Scaphoid nonunion and SNAC treatment

Introduction Scaphoid nonunion can result in progressive scaphoid nonunion advanced collapse (SNAC) and  have an impact on the quality of life in younger patients. The social significance of the pathological condition induces original research and literature analysis.

The objective was to identify methods for preventing scaphoid nonunion and improving treatment outcomes for SNAC patients based on the literature on etiology, diagnosis and treatment of the disease.

Material and methods The original literature search was conducted on key resources including Scientific Electronic Library (www.elibrary.ru) and the National Library of Medicine (www.pubmed.org) and using the  keywords: scaphoid nonunion, scaphoid, bone grafting, scaphoid nonunion, vascularized bone graft. The  search yielded 355 results. Literature searches included both Russian and English studies published between 1984 and 2024. Inclusion criteria included original articles, systematic reviews, meta-analyses relevant to the search topic. Non-inclusion criteria included a case report, case/control, and articles available only on a fee-paying basis. There were 67 articles identified.

Results and discussion The topography of the scaphoid is associated with a high incidence of avascular necrosis, delayed healing and fracture nonunion. Clinical testing and imaging are essential for diagnosis of scaphoid fractures in the acute period of injury, and fracture instability would be important for surgical indications. There is a classification of scaphoid nonunions that is practical for the choice of a surgical treatment (osteosynthesis with compression screws, debridement and bone grafts or “salvage” operations). Scaphoid nonunions treated with the Ilizarov method employing no open approaches or grafts was reported in  a few publications. Treatment of SNAC patients is traditionally based on the stage of the disease: 1 —  scaphoid reconstruction, resection of the styloid process of the radius; 2–3 — 4-corner arthrodesis or the proximal row carpectomy. Meta-analyses highlight the need for the research into the effectiveness of  various treatments. Arthroscopic techniques are common in wrist surgery improving diagnostic capabilities and minimally invasive interventions.

Conclusion Timely healing of a scaphoid fracture is essential for preventing carpal instability and SNAC. The choice of SNAC treatment is associated with the stage of the disease and functional needs of the patient.

1. Shahabpour M, Abid W, Van Overstraeten L, De Maeseneer M. Wrist Trauma: More Than Bones. J Belg Soc Radiol. 2021;105(1):90. doi: 10.5334/jbsr.2709.

2. Czarnecki P, Siemionow M, Baek GH, et al. Hand and wrist - what the hand surgeon wants to know from the radiologist. Pol J Radiol. 2024;89:e70-e79. doi: 10.5114/pjr.2024.135304.

3. D'Itri L, Gattuso MS, Cobisi CD, et al. Bilateral Scaphoid Fractures: A Systematic Literature Review. J Pers Med. 2024;14(4):424. doi: 10.3390/jpm14040424.

4. Gray RRL, Halpern AL, King SR, Anderson JE. Scaphoid fracture and nonunion: new directions. J Hand Surg Eur Vol. 2023;48(2_suppl):4S-10S. doi: 10.1177/17531934231165419.

5. Maris S, Apergis E, Apostolopoulos A, et al. Scapholunate Advanced Collapse (SLAC) and Scaphoid Nonunion Advanced Collapse (SNAC): A Review of Treatment Options for Stage II. Cureus. 2024;16(4):e59014. doi: 10.7759/cureus.59014.

6. Rhemrev SJ, Ootes D, Beeres FJ, et al. Current methods of diagnosis and treatment of scaphoid fractures. Int J Emerg Med. 2011;4:4. doi: 10.1186/1865-1380-4-4.

7. Van Tassel DC, Owens BD, Wolf JM. Incidence estimates and demographics of scaphoid fracture in the U.S. population. J Hand Surg Am. 2010;35(8):1242-1245. doi: 10.1016/j.jhsa.2010.05.017.

8. Sommerkamp TG. Hand and Wrist Injuries in Baseball: Scaphoid Fractures. In: Lourie GM. (ed.) Hand and Wrist Injuries in Baseball. Springer, Cham. Publ.; 2022:21-34. doi: 10.1007/978-3-030-81659-9_2.

9. Alsawadi A, Stanton J. Scaphoid fracture in the elderly: a review. Hand Surg. 2012;17(2):295-298. doi: 10.1142/S0218810412300021.

10. Jørgsholm P, Ossowski D, Thomsen N, Björkman A. Epidemiology of scaphoid fractures and non-unions: A systematic review. Handchir Mikrochir Plast Chir. 2020;52(5):374-381. English. doi: 10.1055/a-1250-8190.

11. Bulstra AE, Doornberg JN, Buijze GA, Bain GI. Anatomy of the Scaphoid Bone and Ligaments. In: Scaphoid Fractures: Evidence-Based Management: Evidence-Based Management. Elsevier Inc. Publ.; 2018:21-34. doi: 10.1016/B978-0-323-48564-7.00003-4.

12. Ahrend MD, Teunis T, Noser H, et al. 3D computational anatomy of the scaphoid and its waist for use in fracture treatment. J Orthop Surg Res. 2021;16(1):216. doi: 10.1186/s13018-021-02330-8.

13. Haisman JM, Rohde RS, Weiland AJ; American Academy of Orthopaedic Surgeons. Acute fractures of the scaphoid. J Bone Joint Surg Am. 2006;88(12):2750-2758. doi: 10.2106/00004623-200612000-00026.

14. Berger RA. The anatomy of the scaphoid. Hand Clin. 2001;17(4):525-532.

15. Sauerbier M, Germann G, Dacho A. Current Concepts in the Treatment of Scaphoid Fractures. Eur J Trauma. 2004;30(2):80-92. doi: 10.1007/s00068-004-1408-7.

16. Vannabouathong C, Schemitsch E, Petrisor B, Bhandari M. Closed Limb Fractures With Compromised Vascularization: A Narrative Review. Clin Med Insights Arthritis Musculoskelet Disord. 2019;12:1179544119836742. doi: 10.1177/1179544119836742.

17. Tysver T, Jawa A. Fractures in brief: scaphoid fractures. Clin Orthop Relat Res. 2010;468(9):2553-2555. doi: 10.1007/s11999-010-1261-4.

18. Trumble TE, Salas P, Barthel T, Robert KQ 3rd. Management of scaphoid nonunions. J Am Acad Orthop Surg. 2003;11(6):380-391. doi: 10.5435/00124635-200311000-00002.

19. Nguyen Q, Chaudhry S, Sloan R, et al. The clinical scaphoid fracture: early computed tomography as a practical approach. Ann R Coll Surg Engl. 2008;90(6):488-491. doi: 10.1308/003588408X300948.

20. Parvizi J, Wayman J, Kelly P, Moran CG. Combining the clinical signs improves diagnosis of scaphoid fractures. A prospective study with follow-up. J Hand Surg Br. 1998;23(3):324-327. doi: 10.1016/s0266-7681(98)80050-8.

21. Grover R. Clinical assessment of scaphoid injuries and the detection of fractures. J Hand Surg Br. 1996;21(3):341-343. doi: 10.1016/s0266-7681(05)80197-4.

22. Mallee WH, Walenkamp MMJ, Mulders MAM, et al. Detecting scaphoid fractures in wrist injury: a clinical decision rule. Arch Orthop Trauma Surg. 2020;140(4):575-581. doi: 10.1007/s00402-020-03383-w.

23. Bäcker HC, Wu CH, Strauch RJ. Systematic Review of Diagnosis of Clinically Suspected Scaphoid Fractures. J Wrist Surg. 2020;9(1):81‑89. doi: 10.1055/s-0039-1693147.

24. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br. 1984;66(1):114-123. doi: 10.1302/0301-620X.66B1.6693468.

25. Ten Berg PW, Drijkoningen T, Strackee SD, Buijze GA. Classifications of Acute Scaphoid Fractures: A Systematic Literature Review. J Wrist Surg. 2016;5(2):152-159. doi: 10.1055/s-0036-1571280.

26. Clementson M, Björkman A, Thomsen NOB. Acute scaphoid fractures: guidelines for diagnosis and treatment. EFORT Open Rev. 2020;5(2):96-103. doi: 10.1302/2058-5241.5.190025.

27. Szabo RM, Manske D. Displaced fractures of the scaphoid. Clin Orthop Relat Res. 1988;(230):30-38.

28. Clementson M, Jørgsholm P, Besjakov J, et al. Union of Scaphoid Waist Fractures Assessed by CT Scan. J Wrist Surg. 2015;4(1):49-55. doi: 10.1055/s-0034-1398472.

29. Jørgsholm P, Thomsen NO, Björkman A, et al. The incidence of intrinsic and extrinsic ligament injuries in scaphoid waist fractures. J Hand Surg Am. 2010;35(3):368-374. doi: 10.1016/j.jhsa.2009.12.023.

30. Gray RRL, Halpern AL, King SR, Anderson JE. Scaphoid fracture and nonunion: new directions. J Hand Surg Eur Vol. 2023;48(2_suppl):4S-10S. doi: 10.1177/17531934231165419.

31. Bumbaširević M, Tomić S, Lešić A, et al. The treatment of scaphoid nonunion using the Ilizarov fixator without bone graft, a study of 18 cases. J Orthop Surg Res. 2011;6:57. doi: 10.1186/1749-799X-6-57.

32. Yin Y, Xu K, Zhang N, et al. Clinical and Epidemiological Features of Scaphoid Fracture Nonunion: A Hospital-Based Study in Beijing, China. Orthop Surg. 2022;14(10):2455-2461. doi: 10.1111/os.13478.

33. Zura R, Xiong Z, Einhorn T, et al. Epidemiology of Fracture Nonunion in 18 Human Bones. JAMA Surg. 2016;151(11):e162775. doi: 10.1001/jamasurg.2016.2775.

34. Prabhakar P, Wessel L, Nguyen J, et al. Factors Associated with Scaphoid Nonunion following Early Open Reduction and Internal Fixation. J Wrist Surg. 2020;9(2):141-149. doi: 10.1055/s-0039-3402769.

35. Григоровский В., Страфун С., Тимошенко С. Гистопатология тканей кистевого сустава и некоторые клинико-морфологические корреляции у больных с последствиями переломов ладьевидной кости. Гений ортопедии. 2017;23(1):30-37. doi: 10.18019/1028-4427-2017-23-1-30-37.

36. Slade JF 3rd, Merrell GA, Geissler WB. Geissler WB. Fixation of acute and selected nonunion scaphoid fractures. In: Geissler WB. (ed.) Wrist Arthroscopy. New York: Springer; 2005:112-124.

37. Sailer S, Lechner S, Floßmann A, et al. Treatment of scaphoid fractures and pseudarthroses with the human allogeneic cortical bone screw. A multicentric retrospective study. J Orthop Traumatol. 2023;24(1):6. doi: 10.1186/s10195-023-00686-7.

38. Губочкин Н.Г., Микитюк С.И., Иванов В.С. Пересадка кровоснабжаемых костных трансплантатов для лечения ложных суставов и дефектов костей. Гений ортопедии. 2014;(4):5-10.

39. Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. J Hand Surg Am. 2006;31(3):387-396. doi: 10.1016/j.jhsa.2005.10.019.

40. Hirche C, Heffinger C, Xiong L, et al. The 1,2-intercompartmental supraretinacular artery vascularized bone graft for scaphoid nonunion: management and clinical outcome. J Hand Surg Am. 2014;39(3):423-429. doi: 10.1016/j.jhsa.2013.10.028.

41. Straw RG, Davis TR, Dias JJ. Scaphoid nonunion: treatment with a pedicled vascularized bone graft based on the 1,2 intercompartmental supraretinacular branch of the radial artery. J Hand Surg Br. 2002;27(5):413. doi: 10.1054/jhsb.2002.0808.

42. Pinder RM, Brkljac M, Rix L, et al. Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence. J Hand Surg Am. 2015;40(9):1797-1805.e3. doi: 10.1016/j.jhsa.2015.05.003.

43. Fujihara Y, Yamamoto M, Hidaka S, et al. Vascularised versus non-vascularised bone graft for scaphoid nonunion: Meta-analysis of randomised controlled trials and comparative studies. JPRAS Open. 2022;35:76-88. doi: 10.1016/j.jpra.2022.12.001.

44. Rancy SK, Swanstrom MM, DiCarlo EF, et al. Success of scaphoid nonunion surgery is independent of proximal pole vascularity. J Hand Surg Eur Vol. 2018;43(1):32-40. doi: 10.1177/1753193417732003.

45. Lamon B, Ardouin L, Bellemère P, et al. Arthroscopic Bone Grafting for Scaphoid Nonunion: A Retrospective Study of 42 Cases. J Hand Surg Asian Pac Vol. 2021;26(4):545-554. doi: 10.1142/S242483552150051X.

46. Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand Surg Am. 2008;33(6):988-997. doi: 10.1016/j.jhsa.2008.04.026.

47. Aldairi MM, Sindi GJ. Treatment of scaphoid fracture non-union: a systematic review of the current evidence. IJMDC. 2024; 8(1):305‑314. doi: 10.24911/IJMDC.51-1697184483.

48. Bari M, Konchada S, Pradhan S, et al. Management of Scaphoid Nonunion (SNU) With Ilizarov Ring Fixator Using Two Olive Wire Compression Without Bone Grafting: A Case Series. Cureus. 2022;14(11):e31646. doi: 10.7759/cureus.31646.

49. Eggli S, Fernandez DL, Beck T. Unstable scaphoid fracture nonunion: a medium-term study of anterior wedge grafting procedures. J Hand Surg Br. 2002;27(1):36-41. doi: 10.1054/jhsb.2001.0651.

50. Düppe H, Johnell O, Lundborg G, et al. Long-term results of fracture of the scaphoid. A follow-up study of more than thirty years. J Bone Joint Surg Am. 1994;76(2):249-252. doi: 10.2106/00004623-199402000-00012.

51. Vender MI, Watson HK, Wiener BD, Black DM. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg Am. 1987;12(4):514-519. doi: 10.1016/s0363-5023(87)80198-3.

52. Penteado FT, Dos Santos JB, Caporrino FA, et al. Scaphoid nonunion advanced collapse classifications: a reliability study. J Hand Microsurg. 2012;4(1):12-15. doi: 10.1007/s12593-012-0062-2.

53. Moritomo H, Tada K, Yoshida T, Masatomi T. The relationship between the site of nonunion of the scaphoid and scaphoid nonunion advanced collapse (SNAC). J Bone Joint Surg Br. 1999;81(5):871-876. doi: 10.1302/0301-620x.81b5.9333.

54. Meier R. Treatment options for scaphoid nonunion advanced collapse. Unfallchirurg. 2019;122(3):211-218. (In German). doi: 10.1007/s00113-019-0631-y.

55. Lee YK, Jung YR. Arthroscopy-assisted bone grafting for the treatment of SNAC stage I without radial styloidectomy. Medicine (Baltimore). 2022;101(32):e29930. doi: 10.1097/MD.0000000000029930.

56. De Cheviegne C. Long-Term Results of Scaphoid Grafting in 52 SNAC Wrists: Should We Cut Down on Salvage Procedures? J Hand Surg. 2018;43(9):54-55. doi: 10.1016/j.jhsa.2018.06.104.

57. Daar DA, Shah A, Mirrer JT, et al. Proximal Row Carpectomy versus Four-Corner Arthrodesis for the Treatment of Scapholunate Advanced Collapse/Scaphoid Nonunion Advanced Collapse Wrist: A Cost-Utility Analysis. Plast Reconstr Surg. 2019;143(5):1432‑1445. doi: 10.1097/PRS.0000000000005558.

58. El-Mowafi H, El-Hadidi M, Boghdady GW, Hasanein EY. Functional outcome of four-corner arthrodesis for treatment of grade IV scaphoid non-union. Acta Orthop Belg. 2007;73(5):604-611.

59. Ghargozloo D, Tomarchio A, Ballerini M, et al. High results and lower cost in four-bone arthrodesis with retrograde screws. Med Glas (Zenica). 2022;19(1):75-78. doi: 10.17392/1450-21.

60. Chammas PE, Hadouiri N, Chammas M, et al. Proximal row carpectomy generates better mid- to long-term outcomes than four-corner arthrodesis for post-traumatic wrist arthritis: A meta-analysis. Orthop Traumatol Surg Res. 2022;108(7):103373. doi: 10.1016/j.otsr.2022.103373.

61. Bastard C, Goubier JN, Teboul F. Proximal Row Carpectomy with Resurfacing Capitate Pyrocarbon Implant with Bone Graft for Scaphoid Nonunion Advanced Collapse III Wrist with Total Intramedullary Bone Resorption of the Capitate: A Case Report. J Orthop Case Rep. 2018;8(4):35-37. doi: 10.13107/jocr.2250-0685.1148.

62. Hegazy G. Capitolunate Arthrodesis for Treatment of Scaphoid Nonunion Advanced Collapse (SNAC) Wrist Arthritis. J Hand Microsurg. 2015;7(1):79-86. doi: 10.1007/s12593-015-0182-6.

63. Goubier JN, Teboul F. Capitolunate arthrodesis with compression screws. Tech Hand Up Extrem Surg. 2007;11(1):24-28. doi: 10.1097/bth.0b013e31802caa87.

64. Wang ML, Bednar JM. Lunatocapitate and triquetrohamate arthrodeses for degenerative arthritis of the wrist. J Hand Surg Am. 2012;37(6):1136-1141. doi: 10.1016/j.jhsa.2012.03.023.

65. Solgård L, Gvozdenovic R. Single- and Bicolumn Limited Intercarpal Fusion: A Solution for the SLAC or SNAC Wrist. J Wrist Surg. 2023;13(1):16-23. doi: 10.1055/s-0043-1762932.

66. Gvozdenovic R, Schioedt MA, Solgaard L, et al. Limited intercarpal fusion versus proximal row carpectomy in the treatment of SLAC or SNAC wrist, results after 3.5 years. J Orthop Surg Res. 2023;18(1):681. doi: 10.1186/s13018-023-04177-7.