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Dr. P and Dr. Stern here with a 53-year-old

0:01

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lady who fell while skiing.

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Um, I've learned to avoid that

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sport, now that I'm over 60.

0:09

And we've got a coronal PD fat suppression on

0:13

the left, a gradient echo cartilage sequence in

0:16

the middle, a detector sequence on the left, and

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then sort of the refining T1 anatomic sequence.

0:23

And this study was done the right

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way, as we'll see in a minute.

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Now, the coronals are straight orthogonal coronals.

0:29

And one thing I would mention to the audience,

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both imagers and orthopedic surgeons and hand surgeons

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out there, is when you see a line in the bone,

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you should assess the thickness of that line.

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And this one's pretty thick.

0:44

You know, typically a microtrabecular

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injury, a millimeter or less,

0:48

looks like a little spidery line.

0:51

Whereas this one has more or less of a gap in it.

0:54

Now, there may not be an anatomic gap

0:56

between the two edges of the medullary bone.

0:58

But the actual signal is pretty confluent.

1:01

And sometimes it'll even have what

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I would consider a lentiform shape.

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This is very common in small bones.

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Here's the lentiform shape right there.

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And now I'll take it away.

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So that means you're dealing with

1:12

a more substantive injury.

1:14

So one of your jobs is to determine if you

1:17

have an honest-to-goodness real fracture

1:20

even though you may not see it on X-ray.

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In other words, is it transcortical?

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Does it go all the way through?

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Is there displacement?

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Is there angulation?

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Is there deformity?

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And at the break, Dr.

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Stern mentioned to me that you also

1:33

have to assess the adjacent SL ligament,

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which in this case looks pretty good.

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Now, we're going to

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show you the other views.

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And let's look at how they are obtained.

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I'm going to produce a sagittal GRE view.

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And this one was reconstructed

1:52

as opposed to directly acquired.

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But look at how it is reconstructed.

1:56

It's reconstructed along the long axis of the scaphoid.

2:00

And now it looks like a pretty nasty

2:01

injury, but the cortex doesn't look too bad.

2:04

Maybe there's a little step-off here, maybe not.

2:06

Now it is absolutely clear.

2:09

There is a gap, there's diastasis.

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This fracture goes all the way through from the

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dorsal portion of the scaphoid to the front.

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And then finally we bring down a short-axis view.

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Here's another sagittal, by the way.

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Same angulation, this is a

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sagittal water-weighted sequence.

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You can see the break in the cortex

2:29

back here and the edema on either side.

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So there is a little gap there and it does

2:33

go all the way through to the palmar surface.

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And finally, the last oblique down the long

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axis of this sagittal oblique gives you this

2:42

curvilinear tangent view of the scaphoid.

2:45

And there is your fracture with a

2:48

big gap seen in the middle on T1.

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So, how do we manage this one, and what's

2:53

important, what's relevant in this true fracture?

2:57

Yeah, so Steve, these are beautiful images,

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and if you look at the coronal views,

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one would think that—at least I would

3:08

say that this is a very high-grade, complete

3:11

fracture, absolutely without displacement.

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But when you look at the sagittal view on the

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left, as you point out, and as I off-camera

3:21

missed, there's definitely dorsal gapping.

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And eventually, this will lead on

3:27

plane radiographs to what we call a humpback

3:30

or kyphotic deformity of the scaphoid.

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Basically, what happens is the proximal pole and distal

3:37

pole of the scaphoid fold in towards each other.

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So, let me have the pen here.

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Sure.

3:44

So, you see a dorsal gap right

3:48

here, and these two poles will fold in as

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Steve's drawn, and I'll make it more clear.

3:55

Dramatic with the arrows.

3:56

They fold into each other.

3:58

So I think with this information, a clinician,

4:02

at least I would be very inclined to treat this

4:06

surgically with a headless compression screw.

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What's the prognosis for somebody like this?

4:13

She's 53 years old.

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It's a waist fracture.

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What's the, you know, would you follow

4:17

it up to see if she gets AVN, or would

4:19

you only do it if she doesn't improve?

4:21

Well, I would, if I was having a

4:24

conversation with the patient, I would be

4:26

inclined to recommend surgical intervention.

4:30

If she elected not to have

4:33

anything done surgically, we

4:35

would immobilize her in a thumb spica.

4:39

And, uh, see her serially and obtain plain radiographs.

4:43

The problem is that, in general,

4:46

you can't get an MRI from an insurance

4:49

standpoint, cost standpoint, every four weeks.

4:52

I mean, I guess you could if

4:53

but not in this country.

4:55

So, I would lean towards operative fixation.

4:59

If she's skiing at age 54 or 55, I think

5:03

that's her best shot to get this to heal up

5:06

and return to her activities, which she enjoys.

5:10

One question I have as a layperson.

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If I choose not to have a screw placed

5:15

in there, does that increase my risk for AVN?

5:18

Not sure I can answer that question.

5:20

My guess would be probably not, but

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AVN.

5:23

Anderson, as you say, as you said, there

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are many, many factors in terms of

5:29

prognosticating whether or not a scaphoid will heal.

5:32

And if I, over my career, and I think the

5:35

literature would support this, the single

5:37

most important thing, and this is non-unions,

5:41

that the time from injury to seeing the

5:44

patient is the most critical determinant.

5:47

Of whether or not a bone's going to unite.

5:49

Certainly displacement, whether they smoke

5:51

or not, location of the fracture, as

5:54

you mentioned, more proximal fractures in

5:57

general, almost always need treatment.

6:00

Associated injuries, a trans-scaphoid

6:03

perilunate or trans-capitate injury,

6:06

those also would require fixation.

6:09

Are younger patients less likely to get AVN?

6:11

Because I see a lot of them with AVN.

6:14

I don't think so.

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I don't think they have any

6:17

privilege in that regard.

6:19

Okay.

6:20

Dr. P and Dr. Stern out.