Classification

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Three classification systems have been devised for grading scaphoids afflicted with Preiser's disease [8,22]. The first scheme, derived by Herbert and Lanzetta in 1993 [8], is based on the progression of the disease as seen with plain radiographs. Based on four stages, this system

Slil Ligament

Fig. 3. Illustration demonstrating some of the ligamentous attachments of the scaphoid. Note the three segments of the SLIL, including the strong dorsal portion and the weaker membranous and palmar sections. This ligamentous attachment site may represent an area through which some patients receive blood flow. (From Trumble TE. Principles of hand surgery and therapy. Philadelphia: W.B. Saunders; 1999. p. 92; with permission.)

Fig. 3. Illustration demonstrating some of the ligamentous attachments of the scaphoid. Note the three segments of the SLIL, including the strong dorsal portion and the weaker membranous and palmar sections. This ligamentous attachment site may represent an area through which some patients receive blood flow. (From Trumble TE. Principles of hand surgery and therapy. Philadelphia: W.B. Saunders; 1999. p. 92; with permission.)

starts at stage 1 with normal radiographs but a positive bone scan, and ends at stage 4 with total collapse of the scaphoid and periscaphoid arthritis (Table 1). Looking at the patient outcomes makes it difficult to derive the prognostic value of this

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Fig. 4. Ulnar variance is measured as the distance between lines 3 and 4. When the ulna is shorter than the radius it is termed negative ulnar variance. Positive ulnar variance occurs when line 4 is more distal than line 3. RL, relative length of the radius; UV, ulnar variance. (From Trumble TE. Principles of hand surgery and therapy. Philadelphia: W.B. Saunders; 1999. p. 130; with permission.)

classification system. Although the study by Herbert and Lanzetta only looked at eight patients, it was interesting to note that two patients who had stage 4 disease fared ''Satisfactory'' and ''Good,'' whereas one patient who had stage 2/3 disease had only a ''Fair'' result [8].

Two other systems have been developed, both from the same authors. Kalainov and colleagues [22] described their modified version of the Herbert and Lanzetta system in a 2003 study (Table 2). Ultimately the modifications were relatively minor. These authors implemented another classification scheme based on MRI findings in all 19 of their patients. Individuals were classified as Preiser's type 1 if they had diffuse necrosis of the scaphoid, and as Preiser's type 2 if the necrosis was localized to only a section of the scaphoid

Table 1

Preiser's disease staging as proposed by Herbert and Lanzetta [8]

Stage

Findings (based on plain radiographs)

1 Normal radiographs but positive bone scan

2 Increased proximal pole density plus generalized osteopenia

3 Fragmentation of proximal pole +/—

pathologic fracture

4 Carpal collapse with osteoarthritis

Table 2

Modified Herbert and Lanzetta Preiser's disease staging [8] as modified by Kalainov and colleagues [22]

Stage Findings (based on plain radiographs)

1 Normal radiographs

2 Scaphoid sclerosis, lucencies, and fissuring on plain radiographs

3 Fragmentation of scaphoid

4 Scaphoid collapse and fragmentation with periscaphoid arthritis

(Table 3). Patients who had type 1 necrosis were noted to have higher rates of scaphoid degeneration, lower Mayo wrist scores, and decreased grip strength compared with the patients who had type 2 disease. In addition to better outcome scores, patients who had type 2 necrosis had a higher incidence of reported wrist trauma [22].

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