Outcomes of Local Bone Graft and Fixation of Proximal Pole Scaphoid Nascent Nonunions and Nonunions.

Fractures of the proximal pole of the scaphoid have an increased risk of nonunion due to its tenuous blood supply. The optimal treatment of proximal pole scaphoid nonunions remains controversial.  To review a single surgeon's experience with proximal pole scaphoid nascent nonunions (delayed unions) and nonunions that underwent surgical fixation with a cannulated headless compression screw and local autologous bone graft from the distal radius.  After obtaining Institutional Review Board approval, the electronic medical record of one tertiary care center was queried for patients with the diagnosis of "proximal pole scaphoid fractures" who underwent surgical fixation by a single surgeon over an 11-year period (2006-2017). Fifteen patients met initial query criteria; upon review of records, four patients were excluded due to the acute nature of the fracture, and one was excluded as surgical fixation included a vascularized bone graft.  The final study cohort consisted of 10 patients with a total of 10 proximal pole scaphoid nonunions. Almost all of the patients in this study were male (9/10 [90%]), and sporting activities were the most common mechanism of injury (8/10 [80%]). Volumetric measurements of the scaphoid fractures on computed tomography (CT) revealed that the mean total volume of the scaphoid was 2.4 ± 0.48 cm and the mean volume of the proximal pole fragment was 0.38 ± 0.15 cm . Postoperative CT scans were performed at a mean of 12.4 weeks (range: 8-16 weeks), with seven (7/10 [70%]) showing signs of complete union and three (3/10 [30%]) demonstrating partial union. None of the patients required additional procedures and there were no complications.  Our results suggest that proximal pole scaphoid fractures with delayed union and nonunion treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. The volume of the proximal pole fragment did not correlate with increased risk of ongoing nonunion after the index procedure.  This is a Level IV, case series study.