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Spontaneous healing of a non-union of the scaphoid
SPONTANEOUS
HEALING OF A NON-UNION SCAPHOID
OF THE
W. ROOLKER, M. J. P. F. R1TT and K. E. BOS
From the Departments of Nuclear Medicine and Plastic, Reconstructive and Hand Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands We describe a case of a symptomatic non-union of the scaphoid in a 19-year-old man which spontaneously healed 3 years after the injury.
Journal of Hand Surgery (British and European Volume, 1998) 23B." 1:86-87
relative movement of both fragments and abutment of the distal pole of the scaphoid on the styloid process of the radius. Because he still had complaints, operation was advised. However, the operation was postponed for 1 year at the patient's request because of study commitments. However, these lasted 18 months after which he was evaluated again. He had no complaints and there were no clinical signs of scaphoid non-union. New X-rays were obtained, and showed complete union. Additional planar tomography was done in two directions, and the union of the scaphoid was confirmed (Fig 2).
Scaphoid fracture is one of the most common injuries to the wrist and the most frequent injury of the bony carpus. In order to achieve uncomplicated healing of the fracture, early and adequate immobilization is considered of paramount importance. For a variety of reasons, however, a rate of 5 to 10% non-union is likely (Leslie and Dickson 1981; Russe, 1960). The natural history of symptomatic scaphoid non-hnion is said to be one of progressive arthritis (Leslie and Dickson, 1981; Lindstr6m and Nystr6m, 1992; Mack et al, 1984; Ruby et al, 1985; Russe, 1960; Vender et al, 1987). Although patients with a scaphoid non-union can remain symptom-free for many years, it is generally accepted that surgery is indicated when healing cannot be achieved by conservative methods. The aim of the operation is either to achieve bony union or to obtain a good functional wrist, without pain in the absence of union. In this paper we present a case in which union in a well established scaphoid non-union occurred spontaneously without treatment. To our knowledge, this has not been described before.
DISCUSSION Late diagnosis or inadequate primary treatment of a scaphoid fracture may result in delayed union or nonunion. Generally, it is accepted that prompt and adequate immobilization is necessary for the successful treatment of scaphoid fractures. Even so, a 5 to 10% rate of non-union is likely to occurr ~(Leslie and Dickson, 1981; Russe, 1960). Several studies of scaphoid non-union have been reported in the literature (Inoue and Sakuma, 1996; Leslie and Dickson, 1981; Mack et al, 1984; Ruby et al, 1985; Russe, 1960; Vender et al, -1987). In general, these studies have shown that most patidnts with symptomatic scaphoid non-union will develop arthritis in the wrist, although not all develop symptoms. None of these studies reported a case of spontaneous union following an established non-union. Kerluke and McCabe (1993) have questioned the methodology of these studies and concluded that the natural history of the non-union of the scaphoid is not as pessimistic as has been reported. Nevertheless, in a well conducted study Lindstr6m and Nystr6m (1992) again found that all non-unions of the scaphoid developed progressive osteoarthritis. We believe that this is the first well documented case of an established non-union progressing to full bony union spontaneously without any treatment. Although at his last visit the patient was symptom free and no osteoarthritic changes were seen on the radiographs, it is possible that in the long run osteoarthritic changes will occur because a non-union of the scaphoid has been present for more than 1 year. During that time, there was abnormal movement between the two fragments and abutment of the distal pole of the scaphoid on the styloid process of the radius.
CASE R E P O R T
A 19-year-old, right hand dominant male farmworker sustained an injury to the right wrist in a fall from a bicycle in June 1994. He did not seek medical attention immediately, although the wrist was tender and swollen. Three weeks later he consulted his family doctor as he still had complaints. No X-rays were obtained and no treatment was given. Ten months later the patient was referred to an orthopaedic surgeon at his own request because of persistent complaints. X-ray examination at that time revealed a non-union of the scaphoid. Additional three-phase bone scintigraphy showed increased uptake on both dynamic and static images in the region of the scaphoid. Subsequently, the patient was referred to our clinic. On examination in July 1995 there was tenderness in the anatomical snuffbox, wrist movement was good in all directions, and grip strength was measured to be 35 kgf in both hands using a Jamar dynamometer. X-ray examination of the wrist showed an ununited fracture at the waist of the scaphoid. Plane tomograms were made in two directions (frontal and lateral). In both directions the non-union was evident (Fig 1). Cinematographic evaluation showed 86
SPONTANEOUS H E A L I N G OF A SCAPHOID N O N - U N I O N
a Fig 1
b Plane tomogram view of the scaphoid with evidence of non-union: (a) frontal view, (b) lateral view.
b
a Fig 2
87
Plane tomogram after 18 months, showing union of the scaphoid: (a) frontal view, (b) lateral view.
References lnoue G, Sakuma M (11996). The natural history of scaphoid non-union. Radiographical and clinical analysis in 102 cases. Archives of Orthopaedic and Trauma Surgery, 115: 1 4 . Kerluke L, McCabe SJ (1993). Non-union of the scaphoid: a critical analysis of recent natural history studies. Journal of H a n d Surgery, 18A: 1-3. Leslie I J, Dickson R A (1981). The fractured carpal scaphoid: natural history and factors influencing outcome. Journal of Bone and Joint Surgery, 63B: 225 230. Lindstr6m G, Nystr6m A (1992). Natural history of scaphoid non-union, with special reference to "asymptomatic" cases. Journal of H a n d Surgery, 17B: 697-700. Mack GR, Bosse MJ, Gelberman RH, Yu E (1984). The natural history of scaphoid non-union. Journal of Bone and Joint Surgery, 66A: 504-509.
Ruby LK, Stinson J, Belsky M R (1985). The natural history of scaphoid nonunion. A review of fifty-five cases. Journal of Bone and Joint Surgery, 67A: 4 2 8 4 3 2 . Russe O (1960). Fracture of the carpal navicular. Journal of Bone and Joint Surgery, 42A: 759 768. Vender MI, Watson HK, Wiener BD, Black D M (1987). Degenerative change in symptomatic scaphoid non-union. Journal of H a n d Surgery, 12A: 514-519. Received: 29 July 1997 Accepted after revision: 8 September 1997 Miss W Roolker, Academic Medical Centre, Department of Nuclear Medicine, Meibergdreef 9, 1105Amsterdam, The Netherlands. © 1997The British Society for Surgery of the Hand
HEALING OF A NON-UNION SCAPHOID
OF THE
W. ROOLKER, M. J. P. F. R1TT and K. E. BOS
From the Departments of Nuclear Medicine and Plastic, Reconstructive and Hand Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands We describe a case of a symptomatic non-union of the scaphoid in a 19-year-old man which spontaneously healed 3 years after the injury.
Journal of Hand Surgery (British and European Volume, 1998) 23B." 1:86-87
relative movement of both fragments and abutment of the distal pole of the scaphoid on the styloid process of the radius. Because he still had complaints, operation was advised. However, the operation was postponed for 1 year at the patient's request because of study commitments. However, these lasted 18 months after which he was evaluated again. He had no complaints and there were no clinical signs of scaphoid non-union. New X-rays were obtained, and showed complete union. Additional planar tomography was done in two directions, and the union of the scaphoid was confirmed (Fig 2).
Scaphoid fracture is one of the most common injuries to the wrist and the most frequent injury of the bony carpus. In order to achieve uncomplicated healing of the fracture, early and adequate immobilization is considered of paramount importance. For a variety of reasons, however, a rate of 5 to 10% non-union is likely (Leslie and Dickson 1981; Russe, 1960). The natural history of symptomatic scaphoid non-hnion is said to be one of progressive arthritis (Leslie and Dickson, 1981; Lindstr6m and Nystr6m, 1992; Mack et al, 1984; Ruby et al, 1985; Russe, 1960; Vender et al, 1987). Although patients with a scaphoid non-union can remain symptom-free for many years, it is generally accepted that surgery is indicated when healing cannot be achieved by conservative methods. The aim of the operation is either to achieve bony union or to obtain a good functional wrist, without pain in the absence of union. In this paper we present a case in which union in a well established scaphoid non-union occurred spontaneously without treatment. To our knowledge, this has not been described before.
DISCUSSION Late diagnosis or inadequate primary treatment of a scaphoid fracture may result in delayed union or nonunion. Generally, it is accepted that prompt and adequate immobilization is necessary for the successful treatment of scaphoid fractures. Even so, a 5 to 10% rate of non-union is likely to occurr ~(Leslie and Dickson, 1981; Russe, 1960). Several studies of scaphoid non-union have been reported in the literature (Inoue and Sakuma, 1996; Leslie and Dickson, 1981; Mack et al, 1984; Ruby et al, 1985; Russe, 1960; Vender et al, -1987). In general, these studies have shown that most patidnts with symptomatic scaphoid non-union will develop arthritis in the wrist, although not all develop symptoms. None of these studies reported a case of spontaneous union following an established non-union. Kerluke and McCabe (1993) have questioned the methodology of these studies and concluded that the natural history of the non-union of the scaphoid is not as pessimistic as has been reported. Nevertheless, in a well conducted study Lindstr6m and Nystr6m (1992) again found that all non-unions of the scaphoid developed progressive osteoarthritis. We believe that this is the first well documented case of an established non-union progressing to full bony union spontaneously without any treatment. Although at his last visit the patient was symptom free and no osteoarthritic changes were seen on the radiographs, it is possible that in the long run osteoarthritic changes will occur because a non-union of the scaphoid has been present for more than 1 year. During that time, there was abnormal movement between the two fragments and abutment of the distal pole of the scaphoid on the styloid process of the radius.
CASE R E P O R T
A 19-year-old, right hand dominant male farmworker sustained an injury to the right wrist in a fall from a bicycle in June 1994. He did not seek medical attention immediately, although the wrist was tender and swollen. Three weeks later he consulted his family doctor as he still had complaints. No X-rays were obtained and no treatment was given. Ten months later the patient was referred to an orthopaedic surgeon at his own request because of persistent complaints. X-ray examination at that time revealed a non-union of the scaphoid. Additional three-phase bone scintigraphy showed increased uptake on both dynamic and static images in the region of the scaphoid. Subsequently, the patient was referred to our clinic. On examination in July 1995 there was tenderness in the anatomical snuffbox, wrist movement was good in all directions, and grip strength was measured to be 35 kgf in both hands using a Jamar dynamometer. X-ray examination of the wrist showed an ununited fracture at the waist of the scaphoid. Plane tomograms were made in two directions (frontal and lateral). In both directions the non-union was evident (Fig 1). Cinematographic evaluation showed 86
SPONTANEOUS H E A L I N G OF A SCAPHOID N O N - U N I O N
a Fig 1
b Plane tomogram view of the scaphoid with evidence of non-union: (a) frontal view, (b) lateral view.
b
a Fig 2
87
Plane tomogram after 18 months, showing union of the scaphoid: (a) frontal view, (b) lateral view.
References lnoue G, Sakuma M (11996). The natural history of scaphoid non-union. Radiographical and clinical analysis in 102 cases. Archives of Orthopaedic and Trauma Surgery, 115: 1 4 . Kerluke L, McCabe SJ (1993). Non-union of the scaphoid: a critical analysis of recent natural history studies. Journal of H a n d Surgery, 18A: 1-3. Leslie I J, Dickson R A (1981). The fractured carpal scaphoid: natural history and factors influencing outcome. Journal of Bone and Joint Surgery, 63B: 225 230. Lindstr6m G, Nystr6m A (1992). Natural history of scaphoid non-union, with special reference to "asymptomatic" cases. Journal of H a n d Surgery, 17B: 697-700. Mack GR, Bosse MJ, Gelberman RH, Yu E (1984). The natural history of scaphoid non-union. Journal of Bone and Joint Surgery, 66A: 504-509.
Ruby LK, Stinson J, Belsky M R (1985). The natural history of scaphoid nonunion. A review of fifty-five cases. Journal of Bone and Joint Surgery, 67A: 4 2 8 4 3 2 . Russe O (1960). Fracture of the carpal navicular. Journal of Bone and Joint Surgery, 42A: 759 768. Vender MI, Watson HK, Wiener BD, Black D M (1987). Degenerative change in symptomatic scaphoid non-union. Journal of H a n d Surgery, 12A: 514-519. Received: 29 July 1997 Accepted after revision: 8 September 1997 Miss W Roolker, Academic Medical Centre, Department of Nuclear Medicine, Meibergdreef 9, 1105Amsterdam, The Netherlands. © 1997The British Society for Surgery of the Hand