Review Article

Management of Nonunion
Following Surgical Management
of Scaphoid Fractures: Current
Concepts

Edward S. Moon, MD
Christopher J. Dy, MD, MSPH
Peter Derman, MD
Michael C. Vance, MD
Michelle G. Carlson, MD
JAAOS Plus Webinar
Join Dr. Carlson and Dr. Moon for
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discussing “Management of
Nonunion Following Surgical
Management of Scaphoid Fractures:
Current Concepts,” on Thursday,
September 19, 2013, at 9 PM
Eastern. The moderator will be
Robert J. Strauch, MD, the Journal’s
Abstract
Management of scaphoid nonunion after failed surgery for acute
scaphoid fracture presents a unique treatment challenge. Prior
surgery complicates patient evaluation and increases the technical
difficulty of future procedures. Healing of nonunion is crucial to
prevent carpal collapse and progressive arthritis. A thorough
workup is required to identify technical factors or treatment
decisions that may have resulted in a poor outcome after initial
fixation attempts. CT is particularly useful for characterizing
nonunion and planning revision surgery. Several studies have
described the use of bone grafts and fixation devices for scaphoid
nonunion repair, including nonvascularized and vascularized bone
grafts, screws, pins, and plates. Reliable rates of union have been
achieved using nonvascularized bone graft supplemented with
screw or wire fixation, particularly in the absence of osteonecrosis.
Although vascularized grafts are more technically challenging, they
improve the odds of union in the setting of osteonecrosis.

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From the Hospital for Special
Surgery, New York, NY.
J Am Acad Orthop Surg 2013;21:
548-557
http://dx.doi.org/10.5435/
JAAOS-21-09-548
Copyright 2013 by the American
Academy of Orthopaedic Surgeons.
S
caphoid fractures are the most
common carpal fracture and
continue to present diagnostic and
therapeutic challenges. Although cast
immobilization has been the conven-
tional management option for non-
displaced or minimally displaced
acute fractures, surgery has become
increasingly popular because it
avoids prolonged immobilization
and allows for earlier return to activ-
ity.1 Surgical fixation is the treatment
of choice for acute displaced scaph-
oid fractures because of the high risk
of nonunion associated with nonsur-
gical management.2
Scaphoid nonunion is a debilitating
condition that can result in persistent
wrist pain; stiffness; and scaphoid non-
union advanced collapse (SNAC),
which is a pattern of progressive degen-
erative radiocarpal and midcarpal ar-
thritis secondary to posttraumatic
pathomechanics of the scapholunate
joint3 (Figure 1). The frequency of
nonunion following surgical fixation
of scaphoid fractures is unknown,
and management of nonunion fol-
lowing failed surgical fixation of an
acute scaphoid fracture has not been
well studied.
Several meta-analyses have reported
that union rates after surgical fixa-
tion of acute fractures approach
100%,2,4-7 but these outcomes should
be interpreted with caution; they may
be influenced by several factors, includ-
ing surgeon expertise, referral bias, and
the criteria used to determine union.
Most research on surgical manage-

548 Journal of the American Academy of Orthopaedic Surgeons


Figure 1
PA radiograph demonstrating
scaphoid nonunion advanced
collapse. The capitolunate (1) and
proximal scaphocapitate (2)
articulations are free of
degenerative disease, but the distal
scaphocapitate (3) and
radioscaphoid (4) have arthritic
changes. (Reproduced with
permission from Malerich MM,
Clifford J, Eaton B, Eaton R, Littler
JW: Distal scaphoid resection
arthroplasty for the treatment of
degenerative arthritis secondary to
scaphoid nonunion. J Hand Surg
Am 1999;24[6]:1196-1205.)
ment of scaphoid nonunion focuses
on fixation after failed nonsurgical
treatment. However, the orthopaedic
surgeon may encounter patients with
persistent nonunion despite previous
surgical treatment. In a meta-
analysis, Merrell et al8 identified 11
studies with 61 patients who under-
went a revision procedure to treat
scaphoid nonunion. Since then, 15
additional studies have reported on
181 patients who underwent revision
for scaphoid nonunion after failed
surgery.9-23 This suggests that non-
union following surgical fixation of
Dr. Dy or an immediate family member serves as a board member, owner, officer, or committee member of the Accreditation Council
for Graduate Medical Education. Dr. Carlson or an immediate family member serves as a board member, owner, officer, or committee
member of the American Society for Surgery of the Hand. None of the following authors or any immediate family member has
received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly
to the subject of this article: Dr. Moon, Dr. Derman, and Dr. Vance.
September 2013, Vol 21, No 9
scaphoid fractures may be more
common than previously thought.
Anatomy
The scaphoid has a complex three-
dimensional anatomy, and most of
its surface is covered with articular
cartilage. This unique anatomy gives
rise to a blood supply that branches
from the radial artery, enters at the
dorsal ridge near the scaphoid waist,
and supplies the proximal 80% of
the scaphoid in a retrograde man-
ner.24 The remaining 20% of the
scaphoid is perfused from volar ves-
sels entering at the distal tubercle.
The tenuous blood supply of the
scaphoid is often cited as the primary
reason for nonunion and osteonecro-
sis (ON) following trauma or surgi-
cal intervention. Thus, if possible, re-
peat surgery should be performed
from the same approach as the initial
surgery to protect the fragile blood
supply of the scaphoid.
Classification
Currently, no classification system spe-
cifically addresses scaphoid nonunion
following surgery. The Alnot classifica-
tion categorizes scaphoid nonunions
based on the presence of carpal insta-
bility, degenerative changes, and prox-
imal fragment necrosis.25 Scaphoid
nonunions can be defined as unstable
or stable based on whether the
length and alignment of the scaphoid
has been preserved with a fibrous
connection between the fracture
fragments.26 Unstable nonunions
may have signs of carpal instability
and degenerative changes associated
with SNAC.
Edward S. Moon, MD, et al
Evaluation
History and Physical
Examination
A thorough history is essential in the
setting of scaphoid nonunion after
failed surgery, particularly if the in-
dex procedure was performed by an-
other surgeon. For example, a his-
tory of remote trauma may give clues
to the chronicity of the fracture,
which in turn may have implications
for healing. Patients often present
with persistent pain at the fracture
site and loss of wrist motion despite
sufficient time for bone healing and
rehabilitation after initial treatment
of the scaphoid fracture. Clinical and
surgical records should be obtained
to clarify the time course for treat-
ment, types of approaches and im-
plants used during surgery, and com-
plications—information that may be
useful for developing a treatment
plan. In addition, the size and loca-
tion of previous surgical incisions
should be considered for future sur-
gical planning.
Radiographic Evaluation
Initial radiographic evaluation of the
wrist should include the following
views: PA, lateral, 45° pronated and
supinated oblique, and scaphoid (PA
in ulnar deviation). Radiographs
may reveal evidence of sclerosis, cyst
formation, bone resorption at the
fracture site, or hardware loosening.
All prior imaging should be obtained
because hardware may obscure the
original fracture pattern. Reviewing
the original injury may offer insight
into the causes of nonunion, which
can aid clinicians in developing a
strategy for revision surgery. Careful
549
Management of Nonunion Following Surgical Management of Scaphoid Fractures: Current Concepts
attention must be paid to the pres-
ence of midcarpal instability or
SNAC-pattern arthritis of the ra-
dioscaphoid and capitolunate joints
because this may alter management
options. CT can be used in addition
to plain radiography to evaluate the
wrist for early evidence of arthritic
changes. When these changes are
noted in the articular cartilage of
the radioscaphoid or scaphocapitate
joint on plain radiographs, CT scan,
or intraoperative inspection, a deci-
sion must be made whether to pro-
ceed with repair of the nonunion or
management of the SNAC. If the
changes are mild, we proceed with
nonunion repair but advise patients
that the arthritis may progress and that
they may require a subsequent proce-
dure, such as proximal row carpec-
tomy or midcarpal arthrodesis.
CT provides much greater bony
detail of scaphoid union than does
plain radiography. To maximize de-
tail in the area of interest, the CT
scanning plane should be oriented
parallel to the longitudinal axis of
the scaphoid instead of the wrist.
Combined with plain radiography,
CT can be used to identify fracture
displacement and diagnose scaphoid
union with high interobserver reli-
ability.27 Modern CT protocols can
minimize the artifact produced by
existing hardware, allowing simulta-
neous visualization of the nonunion
and previous fixation. CT can be
useful for identifying technical errors
in screw placement or inadequate
fracture reduction and visualizing in-
creased radiodensity of the proximal
pole and the absence of bridging tra-
beculae between the fragments,
which can help to predict ON of the
proximal pole.28
MRI is also a useful adjunct for di-
agnosis and treatment of acute
scaphoid fractures. However, its ef-
fectiveness in predicting ON of the
proximal pole is inconsistent,29
thereby limiting its clinical utility for
550
evaluation of scaphoid nonunion af-
ter previous treatment.
Nonsurgical Management
If union has not been achieved
within 3 months of the initial sur-
gery, the potential causes of delay
should be evaluated. In the absence
of technical error, immobilization
can be continued for a total of 6
months after a thorough discussion
with the patient about the risks and
sequelae of persistent nonunion. Se-
rial radiographs should be obtained
during the extended monitoring pe-
riod to evaluate for increasing cavita-
tion or gapping at the fracture site.
In patients who are unable or unwill-
ing to undergo surgery, cast immobi-
lization combined with pulsed elec-
tromagnetic fields for an average of
4 months has been shown to achieve
union in up to 69% of cases.30 If
there is evidence of improper screw
placement (at least 3 to 4 screw
threads in each fracture fragment);
insufficient compression across the
fracture site (based on the presence
of gapping); inadequate fixation; or
lack of appropriate bone grafting
(based on review of the previous sur-
gical report or discussion with the
original surgeon) in the 3 months af-
ter the initial surgery, we advise re-
operation to provide an optimal en-
vironment for scaphoid healing.
Surgical Management
Typically, surgical intervention is in-
dicated to prevent progressive carpal
instability and arthritis if fracture
union is not achieved by 6 months
after initial surgery. Scaphoid reoper-
ation is not advised if there is evi-
dence of arthritis on preoperative im-
aging or intraoperative evaluation.
The presence of hardware, decreased
bone stock, previous surgical dissec-
tion, and altered scaphoid vascular-
Journal of the American Academy of Orthopaedic Surgeons
ity add to the difficulty in managing
persistent scaphoid nonunion. Sev-
eral studies have reported on non-
union repair after previous scaphoid
surgery9-23,31-41 (Table 1). These stud-
ies can be categorized by manage-
ment method: nonvascularized bone
graft (NVBG), vascularized bone
graft (VBG), arterialization, and
plate fixation.
Nonvascularized Bone Graft
Traditionally, NVBG has been the
treatment of choice for scaphoid
nonunion. Graft donor sites vary,
but the distal radius and iliac crest
are the most common. Revision
screw fixation with NVBG may be
particularly useful when technical er-
ror (eg, screw malposition, fracture
malreduction) is the primary cause of
nonunion.32 Tricortical iliac crest
wedge graft offers solid structural
support that can be used to stabilize
scaphoid nonunion when a hump-
back deformity is present.31 This re-
stores the length and alignment of
the scaphoid and helps to improve
carpal mechanics. Harvest and place-
ment of NVBG is less technically
challenging than that of VBG; how-
ever, healing occurs by creeping sub-
stitution and resorption, which pro-
longs time to union and reduces
mechanical stability during the heal-
ing phase.21
In nine studies, a total of 78 pa-
tients with scaphoid nonunion after
previous surgery were treated with
NVBGs, with an overall estimated
unadjusted average union rate of
70%9-11,23,31-35 (Table 1). Daly et al31
reported on 11 patients with non-
unions associated with humpback
deformity (flexion deformity of the
unhealed scaphoid) after previous
surgery. They were then treated with
wedge grafting and screw fixation.
Nine patients were able to return to
previous employment and 10
achieved radiographic union at an
 Edward S. Moon, MD, et al

Table 1
Outcomes of Surgical Management of Nonunion Following Prior Surgical Treatment of Scaphoid Fracturesa
No. of Patients ON Prior to
Who Had Prior Revision Mean Union (Time
Study Surgery Graft Used Surgery (%) Follow-up to Union) Outcomes

Daly et al31 11 Nonvascularized: None 20 mo 91% (6 mo) 7 patients were pain free,
iliac crest wedge 9 returned to work, 6
had reduced function
Carrozzella 9 Nonvascularized: 33 24 mo 56% 5 patients had persistent
et al34 inlay bone graft, 1 pain at final evaluation.
trapezoidal graft Complications NR.
Smith and 15 Nonvascularized: 4 None 54.6 mo over- 73% (27 wk 3 patients had salvage
Cooney35 Russe, 6 Maltese all overall) operations. Complica-
cross, 5 iliac crest tions NR.
wedge
Tu et al16 35 Vascularized: 70 overall 5 y overall 90% (14.8 wk 82% good and excellent
ICSRA (1,2 or overall) Mayo wrist scores. No
2,3) complications. 7 pa-
tients had salvage pro-
cedures.
Mathoulin and 10 Vascularized: None 16.7 mo 100% (9.2 wk) All patients returned to
Haerle36 volar radius work. 1 transient Su-
deck dystrophy.
Mathoulin and 15 Vascularized: NR 5y 93% (4 mo) Grip strength improved
Brunelli37 second metacar- 25%. Pain relief in 10
pal bone graft patients. Postoperative
ROM increased an av-
erage of 15% compared
with preoperative ROM.
2 patients had radial
neuritis.
Jones et al19 9 Vascularized: 100 37 wk 100% (13 wk) Improved or resolved
medial femoral pain in all patients. 1
condyle thigh suture abscess
débridement. 1 subse-
quent radial styloidec-
tomy.
Guimberteau 8 Vascularized: NR 22 mo 100% (4.6 mo) 6 patients returned to
and Pan- ulnar bone graft work. No complications.
coni39
Fernandez 6 Vascularized: 100 5.4 y 100% (10.3 2 radial styloidectomy. 2
and Eggli40 second intermeta- wk) patients had salvage
carpal artery arte- operations. No compli-
rialization and cations.
iliac crest graft
Leixnering 6 Nonvascularized: NR 14 mo 100% (5 mo) 4 patients had full ROM.
et al22 iliac crest with No complications.
titanium miniplate

ICSRA = intracompartmental supraretinacular artery, NR = not reported, ON = osteonecrosis, ROM = range of motion
a
Overall reported values for entire cohort when patient-level data were not available.

average of 6 months. Smith and
Cooney35 described the use of three
different NVBGs to manage scaph-
oid nonunion after previous surgery
in 15 patients. A Russe inlay bone
graft (primarily cancellous iliac bone
graft laid into a generous trough)
was used in patients with preserved
bone stock and minimal humpback
deformity. The interpositional wedge
graft (a bicortical wedge of iliac crest
used to reduce scaphoid shortening)
and Maltese cross graft (a cross-
shaped graft fashioned from tricorti-
cal iliac crest; the transverse limbs
assist in reducing the humpback
deformity) were used in patients with
marked humpback deformity and

September 2013, Vol 21, No 9 551

Management of Nonunion Following Surgical Management of Scaphoid Fractures: Current Concepts
Figure 2
Illustrations of the dorsal (A) and volar (B) distal radius and ulna
demonstrating extraosseous vessels. ECA = extensor compartment artery,
ICSRA = intercompartmental supraretinacular artery
significant bone resorption. The au-
thors reported a union rate of 50%
with Russe bone grafts and a union
rate of 83% with the wedge and
Maltese cross grafts.
Vascularized Bone Graft
VBGs are an important tool for
scaphoid nonunion surgery, particu-
larly in the setting of ON. Although
the use of VBG is more technically
challenging than that of NVBG,
VBG improves the biology of heal-
552
ing, maximizes the odds of achieving
union, and may help revascularize a
necrotic proximal pole.42 Several
techniques that use grafts from a va-
riety of donor sites have been de-
scribed. Grafts harvested from the
distal radius and rotated on a pedicle
are most commonly used. Free graft
and arterialization procedures have
also been described. In 19 studies,
184 VBGs were used to manage
scaphoid nonunion after previous
surgery, with an overall estimated
Journal of the American Academy of Orthopaedic Surgeons
unadjusted average union rate of
86%.12-17,28,34,36
Distal Radius Bone Graft
Techniques that use bone graft har-
vested from the distal radius offer
several distinct advantages over
other grafting techniques. The prox-
imity of the distal radius allows for
rotation of a pedicle without the
need for microvascular anastomoses.
In many cases, graft harvest and re-
repair of the scaphoid can be accom-
plished through a single approach,
provided that it is not the previously
used approach. Using a single ap-
proach limits the amount of dissec-
tion required and avoids further dis-
ruption of the tenuous blood supply
to the scaphoid; however, if the sur-
rounding tissue was exposed during
the initial surgery, the orthopaedic
surgeon must assume that the pedicle
is compromised. If a single approach
can be performed safely, a dorsal or
volar pedicle graft can be obtained.
The dorsal bone graft is typically
based on either the 1,2 or 2,3 intra-
compartmental supraretinacular ar-
tery (ICSRA; Figure 2, A). The volar
bone graft is based on the volar car-
pal artery (Figure 2, B). The use of
other pedicle grafts (eg, capsular-
based grafts) has been described but
not in the setting of scaphoid non-
union after previous surgery.
Tu et al16 reported on a series of 72
patients with scaphoid nonunions
treated with VBG, 35 of whom had
previous surgery. The dorsal vascu-
larized distal radius graft was based
on either the 1,2 ICSRA or 2,3
ICSRA, with the latter able to pro-
vide a longer pedicle to reach the
scaphoid with less tension. A sepa-
rate volar approach was used to re-
duce the scaphoid and place a
3.0-mm cannulated screw with
5.5-mm washer. The authors re-
ported that the rate of union was
90% in the entire cohort. Subgroup
analysis of patients with fractures

who underwent reoperation was not
performed; however, ON was con-
firmed via MRI or surgery in all pa-
tients who had salvage surgery after
failed reoperation. These findings
emphasize the importance of identi-
fying the likelihood of ON to appro-
priately adjust management strate-
gies.
Some authors have commented on
the drawbacks of using dorsal vascu-
larized graft, including an obscured
view of the graft in the nonunion
bed; graft friability; and graft split-
ting, with disruption of the blood
supply caused by rigid fixation.12
Union can be achieved with dorsal
vascularized radius graft in the
setting of ON after previous
surgery;13,35 however, Straw et al12
concluded that the limitations of the
technique outweighed the biologic
advantage of the graft.
The use of VBG harvested from the
radius and based on the volar carpal ar-
tery has also been described. Gras and
Mathoulin17 reported on 38 persistent
scaphoid nonunions (with no evidence
of ON) following previous surgical
management with a volar vascularized
radius bone graft. The authors reported
a union rate of 89.5%, with an average
time to union of 10.8 weeks. Two of
the four nonunions were subsequently
managed with limited carpal arthrode-
sis.
Dorsal grafts may be better suited
for management of scaphoid non-
unions that involve the proximal
pole and those without significant
humpback deformity because ade-
quate correction of the deformity of-
ten requires a separate volar ap-
proach and increased soft-tissue
dissection. The 2,3 ICSRA provides a
longer pedicle and allows for a
greater arc of graft rotation. Volar-
based grafts may be more useful
when deformity correction is needed,
but these grafts may be limited by a
short pedicle.
September 2013, Vol 21, No 9
Metacarpal Bone Graft
Vascularized grafts harvested from
the second metacarpal are based on
the second dorsal metacarpal artery
or the dorsal intercarpal arch. Much
like grafts harvested from the radius,
the vascularized metacarpal bone
can be rotated on its pedicle and
placed into the scaphoid. One dis-
tinct difference is that the vascular
pedicle does not cross the mobile
wrist joint, theoretically decreasing
the risk of kinking. Based on the
character of the scaphoid nonunion,
metacarpal bone graft can be har-
vested and fixed into position using a
single dorsal approach or a com-
bined dorsal and volar approach.
Mathoulin and Brunelli37 described
the use of vascularized graft har-
vested from the head of the index
metacarpal to treat 15 patients with
persistent scaphoid nonunion. The
average follow-up was 5 years. All
patients underwent an average of
two surgeries before repair was per-
formed with a vascularized metacar-
pal graft. The authors reported a
union rate of 93%, with an average
time to union of 4 months. Compli-
cations included two cases of radial
nerve irritation. Although a high rate
of union was reported, only 10 pa-
tients were deemed to have accept-
able functional results.
Sawaizumi et al18 described a vas-
cularized metacarpal graft taken
from the proximal metacarpal in 14
patients, 5 of whom had previous
surgery. The graft was harvested and
secured to the scaphoid through a
dorsal approach except in the setting
of scaphoid collapse, which was
managed by creating a separate volar
incision and placing the graft in the
volar aspect of the scaphoid to cor-
rect the deformity. The union rate
was 100% at an average of 10.2
weeks, but the presence of ON at the
time of surgery was not documented.
The authors felt that a proximal
metacarpal graft was superior to pre-
Edward S. Moon, MD, et al
viously described techniques because
it allowed the harvest of a larger
piece of cancellous bone.
Medial Femoral Condyle
Bone Graft
One drawback of vascularized radius
grafts is that they are structurally in-
adequate for correction of a hump-
back deformity.43 Free vascularized
medial femoral condyle grafts pro-
vide a blood supply and greater
structural support, which improves
deformity correction.18 However,
harvesting the graft requires a sepa-
rate surgical site, increasing the po-
tential for morbidity, and a microsur-
gical technique must be used to place
the graft. A vascularized corticocan-
cellous bone graft is harvested from
the ipsilateral medial femoral con-
dyle using a pedicle from the de-
scending genicular vessels or the su-
perior medial genicular vessels.19
Jones et al19 successfully used a free
vascularized medial femoral condyle
graft in nine patients who had failed
previous scaphoid surgery and had
ON at the time of revision surgery.
Deformity correction was achieved
using a volar exposure, and grafts
were secured with screws or Kirsch-
ner wires depending on the size of
the fragment. All nonunions healed
at an average of 13 weeks, and all
patients reported improved or re-
solved pain. Similarly, in a study of
10 patients with scaphoid nonunion
secondary to ON, Doi et al20 re-
ported a union rate of 100% follow-
ing surgery with free VBGs.
Iliac Bone Graft
Vascularized iliac bone graft has
many of the same advantages and
disadvantages as graft harvested
from the medial femoral condyle.
The iliac bone provides structural
support that can be used to correct
humpback deformity. A vascularized
tricortical bone graft is harvested
from the iliac crest, using branches
553
Management of Nonunion Following Surgical Management of Scaphoid Fractures: Current Concepts
from the deep circumflex iliac vessels
as a pedicle.21 Arora et al21 used free
vascularized iliac bone graft to treat
21 patients who underwent reopera-
tion secondary to persistent non-
union and documented ON. The au-
thors reported a union rate of 76%,
with an average time to union of 17
weeks. Four minor complications
were reported, including three super-
ficial infections that were treated
with dressing changes. No donor-site
complications were reported.
Ulnar Bone Graft
Vascularized ulnar bone grafts were
developed as an alternative to grafts
harvested from the distal radius. A
corticocancellous graft is harvested
with its periosteum from the medial
distal third of the ulna, with the ul-
nar artery serving as the pedicle.39
Advantages include an anatomically
predictable vascular pedicle, the abil-
ity to include a large periosteal layer
with the graft, and reduced donor-
site morbidity.39 However, the graft-
ing technique requires sacrificing the
ulnar artery and reconstructing it
with an interposition vein graft. In a
study of eight patients with recalci-
trant scaphoid nonunion treated
with vascularized ulnar bone graft,
Guimberteau and Panconi39 reported
a union rate of 100%, with an aver-
age time to union of 4.6 months.
Notably, each patient had an average
of two failed surgeries before the
vascularized ulnar bone grafting. No
complications were noted, and all
patients were able to return to their
previous occupational or athletic ac-
tivities.
Arterialization
Direct implantation of the second
dorsal intermetacarpal artery or the
dorsal index artery into the scaphoid
has also been described in the setting
of nonunion after previous sur-
gery.35,40,41 This option may be neces-
sary when previous bone grafting
554
Figure 3
A, Intraoperative photograph of the wrist after plating. B, AP radiograph of
the wrist obtained 16 weeks after plating. (Reproduced with permission from
Ghoneim A: The unstable nonunited scaphoid waist fracture: Results of
treatment by open reduction, anterior wedge grafting, and internal fixation by
volar buttress plating. J Hand Surg Am 2011;36[1]:17-24.)
procedures have limited the options the potential need for hardware re-
for VBGs. A total of eight cases in moval. However, advances have been
three different studies were reported made in plate technology and design,
to have a 100% union rate even in and two recent studies have de-
the setting of confirmed ON and pre- scribed the successful use of mini-
vious surgery.35,40,41 The time to plates22,23 (Figure 3). Theoretically,
union ranged from 10 to 23 weeks. plates offer an increase in torsional
In the largest series, Fernandez and stability at the nonunion site. Leix-
Eggli40 reported on 11 patients with nering et al22 treated six scaphoid
scaphoid nonunion associated with nonunions in six patients who
ON (6 of which had previous un- had been previously treated with
successful surgical attempts at ob- Herbert or AO screws. The average
taining union). Although union was follow-up was 14 months. Three pa-
achieved in 10 patients, the rate of tients had undergone previous un-
subsequent operations, including ra- successful bone grafting procedures.
dial styloidectomy and limited carpal The authors reported a union rate of
arthrodesis, was almost 50%. 100% at an average 5 months, with
no complications. Four patients had
Plate Fixation full range of motion compared to the
Plate fixation of the scaphoid was uninjured side, and most patients re-
originally described by Ender44 in turned to previous activities and
1977. The use of this fixation sports. The authors recommended
method has been overshadowed by the use of plate osteosynthesis in the
the popularity of screw osteosynthe- setting of a stable pseudarthrosis that
sis. Plating has several drawbacks, has failed screw fixation secondary
including increased soft-tissue dissec- to a lack of rotational stability.
tion, potential impingement of the Reigstad et al23 reported on four
hardware on articular cartilage, and patients treated with plate osteosyn-
Journal of the American Academy of Orthopaedic Surgeons

thesis after scaphoid nonunion. The
average follow-up was 9 years.
Union was achieved in three of these
cases, but the time to union was not
reported. Persistent nonunion in one
patient healed after a third operation
(bone grafting, screw fixation, radial
styloidectomy) was performed. No-
tably, two patients had the plate re-
moved after confirmation of union,
but none required salvage proce-
dures.
Neither of these studies comments
on the presence of ON, and it is un-
known whether plate fixation could
be used in combination with a vascu-
larized graft. Although plate osteo-
synthesis appears to be a viable op-
tion in the setting of scaphoid
nonunion after failed surgery, further
research with greater numbers of pa-
tients and longer follow-up are
needed to evaluate the rate of sec-
ondary procedures, including hard-
ware removal.
Authors’ Preferred
Treatment
Approach to Management
When evaluating a scaphoid non-
union after internal fixation, the or-
thopaedic surgeon must decide
whether the scaphoid alignment and
initial screw position are acceptable
and if the scaphoid is viable. If so,
revision surgery is possible with
placement of a larger diameter screw
inserted into the same tract with the
addition of distal radius bone graft.
Proper preparation and grafting is
likely as critical as replacing the
screw. After removing the original
hardware, the screw path and non-
union site are prepared with curet-
tage. Local cancellous graft can be
applied to the nonunion site, typi-
cally without considerable additional
dissection, and aggressively packed
down the screw hole. The original
screw is replaced with a larger
September 2013, Vol 21, No 9
variable-pitch screw to compress the
graft internally and apply compres-
sive load across the nonunion site.
If the direction of initial screw
placement is not acceptable, redirec-
tion of a new screw is necessary.
Achieving adequate purchase in the
scaphoid after removal of the previ-
ous screw can be accomplished by
packing cancellous bone graft down
the initial screw hole, selecting a new
entry point, or changing the ap-
proach for fixation from volar to
dorsal (or vice versa). However, if an
extensive open approach was ini-
tially performed, we would caution
against a formal open exposure from
the opposite side because this may
result in devascularization of the
scaphoid. Percutaneous or limited
approaches are ideal for screw place-
ment in such a situation. Utilization
of a microscrew is also an alternative
for screw repositioning, particularly
if a new starting point adjacent to
the previously placed screw is needed
or if the fragment size prohibits revi-
sion to a larger implant. This is infre-
quently necessary, but the small head
size of the microscrews makes for an
attractive option in these scenarios.
The senior author (M.G.C.) fre-
quently uses these screws in patients
with small proximal pole fractures.
Case Study
A 26-year-old man sustained a right
scaphoid waist fracture that was
acutely treated by another surgeon
with a mini Acutrak screw (Acumed)
and 12 weeks of immobilization. The
patient presented with continued pain
9 months after the initial surgery. Ra-
diography and CT showed nonunion
of the right scaphoid waist fracture
with acceptable scaphoid alignment
and screw position (Figure 4, A). An
MRI obtained before our evaluation
suggested proximal pole viability. The
senior author (M.G.C.) decided to per-
form revision open reduction and inter-
Edward S. Moon, MD, et al
nal fixation with NVBG.
The wrist was approached dorsally
via the previous incision, and the
original mini screw was removed.
The nonunion site was prepared with
curettage, and cancellous bone graft
harvested from the distal radius was
packed into the nonunion site dor-
sally and down the original screw
hole. Instead of using another mini
screw, a larger standard size Acutrak
2 screw was placed across the frac-
ture site through the previous screw
hole.
Postoperatively, the wrist was im-
mobilized in a short arm thumb
spica cast, and daily bone stimulator
therapy was performed. Bone stimu-
lation was used given the chronicity
between index and revision opera-
tions (9 months). At 12 weeks post-
operatively, the fracture showed
40% healing on CT and range-of-
motion exercises were initiated (Fig-
ure 4, B). At the most recent follow-
up, 7 months after reoperation, the
patient lacked 10° of volar flexion
but otherwise had full range of mo-
tion. He had no tenderness at the
fracture site and grip strength was
94% of the contralateral side. Radio-
graphs confirmed union (Figure 4,
C).
Summary
Scaphoid nonunions after failed fixa-
tion can be challenging to evaluate
and treat. CT is useful for identifying
factors that may have contributed to
persistent nonunion and can facili-
tate further surgical planning. When
surgery is indicated, NVBG tech-
niques can achieve high rates of
union when the scaphoid has ade-
quate perfusion and the grafts are
rigidly fixed. In the setting of ON,
VBG improves the chance of union,
although it is technically more chal-
lenging than NVBG. Selection of a
vascular pedicle is dependent on the
555
Management of Nonunion Following Surgical Management of Scaphoid Fractures: Current Concepts

Figure 4

A, PA radiograph of the wrist demonstrating a transverse scaphoid waist nonunion in a 26-year-old man who
presented with continued pain 9 months after undergoing open reduction and internal fixation (ORIF) with a mini screw.
Scaphoid alignment and screw position are acceptable. Revision ORIF was performed with bone graft, and the mini
screw was replaced with a standard screw. B, Postoperative sagittal CT scan of the wrist in the plane of the scaphoid
showing bony bridging at 12 weeks after surgery. C, Postoperative PA radiograph of the wrist demonstrating union.

surgeon’s familiarity and comfort
level with the technique. The role of
modern plate fixation in scaphoid
nonunion surgery has shown limited
success and warrants additional
long-term investigation.
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