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Scaphoid fractures occur most

commonly in young adults after a fall

onto an outstretched hand, often during

sports. Patients present with wrist pain,

sometimes with swelling, and often with

tenderness in the ‘anatomical snuff-box’.

The treatment of this injury presents a

number of challenges:

• The diagnosis of a fractured scaphoid

can be difficult in the first few weeks,

as scaphoid fractures are not always

recognised using conventional X-rays.

In this situation, the use of more

sophisticated imaging techniques, in

particular MRI scans, is helpful.

• The scaphoid has a blood supply that

favours the distal end of the bone, so

some fractures are at significant risk

of not healing (scaphoid non-union).

This is particularly common if the

fracture is within the proximal pole of

the bone, if the fracture is displaced

by as little as 1-2mm, or if the fracture

is not detected and the wrist not

immobilised within four weeks of the

injury. Smoking has also been shown to

prejudice the healing of these fractures.

Percutaneous screw

fixation for fractures

of the scaphoid

A useful technique for a problematic injury

Scaphoid Fractures

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• The operative treatment of scaphoid

non-union is usually more complex and

potentially less successful than that of

acute fractures.

• The natural history of scaphoid non-

union is of the gradual development

of osteoarthritis within the wrist,

often within a few years. A predictable

pattern of cartilage wear occurs

(known as Scaphoid Non-union

Advanced Collapse or SNAC wrist).

Un-displaced fractures of the scaphoid

wrist or distal pole are generally treated

with cast immobilisation for a period

of six to twelve weeks, depending on

the progress of healing of the fracture.

Usually, six to eight weeks is sufficient.

The indications for surgical fixation

of isolated scaphoid fractures are:

1. All proximal pole fractures

2. Displaced waist fractures

3. A fracture that has not been detected

and therefore not appropriately

immobilised for the first four weeks.

A relative indication for surgical fixation

is an active patient who does not wish

to have their wrist immobilised in a

below-elbow cast for between six and

twelve weeks.

Percutaneous screw fixation (i.e. using

only a small incision of approximately

5mm in length, rather than the

conventional open technique) can

be used in the majority of these

situations, and the patient’s wrist is only

immobilised in a cast for one to two

weeks after surgery. After this time, a

removable splint is worn which allows

an early range of motion exercises,

and unprotected use of the wrist for

low-demand daily activities (e.g. washing,

dressing, writing).

Percutaneous screw fixation also has a

role in the treatment of selected patients

with delayed or non-union of the

scaphoid – although this is not always

possible because of bone resorption at

the fracture site and the consequent

need for bone grafting, or because of

significant displacement. Pre-operative

CT scans are invaluable for surgical

decision-making in this context.

Scaphoid Fractures