Mateusz Gładysz FESSH prep

FESSH prep Wrist trauma Scaphoid management

Scaphoid fracture management and complications

Last reviewed v2.0

FESSH-027Wrist trauma●●● advanced

Regarding the management and complications of acute scaphoid fractures and their established non-unions:

  1. 1.Among acute scaphoid fractures managed nonoperatively, proximal pole fractures carry the highest risk of non-union.

  2. 2.Untreated scaphoid non-union can progress to a characteristic pattern of carpal arthrosis termed scaphoid non-union advanced collapse (SNAC).

  3. 3.Percutaneous fixation is the preferred surgical treatment for all acute scaphoid fractures.

  4. 4.Avascular necrosis of the scaphoid is more common in waist fractures than in proximal pole fractures.

  5. 5.Vascularised bone grafting is preferred over non-vascularised graft for scaphoid non-union with confirmed proximal pole avascular necrosis.

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Question ID
FESSH-027
First published
Last reviewed
Version
v2.0
Answer key and explanations — open after answering

  1. 1. Among acute scaphoid fractures managed nonoperatively, proximal pole fractures carry the highest risk of non-union.

    True

    Eastley and colleagues' meta-analysis pooled 1,147 acute scaphoid fractures managed nonoperatively and found that 34% of acute proximal pole fractures progressed to non-union, with a relative risk of 7.5 compared with more distal fractures. The differential reflects the scaphoid's retrograde vascular supply, with the risk approaching 100% in fractures isolating the proximal fifth.

    • Eastley N, Singh H, Dias JJ, Taub N. Union rates after proximal scaphoid fractures; meta-analyses and review of available evidence. J Hand Surg Eur Vol. 2013;38(8):888-897. PMID 22736744
    • Filan SL, Herbert TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg Br. 1996;78(4):519-529. PMID 8682813

  2. 2. Untreated scaphoid non-union can progress to a characteristic pattern of carpal arthrosis termed scaphoid non-union advanced collapse (SNAC).

    True

    Mack and colleagues' natural-history study, with follow-up of up to 53 years, demonstrated three radiographic stages with fracture displacement and lunate dorsiflexion correlating with severity. Ruby, Stinson and Belsky found wrist osteoarthritis in 31 of 32 patients (97%) whose injury had occurred five years or more earlier. A separate patient who developed osteoarthritis less than four years after injury also had avascular necrosis.

    • Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non-union. J Bone Joint Surg Am. 1984;66(4):504-509. PMID 6707028
    • Ruby LK, Stinson J, Belsky MR. The natural history of scaphoid non-union. A review of fifty-five cases. J Bone Joint Surg Am. 1985;67(3):428-432. PMID 3972868
    • Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984;9(3):358-365. PMID 6725894

  3. 3. Percutaneous fixation is the preferred surgical treatment for all acute scaphoid fractures.

    False

    The SWIFFT trial established clinical equivalence between below-elbow cast immobilisation and primary surgical fixation for waist fractures displaced ≤ 2 mm, with cast more cost-effective; the 2026 five-year follow-up confirmed sustained equivalence. Primary fixation — most often by percutaneous or arthroscopic-assisted headless compression screw — remains appropriate for proximal pole fractures, for displaced waist fractures (≥ 1.5–2 mm step or gap), and for trans-scaphoid perilunate injuries.

    • Dias JJ, Brealey SD, Fairhurst C, Amirfeyz R, Bhowal B, Blewitt N, et al.. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial. Lancet. 2020;396(10248):390-401. PMID 32771106
    • Dias JJ, Brealey SD, Coleman E, Hicks K, Laycock J, Cook E, et al.. Clinical effectiveness of early surgical fixation versus cast immobilization for adults with a scaphoid waist fracture: five-year follow-up of the Scaphoid Waist Internal Fixation for Fractures Trial. Bone Joint J. 2026;108-B(1):70-78. PMID 41475372
    • Clementson M, Björkman A, Thomsen NOB. Acute scaphoid fractures: guidelines for diagnosis and treatment. EFORT Open Rev. 2020;5(2):96-103. PMID 32175096

  4. 4. Avascular necrosis of the scaphoid is more common in waist fractures than in proximal pole fractures.

    False

    Proximal pole fractures carry the highest avascular necrosis risk because the dorsal ridge entry of the radial-artery branches at the scaphoid waist devascularises the proximal fragment in retrograde fashion. Avascular necrosis of the waist or distal pole is uncommon, and the risk approaches 100% in fractures isolating the proximal fifth.

    • Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am. 1980;5(5):508-513. PMID 7430591
    • Filan SL, Herbert TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg Br. 1996;78(4):519-529. PMID 8682813

  5. 5. Vascularised bone grafting is preferred over non-vascularised graft for scaphoid non-union with confirmed proximal pole avascular necrosis.

    True

    Recent systematic reviews converge on a higher union rate for vascularised over non-vascularised graft in established non-union with proximal-pole avascular necrosis and in revision cases. In simpler waist non-union without avascular necrosis or significant deformity the difference narrows; the choice is now a stratified decision rather than a categorical preference. The Zaidemberg 1,2-intercompartmental supraretinacular artery pedicled graft remains the seminal pedicled technique.

    • Karimnazhand R, Shams R, Behmanesh A, Vosough M, Gharooee Ahangar A, Serrano Barrenechea L. Comparative efficacy of non-vascularized and vascularized bone grafts, with emerging insights into bone biomaterial grafts, in scaphoid fracture nonunion treatment: a systematic review and meta-analysis. J Orthop Translat. 2025;53:231-245. PMID 40678609
    • Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg Am. 1991;16(3):474-478. PMID 1861030