ORIGINAL RESEARCH

Screw Fixation Without Bone Grafting for Delayed Unions and Nonunions of Minimally Displaced Scaphoids

Publish date: August 8, 2018

References

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Hand surgeons have several surgical options when managing scaphoid injuries. Mahmoud and Koptan⁴ used a volar approach to percutaneously deliver a headless compression screw into 27 nonunions. Postoperative CT scans demonstrated fracture union in all 27 patients, and no patient underwent revision surgery. Interestingly, 14 of their patients had extensive preoperative resorption (but no deformity) of >5 mm.

Although volar percutaneous approaches for internal fixation have been cited to provide high rates of union and high patient satisfaction in acute scaphoid fracture fixation, this study utilized a dorsal approach. Both Wozasek and Moser¹² and Haddad and Goddard¹³ reported excellent results and high union rates using a volar approach in consecutive acute scaphoid fractures. Despite these results, there are concerns that using a volar approach may damage the scaphotrapezial joint and may be prone to eccentric placement of compression screws.^8,14

Slade and colleagues³ did utilize the dorsal approach with arthroscopic assistance to deliver a compression screw into scaphoid nonunions in 15 consecutive patients without any evidence of deformity, sclerosis, or resorption. Similar to our investigation, they treated patients with both delayed unions and nonunions. CT scans were used to confirm unions in all their patients. Using a dorsal approach, Yassaee and Yang¹⁵ treated 9 consecutive patients using a compression screw without bone grafting for both delayed and nonunion scaphoid injuries. Other authors have used both volar and dorsal approaches in 12 consecutive delayed and nonunion scaphoid injuries and found that 11 of the 12 injuries progressed to unions.⁶

Although these authors and several others advocate the use of CT scans to assess unions, our investigation used bridging trabeculation obliteration of the fracture line on 3 standard radiographic views to confirm unions in addition to the absence of pain clinically.^16,17 CT scans expose the patient to increased radiation that, in our experience, does not alter the postoperative clinical course.¹⁸ If there is clear evidence of bridged callus and no pain on physical examination, a CT scan performed to reconfirm the union affords little benefit to clinical management.¹⁹

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