Scaphoid Fractures

Focus On Scaphoid fractures

Introduction third.2 Fractures occurring in these scaphoids may therefore be The ‘scaphoid’ (Greek word ‘skaphe’ for boat) is an obliquely ori- left without adequate blood supply to the proximal pole. ented bone on the radial side of the wrist, which bridges the Although the scaphoid is mainly intra-articular and covered distal and proximal carpal rows. The body of scaphoid is bean- with cartilage, there are important sites for attachment of liga- shaped with a dorsal sulcus and a ridge. (Fig. 1) The tubercle is ments. Along the ulnar aspect of the proximal pole, the scapho- offset from the distal end by about 45.1 lunate interosseous ligament joins the scaphoid to the lunate. It has six surfaces, four of which are articular facets; the More radial is the radioscaphocapitate ligament, which has a sub- dorsal and palmar surfaces are non-articular with multiple arte- stantial insertion on the waist of the scaphoid. At the distal articu- rial foramina. The blood supply is mainly (75%) from branches of lation of the scaphoid is the v-shaped scaphotrapezial ligament.3 the radial artery that pass through the attachment of capsule to the dorsal ridge and these also supply the proximal pole. In 20% Mechanism of injury of scaphoids, most of the arterial foramina are in the waist area Extreme dorsiflexion of the wrist with compression of the radial of the bone with no more than a single foramen in the proximal side of the palm commonly causes middle-third scaphoid fractures.4 Falls backward, with a hand directed anteriorly, are most likely to force extreme dorsiflexion.5 Less commonly, forced dorsiflexion against a steering wheel in a motor vehicle accident or RADIAL VOLAR TUB a ball forcing the palm dorsally can cause a scaphoid fracture. TUB ST Rare mechanisms may involve forced palmar flexion of the wrist or axial loading with the hand clenched in a fist.6

LA LA Assessment7-10 (Table I) and classification11-14 Dorsal sulcus (Table II) DA Dorsal ridge R-S R-S Table I. Accuracy of clinical tests in diagnosis of scaphoid fractures DISTAL Clinical tests Specificity (%)* Sensitivity (%)† Snuff box tenderness7 40 90 Effusion (On ultrasound)8 91 50 PROXIMAL TUB Tenderness over scaphoid tubercle7 57 87 S-T-T Scaphoid compression test9 92 94 Combined10 74 100 Specificity= Number of true negatives/(Number of true negatives+ Number S-C of false positives) LA Sensitivity= Number of true positives/(Number of true positives+ Number of DA false negatives) Dorsal sulcus Dorsal ridge S-L R-S DA DORSAL ULNAR Investigations Fig. 1 The standard radiographs for a scaphoid fracture include four Four views of the right scaphoid demonstrate the complex views of the wrist: the postero-anterior (PA) with ulnar devia- shape of the bone. The fracture line depicts the pattern of waist fracture. (With permission from Elsevier, from tion; lateral; semi-pronated oblique; and semi-supinated Compson JP, Waterman JK, Heatley FW. The radiological oblique. Other authors have suggested even more views.15 anatomy of the scaphoid. Part 1: Osteology. J Hand Surg Br. 1994 Apr; 19(2):183-7) R-S: Radio scaphoid articula- Scaphoid waist fractures are best seen on an ulnar deviated tion, DA: Dorsal apex of the ridge, TUB: Tuberosity, S-L: angled PA view and true lateral film.15 Dorsal sulcal fractures Scapho lunate articulation, LA: Lateral apex of the ridge, STT: Scapho-trapezio trapezoidal articulation, S-C: Sca- are best seen on a 45° semi-pronated oblique view on which pho-Capitate joint.

1 2 H. P. SINGH, J. J. DIAS

Table II. Classifications of scaphoid fractures Site of fracture Russe11 Herbert12 Mayo clinic13 Prosser14 Compson15 (Distal pole) (Radiographic) Tuberosity fracture Type A (Stable) Distal (5%) Type I Type 2 A1 Tubercle (Union rate 100%) Fractures of tuberosity The dorsal sulcus A2 Incomplete Type II Distal intra-articular

Type III Osteochondral fracture Waist fracture Horizontal oblique Type B (Unstable) Middle (65%) Type 1 B1 Oblique distal third (Union rate 80%) The ‘surgical waist’ Transverse B2 Displaced B4 Fracture dislocations Vertical oblique (5%) Type C Delayed union 6 weeks after plaster

Type D D1 Fibrous nonunion D2 Sclerotic Nonunion D3 Nonunion with fixed DISI

Proximal pole fracture Type B3 Proximal (30%), Type 3 Proximal third (Union rate 64%) The proximal pole

Type D4 Nonunion with AVN

the fracture line runs from the dorsal apex of the ridge adjacent is superior to a repeat radiograph21 and bone to the lunate. (Fig.1). Proximal pole fractures are best seen on scintigraphy22 for occult fractures of scaphoid. a 45° semi-supinated oblique view.15 • Another alternative is high-resolution ultrasonography23 to ‘Clinical’ scaphoid fracture (diagnosis not certain) (Fig. 2). A identify cortical disruption. Radiocarpal effusion, and patient who has sustained a dorsiflexion injury, has pain and scapho-trapezium-trapezoid effusion may also indicate a tenderness on the radial side of the wrist but whose adequate fracture.24 Ultrasonography is user dependent. radiographs don't show a fracture is considered to have a ‘clini- • In acute fractures, Dynamic MRI scans after bolus adminis- cal’ scaphoid fracture. Initial radiographs detect a fracture in tration of gadolinium estimates blood flow through bone 85–90%16 but it can be occult in up to 10-15% of cases.17 although it doesn't measure perfusion. This technique Adequate management includes: assesses bone marrow vascularity and by implication, a. Advise the patient of the possibility of a fracture and 10% or scaphoid vascularity.25 There is a no clear correlation so rate of non-union. between sclerosis seen on plain radiographs and blood flow b. Advise the patient to restrict activity or to use a removable assessed by dynamic MRI.26 splint to limit wrist, and therefore scaphoid, movement. c. Give the patient the option of being treated in a cast with a 3% Treatment chance18 of subsequently identifying a fracture, and The options for treatment of the broken scaphoid include cast d. Review the patient after two or three weeks; if at this interval, immobilisation and surgical fixation. clinical signs still suggest a fracture (swelling, tenderness in Cast immobilization. Short arm casts with the thumb left free the anatomical snuff box and more than 20% restriction of provide adequate immobilisation for scaphoid fractures27 as grip strength) further radiographs or other imaging is restriction of wrist motion will prevent movements at the obtained: scaphoid fracture site. Such a cast allows the use of the hand • If it is readily available, Computed Tomography (CT) scan of and the elbow is not immobilized. Long-arm casts have offered scaphoid in the sagittal plane can be used to rule out a no advantage over short-arm casts in preventing interfragmen- scaphoid fracture. This is obtained by placing the patient tary motion with forearm rotation.28 The position of the wrist in prone in the scanner with the hand above the head, in full the cast does not affect healing.29 Casting for 6–8 weeks will pronation and neutral flexion.19 This identifies the true lon- predictably heal 90% to 95% of scaphoid waist fractures.30,31 gitudinal axis of the scaphoid20 and can define the location, but possible patient inconvenience and work restrictions when pattern, and displacement of the scaphoid fracture. in the cast have prompted some to advocate internal fixation • A magnetic resonance imaging (MRI) can be used to identify with a screw.32,33 a scaphoid fracture but is more useful for non-specific wrist Undisplaced fractures (Fig. 3). The best approach for a patient pain and can detect other associated injuries to the wrist. It with an undisplaced acute scaphoid fracture is to consider

THE JOURNAL OF BONE AND JOINT SURGERY SCAPHOID FRACTURES 3

Fig. 2

Diagram showing options and outcomes after a “Clinical scaphoid” fracture. The options are to assume a fracture has occurred and splint accordingly at a risk of over treating, or to investigate and look for a definite fracture. CT/MRI scan is sensitive and specific. (Costs assessed in 2010 in the UK).

patient's unique circumstances and discuss risks and benefits each scaphoid fragment as joysticks allow manipulation of the of both non-operative management and surgery. There are at fragments to achieve reduction. In patients with fracture commi- present six clinical trials34 comparing casting with surgery in nution, particularly with compromise of the palmar cortex, pri- acute scaphoid fractures. The rate of bony union for both meth- mary bone grafting may be needed. The screw must be ods is greater than 90%. Systematic reviews31,35 have found no positioned within the centre of the scaphoid, as the time to heal- difference in union rate or time to return to work, and any sur- ing is shorter. Central screw placement is achieved more consist- gical benefits are transient. A cost-utility analysis of open ently with cannulated screws than with Herbert screws.39 reduction and internal fixation (ORIF) versus cast immobiliza- Identify union. Assessment of union is by repeat clinical obser- tion a long arm plaster36 for acute non-displaced scaphoid frac- vation and serial radiographs. We believe union is a process tures showed that casting was less costly than ORIF but rather than a single event at a specific time in the natural history surgery reduced immobilization time and patient had a of healing. Time to union is a flawed observation as it depends "shorter time off work". However, patients are exposed to com- on when the observer conducts the radiographs or scans. Radi- plications with surgery.37 ograph can be unreliable at identifying union and even experi- Displaced fractures (Fig. 4). Displaced fractures risk nonunion. enced observers (both surgeons and radiologists) may not They can heal with conservative treatment but malunite. Dis- consistently agree on scaphoid union on radiographs taken 12 placed fractures could benefit from realignment of the fracture weeks after injury.19 If doubt persists about union, a CT scan of fragments followed by stable internal fixation. In most cases, scaphoid will resolve it. Bridging trabeculae across the whole palmar exposure of the scaphoid limits injury to the blood supply cross-section of the scaphoid on CT scan confirms union and the of the scaphoid.38 It is easier to address very proximal fractures wrist can be mobilized. Partial union of the scaphoid is common through a dorsal exposure. The headless screw has become a (up to 40%) and with bridging trabeculae across more than 25% popular device but the use of alignment jig has been abandoned of the cross-section of the scaphoid, it progresses to full union as it can damage the scaphotrapezial joint. without the need for further plaster immobilization.40 Nonunion Cannulated screw fixation has become popular for open as is the absence of radiographic signs of healing at 12 weeks and well as percutaneous fixation. Kirschner wires inserted into the a clear gap on a CT scan. 4 H. P. SINGH, J. J. DIAS

Fig. 3

Diagram showing the options for diagnosis and management of undisplaced scaphoid fractures. CT scans are most useful while operative fixation can allow an early return to activity but at a higher risk of complications.

Fig. 4

Diagram showing options for diagnosis and management of displaced fractures of the scaphoid. The risk of nonunion and avascular necrosis is higher with displaced fractures; surgery reduces the risk of nonunion. A displaced fracture is considered to be present if there is a fracture gap or degree of displacement ≥ 1 mm.

Return to activity. This has to be individualised to the patient casts on game days. The soft casts are required to minimise the and the personality of the fracture. The patient is advised potential for injury to other athletes. This has not caused healing against contact sport for two to three months and counselled problems provided treatment is not delayed.41 An alternative about the risk of refracture. Grip strength and range of move- approach is internal fixation of minimally or undisplaced frac- ment is initially better in those who undergo surgical fixation tures, which avoids cast immobilisation. The fixation is not compared with those treated in different casts for 8 to 12 weeks strong enough to allow impact on the hand in contact sports. but no difference is found after that time. Prolonged above- Fractures of the proximal pole of the scaphoid. 5% of all elbow cast immobilisation beyond 8 weeks is not well tolerated, scaphoid fractures involve the proximal pole (proximal fifth of especially by younger patients who want to return to work and the scaphoid).42 The primary concerns are the small size and sports as soon as possible and should be avoided. avascularity of the proximal fragment. Prolonged immobilization For athletes, treatment programs have been modified such and a high rate (30%) of nonunion have been reported27 so fixa- that standard fiberglass casts are exchanged for soft or padded tion may be favored for these fractures.

THE JOURNAL OF BONE AND JOINT SURGERY SCAPHOID FRACTURES 5

Fig. 5

Diagram showing risk factors, types and management of nonunion of scaphoid fractures. There is a significant risk of nonunion despite surgery. The main determinants for treatment are stability at the fracture site and vascularity of the fracture fragments. CRPS: Complex regional pain syndrome, PIN: Posterior interosseous nerve, AIN: Anterior interosseous nerve, PRC: Proximal row carpectomy, OA: Osteoarthritis, ROM: Range of motion.

If the fragment is large, a headless compression screw can be delayed union and stable nonunions had significantly better used. It is critical to obtain good, preferably central, purchase on union rate (87%) compared with those with unstable nonun- the proximal fragment, and ideally the screw should be placed ions (60%) (Table III).49 orthogonal to the plane of the fracture. If the fragment is too Malunion. Malunion is usually a flexion deformity of scaphoid small to accept such a screw, then Kirschner wires can be used but can be an ulnar translation or pronation of the distal frag- to hold the fracture reduced, and sometimes trans-articular fix- ment. The effect of malunion of the scaphoid on wrist function ation is required. Union rate after open reduction and internal remains unclear. In a study on cadavers, the simulated scaphoid fixation is around 66%.43 malunion reduced wrist extension and this was proportional to Outcome. After a healed fracture, 20% patients have some pain the angular deformity.50 Clinical studies have, however, shown and tenderness at 1.7 to 2.6 years but grip strength and wrist that mild malunion is well-tolerated.51,52 Treated nonunion53 can movement were nearly normal.44 Marked radiocarpal osteo- lead to malunion with a humpback scaphoid and this has previ- arthritis developed in only 2% of cases 36 years after a healed ously been reported to have a significant impairment of function fracture and can be associated with pain or weakness; work has and restriction of movements but it is not clear whether it leads shown that osteoarthritis can develop in only 6% of patients who to early osteoarthritis. do not have any symptoms on re-examination, compared with Avascularity. Increased radio-opacity of the proximal fragment is three of the seven who had symptoms.45 thought to represent avascular necrosis of the scaphoid. There is poor agreement between observers on whether the proximal part Complications of the scaphoid was avascular in radiographs taken 12 weeks Nonunion46,47 (Fig. 5) (Table III). after a scaphoid fracture.30 This appearance is a poor predictor of • Untreated nonunion: Asymptomatic patients with an undis- vascularity of scaphoid seen at operation. Vascularity can also be placed, stable non-union should be advised of the possibility assessed at the time of surgery and by taking a biopsy. Biopsy of late degenerative changes.48 Osteoarthritis is found in can, however, be misleading because of the patchy pattern of 100% of patients with symptomatic nonunion after 10 year avascular necrosis and the sample can contain both viable and but symptoms do not correlate with the severity of arthritis or dead osteocytes.54 Radionuclide bone scanning is sensitive and the duration of nonunion. Long-term follow-up after untreated can reveal early avascular necrosis but is inaccurate in acute frac- scaphoid nonunion has shown radiological osteoarthritis but tures and is not quantifiable.55 Gadolinium contrast-enhanced many patients retain satisfactory function. MR imaging quantifies the extent of necrosis of the proximal frag- • Treated nonunion: The overall union rate of scaphoid nonun- ment and has a good correlation with surgical and histologic find- ions treated by Herbert screw and bone grafting was 84% but ings and the subsequent healing of the nonunion.25 6 H. P. SINGH, J. J. DIAS

Table III. Classification systems for scaphoid nonunion Number Type of Issues Treatment options Slade and Mack and Gupta49 Nonunion (Dias46) Geissler Lichtman (Treatment)32 (Treatment)47 Fixation Grafting Revasculariza- Pain-relieving tion procedures 1No DeformityStability Percutaneous Cancellous Grade I Type I Group 1 Early Percutaneous Cancellous Acute fractures Non-displaced Fractures with Cystic with late presen- stable nonunion delayed Union tation (rigid fixa- without degen- tion) erative changes Group 2 (bone grafting Stable Nonunion Grade II with or without Fibrous union hardware) (rigid fixation) 2 Mobile Stability/ Open reduction Usually cortic- Rarely Grade III Type II Group 3A reconstruction cancellous Cancellous Correctly aligned Unstable owing Nonunion alone nonunions with to fragment dis- without DISI <1mm gap (rigid placement, fixation) require (restora- Group 3B tion normal car- Nonunion with Grade IV pal stability with DISI deformity Non-unions with graft) cystic changes between 1 and 5mm. (debride- ment, bone grafting and rigid fixation) 3 Deformed Reconstruction Open reduction Tricortical Grade V Type III Stable fixation Non-unions with Accompanying may require Russe deformity requir- mild arthritis second wire ing structural (Initial radiocar- bone grafting pal then narrow- ing between the radius and scaphoid) (ORIF with bone graft with or without radial styloidec- tomy) 4 Osteonecrotic Prevent Collapse Vascularised Grade VI bone graft Non-unions with necrosis (vascu- Palmar or larised bone Radial graft) and nonunions with SNAC deformity (scaphoid excision and carpal reconstruction 5 Arthritic Pain Denervation, Type IV Management Exostectomy, Midcarpal arthri- Partial scaphoid tis without radio- excision, lunate arthritis Partial/Full (partial/ com- fusion plete wrist arthrodesis)

Type V Midcarpal arthritis & radio- lunate arthritis (partial/ com- plete wrist arthrodesis)

Summary deformity, proximal pole fractures, associated perilunate inju- We treat almost all our patients with a scaphoid fracture in a ries, open fractures, and fractures in multiply injured patients. below elbow plaster with the thumb free for 6–8 weeks. At that Other decision-making factors are whether there is a great stage, if there is any doubt about union, we get a CT scan and potential for morbidity from prolonged immobilization, the occu- operate if needed. We consider surgery for displaced scaphoid pation of the patient, and a clear failure of healing after non- fractures causing dorsal intercalated segment instability (DISI) operative treatment of the fracture.

THE JOURNAL OF BONE AND JOINT SURGERY SCAPHOID FRACTURES 7

H P Singh MRCS Ed, MS Specialty Registrar 26. Downing ND, Oni JA, Davis TR, Vu TQ, Dawson JS, Martel AL. The relationship Joseph J Dias MD, FRCS Professor between proximal pole blood flow and the subjective assessment of increased den- sity of the proximal pole in acute scaphoid fractures. J Hand Surg Am 2002;27-3:402- University Hospitals of Leicester NHS Trust, Leicester General Hospital 8. Gwendolen Road, Leicester LE5 4PW 27. Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ. Need the thumb be immo- bilised in scaphoid fractures? A randomised prospective trial. J Bone Joint Surg [Br] 1991;73-B:828-32. Correspondence 28. McAdams TR, Spisak S, Beaulieu CF, Ladd AL. The effect of pronation and supi- Mr. Harvinder Pal Singh, Department of Orthopaedic Surgery, University nation on the minimally displaced scaphoid fracture. Clin Orthop 2003-411:255-9. Hospitals of Leicester, Gwendolen Road, Leicester LE5 4PW 29. Hambidge JE, Desai VV, Schranz PJ, Compson JP, Davis TR, Barton NJ. Acute Telephone: 0116 2584702; Fax Number: 0116 2502676; E-mail: fractures of the scaphoid. Treatment by cast immobilisation with the wrist in flexion or extension? J Bone Joint Surg [Br] 1999;81-B:91-2. [email protected] 30. Dias JJ, Taylor M, Thompson J, Brenkel IJ, Gregg PJ. Radiographic signs of union of scaphoid fractures. An analysis of inter-observer agreement and reproduci- bility. J Bone Joint Surg [Br] 1988;70-B:299-301. References 31. Yin ZG, Zhang JB, Kan SL, Wang P. Treatment of acute scaphoid fractures: system- 1. Compson JP, Waterman JK, Heatley FW. The radiological anatomy of the atic review and meta-analysis. Clin Orthop 2007;460:142-51. scaphoid. Part 1: Osteology. J Hand Surg Br 1994;19-2:183-7. 32. Slade JF, 3rd, Geissler WB, Gutow AP, Merrell GA. Percutaneous internal fixa- 2. Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am tion of selected scaphoid nonunions with an arthroscopically assisted dorsal 1980;5-5:508-13. approach. J Bone Joint Surg [Am] 2003;85-A (Suppl 4):20-32. 3. Bettinger PC, Linscheid RL, Berger RA, Cooney WP, 3rd, An KN. An anatomic 33. Rettig ME, Kozin SH, Cooney WP. Open reduction and internal fixation of acute study of the stabilizing ligaments of the trapezium and trapeziometacarpal joint. J displaced scaphoid waist fractures. J Hand Surg Am 2001;26-2:271-6. Hand Surg Am 1999;24-4:786-98. 34. Grewal R, King GJ. An evidence-based approach to the management of acute 4. Weber ER, Chao EY. An experimental approach to the mechanism of scaphoid waist scaphoid fractures. J Hand Surg Am 2009;34-4:732-4. fractures. J Hand Surg Am 1978;3-2:142-8. 35. Buijze GA, Doornberg JN, Ham JS, Ring D, Bhandari M, Poolman RW. Surgical 5. Cockshott WP. Distal avulsion fractures of the scaphoid. Br J Radiol 1980;53- compared with conservative treatment for acute nondisplaced or minimally displaced 635:1037-40. scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. J Bone Joint Surg [Am] 2010;92-A:1534-44. 6. Horii E, Nakamura R, Watanabe K, Tsunoda K. Scaphoid fracture as a “puncher's fracture.” J Orthop Trauma 1994;8-2:107-10. 36. Davis EN, Chung KC, Kotsis SV, Lau FH, Vijan S. A cost/utility analysis of open reduction and internal fixation versus cast immobilization for acute nondisplaced mid- 7. Freeland P. Scaphoid tubercle tenderness: a better indicator of scaphoid fractures? waist scaphoid fractures. Plast Reconstr Surg 2006;117-4:1223-35; discussion 36-8. Arch Emerg Med 1989;6-1:46-50. 37. Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M. Fixation of 8. Munk B, Bolvig L, Kroner K, Christiansen T, Borris L, Boe S. Ultrasound for diag- nondisplaced scaphoid fractures: making treatment cost effective. Prospective con- nosis of scaphoid fractures. J Hand Surg Br 2000;25-4:369-71. trolled trial. Arch Orthop Trauma Surg 2007;127-1:39-46. 9. Chen SC. The scaphoid compression test. J Hand Surg Br 1989;14-3:323-5. 38. Gelberman RH, Wolock BS, Siegel DB. Fractures and non-unions of the carpal 10. Parvizi J, Wayman J, Kelly P, Moran CG. Combining the clinical signs improves scaphoid. J Bone Joint Surg [Am] 1989;71-A:1560-5. diagnosis of scaphoid fractures. A prospective study with follow-up. J Hand Surg Br 39. Trumble TE, Clarke T, Kreder HJ. Non-union of the scaphoid. Treatment with can- 1998;23-3:324-7. nulated screws compared with treatment with Herbert screws. J Bone Joint Surg 11. Russe O. Follow-up study results of 22 cases of operated old fractures and pseudar- [Am] 1996;78-A:1829-37. throses of the scaphoid bone of the hand. Z Orthop Ihre Grenzgeb 1960;93:5-14. 40. Singh HP, Forward D, Davis TR, Dawson JS, Oni JA, Downing ND. Partial union 12. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone of acute scaphoid fractures. J Hand Surg Br 2005;30-5:440-5. screw. J Bone Joint Surg [Br] 1984;66-B:114-23. 41. Riester JN, Baker BE, Mosher JF, Lowe D. A review of scaphoid fracture healing 13. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational in competitive athletes. Am J Sports Med 1985;13-3:159-61. approach to management. Clin Orthop 1980-149:90-7. 42. Kozin SH. Incidence, mechanism, and natural history of scaphoid fractures. Hand Clin 14. Prosser AJ, Brenkel IJ, Irvine GB. Articular fractures of the distal scaphoid. J 2001;17-4:515-24. Hand Surg Br 1988;13-1:87-91. 43. Cooney WP, Linscheid RL, Dobyns JH, Wood MB. Scaphoid nonunion: role of 15. Compson JP, Waterman JK, Heatley FW. The radiological anatomy of the anterior interpositional bone grafts. J Hand Surg Am 1988;13-5:635-50. scaphoid. Part 2: Radiology. J Hand Surg Br 1997;22-1:8-15. 44. Dias JJ, Brenkel IJ, Finlay DB. Patterns of union in fractures of the waist of the 16. Leslie IJ, Dickson RA. The fractured carpal scaphoid. Natural history and factors scaphoid. J Bone Joint Surg [Br] 1989;71-B:307-10. influencing outcome. J Bone Joint Surg [Br] 1981;63-B-2:225-30. 45. Duppe H, Johnell O, Lundborg G, Karlsson M, Redlund-Johnell I. Long-term 17. Hunter JC, Escobedo EM, Wilson AJ, Hanel DP, Zink-Brody GC, Mann FA. MR results of fracture of the scaphoid. A follow-up study of more than thirty years. J Bone imaging of clinically suspected scaphoid fractures. Am J Roentgenol 1997;168- Joint Surg [Am] 1994;76-A:249-52. 5:1287-93. 46. Gunal I, Barton NJ, Calli I. Current management of scaphoid fractures: twenty 18. DaCruz DJ, Bodiwala GG, Finlay DB. The suspected fracture of the scaphoid: a questions answered. London: Royal Society of Medicine Press, 2002:ix, 110 p. rational approach to diagnosis. Injury 1988;19-3:149-52. 47. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non- 19. Bain GI, Bennett JD, Richards RS, Slethaug GP, Roth JH. Longitudinal computed union. J Bone Joint Surg [Am] 1984;66-A:504-9. tomography of the scaphoid: a new technique. Skeletal Radiol 1995;24-4:271-3. 48. Inoue G, Sakuma M. The natural history of scaphoid non-union. Radiographical and 20. Sanders WE. Evaluation of the humpback scaphoid by computed tomography in the clinical analysis in 102 cases. Arch Orthop Trauma Surg 1996;115-1:1-4. longitudinal axial plane of the scaphoid. J Hand Surg Am 1988;13-2:182-7. 49. Gupta A, Risitano G, Crawford RJ, Burke FD. The Ununited Scaphoid:Prognostic 21. Kukla C, Gaebler C, Breitenseher MJ, Trattnig S, Vecsei V. Occult fractures of Factors in Delayed and Nonunions of the Scaphoid. Hand Surg 1999;4-1:11-19. the scaphoid. The diagnostic usefulness and indirect economic repercussions of radi- 50. Burgess RC. The effect of a simulated scaphoid malunion on wrist motion. J Hand ography versus magnetic resonance scanning. J Hand Surg Br 1997;22-6:810-3. Surg Am 1987;12-5 Pt 1:774-6. 22. Fowler C, Sullivan B, Williams LA, McCarthy G, Savage R, Palmer A. A com- 51. Forward DP, Singh HP, Dawson S, Davis TR. The clinical outcome of scaphoid parison of bone scintigraphy and MRI in the early diagnosis of the occult scaphoid fracture malunion at 1 year. J Hand Surg Eur Vol 2009;34-1:40-6. waist fracture. Skeletal Radiol 1998;27-12:683-7. 52. Dias JJ, Wildin CJ, Bhowal B, Thompson JR. Should acute scaphoid fractures be 23. Hauger O, Bonnefoy O, Moinard M, Bersani D, Diard F. Occult fractures of the fixed? A randomized controlled trial. J Bone Joint Surg [Am] 2005;87-A:2160-8. waist of the scaphoid: early diagnosis by high-spatial-resolution sonography. Am J Roentgenol 2002;178-5:1239-45. 53. Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP, 3rd, Linscheid RL. Scaphoid malunion. J Hand Surg Am 1989;14-4:679-87. 24. Fusetti C, Poletti PA, Pradel PH, Garavaglia G, Platon A, Della Santa DR, Bianchi S. Diagnosis of occult scaphoid fracture with high-spatial-resolution sonog- 54. Urban MA, Green DP, Aufdemorte TB. The patchy configuration of scaphoid avas- raphy: a prospective blind study. J Trauma 2005;59-3:677-81. cular necrosis. J Hand Surg Am 1993;18-4:669-74. 25. Munk PL, Lee MJ. Gadolinium-enhanced MR imaging of scaphoid nonunions. Am J 55. Reinus WR, Conway WF, Totty WG, Gilula LA, Murphy WA, Siegel BA, Weeks Roentgenol 2000;175-4:1184-5. PM, Young VL, Manske PR. Carpal avascular necrosis: MR imaging. Radiology 1986;160-3:689-93.