Scaphoid Proximal Pole Fracture Following Headless Screw Fixation

Abstract

Nondisplaced scaphoid waist fractures may be managed nonoperatively, but require strict and prolonged immobilization. Fracture nonunion is a troublesome complication that leads to prolonged casting or secondary surgery and, if untreated, to carpal collapse and degenerative arthritis. 1,2 Unstable or displaced fractures, fracture-dislocations, and fractures involving the proximal pole require anatomic reduction with rigid fixation. Modern headless compression screws demonstrate high union rates, rapid recovery, and good-to-excellent outcomes in most series. 1,3-8 We were unable to identify reports detailing the potential for secondary proximal pole fracture following scaphoid screw fixation.In this series we describe three young men with scaphoid fracture nonunion that healed after antegrade headless compression screw fixation (Acumed, Hillsboro, OR, USA). Months later, the men presented with secondary fracture of the proximal pole (►Table 1). A consistently proximal and volar fracture pattern was observed that was contiguous with the screw insertion site. The purpose of this case series is to report our experience and raise awareness of a possible risk of retained hardware following antegrade scaphoid nonunion fixation, offer treatment strategies, and report outcomes. Case 1A 15-year-old right-handed lacrosse player presented to our institution after 3.5 months of sport-related left wrist pain had not abated. A scaphoid fracture had been treated as a AbstractBackground Headless screw fixation of scaphoid fractures and nonunions yields predictably excellent outcomes with a relatively low complication profile. However, intramedullary implants affect the load to failure and stress distribution within bone and may be implicated in subsequent fracture. Case Description We describe a posttraumatic fracture pattern of the scaphoid proximal pole originating at the previous headless screw insertion site in three young male patients with healed scaphoid nonunions. Each fracture was remarkably similar in shape and size, comprised the volar proximal pole, and was contiguous with the screw entry point. Treatment was challenging but successful in all cases. Literature Review Previous reports have posited that stress-raisers secondary to screw orientation may be implicated in subsequent peri-implant fracture of the femoral neck. Repeat scaphoid fracture after screw fixation has also been reported. However, the shape and locality of secondary fracture have not been described, nor has the potential role of screw fixation in the production of distinct fracture patterns. Clinical Relevance Hand surgeons must be aware of this difficult complication that may follow antegrade headless screw fixation of scaphoid fracture nonunion, and of available treatment strategies.

Can headless screw used in fixation of the scaphoid proximal pole fracture be broken after wrist trauma? An unreported complication of scaphoid surgery

“…Therefore, some authors recommend the HerbertTM screw instead of Acutrak® while fixing the proximal pole fracture of the scaphoid. [ 7 , 10 ] In our case, it is worth mentioning that, if we had a HerbertTM screw, we would definitely use it. In such a case, what is more important than the choice of the screw type is a rigid fixation to be made with a bone graft without creating a new fracture line.…”

“…Fixation with screws are shown to provide more successful union rates than fixation with K-wires. [ 7 ] However, it is still controversial which screw type is more suitable for proximal pole nonunion. There are two types of headless compression screws which are mostly used in our clinic.…”

Controversies and best practices for acute scaphoid fracture management

“…Apart from nonunions, operative complications of acute proximal pole fractures are rare but include such issues such as superficial wound infections (De Vos and Vandenberghe, 2003) or re-fracture of the proximal pole at the screw head (Rancy et al., 2016; Riester et al., 1985; Vinnars et al., 2008).…”

Porous Mg–Hydroxyapatite Composite Incorporated with Aloe barbadensis Miller for Scaphoid Fracture Fixation: A Natural Drug Loaded Orthopedic Implant

“…The last decade has witnessed an immense increase in carpal injuries, of which 60-70% of injuries seem to be scaphoid fractures of the carpal bone [1]. The development of metallic biomaterials for the regeneration of bone after fractures has proven an effective therapeutic solution.…”