Proximal Pole Fractures Research Articles

Acute scaphoid fractures and non-unions

The diagnosis of scaphoid fractures requires a high index of suspicion, with a focus on the mechanism of injury and careful clinical examination. A scaphoid series of radiographs is required but if negative does not rule out a fracture. If there is clinical suspicion for fracture, one should obtain an MRI scan, which has the highest sensitivity and specificity for diagnosis. The management of acute scaphoid fractures is dependent largely on fracture location and displacement, although there are other factors to consider. On the whole, distal pole fractures can be managed conservatively and proximal pole fractures surgically, as the latter have poorer healing potential with a risk of avascular necrosis, due to a retrograde blood supply. The controversy lies with scaphoid waist fractures. One should consider surgical management for displaced waist fractures. The surgical approach is dependent on the fracture location and the surgeon's individual preference. Scaphoid non-union predictably leads to arthritis of the wrist, and therefore should be managed upon diagnosis. Reconstructive surgery provides the best outcomes, and more research is required into conservative treatments. Recent times have seen an increase in the use of vascularized bone grafts. In cases where there is established arthritis, salvage options include scaphoidectomy with four-corner fusion, proximal row carpectomy, total wrist arthroplasty and arthrodesis.

Proximal Pole Scaphoid Fractures: A Computed Tomographic Assessment of Outcomes

To report on union rates and times for a cohort of acute nondisplaced or minimally displaced proximal pole fractures evaluated with serial computed tomography (CT) scans. All patients with isolated acute proximal pole scaphoid fractures (< 6 weeks from injury) who presented at our institution between 2006 and 2013 were identified. Each subject's health record, CT scans (performed at initial assessment and serially to document healing), and x-rays were retrospectively reviewed to determine details of injury, treatment course, and treatment outcome. Union incidence and time to union were determined based on CT scan results. The effect that each predictor variable had on union, nonunion, and delayed union was assessed. This cohort consisted of 53 patients with proximal pole scaphoid fractures (47 males and 6 females; mean age, 30 ± 17 years). The overall union incidence with cast treatment was 90% (47 of 52). The study was underpowered to detect any factors that were predictive of developing a nonunion with cast treatment with the exception of a slight delay to seeking treatment. Average time to union was 14 ± 8 weeks for cases treated with surgical fixation (n= 4; cases that failed casting and were subsequently treated surgically) and 14 ± 12 weeks for cases treated with casting alone. Factors found to be correlated to longer union times included fracture translation (r= 0.30) and the presence of cysts or comminution. The reported union incidence and union times in this study compared favorably with the literature. Risk factors that were associated with a significantly greater time to union included fracture comminution, the presence of cysts, and fracture translation. Our sample size was relatively small, and other limitations inherent in the retrospective design must be considered. Prognostic IV.

Current concepts for the treatment of acute scaphoid fractures.

Fractures of the scaphoid are common injuries, accounting for approximately 80 % of carpal fractures. Differentiation between stable and unstable fractures (Herbert classification) cannot be made with conventional X-rays, so evaluation by computed tomography should additionally be performed. Under most circumstances, minimally invasive surgery with cannulated screws is the treatment of choice. A longer cast immobilization after minimal-invasive surgery is not necessary. Conservative treatment still has a place if the fracture is not dislocated nor unstable, but operative treatment can be offered to reduce the period of cast immobilization. Displaced fractures have a greater risk for nonunion and therefore should be treated operatively. Proximal pole fractures are definitely unstable, requiring treatment with screw fixation. The surgical approach depends on the location of the fracture and the preference of the surgeon.

The Palpable Scaphoid Surface Area in Various Wrist Positions

To determine the theoretical amount of surface area available for palpation of the scaphoid in various wrist positions and to provide a guide depicting which wrist position will expose proximal pole, waist, and distal pole fractures. Using 3 fresh-frozen male cadaver wrists, we digitized palpable surface areas (dorsal, volar, and snuffbox) of the scaphoid in several wrist positions. The entire scaphoid was then excised and a digitized 3-dimensional reconstruction of the entire scaphoid was obtained. The 2 images were superimposed and the surface area was calculated The maximum palpable area of the scaphoid was achieved with the wrist in neutral extension and maximum ulnar deviation and the wrist in maximum flexion and neutral deviation. Neutral wrist extension and ulnar deviation exposed all but the most proximal portion of the proximal pole and the distal pole, which made this the ideal position to detect tenderness from a scaphoid waist fracture and larger proximal pole fractures. Maximum wrist flexion with neutral wrist deviation exposed the entire proximal pole, which made this the ideal position to detect tenderness from a proximal pole scaphoid fracture. Wrist position influences the amount of scaphoid surface area available for palpation and should be considered when examining a patient with a suspected scaphoid fracture. The scaphoid should be palpated in 3 anatomic regions with the wrist placed in different positions to maximally expose the anatomical region being palpated.

Fixation and Grafting After Limited Debridement of Scaphoid Nonunions

To evaluate a surgical technique of treating nondisplaced waist and proximal pole scaphoid nonunions without avascular necrosis (AVN). We performed a retrospective review of all patients with nondisplaced, scaphoid waist or proximal pole nonunions without AVN treated with the following technique. Two K-wires are positioned along the scaphoid axis to stabilize the proximal and distal poles. Debridement with a curette or burr is performed parallel to the nonunion site until the K-wires are visualized and punctate bleeding of the proximal and distal fragments is encountered. The volar, radial fibrous union is left intact. Distal radius cancellous bone graft is packed into the nonunion site. A headless screw is placed perpendicular to the fracture and the K-wires are removed. Between 2012 and 2014, 12 patients (ages 13-29 y) with clinical and radiographic evidence (10 had computed tomography or magnetic resonance imaging; 2 had radiographs only) of scaphoid nonunion were identified (10 transverse waist and 2 proximal pole fractures). Median interval from injury to surgery was 38 weeks (range, 3 mo to 9 y). Four patients were active smokers and 2 had failed previous iliac crest bone grafting. All patients healed as confirmed by computed tomography. Average time to union was 14 weeks (range, 6-31 wk). Four patients had delayed union requiring a bone stimulator. All patients had resolution of pain and there were no complications. The technique described is an effective and efficient method of treating nondisplaced scaphoid nonunions without AVN. We suggest that complete debridement of the nonunion is not essential to achieve union. In addition, pinning the proximal and distal scaphoid poles initially and maintaining the volar fibrous union of the scaphoid nonunion stabilizes the fracture fragments, increasing the technical ease of grafting and fixation. Therapeutic IV.

Low-intensity pulsed ultrasound for treating delayed union scaphoid fractures: case series.

BackgroundThe standard treatment to enhance fracture healing of scaphoid nonunions is surgery. Low-intensity pulsed ultrasound (LIPUS) is gaining in popularity as an alternative treatment to improve fracture healing; however, little is known about success rates of this treatment in scaphoid-delayed unions. The purpose of our study is to define the success rate of LIPUS treatment for delayed union of scaphoid fractures and further analyze whether initial management or fracture type influences success rate.MethodsDuring the period of 2011–2013, in the central orthopedic clinic of our institution, patients diagnosed with delayed union of the scaphoid were offered with LIPUS treatment as an alternative to conventional surgical treatment. These patients were then divided into subgroups according to the time elapsed from initial injury until diagnosis of the fracture.ResultsOverall, 22 of 29 (76 %) fractures healed, 12 of 13 (92 %) of the early diagnosed group, and 10 of 16 (63 %) of the late diagnosed group. Difference in healing rate between proximal pole, waist, and distal pole fractures was not statistically significant.ConclusionLIPUS can help heal delayed union scaphoid fractures, especially in fractures diagnosed and treated soon after injury and may serve as an alternative to surgical treatment.

Compression screw fixation without bone grafting for scaphoid fibrous nonunion.

Bone graft is often recommended as an adjuvant for treatment of scaphoid nonunions. However, recent literature has suggested that fibrous nonunion may be suited to treatment with rigid fixation without bone grafting. This work reported on outcomes of compression screw fixation for established scaphoid fibrous nonunions without bone graft. Fourteen patients underwent surgical compression screw fixation without bone grafting of scaphoid fibrous nonunion between January 1, 2000, and December 31, 2012, with minimum follow-up until the time of clinical and radiographic healing. Fibrous nonunion of the scaphoid was defined as a scaphoid fracture with all of the following features: (1) persistent tenderness, (2) incomplete trabecular bridging on three X-ray views, (3) injury that had occurred at a minimum of 6months prior to surgery, and (4) identification of fibrous union at the time of surgery. Outcomes were assessed with range of motion assessment, Disability of the Arm, Shoulder and Hand (DASH) scores, and plain radiographs. Twelve of the 14 patients healed successfully, while two patients required secondary vascularized bone grafting. Both unhealed patients sustained proximal pole fractures and had a duration of ≥1year from injury to surgery. Average time to healing was 4.4 ± 2.0months. Average flexion was 73 ± 22° and average extension was 66 ± 22° postoperatively. Average grip strength was 90 ± 25 lbs on the operative side. Mean postoperative pain score was 1.4 (range, 0 to 7). Mean postoperative DASH score was 10.2 (range, 0 to 52). Increasing age and an interval from injury to surgery of >1year correlated with worse DASH and pain scores. Patients with fibrous scaphoid nonunion demonstrated good results with rigid fixation without bone grafting. Increasing age and >1-year interval between injury and surgery resulted in lower self-assessed outcomes. Therapeutic Level IV, retrospective case series.

The Pediatric Fracture of the Scaphoid in Patients Aged 13 Years and Under

Fractures of the scaphoid are uncommon in the pediatric population. Despite their rarity, a significant number of children are referred to the fracture clinic for a suspected scaphoid fracture. The aim of this study was to report on the current incidence, pattern of injury, and the long-term outcomes following this injury in the pediatric population. Analysis of all pediatric scaphoid fractures presenting to a tertiary pediatric hospital (aged 13 y and under) over a 5-year period was performed. The case notes, radiographs, and other imaging studies for these patients were reviewed. Long-term functional outcome was assessed using Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Fifty-six patients of the 838 (6.7%) referred for a suspected scaphoid fracture were identified as having a confirmed diagnosis of a scaphoid fracture, giving an average annual incidence of 11 per 100,000. This group consisted of 39 boys (70%) and 17 girls (30%). The average age of incidence in boys was 12.2 years and in girls was 10.3 years (P<0.001). No scaphoid fractures were observed in boys below the age of 11 years and in girls below the age of 9 years. The most common type of fracture was a distal pole fracture (45 patients). One patient sustained a proximal pole fracture and went on to develop a nonunion. The duration of treatment in cast was shorter in distal pole fractures than in other types (P<0.001). At a mean follow-up of 70 months (range, 46 to 104 mo), 60% reported no limitation or impact when reporting a range of daily functional activities (mean DASH score=3.0). There is a suggestion that the overall incidence of scaphoid fractures in the pediatric population is increasing, but children aged 13 years and under continue to maintain a distinct fracture pattern when compared with adolescents and adults. The majority involves the distal third of the scaphoid and carries a good prognosis with conservative management. Prognostic study, Level 4.

Use of Computed Tomography to Predict Union and Time to Union in Acute Scaphoid Fractures Treated Nonoperatively

To use computed tomography to determine whether factors could be identified to predict union for acute scaphoid fractures treated nonoperatively. We used a radiology database at a tertiary care center to identify scaphoid computed tomography scans performed between 2004 and 2010. We noted fracture location, fracture orientation, translation between fragments, humpback deformity, comminution, cysts, and sclerosis. We determined the associations between imaging variables on union rates and time to achieve union with casting alone in a cohort of 219 patients (mean age, 31 y; 83% males). Most fractures were scaphoid waist fractures (173 of 219; 79%), of which 178 (81% of total group) were nondisplaced. There were 28 proximal pole fractures (13%) and 18 distal pole fractures (8%). The overall union rate was 95% (207 of 219). The odds of developing a nonunion were increased in fractures with translation (odds ratio, 3.4) or with a humpback deformity (odds ratio, 6.9). The presence of sclerosis or cysts did not correlate with union rates. There was no statistical association between successful union and fracture location, although, given the small number of proximal pole fractures, we were underpowered for this finding. Time to union was longer for proximal pole fractures (113 d) versus distal pole (53 d) and waist fractures (65 d) and for fractures with sclerosis (166 vs 67 d) or comminution (103 vs 66 d). We were able to identify a number of features that contributed to risk of nonunion or delayed union based on computed tomography scan. Factors such as fracture translation, comminution, and humpback were related to a higher risk of scaphoid nonunion. Factors such as sclerosis, comminution, translation, and location in the proximal pole were associated with longer times to union. These variables were independently significant in increasing the time required to achieve union and were shown to have an overall additive effect. Prognostic II.

INTERCALATED BONE PEG IN THE TREATMENT OF NON-UNITED SCAPHOID FRACTURES

Untreated ununited scaphoid fractures will almost inevitably progress to radiographic and symptomatic osteoarthritis of the wrist. This may lead to subsequent morbidity and lifelong disability especially in young males in which the fracture scaphoid is more common. Twenty-one patients presenting non-united fracture scaphoid were operated upon by using disto-proximal bone peg technique with average time between injury and operation as 11 months (6-18 months). All of them male with average age of 26 years (17-35 years). There were 17 patients with fracture waist (80.9%) and four patients with fracture proximal pole (19.1%). Anatomy of the wrist was restored and radiological healing confirmed in 17/21, partial healing in 3/21 and non-union in 3/21 patients. Eighteen patients (85.7%) were graded as satisfactory, 5 patients (23.8%) were graded as excellent, ten patients (47.6%) were graded as good, and three patients (14.3%) were graded as fair. The remaining three patients (14.3%) were graded as unsatisfactory. We conclude that the disto-proximal bone peg technique of taking the graft from the ipsilateral ulna without using any metal work for fixing scaphoid non-union fracture is a reliable, easy, and inexpensive alternative method. However, we would not recommend it for the non-union of the scaphoid proximal pole fracture. Also we find the time lag before operation is one of the most important factors to achieve union in non-united fractures of the scaphoid. Therapeutic case series, level 1V.

Central Versus Eccentric Internal Fixation of Acute Scaphoid Fractures

To accurately calculate the cross-sectional area of typical scaphoid fracture patterns and compare the amount of fracture surface area available for healing when a screw was positioned in the center of the scaphoid (central) versus perpendicular (eccentric) to the fracture plane. We employed a laser scanning technique to create 3-dimensional models of the scaphoid and permit the precise calculation of area along any cross-sectional cut of the bone. We computed approximate bone apposition areas for typical acute Herbert and Fisher fractures for 10 dry bone specimens. Next, we modeled internal fixation for each of these fracture geometries with screws placed either along the central axis of the scaphoid or eccentrically, perpendicular to the fracture plane. We calculated the proportional areas occupied by the screw and remaining area available for fracture healing. The mean surface area of the simulated distal oblique, complete waist, and proximal pole fractures was 131, 86, and 58 mm(2), respectively. There was little difference in available area for complete waist and proximal pole fractures, but eccentric screw fixation perpendicular to the plane in distal oblique fractures consumed significantly less area than the centrally placed position. The area available for apposition is widely variable and depends on each bone's unique morphology, the orientation of the fracture plane, and the design of the screw. Of the 3 fracture patterns studied, the obliquity of the screw with respect to the long axis was greatest for distal oblique fractures where perpendicular (eccentric) placement is preferable to maximize surface area available for healing. Given the poor vascular supply of the scaphoid and morbidity associated with scaphoid fracture nonunions, this study examined a key determinant of bone healing by characterizing the area of these fractures and amount of bone apposition available for blood flow and healing when internally fixed with a compression screw.

Non-vascularized bone graft with Herbert-type screw fixation for proximal pole scaphoid nonunion

BackgroundSince proximal pole fractures of the scaphoid are frequently overlooked, the poor vascularity in the proximal pole fragment often leads to nonunion. Vascularized bone grafts have been recently tested in cases with scaphoid proximal pole nonunion, but the indication for this treatment has not been well established. Alternatively, we have been treating such patients with a non-vascularized iliac bone graft and Herbert-type screw fixation with considerable success. The purpose of this investigation is to evaluate these cases retrospectively and clarify the surgical efficacy of our procedure. MethodsBetween 1996 and 2009, 11 consecutive patients with proximal pole scaphoid nonunion were treated with a non-vascularized corticocancellous iliac bone graft and Herbert-type screw fixation. They were all male aged from 12 to 26 years. In two patients, avascular changes were recognized in the proximal pole in preoperative radiographs or MRI. Follow-up ranged from 12 to 76 months. ResultsBone union was radiographically confirmed in all patients, who returned to their former activities without any complications. The period from operation to union ranged from 12 to 24 weeks. The mean Mayo modified wrist score was 76.4 points preoperatively and 91.4 points postoperatively, and was improved in all cases. ConclusionsA non-vascularized iliac bone graft with Herbert-type screw fixation obtained satisfactory clinical and radiographic results in cases with scaphoid proximal pole nonunion, regardless of the vascularity in the proximal fragment.

Bilateral Simultaneous Fracture of the Carpal Scaphoid Successfully Treated with Conservative Cast Immobilisation: A Case Report

The scaphoid is the most prominent of the carpal bones in the first row and the most frequently fractured of all the carpal bones. Bilateral simultaneous scaphoid fractures are uncommon. To report bilateral simultaneous fractures of the carpal scaphoid bones and their successful treatment with bilateral thumb spica casts A 28-year-old medical practitioner presented with a day history of painful swollen wrists following a fall on both outstretched hands. He was fully examined and had both wrists X-rayed. He was subsequently treated with bilateral below elbow thumb spica POP cast. He had previously been healthy until this fall. Physical examination showed a healthy looking young man in pain. There were swelling and tenderness over both anatomical snuff boxes with associated limitation of movements at the wrists. X-rays revealed an undisplaced scaphoid wrist fracture and proximal pole fracture on the right and left respectively. He was successfully treated with bilateral below elbow thumb spica POP cast applied over a period of eight weeks. Although recent opinions tend to favour internal fixation for bilateral simultaneous fractures of the scaphoid bones to avoid prolonged cast immobilization and loss of man hours at work, they can be successfully treated with conservative cast immobilisation with comparatively early return to full activity.

Delays and Poor Management of Scaphoid Fractures: Factors Contributing to Nonunion

Scaphoid fracture nonunion remains prevalent, and it was our purpose to examine the initial care, fracture site, and patient gender and age to determine factors contributing to fracture nonunion. The charts of 96 consecutive patients with 99 scaphoid fracture nonunions were reviewed for demographic information, and contact was made with 85 patients (with 88 scaphoid nonunions) to determine the pattern of presentation and initial treatment, if any. Of the 88 scaphoid nonunions, 78 were in men, and 46 were sports injuries; 7 patients had no recollection of an injury. Twenty were proximal pole fractures. For 57 fractures, patients sought care following their injury, but only 42 were diagnosed with scaphoid fractures and received appropriate treatment, although one did not follow up in the clinic. Fifteen patients with nonunions did not receive radiographic investigations or did not have an identifiable fracture on initial x-rays and received no further follow-up or treatment. For 27 nonunions, medical attention was sought but was delayed, with an average time of 57 days between injury and initial assessment. For 31 fractures, medical attention was not sought for the acute injury but presented later following a re-injury (17 nonunions) or with progressive pain or stiffness (13 nonunions). The high rates of delayed presentation and incomplete evaluation and treatment suggest a strong need for better patient and doctor education on the subject of scaphoid injuries and nonunions particularly because the initial injury is, unfortunately, sometimes perceived as trivial. Nonunions do occur despite appropriate immobilization. Proximal pole fractures and fractures that show inadequate progression toward union while being treated in a cast should be considered for surgical intervention based on the high number of such cases identified in this study.

Fixation Techniques for Non-Union of the Scaphoid

To compare outcomes of 3 fixation modalities for scaphoid non-union. 27 men and 6 women aged 20 to 48 (mean, 28) years with non-union of the scaphoid involving the proximal pole (n=13), waist (n=12), and distal pole (n=8) were randomised to undergo the Herbert screw fixation (n=11), the Matti Russe bone grafting (n=9), or the Kohlman modification of vascularised muscle pedicle graft procedure (n=13). The mean duration of non-union was 10 (range, 6-30) months. The mean follow-up duration was 28 months. 30 of 33 achieved correction of both scapholunate and radiolunate angles. The mean range of motion increased from 112 to 155 degrees. The mean grip strength increased by 30%. Functional outcomes of the 3 groups were comparable; they were excellent in 13 patients, good in 10, fair in 6, and poor in 4. There was no hardware failure or any iatrogenic fracture during pedicle dissection. One patient had a superficial infection, which was resolved after antibiotic treatment. At the 6-month follow-up, in the respective 3 groups, 8, 6 and 11 patients achieved scaphoid union after mean intervals of 17, 16, and 15 weeks. The time to union was earliest in the Kohlman modification of vascularised muscle pedicle graft procedure, which is recommended for patients with old non-union (>1 year) or proximal pole fractures.

The assessment and management of acute scaphoid fractures and non-union

Abstract The management of scaphoid fractures can be challenging. The diagnosis of a fracture should be made following a suggestive mechanism of injury, positive clinical findings and confirmatory radiographs. In the case of normal radiographs the patient should be immobilized and re-examined in 2 weeks. If a scaphoid fracture is still clinically suspected but repeat radiographs are normal, further imaging is indicated. The gold standard is an MRI scan, but this is dependent on the facilities available in the local hospital. An MRI has the added benefits of not only identifying a potential scaphoid fracture but also other causes for the symptoms such as a ligament injury. Stable fractures can be safely treated by immobilizing in a cast; usually a simple below elbow cast with the wrist in slight extension and the thumb left free is adequate. If a patient elects to have a proximal pole fracture treated non-operatively then the thumb should probably be included. The cast should be continued for a maximum of 12 weeks and then removed regardless of clinical or radiological features. Surgical treatment should be considered for unstable fractures of the scaphoid, which includes displaced waist and proximal pole fractures. The surgical approach will depend upon the fracture location and preference of the individual surgeon. Compression screws should be used whenever possible. There are occasions in which fixation of undisplaced waist fractures using percutaneous techniques may be beneficial and this should be considered on a case-by-case basis. The management of scaphoid non-unions can be daunting and controversial. The best treatment of non-unions is to prevent them from developing by identifying those fractures which are unlikely to unite and treating them properly acutely. Whilst the development of non-union can be anticipated in approximately 10% of all fractures, it is more common in proximal fractures, displaced fractures, comminuted fractures, and those which have a delayed presentation. The decision of who and when to treat can be difficult and the patient must be involved in this process. Once it is decided that operative treatment is necessary the available options depend upon the presence of arthritis and the blood supply of the proximal pole. Union is most reliably achieved with a cortico-cancellous bone graft and headless compression screw fixation. If avascular necrosis (AVN) is evident then the best results are achieved with a vascularized graft. Despite grafting 20% will still not unite and a salvage procedure may prove necessary.

A Computational Approach to the “Optimal” Screw Axis Location and Orientation in the Scaphoid Bone

The development of small cannulated screws permitted minimally invasive percutaneous fixation of acute scaphoid fractures. There are known mechanical advantages to increased screw length and central screw placement, as well as documented deleterious effects of screw malposition, including articular protrusion, proximal pole fracture, and nonunion. The purpose of this study was to compare 2 methods of calculating a screw axis accessible via a volar surgical approach. To prevent screw protrusion through the surface of the scaphoid, we required the central screw axis to be contained completely within a "safe zone," defined as a 3-dimensional region located a fixed distance from the inner cortical surface. Safe zones were calculated based on computed tomography-generated models of the right scaphoid from 10 healthy subjects. Two methods for screw axis calculation were compared: (1) maximum screw length (MSL) within the safe zone and (2) a cylinder best-fit (CYL) to the safe zone. The volar approach was defined as percutaneous screw placement through the scaphoid tubercle without violation of the trapezium. Resultant screw axes were compared between the 2 methods for volar accessibility, screw length, and location of the screw axis. The MSL axes were completely accessible without violating the trapezium in all but 2 subjects. The average MSL axes were 11% longer than the CYL axes and passed significantly closer to the scaphoid tubercle than did the CYL axes (1.8 mm vs 6.4 mm). The MSL axes passed significantly farther (1.6 mm) from the bone centroid than did the CYL axes (0.4 mm). All 10 MSL axes were located in the central one-third of the proximal pole. Without violation of the trapezium, MSL axis can be attained via the volar percutaneous approach to the scaphoid. Using this approach, the ideal starting point for maximal screw length was located 1.7 mm dorsal and 0.2 mm radial to the apex of the scaphoid tubercle.

Retrospective Review of 234 Scaphoid Fractures and Nonunions Treated with Arthroscopy for Union and Complications

The purpose of this paper is to retrospectively review 234 consecutive cases of scaphoid fractures and nonunions treated using arthroscopy with the dorsal percutaneous implantation of a headless compression screw for healing and complications. Solid union of fracture is determined by CT scan. We identified 126 acute injuries, including 65 proximal pole fractures; 67 grossly displaced fractures; 12 trans-scaphoid perilunate dislocations including four trans-scaphoid trans-capitate fractures; and ten combined scaphoid and distal radius fractures. 108 scaphoid nonunions were identified. 98 were correctly aligned and ten had a humpback deformity which was correctable using arthroscopic assisted reduction techniques at the time of surgery. 82 presented with a fracture gap 2mm or greater requiring percutaneous bone grafting. 12 cases of avascular necrosis (AVN) were identified by MRI. 20 nonunions had surgery performed at other institutions. The mean time to surgery for the nonunions was 20 months. 99% union rate of acute scaphoid fractures was obtained by 12 weeks, as determined by CT scan. Two complications were identified (3%). One case of delayed healing was identified. this delayed union was treated with percutaneous bone grafting and continued on to heal uneventfully. The other complication was a case of volar trans-scaphoid peri-lunate dislocation. While the fracture healed, the patient developed a traumatic dislocation requiring a capitate-lunate arthrodesis. Treatment of scaphoid nonunions resulted in ten cases of delayed healing, which were treated with repeat percutaneous bone grafting. This represented a 9% complication rate. of the ten cases of delayed unions that were re-bone grafted, four failed to heal by nine months. This resulted in a 96% union rate of our nonunion group by nine months. when acute fracture healing was compared to nonunions the average healing of acute fractures as determined by CT scanning measuring trabecular bridging was 12 weeks, while the average healing of non-unions was 22 weeks. We conclude that the dorsal percutaneous treatment of scaphoid fractures and nonunions using arthroscopy is safe and effective. CT scans to evaluate scaphoid healing by measuring trabecular bridging at the fracture site was determined to be an excellent modality to evaluate scaphoid healing. While not witnessed in this series, the potential for complications requires proper training.

Treatment of Acute Scaphoid Fractures

Whether operative treatment is a better option than nonoperative treatment for acute nondisplaced or minimally displaced fractures of the scaphoid is controversial. The type of cast that should be used for nonoperative treatment is not known. We performed a systematic review and meta-analysis of randomized and quasirandomized trials to evaluate the effect of operative versus nonoperative treatment and the effect of different casting methods for nonoperative treatment of acute scaphoid fractures on nonunion rate, return to work, grip strength, range of wrist motion, complications, patient evaluation, and incidence of osteoarthritis. Two investigators assessed trial quality and extracted data. Operative treatment of acute nondisplaced or minimally displaced fractures of the scaphoid waist does not provide greater benefits regarding nonunion rate, return to work, grip strength, range of wrist motion, or patient satisfaction than cast immobilization; however, it causes more complications and, perhaps, a higher risk of scaphotrapezial osteoarthritis. There is no evidence from randomized trials to determine whether operative treatment is superior to nonoperative treatment for an acute proximal pole fracture of scaphoid bones. There is insufficient evidence to determine which type of cast should be used in nonoperative treatment of nondisplaced scaphoid fractures.

Dorsal Distal Radius Vascularized Pedicled Bone Grafts for Scaphoid Nonunions

Fractures of the scaphoid, particularly its proximal pole, are at risk of progressing to nonunion because of the tenuous, retrograde blood supply. The overall incidence of scaphoid fractures developing nonunion ranges from 10% to 15%, whereas proximal pole fractures of the scaphoid can have up to a 30% incidence of nonunion. Avascular necrosis of these proximal pole fractures can occur in 14% to 39% of cases. Dorsal distal radius vascularized pedicled bone grafting is an alternative to conventional measures for the treatment of displaced proximal pole fractures, established nonunions, and avascular necrosis of the proximal fragment. This graft is based on the 1,2-intercompartmental supraretinacular artery, which has reliable anatomy and predictable course between the first and second extensor compartments. The graft can be harvested and inset into the prepared fracture site using a single-incision approach. The indications, contraindications, technique, and results of treatment are reviewed and detailed.