Scaphoid Non-union

Dr. Randale Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today we'll be talking remotely with Dr. Walter Short. Dr. Short is a hand surgeon who practices hand surgery at the SOS Hand and Wrist Surgery Center at the Syracuse Orthopedic Specialists in Syracuse, New York. Dr. Short is a recognized leader in the field of orthopedic hand surgery, publishing over 200 articles and scholarly presentations and receiving numerous research grants from the federal government while serving as a professor at Upstate Medical University. He is also recognized for premier patient care, having received a National Patient Choice Award for three consecutive years and a 5 Star rating by HealthGrades. Dr. Short attended medical school at Upstate Medical University followed by general surgery internship at the University of Connecticut and a surgical orthopedic residency at Upstate Medical University. Dr. Short continued his education with a hand fellowship at Yale University and the the University of Connecticut. Thanks for joining us today, Dr. Short.

Dr. Walter Short: Thank you for having me today.

Dr. Randale Sechrest: Dr, Short, today what I thought we would talk about is a condition called a scaphoid, or a navicular nonunion. And, this is a problem that occurs fairly commonly in the wrist after a fracture of the scaphoid, or sometimes called the navicular bone. So, let's start by having you tell the patients a little about what this bone does, where it's located, and how we come to have a nonunion of a scaphoid fracture.

Dr. Walter Short: Uh, the scaphoid or the navicular is a is probably the most important bone in the wrist. The wrist itself is made up of eight little bones that are all irregularly shaped and they act like little ball bearing, which allows the wrist to move in a variety of different directions. The scaphoid sort of looks like a cashew. And, the scaphoid is the most commonly broken bone in the wrist. And ah, approximately ten or 15 per cent of scaphoid fractures go on to not heal or what they call become a nonunion. The reason for that is that the blood supply to this particular bone is different than most bones. So all of the blood supply comes in from one end of the bone and if the bone is broken in two, ah, the blood inside the bone can't get to the fractured part of the bone. Therefore it delays the healing of this bone.

Dr. Randale Sechrest: You know I think we probably ought to point out as well, we talked earlier about the concept of a wrist sprain in one of our earlier discussion, and this is one of those bones that I think sometimes is missed initially. Or a fracture of this bone is missed initially. And you may go to the emergency room with a fall on an outstretched hand, get an x-ray and the ER doctor or the radiologist read that initially as no fracture. I think that one of the causes of a nonunion that we probably ought to point out, is people not recognizing that they actually have a fracture of this bone, and it not being treated initially.

Dr. Walter Short: You're absolutely correct. Ah, ah, A large portion of people, they go to the emergency room, they fall on their hand, or their involved in a sporting activity and fall on their hand, uh, this bone is so irregularly shaped, it's sometimes very difficult to see if it's fractured. So what should happen, if the patient continues to have pain in the wrist, they should go back to the emergency room for follow-up or they should go to an orthopedic surgeon or a hand surgeon to get more x-rays or specialized views to see if they do have a fracture. The problem with this fracture is that if it doesn't heal, or they continue to ignore it, 5-10 years down the road, the vast majority of people that have a nonunion of this scaphoid, or this bone, develop arthritis.

Dr. Randale Sechrest: And how does a person know if they have a nonunion? Is there any way that they should be suspicious other than just having pain that persists, that perhaps they have a nonunion of the navicular of scaphoid?

Dr. Walter Short: They would know that because if they are athletic, they can't do the athletic activities that they did before. Things like push-ups, throwing a ball, uh, uh, catching a ball is more painful than usual. The pain persists. A sprain, usually after a few days or a week or so will eventually go away. If they have a fracture, the pain will persist. And if they have a fracture and its not treated, then it becomes more and more difficult to get it to heal.

Dr. Randale Sechrest: Now, when that patient presents to you, let's say they've had this wrist injury six months beforehand and perhaps they either did not have treatment, or perhaps the treatment was commenced immediately but the fracture just failed to heal. How are you going to approach that in terms of evaluations? How do you start with that patient, trying to figure out what's the best treatment for them?

Dr. Walter Short: Ah, the best ah start is to get specialized studies. And that would either be a computerized x-ray or a CT scan, possibly an MRI may be done. Because the key part of treatment when it hasn't been treated for 6 months is to see if both of the pieces of bone which are broken have a blood supply. If they don't have a blood supply, then they needed to be treated in a certain fashion. If both pieces of bone have a blood supply, there is a different way of treating it. So if you get an MRI and one of the pieces of bone, one of the parts of the bone which has been fractured, doesn't have a blood supply, then it has to be treated with a specialized surgical techniques to implant a blood supply into that bone, which has no blood flow in order to stimulate it to heal. It also needs to be, the two pieces of bone have to be connected together with specialized screws to hold it in a rigid position while it heals and while that piece of bone gets a new blood supply.

Dr. Randale Sechrest: Now, I think we ought to probably distinguish for patients, because these are two very different situations I think that you've just described. One with the lack of a blood supply in one or both pieces of the bone, normally I think it's usually just one of the pieces. But I really think really stress to patients how difficult a situation that is. Can you describe a little bit more about what you're worried about as a hand surgeon when you see this condition where the patient has no blood supply to one of these fragments, or what we might term avascular necrosis of a piece of that bone. How do you approach that differently?

Dr. Walter Short: Typically the the patient ah that has avascular necrosis or loss of blood supply to this fragment of bone, and most, and always it is the part of the bone which is closest to the forearm, not the part of the bone which is closest to the fingers. And if this bone, if this part of the scaphoid doesn't have a blood supply, what happens is that the bone starts to get soft, it looses it's contour, it starts to fragment apart, and if that's the case, ah, ah, it is extremely difficult to get it to heal. And even if you can get it to heal, the shape of the bone is abnormal, which will eventually lead to arthritis. So, it's important to determine if that piece of bone has a blood supply, and that is done either with an MRI and at the time of surgery you can tell if there is bleeding in that bone. Because if it isn't bleeding, the surgeon needs to do something to restore the blood flow to that bone and that's with a specialized surgical procedure. Most of the time these people are very young, and if you can't get it to heal, they are sort of doomed to develop arthritis at a later date.

Dr. Randale Sechrest: Well, it sounds like this is probably the worst case scenario, where you have avascular necrosis, you have a nonunion, and you're having to do some fairly specialized surgery in terms of trying to get this to heal and restore whatever you can salvage from this situation. Let's talk a little bit about the situation where both pieces of bone do have a blood supply and what you have is, in some ways, a simpler situation, where you have a fracture that's not healed. Perhaps it's six months down the road. What are our options there?

Dr. Walter Short: If it's six months and it has not healed, it is very unlikely to heal. Especially if it hasn't been treated. In many cases, ah what happens it that ah, athletes come into the office, they got injured in the beginning part of the season, typically it's football. They are afraid to tell anybody that they injured the wrist for fear that they won't be able to finish out the season, so they sort of mask their symptoms. And at the end of the season they come and x-rays and specialized studies show that they have a nonunion of this scaphoid. If both of the pieces are ah, have a blood supply, in many cases the bone is not in the normal shape or normal position. Since the bone is shaped sort of like a kidney bean or a cashew, what happens is that the bone continues to bend and becomes what is termed a hump-backed deformity, which is an accentuated shape of the bone. In that case, you'd have to surgically restore the normal shape of the bone and when you do that there is always a gap in the bone so you have to fill that in with bone that you obtain from a different part of the wrist or the hip, and you have to stabilize the bone, the scaphoid, with a screw that maintains it's normal, or what they term “anatomic” position. Because if it doesn't it'll just drift back into the shape it was 6 months after it fractures and there was no treatment. So, it's important to restore the position and normal contour of the bone.

Dr. Randale Sechrest: Is there any situation where you would consider treating a nonunion that has not healed and simply putting the patient in a cast, treating them non-surgically?

Dr. Walter Short: Ah, if they, ah came and immediately, if they came right away and had a diagnosis of a fractured scaphoid, and the scaphoid was in it's normal shape and normal position, then I would treat that person in a cast. If they came 6 months later and it hadn't healed, ah, most of the studies that have been done show that it will not heal in a cast and it needs to be surgically fixed.

Dr. Randale Sechrest: So, if I understand you correctly, what you're suggesting is that if you get one of these fractures relatively soon after the injury, and maybe it's not been treated, and maybe it has been treated in appropriately, for example with a brace or something like that. Then you might go ahead and try to heal that fracture with a cast. How long would you attempt cast treatment in that case before you abandon cast treatment and said this needs an operation.

Dr. Walter Short: If you treat it in a cast for 6, 8, 10 weeks, and you get x-rays and the x-rays show that there has been no healing at all, that is an indication to abandon cast treatment and treat it surgically. If you inish, ah initially you have a fractured scaphoid which is in the correct position and you treat it in a cast and later on you see that the fracture fragments have shifter in position, that's an indication to treat it surgically. Ah, and if you see, ah, x-rays after it's been in a cast which show that there may be some signs that the bone is losing it's blood supply, then it's important to determine if it has a blood supply and treat it appropriately.

Dr. Randale Sechrest: Now what is the current thinking in terms of doing an operation to put a screw in percutaneously for example, so that you don't actually make an incision, you don't actually open up the wrist and look at the scaphoid, but you put a wire down through using a fluoroscope and then put a screw across to stabilize it? Is that currently done for any of these fractures or are we now opening most of these and trying to fix them more definitively by looking at the fracture and putting the hardware in and the bone graft if necessary under direct vision?

Dr. Walter Short: If ah the indications to do surgery percutaneously, which means either no incision, or a very small incision, if if the scaphoid fracture is not grossly displaced. And uh, it needs only a little bone graft or no bone graft. Some non unions are uh, the fracture has just not healed, but it has maintained it's normal shape. And if that's the case, then all you need to do is put a screw across the fracture site and the screw not only maintains the normal shape of the bone, but as you put the screw in, the two pieces of bone squeeze together, or compress, which stimulates healing to occur. So, fractures or non unions which have not been displaced or don't have a gap between the two ends of the bone are most commonly treated in this percutaneous manner.

Dr. Randale Sechrest: Well, lets talk a little bit about some of the more specialized surgery that you alluded to earlier when you've got the situation that not only do you have a non union, but you also have the avascular necrosis, or the lack of blood supply into that proximal pole, or that piece of the bone that's near the forearm. Can you describe the nature of that surgery? What you are trying to do to increase the blood supply to that fragments?

Dr. Walter Short: Ah, the, the problems is that this bone has no blood supply, And the reason, there are two reasons why it doesn't have, why it's lost it's blood supply. One, because of the fracture and when the bone is broken ah the blood flow inside the bone has been disrupted, because now that one bone is two bones. And the second reason is that this bone has a lot of cartilage covering it. Probably almost 80% of this bone is cartilage or a covering to allow the bone to glide. And if there's cartilage, there's no areas where a blood vessel can enter the bone to allow it to heal. So in these fractures where there is no blood supply or they've lost the blood supply, there are surgical techniques where using a microscope we can find other blood vessels which instead of going into the scaphoid, they go into the radius, one of the forearm bones. And by taking a piece of bone and the blood supply of the radius, we plug that into the scaphoid, So now, instead of supplying blood to the radius, which it originally did, now it supplies blood to the scaphoid. The radius has multiple blood vessels that go into it, so the radius is not going to miss one out of multiple blood vessels that enter it, whereas the scaphoid desperately needs a new blood supply. So, you're sort of “robbing Peter to pay Paul” but Peter has a lot of blood vessels, to the radius will never miss it.

Dr. Randale Sechrest: So how successful is this operation for this situation?

Dr. Walter Short: Ah, studies have shown that if there is no blood supply to the bone, and you do a regular bone graft, which means there is no blood supply to that bone graft, it is only successful about 35 – 40%. Whereas if you do a surgical procedure where you take the blood vessel and the bone and put it into the avascular scaphoid, the success rate goes somewhere near 90%.

Dr. Randale Sechrest: So it's a pretty significant improvement in terms of the success rate.

Dr. Walter Short: Absolutely.

Dr. Randale Sechrest: Well, lets talk a little bit about after care. In all of these procedures we're try to get thin bone to heal, trying to get the non union to heal and in the case where we're worried about the avascular necrosis we're trying to get that bone to revascularize and keep that blood supply going as best we can. So, lets talk a little bit about the post op care in terms of what patients should expect after they've had one of these surgeries. How long are they in a cast and how long is it before they begin physical therapy and maybe how long is before they can go back to using their wrists for normal, everyday activities?

Dr. Walter Short: If ah they need a blood vessel put into the scaphoid, that is a fairly lengthy procedure. The fracture is still somewhat delicate. And ah, in my patients they all go into a cast. The cast is below the elbow, they are , it does not include the fingers, but it goes include the thumb. They are typically in a cast somewhere around 6-8 weeks. What I would like to see is that there is evidence that the fracture is starting to heal and the line that you see on an x-ray where, which indicates a fracture is starting to become obliterated before they come out of the cast. Ah, the average amount of time after a vascularized bone graft, where we put a blood vessel into the bone is somewhere between 8-12 weeks for it to heal.

Dr. Randale Sechrest: And physical therapy, when they come out of the cast, does everyone work with a physical therapist to regain strength and motion.

Dr. Walter Short: Ah, the majority of people are sent to physical therapy and the duration of the physical therapy is usually based upon the motivation of the patient. A well-motivated patients will start doing physical therapy at home. Ah, pain, most people don't have a lot of pain after this surgery. And ah, so physical therapy isn't long and extensive usually.

Dr. Randale Sechrest: Dr. Short, lets talk a little bit about potential complications for these procedures that you've just outlined. What do you worry about as an orthopedic hand surgeon when you are taking care of patients in terms of the after care.

Dr. Walter Short: I worry about whether the blood vessel will continue to supply blood to this bone, I worry about the fact that the screw that hold the two bones together and is stable enough to allow feeling. I worry about, especially when I put a blood vessel into the bone, uh, uh, things like smoking will in some cases decrease the success rate of the surgical procedure.

Dr. Randale Sechrest: And so you tend to discourage people from smoking, or have them stop smoking before you do this procedure? Is that something you actually require before doing this procedure/

Dr. Walter Short: I tell people that if they are smokers, that they should quit. I tell then that the chemicals in the cigarette smoke will constrict the blood vessels and in most likelihood greatly decrease their chance of successful outcome.

Dr. Randale Sechrest: Well, what about the long-term effects? Now, you've mentioned that in some cases, especially when you have a condition where you have avascular necrosis and the nonunion, that situation never gets back to normal, so what should these people expect years down the road? Are they at higher risk of developing arthritis in the wrist? Are they going to need another operation at some point?

Dr. Walter Short: Uh, studies have been done that have shown if a person ah, has a scaphoid non union and chooses not to treat that, uh, five years down the road approximately 90-95% of the people have arthritis on x-ray and about 85% of those patients have symptoms from the arthritis which would include pain, decreased mobility, decreased strength.

Dr. Randale Sechrest: Well, Dr. Short, if I understand you correctly, it's to the patient's advantage to consider surgery when they have this situation with a scaphoid non union and even if they have avascular necrosis or not. I guess one of the questions would be, what's the risk of osteoarthritis in that wrist after a successful surgery when the patient has the situation you've described. Where they have a nonunion and they have avascular necrosis of the proximal pole where even though you've completed the surgery, they've healed the fracture, the bone is still not quite normal. Are they still at risk for osteoarthritis down the road. And should they expect another operation down the road.

Dr. Walter Short: If, us, the surgery restores the blood flow and the fracture unite, then they are spared the increased risk of arthritis. Uh, the surgical procedure may decrease their motion slightly, but once you restore the blood flow and have healed the fracture, the patient can expect a relatively successful outcome from the surgical procedure.

Dr. Randale Sechrest: Well, I think that's good news. Lets talk a little bit about, again what to expect long term. Do you restrict patients such as this in any of their activities or once they're healed do you pretty much let them go back to sports for example. You mentioned football players, are these patients allowed to go back to contact sports like football?

Dr. Walter Short: Ah, yes, that's the whole idea of doing the surgical procedure is to allow them to resume their normal activities or the sporting activity which they were doing prior to the injury. Once a fracture has healed, the bone in the vast majority of cases is restored to full strength and full function, and I anticipate that no further surgery needs to be done. The screw that is placed inside the bone is buried inside the bone, so there really is never any need to remove screws or hardware after the surgery. So, my expectation if the surgery is successful that they will return to all the activities they were doing before they got injured.

Dr. Randale Sechrest: Well I think this has been a great discussion about scaphoid non unions and I think we've covered the terrain pretty comprehensively. Is there anything as we close that you feel like patients need to know if they have this injury or if they suspect they may have this injury in terms of getting the appropriate care?

Dr. Walter Short: My advise to patients is if the have persistent pain after a fall or an injury, and they goto the emergency room and the x-rays are normal, just because the x-rays are normal does not necessarily mean that they don't have a fracture. There is multiple cases where the initial x-ray is normal and a follow-up x-ray one or two or three weeks later, ah, visualizes a fracture that was not seen in the emergency room. It sometimes takes a while to see the fracture on a plain x-ray.

Dr. Randale Sechrest: Well, thanks, I think that is good advice. I think that people ought to be persistent if they think they've got a problem, especially. And again as we discussed earlier in a different lecture. You know there's not many people that have a simple wrist sprain. When wrist pain persists, you and I would probably consider that a significant problem and I think people ought to be somewhat persistent in trying to get an accurate diagnosis there. So, I want to thank you for joining us today and that you for this useful information.

Dr. Walter Short: Thank you.