Scaphoid Fracture Fixation

Why this approach — at MOS

Scaphoid fracture fixation is a technically demanding procedure because getting the headless compression screw perfectly centered along the scaphoid's long axis — the "central axis" screw position — significantly affects union rates and strength of fixation. Placement that deviates from the central axis provides less compression and is associated with higher rates of fixation failure. Dr. Fitzgibbons uses fluoroscopic guidance with multiple views and a dedicated scaphoid axis fluoroscopy technique to confirm central placement before screw insertion.

For established nonunions, the treatment is more complex and the surgeon's experience managing this complication matters. Non-vascularized bone graft (from the distal radius) works well for nonunions without avascular necrosis. When MRI confirms signal change suggesting avascular necrosis of the proximal pole, a vascularized bone graft — which brings its own blood supply — is the preferred biological solution to restart bone remodeling.

Patients presenting to our Bethesda and Germantown offices with wrist pain after a fall, especially on the radial (thumb) side of the wrist, receive early imaging including CT scan when initial X-rays are normal but clinical suspicion for scaphoid fracture is high. Missed or late-diagnosed scaphoid fractures that progress to nonunion and scaphoid nonunion advanced collapse (SNAC) arthritis are a preventable outcome with timely diagnosis and treatment.

Who is a candidate?

Indications

• Displaced scaphoid fracture (any displacement > 1–2 mm, angular deformity, or humpback deformity)
• Proximal pole fracture (high nonunion risk due to tenuous blood supply)
• Scaphoid waist fracture in an active patient who cannot tolerate 10–12 weeks of cast immobilization
• Competitive athlete who needs early return to sport
• Delayed presentation or established nonunion with or without avascular necrosis
• Associated wrist ligament injury (perilunate instability) requiring surgical management

Contraindications

• Non-displaced distal third fracture with acceptable alignment — cast immobilization is highly effective and surgery is not needed
• Patients who refuse surgery and accept prolonged cast treatment and its associated risks of nonunion
• Active infection at the wrist

Conservative Treatment First

Non-displaced or minimally displaced scaphoid waist fractures have union rates of 85–90% with proper cast immobilization. A thumb spica cast (which immobilizes the wrist and thumb) worn for 10–12 weeks is the standard non-surgical treatment. Compliance with cast immobilization is essential — partial immobilization leads to higher nonunion rates.

Even with perfect casting, a non-displaced waist fracture requires at least 10–12 weeks to heal, and proximal pole fractures may need 16–20 weeks or more. For many active patients, athletes, and workers, this duration of immobilization is not practical. Surgery reduces healing time and allows earlier return to activity, which is why operative management is increasingly offered to active patients even for non-displaced waist fractures after an informed discussion of the risks and benefits.

The procedure

What Is Scaphoid Fracture Fixation?

Scaphoid fracture fixation is surgery to stabilize a broken scaphoid bone in the wrist using a headless compression screw. The scaphoid has a fragile blood supply, making certain fractures — particularly displaced or proximal pole fractures — prone to nonunion or avascular necrosis if not surgically fixed. Surgery promotes reliable healing and allows faster return to activity than cast immobilization alone.

The scaphoid is the carpal bone on the thumb side of the wrist, roughly the shape and size of a cashew nut. It is the most commonly fractured carpal bone and the most commonly missed wrist fracture — many patients dismiss a scaphoid fracture as a "sprained wrist" because initial X-rays can appear normal (CT or MRI is often needed for diagnosis). The injury typically occurs from a fall onto an outstretched hand.

The scaphoid's blood supply is precarious: the main vessels enter at the distal pole and travel proximally through the bone. A fracture at the waist (middle) or proximal pole can interrupt this supply to the proximal fragment. Without adequate blood flow, the proximal scaphoid can fail to heal (nonunion) or undergo avascular necrosis (bone death) — complications that lead to progressive wrist arthritis if untreated.

Surgical fixation using a headless compression screw achieves stable internal fixation that holds the fracture reduced while healing proceeds. It is preferred over prolonged cast treatment for displaced fractures, proximal pole fractures, and active patients who cannot afford 10–12 weeks in a thumb spica cast.

What Happens During Scaphoid Fracture Fixation?

Setting and anesthesia: Performed at an ambulatory surgery center under regional anesthesia (wrist or brachial plexus block) or general anesthesia. The procedure takes 45–75 minutes.

Percutaneous technique (most common for non-displaced fractures): A small stab incision is made at the dorsal wrist. Under fluoroscopic guidance, a guidewire is passed centrally along the long axis of the scaphoid from proximal to distal. Central guidewire placement is confirmed in both anteroposterior and lateral projections, as well as a scaphoid-specific view. A cannulated headless compression screw is advanced over the guidewire and seated so that it compresses the fracture while remaining entirely within the bone (no prominent hardware). The stab incision is closed with a single suture.

Open technique (required for displaced fractures or nonunion): An incision is made at the dorsal or volar wrist to directly expose the fracture. For displaced fractures, the fragments are reduced under direct vision before guidewire placement and screw fixation. For established nonunion, bone graft (typically from the distal radius or iliac crest) is packed into the nonunion site before screw fixation to stimulate healing. Vascularized bone graft is used when avascular necrosis of the proximal pole is confirmed.

A short-arm thumb spica splint is applied at the end of the procedure.

Recovery timeline

Frequently Asked Questions