Avascular Necrosis of the Hand and Wrist

Avascular Necrosis of the Hand and Wrist

Michael Guju

Evan H. Horowitz

Francisco A. Schwartz-Fernandes

The article by Gelberman and Gross on the vascularity of the wrist divided the bones of the wrist into three groups based on decreasing risk of avascular necrosis (AVN).1



At-Risk Anatomy

Group 1

Scaphoid, capitate, and 80% of lunate

Supplied by only one vessel or had large areas of bone only supplied by one vessel. Most vulnerable group to avascular necrosis (AVN)

Group 2

Hamate and trapezoid

Do not have internal anastomosis. Minimal risk of AVN

Group 3

Trapezium, triquetrum, pisiform, and 92% of lunates

Have rich internal anastomoses. Least risk for AVN

They further expanded their examination by examining the extent and type of vascular occlusion required to cause AVN (Table 22.1).



  • Cause of AVN—trauma

    • Epidemiology

      • Osteonecrosis is said to occur in 13% to 50% of cases of fracture of the scaphoid.

      • Incidence of osteonecrosis is even higher in those with involvement of the proximal one-fifth of the scaphoid.2,3

  • Anatomy

    • The blood supply of the scaphoid is primarily from the radial artery via the artery to the dorsal ridge of the scaphoid.

      • The branches enter the scaphoid via foramina at the dorsal ridge at the level of the waist of the scaphoid.4,5

    • The proximal pole of the scaphoid relies entirely on this interosseous blood supply.

  • Pathophysiology

    • Low-energy falls from a standing height were most common (40.4%).

    • Males are significantly more likely to sustain their fracture after a high-energy injury.6

  • Clinical history

    • Scaphoid fractures are commonly seen in young, healthy individuals and may occur as a result of a fall on the outstretched arm or a forced dorsiflexion injury of the wrist.2

  • Physical examination

    • A reliable correlation exists between scaphoid fracture and pain provoked by deep palpation at the volar tubercle of the scaphoid, which is the first bony prominence distal to the volar distal radius. Scaphoid fracture is not very likely when tubercle palpation does not provoke pain in the snuffbox.

  • Special provocation maneuvers

    • Watson (scaphoid shift) test—The patient sits with the forearm pronated. The examiner takes the patient’s wrist into full ulnar deviation and extension. The examiner presses the patient’s thumb with his/her other hand and then begins radial deviation and flexion of the patient’s hand.

    • Scaphoid stress test—The patient sits while the examiner holds the patient’s wrist with one hand, with the examiner applying pressure with his/her thumb over the patient’s distal scaphoid. The patient then attempts radial deviation of the wrist.

  • Classification/imaging

    • A computed tomography bone scan in the long axis of the scaphoid is the best means of differentiating between stable and unstable fractures. Type B fractures should be corrected operatively (Table 22.2).7

  • Preiser’s disease

    • Preiser’s disease is a rare condition where ischemia and necrosis of the scaphoid bone occur bilaterally without previous fracture. The lack of perfusion to the proximal pole is often associated with prolonged use of corticosteroids or chemotherapy. X-ray and magnetic resonance imaging (MRI) are used to confirm diagnosis.

  • Classification/imaging

  • Treatment

    • Initial treatment is immobilization

    • There are two surgical procedures to treat Preiser’s disease.

      • Proximal row carpectomy (PRC), which is the removal of the proximal row of carpal bones (scaphoid, lunate, and triquetrum)

      • Four-corner fusion with scaphoid excision, which is the removal of the scaphoid bone and fixing of the remaining wrist bones using a “spider plate” or wires (Figure 22.1)8,9

TABLE 22.1 Risk of Avascular Necrosis According to Gelberman and Gross1


Type of Occlusion Resulting in AVN

Scaphoid and capitate

Intraosseous disruption

Lunates (minority)

Extraosseous disruption

Lunates (majority)

Both extraosseous and intraosseous disruption

AVN, avascular necrosis.

TABLE 22.2 Scaphoid Fracture—Herbert Classification


Acute, stable




Nondisplaced crack in the waist


Acute, unstable


Oblique, distal third


Displaced or mobile, waist


Proximal pole






Delayed union


Established nonunion






Special studies

Scaphoid view

Kinematic wrist views

TABLE 22.3 Preiser Disease Classification38


Radiologic Findings


Normal radiograph. Abnormal findings on MRI. Positive bone scan


Proximal pole sclerosis of the scaphoid. Generalized osteoporosis


Fragmentation of the proximal scaphoid pole with/without pathological fracture


Periscaphoid collapse, fragmentation, and osteoarthritis

Abbreviation: MRI, magnetic resonance imaging.

FIGURE 22.1 Four-corner fusion, x-rays on anteroposterior (A) and lateral (B) views.


May 7, 2019 | Posted by in ORTHOPEDIC | Comments Off on Avascular Necrosis of the Hand and Wrist
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