Scaphoid non union
I would like to read your advice concerning the case of this 17 years old young girl.
She is (was) playing handball at a regional level
She presented to me in summer 2016 with a proximal pole scaphoid nonunion dating back about 4-6 weeks (pictures 0-preop 1 to 7)
We decided to do a cancellous graft through an open posterior approach without immobilisation
healing was uneventful. However the X-rays post-op, at 3 months and 6 months revealed no changes
She is slightly painful if she does pushups bu she did not return to handball yet
The screw is in place, there is no lucency and I wonder if I should leave it as she is or do somethin
Thank you for your help
Arthroscopic bone grafting + scapholunate pinning
It will work !
what do you think about a CT scan. Potentially there is a partial bony healing?
I think the screw is a bit protruding and I would at least propose to remove it.
Further treatment would depend on CT scan. ..Non union?, Size if proximal pole fragment?, Vascularity (MRI?) and pain.
See you in Budapest!
For me Christian only take off the screw which seems too long at proximal pole even when we know that cartilage is thick at this level.
But very difficult fracture to treat
But but…I did never treat that cases without immobilisation specially in sport patients.
The new obsession not to immobilise because we perform relatively stable osteosynthesis is « for me » a mistake in such a case.
That screw is only for stabilize the small fragment but with movements of the wrist the scaphoid moves and stress the fracture.
My choice would be screw removal and VBG + pinning
Yes I would remoove the screw.
Then or artroscopic procedure or vascularize graft from the palmar radius.
I tend to do still the vasularized graft in these case.
Maybe Martin is right to a little more diagnosis after screw removal.
M. Haerle Chefarzt
Thanks Christian for sharing this tough case. A wonderful discussion viewing the email thread.
Please find attached an article based on a similar case to yours. We reconstructed this with an ipsilateral proximal hamate to scaphoid transfer.
Currently, we have ongoing studies on this topic and will share the results soon.
Best of luck and please let us know what you decide.
Kakar, Sanjeev (Sanj)
I am concerned that the screw is long and there is still a large cyst. I would get a CT to confirm where the cyst is exactly and confirm true non-union.
I would check the screw with a scope, insert a guidewire, remove the screw and open the non-union arthroscopically at the easiest site to excise the fibrous tissue. Pack in lots of graft through this approach and probably through the screw hole also.
I would replace the screw and insert it further. I would be tempted to pin the SL also and definitely cast it until it unites.
I would have propose
1. screw removal
2. arthroscopic cancelous bone graft (distal radius)
3. scapho lunate pinning with 2 or 3 small K-Wire (0.8 or 1mm)
4. immobilization until complete consolidation
Good Luck with this hard one !
nice case , remove screw - it surely iritates and through the sam approach a litle bit extended take graft from Lister? area with fine 3mm bone harvester and put it into the screw channel press fit.
With best regards,
Age, size and localization of fragment are ideal indication for arthroscopique procedure grafting and scapho-lunate pining.
but you have to remove the screw by dorsal approach and i have no experience with this combined with arthroscopy.
does anyone have?
My advice for this case:
Remove the screw
With arthroscopy, remove the fibrotic tissue in the no union site and add cancellous bone
K Wire fixation of the scaphoid and between lunate and scaphoid.
Immobilization until consolidation.
My best wishes
Raúl Ulloa V.
Remove the screw. Debride nonunion site. Pack the nonunion with a lot of cancelous bone from the iliac crest (I find it more compact than one from the radius. Yes, the donor site morbidity...), fill the screw channel. If you "overstuff" the nonunion site, then this is quite stable (like Matti Russe technique) and with some confidence you don't need additional fixation. Although I would probably use two small diameter K wires. Splint / immobilization until radiographic union.