Partial wrist arthrodesis is a commonly performed procedure for the treatment of posttraumatic wrist arthritis because of its ability to provide pain relief without sacrificing complete wrist motion. The purpose of this study was to evaluate the redistribution of force after four-corner fusion and scaphoid excision, and to correlate the findings with the reported clinical outcomes.
Fifteen cadaveric wrists were used to study the biomechanics of the four-corner fusion. Pressure-sensitive film (super-low-pressure-indicating film—Pressurex, Sensor Products Inc, Madison, NJ) was inserted into the radiocarpal joint. Using the MTS 858 Mini Bionix (MTS System, Eden Prairie, MN), 50-kg loads (220 N) were applied to the wrists before and after simulated four-corner fusion and scaphoid excision. Statistically, we compared the pressure in the normal (intact) wrists versus four-corner fusion and scaphoid excision. The pressure measurements across the scaphoid fossa, lunate fossa, and triangular fibrocartilage complex (TFCC) were compared.
There is a statistical significant difference between scaphoid, lunate, and TFCC mean total force when pre and post-fusion were compared (p = 0.0001). Our study revealed a statistical significant decrease in the mean scaphoid total force after scaphoid excision and four-corner fusion (p = 0.0001). We also found a subsequent increase in mean total force after scaphoid excision and four-corner fusion for the lunate fossa that did not reach statistical significance (p = 0.08), and no difference in load across the TFCC area (p = 0.995).
Our findings suggest that load is preferentially transferred to the radiolunate joint after scaphoid excision with four-corner fusion.
Wrist joint; Arthodesis; Biomechanics; Four-corner fusion
The purpose of this study was to compare the clinical outcome, union rate, and complications of a consecutive series of Scaphoid excision and limited wrist arthrodesis performed by a single surgeon using distal radius bone graft and K-wires or circular plate fixation. A sequential series of ten patients(11 wrists) who were stabilized with temporary K-wires were compared to 11 patients (11 wrists) who were stabilized with a circular plate. Minimum follow-up was 1 year. One patient in the K-wire group was converted to a wrist fusion. Six of the remaining ten patients in the K-wire fixation group and 8 of the 11 patients in the circular plate fixation group returned for the following blinded evaluations: Quick DASH, analog pain scale, range of motion, grip and pinch strength, plain x-ray, and multi-detector computed tomography evaluation. One non-union occurred in the K-wire group. There were no non-unions in the circular plate fixation group. There was no difference in any of remaining measures or rate of complications. This study shows that equivalent results can be obtained using circular plate fixation compared to K-wires when equivalent bone graft source and fusion technique are used. If K-wire removal requires a return to the OR, circular plate fixation is more cost-effective.
Wrist; Arthritis; Limited wrist arthrodesis
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.
Screws with different levels of compression force are available for scaphoid fixation and it is known that the Acutrak screw generates greater compression than the Herbert screw. We retrospectively compared two types of headless compression screw for their effectiveness in the repair of scaphoid nonunion. Twenty-nine cases of proximal scaphoid nonunion were surgically treated with non-vascularised bone graft: the Acutrak screw was used in 17 patients and the cannulated Herbert screw in 12 patients. Wrist range of motion, Mayo wrist score, grip strength and QuickDASH scores were indicators used for the functional evaluation. Radiographic findings were assessed for consolidation of nonunion and signs of arthrosis. The mean follow-up time was 49.2 months (range 12–96). Statistically, there was no significant difference between the Acutrak and Herbert screw types in terms of functional evaluation and time required for consolidation. Greater compression did not influence the functional outcome, consolidation rate or time to consolidation. The need for greater compression in the treatment of proximal scaphoid nonunions is thus questionable because it may increase the risk of proximal fragment communition.
To compare the functional results of carpectomy and four‐corner fusion surgical procedures for treating osteoarthrosis following carpal trauma.
In this prospective randomized study, 20 patients underwent proximal row carpectomy or four‐corner fusion to treat wrist arthritis and their functional results were compared. The midcarpal joint was free of lesions in all patients.
Both proximal row carpectomy and four‐corner fusion reduced the pain. All patients had a decreased range of motion after surgery. The differences between groups were not statistically significant.
Functional results of the two procedures were similar as both reduced pain in patients with scapholunate advanced collapse/scaphoid non‐union advanced collapse (SLAC/SNAC) wrist without degenerative changes in the midcarpal joint.
Arthritis; Degenerative; Wrist injuries; Carpal bones; Arthrodesis; Wrist joint
Scaphoid stress fractures are rare and can be a cause of wrist pain in sportspersons. All the cases reported in the literature have been sportspersons. Missing a scaphoid stress fracture could lead to non-union of the scaphoid and early degenerative arthritis of the radio-carpal joint. This can cause chronic wrist pain and can reduce the career span of a sportsperson. We report a case of non union of a scaphoid fracture in a cricketer possibly secondary to a stress fracture.
If neglected or misdiagnosed, non-union of a scaphoid fracture will almost inevitably progress to radiographic and symptomatic osteoarthritis of the wrist with subsequent morbidity and lifelong disability, especially in young males in which the fracture is more common. Fractures of the scaphoid bone are the most common fractures of the carpus and second in occurrence among fractures of the wrist.
The diagnosis and treatment are not simple. Familiarity with different imaging methods and treatment options is required. The treatment in most cases is conservative and will lead to uneventful union, but an operation may be needed in certain cases primarily and in the treatment of non-union.
The current literature on the diagnosis and treatment of scaphoid fractures is reviewed, and the authors try to make a clear and concise picture of this complex and sometimes controversial field.
Keywords: scaphoid; fracture
Fractures of the scaphoid bone mainly occur in young adults and constitute 2-7% of all fractures. The specific blood supply in combination with the demanding functional requirements can easily lead to disturbed fracture healing. Displaced scaphoid fractures are seen on radiographs. The diagnostic strategy of suspected scaphoid fractures, however, is surrounded by controversy. Bone scintigraphy, magnetic resonance imaging and computed tomography have their shortcomings. Early treatment leads to a better outcome. Scaphoid fractures can be treated conservatively and operatively. Proximal scaphoid fractures and displaced scaphoid fractures have a worse outcome and might be better off with an open or closed reduction and internal fixation. The incidence of scaphoid non-unions has been reported to be between 5 and 15%. Non-unions are mostly treated operatively by restoring the anatomy to avoid degenerative wrist arthritis.
Distal radial fractures are a common type of fracture. In the case of intra-articular fractures, they often result in post-traumatic arthrosis. The objective of this study is to describe a novel alternative to the established salvage techniques for the treatment of post-traumatic arthrosis of the radio-carpal and distal radio-ulnar joints (DRUJ). Six patients with radio-carpal and DRUJ arthrosis were treated with a combined radius, scaphoid, and lunate (RSL) arthrodesis and as a Herbert ulnar head prosthesis. Follow-up consisted of both radiographic and functional assessments. Functional measurements were noted both pre- and postoperatively. No non-union or pseudoarthrosis was seen; neither did any of the ulnar head prostheses show loosening. Clinical examination showed an improvement in strength, pain, and range of movement, as well as a decrease in disability. Combining RSL arthrodesis with a Herbert ulnar head prosthesis, which deals with pain while retaining partial wrist movement, can be an alternative to established salvage procedures.
Wrist; Partial arthrodesis; Endoprosthetics; Post-traumatic arthrosis
We reviewed 12 male patients with scaphoid nonunions treated by open reduction, bone grafting, and internal fixation with biodegradable implants made of self-reinforced poly-l-lactic acid. Mean patient age was 22.5 (20–25) years. Ten patients had type D2 scaphoid nonunions with a fracture line in the middle one third, one patient had type D2 nonunion with a fracture line in the proximal one third, and one patient had type D1 distal one-third fibrous union. The mean wrist score (modified Mayo wrist score) was 20.8 (10–40) preoperatively and improved after 22–80 months (55–90). All nonunions healed, and the mean solid union time was 4.5 (3.5–7) months. We obtained excellent results in five patients, good results in four, fair results in two, and a poor result in one. The results of this study offer a valid alternative in the fixation of scaphoid nonunions. The major advantage of biodegradable materials is to eliminate the requirement for the removal of the fixation material.
The purpose of this review was to assess the current evidence supporting operative fixation versus casting for acute scaphoid fractures through a systematic review and meta-analysis of the literature.
Our search yielded 59 articles that met our inclusion criteria with five studies achieving high, 22 moderate, and 32 low Structured Effectiveness Quality Evaluation Scale scores. Pooled results of the four Sackett level 1 evidence studies showed no significant difference between the operative (114/115, 99%) versus non-operative group (106/112, 95%) (p = 0.07) when the definition of nonunion was based on more definitive criterion versus plain radiographs that may be insufficient to assess bony union. Similar results were found for the Sackett level 2 and 4 articles.
This systematic review reveals that significant weaknesses exist in the literature with respect to the level of evidence and quality of published studies on this topic. Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures.
Acute scaphoid fractures; Systematic review; Treatment scaphoid fractures
Wrist degeneration, resulting from scaphoid nonunion or scapholunate ligamentous disruption, is widely managed with scaphoid excision with four-corner fusion. There are no specific details in the literature regarding “salvage” of nonunion after attempted “four-corner fusions” or the patient outcomes. The purpose of this paper is to present the results of patients who underwent treatment for nonunion after four-corner fusion, the subsequent surgeries done for wrist salvage and the functional results.
We reviewed, retrospectively, 37 patients who underwent limited wrist fusion using circular plate fixation, of which eight cases (22%) went on to nonunion and necessitated revision surgeries with plate exchange and bone graft. (Table 1) Five of eight patients were available to return to the clinic, and the wrist range of motion and the disabilities of the arm, shoulder, and hand (DASH) score were recorded.
The average DASH score was 46 (range, 15 to 60.8). Grip on the affected limb was, on the average, 62% of the contralateral limb. Average arc of wrist motion was 70° (35.7° of flexion and 34.3° of extension). Three of the five patients were laborers, and two returned to the previous employment. The remaining two patients returned to their previous sedentary jobs. All patients reported difficulty with recreational activities involving heavy activity.
Complications of four-corner arthrodesis using circular plate fixation were recorded, revealing a high number of nonunions and hardware failures. All nonunions were salvaged with allograft or autogenous grafting with plate revision; however, the patients did have considerable limitations.
Non-united; Four-corner fusions; Management; Circular plate
Fracture of the scaphoid bone is the most common fracture of the carpus, and frequently, diagnosis is delayed. The unique anatomy and blood supply of the scaphoid itself predisposes to delayed union or nonunion. The Synthes scaphoid screw is a cannulated headed screw, which provides superior compression compared with some other devices used to internally fix scaphoid nonunions. Our aim was to conduct a retrospective study looking at the union rate, time to union, and complications and correlating the outcome of treatment against the delay between injury and surgery and location of the fracture within the bone. This study is a review of a cohort of 30 patients treated with a cannulated Synthes scaphoid screw and corticocancellous bone grafting for scaphoid waist delayed union and nonunion at our center. We achieved 86% overall union rate. The patients with delayed union achieved a 100% union rate. Three out of four patients with persistent nonunion after surgery reported no pain and improved function. The failure rate was 75% in patients who had sustained their fracture more than 5 years previously. Our study demonstrates that delayed union of scaphoid waist fractures and scaphoid waist nonunions present for less than 5 years can be successfully treated by fracture compression and bone grafting.
Scaphoid; Delayed union; Nonunion; Synthes scaphoid screw fixation; Bone graft
The scaphoid bone is the most commonly fractured of the carpal bones. In the Netherlands 90% of all carpal fractures is a fracture of the scaphoid bone. The scaphoid has an essential role in functionality of the wrist, acting as a pivot. Complications in healing can result in poor functional outcome. The scaphoid fracture is a troublesome fracture and failure of treatment can result in avascular necrosis (up to 40%), non-union (5-21%) and early osteo-arthritis (up to 32%) which may seriously impair wrist function. Impaired consolidation of scaphoid fractures results in longer immobilization and more days lost at work with significant psychosocial and financial consequences.
Initially Pulsed Electromagnetic Fields was used in the treatment of tibial pseudoarthrosis and non-union. More recently there is evidence that physical forces can also be used in the treatment of fresh fractures, showing accelerated healing by 30% and 71% reduction in nonunion within 12 weeks after initiation of therapy. Until now no double blind randomized, placebo controlled trial has been conducted to investigate the effect of this treatment on the healing of fresh fractures of the scaphoid.
This is a multi center, prospective, double blind, placebo controlled, randomized trial. Study population consists of all patients with unilateral acute scaphoid fracture. Pregnant women, patients having a life supporting implanted electronic device, patients with additional fractures of wrist, carpal or metacarpal bones and pre-existing impairment in wrist function are excluded. The scaphoid fracture is diagnosed by a combination of physical and radiographic examination (CT-scanning).
Proven scaphoid fractures are treated with cast immobilization and a small Pulsed Electromagnetic Fields bone growth stimulating device placed on the cast. Half of the devices will be disabled at random in the factory.
Study parameters are clinical consolidation, radiological consolidation evaluated by CT-scanning, functional status of the wrist, including assessment by means of the patient rated wrist evaluation (PRWE) questionnaire and quality of life using SF-36 health survey questionnaire.
Primary endpoint is number of scaphoid unions at six weeks, secondary endpoints are time interval to clinical and radiological consolidation, number of non-unions, functional status at 52 weeks and non-adherence to the treatment protocol.
Netherlands Trial Register (NTR): NTR2064
Cavitary-type scaphoid non-unions represent one of the most difficult treatment challenges amongst all scaphoid non-unions as they exhibit bone loss, scaphoid shortening, flexion (‘humpback’) deformity and dorsal intercalated segmental instability (DISI), creating altered carpal mechanics which may proceed to the degenerative changes of scapholunate advanced collapse of the wrist. Our technique and its rationale are presented in the largest-to-date series on cavitary scaphoid non-unions exhibiting DISI.
Our technique for treatment of these cavitary non-unions is presented through a series of 27 patients.
Union was achieved in (26/27) 96% of cases, with no complications. Carpal mechanics was restored, with an average carpal height index of 1.52 ± 0.06, and an average scapholunate angle was 46 ± 9°. Average follow-up was 2.2 years.
In this subset of patients, we believe this technique is less technically demanding than the use of either cortico-cancellous grafts or various compression screws. Our success equals or betters that of other published techniques, with all patients enjoying a full return to work, even in occupations demanding heavy labour. We believe that scaphoid union, coupled with the often difficult restoration of carpal height and intra-carpal angles, has produced very good functional outcomes in the management of these challenging cases.
Scaphoid non-union; Scapholunate angle; Carpal height index; Distal radius cancellous autograft; Kirschner wires
Isolated dislocation of the scaphoid is very rare. A 45-year old male, industrial worker reported two and half months after injury with wrist pain and swelling on the dorsum of left wrist. He was diagnosed as neglected dorsal dislocation of scaphoid. Proximal row carpectomy with capsular interposition was done stabilizing the distal carpus on the radius using Kirschner wires. At-12 months follow-up the patient had good wrist function and was satisfied with the outcome of the treatment. We hereby report this neglected dorsal dislocation of scaphoid in view of rarity and discuss the various options for management.
Neglected scaphoid dislocation; proximal row carpectomy; scaphoid
Scaphoid excision and four-corner fusion is commonly performed to reconstruct advanced scapholunate collapse and scaphoid nonunion with collapse. Metallic plates were introduced for achieving fixation of the four carpal bones. Although the developer reported high rates of fusion, several other early reports of circular plate fixation suggest higher complication rates and inferior outcomes compared with traditional fixation techniques.
To clarify the controversy in the literature we determined the fusion rates, complications, and functional outcomes of patients having circular plate fixation for four-corner fusion.
We retrospectively reviewed 15 patients treated for radioscaphoid arthritis with four-corner fusion using circular plate fixation. The minimum followup was 11 months (mean, 22 months; range, 11–39 months).
Radiographic union was achieved by all 15 patients. There was only one postoperative complication. ROM was 71% and grip strength was 78% of the opposite normal side.
Our results compare favorably with those using traditional fixation techniques. ROM measurements seem superior to those reported in the literature.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
We treated 18 patients with advanced Kienbock's disease surgically. Six had total wrist fusions and 12 had limited carpal fusions. The average age was 39.6 yrs and the average follow up was 61.8 months and 66.8 months respectively. The visual analogue pain scores, the patient satisfaction scores and the SF 12 were better in the total wrist fusion group. The DASH (Disabilities of the Arm, Shoulder and Hand) scores, the range of movement and the grip strengths were better in the limited carpal fusions group but this was not statistically significant. Four patients with limited carpal fusions had a non-union that required revising. We believe that total wrist fusion should be offered earlier to patients with advanced stages of the disease, as there are less surgical failures, more satisfied patients, better post operative pain scores and consistent long-term results with less potential for further deterioration with time as compared to other treatment methods.
Up to 40% of scaphoid fractures are missed at initial presentation as clinical examination and plain radiographs are poor at identifying scaphoid fractures immediately after the injury. Avoiding a delay in diagnosis is essential to prevent the risk of non-union and early wrist arthritis. We demonstrate the use of CT scanning for the early confirmation of a scaphoid fracture.
PATIENTS AND METHODS
We conducted a retrospective, chronological review of patients who attended an upper limb fracture clinic from January 2001 to October 2003 in a small district general hospital. We performed a CT scan on all ‘clinical scaphoid’ patients who had negative plain X-ray films.
Overall, 70% of patients had a CT scan within 1 week of injury and not from date of accident and emergency attendance; 83% of patients had a CT scan within 2 weeks of injury. Of 118 patients identified, 32% had positive findings and 22% of ‘clinical scaphoid’ patients had scaphoid fractures. The proportion of positive findings for an acute scaphoid fracture was 68%. Additional pathologies identified on CT were capitate, triquetral and radial fractures.
Our audit shows that it is practical to perform CT on suspicious scaphoid fractures in a small district general hospital. We identified an extremely high false-negative rate for plain X-rays and demonstrate that the appropriate use of CT at initial fracture clinic attendance with ‘clinical scaphoid’ leads to an earlier diagnosis and reduces the need for prolonged immobilisation and repeated clinical review.
Scaphoid fracture; Computed tomography; Fracture clinic
The purpose of this case series is to identify and illustrate the phenomenon of scaphoid remodeling in skeletally mature subjects following bone grafting for scaphoid nonunion. Nine patients with scaphoid nonunions were treated with interpositional bone grafting (with iliac crest bone graft) and K-wire fixation. The mean length of follow-up was 28.6 ± 9 months. Radiographs and CT scans were reviewed and assessed for degree of union and a qualitative assessment of scaphoid architecture. Following surgery, there was marked distortion of the scaphoid. Once healed, the contour of the scaphoid was still significantly distorted in all nine patients. Remodeling then became evident along the articular surfaces between 8 and 12 months. By 3 years, the scaphoid was completely recontoured and the normal architecture was completely restored in all nine patients. We conclude that the articular surface of the scaphoid remodels over time in skeletally mature subjects.
Scaphoid; Nonunion; Remodeling
The aim of our study was to evaluate clinical, radiological and functional outcomes of selected cases of percutaneous fixation of scaphoid fractures via a dorsal approach. Percutaneous fixation by dorsal approach was done in 32 patients (mean age 32.2 years) involving both fresh and late scaphoid fracture presentations (mean 17 days). Fourteen cases of B1 type, ten cases of B2 and eight cases of C type (Herbert’s classification) were treated. The patients were prospectively followed up clinically and radiologically for a minimum follow-up of 14 months (mean 16 months), and functional outcome and complications were assessed. All fractures united over an average of nine weeks. There was no avascular necrosis or screw cutout with preservation of wrist movement and grip strength. There were no injuries to any at risk anatomical structures. Percutaneous fixation of scaphoid fractures through dorsal approach gives good clinical and functional outcome in acute and chronic scaphoid fractures of B1, B2 and C types (Herbert’s classification).
The ideal treatment of nonunion of the scaphoid remains unresolved and controversial. It was hypothesized that scaphoid nonunion could be treated successfully using a closed-wedge osteotomy of the distal radius which reduces the inclination of the joint surface and decreases the pressure between the radial and scaphoid surfaces with a reduction of the force applied by the styloid process. We present a preliminary report in six patients with nonunion of the carpal scaphoid using this procedure. The main objective of the osteotomy is to achieve fusion, alleviate pain, and improve function.
Materials and Methods
Six closed-wedge osteotomies to reduce the inclination of the distal radial surface were performed in patients with scaphoid waist nonunion and a viable proximal pole, without posttrauma osteoarthritis or with moderate posttraumatic osteoarthritis confined to the radio-scaphoid joint. The present series of six patients (all men) were followed for at least 8 months (mean follow-up 14.2 months, range 8–21 months).
Solid union was achieved in five patients. Postoperatively, three patients were pain-free, two presented mild pain for heavy work, and one had moderate pain. This type of osteotomy reduced the inclination of the joint surface (radial angulation) 6.2° on average. There was an improvement in joint flexion from a preoperative mean of 40° to 52.5° at last follow-up, in extension from 40.8° to 66.7°, in radial deviation from 15° to 22.5°, and in ulnar deviation from 30.8° to 41.7°.
This preliminary study suggests that a closed-wedge osteotomy of the distal radius could be an alternative approach for patients with scaphoid waist nonunion and a viable proximal pole, without posttrauma osteoarthritis or with moderate posttraumatic osteoarthritis confined to the radio-scaphoid joint. The number of cases was small; however, further studies with a much larger series are needed before routine use of wedge osteotomy in scaphoid nonunion can be recommended.
Radius osteotomy; Scaphoid; Nonunion; Carpal collapse
Acute scaphoid fractures are common in active adults and do lead to reasonable time lost to work. One important goal of treatment is early return to work or sport. On this background, the adequate treatment of non-displaced acute scaphoid fractures is still under discussion. The aim of this study is to compare time to return to previous activity level comparing surgical versus non-surgical treatment of non-displaced acute scaphoid fractures.
The study is designed as a non-randomized multiple center cohort study including 12 sites in Germany and Austria. The inclusion period is planned to be 12 months with a follow up of 6 months. Allocation to operative or non-operative treatment is choosen by the patient together with his treating surgeon. The primary outcome is time to return to previous activity level adapted for loading of the wrist in daily life as measured by a newly developed questionnaire (PLDL-wrist). Factors identified a priori to be associated with the outcome, e.g., poverty status, age, education, smoking status, gender, and occupation, are measured to ensure adequate control for their potential confounding effects.
The rationale and the design of a multiple center cohort study are presented. As it is not considered feasible to randomize patients in this study, potential confounding effects need to be controlled adequately.
Post traumatic osteonecrosis of distal pole of scaphoid is very rare. We present a case of 34 years old male, drill operator by occupation with nontraumatic osteonecrosis of distal pole of the scaphoid. The patient was managed conservatively and was kept under regular follow-up every three months. The patient was also asked to change his profession. Two years later, the patient had no pain and had mild restriction of wrist movements (less than 15 degrees in either direction). The radiographs revealed normal density of the scaphoid suggesting revascularization.
Scaphoid; AVN scaphoid; nontraumatic AVN scaphoid
The present study is a review of patients with scaphoid non-unions treated with a dorsal vascularized bone graft. The study highlights a subset of patients incorrectly diagnosed as graft failures.
A retrospective review of patients who received vascularized grafts for scaphoid nonunions was performed over a four-year period. The vascularized graft of choice for this group was the dorsal radial extensor compartment artery.
Five patients from a scaphoid fracture group who were treated with vascularized grafts were diagnosed as being failures (average of five months). None of these patients had tenderness on palpation of the scaphoid, and they were scheduled for revised vascularized grafts. All patients at the time of surgery were found to have healed. These patients were treated with arthrolysis, resulting in healing and full range of motion.
Scaphoid vascularized grafts may have a markedly delayed radiographic healing time. Reoperation to perform secondary vascularized procedures may result in unnecessary surgery. Early imaging following a scaphoid vascularized graft may be inaccurate and may demonstrate a continued nonunion.
Avascular necrosis; Nonunion; Scaphoid; Vascular graft