Scaphoid fractures: Concepts of management

The scaphoid fracture is a common and serious carpal injury and a source of both immediate and potential problems. The scaphoid blood supply is relatively insufficient for its needs and is the basis for the common problems of delayed fracture union and avascular necrosis. Inadequate circulation also predisposes the fracture to pseudarthrosis. The fracture is usually associated with significant, but frequently unrecognized, ligamentous injury which may lead to fracture displacement and wrist instability. Stability of the link mechanism of the wrist depends largely upon integrity of the scaphoid and its soft tissue attachments. Their injury often creates imbalance in the system and deformity. Fracture displacement, if persistent, is a major cause of pseudarthrosis. For these reasons each fracture represents a potential cause of serious late complications from pseudarthrosis, instability, deformity, and ultimately osteoarthritis. Despite the many problems, appropriate management will prevent most disabling complications in the majority of cases. Optimal care requires early and accurate diagnosis based on careful radiographic interpretation followed by prompt and specific treatment. Fracture treatment should be based on stability and healing potential, factors which will be variable for each fracture. Radiographic evaluation is the key in differentiating a delayed union from pseudarthrosis. This is a critical point since the former usually heals with conservative methods while the latter requires surgical treatment, usually bone grafting. Following an anatomic reduction, effective immobilization is continued until there is radiographic evidence of complete healing and revascularization of the fracture fragments or pseudarthrosis is established. In view of the serious late complications that result from inadequate treatment, we should abandon the often used expression 'asymptomatic non-union', for it implies that treatment is unnecessary for these potentially disabling injuries.