Due to a tenuous blood supply, displaced scaphoid fractures are prone to non-union and avascular necrosis. Scaphoid non-union occurs in 5% of all scaphoid fractures.1 Scaphoid fractures that fail to heal can progress to scaphoid non-union advanced collapse (SNAC), which can lead to wrist arthritis. The diagnosis of scaphoid non-union is established after failure of conservative treatment for 6 months. Characteristics that may result in an unhealed non-union include smoking, working as a heavy laborer, age of non-union >5 years, and duration of immobilization.

Displaced scaphoid fractures often require bone graft to improve healing.1,2 This patient has a large fracture gap that will require a sizable bone graft, either vascularized or nonvascularized. Vascularized bone grafts are a superior option when there is nonvascular sclerotic bone in patients with proximal pole avascular necrosis. Vascular bone grafts are often obtained from the radius and medial femoral condyle, and a common source for a nonvascularized bone graft is the iliac crest. Vascular grafts can be more technically demanding as they often require microsurgical techniques.

Similar outcomes have been found between graft options; few studies show a benefit of one modality over the other. Given this patient had no signs of osteonecrosis and symptoms for <1 year, he underwent open reduction and internal fixation with an iliac crest bone graft.

References

  1. Hirche C, Xiong L, Heffinger C, et al. Vascularized versus non-vascularized bone grafts in the treatment of scaphoid non-union. J Orthop Surg (Hong Kong). 2017;25(1):2309499016684291.
  2. Abbasi D. Scaphoid fracture. Available at: https://www.orthobullets.com/hand/6034/scaphoid-fracture. Accessed September 11, 2018.
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