Symptomatic Extra-Articular Scaphoid Tuberosity Nonunion: Surgical Excision of the Ununited Fragment after Failed Nonoperative Management

Abstract

Listen

Translate article

Scaphoid fractures are the commonest fractures of the carpus [2], accounting for 60–70 % of carpal fractures; they most commonly affect young men following a fall on the outstretched hand [8], with forced dorsiflexion of the wrist, particularly during sports [5]. The management of scaphoid fractures falls into two general categories: nonoperative or surgical management. Nonoperative management with immobilisation in a cast or splint is commonly used for stable, undisplaced waist or tubercle fractures (Herbert type A). Surgical treatment by means of percutaneous or open fixation, with or without bone grafting, is used for unstable, displaced or ununited fractures (Herbert types B, C and D) [5]. Fractures of the scaphoid tuberosity account for between 8 and 20 % of scaphoid fractures [9, 11]. In a series of 222 scaphoid fractures, 38 (17 %) were of the scaphoid tubercle, and all of these were confirmed as united on imaging at 39 days, following an average of 30 days of immobilisation in a cast [8]. Other authors reported a 4 % incidence of tuberosity fractures in a series of 81 scaphoid fractures and advocated conservative management for the extra-articular type [7]. Management of symptomatic nonunion of the scaphoid tuberosity is a rare clinical dilemma which does not appear to fall into the algorithm based on the Herbert classification. Two male patients presented to our unit with long-standing symptoms from ununited extra-articular scaphoid tuberosity fractures following failed nonoperative management. Mean age at presentation was 23 (range 22–24 years). Surgical excision was offered as a management option to both of these patients. To our knowledge, only one case of surgical excision for failed nonoperative management has been previously reported in the international literature [10].