Proximal pole scaphoid fractures and nonunion

Abstract

Proximal pole fractures and nonunions of the scaphoid present an extremely challenging treatment problem. Untreated, proximal pole fractures have a high rate of developing a nonunion that may lead to painful arthritis. Cast immobilization is not adequate, and surgery is recommended for the treatment of acute fractures and nonunions. The fractures are difficult to treat through a conventional volar approach, and the preferred treatment is open reduction and internal fixation using a dorsal approach with a screw that is specially designed for the scaphoid. The type of fixation implant used is important, because the end of the screw must be buried beneath the articular cartilage when the dorsal approach is used. The main blood supply of the scaphoid enters through the dorsoradial ridge of the scaphoid. By definition, proximal pole nonunions have partial ischemia or complete avascular necrosis, because the fracture line isolates the proximal pole from the perforating vessels. The definitive treatment for these fractures is a standard or vascularized bone graft, depending on the vascularity of the proximal pole of the scaphoid in addition to internal fixation via a dorsal approach. Using this treatment algorithm, the surgeon can optimize the success rate of achieving a successful scaphoid union in the shortest possible time of immobilization. Copyright © 2001 by the American Society for Surgery of the Hand