CME

Management of Scaphoid Fractures

Jason H. Ko, M.D.
Learning Objectives: After reading this article, the participant should be able
Mitchell A. Pet, M.D.
to: 1. Understand the epidemiology, classification, and anatomy pertinent to
Joseph S. Khouri, M.D.
the scaphoid. 2. Appropriately evaluate a patient with suspected scaphoid frac-
Warren C. Hammert, M.D. ture, including appropriate imaging. 3. Understand the indications for opera-
Chicago, Ill.; Seattle, Wash.; and tive treatment of scaphoid fractures, and be familiar with the various surgical
Rochester, N.Y. approaches. 4. Describe the treatment options for scaphoid nonunion and
avascular necrosis of the proximal pole.
Summary: The goal of this continuing medical education module is to present
the preoperative assessment and the formation and execution of a surgical
treatment plan for acute fractures of the scaphoid. In addition, secondary
surgical options for treatment of scaphoid nonunion and avascular necrosis
are discussed. (Plast. Reconstr. Surg. 140: 333e, 2017.)

T ANATOMY
he scaphoid is essential for normal carpal
kinematics and wrist function. Its unusual The scaphoid has an irregular shape, is cov-
shape and delicate blood supply make suc- ered mostly with cartilage, has a delicate vascular
cessful treatment of scaphoid fractures a chal- supply, and is situated in an oblique orientation
lenge for hand surgeons. Despite many advances that links the proximal and distal carpal rows.
in the evidence-based treatment of scaphoid frac- For these reasons, there is extensive literature
tures, nonunion is still relatively common, and devoted to describing scaphoid anatomy and
remains a difficult problem. pathoanatomy as it relates to evolving clinical
practice.5–7 The long axis of the bone is tilted
EPIDEMIOLOGY volarly and radially with respect to the longitu-
The scaphoid accounts for 60 to 70 percent of all dinal axis of the limb. Fractures are generally
carpal fractures1 and is the second most commonly described at the proximal pole, waist, distal pole,
fractured bone in the upper extremity (after the or tubercle. The waist is the most common site
distal radius). Scaphoid fractures commonly occur of fracture, accounting for approximately 75 per-
during sporting events, or after falling onto an out- cent of injuries.8
stretched hand.1,2 Hove reported that 82 percent of Gelberman and Menon studied the vascu-
the scaphoid fractures in Norway occurred in male larity of the carpus in fresh cadaver specimens,
subjects, with an average age of 25.1 Studying a large demonstrating that 70 to 80 percent of the
U.S. military population, Wolf et al. measured the intraosseous vascularity comes from the dorsal
incidence of scaphoid fracture at 121 per 100,000 scaphoid branches of the radial artery, entering
person-years, with a peak occurring in men between through the dorsal ridge. These dorsal vessels
the ages of 20 and 24 years.3 In a large-scale epide- enter the scaphoid waist in a retrograde direc-
miologic study, the incidence of scaphoid fracture tion, providing the single dominant intraosseous
was 12.4 in 100,000 in the general population.4 vessel to the proximal pole of the scaphoid.9 A
minor volar contribution comes from the radial
From the Division of Plastic and Reconstructive Surgery, artery or its superficial palmar branch, which
Northwestern University; the Division of Plastic and Recon-
structive Surgery, University of Washington; and the Division
of Plastic and Reconstructive Surgery and the Department of Disclosure: The authors have no financial interest
Orthopaedics and Rehabilitation, University of Rochester. to declare in relation to the content of this article.
Received for publication July 8, 2016; accepted October 24,
2016.
This CME article does not contain original research on Related Video content is available for this
­human subjects performed by the authors, and as such is not article. The videos can be found under the
subject to approval by an institutional review board, or the “Related Videos” section of the full-text article,
Declaration of Helsinki. or, for Ovid users, using the URL citations pub-
Copyright © 2017 by the American Society of Plastic Surgeons lished in the article.
DOI: 10.1097/PRS.0000000000003558

www.PRSJournal.com 333e
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 Plastic and Reconstructive Surgery • August 2017

gives off several volar scaphoid branches at the suspicion for a fracture based on history or exami-
level of the radioscaphoid joint, entering the nation findings has become increasingly popular.
bone at its distal tubercle.9,10 The anterior inter- Options for advanced imaging of the scaphoid
osseous artery provides collateral circulation, are computed tomography and magnetic resonance
which is ample for preserving scaphoid vascular- imaging. Combining data from several recent studies,
ity in cases of radial artery discontinuity. Because Yin et al. estimated that computed tomography has
of this unique vascular anatomy, the proximal a sensitivity and specificity of 90.7 and 98.2 percent,
pole of a fractured scaphoid is particularly prone respectively, whereas magnetic resonance imaging
to avascular necrosis, especially when the frag- has superior sensitivity of 97.2 percent and a speci-
ment is small. The dorsal location of the domi- ficity of 99.3 percent21 and also allows the assessment
nant blood supply is the basis of one argument of the osseous blood supply and soft-tissue changes.
for giving preference to volar approaches during Pillai and Jain reported that more than 80 percent
fracture fixation.9 of patients with suspected scaphoid fractures and
negative radiographs undergo unnecessary immo-
CLASSIFICATION bilization.22 There is increasing high-level evidence
that when lost economic productivity is considered,
Classification of scaphoid fractures is impor- immediate magnetic resonance imaging is more
tant to help guide prognosis and treatment and cost-effective than immobilization and follow-up
to allow comparison of treatment outcomes. Over radiography for patients with suspected scaphoid
the past 65 years, at least 13 distinct schemes for fracture and negative radiographic results.19–21 How-
classification of acute scaphoid fractures have ever, this conclusion is predicated on a system’s
been proposed. Each is based on assessment by willingness-to-pay threshold, and may not apply to
plain radiography, and schemes generally divide settings where resources are more limited.21
fractures by anatomical location, fracture plane Computed tomography still has a role, as this
orientation, and/or stability and displacement.11 technology is more widely available than mag-
The most commonly cited11 classification scheme netic resonance imaging, and is the advanced
is the Herbert12/Modified Herbert13 system, fol- imaging modality of choice in settings where
lowed by the Russe14 system. A summary of the magnetic resonance imaging is unavailable. Fur-
Modified Herbert and Russe classifications can be thermore, once a scaphoid fracture is identi-
found in Figures 1 and 2. fied, a computed tomographic scan oriented in
the long axis of the scaphoid is more helpful for
DIAGNOSIS determining displacement and alignment of the
In the acute setting, patients will present scaphoid.
with edema, ecchymosis, decreased motion, and
pain with palpation of the anatomical snuffbox TREATMENT
and tubercle or with axial loading of the thumb.
Physical examination has a high sensitivity but a Nonoperative Treatment
low specificity for the detection of acute scaph- Nondisplaced scaphoid waist fractures can be
oid fracture.15,16 Clinical suspicion should prompt treated by cast immobilization for 8 to 12 weeks,
radiographic imaging, including posteroanterior, with an expected healing rate of 88 to 95 percent.23
lateral, and oblique views, in addition to a scaph- Traditionally, an above-elbow thumb spica cast is
oid view (partially supinated posteroanterior with recommended for the first 4 to 6 weeks to elimi-
ulnar deviation). Approximately 20 percent of nate forearm rotational forces on the scaphoid
patients with negative plain radiographs have an fracture, followed by below-elbow immobilization.
occult acute scaphoid fracture.17 Because of this, This approach was confirmed in a prospective ran-
negative radiographs have historically been fol- domized trial by Gellman and colleagues where
lowed by immobilization in a thumb spica cast and patients treated with an above-elbow thumb spica
follow-up radiographic examination at 2 weeks cast for 6 weeks before transitioning to a below-
looking for interval displacement or perifracture elbow thumb spica cast had shorter times to union
resorption. This strategy still fails to detect 9 per- and a decreased incidence of nonunion compared
cent of scaphoid fractures,18 results in delayed with patients treated entirely in a below-elbow
fracture diagnosis, and unnecessarily immobilizes cast.24 In a prospective randomized study of 121
57 to 80 percent of patients with negative initial patients, Hambidge et al. reported that the position
radiographs.19–21 For these reasons, early advanced of the wrist in a below-elbow cast with no thumb
imaging in patients with negative plain films and immobilization did not influence fracture healing

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 Volume 140, Number 2 • Management of Scaphoid Fractures

Fig. 1. Modified Herbert classification of scaphoid fractures.

or functional outcomes.25 Clay and colleagues ran- Operative Treatment

domized 392 waist fractures to below-elbow casts Fracture displacement and proximal pole frac-
with or without immobilization of the thumb, ture are indications for operative treatment. Conser-
demonstrating no differences in fracture healing.26 vative management in a cast has been demonstrated
However, a prospective, multicenter, randomized to allow healing of 90 to 95 percent of scaphoid waist
trial evaluating nonoperative treatment in a below- fractures by 3 months,28–30 but the advent of mini-
elbow cast including or excluding the thumb dem- mally invasive techniques and improved fixation sys-
onstrated a significant improvement (85 percent tems has started to swing the pendulum in favor of
versus 70 percent; p = 0.48) in union on computed operative fixation even for nondisplaced scaphoid
tomographic scan at 10 weeks in the patients waist fractures. Six separate clinical trials compar-
for whom the thumb was not immobilized.27 All ing casting to surgery for acute scaphoid fractures
patients in this trial achieved union by 6 months, have been summarized by Grewal and King31 and
regardless of casting technique. Ram and Chung.32 Time to union was reported in

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 Plastic and Reconstructive Surgery • August 2017

Fig. 2. Russe classification of scaphoid fractures.

only three of the six studies, with two reporting a When comparing volar and dorsal approaches
faster time to union in the surgery group.33–35 Only to the acutely fractured scaphoid, no significant dif-
one study demonstrated a significant (p = 0.001) ferences have been identified in the realms of frac-
difference in union rate, with all 44 healing in the ture union and functional outcomes. The dorsal
surgery group compared with 10 nonunions of 44 location of the dominant blood supply is the basis
in the cast group.36 Grip strength and motion in the of one argument for giving preference to the volar
operative group were limited early35,36 but improved approach when allowed by the fracture pattern.9
by the time of final assessment.33–37 Two studies dem- Proximal pole fractures are more easily visualized
onstrated faster return to sport34,35 and four studies using a dorsal, antegrade approach, whereas distal
reported faster return to work with surgery.33,34,37,38 pole fractures are amenable to a volar, retrograde
Vinnars and colleagues reported long-term follow- approach. Waist fractures can be addressed either
up of their previous trial, concluding that there volarly or dorsally, depending on fracture pattern,
is no long-term benefit of internal fixation when the need for bone grafting, and surgeon preference.
compared to casting.39 In a pairwise meta-analysis
of randomized controlled trials, Ibrahim and col-
PERCUTANEOUS AND MINI-OPEN
leagues40 analyzed the aforementioned six trials, in
addition to the follow-up study by Vinnars et al.,39 APPROACH
confirming that although operative fixation leads Percutaneous fixation of acute scaphoid frac-
to improvements in fracture union, the difference tures was first described by Streli in 1962.46 The
was not statistically significant. Surgery was associ- introduction of the headless compression screw
ated with a significantly increased risk of complica- by Herbert and Fisher12—followed by its modifi-
tions compared to cast immobilization (odds ratio, cation into a headless cannulated screw by Whip-
6.96; p = 0.001).40 Another prospective randomized ple47—revolutionized the treatment of acute
trial by Clementson and colleagues compared con- scaphoid fractures, allowing for fixation with mini-
servative treatment with arthroscope-assisted screw mal exposure, resulting in less soft-tissue damage
fixation of scaphoid fractures and found no differ- to the radiocarpal ligaments and dorsal wrist cap-
ence in time to union.41 sule. Early series of percutaneous fixation of acute
scaphoid fractures reported union rates of 70 to 89
percent,42,46 and subsequent studies have demon-
OPERATIVE TECHNIQUES: ACUTE strated union rates up to 100 percent using both
FRACTURES volar and dorsal percutaneous or mini-open tech-
Nondisplaced or minimally displaced fractures niques.33,42–45,48 In a direct comparison study, Jeon
can be managed with percutaneous or minimally and colleagues found that the dorsal percutane-
open approaches with predictable good out- ous technique allowed screw placement parallel to
comes.33,35,42–45 Displaced fractures require reduction the long axis of the scaphoid and perpendicular
through either an open or arthroscopic approach. to the fracture line in transverse waist fractures.49
When there is bone loss or comminution, autog- Percutaneous approaches are best suited for non-
enous bone grafting fills the void and aids healing. displaced fractures, although displaced fractures

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 Volume 140, Number 2 • Management of Scaphoid Fractures

can still be treated percutaneously with the aid of be removed, or the guidewire and drill have to be
joystick manipulation using Kirschner wires and placed through the edge of the trapezium. Because
arthroscopic visualization. Complication rates have of this, the volar approach can damage the sca-
ranged from 0 to 29 percent using the dorsal per- photrapezial joint,56 although studies of the trans-
cutaneous technique,50,51 and from 0 to 30 percent trapezial approach have not shown an increased
for the volar percutaneous technique.33,35,36,52 (See incidence of symptomatic scaphotrapezial osteoar-
Video, Supplemental Digital Content 1, which dis- thritis in the short and medium term.57
plays dorsal percutaneous fixation of a scaphoid
fracture using a headless cannulated screw. This
video is available in the “Related Videos” section of ARTHROSCOPE-ASSISTED
the full-text article on PRSJournal.com or at http:// TECHNIQUES
links.lww.com/PRS/C249.) Arthroscopy is an effective adjunct that allows
the surgeon to confirm fracture reduction58–62 and
OPEN APPROACH diagnose concomitant ligamentous injuries of the
wrist.63 In a series of 27 scaphoid fractures, Slade
The classic studies by Herbert and Fisher using and colleagues reported a 100 percent union
headless compression screws placed by means of an
rate at 12 weeks using an arthroscope-assisted
open approach demonstrated high union rates with
approach.60 In a subsequent study, Slade and Gil-
minimal complications.12,53 Comparable success and
lon demonstrated a 99 percent union rate, con-
complication rates have been reported with both
volar or dorsal approaches.44,54 Fractures with volar firmed by computed tomographic scan, at 12
collapse (humpback deformity) are more easily cor- weeks in 126 acute fractures using an arthroscope-
rected through a volar approach. Disadvantages of assisted technique.61
the dorsal approach include the risk of iatrogenic
humpback deformity when the wrist is flexed dur- NONUNION
ing screw placement, in addition to potential disrup- The incidence of scaphoid nonunion is
tion of the dorsal blood supply. The volar approach between 4 and 50 percent, and is defined by
comes with a higher chance of injuring the volar failure of the fracture to heal within 6 months.
carpal ligaments, leading to carpal instability, as Fracture type, displacement, bone loss, patient
emphasized by Garcia-Elias et al.55 Therefore, if the factors, and treatment modality are all factors that
radioscaphocapitate ligament is released when per- contribute to this wide variation.64–68 Nonunion
forming a volar approach, it is important to repair
may be evidenced by pain and tenderness at the
it. In addition, because it is difficult to place a screw
anatomical snuffbox and scaphoid tubercle, and
parallel to the central axis of the scaphoid using the
decreased wrist extension may be seen. Radio-
volar approach, a portion of the trapezium has to
graphs demonstrate a wide, sclerotic fracture
cleft, potentially with cyst formation. Computed
tomography will define the scaphoid architecture
in cases of delayed union when healing intervals
are less than 6 months,69 and can be helpful for
surgical planning. Unstable nonunions demon-
strate loss of the normal length and shape of the
scaphoid, often with a dorsal intercalated seg-
mental instability pattern.70 When not corrected,
carpal instability ensues, and a predictable pat-
tern of degenerative changes known as scaphoid
nonunion advanced collapse arthritis occurs.64
The preferred treatment for scaphoid nonunions
is internal fixation with bone grafting.71–74 To pre-
vent future degenerative changes, it is important
Video 1. Supplemental Digital Content 1 displays dorsal percu- to restore height, length, and alignment.75 The
taneous fixation of a scaphoid fracture using a headless cannu- use of intramedullary screw fixation has shown
lated screw. This video is available in the “Related Videos” section improvements in carpal instability and union in
of the full-text article on PRSJournal.com or at http://links.lww. 71 to 100 percent of patients.76,77 Garcia and col-
com/PRS/C249. leagues reported a technique using two headless

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 Plastic and Reconstructive Surgery • August 2017

compression screws for improved biomechanical graft can be press-fit without any fixation, relying
and rotational stability.78 only on the tight fit and external immobilization
for stability.
Nonvascularized Bone Grafting Treatment of unsalvageable proximal pole
Nonvascularized bone grafts have been the fractures with nonvascularized osteochondral rib
traditional treatment for scaphoid nonunion. autografts appears promising. Sandow described
In 1936, Matti described the original technique 47 osteochondral rib arthroplasties of the proxi-
using an iliac crest corticocancellous bone strut mal pole, and all patients experienced improved
as an inlay through a dorsal approach, and Russe wrist function at a mean follow-up of 15 months.86
later offered a modified technique performed by Veitch et al. reported improved pain and wrist func-
means of a volar approach to spare the blood sup- tion in 13 of 14 patients that underwent rib graft
ply and correct volar collapse.14 This technique arthroplasty at a mean follow-up of 64 months,87
demonstrated union rates ranging from 81 to 97 and Yao and colleagues reported three success-
percent.79,80 The Fisk-Fernandez technique uses a ful cases using rib osteochondral grafting.88 The
triangular or trapezoidal corticocancellous wedge aforementioned studies support nonvascularized
from the iliac crest or distal radius that is placed rib osteochondral grafting as an effective treat-
as an intercalary structural graft to restore scaph- ment for the otherwise unreconstructable proxi-
oid length and correct carpal alignment.72,74 Such mal pole scaphoid nonunion, especially in young,
wedge-grafting techniques have demonstrated active patients for whom salvage procedures may
improved union rates when compared to the not be ideal. In this procedure, the scapholunate
Matti-Russe inlay grafting technique.76,81,82 ligament is not reconstructed, but “overstuffing”
Despite the benefits of intercalated wedge of the joint seems to prevent carpal collapse typi-
grafting, there may be technical difficulties with cally seen with scapholunate injuries.87
sizing the graft, intraoperative or postoperative
graft extrusion, and donor-site morbidity.83 For Vascularized Bone Grafting
these reasons, alternative techniques for nonvascu- Vascularized bone grafting for the treatment
larized bone grafts continue to be explored. Lee of scaphoid nonunions, especially in the setting of
et al. described a hybrid Russe procedure using a avascular necrosis, offers the potential for revascu-
corticocancellous volar strut from the volar distal larization of the avascular proximal pole. A meta-
radius along with cancellous autograft and head- analysis reported that vascularized bone grafting
less compression screw fixation to correct scaphoid achieved union in 88 percent of scaphoid frac-
waist fracture nonunion with humpback deformity tures with avascular necrosis, compared to 47 per-
in 17 patients.84 At a mean follow-up of 32 months, cent after treatment with a screw and intercalated
they reported 100 percent union occurring at a wedge grafting.76 Zaidemberg et al. described a
mean of 3.6 months postoperatively. Cohen and vascularized bone graft derived from the dorsora-
colleagues reported on 12 scaphoid nonunions dial aspect of the distal radius, which is supplied
treated with headless compression screws and by the 1,2-intercompartmental supraretinacular
cancellous autograft with 100 percent union at a artery89 (Fig. 4). (See Video, Supplemental D ­ igital
minimum 2-year follow-up.75 The benefits of can- Content 2, which displays 1,2-intercompartmental
cellous graft alone were reported to be technical supraretinacular artery vascularized bone graft
ease, local donor site, and rapid graft incorpora- for scaphoid nonunion. This video is available
tion. Sayegh and Strauch performed a systematic in the “Related Videos” section of the full-text
review comparing cancellous-only and corticocan- article on PRSJournal.com or at http://links.lww.
cellous grafts, reporting that cancellous-only grafts com/PRS/C250.) In their series of 10 proximal
provided a shorter interval to union, but cortico- pole nonunions with avascular necrosis, Boyer
cancellous grafts were associated with consistent and colleagues reported that six of the 10 healed
deformity correction and improved Mayo wrist using the 1,2-intercompartmental supraretinacu-
scores85 (Fig. 3). lar artery grafting technique,90 whereas Straw et al.
Although our preference is to stabilize bone- reported that only two of 16 nonunions with avas-
grafted nonunions with a cannulated compres- cular necrosis healed using the 1,2-intercompart-
sion screw, this can be challenging to accomplish. mental supraretinacular artery graft.91 In a larger
The surgeon must ensure that the graft does not series of 1,2-intercompartmental supraretinacular
displace or come out of the scaphoid when insert- artery grafts, Chang and colleagues demonstrated
ing the screw. Alternatively, one can perform fixa- that 71 percent of 48 scaphoid nonunions healed,
tion with Kirschner wires, or in some cases the with a union rate of 91 percent when there was no

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 Volume 140, Number 2 • Management of Scaphoid Fractures

Fig. 3. Nonvascularized bone grafting for scaphoid nonunion. A 22-year-old man presented with scaphoid waist
nonunion after a previously undetected scaphoid waist fracture sustained in a bicycle accident 6 years prior (above,
left). The nonunion was exposed by means of a volar approach, and Kirschner wires were placed in the proximal and
distal fragments (above, right). Nonvascularized corticocancellous bone graft was harvested from the volar distal
radius, deep to the pronator quadratus (below, left), and was fixed into the bony defect with a cannulated headless
compression screw (below, right). Kirschner wires were removed at the end of the case.

Fig. 4. 1,2-Intercompartmental supraretinacular artery vascularized bone graft. The 1,2-intercompartmental supra-
retinacular artery is located between the first and second extensor compartments, superficial to the extensor reti-
naculum (left). This distally based pedicle supports a section of corticocancellous bone taken from the dorsum of the
distal radius (right).

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 Plastic and Reconstructive Surgery • August 2017

avascular necrosis but only 63 percent when there

was avascular necrosis.92 Hirche et al. reported a
union rate of 75 percent in 28 patients treated with
a 1,2-intercompartmental supraretinacular artery,
with a 78 percent union rate in 18 patients with
avascular necrosis.93 In a randomized controlled
trial comparing nonvascularized iliac crest bone
grafting to the 1,2-intercompartmental suprareti-
nacular artery, Braga-Silva and colleagues demon-
strated no significant differences with regard to
union rate, time to union, or functional results
between groups.94
Sotereanos and colleagues described the use
of a vascularized bone graft from the distal aspect
Video 2. Supplemental Digital Content 2 displays 1,2-inter- of the dorsal radius that was attached to a wide
compartmental supraretinacular artery vascularized bone graft distally based strip of dorsal wrist capsule from
for scaphoid nonunion. This video is available in the “Related the fourth dorsal compartment.95 Ten of 13 non-
Videos” section of the full-text article on PRSJournal.com or at unions (77 percent) (eight of 10 with avascular
http://links.lww.com/PRS/C250. necrosis) achieved union using this technique at

Fig. 5. Dorsal capsular-based vascularized bone grafting for scaphoid nonunion. The extensor retinaculum is divided
over the fourth dorsal compartment, and the dorsal wrist capsule is exposed between the third and fourth extensor
compartments. A wide distally based capsular pedicle is outlined (above, left) and then raised with a corticocancel-
lous bone block from the dorsal distal radius (above, right). After release of the tourniquet, the bone demonstrated
excellent vascularity (below, left), and is inset into the scaphoid defect (below, right). (Orientation: dorsal surface of the
right wrist; distal is to the right, and proximal is to the left.)

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 Volume 140, Number 2 • Management of Scaphoid Fractures

a mean follow-up of 19 months. The purported portion of the pronator quadratus muscle, based
benefits of this procedure include technical ease, on the anterior interosseous artery,98,99 has dem-
because dissection of a specific vascular pedicle is onstrated 100 percent union in 27 patients, with a
not required. One major drawback of dorsal vas- mean time to union of 11.5 weeks.100
cularized bone grafts is unreliable correction of a A free vascularized bone flap from the medial
humpback deformity, as it is difficult to place the condyle of the femur, based on the descend-
graft in a volar defect (Fig. 5). ing genicular artery, was originally described
Mathoulin and Haerle described a technique as a free vascularized corticoperiosteal flap by
of vascularized bone grafting from the volar dis- Sakai et al.101 and Doi and Sakai.102 Doi et al.
tal radius based on the volar carpal artery, and later described the technique of the medial
reported on 17 patients with 100 percent union at femoral condyle free flap for the treatment of
an average of 60 days.96 They further characterized scaphoid nonunions, demonstrating 100 per-
the vascular anatomy of the volar distal radius and cent union in 10 patients.103 In a retrospective
ulna as it pertains to potential vascularized bone review of 22 patients from two institutions, Jones
grafts.86 In a series of 111 patients treated with a et al. compared the efficacy of the 1,2-intercom-
vascularized bone graft based on the transverse partmental supraretinacular artery vascularized
volar carpal artery, Gras and Mathoulin reported bone graft in 10 patients versus the free medial
a union rate of 96 percent in 73 primary cases femoral condyle flap in 12 patients for the treat-
and 89.5 percent in 38 cases treated secondarily97 ment of scaphoid waist nonunion with proximal
(Fig. 6). A vascularized bone graft that includes a pole avascular necrosis and carpal collapse.104

Fig. 6. Volar carpal artery–based vascularized bone flap for reconstruction of a scaphoid nonunion. A volar-radial
approach is planned (above, left). The palmar cutaneous branch of the median nerve is avoided as it courses superfi-
cially just ulnar the to flexor carpi radialis. After retracting the flexor carpi radialis and flexor pollicis longus, the volar
carpal artery is identified beneath the pronator quadratus (above, right). This is taken within a cuff of periosteum, and
supports a small block of corticocancellous volar radial bone (below, left). This bone block is inset into the scaphoid
nonunion, between the Kirschner wires controlling the proximal and distal poles (below, right).

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 Plastic and Reconstructive Surgery • August 2017

Fig. 7. Medial femoral condyle flap for treatment of scaphoid nonunion (clinical photographs). The vastus medialis is
retracted anteriorly to expose the descending genicular artery, and a bone block is outlined (above, left) and elevated
from the medial femoral condyle (above, right and below, left). The pedicle is sectioned and the flap readied for trans-
fer (below, right).

Fig. 8. Radiographs showing medial femoral condyle flap for treatment of scaphoid nonunion.
Kirschner wires are inserted into the proximal and distal poles, and a large defect in the scaphoid
waist is demonstrated (left). The bone flap is fixated using a headless compression screw (right)
and vascular anastomosis is performed.

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 Volume 140, Number 2 • Management of Scaphoid Fractures

Forty percent of the nonunions treated with the 3. Wolf JM, Dawson L, Mountcastle SB, Owens BD. The inci-
1,2-intercompartmental supraretinacular artery dence of scaphoid fracture in a military population. Injury
2009;40:1316–1319.
graft healed at a median of 19 weeks, whereas 4. Garala K, Taub NA, Dias JJ. The epidemiology of fractures of
100 percent of the nonunions treated with the the scaphoid: Impact of age, gender, deprivation and season-
free medial femoral condyle flap healed at a ality. Bone Joint J. 2016;98:654–659.
median of 13 weeks. The free medial femoral 5. Compson JP, Waterman JK, Heatley FW. The radiological
condyle flap demonstrated a significantly higher anatomy of the scaphoid: Part 1. Osteology. J Hand Surg Br.
1994;19:183–187.
rate of union (p = 0.005) and significantly shorter 6. Buijze GA, Lozano-Calderon SA, Strackee SD, Blankevoort
time to union (p < 0.001) than the pedicled L, Jupiter JB. Osseous and ligamentous scaphoid anatomy:
1,2-intercompartmental supraretinacular artery, Part I. A systematic literature review highlighting controver-
establishing its effectiveness as a treatment for sies. J Hand Surg Am. 2011;36:1926–1935.
scaphoid nonunions with avascular necrosis and 7. Buijze GA, Dvinskikh NA, Strackee SD, Streekstra GJ,
Blankevoort L. Osseous and ligamentous scaphoid anat-
humpback deformity. In a retrospective series of omy: Part II. Evaluation of ligament morphology using
12 patients treated with a free medial femoral three-dimensional anatomical imaging. J Hand Surg Am.
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 Volume 140, Number 2 • Management of Scaphoid Fractures

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