Inlay bone grafting for non-union of the scaphoid bone by the anterior approach.

Non-union of fractures of the scaphoid bone usually results from failure to recognise or adequately to treat a fresh fracture. It is important to differentiate delayed union from established non-union. In the former, even if a year has elapsed since fracture, and even if the radiograph shows a wide cystic fracture line with or without avascular changes in the proximal fragment, union is still possible with immobilisation (Speed 1935, Wagner 1952, Stewart 1954). In established non-union, however, the fracture surfaces are sclerosed, and union is possible only after bone grafting. The decision to operate is made the more difficult because of the varying disability resulting from non-union of these fractures ; with some it is very slight, with others it may be severe, particularly if the wrist is subjected to further injury or excessive use. The disability varies with the occupation of the patient ; it is dependent also on the firmness of the fibrous union across the fracture site and its location in relation to the radial styloid process, as well as on the amount of local and general arthritic changes in the wrist joint. Barr, Elliston, Musnick, Delorne, Hanelin and Thibodeau (1953) found severe disability in every case of non-union, even without arthritic changes in the radiocarpal joint. In contrast, London (1961) found that non-union was seldom a cause of disability, and that patients presented only when further injury had aggravated the condition, which settled again with rest. It is generally agreed, however, that no wrist with an ununited fracture ofthe scaphoid bone can be classed as normal, or remain normal, until union of the fracture has occurred in good position and without avascular change in the bone or cartilage of the proximal fragment.