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.
fixation for fractures
of the scaphoid
A useful technique for a problematic injury
• The operative treatment of scaphoid
non-union is usually more complex and
potentially less successful than that of
• 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
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,
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.