Background: Several operative treatments exist for scaphoid fractures, varying by approach (e.g., ercutaneous, volar, or dorsal), implant type (e.g., screw or Kirschner wire), and bone raft choice (e.g., none, nonvascularized, or vascularized). Many previous systematic eviews and meta-analyses have investigated outcomes following different surgicalÚpproaches, the use of vascularized versus nonvascularized bone graft for scaphoidßracture nonunions, and treatment for specific fracture patterns. However, given the advancements n scaphoid fracture treatment in recent years, there is a need for updated treatment recommendations hat would be beneficial to hand surgeons. Purpose: We present a comprehensive review of the operative treatment of scaphoid fractures based on recent literature and propose a unified treatment algorithm for managing these fractures. Methods: The English-language literature was searched from 2002 to 2023 for high evidence level (e.g., randomized trials), review, and meta-analysis articles with the following search terms: \"scaphoid, \"u8220\"scaphoid\" AND \"nonunion, \" and \"scaphoid\" AND \"malunion. \" Each article was creened by the authors to determine the scaphoid fracture scenario addressed and ubsequent treatment recommendations. The findings from article reviews were then rganized by scaphoid fracture types in this manuscript. Results: A total of 95 pertinent articles were ultimately selected and used as the basis for reviewing different scaphoid fracture scenarios. A treatment algorithm was then proposed based on literature review. Conclusion: This summary of the recent literature can guide hand surgeons in addressing scaphoidßractures. Future research in scaphoid fracture treatment, particularly for nonunions, would be most beneficial n the form of systematic review, meta-analysis, or multicenter prospective randomized clinical trials. Level of Evidence: IV.

BACKGROUND: Bone grafts for scaphoid nonunion with deformity include cortcicocancellous or pure cancellous bone grafts. This study compared the outcomes between two types of bone grafts when employing a volar locking-plate in patients with scaphoid nonunion with dorsal intercalated segmental instability (DISI).
METHODS: This retrospective study included 34 patients with scaphoid nonunion and DISI due to humpback deformity treated between March 2017 and January 2022. Two types of bone grafts were obtained from iliac crest. Twenty of the corticocancellous (CC) group underwent a wedge-shaped graft, while 14 patients of the pure cancellous (C-only) group received graft chips. In both groups, a 1.5-mm anatomically pre-contoured locking plate was used for fixation. Radiographic evaluations included the union rate and carpal alignment including scapholunate angle (SLA), radiolunate angle (RLA), intrascaphoid angle (ISA) and scaphoid height to length ratio (HLR). Clinical assessments encompassed wrist range-of-motion, grip strength, and patient-reported outcomes.
RESULTS: Nineteen of the 20 patients in the CC group and 12 of the 14 patients in the C-only group respectively, achieving osseous union. The mean follow-up period in CC group was 14.7 (range, 12 ∼ 24) months and that in C-only group was 12.6 (range, 12 ∼ 15) months. Postoperatively, there were no significant intergroup differences of radiographic parameters including SLA (CC; 49.9° ± 6.7° vs. C-only; 48.9° ± 3.5°, P = 0.676), RLA (1.7° ± 6.4° vs. 2.4° ± 3.3°, P = 0.74), ISA (36° ± 7.5° vs. 36.6° ± 12.2°, P = 0.881), and HLR (0.54 ± 0.09 vs. 0.53 ± 0.05, P = 0.587). Clinical outcomes, including the flexion-extension arc (137° ± 30° vs. 158° ± 33°, P = 0.122), grip strength (93.4 % ± 15.4% vs. 99.5 % ± 16.7 %, P = 0.39), Quick Disabilities of the Arm, Shoulder, and Hand scores (11.2 ± 8.3 vs. 12.5 ± 7.7, P = 0.74) and Mayo Wrist Scores (81.2 ± 13.1 vs. 89 ± 11.4, P = 0.242) also showed no significant intergroup differences.
CONCLUSIONS: Volar locking-plate fixation with pure cancellous bone grafts achieved outcomes comparable to those achieved with corticocancellous bone grafts in scaphoid nonunion with deformity, possibly due to the biomechanical advantages of the volar plate to provide structural supports.

A total of 26 adolescent patients were treated for scaphoid nonunion with a vascularized bone graft from either the medial femoral condyle or dorsal distal radius. There was an 85% union incidence, improved carpal alignment and a low incidence of complications.

UNASSIGNED: This study reports the clinical outcomes of double-screw fixation with bone grafting for displaced scaphoid nonunions.
UNASSIGNED: This study was a retrospective survey. From January 2018 to December 2019, 21 patients with displaced scaphoid fractures underwent open debridement and two headless compression screw fixation with bone grafting. The preoperative and postoperative lateral intrascaphoid angle (LISA) and scapholunate angle (SLA) were recorded. Preoperative and postoperative grip strength (% of the healthy side), active range of motion (AROM), visual analogue scale (VAS), and patient-rated wrist evaluation (PRWE) scores at the final follow-up were obtained for all patients for comparison.
UNASSIGNED: Patients were treated for an average of 38.3 months (range 12-250) after the injury. The average time of postoperative follow-up was 30.5 months (range 24-48). All fractures achieved union at a mean of 2.7 months (range 2-4) after surgery, and 14 scaphoids of 21 patients (66.7%) healed by 8 weeks. CT scans showed no evidence of cortical penetration of either screw in all patients. There was a statistically significant improvement in AROM, grip strength, and PRWE. No complications occurred in this study, and all patients returned to work.
UNASSIGNED: This study indicates that double-screw fixation with bone grafting is an effective technique for treating displaced scaphoid nonunions.

The mechanism of scaphoid waist fracture is not completely understood. We used finite element analysis to study the formation of scaphoid waist fractures. Clinical computed tomography scans of 12 wrists were used to create models for finite element analysis. The points of application of load were at different sites along the scaphotrapeziotrapezoid joint distally, and the scaphoid fossa plus the area underlying the radioscaphocapitate ligament was regarded as the fixed proximal support. A fracture was produced at the scaphoid waist in all cases. The location of failure of bone at its anterior or dorsal cortex, either in tension or in compression, was determined by the site of application of the load. The anterior cortex failed in compression when the point of impact was located along the trapezium facet or the entire distal pole, whereas it failed in tension when the point of impact was along the trapezoid facet.

Objective  This article compares predictors of failure for vascularized (VBG) and nonvascularized bone grafting (NVBG) of scaphoid nonunions. Methods  We conducted a systematic literature review of outcomes after VBG and NVBG of scaphoid nonunion. Fifty-one VBG studies ( N  = 1,419 patients) and 81 NVBG studies ( N  = 3,019 patients) met the inclusion criteria. Data were collected on surgical technique, type of fixation, time from injury to surgery, fracture location, abnormal carpal posture (humpback deformity and/or dorsal intercalated segmental instability [DISI]), radiographic parameters of carpal alignment, prior failed surgery, smoking status, and avascular necrosis (AVN) as defined by punctate bleeding, magnetic resonance imaging (MRI) with contrast, MRI without contrast, X-ray, and histology. Meta-analysis of proportions was conducted with Freeman-Tukey double arcsine transformation. Multilevel mixed-effects analyses were performed with univariable and multivariable Poisson regression to identify confounders and evaluate predictors of failure. Results  The pooled failure incidence effect size was comparable between VBG and NVBG (0.09 [95% confidence interval [CI] 0.05-0.13] and 0.08 [95% CI 0.06-0.11], respectively). Humpback deformity and/or DISI (incidence-rate radios [IRRs] 1.57, CI: 1.04-2.36) and lateral intrascaphoid angle (IRR 1.21, CI: 1.08-1.37) were significantly associated with an increased VBG failure incidence. Time from injury to surgery (IRR 1.09, CI: 1.06-1.12) and height-to-length (H/L) ratio (IRR 53.98, CI: 1.16-2,504.24) were significantly associated with an increased NVBG failure incidence, though H/L ratio demonstrated a wide CI. Decreased proximal fragment contrast uptake on MRI was a statistically significant predictor of increased failure incidence for both VBG (IRR 2.03 CI: 1.13-3.66) and NVBG (IRR 1.39, CI: 1.16-1.66). Punctate bleeding or radiographic AVN, scapholunate angle, radiolunate angle, and prior failed surgery were not associated with failure incidence for either bone graft type ( p > 0.05). Conclusion  Humpback deformity and/or DISI and increasing lateral intrascaphoid angle may be predictors of VBG failure. Time from injury to surgery may be a predictor of NVBG failure. AVN as defined by decreased contrast uptake on MRI may be a marker of increased failure risk for both bone graft types.

The clinical implication of a residual flexion deformity following surgery for scaphoid nonunion is unclear. Sixty-three patients who underwent scaphoid nonunion surgery were assessed after a mean of 7 years (range 5-10) to analyse the outcomes based on the presence of residual scaphoid deformity. Primary outcome was Disabilities of the Arm, Shoulder and Hand score. Secondary outcomes were Patient-Rated Wrist Evaluation score, wrist range of motion and strength. Patients were dichotomized to residual deformity or no deformity. Scaphoid deformity was calculated from CT scans based on the median difference between the height-length ratio of the operated versus the uninjured scaphoid. There were no differences between residual deformity (n = 33) and no deformity (n = 30) in any outcome variables, except for wrist extension which was slightly worse in the deformity group. The deformity group had a greater number of radiographic osteoarthritis, but all cases were mild, and osteoarthritis did not correlate to a worse outcome. We conclude that residual scaphoid deformity has no relevant negative impact on mid-term wrist function.Level of evidence: IV.

BACKGROUND: The aim of this study was to assess residual humpback deformity after arthroscopic treatment of scaphoid nonunion.
METHODS: We reviewed the medical records of 47 patients with scaphoid nonunion who underwent arthroscopic treatment between 2012 and 2018. Patients who did not receive an intraoperative bone graft were excluded (10 patients), as were those who did not achieve bone union (three patients). The radiographic assessment consisted of pre- and postoperative radiographs and CT scans.
RESULTS: The radiolunate angle, scapholunate angle and Youm index were measured. At the final follow-up, the scapholunate angle was 54° ± 8° (36°-80°) and the radiolunate angle was 11° ± 7° (2°-45°). The scapholunate angle was significantly different between the preoperative measurement and the last follow-up; however, the radiolunate angle and Youm index did not change significantly.
CONCLUSIONS: Our study found that arthroscopic treatment of scaphoid nonunion with a cancellous bone graft taken from the distal radius results corrects the humpback deformity.
METHODS:

UNASSIGNED: Scaphoid nonunion remains a major problem in hand surgery. The 1,2 intercompartmental supraretinacular artery flap (1,2 ICSRA), as first described by Zaidemberg et al, is widely used with reported union rates of approximately 80%. However, its use is limited in the case of associated carpal collapse as in dorsal intercalated segmental instability (DISI) and humpback deformity. In this study, we present a novel approach to this flap enabling the correction of associated carpal collapse.
UNASSIGNED: Between 2006 and 2015, 9 patients with scaphoid nonunion or delayed union with carpal collapse were treated with a vascularized bone flap based on the 1,2 ICSRA using a combined volar and dorsal approach. Immobilization in a short-arm cast was applied for 8 weeks. Union rates, correction of DISI and humpback deformity, as well as clinical end points were noted. In addition, scapholunate (SL) angles were measured using 2 accepted radiological techniques, employing either the scaphoid midline axis or its proximal radiological landmarks as a reference.
UNASSIGNED: All cases united and a median time to bone consolidation of 4 months (range, 2-5 months) was observed. Preoperative DISI deformities (n = 4) were corrected in all patients. Humpback deformities (n = 5) were also corrected. Two patients had repeat surgery: one for K-wire removal after bony consolidation and the other for neuropathic pain.
UNASSIGNED: The 1,2 ICSRA bone flap is a reliable treatment for scaphoid nonunion associated with carpal collapse. This combined volar and dorsal approach permits the correction of DISI and humpback deformity without compromising the scaphoid vascular supply, which eliminates the need to use free bone flaps from other sites. In this series, we observed a 100% union rate. Two patients required reoperation for symptomatic hardware and dorsal wrist pain linked to superficial neuritis.
UNASSIGNED: Therapeutic IV.

Objective  Scaphoid fractures are associated with high rates of late- or nonunion after conservative treatment. Nonunion is reported to occur in approximately 10% of all scaphoid fractures. It is known that the union of scaphoid fractures is affected by factors such as location at proximal pole, tobacco smoking, and the time from injury to treatment. Same factors seem to affect the healing after surgery for scaphoid nonunion. While the impact of preoperative humpback deformity on the functional outcome after surgery has been previously reported, the impact of humpback deformity, displacement, and the presence of bony cysts on union rate and time to healing after surgery has not been studied. Purpose  The primary purpose of this study is to assess the association of humpback deformity, fragment displacement, and the size of cysts along the fracture line with the union rate and union time, following surgery of scaphoid nonunion. The second purpose of the study is to investigate the interobserver reliability in the evaluation of computed tomography (CT) scans of scaphoid nonunion. Patients and Methods  From January 2008 to December 2018, 178 patients were surgically treated in our institution. After exclusion criteria were met, 63 patients with scaphoid delayed- or established nonunion, and preoperative CT scans of high quality (<2mm./ slice), were retrospectively analyzed. There was 58 men and 5 women with a mean age of 30 years (range: 16-72 years). Four orthopaedic surgeons and one radiologist independently analyzed the CT scans. The dorsal cortical angle (DCA), lateral intrascaphoid angle (LISA), the height-to-length ratio, the size of the cysts, and displacement of the fragments were measured. Healing was defined by CT scan, or by conventional X-ray, and status of no pain at clinical examination. Thirty-two of the patients had developed nonunion (>6 months postinjury), while 31 were in a stage of delayed union (3-6 months postinjury). Results  Open surgery with cancellous or structural bone graft was the treatment of choice in 49 patients, 8 patients were treated with arthroscopic bone grafting, and 6 patients with delayed union were operated with percutaneous screw fixation, without bone graft. Overall union rate was 86% (54/63) and was achieved after 84 days (12 weeks) (mean). The failure rate and time to healing were not associated with the degree of the humpback deformity, size of the cysts, or displacement of the nonunion in general. However, greater dislocation, and the localization of the nonunion at the scaphoid waist, showed significant influence on the union rate. Dislocation at nonunion site, in the group of the patients who united after surgery, was 2.7 mm (95% confidence interval [CI]: 1.5-3.7), and in the group who did not unite was 4.2 mm (95% CI: 2.9-5.7); p  = 0.048). Time from injury to surgery was significantly correlated with time to union ( p  < 0.05), but not associated with the union rate ( p  < 0.4). Patients treated arthroscopically achieved faster healing (42 days), (standard deviation [SD]: 22.27) as compared with patients treated by open techniques (92 days; SD: 70.86). Agreement among five observers calculated as intraclass correlation coefficient was for LISA: 0.92; for height-to-length ratio: 0.73; for DCA: 0.65; for size of cysts: 0.61; and for displacement in millimeters: 0.24, respectively. Conclusions  The degree of humpback deformity and the size of cysts along the fracture line of scaphoid nonunion have no predictive value for the result, neither for the union rate nor the union time after surgery for the scaphoid nonunion. However, larger dislocation of the fragments measured at the scaphoid waist showed lower union rate. Time to healing following surgery is mainly influenced by the time from injury to the surgical treatment and may be influenced by the choice of the surgical technique. Interrater reliability calculation was best with LISA measurements, and worse with the measurements of the dislocation. Level of Evidence  This is a Level III, observational, case-control study.