From the Guidelines
Surgery is indicated for scaphoid fractures with a displacement of more than 1 mm between the fracture fragments, and while the provided evidence does not directly address scaphoid fractures, the principle of surgical fixation for fractures with significant displacement can be applied. When considering the indications for surgery in scaphoid fractures, several factors come into play, including the degree of displacement, angulation, and the presence of comminution or carpal instability.
- Displacement greater than 1 mm is a key indicator for surgical intervention, as it increases the risk of nonunion and avascular necrosis.
- Fracture angulation exceeding 15 degrees also warrants surgical consideration due to the potential for malunion and subsequent functional impairment.
- The location of the fracture, particularly those involving the proximal pole, is significant because the blood supply to this area is limited, increasing the risk of complications without prompt and proper fixation.
- Scaphoid nonunion, delayed presentation (more than 4 weeks after injury), and unstable fractures (including those with comminution, vertical oblique fracture patterns, or associated carpal instability) are additional indications for surgical intervention. The surgical approach typically involves open reduction and internal fixation (ORIF) with headless compression screws to provide stable fixation and allow for early mobilization, as seen in the treatment of other fractures such as distal radius fractures, where surgical fixation is suggested for fractures with postreduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement 1. Postoperative management usually includes immobilization followed by a progressive rehabilitation program to optimize outcomes and minimize the risk of long-term complications such as scaphoid nonunion advanced collapse (SNAC) and subsequent osteoarthritis. Given the potential for significant morbidity and impact on quality of life associated with scaphoid fractures, a proactive approach to surgical intervention when indicated is crucial for achieving the best possible outcomes.
From the Research
Indications for Surgery in Scaphoid Fractures
The decision to operate on a scaphoid fracture is largely based on the degree of displacement and the location of the fracture.
- Displacement of more than 1 mm is a common indication for surgical intervention 2, 3.
- Fractures with a displacement of ≥1.5 mm are recommended to be treated surgically with internal fixation 4.
- Proximal scaphoid fractures are also generally recommended for surgical treatment due to their high risk of nonunion and avascular necrosis 4.
Displacement and Nonunion Risk
- The risk of nonunion is significantly higher in displaced scaphoid fractures compared to nondisplaced fractures, with a pooled relative risk of 4.4 2.
- Displaced fractures treated with plaster cast have a higher odds of nonunion compared to those treated surgically, with the odds of nonunion being 17 times higher with plaster cast treatment 2.
Surgical Treatment
- Surgical options include open reduction and internal fixation, which can restore scaphoid alignment and lead to predictable union 5.
- Percutaneous fixation with bone grafting is also a viable option for treating scaphoid nonunions, offering minimal damage to surrounding tissues and promising results 6.