Delays and poor management of scaphoid fractures: factors contributing to nonunion

Scaphoid fracture nonunion remains prevalent, and it was our purpose to examine the initial care, fracture site, and patient gender and age to determine factors contributing to fracture nonunion.

The charts of 96 consecutive patients with 99 scaphoid fracture nonunions were reviewed for demographic information, and contact was made with 85 patients (with 88 scaphoid nonunions) to determine the pattern of presentation and initial treatment, if any.

Of the 88 scaphoid nonunions, 78 were in men, and 46 were sports injuries; 7 patients had no recollection of an injury. Twenty were proximal pole fractures. For 57 fractures, patients sought care following their injury, but only 42 were diagnosed with scaphoid fractures and received appropriate treatment, although one did not follow up in the clinic. Fifteen patients with nonunions did not receive radiographic investigations or did not have an identifiable fracture on initial x-rays and received no further follow-up or treatment. For 27 nonunions, medical attention was sought but was delayed, with an average time of 57 days between injury and initial assessment. For 31 fractures, medical attention was not sought for the acute injury but presented later following a re-injury (17 nonunions) or with progressive pain or stiffness (13 nonunions).

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 particularly because the initial injury is, unfortunately, sometimes perceived as trivial. Nonunions do occur despite appropriate immobilization. Proximal pole fractures and fractures that show inadequate progression toward union while being treated in a cast should be considered for surgical intervention based on the high number of such cases identified in this study.