Surgical treatment of pediatric scaphoid fracture nonunions

Scaphoid fractures in the pediatric population are uncommon but can usually be successfully managed with standard immobilization techniques. However, nonunions of pediatric scaphoid wrist fractures have been reported. We present the treatment and outcome of 13 pediatric scaphoid fracture nonunions in 12 children treated over an 18-year period. The average time elapsed between time of fracture and time of surgery was 16.7 months. Four of the nonunions were treated by using the Matti-Russe procedure, and nine were treated with Herbert screw fixation and iliac crest bone grafting. The average time of follow-up was 6.9 years (range, 2-19 years). All cases went on to clinical and radiographic union. There was no statistically significant difference in range of motion or strength between the operative and nonoperative wrist. Eleven of 12 patients demonstrated an excellent rating based on the Mayo Modified Wrist score. The length of time for postoperative immobilization in the Herbert screw group was significantly less than that in the Matti-Russe group. Currently our standard approach to the treatment of scaphoid fracture nonunions in the skeletally immature patient is the use of the Herbert screw and iliac crest bone graft.     

Comparison of headless screws used in the treatment of proximal nonunion of scaphoid bone

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.     

Perilunate fracture-dislocations of the wrist: comparison of temporary screw versus K-wire fixation

PURPOSE: Temporary intercarpal screw fixation has been suggested as an alternative to temporary K-wire fixation in the treatment of perilunate wrist dislocations. We compared the 2 treatment methods in 2 retrospective cohorts with a null hypothesis that there would be no difference in final wrist motion. METHODS: Eighteen patients with surgically treated perilunate wrist dislocations (9 treated with intercarpal screws, 9 with intercarpal K-wires) were evaluated an average of 44 months after injury. The intercarpal screws were removed an average of 5 months and the K-wires an average of 3 months after the initial procedure. Complications included 3 pin track infections (1 with wrist sepsis), 2 scaphoid nonunions (screw fixation), and 2 patients with loss of reduction (K-wire fixation) treated with repeat surgery. RESULTS: Four patients (2 in each cohort) had wrist arthrodesis with poor results. Among the 14 remaining patients the final flexion arc was 97 degrees for patients treated with screw fixation compared with 73 degrees for patients treated with K-wires. The mean grip strength was 74% (screw fixation) and 67% (K-wire) that of the uninjured arm. According to the Mayo Modified Wrist Score, the functional result was excellent in 1 patient (screw), good in 2 patients (1 each group), fair in 6 patients (3 in each group), and poor in 9 patients (4 screws, 5 K-wire). Seven patients (2 screws, 5 K-wires) had grade 2 or 3 midcarpal arthritis according to the criteria of Knirk and Jupiter, but none had more than mild radiocarpal arthritis. CONCLUSIONS: The results of treatment with temporary screws are comparable to the results of treatment with temporary K-wires. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.     

A capsular-based vascularized distal radius graft for proximal pole scaphoid pseudarthrosis

PURPOSE: To evaluate the clinical results of the application of a capsular-based dorsal distal radius vascularized bone graft in scaphoid proximal pole nonunions. METHODS: Thirteen patients with symptomatic nonunion at the proximal pole of the scaphoid (10 with avascular necrosis) were treated and reviewed retrospectively. The vascularized bone graft was harvested from the distal aspect of the dorsal radius and was attached to a wide distally based strip of the dorsal wrist capsule. It was inserted press-fit into a dorsal trough across the nonunion site after scaphoid fixation with a Herbert screw. RESULTS: After a mean follow-up period of 19 months 10 of the 13 nonunions (8 of the 10 with avascular necrosis) achieved solid bone union. No complications other than the 3 persistent nonunions occurred. CONCLUSIONS: Results of the use of a capsular-based vascularized bone graft from the distal radius for proximal pole scaphoid nonunions compare favorably with the results of pedicled or free vascularized grafts. It is a simple technique that eliminates the need for dissection of small-caliber pedicle or microsurgical anastomoses. No donor site morbidity was observed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Treatment of scaphoid nonunion with 1,2 intercompartmental supraretinacular artery vascularized graft and compression screw fixation

PurposeAim of the present study was to evaluate the clinical, functional, and radiological outcomes of 1,2-intercompartmental supraretinacular artery (1.2-ICSRA) vascularized graft technique together with compression screw fixation for the management of scaphoid nonunions.MethodsA retrospective study was designed to evaluate the medical records of the 21 patients treated with 1,2-ICSRA vascularized graft for established scaphoid nonunion of the waist or proximal pole between 2015 and 2018. Seventeen patients who met the criteria were included in the study. The retrospectively analysed demographic parameters included age, gender, injured hand (dominant/non-dominant), aetiology of the injury, delay between injury and operation, initial treatments following the fracture, tobacco use, and background diseases that may affect healing (diabetes, vasculopathy etc.). Radiological and clinical examinations were routinely performed 2 weeks, 6 weeks, 3 months and 6 months after surgery and during the final follow-up. Postoperative clinical and functional outcomes at the latest follow-up were evaluated by measuring active wrist range of motion, grip strength, Turkish version of Quick Disabilities of the Arm, Shoulder and Hand Questionnare (Quick DASH) and Mayo Wrist scores and comparing them with preoperative values.ResultsAll 17 patients were male with an average age of 26.82 ± 4.08 years (range 20–35 years). The fracture site was located in the scaphoid waist and proximal pole in 5 (29.4%) and 12 (70.6%) patients, respectively. Avascular necrosis was observed in 13 patients (2 at the waist, 11 at the proximal pole). The mean follow-up duration was 18.88 ± 11.98 months (range 6–44 months). No graft extrusion occurred, and no other complication was observed in any of the patients. Amongst the 17 patients, 15 (88.2%) achieved union. The total wrist motions of patients were better postoperatively than preoperatively. However, only improvement in wrist extension was found to be statistically significant. Quick DASH and Mayo Wrist scores of the patients and grip strength were significantly improved postoperatively.ConclusionThe 1,2-ICSRA vascularized graft technique together with compression screw fixation offers an easy and reliable option for the treatment of scaphoid nonunions with a high union rate and good functional and clinical outcomes.Level of Evidence : IV Therapautic     

The treatment of pseudoarthrosis of the scaphoid by bone grafting and three methods of internal fixation.

OBJECTIVES: To measure the rate of union in patients with pseudoarthosis of the scaphoid, treated with trapezoidal bone grafting as outlined by Fernandez and 1 of 3 methods of internal fixation and to compare unions versus nonunions and potential predictors of union to determine if associations exist. DESIGN: A retrospective radiologic study of scaphoid pseudoarthroses. SETTING: Division of Orthopedic Surgery, Ottawa Hospital, General Site, a tertiary care facility. PATIENTS: Thirty-four patients with nonunion of scaphoid fractures, treated between 1990 and 1997, with an average follow-up of 19.8 months. INTERVENTIONS: Trapezoidal bone grafting and internal fixation with Kirschner (K) wires, an AO cannulated screw or a Herbert screw. OUTCOME MEASURES: The time to union of scaphoid pseudoarthroses and predictors of union, including the classification, location of pseudoarthrosis, type of internal fixation and length of bone graft. RESULTS: The results showed a correlation between the classification and location of the fracture as determined radiologically, and the outcome. There was no correlation between the type of internal fixation used and the outcome, or between the length of the bone graft and the outcome. Twenty-three patients had radiologically demonstrated union after a mean time of 8.2 months; 16 of 24 patients achieved successful union when treated with K-wire implants, after a mean time of 7.2 months. CONCLUSIONS: Trapezoidal bone grafting and internal fixation with K wires is a practical technique, classification and location of the fracture notwithstanding. Time to union is long, and the results may be unpredictable. Use of K wires for internal fixation presents the clinician with an alternative to fixation with either the AO cannulated screw or the Herbert screw, and has the advantages of cost, ease of insertion and accessibility. This method may therefore be the treatment of choice in developing countries. Resection of the area of pseudoarthrosis must include all fibrous tissue and sclerotic bone. The length of graft, within the parameters of this study, did not affect the outcome.     

Volar Percutaneous Screw Fixation for Scaphoid Waist Delayed Union

Volar percutaneous cannulated screw fixation of acute scaphoid waist fractures reportedly produces high rates of healing and early return to work, but the method has not been reported for treating scaphoid waist delayed unions. We therefore report the surgical results of percutaneous screw fixation in scaphoid waist delayed union in 12 patients. All patients were male with an average age of 31.1 years. Duration of injury was 12 weeks (range, 6–20 weeks). However, no patient had carpal instability, scaphoid deformity, or avascular necrosis of the proximal fracture fragment. The minimal followup was 12 months (mean, 20 months; range, 12–24 months). Preoperative radiographs showed slight bone resorption at the fracture site in five patients and cyst formation in three patients. A cannulated screw was introduced volarly under image intensifier guidance in all patients. All fractures united uneventfully. At 12 month followups, the flexion and extension arcs of the injured wrist were 94% and 93% of the uninjured wrist. Grip strength averaged 34 ± 3 kg, which was 92% of the grip strength of the uninjured hand. The Mayo Modified Wrist Score was 94 ± 6 points and the Disabilities of the Arm, Shoulder, and Hand score was 9 ± 6 points. Our experience suggests volar percutaneous screw fixation is a reliable method to treat scaphoid waist delayed union.     

Internal fixation of acute, nondisplaced scaphoid waist fractures via a limited dorsal approach: an assessment of radiographic and functional outcomes

PURPOSE: To evaluate the clinical and radiographic outcomes of a consecutive series of patients who had internal fixation of an acute, nondisplaced scaphoid waist fracture via a limited dorsal approach. METHODS: Twenty consecutive patients had surgical fixation of a nondisplaced scaphoid waist (Herbert B2) fracture via a limited dorsal approach. Eighteen patients were available for follow-up evaluation at a mean duration of 98 weeks after surgery (range, 12-272 wk). Fifteen males and 3 females with a mean age of 25 years (range, 16-62 y) were examined. Wrist range of motion; grip strength; visual analog and numeric pain scores; and a Disabilities of the Arm, Shoulder, and Hand (DASH) outcomes questionnaire were assessed. Postoperative radiographs were reviewed in a blinded fashion to assess the fracture union and screw position. RESULTS: Seventeen of 18 fractures healed at a mean duration of 8 weeks. No case of proximal pole avascular necrosis occurred. All patients were satisfied and returned to their pre-injury level of employment. Five of 6 collegiate or professional athletes returned to play without limitations. The mean subjective and visual analog pain scores were 0.3 and 0.4 (maximum of 10 for each scale). The mean DASH score was 6.12 (out of 100), which is consistent with an excellent functional outcome. Central axis screw position was achieved on anteroposterior and lateral radiographs in 17 of 18 patients. CONCLUSIONS: Fixation of an acute, nondisplaced scaphoid waist fracture via a limited dorsal approach is safe and effective. The limited dorsal approach allows for accurate insertion of the screw in the central scaphoid, which is biomechanically advantageous for fracture union and early restoration of function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Treatment of scaphoid nonunion by radical curettage, trapezoidal iliac crest bone graft, and internal fixation with a Herbert screw

Ten adult male patients with scaphoid nonunions were treated by radical curettage, trapezoidal iliac crest bone grafting, and internal fixation with a Herbert screw. The mean patient age was 24.7 years, and the mean duration of the nonunion before surgery was 37.3 months. Mean follow-up time was 30.4 months. Nine of the ten nonunions healed, although one patient required a second bone-grafting procedure. The mean postoperative grip strength was 45.0 kg, and the mean postoperative pinch strength was 11.5 kg. The mean postoperative range of motion was volar flexion, 76.1 degrees; dorsiflexion, 74.2 degrees; radial deviation, 22.1 degrees; and ulnar deviation, 40.1 degrees. The scapholunate angle decreased from a mean of 72.8 degrees preoperatively to 60.6 degrees postoperatively (p less than 0.025). The mean carpal index was 0.57 postoperatively. Mean scaphoid length increased postoperatively and was within 0.2 mm of the opposite (normal) scaphoid in every patient except the single patient with a persistent nonunion (p less than 0.025). All patients returned to work (eight as laborers), and nine of ten wrists were subjectively rated as good or excellent. The results of the series suggests that treatment of displaced scaphoid nonunion by radical curettage, trapezoidal iliac crest bone grafting, and internal fixation with a Herbert screw is an effective method of treatment that reconstitutes scaphoid anatomy and promotes excellent wrist function.     

Osteosynthesis of carpal scaphoid nonunion with interpositional bone graft and Kirschner wires: a 3- to 6-year follow-up.

BACKGROUND: Malreduced or neglected unstable carpal scaphoid fractures may lead to nonunion, which is often difficult to treat and carries the risk of carpal instability and degenerative arthrosis. Here, we describe a new "sandwich" method, which takes advantage of minimal dissection and has promising results. METHODS: From 1989 through 1992, we treated 39 patients with scaphoid nonunion by using the sandwich method that consisted of a wedge corticocancellous strut graft and numerous cancellous bone chips. Divergent Kirschner wires were used for fixation of reduction. We retrospectively review 26 scaphoids with follow-up periods of 3 to 6 years. The functional outcome was evaluated with modification of the Mayo Wrist Scoring Chart. The radiographs were analyzed, and tomographs were used for confirmation of osseous union. RESULTS: All 26 scaphoids united within 4 months. The carpal instability and humpback deformity were corrected. In all cases, the functional results were either good or excellent. CONCLUSION: Interpositional bone grafts corrected scaphoid angulation and length. Divergent multiple pinning rather than screws avoids unwanted shearing and rotational force during application and provides stable fixation with minimal dissection. Most of scaphoid nonunions in our series were the oblique type in which the lag screw never created perfect compression because of a shearing force.     

闭合复位经皮Herbert螺钉内固定治疗新鲜稳定型舟骨腰部骨折

目的：观察闭合复位经皮Herbert螺钉内固定治疗新鲜稳定型舟骨腰部骨折的临床疗效。方法对采用闭合复位经皮Herbert螺钉内固定治疗的12例新鲜稳定型舟骨腰部骨折患者进行随访,采用修订后Mayo腕关节评分标准对临床效果进行评价。结果所有患者均获得随访,随访时间13~23个月（平均15个月）,无感染、螺钉松动、过敏排斥反应及关节炎的发生。所有患者骨折均愈合,骨折愈合时间为8~14周,平均10周。按修订后Mayo腕关节评分标准：优7例,良4例,可1例,优良率91.7%。结论闭合复位经皮Herbert螺钉内固定治疗新鲜稳定型舟骨腰部骨折,具有操作简单,固定可靠,并发症少及能早期进行功能锻炼等优点。     

Percutaneous screw fixation for unstable scaphoid fractures

BACKGROUND: The technique of percutaneous screw fixation, with increasing popularity, has been successfully conducted in non-displaced, stable scaphoid fractures resulting in shortened immobilization duration and prompt functional retrieval. The purpose of this study was to evaluate the surgical technique and to explore the potential benefits of using percutaneous screw fixation in unstable scaphoid fractures. METHODS: Eleven of 97 patients with scaphoid fractures surgically treated between 1994 and 2002 were enrolled in this study. All were acute unstable fractures and underwent closed reduction and percutaneous screw fixation. All the records were meticulously reviewed and reported, including the complete radiographic examination before and after operation, time to fracture union, wrist motion, grip strength, and time of return to work, as well as overall patient satisfaction at the time of the most recent follow-up. RESULTS: Eleven fractures in an equal number of patients were followed up for a mean period of 1.6 years. All fractures acquired radiographic union in an average of 10.6 weeks. The modified Mayo Wrist score averaged 88.2. The functional result was ranked as excellent in 6 patients, and good in 5 patients. All returned to work or the pre-injury level of activity, and were satisfied with the surgical outcome. CONCLUSION: The technique of percutaneous screw fixation was successfully used to treat 11 unstable scaphoid fractures. The encouraging outcome of this treatment option and the prompt functional recovery deserve further investigation. Further randomized prospective studies to explore the specific indications and ubiquitous benefits of the technique presented herein are recommended.     

Percutaneous Herbert screw fixation for fractures of the scaphoid: review of 30 cases

INTRODUCTION: The purpose of this study was to evaluate the results of percutaneous fixation of undisplaced or minimally displaced fractures of the scaphoid using the first generation Herbert screw in terms of union, functional results and scaphoid mobility. METHODS: 30 of the 50 patients operated on in our department between 1995 and 2000 were available for evaluation by an independent observer. Wrist mobility, grip strength and key pinch were measured. Scaphoid mobility was evaluated by measuring radioscaphoid angles in flexed and extended positions on dynamic X-rays. RESULTS: The union rate was comparable to that achieved by non-operative management (90%). Resumption of professional activities was possible long before bony union because immobilization was short. Grip strength, wrist and scaphoid mobilities were comparable to the controlateral sides except for scaphoid flexion. Persistent symptoms were found in 30% of the patients despite union of their fracture. DISCUSSION: Our results demonstrate that percutaneous stabilization of undisplaced or minimally displaced fractures of the scaphoid preserves the mobility of the wrist and minimally alters the normal dynamics of the carpus. The duration of work inability is short.     

Open reduction and internal fixation of acute displaced scaphoid waist fractures

Fourteen consecutive patients with acute displaced scaphoid waist fractures were treated with open reduction and internal fixation. The operative technique consisted of anatomic reduction of the displaced scaphoid waist fracture, correction of carpal instability, radial bone grafting for comminution, and internal fixation with K-wires or Herbert screw. The patients were evaluated an average of 26 months (range, 4-48 months) after surgery. Thirteen of the 14 (93%) fractures united. The average time to union was 11.5 weeks (range, 8-20 weeks). Fracture union was confirmed with trispiral tomography. Final radiographic assessment consistently revealed a healed scaphoid fracture, restored intrascaphoid alignment, and no evidence of carpal instability. All patients regained functional wrist range of motion (wrist extension, 57 degrees; wrist flexion, 52 degrees ) and grip strength. Open reduction and internal fixation of acute displaced scaphoid waist fractures restores scaphoid alignment and leads to predictable union. Early operative intervention avoids malunion and carpal instability that often occurs with closed management of these complex fractures.     

Aktueller Stand der Kahnbeinchirurgie

Conservative and various operative treatment options are available for fractures of the scaphoid. Nonunion of the scaphoid requires an operative treatment. Of the patients who underwent surgery for fractures of the scaphoid from 1999 to 2001, 74 were treated with Herbert screw fixation. Nonunion of the scaphoid in 52 cases was treated by iliac crest bone grafting and Herbert screw implantation following resection of the affected bony parts. The cannulated, self-tapping headless bone screw system (cannulated Herbert screw) was used, which allows for easier implantation of the screw. Bony consolidation was achieved in a high proportion of these cases; bony fusion was achieved in all cases of scaphoid fracture. Operative treatment was followed by healing in 47 cases of scaphoid nonunions.     

掌侧切开双螺钉顺行固定治疗Herbert B2型腕舟骨骨折的疗效观察

目的：探讨掌侧切开顺行双螺钉固定治疗Herbert B2型腕舟骨骨折的临床及功能疗效。方法：自2005年12月至2010年6月,应用掌侧切开双螺钉顺行固定技术治疗18例Herbert B2型腕舟骨骨折患者,男14例,女4例;年龄21～52岁,平均33.11岁。术后通过X线检查评价其骨折愈合情况,采用改良Mayo腕关节功能评分评价腕关节功能。结果：18例患者获随访,平均随访时间（25.06±4.00）个月,骨折愈合时间（3.55±0.65）个月。18例患者术后4个月腕关节疼痛情况、活动范围、握力均优于术前（P<0.05）.改良Mayo腕关节功能评分由术前42.78±7.32改善至术后4个月的93.89±5.83,术后4个月各项评分及总分均明显优于术前（P<0.05）,优9例,良9例。结论：应用掌侧切开顺行固定技术治疗Herbert B2型腕舟骨骨折,其临床及功能疗效可靠。     

Scaphoid fracture in the young athlete--therapeutic outcome of internal fixation using the Herbert screw

BACKGROUND: A fractured scaphoid is a common disabling injury occurring in contact sports. This study was designed to evaluate the therapeutic outcome of Herbert screw fixation for scaphoid fracture in young athletes. METHODS: Thirty athletes with 30 scaphoid fractures were treated. According to the Herbert classification, 10 were classified as acute fracture (group I), 6 as fibrous union (group II) and 14 as pseudoarthrosis (group III). Twenty scaphoid non-unions were due to missed diagnosis or unsuccessful immobilisation. RESULTS: Bony union was evident at an average of 9.2, 8.0 and 11.9 weeks postoperatively in groups I, II and III, respectively, and times for returning to sports were 10.7, 14.0 and 22.9 weeks. The clinical outcome assessed using the Mayo wrist score was excellent in groups I (97.5 points) and II (93.3) and good in group III (85.4). CONCLUSION: Early definitive diagnosis and treatment can allow early return to sports in young athletes. The Herbert screw technique produces an excellent clinical result for scaphoid fracture.     

1，2伸肌室间支持带上动脉为蒂骨瓣移植治疗舟骨骨折不愈合

目的探讨1,2伸肌室间支持带上动脉（1,2 intracompartmental supraretinacular artery 1,2 ICSRA）的解剖特点及治疗舟骨骨折不愈合的临床疗效。方法2008年7月-2010年9月共收治确诊的舟骨骨折不愈合患者11例,均采用逆行的1,2ICSRA为蒂骨瓣植入术结合Herbert螺钉内固定进行治疗,观察患者的骨折愈合情况及并发症,并以DASH评分对腕关节功能进行评价。结果所有患者均获6～33个月随访,平均17个月。11例患者均获骨性愈合,骨折愈合时间为9～14周。平均12周。术后6个月DASH评分平均为6．5分,腕关节功能接近正常。结论慎重的选择适应证,熟悉相关解剖知识,仔细的手术操作,采用逆行的1,2ICSRA为蒂骨瓣植入术结合Herbeft螺钉内固定治疗舟骨骨折不愈合可取得满意的临床疗效。     

Retrograde compression screw fixation of acute proximal pole scaphoid fractures

Seventeen consecutive patients with acute unstable proximal pole scaphoid fractures were managed over the past 5 years with open reduction and internal fixation. Four fractures were displaced, with greater than 1 mm of fragment offset and intercarpal malalignment. The operative technique consisted of a dorsal approach to the scaphoid, radius bone grafting, and freehand retrograde Herbert compression screw fixation. The patients were evaluated at an average of 37 months (range, 12-63 months) after surgery. All fractures healed within 13 weeks (average, 10 weeks). Functional wrist range of motion and grip strength were achieved in all patients. No patients developed osteonecrosis or radioscaphoid arthritis. Open reduction and internal fixation rather than primary casting is a better means of reducing the complications of delayed union, nonunion, and irreparable osteonecrosis that often occur after acute proximal pole scaphoid fracture treated with cast immobilization.     

Management of proximal scaphoid bone pseudarthroses and fractures with the mini-Herbert screw via a dorsal approach

32 patients, aged 16 to 49 years, were treated by osteosynthesis using the Herbert mini screw. The indications were five fractures (type B3, Herbert classification), two delayed unions (type C) and 25 nonunions (type D1 to D3, Filan and Herbert classification). Six patients received no bone grafts, 19 received cancellous bone graft from the radius. An interpositional iliac crest bone graft was used in four, and a vascularized bone graft from the distal radius in three cases respectively. The average postoperative immobilisation in a forearm splint was nine weeks. 26 patients could be recruited for clinical follow-up at an average of 14,5 months. The radiological results were assessed in 30 cases (94%). Bony consolidation was achieved in 26 cases (100% of the fractures, 84% of the nonunions). In three cases a loosening of the screw, and in three further cases a dislocation into the radiocarpal joint were observed. A humpback deformity was present in four cases. Three patients showed a persisting nonunion, one patient a fibrous union. Early degenerative changes of the radiocarpal joint were observed in six cases. The clinical follow up examination showed an average grip strength of 91% (JAMAR II), 94% for the three finger, and 95% for the pinch grip compared to the contralateral side. The mean postoperative pain score on the visual analog scale was one for resting conditions, eleven for motion and 33 under stress. The range of motion was 79% of the opposite side for extension/flexion and 83% for radial/ulnar deviation. The average DASH-score reached 15 points. The Herbert mini screw has proven to be a reliable implant for reconstruction of proximal pole fractures and nonunions of the scaphoid.