Scaphoid fractures are the most frequently encountered injuries among the carpal bones, accounting for approximately 60–70% of all carpal fractures [1]. These injuries are predominantly observed in young, active adults and are typically caused by falls on an outstretched hand (FOOSH), resulting in hyperextension and axial loading of the wrist [2]. The scaphoid’s unique anatomical location, bridging the proximal and distal carpal rows, combined with its retrograde blood supply, predisposes it to complications such as non-union, avascular necrosis, and eventual carpal instability if timely and appropriate management is not instituted [3,6].

Early diagnosis remains challenging, as initial radiographs may fail to reveal the fracture, often leading to delayed treatment and poor outcomes. Prompt and accurate diagnosis followed by surgical intervention is essential to minimize long-term morbidity [4]. Among various treatment modalities, internal fixation using the Herbert screw has gained popularity for managing unstable or displaced scaphoid fractures. This headless, double-threaded implant allows for stable interfragmentary compression and facilitates early mobilization, promoting rapid functional recovery and bone healing [1,5].

The choice of surgical approach volar or dorsal—is determined based on the location and configuration of the fracture. The volar approach offers better exposure for waist and distal pole fractures, while the dorsal route is preferred for proximal pole fractures due to its superior visualization and screw trajectory [1,3].

This study was conducted to evaluate the functional and radiological outcomes of scaphoid fractures treated with Herbert screw fixation and to compare the results based on fracture type and surgical approach.

Study Design and Setting:

This was a prospective observational study conducted over a period of 18 months, from december 2022 to May 2024, at the Department of Orthopaedics, Osmania General Hospital, Hyderabad, a tertiary care teaching hospital in Telangana.

Sample Size and Selection Criteria:

A total of 20 adult patients (age >18 years) presenting with displaced scaphoid waist (type B2) and proximal pole (type B3) fractures were included. Fractures were classified using the Herbert-Fischer classification system. Patients with tuberosity fractures, compound injuries, or associated wrist fractures/dislocations were excluded.

Diagnostic and Preoperative Assessment:

All patients underwent initial clinical evaluation followed by a dedicated scaphoid series radiograph (PA, lateral, and ulnar-deviation views). When radiographic evidence was inconclusive, CT imaging was used to confirm diagnosis and evaluate fracture characteristics.

Surgical Procedure:

Open reduction and internal fixation using Herbert screws was performed under regional or general anesthesia. Volar approach was employed for waist and distal pole fractures, while the dorsal approach was preferred for proximal pole fractures. Percutaneous fixation was performed in minimally displaced fractures. Screw length selection was guided by intraoperative fluoroscopy to ensure central placement across the fracture site.

Postoperative Protocol and Follow-Up:

Postoperatively, patients received antibiotics and were immobilized with a thumb spica cast for two weeks, followed by a removable wrist brace and physiotherapy. Clinical and radiological follow-up was performed at 4-week intervals until union. Union was defined as absence of tenderness over the scaphoid with radiographic evidence of trabecular continuity on at least two views.

Outcome Measures:

Functional outcomes were assessed using the Modified Mayo Wrist Score (MMWS). Grip strength was evaluated using contralateral comparison, and range of motion was measured using a goniometer. Complications such as wrist pain, stiffness, or scar sensitivity were also documented.

A total of 20 patients with scaphoid fractures were included in this prospective study. The majority of patients were male (80%), with the most common age group being 25–34 years (60%). The right wrist was more frequently involved (65%), likely reflecting dominant-hand injury patterns associated with falls and trauma (Table 1).

Table 1: Demographic Profile of Study Participants (n = 20)

Road traffic accidents (RTAs) were the predominant cause of injury (65%), followed by sports-related trauma (25%) and self-falls (10%). Most patients underwent surgical intervention within 10–19 days of injury (65%), while a smaller subset received delayed treatment between 20–59 days (Table 2).

Table 2: Mechanism of Injury and Timing of Surgery

Figure 1. Mode of Injury Distribution

Figure 2. Timing of Surgical Intervention

Fractures were classified according to the Herbert classification. Type B2 (displaced waist fractures) accounted for the majority (60%), followed by type B1 (20%) and type B3 (20%). The volar approach was preferred in 75% of patients, particularly for waist and distal pole fractures, while the dorsal approach was utilized in 25%, mainly for proximal pole involvement (Table 3).

Table 3: Fracture Type and Surgical Approach

Figure 3. Distribution of Surgical Approach by Fracture Type

Functional outcomes were assessed using the Modified Mayo Wrist Score (MMWS). At final follow-up, 65% of patients had excellent outcomes, 30% had good outcomes, and 5% had fair outcomes (Table 4).

Figure 1: Preoperative Radiograph Showing Displaced Scaphoid Waist Fracture (Herbert Type B2)
This image demonstrates the typical radiographic appearance of a Herbert type B2 fracture involving the waist of the scaphoid prior to surgical intervention.

Figure 2: Intraoperative Fluoroscopic Image Demonstrating Central Herbert Screw Placement
An intraoperative fluoroscopic view showing the guidewire and final Herbert screw positioned centrally across the scaphoid fracture site, ensuring optimal interfragmentary compression.

Figure 3: Postoperative Follow-Up Radiograph Demonstrating Union at 12 Weeks
Follow-up X-ray at 12 weeks post-surgery indicating complete trabecular continuity across the fracture site, consistent with radiological union.

Table 4: Functional Outcome Based on Modified Mayo Wrist Score (MMWS)

All patients achieved radiological union, typically within 6–10 weeks of surgery.

Figure 4. Functional Outcome Based on Modified Mayo Wrist Score (MMWS)

Postoperative complications were observed in 45% of patients. Wrist pain was the most common (20%), followed by transient wrist stiffness (15%) and scar sensitivity (10%). No severe complications such as non-union or implant failure were reported. More than half of the cohort (55%) had no postoperative issues (Table 5).

Table 5: Postoperative Complications

Scaphoid fractures, particularly those involving the waist and proximal pole, present significant clinical challenges due to their susceptibility to non-union and avascular necrosis, primarily because of the scaphoid’s retrograde vascular supply [11]. In this prospective study of 20 patients treated with Herbert screw fixation, we observed high union rates and favorable functional outcomes, supporting the effectiveness of this surgical technique.

The demographic profile in our study, with a predominance of young males aged 25–34 years, is consistent with existing literature indicating that physically active males are more prone to high-energy trauma such as road traffic accidents and sports injuries. These observations are aligned with findings from Saedén et al. and others who reported similar epidemiological patterns in scaphoid injuries [7].

Type B2 fractures (displaced waist) were the most common, accounting for 60% of cases, reflecting the biomechanical vulnerability of the scaphoid waist to axial loading and bending forces during wrist hyperextension [8]. The volar approach was employed in 75% of cases, offering direct access for waist and distal pole fixation, while the dorsal approach was used in proximal pole fractures to achieve optimal screw placement and maintain blood supply integrity [12].

Radiological union was achieved in all patients, typically within 6–10 weeks, which is comparable to outcomes reported by Inoue et al. and Parajuli et al., who noted earlier union and restoration of grip strength with Herbert screw fixation [9,10]. Functional outcomes based on the Modified Mayo Wrist Score were excellent in 65% and good in 30%, reaffirming the role of stable internal fixation in achieving pain-free motion and early return to activity.

Postoperative complications in our cohort were minimal and included transient wrist pain, stiffness, and scar sensitivity, all of which resolved with conservative management. These findings are consistent with the literature, which emphasizes meticulous surgical technique and appropriate approach selection to minimize iatrogenic damage and enhance patient recovery [11,12].

While the study supports the safety and efficacy of Herbert screw fixation, limitations include a small sample size, lack of a conservatively treated comparison group, and absence of long-term follow-up to assess for late complications such as post-traumatic arthritis. Nonetheless, our results corroborate the existing evidence favoring Herbert screw fixation as a reliable method for treating displaced scaphoid fractures [7,10].

This prospective study demonstrates that Herbert screw fixation is a safe, effective, and reliable method for managing displaced scaphoid fractures, particularly those involving the waist and proximal pole. All patients achieved radiological union, with the majority exhibiting excellent (65%) or good (30%) functional outcomes based on the Modified Mayo Wrist Score. Early surgical intervention, appropriate selection of surgical approach, and adherence to post-operative rehabilitation protocols contributed to successful outcomes. Complications were minimal and transient, with no cases of non-union or implant failure. These findings reinforce Herbert screw fixation as the preferred surgical technique for scaphoid fractures requiring internal stabilization and early mobilization.

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