A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability

This article presents a brief description of the following modifications of the original Fisk procedure for navicular nonunions with carpal instability: (1) preoperative calculation of exact scaphoid length and form based on comparative roentgenograms of the opposite wrist, (2) the use of a palmar approach, (3) the insertion of a wedge-shaped corticocancellous graft from the iliac crest after resection of the pseudarthrosis, and (4) the use of internal fixation. Preoperative planning is considered essential to restore the anatomic length, analyze the angular deformity, evaluate the pathologic scapholunate angle, and calculate the resection and size of the graft needed. The palmar approach reduces the danger of iatrogenic damage of the vascular supply of the scaphoid and accidental lesions of the superficial branches of the radial nerve. Furthermore it provides a better exposure of the scapholunate joint to correct lunate rotation. Iliac bone is preferred to the radial styloid graft, as proposed by Fisk, because of its better ability to resist compression forces. Internal fixation adds rotational stability so that continued postoperative plaster immobilization can be reduced to a minimum of 8 weeks.