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Scaphoid fracture- Zaidemberg (1-2 Intercompartmental Supraretinacular) vascularised bone graft with Acumed Screw Fixation for non-union

    Overview

    Learn the Scaphoid fracture: Zaidemberg (1-2 Intercompartmental Supraretinacular) vascularised bone graft with Acumed Screw Fixation for non-union surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Scaphoid fracture: Zaidemberg (1-2 Intercompartmental Supraretinacular) vascularised bone graft with Acumed Screw Fixation for non-union surgical procedure.
    This is a detailed step by step instruction through the procedure of a vascularised graft for scaphoid non-union. The graft used in this case is based on the 1-2 intercompartmental supraretinacular (1,2-ICSR) artery, a branch of the radial artery. It is also often referred to by the name of the surgeon who described it in 1991, Zaidemberg (J Hand Surg Am. 1991 May;16(3):474-8).
    The graft, which is accessed via a dorsal approach, is most commonly used for proximal pole non-unions. The scaphoid and graft were then fixed with a Micro Acutrak TM screw in this case.
    Scaphoid non-unions in general are best diagnosed and morphology assessed using a CT scan, although they are usually clearly seen in a scaphoid series of radiographs. An MRI can be used to try to assess the vascularity of the proximal fragment in proximal pole fractures however MRI scans (with or without Gadolinium enhancement) are far from infallible and the gold standard test for vascularity remains punctate bleeding from the bone intra-operatively.
    When an non-union is established (minimum 6 months duration), symptomatic and without associated arthritis, it usually requires treatment for which there are a number of options available. Non-operative treatment with splint and analgesia or less invasive procedures such as wrist denervation are often used in cases where the patients are older or patients do not want major surgery. However as the natural history of the scaphoid non-union is to develop arthritis over 5-10yrs then surgical treatment to unite the scaphoid is indicated for the majority of cases.
    The exact nature of the potential surgery will often vary depending on the amount of collapse of the scaphoid, sclerosis or cyst formation around the non-union, the location of the non-union within the scaphoid and the preferences of the surgeon.
    Options include compressive screw fixation, k-wire, staple or plate fixation with or without graft. Grafting open or arthroscopic which can be vascularised or non-vascularised, cancellous or cortico-cancellous with the most common donor sites being distal radius and iliac crest.
    Following an scaphoid grafting and screw fixation patients are usually placed in plaster cast for 6-8 weeks with physio therapy of the fingers and thumb followed by cast removal and physiotherapy of the wrist once union is confirmed radiologically and clinically.
    Complications in this procedure include non-union, metalwork issues, infection, iatrogenic cartilage injuries and tendon and nerve injuries.
    Other related techniques that can be usefully read on this topic on OrthOracle are https://www.orthoracle.com/library/arthroscopic-scaphoid-non-union-grafting-fixation-using-acutrak-screw-tm/ , and https://www.orthoracle.com/library/scaphoid-non-union-vascularised-graft-based-on-the-volar-carpal-artery/

    Indications

    Indications
    Scaphoid non-unions, if left untreated, risk progressing to Scaphoid Non-union Advanced Collapse (SNAC). What is unclear is how many patients with SNAC wrists are symptomatic enough to require intervention. This is why scaphoid non-union surgery is only indicated in symptomatic non-unions and not for those patients where the non-union is an incidental radiographic finding. Given that the natural history is unclear a patient with an asymptomatic non-union can only be made worse or the same by intervention.
    Scaphoid vascular grafting and screw fixation is indicated for scaphoid non-unions without associated arthritis. An additional radial styloidectomy can be supplemented in cases of SNAC grade I.
    Whether to use a vascularised or non-vascularised grafts is still a great topic of debate amongst wrist surgeons.
    There is no outstanding evidence to support the use of vascularised grafts over non-vascularised grafts, however many case series where fractures included worse prognostic factors (avascular necrosis (AVN), proximal pole fractures, revision surgery) lean towards an increased used of vascularised grafts. This then biases the published papers as the vascularised grafts are being used in cases where a lower non-union rate is already expected.
    That said, there is definitely no good evidence to use vascularised grafts for scaphoid waist fractures. There is however a trend towards better outcomes in proximal pole and AVN cases for vascularised grafts. This potential benefit however will be completely negated and lead to worse outcomes if the quality of the bone graft or fixation are compromised to achieve ‘vascularity’. This is not uncommon when unfamiliar with these more complex graft technique or when using certain grafts such as the Khulmann volar carpal artery graft which can often delaminate and be of poor quality in older patients.
    The Zaidemberg technique can inmost commonly used for proximal pole and AVN cases however can be used to correct a volar, humpback deformity although this is even more challenging.
    Symptoms
    The symptoms experienced will often depend on the deformity of the scaphoid.
    Pain is usually a feature and this may be continuous and even disturb sleep or occur only during specific activities such a wrist extension and loading.
    A reduced range of movement is also common and will depend on the severity of the pain and the amount of scaphoid collapse. Although pain from the non-union or surrounding synovitis can limit movement there is also a restriction when the scaphoid has assumed a flexed, hump back deformity along the non-union site. This deformity can create a Dorsal Intercalated Segement Instability (DISI) and with this abnormal wrist mechanics and a reduction in the range of movement tend to occur.
    With pain and loss of movement also comes weakness usually associated with underuse, particularly in heavy loading tasks.
    The impact these symptoms have on a patient will depend on hand dominance, occupation and hobbies ( in particular sports).
    Examination
    Inspect for any scars from previous surgeries, this may also include donor sites if a bone graft has previously been used (distal radius, olecranon, iliac crest). These may be very small in the case of a volar percutaneous screw placement. Look for muscle wasting and and changes in the callosities or state of the skin which may signal disuse or even Chronic regional pain syndrome (CRPS). A very important positive finding is nicotine staining on the fingers.
    Systematic palpation (usually starting with the normal wrist) – starting away from the most painful site and progressing around the wrist generally over the radio-carpal, mid-carpal and distal radio-ulna joint lines but also more specifically over bony prominences such as the scaphoid tubercle, pisiform and hook of hamate. Palpation may also yield more information with different wrist positioning i.e. in flexion more of the scapho-lunate ligament is exposed to palpation and in ulnar deviation more of the waist of the scaphoid is palpable beyond the radial styloid. On the ulna side of the wrist tenderness over the Extensor carpi ulnaris (ECU) may actually be deeper pain within the TFCC and can be differentiated by palpation in supination where the tendon lies more dorsally and pronation where it lies more ulnarly
    In the case of scaphoid non-union pain it is often elicited at the scaphoid tubercle, anatomical snuff box and dorsally over the scaphoid and scapholunate ligament just distal to Lister’s tubercle.
    The range of movement is assessed and measured(The expected normal ranges in degrees being shown in brackets): (flexion (75), extension (70), supination (85), pronation (70) and radial (20) and ulnar deviation (35) . All movements except pronation and supination are often reduced.
    Special tests-
    Telescoping of the thumb – positive test when pain experienced on stabilising the thumb metacarpal and twisting and grinding the thumb into the trapezium.
    Kirk-Waston test for scapholunate instability which can be associated – Test is executed by moving from ulnar to radial deviation with the thumb over the scaphoid tubercle while exerting pressure and the finger over the dorsal proximal scaphoid. Normally the scaphoid pushes the thumb away however if unstable due to a scapholunate ligament injury the proximal scaphoid sublimes dorsally of the radius. A positive test is when there is a clunk and pain is experienced.
    Kleinman shear test and Reagan test for Luno-triquetral instability – may be present in trans-scaphoid perilunate non-unions
    Reagan ballotment test – Push the lunate and triquetrum in opposite directions with your index finger from each hand to ballot them past each other to elicit pain if unstable or injured ligament.
    Kleinman shear test – Use the thumb and index on each hand to shear the lunate across the triquetrum to elicit pain and instability if ligament injury present.
    On the patient’s effected hand, push up on the triquetrum and down on the lunate.
    Observe the patient’s hand for tenderness and pain.
    Repeat this movement and observation on the patient’s other hand for comparison.
    Strength testing using pinch or grip dynamometers
    Investigation
    These include a 5 shot plain X-ray scaphoid series of radiographs. The required views being, Posterior-anterior, lateral, semi 45 degree prone, semi 45 degree supine and elongated scaphoid (Zitter) view.
    A CT may be useful to identify the exact morphology of the scaphoid and extent of any cysts or arthritic change.
    3T MRI scan (with or without Gadolinium) can give information about the likely vascularity of a proximal pole however the gold standard is still intra-operative assessment of punctate bleeding. The MRI may also reveal associated inter-carpal ligament injuries.
    Non-operative Management
    Non-operative management will depend completely on the pathology and symptoms.
    Symptomatic non-union can be treated with analgesia, splintage, wrist strengthening physiotherapy and activity modification to help manage symptoms.
    One non-operative treatment which may actual promote union, although is currently has limited evidence for use in scaphoid fractures, is low intensity ultra-sound wave such as the Exogen TM machine. The machine is used 20 minutes daily for up to 4 months to promote bone healing.

    Alternative operative Management
    Common alternative operative methods include arthroscopic grafting, other vascularised and non-vascularised open grafting techniques with screw or k-wire fixation.
    The grafts can be cancellous or cortico-cancellous.
    They can be non-vascularised (most common – iliac crest, distal radius and olecronon), vascular pedicled (most common distal radius – Kuhlmann, Zaidemberg) or free vascular (most common – iliac crest, medial femoral condyle).
    Contraindications
    Relative contra-indications include patients with a SNAC grade 2-3 wrist or an asymptomatic non-union. Absolute contra-indications include infection and ongoing untreated CRPS.

    Setup

    Pre-operative preparations and Equipment
    The operation can be performed under general (GA) or regional anaesthetic.
    As additional ligament injuries can accompany scaphoid non-union it is essential to perform an examination under anaesthetic (EUA) then an EUA with fluoroscopy to gain as much information as possible to aid additional diagnoses. The clinical examination in the outpatients department, the EUA and the operative findings are then all combined to assess what findings are clinically relevant.
    NB – Only surgically treat findings which correlate with clinical findings e.g. If a patient presents with pure radial sided wrist pain and an arthroscopy finds only a TFCC tear – DO NOT TREAT – as this is not symptomatic.
    A single dose of antibiotics are given pre-operatively and no thromboprophylaxis is used unless the patient is under a GA.
    The procedure takes around 120-150 mins.
    Patients under axillary block often notice tourniquet discomfort between 90-120 minutes (this can be delayed with use of local infiltration beneath the tourniquet and/or distraction techniques such as watching a film or listening to music on a portable device).
    The patient is lay supine with an arm on the arm board, the arm prepped and draped. All EUA and incision marking is completed PRIOR to exsanguination with a sterile Esmarch to reduce tourniquet time.
    Kit
    Sterile Esmarch, small curette, self retainers, osteotomes, saw, burr (optional in sclerotic cases), Acutrak Mini/Micro TM screw and set, additional 1.25 or 1.6mm k-wires, Mini C-arm for intra-operative radiographs. Micro instruments can be used around the pedicle if required.

    Operation – 1

    The surgical incision is marked running over Lister’s tubercle almost in line with the Extensor Pollicis Longus (EPL).
    The incision extends around 3cm proximal and distal to the radoiocarpal joint line. The Lister’s tubercle (LT), radius and ulna are also outlined to aid incision location.
    Once the arm is marked and confirmed to be numb (if under regional block) then the Esmarch bandage is used to exsanguinate the limb and the tourniquet inflated to 250mmHg.

    The incision is made down to the extensor retinaculum.Care must be taken to identify and protect any branches or the superficial radial nerve (SRN) and lateral cutaneous nerve of the forearm (LCN) in the field.

    The skin is elevated off the extensor retinaculum over the 1st and 2nd extensor compartments (EC).This can be performed with sharp dissection or blunt. Often a pair of forceps can simply be placed on the retinaculum and pushed proximally and distally to elevate the skin, fat and nerves as one flap. If performed carefully the forceps will only get held up where a perforator vessel crosses from the flap to the retinaculum and therefore needs to be identified and cauterised. The exception to this is at the distal end of the wound where vessels are left intact until the 1,2 ICSR vessel and its source is identified

    The forceps can be seen pointing to the SRN in the skin flap.

    With the skin flap elevated the 1,2 Intercompartmental Supraretinacular vessel is exposed, highlighted at the tip of the forceps.The vessel is seen overlying the retinaculum between the 1st and 2nd EC as the name suggests.
    Care must be taken each time a self retainer or retractor is placed in the skin flap as the SRN is very sensitive to trauma and can result in lasting pain issues if damaged.

    When dissecting more distally care must be taken to preserve the origin of the 1,2 ICSR vessel arising from the radial artery which supplies the graft (seen at the tip of the scissors).

    The 3rd EC is next dissected open, sharp dissecting onto Listers tubercle and leaving Although the graft pedicle is between the 1st and 2nd EC the exposure of the scaphoid, preparation of graft site and screw insertion is performed between the 3rd and 4th EC which need to be opened.
    To access the 3rd EC sharp dissection onto Lister’s tubercle allows a thick cuff of tissue to be elevated off the bone which enables an easier repair the retinaculum during closure.

    The EPL is exposed and location confirmed, then the compartment is opened proximally and distally.With the compartment opened the thumb is moved to ensure the correct location and view movement of the EPL tendon.

    The 3rd Extensor compartment. is opened proximally
    The scissors are used by sitting a blade of the scissors either side of the retinaculum just open wide enough to allow the scissors to be pushed proximally and open the compartment. Care must be taken as if this technique is used incorrectly and the blades of the scissors are wide open, they can catch and divide an extensor tendon.

    The same technique using the scissors is employed here and the 3rd EC is opened distally to reveal the length of EPL over the wrist.

    The EPL is exposed with the Extensor Carpi Radials Brevis (ECRB) visible beneath.

    The location of the joint line is confirmed using a blunt periosteal elevator or by inserting a needle and using an image intensifier if there is uncertainty.The EPL has been retracted volarly in this image.

    The volar aspect of the 2nd EC is opened using sharp dissection, and it is elevated dorsally following a subperiosteal dissection of the compartment.This is performed with a clear margin away from the graft vessel on the dorsal edge of the bony prominency between the 1st and 2nd EC on which the vessel lies.

    If possible, the 2nd EC is then elevated dorsally after subperiosteal dissection of the compartment.
    The forceps are pointing to the base of the 2nd EC with the tendons retracted.

    The self retainers are then placed between the tendons of the 2nd and 4th EC to expose the dorsal wrist capsule over the scaphoid.The periosteal elevator is placed over the radoiocarpal joint line between the radius and the scaphoid.

    The wrist joint capsule is incised leaving a cuff of tissue to repair back to on the radius.The incision extends from the radial styloid beneath the 2nd EC (under direct vision) then ulnarward until the scaphoid is clearly exposed as in this case.
    Skin hooks are useful to retract the capsule without impeding the view of the scaphoid.

    The Scapho-lunate ligament is a landmark (identified here at the tip of the forceps) to ensure adequate exposure has been achieved. This is also the entry point for fixation.

    The radial styloid is carefully exposed to its tip on the dorsal aspect only. This exposure ensures good visibility for the later styloidectomy and access for the graft pedicle however must not extend to the radial aspect off the radius at this point as it would risk damage to the graft vessel.
    The Watson-cheyne elevator is used to locate the tip of the styloid.

    The scaphoid fracture location, although clear in this case, is confirmed by inserting a 15 blade into the scaphoid.It is not possible to push a blade into the scaphoid bone in this group of patients unless it is along a non-union plane. will not

    An osteotome is used to cut the sclerotic bone from the scaphoid non-union edges.The osteotome can be seen here in the non-union site. Parallel cuts edges are made in the scaphoid removing 1mm of sclerotic bone. If this is enough to exposing bleeding bone on both fracture faces of the scaphoid then no further debridement is required. Often a curette of osteotome is used to scrape out fibrous tissue from cysts within the bone. A burr may even be used if very sclerotic.
    In this image the red face of the proximal pole (PP) reveal a vascular fragment with bleeding bone post debridement.

    Debridement of the scaphoid is completed to reveal 2 bleeding bone faces.
    Skin hooks can be used to pull the fragments apart to estimated the size of graft required and how the scaphoid will sit once grafted.

    The graft size required is estimated with a Ragnell retractor.The retractors small or large end is used to estimate the ideal graft size. If this method does not work due to the defect being to large then a osteotome width of tape measure can be used.
    In this case the graft required is the same wide and length as the Ragnell.

    Diagram of the graft shape and styloidectomy level.
    The picture reveal the insertion of the vessel into the radius around 1cm from the styloid tip, the level of the styloidectomy (shaded area to be removed) and the sloped nature of the distal aspect of the graft (Z) to avoid breeching the radio-carpal joint when the graft is taken.

    The 1st EC is then subperiosteally elevated off the radius with a similar cuff of tissue left with the vessel as dissected previously on the 2nd EC side.The self retainer has been moved to between the 2nd EC dorsally and the EPL sitting subluxed volarly.
    Care is taken to protect the pedicle distally.

    The retinaculum and vessel are elevated “as one” off the distal 5mm of the radial styloid to allow for styloidectomy.The self retainer is now on the tendons of the 1st and 2nd ECs.

    Operation – 2

    The tip of the radial styloid is exposed.
    White cartilage of the styloid can be seen at the tip of the lower set of forceps.

    Through this view the scaphoid defect is also visualised.
    The defect in the scaphoid is being indicated with the tips of the lower set of forceps.
    PP – Scaphoid proximal pole

    Scissors are passed beneath the pedicle to ensure it is clear of the styloid.In this image the scissors are now beneath the pedicle which can be more easily protected. The pedicle is the branch of the radial artery which has been elevated with the fascia and fat to protect the vessel during its mobilisation. The retinaculum will however need to be thinned around the vessel to allow adequate transposition of the graft into position.

    An osteotomy is made to remove 5mm of the radial styloid while protecting the graft pedicle.

    The styloidectomy completed now revealed a larger access to the scaphoid defect.

    The Rangell retractor used to measure the scaphoid defect is now used to mark the graft donor site.This graft when measured starts around 8mm from the styloid tip of 3mm from the tip now present following the styloidectomy. This ensure a cortical bridge at the tip of the radius and is not so proximal as to devascularise the graft damaging the vessel perforating the styloid around 10mm from the tip.

    The diagram reveals how the graft is swung around 120 degrees so that the vessel originally longitudinal on the styloid will then sit transverse on the scaphoid.
    The pedicle moves from position 1 to position 2 on the diagram.

    A 5mm wide saw is used to cut the dorsal and volar limbs of the graft.The saw is used to cut to a depth of around 10mm although care must be taken distally not to breach the deeper cortex and enter the radoiocarpal joint.

    After cauterising the pedicle vessel at the grafts proximal tip, the saw is used to cut the proximal edge of the graft.

    An osteotome is used at 45 degrees to complete the distal mobilisation of the graft.
    It is important to protect the pedicle at this point and to ensure at least a 45 degree slow to prevent breach of the radoiocarpal joint.

    The graft is lifted out of the radius.
    Note the triangle shape of the graft due to the 45 degree slope the osteotome was introduced at to protect the radio-carpal joint.

    The graft is lifted out of the radius and its pedicle is now mobilised to gain length for transposition into place.With the bone graft free from the bony attachment to the radius it becomes much simpler and safer to now release the remaining soft tissues from the radius to mobilise the pedicle. Care must always be taken to protect the pedicle which is being pointed to in the image with the scalpel tip.

    While the donor site is easily accessible some cancellous bone graft may be harvested.
    As the vascularised graft is flat walled some cancellous graft is often required to backfill cysts which have been curretaged within the two fragments of the scaphoid.

    Once mobilised the pedicled graft is passed beneath the 2nd EC to allow positioning in the scaphoid.

    The graft is seated next to the scaphoid defect and trimmed if necessary.The self retainer is now between the 2nd and 4th ECs.
    It may take a couple of attempts to site the graft and then trim it perfectly to size. This however is essential to reduce the risk of impingement when the graft is fixed in place.
    Priory to final placement of the graft, the cyst defects if present are packed with cancellous bone graft.

    Scaphoid laminar spreaders.
    This specially designed instrument is the correct size to spread a scaphoid during surgery and also due to the shape of its tips it can be removed without pulling the graft with it, unlikely more standard laminar spreaders.

    The laminar spreaders are inserted into the scpahoid.

    As the spreaders are held open on a ratchet system the graft can easily be sited between its limbs and then impacted.

    To press the graft into place the Ragnell retractor is a stable well sized instrument.
    If the Ragnell is left in place it will stabilise the graft when removing the laminar spreaders.

    With the graft in situ the wrist is gently mobilised to make sure there is not impingement and the scaphoid and graft move as one before the fixation takes place.A well sized graft will usually wedge open the scaphoid well enough that the bone and graft will move as one during gently mobilisation on table.

    PP – Proximal pole of scaphoid
    Waist – Scaphoid waist/distal fragment

    Under x-ray guidance a k-wire from the the screw set is inserted into the proximal fragment.The insertion point of the wire is just distal to radius dorsal lip with the wrist almost fully flexed and at the insertion of the scalpholunate ligament. As the wrist is so flexed then the entry point will only damage the non-structural proximal part of the scalpholunate ligament.
    The k-wire that is appropriate to the screw being used must be inserted. It is always best to check for yourself as a surgeon that the wire you are given glides smoothly through the corresponding drill bit. It is very disheartening to place a k-wire perfectly only to find it is the wrong size and needs to be changed before over-drilling can be undertaken.
    In this case, due to the small proximal pole size, a Micro Acutrak TM screw set was used. For sized beyond 18mm, as many scaphoid are, the Micro-extension kit is required. This kit has a different measuring device, drill and k-wires with a laser mark to read the length from.

    Once the trajectory of the wire is satisfactory on the imaging it can be advance across the graft with a finger placed on the graft to stabilise it.

    The position of graft, scapoid and K-wires is checked using Image intensification.When performing x-rays it is vital the wrist remains flexed to prevent bending of the wire. As the wire was inserted with the wrist already flexed, extension of the wrist when taking radiographs will bend the wire and make it impossible to ream over.

    Once happy with the K-wire wire position across the fracture the wire is measured.A laser mark on the wire can be read across to the size.
    In this case it read 26 on the Micro. 2mm were subtracted as the wire was just through the cortex distally and 4 mm were subtracted to allow for compression of the graft and burying of the screw. A 20mm screw was therefore chosen.

    It is useful to note in this picture that there is a gap between the head of the screw and the wider part of the screwdriver shaft of around 2mm. Therefore if the screw is driven in until this narrowed part of the screw driver is not visible then the screw should be sunk at least 2mm deep to the cartilage.
    Also note the flared size of the head of the screw.

    Operation – 3

    The wire is over drilled and then an over reamer is used by hand. This reamer, seen in the image, is wider than the drill and is used to accommodate the flared head of the screw to reduce the possibility of fragment fracture which is especially of concern in small proximal pole fragments.

    The screw in inserted in the proximal fragment slowly.

    When the graft is reached by the screw a finger is placed on it to stabilise it and reduce the risk of graft extrusion during compression.

    The screw is inserted until the narrow part of the screwdriver can no longer be seen above the cartilage.

    The pedicle is check for tethering or compression after which the dorsal wrist capsule is closed with 3/0 vicryl.The forceps point to the pedicle leading to the graft.

    The dorsal wrist capsule is closed with 3/0 vicryl.
    Interrupted sutures are used so as not to impede the pedicle. The pedicle location is at the tip of the forceps and often entered the wrist at the site of the styloidectomy where the capsule is left open.

    The 2nd EC is relocated by repairing the retinaculum between the 1st and 2nd EC.ER – Extensor retinaculum

    The 3rd EC is closed to prevent EPL subluxation.

    The skin is closed with an absorbable monofilament continuous sub-cutaneous suture.For this suture the ends are knotted outside the skin and will fall off under the cast at around 3 weeks.

    Occlusive dressings are applied.
    The tourniquet is released and we wait 5mins for initial swelling before applying the plaster cast.

    The wool is applied as standard for a below elbow plaster cast however the circumferential wool around the wrist is split then covered with a layer of non circumferential wool to allow for swelling and reduce painful constriction of the dressings.

    A dorsal below elbow plaster slab and bandage are applied.

    PA radiograph showing non union of scaphoid

    Pre-operative sagittal CT of scaphoid non union

    Pre-operative coronal CT of scaphoid non union

    Elongated PA of united scaphoid post operation 8 weeks – screw placement is slightly ulnarward but not within the mid carpal joint.

    Lateral Radiograph of united scaphoid post operation 8 weeks

    Coronal CT of united scaphoid post operation 8 weeks

    Sagittal CT of united scaphoid post operation 8 weeks

    Post Operative

    The post operative plan for patients undergoing a fixation for non-union surgery such as this case are to be performed as an Day Case procedure and be discharged the same day with a Bradford sling, Paracetamol, Codeine, Oral Morphine, Senna and Cyclizine.
    In the initial post operative phase the patient is in a plaster cast for 1 week and then the wounds are reviewed and the cast replaced for a further 5-7 weeks depending on complexity of non-union.
    During these weeks the patient must regain full movement of their finger and thumb with the physiotherapists to allow focused wrist physiotherapy and strengthening to commence once the cast is removed and a radiograph confirms union. A splint may be provided for comfort at nights and in crowds once the plaster is removed.
    If a non-union is suspected the plaster cast is replaced to complete a total of 10-12 weeks in cast and an urgent CT scan is organised to confirm progress of union.
    For the majority of patients the bone heals in 6-8 weeks and they should be back to most activities by 3 months and heavy lifting and sports by 6 months.

    Recommended Reading


    It is important that a surgeon is aware of the potential complications of this intervention. As well as doing all they can to minimise the risk of complications, the patient should be informed of them and understand their implications.
    All complications are rare and with simple fractures the non-union rate is around 3% however this may change the more complex the fracture with some rates as high as 33%.
    The “common” complications are iatrogenic cartilage damage, tendon injury, nerve injury, infection, CRPS, scaphoid non-union and metal work issues such as joint penetration and damage.
    Below are a couple of papers we recommend reading to gain a greater a overview of the outcomes of this procedure and of scaphoid non-unions in general.

    The outcome of bone graft surgery for nonunion of fractures of the scaphoid.
    J Hand Surg Eur Vol. 2019 Sep;44(7):676-684. Ammori MB, et al.
    This team collecting data for the British Society for the Surgery of the Hand collected retrospective data on 806 scaphoid non-union surgery patients from 19 centres in the UK. 462 patient data sets were analysed. 9% of cases had uncertain outcomes and 69% united. There was a trend to worse outcomes for smokers and delays to surgery. The type of graft vascular versus non-vascular did not influence outcomes.

    Treatment of Scaphoid Nonunion: Radiologic Outcome of 286 Patients in 10 Years.
    Eplasty. 2019 Mar 15;19:e5. Jaminet P1, Götz M2, Gonser P3, Schaller HE4, Lotter O5.
    This team from Germany retrospectively review 149 cases. All AVN cases were treated with a 1,2 ICSR graft (union 81%), all non-AVN cases treated with non-vascularised iliac crest graft (union 82%) and all revision cases were treated with Khulmann volar carpal artery graft (91%). A larger series of specific indications and therefore not comparable between different graft types.
    Treatment of Scaphoid Nonunion: Radiologic Outcome of 286 Patients in 10 Years.
    Eplasty. 2019 Mar 15;19:e5. Jaminet P1, Götz M2, Gonser P3, Schaller HE4, Lotter O5.

    Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence.
    Pinder RM1, Brkljac M2, Rix L2, Muir L3, Brewster M4.J Hand Surg Am. 2015 Sep;40(9):1797-1805.e3. doi: 10.1016/j.jhsa.2015.05.003. Epub 2015 Jun 24.
    This systematic review looked at 48 publications and 1602 patients and concluded that there is no strong evidence for screw fixation over k-wire fixation or vascularised grafts over non-vasculasrised grafts in scaphoid non-union surgery.

    Reference

    • orthoracle.com

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