- A continuing controversy in orthopedic surgery is how to treat proximal pole scaphoid fractures that present with delayed union or nonunion
- This study reviewed a single surgeon's experience in using surgical fixation and local autologous bone graft in this setting
- Postoperatively, seven of 10 patients had complete union and the three others demonstrated healing of ≥50% of the fracture surface
- No patient reported pain at the final visit and none have required any subsequent procedures related to the scaphoid nonunion
Compared with fractures at the wrist or distal pole, fractures of the proximal pole of the scaphoid more frequently present with delayed union and nonunion because of more tenuous blood supply. Some authors have reported unfavorable results of conventional autologous bone graft, and various vascularized bone grafting techniques have been described. However, there is no consensus about optimal treatment.
Kristin E. Shoji, MD, former orthopedic surgery resident, and Chaitanya S. Mudgal, MD, orthopedic surgeon in the Hand and Arm Center at Massachusetts General Hospital, and colleagues reviewed a single surgeon's experience in using surgical fixation and local autologous bone grafts to treat delayed union or nonunion of proximal pole scaphoid fractures. In the Journal of Wrist Surgery, they report that all patients healed without the need for more complex vascularized procedures.
The researchers identified 10 patients at Mass General (nine men, average age 26) who were treated between 2006 and 2017 for non-acute proximal pole scaphoid fractures and had delayed union or nonunion.
There is no consensus about the definition of proximal pole scaphoid fractures; those in this study were required to have the majority of the fracture line proximal to the head of the capitate. Nonunion was defined as more than three months of symptoms.
Surgical Procedures and Follow-up
The median time from injury to surgery was six months (range, 2–25 months). All patients underwent open reduction internal fixation of the proximal pole nonunion or nascent nonunion. Eight patients also underwent local bone grafting: at the site of fracture in seven patients and in the screw track in one patient.
The surgical procedures are described in the paper. Briefly, there was very delicate handling of the proximal pole fracture fragment with thorough preparation of fracture surfaces, careful management of the local bone graft and then meticulous fixation of the small proximal pole fragments. To avoid fragmenting the proximal pole, screw size was chosen such that the amount of bone available around the proposed insertion site of the screw was at least two to three times the diameter of the trailing end of the screw.
The median duration of follow-up after surgery was four months (range, 3–16 months). To confirm the union, CT was performed 12 to 16 weeks postoperatively.
Postoperatively, seven patients had CT signs of complete union and the others demonstrated healing of ≥50% of the fracture surface. No patient reported pain at the final visit. None have required any subsequent procedures related to the scaphoid nonunion.
Local bone graft with screw fixation should be considered an option for the treatment of delayed union or nonunion of proximal pole scaphoid fractures. New treatments may be alluring, but vascularized pedicle bone graft and free vascular grafts are technically challenging and fragile.
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