The assessment and management of acute scaphoid fractures and non-union

Abstract

Abstract The management of scaphoid fractures can be challenging. The diagnosis of a fracture should be made following a suggestive mechanism of injury, positive clinical findings and confirmatory radiographs. In the case of normal radiographs the patient should be immobilized and re-examined in 2 weeks. If a scaphoid fracture is still clinically suspected but repeat radiographs are normal, further imaging is indicated. The gold standard is an MRI scan, but this is dependent on the facilities available in the local hospital. An MRI has the added benefits of not only identifying a potential scaphoid fracture but also other causes for the symptoms such as a ligament injury. Stable fractures can be safely treated by immobilizing in a cast; usually a simple below elbow cast with the wrist in slight extension and the thumb left free is adequate. If a patient elects to have a proximal pole fracture treated non-operatively then the thumb should probably be included. The cast should be continued for a maximum of 12 weeks and then removed regardless of clinical or radiological features. Surgical treatment should be considered for unstable fractures of the scaphoid, which includes displaced waist and proximal pole fractures. The surgical approach will depend upon the fracture location and preference of the individual surgeon. Compression screws should be used whenever possible. There are occasions in which fixation of undisplaced waist fractures using percutaneous techniques may be beneficial and this should be considered on a case-by-case basis. The management of scaphoid non-unions can be daunting and controversial. The best treatment of non-unions is to prevent them from developing by identifying those fractures which are unlikely to unite and treating them properly acutely. Whilst the development of non-union can be anticipated in approximately 10% of all fractures, it is more common in proximal fractures, displaced fractures, comminuted fractures, and those which have a delayed presentation. The decision of who and when to treat can be difficult and the patient must be involved in this process. Once it is decided that operative treatment is necessary the available options depend upon the presence of arthritis and the blood supply of the proximal pole. Union is most reliably achieved with a cortico-cancellous bone graft and headless compression screw fixation. If avascular necrosis (AVN) is evident then the best results are achieved with a vascularized graft. Despite grafting 20% will still not unite and a salvage procedure may prove necessary.