Background Small proximal bone fragments are a known risk factor for nonunion, but it is not known what ratio of proximal to distal bone fragments actually results in nonunion.

Objective We hypothesized that a small proximal ratio of proximal scaphoid fragment volume to distal scaphoid volume as measured by preoperative computed tomography (CT) would be a risk factor for postoperative scaphoid nonunion.

Patients and Methods We retrospectively examined the factors that led to postoperative nonunion in 78 patients who underwent surgery using free bone grafts for scaphoid nonunion. Nonunion was defined as no evidence of union on plain radiography or CT more than 3 months after injury. Three-dimensional models of scaphoid fractures were created from the preoperative CT of all cases, and volumes were measured. Other patient characteristics, surgical methods, and imaging were investigated.

Results Persistent nonunion was observed in 13 patients after surgery, a rate of 16.7%. A multivariate analysis showed that only the proximal fragment ratio was an independent factor (union group 0.94, persistent nonunion group 0.54, p = 0.03). Receiver operating characteristic analysis showed that a proximal fragment ratio less than 0.66 was associated with persistent nonunion.

Conclusion Treatment of scaphoid nonunion with a small proximal fragment ratio should be based on a thorough understanding of the anatomy, blood flow, and carpal kinematics of the scaphoid bone itself.

Level of Evidence Level IV, prognostic study.

The study protocol was approved by the Institutional Review Boards of each hospital, and consent was obtained from all patients.

Work on this study was performed at three collaborating hospitals where the following departments are located: Department of Human Enhancement and Hand Surgery, Nagoya University Graduate School of Medicine; Department of Orthopaedic Surgery, Nagoya Hand Surgery Center, Chunichi Hospital; and Department of Orthopaedic Surgery, Suzuka Kaisei Hospital.

Received: 07 September 2023

Accepted: 27 December 2023

Article published online:
31 January 2024

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