ORTHOPEDICS

1. P R E S E N T E D B Y :
D R . N . B E N T H U N G O T U N G O E
P . G , M S ( O R T H O P E D I C S )
C E N T R A L I N S T I T U T E O F O R T H O P E D I C S
V M M C & S A F D A R J U N G H O S P I T A L
N E W D E L H I
SCAPHOID NON UNION

3. Management of scaphoid non
union

4. Introduction
 The incidence of scaphoid nonunion for undisplaced fx
is 5-10%
 The incidence increases up to 90% in displaced
proximal pole fractures
 Failure to heal after 6 months establishes the Dx of
nonunion
 Recent studies indicated that virtually that all unstable
nonunions lead to carpal collapse and posttraumatic
arthritis,, for this reason treatment is recommended for
all scaphoid nonunions even if asymptomatic

6. INTRODUCTION
 According to FISK, in established non unions of the
scaphoid, proximal scaphoid rotates dorsally into
extension and the distal part faces downward in flexion
leading totriplane angulation and subsequent humpback
deformity of the scaphoid.
 Impingement between the palmar-flexed scaphoid distal
pole and the radial styloid process leads to the
development of radiocarpal osteoarthritis.
 At the same time, the unsupported carpus collapses into
a DISI deformity with increasing subluxation and
secondary arthritis of the midcarpal joint.

7. CAUSES/FACTORS
 Delayed diagnosis: upto 40% undiagnosed at time of
injury
 Gross displacement: upto nonunion rate of 92% in
displaced fractures
 Associated injuries of the carpus and ligaments.
 Impaired blood supply(30% to 40% of osteonecrosis
occur most frequently in fractures of the proximal
third)
 Inadequate immobilization/ poor fixation techniques
 Immunocompromised states/ smoking etc

8. Vascular supply

9. SYMPTOMS
 radial-sided wrist pain,
 reduced wrist motion with pain at the limits of
motion,
 reduced grip strength

10. Radiological assesment
 Xray
 CT Scan
 Gadolinium enhanced MRI
 Bone scan

11. Radiographic findings
Classic findings of nonunion,
 including widening of the fracture gap,
 cystic changes,
 fracture line sclerosis even when the fracture is healing

12. Hump back deformity

13. Goals of management
1. relieve symptoms,
2. correct the carpal deformity,
3. achieve union,
4.delay the onset of wrist arthrosis
The major principles to follow are the following:
 1. Make an early diagnosis
 2. Perform a complete resection of the nonunion
 3. Correct the deformity secondary to carpal collapse and carpal instability
 4. Preserve the blood supply throughout
 5. Achieve bone apposition by an inlay graft
 6. Achieve stability with screw fixation

14. Knoll and Trumble algorithm for management of
scaphoid non union

15. Types of non union:
Stable Nonunions.
1. The stable scaphoid nonunion is characterized by a firm fibrous
nonunion that prevents deformity.
2. The risk of osteoarthritis is small.
The indications to manage patients surgically with a stable nonunion
are limited
 to improvement in symptoms,
 prevention of progression to an unstable nonunion,
 delaying the development of degenerative changes.
3. For stable nonunions, structural graft support is not required, simply graft
that will promote union;

16. Unstable Nonunions.
 The quoted success rates of achieving union with
internal fixation and bone grafting for unstable
nonunions range from 60% to 95%.

18. Treatment of non union
Non operative management:
1. Electrical stimulation:
Operative management:
1. Radial styloidectomy.
2. Excision of the scaphoid(proximal, distal, entire)
3. Proximal row carpectomy
4. Traditional bone grafting
5.Vascularised bone grafting
6. Wrist arthodesis( partial or complete)

20. STYLOIDECTOMY
 Styloidectomy alone probably is of little value in
treating nonunions of the scaphoid.
 If arthritic changes involve only the scaphoid fossa of
the radiocarpal joint, however, styloidectomy is
indicated in conjunction with any grafting of the
scaphoid or excision of its ulnar fragment.
 Technique: Stewart

21. EXCISION OF THE PROXIMAL
FRAGMENT
 Excising both fragments of the scaphoid as the only procedure is
unwise; although the immediate result may be satisfactory, eventual
derangement of the wrist is likely.
 Soto-Hall and Haldeman reported gradual migration of the
 capitate into the space previously occupied by the scaphoid.
 If excision of both fragments is considered, it is preferable to add
some other procedure to stabilize the capitolunate joint (e.g.,
capitolunate or capital-lunate-triquetral-hamate fusions).
 Excising the proximal scaphoid fragment usually is satisfactory; the
loss of one fourth or less of the scaphoid usually causes minimal
impairment of wrist motion. Because postoperative immobilization
is brief, function usually returns rapidly.

22. Indications for excising the proximal fragment of
a scaphoid nonunion:
1. The fragment is one fourth or less of the scaphoid.
2. The fragment is one fourth or less of the scaphoid and is
sclerotic, comminuted, or severely displaced.
3. The fragment is one fourth or less of the scaphoid, and
grafting has failed.
4. Arthritic changes are present in the region of the radial
styloid.

23. Excision of the Distal Scaphoid
 Satisfactory results have been reported with distal
scaphoid resection for the treatment of scaphoid
nonunions with radioscaphoid arthritis treated with
distal scaphoid resection.
 If capitolunate arthritis is present, an additional
procedure (e.g., limited intercarpal arthrodesis)
should be added to distal scaphoid excision.

24. PROXIMAL ROW CARPECTOMY
 Proximal row carpectomy is used as a reconstructive procedure for posttraumatic
degenerative conditions in the wrist, especially conditions involving the scaphoid
and lunate.
 alternative to arthrodesis.
 is considered to be a satisfactory procedure in patients who have limited
requirements, desire some wrist mobility, and accept the possibility of minimal
persistent pain
 When proximal row carpectomy is done for degenerative changes, healthy
articular surfaces should be present in the lunate fossa of the radius and the
proximal articular surface of the capitate to allow for satisfactory articulation
between these surfaces.
 Excision of the triquetrum, lunate, and entire scaphoid usually is recommended.
 The distal pole of the scaphoid at its articulation with the trapezium can be left,
however, to provide a more stable base for the thumb.( in addition, radial
styloidectomy should be done to avoid impingement of the distal scaphoid pole
and trapezium on the radial styloid)

25. After proximal carpectomy

26. ARTHROSCOPIC PROXIMAL
ROW CARPECTOMY by WEISS et.al

27. 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. This technique is
most useful for ununited fractures that do not have
associated shortening or angulation.

28. TYPES OF BONE GRAFTING
1. Russe bone graft (Inlay):
Used for stable nonunions .
The initial procedure used a single corticocancellous
strut across the fracture line;a later modification
involved two corticocancellous struts inserted into
the scaphoid excavation with their cancellous sides
facing each other,the remainder of the cavity is filled
with cancellous chips.
Usually k-wires are added to
secure the construct.

29.  The time to union with this procedure is relatively
long ,generally requiring cast immobilization for 6-4
months
 Healing rates of 85-90 % have been reported
 Satisfactory relief of symptoms has been reported ;
78 % of painful wrist became free of symptoms and
88 % of patients were satisfied with the results.

30. Inlay graft

31. 2. Fernandez bone graft
(interpositional graft):
 angulated nonunions with a dorsal humpback
deformity require interpositional grafting.
 Fernandez has described the use of a trapezoidal iliac
graft to correct the angulation and carpal collapse
pattern.Fixation is achieved with screws or k-wires
 In both types of bone grafting ,a volar approach is
used, and care must be taken to preserve the
vascularity of the fragments

32. Interpositional graft

33. Malpositioned Nonunion of Scaphoid
Fractures (“Humpback” Deformity).
 Due to resorption or comminution, shortening and
angulation, with its convexity dorsal and radial
occurs in non union fractures of scaphoid leading to
“humpback” deformity
 The deformity includes extension of the proximal
pole of the scaphoid, resulting extension of the
lunate, and a form of dorsal intercalated instability
pattern seen on lateral plain radiographs

34.  Electrical stimulation:
 Pulsed Electromagnetic Field ( PEMF ) stimulation has been
investigated as a noninvasive treatment for scaphoid nonunion
.Although controversial, there appears to be some benefit
(shorter healing time)when electric stimulation is combined
with bone grafting procedures

35.  C) Proximal pole excision:
when a small proximal fragment is not amenable to bone grafting
,proximal pole excision and fascial hemiarthroplasty are
recommended
 ) Salvage procedures :
Are indicated when nonunion has lead to carpal collapse and
secondary degenerative changes
Proximal row carpectomy,intercarpal arthrodesis, or radiocarpal
arthrodesis is recommended in patients with chronic wrist pain and
stiffness
Radial styloidectomy and scaphoid interposition arthroplasty may be
combined with other procedures or performed independently in the
younger patient with less severe symptoms
Silicone implants have been used in the past but are now avoided
because of silicone synovitis

36. GRAFTING OPERATIONS TECHNIQUES
 FERNANDEZ
 TOMAINO ET AL.
 STARK ET AL.

37. TOMAINO ET AL.)

38. STARK et.al TECHNIQUE:
A, Excavation of scaphoid and placement ofKirschner wires; Chandler
retractor is used to protect articular cartilage of radioscaphoid joint.
B, Cortical graft is inserted into cavity.
C, Kirschner wire is inserted to stabilize bone graft.

39. VASCULARIZED BONE GRAFTS
 Especially nonunions with an avascular proximal pole
and those that have failed to heal after previous
procedures.
SOURCES:
 pronator quadratus pedicle graft from the distal radius
 iliac crest free flap
 a vascularized bone graft fromthe distal dorsolateral
radius
 pedicle bone grafts based on the 1,2
intercompartmental supraretinacular artery.
TECHNIQUES:
1) KAWAI AND YAMAMOTO
2) ZAIDEMBERG ET AL.

40. Pronator quadratus pedicle bone graft
Non union scaphoid fracture
Pronator quadratus

41. Arthrodesis of the Wrist
 a salvage procedure for old ununited or malunited
fractures of the scaphoid with associated radiocarpal
traumatic arthritis.

42. THANK YOU