Scaphoid fractures represent approximately 11% of all hand fractures and 60% of all carpal fractures.¹ They occur most often in men between 20 and 30 years of age and typically follow a traumatic event.² The unique anatomy of the scaphoid provides it with articular cartilage over most of its surface, with five bony articulations, five ligamentous attachments, and a unique retrograde blood supply.³ The radial and volar flexed posture of the scaphoid, combined with its unique anatomy, make it vulnerable to trauma when the wrist is positioned in greater than 95° of extension with a force directed over the thenar eminence.⁴ A spectrum of injuries exist, ranging from an occult fracture (without displacement or initial radiographic findings) to a completely displaced scaphoid fracture with carpal dislocations (transscaphoid perilunate injury). Inadequate treatment of scaphoid fractures can result in chronic pain, weakness, fracture nonunion, and, ultimately, arthritic changes in the wrist. The purpose of this chapter is to describe the basic open surgical approaches to the fractured scaphoid.

After an appropriate history and physical examination as well as diagnostic studies (multiple view plain radiographs and CT if needed), patients are counseled regarding surgical versus nonsurgical treatment. Fractures that are displaced greater than 1 mm have significant angulation into the volar or the dorsal plane, exhibit carpal collapse, or are comminuted and thus indicated for surgical fixation.⁵ The radiographs must also be scrutinized for any type of carpal malalignment, associated injuries, increased volar angulation of the distal fragment (humpback deformity), or step-off within the scaphocapitate articular surface. The goals of surgical fixation include accurate reduction, restoration of carpal alignment, earlier return to work, and an attempt to decrease time to union.

Nonsurgical treatment is the modality of choice for patients who have no fracture gap or displacement and no comminution in the volar or dorsal plane. The debate on surgical versus nonsurgical treatment of nondisplaced scaphoid fractures is beyond the scope of this chapter. However, careful discussion with the patient should be undertaken to review the benefits and risks of both types of treatment. Distal pole fractures of the scaphoid readily heal given their abundant blood supply and are treated most often with nonsurgical treatment. Comorbidities and the inability to tolerate anesthesia are relative contraindications.

During the patient’s initial evaluation, standard PA, lateral, and oblique radiographs should be obtained. A scaphoid view, which is obtained by holding the wrist in approximately 30° of extension and ulnar deviation while pointing the radiographic beam perpendicular to the radial shaft, will show the long axis of the scaphoid and can be used for preoperative templating (Figure 1). The amount of extension required for the scaphoid view is often best approximated by having the patient make
a clenched fist and rest this on the radiograph cassette. The lateral radiograph should be examined for any type of carpal malalignment, including a DISI or VISI (dorsal or volar intercalated segment instability) deformity, as well as to assess the intrascaphoid angle, which typically is less than 30°. The PA radiograph should be specifically examined for loss of carpal height, any type of intercarpal widening (which may be suggestive of a scapholunate interosseous ligament or lunotriquetral interosseous ligament injury), or any other associated fractures. Fluoroscopy and comparison views of the uninjured views of the uninjured hand can be helpful.

Initial radiographic imaging can fail to demonstrate nondisplaced fractures. When this is the case, and the index of suspicion is high, such as in the patient with substantial anatomic snuffbox pain or pain at the distal pole of the scaphoid, the patient must be protected and further imaging obtained to prove or disprove the presence of an occult scaphoid fracture. In the past, patients have been immobilized for approximately 10 to 14 days, with repeat radiographs obtained following this interval to assess for any type of occult fracture once there has been bone resorption along the fracture lines.⁶ However, active or working patients often may not be able to tolerate this type of delay and would like more rapid information that can lead to either continuation of immobilization or freedom from the cast and return to activities.

Additional imaging options can be used for evaluation of suspected or occult scaphoid fractures (Figure 2). Historically, technetium MDP (methylene diphosphonate)-99 bone scan has a sensitivity rate of 100% and a positive predictive rate of 93% with a specificity of 98%.⁷ However, bone scans have been largely replaced with the use of MRI, which have reported a 100% sensitivity and specificity rate in the diagnosis of acute occult scaphoid fractures (Figure 3). MRI can be performed as soon as 24 hours after the injury and is very sensitive in detecting concomitant ligamentous injuries in the wrist. Although false-positive results can occur secondary to marrow edema, which can lead to excessive treatment,⁸ MRI is a cost-effective option, yielding less lost worker productivity.⁹

Nondisplaced fractures particularly of the distal scaphoid or even of the waist, or those that are visible only on MRI are most commonly amenable to nonsurgical treatment, although in some cases operative treatment may be chosen to allow return to activity sooner or for other patient specific fractures. For scaphoid fractures that are displaced as defined above, surgical intervention is generally required.

VIDEO 43.1 Open Reduction and Internal Fixation of Scaphoid Fractures. Kristofer S. Matullo, MD; Alexander Y. Shin, MD (2 min)