Definition
Loss of blood supply to the proximal pole of the scaphoid
Progressive sclerosis / fragmentation / collapse
Risk factors
Fracture location - increased risk with proximal pole fractures than waist fractures
Smoking
Blood supply
1. Dorsal scaphoid branch
- dorsal ridge artery via branch of radial artery
- supplies 70- 80% scaphoid including proximal pole
- enters through the non articular dorsal ridge
2. Volar scaphoid branch
- superficial palmar arch via distal tubercle
- distal 20% to 30% of scaphoid
Diagnosis
Xray
CT
MRI
Surgical findings - absence of bleeding upon drilling
Xray
Increased sclerosis proximal pole consistent with AVN
Increased sclerosis proximal pole post surgery
CT
Increased sclerosis of the proximal pole
Fragmentation and collapse of the proximal pole
MRI
Nasab et al Eur J Med Res 2025
- systematic review of MRI for detecting AVN
- MRI sensitivity of 0.6 and specificity of 0.85
- MRA sensitivity 0.77 and specificity 0.87
Low vascularity of scaphoid on T1 MRI and reduced gadolinium uptake proximal pole scaphoid
Management
Options
No radiocarpal OA / SNAC
1. No proximal scaphoid collapse: ORIF + vascularized bone graft
2. Proximal scaphoid collapse / fragment non salvageable: reconstruction / excision
SNAC wrist: www.boneschool.com/SNAC-wrist
| Pre proximal scaphoid collapse / Salvageable | Post proximal scaphoid collapse / non salvageable |
|---|---|
|
|
|
Non vascularized bone grafts + ORIF
Vascularized bone graft + ORIF - volar / dorsal pedicle grafts - free medial femoral condyle grafts
|
Scaphoid reconstruction - hamate - medial femoral condyle osteochondral autograft - rib osteochondral autograft
Scaphoid excision |
Pre-collapse / salvageable
Options
Non vascularized bone grafts + ORIF
Vascularized bone graft + ORIF
- volar / dorsal pedicle grafts
- free medial femoral condyle grafts
Results
Cancellous bone graft
Putnam et al J Hand Surg Am 2019
- 12 proximal pole nonunions
- treated with cancellous bone graft and volar plate
- 100% union
Non vascularized bone graft v vascularised bone graft
Ferguson et al J Hand Surg Eur 2016
- meta-analysis
- non vascularized bone graft with proximal pole AVN: union rate 62%
- vascularised bone graft with proximal pole AVN: union rate 74%
Vascularized bone grafts
| Dorsal distal radius | Volar distal radius | Free |
|---|---|---|
|
1,2 intercompartmental supraretinacular artery (ICSRA) - branch radial artery - travels between 1st and 2nd extensor compartment
4,5 extensor compartment artery
|
Volar carpal artery
Pronator quadratus
|
Medial femoral condyle - harvested on medial genicular artery pedicle - pedicle sutured into radial artery
Iliac crest
|
Dorsal vascularized bone graft (VBG)
Papatheodorou et al Injury 2021
- 64 proximal pole nonunion with AVN
- ORIF with dorsal capsular based VBG
- union rate 86%
Distal radius VBG versus free medial condyle VBG
- 22 patients with proximal pole nonunion with AVN
- distal radius VBG: union 40%
- free medial condyle VBG: union 100%
Free medial condyle VBG versus free iliac crest VBG
Al-Jabri et al J Orthop Surg Res 2014
- meta-analysis
- 56 free medial condyle VBG: union rate 100%
- 188 free iliac crest VBG: union rate 88%
Volar techniques
Vumedi scaphoid plate + volar carpal artery
Dorsal techniques
Dorsal techniques
| 4th extensor artery VBG | 1,2 ICSRA VBG |
|---|---|
|
Vumedi 4th extensor artery VBG
|
Youtube 1/2 ICSRA VBG |
 |
 |
Post collapse / non salvageable
Indications
Fragmented / collapsed proximal pole
Proximal pole too small for fixation
Options
Scaphoid reconstruction
- hamate
- medial femoral condyle osteochondral autograft
- rib osteochondral autograft
Scaphoid excision +/- arthroplasty
Results
Hamate reconstruction
Colon-Morillo et al J Hand Surg Am 2025
- 11 patients with fragmented proximal pole nonunions
- excision + ipsilateral proximal hamate transfer
- union rate 10/11
Free medial femoral osteochondral graft
- systematic review of free medial femoral osteochondral graft for scaphoid reconstruction
- 94% union
- 3 patients early revision for vascular thrombosis
- 1 patient suffered a volar carpal dislocation
- 3 patients underwent salvage procedures for ongoing pain
Rib osteochondral autograft
Zechmann-Mueller et al J Hand Surg Eur 2020
- 21 patients with proximal pole nonunion treated with rib osteochondral allograft
- 100% union rate
Rib osteochondral autograft versus medial femoral trochlea osteochondral autograft
Scaphoid excision and arthroplasty
Cioffi et al Healthcare (Basil) 2023
- 9 partial and 10 total scaphoid prosthesis
- custom 3D printed titanium implants + ligament reconstruction
- good results at one year
Techniques
Vumedi proximal pole reconstruction with hamate osteochondral graft video
Vumedi medial femoral condyle pedicle graft