Abstract
The carpal bones can be fraught with difficulties in trying to obtain union in these bones that have large articular surfaces. Of these bones, the scaphoid is the most notorious because of its unique blood supply. However, the lunate is well known for its predilection to develop avascular necrosis. Furthermore, even the hook of the hamate despite its rich muscular attachments and blood supply usually does better with simple excision than attempts to provide internal fixation. There exist options to try and correct the nonunion or malunion in the scaphoid. However, ultimately, if the carpal bones do not heal, the patient is potentially looking at a partial wrist fusion or complete wrist fusion, depending on which bones are involved and how much degeneration involves the proximal and midcarpal rows. The goal in most of these patients is to try to improve their pain. In counseling patients, they should have the reconstructive ladder discussed with them so that they can participate in the decision making process as some patients may prefer to go straight to a partial fusion or total fusion rather than subject themselves to a sequence of multiple surgeries.
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Appendices
Case 9.1: Malpositioned Screw
(a) Minimally displaced scaphoid waist fracture
(b) Treated with a compression screw via percutaneous volar technique. Note that the malpositioned screw is too vertical, abutting the volar scaphoid cortex, and ideally should be center in both planes
(c) A few months post-op: Hardware loosening and lucency around the screw due to poor proximal purchase
(d) Proximal migration of the hardware with a nonunion and proximal fragment trabecular collapse and minimal osteogenic activity at the fracture site
Case 9.2: Proximal Pole Nonunion After Failed Fixation. Healed After Intercalary Iliac Crest Graft and K-Wire Fixation
(a) Preoperative X-ray of patient who underwent percutaneous volar screw fixation of a proximal pole fracture that subsequently developed a nonunion
(b) One year post-op s/p hardware removal after undergoing intercalary bone graft and K-wire fixation of proximal pole nonunion
(c, d) 2.5 years post-op showing a viable proximal pole and some early degenerative process
Case 9.3: Proximal Pole Nonunion Treated with 1,2 ICSRA
(a) Scaphoid nonunion after screw fixation with proximal pole collapse from impaired vascularity
(b) CT scan confirming an established nonunion with sclerotic edges, a small proximal fragment, and bone loss
(c) MRI confirming proximal pole avascular necrosis. Determining the vascularity of the proximal pole preoperatively is important in determining if a vascularized bone graft is necessary
(d) Six weeks after revision fixation and 1,2 ICSRA
(e) Nine weeks after revision fixation and 1,2 ICSRA
(f) Nine months post-op. Well-incorporated vascularized graft with a viable proximal pole
(g) 1.2 years post-op after hardware removal
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Patel, V.P., Jupiter, J.B. (2012). Reoperative Issues Following Carpal Bone Fracture Surgery. In: Duncan, S. (eds) Reoperative Hand Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-2373-7_9
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