How late can you operate on a fractured scaphoid in an otherwise healthy adult?

Timing for Surgical Fixation of Scaphoid Fractures

For acute scaphoid fractures in healthy adults, surgery can be successfully performed up to 6 months after injury, though outcomes are optimized when performed within the first 6-8 weeks. Beyond 6 months, the fracture is considered a chronic nonunion requiring bone grafting procedures rather than simple fixation. 1

Evidence-Based Timeline for Surgical Intervention

Acute Period (0-6 weeks)

• Immediate surgery is NOT mandatory for undisplaced or minimally displaced scaphoid waist fractures, as these heal successfully with cast immobilization in over 95% of cases 2
• Early surgical fixation within the first few weeks offers no clear overall benefit compared to conservative treatment for stable fractures, though it does allow earlier return to activities 2
• The primary advantage of early surgery is avoiding 8-12 weeks of cast immobilization, not improved union rates 2

Subacute Period (6 weeks to 6 months)

• This is the critical window where delayed diagnosis does NOT preclude successful treatment 1
• Subacute scaphoid fractures (presenting between 6 weeks and 6 months) achieve an 82% overall union rate with casting alone, or 96% when excluding high-risk features 1
• Expected casting time for subacute waist fractures is 11 weeks, and 14 weeks for proximal pole fractures 1
• Surgery remains highly effective during this period if casting fails or is undesirable 1

High-Risk Features Requiring Earlier Intervention

• Displacement >1-2 mm on any radiographic view 3
• Proximal pole fractures (higher risk of avascular necrosis) 4, 5
• Scapholunate angle abnormalities or carpal instability 4
• Comminution, humpback deformity, or diabetes (these increase nonunion risk significantly) 1

Practical Management Algorithm

For Stable, Undisplaced Fractures:

1. Initial treatment: Cast immobilization for 6-8 weeks 2
2. Reassess with plain radiographs and CT if needed at 6-8 weeks 2
3. If gap persists at fracture site: Proceed to surgical fixation with or without bone grafting 2
4. This "aggressive conservative" approach results in >95% union rates while avoiding unnecessary surgery 2

For Unstable or Displaced Fractures:

1. Immediate surgical fixation is recommended 3, 5
2. Open reduction and internal fixation should be performed if accurate closed reduction cannot be achieved or maintained 3

For Delayed Presentations (6 weeks to 6 months):

1. Trial of cast immobilization is reasonable if no high-risk features present 1
2. Expected union time: 11-14 weeks of casting 1
3. If patient prefers to avoid prolonged immobilization or has high-risk features, proceed directly to surgery 1, 5

Critical Pitfalls to Avoid

• Do not assume a fracture presenting late is automatically a nonunion requiring bone grafting - many will heal with casting alone up to 6 months post-injury 1
• Do not rush stable fractures to surgery - the complication rate from surgery (including 10 patients with scar-related issues in one study) may outweigh benefits for fractures that would heal in a cast 2
• Do not delay surgery beyond 6 months - after this point, the fracture becomes a true nonunion requiring bone grafting procedures with minimum 4 months additional immobilization 3
• Do not miss high-risk features on initial imaging - displacement, proximal pole location, and carpal instability all mandate earlier surgical intervention 4, 3, 5

The Upper Limit: Beyond 6 Months

After 6 months, the fracture is classified as a nonunion and requires different surgical techniques 3:

• Undisplaced nonunions: Inlay bone graft (dorsal or volar approach) 3
• Displaced nonunions: Bone graft with internal fixation 3
• Minimum 4 months postoperative immobilization required 3

The practical answer: Surgery can be performed successfully up to 6 months after injury with standard fixation techniques, though earlier intervention (within 6-8 weeks) optimizes outcomes and reduces treatment duration. 1