Natural History Of Scaphoid Nonunion Research Articles

Revisiting the Natural History of Chronic Scaphoid Nonunions: A Retrospective Study of 20 Cases.

Background The natural history of scaphoid nonunion is the development of degenerative arthritis. A lot of information is still unclear about this progression. The purpose of this study is to analyze patients with scaphoid nonunions who had not received any kind of treatment and to assess the functional outcome. Materials and Methods This is a retrospective study that analyzed the patients with chronic scaphoid nonunions between 2009 and 2019. None of the patients received any treatment. The age at the time of injury, examination, pattern of fracture, types of scaphoid nonunion, symptoms, and duration of nonunion were noted. Diagnosis was confirmed by radiographs, computed tomography (CT) scan, and magnetic resonance imaging (MRI). Scapholunate and radiolunate angles were recorded. Pain score, modified mayo wrist score, grip strength, range of movement, and the functional outcome of these scaphoid nonunions were analyzed. A statistical correlation between the scaphoid nonunion presentations and the functional outcome was assessed. Results The mean age of the patients was 62 years (range: 35-82 years.). There were 17 male and 3 female patients. There were 9 waist and 11 proximal pole scaphoid nonunions. The mean duration of scaphoid nonunion was 34 years (range: 10-62 years). None of the patients had avascular necrosis (AVN) of the proximal scaphoid. The age at examination, gender, side of injury, fracture pattern (waist/proximal pole), fracture displacement ≤ 1 mm or > 1 mm, nonunion duration, and radiographic arthritic parameters had no significant impact on the functional outcome. Conclusions Untreated chronic scaphoid nonunion leads to the development of degenerative arthritis over a period of years, which is still unpredictable. Most of the patients become aware of the nonunion following a precedent injury or other reasons. Most of the patients have fair/good functional outcome despite reduced range of movements and grip strength. Many do not favor surgical intervention in the course of nonunion. Chronic nonunions open a lot of unanswered questions. Clinical Relevance There have been numerous studies on the treatment aspects of scaphoid nonunion, with little knowledge about certain people with nonunion who did not have any kind of treatment. The demographics, clinical findings, and radiological parameters do confirm the progression of these nonunion to arthritis, but most of them had fair-to-good outcome throughout their life. It opens our thinking about the real need of treatment in such nonunions and raises numerous questions about the disease. Level of Evidence This is a Level IV study.

Current Management of Scaphoid Nonunion Based on the Biomechanical Study.

Scaphoid nonunion causes abnormal wrist kinematics and typically leads to carpal collapse and subsequent degenerative arthritis of the wrist. However, the natural history, including carpal collapse and degenerative arthritis of scaphoid nonunion, may vary at different fracture locations. This article reviews recent biomechanical studies related to the natural history of scaphoid nonunion. In the distal-type fractures (type B2 in Herbert classification), where the fracture located distal to the scaphoid apex, the proximal scaphoid fragment and lunate, which are connected through the dorsal scapholunate interosseous ligament (DSLIL) and dorsal intercarpal ligament (DIC), extend together, and the distal fragment of the scaphoid flexes individually. Therefore, untreated type B2 fractures normally show the humpback deformity, resulting in dorsal intercalated segment instability deformity relatively earlier after the injury. In the proximal-type fractures (type B1), where the fracture is located proximal to the scaphoid apex, the connection between the distal fragment and lunate is preserved through the DSLIL and DIC so that the scaphoid-lunate complex remains stable and the carpal collapse is less severe than that in distal-type fractures. The fracture location relative to the apex of the dorsal scaphoid ridge is a reliable landmark in the determination of the natural history of scaphoid nonunion.

The presentation of scaphoid non-union

A retrospective study of 30 patients presenting with scaphoid non-union was performed. The results showed that eight had been treated in plaster for a mean of 6 weeks and discharged from follow-up. They presented with established non-union at a mean of 60.3 months after the original fracture. Three of these cases have resulted in litigation against the surgeon. A total of 27 patients underwent bone grafting and Herbert’s screw fixation achieving in union in 24. The natural history of scaphoid non-union has been examined in some detail in the literature. These studies have shown that scaphoid non-union is inevitably associated with arthritic changes that become worse with time and that freedom from symptoms is not protective from these changes. Therefore, prompt diagnosis and treatment of scaphoid non-union is vital, whether symptomatic or not, to prevent osteoarthritis developing in the future. Inadequate follow-up of treated scaphoid fractures will result in delayed diagnosis and treatment of non-union with a potentially impaired outcome and even litigation against the surgeon. It is the authors’ advice that all scaphoid fractures treated in a plaster cast are reassessed clinically and radiologically 6 months post-injury.

The natural history of scaphoid non-union. Radiographical and clinical analysis in 102 cases.

A retrospective radiographic and clinical analysis of 102 symptomatic patients with 104 scaphoid nonunions of at least 1 year's duration was conducted. Osteoarthritis occurred in 22% of non-unions of less than 5 years' duration, 75% of those of 5 to 9 years' duration, and 100% of those of 10 years' duration or more. An all-over incidence of osteoarthritis in the wrist was 55%. Osteoarthritic changes occurred initially at the scaphoid-radial styloid joint which were manifested by radial styloid pointing and/or dorsal radioscaphoid osteophyte formation, later progressing to the midcarpal joint. Osteoarthritis at the scaphoid-radial styloid joint was significantly associated with dorsiflexed intercalated segment instability (DISI) deformity. An overall incidence of DISI deformity of the wrist was 56%, and the frequency of DISI pattern increased with longer duration of non-union. There was an increased incidence of avascular necrosis of the proximal fragment with time, especially after 20 years. There was no correlation between symptoms of pain and the severity of arthritis or the duration of non-union, but a good correlation between the duration of non-union and reduced grip strength or decreased wrist motion. A symptomatic non-union of the scaphoid is significantly likely to progress to osteoarthritis according to a predictable sequence, becoming worse both radiographically and clinically with time.

Nonunion of the scaphoid: A critical analysis of recent natural history studies

To determine whether treatment of a disorder is effective, a surgeon must first understand the natural history of the disorder without treatment. We used guidelines for the performance of a valid natural history study that appear in the literature and applied them to articles on the natural history of scaphoid nonunion. No study satisfied all criteria. Moreover, none developed an inception cohort, which is the single most important method of a valid natural history study. In each study, the direction of the bias was identifiable: the natural history of scaphoid nonunion was distorted to make the outcome more severe than if methodologic problems had not been present. We conclude that the natural history of nonunion of the scaphoid is not as severe as has been reported in the literature. The magnitude of the difference is not known at this time.

Natural history of scaphoid non-union, with special reference to "asymptomatic" cases.

33 patients with non-union of the carpal scaphoid were diagnosed by X-ray examination two to 37 years following the original trauma. All of the patients could be contacted and summoned for a re-examination ten to 17 years later. X-rays revealed a 100% incidence of progressive radio-carpal osteoarthritis. It is concluded that freedom of pain is not a reliable prognostic indicator, and that all patients with non-union of the carpal scaphoid are likely to benefit from surgical treatment of the pseudarthrosis. The only exception to this rule might be the patient in whom the radio-carpal joint is already deteriorated by an advanced degenerative arthritis.

Scaphoid Nonunion

Scaphoid nonunion is common, but the exact pathophysiology of this complication is unclear. Explanations include lack of treatment, poor initial treatment, delay in diagnosis, synovial fluid dynamics, precarious vascularity, fracture displacement, and carpal instability. Currently, the diagnosis is best confirmed by classic changes on plain radiographs, instability testing, arthrography, and arthroscopy in selected cases. Nine carpal bones are not benign. The natural history of scaphoid nonunion is one of progressive arthritis. Attempts at obtaining bony healing are therefore recommended. In treating established nonunions without arthritis, the Russe bone graft technique is the mainstay of treatment. A union rate of 90 per cent is to be expected. Electrical stimulation is an alternative when there is no synovial pseudarthrosis or scaphoid collapse deformity, or if a previous Russe graft has failed. If a significant humpback scaphoid or collapse deformity is present, internal fixation with the Herbert screw and scaphoid reconstruction with a bone graft are our choices. Healing rates are less than those with the Russe graft, but one may achieve improved motion of the wrist and earlier return to function. When scaphoid nonunion is accompanied by degenerative arthritis, salvage procedures are recommended. Radial styloidectomy is a simple procedure that will preserve motion and buy time. Soft tissue interposition with excision of a small proximal pole is useful, particularly if no collapse deformity is present. Silicone replacement alone has fallen into increasing disfavor because of the high incidence of subluxation and silicone synovitis. Combining silicone replacement with intercarpal fusion (the SLAC procedure) may lessen these complications. Proximal row carpectomy is another procedure that may preserve motion, though often at the expense of weakness, particularly in the younger patient requiring significant grip strength. In these cases, standard wrist fusion seems the most predictable alternative.

The natural history of scaphoid non-union. A review of fifty-five cases.

We reviewed the cases of fifty-six scaphoid non-unions in fifty-five patients, none of whom had received treatment of any kind before examination. In the thirty-two patients who had been injured five years or more earlier, arthritis developed in thirty-one (97 per cent). The one patient in whom osteoarthritis developed less than four years after injury also had avascular necrosis of the scaphoid. The incidence of osteoarthritis increased with time after injury. We concluded that patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop.

The natural history of scaphoid non-union.

We reviewed the clinical and roentgenographic findings of forty-seven non-unions of a fracture of the scaphoid in forty-six symptomatic patients in order to assess the incidence and severity of degenerative changes of the wrist. The duration of non-union ranged from five to fifty-three years. Three roentgenographic patterns were seen: twenty-three lesions had sclerosis, cyst formation, or resorptive changes confined to the scaphoid bone (Group I); fourteen had radioscaphoid arthritis (Group II); and ten had generalized arthritis of the wrist (Group III). The duration of Group-I non-unions averaged 8.2 years; Group-II, 17.0 years; and Group-III non-unions, 31.6 years. Fracture displacement and carpal instability correlated with the severity of degenerative changes. Lunate dorsiflexion of 10 degrees or more was a useful guide to carpal instability. Few of the forty-seven non-unions were undisplaced, stable, or free of arthritis after ten years. Based on the high probability of arthritis, we recommend that all displaced ununited scaphoid fractures be reduced and grafted, regardless of symptoms, before degenerative changes occur. Asymptomatic patients with an undisplaced, stable non-union should be advised of the possibility of late degenerative changes.