This document discusses the treatment of scaphoid non-union bone fractures. Scaphoid non-union can be caused by delayed diagnosis, displacement of the fracture, smoking, and other factors. Treatment options include traditional bone grafting, vascularized bone grafting, fragment excision, and wrist fusion or replacement. The Matti-Russe and Fernandez techniques use bone grafts to fill the fracture site and stabilize the bone fragments, while vascularized grafts from the radius or iliac crest aim to improve healing rates. Postoperative immobilization lasting several months is usually needed to allow the bone to fuse.

1. TREATMENT OF SCAPHOID
NON-UNION
BY DR. ANIL KUMAR P
Junior Resident
Dept of Orthopaedics
SDUMC, KOLAR
MODERATOR :DR. HARIPRASAD SIR
ASSOCIATE PROFESSOR
DEPT OF ORTHOPAEDICS

2. INTRODUCTION
• Fracture of the carpal scaphoid bone is the most common.
• A Fracture is said to be non united, when atleast 9 months had
passed since injury and the last 3 months have elapsed without
progress in healing, clinically and radiologically
• Nonunion of scaphoid fractures is influenced by delayed
diagnosis, gross displacement, associated injuries of the
carpus, and impaired blood supply.

3. • Displaced scaphoid fractures have been suggested to have a
nonunion rate of 92%.
• The incidence of scaphoid nonunion for undisplaced fractures is 5-
10%
• Male>female
• Nonunion is expected more often if the scaphoid fracture is untreated
untreated for 4 or more weeks

4. ETIOLOGY
• 10 to 70 years old,
• Proximal pole fractures.
• Displacement
• Late diagnosis
• Inadequate immobilization
• Associated ligamentous injuries
• Smoking
• Communited fractures

5. ANATOMY AND BLOOD SUPPLY OF
THE SCAPHOID BONE
• The unique anatomy of the scaphoid predisposes fracture of
this carpal bone to delayed union or nonunion and to disability
of the wrist.
• The scaphoid moves with nearly all carpal motions, especially
volar flexion.

6. Blood supply to scaphoid
Radial artery
Volar branch
distal 20%-30%
via tubercle
Dorsal branch
2-4 branches
supply 60-70%
till proximal

7. CLASSIFICATION:HERBERT AND FISCHER

8. TYPES OF SCAPHOID NON UNION
1. STABLE- No displacement, No degenerative changes
2.UNSTABLE-Displacement >1 mm or Scapholunate angle >70 degrees.
3. EARLY ARTHRITIS – Radio scaphoid arthritis
4. SCAPHOID NON UNION ADVANCED COLLAPSE(SNAC)- Radio
scaphoid and mid carpal arthritis
5.SCAPHOID NON UNION ADVANCED COLLAPSE PLUS (SNAC PLUS)-
Arthritis through wrist.

9. INVESTIGATIONS
RADIOLOGICAL FEATURES OF NON
UNION
1.Resorption at fracture site.
2.Subchondral bony sclerosis.
3.Subchondral bony collapse and
reduction of carpal height.
4.Cystic changes.
5.Loss of trabecular pattern.
6.Deformity of osseous segment.

11. MANAGEMENT
The following operations can be useful for nonunions of the
scaphoid:
(1) Traditional bone grafting,
(2) Vascularized bone grafting,
(3) Excision of the proximal fragment, the distal fragment, and,
occasionally, the entire scaphoid,
(4) Radial styloidectomy,
(5) Proximal row carpectomy, and
(6) Partial or Total arthrodesis of the wrist.

12. scheme for scaphoid nonunion treatment

13. GRAFTING OPERATIONS
• Cancellous bone grafting for scaphoid nonunion, as first
described by Matti and modified by Russe, has proved to be a
reliable procedure,
• producing bony union in 80% to 97% of patients.
• Done in case of stable non union
• C/I: shortening and angulation

14. MATTI-RUSSE
• patient in supine
• prepare one iliac crest for possible bone graft harvest.
• Longitudinal incision 3 to 4 cm long on the volar aspect of the
wrist slightly to the radial side of the flexor carpi radialis tendon.
• Protect the palmar cutaneous branch of the median nerve and
the terminal branches of the superficial radial nerve.
• Retract the flexor carpi radialis tendon ulnar ward. Incise the
wrist capsule, reflecting the radiocarpal ligaments as medial and
lateral flaps to be repaired.

17. • Identify the scaphoid bone and expose the nonunion
• Freshen the sclerotic bone ends with a small gouge and form a
cavity that extends well into each adjacent fragment.
• The cavity can be formed with a high-speed burr;
• From the iliac crest, obtain a piece of cancellous bone and
shape it into a large lozenge-shaped peg to fit into the
preformed cavity and stabilize the two fragments
• Place multiple small bone chips around the peg.

18. • Kirschner wire inserted from distal to proximal (optional )
• suture the capsule and close the skin.
• thumb spica extension, from above the elbow to the palm with
the wrist in neutral position.
• POSTOPERATIVE CARE. If a Kirschner wire
• is used, it is removed at 4 to 6 weeks.
• For 12 to 16 weeks the patient is checked every 1 to 2 weeks
and the cast is replaced when necessary

20. FERNANDEZ BONE GRAFT(INTERPOSITIONAL
GRAFT)
• Preoperatively, calculate the amount of resection, size of graft, and angular
deformity using the radiographic findings of the uninjured wrist as a guide.
• Angulated non unions with a dorsal humpback deformity require inter
positional grafting.
• Fernandez has described the use of a trapezoidal iliac graft to correct the
angulation, flexion deformity, shortening and carpal collapse pattern.
• Fixation is achieved with screws or k wire
• In both types of bone grafting ,a volar approach is used and care must be
taken to preserve the vascularity of the fragments.

22. video

23. VASCULARIZED BONE
GRAFTS
• INDICATION: Nonunion and avascular necrosis and if previous
iliac grafting has failed.
SOURCES:
• Pronator quadratus pedicle graft from the distal radius
• Iliac crest free flap with micro vascular techniques.
• A vascularized bone graft from the distal dorsolateral radius
• Pedicle bone grafts based on the 1,2 intercompartmental
supraretinacular artery.

24. TECHNIQUES:
• KAWAI AND YAMAMOTO
• ZAIDEMBERG ET AL.
Volar approach

25. PEDICLE BONE GRAFT BY
KAWAI AND YAMAMOTO
• Volar approach bone exposed, sclerotic ends excised.
• Large oval cavity 10-20mm long created, pronator quadratus
identified and block of bone graft 11-20mm outlined at its distal
insertion on the distal radius close to the abductor pollicis
longus tendon
• Outline margin of the graft with k-wire holes separate with fine
osteotomy, dissect the muscle towards ulna to secure a pedicle
20mm thick.
• Align the fracture fragments and insert into the cavity and
introduce 2 k-wires from the tuberosity.

27. • POSTOPERATIVE CARE.
• The long arm thumb spica cast is worn for 1 month, followed by
the wearing of a short arm thumb spica cast for another month.
• At 2 months, union is evaluated with radiographs and, in case of
doubt, tomograms.
• The wrist is braced in a functional position for another 1 to 2
months, and then active exercises are begun.
• When stable bony union is certain, the Kirschner wires are
removed, usually about 4 months after surgery.

28. Dorsal approach

31. ZAIDEMBERG
• Oblique Incision on the dorsoradial side of the wrist- centered
on the radiocarpal joint.
• On distal radius identify the longitudinal course of ascending
irrigating branch of the radial artery
• Design a bone graft with longitudinal vessel at its center and
use a small gauge to harvest a graft beneath the periosteal
vessel and transpose it in the long trough created in the
scaphoid and stabilize it with k-wires

34. video

35. • POSTOPERATIVE CARE.
• long arm thumb spica cast is worn for 1 month.
• At 1 month, a short arm thumb spica cast is applied and is worn for
at least 2 weeks.
• At 6 weeks, bone union is evaluated with plain radiographs.
• Immobilization is continued until union is seen on plain radiographs
or evaluation with tomograms is obtained as needed.
• Wrist motion and forearm rehabilitation are begun when union is
established.

36. Thank you