Prognostic factors in the treatment of carpal scaphoid nonunions

Vascularized bone grafts for the treatment of carpal bone pathology

Primary bone healing fails to occur in 5-15 % of scaphoid bones that undergo fracture fixation. Untreated, occult fractures result in nonunion up to 12 % of the time. Conventional bone grafting is the accepted management in the treatment algorithm of scaphoid nonunion if the proximal pole is vascularized. Osteonecrosis of the proximal scaphoid pole intuitively suggests a need for transfer of the vascularized bone to the nonunion site. Scaphoid nonunion treatment aims to prevent biological and mechanical subsidence of the involved bone, destabilization of the carpus, and early degenerative changes associated with scaphoid nonunion advanced collapse. Pedicled distal radius and free vascularized bone grafts (VBGs) offer hand surgeons an alternative treatment option in the management of carpal bone nonunion. VBGs are also indicated in the treatment of avascular necrosis of the scaphoid (Preiser's disease), lunate (Kienböck's disease), and capitate. Relative contraindications to pedicled dorsal radius vascularized bone grafting include humpback deformity, carpal instability, or collapse. The free medial femoral condyle bone graft has offered a novel treatment option for the humpback deformity to restore geometry of the carpus, otherwise not provided by pedicled grafts. In general, VBGs are contraindicated in the setting of a carpal bone without an intact cartilaginous shell, in advanced carpal collapse with degenerative changes, and in attempts to salvage small or collapsed bone fragments. Wrist salvage procedures are generally accepted as the more definitive treatment option under such circumstances. This manuscript offers a current review of the techniques and outcomes of VBGs to the carpal bones.

The clinical and radiological outcome of pulsed electromagnetic field treatment for acute scaphoid fractures

The use of pulsed electromagnetic fields (PEMF) to stimulate bone growth has been recommended as an alternative to the surgical treatment of ununited scaphoid fractures, but has never been examined in acute fractures. We hypothesised that the use of PEMF in acute scaphoid fractures would accelerate the time to union by 30% in a randomised, double-blind, placebo-controlled, multicentre trial. A total of 53 patients in three different medical centres with a unilateral undisplaced acute scaphoid fracture were randomly assigned to receive either treatment with PEMF (n = 24) or a placebo (n = 29). The clinical and radiological outcomes were assessed at four, six, nine, 12, 24 and 52 weeks.

A log-rank analysis showed that neither time to clinical and radiological union nor the functional outcome differed significantly between the groups. The clinical assessment of union indicated that at six weeks tenderness in the anatomic snuffbox (p = 0.03) as well as tenderness on longitudinal compression of the scaphoid (p = 0.008) differed significantly in favour of the placebo group.

We conclude that stimulation of bone growth by PEMF has no additional value in the conservative treatment of acute scaphoid fractures.

Scaphoid nonunion in the presence of a degenerate carpus: don't rush to salvage surgery

We retrospectively studied 13 patients with degenerative change associated with a scaphoid nonunion treated by internal fixation and bone graft. All patients had radiological signs of radioscaphoid degenerative change (scaphoid nonunion advanced collapse--scaphoid nonunion advanced collapse-- grade II or more) and had surgery more than 2 years after injury. Ten of the 13 patients achieved union at 6 months with all but one of these demonstrating improvement on the Disability of Arm, Shoulder and Hand (DASH) score. Surgeons presented with this difficult patient group might consider reconstruction before salvage procedures.

The treatment of scaphoid nonunion using the Ilizarov fixator without bone graft, a study of 18 cases

Objectives

Evaluating the safety and efficacy of the Ilizarov fine-wire compression/distraction technique in the treatment of scaphoid nonunion (SNU), without the use of bone graft.

Design

A retrospective review of 18 consecutive patients in one centre.

Patients and Methods

18 patients; 17 males; 1 female, with a mean SNU duration of 13.9 months. Patients with carpal instability, humpback deformity, carpal collapse, avascular necrosis or marked degenerative change, were excluded. Following frame application the treatment consisted of three stages: the frame was distracted 1 mm per day until radiographs showed a 2-3 mm opening at the SNU site (mean 10 days); the SNU site was then compressed for 5 days, at a rate of 1 mm per day, with the wrist in 15 degrees of flexion and 15 degrees of radial deviation; the third stage involved immobilization with the Ilizarov fixator for 6 weeks. The technique is detailed herein.

Results

Radiographic (CT) and clinical bony union was achieved in all 18 patients after a mean of 89 days (70-130 days). Mean modified Mayo wrist scores improved from 21 to 86 at a mean follow-up of 37 months (24-72 months), with good/excellent results in 14 patients. All patients returned to their pre-injury occupations and levels of activity at a mean of 117 days. Three patients suffered superficial K-wire infections, which resolved with oral antibiotics.

Conclusions

In these selected patients this technique safely achieved bony union without the need to open the SNU site and without the use of bone graft.

Percutaneous screw fixation without bone grafting for established scaphoid nonunion with substantial bone loss

Ununited fractures of the scaphoid with extensive bone resorption are usually treated by bone grafting and internal fixation, using either an open or a minimally invasive technique. We studied the feasibility of percutaneous fixation without bone grafting in a consecutive series of 27 patients with established nonunion of an undisplaced fracture of the scaphoid and extensive local resorption of bone. They were treated by a single surgeon with rigid fixation alone, using a headless cannulated screw inserted through a volar percutaneous technique. Clinical examination, standard radiographs and CT confirmed that the fracture had united in all patients at a mean of 11.6 weeks (8 to 16), and that their functional scores had improved.

We concluded that extensive resorption at the fracture site is not an absolute indication for bone grafting, and that percutaneous fixation alone will eventually produce healing of ununited undisplaced fractures of the scaphoid regardless of the size of the gap.

Arthroscopically assisted use of injectable bone graft substitutes for management of scaphoid nonunions

PURPOSE

The purpose of this study was to analyze the clinical follow-up results (minimum, 2 years) in patients with nonunions of the scaphoid with minimal sclerosis treated with arthroscopically assisted percutaneous internal fixation augmented by injection of a bone graft substitute.

METHODS

From January 2006 through November 2007, a consecutive series of 15 patients with fibrous union or nonunion of a carpal scaphoid fracture with minimal sclerosis or resorption at the nonunion site were treated with arthroscopically assisted percutaneous internal fixation combined with the use of injectable bone graft substitute. Preoperative and postoperative evaluations included measurement of clinical (grip strength and range of motion), radiographic, and functional (Mayo Modified Wrist Score) parameters, as well as satisfaction. The sample included 13 men and 2 women with a mean age of 31 years (range, 20 to 45 years). We recorded union and return to activity and analyzed data with regular clinical follow-up at a mean of 33 months (range, 24 to 46 months).

RESULTS

We confirmed union in 14 of 15 patients (93%) at a mean of 15.4 weeks according to clinical examinations and standard radiography. For the Mayo Modified Wrist Score, there were 10 excellent and 4 good results. A total of 14 of 15 patients (93%) returned to work or sports activities at their preinjury level.

CONCLUSIONS

Arthroscopically assisted treatment with percutaneous internal fixation with injectable bone graft substitute is a reliable and minimally invasive method to achieve union and scaphoid healing.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Management of scaphoid nonunions

Scaphoid nonunions can exist with or without avascular necrosis of the proximal pole, and waist fractures may have an associated humpback deformity. CT best shows the deformity and bone loss, whereas MRI will show avascular necrosis. Operative treatment should be directed at correcting the deformity with open reduction and internal fixation and bone grafting. Vascularized bone grafts should be used in cases of avascular necrosis.

Treatment of scaphoid nonunion with vascularised and nonvascularised dorsal bone grafting from the distal radius

We conducted a prospective randomised study comparing the clinical, functional and radiographic results of 46 patients treated for scaphoid nonunion using a vascularised bone graft from the dorsal and distal aspect of the radius (group I), relative to 40 patients treated by means of a conventional non-vascularised bone graft from the distal radius (group II). Surgical findings included 30 sclerotic, poorly-vascularised scaphoids in group I versus 20 in group II. Bone fusion was achieved in 89.1% of group I and 72.5% of group II patients (p=0.024). Functional results were good to excellent in 72.0% of the patients in group I and 57.5% in group II. Considering only patients with sclerotic, poorly-vascularised scaphoids, the mean final outcome scores obtained were 7.5 and 6.0 for groups I and group II, respectively. We conclude that vascularised bone grafting yields superior results and is more efficient when there is a sclerotic, poorly-vascularised proximal pole in patients in scaphoid nonunion.

The use of a vascularised periosteal patch onlay graft in the management of nonunion of the proximal scaphoid

We describe the use of a vascularised periosteal patch onlay graft based on the 1,2 intercompartmental supraretinacular artery in the management of 11 patients (ten men, one woman) with chronic nonunion involving the proximal third of the scaphoid. The mean age of the patients was 31 years (21 to 45) with the dominant hand affected in eight. Six of the patients were smokers and three had undergone previous surgery to the scaphoid. All of the proximal fragments were avascular. The presence of union was assessed using longitudinal axis CT.

Only three patients progressed to union of the scaphoid and four required a salvage operation for a symptomatic nonunion. The remaining four patients with a persistent nonunion are asymptomatic with low pain scores, good grip strength and a functional range of wrist movement.

Although this technique has potential technical advantages over vascularised pedicled bone grafting, the rate of union has been disappointing and we do not recommend it as a method of treatment.

Retrospective Review of 234 Scaphoid Fractures and Nonunions Treated with Arthroscopy for Union and Complications

The purpose of this paper is to retrospectively review 234 consecutive cases of scaphoid fractures and nonunions treated using arthroscopy with the dorsal percutaneous implantation of a headless compression screw for healing and complications. Solid union of fracture is determined by CT scan. We identified 126 acute injuries, including 65 proximal pole fractures; 67 grossly displaced fractures; 12 trans-scaphoid perilunate dislocations including four trans-scaphoid trans-capitate fractures; and ten combined scaphoid and distal radius fractures. 108 scaphoid nonunions were identified. 98 were correctly aligned and ten had a humpback deformity which was correctable using arthroscopic assisted reduction techniques at the time of surgery. 82 presented with a fracture gap 2mm or greater requiring percutaneous bone grafting. 12 cases of avascular necrosis (AVN) were identified by MRI. 20 nonunions had surgery performed at other institutions. The mean time to surgery for the nonunions was 20 months.

99% union rate of acute scaphoid fractures was obtained by 12 weeks, as determined by CT scan. Two complications were identified (3%). One case of delayed healing was identified. This delayed union was treated with percutaneous bone grafting and continued on to heal uneventfully. The other complication was a case of volar trans-scaphoid peri-lunate dislocation. While the fracture healed, the patient developed a traumatic dislocation requiring a capitate-lunate arthrodesis. Treatment of scaphoid nonunions resulted in ten cases of delayed healing, which were treated with repeat percutaneous bone grafting. This represented a 9% complication rate. Of the ten cases of delayed unions that were re-bone grafted, four failed to heal by nine months. This resulted in a 96% union rate of our nonunion group by nine months. When acute fracture healing was compared to nonunions the average healing of acute fractures as determined by CT scanning measuring trabecular bridging was 12 weeks, while the average healing of nonunions was 22 weeks. We conclude that the dorsal percutaneous treatment of scaphoid fractures and nonunions using arthroscopy is safe and effective. CT scans to evaluate scaphoid healing by measuring trabecular bridging at the fracture site was determined to be an excellent modality to evaluate scaphoid healing. While not witnessed in this series, the potential for complications requires proper training.

Long-term results of scaphoid nonunion treated by intercalated bone grafting and Herbert's screw fixation--a study of 49 patients for at least five years

The objective of this article is to report our clinical experience in the treatment of patients with scaphoid nonunion using intercalated bone graft and Herbert's screw and the long-term postoperative results with a minimum of five years of follow-up. We retrospectively reviewed 49 patients treated with carved intercalated bone graft and Herbert's screw fixation from September 1987 to June 2001. Preoperative clinical manifestations and postoperative results were assessed by radiography, and functional results, including grip force, range of motion of the wrist joint, and Cooney's scoring chart, were evaluated. The union rate was 93.9%. The average grip power, as well as wrist flexion and extension were significantly improved. Using Cooney's scoring system, 29 patients were rated excellent and 17 good. For successful union, anatomical reduction with carved intercalated bone grafting and Herbert's screw fixation is definitely a reliable option. This method leads to a satisfactory long-term functional outcome.

Vascularised bone grafting in the management of scaphoid non-union - a review of 34 cases

We reviewed the outcomes of 34 patients who had undergone vascularised bone grafting for a chronic scaphoid non-union. Mean age was 27 years (range 16-46 years). The dominant hand was involved in 17 cases. Eleven patients were smokers. In 18 cases the fracture involved the proximal and in 16 cases the middle third of the scaphoid. In 26 patients the proximal scaphoid fragment was deemed avascular. Sixteen patients had previously undergone scaphoid fixation and non-vascularised bone grafting. At a follow-up of 1 to 3 years (mean 1.6 years), 15 of the 34 scaphoid non-unions had united. Injury to the dominant hand and duration of the non-union significantly increased the risk of failure. Persistent non-union was more common in proximal third fractures and in the presence of an avascular proximal pole but these findings did not reach statistical significance.

A comparative analysis of the accuracy, diagnostic uncertainty and cost of imaging modalities in suspected scaphoid fractures

INTRODUCTION

Clinical examination of suspected scaphoid fractures is sensitive, but not specific, and initial plain radiographs lack sensitivity. A variety of second-line imaging techniques have been proposed to improve immediate diagnosis and reduce overtreatment. Different sample populations and methods of reporting test performance have made side-by-side comparison difficult. The aim of this study is to describe the epidemiology of clinically suspected scaphoid fracture and determine the prevalence of true fracture. These data are used to compare second-line imaging techniques in our population.

PATIENTS AND METHODS

200 consecutive patients attending a trauma service with clinically suspected scaphoid fracture were followed through diagnosis to discharge.

RESULTS

The prevalence of true fracture was 16% and was associated with male sex and injury playing sport. Magnetic resonance imaging has the best diagnostic performance, with the added benefit of soft tissue evaluation, but was the most expensive option. Ultrasound examination was least effective in detecting true fractures.

CONCLUSIONS

Future studies should further evaluate the clinical and economic sequelae of overtreatment of suspected fractures. Clinicians should examine alternatives to "empirical" treatment without definite diagnosis based on their local facilities and patient demographics.

The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid

This study identified variables which influence the outcome of surgical management on 126 ununited scaphoid fractures managed by internal fixation and non-vascular bone grafting. The site of fracture was defined by a new method: the ratio of the length of the proximal fragment to the sum of the lengths of both fragments, calculated using specific views in the plain radiographs. Bone healing occurred in 71% (89) of cases. Only the site of nonunion (p = 1 × 10−6) and the delay to surgery (p = 0.001) remained significant on multivariate analysis. The effect of surgical delay on the probability of union increased as the fracture site moved proximally. A prediction model was produced by stepwise logistic regression analysis, enabling the surgeon to predict the success of surgery where the site of the nonunion and delay to surgery is known.

Management of scaphoid nonunions

Scaphoid nonunions can exist with or without avascular necrosis of the proximal pole, and waist fractures may have an associated humpback deformity. CT best shows the deformity and bone loss, whereas MRI will show avascular necrosis. Operative treatment should be directed at correcting the deformity with open reduction and internal fixation and bone grafting. Vascularized bone grafts should be used in cases of avascular necrosis.

The role of MR imaging in scaphoid disorders

The scaphoid bone of the wrist is one of the most commonly fractured bones in the body. Due to its importance in the biomechanics and functionality of the wrist, it is important to depict and characterize the type of injury. Plain radiographs and scintigraphy may fail to disclose the type and severity of the injury. In patients with normal initial plain radiographs, MR imaging can discriminate occult fractures from bone bruises and may also demonstrate ligamentous disruption. MR imaging can also discriminate the proximal pole viability versus avascular necrosis secondary to previous fracture, which is important for treatment planning. Treatment of non-united fractures with vascularized grafts can be evaluated with contrast-enhanced MR imaging. Idiopathic osteonecrosis or Preiser's disease was originally described after trauma. The non-traumatic disorders of the scaphoid include post-traumatic osteoarthritis, inflammatory bone marrow edema in patients with rheumatoid arthritis, and osteomyelitis. MR imaging is helpful in all the above disorders to demonstrate early bone marrow edema, cartilage degeneration and associated subchondral marrow changes. The most commonly found tumors in the scaphoid are usually benign and include enchondroma, osteoblastoma and osteoid osteoma. MR imaging is not mandatory for the initial diagnosis, which should be based on plain X-ray findings.

Scaphoid nonunion treated with vascular bone grafts pedicled on the dorsal supra-retinacular artery of the distal radius

BACKGROUND

Nonunion and avascular necrosis (AVN) are frequent complications of scaphoid fractures. We describe the operative technique and long-term results of treatment with pedicle vascularized bone grafts (VBGs) of the distal radius in patients with scaphoid fractures in whom nonunion and AVN developed.

METHODS

During a 4-year period (1997-2000), VBGs pedicled on either the first and second or second and third compartments of the supraretinacular artery of the distal radius were in our hospital used to treat 11 patients with symptomatic scaphoid nonunion involving AVN of the proximal fragment (one with perilunate transscaphoid fracture dislocation and 10 with displaced scaphoid fractures with nonunion). Nine of these 11 patients received fixation with divergent K-wires fixation and two received Herbert screws fixation.

RESULTS

Osseous union was achieved in all 11 patients treated with VBGs within an average period of 13 weeks. Functional results of treatment, which were measured using the modified Mayo Wrist Score, were encouraging in all patients in this series (four excellent, six good, and one fair). The deformity of ununited scaphoid was well corrected.

CONCLUSIONS

The index study suggests that this treatment can be used not only to revascularize necrotic scaphoid, but also to correct humpback deformity and the resulting carpal instability.

Scaphoid fractures and nonunions: diagnosis and treatment

BACKGROUND

Scaphoid fractures are commonly seen in orthopedic practice. An organized and thoughtful approach to diagnosis and treatment can facilitate good outcomes. However, despite optimal treatment, complications may ensue. In the setting of nonunion or an avascular proximal pole, vascularized bone grafting may be needed.

METHODS AND RESULTS

In this article we review the literature regarding these injuries and describe an approach to diagnosis, treatment, and management of scaphoid fractures and nonunions.

CONCLUSION

Scaphoid fractures and nonunions may present as challenging problems in practice, but a systematic and deliberate approach can facilitate optimal results.

The effect of intermittent pneumatic compression on fracture healing

OBJECTIVES

Continuously increased venous pressure has been shown to enhance bone growth, stimulate fracture healing, and prevent bone loss, but also causes soft-tissue breakdown as a result of chronic edema. This study was designed to test the hypothesis that intermittently increased venous pressure improves fracture healing without injuring soft tissue.

DESIGN

An ostectomy was created in the right radius of 30 skeletally mature male beagles. On postoperative day 7, a pneumatic cuff was placed around the forelimb of each dog. In experimental animals (n = 13), the cuff compressed for 5 minutes followed by no compression for 2.5 minutes. This cycle was repeated 100 times per day for 8 weeks. Control animals (n = 15) wore a nonfunctional cuff. Fracture healing was assessed with dual-energy x-ray absorptiometry, histologic analysis, and biomechanical testing.

RESULTS

No soft-tissue complications were noted. Bone mineral content at the ostectomy increased significantly more in the experimental group than in the control group (P < 0.05). Histology revealed that the bone defects in the experimental group were significantly more healed than those in the control group (P < 0.005). No differences were noted between groups in the biomechanical properties of the healing bones.

CONCLUSIONS

Intermittently increased venous pressure proximal to a bone defect seems to enhance the formation of new bone without soft-tissue complications. These findings can potentially be applied to the clinical treatment of "difficult to heal" fractures. Further work is necessary to determine the most effective ratio of the presence and absence of pneumatic compression.

Thumb metacarpal vascularized bone graft in long-standing scaphoid nonunion--a useful graft via dorsal or palmar approach: a cohort study of 24 patients

PURPOSE

Long-standing scaphoid nonunion preferentially is treated by using a vascularized bone graft because of its superiority in achieving bone healing. In the present study nonunion was repaired using a bone graft raised from the thumb metacarpal and vascularized by the first dorsal metacarpal artery.

METHODS

Twenty-four patients with scaphoid nonunion for longer than 5 years, without ligament injuries and panarthrosis, had surgery. According to the location of the nonunion and presence of dorsal intercalated segment instability deformity, surgery was performed by either a dorsal or palmar approach. The patients had a final clinical and radiographic evaluation 12 months after surgery.

RESULTS

Complete healing was shown in 21 patients but incomplete healing was observed in the remaining 3 patients. After surgery patients had marked pain relief, with an improved range of motion and grasping strength. Anatomic restoration of carpal angles and scaphoid length was observed. None of the patients required additional surgery. Before surgery 15 patients presented radiographic signs of wrist arthrosis. During surgery, however, cartilage erosion on the proximal pole or on the radius articular surface was not confirmed. Despite the presence of radiographic arthrosis, wrist symptoms, motion, and grasping strength improved after surgery.

CONCLUSIONS

Long-standing scaphoid nonunion, even in the presence of limited arthrosis, can be treated with surgery and healing promoted by a vascularized bone graft. Because of its versatility for use by dorsal or palmar approach and reliability, the first dorsal metacarpal artery vascularized bone graft represents our method of choice.

Valeur de l’IRM dans l’évaluation du potentiel de guérison des pseudarthroses du scaphoïde traitées par greffe osseuse

PURPOSE

To determine the accuracy of MR imaging in predicting bone graft healing in patients with scaphoid non-union.

MATERIAL AND METHODS

21 patients with scaphoid non-union were examined with MR imaging prior to bone grafting (conventional bone graft in 14 cases and vascularized bone graft in 7 cases). The protocol included unenhanced and Gadolinium-enhanced sequences. Signal intensity and homogeneity of the proximal fragment was analysed by two independent radiologists. MRI findings were then correlated to the postoperative rate of union.

RESULTS

Healing occurred in 17 cases and failed in 4 cases with a mean follow up of 14 months. Intraobserver agreement in MR reading was respectively 0.92 et 0.86. Interobserver agreement was 0.88. On Tl-wi, the proximal fragment was hyperintense in 1 case (with positive surgical result), heterogeneous low signal intensity in 7 cases (healing in n = 7) and homogeneous low signal intensity in 13 cases (healing in n = 9). On T2-wi, the proximal fragment was hypointense in 4 cases (healing in n = 3), homogeneous high signal in 5 cases (healing in n = 4) and heterogeneous high signal intensity in 12 cases (healing in n = 10). After Gadolinium injection, enhancement was homogeneous in 4 cases (healing in n = 4), heterogeneous in 8 cases (healing in n = 7) and absent in 9 cases (healing in n = 6). In the group with no enhancement, 5 patients were treated with vascularized bone graft (healing in n = 4) and 4 with conventional bone graft (healing in n = 2).

CONCLUSION

The absence of enhancement of the proximal scaphoid fragment leads to poor surgical results except for vascularized bone graft.

Scaphoid nonunion: diagnosis and treatment

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the anatomy and pathophysiology of scaphoid fractures. 2. Understand the risk factors for scaphoid nonunion. 3. Identify treatment options for scaphoid nonunion and their respective advantages and disadvantages. 4. Identify salvage procedures for scaphoid nonunion advanced collapse of the wrist. Scaphoid nonunion is a common but difficult problem for hand surgeons. The diagnosis of scaphoid nonunion is often delayed, and therefore, treatment must be tailored to the type of fracture, the duration of nonunion, and the presence or absence of resulting arthritis. This article reviews the diagnosis and work-up of scaphoid nonunion, classification schemes for scaphoid nonunion, and various treatment options, including internal fixation, nonvascularized and vascularized bone grafting, and salvage procedures.

Percutaneous internal fixation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach

BACKGROUND

Preliminary reports have indicated that selected scaphoid nonunions-i.e., those that are well aligned and without extensive sclerosis or bone resorption at the nonunion site-can be treated effectively with internal fixation alone. We examined the feasibility of percutaneous fixation in a series of such nonunions.

METHODS

A consecutive series of fifteen patients with fibrous union or nonunion of a carpal scaphoid fracture with minimal sclerosis or resorption at the nonunion site were treated with rigid fixation alone (without bone graft) with a headless compression screw inserted with a dorsal percutaneous technique.

RESULTS

Clinical examination, standard radiographs, and computed tomography scans confirmed union in all patients at an average of fourteen weeks. Nonunions treated less than six months after the injury healed faster than those treated later (p < 0.02). According to the Mayo modified wrist score, there were twelve excellent and three good results.

CONCLUSIONS

The results in our series were due to careful examination and grading of the scaphoid nonunions preoperatively. The findings in this small series support the observation in earlier reports that percutaneous repair of selected scaphoid nonunions requires only rigid fixation to achieve healing.