Treatment

Scaphoid fractures have been classified in a number of different ways but the critical distinction is placing the fracture type into either undisplaced or displaced groups. The position of the fracture in the scaphoid is also important as the closer the fracture to the proximal pole the higher the risk of non-union.

There is good evidence to indicate that there is a much higher risk of non-union in the displaced fracture group. Thus there is a tendency to perform surgery on patients with these fractures to try and reduce the risk of non-union and promote healing. Totally undisplaced fractures have traditionally been treated in a cast for up to 8 to 10 weeks but should they be fixed acutely? A number of trials are looking at percutaneous (through the skin) fixation of the scaphoid as a primary treatment. This would avoid the need for a full cast though a protective removeable splint is still needed. Some recommend fixation but others are not so convincing.

One thing that years of treating fractured scaphoids has taught me is that it is a very querky bone. It is extremely unpredictable when trying to predict healing. There are no absolute guarantees when it comes to the scaphoid! Some scaphoid fractures which one would expect to heal don't and some which look unlikely to heal do!

My current practice for acute fractures is as follows:

 
Competely undisplaced waist fracture
 
Cast immobilisation for 8 weeks
Displaced waist fracture
Percutaneous internal screw fixation
Proximal pole fractures
Internal fixation
Distal pole fractures
Cast immobilisation

These treatment options are guidelines as each patient and his/her fracture has to be put into context with other factors. Are there any other injuries? Is it an isolated fracture or part of a high energy injury scenario? Is the other wrist injured? The restriction of having casts on both wrists is huge, so there would be a strong indication to fix at least one side to aid in washing and one's normal bodily functions.