Published online: 2020-01-20

Scientific Article

Factors Associated with Scaphoid Nonunion following

Early Open Reduction and Internal Fixation
Pooja Prabhakar, MD1 Lauren Wessel, MD2 Joseph Nguyen, MPH3 Jeffrey Stepan, MD, Msc2
Michelle Carlson, MD2 Duretti Fufa, MD2

1 Department of Orthopedic Surgery, UT Southwestern Medical Address for correspondence Pooja Prabhakar, MD, UT Southwestern
Center, Dallas, Texas Medical Center, Dallas, TX (e-mail: [email protected]).
2 Department of Hand and Upper Extremity Surgery, Hospital for
Special Surgery, New York, New York
3 Department of Biostatistics, Hospital for Special Surgery,
New York, New York

J Wrist Surg

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Abstract Background Nonunion after open reduction and internal fixation (ORIF) of scaphoid
fractures is reported in 5 to 30% of cases; however, predictors of nonunion are not
clearly defined.
Objective The purpose of this study is to determine fracture characteristics and surgical
factors which may influence progression to nonunion after scaphoid fracture ORIF.
Patients and Methods We performed a retrospective case–control study of scaphoid
fractures treated by early ORIF between 2003 and 2017. Inclusion criteria were surgical
fixation within 6 months from date of injury and postoperative CT with minimum
clinical follow-up of 6 months to evaluate healing. Forty-eight patients were included in
this study. Nonunion cases were matched by age, sex, and fracture location to patients
who progressed to fracture union in the 1:2 ratio.
Results This series of 48 patients matched 16 nonunion cases with 32 cases that
progressed to union. Fracture location was proximal pole in 15% (7/48) and waist in 85%
(41/48). Multivariate regression demonstrated that shorter length of time from injury to
Keywords initial ORIF and smaller percent of proximal fracture fragment volume were significantly
► postoperative associated with scaphoid nonunion after ORIF (63 vs. 27 days and 34 vs. 40%, respectively).
► scaphoid fracture Receiver operating curve analysis revealed that fracture volume below 38% and time from
► nonunion injury to surgery greater than 31 days were associated with nonunion.
► open reduction Conclusion Increased likelihood for nonunion was found when the fracture was
internal fixation treated greater than 31 days from injury and when fracture volume was less than 38% of
► open reduction and the entire scaphoid.
internal fixation Level of Evidence This is a Level III, therapeutic study.

Scaphoid fractures account for 60% of all carpal fractures,1 and fixation has been reported to be between 5 and 30%.4–7
nonunion is a relatively common complication of these injuries, Scaphoid nonunion has serious consequences including pain,
being reported at rates ranging from 5 to 50% for all fracture disability, and carpal collapse and degenerative arthritis in
patterns and treatment modalities.2,3 Even in the cases of long-term follow-up.6 Both fracture characteristics and surgi-
timely surgical treatment, the nonunion rate after surgical cal factors have been proposed to contribute to nonunion.

received Copyright © by Thieme Medical DOI https://doi.org/

June 30, 2019 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0039-3402769.
accepted after revision New York, NY 10001, USA. ISSN 2163-3916.
December 2, 2019 Tel: +1(212) 760-0888.
Scaphoid Nonunion after ORIF Prabhakar et al.

Traditionally, scaphoid fractures have been classified Among 199 patients who met these criteria, fractures were
according to anatomic location as proximal pole, waist, and then classified according to progression to union. Nonunion
distal pole fractures. Anatomic location of these fractures has was defined as either a fracture without signs of healing on CT
been thought to be associated with risk of nonunion and or radiograph at 6 months after ORIF or a fracture that required
avascular necrosis, as several studies have independently a revision ORIF after initial fixation. Union was determined if
found that location is an important predictor of scaphoid two criteria were met: (1) evidence of healing without mention
vascularity given the retrograde blood supply to the bone. of progression toward nonunion on the postoperative CT as
This is thought to contribute to nonunion being more likely in determined by the report of a musculoskeletal radiologist, and
fractures of the proximal zone.5,8–11 In an analysis of a large (2) no secondary surgery for scaphoid nonunion at minimum
series of scaphoid nonunions treated operatively, Ramamur- 1 year following ORIF. Conversely, cases with CT reported of
thy et al found a 32% nonunion rate in proximal pole fractures evidence of nonunion and those that underwent revision
versus 23% in waist fractures.12 Similarly, Lim et al also scaphoid surgery were classified as nonunion. Sixteen patients
suggested that fracture fragment size may influence outcomes were identified in the nonunion group, while fractures in the
after scaphoid nonunion surgery.13 Despite traditional believe remaining 183 patients united. The sixteen nonunion patients
that blood supply is linked to risk for nonunion, newer (case group) were matched by age (within a 10-year range), sex,
evidence suggests proximal pole vascularity may not play as and fracture location in the 1:2 fashion to patients with united

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critical a role in ability to progress to union after nonunion fractures, by random number assignment. Fracture location
ORIF as has classically been thought.14 was defined in a three-zone fashion as proximal, waist, or distal
Surgical factors have also been investigated for their role based on the description given by a musculoskeletal fellowship
in scaphoid nonunion. Missed diagnosis frequently results in trained radiologist in the CT report. Our control group consisted
delay in initial treatment and may contribute to increased of 32 matched union patients (control group; ►Fig. 1). Chart
risk of both nonunion and malunion.10,12,15–17 Additional review was performed to gather data on patient demographics,
factors that have been investigated to affect the rate of union comorbidities, mechanism of injury, surgical details, and post-
following open reduction internal fixation (ORIF) include operative follow-up. Qualitative displacement of the fracture
screw trajectory18–21 and implant type.22–24 There are con- based on preoperative imaging was available for 38 of the 48
flicting data regarding optimal screw orientation, with some patients. Follow-up phone calls were made to all patients in the
studies show greater compression with central placement control group to ensure no further surgery was performed with
along the longitudinal axis of the scaphoid25 while others a change in provider.
demonstrate the biomechanical advantage of screws placed
more perpendicular to the fracture plane.19,20,26 Still other Description of Three-Dimensional Computer Analysis
biomechanical studies suggest screw purchase into the Three-dimensional models were created using postoperative
dense 2-mm subchondral shell as a key factor in stability CT scans. Mimics software (Materialise, Leuven, Belgium) was
of scaphoid fractures.21,27 While these studies provide bio- used to segment the scaphoid, fracture fragments, and
mechanical data, they are limited in that they do not provide implants (►Fig. 2) into surface meshes. Volumes of the scaph-
clinical correlates in patient series. oid and its fragments were calculated from volume-filled
Given the severity of sequela associated with scaphoid masks of the surface meshes. The masks were created by
nonunion, it is critical to understand the multitude of factors calculating three-dimensional objects, calculating polylines,
affecting rate of union in the clinical setting. However, the and cavity-filling the meshes. The masks were imported as
current literature is lacking in data that considers each of stereolithography files into Geomagic Design X (3D Systems,
these factors in a clinical series. The purpose of this study is Rock Hill, SC) for further measurements. Virtual reduction was
to determine the fracture characteristics and surgical factors manually performed by transforming the distal fragment
associated with nonunion following early, primary scaphoid toward the proximal fragment.28,29
ORIF. We hypothesize that fracture characteristics and After modeling the fracture fragments, relevant indices
surgical factors are associated with a difference in nonunion were modeled including longitudinal axis of the scaphoid,
rate after scaphoid ORIF at a minimum of 1 year following fracture plane and area, and screw trajectory and screw
fixation. distance from subchondral bone. To approximate the longitu-
dinal axis of the scaphoid, a cylinder best fit vector was created
for the scaphoid mask30 (►Fig. 3). The fracture plane was
Methods
modeled using a best fit plane created on the proximal
Study Design fragment. The angle between the fracture plane and longitu-
This retrospective, case–control study reviewed the imaging dinal axis was measured, depicting the smallest angle between
database at our institution and identified 2,855 wrist computed the plane and axis.28
tomography (CT) scans with scaphoid reformatting over a After delineation of fracture characteristics, fixation con-
period of 14 years (January 2003–March 2017). Inclusion cri- structs were evaluated. The angle between the screw axis and
teria were scaphoid fractures treated with ORIF with screw the scaphoid longitudinal axis was measured. Additionally, the
fixation within 6 months from date of injury, minimum of angle between the screw axis and the fracture plane was
6 months of postoperative clinical follow-up, and a postopera- measured (►Fig. 4). This value subtracted from 90 degrees is
tive CT to evaluate healing. the angle between the screw and perpendicular axis to the

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Fig. 1 Study recruitment shown in exclusion flowchart.

fracture.20 Finally, to determine screw distance from subchon- treatment that would best predict fracture nonunion. All
dral bone, a plane was created at the distal end of the screw analyses were performed using SPSS version 23.0 (IBM Corp.,
perpendicular to the screw longitudinal axis. The distance Armonk, NY).
between this plane and the end of the distal scaphoid fragment Post hoc power analysis demonstrated group sample sizes
was measured digitally. of 16 and 32 achieve 74% power to detect a difference in
length of time to initial treatment and a 30% power to detect
Statistical Analysis a difference in average proximal fragment percent of total
Descriptive statistics were reported as means and standard scaphoid volume.
deviations for continuous variables, while discrete variables
were reported as frequencies and percentages. Assumption
Results
of normality of continuous variables was found to be violated
using Shapiro–Wilk’s tests. Differences in continuous varia- The mean period of follow-up to determine if additional
bles between patients with union versus nonunion were surgery was performed was 3.2 years (range ¼ 1–10.4). Of
evaluated using Mann–Whitney’s U tests. Fisher’s exact tests the 48 total patients, there were six female and 42 male
were used to compare differences in discrete variables patients with no difference between union and nonunion
between study groups. patients (p > 0.99). The mean age was 30.8 (range ¼ 17–57)
Because of the limited sample size available, variables in years and mean BMI was 25.1 kg/m2 (range ¼ 19.4–39.6) with
the univariate analysis that achieved a p value of 0.20 or less no statistical difference between study groups. A total of 23%
were considered as candidate variables eligible for evalua- patients were nonwhite. Low energy trauma accounted for 73%
tion in a conditional logistic regression model. Conditional of all fractures, with 66% in the union group and 88% in the
regression modeling was used to account for the matched nonunion group. There were seven proximal pole and 41 waist
design of the nonunion and union patients in the study to fractures, as one fracture was reclassified from its initial
identify potential risk factors associated with nonunion. To radiology read based on the consensus of all authors
prevent overfitting of variables in the model, stepwise iter- (►Table 1). Among the 38 fractures that had preoperative
ations were performed until a final model converged. Vari- imaging available, 95% were read as nondisplaced and 5% were
ables that achieved a p value of 0.20 or less were retained in minimally displaced. Of the two fractures that were minimally
the final model, while those that achieved a p value of 0.05 or displaced, one went on to union and one went on to nonunion.
less were called statistically significant. Results from the Qualitative displacement was excluded from statistical analy-
regression analysis are reported as odds ratio (OR) and 95% sis due to incomplete data and small sample size.
confidence intervals (CI). Receiver operating characteristic Length of time from injury to initial ORIF was significantly
(ROC) curve was generated to determine if there was any higher in the nonunion group (63.3 vs. 27 days, p ¼ 0.02). The
potential threshold in fracture volume or time from injury to mean proximal fragment volume percent of total scaphoid

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Fig. 2 Segmentation of scaphoid was done from CT scans. CT, computed tomography.

not statistically significant (19.6 vs. 14.4 degrees,

p ¼ 0.18; ►Table 2).
The majority (94%) of patients in the cohort was treated
by dorsal approach and 48% were treated with bone graft.
The length of implant in the union group was significantly
longer than the length in the nonunion group (21.8 vs.
19.8 mm, p ¼ 0.02). The caliber of implant, surgical approach
and use of bone graft were similar between the groups.
Neither the angle of the screw to the fracture plane, the
distance of the screw to subchondral bone, nor the caliber of
the implant were significantly different between the groups
(►Table 3).
The variables that achieved a p value of 0.20 or less in the
univariate analysis were considered as candidate variables
Fig. 3 A cylinder best fit algorithm approximated the scaphoid for analysis in the conditional logistic regression model.
longitudinal axis.
These variables were BMI, mechanism of trauma, average
volume was 37.9% for all fractures, and 40% for the union percent of fragment volume, angle of screw to long axis,
group and 33.8% for the nonunion group (p ¼ 0.12). The screw length of time to initial surgery, and length of implants. After
obliquity to the longitudinal axis of the scaphoid was greater stepwise iterations to achieve a final model, the only varia-
for the nonunion group than the union group, but this was bles that were retained in the final model and identified as

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Fig. 4 The angle of screw axis to scaphoid longitudinal axis (A) and angle of screw axis to fracture plane (B) were measured.

Table 1 Demographics by union versus nonunion

Variable Total Union Nonunion p-Value

Mean or n SD or % Mean or n SD or % Mean or n SD or %
Age (at time of surgery) 30.8 11.7 30.5 11.9 31.5 11.6 0.66
BMI 25.1 3.8 24.3 2.8 26.6 5.1 0.17a
Sex
Female 6 13% 4 13% 2 13% 1.00
Male 42 88% 28 88% 14 88%
Smoking status
Former/nonsmoker 47 98% 32 100% 15 94% 0.33
Current smoker 1 2% 0 0% 1 6%
Race
Caucasian 37 77% 25 78% 12 75% 1.00
Non-Caucasian 11 23% 7 22% 4 25%
Mechanism of trauma
Low energy 35 73% 21 66% 14 88% 0.17a
High energy 13 27% 11 34% 2 13%

Abbreviations: BMI, body mass index; SD, standard deviation.

a
Variables that achieved a p value of 0.20 or less in the univariate analysis which were included in the multivariate regression.

Table 2 Fracture characteristics by union versus nonunion

Variable Total Union Nonunion p-Value

Mean or n SD Mean or n SD Mean or n SD
Fracture location
Proximal 7 15% 4 13% 3 19% 0.67
Waist 41 85% 28 88% 13 81%
Avg. % of fragment volume (proximal) 37.9 15.0 40.0 14.3 33.8 16.0 0.12a
Long axis-fracture plane angle (obliquity) 47.0 16.6 49.1 14.7 43.2 19.6 0.36

Abbreviation; SD, standard deviation.

a
Variables that achieved a p value of 0.20 or less in the univariate analysis that were included in the multivariate regression.

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Table 3 Surgical factors by union versus nonunion

Variable Total Union Nonunion p-Value

Mean or n SD or % Mean or n SD or % Mean or n SD or %
Angle of screw to long axis (degrees) 16.2 9.1 14.4 7.2 19.6 11.7 0.18a
Angle of screw to fracture plane (degrees) 54.1 17.4 53.0 19.2 56.3 13.1 0.62
Distance from screw to distal cortex (mm) 1.4 1.6 1.3 1.4 1.8 1.9 0.65
Length of implants (mm) 21.1 2.6 21.8 2.4 19.8 2.5 0.02a
Caliber of implants (mm) 2.2 0.6 2.2 0.6 2.4 0.6 0.38
Length of time to initial treatment (d) 39.1 41.0 27.0 31.5 63.3 47.9 0.02a
Initial treatment type
Operative - ORIF Dorsal Approach 45 94% 31 97% 14 88% 0.25
Operative - ORIF Volar Approach 3 6% 1 3% 2 13%
Bone graft during initial surgery

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No 25 52% 18 56% 7 44% 0.41
Yes 23 48% 14 44% 9 56%

Abbreviation: ORIF, open reduction and internal fixation.

a
Variables that achieved a p value of 0.20 or less in the univariate analysis that were included in the multivariate regression.

potential risk factors with fracture nonunion were lower progression to nonunion. Specifically, patients undergoing
average percent of fragment volume and increased length of fixation greater than 1 month from injury have greater risk
time from injury to surgery (►Table 4). For every 1% increase for nonunion after ORIF. Additionally, our results suggest that
in fracture volume, there was a 10% decrease in risk of when the fracture volume is less than 38% of the entire
nonunion (OR: 0.90, 95% CI: 0.81–1.01). Conversely, for scaphoid, there is an increased risk for nonunion after surgery.
every day delayed in initial treatment, the risk of nonunion We did not find volar versus dorsal surgical approach, use of
increases by 4% (OR: 1.04, 95% CI: 1.01–1.07). Receiver bone graft, fracture obliquity, nor screw angle relationship to
operating curve analysis revealed that fracture volume the fracture plane or scaphoid longitudinal axis to be signifi-
below 38% and time from injury to surgery greater than cantly different between the union and nonunion cohorts.
31 days were associated with nonunion (78% specificity and Previous investigations have cited time to treatment as a
44% sensitivity; and 63% sensitivity, and 28% false positive critical factor in union after scaphoid fracture. Ramamurthy
rate, respectively; ►Fig. 5). et al evaluated 126 scaphoid nonunions presenting after
initial nonoperative management with an average time to
operative treatment of 42 months (3 months–16 years). The
Discussion
study also demonstrated that time between injury and
This study was performed to assess both fracture-specific and surgery to be significant (p ¼ 0.02) in a stepwise multivariate
surgical factors that affect progression to nonunion after logistic regression.12 Nakamura et al found that functional
scaphoid ORIF. We found that timeliness of surgery following outcome, including motion, wrist pain, and strength was
injury and fracture volume are critical factors associated with worse when surgery was performed more than 5 years from

Table 4 Multivariate regression

Model Variable Odds ratio 95% CI p-Value

Lower Upper
Full BMI 0.50 0.00 180.39 0.817
Mechanism of trauma 0.00 0.00 7.62E þ 21 0.607
Average % of fragment volume (proximal) 1.31 0.45 3.87 0.621
Angle of screw to long axis 0.99 0.12 8.36 0.994
Length of implants 8.34 0.00 2.35E þ 04 0.601
Length of time to initial treatment (d) 1.21 0.70 2.11 0.493
Final Average % of fragment volume (proximal) 0.90 0.81 1.01 0.05
Length of time to initial treatment (d) 1.04 1.01 1.07 0.02

Abbreviations: BMI, body mass index; CI, confidence interval.

Dependent variable: nonunion.

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Fig. 5 Receiver operating characteristic curve analysis was completed to find the (A) average percent of fragment volume (proximal) on union
and (B) length of time to initial treatment (days) on nonunion.

injury regardless of bony union.15 The current study also ing fractures that had may have progressed to nonunion prior to
confirms the impact of time to treatment on scaphoid union initiation of treatment. Furthermore, we only included cases if
but is unique in its identification of the importance of time to postoperative CT imaging was available to accurately charac-
surgery even when scaphoid fracture is treated within terize fracture segments, volumes, and angles and to provide
6 months of injury. This novel finding, emphasizing the consistent verification of fracture union postoperatively. This
importance of early ORIF, may suggest the advantage of resulted in exclusion of patients if they were lost to follow up or
earlier identification and treatment of scaphoid fractures were not imaged with CT postoperatively. While there is a large
in the acute setting instead of a trial of nonoperative difference in proportion of nonunion to union in the initial
management. population and the study population, this case–control study
Several studies have suggested that a larger proximal pole carefully matched patients to precisely define these exposures
fracture fragments are associated with better outcomes.9,10 In and outcomes. Second, as our primary aim was to report on the
a study of 222 patients presenting with acute scaphoid frac- radiographic outcome of union after ORIF, we do not report any
tures managed by cast immobilization, Leslie and Dickson patient outcome data. As a retrospective review, our ability to
demonstrated that fracture location had the greatest influence evaluate history, presenting symptoms and signs as well as
on union rates with proximal pole fractures demonstrating postoperative outcomes was limited to the medical record.
the greatest delay to radiological and clinical union as well as Given heterogeneity in data recording, functional metrics such
the greatest rate of nonunion.31 Similarly, Herbert found that as pain and range of motion were not reported in our manu-
proximal pole fractures have the greatest rate of nonunion and script. Additionally, we are unable to analyze the effect of
avascular necrosis and suggested that all proximal pole frac- displacement at the time of injury on nonunion risk due to
tures should be managed operatively in the acute setting.32 incomplete preoperative imaging records. In the 38 of 48
Our study further demonstrates that even in the setting of patients with preoperative imaging, there was a similar distri-
acute operative management, fractures with smaller proximal bution of initial fracture displacement, which did not lead to
pole fragments, have increased rates of nonunion. While in the difference in rate of nonunion. However, as we were under-
current study, we controlled for qualitative fracture location powered for this analysis, we did not report fracture displace-
(proximal, waist, or distal), we nonetheless found quantita- ment at the time of injury as a factor in our models. This factor
tively that when the fracture fragment was less than 38% of the may represent an important consideration for future study.
total volume of the scaphoid, risk for nonunion was greatest. These inherent limitations to our retrospective review are
Several limitations are inherent in our study. Because scaph- considered versus the value of the highly quantitative and
oid nonunion is a relatively rare event following early manage- objective data provided by three-dimensional (3D) CT analysis
ment by ORIF, our cohort of nonunion cases is small. We of several fracture and surgical parameters. Finally, with regard
intentionally limited the series to cases treated within 6 months to 3D analysis, postoperative CT scans were used to calculate all
from time of injury to specifically investigate factors impacting computer-based metrics, which may have led to variation and
nonunion in fractures that were recognized early, thus exclud- underreporting of fragment volume given bone loss. In spite of

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these limitations, computer modeling from CT DICOM files Keith Crivello, MD, Mercer-Bucks Orthopaedics, P.C.; Edward
more accurately reflects fracture plane in relationship to the McCarthy MD—Department of Pathology, The Johns Hop-
long axis of the scaphoid and to hardware when compared with kins Hospital; and Hollis G. Potter MD—Department of
conventional radiographs.28 Radiology and Imaging Hospital for Special Surgery.
Using 3D CT imaging and modeling of fracture pattern and
screw fixation, our study investigated both fracture and
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