At 7 weeks postinjury, the fracture showed no signs of healing, and the patient elected to undergo surgical treatment. Nonunion is directly related to an interruption of the tenuous blood supply to the scaphoid. Treatment options for scaphoid nonunion case 1 feat. The disadvantages of surgery include the potential for infection, wound. Lowintensity pulsed ultrasound treatment for scaphoid. Three techniques are recommended for surgical correction of scaphoid nonunion with bone graft and internal fixation with a screw. Arthroscopic surgery of scaphoid nonunion arthroscopy of. There are no particular laboratory tests but if surgery is to be done then routine. Acute nonunion treatment technique depends on nonunion location, vascular status of the proximal pole, fracture malalignment, and preexisting evidence of arthrosis. Management of scaphoid fractures northwestern scholars. The purpose of this paper is to present medium term results of distal scaphoid resection arthroplasty for treatment of advanced osteoarthritis of scapholunate advanced collapse slac stage ii and iii due to longstanding scaphoid nonunion. Open surgical treatment of scaphoid nonunion relies on vascularized or nonvascularized grafts, typically in combination with internal fixation. Plancher history and clinical presentation a 38yearold police officer presents with the chief complaint of progressively worsening pain and decreased range of motion in his dominant right wrist.
Surgical treatment of scaphoid nonunion by excision back to bleeding bone, insertion of a corticocancellous bone graft and stabilization, usually with a screw, can be highly successful at achieving union. Scaphoid fracture is the most common type of bone fracture in the carpus ie, wrist. Herbert screw fixation and bone graft in nonunited scaphoid. The pros and cons of various operations are discussed. Percutaneous management of scaphoid nonunions offers the advantage of inducing. Surgical techniques scaphoid nonunion orthobullets. Fixation of proximal pole scaphoid nonunion with nonvascularized cancellous autograft timothy j.
We test a hypothesis that risk factors associated with pediatric fracture nonunion are similar to adult nonunion risk factors inception cohort study in a large payer database of pediatric fracture. What is the optimal treatment of atrophic scaphoid nonunion. Scaphoid fixation can be quite difficult due to the cashew nut shape and the need to place the screw in the midaxis of the scaphoid, without violating the radial and ulnar articular surfaces. In this article, the surgical treatment of scaphoid nonunion is presented. The best treatment for scaphoid nonunion fractures is still controversial. If the proximal pole of the scaphoid, with or without necrosis, was the site of nonunion, or the previous autogenous bone graft had failed, curettage, vascularized bone. The dorsal approach is a simpler approach, is better for very small proximal fragments, but may interfere more with the blood supply of the scaphoid. Scaphoid nonunions pose a formidable challenge to surgeons because of the multiple factors that may contribute to their causation. Treatment of nonunion of the scaphoid by a limited. Surgical and nonsurgical treatment varies depending on the pattern of the fracture. A scaphoid navicular fracture is a break in one of the small bones of the wrist. Nonvascularized vs vascularized grafting for scaphoid bone. The patient underwent arthroscopic resection of the pseudarthrosis followed by bone grafting and percutaneous screw fixation.
Prognostic factors in the treatment of carpal scaphoid nonunions. Scaphoid problems surgical treatment of scaphoid nonunion leung yf department of orthopaedics and traumatology, yan chai hospital, hong kong. Delayed management is an important factor that affects longterm outcomes. Scaphoid nonunion procedure treatment of a scaphoid nonunion is dependent on several factors including the patients age, function, current symptoms pain, stiffness, associated conditions, patient factors such as tobacco use smoking, and their general medical condition. If your arm was numbed blocked for the surgery by the anesthesiologist, begin taking pain medication before the block wears o. The authors point out that without surgical treatment, a scaphoid nonunion can get much worse. In the surgery of type b2 scaphoid nonunion, a volar approach is preferable to allow easy correction of.
In recent decades, vascularized bone grafting has gained popularity, particularly in cases of proximal pole involvement. This type of fracture occurs most often after a fall onto an outstretched hand. The scaphoid is the most commonly fractured carpal bone accounting for 60% of fractures 1, 2. The surgical techniques performed in the case of nonunion of the scaphoid waist were curettage, autogenous iliac bone grafting, and internal fixation with screws or pins. They found that cancellous grafts were associated with shorter time to union, but there was no difference in the overall percentages of union between these grafts. Scaphoid fractures are the most common of the carpal fractures and tend to occur.
He notes a history of a wrist injury from a fall 5 years ago when playing basketball. Review of surgical treatment for scaphoid nonunion. A simple and minimally invasive way to treat scaphoid waist nonunion stage iia. Scaphoid nonunion fixation with distal radius bone graft. Resection of the scaphoid distal pole for symptomatic. Treatment of delayednonunion of scaphoid waist with. Raising of distal radius bone graft for scaphoid nonunion. In addition, secondary surgical options for treatment of scaphoid nonunion and avascular necrosis are discussed. If a scaphoid fracture does not heal, it is called a scaphoid fracture nonunion. These symptoms may worsen when you try to pinch or grasp something. Perilunate injuries represent a severe disruption of the carpal anatomy. This video discusses the case presentation of a 24yearold man who sustained a midwaist scaphoid fracture after a fall onto his outstretched right hand. Access to the scaphoid can be via a dorsal or volar approach. Taking a ct arthrogram or an mri of the wrist is essential to diagnose scaphoid nonunion accurately.
For fixation of small bones and small bone fragments 2. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis. The electromagnetic coils are attached by a velcro strap over a thumb splca cast and applied to a patient with a scaphoid nonunion. Our data suggest that nonvascularized iliac crest bone graft is the most common choice for scaphoid nonunion surgery in the united kingdom. These worthy objectives are accomplished by the four hand surgeon authors.
Perform physical examination to recognize occult scaphoid fractures. Wysocki abstract we present 20 patients with established proximal pole scaphoid nonunions treated with curettage and cancellous autograft from the distal radius and screw. Surgical treatment of scaphoid nonunion springerlink. Risk factors for nonunion of bone fracture in pediatric. Plain radiographs are helpful, but notfoolproof,indeterminingwhether the scaphoid fracture involves the proximalpole. The following symptoms are not meant to diagnose a condition. This treatment leads to union in 80% to 91% of cases, depending on the technique used. Scaphoid nonunion wheeless textbook of orthopaedics. Arthroscopic grafting of scaphoid nonunion surgical. Three techniques are recom mended for surgical correction of scaphoid nonunion with bone graft and internal fixation with a screw. Dorsal approach to scaphoid with insertion of mini. Clinical outcome of scaphoid malunion as a result of.
For many years, we have been using a simplified reconstruction technique for scaphoid nonunions that involves the use of precise iliac bone. The management of scaphoid pseudarthrosis is still controversial. Twentyfive percent of perilunate injuries are missed on initial presentation. Scaphoid fixation approaches cambridge orthopaedics. The use of the free vascularised bone graft for nonunion. Edward abraham, md university of illinois at chicago college of medicine description. 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. Surgical treatment of scaphoid fracture nonunion using internal fixation by houston tx hand surgeon duration.
Scaphoid nonunions can present with or without avascular necrosis of the proximal pole and may show a humpback deformity on the radiograph. 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. Transscaphoid perilunate fracture dislocations involve ligamentous and bony injuries and account for 60% of all perilunate injuries. Scaphoid fracture open reduction and internal fixation patient postoperative instructions laith alshihabi, md 02 weeks pain medication. Sequential images of the technique for fixation of this injury form the basis for discussion of this chapter. The investigators found a statistically significant reduction in time to healing in the intervention. Use your prescription pain medication as needed to control pain. Surgical technique determining the location of the scaphoid nonunion, degree of carpal collapse, and viability of the proximal fragment is important in developing a treatment algorithm for scaphoid nonunion figure 1. Features comprehensive information on arthroscopic bone grafting, vascularized grafts, salvage procedures, the various types of implants, and much more 600 vivid illustrations including 300 in fullcolor enhance. Arthroscopic treatment of scaphoid non union youtube. Russe 23 described a volar approach to the scaphoid with fig. Most scaphoid fractures heal when appropriately treated. Therefore a patient who has significant tenderness directly over the scaphoid bone which is located in the hollow at the thumb side of the wrist, or snuffbox should be suspected of having a scaphoid fracture and be splinted.
Ricardo et al performed a doubleblinded randomized controlled trial of the effect of ultrasound on scaphoid nonunion healing following surgical treatment with vascularized pedicle bone grafting. Experience of the technique is now reported in seven patients. Osteonecrosis is said to occur in %50% of cases of fracture of the scaphoid, and the. The scaphoid bone in the wrist can present some complex treatment problems if and when a fracture doesnt heal. Perform all the latest procedures and get the best results with the new edition of operative techniques. Nonsurgical scaphoid fracture treatment if the acute fractured scaphoid bone remains aligned, a scaphoid fracture splint fig. Scaphoid fractures and nonunions, nonunion with avascular necrosis, and salvage. Patients and methods between july 1996 and august 1998, seven patients were treated using the limited combined approach. The etiology of the nonunion may be because of anatomic variations, fracture configuration, vascular problems, underlying metabolic problems, or the inadequacy of initial treatment. Herbert and fischer defined delayed union as nonunion of the scaphoid fracture even 6 weeks after injury and established nonunion as nonunion of the fracture even 6 months after injury.
Simultaneous fractures of the scaphoid and distal radius. Surgical procedures of screw fixation for a scaphoid fracture with the dorsal approach. Scaphoid nonunions can present with or without avascular necrosis of the proximal pole, and may show a humpback deformity on the radiograph. Whilst most scaphoid fractures may heal, a number of case series have identified a 10%15% nonunion rate. The expert authors then present stepbystep demonstrations of each surgical approach complemented by clearly labeled illustrations that help readers to visualize the specific procedure while reinforcing their understanding of the basic principles of scaphoid fracture fixation. Treatment of scaphoid fractures and nonunions ncbi. For scaphoid waist nonunion with a viable proximal pole, the volar approach is used with interpositional wedge or inlay bone graft and screw fixation. Scaphoid nonunions have been traditionally treated with nonvascularized bone grafting with or without bony fixation. To be included in this study, the scaphoid biosteogen, system electrobiology inc.
The goal of this continuing medical education module is to present the preoperative assessment and the formation and execution of a surgical treatment plan for acute fractures of the scaphoid. Fixation of proximal pole scaphoid nonunion with non. This technique is simple, fast and precise, only used for an established scaphoid nonunion without significant arthritis, chronic nonunion with. Featuring insights from pioneers in the field, its comprehensive coverage extends from standard open procedures to stateoftheart percutaneous methods and miniincision techniques. Treatment options for scaphoid nonunion case 2 feat. Non union of scaphoid a non union of scaphoid fractures are influenced by 1. To evaluate the results of resection of the scaphoid distal pole for symptomatic scaphoid nonunion after failed prior surgical treatment. These examinations will look for signs of osteonecrosis of the proximal pole. Depending on the type and location of the fracture, a dorsal approach to the scaphoid may be preferred. The purpose is to describe 72 wrist operations with the emphasis on surgical techniques. Nonunited fracture scaphoid surgery, simple step by step. A variety of implants suitable for treating nonunion of the scaphoid are available.
Results of treatment of scaphoid nonunions without deformity correction for many years, the most common treatment for symptomatic scaphoid nonunion was the inlay technique of bone grafting 23. The box transforms 110 volt ac line curreat to the proper pulsed signal. Treatment of scaphoid fractures and nonunions hand therapy hub. Thirteen patients who were treated with resection of the scaphoid distal pole for persistent nonunion after previous surgical treatment were included in this study. Scaphoid fracture and nonunion linkedin slideshare. Complications with the use of bmp2 in scaphoid nonunion surgery. The scaphoid brings together in one definitive reference every aspect of carpal scaphoid injury treatment. Scaphoid fractures and nonunions a clinical casebook jeffrey. Treatment of nonunited scaphoid fractures by pulsed.
The numerous methods that have been proposed can be roughly classified according to their aim relief of pain or healing of bone. Scaphoid fractures which do not heal are termed scaphoid nonunion. The scaphoid is a 376page, 42chapter book dedicated to the most. Each chapter covers a different procedure, beginning with a discussion of. Smoking is strongly associated with nonunion after surgical fixation of the scaphoid. A nondisplaced scaphoid fracture could thus be incorrectly diagnosed as a sprain. Arthroscopic assisted fixation and percutaneous grafting of scaphoid non. This book is distributed under the terms of the creative commons attribution.