[MUSIC] [MUSIC] Once again, let us start with a few basic principles of anatomy: The scaphoid is located in the proximal row carpectomy on the radial side. Among other bones, it articulates with the radius and the lunate bone. It is important to know that the supply of blood flows in from distal, as the proximal area is more or less completely covered by cartilage. Here once again are the key basic points: The scaphoid is located in the proximal row carpectomy, it forms a part of the distal wrist and adjoins the distal radius. It is joined to the lunate bone by means of the scapholunate ligament. The scaphoid is the second largest carpal bone and the vascular supply is only provided from distal. This x-ray image provides an example of how the scaphoid and the lunate bone are positioned. Both bones are attached to one another with a ligament , called the scapholunate ligament. The position of both these bones must be taken into account in every case of injury to the row carpectomy, as both bones can become separated in the event of this scapholunate ligament being ruptured. This slide shows in diagrammatic form how the scaphoid bone is supplied with blood. The dorsal formation can be seen on the left side and the palmar formation on the right side. What can be clearly recognised is that the entire supply of blood of the scaphoid is undertaken from distal. This is important in terms of making therapeutic decisions in the case of corresponding fractures. >> Hello. My name is Dr. Vester. What can I do for you? >> I was jogging in the “English Garden” [large central park in Munich] today >> and, as we all know, it was snowing during this time. and, as we all know, it was snowing during this time. >> How did you fall? >> Yes, I mainly fell onto this area, like this. Well, onto that part of course and probably also here, but not therefore onto the whole ball of the hand. >> Ok. >> That's right and it now hurts like crazy, including from the thumb, of course, but it, the pain, also stretches right down here, across here, in other words really the whole area from here. >> Okay. Can I have a look? Does that hurt? >> No. Hier? >> Yes, yes, yes, yes, yes, yes, yes! >> And what about now? [NO_AUDIO] A little better now, though? There? >> No. Here is OK as well? Excuse me. The other way round. Let it go loose. I am afraid I have got to make things a little uncomfortable for you. >> Woah! >> Yes, excuse me. How is that? - Okay. The fingers are free. What is the feeling in your hand like?? When I stroke it like that. Normal. >> Quite normal. >> Not numb. >> Okay. Blood flow is therefore normal. The way I understand things from what you have told me about the fall you took, meaning the way you fell, you say you fell onto your hand like this - and it particularly hurts here, where I have pressed on your hand and also down here as well? There are two possibilities. It may well be the case that you have broken one of your carpal bones. What we call the scaphoid bone is located here, just where it hurts so much at the moment. It can, however, also be the case that something has broken at the end of the radial bone, here, as it also hurts so much there as well. I cannot distinguish so precisely here in this examination. In order to be able to make a better assessment, I would like to have an x-ray image made of the hand so that we can have a look at the bony structures in detail. After that, we’ll talk about how things go from there. OK? Would you now please like to go and have the x-ray taken? We’ll then meet up again immediately afterwards. >> Understood. Thank you. >> Scaphoid fractures form the most frequently encountered type of carpal injury. It is predominantly young male adult patients who are basically affected. Falling onto an outstretched hand is frequently the mechanism by which the accident occurs. The fractures are usually unstable. A typical feature of injuries of the scaphoid is tenderness to pressure in the anatomical snuff box. Compression pains occurring in the first or second finger can likewise indicate an injury to the scaphoid. X-ray diagnostic investigation provides for viewing the wrist at 30°, together with the scaphoid quartet. If anything is not clear, then the indication should be made for an extensive MRI examination. [NO_AUDIO] [NO_AUDIO] [KNOCK] Please come in. There you are once again. Please, take a seat. I have already received your x-ray image. >> That was quick! >> If I can now just show you here: That is your wrist. Look here, that is the radial bone and that is the ulna. >> Yes, everything clear. >> Those are the fingers and here are the carpal bones. What is causing you so much pain is what is called the scaphoid bone. That is this bone here. And if you take a look at it, then you will see all the edges are nice and smooth, but there is a small line running through it just here. Can you recognise what that is? That is a fracture. >> I see. >> This is what >> is called a fracure in the scaphoid bone, in other words a fracture. Somebody might imagine that everything looks OK with just such a really, really thin line being visible and the two ends of the fracture are are nicely joined and not somehow badly dislocated. The problem with scaphoid bones is, however, that the blood flow for the bone comes from up here and down here is precisely an area in which the blood flows very poorly. This is therefore a kind of fracture which heals very poorly and that is therefore also a kind of fracture which we prefer to treat surgically. Yes. I’ll show you the surgical procedure here once again. So, once again, this is your wrist. That is what we refer to as the scaphoid and you can clearly see this fracture gap here, We use a screw, what is termed a Herbert screw, in the operation. This goes upwards about here so that everything here looks like this and its thread provides it with a special feature, namely it pulls the fracture together once again. This allows the fracture ends to join up and heal well and the fracture becomes firmer again. It is also usually not necessary to remove the screw again. >> This chart shows the classification of scaphoid fractures according to Herbert. Type A fractures are shown at the top and are in principle of a stable nature. Type B fractures are shown in the second row and these are in principle classified as being unstable. Type C fractures are fractures which do not reveal any consolidation of the bone for longer than six weeks and Type D ones are what are termed pseudarthroses which still reveal no consolidation of the bone after more than six months. Treatment of scaphoid fractures prescribes non-operative immobilisation for Type A1 fractures. A2 to B1 have to be assessed carefully in terms of how stable the situation really is. The preference is for B1 - B2 fractures to be treated surgically and the same applies to B3 and B4 ones. The reason for this is to be found in the fact that in the case of B injuries, the blood supply to the proximal section is completely cut off. Type C and D injuries require the form of treatment which is standard for pseudarthrosis. Non-operative treatment consists of a forearm plaster cast with the thumb being included. The most recent studies have revealed that including the thumb does not, however, probably bring any significant advantage. These illustrations show examples of surgical treatment with a screw which reveals two different thread pathways. This type of screw is named after Herbert and produces compression between both fragments upon being screwed in. The important thing, as is shown in the second illustration from the left, is that both threads are located in different pieces of bone, as the compression mechanism can otherwise not function. X-ray images of a scaphoid fracture which has undergone treatment with a Herbert screw are shown on the right side as a clinical example. [NO_AUDIO] These x-ray images show examples of scaphoid fractures. Please note that the fracture line cannot be recognised all that clearly. This means that extra attention has to be paid to the row carpectomy when looking at every image. This particularly applies in the case of lack of clarity or persisting clinical symptoms, when an indication is to be given for an extensive computerised tomogram to be conducted. This clinical example shows a Type B1 scaphoid fracture. Due to the blocking of perfusion in the proximal section of the scaphoid, this type of fracture has to be treated by means of a compression or Herbert screw. These x-ray images show examples of the treatment of a scaphoid fracture with a Herbert screw. These postoperative x-ray images show the treatment of a scaphoid fracture by means of a Herbert screw in an enlarged format. The position of the scaphoid and of the screw can be seen clearly. >> If the fracture is not surgically treated and is treated non-operatively instead by means of plaster cast, the cast needs to be applied for at least six weeks, with the thumb being included, while there is also a very great danger of pseudarthrosis occurring, that is to say the danger of the two bones not joining and healing. >> Even though the fracture is such a thin one? >> Yes. >> It is only barely a hair-line fracture: I do not really know about any of this, but... >> … because the blood flow comes from this bone up here. That means that if lots of nutrients no longer reach the area down here, then the bone cannot, as it were, heal itself. >> I don’t need to decide immediately, though, do I? >> Well, it is not so urgent that we need to operate this very evening, but I would not wait too long. >> What does that really mean? >> Well, I would certainly recommend you undergo the operation in the course of the next few weeks. >> Good. >> Yes. Naturally, you can take your time and think it over. It is not a major operation. You will not need to undergo a general anaesthetic for it. It can be carried out under what is referred to as plexus anaesthesia, which means that just your arm goes numb and patients also generally do not need to spend long in hospital. OK. I’ll think about it. >> You don’t need to decide >> whether to undergo the operation this very second. I would, though, advise you to undergo it as the high level of pseudarthrosis formation means that the longer you wait, the more difficult it will be and the less treatment this fragment here simply receives. Once you have incurred pseudarthrosis, it cannot simply be fixated with a screw, but the bone ends then have to be freshly prepared and if necessary a piece of bone even has to be taken from another bone and inserted there as a cancellous bone as it were. >> OK, and.... Everything understood. In any case, I would like to have a plaster cast fitted and with the wrist being included. Yes, that will reduce the pain for you a little and it will also prevent any slippage of any kind occurring. I would then like to ask that we meet up again in three days and up to then you can think about whether you would like to undergo the operation or not. >> OK, everything clear. >> Yes. I would recommend it. Good, then the nurse will fit the cast. Goodbye. [NO_AUDIO] >> Let me summarise: A scaphoid fracture is a type of fracture which is very typically sustained following a fall onto an outstretched hand. The special features of blood supply are important when it comes to treatment. A non-operative procedure is indicated for non-dislocated A1 or B fractures. Otherwise, there is a major danger of pseudarthrosis occurring. Surgical procedures foresee treatment by means of Herbert screw. [MUSIC] [MUSIK] [MUSIC]