Courtesy – Dr. Esther Chow, Dr Ashok Shyam, Ortho TV

Introduction

Scaphoid fractures are the most common carpal bone fractures of the wrist.

Management of undisplaced scaphoid waist fractures (Herbert Type B2) remains controversial, with both conservative and surgical options being widely used.

Definition of Undisplaced Fracture

< 1 mm displacement
No step or gap on imaging

Indications for Surgical Management

Surgery is clearly indicated in the following situations:

Perilunate fracture-dislocations
Displaced or comminuted fractures
Established nonunion
Proximal pole fractures (due to poor vascularity)

Conservative Treatment

Method

Immobilization using:
- Long arm cast or
- Short arm cast
Often includes thumb spica immobilization

Evidence

No strong evidence favoring:
- Long arm vs short arm cast

Surgical Treatment

Current Trend

Percutaneous screw fixation

Techniques

Retrograde screw insertion
Antegrade screw insertion

Proposed Advantages

Faster return to work
Earlier return to sports
Slightly earlier fracture union

Surgeon Preference: Survey Insights

Study Findings (n = 56)

~32% preferred conservative treatment
Very small percentage preferred surgery

Observations

Male non-hand surgeons – more likely to prefer surgery
Female hand surgeons – more likely to prefer conservative treatment

No Significant Influence From

Age
Gender (overall)
Occupation
Sports or musical activity

Evidence from Literature

2016 Systematic Review

Surgery:
- Faster return to work
- Faster union
Conservative:
- Lower complication rate

2018 Meta-analysis

Surgery:
- Slightly faster union
- Earlier return to work

No Significant Difference In

Range of motion
Functional outcomes
Complication rates

Overall Conclusion

No strong evidence proving surgery is superior

Functional Outcomes

Return to Work

Surgery – ~6 weeks
Conservative – ~11.5 weeks

Range of Motion

Early (8–16 weeks) – Better with surgery
Long-term – No difference

Grip Strength

Early – Better with surgery
Long-term – No difference

Functional Scores

Early – Better with surgery
At 1 year – No difference

Time to Union

Surgery – ~7.4 weeks
Conservative – ~10 weeks

Difference: ~2–3 weeks

Depends on imaging modality (CT vs X-ray)

Nonunion Rates

No significant difference between both treatments

Complications

Overall

Lower complication rate with conservative treatment

Surgical Complications

Implant-Related

Screw protrusion (~12.5%)
Implant breakage (~8%)
Broken guide wires or drill bits

Tendon Injuries

Volar Approach

Flexor carpi radialis injury (up to 27%)
Flexor pollicis longus rupture

Dorsal Approach

Extensor tendon injury (~12.5%)

Nerve Injury

Median nerve compression

Vascular Injury

Superficial palmar branch of radial artery

Radiation Exposure

Increased due to fluoroscopy

Clinical Example

28-year-old IT professional
Undisplaced scaphoid fracture
Previous surgical complication on opposite wrist
Opted for conservative treatment

Outcome

Fracture united at 8 weeks
Good functional recovery

Conclusion

Advantages of Surgery

Faster return to work
Slightly earlier union

Limitations of Surgery

Surgical risks
Radiation exposure
Higher cost

Advantages of Conservative Treatment

No surgical complications
No radiation exposure
Lower cost
Lower complication rates
Possibly lower risk of long-term arthritis

Final Take-Home Message

Long-term outcomes (ROM, grip strength, function) are similar

Conservative treatment remains a safe and often preferred option for undisplaced scaphoid fractures

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