous injuries associated with a
fracture of one or more of the bones around the
lunate.
◈ Common pattern -transscaphoid perilunate
fracture dislocation
-Fracture neck of the capitate
-Sagittal fracture of the triquetrum
◈ Scaphocapitate syndrome:
both capitate & scaphoid fragments are

37. ◈ Lesser arc injury:
◈ Pure ligamentous injuries around the lunate
◈ Disruption of capsular & ligamentous connections of the lunate to
the adjacent carpal bones & radius without fracture
◈ Classically, the distal row dislocates in a dorsal or dorsoradial
direction
◈ SLD or LTD often persists even after relocation lead to recurrence of
instability and late carpal collapse
◈ Fracture dislocations are twice as frequent as a dislocation alone

38. Classification

39. Mayfield classification
◈ Progressive perilunate instability from a radial to
ulnar direction
◈ Stage 1:
◈ As the distal carpal row is violently extended
,supinated & ulnarly deviated, STT and SC
ligaments are tightened causing the scaphoid to
extend
◈ As the scaphoid extends, SL ligament transmits
the force to lunate, which can’t rotate as much as
scaphoid because its constrained by the
palmarly located radiolunate & ulnolunate
ligaments leading to scaphoid # or SLD

40. ◈ STAGE II:
◈ If the extension-supination force persists, once the
proximal row has been dislocated, transmissiom of the
force distally to capitate may lead to displacement
through the space of Poirier
◈ Space of Poirier-ligament free area b/w
radioscapholunate ligament & long radiolunate
ligament at the midcarpal joint level; an area of
potential weakness.
◈ STAGE III:
◈ If the force persists, once the capitate is displace
dorsally lunotriquetral ligament disruption will occur

41. ◈ STAGE IV:
◈ If the force continues,the dorsally displaced capitate is pulled
proximally.
◈ Pressure is applied onto the drsal aspect of lunate,forcing it to
dislocate
◈ As the palmar ligaments are much stronger than the dorsal capsule,
dislocation never involves a pure palmar displacement
◈ Note-lunate dislocation is the end stage of progressive perilunate
dislocation

42. Other classification system
◈ WITVOET & ALLIEU CLASSIFICATION:
◈ Grade I - lunate appears normally
aligned
◈ Grade II - rotated palmarly <90degrees
◈ Grade III ->90 degrees but still attached
to the radius by its palmar ligaments
◈ Grade IV –totally enucleated

43. ◈ HERZBERG et al – three stage classification
◈ Stage I - dorsal dislocation of capitate but lunate
remains in fossa
◈ Stage II A - dorsal dislocation of capitate + lunate
dislocation ,rotation <90 degrees
◈ Stage II B - dislocation of capitate+lunate ,rotation >90
degrees

44. Clinical features
◈ Often young male, high energy trauma
◈ h/o hyperextension injury
◈ Wrist pain, swelling & deformity
◈ Signs- tenderness distal to lister tubercle
◈ marked prominence of entire carpus dorsally
◈ compressive test-palpable and audible snap, click or clunk
◈ Midcarpal shift test:
◈ Pressure applied over dorsum of the capitate, wrist moving from radial
to ulnar deviation
◈ Positive-clunk presents as the lunate reduces from the palmar flexed
position

45. ◈ 1/3rd
associated with polytrauma
◈ 16% -median nerve symptoms and signs
◈ Other features- ulnar neuropathy, arterial
injury or tendon disruption
◈ Late presentations:
increasing nerve symptoms or tendon
rupture than wrist deformity because to
which patient has often become accustomed

46. Investigations
◈ Xray
◈ neutral PA and lateral view
◈ In PA view –normally the anatomic axis of forearm will pass through the
head & base of 3rd
metacarpal, capitate, radial aspect of lunate, center of the
lunate fossa of radius
◈ In lateral view-line will pass through the longitudinal axis of index finger
metacarpal, capitate, lunate and the radius with the scaphoid on an axis at a
45* angle to this line
◈ Normal joint space (b/w carpal bones, carpal & metacarpals, carpal bones
&radius)
◈ < 2mm –normal
◈ >3mm -suspected ligament disruption
◈ >5mm -diagnostic

47. Spilled tea spot sign
◈ Due to palmar rotation of the lunate & disruption of lunate –capitate
articulation

48. Piece of pie sign
◈ Triangular appearance of lunate secondary to rotation

49. Gilula lines
Arc 1- along the proximal articular surface of
proximal carpal row
Arc 2-along the distal articular surface
Arc 3-proximal cortical margins of the capitate &
hamate
Normally - smooth curves
Broken arc-diagnostic of fracture and or
dislocation

50. Scapholunate angle
◈ Angle created by the longitudinal axes
of the scaphoid and the lunate
◈ Long axis of scaphoid –is a line
tangential to the palmar convex surface
of the proximal & distal poles
◈ Long axis of lunate- line perpendicular
to the line connecting the dorsal &
palmar lips of the lunate.
◈ Normal range- 30 to 60 degrees

51. >60 degree –DISI pattern
<30 degree –VISI pattern

52. Carpal-height ratio
◈ Carpal height/length of third metacarpal
◈ Carpal height(L2) is the distance b/w the base
of 3rd
metacarpal to subchondral sclerotic line
of distal radius
◈ Normal ratio 0.5
◈ <0.45 indicates carpal collapse
◈ Alternate method - Height of capitate is used
instead of third metacarpal

53. ◈ Stress radiographs- clenched fist view
To evaluate the widening of scapholunate interval
Often performed bilaterally
◈ CT & MRI to determine the extent of lesion
◈ Arthroscopy and arthrography

54. Thank you