Scaphoid Fracture

Scaphoid fractures — recognition, the high non-union risk, casting and percutaneous/open fixation.

Overview

Management of scaphoid fractures often relies on small case series due to insufficient evidence supporting many principles [1]. Despite diagnostic and surgical advancements, nonunion rates remain high [5]. Pediatric fractures, however, demonstrate excellent outcomes [3]. While virtually all united fractures yield good results regardless of malunion [14], the optimal postoperative immobilization protocol remains controversial [13].

Treatment selection depends on displacement and timing. Nondisplaced fractures can be effectively managed nonoperatively with union rates approaching or exceeding operative intervention [22], though early internal fixation is increasingly favored for this group [5]. Conversely, operative intervention is recommended for displaced fractures [22]. Appropriately performed acute percutaneous internal fixation serves as a standard option for selected patients with acute fractures [6], although internal fixation does not demonstrate a true long-term benefit over nonoperative treatment for acute nondisplaced or minimally displaced cases [32].

For recent scaphoid nonunions, double antirotation screw fixation performed with arthroscopy is considered pertinent in certain cases [11]. Bone grafts are utilized in surgical management to augment fixation, promote healing, and restore carpal alignment [84]. Patients with recent fractures that have failed prior treatment may be treated with distal scaphoid resection [33].

Anatomy & Pathophysiology

Osseous Morphology and Articulation

The scaphoid is a small, irregular S-shaped tubular bone, often described as boat-shaped ("skaphos" in Greek), a twisted peanut, or bean-shaped, located in the proximal carpal row on the radial aspect of the wrist [48][54][66]. Oriented at a 45-degree plane to the longitudinal and horizontal axes of the wrist, the bone lies entirely within the wrist joint and acts as a midcarpal "bridge" and tie-rod linking and synchronizing the motions of the proximal and distal carpal rows [48][66]. Over 80% of the scaphoid surface is covered with articular cartilage, limiting periosteal healing capacity and increasing the tendency for delayed union and nonunion [48][54]. The proximal articular surface is convex and articulates with the radius, while the distal surface features two distinct facets for the trapezium and trapezoid forming the scaphotrapeziotrapezoid (STT) joint [48]. The capitate head articulates with a sulcus on the scaphoid's radial articular surface, providing a socket-like fit [48]. The bone gently pronates and flexes distally so the distal pole sits ulnarly angulated relative to the proximal pole [48]. Anatomically, the scaphoid is divided into three regions: the proximal pole, waist, and distal pole (tubercle) [66]. The intrascaphoid angle averages 40 ± 3 degrees in the coronal plane and 32 ± 5 degrees in the sagittal plane, with a normal angle of 24 degrees [54][66].

Ligamentous Attachments and Stability

Ligamentous attachments are predominantly found on the nonarticular dorsoradial surface, which is ridged along the critical dorsal ridge vessels [48]. The dorsal ridge serves as the insertion point for both the dorsal component of the scapholunate and intercarpal ligaments [48]. Short intrinsic ligaments provide stability through attachments to other carpal bones, particularly the lunate, merging with extrinsic ligaments and the wrist capsule [48]. The radioscapocapitate (RSC) ligament does not attach to the scaphoid bone itself but crosses the waist, acting as a sling allowing rotation and a fulcrum around which the scaphoid rotates [48][66]. The scaphoid can fracture around this RSC ligament fulcrum at the waist [66]. The scapholunate interosseous ligament (SLIL) is the primary stabilizer connecting the scaphoid to the lunate, with only 20 to 30 degrees of motion possible at an intact interval [66]. The dorsal aspect of the SLIL is composed of transverse collagen fibers and is twice as strong as the palmar portion, which is composed of oblique fibers inserting to volar capsular ligaments [66]. The dorsal region of the SLIL resists palmar-dorsal translation and gap, whereas the volar portion resists rotation [66]. The scaphocapitate ligament originates from the distal scaphoid and inserts into the border between the trapezoid and capitate facets on the volar waist of the capitate, functioning with the scaphotrapezial ligament as a primary restraint of the distal pole [66]. There are no tendon attachments to the scaphoid [48].

Vascular Supply and Pathophysiology of Nonunion

The scaphoid blood supply is largely retrograde, derived from two vascular pedicles originating from the scaphoid branches of the radial artery [48]. The dorsal branch of the radial artery enters via small foramina along the spiral groove and dorsal ridge, supplying 70% to 80% of the scaphoid proximally, including the proximal pole [48]. The volar branch enters via the scaphoid tubercle and supplies the remaining 20% to 30% of the distal scaphoid [48]. The waist of the scaphoid has minimal or no perforating vasculature, and no vessels perforate the proximal dorsal cartilaginous area or through the scapholunate ligament [48]. Proximal fractures are associated with at least temporary disruption of the interosseous blood supply to the proximal pole [48]. The proximal pole also receives blood from the radioscapholunate ligament (ligament of Testut) and direct scapholunate branches from the palmar and dorsal transverse carpal arches [66]. Venous drainage from the proximal pole occurs via the dorsal ridge into the venae comitantes of the radial artery [66]. The more proximal the fracture, the more likely the bone is to be dysvascular and the higher the risk of nonunion [66]. Proximal pole fractures have an incidence of avascular necrosis (AVN) of 13% to 50% [66]. Nonunion occurs in 10% to 15% of all scaphoid fractures, with risk increasing with treatment delay >4 weeks, proximal pole location, displacement >1 mm, osteonecrosis, tobacco use, and associated carpal instability (DISI with scapholunate angle >60 degrees and capitolunate angle >15 degrees) [54]. Untreated displaced waist fractures typically angulate as the volar bone is reabsorbed, yielding a "humpback" flexion deformity (intrascaphoid angle >45 degrees) [54]. This radial column shortening and proximal pole extension releases the lunate to rotate into DISI under the influence of the attached triquetrum [54]. Untreated scaphoid nonunion predictably progresses to scaphoid nonunion advanced collapse (SNAC), where arthritic change arises at the radial styloid (stage I), followed by the scaphocapitate joint (stage II), and ultimately the midcarpal joint (stage III) [54]. Arthritic changes are found in 97% of patients assessed at least 5 years after injury, with severity proportionate to nonunion duration [54]. In a 30-year follow-up, 10% of patients developed nonunion, 60% of these demonstrated radiocarpal osteoarthritis, while only 2% of the healed group showed degenerative change [54].

Epidemiology and Mechanisms of Injury

Acute scaphoid fractures account for 2% to 3% of all fractures, approximately 10% of all hand fractures, and between 60% and 80% of all carpal fractures [34]. Incidence ranges from 1.5 to 121 fractures per 100,000 persons per year; an Edinburgh dataset documented 29 per 100,000 for true radiographically confirmed acute fractures, while Scandinavian studies quote 26 to 39 per 100,000 [34]. The mean age of patients ranges from 25 to 35 years, with males significantly younger at injury and a male-to-female ratio of approximately 2.5:1 [34]. Male sex is a documented risk factor, with males more likely to sustain fractures after high-energy injuries like sports or motor-vehicle collisions, while females more frequently sustain low-energy falls from standing height [34]. Sports injuries are associated with true scaphoid fractures, with increased risk in football, basketball, cycling, and skateboarding [34]. Fractures also occur after punching or assault-related injuries [34]. The usual mechanism is a fall on an outstretched hand (FOOSH) with hyperextension past 95 degrees; other postulated mechanisms include axial loading and hyperflexion [34][54]. With hyperextension, fractures usually begin at the volar waist with tensile failure, propagating to the dorsal surface with compression loading until failure [54]. Cadaveric studies show extreme dorsiflexion and ulnar deviation produce fractures through the waist as the scaphoid impinges on the dorsal rim of the radius [54]. Proximal fractures result from dorsal subluxation during forced hyperextension, while carpal dislocations and SLIL tears are reproduced with extension, ulnar deviation, and intercarpal supination [54]. In the pediatric population, scaphoid fractures are the most common carpal injury (3% of hand/carpal fractures, 0.34% of all fractures) [35]. While traditional thinking held pediatric fractures involved the distal pole with excellent healing, current patterns show increased incidence and waist fractures similar to adults [35]. Pain and swelling in the anatomic snuffbox can be subtle in pediatric cases [35]. Nondisplaced acute pediatric fractures treated in short arm thumb spica casts have a reported union rate of 90% [35]. Associated injuries like distal radius fracture, transscaphoid perilunate dislocations, ulnar styloid fractures, capitate fractures, and bilateral injuries can be present in up to 10% of patients [35].

Meniscal and Adjacent Structures

The deep and superficial fibers of the triangular fibrocartilage complex (TFCC) begin on the ulnar side of the lunate fossa of the radius [49]. Deep fibers attach ulnarly at the ulnar head fovea, while superficial fibers attach to the ulnar styloid tip where they join with the ulnar collateral ligaments [49]. Articular surface contact in the shallow sigmoid notch accounts for about 20% of distal radioulnar joint (DRUJ) stability [49]. During forearm rotation, the ulnar head moves from dorsal and distal in full pronation to proximal and palmar in full supination [49]. The extensor carpi ulnaris sheath and part of the distal radioulnar ligaments attach to the ulnar styloid, which extends 2 to 6 mm distal to the ulnar head [49]. Most distal radioulnar ligaments and the ulnocapitate ligament attach to the fovea at the base of the ulnar styloid [49]. The articular disc attaches to the distal radioulnar ligaments and passes from the distal margin of the sigmoid notch to the fovea at the base of the ulnar styloid [49]. The thickness of the articular disc has an inverse relationship to the amount of ulnar variance [49]. Cadaver studies show loads applied to the distal radiocarpal and ulnocarpal joints are distributed about 80% to the distal radius and 20% to the ulna [49]. Class 1D injuries are tears of the TFCC from the radius at the distal end of the sigmoid notch, usually oriented anteroposteriorly and potentially involving dorsal and palmar radioulnar ligaments [52]. These injuries frequently associate with distal radial fractures extending into the sigmoid notch [52]. Ulnar shortening or resection during TFCC repair improves results in patients with ulna-positive variation or chronic, retracted TFCC [52]. Arthroscopic repair in ulna-plus variation should be used with caution as the TFCC may be too thin to repair [52]. If the TFCC is retracted more than 5 mm, open reconstruction using a flap of the extensor retinaculum may be more appropriate [52].

Kinematics and Functional Outcomes

Scaphoid motion includes rotation proximally and gliding distally while providing stability to the midcarpal joint [48]. Scaphoid nonunions have a dramatic impact on carpal kinematics, partially uncoupling the proximal and distal carpal rows [50]. SNAC wrists differ from SLAC wrists in exhibiting a decreased sagittal lunotriquetral angle, indicating a distinct pathomechanism of carpal instability [62]. Residual scaphoid deformity has no relevant negative impact on mid-term wrist function [38]. From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function, good wrist motion, and strength [39]. Chronic fractures and osteonecrosis are independent predictors of worse functional outcomes in pediatric scaphoid fractures [35]. However, 95% of pediatric patients with scaphoid fractures reported functional status better than or equal to the general population at median follow-up [35]. Scaphoid motion during forearm and thumb motion was not significant in casts for scaphoid fractures [25]. The earliest recovered wrist functional parameters after surgery for scaphoid nonunion were grip strength, motion arc, and Mayo Wrist score, followed by the DASH score at postoperative 6 months and 12 months, respectively [81].

Surgical Considerations and Reconstruction

Combined palmar and dorsal approaches taking off soft tissue at the tubercle and the dorsal ridge would not be advisable due to vascular anatomy [66]. During the dorsal approach to the scaphoid, the majority of the dorsal ridge tissue and vessels can and should be left intact [66]. Measurements of displacement and deformity in scaphoid fractures can be made in the wrist axis with comparative reliability to those in the longitudinal scaphoid axis [79]. The harvest of the proximal hamate for proximal pole scaphoid reconstruction does not appear to adversely affect wrist kinematics [51]. Vascularized bone grafting techniques provide a large graft with a long vascular pedicle to restore normal scaphoid geometry and permit normal carpal kinematics [65]. Biomechanical studies demonstrate that osteotomies can reliably shift load away from the scaphoid and lunate [69]. The method of vascularized bone grafting and distal radius osteotomy for SNAC offers pain relief without compromising wrist motion or grip strength [70]. Recovery of wrist function in patients treated with rib autograft for fragmented proximal pole scaphoid nonunion supports the assessment that this procedure may successfully restore mechanical integrity of the proximal pole in young patients with no evidence of radiocarpal arthritis [71].

Classification

Diagnostic Uncertainty: Many management decisions rely on small case series due to insufficient evidence for established principles [1]. Conventional radiographs combined with two clinical examinations identify true fractures in only about 40% of patients, providing inadequate diagnostic certainty [2]. Adding clinical reassessment to conventional radiographs does not increase diagnostic accuracy compared with radiographs alone [7]. While pediatric scaphoid fractures demonstrate excellent outcomes [3], nonunion rates remain high despite diagnostic and surgical improvements [5].

Imaging and Definition: There is no consensus on the imaging modality or measurements required to define a fracture as 'nondisplaced' [4]. High-resolution peripheral quantitative CT (HRpQCT) provides reliable diagnosis for clinically suspected fractures [20]. Three-dimensional imaging is recommended for assessing nonunions to identify the exact fracture location [37]. A validated prognostic classification system for scaphoid nonunions is needed to facilitate outcome comparisons [55]. Furthermore, a consensus definition for scaphoid fractures on MRI is required to assess reliability, diagnostic performance, and potential harms [12].

Outcomes and Union: Virtually all united scaphoid fractures yield good outcomes regardless of malunion [14]. Scaphoid nonunion results in an uncoupling of the carpal rows [43]. Until methods for diagnosing union are improved for accuracy and precision, caution is warranted in reporting time to union for any fracture or nonunion, particularly the scaphoid [27].

Management Trends: Early internal fixation is increasingly favored even for nondisplaced fractures [5]. Appropriately performed acute percutaneous internal fixation is a standard treatment option for selected patients with acute scaphoid fracture [6]. Scaphoid fracture and nonunion management remains an area of expanding evidence with opportunities to improve knowledge and familiarization with current data [10].

Clinical Presentation

Acute scaphoid fractures represent 2% to 3% of all fractures and approximately 10% of all hand fractures, accounting for between 60% and 80% of all carpal fractures [34]. The incidence ranges from 1.5 to 121 fractures per 100,000 persons annually, with prospective datasets from Edinburgh documenting 29 per 100,000 and Scandinavian studies reporting 26 to 39 per 100,000 [34]. The mean patient age ranges from 25 to 35 years, with males significantly younger at injury and a male-to-female ratio of approximately 2.5:1 [34]. Male sex is a risk factor for true scaphoid fractures, often resulting from high-energy mechanisms such as sports or motor-vehicle collisions [34]. Sports injuries, particularly in football, basketball, cycling, and skateboarding, are associated with true fractures, while assault-related injuries are increasingly documented [34]. Conversely, low-energy falls from standing height occur more frequently in females [34].

Patients classically present with radial-sided wrist pain following a fall onto an outstretched hand (FOOSH), with almost 90% recalling a hyperextension injury [26]. Physical examination typically reveals localized tenderness over the scaphoid in the anatomical snuffbox (ASB), along with pain, swelling, ecchymosis, and tenderness in the acute phase [26]. Anatomical snuffbox tenderness demonstrates a sensitivity of 87–100% and specificity of 3–98% [26]. Other clinical signs include scaphoid tubercle tenderness (sensitivity 82–100%, specificity 17–57%), pain on ulnar deviation (sensitivity 67–100%, specificity 17–60%), pain on radial deviation (sensitivity 67–90%, specificity 31–42%), reduced thumb range of motion (sensitivity 65–66%, specificity 38–59%), and thumb-index finger pinch (sensitivity 75–79%, specificity 44–76%) [26]. Axial compression of the thumb shows a sensitivity of 48–100% and specificity of 22–97% [26]. No single clinical sign is adequately sensitive or specific for diagnosis [26].

Specific combinations of signs improve diagnostic yield. In a study of 246 patients, anatomical snuffbox tenderness had a sensitivity of 90% and specificity of 40%, while scaphoid tubercle tenderness had a sensitivity of 87% and specificity of 57% [26]. A prospective analysis of 73 patients found pain on ulnar deviation of the pronated wrist had a negative predictive value (NPV) of 100% [26]. A combination of anatomical snuffbox tenderness, scaphoid tubercle tenderness, and anatomical snuffbox pain on longitudinal compression of the thumb generated a sensitivity of 100% and specificity of 74%, though this was valid only for the first 24 hours after injury [26]. Pain on thumb-index finger pinch and anatomical snuffbox pain on forearm pronation were most suggestive of a true fracture, while the absence of pain on ulnar deviation and presence of pain on thumb-index finger pinch were the best predictors within 72 hours [26]. Scaphoid tubercle tenderness was most predictive of fracture at week 2 [26].

The Clinical Scaphoid Score (CSS) utilizes three tests: tenderness in the anatomical snuffbox with the wrist in ulnar deviation (3 points), tenderness over the scaphoid tubercle (2 points), and pain upon longitudinal compression of the thumb (1 point) [26]. Patients with a CSS of 4 or higher require an MRI [26]. Despite these signs, up to 30% to 40% of scaphoid fractures are not identified on initial standard four-view radiographs [26]. Patients subsequently found to have a fracture confirmed on repeated assessment and imaging, most frequently at 10 to 14 days, are said to have had an occult fracture [26]. The combination of conventional radiographs and clinical reassessment does not increase diagnostic accuracy compared to radiographs alone, identifying true fractures in only about 40% of patients [2, 7]. Early MRI is recommended as the basis for diagnosing suspected fractures, accurately identifying occult injuries and early excluding non-injuries [9, 17].

Imaging Modalities: * MRI: Early MRI provides immediate diagnosis when radiographs are inconclusive, is cost-effective, minimizes complications, and identifies occult injuries [9, 30]. * CT: CT is a good screen for occult fractures but may not be superior to MRI or bone scanning and risks overtreatment [31]. CT is the most accurate method to assess for union [82]. * Ultrasonography: With a sensitivity of only 50% and five missed fractures in a small series, ultrasonic assessment cannot be recommended for early diagnosis of acute scaphoid fractures [18]. * HRpQCT: Diagnosis is reliable using HRpQCT in clinically suspected cases, raising questions about under- or overdiagnosis when CT is used [20, 28].

Displacement may be difficult to diagnose, and CT or arthroscopy can be helpful [92]. Criteria for minimal displacement require further investigation [92]. The higher the pretest odds of a fracture, the more likely an imaging diagnosis correlates with a true fracture; lower pretest odds reduce this correlation [36]. Patients with suspected occult fractures are reevaluated after 1 to 2 weeks of immobilization, where specialist examination increases sensitivity [36]. If probability remains high and new radiographs are normal, patients may continue immobilization or undergo advanced imaging [36]. Six weeks of splint immobilization with normal radiographs is likely sufficient [36].

Pediatric Presentation: Scaphoid fractures are the most common carpal injury in children, accounting for 3% of hand and carpal fractures and 0.34% of all pediatric fractures [35]. While historically thought to involve the distal pole with excellent healing, increased incidence and adult-like patterns (majority at the waist) are now seen, particularly in older children and adolescents engaging in intense sports [35, 82]. Sports such as football, basketball, snowboarding, and skateboarding are common mechanisms [82]. Males are more commonly affected [82]. High-energy mechanisms, closed physes, and high body mass index are associated with waist or proximal pole fractures [82]. Pain and swelling can be subtle in the anatomic snuffbox, and presentations are often late [35, 82]. Associated injuries like distal radius fractures, transscaphoid perilunate dislocations, ulnar styloid fractures, capitate fractures, and bilateral injuries occur in up to 10% of pediatric cases [35].

Management Implications: Nonoperative management is routine for suspected fractures and tubercle fractures [92]. Percutaneous fixation for undisplaced or minimally displaced waist fractures may reduce cast time, increase return to function, and increase union rates [92]. Surgical management is recommended for displaced fractures, proximal pole fractures, comminuted fractures, and those part of greater perilunate injuries [92]. Surgery is indicated for all proximal pole fractures and displaced waist fractures greater than 1 mm [94]. Surgical fixation is warranted for acute displaced pediatric fractures >1 mm, open pediatric fractures, and those with associated injuries requiring surgery [82]. Surgical fixation is likely successful for pediatric fractures that do not unite with immobilization alone [82]. One study reported a 96.5% union rate in pediatric patients undergoing surgical fixation [82]. Chronic pediatric nonunions are optimally treated surgically, with successful management in 95% of patients [82]. Union rates for pediatric nonunions are 95.6% without bone graft and 94.7% with bone graft [82]. Lower union rates occur in proximal, displaced, and late-presenting pediatric fractures [82]. Union may occur as early as 4 to 6 weeks in younger children, while older children, displaced fractures, proximal fractures, and osteonecrosis lead to longer times to union [82].

Athlete Considerations: Scaphoid fractures are common in competitive and recreational athletes [94]. Athletes often resist long immobilization periods [94]. Physicians may permit activity with a playing cast, sometimes protected with foam padding [94]. Whether gripping forces are detrimental depends on fracture stability [94]. One study reported faster return to play with internal fixation compared to a playing cast [94]. Compliance is a potential problem, as young people often modify or remove casts and are noncompliant with follow-up [94]. Pressure to return to sports may lead to shortened off-field time [94]. Decisions on surgery, playing casts, and restrictions must be customized based on sport requirements and individual circumstances [94]. Educating the patient, family, trainer, and coach is essential [94].

Investigations

Plain radiography: Standard wrist radiographs combined with an additional scaphoid view (approximately 30 degrees of wrist extension and 20 degrees of ulnar deviation) are used for initial diagnosis [57]. Radiographs are initially nondiagnostic in more than 30% of scaphoid fracture cases [57]. The combination of conventional radiographs and two clinical examinations identifies a true scaphoid fracture in only about 40% of patients [2]. The combination of conventional radiographs and clinical reassessment does not increase diagnostic accuracy compared with conventional radiographs alone [7]. If radiographic findings are normal but clinical suspicion is high, the arm should be immobilized with physical examination and radiographs repeated in 2 weeks, or MRI obtained immediately [57]. Failure of identification and immobilization for more than 4 weeks after fracture increases the nonunion rate almost 10-fold [57].

MRI: MRI is the best diagnostic radiological test for triage of suspected scaphoid fractures, though bone scanning, CT, and ultrasound may be useful when MRI is not readily available [78]. MRI has the highest sensitivity, specificity, and accuracy (all >95%) for scaphoid fractures at less than 24 hours [57]. Early MRI in patients with clinically suspected scaphoid fracture accurately and reliably identifies a significant number of radiological occult injuries [9]. Early MRI in patients with clinically suspected scaphoid fracture allows for early identification of patients without acute injuries [9]. Clinical examination combined with early MRI scan should form the basis of diagnosing a suspected fracture [17]. MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers [86]. Routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment, with nearly 70% of MRI findings categorized as distracting and potentially misleading [80]. Routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment due to the high prevalence of distracting signal changes and low prevalence of true fractures [91]. Better standardization of MRI definitions for scaphoid fractures is required, though a definition may not exist to solve the potentially unsolvable issue of diagnostic uncertainty [85]. There is no consensus regarding the imaging modality and measurements used to define a scaphoid fracture as 'nondisplaced' [4]. MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion seen in over 6% despite appropriate initial immobilization [23]. Most patients with nonunion of MRI-detected occult scaphoid fractures require surgery to achieve union [23]. A diagnosis of osteonecrosis can be challenging because of the limited sensitivity of imaging modalities, including contrast-enhanced MRI [53]. The presence of large cavitary lesions or cysts with bone resorption around the midwaist to proximal pole suggests that the bone has a compromised blood supply [53].

CT: CT is a good way to screen occult fractures but may not be any better than MRI or bone scanning in detecting scaphoid fractures without some over treatment [31]. CT improves the reliability of detecting scaphoid fracture displacement but has a more limited effect on accuracy, which remains <80% [95]. Three-dimensional imaging should be considered when assessing scaphoid nonunions to identify the exact location of the fracture [37].

Bone scan: All advanced imaging modalities (bone scan, ultrasonography, CT, and MRI) are better for ruling out rather than ruling in a scaphoid fracture [57].

Ultrasonography: Ultrasonic assessment for the early diagnosis of acute scaphoid fractures is not recommended due to a sensitivity of only 50% and five missed fractures in a small series [18].

Other Considerations: Findings in children with clinical scaphoid fractures suggest a low but non-zero occult scaphoid fracture rate, discordance in radiologic interpretation, and a lack of advanced imaging [42].

Treatment

Management decisions for scaphoid fractures often rely on small case series due to insufficient evidence supporting well-established principles [1]. Conventional radiographs combined with two clinical examinations fail to provide adequate diagnostic certainty, identifying a true fracture in only about 40% of patients [2]. There is no consensus regarding the imaging modality or measurements required to define a fracture as 'nondisplaced' [4]. Despite diagnostic and surgical advancements, nonunion rates remain high [5]. Clinicians must guide patients toward a diagnostic and therapeutic course based on individual values and risk tolerance, as no single strategy is superior for suspected scaphoid fractures [75]. Efforts to reduce management variation should address differences in surgeon tolerance for uncertainty and patient symptom intensity [106].

Non-Operative

Nondisplaced scaphoid fractures can be effectively treated nonoperatively, with union rates approaching or exceeding those of operative intervention [22]. However, patients with nonoperatively managed fractures who were prescribed NSAIDs within one month of diagnosis demonstrated an increased risk of nonunion and subsequent salvage procedures [67]. Low-intensity pulsed ultrasound (LIPUS) may serve as a nonoperative alternative for scaphoid nonunion in certain cases, though surgical intervention remains the standard [72].

Operative

Indications: Surgical treatment is recommended for displaced scaphoid fractures [22]. Early internal fixation is increasingly favored even for nondisplaced fractures [5], and appropriately performed acute percutaneous internal fixation is a standard option for selected patients with acute scaphoid fracture [6]. While surgical treatment for non-displaced and minimally displaced acute fractures may offer slightly favorable standardized functional outcomes on the short term (within 2 years) [8], one study did not demonstrate a true long-term benefit of internal fixation compared with nonoperative treatment for these injuries [32].

Surgical Approach / Technique: The technique of fixation and grafting after limited debridement is an effective and efficient method for treating nondisplaced scaphoid nonunions without avascular necrosis (AVN) [74]. Double antirotation screw fixation performed with arthroscopy is considered pertinent for certain recent scaphoid nonunions [11]. Patients with recent scaphoid fractures that failed treatment may be treated with distal scaphoid resection [33]. Scaphoid nonunions produce new bone at the site, which may have positive implications toward hardware fixation and healing stimulation [99].

Implant Selection: Scaphoid plating achieved bony union in 72% to 100% of cases with no significant difference in union incidence compared to headless compression screws [100]. Magnesium (Mg) screws demonstrate potential benefits for bioabsorbable fixation but indicate a high rate of complications, including non-union and screw instability, in scaphoid fractures [102]. The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunions with segmental defects yields reliable union rates and good patient outcomes [103, 104]. There is no overarching agreement about the best management option or fixation techniques for scaphoid nonunion [77].

Pain Management: The optimal protocol for postoperative immobilization following operative treatment of scaphoid fractures remains controversial [13]. Scaphoid motion during forearm and thumb motion was not significant in casts for scaphoid fractures [25].

Revision: The frequency of non-union after surgical management for closed scaphoid fractures exceeds 10% and remained consistent during the study period [21]. Eight percent of scaphoid open reductions with internal fixation (ORIFs) required at least one reoperation, primarily for removal of hardware [45]. Fourteen percent of repair nonunions required at least one reoperation, primarily for removal of hardware [45].

Other Considerations: Pediatric scaphoid fractures have excellent outcomes [3]. The Matti-Russe technique facilitates scaphoid union without the need for screw fixation and avoids potential complications with hardware in pediatric patients [41]. The approach described for pediatric scaphoid nonunions is a reliable option that obtains excellent results [76]. However, there is a low but non-zero occult scaphoid fracture rate in children, characterized by discordance in radiologic interpretation and a lack of advanced imaging [42]. A case report describes an eight-year-old child with a scaphoid fracture that went on to non-union despite immediate medical attention and rigorous treatment [60]. Scaphoid fracture and nonunion management continues to be an area of expanding evidence with opportunities to improve knowledge and familiarization with current evidence-based data [10].

Complications

Diagnostic Uncertainty and Missed Injury: Conventional radiographs combined with two clinical examinations fail to provide adequate diagnostic certainty, identifying true fractures in only about 40% of patients [2]. Many decisions regarding scaphoid fracture management are based on small case series due to insufficient evidence supporting well-established principles [1]. True scaphoid waist fractures are uncommon among patients with suspected scaphoid fractures [24]. Early MRI in patients with clinically suspected scaphoid fractures accurately identifies a significant number of radiological occult injuries and early identifies patients without acute injuries [9]. Misdiagnosed and maltreated scaphoid fractures result in significant complications, primarily pseudoarthrosis, and high costs for both society and patients [116].

Nonunion and Malunion: The frequency of non-union after surgical management for closed scaphoid fractures exceeds 10% [21]. Persistent nonunion is common after surgery for scaphoid non-union, and surgeries for persistent nonunion are even less successful [118]. While spontaneous healing of a proximal pole scaphoid non-union may occur in isolated cases, it is unusual and non-treatment is not advocated [111]. Virtually all scaphoid fractures that unite have a good outcome regardless of malunion [14]. Based on the high probability of arthritis, all displaced ununited scaphoid fractures should be reduced and grafted before degenerative changes occur [117]. Surgical techniques for malpositioned nonunion of scaphoid fractures, including bone grafting and fixation methods, cite union rates ranging from 74% to 100% depending on the technique and patient factors [122].

Avascular Necrosis (AVN): The development of avascular necrosis (AVN) corresponds with a worse prognosis and increases the likelihood of secondary procedures, though it only correlates with nonunion in the scaphoid [47]. Distal scaphoid resection arthroplasty provides good functional outcomes and pain relief for avascular necrosis of the distal pole secondary to scaphoid nonunion [121].

Hardware and Reoperation: 8% of scaphoid open reductions and internal fixations (ORIFs) and 14% of repair nonunions required at least one reoperation, primarily for hardware removal [45]. There is concern regarding the high proportion of hardware complications and required secondary surgical procedures with volar plate fixation for scaphoid nonunion [114]. The Matti-Russe technique facilitates scaphoid union without the need for screw fixation, avoiding potential complications with hardware [41].

Patient Factors and Prognosis: Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union [123]. The advantages of surgical fixation are transient, possible complications must not be underestimated, and the long-term outcomes of surgical fixation are incompletely understood [124].

Other Considerations: Many decisions regarding scaphoid fracture management are based on small case series due to insufficient evidence supporting well-established principles [1].

Recovery

Light activity (weeks): Patients with non-displaced or minimally displaced acute scaphoid fractures treated surgically return to work significantly faster, with a standardized mean difference of 7 weeks compared to conservative treatment [8]. While the optimal protocol for postoperative immobilization remains controversial [13], initial cast immobilization for minimally displaced fractures, reserving immediate fixation for nonunion cases, is considered optimal for comparable outcomes with reduced healthcare costs [97].

Full activity (months): Surgical intervention for acute non-displaced or minimally displaced fractures may offer slightly favourable short-term functional outcomes within 2 years compared to conservative management [8]. In the acute setting, good clinical outcomes are achievable in prospective NFL athletes [98], though failure of acute fixation often stems from malreduction, failure to restore length, or compromised vascularity [112]. For chronic unstable scaphoid nonunion, arthroscopic reduction and osteosynthesis yield positive effects on the recovery of clinical wrist function, despite limitations in restoring normal carpal alignment [115].

Complete recovery / outcome plateau (months): Functional outcomes for fractures of the scaphoid waist with ≤ 2 mm displacement treated operatively or nonoperatively show no difference at 12 months [46]. Long-term follow-up from 8 to 11 years indicates that patients with distal scaphoid fractures report normal self-assessed hand function, good wrist motion, and strength [39]. Residual scaphoid deformity has no relevant negative impact on mid-term wrist function [38], and pediatric scaphoid fractures demonstrate excellent outcomes [3]. Reestablishment of normal scaphoid anatomy results in a majority of good and excellent outcomes and cessation of scaphoid nonunion advanced collapse deformity [105].

Rehabilitation protocol: The optimal protocol for postoperative immobilization following operative treatment of scaphoid fractures remains controversial [13]. For patients with failed prior scaphoid nonunion surgery, treatment with free-vascularized medial femoral condyle grafts results in healing at a mean of 16 weeks in 84% of cases [110]. Development of avascular necrosis (AVN) corresponds with a worse prognosis and increases the likelihood of secondary procedures, though it only correlates with nonunion in the scaphoid [47].

Functional milestones: Arthroscopic techniques have limitations in restoring normal carpal alignment, particularly in patients with unstable scaphoid nonunion and carpal collapse deformities, although this does not affect the recovery of clinical function [113]. A scaphoid nonunion results in an uncoupling of the carpal rows [43].

Other Considerations: Surgical treatment for non-displaced and minimally displaced acute scaphoid fractures may be slightly favourable compared to conservative treatment for standardised functional outcome on the short term (within 2 years) [8]. Initial cast immobilization of minimally displaced scaphoid fractures, with immediate fixation only offered to patients with nonunion, is the optimal form of treatment, resulting in comparable outcomes with less cost to the healthcare system [97].

Key Evidence

• [L5] Even some well-established and widely used principles of scaphoid fracture management are supported by an insufficient amount of evidence, with many decisions based on small case series. (10.1177/1753193420977241)
• [L5] The combination of conventional radiographs and two clinical examinations does not provide adequate diagnostic certainty for scaphoid fractures, as a true fracture was identified in only about 40% of patients. (10.1097/corr.0000000000002413)
• [L1] Pediatric scaphoid fractures have excellent outcomes. (10.1177/1558944717735948)
• [L5] There is no consensus regarding the imaging modality and measurements to use to define a scaphoid fracture as 'nondisplaced.' (10.1016/j.jhsa.2012.10.025)
• [L5] This article reviews current concepts regarding the treatment of scaphoid fractures and nonunions, highlighting that despite improvements in diagnosis and surgical techniques, nonunion rates remain high and early internal fixation is increasingly favored even for nondisplaced fractures. (10.1016/j.jhsa.2008.04.026)
• [L4] Appropriately performed acute percutaneous internal fixation is now a standard treatment option for a selected group of patients with acute scaphoid fracture. (10.5435/00124635-200708000-00004)
• [L2] The combination of conventional radiographs and clinical reassessment does not increase the accuracy of these diagnostic tests compared with the accuracy of conventional radiographs alone and is therefore also limited in diagnosing scaphoid fractures. (10.1097/corr.0000000000002310)
• [L1] Surgical treatment for non-displaced and minimally displaced acute scaphoid fractures may be slightly favourable compared to conservative treatment for standardised functional outcome on the short term (within 2 years), with a significantly faster return to work (SMD of 7 weeks). (10.1136/jisakos-2015-000024)
• [L2] The use of early MRI in patients with clinically suspected scaphoid fracture results in the accurate and reliable identification of a significant number of radiological occult injuries and early identification of patients without acute injuries. (10.1177/1753193412471008)
• [L5] Scaphoid fracture and nonunion management continues to be an area of expanding evidence with opportunities to improve knowledge and familiarization with current evidence-based data. (10.1016/j.jhsg.2024.06.013)
• [L4] The procedure is considered pertinent for certain recent scaphoid nonunions. (10.1016/j.jhsa.2014.06.089)
• [L3] This review highlights the need for a consensus definition of scaphoid fractures on MRI scans to assess the reliability and diagnostic performance of MRI scans for diagnosing true scaphoid fractures, as well as their potential harms and benefits. (10.1177/17531934251367541)
• [L4] The optimal protocol for postoperative immobilization following operative treatment of scaphoid fractures remains controversial. (10.1177/15589447221093675)
• [L3] Virtually all scaphoid fractures which unite have a good outcome, regardless of malunion. (10.1177/1753193408093327)
• [L3] Clinical examination along with early MRI scan should form the basis of diagnosing a suspected scaphoid fracture. (10.1177/1753193420979465)
• [L4] With a sensitivity of only 50% and five missed scaphoid fractures in this small series, we can not recommend ultrasonic assessment for the early diagnosis of acute scaphoid fractures. (10.1054/jhsb.2000.0432)
• [L4] The diagnosis of scaphoid and other fractures is reliable when using HRpQCT in patients with a clinically-suspected fracture. (10.1302/0301-620x.102b4.bjj-2019-0632.r3)
• [L3] The frequency of non-union after surgical management for closed scaphoid fractures exceeds 10% and remained consistent during the study period. (10.1016/j.jhsa.2015.06.019)
• [L1] Nondisplaced scaphoid fractures can be effectively treated nonoperatively with union rates approaching or exceeding those of operative intervention, while operative intervention is recommended for displaced fractures. (10.2106/jbjs.rvw.15.00073)
• [L3] MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion seen in over 6% despite appropriate initial immobilization, with most of these patients with nonunion requiring surgery to achieve union. (10.1302/0301-620x.106b4.bjj-2023-1171.r1)
• [L2] True scaphoid waist fractures are uncommon among patients with suspected scaphoid fractures. (10.1007/s11552-007-9077-8)
• [L4] However, the scaphoid motion during forearm and thumb motion was not significant. (10.1016/j.jhsa.2017.03.008)
• [L5] Until methods of diagnosing fracture union are better defined and improved for accuracy and precision, caution is warranted in the reporting and interpretation of time to union of any fracture or nonunion, the scaphoid in particular. (10.1016/j.jhsa.2008.03.014)
• [L1] This finding raises the question as to whether scaphoid fractures could be under- or overdiagnosed in daily practice when CT is used to exclude or confirm a fracture. (10.1016/j.jhsa.2012.08.016)
• [L2] The high rates of delayed presentation and incomplete evaluation and treatment suggest a strong need for better patient and doctor education on the subject of scaphoid injuries and nonunions. (10.1016/j.jhsa.2011.06.016)
• [L5] Early magnetic resonance imaging (MRI) provides an immediate diagnosis for suspected scaphoid fractures when initial radiographs are inconclusive, which is cost-effective and minimizes complications. (10.1016/j.jhsa.2013.03.055)
• [Commentary] CT is a good way to screen occult fractures but may not be any better than MRI or bone scanning in detecting scaphoid fractures without some over treatment. (10.1177/1753193412446273)
• [L1] This study did not demonstrate a true long-term benefit of internal fixation, compared with nonoperative treatment, for acute nondisplaced or minimally displaced scaphoid fractures. (10.2106/jbjs.g.00673)
• [L4] Patients with recent scaphoid fractures that failed treatment may also be treated with distal scaphoid resection. (10.1016/j.jhsg.2024.03.013)
• [L4] Three-dimensional imaging should be considered when assessing scaphoid nonunions to identify the exact location of the fracture. (10.1016/j.jhsa.2008.05.035)
• [L4] Residual scaphoid deformity has no relevant negative impact on mid-term wrist function. (10.1177/17531934221125355)
• [L2] From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function as well as good wrist motion and strength. (10.1016/j.jhsa.2017.06.016)
• [L4] It facilitates scaphoid union without the need for screw fixation and avoiding potential complications with hardware. (10.1177/1558944718797340)
• [L4] Findings suggest a low but non-zero occult scaphoid fracture rate, discordance in radiologic interpretation, and a lack of advanced imaging, providing an avenue for future prospective studies. (10.1177/1558944720930293)
• [L3] Additionally, a scaphoid nonunion results in an uncoupling of the carpal rows. (10.1177/1753193419866598)
• [L4] 8% of scaphoid ORIF's and 14% of repair nonunions required at least one reoperation, primarily removal of hardware. (10.1016/j.jhsa.2017.06.073)
• [L1] We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively. (10.1302/0301-620x.104b8.bjj-2022-0085.r2)
• [L4] The development of AVN corresponds with a worse prognosis and increases the likelihood of secondary procedures, though it only correlates with nonunion in the scaphoid. (10.5435/jaaos-d-18-00225)
• [L4] Scaphoid nonunions have a dramatic impact on carpal kinematics, partially uncoupling the proximal and distal carpal rows. (10.1016/j.jhsa.2008.03.008)
• [L5] The harvest of the proximal hamate for proximal pole scaphoid reconstruction does not appear to adversely affect wrist kinematics. (10.1177/1558944718793175)
• [L4] There is a need for a validated prognostic classification system for scaphoid nonunions that can allow comparisons between outcome studies. (10.1177/1753193417739510)
• [L4] This case is interesting as the child is one of the youngest patients described in the literature with a scaphoid fracture, and the fracture went on to non-union despite immediate medical attention and rigorous treatment. (10.2106/00004623-198365080-00026)
• [L4] SNAC wrists differ from SLAC wrists in exhibiting a decreased sagittal lunotriquetral angle, indicating a distinct pathomechanism of carpal instability. (10.1186/s12891-025-08652-6)
• [L4] This technique provides a large graft with a long vascular pedicle to restore normal scaphoid geometry and permit normal carpal kinematics. (10.1016/j.jhsa.2010.10.015)
• [L2] Among patients with nonoperatively managed scaphoid fractures, those prescribed NSAIDs within 1 month of diagnosis demonstrated an increased risk of nonunion and subsequent salvage procedures. (10.1016/j.jhsg.2026.100958)
• [L5] The authors state that biomechanical studies demonstrate osteotomies can reliably shift load away from the scaphoid and lunate, and that the procedure involves limited dissection to protect wrist joint innervation, contrasting with denervation procedures requiring extensive dissection. (10.1016/j.jhsa.2014.05.037)
• [L4] The method offers pain relief and does not compromise wrist motion or grip strength. (10.1016/j.jhsa.2014.01.045)
• [L4] The recovery of wrist function in the 3 patients supports the assessment that this procedure may successfully restore mechanical integrity of the proximal pole of the scaphoid in young patients with no evidence of radiocarpal arthritis. (10.1016/j.jhsa.2013.08.093)
• [L1] While surgical intervention is still the standard, our results show that LIPUS may serve as a nonoperative alternative to scaphoid nonunion in certain cases. (10.1177/1558944717702470)
• [L4] The technique described is an effective and efficient method of treating nondisplaced scaphoid nonunions without AVN. (10.1016/j.jhsa.2015.05.022)
• [L5] The authors argue that comfort with uncertainty is key in suspected scaphoid fracture scenarios, as there is no best strategy; instead, clinicians should help patients choose a diagnostic and therapeutic course based on their individual values and risk tolerance. (10.1097/corr.0000000000003141)
• [L4] The study confirms that this approach is a reliable option that obtains excellent results in pediatric scaphoid nonunions. (10.1016/j.jhsa.2006.11.007)
• [L5] This review serves as an overview of the surgical fixation options for addressing scaphoid nonunion, noting that there is no overarching agreement about the best management option or fixation techniques. (10.5435/jaaos-d-23-00287)
• [L5] According to the existing literature, MRI is the best diagnostic radiological test for triage of suspected scaphoid fractures, but bone scanning, CT, and ultrasound may also be useful, particularly when MRI is not readily available. (10.1016/j.jhsa.2008.04.016)
• [L4] Measurements of displacement and deformity in scaphoid fractures can be made in the wrist axis with comparative reliability to those in the longitudinal scaphoid axis. (10.1016/j.jhsa.2018.05.006)
• [L5] Routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment, with nearly 70% of MRI findings categorized as distracting and potentially misleading, suggesting that stopping the pursuit of occult fractures may prevent unnecessary treatment. (10.1097/corr.0000000000002914)
• [L4] The earliest recovered wrist functional parameters were grip strength, motion arc, Mayo Wrist score and finally the DASH score at postoperative 6 months and 12 months, respectively. (10.1186/s13018-020-02055-0)
• [L4] This review focuses on the indications and role of bone grafts in scaphoid nonunions to help augment internal fixation, promote healing, and restore carpal alignment. (10.5435/jaaos-d-24-00510)
• [L5] The authors argue that better standardization of MRI definitions for scaphoid fractures is required, but acknowledge that a definition may not exist to solve the potentially unsolvable issue of diagnostic uncertainty, suggesting patients should participate in decisions regarding diagnostic and treatment strategies. (10.1177/17531934251394819)
• [Paper] MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers. (10.1016/s0363-5023(10)60085-8)
• [L4] Routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment due to the high prevalence of distracting signal changes and low prevalence of true fractures. (10.1097/corr.0000000000002851)
• [L3] Computed tomography improves the reliability of detecting scaphoid fracture displacement but has a more limited effect on accuracy, which remains <80%. (10.2106/JBJS.E.01211)
• [L1] Initial cast immobilization of minimally displaced scaphoid fractures, with immediate fixation only offered to patients with nonunion, is the optimal form of treatment, resulting in comparable outcomes with less cost to the healthcare system. (10.1302/0301-620x.103b7.bjj-2020-2322.r2)
• [L4] Good clinical outcomes can be achieved after scaphoid fractures in prospective NFL athletes. (10.1016/j.arthro.2017.08.259)
• [L4] The data also show that scaphoid nonunions produce new bone at the site, which may have positive implications toward hardware fixation and healing stimulation. (10.1016/j.jhsa.2008.01.017)
• [L4] Scaphoid plating achieved bony union in 72% to 100% of cases with no significant difference in union incidence compared to headless compression screws. (10.1177/17531934211005637)
• [L4] Mg screws demonstrate potential benefits for bioabsorbable fixation, but findings indicate a high rate of complications, including non-union and screw instability, in scaphoid fractures. (10.1186/s13018-025-05701-7)
• [L4] The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunions with segmental defects yields reliable union rates and good patient outcomes. (10.1016/j.jhsa.2017.06.074)
• [L4] The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunion with segmental defects yields reliable union rates and good patient outcomes. (10.1016/j.jhsa.2018.05.023)
• [L4] Reestablishment of normal scaphoid anatomy results in a majority of good and excellent outcomes and cessation of scaphoid nonunion advanced collapse deformity. (10.1054/jhsb.2001.0651)
• [L4] This study suggests that efforts to reduce variation in the management of suspected scaphoid fractures can address variations in surgeon tolerance of uncertainty and surgeon regard for variations in symptom intensity and patient tolerance of uncertainty. (10.5435/jaaos-d-24-00959)
• [L4] 84% of patients who had failed prior scaphoid nonunion surgery healed at a mean of 16 weeks after treatment with free-vascularized medial femoral condyle grafts. (10.1016/j.jhsa.2017.06.075)
• [L4] The authors note that while this outcome is unusual, it may occur in isolated cases, though they do not advocate for non-treatment of such fractures. (10.1007/s11552-011-9328-6)
• [L4] Failure of acute scaphoid fracture fixation often results from malreduction, failure to restore length, or compromised vascularity. (10.1016/j.jhsa.2014.02.023)
• [L5] Arthroscopic techniques have limitations in restoring normal carpal alignment, especially in patients with unstable scaphoid nonunion and carpal collapse deformities, although this does not affect the recovery of clinical function. (10.1016/j.arthro.2018.07.040)
• [L4] The authors are concerned about the high proportion of hardware complications and required secondary surgical procedures. (10.1016/j.jhsa.2017.12.004)
• [L4] Arthroscopic reduction and osteosynthesis of chronic unstable scaphoid nonunion is limited for restoration of normal carpal alignment but has positive effects on the recovery of clinical wrist function. (10.1016/j.arthro.2014.08.035)
• [L3] Misdiagnosed and maltreated scaphoid fractures result in significant complications, primarily pseudoarthrosis, and high costs for both society and patients. (10.1530/eor-21-0108)
• [L4] Based on the high probability of arthritis, the authors recommend that all displaced ununited scaphoid fractures be reduced and grafted before degenerative changes occur. (10.2106/00004623-198466040-00003)
• [L4] Persistent nonunion is common after surgery for scaphoid non-union, and surgeries for persistent nonunion are even less successful. (10.1016/j.jhsa.2015.06.023)
• [L4] Distal scaphoid resection arthroplasty provides good functional outcomes and pain relief for avascular necrosis of the distal pole secondary to scaphoid nonunion. (10.1177/1753193416680498)
• [L3] Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union. (10.1177/15589447221142894)
• [L1] The data to date have demonstrated that the advantages of surgical fixation are transient, the possible complications must not be underestimated, and the long-term outcomes of surgical fixation are incompletely understood. (10.1016/j.jhsa.2008.12.027)

See Also

• Distal Radius Fracture

References

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