American Society for Peripheral Nerve

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Compression screw fixation without bone grafting for scaphoid fibrous nonunion
Jeremy S. Somerson, MD1; Ramesh C. Srinivasan, MD2; Daniel J. Fletcher2; Mark A. Bagg2; William C. Pederson, MD2; David Person2; Fraser J. Leversedge, MD3; David P. Green2
1Orthopaedics, University of Texas Health Science Center San Antonio, San Antonio, TX; 2Hand Center of San Antonio, San Antonio, TX; 3Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, NC

Introduction: Scaphoid nonunion alters carpal mechanics causing the development of arthrosis associated with wrist pain and loss of motion. We evaluated the clinical and radiographic outcomes of fibrous nonunions of the scaphoid treated with an AO compression screw method without bone grafting.

Materials & Methods: An IRB-approved review identified patients who underwent surgical compression screw fixation without bone grafting of scaphoid fibrous nonunion between January 1, 2000 and December 31, 2012. Fibrous nonunion of the scaphoid was defined as a scaphoid fracture with 1.) persistent tenderness 2.) incomplete trabecular bridging on three x-ray views 3.) injury had occurred > 6 months prior to surgery 4.) no increased displacement when comparing a standard PA view with an ulnar deviated PA stress x-ray (Figure 1). Patients with previous surgery, unstable scaphoid nonunions (increased displacement with ulnar deviation stress x-rays, or “pseudoarthroses”) (Figure 2), and scaphoid nonunions with radiographic signs of avascular necrosis were excluded. Standard metrics were used to assess clinical and radiographic outcomes.

Results: Fifteen patients with a mean age of 20 years (range: 15-54 years) and mean follow up of 7.6 months (range: 3.3-12 months) were included. There were 9 proximal third fractures and 6 middle third fractures. 14/15 patients healed at an average of 3.6 months (range: 1.5-6 months). Average flexion-extension arc improved from 92 degrees pre-operatively to 166.5 degrees post-operatively (p=.02). Average grip strength improved from 58 lbs preoperatively to 86.8 lbs post-operatively (p= .03). Mean post-operative pain score was 1.4. Mean post-operative DASH score was 13.1. 12 out of 14 patients that healed returned to their previous level of activity. There were two complications (13.3%): one patient developed superficial cellulitis that was successfully treated with oral antibiotic treatment and one patient required vascularized bone grafting for persistent nonunion.

Conclusions: Treatment of fibrous nonunions of the scaphoid with an AO compression screw method without intercalary bone grafting is supported by our retrospective study. Scaphoid fibrous nonunions appear to have the potential to heal; however, stabilization may be necessary to facilitate this process.

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