3. • Goal of treatment : consolidation of
fracture in anatomical alignment
• Failure of union leads to predictable
arthritis
4. Classification
• Slade and Geissler
• 1-(1) early nonunion without substantial bone
resorption
– Grade I: fibrous union, minimal sclerosis(<1mm)
Late presentation(>4 weeks)
– Grade II fibrous union apparently united in
xray, but is symptomatic
– Grade III minimal resorption, minimal
sclerosis(<2mm)
5. • (2) chronic nonunion with substantial
bone resorption
– Grade IV: well perfused, substantial
bone loss(2-5mm)
– Grade V: well perfused , substantial
bone loss (5-10)
– Grade VI: pseudoarthrosis W/O AVN
6. Special circumstances
• Proximal pole, AVN, humpback
– ORIF + Tricortical BG
– Vascularized Bone graft
• More surgical dissection
• Generous capsulotomy
• Non-rigid fixation (often)
16. Procedure pearls
• Adequate
decortications of the
joints
• Proper apposition
• Proper fixation(rigid)
• Correction of the
extension of lunate
• Post op immobilization
•
22. When you DO/Do not
• SLAC
• SNAC
• ARTHRITIS
• KIENBACH (IV)
• RA
• DRFX
Farivar Lahiji 2009
Pitfalls
• Wrist instability
with clunking
• Active inflammatory
arthritis
• No useful movement
stiffness
• Dystrophic wrist
pain
peripheral nerve seminar
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23. Patient Selection
• Local anesthetic blocks with
postinjection assessment of pain
relief and functional improvement
Farivar Lahiji 2009
peripheral nerve seminar
23
24. Example
52-y-o north-sea
shore farmer, the only
money maker of the 7mems. family
Fx scaphoid 10 years
PTA
Does not wish to
undergo any extensive
wrist salvage
procedure
Good ROM
CC= pain
Farivar Lahiji 2009
peripheral nerve seminar
24
26. Preoperative Nerve Blockade
• Denervation of the wrist is
indicated only after confirmation
that blockade of the affected nerve
(S) by local anesthetic relieves the
symptoms
• 1 ml Marcaine 0.5%
Farivar Lahiji 2009
peripheral nerve seminar
26
34. Predictive factors
•
•
•
•
•
•
•
•
Vascularity of scaphoid fragment
Site of the fracture
Patient age
Smoking
Previous surgery
Duration of nonunion
Vascularized vs. nonvascularized
Iliac crest vs. distal radius
36. Predictive factors
• TABLE 19-3 -- Distribution of Fractures
and Rate of Union by Fracture Site as
Determined by Fragment Ratio
Fracture Site
0.15−0.30
0.31−0.45
0.46−0.60
0.61−0.75
No. of Fractures
15
33
48
30
No. United(%)
4 (27)
19 (58)
40 (83)
27 (90)
37.
38.
39.
40. Summary
• Try to get union
• Revise if needed
• Salvage if moderate-severe
osteoarthritis
