AND JOHANNA

of the connectivei’erent from that ofmotion of the joint~

le forms about the

ctive, and passive--in restoring of theany means the

~ Method for Serially!d., 14: 6-9, 1956.dioac~ive Gold Reaches the i951.nship between Articular ~

~lization of the Normal Joi:

between the Articular Car[inavica, 21): 156-165, 1950.onal Value of Synovial

~riations in the Thickness of~Experimental Investigation

aorpels und diesen. Acta Orthop.

the Knees of Rabbi

bei dauernder Ruhe

~rticolazioni negli arti

nh. f. Path. Anat.,.ber die Wirkung inn,44: 478-488, 1924.,~e in Its Relation to Joint

’immobilit~ e dello scarico284, 1938..,i d~uernder Ruhe. Deutsche

abranes of the Joints. J.

degli effetti:: 469-488, 1936.lar Synovial Membranes. J. ]

ff Degenerative Joint Disease|the Laboratory Rat.

entitled "Studies onrthopaedic Research Society,!

3UI%NAL OF BONE AND JOINT

:racture of the Carpal Navicular

;IS, .’N’ON-OPERATIVE ’]TRE:kTMENT~ AND OPERATIVE TREATMENT

BY DR. OTTO RUSSE~ S’IENNA, AUSTRIA

of the carpal navicular is an important in.iury in accident surgery.or no treatment leads to non-union and may cause a painful and

,led wrist. In time, severe arthrotic and degenerative changes de-out the possibility of bone-grafting and may necessitate such aas arthrodesis. Early diagnosis and adequate treatment of this in-

yield fuII recovery in almost 100 per cent of the patients. Operativeof non-union has led to bone union in 80 to 90 per cent of the patients

FIG. 1-A FIG. 1-Bright wrist seen from the volar (Fig. l-A) and dorsal (Fig. l-B) aspects.

from the dorsal side is clearly shown, indicating the advantage of the volar

DIAGNOSIS

Technique

is tenderness in the region of the navicular, a fracture of this boneespecially if this sign develops after a fall on the dorsiflexed

on the palm with the wrist in’florsiflexion. In such cases it is con-routinely to make the !Mlowing roentgenograms (Fig. 2) : (1)

with the forearm in neutral position mid-way between pronationand the wrist in slight dorsiflexion with the fingers closed into a fist;

with the forearm in 15 to 20 degrees of supination; (3) a trueforearm in 90 degrees of supination; (4) a dorsovolar view,

in 15 to 20 degrees of pronation. Ulnar deviation of the wristare made should not exceed 10 degrees with fresh

avoid distraction of the fragments. These four roentgenograms arefilm, eighteen by twenty-four centimeters (with the use of a lead

in exceptional cases is it necessary to have further oblique views in50 degrees of supination or in 40 degrees of pronation.

of pain withou~ definite roentgenographic findings, even whenstudied with a magnifying glass, the recommended procedure is to apply

;two weeks and then repeat the roentgenograms. Should tenderness on

Meeting of The American Academy of Orthopaedic Surgeons, Chicago,25, 1960.

~. ~c~.v ~o 759

760OTTO RUSSE

F~. 2Photographs indicating positioning for roentgenograms (routine navicular series) ; four

made on one film, eighteen by twent),-four centimeters.

TABLE I

LOCATION 0~’ FRACTURE AND APPROXIMATE TIM FOR UNION

LOCATION UNION

DISTAL THIRD

io %

MIDDLE THIRD

70 %

PROXIMAL THIRD

20 %

6 - 8 WEEKS

lO - 12

pressure or pain on wrist ~novement persist at this time, even tothe wrist should again be immobilized, and the roentgenogramsanother two weeks (that i..s, four weeks after injury). Fissurednavicular occur that can be demonstrated only after three to fourabsorption has widened the fracture cleft.

~ :,

Location of Fractures (Table I) ,~In round figures, 70 per cent. of navicula~ fractures are located in

third, 20 per cent in the proximal third, and 10 per cent in the distal third

)urine navicular series);

I TI2,~ FOR UNION

UNION

6 - 8 WEEKS

s time, even to a’oentgenogramsry). Fissuredter three to four

~ures are located incent in the distal

I~NAL OF BONE AND

FR~.CTURES OF THE CARPAL NAVICULAR 761

ost of the blood vessels enter the navicular in the distal part (theon the dorsal aspect of the middle part (the waist) of the bone,

for healing are better with fr~ctures in the distal and middle thirds.ax’erage time necessary for bone union to occur is longer for frac-

roximal third, in which the time amounts to ten to twelve weeks,fractures in the distal and mi.ddle thirds for which six to eight weeksion is necessary.

TABLE II

TYPEP~LATION TO LONG AXIS OF NAVICULAR

HORIZONTALOBLIQUE

TRANSVERSE

6O %

VERTIC&LOBLIQUE

I~E4OBILIZATION

DISTIL THIRD 6

MIDDLE TH I P~D 6

?ROXIMAL TIIIRD 10-12 ~fEEKS

6WE~S

~ ÷ 4 TO 6 WF~EKS )

lO - 12 WEF~

TABLE III

CAUSEOF FP~ACTUR~ ~ PORCEI~ ACTING ON TH~ NAVICULA/~

TYPE OFFRACTUP~

ORFORCEASON

BLOW TO

HORIZONTALOBLIQO-E

%TRANSVEP~ E

ACTING

~oVERTICAL

LONG AXISOBLIQUEAND

! ~ACA~A~

AND FINGER P~JSCLESCONTP~ACT

TYPES OF Ft~’,ACTURES

of immobilization necessary, as well as the possibility of bonenot only on the blood supply but also on the type of fracture and

~ acting on the fracture surfaces (Table II). Trojan and Jahna, whoon 500 fractures of the navicular collected by BShler in the period

JULY 1960

762 OTTO RUSSE

FIG. 3The patient was a mechanic, twen~;y-two years old at the time of operation. The two

roentgenograms at the upper left show pseudarthrosis of the navicular six months afterThere was immobilization in plaster for four months after operation. The two oblique roegrams at the upper right were made eight and a half years after operation. Active andmovements eight and a half years after operation are seen in the four photographs.

from 1925 to 1952, distinguished between transverse and oblique fracturesing to the relationship between the long axis of the navicular and theline as seen in the dorsovolar view. Follow-up studies of 220 fresh fractures (1956t1958) treated by my group have confirmed that the prognosis is best in thezontal oblique type of fracture (Table III). Most of these fractures healedsix weeks because the forces exerted by the wrist and finger muscles tendpress the fracture surfaces. In the transverse type of fracture the plane ofture cleft is not exactly vertical to the long axis of the forearm. Because ofoblique relationship, both compression and slight shearing forces act on theture surfaces, and some of these fractures do not unite in six weeks and needther immobilization for four to ~,~ix a~’eeks more. In the rare vertical oblique typefracture the fracture cleft lies i~a the long axis of the forearm. This type ~stimes difficult to visualize iz~ the routine roentgenograms, and the pmentioned special supination ~iews should be made. The fracture is s

TIIE JOUltNAL OF BONE AND JC

FRACTURES OF THE CARPAL NAVICULAR763

~ the time of operation. The~f the navicular six monthser operation. The tworears after operation.m in the four photographs.

verse and obliqueof the navicular andudies of 220,t the prognosis is~st of these fracturesst and fingerpe of fracture the plane;is of the forearm.;ht shearing forces actot unite in sixIn the rare verticalof the forearm. Thisntgenograms, and themade. The fracture is

electrician, twenty-six years old. The roentgenogram at the upper left showsof the navicular nine years after iniury. The second roentgenogram was made after

at three and a half months after operation. The two roentgenograms at theat ten and a half years after operation. Photographs show active and

and a half years after operation.

an almost longitudinal line that is visible only in these supinationThis vertical oblique type of fracture may result from

the thenar region and is transmitted along the long axis of themls to exert a shearing force on the navicular. The prospect for

not so good in this as in the other types of fractures because theexert an almost pure shearing force on the surfaces of the

type of fracture may very well be compared with Pauwels’s Typethe femoral neck, whereas the horizontal oblique and the trans-

Pauwels’s Types I and II fractures. Immobilization in thetype should be continued for at least ten to twelve weeks.

SIGNS OF L~NIONthat immobilization in fractures of the navicular should be

antil the roentgenograms show definite signs of bone union. It is im-~ recognize these signs in order to a~oid unduly prolonged immobiliza-

absence of clearly visible osseous trabeculations brid~in~ the former

JULY 1960

764 OTTO RUSSE

FIG. 5The patient was a man twenty-three years old. The two oblique roentgenograms at the

left show pseudarthrosis of the navicular te~ months after injury. The two oblique ro~grams at the upper right were made nine years after operation; there was iplaster cast for four months after operation. The four photographs at the bottom showpassive movements nine years after operation.

defect, one should look for increased density of the bone at the site of thefracture cleft or on each side of the cleft. It is not generally known thatcalcified bands in the fracture site or on both sides of the fracture siteof bone union in fresh fractures of the navicular~,r. Such calcifications occurabout 40 per cent of fresh fractures. In old fractures, of course, these bandsbe considered as signs of bone union.

IMMOBILIZATIONPlas~cr Cas~

A fresh-fracture should be immobilized in an unpadded plaster castextends frown the elbow to the metacarpophalangeal joints. The wrist is

FRACTURES OF THE CARPAL NAVICULAR 765

e two oblique.s after injury. The twor operation; there wasphotographs at the bottom

of the bone at the siteis not generally knownsides of the fracture

~ular~’7. Suchctures, of course

l in an unpadded plastertlangeal joints. The wrist is

Fro. 6was a baker, eighteen years .~ld, with pseudarthrosis of the navicular two years

two oblique views at the upper left). The two oblique views at the upper rightthere was immobilization in a plaster cast for four months

and passive movements are shox~m in the four photog~raphs below seven

the third metacarpal is in line with the long axis of the forearmor volar flexion and no radial or ulnar deviation. On the day of

dorsal plaster splint is applied, and on the following day the castby the addition of a volar plaster splint and a circular plasterfirst metacarpal is incl.uded in the cast but not the thumb. Move-

and of the other fingers exert useful compression of the frag-of all finger joints is kept completely free. For fractures of thetype the fist cast ~, which extends to the finger tips and pre-

or wrist motion, is ,,~ometimes used. All casts must be carefullyonce a week. A defective or loose cast must be replaced immedi-

iof Immobilization

the middle or distal thirds should be immobilized in an unpadded

~*0. 5, JUL’Y 1960

766OTTO RUSSE

plaster cast for six weeks, and fractures of the proximal third andoblique fractures should be immobilized for ten to twelve weeks.transverse fractures do not heal in six weeks and need additional immofor four to six weeks. After removal of the cast the routine roentgenograra~be made and studied carefully for evidence of bone union.

CONSERVATIVE TREATME.-x,- T OF FRESH AND OLD FRACTUREsHealing Process

Fractures of the navicular immobilized in a cast either heal by visibleunion or show the previously mentioned signs of consolidation in theone or two dense bands. In the absence of immobilization, the fra,widens within a few weel~:s because of absorption of the fracture ends, aador three months after the accident furt.her absorption leads to thetraumatic cavity. Only after several months or years do the fracture ends

Fro. 7

sclerosed to suci~ an extent ~hat we can speak of a true non-union. Untreat~odununited fractures of the navicular may lead to the development of cystsnavicular and in the neighboring bon~s. Aseptic necrosis of theensue, as well as such severe changes as bone deformity and severethe navicular, the radial styloid, or all the bones of the wrist joint.non-union should be treated by bone-grafting, provided Severe arthrotichave not yet developed. EarJ]er stages, including delayed unioncavities, respond well to plaster-cast immobilization of sufficient and

durasince the period of immobilization may in some cases require manyoperative treatment by an experienced surgeon may be consideredIncreased density of the proximal fragment as a result of severance ofblood vessels develops in about 30 per cent of fresh fractures. This is achange and not an absolute indication for operative intervention. Ascirculation improves by the ir~growth of new vessels from the fracturearea of density recedes from the fracture end. Density of a fragment mayunion in fresh fractures but must m)~ be considered as a sign of beginningunion.

Results

Of 220 fresh fractures treated by my group in the years 1956, 1957, and

! the proximal third and ~~r ten to twelve weeks. Scs and need additional imraoast the routine roentgenograrof bone union.

;Sit AND OLD FRACTURES

a cast either heal by visib]gns of consolidation in the

immobilization, the fra,ption of the fracture ends,

absorption leads to the)r years do the fracture end:

rpM navicular e byllnarward. Both ~

! a true non-union. Unthe development of

ie necrosis of theteformity and severess of the wrist joint.,rovided severeag delayed union andation of sufficientne eases require manyt may be consideredesult of severance of~sh fractures. This is a:ative intervention.ssels from the fracIensity of a fragmentred as a sign of

the years 1956, 1957,

*UII~’AL OF BONE AND ~

FRACTURES OF THE CARPAL NAVICULAR

TABLE IV

767

Age Duration Duration Degreeat of of of

Time Location Type Frac- Immobi- Functionof Mid- Hori_ Verti- ture lization Dec.

Opera- carpal Mid- Proxi-zontal cal before after 1959tion Dislo- Distal die real Ob- Trans- Ob- Opera- Operation (Per-

(Years) cation Side Third Third Third lique verse lique tion (Months) centage) Union

" M 22 R X X 2 yrs. 5 95 YesM 32 R X X 5 mos. 5 100 Yes.M 27 L X X 3 yrs. 3~/~ 95 Yes20 R X X 1~ yrs. 4 100 Yes

; M 30 L X X 10 yrs. 4~ 75 YesM 19 R X X i yr. 3~ 95 Yes~I 27 L X X 2 yrs. 4 95 YesM 2l R X X 2 yrs. 4~-~ 95 ~’es3I 21 R X X 1~ yrs. 3~/~ 80 No¯ .M 24 L X X 2 yrs. 4 80 NoM 36 X L X X 7 mos. 5~ 90 YesM 25 X R X X 1 mo. 7 95 YesM 40 R X X 8 mos. 4 100 YesF 25 L X X 2 yrs. 3~ 100 Yes33 X L X X 2~/~ ~nos. 3~ I00 YesM 26 R X X 4 yrs. 5~ 95 YesM 28 L X X 2 yrs. 5~ 80 YesM 21 R X X I4 mos. 5 100 Yes49 R X X 6 mos. 5 95 YesM 23 R X X 3~ yrs. 5 95 YesM 20 R X X 3 yrs. 6~/~ 90 YesM 22 L X X 3 yrs. 4 100 Yes

inot unite, making the incidence of bone union about 97 per cent. ThisBShler’s results in his 500 fresh navicular fractures treated during

1925 to 1952.twenty-seven navicular frac~ures with delayed treatment in the years

and 1958, including those with traumatic cavities, that were treatedby prolonged plaster-c~st fixation, united. The duration of delay

ee weeks and three :years, the average being six months. Plaster-was usually a forearm cast--in some cases, a fist cast extending from

to the tips of all fingers wa.s used. Duration of immobilization variedthirteen months, the average being five months.

OPERATIVE TRE,~.,TMENT OF NON-UNION

the patient under general anesthesia and a tourniquet applied to theincision three to four centimeters in length is made on the

of the wrist. I have used this approach for twenty-two years in aboutThe volar approach to the navicular is easy and, ,in my opinion,

to the dorsal or dorsoradial incision. From anatomical studies and:~ction studies of the blood supply to the navicular, we know that the main

enters the bone on its dorsal side (Figs. 1A and l-B). None of theseand none of the vessels entering at the tuberosity is injured if the

is used. From the cosmetic point of view, the volar incision is alsopalpable landmarks for this incision are the radial styloid, the

the flexor carpi radialis, and the volar aspect of the tuberosity of theA longitudinal incision three to four centimeters in length is placedto the flexor carpi radialis tendon. The tendon is retracted to theand the incision is then carried down through the wrist capsule tothe non-union, which becomes clearly visible on marked dorsiflexion

The f~acture is usually in line with the tip of the radial styloid,easily be felt through the skin towels. The sclerotic bone ends are

with a small gouge, and a cavity is formed; extending well into thefragments (Fig. 7). Then from the patient’s opposite iliac crest an oblong

5, JULY 1960

768 OTTO a~SSE

piece of cancellous bone (about twenty by ten by ten millimeters) is ta~form a peg (ranging from tweb~e by four by four to fifteen by six by fivemeters) and small chips (about one to two millimeters). The peg is placedcenter of the preformed cavity, and the multiple small chips are firralvaround it, completely obliterating the cavity. The process resembles ~h~dentist filling a cavity in a tooth. The peg and the tightly packed chipsosteogenic material and also sts,bilize the fracture. Roentgenograms are ra~two planes before and after filli:ag of the cavity in order to determineof the operative excavation of the fragments and to check the result ofup of the cavity. After removal of the pneumatic tourniquet, the capsuleare sutured, and a plaster cast is applied with the wrist in neutral positio~cast extends from the elbow to 1:he terminal joint of the thumb and to thecarpophalangeal joints of the other fingers. The cast is split immediatelthe plaster has set throughout the whole volar side. Eight to ten daysoperation the stitches are removed, and a new cast is applied of the’sameexcept that it is not split and it is well molded at the palm. This cast shoulvery strong because it is worn for twelve to sixteen weeks after operationshould be checked every week, or" at least every other week, and must beif it is defective or loose.

The operation is not indicated in the presence of a very small ulnar fraPatients with mid-carpal fracture-dislocation of the wrist should be operated:~iif, after a manipulative reduction, a cleft remains between the navicularments, suggesting interposition of ligame~]ts.

ResultsTable IV shows that for fifteen of the twenty-two patients reported

on whom this procedure was performed, the time ~between the accident andoperation was one year or more. This indicates that. a good number of thesetures were complete non-unions and that, therefore, the results are ofsignificance.

The follow-up of the twenty-two patients operated on by this techni~the Accident Hospital, Vienna XL[, during the three years 1956, 1957, andshowed bone union in twenty cases (90 per cent). For the remainder of myipatients and for those treated by this method elsewhere (a total of 120is known to me) the average incidence of bone union was between 80 and 90cent. After healing of the fracture, strength of the grip returns to normal,movements of the wrist become painless (Figs. 3 to 6).were laborers. The results achieved with the described technique haveaged me to choose the subject of ~he fractured navicular for this

REFERENCES1. BSHLER, :L.; TROJAN, E.; and JA~, H.: Die Behandlungsergebnisse yon 734 fr

des KahnbeinkSrpers der Hand. Wiederherst. Traumatol., 2: 86-111, 1954.2. LINDGREN, E. : Some Radiological Aspects on the Carpal Scaphoid and Its Fracture

Scandinavica, 98: 538-548, 1949. ,3. R~B~N, F~TZ; and D~BEN, WALT:~.R: Zur konservativen Behandlung desbeinbruches und der Kalmbeinpseudarthrose. Arch. Orthop. Unfall-Chir. 45:

4. Rcss~, O.: Erfahrungen und Ergebni~se bei der Spongiosaaufffillung der v~raltetenPseudarthrosen des :Kahnbeins der Hand. Wiederherst. TraumatoI., 2:175~rl.84,5. Russ~, O~ro: An Atlas of Operations for Trauma. Vienna, Maudrich, and Newtional Medical Book Corp., 1955.

6. R . r .~uss,~, ,,O.. Nac,hun~t~er, such.ungs.ergebmsse yon 22 Fallen o,eriert~r ....~÷~o- Br[iche~seuuar~nrosen aes ~annbems tier H ~nd Z

7. TROJAN, E.: Der K~hnbeinbruch der Hand, 1960.

THE JOURNAL OF BONE AND JOINT