- Email: [email protected]
Symptomatic non-union of the carpal scaphoid: Matti-Russe bone grafting versus Herbert screw fixation
164
Injury (1989) 20, 164-166
Rinted in Great Brifuin
Symptomatic non-union of the carpal scaphoid: Matti-Russe bone grafting versus Herbert screw fixation R. W. Parkinson Royal Preston Hospital, Preston, Lancashire J.
P. Hodgkinson
Ancoats Hospital, Manchester
E. J. Hargadon Park Hospital, Davyhulme,
Manchester
We have reviewed 19 patienfswho have hadA&f-Ruse bone grafing and 16 pufienfs who have had Herberf screzu fixafion forsympfomafic non-union of fhe caTa scaphoid. The success rate in both groups was similar, 74 per cent in fhe Muff-Rme group and 71 per cent in the Herbert screw group. Only five patients in the Herberf screw group had bone grafis. The advantages and dkufvanfages of both methods of fmfment are dimssed.
Introduction The most common fracture of the carpal bones is a fracture of the carpal scaphoid. The reported non-union rate in those receiving initial conservative treatment is difficult to determine and varies between 3 per cent and 50 per cent (Leslie and Dixon, 1981; Herbert and Fisher, 1984). Many methods of treatment for non-union of the carpal scaphoid have been described: bone grafting (Russe, 1960); screw fixation (Maudsley and Chen, 1972); pulsed electromagnetic field and cast (Frykman et al., 1986); percutaneous pinning (Cosio and Camp, 1986); and Herbert screw fixation (Herbert and Fisher, 1984). Two of the commonest methods of treatment are Mat+Russe bone grafting and Herbert screw fixation, and this paper compares these two surgical treatments from two district general hospitals in the NorthWest Region.
Materials and methods Two groups of patients with symptomatic non-union of the carpal scaphoid were evaluated. The first group of 19 patients from Park Hospital, received Matti-Russe bone grafting. The second group of 16 patients from the Royal Preston Hospital, received Herbert screw fixation. Both groups were of similar age and sex distribution (Table I). 0 1989 Butterworth & Co (Publishers) Ltd OOZO-1383/89/030164-03
$03.00
Table I. Comparing two groups of patients
Number of patients Number of fractures Average age (years) Age range (years) Number of males Dominant hand Date of operation Average time between fracture and operation (months) Average follow-up (months)
Mat&Russe
Herbert screw
19
16 17 26.7 19-41 15 15 1994-l 987 10.1
Es 15& 17 16 1971-l 983 9.5 55
14.6
In both groups, the only indication for surgical treatment was a painful, unstable non-union. Patients who had radiological evidence of non-union but who were asymptomatic were not offered an operation. The first group of patients underwent bone grafting, using a slightly modified Russe technique (Russe, 1960). Through an anterior incision the fracture site was identified and both poles cavitated with a dental burr. Bone graft was inserted from the ipsilateral iliac crest and the wrist immobilized in plaster for a minimum of 12 weeks postoperatively. All patients were operated on by the senior author (EJH). This group of patients was treated between 1971 and 1983, when Matti-Russe grafting was the only technique used in the hospital to treat scaphoid non-union. Three patients with fracture-dislocations of the scaphoid were treated with bone grafting and K-wire fixation, but are excluded from this series. The second group of patients underwent Herbert Screw fixation as described by Herbert and Fisher (1984). Bone graft was used in five cases. Where bone graft was used in the Herbert screw group, it was taken from the ipsilateral distal radius. An anterior incision was extended proximally
Parkinson et al.: Non-union
of the carpal scaphoid
165
in the line of flexor carpi radialis and dissection deepened to the radius. Pronator quadratus was reflected from its insertion, and a cortico-cancellous bone graft was taken from the radial styloid. Suction drainage was not used. The wrist was splinted with a plaster slab for an average of 2.7 weeks postoperatively. The patients were under the care of four senior orthopaedic surgeons and were operated on either by these surgeons or under their direct supervision. This group of patients was treated between 1983 and 1987,1983 being the year the Herbert screw system was introduced to the hospital. During this time symptomatic scaphoid non-union was treated exclusively by Herbert screw fixation. There were no fracturedislocations in this group. All patients were reviewed personally by two of the coauthors (RWP and JPH). Specially designed forms were used to record information on patients included in this trial. Clinical examination included measurement of wrist movement in all four directions and assessment of hand grip and pinch grip using a dynamometer. These measurements were compared with the opposite normal side and used to assess overall function of the wrist.
Results The type of scaphoid fracture was classified as described by Herbert and Fisher (1984). A type C fracture is delayed union with an unhealed fracture 6 weeks after injury. A type Dl is an established fibrous non-union, a type D2 is an established sclerotic non-union or pseudarthrosis. The injuries are graded in Table II. All patients were assessed and graded according to patient satisfaction, clinical results and radiographic appearance, as described by Herbert (Table m). The results are shown in Table IV. The patients with a grade 0 or I result were considered successful. Therefore 74 per cent of patients in the MattiRusse group and 71 per cent of patients in the Herbert screw group had a satisfactory result. Two patients who had Matti-Russe bone grafts and failed, subsequently had internal fixation using a lag screw. Both patients achieved a grade I result, and one of these patients returned to playing professional football as a goalkeeper.
Table II. Classification of type of fracture in the two groups
Grade C Grade 01 Grade 02
Matti-Russe
Herbert screw
1 16 2
2 11 4
Table IV. Grading of results Grade of result Type of fracture Matti-Russe group Herbert screw group
C D C D
0 1 2 3
Patient satisfaction
Vew happy Asymptomatic Improved Minimal symptoms Unchanged Moderate symptoms Worse Severe symptoms
1
2
3
6
a 1 7
1 4 5
-
:
One patient from the Herbert screw group with a grade 2 result, subsequently had a radial styloidectomy, but this did not improve the condition significantly. No patients had to have the screw removed. Two patients treated by Herbert screw fixation, had previously had Matti-Russe bone grafts. One of these patients had avascular necrosis at the time of screw fixation and eventually had a poor (grade2) result. The second patient refractured the scaphoid after a successful Matti-Russe bone graft, and Herbert screw fixation returned him to a grade 0 result. There was no significant difference in the range of movement in the two groups. Dorsiflexion was reduced by an average of 25” and palmar flexion by 20” in both groups. Ulnar and radial deviation were not significantly reduced in either group. There was also no significant difference in objective grip strength testing between the two groups. There were five patients in each group who had grade 3 (unsatisfactory) results. Exclusively these were patients who had proximal pole fractures or avascular necrosis. There were two patients in the Matti-Russe group who had avascular necrosis and one in the Herbert screw group. Three patients in the Matti-Russe group had a proximal pole fracture and four in the Herbert screw group.
Discussion In this study there was no significant difference in the success rate between the two methods of treatment. There were several advantages of the Herbert screw technique over Matti-Russe bone grafting. The Herbert screw patients were in plaster for less time postoperatively (2.7 weeks compared with 16.4 weeks), and therefore returned to work much sooner (4.6 weeks compared with 20 weeks). Despite the much earlier wrist mobilization in the Herbert screw group, this did not improve the eventual range of movement. Superficially this was disappointing, but when patients were reviewed, it was a feature that many patients had not noticed any stiffness until it was pointed out by the examining clinician. This finding was not confirmed by Warren-Smith and Barton (1988), who found a larger arc of dorsiflexion in their Herbert screw group, despite a much longer period of postoperative plaster immobilization (12 weeks on average).
Table III. Grading of results (Herbert and Fisher, 1984)
Grade
0
Clinical result Normal function Unrestricted use Minimal loss of function Unrestricted use Moderate loss of function Some restriction Marked loss of function Restricted use
Radiographic result Sound union No deformity Apparent union Minimal deformity Doubtful union Marked deformity Non-union Loosening of screw
166
Injury: the British Journal of Accident Surgery (1989) Vol. 20/No.
The Herbert screw group were in hospital for less time, with an average stay of one night compared with three nights for the Matti-Russe group. This may be partially due to the recent trend of early hospital discharge, but it is also related to the site of bone graft. In the Herbert screw group, bone graft, when used, was taken from the ipsilateral distal radius, whereas in the Matti-Russe group it was taken from the iliac crest. It was our impression that it was the painful iliac crest wound that was the main reason for the longer stay in hospital. Five of the Herbert screw group were operated on as day cases, and this obviously has important socioeconomic advantages. There were five patients in each group with grade2 (unsatisfactory) results. These were either patients with established avascular necrosis at the time of surgery, or with proximal pole fractures in whom the vascularity of the proximal pole was inevitably diminished, if not completely absent. Russe (1960) stated that a totally avascular proximal fragment excluded a good result with bone grafting. This point was later reinforced by Green (1985) so these results were predictable. All four proximal pole fractures treated by Herbert screw fixation achieved a grade 2 (unsatisfactory) result, so in this small series internal fixation does not appear to be a satisfactory method of treating these difficult nonunions either. Interpretation of radiographs in the assessment of radiological union is notoriously difficult. Dias et al. (1988) showed that there was poor interobserver agreement and poor reproducibility of opinion of whether union had taken place on radiographs taken 12 weeks after a scaphoid fracture. It would be reasonable to assume that there are similar problems when assessing radiographs taken several months or years after a scaphoid fracture. Although bony union is probably preferable to a sound fibrous union, a satisfied patient and a good clinical result are more important than producing the ‘perfect X-ray’. Herbert recommends the use of a bone graft with screw fixation in all type D2 fractures, but he used a bone graft in only nine of the 38 fibrous non-unions (type DI). Where there is an anterior cortical defect, a bone graft is mandatory to prevent an increase in the flexion deformity of the scaphoid. Only five out of 17 fractures in our Herbert screw group had bone grafts. In the series reported by Ford et al. (1987), 9 out of 18 cases of scaphoid non-union treated by Herbert screw fixation had corticocancellous bone grafts added. In the series reported by Warren-Smith and Barton (1988), all 22 patients had bone grafts added. There is obviously some difference in opinion as to whether supplementary bone graft is needed in cases of simple fibrous non-union. The small numbers in this series make it impossible to draw any firm conclusions, but as nine of the 12 patients who had screw fixation alone had ‘successful results’, it may suggest that bone graft is not necessary in every case. One of the disadvantages of the Herbert screw is the high technical demand of the operation, but once the surgeon has familiarized himself with the instrumentation and the tech-
3
nique, the procedure is usually straightforward. There is also concern about the extensive exposure required to insert the Herbert screw and its long-term effect on articular surface damage and blood supply of the scaphoid. In summary, in this series there is no significant difference in the success rate in the treatment of symptomatic carpal scaphoid non-union, between Matti-Russe bone grafting and Herbert screw fixation. Patients treated by the Herbert screw technique had a shorter stay in hospital and significantly less time off work than the Matti-Russe group.
Acknowledgments We should like to thank Mr D. B. Case, Mr M. R. Wharton, Mr J. C. Faux, and Mr R. B. Smith for allowing us to review their patients, Melvyne Cunliffe for helping with the functional assessment of the patients and Gillian Thompson for her help with typing the manuscript.
References Cosio M. Q. and Camp R. A. (1986) Percutaneous pinning of symptomatic scaphoid non-union. J. find Strrg. IIA, 350. Dias J. J., Taylor M., Thompson J. et al. (1988) Radiographic signs of union of scaphoid fractures. An analysis of inter-observer agreement and reproducibility. 1. BoneJoint Strrg 7OB, 299. Ford D. J., Khoury G., El-Hadidi S. et al. (1987) The Herbert screw for fractures of the scaphoid. J, BoneJoint Sqg. 69B, 124. Frykman G. K., Taleisnik J., Peters G. et al. (1986) Treatment of non-united scaphoid fractures by pulsed electromagnetic field and cast. J hiznd Surg. II& 344. Green D. P. (1985) The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion. J Hand Swg. lOA, 597. Herbert T. J. and Fisher W. E. (1984) Management of the fractured scaphoid using a new bone screw. J. Bone joint Surg. 63B, 114. Leslie I. J. and Dixon R. A. (1981) The fractured carpal scaphoid: natural history and factors influencing outcome. J. Bone Joint Surg. 63B, 225. Maudsley R. H. and Chen C. H. (1972) Screw fixation in the management of the fractured carpal scaphoid. J BoneJoint Surg. 54B, 432. Russe 0. (1960) Fracture of the carpal navicular: diagnosis, nonoperative treatment, and operative treatment. J. Bone]oint Sctrg. 42A. 759.
Warren-Smith C. D. and Barton N. J. (1988) Russe graft vs Herbert screw. J. Hand Surg. 13B, 83.,
Paper accepted 9 January 1989.
Requests for reprints skouM be addressed to: R. W. Parkinson, Orthopaedic Registrar, Orthopaedic Department, Hope Hospital, Eccles Old Road, Salford, M6 8HD.
Injury (1989) 20, 164-166
Rinted in Great Brifuin
Symptomatic non-union of the carpal scaphoid: Matti-Russe bone grafting versus Herbert screw fixation R. W. Parkinson Royal Preston Hospital, Preston, Lancashire J.
P. Hodgkinson
Ancoats Hospital, Manchester
E. J. Hargadon Park Hospital, Davyhulme,
Manchester
We have reviewed 19 patienfswho have hadA&f-Ruse bone grafing and 16 pufienfs who have had Herberf screzu fixafion forsympfomafic non-union of fhe caTa scaphoid. The success rate in both groups was similar, 74 per cent in fhe Muff-Rme group and 71 per cent in the Herbert screw group. Only five patients in the Herberf screw group had bone grafis. The advantages and dkufvanfages of both methods of fmfment are dimssed.
Introduction The most common fracture of the carpal bones is a fracture of the carpal scaphoid. The reported non-union rate in those receiving initial conservative treatment is difficult to determine and varies between 3 per cent and 50 per cent (Leslie and Dixon, 1981; Herbert and Fisher, 1984). Many methods of treatment for non-union of the carpal scaphoid have been described: bone grafting (Russe, 1960); screw fixation (Maudsley and Chen, 1972); pulsed electromagnetic field and cast (Frykman et al., 1986); percutaneous pinning (Cosio and Camp, 1986); and Herbert screw fixation (Herbert and Fisher, 1984). Two of the commonest methods of treatment are Mat+Russe bone grafting and Herbert screw fixation, and this paper compares these two surgical treatments from two district general hospitals in the NorthWest Region.
Materials and methods Two groups of patients with symptomatic non-union of the carpal scaphoid were evaluated. The first group of 19 patients from Park Hospital, received Matti-Russe bone grafting. The second group of 16 patients from the Royal Preston Hospital, received Herbert screw fixation. Both groups were of similar age and sex distribution (Table I). 0 1989 Butterworth & Co (Publishers) Ltd OOZO-1383/89/030164-03
$03.00
Table I. Comparing two groups of patients
Number of patients Number of fractures Average age (years) Age range (years) Number of males Dominant hand Date of operation Average time between fracture and operation (months) Average follow-up (months)
Mat&Russe
Herbert screw
19
16 17 26.7 19-41 15 15 1994-l 987 10.1
Es 15& 17 16 1971-l 983 9.5 55
14.6
In both groups, the only indication for surgical treatment was a painful, unstable non-union. Patients who had radiological evidence of non-union but who were asymptomatic were not offered an operation. The first group of patients underwent bone grafting, using a slightly modified Russe technique (Russe, 1960). Through an anterior incision the fracture site was identified and both poles cavitated with a dental burr. Bone graft was inserted from the ipsilateral iliac crest and the wrist immobilized in plaster for a minimum of 12 weeks postoperatively. All patients were operated on by the senior author (EJH). This group of patients was treated between 1971 and 1983, when Matti-Russe grafting was the only technique used in the hospital to treat scaphoid non-union. Three patients with fracture-dislocations of the scaphoid were treated with bone grafting and K-wire fixation, but are excluded from this series. The second group of patients underwent Herbert Screw fixation as described by Herbert and Fisher (1984). Bone graft was used in five cases. Where bone graft was used in the Herbert screw group, it was taken from the ipsilateral distal radius. An anterior incision was extended proximally
Parkinson et al.: Non-union
of the carpal scaphoid
165
in the line of flexor carpi radialis and dissection deepened to the radius. Pronator quadratus was reflected from its insertion, and a cortico-cancellous bone graft was taken from the radial styloid. Suction drainage was not used. The wrist was splinted with a plaster slab for an average of 2.7 weeks postoperatively. The patients were under the care of four senior orthopaedic surgeons and were operated on either by these surgeons or under their direct supervision. This group of patients was treated between 1983 and 1987,1983 being the year the Herbert screw system was introduced to the hospital. During this time symptomatic scaphoid non-union was treated exclusively by Herbert screw fixation. There were no fracturedislocations in this group. All patients were reviewed personally by two of the coauthors (RWP and JPH). Specially designed forms were used to record information on patients included in this trial. Clinical examination included measurement of wrist movement in all four directions and assessment of hand grip and pinch grip using a dynamometer. These measurements were compared with the opposite normal side and used to assess overall function of the wrist.
Results The type of scaphoid fracture was classified as described by Herbert and Fisher (1984). A type C fracture is delayed union with an unhealed fracture 6 weeks after injury. A type Dl is an established fibrous non-union, a type D2 is an established sclerotic non-union or pseudarthrosis. The injuries are graded in Table II. All patients were assessed and graded according to patient satisfaction, clinical results and radiographic appearance, as described by Herbert (Table m). The results are shown in Table IV. The patients with a grade 0 or I result were considered successful. Therefore 74 per cent of patients in the MattiRusse group and 71 per cent of patients in the Herbert screw group had a satisfactory result. Two patients who had Matti-Russe bone grafts and failed, subsequently had internal fixation using a lag screw. Both patients achieved a grade I result, and one of these patients returned to playing professional football as a goalkeeper.
Table II. Classification of type of fracture in the two groups
Grade C Grade 01 Grade 02
Matti-Russe
Herbert screw
1 16 2
2 11 4
Table IV. Grading of results Grade of result Type of fracture Matti-Russe group Herbert screw group
C D C D
0 1 2 3
Patient satisfaction
Vew happy Asymptomatic Improved Minimal symptoms Unchanged Moderate symptoms Worse Severe symptoms
1
2
3
6
a 1 7
1 4 5
-
:
One patient from the Herbert screw group with a grade 2 result, subsequently had a radial styloidectomy, but this did not improve the condition significantly. No patients had to have the screw removed. Two patients treated by Herbert screw fixation, had previously had Matti-Russe bone grafts. One of these patients had avascular necrosis at the time of screw fixation and eventually had a poor (grade2) result. The second patient refractured the scaphoid after a successful Matti-Russe bone graft, and Herbert screw fixation returned him to a grade 0 result. There was no significant difference in the range of movement in the two groups. Dorsiflexion was reduced by an average of 25” and palmar flexion by 20” in both groups. Ulnar and radial deviation were not significantly reduced in either group. There was also no significant difference in objective grip strength testing between the two groups. There were five patients in each group who had grade 3 (unsatisfactory) results. Exclusively these were patients who had proximal pole fractures or avascular necrosis. There were two patients in the Matti-Russe group who had avascular necrosis and one in the Herbert screw group. Three patients in the Matti-Russe group had a proximal pole fracture and four in the Herbert screw group.
Discussion In this study there was no significant difference in the success rate between the two methods of treatment. There were several advantages of the Herbert screw technique over Matti-Russe bone grafting. The Herbert screw patients were in plaster for less time postoperatively (2.7 weeks compared with 16.4 weeks), and therefore returned to work much sooner (4.6 weeks compared with 20 weeks). Despite the much earlier wrist mobilization in the Herbert screw group, this did not improve the eventual range of movement. Superficially this was disappointing, but when patients were reviewed, it was a feature that many patients had not noticed any stiffness until it was pointed out by the examining clinician. This finding was not confirmed by Warren-Smith and Barton (1988), who found a larger arc of dorsiflexion in their Herbert screw group, despite a much longer period of postoperative plaster immobilization (12 weeks on average).
Table III. Grading of results (Herbert and Fisher, 1984)
Grade
0
Clinical result Normal function Unrestricted use Minimal loss of function Unrestricted use Moderate loss of function Some restriction Marked loss of function Restricted use
Radiographic result Sound union No deformity Apparent union Minimal deformity Doubtful union Marked deformity Non-union Loosening of screw
166
Injury: the British Journal of Accident Surgery (1989) Vol. 20/No.
The Herbert screw group were in hospital for less time, with an average stay of one night compared with three nights for the Matti-Russe group. This may be partially due to the recent trend of early hospital discharge, but it is also related to the site of bone graft. In the Herbert screw group, bone graft, when used, was taken from the ipsilateral distal radius, whereas in the Matti-Russe group it was taken from the iliac crest. It was our impression that it was the painful iliac crest wound that was the main reason for the longer stay in hospital. Five of the Herbert screw group were operated on as day cases, and this obviously has important socioeconomic advantages. There were five patients in each group with grade2 (unsatisfactory) results. These were either patients with established avascular necrosis at the time of surgery, or with proximal pole fractures in whom the vascularity of the proximal pole was inevitably diminished, if not completely absent. Russe (1960) stated that a totally avascular proximal fragment excluded a good result with bone grafting. This point was later reinforced by Green (1985) so these results were predictable. All four proximal pole fractures treated by Herbert screw fixation achieved a grade 2 (unsatisfactory) result, so in this small series internal fixation does not appear to be a satisfactory method of treating these difficult nonunions either. Interpretation of radiographs in the assessment of radiological union is notoriously difficult. Dias et al. (1988) showed that there was poor interobserver agreement and poor reproducibility of opinion of whether union had taken place on radiographs taken 12 weeks after a scaphoid fracture. It would be reasonable to assume that there are similar problems when assessing radiographs taken several months or years after a scaphoid fracture. Although bony union is probably preferable to a sound fibrous union, a satisfied patient and a good clinical result are more important than producing the ‘perfect X-ray’. Herbert recommends the use of a bone graft with screw fixation in all type D2 fractures, but he used a bone graft in only nine of the 38 fibrous non-unions (type DI). Where there is an anterior cortical defect, a bone graft is mandatory to prevent an increase in the flexion deformity of the scaphoid. Only five out of 17 fractures in our Herbert screw group had bone grafts. In the series reported by Ford et al. (1987), 9 out of 18 cases of scaphoid non-union treated by Herbert screw fixation had corticocancellous bone grafts added. In the series reported by Warren-Smith and Barton (1988), all 22 patients had bone grafts added. There is obviously some difference in opinion as to whether supplementary bone graft is needed in cases of simple fibrous non-union. The small numbers in this series make it impossible to draw any firm conclusions, but as nine of the 12 patients who had screw fixation alone had ‘successful results’, it may suggest that bone graft is not necessary in every case. One of the disadvantages of the Herbert screw is the high technical demand of the operation, but once the surgeon has familiarized himself with the instrumentation and the tech-
3
nique, the procedure is usually straightforward. There is also concern about the extensive exposure required to insert the Herbert screw and its long-term effect on articular surface damage and blood supply of the scaphoid. In summary, in this series there is no significant difference in the success rate in the treatment of symptomatic carpal scaphoid non-union, between Matti-Russe bone grafting and Herbert screw fixation. Patients treated by the Herbert screw technique had a shorter stay in hospital and significantly less time off work than the Matti-Russe group.
Acknowledgments We should like to thank Mr D. B. Case, Mr M. R. Wharton, Mr J. C. Faux, and Mr R. B. Smith for allowing us to review their patients, Melvyne Cunliffe for helping with the functional assessment of the patients and Gillian Thompson for her help with typing the manuscript.
References Cosio M. Q. and Camp R. A. (1986) Percutaneous pinning of symptomatic scaphoid non-union. J. find Strrg. IIA, 350. Dias J. J., Taylor M., Thompson J. et al. (1988) Radiographic signs of union of scaphoid fractures. An analysis of inter-observer agreement and reproducibility. 1. BoneJoint Strrg 7OB, 299. Ford D. J., Khoury G., El-Hadidi S. et al. (1987) The Herbert screw for fractures of the scaphoid. J, BoneJoint Sqg. 69B, 124. Frykman G. K., Taleisnik J., Peters G. et al. (1986) Treatment of non-united scaphoid fractures by pulsed electromagnetic field and cast. J hiznd Surg. II& 344. Green D. P. (1985) The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion. J Hand Swg. lOA, 597. Herbert T. J. and Fisher W. E. (1984) Management of the fractured scaphoid using a new bone screw. J. Bone joint Surg. 63B, 114. Leslie I. J. and Dixon R. A. (1981) The fractured carpal scaphoid: natural history and factors influencing outcome. J. Bone Joint Surg. 63B, 225. Maudsley R. H. and Chen C. H. (1972) Screw fixation in the management of the fractured carpal scaphoid. J BoneJoint Surg. 54B, 432. Russe 0. (1960) Fracture of the carpal navicular: diagnosis, nonoperative treatment, and operative treatment. J. Bone]oint Sctrg. 42A. 759.
Warren-Smith C. D. and Barton N. J. (1988) Russe graft vs Herbert screw. J. Hand Surg. 13B, 83.,
Paper accepted 9 January 1989.
Requests for reprints skouM be addressed to: R. W. Parkinson, Orthopaedic Registrar, Orthopaedic Department, Hope Hospital, Eccles Old Road, Salford, M6 8HD.