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Review of Surgical Treatment for Scaphoid Nonunion

The scaphoid bone in the wrist can present some complex treatment problems if and when a fracture doesn't heal. This condition is called a scaphoid nonunion. In this article, the surgical treatment of scaphoid nonunion is presented.

The authors point out that without surgical treatment, a scaphoid nonunion can get much worse. The bone itself can collapse. This results in an unstable wrist. The bones don't line up so any use of the wrist causes uneven wear and tear on the joints. Osteonecrosis (death of the bone) arthritis can be the end results.

The goal of surgery is to knit the broken pieces of bone back together. The alignment of the wrist must be treated, too. Some types of breaks can disrupt blood supply to the bone, so the surgeon examines this carefully.

Surgical setup and instrumentation used are described in detail. Whether or not the incision is made from the front (volar) of the wrist or the back (dorsum) of the wrist depends on what's going to be done. The volar approach is used when a bone graft is needed. It also helps save the blood supply.

A dorsal approach is used when the fractured piece is on the wrist-side (rather than the finger) side of the hand. This is called a proximal pole nonunion. Healing is often much slower for this type of fracture injury. Screws or wires are used to hold the bone together during the healing process. This is called fixation or instrumentation.

Rehab and postoperative management tips are also included. The authors list a group of pearls and pitfalls for surgeons to consider with each operation. For example, when operating from the volar side of the wrist, ligaments such as the radioscaphocapitate should be saved as much as possible. This helps prevent the bone from slipping back into a partial dislocation.

Insertion points for the arthroscope are described and shown. For all procedures, X-rays and MRIs help identify problems that should be corrected during the operation.

Patients should be advised prior to the surgery that stiffness and pain are common after the operation. In fact, these symptoms can be worse after surgery than they were before surgery. Nerve damage can also occur, although every effort is made to avoid this.

References: Thanapong Waitayawinyu, MD, et al. Scaphoid Nonunion. In Journal of the American Academy of Orthopaedic Surgeons. May 2007. Vol. 15. No. 5. Pp. 308-320.

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