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Equivalent Union Rates Between Distal Radius and Iliac Crest Nonvascularized Bone Graft for Pediatric Scaphoid Nonunion
Eric R Taleghani, MD
1, Kaitlynn N Jackson, BS
2, Casey C. Kuka, BS
3, Sayaka Mori, BA
3, Roger Cornwall, MD
4, Apurva S. Shah, MD, MBA
3; Kevin J. Little, MD
5(1)University of Cincinnati, Cincinnati, OH, (2)Cincinnati Children's Hospital Medical Center, Cincinnati, OH, (3)Children's Hospital of Philadelphia, Philadelphia, PA, (4)Department of Orthopaedic Surgery, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH, (5)Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
IntroductionUpwards of a third of pediatric scaphoid fractures present as a nonunion, and management remains controversial. Open reduction and internal fixation (ORIF) with nonvascularized bone graft, typically from the iliac crest (IC) or distal radius (DR), is the predominant approach. While IC grafts offer strong osteogenic and biomechanical properties with good healing propensity, they are associated with distant donor site morbidity. There is limited literature on DR grafts for pediatric scaphoid nonunions and few direct comparisons with IC grafts. This study aimed to compare outcomes of pediatric scaphoid nonunions treated with ORIF and nonvascularized bone graft from either the iliac crest or distal radius.
MethodsThis was a multicenter, retrospective review of children and adolescents 0-21 years of age who underwent surgical reconstruction for scaphoid nonunion with nonvascularized bone graft between 2012 - 2024. Patients were divided into two groups depending on whether they underwent IC versus DR grafting, determined by the surgeon's preference. Demographic variables, injury characteristics, surgical details, and clinical and radiographic outcome data were recorded and compared between the two cohorts.
ResultsDuring the study period, 128 patients met inclusion criteria. 51 patients underwent IC bone grafting, and 77 underwent DR bone grafting with average follow-up of 21 and 29 weeks, respectively. There were no differences in demographic factors or injury characteristics between cohorts. On average, IC harvesting procured larger graft sizes (109.6 mm^2 vs 64.9 mm^2, p = 0.027). Patients who underwent DR bone grafting had significantly better radiolunate angles (14.8 vs 19.9 degrees, p = 0.034) and days to complete pain resolution post-operatively (62 vs 85 days, p =0.044). There were otherwise no differences in radiographic or clinical outcomes between groups. Similarly, no difference was noted in terms of persistent nonunion (7.8% vs 2.0%), complications (7.8% vs 11.7%), and unplanned reoperation (7.8% vs 6.4%).
ConclusionPediatric scaphoid nonunions that undergo ORIF using nonvascularized DR and IC bone graft achieve excellent union rates, pain resolution, restoration of functional range of motion, with low complication rates. Patients who underwent DR grafting achieved faster pain resolution and better radiographic alignment, suggesting that inferior biomechanical properties and local donor site morbidity are not of concern. DR and IC grafts can be considered as equivalent nonvascularized grafts in operative management of pediatric scaphoid nonunion.
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