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A 26-year-old man presents with chronic right wrist pain. He believes the pain started after a fall on the wrist during a basketball game approximately 1 year ago but was never evaluated for an injury. The pain had subsided but recently worsened. He is having trouble grasping objects with his right hand. Anteroposterior radiograph of the right wrist (Figure) shows a non-union of the scaphoid with a large fracture gap.
What is the best treatment option?
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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
- 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.
- Abbasi D. Scaphoid fracture. Available at: https://www.orthobullets.com/hand/6034/scaphoid-fracture. Accessed September 11, 2018.
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