On average, patients returned to work 4.7 weeks after surgery and wrist function was significantly improved, even when the fracture failed to unite. Healing rates for acute fractures were better than those reported for plaster immobilisation and were independent of fracture location. In the case of established nonunions, healing depended on the stage and location of the fracture, but the progress of arthritis was halted and carpal collapse significantly improved.Internal fixation of the scaphoid using the Herbert bone screw, although technically demanding, has few complications and appears to offer significant advantages over other methods of treatment.

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Herbert's classification of scaphoid fractures provides the underlying rationale for treatment according to the fracture type. A CT bone scan in the long axis of the scaphoid is the best means of differentiating between stable and unstable fractures. This is difficult from conventional X-rays due to the particular three-dimensional anatomy of the scaphoid. To avoid long-term plaster immobilization and to diminish the risk of a nonunion, unstable fractures of type B should be fixed operatively. With headless screws such as the Herbert screw, which are now available in a cannulated shape, the majority of scaphoid fractures of type B1 and B2 can be stabilized using minimally invasive procedures. Severely displaced fractures require the classical open palmar approach. Proximal pole fractures (B3) are best managed from the dorsal approach, using the Mini-Herbert screw. Stable fractures of type A2 can be treated conservatively in a below-elbow cast or, alternatively, stabilized percutaneously, which allows early mobilization.

We report the results of a retrospective review of 47 ulnar shortening osteotomies carried out for ulnar carpal impaction and/or ulnar carpal instability. The average follow-up was 18 months. Wrist function was graded preoperatively and postoperatively using an assessment system modified from Chun and Palmer (1993) . The results show that distal ulnar shortening osteotomy successfully reduces pain and improves wrist function both for ulnar carpal instability (UCI) and ulnar impaction syndrome (UIS) and is equally effective for those patients with combined UIS and UCI. Grip strength and wrist stability were significantly improved and range of wrist and forearm motion was little affected by the procedure. Oblique osteotomies were found to heal faster and to have a lower non-union rate than transverse osteotomies. Although radiographs did show adaptive changes of the distal radioulnar joint in a significant number of patients, there is no evidence (as yet) to suggest that this leads to the development of secondary osteoarthritis.

Idiopathic avascular necrosis of the scaphoid is a rare condition. A review of the literature shows a variety of conditions labelled as spontaneous avascular necrosis or Preiser's disease. In this paper we report on a study of eight patients with idiopathic avascular necrosis affecting only the proximal pole of the scaphoid. Seven of these patients had positive ulnar variance. The possible aetiology is discussed and the natural history has been studied. A staging system is proposed, as this helps to determine the prognosis and appropriate management. Two of our patients were managed conservatively; the others were treated successfully by partial silastic replacement of the scaphoid.