Excision of the carpal scaphoid for ununited fractures.

During the last twenty years great progress has been made in the diagnosis and treatment of fractures of the carpal scaphoid. Formerly non-union was the accepted end-result (Jones and Lovett 1923), but union by bone is now obtained in a high proportion of recent fractures. Nevertheless, non-union is still common. Most cases are discovered by chance or because the patient has a second injury. Certainly many patients with non-union have performed strenuous work for many years with nothing more than vague discomfort, and the accidental discovery of non-union does not demand special treatment. It must, however, be regarded as a potential source of trouble for two reasons : first, because of the almost inevitable development of osteoarthritic changes ; and second, and far more important, because of the disastrous effects that often follow a further injury, particularly if arthritic changes are already present. The aggravated traumatic arthritis is seldom relieved by conservative treatment and the capacity of the patient for work may be greatly and permanently diminished. Several observers have reported the results of total excision of the scaphoid (B#{246}hler1929, Aleman 1937-38, Soto-Hall 1948), but the relatively small numbers of cases left no margin to allow for the possibility of unfortunate selection. Hirsch (1935) reported favourably on nine patients, and Davidson and Horwitz (1938) were equally satisfied with the results of eight. All these observers believed that the operation should be done before the development of arthritis, but it must be remembered that arthritic changes are often present when the non-union is first recognised. We consider that total excision of the ununited scaphoid is of considerable value in selected cases.