Acute Fractures of the Scaphoid

David Ring, MD, Jesse B. Jupiter, MD, and James H. Herndon, MD, MBA

Abstract

Nondisplaced fractures of the scaphoid heal with cast immobilization in most nondisplaced fractures. However,
cases, but operative treatment is being offered with greater frequency to active displacement can be difficult to eval-
patients as an approach to reduce the period of cast immobilization. Computed uate on standard radiographs and
tomography is more useful for evaluating displacement than standard radiog- may be underrecognized. Computed
raphy. Displaced fractures are at greater risk for nonunion and malunion— tomography (CT) with reconstructions
both of which have been associated with the development of radiocarpal arthri- is useful for detecting displacement.
tis in long-term studies—and should therefore be treated operatively. Surgical The advantages of internal fixa-
treatment is also recommended for complex fractures (open fractures, perilu- tion, which include limited immo-
nate fracture-dislocations, and scaphoid fractures associated with fracture of bilization of the limb and the po-
the distal radius), very proximal fractures, and fractures for which the diagno- tential for earlier return to sports
sis and treatment have been delayed. Operative treatment of fractures of the and manual labor, make it an ap-
scaphoid has been simplified by the development of cannulated screws. pealing option for the treatment of
Internal fixation of fractures of the scaphoid may offer some advantages, nondisplaced fractures in active
including earlier return to athletics or manual labor. individuals. With the advent of
J Am Acad Orthop Surg 2000;8:225-231 percutaneous-screw fixation tech-
niques, some surgeons have begun
offering operative fixation to pa-
tients who would like to decrease
The treatment of fractures of the pret. Most studies do not segregate the duration of cast immobilization
scaphoid can be challenging. It can those fractures most likely to be and possibly avoid it entirely. In
be difficult to initially establish the associated with healing problems particular, competitive athletes and
diagnosis,1-4 recognize the presence (e.g., proximal-pole fractures, dis- manual laborers are often interested
of displacement, 2,5,6 and confirm placed fractures, and fractures for in this treatment option.
union.7 Scaphoid fractures are com- which diagnosis and treatment
mon among active young adults, were delayed) from nondisplaced
many of whom are dependent on fractures, which generally are not
their upper extremities for work or associated with healing problems.
Dr. Ring is Instructor of Orthopaedic Surgery,
sports. Prolonged cast immobiliza- The main clinical outcome measure Harvard Medical School, Boston, and Director
tion and activity restriction can be has been union of the fracture. of Research, Hand Surgery Service, Massa-
problematic. When a fracture of Functional results have been incon- chusetts General Hospital, Boston. Dr. Jupiter
the scaphoid fails to heal or heals sistently reported. A number of is Professor of Orthopaedic Surgery, Harvard
Medical School, and Chief, Hand Surgery
with malalignment, carpal kine- aspects of the management of acute
Service, Department of Orthopaedic Surgery,
matics may be affected; dorsiflex- fractures of the scaphoid remain Massachusetts General Hospital. Dr. Herndon
ion intercalated segment instability incompletely understood. is Chairman, Partners Department of Ortho-
of the carpus is seen most frequent- Displaced fractures of the scaph- paedics, Massachusetts General Hospital.
ly.8-12 The clinical sequelae of non- oid are the most problematic. Most
union or malunion can include surgeons currently recommend Reprint requests: Dr. Ring, Department of
Orthopaedic Surgery, Massachusetts General
pain, diminished motion and grip operative treatment. Operative fixa-
Hospital, ACC 525, 15 Parkman Street,
strength, and radiocarpal arthrosis. tion of the scaphoid is also common- Boston, MA 02114.
Although many clinical studies ly utilized in the treatment of open
have evaluated the results of treat- fractures and perilunate fracture- Copyright 2000 by the American Academy of
ment of fractures of the scaphoid, dislocations. Cast immobilization is Orthopaedic Surgeons.
the data can be difficult to inter- usually the appropriate treatment for

Vol 8, No 4, July/August 2000 225

Acute Fractures of the Scaphoid
Anatomy
The term “scaphoid” is derived from
the Greek word for boat. However,
some authors have felt that the con-
figuration of the scaphoid more
closely resembles a twisted peanut.2
The complex three-dimensional
shape of the scaphoid hinders evalu-
ation of fracture location, the degree
of displacement between fragments,
and the accuracy of screw or wire
placement (Fig. 1).2,5,6,13,14
Because the surface of the scaph-
oid is mostly articular, some have
recommended that implants placed
in the scaphoid be countersunk
beneath the surface of the bone.
While it is true that any violation of
the bone by a screw or wire may
injure a joint, it is often possible to
leave the head of a screw outside the
bone on the volar surface of the dis-
tal tubercle of the scaphoid, at the
margin of the scaphotrapezial joint,
without encountering any adverse
effects. This is often done when per-
cutaneous fixation is employed.
A consequence of the predomi-
nantly articular nature of the sur-
face of the scaphoid is that there are
very few potential sites for the
entrance of its vascular supply.
Anatomic studies of human cadav-
eric material have shown that the
blood supply to the scaphoid enters
primarily through the nonarticular
dorsal ridge but also through the
distal tubercle.15 As a result of this
anatomic configuration, proximal
fractures are more prone to osteo-
necrosis and nonunion, and a volar
operative exposure is less likely to
jeopardize the blood supply to the
scaphoid than a dorsal exposure.2
The ability of the intercarpal and
radiocarpal ligaments to stabilize
the intercalated proximal carpal
row is dependent on the integrity
of the scaphoid. 8 An unstable
scaphoid fracture allows dorsal
rotation of the lunate as its liga-
mentous attachments to the tri-
quetrum become predominant.
226
Radial Volar
LA LA
Distal
*
Proximal
LA
Dorsal Ulnar
A B
Figure 1 A, Four views of a right scaphoid demonstrate the complex shape of the
scaphoid. The surface is predominantly articular, and most of the blood supply enters
through the nonarticular dorsal ridge (LA = lateral apex of the dorsal ridge). The fracture
line depicts the pattern of so-called waist fractures. (Adapted with permission from
Compson JP: The anatomy of acute scaphoid fractures: A three-dimensional analysis of
patterns. J Bone Joint Surg Br 1998;80:218-224.) B, Three-dimensional CT reconstruction of
the wrist illustrates radial deviation and volar flexion of the scaphoid (asterisk).
(Copyright 1999 by Jesse B. Jupiter, MD.)
The proximal pole of the scaphoid placed fractures of the scaphoid
rotates with the lunate while the with regard to the risks of non-
distal pole remains flexed by virtue union, malunion, and osteone-
of its attachments to the trapezium crosis.10,18-21 However, the absolute
and trapezoid. The result is apex magnitude of these risks remains
dorsal (and radial) angulation undetermined. The behavior of
through the fracture of the scaph- nondisplaced fractures is particu-
oid—the so-called humpback de- larly nebulous. Computed tomog-
formity.8 This deformity produces raphy may be necessary to precise-
an alteration of carpal kinematics ly identify a fracture as nondis-
even if the fracture heals.8,9 placed5,6,14; however, this modality
Studies in cadavers have demon- is not used routinely. There are also
strated that deformity of the scaphoid probably a number of active pa-
leads to loss of wrist motion, particu- tients who sustain nondisplaced
larly extension.16 Clinical experience scaphoid fractures but never seek
has shown that scaphoid malunion medical attention because they
or nonunion may produce carpal assume they have a wrist injury.
malalignment and progressive radio- Accurate analysis of nondisplaced
carpal arthrosis.8-12,17 These changes fractures of the scaphoid would
are often associated with pain, weak- have to account for undiagnosed
ness, and diminished motion in the and untreated injuries—a difficult,
presence of a scaphoid nonunion. if not impossible, task.
The impact of malunion on clinical In a prospective, randomized
outcome is less clearly established. trial in which long-arm and short-
arm thumb spica-cast immobiliza-
tion were compared, unstable (dis-
Fracture Displacement placed) fractures of the scaphoid
were identified with standard radio-
There are fundamental differences graphy and excluded.22 Only 2 of
between displaced and nondis- 51 fractures (4%) failed to heal,
Journal of the American Academy of Orthopaedic Surgeons

both in the short-arm-cast cohort.
This number might have been even
lower if CT had been used to iden-
tify and exclude displaced frac-
tures. Some authors have even sug-
gested that nondisplaced fractures
are inherently stable and will heal
with little immobilization.23
In contrast, displaced fractures
have been associated with rates of
nonunion and osteonecrosis in ex-
cess of 50% and 55%, respective-
ly,20,21 not including the incidence
of malunion.8 Long-term follow-up
studies have demonstrated that
malunited and especially ununited
fractures of the scaphoid can lead to
radiocarpal and midcarpal arthrosis
with a pattern resembling that
observed in patients with injury to
the scapholunate interosseous liga-
ment (commonly referred to as
scapholunate advanced collapse,
or SLAC, wrist).8-12,17 Consequently,
many authors suggest that dis-
placed fractures of the scaphoid
should be anatomically reduced
and securely fixed2,18—recommen-
dations that parallel those for other
articular fractures.
Radiologic Evaluation
As a result of the complex shape
and orientation of the scaphoid,
multiple radiographic views are
necessary to accurately image the
bone. Posteroanterior views, even
those taken in ulnar deviation, are
distorted by the flexion and normal
curvature of the scaphoid. The
proximal pole is well visualized,
but most of the anatomic features
of the bone, including the distal
tubercle, are compressed into the
distal half of the radiographic
image. The middle third, or waist,
of the scaphoid is best seen on the
semipronated oblique (45-degree
pronated posteroanterior) and lat-
eral views, although overlap of the
carpal bones frequently limits the
utility of the latter. The distal third
Vol 8, No 4, July/August 2000
of the bone is best seen on the semi-
pronated oblique view. The dorsal
ridge is best seen on the semisupi-
nated oblique view. Cooney et al18
defined displacement (or instabili-
ty) on the basis of the presence of a
fracture gap greater than 1 mm on any
radiographic projection, a scapholu-
nate angle greater than 60 degrees, or
a radiolunate angle greater than 15
degrees. In addition, the intrascaph-
oid angle should not exceed 35 de-
grees.8
Studies performed with the use
of CT,6,14 dry cadaver bones, and
methylmethacrylate models of the
scaphoid5 have demonstrated how
difficult it is to characterize a frac-
ture of the scaphoid with standard
radiographs. Most fractures of the
scaphoid need to be evaluated with
CT to precisely define the location,
pattern, and displacement of the
fracture. The CT scan should be
obtained in the plane of the scaph-
oid. Sagittal-plane images are ob-
tained by placing the patient prone
in the scanner with the hand over
the head, in full pronation and neu-
tral flexion (Fig. 2, A). The sagittal
plane of the scaphoid is similar to
that defined by the axis of the
thumb metacarpal when fully ab-
ducted in the plane of the hand.
The forearm should be angled ap-
proximately 45 degrees across the
gantry. For coronal-plane images,
the forearm is placed in neutral
(Fig. 2, B). Thin (1-mm) sections
are obtained. Reconstructed images
are not usually necessary.
Magnetic resonance imaging is
very sensitive for identifying frac-
tures of the scaphoid, even within
48 hours of injury, and has been sug-
gested as an alternative means of
establishing the presence or ab-
sence of scaphoid injury.3,25 Unfor-
tunately, magnetic resonance imag-
ing is expensive and not always
readily available. Computed tomog-
raphy with thin sections in the
plane of the scaphoid holds prom-
ise for early detection.
David Ring, MD, et al
Clinical Evaluation
When evaluating patients with wrist
injuries who have normal radio-
graphs, it is important to keep three
principles in mind. First, fracture of
the scaphoid is typically an injury of
active young adults; therefore, the
diagnosis of a fracture of the scaph-
oid in a patient older than 50 years is
suspect. As patients age, the wrist is
much more likely to fail at the distal
radial metaphysis than at the scaph-
oid. Second, in addition to palpa-
tion of the scaphoid through the
interval between the tendons of the
first and third dorsal compartments
(the anatomic snuffbox), one can
palpate the distal tuberosity of the
scaphoid volarly. The scaphoid
compression test (axial compression
of the thumb metacarpal toward the
wrist) is a sensitive and specific
examination for injury to the scaph-
oid. Third, as a result of the unusu-
ally complex shape of the scaphoid,
the radiographic views that best
delineate the scaphoid (i.e., pos-
teroanterior views with the wrist in
neutral and ulnar deviation, a true
lateral view, and 45-degree prona-
tion and supination views) should
be obtained before concluding that
the examination is negative.5
A common approach to the man-
agement of a suspected fracture of
the scaphoid is immobilization of the
wrist in a cast or splint for 2 weeks
followed by repeat physical and
radiographic examination.2 If the
physical examination findings re-
main suggestive of fracture of the
scaphoid but the radiographs are still
negative, a bone scan is obtained.2,24
If there is increased activity in the
scaphoid, the injury is treated as a
nondisplaced scaphoid fracture.
Unfortunately, most patients
with suspected fractures have not
actually injured the scaphoid, and a
large number of patients are over-
treated. This is important not only
in terms of the cost of unnecessary
office visits and radiographs, but
227
Acute Fractures of the Scaphoid

A B C

D E F

Figure 2 Computed tomography of the scaphoid is easier to interpret if the images are obtained in the planes defined by the long axis of
the scaphoid. To achieve this, the patient lies prone on the table with the arm overhead. A, For sagittal-plane images, the forearm is held
pronated, and the hand lies flat on the table. The forearm crosses the gantry at an angle of approximately 45 degrees (roughly in line with
the abducted thumb metacarpal). B, Scout images are obtained to confirm appropriate orientation and to ensure that the entire scaphoid is
imaged. Sections are obtained at 1-mm intervals. C, Images obtained in the sagittal plane are best for measuring the intrascaphoid angle.
D, For coronal-plane images, the forearm is in neutral rotation. E, Scout images demonstrate the alignment of the wrist through the gantry
of the scanner. F, Interpretation of images obtained in the coronal plane is straightforward. (Copyright 1999 by Jesse B. Jupiter, MD.)

also because the involved limb in
each of these active young patients
is disabled for the 2 weeks of im-
mobilization or until a scaphoid
fracture is definitively excluded.
Treatment
Nondisplaced Fractures
Computed tomography should
be used as the first step to ensure
that a fracture is truly nondisplaced.
Nondisplaced fractures will nearly
always heal in good alignment with
cast immobilization.18,22 A variety
of types of casts and durations of
immobilization have been utilized,
but there is very little solid informa-
tion to support one type of cast over
another. The tradition of immobi-
lizing the thumb, ascribed to the
teachings of Bohler, has been aban-
doned by some.1,26 Verdan empha-
sized the importance of extending
the cast above the elbow and cited
cadaver studies demonstrating
motion across a scaphoid osteotomy
with pronation and supination of
the forearm.3 Arguments have been
made in favor of a variety of wrist
positions.1,2
Gellman et al22 performed a care-
fully controlled, randomized pro-
spective study of above-elbow and
below-elbow casting techniques.
Unstable (displaced) fractures were
excluded. The authors detected
only a small difference in the inci-
dence of nonunion in favor of an
above-elbow cast (0 of 28 in the
above-elbow-cast cohort compared
with 2 of 23 in the below-elbow-cast
cohort). Because the number of pa-
tients in the study was small and
there were very few adverse out-
comes (two nonunions), the ob-
served differences were not statisti-
cally significant. Nonetheless, on
the basis of these data and personal
experience, many physicians con-
tinue to use an above-elbow thumb
spica cast with the forearm and
wrist in neutral position for the first
6 weeks of cast treatment. 2 A
below-elbow thumb spica cast is
then applied for a minimum of 6
additional weeks or until the frac-
ture is healed.
In spite of the relative success of
cast immobilization (as measured
in terms of the rate of union), there
are reasons to consider alternative

228 Journal of the American Academy of Orthopaedic Surgeons

 David Ring, MD, et al

treatments. Union can be extremely
difficult to confirm on standard
radiographs. Dias et al7 asked eight
senior observers to evaluate radio-
graphs obtained 12 weeks after
scaphoid fracture for the presence
or absence of union and found poor
interobserver agreement (κ = 0.386).
Most patients are initially immo-
bilized for 10 to 12 weeks. How-
ever, if union is uncertain, the period
of immobilization may be extended.
The functional consequences of 10
weeks or more of cast immobiliza-
tion of the wrist have not been well
documented, but stiffness and
muscle atrophy occur to a variable
and often substantial degree. Fur-
thermore, fracture of the scaphoid
is an injury of active young adults,
many of whom are employed as
laborers or involved in competitive
athletics and would therefore like
to avoid prolonged cast immobili-
zation.
For athletes, treatment programs
have been modified such that stan-
dard fiberglass casts are exchanged
for soft or padded casts on game
days.27 The soft casts are required
to minimize the potential for injury
to other athletes. This has not been
associated with healing problems
provided there is no delay between
the injury and diagnosis of the frac-
ture. 27 An alternative approach,
particularly for patients who want
to return to sports requiring manual
dexterity that would be hindered
by a cast, has been to perform in-
ternal fixation through a volar
exposure. In one study,28 operative
fixation of minimally or nondis-
placed fractures allowed 12 athletes
to return to sports such as basket-
ball, baseball, and archery within
an average of 6 weeks. Only one
fracture in that study failed to heal.
The advent of safer, more reli-
able implants and operative tech-
niques for percutaneous fixation
has decreased the incidence of
complications and shortened the
duration of recovery associated
with operative treatment of nondis-
placed fractures.29 Therefore, we
now consider operative treatment
more often. Initial percutaneous
techniques required temporary
Kirschner-wire stabilization fol-
lowed by predrilling and insertion
of a Herbert screw or another non-
cannulated screw. The advent of
cannulated-screw systems has sub-
stantially facilitated percutaneous
fixation (Fig. 3).29 While it is often
challenging to achieve optimal
placement of the guide wire and
verify it with image intensification,
once this is achieved, drilling and
screw placement are relatively
straightforward. Initial data ob-
tained with percutaneous fixation
and immediate postoperative mo-
bilization demonstrate that compli-
cations are rare, with union rates as
high as 100%, excellent functional
results, and return to manual labor
within 5 weeks. 29 More data are
needed to determine the relative
merits of operative and nonopera-
tive approaches to the treatment
of nondisplaced fractures of the
scaphoid.

A B C

Figure 3 Radiographs of a 27-year-old man who injured his wrist in a fall while playing tennis. A, Oblique view of the wrist demon-
strates a nondisplaced fracture of the waist of the scaphoid. Posteroanterior (B) and lateral (C) radiographs depict fracture fixation with a
cannulated 3.0-mm screw inserted by using a percutaneous technique (note that the head of the screw was purposely left outside the
bone). (Copyright 1999 by Jesse B. Jupiter, MD.)

Vol 8, No 4, July/August 2000 229

Acute Fractures of the Scaphoid
Displaced Fractures
The treatment of displaced frac-
tures of the scaphoid consists of re-
alignment of the fracture fragments
followed by stable internal fixation.
In most cases, volar exposure of the
scaphoid will be used in an attempt
to limit injury to the blood supply
of the scaphoid. 2 It is easier to
address very proximal fractures
with a dorsal exposure. The Her-
bert screw has been a popular
device for achieving secure fixation
of fractures of the scaphoid. How-
ever, using the alignment jig ap-
propriately is technically difficult.30
In addition, some authors have
expressed concern that use of the
jig may damage the scaphotrape-
zial joint.2,30 Cannulated screw fix-
ation, which does not require the
use of a jig, has therefore become
popular for open as well as percu-
taneous repairs.
It is often useful to insert Kirsch-
ner wires into the individual scaph-
oid fragments so as to allow manip-
ulation of the fragments to achieve
reduction. These wires are often re-
ferred to as “joysticks.” Additional
Kirschner wires can be inserted to
stabilize the fragments in a reduced
position while the wire intended to
guide the screw is placed. In pa-
tients with fracture comminution,
particularly with compromise of the
volar cortex, bone grafting should
be considered.
The position of the screw within
the scaphoid may influence healing
of the fracture. A recent investiga-
tion of screw fixation of nonunited
fractures of the scaphoid suggested
that the time to healing was shorter
when the screw was placed in the
central third.31 Central screw place-
ment was achieved more consis-
tently with cannulated screws than
with Herbert screws.31
The rate of success in obtaining
a satisfactory reduction with the
use of either closed or limited open
techniques has yet to be fully eval-
uated. It may be possible to reduce
230
and fix some displaced fractures by Initially Unrecognized Fractures
using a percutaneous technique. Several studies have suggested
that a fracture of the scaphoid that
Fractures of the Proximal Pole is unrecognized, and therefore
of the Scaphoid untreated, for 4 weeks or longer is
The perceived difficulty of man- at increased risk for nonunion.32,33
aging fractures of the proximal third The incidence of nonunion with de-
of the scaphoid derives primarily layed immobilization of scaphoid
from the treatment of nonunited fractures in several studies ranged
fractures, many of which feature an from 19% to 88%.32,33 On the basis
avascular proximal fragment. There of these observations, scaphoid frac-
is very little data documenting the tures diagnosed on a delayed basis
behavior of acute fractures of the should be considered for operative
proximal pole. However, higher risks treatment regardless of displace-
of nonunion and the need for pro- ment.
longed immobilization have been
reported in a few small series.26 As Complicated Fractures of the
a result of these clinical observations Scaphoid
and the tenuous vascular supply to Fractures of the scaphoid associ-
the proximal pole observed in cadav- ated with severe soft-tissue injury or
er studies, many surgeons favor open wounds (Fig. 4), associated
operative fixation of all fractures of carpal ligament injuries (perilunate
the proximal third of the scaphoid. fracture-dislocations, scaphocapitate
*
A B
Figure 4 Images of a 27-year-old woman who
sustained fractures of the scaphoid and capitate
with an open wound. A, Radiograph taken in
the emergency department suggested severe
carpal injury. After debridement of the wound,
the injury was defined, and all fractures were
secured with screws. B, Intraoperative photo-
graph (wrist is at right) shows a screw being
placed into the proximal aspect of the capitate
(asterisk) through a dorsal wound. C, Postero-
anterior radiograph of the wrist demonstrates
restoration of alignment of the wrist, with two
screws in the scaphoid and one in the capitate.
(Copyright 1999 by Jesse B. Jupiter, MD.)
C
Journal of the American Academy of Orthopaedic Surgeons

syndrome), or fracture of the distal
radius also merit operative treat-
ment. These complicated fractures
are high-energy injuries associated
with severe soft-tissue damage and
swelling; therefore, cast immobiliza-
tion may not be possible. The goals
of treatment in this situation include
stable fixation of all skeletal injuries
and early initiation of rehabilitation
to enhance articular mobility as well
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complex wrist injuries are indica-
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