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What should I do now with my scaphoid non union

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I had scaphoid non union surgery August of 2011. It was for an old fracture of the scaphoid bone that I had treated 5 years after the initial injury.

Surgeon placed a screw to connect the broken scaphoid bone and also added a bone graft. according to my surgeon, Dr Craig Stirrat of Chestnut Hill, MA there has been some healing and unionizing taken place. But recently a radiologists report of a CT scan taken in april 2012, 8 months post surgery seems to reflect otherwise.

Any ideas of what I should do? I still experience pain in my wrist but my surgeon says that its from a loose piece of bone that broke off from the original fracture that he never removed, bone spurs and also Osteophytes in the area of original injury and that if he removes those piece and removes the bone spurs my pain will go away.

Here are some images of the xrays taken 8 months after surgery











Link to video of the CT scan taken 8 months post surgery http://www.youtube.com/embed/sxJa8Oj2rOY


here is the radiologists report:

CT LEFT WRIST WITHOUT IV CONTRAST:

An Acutrak-type screw transfixes the fracture of the scaphoid waist. There is
1.3 mm of lucency about the distal portion of the screw. The radial and
volar-most aspect of the fracture demonstrates some osseous bridging.
Centrally, there is a mild amount of callus formation; however, the majority
of the fracture demonstrates no significant healing. There is also some
sclerosis of the proximal pole fracture margin. A few well-corticated ossific
fragments are seen on the dorsal and radial aspect of the fracture margins.
These measure up to 4 mm in size. There is a mild humpback deformity. There
is no significant increased sclerosis within the proximal pole.

There is a healed distal radial styloid fracture.

There are mild degenerative changes of the triscaphe joint.

This study is not dedicated to evaluation of the soft tissues; however, there
is soft tissue edema within the volar and radial soft tissues at the level of
the distal radius. There is also a punctate radiodensity within this region
(3:44) which could represent a foreign body.

IMPRESSION:
1. A small area of osseous bridging about the volar and radial-most aspect of
the fracture margin with a mild amount of callus centrally; however, the
majority of the fracture remains ununited.
2. Slight lucency about the distal aspect of the Acutrak-type screw.
3. Possible foreign body in the volar and radial soft tissues at the level of
the first carpal row.
4. Old healed radial styloid fracture.
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replied September 27th, 2012
Especially eHealthy
jonniex,

Sorry about your ongoing problems. Scaphoid fractures and nonunions are very difficult to treat.

As to what you want to do, is up to you. But, it is concerning that the scaphoid has not gone on to a decent union by this time.

Looking at your studies, you may have a very minimal amount of bridging of the fragments, but the remaining parts look very sclerotic, which means that the edges which should be growing back together have formed hard, dense bone. To heal, usually cortical bone will not unite, there has to be the spongy type of bone (cancellous bone) in contact to get the osteocytes to grow new bone to bridge the fracture gap. Once the edges become sclerotic, they usually will just not heal.

You still have a lot of motion of the scaphoid fragments. You can tell this by two things; one you still have significant discomfort in the wrist with motion, and two, if you look at the distal fragment, around the head of the screw, there is radiolucency. This means that there is toggling of the bone around the head of the screw.


However, there is one piece of good news. In the x-rays and the CT scan, there is no evidence of AVN (avascular necrosis) of the proximal pole (no sclerosis). This is very important, because if any further attempts to save the scaphoid are attempted, then the proximal pole would have to be viable.


You are going to have to make a decision in the next year or so. You can try to give it a little more time to see if the fracture is going to bridge anymore. You could try to surgery to remove the osteophytes and small ossicle of bone, to see if that makes your pain better. You have to understand that every surgery done produces scar tissue and usually decreases motion. So, you want to limit the number of surgeries done to the bare minimum.

The next procedure of choice to try to get the bone to heal would probably be a vascularized bone graft with internal fixation. Same as the first, the nonunion would be exposed, the sclerotic bone curetted out, till the remaining bone shows punctuate bleeding. Then a piece of bone is harvested from the distal radius with an artery still attached to it. It is swung around and placed in the defect created by the debridement of the fibrous tissue in the nonunion. Any remaining defect is packed with cancellous bone graft. The scaphoid is then fixed with another screw and possibly a wire to prevent rotation around the screw.

Usually, another attempt at getting the scaphoid nonunion to unite is tried, before going to salvage procedures. If scaphoid nonunions are left to their own devices, they usually go on to a SNAC wrist. This is scaphoid nonunion advanced collapse, where the capitates migrates proximally, through the nonunion. This causes significant degenerative changes and pain in the wrist. This may not happen for several years (could range from a couple of years to a couple of decades), but it is the usual natural history of this problem.


So, you need to sit down with your hand surgeon and discuss your options. Good luck. (A well known hand surgeon used to say of the scaphoid: never trust a bone you can swallow whole.)
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