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Reoperative Issues Following Carpal Bone Fracture Surgery

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Reoperative Hand Surgery

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Abstract

The carpal bones can be fraught with difficulties in trying to obtain union in these bones that have large articular surfaces. Of these bones, the scaphoid is the most notorious because of its unique blood supply. However, the lunate is well known for its predilection to develop avascular necrosis. Furthermore, even the hook of the hamate despite its rich muscular attachments and blood supply usually does better with simple excision than attempts to provide internal fixation. There exist options to try and correct the nonunion or malunion in the scaphoid. However, ultimately, if the carpal bones do not heal, the patient is potentially looking at a partial wrist fusion or complete wrist fusion, depending on which bones are involved and how much degeneration involves the proximal and midcarpal rows. The goal in most of these patients is to try to improve their pain. In counseling patients, they should have the reconstructive ladder discussed with them so that they can participate in the decision making process as some patients may prefer to go straight to a partial fusion or total fusion rather than subject themselves to a sequence of multiple surgeries.

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Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Crystal Run Healthcare, Middletown, NY, USA

    Vipul P. Patel MD

  2. Department of Orthopedic Surgery, Harvard Medical School and Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA, USA

    Jesse B. Jupiter MD

Authors
  1. Vipul P. Patel MD
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  2. Jesse B. Jupiter MD
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Corresponding author

Correspondence to Jesse B. Jupiter MD .

Editor information

Editors and Affiliations

  1. , Chairman, Department of Orthopedic, Ochsner Health System, New Orleans, 70121, Louisiana, USA

    Scott F.M. Duncan

Appendices

Case 9.1: Malpositioned Screw

figure a_9

(a) Minimally displaced scaphoid waist fracture

figure b_9

(b) Treated with a compression screw via percutaneous volar technique. Note that the malpositioned screw is too vertical, abutting the volar scaphoid cortex, and ideally should be center in both planes

figure c_9

(c) A few months post-op: Hardware loosening and lucency around the screw due to poor proximal purchase

figure d_9

(d) Proximal migration of the hardware with a nonunion and proximal fragment trabecular collapse and minimal osteogenic activity at the fracture site

Case 9.2: Proximal Pole Nonunion After Failed Fixation. Healed After Intercalary Iliac Crest Graft and K-Wire Fixation

figure e_9

(a) Preoperative X-ray of patient who underwent percutaneous volar screw fixation of a proximal pole fracture that subsequently developed a nonunion

figure f_9

(b) One year post-op s/p hardware removal after undergoing intercalary bone graft and K-wire fixation of proximal pole nonunion

figure g_9

(c, d) 2.5 years post-op showing a viable proximal pole and some early degenerative process

Case 9.3: Proximal Pole Nonunion Treated with 1,2 ICSRA

figure h_9

(a) Scaphoid nonunion after screw fixation with proximal pole collapse from impaired vascularity

figure i_9

(b) CT scan confirming an established nonunion with sclerotic edges, a small proximal fragment, and bone loss

figure j_9

(c) MRI confirming proximal pole avascular necrosis. Determining the vascularity of the proximal pole preoperatively is important in determining if a vascularized bone graft is necessary

figure k_9

(d) Six weeks after revision fixation and 1,2 ICSRA

figure l_9

(e) Nine weeks after revision fixation and 1,2 ICSRA

figure m_9

(f) Nine months post-op. Well-incorporated vascularized graft with a viable proximal pole

figure n_9

(g) 1.2 years post-op after hardware removal

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Patel, V.P., Jupiter, J.B. (2012). Reoperative Issues Following Carpal Bone Fracture Surgery. In: Duncan, S. (eds) Reoperative Hand Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-2373-7_9

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  • DOI: https://doi.org/10.1007/978-1-4614-2373-7_9

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