Scaphoid ± Bone graft

Scaphoid

Orif & Bone Graft

Aim

  • to restore anatomical & mechanical properties (± vascularity) of scaphoid to prevent development of chronically painful wrist &/or SNAC arthrosis

Principles

  • to acutely fix displaced fractures
  • fix & bone graft ununited fractures with correction of any deformity
  • to vascularise & fix avascular bones.

Options

  • POP / GAMP / GAMP & perc. Fixation / ORIF(volar or dorsal)
  • ORIF + bone graft (onlay, inlay, or vascularised)
  • Salvage procedures
    • Excision of proximal pole (if <1/4, highly fragmented or failed ORIF)
    • Excision scaphoid & 4 corner fusion
    • Wrist arthrodesis

Indications

  • Displaced acute fracture
    • >1mm step
    • SL angle >60°
    • lateral intrascaphoid angle>45°
    • height:length > 0.65
    • Treatment – GAMP & perc fixation or ORIF
  • Failure of non-op mgmt d.t. non union by 12 weeks (5-10% overall, 30% if proximal pole)
    • Treatment – ORIF & bone graft
  • Malunion with deformity
    • Treatment – ORIF & inlay graft
  • Delayed Treatment of previously unrecognised injury – relative indication

Contraindications

  • Degenerative change
  • To ORIF alone – established non union
  • To ORIF & cancellous graft – humpback deformity
  • To non vascularised graft – absence of intraop punctate bleeding from proximal pole

PreOp Planning

  • Good quality radiographs
  • Contralateral films for assessment SL angle
  • Consent

Procedures

  • ORIF volar
  • ORIF dorsal
  • ORIF & cancellous graft
  • ORIF & corrective cortico-cancellous graft
  • ORIF & vascularised graft

Postop Rehab

  • 2 weeks in BE slab + 6 weeks in scaphoid POP, if union splint further 8 weeks, if not, POP further 8 weeks

Results

  • 90 + % union rates if vascular bone with fracture at waist
  • 20% if proximal pole
  • 50% if avascular & non vascularised graft used
  • 70% if avascular & vascularised graft used

Complications

  • General Anaesthetic
  • General Surgical
  • Specific Surgical
    • Neurovascular injury, Scaphoid injury, Scaphoid comminution
    • Screw penetration
    • Donor site morbidity
    • Non union
    • Avascular proximal pole
    • Stiffness, weakness, arthrosis