• Figure 1 shows radiographs of a scaphoid waist fracture with delayed union. There is shortening of the scaphoid on the PA view with an obvious cyst (Fig. 1A, arrows). The lunate is triangular in shape (outlined area) as it has slipped into a dorsal intercalated segment instability (DISI) position.

• On a lateral view (Fig. 1B), the lunate is tilted into DISI and the scapholunate angle is about 90°. There is a pronounced humpback deformity of the scaphoid itself (tracing outlining volar scaphoid) where the scaphoid has effectively folded into the cyst (large black void). This type of delayed union needs structural bone grafting from the volar side. A large iliac crest graft may be needed. Computed tomography (CT) scans are more helpful in this problem (see Fig. 5).

• Figure 2A and 2B are initial radiographs in an 18-year-old male that were read as negative by radiology. Small arrows in Figure 2B show a fracture line in the proximal pole that was missed. Repeat radiographs should have been scheduled but were not done.

• Follow-up at 4 months for the same patient (Fig. 2C) shows obvious nonunion with cyst formation. Splint use might have prevented this complication.

• Figure 3 shows a CT scan of a scaphoid nonunion. There is a loss of volar scaphoid bone stock secondary to cyst formation (arrows). Sclerosis is seen at the fracture ends.

• Obvious increase in the intrascaphoid angle is easily seen on a sagittal CT scan (Fig. 4, angle). As for the delayed union shown in Figure 1, this is a structural problem necessitating a large graft. The sclerotic ends must be removed in order to facilitate invagination of a graft to allow reconstitution of scaphoid length.

• The MRI in Figure 5 shows a waist fracture of the scaphoid. Signal changes on this coronal view show obvious vascularity loss (arrowhead). Change in vascularity of the proximal pole secondary to the fracture and the distal blood supply result in an avascular proximal pole.

• A 3-cm incision is centered over the scaphoid tubercle, extending from the distal aspect of the FCR tendon and then curving toward the base of the thenar mass (Fig. 8).

• A 3-cm curvilinear incision is centered over the anatomical snuff-box, extending from the base of the first metacarpal to 2 cm proximal to the snuff-box (Fig. 9).