PART III WRIST
chapter
18  Fractures of the Carpal Bones
William B. Geissler and Joseph F. Slade
In 1996, Barton described the scaphoid as an “awkward but
important little bone” as he recounted its treatment from the
1950s, beginning with Harrison McLaughlin of Columbia-
Presbyterian Hospital.13 While much has been learned since
the 1950s, little has changed: the scaphoid remains an
“awkward but important little bone.” If all bones heal by the
same process, why are scaphoid fractures difficult to heal?
Often, one’s experience reflects the problems that present
and the timing of their presentation. Problems with manage-
ment of this fracture start with a failure to make a timely
diagnosis; other issues include systemic and local factors, the
extent of injury, and inappropriate treatment.
Bone healing is a complex process requiring viable bone
cells and blood supply and continuous bone-to-bone contact
with minimal shearing at the fracture site. Fractures of all
carpal bones have been reported, but none have challenged
the surgeon as much as the scaphoid. Healing of scaphoid
injuries is particularly impeded as this carpal bone links the
proximal and distal carpal row and hence is subjected to
continuous shearing and bending forces during recovery.
Our understanding of the process of bone healing and the
forces acting at a fracture site has resulted in a more orga-
nized treatment protocol and greater success at achieving
fracture union. Within the past two decades, percutaneous
methods of scaphoid repair have been developed to minimize
additional surgical trauma and optimize stabilization until
healing. Percutaneous fixation has been demonstrated to
have a higher union rate than cast treatment and has rela-
tively few complications. A minimally invasive approach
allows the patient or athlete to return to work or sports
within weeks or months, whereas a failed attempt at healing
with cast immobilization can result in months of lost time,
compounded by the increased complexity, cost, and compli-
cations of nonunion repair. This chapter will explore the
mechanics, biology, and modern treatment regimens for frac-
tures of the scaphoid and neighboring carpal bones.
Joseph Slade passed away prior to this chapter going to press. His coauthors
and editors would like to dedicate this chapter in his memory. Dr. Slade
was a gifted surgeon and creative thinker who has helped transform the
way scaphoid fractures are treated worldwide. Dr. Slade showed an unbri-
dled enthusiasm for the art and science of upper extremity surgery and was
a dedicated and compassionate mentor for a generation of surgeons who
trained with him. May peace be with him.
INCIDENCE AND ETIOLOGY OF
SCAPHOID FRACTURES
The scaphoid is the most commonly fractured carpal bone.
Scaphoid fractures account for 60% to 70% of all carpal
fractures and are second in frequency only to distal radius
fractures. The majority of injuries are low-energy injuries,
either from a sporting event (59%) or from a fall onto an
outstretched wrist (35%); the remainder result from high-
energy trauma such as from a fall from a height or a motor
vehicle injury. Howe documented that 82% of the scaphoid
fractures in Norway occur in males, with an average age of
25 (range, 11 to 79 years).73 The age-specific incidence in
males remained significantly higher than that in females until
age 60, at which point the incidences were similar. The
annual incidence was 43 per 100,000 people, and scaphoid
fractures accounted for 11% of hand fractures and 60% of
carpal fractures.2 The statistics were similar in Larsen’s series;
the mechanism for scaphoid fracture was a fall in 69% of
cases and a blow to the wrist in 28% of cases.92
More recently, Wolf studied a large U.S. military popula-
tion and found a greater incidence of scaphoid fracture than
the previous data, 121 per 100,000 person-years.175 Males
and the 20- to 24-year-old age group were associated with
higher rates of scaphoid injury.175 The more active nature of
the occupations of this population may explain this higher
incidence. With an increased participation of women in
sports and the greater fascination with “extreme sports,” we
might expect an increased incidence in scaphoid injuries.
SCAPHOID ANATOMY
Bony and Ligamentous Anatomy
The carpal bones are aligned in two rows of matching concave
and convex gliding surfaces. The carpal rows are supported
by stout intrinsic ligaments and reinforced by a complex
system of volar and dorsal extrinsic ligaments. The scaphoid
is the only carpal bone that bridges the proximal and distal
carpal rows and acts as a tie-rod. The scaphoid is a bean-
shaped bone, approximately 80% of which is covered by
cartilage, limiting ligamentous attachment and vascular
supply (Figure 18.1).1,7,15
The scaphoid is divided into three regions: proximal
pole, waist, and distal pole (tubercle). The proximal pole
articulates with the scaphoid fossa of the distal radius and
the lunate. The scaphoid is oriented in the carpus with an
639
PART
III
18  X
Wrist

A B
Figure 18.1  A, A three-dimensional reconstruction of the scaphoid, constructed from CT images of 25 normal wrists. Note the
scaphoid’s position spanning the proximal and distal carpal rows and acting as a “tie-rod” to coordinate smooth carpal motion.
B, 80% of the normal scaphoid surface is covered by articular cartilage. The scaphoid derives its name from its peculiar “boat”
or “skiff” contour. (A, From Joseph J. Crisco, PhD, Department of Orthopaedics, The Alpert Medical School of Brown University and
Rhode Island Hospital.)

SLId
SLId

SLIm

DIC
SC

STT

RSC
SLIp RSC

A B

Figure 18.2  Ligamentous attachments to the radial and ulnar aspects of the scaphoid. A, Medial surface of a right scaphoid
demonstrating the attachment zones of the scaphocapitate ligament (SC), the radioscaphocapitate ligament (RSC), and the
dorsal (SLId), membranous (SLIm), and palmar (SLIp) regions of the scapholunate interosseous ligament. B, Right scaphoid from
a dorsal radial perspective demonstrating the attachment zones of the scaphotrapezial-trapezoid ligament (STT),
radioscaphocapitate ligament (RSC), dorsal intercarpal ligament (DIC), and dorsal region of the scapholunate interosseous
ligament (SLId). (Copyright Elizabeth Martin.)

intrascaphoid angle averaging 40 ± 3 degrees in the coronal
plane and 32 ± 5 degrees in the sagittal plane.7,15 The scaph-
olunate interosseous ligament (SLIL) is a stout ligament con-
necting the scaphoid to the lunate. The dorsal aspect of this
ligament is composed of transverse collagen fibers, whereas
the palmar ligament is composed of oblique collagen fibers
inserting to the volar capsular ligaments. The dorsal portion
is twice as strong as the anterior portion. Only 20 to 30
degrees of motion is possible at an intact scapholunate inter-
val.2 The dorsal and palmar regions are critical in maintaining
normal carpal kinematics and function of the scapholunate
interval. The dorsal region resists palmar-dorsal translation
and gap, whereas the volar portion resists rotation. The prox-
imal fibrocartilaginous region is the weakest mechanically
and is well suited to accept the compression and shear loads
at the radiocarpal joint.
A morphologic analysis of the scaphoid by McLean and
colleagues has indicated variations in the morphology of the
scaphoid that can be classified into two types.107 In type 1, a
640
rotating or arclike scaphoid is characterized by a single high
crest obliquely oriented across the dorsal aspect of the waist;
in type 2, three lower crests are oriented along the spine of
the scaphoid. These ridges correspond to the attachment of
the dorsal joint capsule and, significantly, the dorsal intercar-
pal (DIC) ligament and fibers of the radioscaphocapitate
(RSC) ligament radially (Figure 18.2). The RSC ligament
originates from the radial styloid, lies in the volar concavity
of the scaphoid waist, and proceeds ulnarly toward the capi-
tate, acting as a fulcrum around which the scaphoid rotates.
It contains a high density of mechanoreceptors, suggesting a
mechanical and proprioceptive role. In wrists with a type 2
(flexing) scaphoid, the RSC ligament is attached to the waist
of the scaphoid before passing to the capitate, whereas in
wrists with type 1 (rotating) scaphoids, the RSC ligament has
no scaphoid attachments.
The DIC ligament is a stabilizer of the wrist and a dorsal
check for the proximal capitate. It inserts onto the proximal
crest of the scaphoid waist in a flexing (type 2) scaphoid,
whereas in the rotating (type 1) scaphoid it passes over the
scaphoid without attachment to reach the margin of the sca-
photrapeziotrapezoidal complex. The DIC ligament is richly
innervated with nerve endings from the posterior interosse-
ous nerve. It is reinforced by the dorsal radiocarpal ligament
that extends distally in an oblique ulnar direction from the
dorsal lip of the radius to attach to the dorsal aspect of the
triquetrum. The radiocarpal ligament prevents ulnar drift of
the carpus.
The distal scaphoid pole articulates with the capitate, trap-
ezoid, and trapezium. Its ulnar border forms a concave facet
accommodating the capitate head. This facet may be elon-
gated and shallow when associated with a rotating scaphoid
(type 1) or round and deep with a flexing scaphoid (type 2).
1 along the dorsal scaphoid ridge, and the majority of the
2 to dorsal crests. The major palmar blood vessels arise from
Figure 18.3  Gelberman and colleagues in 1980 studied the
intraosseous vascular anatomy of the scaphoid in fresh cadaver
limbs by injection and Spalteholz clearing techniques. Two major
vascular pedicles (1 and 2) supply the scaphoid, and the proximal
pole is vascularized nearly exclusively from intraosseous vessels.
(From Gelberman RH, Menon J: The vascularity of the scaphoid bone,
J Hand Surg [Am] 5:508-513, 1980.)
VOLAR
Superficial
palmar branch
of radial artery
Radial artery
Figure 18.4  Schematic representation of the blood supply of the scaphoid. (Copyright Elizabeth Martin.)
The scaphocapitate ligament originates from the distal scaph- PART
oid at the border between the trapezoid facet and the capitate III
facet. It inserts into the volar waist of the capitate distal to the
RSC ligament. This ligament, along with the scaphotrapezial
18 
ligament, functions as a primary restraint of the distal pole.
Wrist: Fractures of the Carpal Bones
Vascular Anatomy
In 1980, Gelberman and colleagues studied the extraosseous
and intraosseous vascularity of the human carpus (Figure
18.3).58 They studied 15 fresh cadaver scaphoids by injection
and clearing techniques and determined that the major blood
supply to the scaphoid is via the radial artery: 70% to 80%
of the intraosseous vascularity and the entire proximal pole
is from branches of the radial artery entering through the
dorsal ridge. This vessel and its branches enter distally and
dorsally on the scaphoid. The dorsal vessels travel proximally
vessels enter the scaphoid waist and continue as intraosseous
vessels (Figure 18.4). Volar radial artery branches provide
the blood supply to 20% to 30% of the bone in the region
of the distal tuberosity. There is excellent collateral circula-
tion to the scaphoid by way of the dorsal and volar branches
of the anterior interosseous artery.
The major dorsal blood vessels branch off the radial artery
and enter the bone through small foramina located adjacent
either the radial artery directly or the superficial palmar arch
and divide into several smaller branches before coursing
obliquely and distally over the palmar aspect of the scaphoid
to enter through the region of the tubercle. Because of its
dependence on a singular dominant intraosseous vessel, the
scaphoid proximal pole is uniquely susceptible to avascular
necrosis following fracture. Gelberman and colleagues pro-
posed that the volar operative approach would be the least
traumatic to the proximal pole’s blood supply.58
DORSAL
Dorsal
carpal branch
of radial artery
641
PART
III
18 
Wrist

A B C
Figure 18.5  Bindra studied the microarchitecture of the scaphoid using microcomputed tomography. Using this tool, he
determined that the trabecular pattern varies by the region of the scaphoid. At the proximal pole (A) and distal pole (C), the
trabeculae are closely packed. At the waist (B), the trabeculae are laid along the vascular channels. By virtue of their orientation
and distribution, the trabeculae are more spaced out and less dense at the waist. Bindra’s data suggests that the waist is
structurally the weakest part of the bone, which may be one of the factors contributing to the high numbers of fractures
observed at the scaphoid waist. (Personal communication).

The radioscaphoid ligament (ligament of Kuenz and Testut)
is a soft tissue vascular pedicle comprising arterioles, venules,
and small nerves. It is positioned between the scaphoid and
lunate fossa and inserts palmar to the membranous part of
the SLIL. The arterioles originate from the radiocarpal arch.
Handley and colleagues found that the venous drainage from
the proximal pole of the scaphoid was via the dorsal ridge
into the venae comitantes of the radial artery.64
Anthropometry of the Scaphoid
Heinzelmann and colleagues performed morphometric eval-
uation of the human scaphoid, measuring the long axis from
the proximal pole to the distal articular surface.66 Male scaph-
oids were significantly longer (by 4 mm) than female speci-
mens and were also significantly wider in their proximal pole
than the female specimens. When considering operative fixa-
tion from an antegrade approach, the authors suggested that
small screw sizes may be necessary for female patients, as
many of the commercially available standard screws are
larger than the proximal pole of the female scaphoid.
The majority of scaphoid fractures occur at the waist, and
this higher incidence may also be related to the structural
properties of the bone. Bindra, using microcomputed tomog-
raphy (µCT), studied five cadaveric scaphoid specimens with
a slice thickness of 36 µm (unpublished data). He found that
the bone is most dense at the proximal pole, where the tra-
beculae are the thickest and are more tightly packed. In
contrast, at the waist, trabeculae are thinnest and are more
sparsely distributed (Figure 18.5).
BIOMECHANICS OF SCAPHOID
FRACTURES AND IMPLICATIONS
OF NONUNION
Although the exact mechanism of fracture is not completely
understood, the primary requirement appears to be a hyper-
642
extension injury of the wrist past 95 degrees.171 A fracture
of the scaphoid usually begins at the volar waist with a tensile
failure; the forces propagate to the dorsal surface with com-
pression loading, until failure occurs. In another cadaveric
study, wrists placed in extreme dorsiflexion and ulnar devia-
tion produced fractures through the scaphoid waist as the
scaphoid impinged on the dorsal rim of the radius. Proximal
scaphoid fractures resulted from dorsal subluxation during
forced hyperextension. Axial loading has also been postu-
lated to produce scaphoid fractures,72 as has hyperflexion of
the wrist. Carpal dislocations and scapholunate ligament
tears were reproduced with wrist extension and ulnar devia-
tion, combined with intercarpal supination.
As with any fracture, the potential for healing relies on the
fracture’s location and vascularity. Scaphoid fractures heal
by intramembranous ossification; this presents unique prob-
lems for scaphoid healing, because without fracture callus to
provide initial stability, potentially disruptive forces remain
unchecked. This is a particularly difficult problem for the
athlete, who has only a limited period of convalescence
before trying to return to his or her former level of competi-
tion. Premature wrist loading results in progressive flexion
of the distal scaphoid and pronation of the distal scaphoid
pole. The more proximal the fracture, the more the limited
blood supply increases the risk of nonunion and avascular
necrosis (AVN). Given these difficult healing conditions, dis-
placed fractures are associated with a high rate of nonunion.
Fracture displacement of greater than 1 mm or angulation
greater than 15 degrees are accepted risk factors for
nonunion.
Displacement of a scaphoid fracture depends on force loca-
tion and direction and on the plane of the fracture. These
complex forces can be divided into bending, shearing, and
translational forces. Untreated fractures of the waist are
subject to varying degrees of these forces and will predictably
angulate as volar bone is reabsorbed, yielding a “humpback”
of flexion deformity of the scaphoid. Simultaneous extension
of the lunate through its attachment to the proximal scaphoid
fragment and flexion of the distal scaphoid results in a dorsal
intercalated segmental instability (DISI) deformity. Ultimate
treatment of a humpback scaphoid nonunion with DISI
requires both restitution of scaphoid anatomy and reversal
of the secondary changes in carpal kinematics.
Untreated scaphoid nonunion will predictably progress to
arthritic change, in what has been termed scaphoid nonunion
advanced collapse (SNAC). Arthritic change arises at the
radial styloid articulation with the distal scaphoid pole and
is followed by degeneration of the midcarpal joint and ulti-
mately by pan-carpal arthritis. Arthritic changes have been
found in 97% of the patients assessed at least 5 years after
injury, with the degree of arthritic changes being proportion-
ate to the duration of nonunion.98 Patients generally present
with escalating mechanical pain, with limitations in range of
motion. Duppe reviewed 30-year follow-up results of scaph-
oid fractures treated with thumb spica short arm casts. Ten
percent of the patients developed nonunion; 60% of these
demonstrated radiographic evidence of radiocarpal osteoar-
throsis, while only 2% of the healed group demonstrated
degenerative change.41
EXAMINATION AND IMAGING OF
THE SCAPHOID
The diagnosis of a scaphoid fracture is based on clinical sus-
picion, a supporting history, examination, and selected
imaging. After a low-energy injury, the patient typically pre­
sents with low-grade wrist pain. A history of a higher energy
fall with forced hyperextension or palmar flexion, a collision,
or a direct blow to the wrist from a ball or stick should raise
suspicion of a concomitant carpal injury. Patients in the acute
setting will demonstrate swelling, limited range of motion,
tenderness with palpation in the anatomic snuffbox, and pain
with axial loading along the thumb. In chronic presentations,
patients may complain of decreased wrist motion, weakness,
inability to perform pushups, and radial-sided wrist pain.
AUTHORS’ PREFERRED TREATMENT:
DIAGNOSTIC IMAGING
Up to 25% of scaphoid fractures are not visible on initial
radiographs. Plain radiographs for the patient with a sus-
pected scaphoid injury should include posteroanterior (PA),
lateral, oblique, scaphoid (partially supinated PA with ulnar
deviation), and clenched-fist anteroposterior (AP) views.
Unless the x-ray beam lies in the same plane as the fracture,
the fracture line may be missed. Because failure to treat a
stable scaphoid fracture within 4 weeks increases the non-
union rate, all clinically suspected scaphoid fractures are
treated as fractures with short arm cast immobilization until
the cause of the symptoms is clarified. Follow-up radiographs
and clinical examination out of plaster are performed at 10
to 12 days. If a fracture is clinically suspected in the presence
of negative follow-up radiographs, we prefer magnetic reso-
nance imaging (MRI). At our institution, MRI is the most
reliable imaging modality for the diagnosis of acute and
occult fractures and is generally diagnostic within 24
hours of injury. I use computed tomography (CT) only to
provide additional information about the architecture or
PART
III
18 
Wrist: Fractures of the Carpal Bones
HO T VO
Figure 18.6  Classification of fractures of the scaphoid (Russe).
HO, horizontal oblique; T, transverse; VO, vertical oblique. (From
Taleisnik J: The Wrist, New York, Churchill Livingstone, 1985.
Redrawn by Elizabeth Martin.)
displacement of the fracture and to provide guidance in
treatment.
Scaphoid healing cannot be reliably determined by stan-
dard radiographs at 3 months37; CT provides enhanced reso-
lution and more definitive information regarding healing.
Most acutely treated scaphoid fractures require approxi-
mately 3 months to heal.
SCAPHOID FRACTURE CLASSIFICATION
AND IMPLICATIONS FOR TREATMENT
Scaphoid fractures have been classified by fracture plane,
location, and stability. The goal of a fracture classification is
to guide management of injuries to produce rapid healing
with minimal complications and allow a quick return to work
or sports. The consequences of failed healing include a loss
of wrist motion, loss of grip strength, wrist pain, and prema-
ture articular degeneration. Of particular importance is iden-
tifying which scaphoid fractures require surgical intervention
to heal. A failure to identify unstable scaphoid fractures and
treat accordingly will predictably result in 6 months or more
of additional treatment and restricted activities.
One of the earliest efforts to identify unstable fractures was
to examine the scaphoid fracture plane. Russe recognized
that oblique fractures were unstable (Figure 18.6), were dif-
ficult to control with immobilization, and resulted in an
increased rate of nonunion.129 Herbert and Fisher classified
scaphoid fractures according to their stability67 (Figure 18.7).
Stable fractures, classified as type A, included incomplete
fractures or fractures of the scaphoid tubercle. The authors
stated that these fractures could be safely treated with immo-
bilization with expectation of a high rate of union. All other
fractures were considered potentially unstable and merited
rigid fixation, a point of some controversy. Despite the asser-
tions of these authors, however, Desai and colleagues were
unable to predict fracture union with closed treatment using
either the Russe or the Herbert classification systems.35
Cooney further modified fracture classification by identify-
ing unstable injuries.30 These included fractures with greater
than 1 mm of displacement, a lateral intrascaphoid angle
greater than 35 degrees, bone loss or comminution, perilu-
nate fracture-dislocation, DISI alignment, and proximal pole
fractures. He advocated open surgical fixation for all unstable
injuries.
643
PART
III Type A:
Stable acute fractures
18 
A1
Wrist

Incomplete fracture
through waist
A1
Fracture of
tubercle

Type B:
Unstable acute fractures

B4

B1 B2 B3
Trans-scaphoid
Distal oblique Complete fracture Proximal pole perilunate
fracture of waist fracture fracture-dislocation
of carpus

Type C:
Delayed union

C
Delayed union

Type D:
Established nonunion

D1 D2
Fibrous union Pseudarthrosis

Figure 18.7  Herbert has devised an alphanumeric classification system that may have prognostic significance. (From Herbert TJ:
The Fractured Scaphoid, St Louis, Quality Medical Publishing, 1990. Redrawn by Elizabeth Martin.)

MANAGEMENT OF SCAPHOID
is well vascularized, and distal scaphoid pole fractures have
FRACTURES AND NONUNIONS a high rate of union after 6 to 8 weeks of plaster immobiliza-
(Table 18.1) tion in a short arm cast. The two predominant distal fracture
types treated in plaster immobilization are (1) avulsion frac-
Nonoperative Treatment of Acute tures from the radiopalmar lip of the scaphoid tuberosity and
Scaphoid Fractures in Adults (2) impaction fractures of the radial half of the distal scaphoid
Distal Pole Fractures articular surface. However, malunion of impacted radial-
Distal pole and tubercle fractures of the scaphoid are gener- sided compression fractures may result in symptomatic
ally treated nonoperatively. The distal pole of the scaphoid degenerative arthritis. When in doubt, CT can delineate the
644
 bilization of the elbow produced no long-term disability. PART
ALGORITHM FOR ACUTE SCAPHOID
FRACTURE MANAGEMEN Displaced fractures were excluded from this study, and the III
minimum follow-up was 6 months. This carefully conducted
study is probably the best evidence in favor of the long arm
18 
Type of Fracture Treatment
cast for the initial immobilization period.

Wrist: Fractures of the Carpal Bones

Stable Fractures, Nondisplaced
Tubercle fracture
Distal third fracture/incomplete
fracture
Waist fracture
Proximal pole fracture,
nondisplaced
Unstable Fractures
Displacement >1 mm
Lateral intrascaphoid angle
>35°
Bone loss or comminution
Perilunate fracture-dislocation
Dorsal intercalated segmental
instability alignment
Table 18.1  Algorithm for Acute Scaphoid Fracture Management
Short arm cast for 6 to 8
weeks
Short arm cast for 6 to 8
weeks
Long arm thumb spica cast for
6 weeks, short arm cast
for 6 weeks or until CT
confirmed healing,
especially for
Pediatric patients
Sedentary or low-demand
patients
Preference for nonoperative
treatment
Percutaneous or open internal
fixation, especially for
Active, young, manual
worker
Athlete, high-demand
occupation
Preference for early range of
motion
Percutaneous or open internal
fixation
Dorsal percutaneous/open
screw fixation
There is no agreement in the literature as to the optimum
position of immobilization or type of cast, suggesting that
truly stable fractures can be treated in a variety of casts (for
instance, thumb spica casts, wrist extension casts, wrist
neutral casts, ulnar deviation casts) with nearly equivalent
results. Historical literature suggests that the union rate after
cast treatment approaches 90% to 95%; however, there is
little consensus on the definition of healing in the absence of
radiography. Radiographs taken 6 to 12 months after injury
and CT more reliably show fracture healing and tend to show
lower rates of union. At 1 year after injury, Terkelsen had
10 nonunions in 92 waist fractures that were treated with
either a removable splint or long arm cast.154
Displacement of the fracture is a strong risk factor for
delayed or failed union. Therefore, the distinction between
stability and instability is the basis for decisions on treatment.
While it is reasonable to assume that displaced fractures are
unstable, it is not as clear how many nondisplaced fractures
are unstable. Any separation of the fracture surfaces or com-
minution probably indicates a degree of instability and merits
consideration of primary operative treatment. If plaster
immobilization is selected as a treatment, serial radiographs,
CT, or both should be used to confirm fracture reduction
during healing. If displacement or delayed healing is detected,
plans are made for operative fixation.
Delay in treatment reduces the likelihood of union of a
stable scaphoid waist fracture. Langhoff, reporting on a series
of 285 scaphoid fractures, found that fractures that under-
went treatment more than 4 weeks after injury had a sub-
stantially greater risk of delayed union or nonunion.91 Mack
found that five of six unstable subacute middle-third fractures
healed in plaster at an average of 20 weeks and that only
one of three subacute proximal pole fractures healed at 29
weeks.99

Proximal Pole Fractures

articular surface, and operative fixation can be implemented
as necessary to reduce the risk of late degenerative arthritis
of the scaphotrapezial joint.
Waist Fractures
Acute stable fractures or incomplete fractures of the scaphoid
waist may be treated nonoperatively with a high expectation
of union. The debate over long arm casts versus short arm
casts centers on the potential for motion at the fracture site
during rotation of the forearm. Although the amount of
motion that is sufficient to impair fracture healing is unknown,
shearing has been documented to delay if not prevent bone
healing. A short arm cast does not prevent forearm rotation
and may permit displacements that are detrimental to healing
of a scaphoid fracture. One study that compared above-
elbow long thumb spica casts with short thumb spica casts
found a significantly greater incidence of delayed union or
nonunion in the short thumb spica cast group.60 Long arm
casts were changed to short arm casts at 6 weeks, and immo-
Proximal pole nonunion may be attributed to impaired vas-
cularity or instability of the proximal fragment. Proximal
pole fractures are considered unstable, whether or not they
are displaced, because of their small size, their tenuous blood
supply, their interarticular location, and the relatively large
moment arms across the fracture site. Rettig and Raskin
reported 100% healing of 17 proximal pole fractures treated
acutely with operative screw fixation through a dorsal
approach.123 There is consensus that proximal pole fractures
cannot be reliably treated nonoperatively.
Managing Scaphoid Fractures
in Athletes
Scaphoid fractures are common in competitive and recre-
ational athletes, and such patients are reluctant to submit to
the long period of immobilization and restricted activity that
plaster immobilization requires. These factors may influence
our treatment decisions. The treating physician may permit
participation in athletic activity with a playing cast. Some
organizations permit casts that are protected with foam
645
PART
III
18  P1
Wrist
P1 > P2
padding. Whether the forces generated by firm gripping are
detrimental to healing probably depends on the fracture’s
inherent stability. One study reported faster return to play
with internal fixation compared with playing cast alone.124 A
potential problem with plaster immobilization is compliance.
Young men often will modify or remove their casts and are
increasingly noncompliant with follow-up over time. The
pressure to return to sports may lead the patient and coach
to seek ways of shortening the period off the field. The
player’s ability to return to sports before the fracture is
healed depends on the sport and its requirements. Options
to be weighed will be surgery, a playing cast, and playing
restrictions. The goal will be the successful union of the
scaphoid fracture regardless of the patient’s athletic respon-
sibilities. Clearly, educating the patient, family, trainer, and
coach is essential.
Operative Treatment of Acute
Scaphoid Fractures
Techniques for Rigid Fixation
Implants for Rigid Fixation of Scaphoid Fractures
Bone healing requires viable bone cells, adequate blood
supply, and stabilization of the fracture site. Bones with an
articular surface are at greater risk of nonunions because no
external collar of fracture callus is formed to stabilize the
bone. The purpose of implants is to stabilize the fracture site
to prevent shearing that disrupts the internal healing process.
A variety of implants have been used to stabilize scaphoid
fractures. The strength of a fracture implant construct is
determined by five independent variables—bone quality,
fragment geometry, fracture reduction, choice of implant,
and implant placement. Implants used included Kirschner
wires, AO compression screws, headless compression screws,
and bioabsorbable implants. Solid and cannulated screws are
available from several manufacturers. Any implant used
646
P2
Figure 18.8  The difference in pitch between the leading
thread (P1) and the trailing thread (P2) of the Herbert
screw governs the rate of “take-up,” or drawing
together, of the two bone fragments to produce
compression. (Redrawn from Herbert TJ, Fisher WE:
Management of the fractured scaphoid using a new bone
screw. J Bone Joint Surg [Br] 66:114-123, 1984. Redrawn
by Elizabeth Martin.)
must reduce bending, shearing, and translational forces acting
at a fracture site.
Kirschner Wires
Although Kirschner wires are easy to insert, they have a
narrow role for scaphoid fixation today, given the relatively
insecure fixation and minimal compression afforded by these
implants. Kirschner wire fixation must be supplemented with
a cast until healing, and a separate procedure for Kirschner
wire removal is required. Small proximal pole fractures may
be stabilized with Kirschner wires when fragmentation is a
concern using screw fixation. In multitrauma situations or
open fractures, rapid stabilization of an unstable scaphoid
fracture may be expedient.
Screws
In 1954, McLaughlin described fractures of the scaphoid as
“an unsolved problem.”106 His main interest was returning a
“breadwinner” to his occupation with a treatment that would
“hold bone fragments in apposition” until healing. He
reported on the fixation of scaphoid fractures using solid lag
screws. The operative procedure was technically challenging,
optimal screw position was not always achieved, and the
incidence of nonunion in unstable fractures was not substan-
tially reduced over that obtained by casting alone.
Herbert and Fisher in 1984 presented the results of the first
headless screw used to treat 158 patients from 1977 to 1981.
The rate of union was 100% for acute fractures and 83%
overall.67 This screw revolutionized bone fixation because it
permitted compression of a fracture with two heads of dif-
ferential pitches (Figure 18.8). The embedded threaded heads
of headless screws are placed in the most dense bone of both
poles for maximum bony purchase. This paper also demon-
strated that screws placed perpendicular to an acute fracture
plane using compression and rigid fixation could success­
fully heal an acute fracture. The implant, however, is not
160 138.5 N
140
Compression in
Newtons
120
85.6 N
100
80
60 P1
P2
40
20
0 Plate fixation has also been used to stabilize scaphoid frac-
Fracture site Fracture site Fracture site P < .05
Figure 18.9  The next generation in headless screws was the
development of a fully threaded, variable-pitch cannulated screw.
The Acutrak screw (AcuMed, Hillsboro, Oreg.) is a tapered screw
with differential thread pitch. Faran documented that as the screw
was introduced and advanced, the compression increased. This
suggested that proximal pole fractures were more securely fixed if
a screw is introduced dorsally.44
technically easy to insert, and other centers reported lower
rates of union with screw fixation of acute scaphoid fractures
secondary to technical problems.1
Bunker reported results of a prospective multicenter study
of the Herbert screw used to treat 50 scaphoid fractures and
nonunions.24 All fresh fractures and four of the five fracture-
dislocations united, an overall union rate of 92%. Although
the technique was described as demanding, the Herbert
screw was demonstrated to achieve excellent results in the
management of scaphoid fractures. In 13 of 50 fractures some
technical difficulty was encountered during the operation.
Huene subsequently designed a Herbert screw drill guide to
simplify screw placement. The alignment device permitted
surgery to be performed on outpatients under local anesthe-
sia in 30 to 45 minutes.74 The Huene alignment guide is used
to generate trans-scaphoid compressive forces prior to screw
insertion.
The next major development in headless screw design was
the cannulated compression screw. This device greatly sim-
plified accurate placement of the screw within the scaphoid
bone by using a thin guide wire placed under fluoroscopic
control. A fully threaded, variable-pitch implant, the Acutrak
screw [AcuMed, Hillsboro, OR], demonstrated compression
comparable to that of a standard 4.0-mm compression screw
and greater compression when compared to the Herbert
screw in biomechanical testing (Figure 18.9).173 Several man-
ufacturers have developed cannulated compression screws
with unique advantages and disadvantages. Few clinical
studies exist with which to compare implants, and use is
largely a matter of surgeon preference.
Other Implants
Bailey reported on the mechanics of a bioresorbable cannu-
lated screw composed of poly-L-lactic acid and hydroxyapa-
tite that was developed for small bone fracture fixation.12 The
bioresorbable screw has been shown to have good compres-
sive properties compared to commonly used small bone frag-
ment compression screws, but no clinical data have been
presented.
Staple Fixation
Staple fixation has had its proponents as a means to achieve
stable fixation. Early studies demonstrated simple application
and satisfactory healing rates among patients with scaphoid PART
nonunions and acute fractures but long-term degenerative III
changes secondary to hardware impingement.89 New staples
with memory achieve compression after insertion as they
18 
warm to body temperature. These staples are indicated for
Wrist: Fractures of the Carpal Bones
fractures or nonunions requiring open reduction through a
palmar approach, and clinical data are lacking at this time
Plate Fixation
tures.23 Huene and Huene reported their experience in
1991.74 The Ender blade plate is suitable for adding stability
in scaphoid nonunions with AVN, cystic degeneration, and
osseous size discrepancy or compromise. Plate fixation is
indicated with scaphoid or humpback deformity. Hardware
removal is generally necessary when using plate fixation.
Mechanics of Fracture Fixation
For a fixation device to be successful in providing rigid fixa-
tion of scaphoid fractures, it must be able to resist complex
bending, shearing, and translational forces during normal
functional loading. Because the majority of the scaphoid is
covered with cartilage, fracture callus is not produced, so
primary bone healing is entirely dependent on rigid stabiliza-
tion of the fracture fragments until healing.
The mechanical effectiveness of internal fixation is deter-
mined by bone quality, fragment geometry, fracture reduc-
tion, choice of implant, and implant placement. While all five
of these independent variables are important, bone quality
and fragment geometry are intrinsic to the patient. Fracture
reduction, choice of implant, and implant placement are all
under the surgeon’s control. Placement of the implant in the
biomechanically ideal position for the individual patient is
probably the single most important of the five variables.
Trumble and colleagues observed that screws placed in the
central third of the scaphoid produced significantly shorter
healing time than screws placed outside of the central third
axis (P < .05).156 To explain this observation, McAdams and
colleagues simulated scaphoid waist fractures and compared
screws placed in the central axis to screws placed eccentri-
cally.103 This study demonstrated that screws centrally placed
in the proximal fragment of the scaphoid had superior results
compared with screws placed in an eccentric position. Fixa-
tion with central placement of the screw demonstrated 43%
greater stiffness, 113% greater load at 2 mm of displacement,
and 39% greater load at failure. While McAdams and associ-
ates concluded that central placement of the screw in the
proximal fragment of the scaphoid offers a biomechanical
advantage in the internal fixation of an osteotomy of the
scaphoid waist, no biomechanical explanation was provided
for this increase in stiffness.103
Biomechanically, the longer the screw, the more rigid the
fixation, because longer screws reduce forces at the fracture
site and spread bending forces along the screw.39 In a cadav-
eric study in our laboratory, short or long screws were placed
along the central scaphoid axis after an osteotomy was simu-
lated at the waist.39 Scaphoids that were repaired with longer
screws were significantly stiffer than those repaired with
short screws (Figure 18.10). When rigid fixation cannot
be provided by a central screw placement alone (such as
in extreme proximal pole fractures and nonunions),
647
PART
III
18 
Wrist

Long screw central

Short screw central

A B C
Figure 18.10  A and B, It had been clinically observed by several authors that screws placed along the central scaphoid axis
healed faster.1,122,156 The explanation for improved healing was explained biomechanically in a cadaveric study by Dodds and
colleagues.39 In this study, the long-screw group (B) was significantly stronger in resisting bending forces than the short-screw
group (A). C, Biomechanically, the longer the screw placed, the more rigid the fixation because forces are reduced at the
fracture site; bending forces are resisted and are spread along the screw.

augmentation may be necessary to prevent micromotion at

the fracture site. Supplemental fixation is commonly applied
from the distal scaphoid to the capitate using a 0.062-inch
Kirschner wire or a mini-headless screw (Figure 18.11). The
mini-headless screw is advantageous because the screw can
be left in place for 3 to 6 months without local soft tissue
irritation, until CT documents bone healing.

Approaches for Open Reduction and Internal

Fixation of Acute Scaphoid Fractures
Open Dorsal Fixation of Scaphoid Fractures
The dorsal technique of screw insertion is the preferred tech-
nique for proximal pole scaphoid fractures. The open dorsal
approach to the scaphoid involves exposing the dorsal carpus
by release and transposition of the extensor pollicis longus
(EPL) tendon. A portion of the posterior interosseous nerve
as it enters the wrist capsule may be excised at the discretion
of the surgeon. A capsular incision is made through the dorsal
capsular ligaments to expose the scaphoid. The “ligament-
sparing” capsulotomy fashions a radially based triangular
flap by splitting the dorsal radiocarpal and DIC ligaments.16
Extreme care is taken to avoid disruption of the dorsal fibers
of the SLIL when reflecting the capsular flap radially. Dissec-
tion in a plane tangential to the dorsal surfaces of the scaph-
oid and the lunate can be performed with a scalpel to divide
the loose attachments of the DIC ligament to the stout dorsal
SLIL. The distal boundaries of dissection of the scaphoid are Figure 18.11  When rigid fixation cannot be provided by a central
determined by the vascular supply along the dorsal ridge. screw placement alone, provisional augmentation is justified to
Care is taken not to disrupt the blood vessels entering the prevent micromotion at the fracture site. Conditions that warrant
waist of the scaphoid. After fracture hematoma evacuation, this include extreme proximal pole fractures and nonunions
treated with cancellous bone graft, a weak biomaterial.
the fracture reduction is assessed, and the fragments are Supplemental fixation is demonstrated with a mini-headless screw
manipulated with smooth joysticks to atraumatically reduce following treatment of this small proximal pole fracture. The
the fracture site. After the reduction is achieved, the screw may be left in place for 3 to 6 months until CT scan
fragments are provisionally held with a Kirschner wire. This determines bone healing.

648
provisional wire should be inserted in a location that does not
interfere with the definitive placement of the central axis
Kirschner wire and the screw implantation.
Once reduction and provisional Kirschner wire fixation are
obtained, a central axis guide wire is placed under fluoro-
scopic guidance into the proximal pole 1 to 2 mm radial to
its junction with the edge of the membranous portion of the
scapholunate ligament. The wire is advanced toward the
scaphoid tubercle and checked with fluoroscopy. If satisfac-
tory alignment and position of the scaphoid and the wire is
confirmed, final fixation is performed. If a cannulated screw
is being used, the ideal wire position should be down the
central axis of the scaphoid for maximal compression and
fixation.39,104 The wire’s length is measured, and the wire is
driven into the trapezium so that it does not loosen during
drilling. A cannulated hand drill is inserted over the central
axis guide wire, and the scaphoid is reamed to within 1 to
2 mm of the distal scaphoid cortex under fluoroscopic guid-
ance. Internal fixation is obtained by removing the hand drill
and implanting a headless cannulated screw. Overpenetration
of the screw beyond the substantial subchondral bone surface
as well as underpenetration protruding from the proximal
articular surface are to be avoided. A screw that is 1 to 2 mm
too long may inadvertently distract the fracture site as it
impacts the unyielding distal subchondral bone. Generally,
the screw chosen is 4 to 5 mm shorter than that measured
with the instrumentation, to allow for fracture compression
and countersinking below the articular surface.
Rettig and Raskin reported on 17 consecutive patients with
acute unstable proximal pole scaphoid fractures managed
over 5 years with open reduction and internal fixation.123 Four
fractures were displaced with greater than 1 mm of fragment
offset and intercarpal malalignment. The operative technique
consisted of a dorsal approach to the scaphoid, radius bone
grafting, and freehand retrograde Herbert compression screw
fixation. All fractures healed within 13 weeks (average, 10
weeks), as confirmed by radiographs. Functional wrist range
of motion and grip strength were achieved in all patients. No
patients developed osteonecrosis or radioscaphoid arthritis.
Rettig and Raskin determined that open reduction and inter-
nal fixation is better than primary casting for acute proximal
pole scaphoid fractures because it reduces the complications
of delayed union, nonunion, and osteonecrosis that may
occur following cast treatment.123
Open Volar Approach for Acute
Scaphoid Fractures
In the open volar approach, a straight incision is made in the
distal forearm between the distal portion of the flexor carpi
radialis (FCR) and the radial artery and is carried across the
distal wrist crease using a hockey-stick incision that angles
toward the base of the thumb. The FCR tendon is retracted
ulnarly and the radial artery radially. The wrist capsule is
entered through a longitudinal incision from the volar lip of
the radius to the proximal tubercle of the trapezium. The
capsule and intracapsular ligaments are carefully divided and
reflected sharply off the scaphoid with a scalpel. The capsule
needs to be preserved, as it contains the radioscaphoid capi-
tate ligament, and will be repaired at the close of the proce-
dure. The entire volar scaphoid is exposed. Reduction is
performed by manipulation or with joysticks, and Kirschner
wires are used to provide provisional fixation. Bone grafting PART
can be performed as required for volar comminution or in III
subacute fractures, with the grafts harvested from the volar
radius beneath the pronator quadratus by extending the inci-
18 
sion an additional 2 to 3 cm. The scaphotrapezial joint is
Wrist: Fractures of the Carpal Bones
opened to place a central guide wire in preparation for final
fixation. If necessary, a small amount of the proximal trape-
zium can be excised with a rongeur to clear an unobstructed
path for the implant. Rigid internal fixation can be performed
with the implant of choice.
Inoue reported in 1997 on volar-limited access to the
scaphoid for the treatment of acute fractures using a Herbert
screw. The technique employed a shorter incision under
imaging guidance.79 The distal half of the open volar approach
was used, and the scaphoid tubercle and scaphotrapezial joint
were exposed. A guide wire can be inserted under fluoro-
scopic control through the distal pole and centered in the
scaphoid. The ideal starting point to obtain the longest wire
from this approach is 2 mm dorsal and 2 mm ulnar to the tip
of the scaphoid tubercle, within the scaphotrapezial joint.93
This technique resulted in significantly shorter time to union
and allowed an earlier return to manual labor than did non-
operative treatment. There were no complications. This tech-
nique, using a semiclosed insertion, requires considerable
skill but produces consistently satisfactory results after
minimal exposure of the tubercle of the scaphoid.
Percutaneous Scaphoid Screw Fixation
The development of cannulated screw fixation for the scaph-
oid ushered in a new era of percutaneous screw insertion, a
technique first attempted 40 years ago with limited success.
Volar Percutaneous Scaphoid Fixation
Streli was the first to describe volar percutaneous screw fixa-
tion of the scaphoid fracture in 1970 using traction applied
through the thumb and a standard ASIF screw.148 In 1991,
Wozasek and Moser reported an adaptation of Streli’s tech-
nique using cannulated 2.9-mm screws via a volar percutane-
ous approach.176 During a 15-year period ending in 1984, 280
cases were treated by this method. After a mean postopera-
tive time of 82 months, 89% of the recent fractures had
united, as had 81.8% of those with delayed union or non-
union and 42.8% of those with sclerotic nonunion. Haddad
reported on the early rigid fixation of scaphoid fractures
using traction through the thumb and a cannulated compres-
sion screw.63 Fifteen patients with minimally displaced or
nondisplaced fractures were treated percutaneously using a
volar approach, traction, and a cannulated screw. There was
no postoperative immobilization; patients were allowed
movement soon after operation. Union was achieved in all
at a mean of 57 days (range, 38 to 71 days). The range of
movement after union was equal to that of the contralateral
limb, and grip strength was 98% of the contralateral side at
3 months. Patients were able to return to sedentary work
within 4 days and to manual work within 5 weeks. Their
results show that percutaneous scaphoid fixation permitted a
rapid functional recovery.63
Bond prospectively compared nondisplaced stable scaph-
oid waist fractures treated with cast immobilization to volar
percutaneous cannulated screw fixation of scaphoid fractures
with respect to time to radiographic union and to return to
649
PART work.19 Twenty-five full-time military personnel with an
III acute nondisplaced fracture of the scaphoid waist were ran-
domized to either cast immobilization or fixation with a
18  percutaneous cannulated screw. The average time to fracture
union in the screw fixation group was 7 weeks, compared
Wrist

with 12 weeks in the cast immobilization group (P = .0003).

The average time until the patients returned to work was 8
weeks, compared with 15 weeks in the cast immobilization
group (P = .0001). There was no significant difference in the
range of motion of the wrist or in grip strength at the 2-year
follow-up evaluation. Bond concluded that percutaneous
cannulated screw fixation of nondisplaced scaphoid fractures
resulted in faster radiographic union and return to military
duty than cast immobilization.19
Adolfsson and colleagues reported on 53 acute, nondis-
placed fractures of the waist of the scaphoid randomized to
two groups.3 Twenty-eight patients were treated by immo­
bilization in a below-elbow plaster cast for 10 weeks, while
25 were treated by percutaneous insertion of a cannulated
compression screw. Patients who underwent surgery had a
significantly better range of motion at 16 weeks, but there
were no significant differences for grip strength, rate of
union, or time to union. The authors concluded that percu-
taneous fixation enabled earlier mobilization without adverse
effects on healing.
Fractures suitable for treatment with the volar percutane-
ous (distal to proximal) approach are all waist fractures and
some proximal third fractures, depending on the obliquity of
the fracture line. Unsuitable fractures include proximal pole
fractures, which are best treated via a dorsal (proximal to
distal) approach. Humpback deformities or scaphoid collapse
with a DISI deformity usually require open treatment.
AUTHORS’ PREFERRED TECHNIQUE:
VOLAR PERCUTANEOUS SCAPHOID
SCREW FIXATION
The patient is placed supine on an operating table and the
hand is suspended vertically by the thumb using a finger trap
(Figure 18.12).63 This position extends the scaphoid and
ulnar-deviates the wrist to improve access to the distal pole
of the scaphoid. A fluoroscopic imaging unit is rotated paral-
lel to the floor and positioned so that the wrist is in its central
axis. Traction from a tower permits full rotation of the scaph-
oid in the imaging beam. In the majority of cases, longitudinal
traction is enough to reduce the scaphoid fracture. If the
fracture is not reduced, Kirschner wires can be inserted and
used as joysticks to manipulate the fragments into position.
The quality of the reduction can then be checked radio-
graphically. Alternatively, the patient can be positioned in
the supine position with the arm abducted on a radiolucent
arm board.10 A fluoroscopy unit is placed perpendicular to
the table. Two rolled towels are used under the supinated
wrist to allow for adequate extension and ulnar deviation.
(Figure 18.13).
Having achieved an acceptable reduction, the most impor-
tant step is to establish the entry point of the guide wire. The
ulnar deviation of the wrist extends the scaphoid to make the
tubercle more accessible. The entry point, the scaphoid
tuberosity, is then located using a 12- or 14-gauge intrave-
nous needle introduced on the anteroradial aspect of the
wrist, just radial and distal to the scaphoid tuberosity. The
650
Figure 18.12  In 1998, Haddad and Goddard reported on a
simplified volar percutaneous technique using traction and a
cannulated screw to stabilize waist fractures.63 The thumb is
suspended by a single finger trap. It permits free rotation of the
hand throughout the operation, and the scaphoid remains in the
center of an imaging unit. The C-arm is turned to a horizontal
position surrounding the wrist. The most important step is to
establish the entry point of the guide wire and the position of the
screw. The ulnar deviation of the wrist is provided by thumb
traction and allows the distal half of the scaphoid to slide out
from under the radial styloid. The scaphoid tuberosity is easily
palpable and is the key to the insertion point. The entry point is
then located using a 12- or 14-gauge IV needle, which is
introduced radial and distal to the scaphoid tuberosity.
needle serves as a trocar to guide the wire and to establish a
central path along the scaphoid. The needle is then inserted
into the scaphotrapezial joint and tilted into a vertical posi-
tion. The needle is levered on the trapezium, which brings
the distal pole of the scaphoid more radially and facilitates
screw insertion. The wrist is rotated in the fluoroscopic beam
to confirm that the needle is aligned along the axis of the
scaphoid in all planes, with the intent of directing the guide
wire into the proximal pole to a point just radial to the
scapholunate ligament. Leventhal and colleagues identified
the ideal starting point to be approximately 2 mm dorsal and
just radial to the apex of the scaphoid tubercle, in order to
achieve maximum guide wire length within the scaphoid.93
Once the entry point and the direction of the guide wire
are confirmed, the needle is impacted into the soft articular
cartilage over the distal pole of the scaphoid so that the tip
does not slip during the insertion of the guide wire. The guide
wire is then passed down through the needle and drilled
across the fracture, its direction continually checked on the
image intensifier and adjusted as necessary, with the goal of
entering the radial aspect of the proximal pole. The position
is checked in multiple fluoroscopy planes, and if satisfactory,

Figure 18.13  Alternative technique for volar insertion of a percutaneous cannulated screw. Two rolled towels are placed under a
supinated wrist to allow for adequate dorsiflexion. A guide wire for the cannulated screw system is placed through the volar
scaphoid tuberosity, directed proximally, dorsally, and ulnarly with the wrist hyperextended.
a longitudinal incision of 0.5 cm is made at the entry point
of the wire and deepened down to the distal pole of the
scaphoid using a small hemostat and blunt dissection. This is
a relatively safe zone, with minimal risk to the adjacent
neurovascular structures.
The length of the screw is then determined using a depth
gauge or by advancing a second guide wire of the same length
up the distal cortex of the scaphoid and subtracting the dif-
ference between the two. The correct screw size is 4 to 5 mm
shorter than the measured length, which will ensure that the
screw head is fully buried below the cartilage and the sub-
chondral bone on each end. In rare cases a second antirota-
tion wire may be inserted parallel to the first prior to drilling
and reaming. The 12-gauge needle is removed and the can-
nulated drill is passed over the wire and advanced under
imaging guidance, stopping 1 to 2 mm short of the articular
surface. At this point the hand is taken out of traction so that
the screw will adequately compress the scaphoid. A self-
tapping screw is then advanced over the guide wire. Final
position is checked with multiple fluoroscopic views to
confirm complete containment within the scaphoid. A hyper-
pronated PA view profiles the dorsal-radial cortical margin
of the scaphoid, where a perforation of the proximal cortical
bone can occur. Compression of the fracture site is confirmed
radiographically on the image intensifier. The wire is
removed, the skin closed with a suture or Steri-Strips, and
the wound covered with a sterile compressive dressing.
Postoperative Care
A volar plaster splint is removed at 10 days postoperatively,
and a well-molded orthoplast short-arm thumb spica splint is
fashion for 3 additional weeks. The sutures are removed at
PART
III
18 
Wrist: Fractures of the Carpal Bones
True
axis
this stage, and carpal radiographs are taken to confirm that
screw position is satisfactory. Hand therapy may be useful to
regain motion, and no heavy carrying or weight-bearing
activity is permitted. Return to sedentary work is allowed as
soon as the patient feels ready or when 75% of the contra-
lateral range of movement is achieved. When radiographic
and clinical union are achieved, the splint is discontinued and
all previous activities are resumed as tolerated. CT is used to
confirm healing before return to heavy lifting or competitive
athletics.
Potential complications include malposition of the screw,
violation of the cortical surface and hardware protrusion
within the radioscaphoid or scaphocapitate joints proximally,
and breakage of a guide wire. Another potential problem is
a failure to completely bury the head of the screw within the
scaphoid, which can lead to scaphotrapeziotrapezoid arthro-
sis. This problem is avoided by selecting a screw length
approximately 5 mm shorter than measured. Fracture dis-
placement can occur with guide wire malposition or in proxi-
mal pole or oblique fractures. Other risks include transient
dysesthesia just distal to the scar. This is secondary to a
neurapraxia of a sensory branch of the median nerve and
usually resolves within 4 to 6 weeks. Volar fixation of a small
proximal scaphoid fragment is contraindicated because of
tenuous fixation and minimal compression. Nonunions or
delayed unions using the volar approach have occurred with
proximal pole fractures, and small proximal pole fractures
should be treated using a dorsal approach.
Dorsal Percutaneous Scaphoid Fixation
Many surgeons prefer dorsal percutaneous screw fixation
because of its ease of access and the ability to place a screw
651
PART closer to the central axis of the scaphoid.39,93 Dorsal implanta-
III tion of a headless compression screw is recommended for
scaphoid fractures of the proximal pole, whereas volar
18  implantation is recommended for distal pole fractures, to
allow maximum fracture compression. Fractures of the waist
Wrist

may be fixed from a dorsal or volar approach as long as the

screw is implanted as close as possible to the central scaphoid
axis and maximal screw length is attained. The most impor-
tant steps are scaphoid fracture reduction and the percutane-
ous placement of a 0.045-inch, double-cut guide wire along
the central axis of the reduced scaphoid. This permits the
implantation of a cannulated headless compression screw
along the central axis. It has been shown that screws in this
position increase the rate of healing of scaphoid fractures and OrthoScan
increase the stiffness of fixation.104,157 An additional benefit
of screws placed in this position is a reduced risk of thread
penetration and cartilage injury. Fracture reduction and
guide wire placement are achieved using fluoroscopy.142
Required equipment includes a headless cannulated compres-
sion screw, a fluoroscopy unit (preferably a mini-imaging
unit), 0.045- and 0.062-inch double-cut Kirschner wires, and
a wire driver. We prefer screws of standard size with their
larger-core shaft because of their greater ability to resist
lateral displacement forces.

Step 1: Imaging
The patient is supine with the arm extended on a hand table
with a padded tourniquet on the arm. A mini-fluoroscopy
imaging unit is positioned so that the imaging beam is per-
pendicular to the wrist. The unit is placed in a horizontal
position or parallel to the hand table. If a standard fluoros-
copy unit is being used, it is positioned with the image intensi-
fier beneath a radiolucent operating table with the beam
perpendicular to the table and wrist. A fluoroscopic survey of
the carpus is performed for fracture displacement, ligament
injury, and other occult injuries. The scaphoid is examined to
confirm anatomic reduction. Lateral and oblique views of the
scaphoid are particularly useful. Displaced fractures of the
scaphoid waist will appear flexed and on lateral imaging will
be seen to have dorsal “V”-shaped defects. Gross ligament
disruption may also be suggested by diastasis of the scapholu-
nate joint on the PA view. With a displaced scaphoid waist
fracture or scapholunate ligament disruption, the lunate may
assume an extended position on lateral imaging. Conversely,
the lunate may assume a flexed position with a lunotriquetral
ligament tear. Longitudinal traction of the carpus may detect
a subtle step-off between the carpal bones on a PA view.
After this study, the central axis of the scaphoid must be
located. Using the PA projection, the wrist is pronated and
flexed until the scaphoid poles are aligned in the radiographic
beam. The scaphoid assumes a ring shape, and the center of
the circle is the central axis of the scaphoid. This is also the
precise location for screw placement (Figure 18.14).
Step 2: Dorsal Guide Wire Placement in a Reduced
Scaphoid Fracture
The guide wire’s starting position is the proximal pole of the
scaphoid. The base of the scaphoid is covered only by dorsal
capsule, subcutaneous tissue, and skin. The dorsal percutane-
ous approach permits easy access to the central scaphoid axis
for the guide wire. Under mini-fluoroscopic guidance, the
652
Figure 18.14  With the wrist flexed 45 degrees and pronated, the
scaphoid is aligned with the imaging beam to produce a ring
sign. The central axis is readily identified. The Kirschner wire is
placed at the base of the scaphoid proximal pole and aligned and
drilled along its central axis.
dorsal skin is penetrated with a 0.45-inch guide wire and
directed to the apex of the scaphoid, 1 to 2 mm radial to the
insertion of the scapholunate ligament. After confirmation of
a perfect starting point, the wire is aligned with the central
axis and driven toward the tubercle of the scaphoid. The
surgeon’s opposite index finger is typically placed on the
scaphoid tubercle for assistance in targeting the guide wire.
If fluoroscopy confirms central wire placement on multiple
views, the wire is passed to the far cortex and measured
(Step 3).
If the position of the wire is in doubt, the wire may be
advanced through the trapezium and out the thenar skin. The
volar end of the wire exits from the radial base of the thumb,
a safe zone devoid of tendons and neurovascular structures.
The wire driver is disengaged and attached to the distal end
to withdraw the wire until the trailing end of the wire clears
the radiocarpal joint, permitting full extension of the wrist.
Once the dorsal trailing end of the guide wire has been buried
into the proximal scaphoid pole, the wrist can be extended
for imaging to confirm scaphoid fracture alignment and
correct positioning of the guide wire (Figure 18.15).
If multiple unsuccessful attempts at positioning the 0.045-
inch guide wire have been made, an incorrect path in the
scaphoid will have been established. A potential solution is to
use a larger, 0.062-inch wire to establish the correct path.
When the correct path has been established, the larger
wire can be exchanged for a 0.045-inch guide wire prior to

Figure 18.15  The wire is driven through the trapezoid and out
the thenar skin. The wire driver is moved to the distal end of the
wire, and the wire is withdrawn until flush with the proximal
scaphoid articular surface. The wrist is extended to a neutral
position so that the wire position and fracture alignment can be
checked with fluoroscopic imaging. If fracture reduction is
needed, the volar portion of the wire may be withdrawn distally
across fracture site. Joysticks are placed to manipulate the fracture
fragments.
scaphoid drilling. If wire placement is still unsuccessful, a
small mini-incision can be made dorsally over the EPL tendon.
This limited open dorsal approach to the scaphoid allows
quick and easy identification of the scaphoid proximal pole
and the scaphoid’s central axis. The EPL tendon is retracted
radially and the capsule is incised, exposing the proximal
scaphoid pole. A drill guide is placed on the scaphoid proxi-
mal pole and a 0.045-inch, double-cut guide wire is driven in
a radial and distal direction toward the thumb base. Fluoro-
scopic imaging is used to confirm the correct course of the
wire in the scaphoid.
Step 3: Scaphoid Length Assessment and
Screw Size Selection
When positioning is confirmed, the wire can be driven back
out of the dorsal skin and adjusted until the distal end is in
contact with the distal cortex. A second wire of identical
length is placed parallel to the first so that the tip of the wire
touches the cortex of the proximal pole. Fluoroscopy is used
to confirm adjacent tip position. The difference in length
between these two wires is the exact length of the scaphoid.
The most common complication of percutaneous screw
implantation is implantation of too long a screw. There should
be 2 mm of clearance between the screw’s end and the scaph-
oid cortex. Hence, the screw selected should be 4 to 5 mm
shorter than the scaphoid length. This permits the complete
implantation of a headless compression screw in bone without
exposure. After the length of the screw has been determined,
the width must be selected. Biomechanical studies suggest
that the widest screws provide the strongest fixation. One
concern about larger screws introduced dorsally is the result-
ing cartilage defect, but these defects have been shown to heal
over with cartilage without degenerative changes. With
PART
III
18 
Wrist: Fractures of the Carpal Bones
Figure 18.16  When the fracture reduction is confirmed, the wrist
is flexed and the volar exposed wire is driven dorsally. After
exposure, a small incision is made and blunt dissection is made
down to capsule, clearing the Kirschner wire of all soft tissue. A
careful inspection is made to be sure no tendons have been
impaled. If so, the wire is withdrawn and the tendon cleared and
the wire again advanced.
extremely small proximal pole fractures or avulsions, there is
a possible risk of fragmentation with implantation of a large
screw. Under these circumstances, a smaller screw is selected.
Step 4: Screw Implantation
A 3- to 4-mm incision is made along the guide wire. Blunt
dissection along the guide wire exposes a tract to the dorsal
wrist capsule and scaphoid base (Figure 18.16). Prior to drill-
ing, the guide wire is inspected to be sure that no tendons
have been impaled. If tendons have been trapped, the Kirsch-
ner wire is withdrawn volarly until the tendons are free, and
the wire is again advanced dorsally. A portion of the wire is
left protruding distally and a clamp applied to prevent the
wire from becoming dislodged during reaming. The scaphoid
is prepared by drilling a path just past the fracture into the
distal scaphoid (Figure 18.17). With self-cutting screws, this
permits the screw to engage the distal scaphoid without push-
off. I do not recommend reaming closer than 2 mm to the
distal scaphoid cortex. It is critical to use fluoroscopy to check
the position and depth of the drill and screw. The drill is
removed and the cannulated screw, 4 to 5 mm shorter than
the measured length, is inserted (Figure 18.18). The screw is
advanced under fluoroscopic guidance to within 1 to 2 mm
of the opposite cortex with excellent compression (Figure
18.19). With unstable fractures a joystick is left in the distal
scaphoid fragment during both reaming and screw implanta-
tion. As the screw is implanted, a counterforce is exerted
through the joystick, compressing both fracture fragments
and ensuring rigid fixation. Overadvancement of the screw
increases the risk of joint penetration. Screw withdrawal is
discouraged, as it reduces compression in tapered screw
types. It is important to not undersize the screw, as poor
fixation will result in the proximal pole, and the drilled cortex
may be a stress raiser.
In patients with small proximal pole fractures, the midcar-
pal joint is locked with a temporary screw placed between
the distal scaphoid and the capitate to reduce the moment
across the fracture site (see Figure 18.11).
653
PART
III
18 
Wrist
Figure 18.17  After the scaphoid length has been determined, a drill is used to penetrate the proximal scaphoid pole. With
young patients with intense bone density or scaphoid nonunions it becomes necessary to drill across the fracture site and into
the distal pole. With young dense bone, this prevents push-off as a screw crosses the fracture site.
Figure 18.18  A headless compression screw, 4 mm shorter than
the scaphoid length, is implanted. To prevent push-off and
fracture separation, a 0.062-inch Kirschner wire joystick may be
inserted into the distal fracture fragment to apply a counterforce
as the screw is inserted. One caution is that the implantation of a
screw into dense bone may result in push-off and fracture
distraction. Once the screw has been implanted and its position is
checked by imaging, the guide wire is withdrawn distally until it
can clear the radiocarpal joint so the wrist can be extended.
Postoperative Care
Patients are placed in a removable splint at their first postop-
erative visit, and the postoperative protocol is similar to that
employed for the volar percutaneous method. Gentle strength-
ening of the hand grip can be initiated safely because a com-
pression screw secures the fracture site. Traction exercises are
avoided. Small proximal pole fractures are protected from
unrestricted range of motion exercises until CT confirms
healing bone. If a scaphocapitate screw has been inserted, it
is removed following confirmation of healing (approximately
3 months).
Arthroscopy-Assisted Percutaneous
Scaphoid Fixation
The goals of arthroscopy-assisted stabilization of scaphoid
fractures are to reduce displaced fractures without an open
654
incision and provide secure fixation that will permit early
motion until solid union has been achieved.56 The early results
of arthroscopy-assisted percutaneous screw fixation of dis-
placed fractures of the scaphoid suggest that minimally inva-
sive reduction and fracture union can be predictably obtained
with good to excellent functional results.138 Avoidance of
open exposure limits the potential for wrist ligament injury,
may help to preserve blood supply, and minimizes postopera-
tive stiffness.
Surgical Indications and Contraindications
Our surgical indications for arthroscopy-assisted fixation
include unstable fractures, displaced or nondisplaced; delayed
presentation; proximal pole fractures; selected fibrous non-
unions; combined injuries including scaphoid and ipsilateral
displaced distal radius fractures; and scaphoid fractures with
associated ligamentous injury.39 Vertical oblique fractures
have a high longitudinal shear component that makes them
unstable; this fracture pattern is ideal for arthroscopic man-
agement. Scaphoid fractures are considered displaced if there
is any visible displacement, gap, or angulation on radiographs.
Significantly displaced fractures with marked DISI deformity
of the lunate, particularly in the chronic situation, are best
managed using open reduction techniques.
Surgical Techniques
Various arthroscopy-assisted techniques for scaphoid frac-
tures have been described, beginning with the arthroscopy-
assisted reduction and screw fixation technique of Whipple,
which employs a modified cannulated Herbert screw and
jig.174 The Herbert-Whipple modifications to the original
Herbert screw produced a cannulated version for more accu-
rate installation over a preliminary guide wire, incorporated
self-tapping threads, and provided a larger cross-sectional
diameter of the unthreaded portion for increased bending
strength at the fracture site without changing thread diame-
ter. Whipple noted that freehand installation of screws could
result in fracture rotation, displacement, or distraction, and
he thought that compression obtained with an external
jig would be preferable. Among other advantages, the

Figure 18.19  Once the screw has been implanted, the fracture site gap should be obliterated. Fluoroscopic examination is
carefully made to check the screw’s position in the scaphoid. If there is concern about exposed hardware, this must be
confirmed or ruled out with fluoroscopy, plain films, or arthroscopy.
Herbert-Whipple jig obviates the need for division of volar
RSC ligament to expose the scaphoid. The guide barrel of the
jig is compressed against the distal pole of the scaphoid for
compression of the fracture, and the guide wire and screw
can be inserted with less surgical exposure and less need
for postoperative immobilization compared to open
techniques.
The dorsal approach for arthroscopy-assisted fixation of
scaphoid fractures was popularized by Slade.141 This tech-
nique enables arthroscopic evaluation and reduction of the
fracture.138 Arthroscopy is used to confirm fracture reduction
and treat occult injuries.With fracture surfaces firmly apposed,
a headless cannulated compression screw is inserted under
fluoroscopic guidance to achieve rigid fixation of the scaphoid
fracture. For small proximal pole fractures, additional tech-
niques include locking of the midcarpal joint and stiffening
of the fracture site with implantation of parallel mini-screws
into an adjacent carpal bone.
Slade reviewed his results in arthroscopy-assisted fixation
from a dorsal approach in 27 consecutive patients.139 There
were 18 waist fractures and 9 fractures of the proximal pole.
Seventeen patients were treated within 1 month of injury, and
10 patients were treated late. All fractures healed, as docu-
mented by CT.
Arthroscopy-assisted fixation of scaphoid fractures also
allows for simultaneous detection of associated intracarpal
soft tissue injuries. Braithwaite originally reported on four
patients with a fracture of the scaphoid with complete scaph-
olunate dissociation in his series.22 Similar to fractures of the
distal radius, associated soft tissue lesions may occur with
scaphoid fractures, and arthroscopic evaluation allows detec-
tion and management. It is not known whether early
arthroscopic detection and management of the associated
injuries improves the final outcome. However, it is well docu-
mented that the success rate for the management of acute
interosseous ligaments is far better than that for management
of chronic injuries.
PART
III
18 
Wrist: Fractures of the Carpal Bones
AUTHORS’ PREFERRED TECHNIQUE:
ARTHROSCOPY-ASSISTED DORSAL
PERCUTANEOUS SCAPHOID FIXATION
The patient is prepared and draped supine with the affected
arm on the hand table, and the same techniques for scaphoid
imaging and dorsal percutaneous wire placement are
employed. Following an attempt at closed reduction, the
guide wire is placed in the central axis of the proximal pole
and driven across the distal fracture fragment and into the
trapezium. The wire is driven out of the thenar skin and
withdrawn distally by the wire driver until the proximal end
clears the proximal scaphoid articular surface. The wrist is
brought back to a neutral posture in preparation for
arthroscopic surgery.
If the scaphoid remains displaced, the 0.045-inch guide
wire is further withdrawn until it clears the fracture site,
remaining within the distal fragment. The fracture fragments
are reduced percutaneously using dorsally placed 0.062-inch
Kirschner wires as joysticks in each fracture fragment (Figure
18.20). Older or impacted displaced fractures may require
the introduction of a small hemostat at the fracture site to
achieve reduction. The hemostat is introduced through a
midcarpal or accessory portal. Any flexion deformity of the
scaphoid may be corrected by approximation of the dorsal
joysticks. Reduction is best confirmed on fluoroscopy. For
displaced and rotated proximal pole fragments, reduction
may be accomplished by hyperflexing the wrist, which rotates
the extended lunate to a neutral position. A 0.062-inch
Kirschner wire may be driven percutaneously through the
distal radial metaphysis into the lunate under fluoroscopic
guidance to temporarily fix the lunate in a neutral position.
When the wrist is extended, the scaphoid proximal pole is
realigned with the distal pole, using joysticks as necessary.
Once reduction is achieved, the previously placed 0.045-inch
wire in the distal fragment is driven from its volar position
into the proximal fragment to secure reduction (Figure
18.21). These fractures are often very unstable and may
655
PART
III
18 
Wrist

Figure 18.20  Fracture reduction can be accomplished by placing 0.062-inch Kirschner wires dorsally into each fracture fragment.
A flexed displaced scaphoid is corrected under imaging, and the distal fragment is extended and the proximal fragment flexed.
A hemostat can be inserted through an accessory portal to assist the reduction.

Figure 18.21  Once fracture reduction has been accomplished using the joysticks, the central axis guide wire in the distal
scaphoid fragment is driven from volar to dorsal, capturing and holding the fracture reduction. Very unstable fractures may
require two central axis wires to resist bending and fracture rotation.

require the placement of a second parallel antiglide wire
during reaming and screw implantation.
After fluoroscopy confirms that the fracture is correctly
aligned and the guide wire is in the correct position along the
scaphoid central axis, longitudinal traction is applied through
all fingers to allow for safe entry of the small-joint arthro-
scope and instruments. A mini-fluoroscopy unit is placed per-
pendicular to the wrist, and the midcarpal and radiocarpal
portals are located atraumatically using a 19-gauge needle
under fluoroscopy. A small longitudinal incision is made at the
needle site, and a small hemostat is used to bluntly dissect
the soft tissue down to the joint capsule. A blunt trocar is used
to enter the joint. An angled, small-joint arthroscope is placed
in the radial midcarpal portal to confirm fracture reduction
656
(Figure 18.22). Next, an aggressive shaver is used to clear
blood clot and any dorsal synovium that obscures visualiza-
tion. The integrity of the SLIL and lunotriquetral interosseous
(LTIO) ligament can be assessed and probed from both the
radiocarpal and midcarpal joints.
Partial interosseous ligament tears can be treated with
simple débridement. Complete disruptions are best treated
with ligament repair. The appropriate portal incision (i.e., the
3-4 portal for SLIL) is extended, exposing the ligament tear.
0.062-inch joysticks are placed into the affected carpal bones,
and crossing 0.045-inch fixation Kirschner wires are placed
in the scaphoid, lunate, or both under fluoroscopic control.
The joysticks are used to gain reduction, and the reduction is
secured with the crossing Kirschner wires. A bony trough is

Figure 18.22  Under fluoroscopy, the wrist is placed in traction and
the arthroscopic portals are identified and marked with a 19-gauge
needle. An arthroscope placed in the 3-4 portal in the radiocarpal
space can confirm the position of a 14-gauge needle used as a drill
guide for a 0.045-guide wire at the base of proximal pole of the
scaphoid. The midcarpal space is best suited for examining the
reduction of the scaphoid. Seen here are a proximal pole scaphoid
fracture and a dorsal coronal split of the lunate.
created at the site of ligament avulsion using a high-speed
2-mm bur, and bone anchors are placed into the bone trough
to secure the avulsed ligament. This repair should be rein-
forced with a dorsal capsulodesis. Cannulated mini-screws are
placed over the crossing 0.045-inch Kirschner guide wires to
compress and secure the scapholunate repair. An additional
screw is placed across the scaphocapitate joint to minimize
the flexion moment arm (see Figure 18.11). These soft tissue
injuries require 6 weeks of immobilization followed by 6
weeks of protected motion with a splint. I remove the scaph-
ocapitate joint screw at 6 months.
Following fixation of any soft tissue injuries and confirma-
tion of central guide wire placement using fluoroscopy, a
cannulated screw is placed from dorsal to palmar, as dis-
cussed above. Following compression, the anti-glide and
scaphoid screw guide wires are removed and final radio-
graphs obtained. Immobilization and rehabilitation are
guided by fracture stability.
In conclusion, arthroscopy-assisted scaphoid screw fixation
is a viable treatment option in carefully selected patients.
Properly employed, arthroscopy-assisted reduction obviates
the wrist stiffness and muscle atrophy that are associated
with prolonged cast immobilization, reduces cartilage dete-
rioration, preserves the important volar radiocarpal liga-
ments, and facilitates early functional return for the patient.
This results in reduced overall economic consequences for
the patient and potentially an early return to athletic
competition.
Complex Scaphoid Injuries
Combined Fractures of the Scaphoid
and Distal Radius
Combined fractures of the distal radius and scaphoid are
uncommon but present a challenging treatment dilemma.
Scaphoid fractures may not be recognized when associated PART
with a comminuted distal radius fracture and when untreated III
can result in carpal collapse, cystic degeneration, and even-
tual carpal degenerative arthritis. Although an isolated stable
18 
scaphoid fracture might be safely managed with plaster
Wrist: Fractures of the Carpal Bones
immobilization, the 12 to 16 weeks of immobilization
required for healing are not appropriate for the treatment of
the distal radius fracture. Prolonged immobilization may
result in arthrofibrosis and atrophy of the distal radius and
hand, making the recovery of full hand function unlikely. A
review of the published reports on combined scaphoid and
distal radius fractures demonstrates that treatments have
evolved over the past decade.
Trumble and colleagues reported on six patients treated
with internal fixation for ipsilateral combined fractures of the
scaphoid and radius.155 All patients sustained a high-energy
injury from a fall from a substantial height. All of the frac-
tures united, with the radial fractures healing in an average
of 6 weeks and the scaphoid fractures healing in an average
of 13 weeks. Internal fixation of the scaphoid in these com-
bined injuries allowed for earlier and more aggressive therapy
to maximize wrist and forearm motion. Our arthroscopic
approach to combined injuries permits rigid fixation of both
fractures while preserving uninjured soft tissues. Our prelimi-
nary experience with these techniques in seven adults with
displaced scaphoid fractures is favorable, showing early
recovery of hand function with minimal complications
(unpublished data) (Figure 18.23). Six of the scaphoid frac-
tures were located at the waist, and one involved the proxi-
mal pole. An additional carpal fracture identified and treated
arthroscopically involved a coronal split of the lunate. The
distal radius fractures included two displaced radial styloid
fractures and one volar shearing fracture. The remaining
distal radius fractures were a Colles-type fracture with dorsal
comminution and two intra-articular fractures. All fractures
were operatively treated within 2 weeks of injury. All
scaphoid fractures were treated with arthroscopy-assisted
reduction and dorsal percutaneous fixation with a headless
cannulated compression screw. All radius fractures were
treated with arthroscopy-assisted fracture reduction and rigid
fixation. This was accomplished using percutaneous screws
with or without open repair and a dorsal or a volar plate. No
external fixation was used, and allograft was used for struc-
tural support in selected radius fractures. No scaphoid frac-
tures required bone grafting.
AUTHORS’ PREFERRED TECHNIQUE:
ARTHROSCOPY-ASSISTED INTERNAL
FIXATION OF COMBINED SCAPHOID AND
DISTAL RADIUS FRACTURES
The treatment of combined fractures of the scaphoid and
distal radius is a three-step process including arthroscopy-
assisted reduction of both fractures and their percutaneous
or mini-open rigid fixation. First, the scaphoid is reduced
under arthroscopic guidance and provisionally stabilized
with a guide wire placed along its central axis. Second,
arthroscopy-assisted reduction of the distal radius fracture
and percutaneous rigid fixation is performed to permit early
motion. Third, the scaphoid is fixed percutaneously with a
cannulated headless compression screw along the central
scaphoid axis. This surgical staging permits reduction of both
657
PART
III Step 1 Step 2
18  dorsal incision. Rigid fixation of the radius is attained using
Wrist
A B
Step 2 Step 3
C D
Figure 18.23  Treatment of combined fractures of the scaphoid
and radius is a three-step process. A, The first step is the
percutaneous reduction of the scaphoid fracture and provisional
stabilization with a guide wire placed along its central axis. The
scaphoid is not rigidly fixed pending final reduction of the radius.
Bending moments during radius fracture reduction may displace
or loosen scaphoid fracture fixation. B and C, The second step is
percutaneous/arthroscopic-assisted reduction and rigid fixation of
the distal radius fracture to permit early motion. D, The final step
is fixation of the scaphoid fracture. This is accomplished by the
dorsal percutaneous implantation of a cannulated headless
compression screw along the central scaphoid axis. This is
accomplished with minimal stress on the radius fixation.
fractures without compromising the final rigid fixation of
either fracture.
Necessary operative equipment includes a mini-fluoros-
copy unit, 0.045-inch and 0.062-inch double-cut Kirschner
wires, cannulated headless compression screws, a wire driver,
a drill, a distal radius locking plate system, and a small-joint
arthroscopy setup including a traction tower. With the hand
in the tower traction, arthroscopy is used in the radiocarpal
and midcarpal joints to confirm scaphoid and radial articular
reduction and identify occult injuries. Incomplete fracture
reduction is addressed by placing Kirschner wires percutane-
ously as joysticks and adjusting the fracture under direct
vision. Once scaphoid reduction and provisional fixation is
achieved by a centrally placed guide wire, attention is
directed to the distal radius.
Arthroscopic assistance and joysticks are used to align the
articular cartilage of the distal radius. Large styloid fragments
658
can be fixated percutaneously with cannulated compression
screws (see Chapter 17). For comminuted fractures, bony
metaphyseal voids are filled with allograft through a small
a volar locking plate, which is applied to the aligned distal
radius through a standard volar incision. Imaging is used to
confirm plate position and to assist in minor adjustments to
the fracture. We prefer to use a volar locking plate with a
drill and screw-targeting guide to enable the placement of
subchondral locking screws below the reduced articular
surface. Finally, a headless cannulated compression screw is
percutaneously introduced using the scaphoid guide wire to
complete the rigid fixation. We prefer screws of standard
size, as the larger-core shaft increases the ability to resist
lateral displacement forces.
Trans-scaphoid Perilunate
Fracture-Dislocations
Open and Arthroscopic Treatment
Acute fracture-dislocations of the carpus are uncommon.
Perilunate fracture-dislocations represent approximately 5%
of wrist fractures and are about twice as common as pure
ligamentous dislocations. Trans-scaphoid perilunate fracture-
dislocation is the most common type of complex carpal
dislocation.
Treatment of these injuries is difficult owing to the exten-
sive soft tissue, cartilaginous, and bony damage. Various
operative treatment options have been recommended, includ-
ing dorsal, volar, percutaneous, and arthroscopic approaches.
These injuries are usually due to high-energy impacts such
as occur in motor vehicle accidents, a fall from a height, or
contact sports. The mechanism of injury characteristically
involves forceful wrist extension, ulnar deviation, and inter-
carpal supination. Ligament failure begins with palmar cap-
suloligamentous disruption starting radially and propagating
ulnarly, taking a trans-osseous route through the scaphoid
with usual disruption of the LTIO ligament and fracture of
the ulnar styloid. The proximal fragment of the scaphoid and
the lunate remain with the radius, while the distal fragment
of the scaphoid dislocates dorsal to the lunate with the
attached distal carpal row. In 10% of dislocations, the distal
scaphoid fragment and the distal carpal row dislocate pal-
marly to the lunate. Variations of perilunate fracture-dislo-
cations include fractures of the capitate, triquetrum, radial
styloid, and ulnar styloid. A specific variation of the perilu-
nate fracture-dislocation is scaphocapitate syndrome. In this
injury, the injury force passes through the neck of the capi-
tate, fracturing both the scaphoid and the capitate. The proxi-
mal portion of the capitate may rotate 90 to 180 degrees,
with the articular surface of the head of the capitate directed
distally. The injury to the capitate can be missed on plain
radiographs, and additional views must be taken if this injury
is suspected.
Herzberg and Forissier investigated the medium-term
results (mean follow-up, 8 years) of a series of 14 trans-
scaphoid dorsal perilunate fracture-dislocations treated oper-
atively at an average of 6 days following injury.68 Eleven
underwent open reduction and internal fixation through a
dorsal approach. Combined palmar and dorsal approaches
were used in three cases—in two cases, open reduction and
internal fixation, and in one case, proximal row carpectomy.
 PART
III
18 

Wrist: Fractures of the Carpal Bones

A B

C
Figure 18.24  A, Dorsal trans-scaphoid perilunate dislocation. B, The lunate is stabilized with 0.062-inch wire from the radius. A
wire is positioned in the distal scaphoid and a joystick is placed in the distal scaphoid fracture fragment to assist in reduction.
After scaphoid reduction, the distal Kirschner wire is advanced proximally. A small curved hemostat introduced through the ulna
midcarpal portal demonstrates complete disruption of the LTIO ligament, which is also documented on arthroscopy. C, The LTIO
is repaired with absorbable bone anchors, and a headless screw is used to protect the repair for 6 months.

All internally fixed scaphoids healed, and no carpal avascular
necrosis or collapse was observed. Carpal alignment was
satisfactory in most cases. Post-traumatic radiologic midcar-
pal arthritis, radiocarpal arthritis, or both were almost always
observed.
Nearly every combination of radiocarpal and intercarpal
dislocation has been described, but few fit neatly into a par-
ticular pattern or classification scheme. These injuries may be
subtle, and diagnosis is still frequently delayed. Prompt rec-
ognition, accurate reduction, and stable internal fixation all
contribute to improved outcomes. Internal fixation tech-
niques depend on the pathology imparted on the carpus.
Open reduction, arthroscopic techniques, and fluoroscopi-
cally aided percutaneous techniques can be used to success-
fully treat carpal dislocations (Figure 18.24). Associated
LTIO ligament tears should be repaired through a limited
open approach or immobilized in anatomic alignment using
either Kirschner wires or a temporary lunotriquetral screw.
Repairs are generally protected with cast immobilization for
8 weeks, followed by gentle active mobilization of the wrist
over the next 4 to 8 weeks. Temporary screw fixation of the
lunototriquetral joint is removed at 4 to 6 months.
Complications of Scaphoid
Fracture Treatment
The most common complications reported in the literature
are delayed union, nonunion, arthritis, reduced wrist motion,
and loss of strength. Prolonged cast immobilization leads to
muscle atrophy, possible joint contracture, disuse osteopenia,
and potential financial hardship. Closed treatment of scaph-
oid waist fractures may require cast immobilization for 3
months or longer, and fractures of the proximal third of the
scaphoid in particular may take 6 months or longer to heal.
Successful surgical repair of a scaphoid nonunion ranges from
50% to 95%, depending on vascular status, presence of
arthritis, and carpal collapse, and successfully repaired scaph-
oid nonunions require on average an additional 6 months
to heal.
Other complications are reported. Filan in 1996 reported
on 431 patients treated with open reduction and internal
659
PART fixation using the Herbert bone screw.50 Patients were not
III treated with plaster immobilization after surgery, which pro-
moted a rapid functional recovery. Patients returned to work
18  after 4.7 weeks, even when the fracture failed to unite. In
the case of established nonunions, healing depended on the
Wrist

stage and location of the fracture, but the progress of arthritis

was halted and carpal collapse significantly improved. Inter-
nal fixation of the scaphoid using the Herbert bone screw was
technically demanding. Filan reported that 56 patients had
hypertrophic scar, and 20 patients complained of postopera-
tive pain and swelling at the donor site of the bone graft.
Four superficial infections and one deep wound infection
resolved satisfactorily with conservative treatment. Four
patients had early signs of reflex sympathetic dystrophy after
surgery. In two patients these signs resolved spontaneously,
but two patients developed carpal tunnel syndrome, which
required surgical decompression. Only two wrists showed
instability of the scaphoid after surgery. One had sustained
a tear of the scapholunate ligament at the time of injury; the
other appeared to have a late rupture of this ligament. AVN
developed after surgery in 20 scaphoids, all of which required
further operations. In one case, a very small necrotic frag-
ment of the proximal pole was excised and the scaphoid
stabilized by dorsal capsulorrhaphy. Five wrists had a mid-
carpal fusion. The necrotic proximal pole was excised in 14
Figure 18.25  One of the most common complications is screw
cases and was replaced using a stabilized silicone implant in placement. Shown here is a headed AO screw, which on imaging
13 and by an osteochondral autograft in 1. was not properly positioned in the scaphoid.
In another early report of headless screw fixation, Dias and
colleagues investigated 88 patients with minimally displaced
or nondisplaced bicortical fractures of the waist of the scaph- scaphoid. Minor complications included intraoperative equip-
oid in a prospective, randomized controlled study comparing ment breakage—one case involving a screw and one case
plaster immobilization in a below-elbow plaster cast to early involving a guide wire. This study stresses that percutaneous
internal fixation with use of a Herbert or Herbert-Whipple fixation techniques have a steep learning curve and require
screw.38 They detected no difference between the groups with training to be safely performed. Many of these same compli-
respect to range of motion and grip strength. Patients returned cations can be encountered with open surgical fixation.
to work at 5 to 6 weeks after the injury in both groups. At
12 weeks, grip strength was better in the patients who had
had surgery. Ten of the 44 fractures treated nonoperatively Use of Fluoroscopy and Surgical
had not healed radiographically at 12 weeks (a 23% non- Navigation to Reduce
union rate) and were treated with surgery. Complications Screw Malposition
occurred in 13 patients (30%) who had been managed opera- The development of small cannulated screws has permitted
tively. These complications included superficial wound infec- minimally invasive percutaneous fixation of acute scaphoid
tion (in one patient), sensitive scar (in three patients), fractures. There are known mechanical advantages to
hypertrophic scar (in four patients), sensitive and hypertro- increased screw length and central screw placement. As cited
phic scar (in three patients), hypoesthesia in the region of the above, there are potential deleterious effects of eccentric
palmar cutaneous branch of the median nerve (in one patient), screw placement, including articular protrusion, proximal
and mild early complex regional pain syndrome (in one pole fracture, and nonunion. Tumilty and Squire reported
patient). Technical difficulty was experienced in seven patients that the curvilinear surface of the proximal pole of the scaph-
(16%) during surgery. In four of them, there was initial mis- oid may lead to errors in calculation of screw length and
placement of either the drill or the screw (Figure 18.25). In penetration into the joint.160 In this cadaveric study of six
one patient, the scaphoid tuberosity split during screw specimens, two screws were found to be penetrating sub-
insertion. chondral bone. The plain x-ray films were accurate in only
Bushnell reported his complications with repair of scaphoid five of the six specimens, while 360 degree fluoroscopy
fractures using a dorsal percutaneous approach using cannu- was accurate in all six. Fluoroscopy during placement of a
lated headless screw fixation in 24 cases performed over 5 scaphoid screw may decrease the rate of subchondral
years.25 All cases involved nondisplaced (<1 mm) fractures of penetration.
the scaphoid waist. The overall complication rate was 29%; Recently, investigators have evaluated CT-generated
there were 5 major complications (21%) and 2 minor com- models to assist in the development of a targeting system for
plications (8%). Major complications consisted of one case of implantation of screws into a reduced scaphoid fracture.
nonunion, three cases involving hardware problems, and one They determined that a computer-assisted navigation of
case of postoperative fracture of the proximal pole of the volar percutaneous scaphoid screw placement improved
660
accuracy, required less time, and diminished radiation
exposure when compared to traditional percutaneous
techniques.54,93,166
Cost of Surgical versus
Nonsurgical Treatment
The treatment of stable scaphoid waist fractures by surgery
has raised the issue of cost. Would the health care system be
better served by plaster immobilization of these stable frac-
tures, not considering the costs of re-treating those fractures
that failed to heal (6% to 23% nonunion rate)? Arora and
colleagues compared two groups of stable scaphoid fractures,
one treated with plaster immobilization and the other with
internal screw fixation.10 They concluded that internal screw
fixation of nondisplaced scaphoid fractures had a shorter time
to bony union and that the patients returned to work an
average of 7 weeks earlier than with cast immobilization.
Although it is assumed that operative treatment is more
expensive, in this study the cost was not found to be higher.10
Davis and colleagues conducted a cost/utility analysis to
weigh open reduction and internal fixation against cast
immobilization in the treatment of acute nondisplaced mid-
waist scaphoid fractures.33 The authors used a model to cal-
culate the outcomes and costs of open reduction and internal
fixation and of cast immobilization, assuming the societal
perspective. Medical costs were estimated using Medicare
reimbursement rates, and costs of lost productivity were
estimated by average wages obtained from the U.S. Bureau
of Labor Statistics. Open reduction and internal fixation
offered greater quality-adjusted life-years than casting. Open
reduction and internal fixation was less costly than casting
($7940 versus $13,851 per patient) because of a longer
period of lost productivity with casting. When considering
only direct costs, the incremental cost/utility ratio for open
reduction and internal fixation ranged from $5438 per qual-
ity-adjusted life-year for the 25- to 34-year age group to
$11,420 for the 55- to 64-year age group, and $29,850 for
the age group 65 years and older. They concluded that,
unlike casting, open reduction and internal fixation is cost-
effective relative to other widely accepted interventions.33
Bone Growth Stimulators
and Enhancements
Recently there has been great interest in biologic stimulation
of bone healing. Bone morphogenetic proteins play critical
roles in both bone development and fracture healing. Urist
first showed that extracts from demineralized bone matrix
were capable of inducing new bone formation when implanted
in an intramuscular site.161 The osteoinductive properties of
bone morphogenic proteins to induce bone formation in
ectopic sites and to produce healing of critical-sized segmen-
tal bone defects in experimental animal studies are attribut-
able to their ability to stimulate the chemotaxis and
differentiation of mesenchymal stem cells into chondroblasts,
osteoblasts, or both. With the difficulty in treating proximal
pole scaphoid nonunions, it is natural that these biologic
enhancements would be investigated.
In a case reported by Jones and colleagues, a chronic non-
union of a proximal pole fracture of the scaphoid was treated
by curettage of the nonunion, single Kirschner wire fixation,
and implantation of 50 mg of human bone morphogenetic
protein followed by 12 weeks of cast immobilization without PART
any conventional corticocancellous bone grafting or rigid III
screw fixation.86 Radiographs showed signs of bony healing
by 12 weeks, and an MRI 6 years after surgery showed no
18 
signs of AVN. The authors discussed the potential future
Wrist: Fractures of the Carpal Bones
applications of human bone morphogenetic protein in hand
surgery.86
Bilic and colleagues reported on 17 patients with scaphoid
nonunion at the proximal pole treated with and without bone
graft osteogenic protein-1 (OP-1).17 OP-1 improved the per-
formance of both autologous and allogenic bone implants and
reduced radiographic healing time to 4 weeks compared with
9 weeks without OP-1. CT scans and scintigraphy showed that
in OP-1–treated patients, sclerotic bone was replaced by well-
vascularized bone. Allogenic and autologous grafts treated
with OP-1 healed at a similar rate.17 At present, there is insuf-
ficient evidence to derive recommendations concerning the
role of biologics in scaphoid fracture or nonunion treatment.
Pulsed electromagnetic field therapy (PEMF) has been used
to attempt to accelerate scaphoid healing. However, there
are no good randomized controlled data for PEMF in scaph-
oid fractures. There are better randomized controlled data
for ultrasound treatment in acute scaphoid fractures. Mayr
reported on 30 patients randomized to a cast with or without
20 minutes per day of ultrasound.102 His results showed that
fractures that underwent ultrasound treatment healed in
43.2 ± 10.9 days, versus 62 ± 19.2 days in the control group
(P < .01). Trabecular bridging 6 weeks after injury showed
healing in 81.2% ± 10.4% of the ultrasound-stimulated frac-
tures, versus 54.6% ± 29% in the control (P < .05).102
Scaphoid Fracture in Children
Fractures of the immature scaphoid are uncommon and can
be challenging to diagnose. These fractures most commonly
involve the distal scaphoid and are effectively treated with
closed reduction and plaster immobilization. However, the
diagnosis may be missed or delayed because of absent or
minimal symptoms. This is particularly applicable to athletic
adolescents, who may return to sports prematurely after a
seemingly minor injury to the wrist.
The presentation of scaphoid fractures in adolescents has
changed over the years and more closely resembles the adult
pattern. Malunion or nonunion may occur in patients with a
missed diagnosis or delayed presentation and occasionally in
patients treated promptly with immobilization. Because the
natural history in children remains incompletely character-
ized, the optimal treatment of established pediatric scaphoid
nonunions is controversial. Surgical intervention should be
strongly considered for displaced fracture nonunions in
patients who are at or near skeletal maturity or in those in
whom nonsurgical treatment has failed. Mintzer and Waters
presented the outcome of 13 pediatric scaphoid fracture non-
unions in 12 children treated over an 18-year period.111 The
average elapsed time between fracture and surgery was 16.7
months. Four of the nonunions were treated with inlay bone
graft from a palmar approach, and nine were treated with
Herbert screw fixation and iliac crest bone grafting. The
average time of follow-up was 6.9 years (range, 2 to 19
years). All cases went on to clinical and radiographic union.
Patients had no statistically significant difference in range of
motion or strength between the operative and nonoperative
661
PART interposition of an intercalary bone graft and internal fixa-
ALGORITHM FOR SCAPHOID FRACTURE
III NONUNION MANAGEMENT tion. A dorsal approach to proximal scaphoid nonunions
allows immediate access for removing the necrotic bone from
18  small proximal pole nonunions and internal fixation. Vascular-
Type of Fracture Treatment
ized bone graft is recommended to manage scaphoid non-
Wrist

Delayed union Percutaneous or open rigid fixation unions with osteonecrosis.

with a headless compression screw
Established nonunion Open repair and bone grafting
Fibrous nonunion, Dorsal for proximal pole fracture
waist Volar for waist fracture
Sclerotic nonunion,
waist
Humpback nonunion, Volar approach and corticocancellous
waist wedge graft
Proximal pole nonunion, Dorsal approach
nonischemic Percutaneous or open bone grafting
and fixation with headless screw
Lock midcarpal joint with mini-
screw, or
Sandwich proximal fragment
between lunate and scaphoid
waist with headless screw
Vascular nonunion, waist Vascularized bone graft: dorsal or
or proximal pole palmar approach
Table 18.2  Algorithm for Scaphoid Fracture Nonunion
Management
wrists. The length of time for postoperative immobilization
in the Herbert screw group was significantly less than that in
the inlay bone graft group. Though scaphoid nonunions in
children can heal with prolonged cast immobilization, the
authors recommended that the treatment of scaphoid frac-
ture nonunions in the skeletally immature patient be rigid
fixation with a compression screw and iliac crest bone graft.
Weber reported on six children with nonunited scaphoid
fractures treated conservatively.170 Their mean age was 12.8
years (range, 9.7 to 16.3 years), and mean follow-up was 67
months. Five had no previous treatment, and time to diag-
nosis averaged 4.6 months (range, 3 to 7 months) after injury.
Treatment consisted of cast immobilization until clinical and
radiologic union. Fractures united in all six children after a
mean period of immobilization of 5 months (range, 3 to 7
months). All patients returned to regular activities. While
prolonged treatment with cast immobilization resulted in
union of the fracture and an excellent subjective wrist score
in all patients, this delay may not be well tolerated by the
child or family.
Operative Treatment of Scaphoid
Nonunion (Table 18.2)
The failure of a scaphoid fracture to heal results in a predict-
able pattern of wrist arthritis. To prevent arthritis and mini-
mize the incidence of arthrosis, the goal of treatment should
be consolidation of the fracture with the scaphoid in ana-
tomic alignment. Advanced imaging, including CT and MRI,
aids in the evaluation of scaphoid alignment, bone loss,
scaphoid humpback deformity, carpal collapse, and osteone-
crosis. Generally, scaphoid nonunions with severe collapse
and humpback deformity must be approached volarly with
662
Revised Scaphoid Nonunion Classification
In an effort to match the healing potential of a nonunion to
a specific treatment algorithm, Slade and Geissler proposed
a revised classification of aligned scaphoid nonunions.136 In
our classification, scaphoid nonunions can be divided into
two groups: (1) early nonunions without substantial bone
resorption and (2) chronic nonunions with substantial bone
resorption. The classification is further subdivided based on
the width of the devitalized scaphoid zone and the amount
of bone loss, prompting the need for additional structural or
biologic enhancements. Our grading system reflects the
natural degradation that occurs at a scaphoid nonunion site
over time and the difficulties that these changes pose to
healing.
Scaphoid Nonunions Without Substantial Bone
Loss: Grades I to III
Grade I scaphoid nonunions without substantial bone loss
require only rigid fixation to heal if there is adequate perfu-
sion. Grade I includes fractures with fibrous unions and non-
unions with minimal sclerosis (<1 mm). Also included in this
group are subacute fractures (initial presentation >4 weeks
after injury). Stable subacute scaphoid fractures have already
developed bone resorption at the fracture site from shearing
that is not typically detected by standard radiographs, and
they will predictably require 4 to 6 months of cast immobi-
lization to heal.99 Subacute proximal pole fractures have a
high nonunion rate. Grade I nonunions and subacute frac-
tures can be treated with reduction and rigid fixation without
bone grafting for successful though often slower healing.
Grade II fibrous unions may appear healed by radiographs
or on visual inspection, but bone remodeling is insufficient
to resist the stresses of bending and torque. Barton explored
10 symptomatic patients with radiographic nonunion of the
scaphoid and four patients with a suspected nonunion.13
Intraoperatively, 10 scaphoids appeared healed by visual
inspection, but only five of them ultimately united. Another
four patients appeared to have a partial union at surgery, and
all fractures went on to unite. This study underscores the
importance of CT scans to detail the extent of osseous healing
following cast treatment or internal fixation, as the author
noted that visual or radiographic inspection is often insuffi-
cient. Shah and Jones examined 50 scaphoid nonunions
treated with open Herbert screw fixation and noted that
those scaphoid nonunions that had an intact cartilaginous
envelope or a stable fibrous union healed with screw fixation
alone without bone grafting.132 Based on these studies, we
recommend rigid fixation of stable fibrous nonunions to
prevent micromotion and permit bone healing to continue.
Grade III scaphoid nonunions have minimal bone resorp-
tion of the anterior cortical bone and minimal fracture scle-
rosis (<2 mm confirmed by CT scan). These nonunions still
have the potential for healing with rigid fixation without
correction of deformity. We have successfully treated aligned

Figure 18.26  Scaphoid nonunions without substantial bone loss
require only rigid fixation to heal if there is adequate perfusion.
These include fractures with delayed presentation, fibrous
nonunions, and nonunions with minimal sclerosis (<1 mm).
Pre- and postoperative CT is used to confirm healing.
nonunions with minimal bone loss and sclerosis using percu-
taneous headless screw fixation alone (Figure 18.26).140 All
15 patients in this case series healed at an average of 14
weeks and showed bridging cortical bone on CT scans. Non-
unions treated less than 6 months after the injury healed
faster than those treated later (P < .02). Ikeda and colleagues
achieved successful union of 51 of 51 scaphoid nonunions
with sclerosis less than 1 mm and displacement less than
2 mm using cannulated screw fixation without bone graft.76
Correctly Aligned and Perfused Scaphoid
Nonunions with Substantial Bone Loss:
Grades IV to VI
If the scaphoid nonunion fragments are well perfused and
there is substantial bone loss without a flexion deformity, we
feel that bone grafting is essential to achieving union.
Although fracture healing may occur with a minimal gap (1
to 2 mm), the likelihood of bridging greater distances without
bone grafting is marginal. CT provides critical architectural
information on the scaphoid alignment, deformity, and bone
loss or cyst formation and can be used to subdivide these
nonunions (grade IV, 2 to 5 mm of bone loss; grade V, 5 to
10 mm of bone loss). If osteonecrosis is suspected, MRI
allows an accurate assessment of the relative vascularity of
the fragments and the width of the zone of necrosis. If treated PART
by anatomic rigid fixation and bone grafting, these nonunions III
will heal by vascular ingrowth from a viable bone fragment
into the bone graft, followed by creeping substitution and
18 
bridging bone trabeculae. We precede internal fixation with
Wrist: Fractures of the Carpal Bones
arthroscopic examination of the joint to confirm the presence
of fibrous scar tissue at the scaphoid nonunion site and assess
for arthritis. Peripheral fibrocartilaginous scar tissue acts as
a net to prevent any percutaneously placed bone graft at the
nonunion site from leaking into the radiocarpal joint. Percu-
taneous screw implantation then impacts and compresses the
bone graft.
In our experience, a waist or proximal pole nonunion with
no peripheral fibrocartilaginous scar tissue proceeds to a
synovial pseudarthrosis (grade VI). These nonunions are
unable to prevent joint fluid from diluting essential local
osteogenic factors, and they are unable to buttress percutane-
ously inserted cancellous bone graft. These scaphoid non-
unions require an open débridement and interpositional
corticocancellous bone graft to provide structural support
and viable bone matrix, followed by rigid fixation. Grade VI
nonunions may also be candidates for a vascularized bone
graft if avascular; rigid fixation is recommended for optimal
results.
Special Circumstances for Scaphoid Nonunion:
Deformity, Proximal Pole Nonunion, and
Avascular Necrosis
Late scaphoid nonunions with substantial fixed (humpback)
deformity require volar correction, including open débride-
ment, insertion of a tricortical iliac crest bone graft, and rigid
fixation. This type of volar wedge bone grafting may require
3 to 6 months to heal and may result in reduced wrist motion.
In documented avascular cases without punctate bleeding,
volar wedge grafting with an autologous iliac crest graft is
associated with 30% union rates.125 In these circumstances,
a vascularized bone graft may be used to provide improved
blood supply and increase the potential for healing. Down-
sides of vascular graft procedures include the increased surgi-
cal dissection needed to expose the bone graft and the
vascular pedicle, a generous capsulotomy, the need for an
open débridement, and occasional inability to gain rigid
internal fixation.
Bone Grafting and Fixation of a Correctly
Aligned Scaphoid Nonunion
For the last five decades, the Russe modification of the Matti
bone grafting procedure has been one of the standard
approaches for nonunion.129 Russe proposed a palmar
approach, with cavitation of the fragments on each side of
the nonunion site and then packing of the defect with cancel-
lous or corticocancellous bone. The Russe graft is indicated
for (1) a simple, well-aligned, and early or delayed nonunion
and (2) a nonunion without osteoarthritis or carpal malalign-
ment. Contraindications for the Matti-Russe procedure
include the presence of a collapsed (humpback) scaphoid
nonunion with dorsal carpal instability; radial and midcarpal
degenerative changes; large cysts in the scaphoid; and an
avascular proximal scaphoid pole.
Dacho performed a retrospective study of 84 patients with
scaphoid nonunion who were treated with a Matti-Russe graft
663
PART
III
18 
Wrist

FCR
Ligated superficial
palmar branch,
A radial artery

RSC

Radius

C LRL D

Figure 18.27  Original Matti-Russe bone graft technique. A, The incision. B, The flexor carpi radialis tendon (FCR) is retracted to
expose the volar capsule. C, The volar capsule is divided longitudinally to expose the radioscaphocapitate (RSC) and long
radiolunate (LRL) ligaments. Care should be taken to minimize ligament injury. D, An egg-shaped cavity is created distal and
proximal to the fracture line. A corticocancellous bone graft, usually obtained from the ipsilateral iliac crest, is fashioned to fit
snugly into this cavity. E, The corticocancellous bone graft has been wedged into the cavity of the scaphoid. The stability of the
graft and the fracture fragments should be satisfactory. If not, additional fixation with one or two Kirschner wires is
recommended. (Copyright Elizabeth Martin.)

between 1985 and 1997. Bony consolidation could be veri-
fied in 82% of the patients and in 81% of patients with
proximal pole nonunion.32 Barton had less success in long-
term evaluation of Russe bone grafting, especially in proxi-
mal pole nonunions, which demonstrated a success rate of
only 54%.14
Matti-Russe Surgical Technique
The scaphoid is exposed through a radiopalmar incision
between the FCR tendon and the radial artery (Figure 18.27).
A longitudinal incision is made along the radial border of the
FCR tendon from the scaphoid tubercle proximally. The
664
scaphoid is exposed by dissecting radial to the FCR sheath
and retracting the tendon ulnarly. The radiocarpal capsule is
identified just beyond the radial styloid. It is incised obliquely
in line with the scaphoid and beyond the scaphotrapezial
joint to the trapezium. The capsule is reflected a few milli-
meters to each side to expose the palmar aspect of the scaph-
oid. The intracapsular deep palmar radiocarpal ligaments are
either partially or completely divided and tagged for later
repair. To avoid injury to the vascular pedicles, the dorsal
and lateral surfaces of the scaphoid should not be disturbed.
Any fibrous tissue in the pseudarthrosis is resected to expose
the opposing bone surfaces of the proximal and distal

Figure 18.28  Modern Russe technique using two corticocancellous bone grafts. (From Green DP: The effect of a vascular necrosis
on Russe bone grafting for scaphoid nonunion, J Hand Surg [Am] 10:597-605, 1985.)
fragments (Figure 18.28). An osteotome is used to freshen
the fracture line. A cortical window is cut in the palmar
aspect of the scaphoid with osteotomes or a high-speed bur,
and the cortical strip is removed. The bone is curetted by
hand to create a trough for the bone graft. All avascular
cancellous bone is excavated from the proximal fragment.
Small punctate bleeding points within the medullary cavity
may appear during curettage. Reduction is accomplished
using Kirschner wires as joysticks. The trough should be long
enough to accept sufficient graft for adequate stability. A
corticocancellous bone graft is obtained from the anterior
iliac crest or the distal radius and fashioned to fit within the
trough. Green published a modification of the original tech-
nique in which two parallel corticocancellous strips were
placed within the trough so that the cancellous surfaces are
facing each other.62 The remainder of the cavity is filled with
small chips of cancellous bone graft. Parallel Kirschner wires
are inserted for fixation. The wrist is casted until healing,
which may require 16 to 20 weeks.
Open Dorsal Technique for Scaphoid Nonunions
The original Matti graft technique is particularly applicable
for proximal third fractures with minimal displacement and
cystic cavitation without humpback deformity. Kirschner
wire or headless screw fixation can be performed using a
freehand or cannulated technique. Inoue reported 80% suc-
cessful union with cancellous bone grafting and Herbert
screw placement through a dorsal approach.81
PART
III
18 
Wrist: Fractures of the Carpal Bones
Cortical surface
Cancellous surface
The scaphoid is approached through a 3- to 5-cm incision
beginning over Lister’s tubercle and coursing slightly
obliquely toward the base of the index metacarpal. The reti-
naculum is partially divided over Lister’s tubercle for bone
graft exposure, and the EPL is retracted to one side for expo-
sure. The capsule may be divided longitudinally; alterna-
tively, a capsular-splitting incision16 enables excellent
exposure without disruption of the important radiocarpal
ligaments. The capsular incision begins along the dorsoradial
border of the radius and splits the radiocarpal ligament from
a point just distal to Lister’s tubercle to the triquetral inser-
tion. The DIC ligament is split from the triquetrum to the
distal pole of the scaphoid. The resultant capsular flap is
elevated from ulnar to radial, with care to avoid injury to
dorsal SLIL where it blends with the deep fibers of the DIC
ligament. The scaphoid nonunion is usually easily identified,
although a 25-g needle can be inserted under fluoroscopy to
confirm the nonunion location. A small dorsal window is
created to expose the nonunion site, and curets are used to
excavate cystic areas. The proximal and distal poles are
débrided to bleeding cancellous bone, and any displacement
is corrected with Kirschner wire joysticks.
Lister’s tubercle can be removed with an osteotome and
saved for re-placement in the graft cavity. A large amount
of cancellous bone can be harvested and packed into the
scaphoid cavity. Thrombin-soaked Gelfoam may be inserted
into the radial defect, and the tubercle can be replaced or
inverted as a lid. Attention is redirected to the scaphoid for
665
PART internal fixation. Rigid screw fixation yields a higher
III union rate than Kirschner wire fixation108 and is preferred
when at all possible. The scaphoid is flexed and a starting
18  point for the guide wire is chosen 1 to 2 mm radial to
the insertion of the SLIL in the sagittal midline of the
Wrist
scaphoid. The wire is directed freehand toward the scaphoid
tubercle, and position checked with fluoroscopy. When it
is in an ideal position, a correctly sized cannulated screw is
inserted over the guide wire and the wire withdrawn.
Small proximal pole fragments can be temporarily augmented
with a distal scaphocapitate Kirschner wire or screw, as
above. Capsular closure can be performed with a running
absorbable monofilament suture. Skin closure is routine. The
wrist is immobilized in a thumb spica cast or splint until
healing.
Treatment of Aligned Scaphoid Nonunions with
Percutaneous Fixation and Bone Grafting
Evaluation and Planning
Slade and Gillon reviewed their experience with percutane-
ous bone grafting in a series of 234 scaphoid fractures.137
Successful percutaneous treatment of scaphoid nonunions
requires careful planning and the use of a number of imaging
tools, including standard radiography, mini-fluoroscopy, CT
or MRI, and arthroscopy. Nonunions, like acute fractures, are
imaged with standard radiography to identify fracture dis-
placement, plane, position, fragmentation, and the potential
for ligament injury. Real-time fluoroscopic imaging may
review the true nature of the injury and the reasons for failed
union that may not be appreciated using standard radiogra-
phy. Excessive gapping between the carpal bones suggests
ligament injury and may be detected only with passive wrist
motion during fluoroscopic imaging.
CT is performed with 1-mm contiguous or overlapping
slices to better understand the bony anatomy, confirm non-
union, and detail bone loss and cyst formation. MRI is used
as necessary to evaluate proximal pole vascularity, but we
prefer to confirm vascularity by direct arthroscopic inspec-
tion of the proximal pole cancellous bone at the time of
surgery.
Surgical Technique
The patient is positioned supine with a tourniquet on the
affected arm and the digits suspended in a traction tower.
The mini-fluoroscope is used to confirm alignment of the
scaphoid nonunion and absence of flexion deformity or con-
comitant ligament injury. Once the decision has been made
to proceed with percutaneous fixation, bone graft is har-
vested from the distal radius percutaneously.
Percutaneous Harvesting of Bone Graft.  Bone graft can be
percutaneously harvested from the distal radius or iliac crest
using one of several commercially available bone-coring
devices. We prefer a 4-inch, 8-gauge bone biopsy needle
(Baxter Jamshidi; QuadMed, Inc., Jacksonville, FL) to per­
cutaneously harvest cancellous bone graft. A guide wire is
percutaneously inserted into the distal radius just proximal to
Lister’s tubercle. A small incision and blunt dissection exposes
the bone cortex, and a hand reamer is used to penetrate it.
The bone biopsy cannula is introduced over the Kirschner
wire, the Kirschner wire is removed, and several cancellous
bone plugs are harvested (Figure 18.29).
666
Dorsal Guide Wire Placement in the Aligned Scaphoid Non-
union.  The technique for dorsal wire placement is the same
as for acute fractures. The guide wire is introduced into the
proximal scaphoid pole using fluoroscopic imaging and is
guided down the scaphoid central axis toward the trapezium.
The wrist is moderately flexed to avoid bending the guide
wire. If fluoroscopic inspection with the wrist flexed indicates
acceptable wire position, the wire is further advanced to
penetrate the thenar skin and then withdrawn by power until
the dorsal trailing end of the wire clears the radiocarpal joint,
permitting full extension of the wrist. Fluoroscopy is used to
confirm scaphoid alignment and correct positioning of the
guide wire.
Failure to Pass a Guide Wire Requires Use of a Mini-incision.  If
percutaneous wire placement is unsuccessful, a small incision
is made over the 3-4 portal. The EPL tendon is located and
retracted radially and the capsule is incised, exposing the
proximal scaphoid pole. A drill guide is placed on the scaph-
oid proximal pole, and a 0.045-inch, double-cut guide wire is
driven in a radial and distal direction toward the thumb base.
Fluoroscopic imaging is used to confirm the correct course of
the wire in the scaphoid.
Percutaneous Correction of Deformity.  Early nonunions may
be percutaneously manipulated and reduced with the use of
dorsally placed 0.062-inch Kirschner wires used as joysticks.
Parallel 0.045-inch Kirschner wires are inserted along the
long axis of the distal scaphoid fracture fragment as discussed
above. In severely displaced nonunions, a single 0.045-inch
guide wire is not stiff enough and will bend without a second
reinforcing wire. The second wire acts as an antirotation wire
during reaming and screw implantation. The Kirschner wires
are advanced as discussed above in a volar and distal direction
through the thenar skin and withdrawn across the fracture
site. Under imaging, two 0.062-inch Kirschner wires are per-
cutaneously introduced dorsally into each nonunion frag-
ment. The joysticks are manipulated to correct the deformity,
extend the flexed scaphoid, and obtain a reduction. To assist
with difficult reductions, a small curved hemostat can be
percutaneously introduced directly into the fracture site in
order to lever the distal pole into correct alignment. With
severe flexion deformity, the wrist can be flexed until the
lunate assumes a neutral position, and a 0.062-inch Kirschner
wire is provisionally driven from the distal radial metaphysis
into the lunate to hold its reduced position. The wrist can then
be hyperextended and the joystick in the distal scaphoid can
be manipulated until the correct alignment is achieved. While
the joysticks maintain reduction, the volar Kirschner wires
are driven proximally and dorsally into the proximal pole to
capture the reduction.
Arthroscopy and Percutaneous Dorsal Capsular Release.  After
positioning of the guide wire and confirmation of fracture
alignment using fluoroscopy, an arthroscopic survey is per-
formed, the goal being to identify and treat ligament injuries,
directly inspect the quality of the reduction, confirm fibrous
union bridging the nonunion fragments, and rule out degen-
erative arthritis at the radiocarpal joint. Wrists with scaphoid
nonunions may have a concomitant capsular contracture. This
contracture may be released arthroscopically to improve wrist
motion and assist correction of scaphoid deformity.
Arthroscopic capsular release for contracture of the wrist
was first described by Verhellen.163 Fluoroscopy provides

A B
C
Figure 18.29  A, Harvesting distal radius bone graft is accomplished by placing a Kirschner wire in the distal radius B, A
cannulated reamer is used to breach the bone cortex. An 8-gauge 4-inch bone biopsy cannula is used to harvest plugs of
cancellous bone graft. C, Plugs of harvested bone.
valuable guidance when used in tandem with arthroscopy.
Radiocarpal arthrofibrosis is released by placing a small
curved hemostat through the 3-4 arthroscopic portal under
fluoroscopic guidance. Under traction and image guidance,
the curved hemostat is gently swept radially and dorsally to
release capsular fibrosis. The small curved hemostat is rein-
troduced through the 3-4 arthroscopic portal and swept
ulnarly and dorsally, freeing the remaining articular scar
tissue and dorsal capsule. These maneuvers should be per-
formed under fluoroscopic guidance to prevent iatrogenic
injury to the remaining healthy joint cartilage. These same
maneuvers can be performed on the midcarpal joints to
release joint capsule arthrofibrosis. Next, a small-joint
arthroscope and instruments can safely be introduced to com-
plete capsular release and joint fibrosis excision (see also
Chapter 19).
Percutaneous Bone Grafting of Nonunions.  After arthroscopy,
scaphoid reduction, and central axis wire placement, the
scaphoid is reamed from the proximal scaphoid pole, across
the nonunion site, to a point in the distal scaphoid 2 mm from
the far cortex. The reaming of the distal scaphoid establishes
PART
III
18 
Wrist: Fractures of the Carpal Bones
a conduit for fresh blood supply and removes some of the
devitalized bone at the nonunion site. Following reaming, the
arthroscope can be introduced into the proximal pole to
assess vascularity (Figure 18.30). A curet is placed through
the proximal scaphoid portal to the nonunion site using fluo-
roscopic imaging. The outer cortex, which often has fibrous
tissue, must not be violated because this tissue acts as a net,
holding the percutaneously introduced bone graft. Using an
8-gauge, 4-inch bone biopsy needle, the cannula is inserted
over the guide wire and the guide wire withdrawn volarly.
Bone plugs are implanted through the cannula to the non-
union site under imaging. After bone plugs have been
implanted into the scaphoid through the entry hole in the
proximal pole, they are tamped into place (Figure 18.31). The
guide wire is reinserted into the scaphoid, and the screw is
implanted. Scaphoid length is determined by adjusting the
central axis guide wire until the leading end is in the sub-
chondral bone of the distal scaphoid pole. A second wire of
equal length is placed percutaneously at the proximal scaph-
oid pole and parallel to the guide wire. The difference in
length between the trailing ends of each wire is the scaphoid
667
PART
III
18 
Wrist

Figure 18.30  An arthroscopic examination can be used to assess proximal scaphoid fragment vascularity. A guide wire is placed
down the central axis of the scaphoid. A second antiglide wire is placed parallel to the first wire. The proximal scaphoid pole is
reamed with a cannulated drive placed on the central axis guide wire. An arthroscopic cannula is placed over the central axis
guide wire and the wire is withdrawn volarly across the nonunion site. A small 1.9-mm arthroscope is placed into the proximal
scaphoid pole. The tourniquet is deflated, and the cancellous bone is inspected for punctate bleeding. Absence of any punctate
bleeding is indicative of AVN of the proximal fragment. One may consider conversion to a vascularized graft in this situation.

length. The screw selected should be 4 mm shorter than the
scaphoid length. This permits 2 mm of clearance of the screw
at each end of the scaphoid, thus ensuring complete implanta-
tion without screw exposure. For small proximal pole frac-
tures or when there are concerns about the adequacy of
fixation, an additional screw may be used between the distal
scaphoid and capitate to stabilize the fracture site and prevent
fracture site shear until bone healing. Very small proximal
pole nonunions have been treated with a sandwiching com-
pression screw from the mid-scaphoid to the lunate in addi-
tion to the midcarpal locking screw (Figure 18.32).
AUTHORS’ PREFERRED TECHNIQUE:
ARTHROSCOPIC REDUCTION, GRAFTING, AND
INTERNAL FIXATION OF SCAPHOID NONUNIONS
(GEISSLER TECHNIQUE)
Recently, Geissler described his arthroscopic technique for
reduction, fixation, and grafting of selective scaphoid non-
unions (Geissler WB, Slade JF III. Arthroscopic-assisted per-
cutaneous screw fixation for scaphoid nonunion; personal
communication, 2002). The advantage of this technique is
that the starting point for the guide wire is viewed and
selected directly with the arthroscope, and graft material can
be introduced into the nonunion site without an incision. In
addition, the wrist is not hyperflexed, which could potentially
distract scaphoid fragments and disrupt scaphoid alignment.
668
Geissler’s technique of ideal screw localization may be used
for both acute fracture fixation and nonunion surgery.
In this technique, the wrist is suspended in a wrist traction
tower. The arthroscope is initially placed in the 3-4 portal to
evaluate for any associated soft tissue lesions of the interos-
seous ligaments or triangular fibrocartilage complex. Any
soft tissue lesions that are identified are managed arthroscop-
ically. The arthroscope is then transferred to the 6R portal.
The wrist is flexed approximately 30 degrees in the traction
tower (Figure 18.33). A 14-gauge needle is inserted through
the 3-4 portal, and the junction of the SLIL is palpated at its
insertion onto the scaphoid (Figure 18.34). The most ideal
point for screw entry is at the junction of the SLIL and the
scaphoid at its midpoint in the dorsopalmar direction (Figure
18.35). Occasionally, dorsal synovitis may block visualization
of the starting point. It is important to débride the synovitis
to improve visualization. The 14-gauge needle is advanced
and gently impacted by hand into the scaphoid subchondral
bone in this position. The arthroscope is removed in prepara-
tion for guide wire placement.
With the wrist still flexed approximately 30 degrees, the
starting point of the needle is evaluated under fluoroscopy
(Figure 18.36). The needle is aimed toward the thumb, and
a guide wire is advanced through the needle and down the
central axis of the scaphoid to abut the subchondral bone of
the distal pole (Figures 18.37 and 18.38). The position of the
guide wire is then evaluated on the PA, navicular, and lateral
planes under fluoroscopy. This evaluation is done by rotating
the forearm in the traction tower; the fluoroscopic image is
not hindered by the support beam of the tower, which is to
the side. A second guide wire is then introduced adjacent to
the first and is advanced to the starting point on the scaphoid PART
proximal pole. The difference in length between the guide III
wires is measured to determine the length of the screw;
alternatively, a depth gauge may be used. As in the dorsal
18 
percutaneous approach, a screw at least 4 mm shorter is

Wrist: Fractures of the Carpal Bones

A checked on the PA, oblique, and lateral planes under fluo-
B (Figure 18.40). In a scaphoid nonunion, percutaneous cancel-
Figure 18.31  A, Previously harvested cancellous bone plugs are
placed into the trailing end of the 8-gauge cannula. Using
fluoroscopic imaging, a plunger is used to deliver the bone graft
to the nonunion site. B, The nonunion site is radiolucent, but
with implantation of the cancellous bone graft it soon becomes
radiopaque. The central axis Kirschner wire is driven from volar to
dorsal and a headless screw is implanted to provide rigid fixation.
recommended. The reduction of the scaphoid is evaluated
with the arthroscope in the radial and ulnar midcarpal portals.
If further reduction is necessary, the guide wire is advanced
across the trapezium and through the thenar skin and with-
drawn distally to just clear the fracture site. An additional
Kirschner wire may then be placed dorsally into the proximal
pole of the scaphoid. These wires can be used as joysticks to
reduce the fracture anatomically, as viewed directly with the
arthroscope in the midcarpal portal. Traction through the
tower may also be helpful to fracture reduction. If the reduc-
tion is satisfactory, the guide wire is advanced back into the
scaphoid proximal pole and out the dorsal skin.
In acute scaphoid fractures or in fibrous nonunions, demin-
eralized bone matrix putty is not used. An appropriately
sized headless cannulated screw is inserted over the guide
wire across the fracture site. The position of the screw is
roscopy in the traction tower. It is important to arthroscopi-
cally re-evaluate the radiocarpal space and midcarpal spaces
following screw insertion. From the radiocarpal space, the
surgeon must check that the headless screw is recessed below
the articular surface so as to avoid injury to the articular
cartilage of the distal radius (Figure 18.39). Reduction and
compression of the scaphoid fracture is then evaluated with
the arthroscope in the midcarpal space and with fluoroscopy
lous bone grafting or injection of demineralized bone matrix
putty is performed. The scaphoid is reamed through a soft
tissue protector in preparation for the headless cannulated
screw. A bone biopsy needle is filled with demineralized bone
matrix or cancellous bone graft. The bone biopsy needle is
then placed over the dorsally placed guide wire and inserted
through the reamed hole in the scaphoid to the nonunion site

A B
Figure 18.32  The distal scaphoid pole acts as a long lever arm to the proximal scaphoid pole and proximal carpal row during
wrist motion radius. Proximal pole fractures have only a few threads crossing the fracture line. Wrist motion results in continuous
rocking at the fracture site. The forces concentrated here are significant and can result in reduction of compression and
loosening of fixation. Bending forces can be balanced by the placement of a 0.062-inch Kirschner wire or headless compression
screw from the scaphoid into the capitate (A). For very small proximal pole fractures, I have also compressed the proximal
fragment between the scaphoid and the lunate with a second compression screw. After healing has been confirmed with CT
scan, these mechanical blocks are removed (B).

669
PART
III
18 
Wrist

Figure 18.33  The wrist is suspended in approximately 10 pounds

of traction in the AcuMed traction tower (AcuMed, Hillsboro, OR).
The wrist is flexed approximately 30 degrees to allow access to
the proximal pole of the scaphoid.

Figure 18.34  Following arthroscopic evaluation of the wrist with

the arthroscope in the 3-4 portal to evaluate for any soft tissue
injury, the arthroscope is placed in the 6R portal. A 14-gauge
needle is passed through the previously placed 3-4 portal to
palpate the junction of the SLIL to the proximal pole of the
scaphoid. The needle should pass directly through the portal
without engaging the extensor tendons.

Figure 18.36  The arthroscopic tower is then flexed down with

the needle impaled in the proximal pole of the scaphoid. The
Figure 18.35  Arthroscopic view of the 14-gauge needle as it is starting point can be easily confirmed fluoroscopically as the
impaled onto the proximal pole of the scaphoid with the traction bar is off to the side and does not impede radiographic
arthroscope in the 6R portal. examination.

670
 PART
III
18 

Wrist: Fractures of the Carpal Bones

Figure 18.37  The needle is aimed toward the thumb and a guide
wire is inserted through the 14-gauge needle down the central
axis of the scaphoid.

Figure 18.38  Under fluoroscopic visualization, the guide wire is

seen well centered in the scaphoid.

Figure 18.39  Arthroscopic view with the arthroscope in the 3-4

portal confirming that the headless cannulated screw is inserted
up into the scaphoid and is not prominent proximally so as to Figure 18.40  PA radiograph demonstrating ideal placement of
injure the articular cartilage of the scaphoid facet of the distal the headless cannulated screw and good compression of the
radius. scaphoid nonunion site.

671
PART
III
18  eratively. I allow patients with 50% bridging bone at the
Wrist
Figure 18.41  A bone biopsy needle is filled with demineralized
bone matrix and inserted over the guide wire to inject putty in
the nonunion site.
(Figure 18.41). The wire driver is placed on the volar end of
the guide wire and the wire withdrawn until it clears the
nonunion site but remains in the distal pole. The demineral-
ized bone matrix is then injected through the bone biopsy
needle into the nonunion cavity. With the bone biopsy needle
still in place, the guide wire is advanced from distal to proxi-
mal through the biopsy needle and out the dorsal skin. The
bone biopsy needle is then removed. A headless cannulated
screw is inserted over the guide wire across the scaphoid
nonunion. The radiocarpal and midcarpal spaces are re-eval-
uated arthroscopically to confirm reduction and compression
of the fracture and to ensure complete containment of the
screw within the scaphoid.
Postoperative Care
Immediate postoperative care includes a bulky compressive
hand dressing and a volar splint. The patient is encouraged to
initiate immediate digital exercises to reduce swelling. At the
first postoperative visit the therapist fashions a removable
volar splint that holds the wrist and hand in a functional
position, and the patient is started on an immediate strength-
ening program. The purpose of the strengthening program is
to axially load the fracture site (now secured with an intra-
medullary screw) to stimulate healing. This early motion also
decreases swelling and permits an early return of hand func-
tion. Patients with eccentric fractures, particularly proximal
pole fractures, are restricted from wrist motion until CT scan
confirms the presence of early bridging bone at the fracture
site at 6 weeks postoperatively.
Although postoperative radiographs are obtained with the
first postoperative visit and at 6-week intervals, it has been
determined that standard radiographs at 3 months are unreli-
able in determining scaphoid healing. Hence, CT scans with
672
1-mm cuts in the coronal and lateral planes are used to evalu-
ate bridging bone at the fracture site. Usually, 100% bridging
of a nonunion is observed by CT scan by 6 months postop-
fracture site who have internal fixation with a headless com-
pression screw to return to full unrestricted activities, includ-
ing athletics. If bridging bone is not identified by 12 weeks,
one must consider aggressive treatment including repeat
bone grafting. Scaphoid waist nonunions without concomi-
tant ligament injury are started on an immediate range of
motion protocol, whereas proximal pole fractures are pro-
tected for 1 month prior to initiation of therapy. While we do
not routinely cast scaphoid fractures postoperatively, we con-
sider a playing case for athletes in contact sports.
Open Volar Approach for Correction of Scaphoid
Deformity with Nonunion and Malunion
In 1984, Fernandez presented his modification of the Fisk
procedure to treat scaphoid nonunions associated with carpal
instability.46 His article briefly described the following modi-
fications: (1) preoperative calculation of the exact scaphoid
length and form based on comparative radiographs of
the opposite wrist, (2) the use of a palmar approach, (3) the
insertion of a wedge-shaped corticocancellous graft from
the iliac crest after resection of the pseudarthrosis, and
(4) the use of internal fixation (Figure 18.42). Preoperative
planning is considered essential to restore the anatomic
length, analyze the angular deformity, evaluate the patho-
logic scapholunate angle, and calculate the resection and size
of the graft needed. The palmar approach reduces the danger
of iatrogenic damage of the vascular supply of the scaphoid
and accidental lesions of the superficial branches of the radial
nerve. Iliac bone is preferred to the radial styloid graft, as
proposed by Fisk, because of its better ability to resist com-
pression forces. Internal fixation adds rotational stability so
that continued postoperative plaster immobilization can be
reduced to a minimum of 8 weeks.
In 1990, Fernandez reported union of 19 of 20 established
nonunions repaired with this technique, with an average time
off work of 8.9 weeks.47 In a review of the pertinent literature,
he determined that the most common reasons for recalcitrant
nonunion were improper internal fixation techniques, the
absence of bone grafting, or both.
Eggli reported on a retrospective review of 37 patients
with scaphoid fracture nonunions treated by interpositional
bone grafting and internal fixation at an average follow-up
of 5.7 years. Solid radiographic union was achieved in 35
cases. Preexisting AVN was a major adverse factor for
achievement of union and satisfactory outcome. Patients
with preexisting degenerative changes had a significantly
worse clinical outcome. The vast majority of the patients had
satisfactory correction of scaphoid length and the associated
DISI. Although 30 patients showed radiographic evidence of
mild or moderate degenerative changes at their latest follow-
up, there was no significant progression of arthrosis, and
carpal collapse deformity did not progress after healing of the
fracture nonunion.42
Technique: Anterior Wedge Grafting
Preoperative PA, lateral, and ulnar deviation PA radiographs
of the injured wrist and of the opposite normal wrist are used

C 18
L
A B
Figure 18.42  A, Schematic representation of normal alignment of the scaphoid (S), lunate (L), and capitate (C). B, Nonunion of
a fracture of the scaphoid with palmar flexion of the distal fragment and a dorsal intercalated segment instability pattern. C, The
scaphoid alignment is corrected. D, It is maintained by the insertion of a palmar wedge-shaped bone graft. (From Taleisnik J: The
Wrist, New York, Churchill Livingstone, 1985. Redrawn by Elizabeth Martin.)
to determine the amount of resection and size of the graft
needed. One must determine the amount of scaphoid flexion
deformity, the extent of carpal collapse, and the scapholu-
nate and lunocapitate angles (Figure 18.43). The humpback
deformity can be evaluated more exactly using CT scans
taken along the long axis of the scaphoid. MRI is required
only for nonunions with a high suspicion of AVN of the proxi-
mal fragment.
Nonunions of the distal third and waist are approached
through a palmar hockey-stick incision along the FCR,
extended obliquely toward the thenar eminence. The ante-
rior capsule is incised from the distal radius to the scapho-
trapezoidal joint to expose the most palmar-radial corner of
the scaphoid without damaging its blood supply. The capsular
flaps contain the RSC ligament. Sclerotic or irregular borders
of the nonunion site are resected with an oscillating saw to
obtain flat bony surfaces. Cystic defects are curetted and filled
with cancellous bone chips. The extended lunate is corrected
by flexing the wrist until the lunate assumes a neutral position
under fluoroscopy, and a 0.062-inch Kirschner wire is placed
through the diaphyseal-metaphyseal junction of the radial
styloid into the lunate under fluoroscopic control. The flexion
deformity and shortening of the scaphoid are then corrected
by distracting the osteotomy with a bone spreader clamp
while hyperextending the wrist over a rolled towel. A bicorti-
cal or tricortical graft is harvested from the iliac crest, along
with additional curetting of cancellous bone. The graft is kept
in aspirated blood from the iliac wound until ready for use.
Osteotomes of various sizes can be used to measure the
depth, width, and length of the trapezoidal defect of the
scaphoid,125 and the graft is sculpted to the correct dimen-
sions using a saw and osteotomes. The bone graft is impacted
into the defect and scaphoid alignment and posture checked
with fluoroscopy. A guide wire is advanced from distal to
proximal across the scaphoid and intercalated graft. Finally,
compression screw fixation of the scaphoid is performed.
Careful closure of the palmar capsule and repair of the RSC
ligament is done. A long-arm thumb spica postoperative
splint is applied. Sutures are removed at 10 to 12 days, and
PART
III
 
Wrist: Fractures of the Carpal Bones
C D
the above-elbow immobilization is continued until the radio-
lunate pin is removed.
For long-standing DISI deformity that presents with a
radiolunate angle greater than 20 degrees, the radiolunate
transfixion wire is left in place for 4 to 6 weeks to reduce
forces on the healing scaphoid. Short arm casting is preferred
until radiographic or CT evidence of trabecular healing has
occurred. Fernandez’s criteria to establish healing are the
absence of pain, radiographic evidence of bridging bony tra-
beculae on both sides of the interposed graft, a disappearance
of the osteotomy lines in conventional x-rays, and no signs
of screw loosening.46 CT is advised to confirm union prior to
return to athletic activities.
Vascularized Bone Grafting for Treatment of
Scaphoid Avascular Necrosis
Since 1986 there has been great interest in vascularized bone
grafting to treat bony nonunion including the scaphoid. Shi
reported on an experimental study and clinical uses of the
fasciosteal flap for bone healing.134 Zaidemberg and col-
leagues in 1991 demonstrated a consistent vascularized bone
graft source from the distal dorsal radial radius for the treat-
ment of scaphoid nonunions using latex injection tech-
niques.177 In a preliminary series of 11 patients, these authors
reported 100% success.177 The use of various vascularized
bone grafts for carpal pathology has been reported, including
vascularized pisiform grafts, metacarpal head grafts, prona-
tor quadratus grafts, and several supracompartmental and
intracompartmental vessels about the radial metaphysis
(Figure 18.44A).
In 1979, Hori and colleagues performed elegant canine
studies to demonstrate the efficacy of an implanted arter­
iovenous pedicle to treat osteonecrosis.70 Sunagawa and
colleagues, in a subsequent canine study, compared nonvas-
cularized (conventional) grafts with arteriovenous pedicle
graft implantation and quantitatively assessed bone blood
flow, fracture healing, and bone remodeling.150 They found
that 73% of the vascularized grafts and none of the conven-
tional grafts healed. At 6 weeks, bone blood flow in the
673
PART
III
18 
Wrist

S
25
m
40°
m
L

A
Figure 18.43  Preoperative planning for insertion of a
wedge-shaped graft. Tracing of the opposite
20 mm uninjured wrist and measurement of scaphoid length
S and scapholunate angle. S, scaphoid; L, lunate.
52° B, Calculation of size, resection area, and form of
L graft. C, Definitive diagram of the operation.
(Redrawn from Fernandez DL: A technique for anterior
wedge-shaped grafts for scaphoid nonunions with carpal
B instability, J Hand Surg [Am] 9:733-737, 1984.
Redrawn by Elizabeth Martin.)

S
42°
L

25 mm

A
B
Figure 18.44  A, Pronator pedicle bone graft. B, Second intermetacarpal vascular bundle implantation. (From Fernandez DL, Eggli
S: Nonunion of the scaphoid: revascularization of the proximal pole with implantation of a vascular bundle and bone grafting, J Bone
Joint Surg [Am] 6:883-893, 1995. Redrawn by Elizabeth Martin.)

674
 PART
III
18 

Wrist: Fractures of the Carpal Bones

X

X′

A B X Y

X′
C D

Figure 18.45  Use of a dorsal radius vascularized graft in cases of malunion or humpback deformity. A, The scaphoid is prepared
before graft elevation. B, A large graft is harvested that can then be shaped into a wedge. C and D, The graft is then trimmed
to fit the defect dimensions and used as a volar strut. (By permission of Mayo Foundation for Medical Education and Research. All
rights reserved.)

proximal pole was significantly higher on the side of the
vascularized graft. Quantitative histomorphometry of the
avascular proximal segment demonstrated significantly
higher levels of fluorochrome-labeled osteoid- and osteoblast-
covered trabecular surfaces on the vascularized graft side.
These data supported the clinical application of pedicled
vascularized bundle implantation in the treatment of carpal
osteonecrosis including proximal pole scaphoid nonunions48
(Figure 18.44B).
Vascular Anatomy of Dorsal Radius Grafts
The vessels supplying the nutrient arteries to the dorsal
radius are best described by their relationship to the extensor
compartments of the wrist and the extensor retinaculum. The
1,2 intercompartment supraretinacular artery (1,2 ICSRA) is
superficial to the extensor retinaculum and lies between the
first and second compartments. The 2,3 intercompartment
supraretinacular artery (2,3 ICSRA) lies superficial between
the second and third compartments. Both arteries are at areas
where the extensor retinaculum is firmly attached to bone,
allowing nutrient arteries to penetrate the cortex. In addition
to the superficial vessels, two vessels are deep to the extensor
tendons on the floor of the fourth and fifth dorsal compart-
ments. These are the fourth extensor compartment artery
(ECA) and the fifth ECA. The 1,2 ICSRA branches from the
radial artery 5 cm proximal to the radiocarpal joint and rises
dorsally to lie on the extensor retinaculum between the first
and second compartments.
Technique for Surgical Preparation of the
1,2 ICSRA Graft
The 1,2 ICSRA graft for scaphoid nonunion described by
Zaidemberg and colleagues177 (Figure 18.45) is most useful
for scaphoid nonunion, but it has a relatively short pedicle. A
dorsal radial incision is centered over the radiocarpal joint
between the first and second compartments. This allows good
exposure of the dorsal radial scaphoid. Branches of the super-
ficial radial nerve need to be identified and protected. The
1,2 ICSRA is found coursing up dorsally from the radial
artery to lie superficially on the surface of the extensor reti-
naculum between the first and second compartments (Figure
18.46). The first and second compartments are incised at their
675
PART
III
18  and the proximal pole can be curetted or burred out of avas-
Wrist
Figure 18.46  1,2 intercompartmental supraretinacular artery (1,2
ICSRA) is found coursing dorsally from the radial artery to lie
superficially on the surface of the extensor retinaculum between
the first and second compartments’ radius. The vascularized bone
graft is harvested on a pedicle from the 1,2 ICSRA. Branches of
the superficial radial nerve need to be identified and protected
during the isolation of this pedicle. (Figure used with permission
from Seth D. Dodds, MD.)
Figure 18.47  The first and second compartments are incised at
their attachment to bone near the 1,2 ICSRA. The 1,2 ICSRA is
mobilized as a pedicle. The pedicle is not elevated off the bone
more than 10 to 15 mm proximal to the joint line because this is
the area where the nutrient vessels begin to penetrate the cortex
(arrows). The pedicle is freed up almost to the radial artery at the
level of the first compartment. (Figure used with permission from
Seth D. Dodds, MD.)
attachment to bone near the 1,2 ICSRA. The 1,2 ICSRA is
carefully mobilized as a pedicle (Figure 18.47). Care is taken
not to elevate the pedicle off the bone more than 10 to
15 mm proximal to the joint line, because this is the area
where the nutrient vessels begin to penetrate the cortex. The
pedicle is freed almost to the radial artery at the level of the
first compartment.
After elevation of the pedicle, the scaphoid nonunion is
approached through a radial longitudinal incision at the
capsule. The nonunion site is identified and exposed. Ideally,
676
a rectangular slot is created, bridging the fracture site in the
scaphoid that will receive the bone graft. If the fracture is in
the proximal pole, a slot can be created in the distal fragment,
cular bone. In such a case, the graft would slide into the
concavity of the proximal pole and fit into the slot in the
distal fragment. A small limited radiostyloidectomy can
improve visualization but is often not needed. If the scaphoid
is foreshortened with a humpback deformity, a vascularized
graft may be placed as a volar wedge graft. This requires a
wider exposure, which is accomplished by radial
styloidectomy.
Once the nonunion site is prepared, the pedicled graft is
carefully lifted from the radial metaphysis using small osteo-
tomes. The 1,2 ICSRA artery is ligated proximal to the graft,
and the graft is checked for flow by deflating the tourniquet.
The graft is then passed under the radial wrist extensors and
impacted gently into place. If a significant concavity exists in
either the proximal or distal fragment, additional cancellous
bone is harvested from the distal radius to fill out the deep
area of concavity in the scaphoid. Once the graft is in place,
supplemental internal fixation, either Kirschner wires or a
compression screw, is used (Figure 18.48). Alternatively, if the
scaphoid fragments are loose and grossly unstable with respect
to each other, internal fixation can be placed first to stabilize
the scaphoid as a single unit, and then the vascularized graft
can be impacted into place. The screw should be placed in the
volar third of the scaphoid to reduce the chance of dislodging
the graft.
Outcomes
Chang and colleagues evaluated the outcome, complications,
and failures of 1,2 ICSRA-based vascularized bone grafting
from January 1994 through July 2003.28 Fifty scaphoid non-
unions in 49 patients were treated with 1,2 ICSRA-based
vascularized bone grafts. Thirty-four scaphoid nonunions
were united at an average of 15.6 weeks after surgery. Com-
plications occurred in eight patients and consisted of graft
extrusion, superficial infection, deep infection, and failure of
fixation. Risk factors for failure included older age, proximal
pole AVN, preoperative humpback deformity, nonscrew
fixation, tobacco use, and female gender.20 Straw and col-
leagues reported on Zaidemberg’s technique, which they
used to treat 22 established scaphoid fracture nonunions, 16
of which were found to have avascular proximal poles at
surgery.149 After a follow-up of 1 to 3 years, only six (27%)
of the 22 fracture nonunions had united. Only two (12.5%)
of the 16 nonunions with avascular proximal poles united,
compared with four (66%) of the six nonunions with vascular
proximal poles. They concluded that pedicled vascularized
bone grafting may not improve the union rate for scaphoid
fracture nonunions with avascular proximal pole fragments.
It is possible that poor fixation, use of a single Kirschner
wire, or too early removal may be responsible for the poor
union rate.
Vascularized Medial Femoral Condyle Grafting
Jones investigated a new free vascularized bone graft from
the medial femoral condyle and compared it to the 1,2 ICSRA
graft.85 Twenty-two patients with scaphoid waist nonunions
associated with an avascular proximal pole and carpal

A B
Figure 18.48  A, Once the graft is in place, internal fixation is undertaken with either Kirschner wires or a compression screw.
B, After correction of a humpback deformity with a volar vascularized wedge graft, rigid internal fixation is critical. The graft is
secured to the scaphoid with a screw down the central axis, and a second screw is placed from the distal scaphoid to the
capitate to lock the midcarpal joint. This counters the bending force on the scaphoid. Serial CT scans are taken to evaluate
healing.
collapse were treated. Four of the 10 nonunions treated with
the distal radial pedicle graft healed at a median of 19 weeks,
and all 12 nonunions treated with the free medial femoral
condyle graft healed at a median of 13 weeks. The rate of
union was higher (P = .005) and the median time to healing
was significantly shorter (P < .001) for the nonunions treated
with the medial femoral condyle graft.
Prognosis for Healing of
Scaphoid Nonunion
We performed a systematic quantitative meta-review of the
literature to provide evidenced-based suggestions for the
treatment of scaphoid nonunion.108 This search identified
1121 articles, of which 36 met eligibility requirements. In
unstable nonunions, screw fixation with corticocancellous
wedge grafting, which resulted in union in 94% of cases, was
superior to Kirschner wires and wedge grafting, which
resulted in union in 77% of cases. Immediate mobilization
was compared with 6 weeks or more of casting, and they
demonstrated comparable healing rates of 74%. For patients
with AVN of the proximal fragment, union was achieved in
88% of patients with a vascularized graft versus 47% with
screw and intercalated corticocancellous graft. These results
suggest that established unstable nonunions should be treated
with screw fixation rather than Kirschner wires. There is no
evidence to support postoperative immobilization in patients
with solid screw fixation. A vascularized graft may be prefer-
able for patients with AVN of the proximal fragment or with
a previously failed surgery.
Shah and Jones reported on 50 scaphoid nonunions treated
with Herbert screw fixation.132 Success rates fell off as the
duration of nonunion increased. The authors felt that this
may have been related to the increased incidence of AVN
with time. In their series, the major adverse determinants for
outcome were AVN and a history of previous surgery for
nonunion.
Inoue and colleagues retrospectively reviewed 160 cases
of scaphoid nonunion treated by internal fixation using a
Herbert screw with bone grafting at an average follow-up of
24 months.80 Radiographic union was achieved in 90% of
cases. Failure of union was related to the existence of avas-
cular changes of the proximal fragment, instability of the
PART
III
18 
Wrist: Fractures of the Carpal Bones
fracture fragment, the prolonged delay in surgery, and the
location of the fracture site. Persistent flexion deformity of
the scaphoid adversely affected outcome.
Schuind and colleagues reported on a multicenter study of
138 patients following scaphoid nonunion surgery.131 Defini-
tive healing occurred in only 74% of cases. Factors associated
with nonunion included heavy work, duration of nonunion
longer than 5 years, a treatment delay before surgery, associ-
ated radial styloidectomy, and increased duration of postop-
erative immobilization.
Salvage Procedures
Treatment of Scaphoid Malunion
There are insufficient data to justify routine corrective oste-
otomy in patients with malunited scaphoids. Amadio and
colleagues reported on 45 patients with 46 scaphoid fractures
that were studied more than 6 months after union by clinical
examination and trispiral tomography.7 Twenty fractures
healed with normal scaphoid alignment as defined by lateral
intrascaphoid angles less than 35 degrees. There were satis-
factory clinical outcomes in 83% and post-traumatic arthritis
in only 22% of those with normal scaphoid anatomy. Wors-
ening results were associated with increasing lateral scaphoid
angulation and humpback deformity. In patients with greater
than 45 degrees of lateral intrascaphoid angulation present
at the time of union, there was a satisfactory clinical outcome
in 27% and post-traumatic arthritis in 54%. The authors felt
that union alone is an insufficient criterion for measuring
success in treating scaphoid fractures.
Nakamura reported on 10 patients with symptomatic mal-
union of a carpal scaphoid fracture. All had displacement
with DISI and suffered from pain, restricted range of move-
ment at the wrist, and decreased grip strength. The restriction
of flexion-extension and the decreased grip strength corre-
lated with the severity of the DISI deformity. Seven patients
had a corrective osteotomy using an anterior wedge-shaped
bone graft with internal fixation by Herbert screw, and all
had satisfactory results.114
Fernández and colleagues presented a small series of three
patients with painful rotational malalignment of the scaphoid
and significant loss of active wrist extension who were treated
with an opening wedge multiplanar osteotomy that corrected
677
PART flexion, ulnar deviation, and pronatory rotational malalign-
III ment of the distal fragment.49 After a minimum follow-up of
4 years, all three patients were satisfied with the procedure
18  and were pain free. The preoperative range of wrist motion
had improved, and they had returned to their preoperative
Wrist
occupations.
Lynch and Linscheid reported on a long-term follow-up
that was performed on five patients with DISI who under-
went corrective osteotomy for symptomatic scaphoid mal-
union.97 On follow-up 9 years after the procedure (range, 1.5
to 19 years), all patients had healed and demonstrated an
improvement in range of motion and grip strength. The pre-
operative intrascaphoid and carpal malalignments were
reduced as demonstrated by trispiral tomography.
Jiranek and colleagues studied 26 healed scaphoid non-
unions and compared objective and subjective outcomes with
interscaphoid alignment.84 While there were significant objec-
tive differences and increased degenerative changes when
patients with malunited and normally aligned scaphoids were
compared, there were no subjective differences in satisfac-
tion, pain relief, and return to work or sporting activities.
Corrective osteotomy for scaphoid malunion may have a
role in the prevention or slowing of the onset of premature
arthritis in young patients with high functional demands, but
patients should be carefully selected based on severity and
duration of symptoms rather than malalignment alone.
Salvage and Palliative Procedures for SNAC
Radial Styloidectomy
Radial styloidectomy may be performed subperiosteally
through the anatomic snuffbox. Care must be taken to pre-
serve the important volar radial ligament attachments; if
more than 1 cm of styloid is removed, the radioscaphocapi-
tate ligament origin will be significantly compromised.135 Sty-
loidectomies have been unsatisfactory as isolated procedures
for SNAC arthritis, but they have enjoyed success when
combined with bone grafts, with or without internal fixation,
for stage I SNAC arthritis. Although some surgeons have not
considered styloidectomy to be an essential part of the treat-
ment of nonunions, the procedure does consistently improve
on the results of bone grafting alone.
Proximal Row Carpectomy
Proximal row carpectomy for advanced SNAC arthritis is a
motion-preserving salvage operation. Compared with inter-
carpal arthrodesis, it is simple to perform, avoids the risk of
nonunion, requires a short period of immobilization, and
requires little rehabilitation. Several long-term studies have
shown it to be a durable procedure with predictable
results.31,78 Patients can expect to achieve grip strength of
70% to 80% of their contralateral extremity and a wrist arc
range of motion of 50% to 60% of their contralateral extrem-
ity. Although the majority of patients develop radiographic
degenerative change at the radiocapitate articulation, most
are asymptomatic.
Indications and Contraindications
The ideal candidate is a relatively low-demand patient older
than 40 years with stage I or stage II SNAC without capitolu-
nate degenerative disease. The radiocapitate arthritis that
develops over time may limit the longevity of this procedure
678
in younger patients. Heavy laborers are also excluded.
Patients with inflammatory arthropathies, such as rheuma-
toid arthritis with persistent carpal synovitis, are at risk of
developing postoperative ulnar translocation of the carpus
secondary to capsular and ligamentous laxity and are contra-
indicated as candidates.
Surgical Technique
A dorsal incision about 8 cm long is centered over Lister’s
tubercle. The EPL tendon is identified distal to the extensor
retinaculum. It is dissected free from the third dorsal com-
partment and retracted radially. A posterior interosseous
neurectomy may then be performed. The wrist capsule is
entered through a longitudinal incision parallel to the ulnar
border of the extensor carpi radialis brevis. Alternatively, the
capsule may be opened in the ligament-sparing approach
described earlier to expose the scaphoid, lunate, and trique-
trum.16 A subperiosteal dissection is then performed as
needed beneath the dorsal extensor compartments. The wrist
is flexed to expose the proximal carpal row, and the capitate
and the lunate facet of the distal radius are inspected for
degenerative change. If there is full-thickness cartilage loss,
an intracarpal fusion or total wrist arthrodesis should be
considered.
The removal of the proximal row begins with the resection
of the scaphoid. Care must be taken to avoid injury to the
RSC ligament that lies at the volar midportion of the scaph-
oid extending from the volar radial styloid to the volar capi-
tate. The RSC ligament prevents postoperative ulnar
translation of the carpus. The lunate and triquetrum are
removed next, with care taken not to damage the articular
surface of the head of the capitate. It may be helpful to use
a threaded Steinmann pin or 3.5-mm threaded Schanz screw
to drill into the carpal bones for assistance with manipulation
and excision. After resection of the proximal row, the capi-
tate is seated into the lunate fossa of the distal radius. We do
not place temporary fixation across the new radiocarpal
articulation; Kirschner wires can result in pin tract infections
and pin migration. The wrist capsule is then closed, and
intraoperative radiographs are taken to confirm the location
of the capitate within the lunate fossa of the radius. The EPL
tendon is left transposed out of its compartment, and the
extensor retinaculum is also closed. Patients are immobilized
in a bulky conforming dressing until suture removal; a short
arm cast is then applied for 3 to 4 weeks. Gradual increased
motion is permitted using a removable splint for 2 to 4 weeks
or until the patient is capable of free use of the wrist.
Intercarpal Fusion
The purpose of intercarpal fusion is to stabilize the midcarpal
joint after the scaphoid is resected. Four-bone (capitate-
lunate-hamate-triquetrum) fusion with scaphoid excision sat-
isfactorily treats degenerative SNAC arthritis affecting the
radioscaphoid and midcarpal joints while preserving an ana-
tomically congruous radiolunate joint.
The priorities in properly executing four-bone fusion and
scaphoid excision include (1) adequate decortication of joints,
(2) bone apposition, (3) rigid internal fixation, including
Kirschner wires, staples, or cannulated screws, (4) correction
of lunate extension and restoration of capitate and lunate
height, and (5) appropriate postoperative immobilization. If
the lunate is not derotated into neutral from its extended
position and the capitate is fused in a dorsally subluxated
position, as is often present in the SNAC wrist, radiocapitate
abutment will prevent wrist extension and cause pain.
Surgical Technique
The dorsum of the wrist is approached with a midline inci-
sion. The retinaculum is opened between the third and fourth
compartments, and a longitudinal capsulotomy is performed.
The posterior interosseous nerve is routinely excised after it
enters the side of the fourth compartment. The scaphoid is
excised, with care to preserve the critical volar carpal liga-
ments. A threaded Steinmann pin or 3.5-mm Schantz screw
inserted down the axis of the scaphoid may be useful as a
joystick to manipulate and excise the bone. The adjacent
surfaces of the capitate, lunate, triquetrum, and hamate are
decorticated until the adjacent surfaces fit together. Bone
graft is harvested from a small window at Lister’s tubercle
and packed tightly into all intercarpal spaces. Bone graft
substitutes may be used if preferred by the surgeon. The
lunate is derotated to neutral position and the capitate
reduced ulnarward to its anatomic position on the lunate.
Crossed Kirschner wires, staples, or, preferably, cannulated
headless screws are used to obtain compression and fixation.
We prefer a longitudinal compression screw between the
lunate and capitate, a second screw between the triquetrum
and hamate, and a 0.062-inch Kirschner wire or compression
screw between the triquetrum and lunate. Suction bulb drain-
age for 24 hours may help to alleviate pain, and the wrist is
dressed in a bulky compressive bandage with a volar/dorsal
splint for 10 to 12 days. The splint is converted to a short
arm cast until union, generally at 6 weeks postoperatively.
Digital motion exercises are encouraged immediately follow-
ing surgery, and wrist motion rehabilitation and strengthen-
ing are initiated at healing.
Resection of the Distal Scaphoid
Indications
Malerich and colleagues reported on 19 patients with chronic
scaphoid nonunion and SNAC arthritis who were treated
with distal scaphoid fragment excision.100 Range of motion
had improved 85% and grip strength had improved 134% at
an average of 4 years postoperatively. The authors did not
demonstrate worsening of the DISI deformity following
surgery and do not recommend the procedure in patients
with capitolunate arthritis. Ruch and colleagues reported sat-
isfactory results in a cohort of 13 patients treated for SNAC
arthritis with scaphoid distal pole excision at 4 years postop-
eratively.128 They documented significant increases in wrist
range of motion but noted significant increases in DISI
posture in six patients. We believe that distal scaphoid exci-
sion is indicated as a salvage procedure for treatment of
selected scaphoid nonunions in low-demand patients.
Contraindications
After excision of the distal pole of the scaphoid, most of the
load across the scaphotrapezial-trapezoidal (STT) articula-
tion will be transferred to the central portion of the midcarpal
joint. Consequently, the scapholunocapitate ball-and-socket
articulation may suffer from overload. This procedure is con-
traindicated if there are arthritic changes, incongruency, or
instability at the scapholunocapitate joint. Possible conse- PART
quences of distal scaphoid resection are exacerbation of III
dorsal midcarpal instability (DISI pattern of misalignment)
and the development of a painful dorsal subluxation of the
18 
capitate.
Wrist: Fractures of the Carpal Bones
Surgical Technique
Distal Scaphoid Nonunion
A longitudinal, zigzag, or lazy “S” dorsal radial incision is
made over the scaphoid snuffbox. The sensory branches of
the radial nerve are identified and protected. Next, the radial
artery is identified and protected. This approach permits a
radial styloidectomy. A transverse dorsal incision at the STT
level exposes the distal scaphoid with special attention to
protect the palmar RSC ligament, which is located palmarly
just in contact with the anterior concavity of the scaphoid.
The ligament fibers that connect the lateral corner of the
scaphoid tuberosity to the lateral aspects of the trapezium
and trapezoid (STT ligaments) should also be preserved.
The distal scaphoid fragment is excised. In the case of a
proximal scaphoid nonunion, Malerich and colleagues advise
osteotomy of the scaphoid in its midwaist, to retain the sta-
bilizing effects of the dorsal intercarpal ligament and to avoid
exacerbation of DISI.100 Once the distal scaphoid has been
removed, it is essential to test the stability of the distal row
relative to the proximal scapholunate socket. Should the
capitate sublux, a stabilizing procedure, such as a scaphocapi-
tate fusion, scaphoid excision, and four-corner fusion, should
be performed instead. If stable, the capsule is closed and a
bulky dressing applied. The wrist is splinted until suture
removal and wrist motion exercises initiated with therapy.
Aggressive strengthening exercises are postponed until 3
months after surgery; heavy wrist loading in flexion would
promote excessive compressive load of the capitate against
the dorsal lip of the lunate, thus inducing the appearance of
further DISI malalignment and dorsal midcarpal subluxation.
These patients are advised to avoid contact sports for the first
6 months after surgery.
Preiser’s Disease
In 1910, Preiser described a rarefying osteitis of the scaphoid
that he distinguished from a scaphoid fracture.121 He com-
pared the condition with Kienbock’s disease and thought that
the etiologies were similar. Since Preiser’s time, both whole-
bone and proximal pole avascular necrosis of the scaphoid
have been described. The etiology has been variously related
to collagen vascular disease, steroid therapy, repetitive
trauma, or idiopathic causes. Clinical findings are related to
local pain and tenderness. Radiographically, involved areas
are typically sclerotic, and often there is fragmentation of the
proximal articular surfaces. CT and MRI may be helpful to
define the changes. This condition can present in children.
Treatment of Preiser’s disease has not been standardized.
Nonoperative symptomatic management, joint débridement,
silicone replacement arthroplasty, and electrical stimulation
have all been tried, with mixed results. Reversed-flow vas-
cularized bundle implantation has been performed in a
limited number of cases with variable success. Vascularized
bone grafting may also be considered, but results have been
variable and revascularization incomplete.113 The success of
scaphoid-preserving procedures may be compromised by
679
PART
RELATIVE INCIDENCE OF CARPAL BONE FRACTURES
III
18  Bone Fractured
Source Total Number of Fractures Scaphoid Lunate
Wrist
Garcia-Elias52 249 153 2 64
11
Auffray 245 144 10
Snodgrass145 170 144 11
Borgeskov20 143 102 2 29
Franz51 122 81 13
Dunn40 72 59 1 5
Table 18.3  Relative Incidence of Carpal Bone Fractures
chronic degenerative changes that are often present in the
carpus at the time of reconstruction, particularly at the radial
styloid and radioscaphoid articulation; this makes pain-free
motion following successful salvage difficult. Furthermore,
there is often insufficient satisfactory cortical bone into which
a graft can be inserted, as the surface is too fragmented.
Therefore, if revascularization is to be considered, the patient
should also consent to scaphoid excision and midcarpal
arthrodesis should vascularized grafting prove technically
impossible. If revascularization is attempted and proves
unsuccessful, scaphoid excision combined with either midcar-
pal arthrodesis or proximal row carpectomy may be appro-
priate for persistently symptomatic cases. Given the lack of
reliable treatment options, in the absence of severe pain and
disability a conservative approach is probably warranted and
should be discussed with the patient.
CARPAL FRACTURES EXCLUDING
THE SCAPHOID
Whereas fractures of the scaphoid are relatively common,
fractures of the remaining carpal bones are relatively rare.21
Larsen and colleagues reported that the relative incidence of
carpal fractures excluding the scaphoid was 1.1% of all frac-
tures.92 They estimated the annual incidence to be 36 frac-
tures per 100,000 people. In a review of 1000 consecutive
hand injuries, only 18% involved fractures of the carpus,
with the scaphoid being the most commonly injured carpal
bone (58%).92 Fractures of the carpus occur in three general
groups—perilunate pattern injuries, axial pattern injuries,
and local avulsion/impaction injuries.
Most carpal fractures are the consequence of a fall onto an
outstretched hand. The energy from the fall may be focused
on the distal carpal row when the distal radius resists tensile
stresses from hyperextension. If the mechanism of injury
continues, it produces an extension moment across the proxi-
mal carpal row transmitted through the volar carpal liga-
ments. These ligaments may be disrupted or result in shear
stress around the area of the lunate. This results in perilunate-
pattern or “lesser arc” injuries. Carpal fractures or ligamen-
tous injuries may occur in an arc around the lunate. Carpal
fractures may occur on the volar aspect of the wrist from
tensile stress, or dorsal cortical comminution may occur from
compression shear stress. Fractures of the scaphoid, capitate,
680
Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate
5 15 1 5 4
72 1 10 — 4 4
7 1 3 1 2 1
1 5 1 2 1
6 4 8 1 6 3
1 2 — — 4
triquetrum, or all three, in conjunction with perilunate insta-
bility, are known as “greater arc” injuries.
Strong AP compression injuries may result in axial-pattern
disruption of the carpus. The forced injury propagates both
radially and ulnarly, separating the carpus on both sides of
the capitate. Frequently, this may result in an open fracture
associated with variable soft tissue injury. These injuries are
frequently unstable and require surgical stabilization.
Lastly, avulsions may occur owing to localized forced con-
centration. These forces commonly cause avulsion injuries at
the volar/dorsal aspect of the triquetrum secondary to liga-
ment insertions, but trapezial ridge, hamate hook, and pisi-
form fractures may occur as well.
Garcia-Elias noted several characteristics common to
carpal fractures.52 First, these injuries generally occur in
young individuals with high functional demands; second,
these injuries are frequently missed at initial presentation;
third, the small size of the fractured carpal bone complicates
surgical reduction and potentially compromises its vascular
supply; fourth, the displaced carpal fracture may significantly
affect the congruency of the articular surface to the wrist,
resulting in post-traumatic degenerative changes; fifth, unsta-
ble carpal fractures frequently are associated with adjacent
ligamentous injury, as previously described; and sixth,
because of the close relationship of the carpus to the tendon
and neurovascular structures, secondary entrapment neu-
ropathies or tendon ruptures can occur by friction of nonre-
duced bone fragments.
The relative frequency of each carpal bone fractured is
controversial (Table 18.3).52 Many authors report that the
triquetrum is second only to the scaphoid as the most com-
monly fractured carpal bone, comprising 3% to 5% of all
carpal fractures.3 Some authors contend that the lunate is the
second most commonly fractured carpal bone, but these
series tend to include AVN or Kienbock’s disease.11,51 Garcia-
Elias reviewed 10,400 consecutive wrist injuries over a
10-year period and reported on 249 carpal fractures.52 In his
series, there were 153 scaphoid fractures, 64 triquetrum frac-
tures, 15 trapezoid fractures, 5 capitate fractures, 5 hamate
fractures, and 2 lunate fractures.
Fractures of the Triquetrum
In most authors’ series, fractures of the triquetrum are
reported to represent the second or third most common

Figure 18.49  Fractures of the body of the triquetrum are
generally the result of very high energy injuries. In this instance,
extensive hand injury was caused secondary to a tire explosion.
carpal bone fracture.11,51,52,94 Three primary fracture patterns
are usually observed with fractures of the triquetrum.
Fracture Patterns
Dorsal Cortical Fracture
The dorsal cortical fracture is by far the most common.53,69,94
Its frequency is often reported to be as high as 93% of all
triquetral fractures.94 Different mechanisms of injury have
been proposed for dorsal triquetral fractures.53,69,94 These
include avulsion, shear forces, or impaction. Extreme palmar
flexion with radial deviation would be a primary cause for a
dorsal avulsion fracture due to the attachment of the dorsal
radiotriquetral and triquetroscaphoid ligaments. The most
common mechanism is a fall onto a wrist in dorsiflexion and
ulnar deviation. The ulnar styloid may act as a chisel and is
driven into the dorsal cortex of the triquetrum. Garcia-Elias,
in a study of 76 patients with triquetral fractures as compared
to 100 uninjured patients, noted that the mean size of the
ulnar styloid was significantly (P = .001) longer in the fracture
patients.53 Lastly, the shear force applied by the proximal edge
of the hamate against the distal dorsal triquetrum during wrist
extension has also been shown as a potential mechanism of
injury for dorsal triquetrum chip fractures.69
Triquetral Body Fracture
Triquetral body fractures are the second most common type
of triquetral fractures. These fractures generally require a high
amount of injury to the wrist (Figures 18.49 and 18.50).
Fractures of the body of the triquetrum are occasionally seen
with perilunate fracture-dislocations. Perilunate fracture-
dislocations are seen in 12% to 25% of triquetral injuries. A
fracture of the body of the triquetrum should alert the physi-
cian to look for associated ligamentous injuries.
PART
III
18 
Wrist: Fractures of the Carpal Bones
Figure 18.50  Photograph of the patient in Figure 18.49 showing
the extent of the high energy involved that caused a fracture to
the body of the triquetrum involving both bone and soft tissue.
Fractures of the body of the triquetrum may be divided into
five categories. These include sagittal fractures, fractures in
the medial tuberosity, transverse fractures of the proximal
pole, transverse fractures of the body, and comminuted frac-
tures. A direct blow to the ulnar border of the wrist may
cause a medial tuberosity fracture and occasionally involves
the palmar articular surface of the triquetrum. Sagittal frac-
tures are commonly associated with axial dislocations, with
flattening of the transverse carpal arch. Small fractures of the
proximal pole are frequently associated with perilunate dis-
locations. Small avulsion fractures to the volar aspect of the
triquetrum may be the result of avulsion of the palmar LTIO
ligaments and carry a much worse prognosis than isolated
dorsal tip fractures, as noted by Smith and Murray.143
Volar Avulsion Fracture
Lastly, volar avulsion fractures have been described in the
triquetrum. These fractures usually represent an avulsion
of the palmar ulnar triquetral ligament and the LTIO
ligament.
Clinical and Radiographic Features
Patients with a fracture of the triquetrum complain of point
tenderness to palpation directly over the triquetrum. A
patient who has a dorsal avulsion fracture is usually symp-
tomatic with wrist flexion and extension.
Most triquetral fractures can be identified with AP, lateral,
and 45-degree pronated oblique radiographs of the wrist. The
lateral and oblique views most often reveal the dorsal cortical
fragments. Radial deviation views are helpful to diagnose a
volar avulsion fragment that may be hidden behind the
hamate or remaining triquetrum.
A dorsal lip fracture is a common finding on the lateral
radiograph, particularly in active young males or athletes. It
is helpful to determine if the fracture is acute or chronic.
Occasionally, CT scans are helpful in identifying occult tri-
quetral fractures.
The triquetrum is best viewed radiographically when the
wrist is partially pronated. This projects the triquetrum away
from the adjacent carpal bones.
Treatment
Management of triquetral fractures depends on the fracture
pattern. The majority of these are dorsal cortical fractures
681
PART
III
18  directed toward restoring carpal stability rather than treating
Wrist
Figure 18.51  PA radiograph of the patient in Figure 18.49
following stabilization of the multiple carpal fractures and
instability, including stabilization of the fracture of the body of
the triquetrum.
and are treated nonoperatively with immobilization for
approximately 4 to 6 weeks. Immobilization is generally used
in treating the underlying soft tissue injury. MRI is occasion-
ally obtained to identify extrinsic intercarpal ligament inju-
ries or occult fractures. It is important for the patient to
understand that despite immobilization the fracture may go
to a fibrous nonunion. Patients generally complain of a mild
discomfort over the dorsum of the wrist for several months.
Hocker reviewed his results in these injuries and showed
excellent return of motion and function of the wrist.69 In
symptomatic nonunions, excision of the painful dorsal frag-
ment may be performed.
Guidelines for treatment of triquetral body fractures are
less clear. Isolated triquetral body fractures can generally be
treated successfully by casting and immobilization for 4 to 6
weeks. Nonunion of a triquetral body fracture is very rare.
Most fractures of the body of the triquetrum are associated
with severe trauma and may be associated with a perilunate
fracture-dislocation. Usually treatment is directed toward
managing the LTIO ligament by pinning the joint, ignoring
the fracture of the body of the triquetrum. However, in cases
of displaced triquetral body fractures, open reduction and
internal fixation has been described (Figure 18.51).120 A
patient with an isolated triquetral body fracture in which the
proximal row initially looks intact should receive close fol-
low-up with radiographs looking for instability, particularly
of the scapholunate interval, or further MRI. Fractures of the
body of the triquetrum associated with scapholunate instabil-
ity are best managed by early primary repair of the ligamen-
tous disruption and fixation of the triquetral fracture with a
compression screw.
682
Volar avulsion fractures of the triquetrum are rare. MRI to
evaluate the fracture pattern and involvement of potential
carpal instability is recommended. Treatment should be
the small avulsion fragment.
Fractures of the Trapezium
The trapezium forms a set articulation for the base of the
thumb metacarpal. Fractures of the trapezium constitute
approximately 1% to 5% of all carpal bone fractures, making
the trapezium the third most commonly fractured carpal
bone in most authors’ series.119,162 The largest series of frac-
tures of the trapezium was described by Pointu and col-
leagues, who reviewed 34 cases.119 Fractures of the trapezium
are usually associated with fractures of other bones, usually
the distal radius or metacarpal. Isolated fractures occur
rarely. Fractures of the trapezium typically involve the body
or the ridge. The longitudinal ridge of the trapezium projects
in a palmar direction and serves as an attachment for the
transverse carpal ligament. The tendon of the FCR passes
along a groove formed by the trapezial ridge. Fractures of
the body are more common. Walker and colleagues described
five different fracture patterns to the trapezium.165 These
include vertical transarticular fractures, horizontal fractures,
fractures of the dorsal radial tuberosity, fractures of the ante-
rior medial ridge, and comminuted fractures. A vertical trans­
articular fracture pattern is the most common, followed by
fractures of the dorsal lateral tuberosity.
Mechanism of Injury
The protected position of the trapezium below the thumb
metacarpal generally protects it from a direct blow, making
this an uncommon etiology of trapezial fracture. Several
mechanisms of injury have been described for fractures of
the trapezium. These fractures are incurred from a fall onto
an outstretched thumb, causing the base of the thumb meta-
carpal to be driven axially into the trapezium. This results in
a vertical shear fracture on the radial aspect of the trapezial
body (Figure 18.52). The body of the trapezium is split and
displaced proximally with the attached metacarpal, resulting
in subluxation or dislocation of the joint. Manon proposed
that dorsal radial trapezial fractures may be the result of
vertical shear when the trapezium is being trapped between
the metacarpal and the tip of the radial styloid.101 Depending
on the angle of compression, a fracture of the trapezium, a
Bennett fracture of the thumb metacarpal, or occasionally
both may occur. Most fractures of the trapezium have a verti-
cal orientation consistent with a vertical shear force.
The ridge of the trapezium is superficial. It can be palpated
just distal to the scaphoid tubercle at the base of the thenar
eminence. Because the ridge is superficial, fractures of this
structure are generally caused by direct trauma such as a fall
onto an outstretched hand or being struck by a pitched ball.
Other mechanisms include avulsion of the transverse carpal
ligament produced by an AP crush.
Radiographic Features and Treatment
Fractures of the body of the trapezium can usually be identi-
fied on standard PA and lateral radiographic views. A pro-
nated AP view further defines the articular surface and is
helpful for detecting any displacement. Bett’s view is obtained
 PART
III
18 

Wrist: Fractures of the Carpal Bones

Figure 18.52  PA radiograph demonstrating a fracture of the body Figure 18.53  The fracture in Figure 18.52 was approached
of the trapezium that is split into volar and dorsal fragments. This through a volar approach, elevating the thenar musculature. The
was secondary to the thumb metacarpal’s being driven proximally fracture was anatomically reduced and provisionally stabilized
into the body of the trapezium. with Kirschner wire fixation.

with the elbow raised from the cassette, the thumb extended
and abducted, and the hand partially pronated. Fractures of
the trapezial ridge are not readily seen on standard PA and
lateral radiographs. A carpal tunnel view is best to identify a
fracture of the ridge of the trapezium when it is suspected.
Fractures of the body of the trapezium are tender just
anterior or dorsal to the abductor pollicis longus tendon distal
to the radial styloid tip. While nondisplaced fractures of the
trapezium are relatively rare, they do require close follow-up,
as these injuries result from fairly high-energy impact, are
unstable, and are prone to displacement. Displaced fractures
of the body of the trapezium are best managed by open reduc-
tion and internal fixation.119 Fractures of the trapezium are
best addressed through a volar approach. The thenar muscle
is elevated, exposing the fracture site. The radial artery is at
risk during the exposure and should be identified and pro-
tected during the procedure. The fracture may be stabilized
by compression screws, Kirschner wires, or a combination of
both (Figures 18.53 and 18.54). Frequently, because of the
compressive forces involved in producing the fracture, bone
grafts may be needed to support the articular surface. Cancel-
lous bone graft may be obtained from the volar aspect of the
distal radius or from the tip of the olecranon. Other options
include allograft bone or various bone substitutes.
Fractures of the ridge of the trapezium may be easily
missed. Patients present with pain at the base of the thumb
and pain with wrist flexion. According to Palmer, two types
of trapezial ridge fractures exist (Figure 18.55).117 Type I frac- Figure 18.54  Following anatomic reduction of the fracture in
tures occur at the base of the ridge, and type II fractures are Figure 18.52, a cannulated screw was placed over the guide
avulsion fractures at the tip of the ridge. Acute type I ridge wire, anatomically reducing the intra-articular fracture to the
nondisplaced fractures are best managed by casting and trapezium.

683
PART
III
18  Type II
Wrist
Type I
Figure 18.55  The fractures of the trapezial ridge were classified
by Palmer. Type I fractures involve the base, and type II fractures
involve the tip.
immobilization. However, similar to scaphoid fractures,
minimal displacement reduces the ability of the fracture to
heal, so operative management is recommended if the frac-
ture is displaced. Cast and immobilization of displaced ridge
fractures usually results in painful nonunion that delays treat-
ment and return to activities. Type II fractures generally result
in painful nonunion and may require excision of the fracture
fragments. Type II ridge fractures are usually treated by a trial
of casting with the thumb in abduction. If symptoms persist,
the fragment is excised. Padded gloves are used to help the
patient return to activities as the scar may be tender for
several months.
Fracture of the trapezium may result in chronic conditions
such as carpal tunnel syndrome, tendinitis, or potential
rupture of the FCR tendon as it passes by the trapezium.
Excision of the fracture fragment is recommended in chronic
injuries that are symptomatic. The fragment is removed
through a volar approach and the thenar musculature is
elevated. The FCR tendon must be identified and carefully
protected as it is easily injured during excision of the
fragment.
Fractures of the Capitate
Similar to the trapezoid, the capitate is centered within the
carpus and is well protected from injury. Fractures of the
capitate account for 1% to 2% of all carpal fractures. Adler
and Shaftan found 72 previously published cases in their
review of the literature and published 12 additional cases
of their own.2 However, isolated fractures of the capitate
are being diagnosed with increased frequency, and a height-
ened awareness of these injuries is important. The capitate
articulates with the scaphoid and lunate proximally and is
well attached along the metacarpal distally to form the central
column of the hand and wrist. Fractures of the capitate are
incurred as an isolated injury or more frequently are part
of a trans-scaphoid perilunate fracture-dislocation. This
was described by Fenton as a scaphocapitate fracture
syndrome.45
684
Four major patterns of fractures have been observed in the
capitate. These include transverse fracture of the proximal
pole of the capitate, transverse fracture of the body of the
capitate, verticofrontal fracture, and a parasagittal fracture
pattern. Transverse fractures of the capitate occur most fre-
quently and are usually associated with a trans-scaphoid,
transcapitate perilunar fracture-dislocation.45
Mechanism of Injury
Stein and Siegel investigated the mechanism of injury for
fractures of the capitate that can result from up to 180
degrees of rotation of the proximal fragment (Figure 18.56).147
In the scaphocapitate perilunar fracture-dislocation, the
mechanism of injury is a high-energy fall with the wrist
hyperextended and radially deviated. The force is initially
transmitted through the scaphoid, which fractures at the
waist. As the wrist continues to extend, the neck of the capi-
tate impacts on the dorsal ridge of the radius and fractures
as a result of tensile forces on the palmar aspect. When the
wrist returns to neutral, shortening of the carpus prevents
reduction of the proximal fragment. As the wrist continues
to go into flexion, the fractured distal portion of the capitate
exerts a flexion moment to the proximal pole, which may
result in complete rotation, causing the articular surface of
the capitate proximal pole to face distally into the capitate
fracture site.
Radiographic Features
Routine PA, lateral, and oblique radiographs are usually suf-
ficient to diagnose a capitate fracture (Figure 18.57). Occa-
sionally, however, initial radiographs of a nondisplaced
capitate fracture may appear normal. Close evaluation of the
radiographs is important. A patient may present with typical
trans-scaphoid perilunate fracture-dislocation, and the capi-
tate fracture may be overlooked. A patient’s continued wrist
pain following trauma may require serial radiographs and
temporary immobilization until the pain resolves or a diag-
nosis is made. The fracture is subsequently recognized when
resorption of the fracture site is noted.
Treatment
The head of the capitate is nearly completely covered with
articular cartilage, similar to the proximal pole of the scaph-
oid. Like proximal pole scaphoid fractures, fractures of the
head and neck of the capitate are subject to major vascular
disruption and hence prolonged healing and poor outcome.
These fractures are inherently unstable and frequently lead
to delayed union or nonunion. These factors need to be con-
sidered if casting and immobilization is recommended,
because the several months of cast immobilization required
for healing may result in additional morbidity. MRI has
helped to evaluate the vascular supply of the proximal pole
of the capitate and the healing capacity of the capitate head.
If the fracture is inadequately immobilized and treated, the
capitate shortens, thus overloading the scaphotrapezial-
trapezoidal and triquetral hamate joints. In this case, a bone
graft restores capitate length, and carpal fusion may be
required.
Displaced fractures of the capitate, delayed diagnosis of
nondisplaced capitate fractures, and trans-scaphoid, trans-
capitate perilunate fracture-dislocations are best managed by

A B
Figure 18.56  The mechanism of injury to fractures of the capitate. A, The neck of the capitate may impact on the dorsal ridge
of the radius once the scaphoid has fractured. B, As the wrist recovers to its neutral position, shortening the carpus prevents
reduction to the capitate fracture. C, As the capitate regains its normal alignment in relation to the radius, it exerts a flexion
moment to the proximal pole that may result in its complete rotation with the fracture site facing the distal aspect of the lunate.
Figure 18.57  PA radiograph during arthroscopic evaluation of a
trans-scaphoid, transcapitate perilunar fracture-dislocation.
open reduction and internal fixation. The capitate is repaired
through a dorsal incision between the third and fourth dorsal
compartments. The incision is in line with the radial border
of the long finger. Palmar flexion of the wrist provides access
to the head of the capitate, which may be rotated 180
degrees. One or two headless compression screws may be
placed from proximal to distal in the capitate to provide
PART
III
18 
Wrist: Fractures of the Carpal Bones
180°
C
adequate stability (Figures 18.58 and 18.59).55 The scaphoid
may be stabilized from the same dorsal approach or through
a separate volar approach if it is fractured. An associated
scaphoid fracture is usually very unstable owing to the soft
tissue injury. The reduction may be facilitated with joysticks.
Associated injury to the scapholunate interosseous ligament
is then repaired dorsally.
It is important to re-establish carpal height of the capitate
when managing an established capitate nonunion. Cortico-
cancellous interposition bone grafts are usually necessary to
re-establish carpal height to prevent carpal collapse and over-
loading to the scaphotrapezial-trapezoidal and triquetral
hamate joints.
Wrist hyperextension may also result in a coronal fracture
of the dorsum of the body of the capitate. A coronal fracture
is caused by transmission of an axial load along the shaft of
the third metacarpal, resulting in a joint compressive force
on the dorsal aspect of the capitate articular surface. This
fracture is not well seen in typical AP radiographs but is seen
on a lateral view. These fractures are managed by open
reduction and internal fixation if displaced.
Avascular Necrosis of the Capitate
The capitate is at risk for AVN because the proximal pole is
essentially intra-articular. The retrograde intraosseous blood
flow to the capitate is similar to that in the scaphoid, which
makes the proximal pole of the capitate prone to AVN at its
waist.162 Dorsal and palmar vessels are present but vary
considerably. Additional etiology of AVN includes vibration
exposure, steroid use, repetitive wrist extension, and liga-
mentous laxity.162
Milliez and colleagues have classified AVN of the capitate
into three groups: type I has proximal involvement, type II
has distal or body involvement, and type III has total involve-
ment.109 Type I appears to be most common. Attempts to
685
PART
III
18  AVN has been reported infrequently in isolated capitate
Wrist
Figure 18.58  This injury was best stabilized through a dorsal
approach. The capitate was stabilized with two headless
cannulated screws, and the fracture of the scaphoid was stabilized
with a single screw inserted in a proximal-distal direction. The
patient had a complete tear of the lunotriquetral interosseous
ligament; it was primarily repaired and provisionally stabilized
with Kirschner wires, which were eventually removed.
Figure 18.59  Lateral radiograph following open reduction and
internal fixation of a trans-scaphoid, transcapitate perilunate
dislocation. The radiograph confirms normal restoration of the
scapholunate angle.
686
promote revascularization with bone grafting have had
mixed results.162 There are no long-term follow-up reports on
AVN.
fractures but is more common in higher-energy fractures,
particularly when the capitate is rotated.
Fractures of the Hamate
Fractures of the hamate are fairly rare and involve approxi-
mately 2% of all carpal fractures. There are approximately
100 cases reported in the literature.51,110 The unique anatomy
of the hamate hook places it at risk: it protrudes from the
base of the hamate into the hypothenar eminence. The hook
of the hamate is the site of origin for the flexor digiti minimi,
opponens digiti minimi, hypothenar muscles, pisohamate
ligaments, and distal attachment of the transverse carpal liga-
ment. Fractures of the hamate may be divided into two
groups, those affecting the hook of the hamate and those
involving the body.
Hook of the Hamate
Fractures of the hook of the hamate are relatively rare in the
general population but more common in athletes.55 The hook
of the hamate is at risk for a fracture in any athlete who
swings a racket, club, or bat. Direct compression of the
handle of the club against the protruding hook is the primary
cause of fracture. In addition, shear forces from the adjacent
flexor tendons or contraction of the attached hypothenar
muscles may contribute to the fracture or displacement. The
wrist nearest the handle is at risk for fracture. The nondomi-
nant hand is usually involved in golfers and baseball players,
whereas the dominant hand is more likely involved in tennis
and racketball players.
Clinical and Radiographic Presentation
Fractures of the hook of the hamate frequently present late
as chronic pain at the base of the hypothenar eminence.
Patients may complain of ulnar nerve paresthesia into the
ring and small fingers and weakened grip strength. Patients
are tender to palpation over the hamate hook approximately
2 cm distal and radial to the pisiform. Patients complain of
pain aggravated by active grasping. Pain with resistance of
ring- and small-finger flexion worst with the wrist in ulnar
deviation and lessened by radial deviation can help further
document a fracture of the hook of the hamate, which irri-
tates the flexor tendons at the ring and small fingers. A
chronic unrecognized hamate hook fracture may present
with a rupture of the fourth or fifth deep or superficial flexor
tendon.
Fractures of the hamate hook are difficult to recognize on
standard anterior, posterior, and lateral radiographs. Clues
to a fracture of the hamate hook on the PA radiograph
include absence of the hook or cortical ring sign or sclerosis
in the region of the hook. The hamate hook can be visualized
with radiographs taken with the wrist in slight supination and
full radial deviation. Three specialized views—the carpal
tunnel view, a supinated oblique view with the wrist dorsi-
flexed, and a lateral view projected through the first web
space with the thumb abducted—have been described to
bring the hamate into better visualization. The carpal tunnel
view is typically used to profile the hook of the hamate but

Figure 18.60  Carpal tunnel view demonstrating a fracture to the
hook of the hamate.
may be difficult in patients with acute pain from a fracture
precluding sufficient extension (Figure 18.60). A CT scan
with the hands in the praying position or tomograms may be
further used to define the fracture. The superiority of CT scan
over conventional radiographs was demonstrated by Andre-
sen and colleagues.8 CT was found to have sensitivity of
100%, specificity of 94%, and accuracy of 97.2% in defining
hook fractures, as compared to radiographs with 72% sensi-
tivity, 88% specificity, and 80.5% accuracy.
Blood Supply
The blood supply to the hamate has been studied exten-
sively.43 The hamate has three vascular pedicles. Palmar and
dorsal vascular pedicles enter the hamate along the midcarpal
capsular attachments and from the interosseous network that
supplies the body of the hamate. One group of small and
nutrient arteries arising from the ulnar artery at the level of
the Guyon canal supplies the hook of the hamate. Few anas-
tomoses exist between the two systems. Failla described a
vascular supply of the hamate as a variable pattern.43 He
described that all hamates have a nutrient vessel that enters
the radial base of the hamate. However, only 71% have a
nutrient vessel entering at its tip. Therefore, approximately
29% of the population is at risk for osteonecrosis of the
hamate hook with a fracture distal to the basal nutrient
artery. This poorly vascularized area adjacent to the base of
the hook results in a greater risk of nonunion if the fracture
is not acutely immobilized.
Treatment
According to Milch, there are three different types of frac-
tures of the hook of the hamate.110 These have been classified
as avulsion fractures of the tip of the hook, fractures through
the base of the hamate hook, and fractures through the waist.
Acute nondisplaced fractures of the hook of the hamate PART
may heal with casting and immobilization. With displaced III
hamate hook fractures or chronic injuries, most authors
advise excision of the hook of the hamate fragment. One
18 
study noted less favorable results if hamate hook fractures
Wrist: Fractures of the Carpal Bones
are treated after the first week.27 The unrecognized or
untreated hamate hook fracture may lead to partial or com-
plete rupture of the fourth or fifth deep or superficial flexor
tendons.
The reported results of hook of the hamate excision have
generally been favorable.144 Some pain and weakness may
persist, but most patients will be able to return to full athletic
and occupational activities. Occasionally, padded gloves are
useful to allow the athlete to return to competition earlier
following hook of the hamate excision. Watson and Rogers,
however, noted that the hook of the hamate constitutes the
medial wall of the carpal concavity, acting as an important
pulley that enhances the action of the flexor tendons of the
small finger by increasing its moment arm.168 Excising the
hamate may affect the function to the small finger. Because
of this, some authors have recommended open reduction and
internal fixation for hamate hook fractures.168 There is little
available literature reporting the results of open reduction
and internal fixation.168
Because of this, most authors recommend excision of
symptomatic hook of the hamate fractures.144 The hook of
the hamate is excised through a curvilinear incision centered
over the hook of the hamate. It is important not to cross over
the flexor wrist crease if possible to avoid scar sensitivity in
the palm. The ulnar nerve and artery are identified proxi-
mally in the incision and traced out distally through the
Guyon canal past the hook of the hamate. The distal portion
of the transcarpal ligament surrounding the tip of the hook
of the hamate is released. The ulnar nerve and artery are
traced along the ulnar border of the hook of the hamate. The
motor branch exits from the ulnar nerve along the dorsal
ulnar aspect of the nerve and passes dorsal to the ulnar nerve
beneath the flexor digiti minimi. This motor branch almost
always lies at the fracture site at the base of the hamate
(Figure 18.61). This nerve must be clearly identified and
immobilized and retracted before the hook of the hamate
fracture is excised. The hook of the hamate is a fairly long
bone in the AP dimension. Close subperiosteal dissection is
performed from anterior to posterior to expose the base of
the hamate at the fracture site clearly while protecting the
motor branch to the ulnar nerve. Once the fracture site has
been clearly dissected and protected, the hook of the hamate
fragment is removed. The remaining periosteum is then
closed over the base of the hamate body to decrease irritation
from the remaining fracture surfaces to the ulnar nerve and
flexor tendons.
An ulnar approach has been described by Ahsoh and col-
leagues.4 The incision is centered over the fifth metacarpal
joint. The abductor and opponens digiti minimi are elevated
to expose the base of the hamate hook. Extreme care must
be taken to avoid injury to the ulnar nerve, which is less well
visualized through this approach.
Postoperative Care
Following removal of the hook of the hamate, patients can
return to sports relatively quickly. Scar sensitivity is the
687
PART
III
18 
Wrist

Figure 18.61  The motor branch of the ulnar nerve runs very near
the base of the hook of the hamate. It should be identified prior
to excision of the hook.

Figure 18.62  Coronal fractures of the hamate are often the result
primary factor limiting return to sports. Physical therapy of axial transmitted forces. Oblique radiograph demonstrating
modalities including scar massage, silicone patch, and padded fracture to the body of the capitate with instability of the base of
gloves help with early return to activities. A 3% complication the fourth and fifth metacarpals.
rate has been reported in association with excision of hamate
hook fractures. Injury to the motor branch of the ulnar nerve
was the most common complication.144

Body of the Hamate

Fractures of the body of the hamate are less common than
hamate hook fractures. These fractures have been divided into
four major groups—proximal pole fractures, fractures of the
medial tuberosity, sagittal oblique fractures, and dorsal
coronal fractures. Proximal pole fractures usually are the
result of shear forces in fracture-dislocations of the wrist.
They are usually small intra-articular osteochondral frac-
tures. Fractures of the medial tuberosity are usually the result
of a direct blow to the ulnar side of the wrist. Sagittal oblique
fractures are the result of high-energy trauma causing severe
flattening of the transverse carpal arch. The ulnar nerve is at
risk with this mechanism of injury. Dorsal coronal fractures
are often the result of axial forces transmitted through the
metacarpal. These fractures are best identified in the lateral
radiograph (Figures 18.62 and 18.63).
The small- and ring-finger hamate carpal metacarpal joints
are important for gripping and normally allow for approxi-
mately 30 degrees of motion. Isolated nondisplaced fractures
of the body are generally stable and may be treated with
casting and immobilization. Displaced fractures of the hamate
that involve the carpometacarpal joint are best managed by
open reduction and internal fixation. The stability of the Figure 18.63  PA radiograph demonstrating a coronal fracture to
carpometacarpal joint must be assessed, and stabilizing the body of the hamate with proximal positioning of the fourth
and fifth metacarpals.
Kirschner wires are used if the joint is unstable. The fracture
is exposed through a dorsal approach between the fourth and
fifth extensor digitorum communis tendons (Figures 18.64
and 18.65). The hamate fracture may be stabilized by small Injuries associated with fractures of the body of the hamate
compression screws or by a small H-plate (Figure 18.66). include dislocation of the small and ring metacarpal bases,
Care must be taken when drilling dorsal to the palmar aspect axial carpal instability, hamate dislocation, ulnar nerve palsy,
of the hamate because of the close association of the motor and compartment syndrome. AVN of the proximal pole of
branch of the ulnar nerve (Figures 18.67 and 18.68). the hamate is a theoretical concern.
688

Figure 18.64  The fracture of the hamate is approached through a
dorsal incision between the fourth and fifth dorsal compartments.
The capsule is opened, demonstrating the displaced fracture to
the body of the hamate.
Figure 18.65  The fracture is anatomically reduced under direct
observation through the dorsal approach.
Fractures of the Pisiform
The pisiform is a sesamoid contained within the flexor carpi
ulnaris tendon. It articulates with a concave facet of the tri-
quetrum. Its articulation may be seen arthroscopically as a
normal variant with the arthroscope in the 4-5 or 6R portal.
The pisiform serves as an attachment of the origin of the
pisohamate and pisotriquetral ligaments, transcarpal liga-
ment, and abductor digiti minimi muscle. Fracture of the
pisiform accounts for approximately 2% of all fractures of
the carpal bones.105 Approximately 200 cases of fractures of
the pisiform have been published in the literature.105
Pisiform fractures occur in sports secondary to a direct
blow, such as being struck by a baseball or a fall onto an
outstretched hand. Occasionally, pisiform fractures are seen
in marksmen from the force transmitted through a handgun,
similar to the fracture of the hook of the hamate seen in
racketball players. Because of the pisiform’s multiple soft
PART
III
18 
Wrist: Fractures of the Carpal Bones
Figure 18.66  Once anatomic reduction to the body of the
hamate has been achieved, the fracture is stabilized by a small
locking H-plate (Medartis, Basel, Switzerland). Close attention
should be made when inserting the screws so as not to
overpenetrate the volar cortex to avoid risk of injury to the motor
branch of the ulnar nerve.
Figure 18.67  PA radiograph following anatomic reduction of the
hamate with stabilization with a small H-plate. Displaced and
unstable fourth and fifth metacarpals are stabilized by transverse
percutaneous Kirschner wires.
tissue attachments, a fracture of the pisiform can also result
from an avulsion mechanism. Fracture of the pisiform is
frequently associated with digital, carpal, or ligamentous
injuries. A high index of suspicion is warranted, as there is a
high chance of an associated injury to the distal radius or
689
PART
III
18  approach. The transverse limb is centered over the distal
Wrist
Figure 18.68  Lateral radiograph demonstrating anatomic
restoration to the fracture of the body of the hamate and
reduction of the fourth and fifth metacarpal bases to the hamate
following Kirschner wire stabilization.
carpus when a fracture of the pisiform is identified. With
pisiform fractures involving the body of the triquetrum, there
is a high incidence of additional injuries, and close follow-up
is needed.
Four different types of pisiform fractures have been
described—transverse fractures, parasagittal fractures, com-
minuted fractures, and pisiform-triquetral impaction frac-
tures. Transverse fractures are most commonly associated
with a sudden contracture of the flexor carpi ulnaris while
the pisiform is locked by the triquetrum against the floor
during a fall onto an outstretched palm. These fractures may
represent discontinuity of the flexor carpi ulnaris tendon
when they are severely displaced. Parasagittal fractures
usually involve the ulnar rim of the pisiform and do not
involve disruption of the flexor carpi ulnaris tendon. These
fractures have a better prognosis. Comminuted fractures
usually result from a direct blow of the base in the hypothe-
nar area and are associated with additional soft tissue inju-
ries, particularly the ulnar neurovascular bundle.
The pisiform is difficult to visualize on standard PA and
lateral radiographs. It is best visualized on oblique radio-
graphs taken with the wrist supinated 45 degrees from the
lateral position in slight extension. Alternatively, the pisi-
form can be visualized on a clenched-fist AP view with the
wrist in ulnar deviation.
Acute nondisplaced pisiform fractures are managed by
casting and immobilization for 3 to 6 weeks. Most heal by
bony or fibrous union. Comminuted fractures, widely dis-
placed transverse fractures, and symptomatic nonunions are
best managed with excision of the pisiform. Incongruence of
the pisotriquetral joint can cause persistent pain, particularly
690
with gripping and radioulnar motion. Athletes will continue
to complain of pain while swinging a bat or golf club.
The pisiform is approached through a volar Z-plasty
palmar crease. The ulnar neurovascular bundle is identified
and kept protected prior to excision of the pisiform. The
pisiform is then carefully shelled out from the flexor carpi
ulnaris tendon. The tendon fibers must be left intact to pre-
serve function of the flexor carpi ulnaris.
Carroll and Coyle reviewed their results with excision of
the pisiform.26 They found little or no functional impairment
with pisiform excision. Pisiform excision appears to have
little effect on wrist flexion strength. Patients are returned to
activities as tolerated.
Ulnar nerve injuries that occur at the same time as the
pisiform fracture are usually neurapraxias. These usually
resolve with observation. Nerve exploration is recommended
with excision of the pisiform if symptoms persist or worsen
after 12 weeks of observation. Immediate exploration of the
ulnar nerve is recommended if ulnar nerve dysfunction
occurs following pisiformectomy during which the nerve was
not identified.
Fractures of the Trapezoid
The trapezoid is a wedge-shaped bone widest dorsally with
strong ligament attachments that bind it to the adjacent
bones. The dorsal surface is twice as wide as the volar surface.
The trapezoid is well positioned between the trapezium,
scaphoid, capitate, and index metacarpal. In its well-
protected position, the trapezoid is the least commonly frac-
tured carpal bone, involving less than 1% of all carpal
fractures. Isolated fractures of the trapezoid are very rare.
When the trapezoid is fractured, the mechanism of injury is
usually a high-energy axial or bending mechanism transmit-
ted through the index metacarpal proximally. This can result
in a shear fracture, dorsal avulsion of the trapezoid, and
dorsal dislocation of the index metacarpal or trapezoid.
Palmar dislocations and fracture-dislocations have also
been reported. Fewer than 20 isolated fractures of the trap-
ezoid have been reported.52
A fracture-dislocation of the trapezoid is usually evident
on standard PA, lateral, and oblique radiographic views.
Fracture-dislocations of the trapezoid–index metacarpal joint
are usually better visualized on the PA view than on the
lateral view. A dislocated trapezoid allows proximal migra-
tion and overlap of the index metacarpal. Patients present
with tenderness at the base of the index metacarpal. Pain can
be elicited with motion of the index metacarpal.
Isolated fractures of the trapezoid without displacement
are usually treated nonoperatively. Displaced fractures are
managed by open reduction and internal fixation. If the frag-
ment is small, occasionally closed reduction with cast protec-
tion may provide satisfactory results. However, if the
fragments are larger, open reduction and internal fixation is
recommended. Fractures are stabilized with pin or screw
fixation. Excision of the trapezoid is contraindicated second-
ary to potential proximal migration of the index metacarpal.
The trapezoid receives approximately 70% of its interosse-
ous blood supply through dorsal branches.59 Dorsal disloca-
tions have been complicated by AVN. Chronic injuries to the
joint are best managed by carpometacarpal arthrodesis owing

A B
Figure 18.69  Plain radiograph (A) and tomographic evaluation (B and C) demonstrating a fracture to the body and volar lip of
the lunate.
to the minimal motion that occurs at the index carpometacar-
pal joint.
Fractures of the Lunate
The lunate is well enclosed within the large lunate fossa of
the distal radius. Hence, isolated fractures of the lunate body
are rare. Acute traumatic fractures of the lunate account for
1% of all carpal fractures.153 However, fractures of the lunate
are controversial. It is difficult to determine whether a frac-
ture of the lunate is acute or whether the fracture is patho-
logic and the result of repetitive trauma on a weakened
osteonecrotic bone resulting from Kienbock’s disease.153
Mechanism of Injury and
Radiographic Presentation
Fractures of the body of the lunate usually occur from direct
axial compression as the head of the capitate is driven proxi-
mally into the lunate. The dorsal lip of the lunate may be
fractured as the head of the capitate impacts on it and on the
dorsal distal edge of the radius in a severe hyperextension
and ulnar deviation injury. If the capitate appears volarly
subluxed on a lateral radiograph, a fracture of the volar lip
of the lunate is suspected.
Teisen and Hjarbaek proposed a classification of fresh
lunate fractures into five groups based on a review of 17
cases collected over 31 years.153 These groups are frontal
fractures of the palmar pole with involvement of the palmar
nutrient arteries, osteochondral fractures of the proximal
articular surface without substantial damage to the nutrient
vessels, frontal fractures of the dorsal pole, transverse frac-
tures of the body, and transarticular frontal fractures of the
body of the lunate. The last fracture type appears to be the
most commonly reported.
Patients present with pain on the dorsum of the wrist and
generalized swelling. Fractures of the lunate may be difficult
to visualize on standard radiographs because of the overlap-
PART
III
18 
Wrist: Fractures of the Carpal Bones
C
ping adjacent carpal bones. CT is extremely helpful to visual-
ize the fracture fragments and particularly to evaluate for
any displacement.
Fractures involving separation of the proximal articular
surface from the body of the lunate are usually the result of
Kienbock’s disease. A crescent line parallel to the proximal
outline of the lunate is usually seen.
Treatment
Fractures of the lunate must be diagnosed and managed
promptly. Of concern is possible association between the
lunate fracture that fails to unite and the eventual develop-
ment of Kienbock’s disease. Nondisplaced fractures of the
lunate are treated by casting and immobilization with close
follow-up for any displacement. Incorporating the flexed
metacarpophalangeal joints into the cast potentially relieves
the compressive forces across the lunate and can reduce the
risk of fragmentation and collapse.
Displaced fractures of the lunate require open reduction
and internal fixation, particularly if the capitate is subluxed
in a volar direction. Fixation of volar lip fractures may
be difficult because usually the fragment is small (Figures
18.69 and 18.70). Fixation of these fractures is important
because of the palmar vascular blood supply and stabilizing
ligaments. If the fragment is too small for screw fixation,
Kirschner wire stabilization across the carpus is used.
Percutaneous transfixing wires from the scaphoid into the
capitate are placed to hold the capitate reduced and to
decrease compressive loads across the lunate if the fixation is
tenuous.
Dorsal ridge fractures occur by shear force transmitted by
the capitate. Most dorsal pole fractures are relatively benign.
Treatment is determined according to the clinical findings
(pain and swelling) and radiographic findings. Small dorsal
chip fractures are treated with a short course of immobiliza-
tion with close imaging follow-up.
691
PART
III
18 
Wrist
Figure 18.70  The fracture was approached through an extended carpal tunnel incision crossing in oblique fashion across the
superficial wrist crease between the wrist flexor tendons and the ulnar nerve vascular bundle. The fracture was stabilized with a
headless screw.
However, avulsions of the dorsal portion of the SLIL need
to be repaired primarily. Malalignment of the capitate over
the lunate or scapholunate diastasis is consistent with carpal
instability. This portion of the SLIL contains the stout trans-
verse fibers important for stability across the scapholunate
interval. The ligament needs to be repaired primarily at the
lunate to prevent further carpal instability to the wrist.
Fractures of the body of the lunate and dorsal chip frac-
tures are approached through a standard dorsal approach
between the third and fourth dorsal compartments. The EPL
is released, the second and fourth dorsal compartments are
elevated, and the capsule is opened by the technique of
Berger and colleagues, exposing the carpus.16 If the avulsion
of the dorsal portion of the SLIL is identified, it must be
repaired back to the lunate to prevent further carpal instabil-
ity. Suture anchors or potentially a small screw may be used
for this purpose. When the joint surface in a fracture of the
body is involved, it is best seen through the dorsal approach
(Figures 18.71 and 18.72). Comminuted fractures may
require cancellous bone grafting harvested from the distal
radius. Occasionally, an external fixator may be used to take
pressure off the healing lunate when internal fixation is
performed.
Volar intercalated segment instability deformity may be
seen with palmar chip fractures. Palmar lunate fractures are
probably the result of a wrist extension injury, with the
proximal pole being avulsed by the short radiolunate liga-
ment. The hyperextended capitate continues to lead the
dorsal portion of the lunate. The dorsal portion of the lunate
shifts dorsally as it is no longer constrained by the palmar
ligaments, and the capitate acts as a proximal wedge. This
causes a separation and a high rate of nonunion and chance
of palmar subluxation of the capitate and eventual degenera-
tive disease.
Volar fragments are reduced through an extended carpal
tunnel approach exposing the volar lunate. Because the inci-
692
sion crosses the palmar wrist crease, it is important that the
incision be made in a zigzag fashion to avoid irritation from
the scar. The incision crosses ulnar to the palmaris longus
tendon proximally so as not to affect the palmar cutaneous
branch of the median nerve. Volar pole fractures are often
small and may not tolerate screw fixation. In these cases, the
fragment may be secured with a Kirschner wire or suture loop
around the volar fibers of the SLIL. Further stabilization by
pinning the scapholunate interval and capitate may be
required to help take stress off the repair.
Blood Supply
The vascular supply of the lunate has been studied exten-
sively (Figure 18.73).43,57,59 Both a palmar and a dorsal blood
supply are present in 74% to 100% of bones.43,57,59 These
studies have demonstrated a single vascular blood supply in
approximately 7% of lunates. Of those lunates with a dual
blood supply, 33% have a single palmar and dorsal vessel
for anastomosis, 66% have a three-vessel anastomosis, and
10% have a four-vessel anastomosis.43,57,59 In those lunates
with a single nutrient vessel, interruption may lead to necro-
sis of the entire bone; similarly, a coronal fracture in these
lunates can lead to avascularity of the opposite pole.
Injection studies of the anterior interosseous vascular
lunate have demonstrated a consistent palmar blood supply
but frequently an inconsistent dorsal blood supply. On the
palmar aspect, the radial, ulnar, and palmar branches of the
anterior interosseous artery combine to form three trans-
verse arches to supply the lunate. Dorsally, the radial, ulnar,
and dorsal branches of the anterior interosseous artery
combine to form three arches. The dorsal blood supply to the
lunate is drawn from the proximal two transverse arches over
the radiocarpal and intercarpal joints.
Internal anastomoses allow that both dorsal and palmar
flow must be interrupted for the lunate to lose circulation.
Fractures that split the lunate into dorsal and palmar halves
 PART
III
18 

Wrist: Fractures of the Carpal Bones

A B C
Figure 18.71  PA (A), oblique (B), and lateral (C) radiographs demonstrating a comminuted fracture of the distal radius,
accompanied by a subtle fracture of the body on the dorsal portion of the lunate.

Figure 18.72  The dorsal fracture of the lunate was approached in a standard dorsal incision between the third and fourth dorsal
compartments. The third compartment was elevated and the joint capsule was opened, exposing the fracture. The fracture was
stabilized with a mini-screw.

or dislocations that leave a dorsal hinge should not be Kienbock’s Disease

expected to result in AVN. However, 20% of lunates have
only a palmar nutrient artery supply in the bone. Displaced
volar fragments left untreated may place predisposed lunates
at risk for AVN. These fractures may be anatomically reduced
and fixed.
AVN of the lunate was first described in 1843 by Peste, who
noted a collapsed lunate in certain cadaver dissections.118
Robert Kienbock, a radiologist, described the x-ray changes
associated with lunatomalacia that is now associated with his
name.88
693
PART Dorsal
III
18 
Wrist
Y pattern X pattern I pattern
I II
Figure 18.74  Antuna Zapico described the relationship between the shape of the lunate and ulnar length. He noted that a type
I lunate coexists with ulnar-negative variance. Type II and type III lunates coexist with zero and ulnar-positive variance. Antuna
Zapico felt the pattern in type I was the weakest configuration with the greatest potential for both fatigue and stress fracture
under loads.
Etiology
There is no consensus about the relationship between acute
lunate fractures and Kienbock’s disease. Teisen and Hjarbaek
noted in a long-term follow-up series that lunate fractures
had failed to show AVN despite half of the patients’ having
ulnar-negative variance.153 Persistent pain in a patient follow-
ing a lunate fracture can be evaluated by MRI for the pres-
ence of Kienbock’s disease.153 However, radiographic findings
of AVN in a patient with a fracture can be difficult to define.
AVN of the lunate should be considered when there is homo-
geneous signal loss of the entire lunate, rather than signal loss
of a portion secondary to fracture.
Despite years of clinical experience, the origin and natural
history of Kienbock’s disease remain unclear. The loss of
blood supply to the lunate has been attributed to primary
circulatory problems, traumatic interference, poor circula-
tion, ligament injury with collapse, and single or multiple
fractures resulting in secondary vascular impairment. While
fracture-dislocation of the carpus may result in transient
radial density of the lunate, the avascular changes of Kien-
bock’s disease are progressive. Kienbock’s disease has been
associated with various medical conditions including sclero-
derma, sickle cell anemia, systemic lupus erythematosus, and
corticosteroid use. However, no consistent correlation with
any specific disease process has been demonstrated. Most
likely, the cause of Kienbock’s disease is multifactorial.
694
Figure 18.73  The vascular supply of the lunate has
been thoroughly studied, and three major vascular
patterns have been identified. These have been
previously described as the Y, X, and I patterns. The I
pattern is the only one with a single vessel to the
lunate and is considered to be most at risk for
development of avascular necrosis.
III
In 1928, Hulten published his classic study comparing ulnar
variance in normal subjects and patients with Kienbock’s
disease.75 In his series, in normal subjects the distal articular
surface of the radius and ulna was neutral in 51% but was
found to be ulnar negative in 23%. In contrast to the normal
control group, 5 patients with Kienbock’s disease were ulnar
neutral, but the majority (18 to 23) showed an ulnar-negative
variant. Gelberman and colleagues also described a signifi-
cant relationship between ulnar-negative variance and Kien-
bock’s disease.57 However, D’Hoore and colleagues reviewed
125 normal wrists in 52 patients with Kienbock’s disease and
found no significant statistical relationship between ulnar
variance and Kienbock’s disease.36 It was also noted that if
Kienbock’s disease were related to ulnar-negative variance,
the incidence of Kienbock’s disease would be more frequent,
particularly in those patients who had undergone Darrach
procedures or ulnar shortenings. Nakamura and colleagues
reviewed Kienbock’s disease in the Japanese population.116
They found that ulnar-negative variance occurs with equal
frequency in the general population and in the population
with Kienbock’s disease.
Antuna Zapico and colleagues described the relationship
between the shape of the lunate and ulnar length (Figure
18.74).9 In their description, a type I lunate is present in
ulnar-negative patients and is characterized by a proximal
apex or crest. Types II and III lunates are rectangular or
square and coexist with zero and positive variance. They felt
that the trabecular pattern in type I is the weakest configura-
tion with the greatest potential for both fatigue and stress
fracture under loads. Fragmentation was more frequent in
ulnar-negative variance with type I lunates. It would seem
intuitive that ulnar-negative wrists provide poor coverage for
the lunate, which may lead to unequal distribution of load,
consequently making the radial half more susceptible to
compression.
Schiltenwolf and colleagues studied the interosseous pres-
sure of the lunate with wrist motion.130 In their study, they
found that the interosseous pressure of the lunate is greater
in wrist extension than in neutral, and the difference was
greater by 40 mm Hg than that seen in the normal capitate
as a control. This rise in intraosseous pressure may explain
the lunate’s predisposition to osteonecrosis.
The slope of the distal radius has been studied as a poten-
tial cause of Kienbock’s disease. Tsuge and Nakamura found
that the radial inclination was lower in patients with Kien-
bock’s disease.159 Other investigators found that the radial
slope in the AP projection has a significant effect on both the
forces transmitted to the lunate and the patient’s age at the
onset of Kienbock’s disease.
Clinical and Radiographic Presentation
The diagnosis of Kienbock’s disease is suspected particularly
in young males with pain and stiffness in the dominant wrist.
Tenderness is centered over the dorsal lunate, and patients
experience decreased grip strength. Patients frequently
describe an insidious onset of dull pain centered over the
radiolunate joint; however, some will provide a history of
recent hyperextension injury. Patients complain of pain aggra-
vated by activity and relieved with rest and immobilization.
On physical examination, patients may demonstrate a
radiocarpal effusion with boggy synovitis of the radiocarpal
joint. Range of motion of the wrist is limited, and grip strength
is decreased compared to the opposite side.
Standard PA and lateral radiographs of the wrist are
obtained with the wrist in neutral rotation. Increased bone
density of the lunate is the early sign of avascularity on plain
radiographs. MRI is the most sensitive imaging study for
Kienbock’s disease. It is important not to confuse Kienbock’s
disease with findings limited to the ulnar side of the lunate
consistent with ulnar impaction. Frequently, radiologists will
diagnose ulnar impaction changes as Kienbock’s disease,
even though the entire lunate must show signal loss on MRI
to warrant this diagnosis.
Bone scintigraphy may also show increased uptake in the
early stage of Kienbock’s disease. Radiographic findings of
Kienbock’s disease depend on the staging of the disease.
Typical radiographic findings include lunate sclerosis, pro-
gressive loss of lunate height, fragmentation of the lunate in
the AP direction, progressive loss of carpal height as the
capitate migrates proximally, and eventual degenerative
joint changes related to rotation of the scaphoid and carpal
collapse.
MRI will demonstrate a uniform decrease in signal intensity
on T1 radial images owing to the decreased vascularity. To
make the diagnosis of Kienbock’s disease, a signal change
must be seen throughout the entire lunate. Ulnar impaction
PART
LICHTMAN CLASSIFICATION FOR KIENBOCK’S DISEASE
III
Stage Description 18 
I Plain radiographs are generally normal, but a linear
Wrist: Fractures of the Carpal Bones
fracture through the lunate may be noted. MRI
demonstrates diffuse T1 signal decrease in lunate.
Bone scan is positive.
II Sclerosis of the lunate is seen on plain radiographs.
Multiple fracture lines may be seen, though
collapse of the lunate has not occurred.
IIIA Lunate collapse has occurred, but the carpal height
alignments have been maintained.
IIIB Lunate collapse has occurred, and the capitate has
migrated proximally. The scaphoid assumes a
hyperflexed position.
IV This is a continuation of stage IIIB disease, with the
addition of carpal (radiocarpal and/or midcarpal)
arthritis.
Table 18.4  Lichtman Classification for Kienbock’s Disease
syndrome, fractures, interosseous ganglions, and enchondro-
mas will cause MRI changes within the lunate, but these
conditions will cause a focal rather than a complete magnetic
imaging change.
Staging
The most common method for staging Kienbock’s disease
was first described by Stahl in 1947.146 Lichtman and col-
leagues’ 1977 modification of the system is still popular.95
This classification system is based on plain radiographs and
MRI findings. Treatment is based on the stage of disease
(Table 18.4).
In stage I disease, plain radiographs may be normal or a
linear compression fracture may be seen. Lunate collapse has
not occurred. Diagnosis at this stage is usually made by a
radionuclide scan with increased uptake within the lunate or
MRI evaluation. A decreased signal on both T1- and
T2-weighted images suggests AVN. Patients have intermit-
tent dorsal wrist pain.
In stage II disease, there is sclerosis of the lunate but no
change in the size or shape of the bone. There may also be
multiple fracture lines, but the lunate is not collapsed. The
lateral radiograph is most sensitive for these early changes.
Clinically, affected patients complain of pain, persistent
swelling, and stiffness of the wrist.
Stage III disease is divided into stages A and B. In stage
IIIA, the lunate has collapsed but the carpus remains
unchanged, with normal alignment and height. Lateral radio-
graphs show that the lunate is wider in its AP dimension. In
stage IIIB, the capitate has migrated proximally and the
scaphoid has assumed a flexed position. As the carpal height
ratio decreases, the lunate collapses and the capitate migrates
proximally (Figure 18.75). Scaphoid rotation produces a DISI
pattern of carpal instability. Patients complain of progressive
stiffness with diminished grip strength. Clunking with radial
and ulnar deviation of the wrist may be found.
695
PART
III
18 
Wrist
3rd metacarpal height (MH)
Carpal height (CH)
Carpal height ratio = CH/MH
Figure 18.75  The carpal height index is measured on the PA
radiograph. The carpal height ratio is determined by measuring
the proximal distal relationship of the carpal height and dividing
by the metacarpal height.
It is important to differentiate stage IIIA from stage IIIB
Kienbock’s disease to determine an appropriate treatment
algorithm. Goldfarb and colleagues found that the interob-
server reliability at differentiating between stages IIIA and
IIIB of the Lichtman classification was poor.61 With the addi-
tional criterion that the radioscaphoid angle must be greater
than 60 degrees to qualify for stage IIIB, interobserver reli-
ability increased to a Kappa value of 0.75. Condit and col-
leagues found that the preoperative radioscaphoid angle
correlated best with clinical outcomes.29 Specifically, wrists
with preoperative radioscaphoid angles greater than 60
degrees tend to do poorly with any procedure aimed at sal-
vaging the lunate. Jensen and colleagues reported a reliability
Kappa value between 0.45 and 0.52 and a reproducible
Kappa coefficient between 0.26 and 0.63.83 Jafarnia and col-
leagues reported an average paired weighted Kappa coeffi-
cient of 0.71 for interobserver reliability of the Lichtman
classification among four observers who reviewed radiographs
from 64 patients and 10 control subjects.82 The coefficient for
interobserver reliability was noted to be 0.77. There was no
statistically significant difference in reliability or reproduc-
ibility between orthopaedic or plastic surgeons who had hand
fellowship training versus orthopaedists who had no hand
fellowship training.
In stage IV disease, continued carpal collapse is related to
arthritic changes in the radiocarpal and midcarpal joints.
Radiographs show subchondral sclerosis with joint space nar-
rowing, osteophyte formation, and degenerative cysts. Patients
complain of decreased range of motion to the wrist with
constant pain and swelling.
Treatment
Treatment algorithms for Kienbock’s disease have primarily
been determined by the stage of the disease according to the
Lichtman classification. There are many treatment options,
but they basically fall into three main groups: procedures to
unload the lunate, procedures to promote revascularization
of the necrotic lunate, and salvage procedures used when
arthritic conditions exist.
696
Figure 18.76  PA radiograph of a 26-year-old male with stage IIIA
Kienbock’s disease with ulnar-negative variance.
Stahl recommended prolonged immobilization for treat-
ment for Kienbock’s disease.146 Tajima reviewed 80 patients
with Kienbock’s disease with a follow-up of 42 years and
found no appreciable difference in the end results of nonop-
erative versus surgical treatment.151
Kristensen and colleagues followed 46 patients with Kien-
bock’s disease treated nonoperatively for a minimum of 5
years with a mean of 20 years.90 While 66% of the patients
had arthritic changes of the wrist at follow-up, only 25% had
significant pain. Taniguchi and colleagues found that while
radiographs worsened in 70% of 20 patients they followed
for 35 years, only 20% of patients had significant symptoms
limiting their activities.152 However, a recent study by Keith
and colleagues reviewed 33 patients treated nonoperatively
for Kienbock’s disease.87 They found a predictable pattern of
deterioration of motion, grip strength, and Disabilities of
Arm, Shoulder, and Hand (DASH) scores.
Stage I, II, or IIIA with Ulnar-Negative Variance
In these stages, carpal collapse into an instability pattern has
not occurred. Salvage of the lunate is possible to maintain
normal carpal kinematics. In a symptomatic patient with
stage I, II, or IIIA disease with ulnar-negative variance, a
joint-leveling procedure should be considered (Figure 18.76).
Some authors have found that unloading the joint can be
useful even in patients with stage IIIB pathology.6,172The most
common procedure for unloading the lunate in patients with
ulnar-negative variance is radial-shortening osteotomy. This
can be done through either a volar or dorsal approach.
Locking forearm-shortening plates have been designed to
simplify the procedure. The goal is to leave the patient with
ulnar-neutral or slightly ulnar-positive variance. Some
authors have described lengthening of the ulna; however, this
technique requires two osteotomy sites and a bone graft, PART
unlike radial shortening. III
Joint-Leveling Procedures.  Radial-shortening osteotomy is
considered for patients with Kienbock’s disease who have an
18 
ulnar-negative variance and no arthritic changes around the

Wrist: Fractures of the Carpal Bones

adjacent intercarpal or radiocarpal joints. Patients who are
ulnar neutral or ulnar positive are at risk for developing
ulnar impaction syndrome after ulnar shortening. Several
biomechanical studies have compared the changes of force
distribution across the carpus. Trumble and colleagues
reviewed the force distribution across the carpus with various
procedures for Kienbock’s disease.158 In this study, capitate-
hamate fusion did not significantly decrease lunate strain.
However, ulnar lengthening, radial shortening, and STT fusion
all produce a 70% decrease in lunate strain. The advantage
of joint-level procedures such as radial shortening is that it
does not affect the final range of motion of the wrist, unlike
intra-articular procedures such as STT fusion, which limits
wrist radial deviation and extension. Trumble and colleagues
noted that 90% of the reduction in lunate strain following
radial shortening or ulnar lengthening occurred in the first
2 mm of length alteration, although strain reduction increased
in both procedures with up to 3 mm of length alteration.158
Length alteration greater than 4 mm showed no further
changes in lunate load; in addition, shortening greater than
4 mm runs the risk of incongruence to the distal radioulnar
joint. Based on the biomechanical studies, the object of radial
Figure 18.77  PA radiograph following radial-shortening
shortening is to shorten the radius approximately 2 to 3 mm osteotomy. A forearm-shortening osteotomy plate (AcuMed,
and not to merely obtain ulnar-neutral variance. Hillsboro, OR) was placed on the volar surface of the radius. The
Similarly, Horii and colleagues used a mathematical model amount of shortening can be seen by the space between the
to evaluate joint-level procedures.71 Ulnar lengthening and screw and the plate in the reduction slot. The patient now is
radial shortening were equivalent in this mathematical model, ulnar neutral.
leading to a 45% decrease in the force transmitted through
the radiolunate joint. This decrease was mostly borne by the
ulnar lunate and ulnar triquetral joints, where force increased of bone approximately 3 mm is removed. The forearm oste-
by 50% and 78%, respectively. The force transmitted to the otomy plate is then replaced and fixed to the radius. The most
radioscaphoid joint increased by 6%, and in the midcarpal distal 3.5-mm locking screw is placed first. The radius is
region there was an increase in the lunatocapitate joint force shortened, and the 3.5-mm nonlocking screw in the reduction
of 13%. Scaphocapitate fusion led to a decrease in the radio- slot is tightened. Additional compression is placed to the
lunate joint force of 12%, capitate hamate fusion had no oblique screw hole proximally in the plate. The remaining
change, and capitate shortening combined with carpal hamate 3.5-mm locking screws are placed, and an oblique lag screw
fusion led to a 66% force decrease. may be used if an oblique osteotomy is performed (Figures
RADIAL-SHORTENING OSTEOTOMY.  Radial shortening may be 18.77 and 18.78). Patients are generally casted until healed,
performed through either a volar or a dorsal approach. In the at approximately 6 weeks for most patients.
volar approach, an incision is centered over the radial border Alternatively, an osteotomy can be performed more distally
of the FCR tendon. The tendon sheath is released and the in the metaphyseal bone. In this incidence, a long distal radius
FCR is retracted radially to protect the radial artery. The plate may be used. The plate is initially placed with distal
flexor pollicis longus is identified and retracted ulnarly to screws, and a proximal screw is inserted. The plate is removed,
protect the median nerve. The pronator quadratus is then a transverse osteotomy is performed in the metaphysis of the
released from the radial border of the radius and retracted distal radius, the radius is shortened, the distal plate is
ulnarly. A forearm-shortening osteotomy plate is placed on replaced, and the radius is compressed. This technique has a
the volar aspect of the radius (see Figure 18.80). It may be potentially better incidence of healing because the osteotomy
slightly pre-bent distally to fit the volar curvature to the distal is made in the metaphyseal bone. However, compression is
radius. A locking screw is placed in the most distal screw hole, more difficult to obtain at the osteotomy site as compared to
and a 3.5-mm nonlocking screw is placed in the reduction a formal forearm osteotomy plate.
slot. The osteotomy will then be performed over the oblique Alternatively, a plate may be placed dorsally. However, a
lag screw hole. This area is marked on the radius with the dorsal plate may be symptomatic because of its more super-
plate in place. The plate is then removed. A transverse or ficial location and may need to be removed in the future.
oblique osteotomy to the distal radius is performed. If an Most authors report good results after a radial-shortening
oblique cut is used, a 2-mm wafer is used because of the osteotomy.6,126,172 Weiss and colleagues reviewed the results
geometry of compression. If a transverse cut is made, a wafer of 29 patients who underwent the procedure for stages I
697
PART
III
18  went ulnar lengthening from 1974 to 1988.96 Overall patient
Wrist
Figure 18.78  Lateral radiograph showing the anatomically
contoured plate along the volar aspect of the radius following
radial-shortening osteotomy.
through IIIB disease.172 At minimum follow-up of 2 years,
they reported that 87% of the patients had decreased pain
and an increase in wrist range of motion averaging 32%.
There was no progressive evidence of carpal collapse. It is
important to note there was no improvement in the radio-
graphic appearance of the lunate. Rock and colleagues
reviewed 16 patients who underwent radial-shortening oste-
otomy.126 Six of those patients were classified as stage III and
four were classified as stage IV. At the average follow-up of
4.5 years, 13 of 16 patients were pain free, and range of
motion improved in the AP plane by 15 degrees. Grip
strength increased by 20% to 30%. Almquist and Burns
reported pain relief in 11 of 12 patients, although no patient
was pain free in their series at 5 to 10 years’ follow-up.6 Wrist
range of motion increased by an average of 40 degrees, and
grip strength improved.
ULNAR-LENGTHENING OSTEOTOMY.  Linscheid described his
technique for ulnar lengthening.96 In this technique, a straight
lateral incision is made at the ulnar neck and carried proxi-
mally along the subcutaneous border of the ulna for 10 to
12 cm. An osteotomy is performed in the distal third of the
ulna so that lengthening will not be resisted by the interosse-
ous membrane. A six-hole slotted plate is applied against the
bone, and the bone is marked at the center of the plate. The
interosseous membrane is released for 1 cm on each side of
the area marked on the bone. A transverse cut perpendicular
to the ulna is made three quarters of the way through the
bone. The plate is applied, and proximal and distal screws are
placed in the plate. The osteotomy is completed and an osteo-
tome is used to wedge open the site until a cervical laminar
698
spreader can be introduced. Iliac crest bone graft is obtained
and placed into the defect cleared by lengthening of the ulna.
Linscheid described his results in 64 patients who under-
satisfaction was high. Range of motion was not diminished
by the procedure. Postoperative grip strength averaged 70%
of that of the opposite hand, as compared to 51% preopera-
tively. Complications occurred in 22% of patients. These
included nine patients who had delayed union or nonunion.
Five patients developed symptoms of ulnar carpal impinge-
ment. Seven patients had additional procedures including
partial carpal fusion and lunate replacements.
Vascularized Bone Grafting.  Vascularized bone grafting is
another useful technique for patients with stage I, II, or IIIA
disease. The dorsal distal radius vascular anatomy is constant
and demonstrates a consistent special relationship to ana-
tomic landmarks. An anatomic network for the intercompart-
mental and compartmental arteries is provided by a series of
arterial arches across the dorsum of the hand and wrist. These
include the dorsum of the carpal arch, the dorsal radiocarpal
arch, and the dorsal supraretinacular arch. These are the
source of the vascularized bone graft from the base of the
second and third metacarpals. The vessels supplying nutrient
branches directly to the dorsal radius and ulna are described
at those locations with respect to the extensor compartments
of the wrist and extensor retinaculum. Intercompartment
vessels are located between compartments, and compartment
vessels lie within an extensor compartment. Vessels lying
superficial to the retinaculum are further described as supra-
retinacular. Two consistent intercompartment supraretinacu-
lar arteries are named by location between the numbered
extensor compartments. These are the 1,2 and 2,3 intercom-
partment supraretinacular arteries (1,2 ICSRA and 2,3
ICSRA). The 1,2 ICSRA originates from the radial artery
approximately 5 cm proximal to the radiocarpal joint. It
courses beneath the brachioradialis muscle to lie on the dorsal
surface of the extensor retinaculum. It enters the anatomic
snuffbox distally to anastomose to the radial artery or the
radiocarpal arch. The 1,2 ICSRA is a straightforward dissec-
tion but has a short pedicle and a short arc of rotation. The
2,3 ICSRA has a proximal origin from the anterior interosse-
ous artery or its posterior division. It lies superficial to the
extensor retinaculum directly over Lister’s tubercle and anas-
tomoses with the dorsal intercarpal arch, the dorsal radiocar-
pal arch, and occasionally the fourth extensor compartmental
artery. It is easily harvested and has an arc of rotation to reach
the entire proximal row.133
TECHNIQUE BASED ON THE FOURTH AND FIFTH EXTENSOR COM-
PARTMENT ARTERIES.  The most useful vessels for vascularized
bone grafting for the treatment of Kienbock’s disease are the
fourth and fifth extensor compartment arteries. A vascular-
ized bone graft using the fifth ECA’s connection to the fourth
ECA by way of their common origin is preferred because of
the large diameter of the fifth ECA. ECA pedicle provides an
ideal pedicle length that can reach anywhere in the carpus.
Other graft options include the 2,3 ICSRA graft based on
antegrade flow through the fifth ECA.
A longitudinal incision is made to expose the lunate and
distal radius. The fifth ECA is exposed by exposing the fifth
dorsal extensor compartment. The fifth ECA is visualized on
the radial aspect of the compartment landing adjacent or

5th ECA
4th ECA
Figure 18.79  The fifth ECA is identified by incising the fifth dorsal
extensor compartment. It is visualized on the radial aspect of the
compartment by an adjacent septum separating the fourth and
fifth dorsal compartments. (By permission of Mayo Foundation for
Medical Education and Research. All rights reserved.)
Figure 18.80  The fifth ECA is identified and traced proximally to
its origin from the anterior interosseous artery. The fourth ECA is
identified and traced distally to the distal radius. A bone graft is
centered approximately 11 mm from the radiocarpal joint
overlying the fourth ECA. (By permission of Mayo Foundation for
Medical Education and Research. All rights reserved.)
partially in the septum separating the fourth and fifth exten-
sor compartments. The fifth ECA is traced proximally to its
origin at the anterior osseous artery while the fourth ECA is
identified and distally traced (Figure 18.79). A bone graft
centered 11 mm proximal to the radiocarpal joint and over-
lying the fourth ECA to include the nutrient vessels is out-
lined (Figure 18.80). The lunate is exposed to a dorsal
ligament–sparing capsulotomy. A dorsal cortical window is
made in the lunate, and the necrotic bone is removed. Liga-
tion of the anterior osseous artery proximally to the fourth
and fifth ECA is performed. Graft elevation is completed
with the use of osteotomes (Figure 18.81). The tourniquet is
deflated to verify blood flow to the graft. Cancellous bone
PART
III
18 
Wrist: Fractures of the Carpal Bones
Figure 18.81  The anterior interosseous artery is then ligated
proximal to the fourth and fifth ECA. The vascularized bone graft
is elevated from its bed from the distal radius. Confirmation of
blood flow may be obtained by deflation of the tourniquet. (By
permission of Mayo Foundation for Medical Education and Research.
All rights reserved.)
Figure 18.82  The vascularized bone graft is then inserted into the
lunate. The pedicle is oriented vertically with the cortical surface
and arranged in proximal-distal orientation to maintain lunate
height. (By permission of Mayo Foundation for Medical Education
and Research. All rights reserved.)
graft can be additionally obtained from the donor site. The
graft is then rotated and transferred into the lunate for addi-
tional cancellous bone grafting (Figure 18.82).
TECHNIQUE BASED ON THE SECOND OR THIRD METACAR-
PAL.  This technique takes advantage of the distal vascular
arcade to use the vascularized bone graft through a single
midline incision. Releasing the distal portion of the fourth
dorsal compartment exposes the distal vascular arcade. The
pedicle may be mobilized in either an ulnar or radial direction
to a length sufficient to reach the lunate. The bone graft is
harvested from the base of the second or third metacarpal,
depending on where the artery has the greatest area of
contact. The vascularized bone graft is harvested and is
inserted into the lunate, as in the previously described tech-
nique using the fourth and fifth ECA (Figure 18.83).
TECHNIQUE FOR VASCULARIZED BONE GRAFT FROM THE
RADIUS.  A curved incision is made in the center of the lunate
699
PART Second dorsal
III metacarpal a.

18 
Wrist

Capitate Lunate

Figure 18.83  An optional source of vascularized bone graft may

be obtained from the base of the second or third metacarpal
based on the dorsal metacarpal arcade.

to the radial border of the distal forearm. The branch of the Figure 18.84  The dorsal second intermittent carpal artery lies just
radial artery from the first and second dorsal compartments beneath the aponeurosis and covers the interosseous muscles. The
(the 1,2 ICSRA) is identified and traced distally to the radial fascia is divided to expose the intermittent carpal artery.
artery by releasing the distal portion of the first compartment.
A bipolar cautery is used to cauterize the vessel proximal to
the planned site of bone graft harvest. The retinaculum in the
first and second dorsal compartments is incised and harvested
along with the bone graft to protect the perforating vessels.
The vascularized bone graft is harvested with its vessel and
transferred into the lunate cavity with the pedicle draped
distally to avoid impingement against the dorsal lip of the
radius. Caution is advised when contemplating this pedicled
vascular graft, as the pedicle may be of insufficient length to
reach the lunate.
Hori and colleagues described a technique for vascular Vascular
bundle implantation using the second dorsal intermetacarpal pedicle
artery.70 Indications for this technique include patients who
maintain a relatively normal arch of the carpus. The second
Radial a.
dorsal metacarpal artery is a branch of the dorsal metacarpal
artery to the index and long fingers. It travels between the
index and long metacarpals. If this vessel is damaged or
cannot be found, the third dorsal metacarpal artery may be
used. A dorsal incision is made starting proximal to the
second metacarpophalangeal joint; it is continued proximally
and curves around Lister’s tubercle. Dissection is continued
Figure 18.85  The distalmost extent of the artery is then ligated
between the second and third extensor compartments, which
with a 5-0 monofilament suture. This provides a 5- to 6-cm
are released, and the extensor carpi radialis and brevis are length of vessel.
retracted radially. The extensor digiti communis tendon is
retracted ulnarly so that the capsule of the carpus is visual-
ized. A proximally based flap is made to visualize the lunate. of the artery, the vessels are ligated with a 5-0 monofilament
In the nonarticular portion of the lunate a dorsal window is suture (Figure 18.85). This should provide a 5- to 6-cm length
made in the bone using 0.035-inch Kirschner wires and a of vessel. The lunate should be unloaded by any number of
sharp osteotome to remove the outer layer of bone. Sclerotic procedures (such as external fixation, capitate shortening, or
bone is removed. The second dorsal intermetacarpal artery temporary scaphocapitate pinning). Devascularized and
lies underneath the aponeurosis that covers the interosseous necrotic bone is removed from the lunate. Cancellous bone
muscles (Figure 18.84). This fascial layer is divided from chips are packed into the defect. A 2.7-mm drill is used to
proximal to distal to the level of the second web space. The create a hole in the proximal avascular portion of the lunate.
artery and venae comitantes are elevated with a thin layer The vascular bundle is then passed through this hole in
of surrounding perivascular tissue. At the distalmost extent a dorsal to volar direction (Figure 18.86). This may be
700

Figure 18.86  The vascular bundle is then passed through a
2.7-mm drill hole in a dorsal-volar direction.
performed by attaching a fine resorbable suture on a straight
needle to the 5-0 monofilament suture. The needle exits
through the palmar skin just ulnar to the FCR tendon. A small
skin incision is made and the suture is tied over the palmar
antebrachial fascia.
Hori and colleagues reported their experience with implan-
tation of the dorsal metacarpal arterial venous pedicle.70 Nine
cases of Kienbock’s disease were reviewed, with improve-
ment described in eight patients. Several authors have
described their experience with transfer of the vascularized
pisiform into the necrotic lunate. Bochud and Buchler
reported on 32 patients with follow-up of 2 years.18 Initial
restoration of lunate anatomy was observed in 95% of the
patients. However, only 33% retained a correction, and
nearly half of the long-term results were only fair or poor.
Moran and colleagues reviewed the results of vascularized
bone grafting in 48 patients with follow-up over a 10-year
period.112 Ninety-eight percent of patients experienced sig-
nificant pain relief. Grip strength improved, although range
of motion did not. Postoperative MRI showed evidence of
vascularization in 60% of the patients in their series.
Stage I, II, or IIIA with Ulnar-Positive or
Ulnar-Neutral Variance
In this situation, the radius is as short as the ulna, and further
shortening is not likely to decrease load on the lunate. The
lunate has not collapsed, so salvage procedures are not
warranted.
Capitate shortening alone or combined with capitate-
hamate fusion has been reported in the literature.5 This tech-
nique was first described by Almquist in 1993, and he
reported lunate revascularization rates as high as 83% with
this technique.5 Stage IV Kienbock’s disease would be a con-
traindication to this surgical technique.
Technique: Capitate Shortening with Capitate-Hamate Fusion.  osteotomy should be performed as distally as possible. The
A dorsal incision is made from the base of the third metacar-
pal to Lister’s tubercle. The fifth dorsal compartment is
released, and the extensor digiti quinti tendon is retracted.
The fourth dorsal compartment is retracted radially, and the
dorsal capsule is opened. Care is taken not to elevate the PART
fourth compartment and disrupt vascular supply. The capitate- III
hamate joint is incised from proximal to distal and the waist
of the capitate is identified for the proposed osteotomy. This
18 
level should correspond to the distal pole of the scaphoid.
Wrist: Fractures of the Carpal Bones
Almquist, in his technique, described using a sharp, thin
osteotome to make the bone cut to avoid disruption of the
volar capsule blood supply. A small curved elevator is inserted
carefully into the capitolunate joint, avoiding injury into the
articular surface. The elevator is then used to compress the
capitate head against the distal segment, and two crossed
0.062-inch Kirschner wires are used to stabilize the osteot-
omy site. If a capitate-hamate fusion is performed, all sub-
chondral bone at the capitate-hamate interface is removed,
and bone harvested from the osteotomy or from a separate
distal radius graft site is packed into the space. Kirschner
wires or headless cannulated screws are placed percutane-
ously from the hamate into each of the capitate fragments.
Viola noted that when performing this procedure, the tip of
the hamate becomes prominent proximally, preventing the
unloading effect of the capitate shortening.164 The tip of the
hamate may be removed to correct this problem.
Alternatively, the surgeon can perform the osteotomy
across both the capitate and the hamate. The composite oste-
otomy is then reduced and secured with Kirschner wires or
buried headless screws inserted from proximal to distal.
Hanel and Hunt noted in the review of their patients that
the initial results in 1 year were remarkable with this tech-
nique.65 Range of motion and strength plateaued between 8
and 12 months. Almquist noted grip strength of the affected
hand to be 80% of the opposite side, and he reported an
83% satisfaction rate in his series.5
Technique: Radial Osteotomy.  Radial-closing radial osteot-
omy with reduction in the angle of radial inclination has been
described.167 Watanabe and colleagues’ rigid body spring
model showed that the axial load through the radiolunate
joint is redistributed to the radioscaphoid joint without
increasing the ulnar carpal load. Radial osteotomy does not
violate the intra-articular space of the wrist, so range of
motion is maintained. The technique is technically demand-
ing. Radial osteotomy is not indicated in advanced Kienbock’s
disease with collapse.
In this technique, a standard volar approach is made to the
distal radius (Figure 18.87). The FCR is released and pro-
tected radially, and the flexor pollicis longus is retracted
ulnarly to protect the median nerve. The pronator quadratus
is released along the radial surface. A trapezoidal wedge-
shaped segment of bone may be harvested from the distal
quarter of the radius or metaphysis. The osteotomy would
be wider radially than ulnarly to decrease the radial inclina-
tion (Figures 18.88 and 18.89).
Alternatively, a step-cut osteotomy may be performed. In
this technique, the long-axis cut of the step-cut osteotomy is
approximately 3 cm. It is made parallel to the palmar surface
of the radius using the sagittal saw with a 10-mm-wide blade.
The transverse cut is made using a 5-mm-wide saw. The
distal segment should be long enough to accept two screws;
one of the two screws is placed at the step-cut osteotomy
site. The distal segment is deviated radially approximately
10 degrees, and coaptation of the osteotomy site is evaluated.
701
PART
III
18 
Wrist

Figure 18.87  PA radiograph of a 23-year-old female with a Figure 18.89  Lateral radiograph following trapezial wedge
congenital abnormality with increased radial tilt and Kienbock’s osteotomy.
disease.

Temporary Kirschner wire fixation is used, and a volar plate

is placed.
Illarramendi and colleagues described their technique of
coring out the metaphyseal region of the distal radius and
ulna for treating Kienbock’s disease.77 The idea for this tech-
nique was from Illarramendi’s observation that complete
resolution of Kienbock’s disease occurred in patients who
sustained a distal radius fracture. By coring out the distal
radius, they felt they would be able to simulate a scenario
similar to a patient who sustained a distal radius fracture.
Twenty-two patients were followed for an average of 10
years. Sixteen patients were pain free and four patients had
occasional pain. No patient required further surgery. This
technique is used mainly to increase venous outflow, which
is similar to cord decompression, and to decrease interosse-
ous congestion.

Figure 18.88  Because of the increased tilt, a trapezoidal wedge
osteotomy was performed. The osteotomy is stabilized by an
Acu-Loc (AcuMed, Hillsboro, OR) volar distal radial plate.
702
Stage IIIB
If the disease has progressed to stage IIIB, the various salvage
procedures should be considered.115 Various intercarpal
fusions have been described, including STT and scaphocapi-
tate arthrodesis. Proximal row carpectomy has also been
reported for stage IIIB. Watson and colleagues reported their
results in 69 patients who underwent 71 triscaphe scaphotra-
pezial arthrodesis procedures for Kienbock’s disease.169 (Two
patients in the series had bilateral disease.) Initially, in the
authors’ series, the lunate was excised and Silastic lunate
arthroplasty was performed. The prevalence of Silastic par-
ticulate synovitis led to the discontinuation of the Silastic
prosthesis. In their series, 46% of the patients had excellent
subjective results and 32% of the patients had a good result.
The carpal height index remained essentially unchanged in
35 of 36 patients. Eighty-two percent returned to their
 PART
III
18 

Wrist: Fractures of the Carpal Bones

Figure 18.90  PA radiograph of a 27-year-old male with stage IIIB Figure 18.91  The patient desired early return to work back to the
Kienbock’s disease and an ulnar-positive wrist. oil fields. Following proximal row carpectomy, the patient
returned to heavy labor in approximately 2 months.

preoperative work or avocational activities. Further wrist

salvage procedures were needed in 5.6% of patients, includ-
ing proximal carpectomy in two patients and total wrist
arthrodesis in two patients.
Scaphocapitate fusion is thought to be technically easier to
perform than STT fusion. It is important to maintain the
normal distance between the scaphoid and capitate and to
place the bone graft carefully to avoid carpal bones.
De Smet and colleagues reported on their results for 21
patients who underwent proximal row carpectomy for
advanced lunate AVN.34 In their series, 13 patients had zero
to mild pain, three patients reported moderate pain, and five
patients had severe pain. Nakamura and colleagues reported
improved results with proximal carpectomy than with limited
wrist arthrodesis for advanced Kienbock’s disease.115 They
recommended proximal carpectomy over STT fusion based
on their experience, although the difference was not statisti-
cally significant (Figures 18.90 and 18.91).
Recently, pyrocarbon arthroplasty has become an option
in patients with late-stage Kienbock’s disease (Figures 18.92
and 18.93). The pyrocarbon lunate may be stabilized by
either suture or tendon (Figures 18.94 and 18.95). There are
no long-term studies with this technique.

Stage IV
In Stage IV disease, there is significant collapse of the lunate
in addition to perilunate arthritis. Generalized degenerative
changes are noted at the radiocarpal and midcarpal joints. Figure 18.92  PA CT radiograph demonstrating stage IIIB
Proximal row carpectomy may be a possibility, but it is Kienbock’s disease with fragmentation and collapse of the lunate.
important to determine that the head of the capitolunate
fossa is relatively well preserved. Potentially, a dorsal capsule
interposition or soft tissue graft may be placed on the lunate
fossa.
703
PART
III
18 
Wrist

Figure 18.93  Lateral CT radiograph of Kienbock’s stage IIIB
collapse of the lunate and proximal migration of the capitate.
Figure 18.95  Lateral radiograph demonstrating pyrocarbon
replacement of the lunate and stage IIIB Kienbock’s disease in a
young male patient. The two tunnels on the implant are to
facilitate either suture or tendon stabilization of the implant to the
carpus.

In most instances with end-stage Kienbock’s disease, wrist

radiocarpal fusion is recommended. Patients frequently
achieve pain relief, but wrist fusion is not without potential
complications and residual symptoms.

ACKNOWLEDGMENT
The authors wish to thank Drs. Peter Amadio and Steven
Moran, whose chapter in the previous edition of Green’s
Operative Hand Surgery was an outstanding foundation to
formulate our chapter. Several of their images and many of
their pioneering concepts were included in this updated
edition. They are true leaders in the field of Hand Surgery.
In addition, we would also like to thank Dr. Julio Taleisnik,
whose ingenious insight and understanding of the complex
mechanics of the wrist were illustrated in the earliest editions
of Fractures of the Carpal Bones and are still used today in
our daily practice.

REFERENCES
Figure 18.94  PA radiograph demonstrating pyrocarbon lunate
replacement in this 25-year-old male with stage IIIB Kienbock’s
disease. Following replacement, the patient had satisfactory pain
relief and range of motion.
1. Adams BD, Blair WF, Reagan DS, et al: Technical factors related to
Herbert screw fixation, J Hand Surg [Am] 13:893-899, 1988.
2. Adler JB, Shaftan GW: Fractures of the capitate, J Bone Joint Surg Am
44:1537-1547, 1962.
3. Adolfsson L, Lindau T, Arner M: Acutrak screw fixation versus cast
immobilization for undisplaced scaphoid waist fractures, J Hand
Surgery [Br] 26:192-195, 2001.
4. Ahsoh K, Kondo M, Torisu T, et al: The lateral approach compared
with the volar approach for exposure of the hook of the hamate, Clin
Orthop Relat Res 239:217-221, 1989.
5. Almquist EE: Capitate shortening in the treatment of Kienbock’s
disease, Hand Clin 9:505-512, 1993.

704
 6. Almquist EE, Burns JF Jr: Radial shortening for the treatment of Kien-
bock’s disease—a 5 to 10 year follow-up, J Hand Surg [Am] 7:348-
352, 1982.
7. Amadio PC, Berquist TH, Smith DK, et al: Scaphoid malunion, J Hand
Surg Am 14:679-687, 1989.
8. Andresen R, Radmer S, Sparmann M, et al: Imaging of hamate bone
fractures in conventional x-rays and high-resolution computed
tomography: an in vitro study, Invest Radiol 34:46-50, 1999.
9. Antuna Zapico JM: Malacia del Semilunar. Tesis doctoral, Industrias y
Editorial Sever Cuesta. Valladolid, Espana: Universidad de Valladolid,
1966.
10. Arora R, Gschwentner M, Krappinger D, et al: Fixation of nondis-
placed scaphoid fractures: making treatment cost effective; prospec-
tive controlled trial, Arch Orthop Trauma Surg 127:34-39, 2007.
11. Auffray Y: Les fractures du pyramidal, Acta Orthop Belg 36:313-345,
1970.
12. Bailey CA, Kuiper JH, Kelly CP: Biomechanical evaluation of a new
composite bioresorbable screw, J Hand Surg [Br] 31:208-212,
2006.
13. Barton NJ: Apparent and partial non-union of the scaphoid, J Hand
Surg [Br] 21:496-500, 1996.
14. Barton NJ: Experience with scaphoid grafting, J Hand Surg [Br]
22:153-160, 1997.
15. Berger RA: The anatomy of the scaphoid, Hand Clin 17:525-532,
2001.
16. Berger RA, Bishop AT, Bettinger PC: New dorsal capsulotomy for the
surgical exposure of the wrist, Ann Plast Surg 35:54-59, 1995.
17. Bilic R, Simic P, Jelic M, et al: Osteogenic protein-1 (BMP-7) acceler-
ates healing of scaphoid non-union with proximal pole sclerosis, Int
Orthop 30:128-134, 2006. Epub Feb 28, 2006.
18. Bochud RC, Buchler U: Kienbock’s disease, early stage 3—Height
reconstruction and core revascularization of the lunate, J Hand Surg
[Br] 19:466-478, 1994.
19. Bond CD, Shin AY, McBride MT, et al: Percutaneous screw fixation or
cast immobilization for nondisplaced scaphoid fractures, J Bone Joint
Surg Am 83:483-488, 2001.
20. Borgeskov S, Christiansen B, Kjaer A, et al: Fractures of the carpal
bones, Acta Orthop Scand 37:276-287, 1966.
21. Botte MJ, Gelberman RH: Fractures of the carpus, excluding scaph-
oid, Hand Clin 3:49-161, 1987.
22. Braithwaite IJ, Jones WA: Scapholunate dissociation occurring with
scaphoid fracture, J Hand Surg [Br] 17:286-288, 1992.
23. Braun C, Gross G, Bühren V: [Osteosynthesis using a buttress plate—a
new principle for stabilizing scaphoid pseudarthroses], Unfallchirurg
96:9-11, 1993.
24. Bunker TD, McNamee PB, Scott TD: The Herbert screw for scaphoid
fractures. A multicentre study, J Bone Joint Surg Br 69:631-634,
1987.
25. Bushnell BD, McWilliams AD, Messer TM: Complications in dorsal
percutaneous cannulated screw fixation of nondisplaced scaphoid
waist fractures, J Hand Surg [Am] 32:827-833, 2007.
26. Carroll RE, Coyle MP: Dysfunction of the pisotriquetral joint: treat-
ment by excision of the pisiform, J Hand Surg [Am] 10:703-707, 1985.
27. Carroll RE, Lakin JF: Fracture of the hook of the hamate: acute treat-
ment, J Trauma 34:803-805, 1993.
28. Chang MA, Bishop AT, Moran SL, et al: The outcomes and complica-
tions of 1,2-intercompartmental supra retinacular artery pedicled
vascularized bone grafting of scaphoid nonunions, J Hand Surg [Am]
31:387-396, 2006.
29. Condit DP, Idler RS, Fischer TJ, et al: Preoperative factors and outcome
after lunate decompression for Kienbock’s disease, J Hand Surg [Am]
18:691-696, 1993.
30. Cooney WP, Dobyns JH, Linscheid RL: Fractures of the scaphoid: a
rational approach to management, Clin Orthop 149:90-97, 1980.
31. Croog AS, Stern PJ: Proximal row carpectomy for advanced Kien-
bock’s disease: average 10-year follow-up, J Hand Surg [Am] 33:1122-
1130, 2008.
32. Dacho A, Germann G, Sauerbier M: [The reconstruction of scaphoid
pseudoarthroses with the operation of Matti-Russe. A retrospective
follow-up analysis of 84 patients], Unfallchirurg 107:388-396, 2004.
33. Davis EN, Chung KC, Kotsis SV, et al: A cost/utility analysis of open
reduction and internal fixation versus cast immobilization for acute
nondisplaced mid-waist scaphoid fractures, Plast Reconstr Surg
117:1223-1235, 2006.
34. De Smet L, Robijns P, Degreef I: Proximal row carpectomy in advanced
Kienbock’s disease, J Hand Surg [Br] 30:585-587, 2005.
35. Desai VV, Davis TR, Barton NJ: The prognostic value and reproduc-
ibility of the radiological features of the fractured scaphoid, J Hand
Surg [Br] 24:586-590, 1999.
36. D’Hoore K, De Smet L, Verellen K, et al: Negative ulnar variance is
not a risk factor for Kienbock’s disease, J Hand Surg [Am] 19:229-231,
1994.
37. Dias JJ, Taylor M, Thompson J, et al: Radiographic signs of union of PART
scaphoid fractures. An analysis of inter-observer agreement and
reproducibility, J Bone Joint Surg Br 70:299-301, 1988.
III
38. Dias JJ, Wildin CJ, Bhowal B, et al: Should acute scaphoid fractures
be fixed? A randomized controlled trial, J Bone Joint Surg Am 87:2160- 18 
2168, 2005.
Wrist: Fractures of the Carpal Bones
39. Dodds SD, Panjabi MM, Slade JF: Screw fixation of scaphoid frac-
tures: a biomechanical assessment of screw length and screw aug-
mentation, J Hand Surg [Am] 31:405-413, 2006.
40. Dunn AW: Fractures and dislocations of the carpus, Surg Clin North
Am 52:1513-1538, 1972
41. Duppe H, Johnell O, Lundborg G, et al: Long-term results of fracture
of the scaphoid. A follow-up study of more than thirty years, J Bone
Joint Surg Am 76:249-252, 1994.
42. Eggli S, Fernandez DL, Beck T: Unstable scaphoid fracture nonunion:
a medium-term study of anterior wedge grafting procedures, J Hand
Surg [Br] 27:36-41, 2002.
43. Failla JM: Hook of the hamate vascularity: vulnerability to osteone-
crosis and nonunion, J Hand Surg [Am] 18:1075-1079, 1993.
44. Faran KJ, Ichioka N, Trzeciak MA, et al: Effect of bone quality on the
forces generated by compression screws, J Biomech 32:861-864.
1999.
45. Fenton RL: The naviculo-capitate fracture syndrome, J Bone Joint Surg
Am 38:681-684, 1956.
46. Fernández DL: A technique for anterior wedge-shaped grafts for
scaphoid nonunions with carpal instability, J Hand Surg [Am] 9:733-
737, 1984.
47. Fernández DL: Anterior bone grafting and conventional lag screw
fixation to treat scaphoid non-unions, J Hand Surg [Am] 15:140-147,
1990.
48. Fernández DL, Eggli S: Non-union of the scaphoid. Revascularization
of the proximal pole with implantation of a vascular bundle and
bone-grafting, J Bone Joint Surg Am 77:883-893, 1995.
49. Fernández DL, Martin CJ, Gonzalez del Pino J: Scaphoid malunion.
The significance of rotational malalignment, J Hand Surg [Br] 23:771-
775, 1998.
50. Filan SL, Herbert TJ: Herbert screw fixation of scaphoid fractures [see
comments], J Bone Joint Surg Br 78:519-529, 1996.
51. Franz A: Contributo allo studio della frattura isolate dell’uncinato,
Chir Org Mov 37:487-495, 1952.
52. Garcia-Elias M: Carpal bone fractures (excluding scaphoid fractures).
In Watson HK, Weinberg J (eds): The Wrist, Philadelphia, Lippincott
Williams & Wilkins, 2001:174-181.
53. Garcia-Elias M: Dorsal fractures of the triquetrum. Avulsion or com-
pression fractures? J Hand Surg [Am] 12:266-268, 1987.
54. Geissler WB: Arthroscopic management of scaphoid fractures in ath-
letes, Hand Clin 25:359-369, 2009.
55. Geissler WB: Carpal fractures in athletes, Clin Sports Med 20:167-188,
2001.
56. Geissler WB, Hammit MD: Arthroscopic aided fixation of scaphoid
fractures, Hand Clin 17:575-588, 2001.
57. Gelberman RH, Bauman TD, Menon J, et al: The vascularity of the
lunate bone and Kienbock’s disease, J Hand Surg [Am] 5:272-278,
1980.
58. Gelberman RH, Menon J: The vascularity of the scaphoid bone, J
Hand Surg [Am] 5:508-513, 1980.
59. Gelberman RH, Panagis JS, Taleisnik J, et al: The arterial anatomy of
the human carpus. Part I: The extraosseous vascularity, J Hand Surg
[Am] 8:367-375, 1983.
60. Gellman H, Caputo RJ, Carter V, et al: Comparison of short and long
thumb-spica casts for nondisplaced fractures of the carpal scaphoid,
J Bone Joint Surg Am 71:354-357, 1989.
61. Goldfarb CA, Hsu J, Gelberman RH, et al: The Lichtman classification
for Kienbock’s disease: an assessment of reliability, J Hand Surg [Am]
28:74-80, 2003.
62. Green DP: The effect of avascular necrosis on Russe bone grafting for
scaphoid nonunion, J Hand Surg [Am] 10:597-605, 1985.
63. Haddad FS, Goddard NJ: Acute percutaneous scaphoid fixation: a
pilot study, J Bone Joint Surg Br 80:95-99, 1998.
64. Handley RC, Pooley J: The venous anatomy of the scaphoid, J Anat
178:115-118, 1991.
65. Hanel DP, Hunt TR: Capitate shortening osteotomy: Kienbock’s
disease, Atlas Hand Clin 4:45-58, 1999.
66. Heinzelmann AD, Archer G, Bindra RR: Anthropometry of the human
scaphoid, J Hand Surg [Am] 32:1005-1008, 2007.
67. Herbert TJ, Fisher WE: Management of the fractured scaphoid using
a new bone screw, J Bone Joint Surg Br 66:114-123, 1984.
68. Herzberg G, Forissier D: Acute dorsal trans-scaphoid perilunate frac-
ture-dislocations: medium-term results, J Hand Surg [Br] 27:498-502,
2002.
69. Hocker K, Menschik A: Chip fractures of the triquetrum. Mechanism,
classification and results, J Hand Surg [Br] 19:584-588, 1994.
705
PART 70. Hori Y, Tamai S, Okuda H, et al: Blood vessel transplantation to bone,
III J Hand Surg [Am] 4:23-33, 1979.
71. Horii E, Garcia-Elias M, Bishop AT, et al: Effect on force transmission
across the carpus in procedures used to treat Kienbock’s disease,
18  J Hand Surg [Am] 15:393-400, 1990.
72. Horii E, Nakamura R, Watanabe K, et al: Scaphoid fracture as a
Wrist
puncher’s fracture, J Orthop Trauma 8:107-110, 1994.
73. Howe LM: Epidemiology of scaphoid fractures in Bergen, Norway,
Scand J Plast Reconstr Surg Hand Surg 33:423-426, 1999.
74. Huene DR, Huene DS: Treatment of nonunions of the scaphoid with
the Ender compression blade plate system, J Hand Surg [Am] 16:913-
922, 1991.
75. Hulten O: Uber die Entstehung und Behandlung der Lunatummalazie
(Morbus Kienbock), Act Chir Scand 76:121, 1928.
76. Ikeda K, Osamura N, Tomita K: Percutaneous screw fixation without
bone graft for cystic-type scaphoid fractures, J Trauma 65:1453-
1458, 2008.
77. Illarramendi AA, Schulz C, De Carli P: The surgical treatment of
Kienbock’s disease by radius and ulna metaphyseal core decompres-
sion, J Hand Surg [Am] 26:252-260, 2001.
78. Imbriglia JE, Broudy AS, Hagberg WC, et al: Proximal row carpec-
tomy: clinical evaluation, J Hand Surg [Am] 15:426-430, 1990.
79. Inoue G, Shionoya K: Herbert screw fixation by limited access for
acute fractures of the scaphoid, J Bone Joint Surg Br 79:418-421,
1997.
80. Inoue G, Shionoya K, Kuwahata Y: Herbert screw fixation for scaphoid
nonunions. An analysis of factors influencing outcome, Clin Orthop
Relat Res Oct(343):99-106, 1997.
81. Inoue G, Shionoya K, Kuwahata Y: Ununited proximal pole scaphoid
fractures. Treatment with a Herbert screw in 16 cases followed for
0.5-8 years, Acta Orthop Scand 68:124-127, 1997.
82. Jafarnia K, Collins ED, Kohl HW III, et al: Reliability of the Lichtman
classification of Kienbock’s disease, J Hand Surg [Am] 25:529-534,
2000.
83. Jensen CH, Thomsen K, Holst-Nielsen F: Radiographic staging of
Kienbock’s disease: poor reproducibility of Stahl’s and Lichtman’s
staging systems, Acta Orthop Scand 67:274-276, 1996.
84. Jiranek WA, Ruby LK, Millender LB, et al: Long-term results after Russe
bone-grafting: the effect of malunion of the scaphoid, J Bone Joint
Surg Am 74:1217-1228, 1992.
85. Jones DB Jr, Burger H, Bishop AT, et al: 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]
90:2616-2625, 2008.
86. Jones NF, Brown EE, Mostofi A, et al: Healing of a Scaphoid Nonunion
Using Human Bone Morphogenetic Protein, J Hand Surg 30(3):528-
533, 2005.
87. Keith PP, Nuttall D, Trail I: Long-term outcome of nonsurgically
managed Kienbock’s disease, J Hand Surg [Am] 29:63-67, 2004.
88. Kienbock R: Uber traumatische Malazie des Monatbeins und ihre
Folgezustande: Entartungsformen und Kompressionsfrakturen,
Fortschrit Rontgenstrallen 16:77, 1910.
89. Korkala OL, Kuokkanen HO, Eerola MS: Compression-staple fixation
for fractures, non-unions, and delayed unions of the carpal scaphoid,
J Bone Joint Surg Am 74:423-426, 1992.
90. Kristensen SS, Thomassen E, Christensen F: Ulnar variance in Kien-
bock’s disease, J Hand Surg [Br] 11:258, 1986.
91. Langhoff O, Andersen JL: Consequences of late immobilization of
scaphoid fractures, J Hand Surg [Br] 13:77-79, 1988.
92. Larsen CF, Brondum V, Skov O: Epidemiology of scaphoid fractures
in Odense, Denmark, Acta Orthop Scand 63:216-218, 1992.
93. Leventhal EL, Wolfe SW, Walsh EF, et al: A computational approach
to the “optimal” screw axis location and orientation in the scaphoid
bone, J Hand Surg [Am] 34:677-684, 2009.
94. Levy M, Fischel RE, Stern GM, et al: Chip fractures of the os trique-
trum. The mechanism of injury, J Bone Joint Surg Br 61:355-357,
1979.
95. Lichtman DM, Mack GR, MacDonald RI, et al: Kienbock’s disease: the
role of silicone replacement arthroplasty, J Bone Joint Surg Am 59:899,
1977.
96. Linscheid RL: Ulnar lengthening and shortening, Hand Clin 3:69-79,
1987.
97. Lynch NM, Linscheid RL: Corrective osteotomy for scaphoid mal-
union: technique and long-term follow-up evaluation, J Hand Surg
[Am] 22:35-43, 1997.
98. Mack GR, Bosse MJ, Gelberman RH, et al: The natural history of
scaphoid non-union, J Bone Joint Surg [Am] 66:504-509, 1984.
99. Mack GR, Wilckens JH, McPherson SA: Subacute scaphoid fractures.
A closer look at closed treatment, Am J Sports Med 26:56-58, 1998.
100. Malerich MM, Clifford J, Eaton B, et al: Distal scaphoid resection
arthroplasty for the treatment of degenerative arthritis secondary to
scaphoid nonunion, J Hand Surg [Am] 24:1196-1205, 1999.
706
101. Manon M: Les fractures du trapeze dans les traumatismes du poignet,
Rev Orthop 11:127-140, 1924.
102. Mayr M, Rudzki M, Borchardt B, et al: Does pulsed low intensity
ultrasound accelerate healing of scaphoid fractures? Handchir Mikro-
chir Plast Chir 32:115-122, 2000.
103. McAdams TR, Spisak S, Beaulieu CF, et al: The effect of pronation
and supination on the minimally displaced scaphoid fracture, Clin
Orthop Relat Res Jun(411):255-259, 2003.
104. McCallister WV, Knight J, Kaliappan R, et al: Central placement of the
screw in simulated fractures of the scaphoid waist: a biomechanical
study, J Bone Joint Surg Am 85:72-77, 2003.
105. McCarty V, Farber H: Isolated fracture of the pisiform bone, J Bone
Joint Surg Am 28:90-91, 1946.
106. McLaughlin HL: Fracture of the carpal navicular (scaphoid) bone, J
Bone Joint Surg Am 36:765-774, 1954.
107. McLean JM, Turner PC, Bain GI, et al: An association between lunate
morphology and scaphoid-trapezium-trapezoid arthritis, J Hand Surg
Eur 34:778-782, 2009.
108. Merrell GA, Wolfe SW, Slade JF III: Treatment of scaphoid nonunions:
quantitative meta-analysis of the literature, J Hand Surg [Am] 27:685-
691, 2002.
109. Milliez PY, Kha HK, Allieu Y, et al: Osteonecrose aseptique essentielle
du grand os: revue de la litterature a propos de 3 nouveauz cas, Int
Orthop 15:85-94, 1991.
110. Milch H: Fracture of the hamate bone, J Bone Joint Surg Am 16:459-
462, 1934.
111. Mintzer CM, Waters PM: Surgical treatment of pediatric scaphoid
fracture nonunions, J Pediatr Orthop 9:236-239, 1999.
112. Moran SL, Cooney WP, Berger RA, et al: Vascularized bone grafts for
the treatment of Kienbock’s disease: a ten-year experience. Presented
before the 57th annual meeting of the ASSH, Phoenix, Arizona,
October 4, 2002.
113. Moran SL, Cooney WP, Shin AY: The use of vascularized grafts from
the distal radius for the treatment of Preiser’s disease, J Hand Surg
[Am] 31:705-710, 2006.
114. Nakamura P, Imaeda T, Miura T: Scaphoid malunion, J Bone Joint Surg
Br 73:134-137, 1991.
115. Nakamura R, Horii E, Watanabe K, et al: Proximal row carpectomy
versus limited wrist arthrodesis for advanced Kienbock’s disease,
J Hand Surg [Br] 23:741-745, 1998.
116. Nakamura R, Watanabe K, Tsunoda K, et al: Radial osteotomy for
Kienbock’s disease evaluated by magnetic resonance imaging. 24
cases followed for 1 to 3 years, Acta Orthop Scand 64:207-211, 1993.
117. Palmer AK: Trapezial ridge fractures, J Hand Surg [Am] 6:561-564,
1981.
118. Peste JL: Discussion, Bull Soc Anat 18:169, 1843.
119. Pointu J, Schwenck JP, Destree G, et al: Fractures of the trapezium.
Mechanism, pathology and indications for treatment, J Orthop Surg
2:380-391, 1988.
120. Porter ML, Seehra K: Fracture-dislocation of the triquetrum treated
with a Herbert screw, J Bone Joint Surg Br 73:347-348, 1991.
121. Preiser G: Eine typische posttraumatische und zur spontanfraktur
fuhrende ostitits des naviculare carpi, Fortschr Geb Roentgenstrahlen
1;15:189-197, 1910.
122. Pring DJ, Hartley EB, Williams DJ: Scaphoid osteosynthesis: early
experience with the Herbert bone screw, J Hand Surg [Br] 12:1-4,
1987.
123. Rettig ME, Raskin KB: Retrograde compression screw fixation of acute
proximal pole scaphoid fractures, J Hand Surg [Am] 24:1206-1210,
1999.
124. Rettig AC, Weidenbener EJ, Gloyeske R: Alternative management of
midthird scaphoid fractures in the athlete, Am J Sports Med 22:711-
714, 1994.
125. Robbins RR, Carter PR: Iliac crest bone grafting and Herbert screw
fixation of nonunions of the scaphoid with avascular proximal poles,
J Hand Surg [Am] 20:818-831, 1995.
126. Rock MG, Roth JH, Martin L: Radial shortening osteotomy for treat-
ment of Kienbock’s disease, J Hand Surg [Am] 16:454-460, 1991.
127. Ruby LK, Cooney WP, An KN, et al: Relative motion of selected carpal
bones: a kinematic analysis of the normal wrist, J Hand Surg [Am]
13:1-10, 1988.
128. Ruch DS, Papadonikolakis A: Resection of the scaphoid distal pole for
symptomatic scaphoid nonunion after failed previous surgical treat-
ment, J Hand Surg [Am] 31:588-593, 2006.
129. Russe O: Fractures of the carpal navicular, J Bone Joint Surg Am
42:759-768, 1960.
130. Schiltenwolf M, Martini AK, Mau HC, et al: Further investigations of
the intraosseous pressure characteristics in necrotic lunates (Kien-
bock’s disease), J Hand Surg [Am] 21:754-758, 1996.
131. Schuind F, Haentjens P, Van Innis F, et al: Prognostic factors in the
treatment of carpal scaphoid nonunions, J Hand Surg [Am] 24:761-
776, 1999.
132. Shah J, Jones WA: Factors affecting the outcome in 50 cases of
scaphoid nonunion treated with Herbert screw fixation, J Hand Surg
[Br] 23:680-685, 1998.
133. 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] 20:902-914, 1995.
134. Shi ZM, Xu ZG: Experimental study and clinical use of the fasciosteal
flap, Plast Reconstr Surg 78:201-210, 1986.
135. Siegel DB, Gelberman RH: Radial styloidectomy: an anatomical study
with special reference to radiocarpal intracapsular ligamentous mor-
phology, J Hand Surg [Am] 16:40-44, 1991.
136. Slade JF III, Geissler WB, Gutow AP, et al: Percutaneous internal fixa-
tion of selected scaphoid nonunions with an arthroscopically assisted
dorsal approach, J Bone Joint Surg Am 85(Suppl 4):20-32, 2003.
137. Slade JF, Gillon T: Retrospective review of 234 scaphoid fractures and
nonunions treated with arthroscopy for union and complications,
Scand J Surg 97:280-289, 2008.
138. Slade JF III, Grauer JN, Mahoney JD: Arthroscopic reduction and
percutaneous fixation of scaphoid fractures with a novel dorsal tech-
nique, Orthop Clin North Am 32:247-261, 2001.
139. Slade JF III, Gutow AP, Geissler WB: Percutaneous internal fixation of
scaphoid fractures via an arthroscopically assisted dorsal approach,
J Bone Joint Surg Am 84(Suppl 2):21-36, 2002.
140. Slade JF III, Gutow AP, Geissler WB, et al: Percutaneous internal fixa-
tion of scaphoid fractures and selected nonunions via an arthroscopi-
cally assisted dorsal approach, J Bone Joint Surg Am 85(Suppl 4):20-
32, 2003.
141. Slade JF, Lozano-Calderon S, Merrell G, et al: Arthroscopic-assisted
percutaneous reduction and screw fixation of displaced scaphoid
fractures, J Hand Surg Eur 33:350-354, 2008.
142. Slade JF III, Moore AE: Dorsal percutaneous fixation of stable, unsta-
ble, and displaced scaphoid fractures and selected non-unions, Atlas
Hand Clin 8:1-18, 2003. Scaphoid Injuries (ed) J. Slade III.
143. Smith DK, Murray PM: Avulsion fractures of the volar aspect of tri-
quetral bone of the wrist: a subtle sign of carpal ligament injury, AJR
Am J Roentgenol 166:609-614, 1996.
144. Smith P, Wright TW, Wallace PF, et al: Excision of the hook of the
hamate: a retrospective survey and review of the literature, J Hand
Surg [Br] 13:612-615, 1988.
145. Snodgrass LE: Fractures of the carpal bones, Am J Surg 38:539-548,
1937.
146. Stahl F: On lunatomalacia (Kienbock’s disease): a clinical and roent-
genological study, especially on its pathogenesis and the late results
of immobilization treatment, Acta Chir Scand 95 Suppl (126):3, 1947.
147. Stein E, Siegel MW: Naviculocapitate fracture syndrome. A case
report: new thoughts on the mechanism of injury, J Bone Joint Surg
Am 51:291-295, 1969100.
148. Streli R: Perkutane verschraubung des handkahnbeines mit bohrdraht-
compressionsscraube, Zentralbl Chir 95:1060-1078, 1970.
149. Straw RG, Davis TR, Dias JJ: Scaphoid nonunion: treatment with a
pedicled vascularized bone graft based on the 1,2 intercompartmen-
tal supraretinacular branch of the radial artery, J Hand Surg [Br]
27:413-416, 2002.
150. Sunagawa T, Bishop AT, Muramatsu K: Role of conventional and
vascularized bone grafts in scaphoid nonunion with avascular necro-
sis: a canine experimental study, J Hand Surg [Am] 25:849-859, 2000.
151. Tajima T: An investigation of the treatment of Kienbock’s disease
(abstract), J Bone Joint Surg Am 48:1649, 1966.
152. Taniguchi Y, Tamaki T, Nakatan N: Long-term results of non-surgical
treatment in Kienbock’s disease, J Jpn Soc Surg Hand 9:962-968,
1993.
153. Teisen H, Hjarbaek J: Classification of fresh fractures of the lunate, J
Hand Surg [Br] 13:458-462, 1988.
154. Terkelsen CJ, Jepsen JM: Treatment of scaphoid fractures with a PART
removable cast, Acta Orthop Scand 59:452-453, 1988.
155. Trumble TE, Benirschke SK, Vedder NB: Ipsilateral fractures of the
III
scaphoid and radius, J Hand Surg [Am] 18:8-14, 1993.
156. Trumble TE, Clarke T, Kreder HJ: Non-union of the scaphoid. Treat- 18 
ment with cannulated screws compared with treatment with Herbert
Wrist: Fractures of the Carpal Bones
screws, J Bone Joint Surg Am 78:1829-1837, 1996.
157. Trumble TE, Gilbert M, Murray LW, et al: Displaced scaphoid fractures
treated with open reduction and internal fixation with a cannulated
screw, J Bone Joint Surg Am 82:633-641, 2000.
158. Trumble T, Glisson RR, Seaber AV, et al: A biomechanical comparison
of the methods for treating Kienbock’s disease, J Hand Surg [Am]
11:88-93, 1986.
159. Tsuge S, Nakamura R: Anatomical risk factors for Kienbock’s disease,
J Hand Surg [Br] 18:70-75, 1993.
160. Tumilty JA, Squire DS: Unrecognized chondral penetration by a
Herbert screw in the scaphoid, J Hand Surg [Am] 21:66-68, 1996.
161. Urist MR, Strates BS: Bone formation in implants of partially and
wholly demineralized bone matrix. Including observations on ace-
tone-fixed intra- and extracellular proteins, Clin Orthop Relat Res
71:271-278, 1970
162. Vander Grend R, Dell PC, Glowczewskie F, et al: Intraosseous blood
supply of the capitate and its correlation with aseptic necrosis, J Hand
Surg [Am] 9:677-680, 1984.
163. Verhellen R, Bain GI: Arthroscopic capsular release for contracture of
the wrist: a new technique, Arthroscopy 16:106-110, 2000.
164. Viola RW, Kiser PK, Bach AW, et al: Biomechanical analysis of capitate
shortening with capitate hamate fusion in the treatment of Kien-
böck’s disease, J Hand Surg [Am] 23:395-401, 1998.
165. Walker JL, Greene TL, Lunseth PA: Fractures of the body of the tra-
pezium, J Orthop Trauma 2:22-28, 1988.
166. Walsh E, Crisco JJ, Wolfe SW: Computer-assisted navigation of volar
percutaneous scaphoid placement, J Hand Surg [Am] 34:1722-1728,
2009.
167. Watanabe K, Nakamura R, Horii E, et al: Biomechanical analysis of
radial wedge osteotomy for the treatment of Kienbock’s disease, J
Hand Surg [Am] 18:686-690, 1993.
168. Watson HK, Rogers WD: Nonunion of the hook of the hamate: an
argument for bone grafting the nonunion, J Hand Surg [Am] 14:486-
490, 1989.
169. Watson HK, Ryu J, DiBella A: An approach to Kienbock’s disease:
triscaphe arthrodesis, J Hand Surg [Am] 10:179-187, 1985.
170. Weber DM, Fricker R, Ramseier LE: Conservative treatment of scaph-
oid nonunion in children and adolescents, J Bone Joint Surg Br
91:1213-1216, 2009.
171. Weber ER, Chao EY: An experimental approach to the mechanism of
scaphoid waist fracture, J Hand Surg [Am] 3:142-148, 1978.
172. Weiss AP, Weiland AJ, Moore JR, et al: Radial shortening for Kienbock
disease, J Bone Joint Surg Am 73:384-391, 1991.
173. Wheeler DL, McLoughlin SW: Biomechanical assessment of compres-
sion screws, Clin Orthop Relat Res May(350):237-245, 1998.
174. Whipple TL: The role of arthroscopy in the treatment of intra-articular
wrist fractures, Hand Clin 11:13-18, 1995.
175. Wolf JM, Dawson L, Mountcastle SB, et al: The incidence of scaphoid
fracture in a military population, Injury 40:1316-1319, 2009. Epub
Jun 16, 2009.
176. Wozasek GE, Moser KD: Percutaneous screw fixation for fractures of
the scaphoid [published erratum appears in J Bone Joint Surg Br 1991
May; 73(3):524], J Bone Joint Surg Br 73:138-142, 1991.
177. Zaidemberg C, Siebert JW, Angrigiani C: A new vascularized bone
graft for scaphoid nonunion, J Hand Surg [Am] 16:474-478, 1991.
707