Pronator quadratus pedicled bone graft for scaphoid non-unions


  • Harsha Vardhan Department of Plastic Surgery, King George’s Medical University, Lucknow, Uttar Pradesh, India
  • Anto Francis Consultant Plastic Surgeon, Sushrutha Institute of Plastic Reconstructive and Aesthetic Surgery, Elite Mission Hospital, Thrissur, Kerala, India



Scaphoid, Non-unions, Pedicled pronator quadratus, Vascularised bone graft


Scaphoid fractures frequently present with nonunion and proximal pole necrosis, the treatment of which is bone grafting. Pronator quadratus pedicled vascularized bone graft is an option especially in the setting of proximal pole necrosis. We describe our experience of managing such scaphoid non-unions using pronator quadratus pedicled vascularized bone graft. Six patients were managed using pronator quadratus pedicled vascularized bone graft following scaphoid fracture nonunion with proximal pole necrosis. All patients had good fracture healing and symptom resolution. Mild deficit in wrist extension was noted in all patients. Pronator quadratus pedicled vascularized bone graft is an attractive option for managing scaphoid nonunion. Lying adjacent to the fracture site, bone can be harvested and transferred without making any other incisions. This procedure introduces another source of blood supply to the fracture site and hence improves fracture healing.


Larson AN, Bishop AT, Shin AY. Dorsal distal radius vascularized pedicled bone grafts for scaphoid non-unions. Tech Hand Up Extrem Surg. 2006;10(4):212-23.

Kawamura K, Chung KC. Treatment of Scaphoid Fractures and Nonunions. J Hand Surg Am. 2008;33(6):988-97.

Watson HK, Ballet FL. The SLAC wrist: Scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984;9(3):358-65.

Braun RM. Proximal pedicle bone grafting in the forearm and proximal carpal row. Orthop Trans. 1983;7(1):35.

Merrell G, Wolfe S, Slade J. Treatment of scaphoid nonunions: Quantitative meta-analysis of the literature. J Hand Surg. 2002;27:685-91.

Rath S, Hung LK, Leung PC. Vascular anatomy of the pronator quadratus muscle-bone flap: a justification for its use with a distally based blood supply. J Hand Surg Am. 1990;15(4):630-6.

Tu YK, Bishop AT, Kato T, Adams ML, Wood MB. Experimental carpal reverse-flow pedicle vascularized bone grafts. Part II: Bone blood flow measurement by radioactive-labelled microspheres in a canine model. J Hand Surg Am. 2000;25(1):46-54.

Munk B, Larsen CF. Bone grafting the scaphoid nonunion: A systematic review of 147 publications including 5 246 cases of scaphoid nonunion. Acta Orthop Scand. 2004;75(5):618-29.

Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid non-union. J Hand Surg Am. 1991;16(3):474-8.

Kuhlmann J, Mimoun M, Boabighi A, Baux S. Vascularized bone graft pedicled on the volar carpal artery for non-union of the scaphoid. J Hand Surg J Br Soc Surg Hand. 1987;12(2):203-10.

Brunelli F, Brunelli G, Nanfito F. An anatomical study of the vascularisation of the first dorsal interosseous space in the hand, and a description of a bony pedicle graft arising from the second metacarpal bone. Surg Radiol Anat. 1991;13(1):73-5.

Sheetz KK, Bishop AT, Berger RA. The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg Am. 1995;20(6):902-14.

Chan AHW, Elhassan BT, Suh N. The Use of the Proximal Hamate as an Autograft for Proximal Pole Scaphoid Fractures: Clinical Outcomes and Biomechanical Implications. Hand Clinics. 2019;35(3):287-94.

Larson AN, Bishop AT, Shin AY. Free Medial Femoral Condyle Bone Grafting for Scaphoid Nonunions With Humpback Deformity and Proximal Pole Avascular Necrosis. Techniques Hand Upper Extremity Surg. 2007;11:4:246-58.

Tsantes A, Papadopoulos D, Gelalis I, Vekris M, Pakos E, Korompilias A. The Efficacy of Vascularized Bone Grafts in the Treatment of Scaphoid Non-unions and Kienbock Disease: A Systematic Review in 917 Patients. J Hand Microsurg. 2019;26:11(1):6-13.

Gras M, Mathoulin C. Vascularized bone graft pedicled on the volar carpal artery from the volar distal radius as primary procedure for scaphoid non-union. Orthop Traumatol Surg Res. 2011;97(8):800-6.

Rancy SK, Schmidle G, Wolfe SW. Does Anyone Need a Vascularized Graft? Hand Clin. 2019;35(3):323-44.






Case Series