Markiewitz Andrew D, Stern Peter J
Uniformed Services, University of the Health Sciences, Ohio, USA.
Instr Course Lect. 2005;54:99-113.
When left untreated, scaphoid fractures follow a downward spiral resulting in carpal collapse and arthritis. The purpose of intervention is to allow a cartilage-wrapped bone to heal and maintain a smooth articular surface. Proposed treatment options for scaphoid nonunions have varied success rates. Using the Mack-Lichtman classification for nonunions, a plan can be formulated for individual patients based on motion loss, degenerative changes, carpal collapse, and fracture instability manifested by bone loss. Stable nonunions may benefit from bone grafting and internal fixation. Unstable nonunions require grafting and fixation. With the development of arthritis, grafting and fixation must be weighed against suitability of a proximal row carpectomy or a four-corner fusion with scaphoid excision. Advanced carpal collapse and arthritis mandates fusion, either limited or complete. CT allows preoperative planning to assess grafting requirements. MRI defines vascular supply fa vascular graft is considered. Vascularized graft options have multiplied as attention has been focused on the impact of improved blood supply on the avascular scaphoid. Patient- and fracture-specific factors are important considerations when determining surgical options; underestimating their importance can compromise surgical results even with a high level of technical skill. Successful treatment of scaphoid nonunions remains a difficult challenge despite improvement in fixation devices and surgical options. By regarding injury status together with patient factors, surgical options can be narrowed and patient expectations managed more realistically.
舟骨骨折若不治疗，会呈螺旋式恶化，导致腕骨塌陷和关节炎。治疗的目的是使包裹着软骨的骨头愈合，并保持光滑的关节面。针对舟骨不愈合的治疗方案成功率各异。根据Mack-Lichtman不愈合分类法，可依据运动丧失、退行性改变、腕骨塌陷以及骨质流失所表现出的骨折不稳定性，为个体患者制定治疗方案。稳定的不愈合可能从植骨和内固定中获益。不稳定的不愈合则需要植骨和固定。随着关节炎的发展，必须权衡植骨和固定与近端排腕骨切除术或舟骨切除四角融合术的适用性。严重的腕骨塌陷和关节炎需要进行有限或完全融合。CT有助于术前规划，以评估植骨需求。当考虑使用血管化骨移植时，MRI可确定血管供应情况。随着人们对改善血供对缺血性舟骨影响的关注，血管化骨移植的选择增多。在确定手术方案时，患者和骨折的特定因素是重要的考虑因素；即便技术水平很高，低估其重要性也可能影响手术效果。尽管固定装置和手术选择有所改进，但成功治疗舟骨不愈合仍是一项艰巨挑战。综合考虑损伤状况和患者因素，可缩小手术选择范围，并更现实地管理患者预期。
