Scaphoid fractures: what's hot, what's not.

The scaphoid is the most commonly fractured carpal bone of the wrist. It is an unusual carpal bone in that it bridges both the proximal and the distal rows; this subjects it to continuous shearing and bending forces. Approximately 80% of the scaphoid is covered by cartilage, which limits its ligamentous attachment and vascular supply. Most scaphoid fractures occur at the waist. Acute stable fractures or incomplete fractures of the scaphoid may be treated nonsurgically; a high rate of union can be expected. However, there is considerable debate about the type of immobilization needed. Although closed treatment of stable wrist fractures of the scaphoid achieve a high rate of healing, prolonged cast immobilization may lead to complications, including muscle atrophy, possible joint contracture, and disuse osteopenia. Because of this, internal fixation of minimally displaced fractures of the scaphoid has recently become popular. There is consensus in the literature that nonunion of the scaphoid and proximal pole fractures should be treated surgically. In the past several decades, percutaneous arthroscopic techniques of scaphoid stabilization, which minimize surgical morbidity, have become popular. There also has been a significant improvement in the management of difficult scaphoid nonunions, with or without deformity. Improved techniques include open and dorsal approaches and vascularized bone grafting of resistant scaphoid nonunions. Declining in popularity is the prolonged immobilization of unstable fractures when surgical stabilization may have been a better treatment option.