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 arthritis, as displaced ununited scaphoid fractures have a high probability of developing generalized wrist arthritis within 10-30 years if left untreated. 1
Surgical Indication and Rationale
All displaced ununited scaphoid fractures should be reduced and grafted, regardless of current symptom severity, before degenerative changes progress further. 1 The natural history data demonstrates a clear progression pattern:
- Sclerosis/cyst formation confined to scaphoid (average 8.2 years) 1
- Radioscaphoid arthritis (average 17.0 years) 1
- Generalized wrist arthritis (average 31.6 years) 1
This patient already demonstrates radiocarpal compartment narrowing and heterotopic ossifications, indicating Stage II disease with established radioscaphoid arthritis. 1
Key Assessment Parameters
Evaluate carpal instability by measuring lunate dorsiflexion on lateral radiographs—dorsiflexion ≥10 degrees indicates significant instability and correlates with severity of degenerative changes. 1 Fracture displacement and carpal instability are the primary predictors of arthritis progression. 1
Few ununited scaphoid fractures remain undisplaced, stable, or arthritis-free after 10 years. 1
Surgical Approach
Perform open reduction and internal fixation with bone grafting to restore scaphoid anatomy. 2, 3 The specific technique considerations include:
- Vascularized versus nonvascularized bone graft: Recent evidence shows no significant difference in union rates or healing time between these approaches 4
- Anatomic reduction is essential: Displaced fractures (>1mm) that are not anatomically reduced have a 55% nonunion rate and 50% avascular necrosis rate 3
- Proximal pole fractures and displaced fractures have worse outcomes with conservative management 2
Conservative Management Is Not Appropriate
Conservative treatment is contraindicated in this case because:
- Displaced scaphoid fractures that unite spontaneously require prolonged immobilization and have higher rates of painful malunion 3
- Malunion or persistent nonunion leads to progressive carpal osteoarthritis 3
- The patient already has established radiocarpal arthritis, indicating failed conservative healing 1
Postoperative Rehabilitation
Initiate early finger motion immediately after surgery to prevent edema and stiffness, followed by aggressive finger and hand motion once immobilization is discontinued. 5 The rehabilitation protocol should include:
- Early postfracture physical training and muscle strengthening 5
- Long-term balance training and multidimensional fall prevention 5
Secondary Fracture Prevention
Since this patient is over 50 years old with a fragility fracture pattern, systematic evaluation for subsequent fracture risk is mandatory. 6, 5 This includes:
- DXA scanning of spine and hip 6
- Assessment for secondary osteoporosis 6
- Falls risk evaluation 6
- Calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 5
- Consider pharmacological treatment with bisphosphonates if high fracture risk identified 5
Critical Pitfall to Avoid
Do not delay surgical referral based on current pain levels—asymptomatic patients with displaced nonunions still require surgical intervention before degenerative changes progress to generalized wrist arthritis. 1 The presence of existing radiocarpal arthritis makes this case even more urgent, as progression to Stage III generalized arthritis will significantly compromise surgical outcomes and functional recovery.