Scaphoid Fractures – Evaluation, Treatment & Nonunion Management

Overview

• Common wrist injury, especially in adolescents and young adults
• Usually occurs after a fall on an outstretched hand
• Early diagnosis is critical to prevent nonunion and avascular necrosis
• Management depends on:
  • Fracture displacement
  • Stability
  • Blood supply
  • Presence of nonunion

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Anatomy & Blood Supply

• Scaphoid links proximal and distal carpal rows
• About 80% of the bone is covered by cartilage
• Blood supply is mainly retrograde and enters distally
• Proximal pole has poor vascularity and higher risk of AVN

Clinical implication:

• Proximal pole fractures heal slowly
• Higher risk of nonunion and avascular necrosis

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Mechanism of Injury

Typical mechanism:

• Fall on outstretched hand
• Wrist extension + pronation
• Force transmitted through thenar eminence

Common in:

• Sports injuries
• Falls
• Young active individuals

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Clinical Evaluation

Important examination findings:

• Anatomical snuffbox tenderness
• Tenderness over scaphoid tubercle
• Pain with axial loading of thumb
• Reduced grip strength
• Painful wrist motion

Always assess for:

• Associated ligament injury
• Neurovascular injury
• Soft tissue damage

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Imaging

Initial X-rays

Essential views:

• PA view
• Lateral view
• Oblique view
• Scaphoid view with ulnar deviation

Important point:

• 10–15% of fractures may not appear initially

If suspicion remains high:

• Repeat X-rays after 10–14 days

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Advanced Imaging

MRI

Advantages:

• Highest sensitivity and specificity
• Detects occult fractures
• Shows bone contusion and soft tissue injury
• Identifies alternative diagnoses

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CT Scan

Best for:

• Assessing displacement
• Evaluating healing/union
• Surgical planning

Important point:

• CT is more reliable than X-ray for assessing union

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Fracture Classification

Stable Fractures

• Incomplete fractures
• Minimal or no displacement

Usually treated conservatively.

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Unstable Fractures

Features:

• Displacement
• Comminution
• Ligament injury
• Proximal pole involvement

Usually require surgery.

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Management of Acute Scaphoid Fractures

Non-operative Treatment

Indications:

• Non-displaced fractures
• Stable fracture pattern

Treatment:

• Cast immobilization
• Usually around 12 weeks

Results:

• Union rate >90%
• Slower return to work/sports

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Operative Treatment

Indications:

• Displaced fractures
• Unstable fractures
• High-demand patients

Technique:

• Headless compression screw fixation

Surgical Approaches

Volar Approach

Best for:

• Waist fractures

Advantages:

• Better visualization

Dorsal Approach

Best for:

• Proximal pole fractures

Advantages:

• Better screw trajectory

Benefits of surgery:

• Faster return to activity
• Shorter immobilization

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Assessment of Healing

Methods:

• Clinical examination
• Serial radiographs
• CT scan

Important point:

• CT is most reliable for union assessment
• Around 50% healing on CT may allow return to activity

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Scaphoid Nonunion

Definition

Failure of fracture healing, usually beyond 4–6 months.

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Risk Factors

• Delayed diagnosis
• Poor blood supply
• Inadequate immobilization
• Mechanical stress
• Proximal pole fracture

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Treatment of Nonunion

Stable Nonunion

• Percutaneous bone grafting

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Unstable Nonunion

• Open reduction and internal fixation
• Bone grafting

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AVN or Failed Surgery

• Vascularized bone grafts

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Deformity Correction

• Structural corticocancellous grafts

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Surgical Techniques in Nonunion

Fixation methods:

• Headless compression screw
• Dual screw fixation
• Plate fixation (complex cases)

Bone graft options:

• Cancellous graft
• Corticocancellous graft
• Vascularized graft

Plate fixation:

• Better alignment control
• Higher complication rates

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Salvage Procedures

Used for:

• Advanced arthritis
• Failed reconstruction
• Irreparable collapse

Options:

• Distal scaphoid excision
• Proximal row carpectomy
• Four-corner fusion

Choice depends on:

• Age
• Activity level
• Degree of arthritis

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Key Clinical Pearls

• Snuffbox tenderness = scaphoid fracture until proven otherwise
• Normal initial X-ray does not exclude fracture
• MRI is best for occult fractures
• CT is best for union assessment
• Proximal pole fractures have highest AVN risk
• Stable fractures can heal well with casting
• Displaced fractures usually need fixation
• Nonunion requires careful surgical planning