Treatment of scaphoid fractures and nonunions

Abstract

Scaphoid fractures are common but present unique challenges because of the particular geometry of the fractures and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures can lead to nonunions and subsequent degenerative wrist arthritis. Improvements in diagnosis, surgical treatment, and implant materials have encouraged a trend toward early internal fixation, even for nondisplaced scaphoid fractures that could potentially be treated nonoperatively. Despite the advent of newly developed fixation techniques, including open and percutaneous fixation, the nonunion rate for scaphoid fractures remains as high as 10% after surgical treatment. Scaphoid nonunions can present with or without avascular necrosis of the proximal pole and may show a humpback deformity on the radiograph. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis. Surgical treatment is directed at correcting the deformity with open reduction and internal fixation with bone grafting. Recently, vascularized bone grafts have gained popularity in the treatment of scaphoid nonunions, particularly in cases with avascular necrosis. This article reviews current concepts regarding the treatment of scaphoid fractures and nonunions.

Figure 1

Algorithm for suspected scaphoid fracture management

Figure 2

Surgical procedures of screw fixation for a scaphoid fracture with the dorsal approach. (A) Preoperative X-ray showing a displaced fracture of the waist of the scaphoid. (B) Skin incision for the dorsal approach. (C) The scaphoid is exposed by making a longitudinal incision of the wrist capsule between the tendons of the extensor carpi radialis longus and the extensor carpi radialis brevis. (D) The fracture fragments are reduced by using K-wires inserted as joysticks. (E) Reduction of the fracture and guidewire placement within the center of the scaphoid is confirmed under fluoroscopy. (F) An appropriate length screw is inserted and buried below the articular cartilage. (G) Postoperative X-ray showing proper screw placement within the center of the scaphoid.

Figure 2

Surgical procedures of screw fixation for a scaphoid fracture with the dorsal approach. (A) Preoperative X-ray showing a displaced fracture of the waist of the scaphoid. (B) Skin incision for the dorsal approach. (C) The scaphoid is exposed by making a longitudinal incision of the wrist capsule between the tendons of the extensor carpi radialis longus and the extensor carpi radialis brevis. (D) The fracture fragments are reduced by using K-wires inserted as joysticks. (E) Reduction of the fracture and guidewire placement within the center of the scaphoid is confirmed under fluoroscopy. (F) An appropriate length screw is inserted and buried below the articular cartilage. (G) Postoperative X-ray showing proper screw placement within the center of the scaphoid.

Figure 2

Surgical procedures of screw fixation for a scaphoid fracture with the dorsal approach. (A) Preoperative X-ray showing a displaced fracture of the waist of the scaphoid. (B) Skin incision for the dorsal approach. (C) The scaphoid is exposed by making a longitudinal incision of the wrist capsule between the tendons of the extensor carpi radialis longus and the extensor carpi radialis brevis. (D) The fracture fragments are reduced by using K-wires inserted as joysticks. (E) Reduction of the fracture and guidewire placement within the center of the scaphoid is confirmed under fluoroscopy. (F) An appropriate length screw is inserted and buried below the articular cartilage. (G) Postoperative X-ray showing proper screw placement within the center of the scaphoid.

Figure 2

Surgical procedures of screw fixation for a scaphoid fracture with the dorsal approach. (A) Preoperative X-ray showing a displaced fracture of the waist of the scaphoid. (B) Skin incision for the dorsal approach. (C) The scaphoid is exposed by making a longitudinal incision of the wrist capsule between the tendons of the extensor carpi radialis longus and the extensor carpi radialis brevis. (D) The fracture fragments are reduced by using K-wires inserted as joysticks. (E) Reduction of the fracture and guidewire placement within the center of the scaphoid is confirmed under fluoroscopy. (F) An appropriate length screw is inserted and buried below the articular cartilage. (G) Postoperative X-ray showing proper screw placement within the center of the scaphoid.

Figure 2

Surgical procedures of screw fixation for a scaphoid fracture with the dorsal approach. (A) Preoperative X-ray showing a displaced fracture of the waist of the scaphoid. (B) Skin incision for the dorsal approach. (C) The scaphoid is exposed by making a longitudinal incision of the wrist capsule between the tendons of the extensor carpi radialis longus and the extensor carpi radialis brevis. (D) The fracture fragments are reduced by using K-wires inserted as joysticks. (E) Reduction of the fracture and guidewire placement within the center of the scaphoid is confirmed under fluoroscopy. (F) An appropriate length screw is inserted and buried below the articular cartilage. (G) Postoperative X-ray showing proper screw placement within the center of the scaphoid.

Figure 2

Surgical procedures of screw fixation for a scaphoid fracture with the dorsal approach. (A) Preoperative X-ray showing a displaced fracture of the waist of the scaphoid. (B) Skin incision for the dorsal approach. (C) The scaphoid is exposed by making a longitudinal incision of the wrist capsule between the tendons of the extensor carpi radialis longus and the extensor carpi radialis brevis. (D) The fracture fragments are reduced by using K-wires inserted as joysticks. (E) Reduction of the fracture and guidewire placement within the center of the scaphoid is confirmed under fluoroscopy. (F) An appropriate length screw is inserted and buried below the articular cartilage. (G) Postoperative X-ray showing proper screw placement within the center of the scaphoid.

Figure 2

Surgical procedures of screw fixation for a scaphoid fracture with the dorsal approach. (A) Preoperative X-ray showing a displaced fracture of the waist of the scaphoid. (B) Skin incision for the dorsal approach. (C) The scaphoid is exposed by making a longitudinal incision of the wrist capsule between the tendons of the extensor carpi radialis longus and the extensor carpi radialis brevis. (D) The fracture fragments are reduced by using K-wires inserted as joysticks. (E) Reduction of the fracture and guidewire placement within the center of the scaphoid is confirmed under fluoroscopy. (F) An appropriate length screw is inserted and buried below the articular cartilage. (G) Postoperative X-ray showing proper screw placement within the center of the scaphoid.

Figure 3

(A) The PA view showing a scaphoid nonunion at the waist. (B) On the lateral view, the distal scaphoid fragment is flexed (white arrow) whereas the lunate is rotated dorsally with the proximal scaphoid fragment (black arrow), indicating the DISI deformity.

Figure 3

(A) The PA view showing a scaphoid nonunion at the waist. (B) On the lateral view, the distal scaphoid fragment is flexed (white arrow) whereas the lunate is rotated dorsally with the proximal scaphoid fragment (black arrow), indicating the DISI deformity.

Figure 4

Surgical procedures of the 1,2 ICSRA vascularized bone graft for a scaphoid nonunion. (A) X-ray showing a sclerotic proximal pole indicating possible avascular necrosis (arrow pointing to the nonunion line). (B) MRI confirmed the avascularity of the proximal pole (arrow). (C) The 1,2 ICSRA is found on the surface of the extensor retinaculum between the first and second extensor compartment (arrow). (D) Before elevating the graft, the scaphoid is exposed and curetting is performed to remove any fibrous tissue from the nonunion site. (E) The bone is elevated with the osteotome. (F) The graft with vascular pedicle is elevated from the distal radius. (G) The graft is transposed beneath the wrist extensors and impacted into the scaphoid defect. Internal fixation with K-wires is performed. (H) Proper K-wires placement is confirmed under fluoroscopy.

Figure 4

Surgical procedures of the 1,2 ICSRA vascularized bone graft for a scaphoid nonunion. (A) X-ray showing a sclerotic proximal pole indicating possible avascular necrosis (arrow pointing to the nonunion line). (B) MRI confirmed the avascularity of the proximal pole (arrow). (C) The 1,2 ICSRA is found on the surface of the extensor retinaculum between the first and second extensor compartment (arrow). (D) Before elevating the graft, the scaphoid is exposed and curetting is performed to remove any fibrous tissue from the nonunion site. (E) The bone is elevated with the osteotome. (F) The graft with vascular pedicle is elevated from the distal radius. (G) The graft is transposed beneath the wrist extensors and impacted into the scaphoid defect. Internal fixation with K-wires is performed. (H) Proper K-wires placement is confirmed under fluoroscopy.

Figure 4

Surgical procedures of the 1,2 ICSRA vascularized bone graft for a scaphoid nonunion. (A) X-ray showing a sclerotic proximal pole indicating possible avascular necrosis (arrow pointing to the nonunion line). (B) MRI confirmed the avascularity of the proximal pole (arrow). (C) The 1,2 ICSRA is found on the surface of the extensor retinaculum between the first and second extensor compartment (arrow). (D) Before elevating the graft, the scaphoid is exposed and curetting is performed to remove any fibrous tissue from the nonunion site. (E) The bone is elevated with the osteotome. (F) The graft with vascular pedicle is elevated from the distal radius. (G) The graft is transposed beneath the wrist extensors and impacted into the scaphoid defect. Internal fixation with K-wires is performed. (H) Proper K-wires placement is confirmed under fluoroscopy.

Figure 4

Surgical procedures of the 1,2 ICSRA vascularized bone graft for a scaphoid nonunion. (A) X-ray showing a sclerotic proximal pole indicating possible avascular necrosis (arrow pointing to the nonunion line). (B) MRI confirmed the avascularity of the proximal pole (arrow). (C) The 1,2 ICSRA is found on the surface of the extensor retinaculum between the first and second extensor compartment (arrow). (D) Before elevating the graft, the scaphoid is exposed and curetting is performed to remove any fibrous tissue from the nonunion site. (E) The bone is elevated with the osteotome. (F) The graft with vascular pedicle is elevated from the distal radius. (G) The graft is transposed beneath the wrist extensors and impacted into the scaphoid defect. Internal fixation with K-wires is performed. (H) Proper K-wires placement is confirmed under fluoroscopy.

Figure 4

Surgical procedures of the 1,2 ICSRA vascularized bone graft for a scaphoid nonunion. (A) X-ray showing a sclerotic proximal pole indicating possible avascular necrosis (arrow pointing to the nonunion line). (B) MRI confirmed the avascularity of the proximal pole (arrow). (C) The 1,2 ICSRA is found on the surface of the extensor retinaculum between the first and second extensor compartment (arrow). (D) Before elevating the graft, the scaphoid is exposed and curetting is performed to remove any fibrous tissue from the nonunion site. (E) The bone is elevated with the osteotome. (F) The graft with vascular pedicle is elevated from the distal radius. (G) The graft is transposed beneath the wrist extensors and impacted into the scaphoid defect. Internal fixation with K-wires is performed. (H) Proper K-wires placement is confirmed under fluoroscopy.

Figure 4

Surgical procedures of the 1,2 ICSRA vascularized bone graft for a scaphoid nonunion. (A) X-ray showing a sclerotic proximal pole indicating possible avascular necrosis (arrow pointing to the nonunion line). (B) MRI confirmed the avascularity of the proximal pole (arrow). (C) The 1,2 ICSRA is found on the surface of the extensor retinaculum between the first and second extensor compartment (arrow). (D) Before elevating the graft, the scaphoid is exposed and curetting is performed to remove any fibrous tissue from the nonunion site. (E) The bone is elevated with the osteotome. (F) The graft with vascular pedicle is elevated from the distal radius. (G) The graft is transposed beneath the wrist extensors and impacted into the scaphoid defect. Internal fixation with K-wires is performed. (H) Proper K-wires placement is confirmed under fluoroscopy.

Figure 4

Surgical procedures of the 1,2 ICSRA vascularized bone graft for a scaphoid nonunion. (A) X-ray showing a sclerotic proximal pole indicating possible avascular necrosis (arrow pointing to the nonunion line). (B) MRI confirmed the avascularity of the proximal pole (arrow). (C) The 1,2 ICSRA is found on the surface of the extensor retinaculum between the first and second extensor compartment (arrow). (D) Before elevating the graft, the scaphoid is exposed and curetting is performed to remove any fibrous tissue from the nonunion site. (E) The bone is elevated with the osteotome. (F) The graft with vascular pedicle is elevated from the distal radius. (G) The graft is transposed beneath the wrist extensors and impacted into the scaphoid defect. Internal fixation with K-wires is performed. (H) Proper K-wires placement is confirmed under fluoroscopy.

Figure 4

Surgical procedures of the 1,2 ICSRA vascularized bone graft for a scaphoid nonunion. (A) X-ray showing a sclerotic proximal pole indicating possible avascular necrosis (arrow pointing to the nonunion line). (B) MRI confirmed the avascularity of the proximal pole (arrow). (C) The 1,2 ICSRA is found on the surface of the extensor retinaculum between the first and second extensor compartment (arrow). (D) Before elevating the graft, the scaphoid is exposed and curetting is performed to remove any fibrous tissue from the nonunion site. (E) The bone is elevated with the osteotome. (F) The graft with vascular pedicle is elevated from the distal radius. (G) The graft is transposed beneath the wrist extensors and impacted into the scaphoid defect. Internal fixation with K-wires is performed. (H) Proper K-wires placement is confirmed under fluoroscopy.