Current perspectives in the management of scaphoid nonunions.

When left untreated, scaphoid fractures follow a downward spiral resulting in carpal collapse and arthritis. The purpose of intervention is to allow a cartilage-wrapped bone to heal and maintain a smooth articular surface. Proposed treatment options for scaphoid nonunions have varied success rates. Using the Mack-Lichtman classification for nonunions, a plan can be formulated for individual patients based on motion loss, degenerative changes, carpal collapse, and fracture instability manifested by bone loss. Stable nonunions may benefit from bone grafting and internal fixation. Unstable nonunions require grafting and fixation. With the development of arthritis, grafting and fixation must be weighed against suitability of a proximal row carpectomy or a four-corner fusion with scaphoid excision. Advanced carpal collapse and arthritis mandates fusion, either limited or complete. CT allows preoperative planning to assess grafting requirements. MRI defines vascular supply fa vascular graft is considered. Vascularized graft options have multiplied as attention has been focused on the impact of improved blood supply on the avascular scaphoid. Patient- and fracture-specific factors are important considerations when determining surgical options; underestimating their importance can compromise surgical results even with a high level of technical skill. Successful treatment of scaphoid nonunions remains a difficult challenge despite improvement in fixation devices and surgical options. By regarding injury status together with patient factors, surgical options can be narrowed and patient expectations managed more realistically.