Fractures of the scaphoid: a rational approach to management

Fractures of the scaphoid can be classified into either undisplaced, stable fractures or displaced, unstable fractures by their roentgenographic appearance. When there is greater than 1 mm of fracture offset or an instability collapse pattern (dorsal lunate rotation) on the lateral view, an unstable, displaced fracture is present. When doubt exists after reviewing routine films, special X-rays, such as radial-ulnar deviation stress views, traction oblique views, or trispiral tomography should be obtained. In acute scaphoid fractures, where no displacement of the fracture fragments or lunate dorsal tilting can be seen, a short-arm thumb spica cast provides satisfactory support for fracture union. A wrist position of volar flexion-radial deviation is preferred to the more traditional positions of wrist extension with radial deviation or wrist extension with ulnar deviation with 100% union rate and no malunions. In displaced scaphoid fractures, a long-arm cast is recommended, with reduction of the fracture by wrist flexion and radial deviation. If accurate reduction is not obtained or is lost during the course of treatment, open reduction and internal fixation should be strongly considered. In scaphoid nonunions, undisplaced fractures can be treated satisfactorily by an inlay bone graft, using either a dorsal or a volar approach. For displaced scaphoid nonunions, either a dorsal approach with internal fixation should be done (particularly if there is evidence of radioscaphoid arthrosis), or a volar approach with internal fixation can be performed. Peg graft techniques had a higher rate of nonunion and secondary arthritis. Nonunions should be immobilized a minimum of 4 months or until roentgenographic union is present.