Avascular necrosis of the scaphoid following a fracture in children is rare and there is no established treatment protocol in the literature. We present two boys with nonunion and avascular necrosis of the scaphoid treated by simple immobilisation. Both cases healed with painless wrists and full movements. Our cases confirm that an ununited scaphoid fracture in children may heal with conservative treatment, even when an MRI scan suggests avascular necrosis. Unlike in adults, operative treatment need only be considered in children when conservative treatment fails

Ununited fractures of the scaphoid with extensive bone resorption are usually treated by bone grafting and internal fixation, using either an open or a minimally invasive technique. We studied the feasibility of percutaneous fixation without bone grafting in a consecutive series of 27 patients with established nonunion of an undisplaced fracture of the scaphoid and extensive local resorption of bone. They were treated by a single surgeon with rigid fixation alone, using a headless cannulated screw inserted through a volar percutaneous technique. Clinical examination, standard radiographs and CT confirmed that the fracture had united in all patients at a mean of 11.6 weeks (8 to 16), and that their functional scores had improved. We concluded that extensive resorption at the fracture site is not an absolute indication for bone grafting, and that percutaneous fixation alone will eventually produce healing of ununited undisplaced fractures of the scaphoid regardless of the size of the gap

The movements of the carpal bones during the scaphoid shift test were evaluated radiographically in 60 wrists. The clinical results were graded according to the degree of subluxation of the scaphoid and pain on the dorsum of the wrist. Lateral radiographs at rest and under stress were taken and the relative movements of the scaphoid with respect to the radius and lunate, and the rotation of the scaphoid and lunate were calculated. Dorsal displacement of the scaphoid with respect to the radius was significantly associated with the clinical grade of subluxation. There was correlation between the amount of pain and the displacement of the scaphoid from the lunate, but not from the radius. The wrists with a painful shift test had greater relative displacement of the scaphoid from the lunate than those with painless subluxation. These observations support the view that pain associated with subluxation of the scaphoid during the shift test is a significant finding, and that radiographic analysis of the test may confirm a positive result when dynamic scaphoid instability is suspected

We describe the use of a vascularised periosteal patch onlay graft based on the 1,2 intercompartmental supraretinacular artery in the management of 11 patients (ten men, one woman) with chronic nonunion involving the proximal third of the scaphoid. The mean age of the patients was 31 years (21 to 45) with the dominant hand affected in eight. Six of the patients were smokers and three had undergone previous surgery to the scaphoid. All of the proximal fragments were avascular. The presence of union was assessed using longitudinal axis CT. Only three patients progressed to union of the scaphoid and four required a salvage operation for a symptomatic nonunion. The remaining four patients with a persistent nonunion are asymptomatic with low pain scores, good grip strength and a functional range of wrist movement. Although this technique has potential technical advantages over vascularised pedicled bone grafting, the rate of union has been disappointing and we do not recommend it as a method of treatment

We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive. At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side. Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid

We randomly allocated 60 consecutive patients with fractures of the waist of the scaphoid to percutaneous fixation with a cannulated Acutrak screw or immobilisation in a cast. The range of movement, the grip and pinch strength, the modified Green/O’Brien functional score, return to work and sports, and radiological evidence of union were evaluated at each follow-up visit. Patients were followed sequentially for one year. Those undergoing percutaneous screw fixation showed a quicker time to union (9.2 weeks vs 13.9 weeks, p < 0.001) than those treated with a cast. There was a trend towards a higher rate of nonunion in the non-operative group, although this was not statistically significant. Patients treated by operation had a more rapid return of function and to sport and full work compared with those managed conservatively. There was a very low complication rate. We recommend that all active patients should be offered percutaneous stabilisation for fractures of the waist of the scaphoid

1. Nine cases of disturbance of the relationship between the scaphoid and the radius and between the scaphoid and the lunate bones are described. 2. Persistent dislocation of the scaphoid bone may follow reduction of perilunar dislocations or of other dislocations of the proximal row of the carpus. It may be obvious, as in waist-deep dislocation, or may be solely a rotational dislocation which may be difficult to diagnose. 3. Uncorrected rotational dislocation of the scaphoid bone caused significant disability in six of seven cases. 4. Aids to the diagnosis of this condition are described and a vigorous approach to the problem of correction is advocated. 5. The experience of other workers in this field is reviewed and discussed

We have investigated whether assessment of blood flow to the proximal scaphoid can be used to predict nonunion in acute fractures of the scaphoid. We studied 32 fractures of the scaphoid one to two weeks after injury, by dynamic fat-suppressed T1-weighted gradient-echo MRI after the intravenous administration of gadopentetate dimeglumine (0.1 mmol/kg body-weight). Steepest slope values (SSV) and percentage enhancement values (%E) were calculated for the distal and proximal fragments and poles. All the fractures were treated by immobilisation in a cast, and union was assessed by CT at 12 weeks. Nonunion occurred in four fractures (12%), and there was no statistically significant difference between the proximal fragment SSV and %E values for the fractures which united and those with nonunion. The difference between the proximal pole SSV and %E values for the union and nonunion groups reached statistical significance (p < 0.05), but with higher enhancement parameters for the nonunion group. Our results suggest that poor proximal vascularity is not an important determinant of union in fractures of the scaphoid

Fractures of the scaphoid are most common in young men; immobilisation in a cast usually means a long period away from work and athletic activities. Early rigid fixation has been shown to promote a rapid functional recovery, but open reduction and internal fixation is technically demanding with the dangers of damage to the radiocarpal ligaments, the scaphotrapezial joint, and the blood supply of the scaphoid. For minimally displaced or undisplaced B1 or B2 fractures, these problems can be overcome by percutaneous fixation. We report our technique and the results of a pilot study in 15 patients. There was no immobilisation; patients were allowed movement soon after operation, but union was obtained in all at a mean of 57 days (38 to 71). The range of movement after union was equal to that of the contralateral limb and grip strength was 98% of the contralateral side at three months. Patients were able to return to sedentary work within four days and to manual work within five weeks. Our initial results show that percutaneous scaphoid fixation for acute fractures is satisfactory and gives rapid functional recovery

We describe a case of osteosarcoma of the scaphoid bone, which to our knowledge is only the second reported case of osteosarcoma in the carpus. A 38-year-old man complained of intense pain in the right wrist and had curettage and a bone graft for a lesion in the scaphoid. Histological examination showed this to be an osteosarcoma. Below-elbow amputation was performed and adjuvant chemotherapy given. There has been no evidence of recurrence or metastases at 33 months after amputation

Acute fractures of the scaphoid were randomly allocated for conservative treatment in a Colles’-type plaster cast with the wrist immobilised in either 20° flexion or 20° extension. The position of the wrist did not influence the rate of union of the fracture (89%) but when reviewed after six months the wrists which had been immobilised in flexion had a greater restriction of extension. We recommend that acute fractures of the scaphoid should be treated in a Colles’-type cast with the wrist in slight extension

1. Operative treatment of scaphoid pseudarthrosis by the Matti-Russe method is a reliable procedure which in our series has given ninety-seven cases of bony union in a total of 100 operations. 2. We do not hesitate to advise operation for this condition as soon as it is discovered, except in cases with severe secondary osteoarthritis. Equally good results have been reported by Murray (1946) from a series of 100 cases treated with cortical grafts from the tibia (blind method) and by Agner (1963) from a series of twenty-four patients treated by Bentzon's operation (interposition of a pedicled soft-tissue flap). 3. In our opinion, Russe's open operation has great technical advantages over Murray's blind method. 4. We have no experience of Bentzon's operation, which seems attractive on account of its technical simplicity and as not more than two weeks' immobilisation in plaster after operation are needed. 5. It would be interesting to see Agner's results confirmed from other sources. It is true that many scaphoid pseudarthroses remain symptomless for years, as London (1961) has pointed out, but many of them sooner or later cause pain, and we do not agree with London's opinion that a few weeks of immobilisation will usually make the wrist painless. 6. Although severe osteoarthritis is very slow to develop in wrists with pseudarthrosis of the scaphoid bone it cannot be denied that these wrists are constantly threatened with suddenly developing pain and by progressive deterioration of function. 7. Therefore, early repair of pseudarthrosis of the scaphoid bone is advisable; it can be expected to save many wrists from progressive loss of function and from final development of severe degenerative change

A review of 61 patients with dislocation of the lunate (some with and some without fracture of the scaphoid) showed that the majority had satisfactory results at an average follow-up of three and a half years. Most patients with a simple dislocation had a good or satisfactory result; radiological instability was noted in a quarter of the wrists but was not often associated with symptoms. Two-thirds of the patients with an associated fracture of the scaphoid had a good or satisfactory result. Immediate percutaneous wire fixation of the reduced scaphoid, whether it is fractured or not, is the best way of maintaining normal anatomical relationship while the ligaments and fracture heal; this may further improve the prognosis. In most cases extreme dorsiflexion of the wrist appeared to be the mechanism of injury

We reviewed the records of 431 patients who had open reduction and internal fixation of the scaphoid performed by one surgeon (TJH) over a 13-year period. The Herbert bone screw provided adequate internal fixation without the use of plaster immobilisation, promoting a rapid functional recovery. On average, patients returned to work 4.7 weeks after surgery and wrist function was significantly improved, even when the fracture failed to unite. Healing rates for acute fractures were better than those reported for plaster immobilisation and were independent of fracture location. In the case of established nonunions, healing depended on the stage and location of the fracture, but the progress of arthritis was halted and carpal collapse significantly improved. Internal fixation of the scaphoid using the Herbert bone screw, although technically demanding, has few complications and appears to offer significant advantages over other methods of treatment

We have examined whether the rotatory subluxation of the scaphoid which is seen in patients with advanced Kienböck’s disease is associated with scapholunate advanced collapse (SLAC) wrist. We studied 16 patients (11 men, 5 women) who had stage-IV Kienböck’s disease with chronic subluxation of the scaphoid. All had received conservative treatment. The mean period of affection with Kienböck’s disease was 30 years (14 to 49). No wrist had SLAC. In eight patients, 24 years or more after the onset of the disease, the articular surface of the radius had been remodelled by the subluxed scaphoid with maintenance of the joint space. The wrists of six patients were considered to be excellent, nine good, and one fair according to the clinical criteria of Dornan. Our findings have shown that rotatory subluxation of the scaphoid in Kienböck’s disease is not a cause of SLAC wrist and therefore that scaphotrapezio-trapezoid arthrodesis is not required for the management of these patients

Aims

There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures.

A new and simple operative technique has been developed to provide rigid internal fixation for all types of fractures of the scaphoid. This involves the use of a double-threaded bone screw which provides such good fixation that, after operation, a plaster cast is rarely required and most patients are able to return to work within a few weeks. A classification of scaphoid fractures is proposed. The indications for operation included not only acute unstable fractures, but also fractures with delayed healing and those with established non-union; screw fixation was combined with bone grafting to treat non-union. In a prospective trial, 158 operations using this technique were carried out between 1977 and 1981. The rate of union was 100 per cent for acute fractures and 83 per cent overall. This method of treatment appears to offer significant advantages over conventional techniques in the management of the fractured scaphoid

We describe a semi-closed method of Herbert screw fixation for acute fractures of the scaphoid. All 40 patients treated achieved solid union with satisfactory wrist function. This technique gave a significantly shorter time to union and allowed an earlier return to manual labour compared with conservative treatment. There were no complications. Semi-closed insertion requires considerable skill, but produces consistently satisfactory results after minimal exposure of the scaphoid

Cancellous inlay bone grafting for delayed union or non-union of the scaphoid bone gives good results in most cases (Table IV). The operation is easy, does not require radiological control and does not damage the dorsal arterial plexus. The indications for the operation are twofold: firstly for patients complaining of disabling symptoms in the wrist joint with an established pseudarthrosis of the scaphoid bone, with neither arthritic changes nor severe avascularity of the proximal fragment; and, secondly, for delayed union in recent fractures despite adequate immobilisation. Union may still occur if conservative treatment is continued further, but because this may take up to eighteen months (during which time most patients would be unable to work), operation is a reasonable alternative. In this series two scaphoid fractures united after operation with some collapse of the proximal fragment. This probably resulted from removal of too much bone (preliminary to inlaying the graft) from an already small fragment with a poor blood supply. The operation can be performed even in the presence of a small proximal fragment and gave a satisfactory result in two out of three such cases

We reviewed 10 patients with symptomatic malunion of a carpal scaphoid fracture. All had displacement with dorsiflexed intercalated segment instability, and suffered from pain, restricted range of movement at the wrist and decreased grip strength. The restriction of flexion-extension and the decreased grip strength correlated with the severity of the DISI deformity. Seven patients had a corrective osteotomy, using an anterior wedge-shape bone graft with internal fixation by Herbert screw, and all had satisfactory results. We believe that symptoms associated with scaphoid malunion are related to consequent carpal deformity