Scaphoid fractures accounts for approximately 15% of all fractures of hand and wrist. Proximal pole fractures represent 10–20% of scaphoid fractures. Non –operative treatment shows high incidence of non-union and avascular necrosis. Surgical intervention with bone graft is associated with better outcome. The aim of this study was to evaluate the radiological and functional outcome of management of proximal pole scaphoid non-union with internal fixation and bone grafting. We included 35 patients with proximal pole scaphoid non-union (2008–2015). All patients underwent antegrade headless compression screw fixation and bone grafting at King's College Hospital, London (except one, who was fixed with Kirschner wire). 33 patients had bone graft from distal radius and two from iliac crest. Postoperatively patients were treated in plaster for 6–8 weeks, followed by splinting for 4–6 weeks and hand physiotherapy. All the patients were analysed at the final follow-up using DASH score and x-rays. Mean age of the patients was 28 years (20–61) in 32 men and 3 women. We lost three patients (9%) to follow up. At a mean follow up of 16 weeks (12–18) twenty three patients (66%) achieved radiological union. All patients but three (91%) achieved good functional outcome at mean follow up of 14 weeks (10–16). A good functional outcome can be achieved with surgical fixation and bone graft in proximal pole scaphoid fractures non-union. Pre-operative fragmentation of proximal pole dictates type of fixation (screw or k wire or no fixation). There was no difference in outcome whether graft was harvested from distal radius or iliac crest.
Femoral head fractures i.e. Pipkin fractures are uncommon injuries and there are very few large series in literature with reported outcomes. There remain many controversies regarding diagnosis and management. This study, which is the largest single surgeon experience, is an attempt to get answers to some of these controversies. This series is an analysis of 51 patients with femoral head fractures. There were 44 males and seven females. The right side was involved in 36 and left in 16 patients. According to Pipkin classification these were 13 Pipkin-I, 27 Pipkin-11, three Pipkin-111 and eight Pipkin-IV fractures. Thirty-two patients were managed by surgical intervention. The surgical approach was posterior in Pipkin-I and in seven cases of Pipkin-II fractures. Another eight Pipkin II cases were managed surgically by anterior Smith-Peterson approach while another eight fractures were accessed by posterior approach with flip osteotomy. The Pipkin III and IV cases were managed using surgical approaches that varied depending on the pattern of associated acetabular injury. The fractured fragment, if small, was excised and, if large, was re-fixed using small fragment partially threaded cancellous screw. Follow-up of two to eight years was available in 39 cases. Using Thompson and Epstein criteria, 26 patients were rated as having good results, eight fair and five poor results. Early osteoarthritic changes were seen in five patients, avascular necrosis of the femoral head in three patients and one patient had re-fracture in same hip during an epileptic fit with subsequent fixation problems. Of four patients with sciatic nerve injury, two had persisting motor deficit. There was one case of heterotopic ossification. Most Pipkin-I fractures can be managed by closed reduction, Pipkin-II fractures usually require ORIF. The best results have been obtained by a Smith-Peterson approach if the hip has already been reduced, but posterior approach with flip osteotomy offers the best exposure if the hip is still unreduced. Pipkin III patients need hip replacement if presentation is late, while ORIF gives acceptable outcome in Pipkin IV fractures.
