A Rare Case of a Vertical Oblique Scaphoid Fracture Nonunion

Abstract

Three-dimensional computed tomography (CT) modeling enables accurate evaluation of fracture plane orientation in scaphoid fractures. Recently, Luria et al 1 used this technique in 124 scaphoid fractures and concluded that practically all fractures were horizontal oblique, and not transverse.We wish to report an unusual case of a vertical oblique (VO) scaphoid fracture-a distinct subgroup in Russe's classification. 2 After punching a boxing ball, a 17-yearold male patient presented to the emergency department with immediate right-sided wrist pain. Radiographs (Fig. 1A) and an additional technetium bone scan indicated a proximal scaphoid fracture, which was immobilized for 12 weeks. Follow-up radiographs showed fracture union. Nine years later, he was referred to our tertiary center, due to, again, right-sided wrist complaints. A CT scan showed a proximal VO fracture nonunion ( Fig. 1B), which was satisfactorily treated with proximal row carpectomy because of painful osteoarthritis.VO fractures are rare (<5% of scaphoid fractures) and typically caused by an axial loading injury. 3,4 They are notorious for their misinterpretation on plane radiographs. 4 Therefore, we recommend using a CT scan to evaluate the acute fracture morphology and, in direct follow-up, bony consolidation. If an acute VO fracture is recognized, we also recommend using immediate screw fixation because of its unstable nature and higher risk to nonunion. 4 VO fractures may need a distinct surgical plan. To analyze optimal screw placement, we retrospectively used the nonunion CT scan to obtain 3-dimensional CT models of the fragments, and virtually realigned them using the intact scaphoid as template (Fig. 1C). After obtaining a standardized midsagittal fracture outline, 5 the fracture angle relative to the central scaphoid axis was calculated to be 65 (Fig. 1D). Thus, theoretically, only a screw placed 25 eccentrically to the scaphoid central axis would allow for a position perpendicular to the fracture line, which is associated with favorable fixation stability. 1 REFERENCES 1. Luria S, Schwarcz Y, Wollstein R, Emelife P, Zinger G, Peleg E. 3-Dimensional analysis of scaphoid fracture angle morphology. J Hand Surg Am. 2015;40(3):508e514. 2. Russe O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg Am. 1960;42-A:759e768. 3. Brondum V, Larsen CF, Skov O. Fracture of the carpal scaphoid: frequency and distribution in a well-defined population. Eur J Radiol. 1992;15(2):118e122. 4. Herzberg G, Forissier D, Falaise C. Coronal fractures of the proximal scaphoid: the proximal ring sign. J Hand Surg Br. 2003;28(5):500e503. 5. ten Berg PW, Dobbe JG, Strackee SD, Streekstra GJ. Quantifying scaphoid malalignment based upon height-to-length ratios obtained by 3-dimensional computed tomography. J Hand Surg Am. 2015;40(1):67e73.FIGURE 1: A Initial anteroposterior radiograph of the right wrist after the acute injury. B Sagittal CT image showing a proximal scaphoid nonunion with a VO fracture line. C...