What is the treatment for a navicular (scaphoid) wrist fracture?

Treatment of Scaphoid (Navicular) Wrist Fractures

For nondisplaced or minimally displaced scaphoid waist fractures, immobilize in a below-elbow cast WITHOUT thumb immobilization for 10 weeks, as this achieves superior radiographic union compared to thumb-spica casting. 1

Initial Management and Immobilization

Cast Selection and Duration

• Use a below-elbow cast that excludes the thumb for nondisplaced or minimally displaced waist fractures 1
• A multicenter randomized trial demonstrated 85% fracture line bridging at 10 weeks with thumb-free casting versus only 70% with thumb immobilization, with an overall 98% union rate 1
• Continue immobilization until complete union occurs, which may require many months even for acute fractures 2
• Radiographic follow-up should occur at approximately 3 weeks and at cessation of immobilization 3, 4

Critical Early Intervention

• Immediately initiate active finger motion exercises to prevent hand stiffness, which is the most functionally disabling complication 3, 4
• Finger motion does not adversely affect adequately stabilized fractures and is extremely cost-effective in preventing complications that require extensive therapy or surgery 3, 4

Surgical Indications

When to Operate

Surgical treatment is indicated for:

• Gross displacement of fragments requiring reduction 2
• Fractures at the middle or proximal third with displacement or malposition in axial/rotary planes 5
• Failed conservative treatment after 6+ weeks 6

Surgical Approach

• Primary open reduction and internal fixation allows athletes to participate in protected sports during healing and return to contact sports at 6-8 weeks 5
• For nonunions with carpal instability, use a palmar approach with wedge-shaped corticocancellous iliac crest graft and internal fixation, which reduces vascular damage risk and provides better exposure 7
• Styloidectomy combined with bone grafting is more effective than styloidectomy alone for old nonunions 2

Special Populations: Athletes and Stress Fractures

Stress Fracture Management

• Nonweightbearing cast immobilization for at least 6 weeks is the treatment of choice for navicular stress fractures 6
• This approach achieved 86% return to sports compared to only 26% with continued weightbearing and activity limitation 6
• After failed weightbearing treatment, nonweightbearing casting (86% success) compares favorably to surgery (73% success) 6

Treatment Failures and Salvage

Old Fractures and Nonunions

• Fractures ≥1 year old can still unite with prolonged immobilization if fragments are not grossly displaced, sclerosis is absent, and no arthritic changes exist 2
• Excision of part or all of the scaphoid often results in painful wrist with limited function and is not recommended 2
• Wrist fusion relieves pain but eliminates motion; reserve for salvage of comparatively useless wrists 2

Key Clinical Pitfalls

• Do not immobilize the thumb for waist fractures—this provides no benefit and may impair healing 1
• Do not restrict finger motion—failure to encourage early finger exercises leads to severe stiffness requiring extensive intervention 3, 4
• Hairline fractures and comminuted fractures are not candidates for primary surgical fixation 5
• CT appearance of healing does not necessarily mirror clinical union; monitor postimmobilization management clinically 6
• Not every nonunion requires active treatment—patients without manual labor demands may function adequately with some limitation 2