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The Management of Carpal Scaphoid Fractures and Nonunions and the Role of Capacitive Systems

  • Pier Paolo Borelli
Chapter

Abstract

Scaphoid fractures and nonunions occur commonly in young and adult patients but, generally in the athlete, and even more in combat sports, should be treated promptly and appropriately to avoid undesired late complications.

X-ray-specific views and CT scan, cone beam CT when possible, are essential for a “global” and three-dimensional assessment of fractures and nonunions.

MRI may be helpful to obtain further prognostic informations so that an appropriate (early treatment in fresh fractures and delayed union and optimal choice of bone grafting in nonunions reconstructive surgery) treatment strategy can be planned.

Cast immobilisation in acute, undisplaced scaphoid fractures can be considered, in particular circumstances, a valid alternative to surgical treatment and a less aggressive approach, especially if supported by an early use of capacitive systems when justified by CT and MRI, and can be given as an option even in athletes with high-level sport activity. Anyway, limiting the immobilisation period in the athlete will allow earlier restoration of pre-injury level function and eventual return to sport activity, and nowadays the trend is to recommend a minimally invasive surgical approach with a cannulated headless compression screw even in undisplaced fractures. Percutaneous techniques with or without arthroscopy assistance have been advocated as less invasive surgical approaches that may have an added benefit in the athlete, but a mini-open approach to scaphoid tuberosity can facilitate screw placement. Displaced and unstable fractures are usually approached with a volar or dorsal open technique to achieve an anatomic reduction before screw placement. Regardless of what type of technique, open or percutaneous, screw placement from the volar approach is not always feasible and requires to know the morphology of the scaphoid and location and spatial orientation of fractures and nonunions for an appropriate stable screw fixation. In junctional or proximal pole nonunions, not amenable for screw fixation, a stable fixation can be obtained with Kirschner wires as well. The advent of arthroscopy has modified the approach to the management of scaphoid nonunions proving once again that, regardless of the vascular status, it is the stability of fixation, by means of screw or K wires, which creates the conditions for the revascularisation of the proximal pole, so avascular changes in the proximal pole are not an absolute indication for a vascularised bone graft (VBG). A minimally invasive open volar approach can be competitive with the arthroscopic bone graft technique (ABG), with the advantage that harvesting the graft from the radius, you may have a radius metaphyseal “core decompression” effect that can be early combined with a capacitive system stimulation of the osteogenesis. Nowadays a NVBG, open or arthroscopic, may be a valid alternative to the VBG.

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Pier Paolo Borelli
    • 1
  1. 1.Divisione di Ortopedia e TraumatologiaAzienda Spedali Civili di BresciaBresciaItaly

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