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Coimbatore, India.

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Scaphoid Fracture And Nonunion


What is a scaphoid fracture?

The scaphoid is a boat shaped bone in the wrist. It is the most commonly fractured bone in the wrist, usually due to a fall on an outstretched hand. The shape of the bone, along with its position and mobility within the wrist, make it so prone to injury.

What is scaphoid non-union?

Due to certain reasons [see below], the fracture of the scaphoid has a tendency to not heal or unite. When such nonunion occurs, the mechanics of the joint is altered leading to early degeneration or arthritis of the joint.

Why does the scaphoid not unite?

Being a small bone, it is difficult to hold correct position and keep the fracture stable. In addition, the blood supply of the bone also gets affected severely with a fracture, also impairing healing.

How is a scaphoid fracture treated?

A fracture that has not displaced at all can be managed without surgery, with only a plaster cast for 3 months. However, such fractures are a minority. So the preferred method is screw fixation. In some fractures, this can be done without open surgery by placing the screw directly while viewing under a portable XRay. More severe injuries require open surgery for placing a screw.

How long does this take?

Given the high risk and grave danger of the fracture not uniting, it is wise to tread carefully in such cases. The patient is placed in a cast or plastic splint for 3 months. Hospital stay for surgery is only two days.

After initial treatment I have developed a nonunion. What can now be done?

Nonunion requires open surgery. Apart from screw fixation, bone graft taken from elsewhere also needs to be placed on the fracture to promote healing. However, some may develop avascular necrosis of the bone and this needs problem needs a different approach to management.

What is avascular necrosis [AVN]?

Lack of blood supply to a fracture fragment causes the tissue to die. This is termed avascular necrosis or AVN. In scaphoid fractures, they are usually seen along with nonunions though not all nonunions lead to AVN.

How can AVN be treated?

AVN requires that the blood supply to the bone also be improved. Hence, the bone graft is taken along with its own blood supply [vascularised bone graft]. This is usually done from the radius bone of the forearm.

I have an old scaphoid injury, undergone multiple surgeries and still have pain. Can anything be done now?

Old injuries are quite complex problems that require detailed evaluation and planning. They are best taken care of in experienced wrist centres like Ganga Hospital. Each patient has to be assessed and a personalised plan formulated. Many of these patients have been operated upon with substantial improvement in their quality of life.

Preoperative Xrays of Scaphoid Fracture



United after Screw Fixation



Post Operative Wrist Movement



Nonunion of Scaphoid



United Fracture after Bone Grafting



Post Operative Wrist Movement.





SCAPHOID NON-UNION RECONSTRUCTED WITH MEDIAL FEMORAL CONDYLE CORTICO CANCELOUS FREE FLAP


What is the problem?

Scaphoid fracture resulting in non-union with avascular necrosis is a reconstructive challenge. Surgical options are many which include non-vascularized and vascularized bone graft.

What is the role of vascularized bone graft?

Medial femoral condyle (MFC) flap contains cortico cancelous bone. This flap is based on descending genicular artery. The healing rate achieved by this flap over conventional bone graft is far superior. This technique also preserves the scapholunate ligament which is very important for the wrist stability and movement.

How is it done?

Patients with scaphiod non-union after thorough curettage of the nonviable bone a defect is created. Medial femoral condyle flap is harvested from the inner aspect of the knee and distal third of thigh. The desired size of bone is custom planned and is raised using saw and the pedicle containing artery and vein is dissected up to the femoral artery.

What role Microsurgeons play?

This flap after harvesting from the thigh is brought to the wrist and the bone is inset into the defect and fixed with k-wire. After this microvascular anastamosis is carried out between the flap pedicle and the radial artery and cephalic vein.

What happens to the donor site?

The bone defect in the femur heals quickly and does not cause any long term morbidity.

How long does the healing take?

Once the bone flap is in place and its blood supply connected, the fracture site takes approximately four to five months to heal completely. Once there is bridging bone seen, k-wires are removed, but protection is maintained till complete bone union.

What are the advantages of this technique?

The bony union is faster. The ligaments are preserved resulting in better postop range of movement and early return to work.

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