Review Question - QID 218161

The patient has sustained a fracture of the proximal pole of the scaphoid which relies on retrograde blood flow and has an increased risk of going on to nonunion without ORIF.

Proximal pole scaphoid fractures represent roughly 25% of all scaphoid fractures by anatomic location. Because the major blood supply to the scaphoid (dorsal carpal branch of the radial artery) reaches the proximal pole via retrograde flow, injury to this area creates a watershed region that is prone to nonunion. Because of this, proximal pole fractures are often fixed with percutaneous screw fixation in order to prevent the sequelae of nonunion.

Grewal et al. performed a CT assessment of outcomes of proximal pole scaphoid fractures. The authors reviewed the CT scans of 53 patients with proximal pole scaphoid fractures between 2006 and 2013 and found that risk factors associated with a significantly greater time to union included fracture comminution, the presence of cysts, and fracture translation.

Tait et al. performed a critical analysis review of acute scaphoid fractures. The authors noted that nondisplaced scaphoid fractures can be effectively treated nonoperatively, with union rates approaching or, in some series, exceeding the rates attained with operative intervention. However, they also note that indications for operative treatment include fracture instability, displacement, angulation, malrotation, and fractures of the proximal pole.

Suh et al. review the controversies and best practices for acute scaphoid management. The authors note that proximal pole fractures are associated with the poorest union rates and the longest time to union; it is well established that displaced proximal pole fractures should be treated surgically, as nonunion rates for displaced fractures are reported to be as high as 50%. They conclude that proximal scaphoid fractures should be treated operatively to maximize union rates and shorten time to union, with a dorsal antegrade approach using a single compression screw through the central axis of the scaphoid being preferable for proximal pole fixation.

Figure A is a PA scaphoid view radiograph demonstrating a displaced proximal poled scaphoid fracture.

Incorrect Answers:
Answer 1: The fracture is still in the acute phase at one week out and, though appropriate for ORIF, is not the most compelling reason to offer the patient surgery.
Answers 3-5: Patient age, occupation, and handedness are not the most important factors to consider in this situation when considering risk of nonunion.