Scaphoid Nonunion S62.023K 733.8

synonyms: wrist scaphoid fracture nonunion, wrist navicular fracture nonunion

Scaphoid Nonunion ICD-10

• See all Scaphoid nonunion ICD-10
• S62.032K Displaced fracture proximal third navicular [scaphoid] bone left wrist, subsequent fracture with nonunion  
• S62.012K Displaced fracture distal pole navicular [scaphoid] bone left wrist, subsequent fracture with nonunion  
• S62.022K Displaced fracture middle third navicular [scaphoid] bone left wrist, subsequent fracture with nonunion   
• S62.031K Displaced fracture proximal third navicular [scaphoid] bone right wrist, subsequent fracture with nonunion  
• S62.011K Displaced fracture distal pole navicular [scaphoid] bone right wrist, subsequent fracture with nonunion  
• S62.021K Displaced fracture middle third navicular [scaphoid] bone right wrist, subsequent fracture with nonunion

Scaphoid Nonunion ICD-9

• 733.8 = Nonuion of fracture

Scaphoid Nonunion Etiology / Epidemiology / Natural History

• scaphoid fx that have not healed with 3 months of cast immobiliztion
• scaphoid fx’s that do not show radiographic signs of healing in 6-8wks or those that are diagnosed 6wks after injury are less likely to heal.
• acute fx with collapse, humpback deformity,  comminution, displacement >1mm, intrascaphoid angle >45, height-to-length ratio >0.65, poor pt compliance have higher incidence of malunion and nonunion

Scaphoid Nonunion Anatomy

• dorsal scaphoid branch of radial artery supplies 70-80% of scaphoid.(Gelberman J Hand Surg 5A:508, 1980)

Scaphoid Nonunion Clinical Evaluation

• usually asymptomatic early
• wrist pain, loss of motion
• pain in snuffbox  is unreliable
• lead to wrist pain, a collapse deformity and progressive arthrosis

Scaphoid Nonunion Xray / Diagnositc Tests

• p/a, lateral wrist and scaphoid (p/a in ulnar deviation) and oblique 45-60 degree pronation views
• look for arthritis, cyst formation, bone resorption
• on lateral view a scapholumate angle >60 or a radiolunate angle >30 indicates DISI
• CT scan in the sagittal plane of the scaphoid is useful to quantify cortical healing and pre-op evaluation.
• height-to-length ratio on sagittal plane CT >0.65 corrresponds to significant scaphoid collapse.(Bain, J Hand Surg 23A:76, 1998)
• MRI useful pre-op to vascularity especially with waist fx and prox pole fx’s.  MRI with gadolinium will demonstrate low signal intensity in T1 and T2 images in avascular areas. (Perlik PC, J Hand Surg Am 1991;16:479), (Trumble TE, J Hand Surg 1990;15A:557).

Scaphoid Nonunion Classification / Treatment

• cast and pulsed electromagnetic fields =69% union(Adams, J Hand Surg 17A:910, 1992
• avascular Proximal pole nonunion use dorsal approach
• Waist nonunion use volar approach
• >90% union with ORIF and bone grafting(vascularized bone grafting if avascular)
• Viable proximal pole fx=volar approach, incision over FCR extending distal over glaborous skin border of thenar eminence.  Open FCR sheath, Incise floor of FCR sheath exposing prox pole.  Preserve radioscaphocapitate ligament.  K-wire joysticks reduction, bone graft, Remove volar lip of trapezium to allow proper longitudinal screw placement.  Screw inserted over guide wire from distal to proximal.
• Avascular proximal pole fx=Dorsal approach.  Midline longitudinal incision center on radiocarpal joint.  3^rd extensor compartment entered and incised to enter joint.  4^thcompartment and capsule reflected exposing scapholunate articulation.  Debride nonunion.  Flex wrist to visualize entery point adjacent to scapholunate interosseous ligament.  Insert guide pin, measure, drive guidepin into trapezium, +/- derotation wire.
• Prox pole vascularized graft-relies on blood supply from 1,2 intracompartmental supraretinacular artery (1,2 ISRA)—(Zaidemberg, J Hand Surg 16A;474, 1991)
• salvage procedure = radial styloidectomy, proximal row carpectomy, limited intercarpal fusion, complete wrist fusion

Scaphoid Nonunion Associated Injuries / Differential Diagnosis

• Preiser's Disease
• Scaphoid fracture
• Scaphoid nonunion
• Keinbock's disease
• Ulnocarpal impaction syndrome
• SNAC
• SLAC

Scaphoid Nonunion Complications

• Nonunion
• Malunion
• Scaphoid subsidence or shortening with secondary screw penetration
• Neurovascular injury (cutaneous nerve, radial artery)
• Incorrect placement of a fixation screw
• Failure to recognize concomitant injuries.

Scaphoid Nonunion Follow-up Care

• Post-op: Place in volar thumb spica splint.
• 7-10 Days: If rigid fixation in good bone was achieved start controlled motion program with a removable splint and range-of-motion and gripping exercises.
• 6 Weeks: Consider CT to determine when union has occurred. Unprotected activity is not allowed until bridging bone is seen
• 3 Months: Consider bone stimulator if unionnot confimed
• 6 Months: assess ROM
• 1Yr: follow-up xrays, assess outcome

Scaphoid Nonunion Review References

• Trumble, JAAOS 11:380, 2003
• Greens Hand Surgery