Operative Technique in Plastic Surgery – Kevin C.Chung

FIG 3 • A. Coronal and (B) sagittal CT slices showing a
nondisplaced comminuted fracture of the scaphoid
waist. Preoperative CT scans can provide additional
diagnostic utility especially concerning degree of
comminution, and postoperative scans can also allow
for superior evaluation of malunion or nonunion. S,
scaphoid; L, lunate; Rs, radius; Ua, ulna; C, capitate; H,
hamate; Tq, triquetrum; Td, trapezoid; Tm, trapezium;
R, radial; U, ulnar; V, volar; D, dorsal.
■ A displaced/unstable scaphoid fracture is defined as:
■ Cortical displacement 1 mm or greater
■ More than 10 degrees of angular displacement
■ Comminution at the fracture site
■ Radiolunate angle of more than 15 degrees
■ Scapholunate angle of more than 60 degrees
■ Intrascaphoid angle of more than 35 degrees
DIFFERENTIAL DIAGNOSIS
■ Wrist sprain
■ Distal radius fracture
■ Fracture of other carpal bones
■ Ligamentous injury (most commonly, SL)
■ Preiser disease (spontaneous AVN of the scaphoid)

NONOPERATIVE MANAGEMENT
■ Nonoperative management, in the form of cast immobilization, is effective
only in low-risk scaphoid fractures that meet all of the following criteria:
■ Acute fractures (less than 4 weeks old)
■ Nondisplaced
■ Favorable location (distal pole)
■ Nondisplaced fractures of the scaphoid waist remain controversial regarding
operative vs nonoperative treatment.
■ Nondisplaced waist fractures can be treated nonoperatively with
immobilization for 10 to 12 weeks with close follow-up, with union rates as
high as 90% in this scenario.1
■ Patients with a nondisplaced scaphoid waist fracture who wish to mobilize
early (highly active persons, athletes, manual workers, or those in high-
demand occupations) should undergo operative fixation.
■ Nondisplaced and displaced fractures of the proximal pole should be surgically
managed to minimize the risk of AVN.
■ Splint or cast immobilization should immobilize at least the wrist and thumb
CMC but does not need to include the entire thumb.7 Above-elbow casting is
not needed.
■ Nondisplaced distal pole fractures have a high rate of union after cast
immobilization for 6 to 8 weeks.
■ Union, especially for conservatively treated scaphoid waist fractures, should
be assessed with a CT scan to assess for bony bridging at approximately 8 to
10 weeks after the injury.
SURGICAL MANAGEMENT
■ Surgical management is best for fractures that are unstable or displaced.
■ An open approach is indicated for8 the following:
■ Proximal pole fractures
■ A displaced, unstable fracture of the scaphoid waist
■ Associated carpal instability or perilunate instability
■ Associated distal radius fracture. Both fractures can be addressed at one
operative time and will allow for early mobility.
■ A percutaneous approach is indicated for the following:
■ Nondisplaced fractures of the scaphoid waist
■ A displaced fracture of the scaphoid waist

■ Proximal pole fractures
■ Percutaneous fixation is technically difficult and has not been shown to have
better outcomes. Thus, the authors advocate for an open approach to the
scaphoid.
■ Both percutaneous and open procedures can be performed from the volar or
dorsal approach depending on fracture characteristics.
■ In general, fractures of the proximal pole are approached dorsally to allow for
anterograde screw fixation and compression across the fracture. This
approach maximizes the amount of screw threads distally.
■ Scaphoid fractures with associated carpal instability are also approached
dorsally to allow for adequate exposure of the proximal carpal row. A K-wire
can be placed in the lunate to assist reduction of the proximal scaphoid pole
via its attachment through the scapholunate ligament. This assists obtaining
and maintaining carpal realignment with scaphoid screw fixation.
■ Approaching scaphoid waist fractures, which have a tendency to flex volarly
at the fracture site, from the dorsal approach makes reduction more
challenging, as the wrist must be flexed to bring the axis of the scaphoid
above the dorsal lip of the distal radius. In these cases, a volar approach can
be used.
Preoperative Planning
■ Imaging studies should be thoroughly reviewed to confirm fracture geometry.
■ Required equipment includes
■ K-wires
■ Portable mini-fluoroscopy (“mini C-arm”)

FIG 4 • A. The patient should be positioned supine, with
the shoulder abducted to 90 degrees on an arm board.
B,C. The forearm can then be supinated or pronated
depending on the choice of a volar or dorsal approach,
respectively.
■ Cannulated headless compression screws, in which the differential thread
pitch exerts compression across the fracture site1
Positioning
■ Anesthesia should be general or regional.
■ The patient should be positioned supine, with the shoulder of the affected
upper extremity abducted to 90 degrees on an arm board (FIG 4).
■ The fluoroscopy unit should be draped and readily available.
■ A pneumatic tourniquet should be applied to the proximal upper arm.
■ Intravenous antibiotic prophylaxis should be provided prior to tourniquet
inflation.
■ The upper extremity should be prepped and draped in the standard sterile
fashion.
■ The upper extremity should then be exsanguinated using an Esmarch bandage,
and then the tourniquet should be inflated (to either 250 mm Hg or at least 100

more than systolic blood pressure).
Approach
■ Scaphoid fractures can be approached from a volar or dorsal approach.
T E C H N I Q U E S
■ Open Reduction and Internal Fixation of Scaphoid
Fracture: Dorsal Approach
Exposure
■ Make a longitudinal 3- to 4-cm-long incision in the dorsal forearm and hand
starting at the ulnar aspect of the Lister tubercle and extending distally
(TECH FIG 1A).
■ Dissect through subcutaneous tissue; elevate skin flaps on either side above
level of extensor retinaculum. Identify and protect any crossing radial
sensory nerve branches.
■ Incise the distal aspect of the extensor retinaculum over the third
compartment. Identify the junction of the second and third dorsal
compartments.
■ Identify and retract EDC ulnarly and ECRB, ECRL, and EPL radially to
expose the underlying radiocarpal capsule. The tendons can remain in their
compartment but must be identified to avoid inadvertent transection during
exposure of the capsule.
■ Make a limited capsulotomy to expose the scaphoid. The scaphoid can be
approached through a transverse limb just distal to dorsal radius (TECH FIG
1B). An inverted T incision can be extended if further exposure is needed.
■ Elevate the capsular flap to expose the proximal pole of the scaphoid, the S-
L ligament, and the underlying fracture. Be careful to avoid stripping the
dorsal ridge vessels entering at scaphoid waist.
■ Evacuate fracture hematoma.

TECH FIG 1 • A. Longitudinal approximately 4-cm
incision designed along the axis from the Lister
tubercle to the long finger metacarpal. This incision is
used for a dorsal approach to the scaphoid. B.
Intraoperative photograph of the dorsal approach
depicting scaphoid and intact scapholunate (SL)
ligament. Note the position of the buried screw head
as well. P, proximal; D, distal; U, ulnar; R, radial.
Fracture Reduction and Fixation
■ Apply longitudinal traction on IF and LF to distract the carpus.
■ If needed to assist in fracture reduction, insert 0.045-in. K-wires
perpendicular into proximal and distal scaphoid fragments (TECH FIG 2).
■ Reduce fracture; confirm by assessing congruity of radioscaphoid and
scaphocapitate articulations.
■ Once reduction is confirmed, temporarily fixate with derotational 0.045-in.
K-wires. Drill first wire dorsoulnar to central axis of scaphoid, into the
trapezium. Drill a second wire, if needed, volar and radial to central axis of
scaphoid. Be careful to ensure that derotational wires will not interfere with
screw placement and/or prevent compression within the central axis of the
scaphoid (see TECH FIG 2).

TECH FIG 2 • Inserting 0.045-in. K-wires into proximal
and distal fragments to act as “joysticks” may
significantly assist in fracture reduction. Also note the
placement of a derotational 0.045-in. K-wire for
temporary fixation, once the fracture is appropriately
reduced. Importantly, this wire should be placed
parallel to but not within the central axis of the
scaphoid, to avoid interfering with screw placement.
Guidewire Placement
■ Guidewire placement should originate at the membranous portion of the
origin of the scapholunate ligament. For very proximal fractures, the starting
point should be the mid-aspect of the membranous portion of the
scapholunate ligament, to be as proximal as possible.
■ Flex the wrist, and insert the guidewire down the central axis of the
scaphoid. This should be in line with the thumb metacarpal.

■ Confirm central axis placement via PA, lateral, and 30-degree pronated
lateral radiographs.
■ Advance the wire up to the scaphotrapezial joint without entering the joint
itself.
Screw Insertion
■ Determine screw length via the guidewire. With minimal displacement of the
fracture, screw length should be 4 mm shorter than guidewire length to
account for the cartilage thickness.
■ Advance the guidewire into the trapezium.
■ Use the cannulated drill to manually drill over the wire. Be careful to not
overdrill the distal scaphoid, which could result in screw migration into the
scaphotrapezial joint.
■ Remove the drill and insert the screw along the central axis of the scaphoid.
■ Remove the guidewire.
■ Confirm screw position via radiographs (TECH FIG 3).
■ Close the radiocarpal capsule and then the extensor retinaculum if
completely released, then skin.
TECH FIG 3 • Final confirmation of appropriate screw
position via PA (A), lateral (B), and 30-degree
pronated lateral (C) radiographs. Note the screw
positioning lies within the scaphoid cortex on all views,
reducing the chance of undesired prominence.

■ Open Reduction and Internal Fixation of Scaphoid
Fractures: Volar Approach
Exposure
■ Palpate the tubercle of the scaphoid after radially deviating the wrist.
■ Design a 3- to 4-cm incision centered over the palpated tubercle, extending
proximally over the FCR tendon sheath and distally over the base of the
thumb.
■ Incise the FCR sheath and retract the tendon ulnarly, exposing underlying
volar wrist capsule.
■ Distally, divide thenar muscles over the distal scaphoid and trapezium.
■ Incise the volar wrist capsule longitudinally, avoiding injury to the articular
cartilage.
■ Divide the radiolunate and radioscaphocapitate ligaments in the proximal
field to visualize the proximal pole of the scaphoid.
■ Use a Freer elevator to expose the scaphotrapezial joint. Limit dissection
over the radial scaphoid to avoid injury to dorsal vessels.
■ Evacuate fracture hematoma and irrigate.
Fracture Reduction and Fixation
■ Apply longitudinal traction to the wrist and reduce the fracture. Consider
using pointed reduction forceps or placing 0.045-in. K-wires into proximal
and distal scaphoid fragments to assist in reduction.
■ Place provisional 0.045-in. K-wire, starting from volar distal to dorsal
proximal, for temporary fixation. Ensure the trajectory is not along the
central axis of the scaphoid.
■ To expose starting position for screw placement dorsally, resect small
portion of proximal volar trapezium.
■ Place central axis guidewire.
■ Determine screw length via the guidewire. With minimal displacement of the
fracture, screw length should be 4 mm shorter than guidewire length to
account for the cartilage thickness.
■ Advance the guidewire into the radius.
■ Use the cannulated drill to manually drill over the wire.
■ Insert the cannulated screw along the central axis; confirm via PA, lateral,
and 30-degree pronated lateral radiographs.

■ Repair radiolunate and radioscaphocapitate ligaments.
■ Close the volar wrist capsule, then skin.
PEARLS AND PITFALLS
Preservation of
scaphoid blood
supply
■ Avoid dissection on the dorsal ridge of the scaphoid.
■ Limit dissection of capsule.
Guidewire
positioning
■ During dorsal approach, pronate and flex the wrist to ensure
appropriate trajectory.
■ During volar approach, resect small volar lip of trapezium to
expose starting position in distal pole of scaphoid.
■ Ensure the guidewire is placed along the central axis.
Screw position
■ Assess screw length and prominence intraoperatively via 45-
degree supination oblique and pronated oblique radiographs.
■ Screw length should be 4 mm shorter than measured length.
■ Stop drilling 2 mm short of the distal pole when using the
dorsal approach.
■ Place the screw in the central axis.
■ Bury the headless compression screw beneath the cortical
surface of the scaphoid to prevent screw prominence and
cartilage erosion.
Small proximal
pole fracture
■ Consider a smaller screw such as Acutrak Mini to prevent
proximal fragment comminution.
Unstable fracture
reduction
■ Place perpendicular joystick K-wires into proximal and distal
fragments to aid in reduction.
■ Stabilize fragments prior to screw insertion via derotational
K-wires.
POSTOPERATIVE CARE
■ Patients should be placed in a volar thumb spica splint.
■ Patients should strictly elevate at home to reduce edema and pain.
■ Frequent ROM exercises of the digits are crucial to prevent unwanted
stiffness.

■ At 2 weeks postoperatively, patients should return for suture removal and
exchange to a removable forearm-based thumb spica splint. ROM exercises of
the thumb are started at this point.
■ Fractures that involve the proximal pole, or fractures with significant
comminution, should be immobilized for 6 to 10 weeks.
■ Radiographs should be taken at the 2-, 6-, and 12-week postoperative time
points to assess for fracture healing (FIG 5).
■ CT scans can be considered to better assess for fracture union at 12 weeks or
later if there are concerns about healing.
OUTCOMES
■ Outcomes depend on type of treatment, timing of treatment, and location of
screw placement.
■ A recent systematic review concluded that internal fixation reduces the risk of
nonunion compared with cast immobilization (1.7% vs 10%, respectively).
However, the two treatments did not differ in terms of eventual postoperative
pain, tenderness, long-term grip strength, ROM, functional outcome, and
satisfaction, although internal fixation may produce quicker return to function
and transiently improved ROM and grip strength.9
■ Rigid internal fixation theoretically allows for earlier physical therapy, lesser
time to union, improved ROM, and quicker functional recovery. This has been
corroborated by studies that have showed high rates of union and good overall
outcomes using open techniques10 (FIG 6).
■ Time to initiation of treatment highly influences union rates:
■ Scaphoid fractures treated before 4 weeks have a significantly higher union
rate than do those treated after 4 weeks.11
■ Nondisplaced fractures casted within 3 weeks of injury have a 90% to 100%
union rate,12 whereas those casted between 6 weeks and 6 months from
injury demonstrate a 90% union rate, but approximately twice as long
duration to achieve a union.13
■ Central screw placement exhibits more rapid progression to union, in cases of
scaphoid nonunion.14

FIG 5 • A: PA and (B) lateral PA and lateral radiographs
showing reduced, internally fixed, and united scaphoid
waist fracture at roughly 3 months postoperatively.

FIG 6 • Early outcome (at 12 weeks postoperatively)
depicting intact grip and wrist flexion/extension.
COMPLICATIONS
■ Screw prominence, erosion of the scaphotrapezial articulation, and erosion of
the distal radius articular surface are possible if the screw length is not
accurately estimated intraoperatively.
■ Displaced waist and proximal pole fractures can lead to nonunion and
potential AVN.
■ Rare but potential other complications include wound infections, hypertrophic
scarring, injury to sensory branch of radial nerve, and damage to
scaphotrapezial articulation.
REFERENCES
1. Kang L. Operative treatment of acute scaphoid fractures. Hand Surg.
2015;20(2):210-214.
2. Ruby LK, Stinson J, Belsky MR. The natural history of scaphoid nonunion: a
review of fifty-five cases. J Bone Joint Surg Am. 1985;67A:
428-432.
3. Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg
[Am]. 1980;5:508-513.
4. Weber ER, Chao EY. An experimental approach to the mechanism of scaphoid
waist fracture. J Hand Surg [Am]. 1978;3:142-148.
5. Mack GR, Bosse MJ, Gelberman RH, et al. The natural history of scaphoid
non-union. J Bone Joint Surg Am. 1984;66:504-509.
6. Lindstrom G, Nystrom A. Natural history of scaphoid non-union with special
reference to “asymptomatic” cases. J Hand Surg Br. 1992;17:697-700.
7. Buijze GA, Goslings JC, Rhemrev SJ, et al. Cast immobilization with and
without immobilization of the thumb for nondisplaced and minimally displaced
scaphoid waist fractures: a multicenter, randomized, control trial. J Hand Surg
[Am]. 2014;39(4):621-627.
8. Leslie IJ, Dickson RA. The fractured carpal scaphoid: natural history and
factors influencing outcome. J Bone Joint Surg Br. 1981;16B:
225-230.
9. Symes TH, Stothard J. A systematic review of the treatment of acute fractures
of the scaphoid. J Hand Surg Eur. 2011;36E:802-810.

10. Bedi A, Jebson PJL, Hayden RJ, et al. Internal fixation of acute, non-
displaced scaphoid waist fractures via a limited dorsal approach: an assessment
of radiographic and functional outcomes. J Hand Surg [Am]. 2007;32A:326-
333.
11. Langhoff O, Andersen JL. Consequence of late immobilization of scaphoid
fractures. J Hand Surg Br. 1998;13B:77-79.
12. Cooney WP, Dobyns JH, Linsheid RL. Nonunion of the scaphoid: analysis of
the results from bone grafting. J Hand Surg [Am]. 1980;5:434-445.
13. Mack GR, Wilckens JH, McPherson SA. Subacute scaphoid fractures: a
closer look at closed treatment. Am J Sports Med. 1998;26:56-58.
14. Trumble TE, Clarke T, Kreder HJ. Non-union of the scaphoid: treatment with
cannulated screws compared with treatment with Herbert screws. J Bone Joint
Surg Am. 1996;67A:428-432.

18
CHAPTER
Scaphoid Nonunion:
Nonvascularized Bone
Reconstruction
Matthew L. Iorio and Jason H. Ko
DEFINITION
■ Scaphoid nonunion is defined as failure to heal within 6 months. The
incidence of scaphoid nonunion is between 4% and 50%.
■ Nonunion may be evidenced by pain and tenderness at the anatomic snuffbox
and scaphoid tubercle, and decreased wrist extension.
■ Radiographs demonstrate a wide, sclerotic fracture cleft, potentially with cyst
formation (FIG 1).
■ Unstable nonunions demonstrate loss of the normal length and shape of the
scaphoid, often with a dorsal intercalated segmental instability (DISI)
deformity.
■ When not corrected, carpal instability ensues, and a predictable pattern of
degenerative changes known as scaphoid nonunion advanced collapse (SNAC)
arthritis occurs.
■ The preferred treatment for scaphoid nonunions is internal fixation with
autologous bone grafting.
■ Nonvascularized bone grafts have been the traditional treatment for scaphoid
nonunion, although avascular necrosis (AVN) of the proximal pole is an
indication for the use of vascularized bone grafts.
ANATOMY
■ Seventy to 80% of the intraosseous vascularity comes from the dorsal
scaphoid branches of the radial artery, entering through the dorsal ridge. These
dorsal vessels enter the scaphoid waist in a retrograde direction, providing the
single dominant intraosseous vessel to the proximal pole of the scaphoid.

■ A minor volar contribution comes from radial artery or its superficial palmar
branch, which gives off several volar scaphoid branches at the level of the
radioscaphoid joint, entering the bone at its distal tubercle.
FIG 1 • Scaphoid waist nonunion characterized by a
wide sclerotic fracture cleft with no evidence of bony
healing.
■ Because of this unique vascular anatomy, the proximal pole of a fractured
scaphoid is particularly prone to AVN, especially when the fragment is small.
■ A nonunion through the scaphoid waist can lead to progressive flexion of the
distal pole and extension of the proximal pole, leading to a “humpback
deformity.”
■ Treatment and surgical approach will be influenced by whether or not a
humpback deformity or DISI deformity is present.
■ A proximal pole nonunion will not typically develop a humpback deformity;
however, the risk of AVN is higher.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Injury typically involves axial load across a hyperextended and radially
deviated wrist.
■ Tenderness can typically be found over the distal pole of the scaphoid volarly
or along the proximal pole dorsally within the interval between the first and

third extensor compartments.
■ Ulnar-to-radial wrist deviation with pressure over the volar scaphoid pole may
cause increased pain, as will active assist wrist flexion or extension or resisted
pronation.
IMAGING
■ Anteroposterior, oblique, and lateral radiographs of the scaphoid should be
obtained.
■ Standard scaphoid view involves 30 degrees of wrist extension and 20
degrees of ulnar deviation.
■ Stress views with the fist tightly clenched may demonstrate dynamic
instability of the scaphoid or nonunion site.
■ Computed tomography (CT) with fine cuts may be beneficial in further
characterizing the nonunion site, as well as associated humpback deformity,
cyst formation, osteophytosis, and degenerative arthrosis.
■ Increased proximal pole sclerosis or density on imaging may indicate AVN,
which, depending on the location of the nonunion, may limit both the ability
to obtain viable bone margins as well as reliable fixation and osseous union.
■ Magnetic resonance imaging can be used to assess for AVN of the scaphoid
proximal pole.
■ Evaluation of a potential degenerative posture or malunions of the scaphoid
should be measured and documented as part of the initial evaluation. There is
some debate as to which is superior in interobserver reliability, though they
both function to evaluate deviations of scaphoid posture from a normative
comparison in the setting of humpback deformity and collapse.
■ A lateral intrascaphoid angle is obtained by drawing a line perpendicular to
the proximal and distal articular surfaces.
• A normal lateral intrascaphoid angle is 24 ± 5 degrees or less than 3
degrees.1
• Increasing flexion results in a humpback deformity, with a lateral
intrascaphoid angle greater than 35 degrees.
■ The scaphoid height-to length ratio is evaluated on a lateral or sagittal image.
A normal ratio is 0.60 ± 0.04.
• For scaphoid length, a baseline is drawn along the volar scaphoid, and the
length of the scaphoid is found from the most proximal to the most distal
aspect.

• For scaphoid height, the maximum height of the scaphoid was found on a
line perpendicular to the baseline.
SURGICAL MANAGEMENT
■ Nonvascularized bone graft reconstruction should be considered for the
treatment of all scaphoid fracture nonunions that demonstrate no incidence of
AVN of the proximal pole.
■ Contraindications
■ Progressive pan-carpal arthrosis can follow prolonged scaphoid nonunions in
a predictable pattern: SNAC wrist deformity.
■ The presence of radiocarpal or midcarpal sclerosis, with cyst formation, may
indicate advanced disease with continued postoperative pain. In this instance,
salvage procedures including proximal row carpectomy, limited intercarpal
arthrodesis, or total wrist arthrodesis may be more reliable in regard to pain
control.
■ Relative contraindications include the patient’s suitability for surgery,
smoking status, and understanding of the need for prolonged postoperative
immobilization and use restrictions.
Positioning
■ The patient is positioned supine on the operating room table with a well-
padded tourniquet placed on the upper arm.
■ General anesthesia or monitored anesthesia care (MAC) can be used, but
supplementation with an infraclaviular or interscalene nerve block may
markedly improve postoperative pain control.
Approach
■ If a humpback deformity is present, a volar approach is used, which provides
excellent exposure to the waist and distal pole of the scaphoid.
■ It also provides direct access to the extension osteotomy wedge for direct
bone grafting and stabilization.
■ It may be possible that this exposure, by preserving the dorsal ridge vessel,
may prevent iatrogenic devascularization of the scaphoid.
■ If there is no humpback deformity, a dorsal or volar approach can be used,
based on the location of the nonunion. Dorsal approaches are preferred for
more proximal nonunions, and volar approaches are preferred for more distal
nonunions.

■ Either a volar or dorsal approach can be used with a waist nonunion without a
humpback deformity.
T E C H N I Q U E S
■ Scaphoid Bone Grafting: Volar Approach
Exposure and Preparation of the Site
■ Under tourniquet control and loupe magnification, a longitudinal incision is
made in-line with the flexor carpi radialis (FCR) to the level of the proximal
wrist crease, followed by a 60-degree angle at the volar junction of the
glabrous skin. This will protect the radial artery and prevent a longitudinal
scar across the flexor crease. This is also referred to as the Russe approach
(TECH FIG 1A–C).
■ The deep branch of the radial artery is visualized, and retracted radially.
■ An intrasubstance longitudinal incision in the radioscaphocapitate (RSC)
ligament can be created for exposure of the volar scaphoid. The incision and
exposure should be at least distal to the scaphotrapezial joint, for preparation
and visualization of screw placement.
■ Following visualization of the scaphoid, 0.045-in. (or larger) K-wires may be
placed proximal and distal to the fracture as “joysticks” to retract and see,
and correct any humpback deformity that may be present (TECH FIG 1D).
■ In the event of a malunion, an osteotomy can be performed; however, this
should be done judiciously. We recommend only crossing 80% to 90% of the
scaphoid waist with the osteotome to prevent penetration of the dorsal cortex
and injury to the scaphocapitate joint or the dorsal ridge vessel.
■ Disruption of the dorsal scaphoid can create an unstable fracture or make
cancellous bone graft placement less secure.
■ Following exposure, the nonunion site must be cleared of intervening fibrous
material and necrotic bone, but viable cancellous bone should remain. A
small dental pick or curette can be useful in this setting.
Obtaining Bone Graft
■ If volar distal radius autograft is to be used, the pronator quadratus is incised
and dissected subperiosteally to expose the volar cortex of the distal radius

(TECH FIG 2A).
■ The site of bone graft harvest should be confirmed with intraoperative
fluoroscopy, being careful not to harvest graft too close to the radiocarpal
joint.
■ A structural corticocancellous bone graft can be obtained either with straight
and curved osteotomes or with an oscillating saw.
■ If a saw is used, saline irrigation should be applied during the osteotomies
to minimize thermal injury to the bone (TECH FIG 2B,C).
■ Through the aforementioned cortical window, cancellous autograft can be
harvested.
■ For most scaphoid nonunions without AVN, distal radius autograft is
sufficient.
■ However, iliac crest autograft is the traditional standard for scaphoid
nonunion treatment. The anterosuperior iliac spine (ASIS) is palpated, and
bone graft should be harvested 2 cm posterior to the ASIS.
TECH FIG 1 • A–C. A volar Russe incision along the
FCR tendon with an oblique extension over the
scaphoid distal pole provides access to the volar
scaphoid. D. Through this volar approach, 0.054-in.
Kirschner wires used to joystick open the scaphoid
fracture nonunion site, correcting the humpback

deformity.
■ The skin incision is made posterior to the ASIS, and dissection should
proceed with monopolar cautery directly down to the iliac crest.
■ Bicortical grafts from the inner table or outer table, or tricortical grafts, can
be obtained, typically with an oscillating saw.
Stabilizing the Site
■ The nonunion site can then be stabilized by either progressively packing
either corticocancellous or cancellous graft into the site, effectively
expanding the space and increasing the extension of the distal pole.
■ K-wire joysticks can be used to provide an extension force through the
fracture, and a longitudinal K-wire can be placed to provide a mechanical
restraint to flexion.
■ In our experience, a combination of the two may work best, where the
extension is corrected with the K-wires and stabilized longitudinally as best
as possible and confirmed with fluoroscopy.
■ This wire should be placed slightly off axis to avoid the ultimate trajectory
of compression screw placement and directly capture the bone graft.
■ Alternatively, the wire can be placed slightly volar to the bone graft to
prevent extrusion during compression.
■ If a large cortical defect volarly is present in the extension wedge, a bone
graft can be tailored to slightly overfill the space.
■ The longitudinal wire is then backed out just proximal to the fracture, the
graft is press fit into the space, and the wire is readvanced (TECH FIG 3).
Scaphoid Fixation
■ Osteosynthesis is then completed, most frequently with either K-wire or
compression screw placement.

TECH FIG 2 • A. The pronator quadratus has been
elevated subperiosteally off the volar surface of the
distal radius. The purple markings are used to plan the
osteotomies, which were confirmed with intraoperative
fluoroscopy. B,C. A corticocancellous autograft is
harvested from the volar distal radius. This type of
graft can be used as a structural graft to correct a
humpback deformity.
TECH FIG 3 • Corticocancellous autograft is press-fit
into the scaphoid nonunion through a volar approach.
■ For compression screw placement from the volar scaphoid, the guidewire
can be advanced through either the trapeziometacarpal joint or
scaphotrapezial joint, with similar outcomes.
■ In the scaphotrapezial approach, however, the volar beak or footplate of the
trapezium should be first removed with a rongeur to prevent off-axis screw
placement.
■ The stabilizing K-wire should be left in place or repositioned if it is blocking
the guidewire, to provide rotational control during drilling and compression.

■ Following placement of the guidewire, the drill should be advanced with the
aid of fluoroscopy to prevent penetration of the far cortex, as this may
destabilize the distal screw and lead to screw loosening.
■ Screw selection then is performed by drilling to the distal subchondral bone,
measuring based off the guidewire, and selecting a screw length 4 to 6 mm
shorter than the measured length to ensure that the screw is adequately buried
in subchondral bone proximally, without distal extrusion.
■ Depending upon the manufacturer, there may be several screw widths to
choose from, typically between 2 and 3 mm. This becomes relevant in
either revising a prior attempt to heal an acute fracture with a compression
screw or expectations in need for nonunion revision. That is, if the widest
screw is chosen as the initial fixation and it fails, compression screw
fixation may not be an option for salvage given the subsequent bone loss
and instability. Therefore, initial fixation should be performed with a
narrower screw, in case future revision with a wider screw can be
performed (TECH FIG 4).
TECH FIG 4 • AP and lateral intraoperative
fluoroscopic views of a headless compression screw
to provide compression across the corticocancellous
bone graft reconstruction. The radial K-wire in the AP
view is used as a derotational pin, and the volar K-
wire on the lateral view is used to further stabilize the
small bone graft.

■ Scaphoid Bone Grafting: Dorsal Approach
Exposure and Preparation of the Site
■ Under tourniquet control and loupe magnification, a longitudinal incision is
made just ulnar to the Lister tubercle (TECH FIG 5A).
■ A longitudinal cut or step-cut is made through the extensor retinaculum.
■ The third dorsal compartment is released, and the EPL tendon is retracted
radially.
■ Subperiosteal dissection of the second and fourth dorsal compartments is
performed to expose the dorsal distal radius.
■ The posterior interosseous nerve (PIN) is located in the floor of the fourth
compartment, and during the dorsal wrist approach, a PIN neurectomy can be
performed to help minimize postoperative pain.
■ A ligament-sparing capsulotomy or longitudinal capsulotomy is performed
through the dorsal wrist capsule to expose the proximal scaphoid (TECH
FIG 5).
TECH FIG 5 • A. A dorsal longitudinal incision just
ulnar to the Lister tubercle will give the surgeon
access to both the scaphoid nonunion and the dorsal
distal radius bone graft site. B. A ligament-sparing

capsulotomy is performed parallel to the dorsal
intercarpal (DIC) and dorsal radiocarpal (DRC)
ligaments, along with a radial extension.
■ The nonunion site is exposed and fibrous tissue removed until healthy-
appearing cancellous bone is visualized both proximally and distally.
■ Care is taken not to disrupt the scapholunate interosseous ligament during
the procedure.
Scaphoid Fixation
■ As described above, K-wires can be used as joysticks to gain control of the
proximal and distal poles, and corticocancellous or cancellous autograft can
be packed into the nonunion site.
■ Fixation is achieved by headless compression screw, as described above. The
derotational K-wire can be left in for temporary fixation.
■ In proximal pole nonunions, if there is minimal bone proximally, screw
fixation may not be possible, in which case, definitive fixation may be
performed with K-wires.
■ Allograft bone chips can be used to pack the bone graft donor site.
■ With the volar approach, it is important to reapproximate the
radioscaphocapitate ligament if it was cut during the procedure. This can be
performed with 3-0 polyglactin suture.
■ If volar distal radius bone graft was harvested, the pronator quadratus does
not need to be repaired.
Closure
■ The dorsal capsule is carefully closed with an absorbable suture, such as a 3-
0 poliglecaprone-25 or polyglactin suture. The extensor retinaculum is closed
with similar 3-0 suture, leaving the extensor pollicis longus tendon
superficial to the retinaculum.
■ Depending upon the volume of expected postoperative edema and skin
quality, the skin is closed with either deep dermal stitches and a running
subcuticular or horizontal mattress stitches with 4-0 nylon.
■ The wrist is immobilized in a well-padded plaster short-arm spica splint.

PEARLS AND PITFALLS
Scaphoid
preparation
■ Degeneration of the radioscaphoid facet or post-traumatic arthrosis
may predispose to ongoing pain and stiffness and should be
considered a potential contraindication to scaphoid salvage
techniques.
Distal
radius bone
graft
harvest
■ It is important to harvest bone graft 1 cm proximal to the radiocarpal
joint to prevent injury.
PIN
neurectomy
■ During the dorsal wrist approach, the PIN can be identified in the
floor of the fourth dorsal compartment and excised to help minimize
postoperative pain.
FIG 2 • CT scans obtained 6 weeks postoperatively
after volar distal radius corticocancellous reconstruction
of a scaphoid waist nonunion demonstrate healing
across the proximal and distal autograft sites.
POSTOPERATIVE CARE
■ The patient is placed in a well-padded thumb spica splint. At 2 weeks, the
splint and stitches are removed and a thumb spica cast is applied.
■ Casting is typically continued for a total of 10 to 12 weeks, with cast changes

at 3- to 4-week intervals.
■ X-rays should be obtained at each postoperative visit. CT scans can be
obtained at the surgeon’s discretion any time after 6 weeks postoperatively to
determine extent of union (FIG 2).
■ Exposed K-wires should be removed near 3 to 4 weeks to prevent pin site
infections and possible bacterial colonization of the nonunion site. Buried
wires can be removed in the office or operating room once union is verified.
■ Osseous union is identified by bridging trabeculae on radiographs and absence
of fracture site tenderness (FIG 3).
OUTCOMES
■ In 1936, Matti described the original technique using an iliac crest
corticocancellous bone strut as an inlay through a dorsal approach. Russe later
offered a modified technique done via a volar approach to spare the blood
supply and correct volar collapse. This technique demonstrated union rates
ranging from 81% to 97%.2
■ The Fisk-Fernandez technique employs a triangular or trapezoidal
corticocancellous wedge from the iliac crest or distal radius that is placed as an
intercalary structural graft to restore scaphoid length and correct carpal
alignment. Such wedge-grafting techniques have demonstrated improved union
rates when compared to Matti-Russe inlay grafting technique.3–6
FIG 3 • Routine x-rays at 10 months postoperatively
demonstrate complete healing of the scaphoid

nonunion reconstruction, with pain-free range of motion.
■ Sayegh and Strauch performed a systematic review comparing cancellous-only
and corticocancellous grafts, reporting cancellous-only grafts provided a
shorter interval to union, but corticocancellous grafts were associated with
consistent deformity correction and improved Mayo wrist scores.7
COMPLICATIONS
■ The most common complication is superficial wound or pin site infection,
nerve irritation, and complex regional pain syndrome (1.25%).8,9
REFERENCES
1. Amadio PC, Berquist TH, Smith DK, et al. Scaphoid malunion. J Hand Surg
[Am]. 1989;14(4):679-687.
2. Russe O. Fracture of the carpal navicular: diagnosis, non-operative treatment,
and operative treatment. J Bone Joint Surg Am. 1960;42-A:759-768.
3. Fernandez DL. A technique for anterior wedge-shaped grafts for scaphoid
nonunions with carpal instability. J Hand Surg [Am]. 1984;9(5):733-737.
4. Fernandez DL. Anterior bone grafting and conventional lag screw fixation to
treat scaphoid nonunions. J Hand Surg [Am]. 1990;15(1):140-147.
5. Mulder JD. The results of 100 cases of pseudarthrosis in the scaphoid bone
treated by the Matti-Russe operation. J Bone Joint Surg Br. 1968;50(1):110-
115.
6. Stark A, Broström LA, Svartengren G. Scaphoid nonunion treated with the
Matti-Russe technique. Long-term results. Clin Orthop Relat Res. 1987;
(214):175-180.
7. Sayegh ET, Strauch RJ. Graft choice in the management of unstable scaphoid
nonunion: a systematic review. J Hand Surg [Am]. 2014;39(8):1500-1506.e7.
8. Daly K, Gill P, Magnussen PA, Simonis RB. Established nonunion of the
scaphoid treated by volar wedge grafting and Herbert screw fixation. J Bone
Joint Surg Br. 1996;78(4):530-534.
9. Smith BS, Cooney WP. Revision of failed bone grafting for nonunion of the
scaphoid. Treatment options and results. Clin Orthop Relat Res. 1996;
(327):98-109.

19
CHAPTER
Scaphoid Fracture
Nonunion: Vascularized
Bone Reconstruction
Matthew L. Iorio and Jason H. Ko
DEFINITION
■ Scaphoid fractures are among the most common upper extremity fractures,
accounting for 70% of all carpal bone fractures.1
■ Although most scaphoid fractures heal with nonoperative management, the
tenuous blood supply of the scaphoid can lead to nonunion in 5% to 10% of
cases even with appropriate treatment, and up to 55% of cases when there is
displacement on initial injury (FIG 1).2,3
■ The complications of scaphoid nonunion vary widely, from pain and decrease
in function to carpal malalignment, progressive arthrosis, and eventual
scaphoid nonunion advanced collapse (SNAC) (FIG 2).3,4
■ To prevent such complications, surgical advances have been developed to treat
scaphoid nonunions, including screw fixation, bone grafting, and, most
recently, vascularized bone grafting.5
■ Vascularized bone grafts (VBGs) have been shown to promote healing and
realignment of recalcitrant scaphoid nonunions in addition to re-establishing
blood flow in cases with avascular necrosis (AVN).6

FIG 1 • Chronic scaphoid waist nonunion with tapered
cortical edges.

FIG 2 • Radiocarpal joint with avascular proximal
scaphoid pole and cartilage fragmentation (Freer
elevator).
ANATOMY
■ Seventy to 80% of the intraosseous vascularity comes from the dorsal
scaphoid branches of the radial artery, entering through the dorsal ridge. These
dorsal vessels enter the scaphoid waist in a retrograde direction, providing the
single dominant intraosseous vessel to the proximal pole of the scaphoid.
■ A minor volar contribution comes from the radial artery or its superficial
palmar branch, which gives off several volar scaphoid branches at the level of
the radioscaphoid joint, entering the bone at its distal tubercle.
■ Because of this unique vascular anatomy, the proximal pole of a fractured
scaphoid is particularly prone to AVN, especially when the fragment is small.
■ Progressive collapse and flexion through the nonunion cause dorsal rotation of
the lunate or subluxation of the midcarpal joint leading to a DISI deformity
(dorsal intercalated segment instability).
PATIENT HISTORY
■ Injury typically involves axial load across a hyperextended and radially
deviated wrist.
■ Tenderness can typically be found over the volar pole of the scaphoid or along

the dorsal pole within the interval between the first and third extensor
compartments.
■ Ulnar-to-radial wrist deviation with pressure over the volar scaphoid pole may
cause increased pain, as will active assist wrist flexion or extension or resisted
pronation.
IMAGING
■ Anteroposterior, oblique, and lateral radiographs of the scaphoid should be
obtained.
■ Standard scaphoid view involves 30 degrees of wrist extension and 20 degrees
of ulnar deviation.
■ Stress views with the fist tightly clenched may demonstrate dynamic
instability of the scaphoid or nonunion site.
■ Computed tomography (CT) with fine cuts may be beneficial in further
characterizing the nonunion site, as well as associated collapse, cyst formation,
osteophytosis, and degenerative arthrosis.
■ Increased proximal pole sclerosis or density on imaging may indicate AVN,
which, depending on the location of the nonunion, may limit both the ability
obtain viable bone margins as well as reliable fixation and osseous union.
■ Magnetic resonance imaging can be used to assess for AVN of the scaphoid
proximal pole.
■ Evaluation of a potential degenerative posture or malunions of the scaphoid
should be measured and documented as part of the initial evaluation. There is
some debate as to which is superior in interobserver reliability, though they
both function to evaluation deviations of scaphoid posture from a normative
comparison in the setting of humpback deformity and collapse.
■ A lateral intrascaphoid angle is obtained by drawing a line perpendicular to the
proximal and distal articular surfaces.
■ A normal lateral intrascaphoid angle is 24 ± 5 degrees, or less than 3 degrees.
■ Increasing flexion results in a humpback deformity, with a lateral
intrascaphoid angle greater than 35 degrees.
■ The scaphoid height-to-length ratio is evaluated on a lateral or sagittal image.
A normal ratio is 0.60 ± 0.04.
■ For scaphoid length, a baseline is drawn along the volar scaphoid, and the
length of the scaphoid is found from the most proximal to the most distal
aspect.

■ For scaphoid height, the maximum height of the scaphoid was found on a
line perpendicular to the baseline.
SURGICAL MANAGEMENT
■ Harvest of the osteocutaneous medial femoral condyle (MFC) microvascular
flap provides simultaneous soft tissue and bone for reconstruction, ease of soft
tissue recipient closure, and the ability to provide accurate postoperative
monitoring of the microcirculation of the flap. Its routine use requires an
understanding of the arterial variation of the descending geniculate arterial tree,
as well as the blood supply to the overlying skin of the medial aspect of the
knee.
■ The free MFC corticoperiosteal flap has garnered increasing attention due to
its many desirable attributes, including ease of dissection, surgical positioning
facilitating a two-team approach, low donor-site morbidity, preservation of all
major arteries to the distal extremity, variable size and shape for harvest and
in-setting, and osteogenic potential.7
Contraindications
■ Progressive pan-carpal arthrosis can follow prolonged scaphoid nonunions in a
predictable pattern: SNAC wrist deformity.
■ The presence of radiocarpal or midcarpal sclerosis, with cyst formation, may
indicate advanced disease with continued postoperative pain. In this instance,
salvage procedures, including proximal row carpectomy, limited intercarpal
arthrodesis, or total wrist arthrodesis, may be more reliable for pain control.
■ Relative contraindications include the patient’s suitability for surgery, smoking
status, and understanding of the need for prolonged postoperative
immobilization and use restrictions.
Positioning
■ The patient is placed supine on the operating room table, and a well-padded
tourniquet is placed on the upper arm.
■ General anesthesia or monitored anesthesia care (MAC) can be used, but
supplementation with an infraclavicular or interscalene nerve block may
markedly improve postoperative pain control.
T E C H N I Q U E S

■ Approach to Creation of the Bone Flap
■ When there is no humpback deformity, a dorsally based vascularized bone
flap from the distal radius, like the 4 + 5 extensor compartmental artery
(ECA) flap or the 1,2-intercompartmental supraretinacular artery (1,2-
ICSRA) flap, can be used to reconstruct a scaphoid nonunion.
■ When a humpback deformity is present in the setting of AVN, however, a
structural flap must be placed volarly, so a volar vascularized bone flap or a
free MFC (or MFT) flap is required to properly correct the humpback
deformity.
4 + 5 Extensor Compartmental Artery Vascularized Bone Flap
■ The 4 + 5 ECA pedicle is based on retrograde flow between the anterior
interosseous pedicle and the dorsal extensor compartmental arteries (TECH
FIG 1A,B).
■ Under tourniquet control, a standard dorsal approach to the wrist is used for
exposure, incorporating prior incisions when appropriate.
■ The dorsal radial sensory branches are identified and swept radially to
protect them from iatrogenic injury.
■ The third extensor compartment is opened and the tendon transposed.
■ Retinacular flaps are elevated from the ulnar border of the Lister tubercle,
moving radially and incorporating the retinaculum over the second dorsal
compartment.
■ Just distal to the radiocarpal joint and retinaculum, the fourth extensor
compartment and tendons are mobilized from the dorsal capsule, preventing
iatrogenic injury to the vascular pedicle.
■ The tendons are then retracted ulnarly, exposing the anterior interosseous
artery and neurovascular pedicle proximally and its distal anastomotic
connections to the fourth and fifth extensor compartmental arteries.

TECH FIG 1 • A. Illustration demonstrating the fourth
and fifth extensor compartmental artery (4 + 5 ECA)
flap and its axis of rotation. B. Fourth extensor
compartment artery (arrow). C. Capsular vascularized
bone graft distally based on the fourth extensor
compartment artery. D. Placement of the distally
based fourth ECA flap in the proximal pole of the

scaphoid for avascular necrosis.
■ Osteotomies are then designed with the vascular pedicle longitudinally
centered and the distal transverse cut at least 1 cm proximal to the dorsal
ridge of the radius.
■ Distal to the site of osteotomy, the pedicle should be elevated with a sharp
periosteal elevator or Freer.
■ The proximal vessel is clipped, and the osteotomies are performed, taking
great care to prevent disruption of the volar radial cortex.
■ The flap is then reflected, with a wide cuff of capsular tissue around the
retrograde ECA (TECH FIG 1C,D).
■ The tourniquet can be released at this point to verify perfusion of the bone
flap.
1,2-Intercompartmental Supraretinacular Artery Vascularized
Bone Flap
■ The 1,2-intercompartmental supraretinacular artery (1,2-ICSRA) is distally
based from the dorsal continuation of the radial artery into the radiocarpal
arch (TECH FIG 2A).
■ Gentle exsanguination prior to tourniquet elevation can provide some
continued turgor of the vascular pedicle, which can improve visibility and
dissection.
■ Prior dorsal longitudinal incisions can be incorporated when possible into a
curvilinear dorsoradial longitudinal incision that follows the course of the
EPL tendon (TECH FIG 2B).
■ The dorsal radial sensory nerve should be identified in the interval next to
the cephalic vein and carefully protected.
■ Deep to this, the 1,2-ICSRA can be identified on the septum between the
first and second extensor compartments, which are incised laterally to include
a broad cuff of tissue including the accompanying venae comitantes (TECH
FIG 2C,D).
■ The vertical perforating nutrient branches of the pedicle enter the periosteum
at an average of 15 mm proximal to the dorsal radiocarpal joint line.

TECH FIG 2 • A. The 1,2-ICSRA bone flap with
curvilinear incision following the course of the EPL
tendon. B. The incision follows the course of the EPL
tendon. C. 1,2-ICSRA vascular pedicle highlighted by
the Ragnell retractor. D. The 1,2-ICSRA vascularized
bone flap harvested.
■ If desired, a dorsal radiocarpal capsulotomy can be performed to visualize
the scaphoid nonunion.
■ The proximal vessel is ligated with bipolar diathermy, and the flap is
osteotomized with the vascular pedicle longitudinally centered.
■ Prior to performing the distal osteotomy, a periosteal elevator should be used
to elevate the periosteal sleeve and protect the distally based pedicle.
Superficial Palmar Branch of Radial Artery Vascularized Bone
Flap
■ The superficial palmar branch of the radial artery is a terminal transverse
branch of the radial artery that arborizes on the distal cortex of the radius.
The branch can be identified and preserved in the standard volar approach to
the scaphoid, which may be useful especially in settings of humpback or
flexion deformities that are typically approached from the volar wrist (TECH

FIG 3).
■ Following exsanguination and tourniquet control, a longitudinal incision in
line with the flexor carpi radialis (FCR), with a lateral extension
(approximately 45 degrees) at the wrist crease along the glabrous skin
junction can be used for exposure.
■ The superficial palmar branch is then identified in line with the FCR tendon,
potentially originating 5 to 8 mm proximal to the radial styloid. It may be
useful to identify the proximal radial artery and trace it distally to the takeoff
of the palmar vessel, thereby preventing inadvertent injury to the pedicle.
■ The posterior sheath of the FCR tendon is then opened, and the volar wrist
capsule is identified.
■ A longitudinal incision in the radioscaphocapitate (RSC) ligament exposes
the scaphoid and facilitates direct tendon repair at the time of closure.
■ Following scaphoid preparation, the pronator quadratus is incised
longitudinally and transversely to exposure the volar distal radius cortex.
■ Care should be taken to harvest the graft at least 10 mm proximal to the
volar rim to prevent disruption of the radioscaphoid facet.
Medial Femoral Condyle Microvascular Flap
■ Flap dissection can be approached with or without the intent of harvesting a
skin paddle, regardless of the variations in anatomy.

TECH FIG 3 • Volar vascularized bone flap based on
the volar carpal artery.
■ A Doppler signal can be routinely located over the apex of the medial
condyle of the femur.
■ A sweeping, curvilinear incision is created, starting at the Hunter canal and
moving in distal and anterior directions to the midpoint between the medial
border of the patella and the MFC, just anterior to the location of the Doppler
signal (TECH FIG 4A).
■ The incision then continues distal and posterior, stopping 2 to 3 cm below
the joint line and just posterior to the midaxis of the leg.
■ This skin incision is continued to the subfascial plane of the vastus medialis
muscle, which allows the skin paddle to be rapidly elevated and retracted in a
posterior direction as the vastus medialis is dissected in an anterior direction.
■ The DGA can then be identified as the medial column of the femur is
exposed. Dissecting subfascially ensures protection of all skin vessels that
can branch off the distal DGA into the reflected skin.

■ Through the fascial plane of the vastus medialis, the branching vessels
emitting from the DGA can be identified, and the presence or absence of an
SAB and/or DGA-CB is rapidly noted (TECH FIG 4B,C).
■ Branches to the vastus medialis course in an anterior direction (penetrating
the fascial plane) and are ligated.
■ At this point, a decision is made regarding the approach for the skin paddle.
This skin vessel is preferable because of the speed with which it can be
dissected as well as the assurance that the skin and subcutaneous vasculature
can be elevated anterior to the sartorius muscle and adductor tendon, keeping
the skin and bone segments in the same dissection interval (between the
vastus medialis and sartorius muscles).
■ If the SAB is selected as the means of supplying the skin segment, it requires
a careful distal dissection to determine whether it is supported by skin
branches that pass anterior to the sartorius muscle (45%) and in the same
surgical interval as the bone component or posterior to the sartorius muscle
(55%). If it does pass posterior, it will require a distal elevation of the skin
segment and careful passage deep to the sartorius muscle to reunite it with
the bone segment before completing the flap harvest.
■ After determining the presence or absence of the DGA-CB and the SAB, we
prioritize the DGA-CB because of its speed of dissection and ease of
visualization.
■ If the skin segment is quite large, or if initial dissection reveals that the SAB
contributes to the skin perfusion while passing anteriorly to the sartorius
muscle, both sources of skin perfusion (SAB and DGA-CB) can be harvested
en bloc. Otherwise, the SAB is clamped, and the tourniquet is released. The
Doppler signal over the apex of the MFC is again obtained.
■ The initial sweeping incision allows many variations of oblique or
longitudinally oriented ellipses to be designed, using the initial incision as the
anterior border of the skin component, while capturing the Doppler signal for
the benefit of postoperative monitoring.
■ Care is taken to harvest this in such a manner that primary closure is
simply achieved.

TECH FIG 4 • A. Markings for the medial femoral
condyle and trochlea flaps. X marks the Doppler
signal routinely located over the apex of the medial
condyle of the femur. If a skin paddle is required, a
sweeping, curvilinear incision is created at the
midpoint between the medial border of the patella and
the MFC. If no skin paddle is required, a longitudinal
line just posterior to the medial femoral condyle can
be used. B. In situ relationship of the medial femoral
condyle bone flap and skin paddle based on the
descending geniculate artery cutaneous branch
(overlying sartorius tendon at the tip of the forceps). C.
Free medial femoral trochlea flap based on the
descending geniculate artery. Note the proximal origin
of the saphenous artery branch, in this case from the
descending geniculate artery, to provide irrigation for a
skin paddle. D. Medial femoral condyle bone flap and
skin paddle following osteotomy and elevation.

■ The elevation of the posterior margin of the skin requires making note of the
immediate proximity of the DGA-CB to the anterior surface of the adductor
tendon.
■ This posterior incision should be carried down to the region posterior to the
adductor tendon, giving wide berth to the DGA-CB.
■ When deep and posterior to the adductor tendon, the scalpel is then used to
approach the posterior aspect of the tendon and cautiously elevate the DGA-
CB off the adductor tendon while maintaining the adductor tendon integrity
and preserving the critical DGA-CB.
■ This will enable the entire DGA and its periosteal branches to be preserved
undisturbed on the surface of the cortical bone.
■ The bone segment is dissected in the width, length, and depth required, and
the flap is then harvested on the common DGA origin vessel (TECH FIG
4D).
■ Scaphoid Preparation and Fixation
■ If cyst formation or bone loss is present without a humpback deformity, a
longitudinal 1.1-mm K-wire can be placed radial to the longitudinal axis of
the bone to preserve the alignment of the proximal and distal poles.
■ The wire should be placed through the proximal dorsal pole radial and
volar to the longitudinal axis of the bone to avoid interference with the
placement of a subsequent compression screw or visualization of the
fracture.
■ The wire can be advanced anterograde and captured through the volar
hand, bringing the proximal edge flush to cartilage cap to prevent injury to
the scaphoid facet during manipulation.
■ The proximal and distal poles can then be distracted on the wire to
facilitate visualization.
■ Fluoroscopy is used to verify the nonunion site.
■ A no. 15 or beaver blade scalpel can be used to gently open the fracture
site. Small curettes should be used to remove any intervening cystic or
fibrous material (TECH FIG 5A).
■ If desired, a 0.8-mm K-wire can be used to sparingly trephinate the
proximal and distal cancellous surfaces within the fracture, thereby
increasing subsequent blood flow to the fracture site.

■ The bone flap and nonunion site should be contoured using rongeurs or
osteotomes. If an oscillating saw is used, the surgeon should be especially
diligent about water cooling the site and preventing heat-induced
osteonecrosis (TECH FIG 5B).
■ If a humpback deformity (flexion of the scaphoid through the nonunion site)
is identified, a 1.1-mm K-wire should be placed in the proximal and distal
poles to act as joysticks to correct the deformity prior to grafting and final
fixation.
■ If the nonunion site is expansive, the proximal and distal poles should be
packed with cancellous autograft from the bone flap harvest site prior to
insertion of the flap and definitive fixation.
■ Osteosynthesis can be completed with a headless compression screw
advanced from the proximal or distal pole, depending upon the orientation of
the nonunion site.
■ Alternatively, K-wires may be used upon the surgeon’s preference.
■ The dorsal capsule is carefully closed with an absorbable suture, such as a 3-
0 poliglecaprone-25 or polyglactin suture. The extensor retinaculum is closed
with similar 3-0 suture, leaving the extensor pollicis longus superficial to the
retinaculum.
■ Depending upon the volume of expected postoperative edema and skin
quality, the skin is closed with either deep dermal stitches and a running
subcuticular or simply vertical mattress stitches with 4-0 nylon.
■ The wrist is immobilized in a well-padded plaster short-arm spica splint.

TECH FIG 5 • A. Scaphoid waist chronic fibrous
nonunion with osteolysis. B. Preparation of the
scaphoid prior to bone grafting, with resection of all
fibrous and necrotic bone as visualized by bleeding
tissue. Note restoration of the scaphoid distal pole
extension from flexion (“humpback deformity”) and the
resultant bone void.
PEARLS AND PITFALLS
Scaphoid
preparation
■ Degeneration of the radioscaphoid facet or post-traumatic arthrosis
may predispose to ongoing pain and stiffness and should be
considered a potential contraindication to scaphoid salvage
techniques.
■ A radial styloidectomy can be performed as an adjunctive technique
in the setting of mild radioscaphoid arthrosis or to prevent
impingement of the vascular pedicle to the bone flap (FIG 3).

■ A posterior interosseous neurectomy with distal transection, proximal
crush, and transposition may be used during the initial exposure.
■ The adherent capsular tissue on the dorsal ridge of the scaphoid
should be carefully preserved, as this may represent the blood supply
to the scaphoid.
■ Following insertion of the bone flap, a 0.8-mm K-wire can be placed
just dorsal to the flap to prevent migration or extrusion during
application of a compression screw.
4 + 5 ECA;
1,2-ICSRA
■ If prior dorsal capsulotomies have been made, the arterial pedicle
may have been transected, rendering the 4 + 5 ECA vascularized bone
flap unreliable.
■ Depending upon the width of the dorsal distal radius, the fourth or
fifth ECA may be selected. However, great care should be utilized to
prevent violation of the distal radioulnar joint or sigmoid notch when
osteotomizing the fifth ECA-based bone flap as it is more ulnarly
placed.
■ The 4 + 5 ECA bone flap must be osteotomized and elevated prior to
full capsular exposure of the scaphoid; therefore, the surgeon should
be aware of the potential dimensions of the flap based on
preoperative imaging and design the osteotomies to be ample. In
comparison, the 1,2-ICSRA should be identified and protected prior
to the dorsal radiocarpal capsulotomy, but the bone flap does not need
to be osteotomized and elevated prior to exposure of the scaphoid.
■ Osteotomies should be made at least 1 cm proximal to the radiocarpal
joint to avoid penetration or disruption of the radiocarpal facets.
■ Undue traction or injury on the superficial dorsal radial sensory nerve
may lead to increased or prolonged postoperative pain.
MFC
■ Iatrogenic injury to the saphenous nerve should be avoided by careful
identification to the neighboring saphenous artery branch and
elevation of the nerve from the proposed skin paddle.
■ The skin component is usually elevated first, and attention is then
turned to the bone segment. This is because posterior bone cuts will
not be readily accessible until the skin paddle and the DGA-CB are
reflected in an anterior direction.

FIG 3 • Intraoperative image following resection of
the radial styloid and proximal scaphoid pole with
preservation of the scaphocapitate articulation.
POSTOPERATIVE CARE
■ The patient is placed in a well-padded thumb spica splint. At 2 weeks, the
splint and stitches are removed and a thumb spica cast is applied.
■ Casting is typically continued for a total of 10 to 12 weeks, with cast changes
at 3- to 4-week intervals.
■ The authors advocate burying K-wires under the skin, since they are usually
left in for 6 weeks. Buried wires can be removed in the office or operating
room once union is verified. Exposed K-wires should be removed near 3 to 4
weeks to prevent pin site infections and possible bacterial colonization of the
nonunion site.
■ X-rays should be obtained at each postoperative visit. CT scans can be
obtained at the surgeon’s discretion, but the authors recommend 10 to 18 weeks
postoperatively to determine extent of union (FIGS 4 to 6).
■ Osseous union is identified by bridging trabeculae on radiographs and absence
of fracture site tenderness.

FIG 4 • Osseous union following MFC vascularized
bone flap to the scaphoid waist. The dorsal branch of
the radial artery at the wrist was used for inflow to the
descending geniculate artery.
OUTCOMES
■ Vascularized bone grafting of the scaphoid demonstrates union rates near
90%.8
■ Across 6 studies (23.1%) involving 124 subjects following vascularized bone
grafting to the scaphoid, preoperative pain was 5.20 and postoperative pain was
0.99 (on a 10-point scale), a 79.2% improvement. Two studies (7.69%) used
Bach’s criteria of pain and activity (BCPA) and Bach’s criteria of pain activity
limitation (BCPAL).9 Across 34 patients, the BCPA improved from 4.32

preoperatively to 1.96 postoperatively, a 54.6% improvement; the BCPAL
improved from 4.21 preoperatively to 1.77 postoperatively, a 57.9%
improvement.
■ Across all studies, regardless of metric, postoperative pain was improved at
least 50% after vascularized bone grafting.
FIG 5 • A–C. Radiograph and CT scans showing
chronic scaphoid nonunion, with cyst formation and
osteolysis. D–F. Osseous union is seen following dorsal
vascularized fourth + fifth extensor compartmental
artery flap and compression screw.

FIG 6 • Osseous union of the proximal scaphoid pole
following medial femoral trochlea vascularized bone flap
and compression screw.
■ Previous studies have demonstrated that the ability to return to work and
gainful employment have a significantly positive effect on the perceived
health, physical function, and thus quality of life for individuals after injury.
■ Vascularized bone grafting serves as a viable option to restore the normal
anatomy of the radiocarpal joint and thus re-establish a patient’s overall
functionality.6
COMPLICATIONS
■ The most common complication is superficial wound or pin site infection,
nerve irritation, and complex regional pain syndrome (1.25%).
■ Immediate postsurgical complications are typically only seen in microvascular
cases with flap circulatory collapse.