Current Concepts in the Treatment ofScaphoid Fractures

Abstract Fractures of the carpus are frequent injuries andtypically result from of a fall onto the outstretched hand.Scaphoid fractures are the second most frequent fracture type ofthe hand (80%). 95% of the patients with acute scaphoidfractures are male, and the average age is approximately 25years. Conservative treatment of acute scaphoid fractures withimmobilization in a plaster cast was the therapy of choice for along time. Surgical treatment was reserved to severe dislocatedfractures only. A progress could be obtained by the principle ofintramedullary fixation, whose forerunner is represented by theHerbert screw, and the introduction of cannulated screwsguaranteed a continuous improvement. The decision to treat thefracture by surgery requires a clear definition of the fracturetype. Therefore, precise radiologic technique is mandatory todetect the fracture and to analyze the pathomorphologicalcircumstances. In order to get an exact classification for thedecision on how to proceed, three standard X-ray projections(posteroanterior [PA], lateral and Stecher projection) and a CTscan have to be performed. The most well-known classificationhas been defined by Herbert & Fisher which combines fractureanatomy, stability and disease history in order to deriveprognostic and therapeutic criteria. Also, delayed healings andnonunions are considered. To decide on the adequate treatment, aprerequisite for conservative therapy of acute scaphoidfractures is the anatomic position of the scaphoid. Conservativetherapy should be reserved to fracture types, which are stableand heal reliably in the lower-arm plaster cast within 6 weeks.All displaced and unstable acute scaphoid fractures should beoperated, and whenever possible, rigid internal fixation shouldbe achieved because of interfragmentary compression. Therefore,several intramedullary implants are available for surgicaltreatment of acute scaphoid fractures, e. g., Herbert screw,Mini Herbert screw, AO screw (cannulated), Acutrac screw(cannulated), or Twin-fix screw (cannulated). With improvedsurgical and radiologic techniques, most scaphoid fractures areamenable to minimally invasive fixation. The dorsal approachguarantees a good overview in treating proximal pole fractures.Yet, not all types of fractures can be treated in this way.Severely displaced fractures require the classic open palmarapproach. In order to prevent the development of a scaphoidnonunion or an advanced carpal collapse (SNAC-wrist), an earlyand sufficient diagnostic algorithm is necessary. We recommendinternal fixation with a cannulated Herbert screw in B1 and B2fractures and a Mini Herbert screw in fractures of the proximalthird (B3). A2 fractures can be treated conservatively. Earlydiagnosis and operative treatment will shorten the time offwork, minimize the risk of nonunion, and reduce the costs ofhealth care in the long term.