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SCAPHOID NONUNION

Introduction

Scaphoid nonunion can occur as a result of an undiagnosed or conservatively treated scaphoid fracture that fails to heal. Nonunion also occurs after surgical treatments for scaphoid fracture.  Scaphoid fractures are often missed on initial x-rays about 25% of the time.  The most sensitive clinical sign is scaphoid tenderness but it is not specific. Additional exams for tenderness with axial holding the thumb, scaphoid tuberosity tenderness and pain with ulnar deviation help verify the clinical diagnosis of scaphoid fracture.10   Scaphoid nonunion is reliably evaluated with a CT scan but CT scanning is not reliable for accurately diagnosing scaphoid nonunion.  Scaphoid nonunion is defined as a fracture that is unhealed six months after fracture date.9  A precise and reliable diagnosis is difficult.  Subgroups include nonunion of acute fracture without surgery, nonunion of acute fracture with surgery, nonunion after nonunion surgery.1

Pathophysiology

  • Risk factors for are displacement of the fracture, fracture of the proximal pole of the scaphoid, inadequate immobilization, and avascular necrosis.2
  • The scaphoid is particularly susceptible to fracture and nonunion because this carpal bone is covered over much of its surface by cartilage which limits its blood supply.  The majority of the supply enters the bone distally and dorsally.  The scaphoid is also a link between the proximal and distal rows which means it is subject to extensive deformity forces.  Other factors predisposing this bone to nonunion are diabetes mellitus, male gender, opioid use and smoking. To date, there is no consensus on the optimal management of scaphoid nonunion, and a variety of treatments are currently used.7
  • Slade and Dodds’ classification for scaphoid non-unions based on specific findings associated with the nonunion.  Some of these associated findings include delayed presentation of the patient with the fracture, fibrous union at the fracture site, cysts at the fracture site, sclerosis of the fracture ends, pseudoarthrosis at the fracture site, associated intercarpal ligament injuries, proximal pole scaphoid fractures and avascular necrosis of the scaphoid.13

Related Anatomy

  • Scaphoid
  • Lunate
  • Radius

Incidence

  • The scaphoid is the most commonly fractured carpal bone.1,2
  • Overall scaphoid fracture union rate is 15.5% for conservative (cast) treatment of nondisplaced fractures.  Conservative (cast) treatment can result nonunion rate as high as 50% for displaced scaphoid fractures.3,7  Scaphoid fractures treated surgically typically have a 10–15% nonunion rate.2
  • Casting a nondisplaced scaphoid fracture has a healing rate of 88-95%. Proximal pole scaphoid fractures heal poorly in a cast and, therefore, most experts recommend open reduction and internal fixation with or without bone grafting.  Debate remains whether ORIF should be done with or without grafting.7
  • Percutaneous pinning of scaphoid fracture of nondisplaced scaphoid fracture is comparable to cast treatment.  The return to work time and union time is a little better for pinning but cast complication rate 7% and pinning complication rate 14%.12
  • A wrist without a carpal bone or a distal radius fracture has very small risk of developing posttraumatic arthritis.  The study of the natural history of scaphoid fractures demonstrates that a wrist with a healed nondisplaced fracture has a 2% risk of arthritis while a scaphoid nonunion has a 56% risk of osteoarthritis.7,15

Related Conditions

  • Scaphoid nonunion can lead to progressive degenerative changes in the bone,2 which in turn, can lead to:
    • Humpback/flexion deformity
      • Scaphoid fractures  with a persistent “humpback” deformity have poorer clinical outcomes than fractures or nonunions that heal with anatomic alignment.8,14
    • Scaphoid nonunion advanced collapse (SNAC) with an associated dorsal intercalated segment instability (DISI)
ICD-10 Codes

  • WRIST OSTEOARTHRITIS (SNAC)

    Diagnostic Guide Name

    WRIST OSTEOARTHRITIS (SNAC)

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    SCAPHOID/NAVICULAR FRACTURE, NONUNION    
    - DISTAL POLE OF SCAPHOID    
     - DISPLACED S62.012_S62.011_ 
     - NONDISPLACED S62.015_S62.014_ 
    - MIDDLE THIRD OF SCAPHOID    
     - DISPLACED S62.022_S62.021_ 
     - NONDISPLACED S62.025_S62.024_ 
    - PROXIMAL THIRD OF SCAPHOID    
     - DISPLACED S62.032_S62.031_ 
     - NONDISPLACED S62.035_S62.034_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S62
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Scaphoid Non-union
  • Scaphoid non-union left wrist (arrow) with decreased range of motion and pain.
    Scaphoid non-union left wrist (arrow) with decreased range of motion and pain.
Symptoms
History of prior wrist trauma
Radial side pain wrist pain
Limited and painful range of wrist motion
Patient may have an earlier diagnosis of a wrist sprain with an X-ray negative for wrist fracture
Typical History

A typical patient is a 21-year-old right-handed landscaper when enjoyed skateboarding. The patient has a history of numerous falls on to his outstretched hands while skateboarding. He remembered a particular severe fault on the left outstretched upper extremity approximately 3 months ago. This fall occurred while he was trying to jump the skateboard down three concrete steps. He was seen in an emergency room at that time. He was told the x-ray was negative and      he was splinted.   He was advised told to follow up with his orthopedic or hand surgeon in 2 to 3 weeks. In just a few days he discarded the splint and returned to skateboarding without any medical follow-up. Now he presents with the left wrist swollen, painful and markedly tender in the anatomic snuffbox area. Because of these symptoms he finally sought the attention of a hand surgeon. The examination was positive, and the x-ray showed a scaphoid nonunion in the middle third of the scaphoid with no signs of avascular necrosis. Internal fixation and bone grafting were recommended if the patient would agree to comply with the postoperative management recommendations.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Scaphoid Non-union X-rays
  • Right scaphoid non-union (arrow). Injury occurred 5 months earlier. Note absorption and sclerosis at the fracture line.
    Right scaphoid non-union (arrow). Injury occurred 5 months earlier. Note absorption and sclerosis at the fracture line.
  • Chronic left scaphoid non-union with pseudoarthrosis. Note deformed proximal pole with possible AVN.
    Chronic left scaphoid non-union with pseudoarthrosis. Note deformed proximal pole with possible AVN.
  • Right scaphoid non-union with AVN (arrow).
    Right scaphoid non-union with AVN (arrow).
  • Left proximal pole scaphoid non-union (arrow)
    Left proximal pole scaphoid non-union (arrow)
  • Chronic severe scaphoid non-union with marked proximal pole AVN (PP) and lunate AVN and arthritis.
    Chronic severe scaphoid non-union with marked proximal pole AVN (PP) and lunate AVN and arthritis.
Treatment Options
Treatment Goals
  • Accurately diagnosis a scaphoid non-union
  • Successfully treat a scaphoid non-union
  • Maintain normal hand and wrist function
Conservative

Asymptomatic nonunions may be left untreated but there is a risk of earlier osteoarthritis.

Operative
  • After removal of interposed soft tissue and thorough debridement of non-union fibrous tissue, a bone graft is typically needed to restore the scaphoid to its normal length and shape. Additional fixation with a compression screw or K wires is used to provide stability.
  • There are several commonly used grafts and fixation methods:
    • Bone grafts can be cancellous or “structural” incorporating cortical bone. Scaphoid non-union with humpback deformities can be corrected with appropriately shaped corticocancellous grafts while the scaphoid fragments are realigned with an headless internal fixation screws.4
      • Iliac crest: a standard donor site, but falling out of favor as results are not superior, and donor site complications, such as donor site pain, are common.
      • Distal radius: most commonly used; a surgically convenient donor site with minimal complications.
      • Medial femoral condyle: recently proposed donor site that appears to also have minimal complications and can be harvested with a vascular pedicle.
    • Fixation methods include headless screws and K-wires. K-wires are used less frequently.1 The indications for screw only treatment of a scaphoid nonunion are:7
      1. Intact cartilage envelope or solid fibrous union
      2. Less than 1-2 mm bone resorption and/or less than 1 mm sclerosis
      3. Less than a year’s duration of the nonunion
      4. Nonunion of the scaphoid waist
      5. Patient does not have diabetes and does not smoke
      6. No avascular necrosis
    • The Llizarov external fixator technique has also been occassionally used without bone grafting.5
    • Small non-united scaphoid fragments can be surgically excised, such is small proximal pole fragments. These small fragments are not amenable to surgical fixation and are excised with or without a fascial arthroplasty and/or a scapholunate ligament repair or reconstruction.6
    • Vascularized grafts are indicated for scaphoid nonunion with avascular necrosis.  Potential sources for vascularized grafts include dorsally, the distal radius 1.2-ICS RA graft and second metacarpal artery graft.  Volarly the branch to the volar distal radius just distal to the pronator quadratus provides another source of vascularized bone graft.  Currently the most popular vascularized graft is from the medial femoral condyle based on a genicular artery (descending or superior).8
    • Salvage procedure for failed treatment of scaphoid nonunions include distal scaphoid pole excision, proximal row carpectomy, four corner carpal arthrodesis and total wrist arthrodesis.8
Treatment Photos and Diagrams
Surgical Treatment of Scaphoid Non-union -Dorsal Russe Graft
  • Scaphoid non-union (arrow) after removal of fibrous union (arrow) EPL noted.
    Scaphoid non-union (arrow) after removal of fibrous union (arrow) EPL noted.
  • Scaphoid non-union (arrow) with opening for a dorsal Russe bone graft.
    Scaphoid non-union (arrow) with opening for a dorsal Russe bone graft.
  • Scaphoid non-union (arrow) with a dorsal Russe bone graft in place.
    Scaphoid non-union (arrow) with a dorsal Russe bone graft in place.
  • Scaphoid non-union donor site (arrow) with graft removed (insert) and scaphoid (S) exposed through the same volar surgical approach.
    Scaphoid non-union donor site (arrow) with graft removed (insert) and scaphoid (S) exposed through the same volar surgical approach.
Surgical Treatment of Scaphoid Non-union - Graft with Headless Screw
  • Right scaphoid non-union (arrow). Injury occurred 5 months before secondary to an MVA.
    Right scaphoid non-union (arrow). Injury occurred 5 months before secondary to an MVA.
  • Right scaphoid non-union exposed volarly with wedge graft ready for insertion.
    Right scaphoid non-union exposed volarly with wedge graft ready for insertion.
  • Right scaphoid non-union exposed volarly with wedge graft in place.
    Right scaphoid non-union exposed volarly with wedge graft in place.
  • Right scaphoid non-union (arrow) with guide pin and headless screw in place.
    Right scaphoid non-union (arrow) with guide pin and headless screw in place.
  • Right scaphoid non-union with headless screw (arrow) and graft in place. Note excellent alignment of scaphoid fracture.
    Right scaphoid non-union with headless screw (arrow) and graft in place. Note excellent alignment of scaphoid fracture.
Surgical Treatment of Scaphoid Non-union - Complications and Salvage Procedures
  • Failed right scaphoid non-union treatment with a headless screw. Note widen fracture site and micro motion of proximal screw tip.
    Failed right scaphoid non-union treatment with a headless screw. Note widen fracture site and micro motion of proximal screw tip.
  • Failed scaphoid non-union treated with excision of the proximal pole and insertion of a facial arthroplasty (arrow) using palmaris longus tendon.
    Failed scaphoid non-union treated with excision of the proximal pole and insertion of a facial arthroplasty (arrow) using palmaris longus tendon.
  • Failed multiple left scaphoid non-union treatments successfully treated with a total wrist arthrodesis.
    Failed multiple left scaphoid non-union treatments successfully treated with a total wrist arthrodesis.
CPT Codes for Treatment Options

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Common Procedure Name
Bone graft of scaphoid nonunion) Russe bone graft
CPT Description
Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation)
CPT Code Number
25440
Common Procedure Name
Radial styloidectomy
CPT Description
Radial styloidectomy (separate procedure)
CPT Code Number
25230
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Complications
  • SNAC
  • DISI
  • Bone graft donor site morbidity, including pain
  • Osteoarthritis of the wrist
  • Avascular necrosis of the proximal pole of the scaphoid
Outcomes
  • In a systematic review including 48 studies and 1777 patients, no single treatment for SNU produced a significantly superior clinical outcome (see Table below).1
  • In a systematic review of studies evaluating free vascularized grafts, rates of union were significantly higher for medial femoral condyle grafts (100% [56/56]) versus iliac crest grafts (88% [165/188]; p=0.006).2  Medial femoral condyle vascular grafts are now considered the gold standard for treatment of scaphoid nonunion with avascular necrosis of the proximal pole. 

Table. Estimated incidence of union by fixation method and graft vascularity1

  

Patients, N

Estimated Union Incidence (95% CI)

Fixation method

 

Screws

876

88% (83–93)

K-wires

643

92% (86–96)

None

83

79% (62–92)

Graft type

Non-vascularized

Vascularized

993

521

88% (84–92)

92% (85–96)

Fixation method and graft typeScrews and non-vascularized

615

90% (84–95)

Screws and vascularized

197

87% (72–97)

K-wires and non-vascularized

295

88% (77–96)

K-wires and vascularized

324

94% (87–98)

CI, confidence interval.

Key Educational Points
  • More proximal fractures are more susceptible to avascular necrosis and more likely to require a vascularized graft.
  • Asymptomatic pseudarthrosis may develop at a scaphoid fracture non-union site.
  • Distal scaphoid tuberosity fractures which represent about 25% of scaphoid fractures heal well and rarely cause STT osteoarthritis. These fractures are common in teenagers and children.11
  • Cancellous bone graft from the distal radius is the gold standard for bone grafting scaphoid fractures.  The evidence for healing rates after treating scaphoid non-unions without AVN remains inconclusive regarding screws vs. K-wire and vascularized vs non-vascularized bone grafts
  • Avascular necrosis is hard to diagnose accurately. The gold standard for identifying a vascularized scaphoid bone is punctate bone bleeding seen at open surgery.7  
References
  1. Pinder RM, Brkljac M, Rix L, et al. Treatment of scaphoid nonunion: a systematic review of the existing evidence. J Hand Surg Am 2015;40:1797-1805. PMID: 26116095.
  2. Al-Jabri T, Mannan A, Giannoudis P. The use of the free vascularised bone graft for nonunion of the scaphoid: a systematic review. J Orthop Surg Res 2014;9:21. PMID: 24690301
  3. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br 1984;66(1):114-23. PMID: 6693468
  4. Cohen MS, Jupiter JB, Fallahi K, Shukla SK. Scaphoid waist nonunion with humpback deformity treated without structural bone graft. J Hand Surg Am 2013;38(4):701-5. PMID: 23415167
  5. Bumbasirevic M, Tomic S, Lesic A, et al. The treatment of scaphoid nonunion using the llizarov fixator without bone graft, a study of 18 cases. J Orthop Surg Res 2011;6:57. PMID: 22067958
  6. Garagnani L, Muirhead N. Symptomatic extra-articular scaphoid tuberosity nonunion: surgical excision of the ununited fragment after failed nonoperative management. Hand (N Y) 2013;8(3):339-42. PMID: 24426945
  7. Ernst SMC, Green DP, Saucedo JM.  Screw fixation alone for scaphoid fracture nonunion. J Hand Surg Am 2018; 43:837-843  PMID: 29934086 .
  8. Janowski J, Coady C, Catalano LW.  Scaphoid fractures: nonunion and malunion.  J Hand Surg Am 2016; 41(11):1087-1092 PMID: 27671767.
  9. Lutsky K, Matzon JL.  Persistent fracture line after scaphoid fracture fixation.  J Hand Surg Am 2014; 39:2294-2296. PMID: 25282721
  10. Mallee, WH, Henny EP, van Dijk N, Kamminga SP, van Enst WA, Kloen P.  Clinical diagnostic evaluation for scaphoid fractures; a systematic review and meta-analysis.  J Hand Surg Am 2014; 39(9):1683-1691. PMID: 25091335
  11. Clementson M, Thomsen N, Besjakoo J, Jorgholm P, Bjorkman A. Long-Term Outcomes After Distal Scaphoid Fractures: A 10-Year Follow-Up. J Hand Surg Am 2017; 42(11):927. e1-e7. PMID: 28733100
  12. Alnaeem H, Aldekhayel S, Kanevsky J, Neel OF. A Systematic Review and Meta-Analysis Examining the Differences Between Nonsurgical Management and Percutaneous Fixation of Minimally and Nondisplaced Scaphoid Fractures. J Hand Surg Am 2016; 41(12):1135-1144. PMID: 27707564
  13. Slade JF III, Dodds SD. Minimally invasive management of schaphoid nonunions. Clin Orthop Relat Res 2006; 445: 108-119. PMID: 16601412 
  14. Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP III, Linscheid RI. Scaphoid malunion.  J Hand Surg Am 1989; 14(4): 679-687. PMID: 2787817
  15. Duppe H, Johnell O, Lundborg G, Karlsson M, Redlund-Johnell I. Long-term results of fracture of the scaphoid. A follow-up study of more than thirty years. J Bone Joint Surg Am 1994; 76(2): 249-252. PMID: 8113260

Review

  1. Sayegh ET, Strauch RJ. Graft choice in the management of unstable scaphoid nonunion: a systematic review. J Hand Surg Am 2014;39(8):1500-6. PMID: 24997785
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