3 2 Vol. 3, No 2, November 1998. Herbert Screw,. =A bs trac t = Herbert S crew Fix ation in the Carpal S caphoid Wai st Fracture Jun - Mo Lee, M.D. and Young - Geun Lee, M.D.. Departm ent of Orthop edic S urgery, Chonbuk N ational University H osp ital and Institute of Cardiovascular R esearch, Chonbuk N ational University, Chonj u, K orea Scaphoid fractures are the most common fractures in the wrist joint and approximately 70% of the scaphoid fractures occur in the waist area. Displacement of a millimeter or more and apparent angulation between the fragments and increased obliquity with dorsal comminution indicates mechanical instability of the scaphoid fracture and requires the operative treatment. Delayed union and nonunion of the waist fracture also requires open reduction, rigid fixation and autogenous iliac cancellous bone grafting. Herbert screw provides ideal method of fixation for compression across the fracture with the thread on the leading end of the screw having a greater pitch than that at the trailing end. The amount of compression depends on the pitch differential and the number of turns after the trailing thread enters the scaphoid. We had treated 13 carpal scaphoid waist fractures by Herbert screw fixation with or without autogenous iliac cancellous bone grafts from March 1989 through March 1998 at Department of Orthopedic Surgery, Chonbuk National University Hospital and followed up at average 16.7 months and the results are followed. 1. The most common cause was fall on the ground (9 cases, 69%) and followed traffic accident (3 cases, 23%) and direct blow (1 case, 8%). : 634-18, - 216 -
2. Iliac cancellous bone grafting was perfomed in the fresh relatively comminuted waist fracture, the dorsal transscaphoid perilunar dislocation, the delayed union and the established nonunion. 3. Bony union was obtained in average 13.8 weeks in 9 fresh fractures, 14weeks in the the dorsal transscaphoid perilunar dislocation, 16 weeks in 2 delayed union and 13 weeks in the nonunion. 4. Accurate reduction and rigid fixation could restore the scapholunate and capitolunate angle within normal limit in all 13 cases. 5. 3 cases (23%) were in the excellent result and 10 (77%) in good result according to the Maudsley method. Key Words : Scaphoid waist fractures, Herbert screw fixation, 70% 10, 25). Weber 30), 95,,, (RSLL) (RCL), (RCLC) (bending moment), (tensile loads). (snuff box), 1-2. 1mm,,, 16). 9, (transscaphoid perilunar dislocation) 1, 2 1 Herbert. 1989 3 1998 5, Herbert, 1, 13. 1. 9, (dorsal transscaphoid perilunar dislocation) 1, 2, 1, Herbert - 217 -
T able 1. Causes of the fracture Fracture Causes Classification Total (%) Fresh fall B2 6 (46) TA* B2 2 (15) direct blow B2 1 ( 8) DTPD* TA B4 1 ( 8) Delayed union fall C 2 (15) Nonunion fall D1 1 ( 8) Total 13(100) * TA: traffic accident * DTPD: Dorsal transscaphoid perilunar dislocation B B2 (displaced or mobile fractures of the wrist) 9, B4(fracture dislocation of carpus) 1, C (delayed union) 2, D (established non-union) D1 (fibrous nonunion) 1 13, Russe (Transverse) 6, (Horizontal oblique) 3, (Vertical oblique). 30.9, 13, 9 3 1 (Table 1). 2.,,, 9 (snuff box), (PA), (oblique,, partial pronation), (lateral), (scaphoid view), - -. 2 1 12,, 1 15 6,. 3. 2cm, (scaphotrapezial joint), (flexor carpi radialis). 1, 9 Herbert (jig), 1 (0.035 inch) K Herbert, 8 (scaphotrapezial joint) -, - 218 -
(scaphotrapezial joint) freehand Herbert drill bit predrilling 1, Herbert.,, - -. 2 1 (curet) (power burr),, Herbert. 13 10 22mm Herbert, 3 24mm (Table 2). T able 2. Size of the Herbert screw Fracture Cases Herbert screw type (length, mm) Fresh 7 22 2 24 DTPD* 1 24 Delayed union 2 22 Nonunion 1 22 *DTPD: Dorsal transscaphoid perilunar dislocation 7-10 (short arm thumb spica splint), 4-6,. 1 27. 1, 1, (flexor carpi radialis) 4cm, 24mm Herbert. - 60, - 0. 10-14, 6, 14, 1 11 Maudsley, (Fig. 1-A, B, C, D, E). 2 37 15 6, 6., (curet) (power burr) 22mm Herbert - 219 -
A B C D E. - -. 12 16. 2 6 Maudsley, (Fig. 2-A, B, C). Fig. 1- A, B. Preoperative wrist AP and lateral X-Ray reveals dorsal transscaphoid perilunar dislocation in 27 year old man. C, D. Postoperative and follwed up wrist AP X- Ray demonstrates comminuted fracture was fixated with Herbert screw and iliac cancellous bone grafting and scaphoid healing has achieved. E. CT reveals complete union and no fracture line is demonstrable. 3 24 3. 22mm Herbert - 220 -
A B C D E Fig. 2.- A, B. Preoperative wrist AP X- Ray and CT reveals clear waist fracture fragment at ulnar deviation view in 37 year old man. C, D. Follwed up wrist AP and lateral X-Ray demonstrates fracture was fixated with Herbert screw and iliac cancellous bone grafting and scaphoid union has completed. E. CT reveals no fracture line which is obscured by complete union.. 14 15. 5 6 Maudsley, (Fig. 3-A, B, C, D). Herbert B B2 (displaced or mobile fractures of the wrist) 9, B4(fracture dislocation of carpus) 1, C (delayed union) 2, D (established non-union) D1 (fibrous non-union) 1, - 221 -
A B C D Fig. 3.- A. Preoperative wrist AP X-Ray reveals comminuted waist fracture at ulnar deviation view in 24 year old man. B. Postoperative X- Ray shows Herbert screw fixation with iliac cancellous bone grafting. C. Follwed up wrist AP X- Ray demonstrates fracture was completely united. D. CT reveals normal contour of the united scaphoid.. Herbert 22 mm 13 9 (69%). Herbert, 4-6. 2 1 - -. 10 15 ( 13.8 ), (dorsal transscaphoid perilunar dislocation) 1 14, 2 14 18, 1 13., Maudsley (Table 3),, - 222 -
T able 3. Method of assessment (by Maudsley) Headings Clinical Economic Radiologic Assessment Excellent full movement, no limited work normal appearances normal use union Good mild aching, stiffness slight limitation fair appearances normal use union Fair discomfort limited somework, non- union restriction of full use prolonged use good clear outline Poor pain, stiffness change his work to non- union a lighter type poor outline T able 4. Result of treatment Headings Clinical Economic Radiologic Cases Assessment Excellent +1 +1 +1 3 Good +1 +1 ++1(excellent) 8 Good - 1(fair) +1 +1 1 Good +1-1(fair) +1 1 Total 13., +1-1 3 2. +3 3, 2 8, (dorsal transscaphoid perilunar dislocation) 1, 1 (Table 4).,, (trapezium), (trapezoid),,., (laterovolar artery) (dorsal artery) 2/3, (distal artery) - 223 -
(tuberosity), 27), (proximal pole) - - 13, 24)., Frykman 14), Weber Chao 30) 10, 95 10, 209Kg 436Kg., 23), 7),. 13 9 (69%), 3 1., (PA), (oblique,, partial pronation), (lateral), (scaphoid view), - - 20). Dias 12) (snuff box) 1) Cooney 11) 3, (trispiral tomography). 6) 5),. 1-2,, 1. 1 1, 2 1 - - (silhouette) 20). 1 - -, - 60-0. 1-70,. 1mm,,,,. 2) - 224 -
(4 ). Herbert, (leading end of the screw) pitch( ) (trailing end) pitch, pitch differential (trailing end) 16). (A ) (B ), (C ) (D ). Herbert B B2(displaced or mobile fractures of the wrist) 9, B4 (fracture dislocation of carpus) 1, C (delayed union) 2, D (established non-union) D1 (fibrous non-union) 1 13 Herbert 13 10 (77%) 22mm, 3 24mm, 1 1, 2 1 5. K 26), AO 22, 31), (compression- staple) 19), Ender 's plate 17), Herbert 16). K,, 2. AO Herbert washer lag 18,21), (head), (threaded portion). (compression- staple) Ender s plate,. 9 Herbert 1 13.8, (dorsal transscaphoid perilunar dislocation) 1 14, 2 14 18. 28) 8).. 1. 1 mm ( ) 9, 29), 15). 3) 4) 6 Herbert - 225 -
. 1, 12. 8, (dorsal transscaphoid perilunar dislocation) 1, 1. 1989 3 1998 3, Herbert, 1, 13. 1. 9 (69%), 3 (23%), 1 (8%). 2. 1, (transscaphoid perilunar dislocation) 1, 2 1. 3. 6. 4. 10 15 ( 13.8 ), (dorsal transscaphoid perilunar dislocation) 1 14, 2 14 18, 1 12. 5. Maudsley 13 3 (23%), 2 1),, :., 25-3 : 739-746, 1990. 2),,, :., 26-3 : 762-769, 1991. 3),,,, : Herbert screw., 21-5 : 746-752, 1986. 4),,,,, :., 32-4 : 802-811, 1997. 5),, :., 29-7 : 1786-1791, 1994. 6),,, :., 25-3 : 1351-1361, 1990. 7),,, :., 25-3 : 747-752, 1990. 8) Bain GI, Bennett JD, Richards RS, Slethaug GP and Roth JH : Longitudinal computed tomography of the scaphoid: a new technique. Skeletal Radiol 24 : 271-273, 1995. 9) Belsole RJ, Hilbelink DR, Llew ellyn A, Dale M, Greene T and Rayhack JM : Computed analyses of the pathomechanics of scaphoid waist nonunions. J Hand Surg 16A : 899-906, 1991. 10) Borgeskov S, Christiansen B, kaser A : Fractures of the carpal bones. Acta Orthop - 226 -
Scand 37 : 276-287, 1966. 11) Cooney WP, Dobyns JH and Linscheid RL : Fractures of the scaphoid: A rational approach to management. Clin Orthop 149 : 90-97, 1980. 12) Dias JJ, Brenkel IJ and Finlay DB : Patterns of union in fractures of the waist of the scaphoid. J B one Joint Surg, 71- B : 307-310, 1989. 13) Dooley B : Inlay bone grafting for nonunion of the scaphoid by anterior approach. J B one Joint Surg, 50- B : 102-111, 1968. 14) Frykman G : Fracture of the distal radius including sequelae- shoulder- hand- finger syndrome, disturbance in the distal radio- ulnar joint and impairment of nerve function: a clinical and experimental study. Acta Orthop Scand Suppl 108 : 1-153, 1967. 15) Guimberteau JC and Panconi B : Recalcitrant non-union of the scaphoid treated with a vascularized bone graft based on the ulnar artery. J Bone Joint Surg, 72-A : 88-97, 1990. 16) Herbert TJ and Fisher WE : Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg, 66-B : 114-123, 1984. 17) Huene DR and Huene DS : Treatment of nonunions of the scaphoid with the Ender compression blade plate system. J Hand Surg 16A : 913-922, 1991. 18) Kaulesar Sukul DMKS, Johannes EJ and Marti RK : Corticocancellous grafting and an AO/ ASIF lag screw for nonunion of the scaphoid. J B one Joint Surg, 72- B : 835-838, 1990. 19) Korkala OL, Kuokkanen HO and Eerola MS : Compression- staple fixation for fractures, non- unions, and delayed unions of the carpal scaphoid. J B one Joint Surg, 74-A : 423-426, 1992. 20) Linscheid RL, Dobyns JH, Beabout JW and Bry an RS : Traumatic instability of the wrist. Diagnosis, classification and pathomechanics. J Bone Joint Surg, 54-A : 1612-1632, 1972. 21) Marshall PD, Ev ans PD and Richards J : Laboratory comparison of the cannulated Herbert bone screw with ASIF cancellous lag screws. J B one Joint Surg, 75- B : 89-92, 1993. 22) Maudsley RH and Chen SC : Screw fixation in the management of the fractured carpal scaphoid. J B one Joint Surg, 54- B : 432-441, 1972. 23) Mayfield JK : Mechanism of carpal injuries. Clin Orthop 149 : 45-54, 1980. 24) Mazet RJ and Hohl M : Fractures of the carpal navicular. Analysis of ninety- one cases and review of the literature. J B one Joint Surg, 45- A : 82-112, 1963. 25) Russe O : Fracture of the carpal navicular. Diagnosis, non- operative treatment and operative treatment. J B one and Joint Surg, 42A : 759-768, 1960. 26) Stark HH, Richard T A, Zemel NP and A shw orth CR : Treatment of united fractures of the scaphoid by iliac bone grafts and Kirschner- wire fixation. J B one and Joint Surg, 70A : 982-991, 1988. 27) T aleisnik J and Kelly PJ : The extraosseous and intraosseous blood supply of the scaphoid bone. J B one Joint Surg, 48- A : 1125-1137, 1966. 28) T rumble TE : Avascular necrosis after scaphoid fracture: A correlation of magnetic imaging and histology. J Hand Surg 15A : 557-564, 1990. 29) Verdan C and Narakas D : Fractures and pseudarthrosis of the scaphoid. Surg Clin North Am 48 : 1083-1095, 1968. 30) Weber ER, Ark LR and Chao EY : An experimental approach to the mechanism of scaphoid waist fractures. J Hand Surg 3A : 142-148, 1978. 31) Wozasek GE and Moser KD : Percutaneous screw fixation for fractures of the scaphoid. J B one Joint Surg, 73- B : 138-142, 1991. - 227 -