Pearls

• A high index of suspicion of a scaphoid fracture is warranted when a patient presents with the history of wrist pain following a fall on an outstretched hand even, if the radiographs initially appear negative. Very commonly, a patient with a scaphoid nonunion experiences an asymptomatic period (sometimes quite a long period) following his initial recovery from the acute trauma. The patient can present later with the history of the insidious onset of wrist symptoms. Alternatively, the patient can present after another traumatic event (often not even associated with high energy) with the onset of wrist symptoms.

• Useful techniques for identifying the nonunion site include identifying the position of the fracture along the longitudinal axis of the scaphoid from the preoperative radiograph, CT scan, or MRI, and scrutinizing the cartilage for the presence of wrinkling, buckling, or fibrous tissue. If the nonunion site cannot be reliably identified by any of these techniques, intraoperative fluoroscopy can be used to identify the location and a 25-gauge needle can be used to mark the location of the nonunion.

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