Treatment of Scaphoid Sclerosis and Cystic Change
For increased sclerosis and cystic change in the proximal scaphoid, surgical intervention with curettage and bone grafting is the definitive treatment, as these findings typically indicate scaphoid nonunion or intraosseous pathology that will not resolve with conservative management. 1, 2
Diagnostic Evaluation
Before proceeding with treatment, confirm the diagnosis and assess the extent of pathology:
- CT without contrast is the optimal imaging modality to evaluate trabecular bridging, assess nonunion characteristics, and define the extent of sclerosis and cyst formation 3
- MRI with IV contrast should be obtained to assess proximal pole viability, as it increases sensitivity (66% vs 36%), specificity (88% vs 78%), and accuracy (83% vs 68%) compared to noncontrast MRI for detecting osteonecrosis 3
- Look specifically for: fracture displacement, carpal instability (lunate dorsiflexion ≥10 degrees), and radioscaphoid arthritis 2
Classification and Treatment Algorithm
Scaphoid Nonunion with Sclerosis/Cysts
The natural history data demonstrates that displaced scaphoid nonunions progress to radioscaphoid arthritis in an average of 17 years and generalized wrist arthritis in 31.6 years, making early surgical intervention critical. 2
- For sclerotic or displaced type nonunions: Screw fixation with bone grafting is required 4
- For cystic type nonunions without displacement: Screw fixation alone may achieve union in select cases, though bone grafting is safer 4
- For proximal pole sclerosis with nonunion: Consider adding osteogenic protein-1 (BMP-7) to bone graft, which reduces healing time from 9 weeks to 4 weeks and replaces sclerotic bone with well-vascularized bone 5
Intraosseous Ganglion Cyst
If imaging suggests an intraosseous ganglion cyst (most common cystic lesion of the scaphoid):
- Treatment consists of curettage and bone grafting 1, 6
- This achieves full wrist range of motion without pain in 78% of patients at average 21-month follow-up 1
- Conservative treatment with anti-inflammatory medications is ineffective 6
Key Clinical Pitfalls
- Do not delay surgery in displaced or sclerotic nonunions: Few nonunions remain undisplaced, stable, or arthritis-free after 10 years 2
- Assess for carpal instability: Lunate dorsiflexion ≥10 degrees correlates with severity of degenerative changes and indicates need for aggressive treatment 2
- Verify proximal pole viability: Contrast-enhanced imaging is essential before surgery, as avascular proximal poles may require modified surgical approach 3, 5
- Consider CT if plain radiographs are ambiguous: Misclassification of fracture type leads to surgical failure 4
Surgical Approach Selection
- Autologous iliac crest bone graft remains the gold standard 5
- Allogenic bone graft + BMP-7 produces equivalent outcomes to autologous graft while avoiding harvest site morbidity 5
- Screw fixation alone without grafting has an 89% union rate in carefully selected linear/cystic type nonunions, but carries risk of failure if sclerosis is underestimated 4