Palmar Radiocarpal Artery Vascularized Bone Graft for the Unstable Humpbacked Scaphoid Nonunion With an Avascular Proximal Pole

Published:February 13, 2020DOI:


      The most challenging scaphoid nonunion is the unstable nonunion with humpbacked collapse coupled with an avascular proximal pole. Dorsal distal radius pedicled vascularized bone grafts (VBGs) are contraindicated in cases of humpback deformity. The free medial femoral condyle VBG is an excellent option but it is an extensive microsurgical procedure with lengthy operative times and dual-limb incisions. In search of a local, volar, vascularized source of bone to treat this challenging subset of scaphoid nonunions, we analyzed our results with a volar distal radius bone graft based on the pedicled palmar radiocarpal artery (PRCA).


      A prospective cohort of 15 unstable nonunions with avascular proximal pole fragments was treated with the PRCA graft and open reduction internal fixation. Preoperative carpal indices revealed a high degree of instability. All 15 lacked punctate bleeding from the proximal pole. All 15 patients were treated with the PRCA VBG technique and scanned with computed tomography at approximately 6 and 12 weeks to assess for interval healing.


      All nonunions healed with an average cross-sectional trabeculation score of 70% at week 6 and 84% at week 12. Sagittal intrascaphoid angles improved from 50° to 27°, radiolunate angle improved from –20° to –7°, scapholunate angle improved from 86° to 64°, and revised carpal height ratio improved from 1.45 to 1.53, indicating correction of the humpback collapse deformity. Patients were observed an average of 22 months to have no sign of further avascular necrosis.


      Pedicled PRCA–VBG successfully addresses the dual needs of the humpbacked scaphoid nonunion with an avascular proximal pole while simultaneously limiting dissection to one limb and avoiding the additional complexities of free tissue transfer.

      Type of study/level of evidence

      Therapeutic II.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kuhlmann J.N.
        • Mimoun M.
        • Boabighi A.
        • Baux S.
        Vascularized bone graft pedicled on the volar carpal artery for non-union of the scaphoid.
        J Hand Surg Br. 1987; 12: 203-210
        • Mathoulin C.
        • Haerle M.
        Vascularized bone graft from the palmar carpal artery for treatment of scaphoid nonunion.
        J Hand Surg Br. 1998; 23: 318-323
        • Dailiana Z.H.
        • Malizos K.N.
        • Zachos V.
        • Varitimidis S.E.
        • Hantes M.
        • Karantanas A.
        Vascularized bone grafts from the palmar radius for the treatment of waist nonunions of the scaphoid.
        J Hand Surg Am. 2006; 31: 397-404
        • Gras M.
        • Mathoulin C.L.
        Vascularized bone graft pedicled on the volar carpal artery from the volar distal radius as primary procedure for scaphoid nonunion.
        Orthop Traumatol Surg Res. 2011; 97: 800-806
        • Sheets K.K.
        • Bishop A.T.
        • Berger R.A.
        The arterial supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts.
        J Hand Surg Am. 1995; 20: 902-914
        • Zaidemberg C.
        • Siebert J.W.
        • Angrigiani C.
        A new vascularized bone graft for scaphoid nonunion.
        J Hand Surg Am. 1991; 16: 474-478
        • Chang M.A.
        • Bishop A.T.
        • Moran S.L.
        • Shin A.Y.
        The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions.
        J Hand Surg Am. 2006; 31: 387-396
        • Jones D.B.
        • Burger H.
        • Shin A.Y.
        • Bishop A.T.
        Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse: a comparison of two vascularized bone grafts.
        J Bone Joint Surg Am. 2008; 90: 2616-2625
        • Pulos N.
        • Kolitz K.
        • Bishop A.
        • Shin A.
        Free vascularized medial femoral condyle bone grafts after failed scaphoid nonunion surgery.
        J Bone Joint Surg Am. 2018; 100: 1379-1386
        • Haerle M.
        • Schaller A.E.
        • Mathoulin C.
        Vascular anatomy of the palmar surfaces of the distal radius and ulna: its relevance to pedicled bone grafts at the distal palmar forearm.
        J Hand Surg Br. 2003; 28: 131-136
        • Green D.P.
        The effect of avascular necrosis on Russe bone grafting of scaphoid nonunion.
        J Hand Surg Am. 1985; 10: 597-605
        • Bertelli J.A.
        • Tacca C.P.
        • Roost J.
        Thumb metacarpal vascularized bone graft in long standing nonunion—A useful graft via dorsal or palmar approach: a cohort study of 24 patients.
        J Hand Surg Am. 2004; 29: 1089-1097

      Linked Article