Elsevier

The Journal of Hand Surgery

Volume 33, Issue 6, July–August 2008, Pages 988-997
The Journal of Hand Surgery

Current concept
Treatment of Scaphoid Fractures and Nonunions

https://doi.org/10.1016/j.jhsa.2008.04.026Get rights and content

Scaphoid fractures are common but present unique challenges because of the particular geometry of the fractures and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures can lead to nonunions and subsequent degenerative wrist arthritis. Improvements in diagnosis, surgical treatment, and implant materials have encouraged a trend toward early internal fixation, even for nondisplaced scaphoid fractures that could potentially be treated nonoperatively. Despite the advent of newly developed fixation techniques, including open and percutaneous fixation, the nonunion rate for scaphoid fractures remains as high as 10% after surgical treatment. Scaphoid nonunions can present with or without avascular necrosis of the proximal pole and may show a humpback deformity on the radiograph. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis. Surgical treatment is directed at correcting the deformity with open reduction and internal fixation with bone grafting. Recently, vascularized bone grafts have gained popularity in the treatment of scaphoid nonunions, particularly in cases with avascular necrosis. This article reviews current concepts regarding the treatment of scaphoid fractures and nonunions.

Section snippets

Classification

Russe classified scaphoid fractures as horizontal oblique, transverse, or vertical oblique, depending on the obliquity of the fracture line.5 Vertical oblique fractures, accounting for only 5% of all scaphoid fractures, are more likely to be displaced by shear forces, whereas horizontal oblique and transverse fractures have greater compressive forces and are less likely to be displaced. Herbert and Fisher defined scaphoid fractures as stable and unstable, as well as having delayed union and

Diagnosis

Scaphoid fractures tend to occur in young adult men between the ages of 15 to 40 years and are rare in those under 10 years of age. The typical mechanism of injury is a fall onto a hyperextended and radially deviated wrist. Tenderness in the anatomic snuff box or scaphoid tubercle may suggest a scaphoid fracture. If there is a scaphoid fracture, the wrist's range of motion is slightly restricted, and thumb movement may be painful. Reduced grip strength may be noted. It is important to recognize

Casting Versus Internal Fixation for Nondisplaced Scaphoid Fractures

Nondisplaced or minimally displaced scaphoid fractures can be treated by immobilization for 8 to 12 weeks with a thumb spica cast. There is no consensus about whether or not the cast should include the elbow joint; however, an above-elbow cast to avoid motion of the scaphoid by eliminating forearm rotation may be preferred for the initial immobilization period of 4 to 6 weeks, followed by a short-arm cast. The healing rate of nondisplaced waist scaphoid fractures with cast immobilization is 88%

Internal Fixation for Displaced Scaphoid Fractures

Internal fixation is indicated for displaced waist and proximal pole scaphoid fractures because they have a high risk of delayed union, nonunion, or AVN. An unstable scaphoid fracture is defined as a displacement of the fractured fragments by more than 1 mm in any view. Fractures progressively displaced during cast immobilization are also considered as unstable fractures, even if there is no initial displacement. Proximal pole fractures are more likely to progress to nonunion or AVN because of

Scaphoid Nonunions

Nonunion of scaphoid fractures can cause scaphoid nonunion advanced collapse, which can lead to degenerative osteoarthritic changes of the wrist. The humpback deformity is a condition in which the lateral intrascaphoid angle is increased because of a shortening of the palmar cortical length. The humpback malunion deformity can cause dorsal intercalated segment instability because of the dorsal rotation of the lunate together with the proximal scaphoid fragment (Fig. 3). The goals of treatment

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    Supported in part by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01 AR047328) and a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120 to K.C.C.).

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    Copyright © 2008 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.