Management of Ununited Old Scaphoid Fracture with Osteoarthritic Changes
This patient requires surgical intervention with open reduction, bone grafting, and internal fixation to prevent progression of radiocarpal osteoarthritis, as displaced or unstable scaphoid nonunions inevitably progress to generalized wrist arthritis over time.
Immediate Surgical Recommendation
The imaging findings demonstrate an established scaphoid nonunion with early osteoarthritic changes (radiocarpal compartment narrowing, heterotopic ossifications, and osteophytes), which represents a critical window for intervention before irreversible degenerative changes occur 1.
All displaced ununited scaphoid fractures should be reduced and grafted, regardless of current symptom severity, before degenerative changes progress 1. The natural history data is compelling:
- Scaphoid nonunions progress through predictable stages: isolated scaphoid changes (average 8.2 years) → radioscaphoid arthritis (average 17.0 years) → generalized wrist arthritis (average 31.6 years) 1
- Few nonunions remain undisplaced, stable, or arthritis-free after 10 years 1
- Displaced fractures have a 55% nonunion rate and 50% avascular necrosis rate without surgical intervention 2
- Fracture displacement and carpal instability directly correlate with severity of degenerative changes 1
Surgical Approach
The operative plan should include 2, 3:
- Open reduction and internal fixation with anatomic restoration of scaphoid alignment 2
- Bone grafting to address the established nonunion 1, 2
- Assessment for lunate dorsiflexion ≥10 degrees, which indicates carpal instability requiring correction 1
- Evaluation of fracture displacement and stability intraoperatively 1
The European literature emphasizes careful patient counseling about treatment alternatives, but the presence of established osteoarthritic changes makes surgical intervention the clear choice to prevent progression 3.
Postoperative Rehabilitation
Following surgical fixation, implement a structured rehabilitation protocol 4:
- Immediate finger motion exercises after surgery to prevent edema and stiffness 4
- Early physical training and muscle strengthening once immobilization is discontinued 4
- Long-term balance training and fall prevention to reduce future fracture risk 4
- Aggressive hand and finger motion exercises after cast removal 4
Secondary Fracture Prevention
Since this patient has sustained a fragility fracture, systematic evaluation for subsequent fracture risk is mandatory 4:
- Calcium supplementation (1000-1200 mg/day) combined with vitamin D (800 IU/day) 4
- Avoid high-pulse vitamin D dosing, which increases fall risk 4
- DXA scanning to assess bone mineral density and guide pharmacological therapy 4
- First-line bisphosphonate therapy (alendronate or risedronate) if high fracture risk is identified 4
- Treatment duration typically 3-5 years, longer if high risk persists 4
Multidisciplinary Coordination
Establish coordinated care between orthopedic surgery, rheumatology/endocrinology, and primary care 4:
- Designate a local responsible lead to coordinate secondary fracture prevention 4
- Provide patient education about disease burden, risk factors, and treatment duration 4
- Implement systematic follow-up to monitor union, detect complications, and ensure adherence 4, 5
Critical Pitfalls to Avoid
Do not adopt a "watchful waiting" approach for established scaphoid nonunions with radiographic arthritis, as osteoarthritis is almost inevitable without surgical intervention 3. The presence of radiocarpal compartment narrowing and osteophytes indicates the degenerative process has already begun 1.
Do not delay surgery based on current pain levels alone—asymptomatic patients with displaced, unstable nonunions should still be advised of the high probability of late degenerative changes and offered surgical correction 1.
Monitor carefully for avascular necrosis during follow-up, as this complication occurs in 50% of displaced scaphoid fractures and significantly impacts surgical planning 2.