Fractures of the carpal (navicular) scaphoid

FRACTURES

OF THE CARPAL

EDWARD K. CRAVENER, M.D.,

P.A.C.S.

(NAVICULAR) AND

DONALD

G.

SCAPHOID

MCELROY,

M.D.

Orthopedic Surgeon, City, County, Benedict MemoriaI, Saratoga and Moses Ludington Hospitals SCHENECTADY,

C

scaphoid fractures are not rare, but their true incidence seems indeterminabIe. Experiences vary: one writer finds an incidence of 8.7 per cent among hand fractures, whiIe a second finds a far Iower incidence. The practitioners among those of youthfu1 activity, or of youth, wiI1 present high rates, whiIe those of a different strata wiI1 find this disorder uncommon. The mechanics of this fracture are disputed, and for this paper we see no advantage in reviewing them. It is sufhcient and necessary to know that we have a fractured carpa scaphoid. An outstretched or dorsiffexed hand, and an intoIerabIe pressure wiI1 bring a fracturing force through the third metacarpa1 and OS magnum onto the immobilized scaphoid. Thus a waist fracture occurs. The extraor intra-articuIar tuberosity fracture is an avuIsion, beautifuIIy exempIified by the diagram iIIustrating the optimum x-ray position in this paper. (Fig. 2.) The scaphoid is not weII-named: the oId name-navicuIar or “boat-shaped”-faiIs to describe its anatomy, for no ffight of imagination wiI1 make this bone Iook Iike a boat. The scaphoid is mereIy an elongated carpa1, angIed in its Iong axis through a few degrees and suppIying most of the keystone of the wrist arch. And in the absence of this arch the wrist is very insecure indeed. SpecificaIIy, the bone consists of a body, a constricting waist, and a tuberosity, named in order from the proxima1 to the *distaI ends. The waist gives insertion to the radiocarpa1 Iigaments and entrance to a varying number of bIood vesseIs. ObIentz and HaIstein (1938) find that 13 per cent have a11 their vesseIs at this constricted area; so fractures above ARPAL

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the IeveI, if we can beIieve the ischemia theory, are destined to nonunion in exactly that number. LutzeIer (rg32), with equa1 emphasis, finds a proxima1 and dista1 bIood suppIy, and no vascuIar reason for nonunion. The five articuIating surfaces of the carpal scaphoid Ieave IittIe room for active osteogenic periosteum and hence IittIe space for cortica1 bone repair. The physioIogic senility of the wrist through its constant activity cannot encourage bone repair. The pecuIiar differentiation of the wrist synovia toward uncontroIIed pannus formation hardIy assists cartiIage restoration or rehabiIitation. In discussing carpal scaphoid fractures, we must first arrive on a common ground. Is the fracture through the tuberosity, the waist, or the body? If it is through the tuberosity we can practicaIIy negIect it, for it wiI1 hea1. If it is through the body it wiI1 not hea easiIy. It is smaI1 wonder that nearIy as many treatments exist for fractured carpa scaphoids as there are carpa scaphoid fractures-and nearIy as many confficting results. If one speaks onIy of tuberosity fractures, a11 resuIts are good; however, here we wiI1 speak onIy of waist or body fractures. Why is this fracture troubIesome, and why is it sIow in heaIing? The theories are here shown-IinaIIy to be forgotten, since a11 we want is a painIess wrist or bone union. The first of the theories is embarrassment of the blood suppIy-Leriche and PoIicard (1928) maintain that this is a requirement of bone union. The next is the interposition of the radiaI-carpa Iigament; Burnett feeIs that Adams is wrong bathing of the in this. The constant

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fracture Iine by the physioIogic Iubricantjoint Auid may contribute to deIayaIthough Johnston is erroneously believed

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Others Ionged “wrist sprains.” be seen on the first x-ray pIate be found onIy after rarefaction LINE

OF

IO I

wiI1 not and wiI1 occurs,

X-RAYS

I

LINE

OF

X-RAYS

If-l

FIG. I. CarpaI region as viewed from paImar side. I, Dark Iine indicates fracture through the tuberosity which heals with IittIe or no treatment 2, Line indicates fracture through the scaphoid waist which may hea with IittIe treatment. 3, Line indicates body fracture which wiII hea only under nearIy idea1 conditions.

to have shown this wrong. Johnston has shown how IittIe the periosteum functions in the scaphoid region. CertainIy, Iack of fixation can be regarded as the Ieast common denominator of a11 nonunions; on this must we pin our faith, and against this must we direct our treatment. If we regard the carpa scaphoid mechanicaIIy, we will see that a great stress is brought in its upper pole. Here the wrist joint pries against the fragment, whiIe the dista1 end of the scaphoid is fixed firmIy between the OS magnum and the radius. Motion, therefore, is most marked in the upper poIe of the scaphoid, and here most nonunions occur. Despite the effect of other and more nebuIous factors, we have one firm beIief: nonunion is predominantIy the resuIt of inadequate fixation, since a11 the mechanisms for nonunion are present in those carpa fractures which always unite -save free mobihty. In treatment, we must first find the fracture. There is no doubt, and we have some proof, that some body carpa fractures spontaneousIy unite. Some cases of heaIing are found at the autopsy tabIe, and some are simply unreasonabIy pro-

B

FIG. 2. A, mechanics of wrist with hand in neutral position. In this position, the scaphoid is so flexed that the fracture Iines overIg each other and may be missed on the x-ray plate. B. oosition of scaohoid with fist clenched. In this’ position, the usua1 scaphoid fracture Iies in the same pIane as the Roentgen rays. By using this position greater chance for fracture demonstration is possibIe. 1

whiIe others wiI1 be suspected Iater by the cystic change which foIIows after impacted or cortica1 scaphoid fractures. We recommend, and have found useful for x-ray diagnosis, the position advocated by Schnek. In this the wrist is dorsiffexed, and the hand puIIed into radia1 deviation. This method exposes the scaphoid in its whoIe Iength, and eIiminates overIying shadows. This we advocate, even if Iocal anesthesia must be used to obtain it. So far, nothing has been said about physica signs of earIy scaphoid fractures. To us they are of IittIe importance, since wrist pain after trauma is an indication for Roentgen examination. Pain in the scaphoid region when the dista1 third metacarpa1 head is tapped, or pain over the snuffbox may indicate fracture, but onIy the Roentgen examination can prove it. Before discussing treatment, we should note the possibIe congenita1 prediIection toward fractures of the carpa scaphoid. Phitzner beIieves this, and we have evidence of this truth, since we know of four

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cases of bilateral fracture of the carpa scaphoid. We must not be misIed, however, by the bogey of bipartite scaphoids or persistent 0s centraIes. AIthough, as we have said, there are nearIy as many treatments of carpa scaphoid fractures as there are fracFracture.......................

I i

j

Ischemia......................

If stopped here nonunion nonunion and

1

1

......

ProIiferation of mesenchyma1 type.. tissues

I

Differentiation ceIIs into. osteobIasts I RecaIcification

of

..

decalcification or degeneration and

Treatment

SpIint

If stopped here fibrous union

. . . . . If stopped here

...... .... .

fibrous union

. If stopped here

fibrous union

I

First Week

I. Tuberosity tures 3. Low waist t”Tes

frac-

Later Weeks

I. Tu berosity

frac-

frac-

Fuse or I. Upper waist fract”IeS t”IeS fuse 2. Upper waist fraca. Body fractures and driI1

.. .

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5. The proxima1 or distal fragments may be removed, or the scaphoid may be entireIy removed. 6. The center of the fractured scaphoid may be scooped out and aIIowed to replace itseIf, during a Iong fixation.

I

DecaIcification.

Fracture

Resect degenerated POP tion

3.

Low waist fractures, if speed is essential

tllres

I. If cystic degeneration or degenerative arthritis A. If arthritis of radiaI articular SUP

II. OutIine of treatment recommended for fractures, oId and new, of the tuberosity, waist, and body of the carpa scaphoid.

CHART

J?

Bony union CHART I. Nonunion, cystic degeneration, absorption, and fibrous union, are shown to be simpIy arrests at certain stages of the norma heaIing processes.

tures, treatment faIIs roughIy into a few categories : I. No treatment save physiotherapy. 2. PIaster fixation in voIar and radia1 ffexion (Speed) ; in voIar and sIight dorsa1 and uInar ffexion (BohIer); in volar and uInar Aexion (Destot) ; in dorsal ffexion to 45 degrees with sIight radia1 deviation (Berlin) ; in 30 to 40 degree extension, with the hand in compIete radial Aexion; and with the thumb in abduction and extension (Soto-Hail). 3. A combination of the above method suppremented by the use of a removable meta or Ieather spIint to continue support and fixation. The time of fixation varies from three weeks to eight months. 4. The fractured scaphoid may be put in pIaster in any of the above positions, and an irritant substance injected into the ancient fracture Iine.

7. The scaphoid may be driIIed directIy across the fracture Iine, thereby encouraging ingress of new blood vessels. 8. Autogenous bone grafts may be pIaced directIy across the fracture (Smith, Adams). From such a mass of conflicting treatments only confusion can come to the occasiona1 operator. CertainIy there must be some basic truths underIying these various therapies. We firmIy beIieve the folIowing: If the fracture is seen earIy, that is, within the frrst week, and if the break is through the waist or tuberosity, conservative treatment can be tried. CertainIy the number of cures without treatment, or with seemingIy inadequate fixation, confirms this behef. The exact position of this fixation seems to be of IittIe importance, since nearIy every hand position has been successfuIIy used by different operators. It is important, of course, to reduce the fracture if the fragments have been dispIaced (though this is rare), and to hoId them in such position as to prevent further distraction. We feel

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that uInar deviation shouId be avoided in tuberosity fractures, since this seems to be simply a repetition of the origina methods of fracture. Dorsiffexion closes the gap between the fragments, and shouId the wrist become stiffened, aIIows the best working position. We recommend for these reasons the use of dorsiffexion and radia1 deviation. It has never seemed important to us to encIose the thumb, and or the index finger. The foregoing roughIy sums up the so-caIIed conservative treatment. The fracture is heId, in the case of tuberosity fractures, for three weeks in the above position. ShouId the fracture be through the Iow waist, under no circumstances shouId the fracture be removed from fixation in Iess than eight weeks, except after x-ray evidence of bone union. Some men prefer to use a removabIe meta spIint for severa weeks foIIowing the cast’s remova1. The necessity of this can be determined by the Roentgen pIates taken during the sixth, seventh and eighth weeks. So much for the so-caIIed “conservative” treatment, aIthough we shouId Iike to quarre1 with the term “conservative.” If an author means simpIy non-surgical treatment, why not state it as such? Conservative treatment, operative or nonoperative, is that treatment which wiI1 give the patient the best possibIe resuIt in the shortest possibIe time. The above treatments appIy onIy to Iow waist or tuberosity fractures seen within the first week. AI1 high waist or upper body fractures, or any other major fractures of the scaphoid a week or more oId, except those through the tuberosity, faI1 in one cIass, and for these we beIieve onIy one treatment can be safeIy prescribed. Here we may we11 quote Todd: “One fact emerges most cIearIy, nameIy, that a11 methods of Iate treatment are uncertain and unsatisfactory.” This statement, made onIy one year ago, must be given proper weight. The simpIe fixation of Iate or complicated cases cannot be regarded as conservative treatment; this is radicaI treatment, since the results are foreordained to be unsatisfactory.

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In the above cases (i.e., compIicated or ancient fractures) the scaphoid must be exposed surgicaIIy, and an autogenous bone graft passed through from the distal to the proxima1 fragment. LateIy we have modified this by making severa driI1 hoIes in the fragments across the fracture Iine, but pass the graft through onIy one of these. By this method we get good fixation and eIiminate a possible causeof nonunion by enhancing bIood suppIy. The hand is then put up in acute dorsiffexion and radia1 deviation, and is so heId for eight weeks. By this method good resuIts have been obtained in fourteen out of fifteen high carpa scaphoid fractures. OnIy one has shown any residua1 disability. Seven have united by bony union, but by reason of surgica1 abuse of the cartiIage of the radius or because of an undiscovered arthritis present at the time of the operation, one wrist is Iimited to 50 per cent of its motions and is painfu1 on attempted motions beyond those points. Such a fracture, were this cartiIaginous damage and this injury found at the time of this operation, wouId have been better treated by remova of the proximal fragment. In other words, if a degenerative type of arthritis has aIready set in, no bone grafting or driIIing wiI1 restore such a wrist to normal. If one wishes to be absoIuteIy certain of the resuIt in waist fractures, then, even though these are Iess than a week oId, he shouId join the fragments with a bone graft. This gives the patient the best possible chance for recovery. If the fracture is through the body, bone grafting should be done immediateIy. If the fracture is more than one week oId, and is anything but a simpIe tuberosity fracture, bone grafting should be done. For ancient ununited fractures, with a degenerative arthritis, onIy remova of the proximaI fragments wiI1 permit a cure. In a11 other fractures, simpIe fixation wiI1 be suffcient. SUMMARY

I.

It

scaphoid

is intended fractures

in this paper to divide as to age and Iocation,

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i.e., they are either Iess or more than one week old-and fractured through the tuberosity, the waist, or the body, and are or are not the site of a degenerative arthritis. 2. A reIiabIe and positive x-ray method for detecting these fractures is shown. 3. We advise pIaster or spIint fixation onIy in tuberosity fractures, regardIess of duration. 4. In low waist fractures, we advise or toIerate pIaster or spIint fixation in those Iess than one week oId. 5. DriIIing and bone pegging are used in a11 high waist and body fractures regardiess of age-unIess degenerative arthritis has aIready set in. 6. Resection of the degenerated fragment is done in those fractures aIready afllicted by degenerative arthritis. 7. FinaIIy, in any case of fractured carpa1 scaphoid, when speed and assurance of a good resuIt are necessary (except in, those fractured through the tuberosity or those who have aIready deveIoped a degenerative arthritis), we unquaIifiedIy advise bone driIIing and grafting of the affected carpa1. REFERENCES (ArticIes cIassified by subject predominance) Treatment ADAMS, J. D., and LEONARD, R. D. Fracture of carpa scaphoid; new method of treatment with report of one case. New England J. Med., 1~8: 401-404 (April 12) 1928. ALEMAN, 0. Ein Beitrag zur BehandIung der Fractura ossis navicuIaris carpi. Acta cbir. Scandinau., 80: 217-237. ‘937. BELOT, M. Traumatismes carpiens successifs. Malacie et fracture secondaires du scaphoide (maladie de KahIer-Mouchet). Rev. d’ortbop., 19: 553-557 (Sept.-Oct.) 1932. BERGERHOFF,W. Fraktur des OS navicuIare manus sin. oder angeborene MissbiIdung. Rhtgenpraxis, 7: 544-546 (Aug.) 1935. BERLIN, D. Position in treatment of fracture of carpa scaphoid. New England J. Med., 201: 574-579 (Sept. rg) 1929. BIANCHERI, T. M. Le Iesioni traumatiche de1 carpo. Cbir. d. org. di movimento, 4: 347-392, rgzo. BIZARRO, A. H. TraumatoIogy of the carpus. Surg., Gynec. & Obst., 34: 574-588, 1922. BLENCKE, H. Bruch des Kahnbeines der rechten Hand durch faIsches Abwehren eines FussbaIIese. Sportmedizin, I: rg (May) 1929.

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BOEREMA, I. ijber die Pseudarthrose des OS naviculare manus. Arch. j. ortbop. u. Unfall-Cbir., 38: 42-53, 1937. BONNET, G., and SARROSTE, J. Les sCqueIIes de la fracture du scaphoide carpien (fracture du gymnaste) (d’aprb 16 observations, suivies d Iongue &ch&ance). Rev. de cbir., 50: 267-296 (April) 193 I. BORDONA, J. M. S., and LOPE. DE LA GARMA, F. Consideraciones sobre veinticinco cases de fractura de1 Escafoides Carpiano. Progresos de la clin., 41: log-1 17 (Feb.) 1933. BFUNDIS, W. ubersehener Kahnbeinbruch. Med. Klin., 25: gg3 (June 21), 1929. BRODERSEN, N. H. Treatment of fracture of carpa scaphoid by Biihler’s method. Norsk mag. j. laegeuidensk., 92: 145-147 (Feb.) 1931. BROWN, K. P. Fracture of navicular. Brit. M.J., I: 591-592 (ApriI 7) 1928. BURNETT, J. H. Fractures of carpal scaphoid. New England J, Med., 200: 126-127 (Jan. 17) 1929. BURNETT, J. H. Fracture of the (navicuIar) carpa scaphoid. New England J. Med., 21 I : 56-60, (July 12) 1934. BURNETT, J. H. Fracture of the scaphoid. Surg., Gynec. & Oh.,

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‘935. BURNETT, J. H. Further observations on treatment of fracture of carpa scaphoid (navicular). J. Bone ti Joint Surg., 19: Iogg-1 Iog (Oct.) 1937. CAULI, G. Lesioni traumatiche de1 carpo (contribute casistico). Riu. ospedal., g: 521, Igrg. c HARBONNELand LAFARGUE.Trois cas de traumatismes fermes du carpe. J. de r&d. de Bordeaux, I : 19, 1920. CHRISTOPHER, F. Fracture dislocation of right carpus. S. Clin. North America, 15: 597-599 (June) 1935. CLERY, A. B. Fracture of scaphoid with dorsal disIocatidn of distal fragment df that bone and of distal carpa row. Irish J. M. SC., pp. 372-373 (Aug.) 1926. CODMAN, E. A., and CHASE, H. M. The diagnosis and treatment of fracture of the carpa scaphoid and disIocation of the semilunar bone; with a report of 30 cases. Pub. Mass. Gen. Hosp., rgo6. COLE, W. H., and WILLIAMSON, G. A. Fractures of the carDa navicular bone. Minnesota Med., 18: 81-83 (Fib.) 1935. CORNEJO SARAVIA, E. Fractura de1 escafoides. Bol. y. trab. de la Sot. de cir. de Buenos Aires, 14: 821-829 (Oct. 29) 1930. CRAVENER, E. K. Fracture of (navicuIar) carpal scaphoid. New York State J. Med., 35: 807-809 (Aug. 15) 1935. CROS, J. M. Contribution B I’Ctude des fractures isoIkes du scaphoide carpien. Paris, 1930. DARIAUX, A. Luxation du semi-Iunaire et fracture du scaphoide. J. de radiol. et d’klectrol., 14: 457 (Aug.) 1930. DAVIDSON,ARTHUR J., and HORWITZ, M. T. An evaIuation of excision in the treatment of ununited fracture of the carpal scaphoid (navicuIar) bone. Ann. Surg., 108: 291-295 (Aug.) 1938. DEGUELDRE and DUCHENE. Fracture comminutive du scaphoide carpien, Arch. m6d. beiges, 83: 305-309 (May) 1930. ELLIOT, C. C. Fracture of navicuIar bone (scaphoid). J. M. A. South Africa, 3: 403 (July 27) 1929.

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FERGUSON, L. K. Fractures of the carpa scaphoid. S. Clin. Nortb America, 17: 1603-161 I (Dec.) 1937. FERRERO, V. Contributo aIIo studio deIIe fratture isolate de110 scafoide de1 carpo de causa diretta. Cbir. d. org. di movimento, 12: 525-530 (Aug.) 1928. FEUTELAIS, P. Fracture du scaphoide carpien d’apparence spontanee. Rev. d’ortbop., Ig: 230-236 (MayJune) 1932. FORSTER, A. Le scapho-semi-Iunaire. Etude comparative de la stabibsation du carpe chez Ies mammif&es et chez l’homme. Arch. d’anat., d’bistol. et d’embryol., x5: 81-217, 1932. FOUCALT, P. Les Iesions du carpe au tours des traumatismes du poignet. Arch. mkd. cbir. de Provence, 14: 313-319, 1924. FROSCH, L. Beitriige zu den Frakturen des OS naviculare manus, Verbandl. d. deutscb. ortbop. Gesellsch., 25: 189-192, 1931. GABRIELLE. H. Fracture du scaphoide avec disIocation du carpe et fracture bi-styloidienne. Lyon cbir., 26: 753-755 (Sept.-Oct.) 1929. GOLD, E. Zur Frage der konservativen Behandhmg der intraartikuliiren Briiche des OS naviculare carpi. Beitr. z. k/in. Cbir., 140: 215-258, 1927. GRACE, R. V. Fracture of carpa scaphoid. Ann. Surg., 89: 752-761 (May) rgzg. HARILD, S. IsoIated fracture of carpal scaphoid. Ugesk. j. laeger., 92: 545-548 (June 5) 1930. HARTMANN. Fracture de scaphoide et phenomenes d’arthrite chronique de poignet. Rev. gbn. de clin. et de tbtrap., 41: 133 (Feb. 26) 1927. oder operative HIRSCH, MAXIMILIAN. Konservative Therapie der Fraktur des OS navicular carpi. Wien. med. Wcbnscbr., 85: 803-804 (July 13) 1935. Comment by B8hIer. Wien. med. Wcbnscbr., 85: 10851086 (Sept. 28) 1935. Reply by Hirsch. Wien. med. Wcbnscbr., 85: 1086 (Sept. 28) 1935. HIRSCH, M., and GOLDHAMMER,K. Beitrag zur Frage der Heilungsmijglichkeiten des Kahnbeinbruches. AnatomischrBntgenoIogische Studie. Arch. j. klin. Cbir., 151: 793-804, 1928. HOFFMEISTER, W. Behandlung von Kahnbeinbrtichen und Pseudarthrosen. Zentralbl. J. Cbir., 61: 2g6o2963 (Dec. 22) 1934. HOOK, F. R., and BOONE, J. D. Fracture of carpa scaphoid. U. S. Nav. M. Bull., 34: 172-181 (April)

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JONCKHEERE, F., and SMETB, W. Traitement

des fractures recentes au scapholde carpien et de Ieurs comphcations. .J. de cbir. et ann. Sot. belge de cbir., 3634: 183-211 (May) 1937. KAISINGER, 0. Ueber sogenannte sekundiire Frakturen und Pseudarthrosen des OS navicurare. Marb., 1935.

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KAPEL, 0. Therapy of ununited fractures of carpal scaphoid bone. Hospitalstid., 75 : 954-958 (JuIy 2 I) 1932. KR.~.JEWSKI,F. Fractures of carpa navicuIar bone. Cbir. narz. rucbu, 5: 45-48 (Jan.-March) 1932. KUEGLE, F. H. Fracture of the carpa scaphoid. Wisconsin M. J., 36: 631-632 (Aug.) 1937. LEAVIW, D. G., and LEAVITT, H. L. CarpaI fracture disIocation. Nortbwest Med., 35: 178-179 (May) 1936, LINDON, L. Certain injuries in the region of the wrist joint. Australas. Nurses’ J., 22: 4.60; 503, 1924. MACMILLAN, FRANCIS B. Injuries to the carpa bones. With particuIar reference to the carpa scaphoid. Am. J. Surg., 42: 633-637 (Dec.) 1938. MAGLIULO, A. Contributo aho studio delIa fratture isoIate ed associate de110 scafoide carpale e Ioro trattamento. Arch. di ortop., 43: 536-572, 1927. MAGLIULO. A. SuIle fratture isolate medio-transversali de110.&afoide de1 carpo con speciale riguardo ai Ioro esiti. Arch. ital. di. cbir., 20: 641-660, 1928. MATTI, H. Uber die Behandlung der Navicularefraktur und der Refractura pateIIar durch Plombierung mit Spongiosa. Zentralbl. f. Cbir., 64: 2353-2359 (Oct. 9) 1937. M~NARD, L. Fracture ancienne partieIIement consoIidee du scaphoide du poignet gauche. Paris mhd., I: 115 (Jan. 29) 1927. MENEGAUX, G. SkmeioIogie des lesions traumatiques du carpe. Presse mkd., 41: gr5-gr6 (June 7) 1933. MININA, R. M. Fractures of navicuIar bone. Sot. krir., pp. 833-836, Nov. I I, 1936. ~IORAES, FERNANDO DE. Fractura do escaphoids carpiano em urn jovende 16 annos. Brasil med., 51: 747-749 (JuIy ro) 1937. MOSELEY, H. F. Non-union of carpa scaphoid. St. Thomas’s Hasp. Rep., I: 178-180, 1936. MOUCHET, A. Fractures isolfes du scaphoide carpien. Presse m6d., 42: 121-122 (Jan. 20) 1934. AIso Gaz. d. asp.. 55: 393-397 (ApriI I) 1934. MOUCHET, A. Fracture du scapholde carpien (douvant &tre prise par une anomalie congenitaIe) (NavicuIare carpi bipartitum). Ann. de mtd. ltg., 16: 307310 (June) 1936. MOUCHET, A. Fracture ancienne du scaphoide carpien meconnue et rCvkIer par un accident recent. Ann. de m6d. Kg., 16: 577-579 (Nov.) 1936. MOUCHET, JEANNE, and MOUCHET, A. Etude chnique therapeutique des I&ions traumatiques du carpe. Bull. mid., 33: 603-605, 1919. MUMFORD, E. B. Fracture of navicuIar (carpal) bone. J. Indiana M. A., 22: 56-58 (Feb.) 1929. MURARD, J. Luxation subtotaIe rCtroIunaire du carpe avec fracture du scaphoide. Intervention sangIante. Resection secondaire totale du carpe. Bull. et mLm. Sot. nat. de cbir., 57: 826-829 (June 6) 1931. MURRAY, D. W. G. Fractures of carpal scaphoid. Canad. M. A. J.. __ 34: 180-182 (Feb.) 10x6. MURRAY, G. Bone-graft for no&&n of carpa scaphoid. &if. J. Surg., 22: 63-68 (JuIy) 1934. MURRAY, G. Bone-graft for non-union of the carpal scaphoid. Surg., Gynec. ti Obst., 60: 540-541 (Feb.) 1935. NEUHBFER, P. Beitrag zur KIinik der Verletzungen im Bereiche des Carpus. Beitr. z. klin. Cbir., 128: 730-753.

1923.

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