Abstract
Background
Carpal fractures (incidence: 30–60 per 100 000 persons per year) are one of the more commonly overlooked fracture types. They can have serious consequences, as the use of the hand is indispensable in everyday life. In the following article, we present the elements of the diagnosis and treatment of fractures of the carpal bones.
Methods
This review is based on meta-analyses and randomized controlled trials (RCTs) published from 2013 to 2023 that were retrieved by a structured literature search, supplemented by guideline recommendations and expert consensus statements. In addition, data on the administrative prevalence of carpal fractures were obtained from the German Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung, KV) and from the German Statutory Accident Insurance (Deutsche Gesetzliche Unfallversicherung, DGUV).
Results
The administrative prevalence of carpal fractures in 2022 was 44 496 outpatient cases (KV, DGUV) in one year. After clinical history-taking, physical examination and x-ray have been performed, thin-slice computed tomography is recommended as part of the diagnostic evaluation. Treatment recommendations are based on evidence of levels II to IV. Multiple RCTs have been carried out on the treatment of scaphoid fractures, and a clinical guideline exists. Proximal, dislocated and unstable scaphoid fractures should be treated surgically. Non-displaced or minimally displaced fractures of the middle third of the scaphoid bone require a shorter period of immobilization with surgical treatment (2–4 weeks) than with conservative treatment (6–8 weeks). The use of plaster casts that do not hinder elbow and thumb mobility yields healing rates similar to those obtained with the immobilization of both of these joints. Failure to treat an unrecognized scaphoid fracture can lead to pseudarthrosis, avascular bony necrosis, and misalignment. Other, rarer types of carpal fractures must be managed on an individual basis, as the available evidence is limited to expert consensus.
Conclusion
Early recognition and appropriate treatment of carpal fractures lead to healing in more than 90% of cases. Although the available evidence on their proper treatment is growing, many questions are subject to expert consensus, and decisions about treatment must be made individually.
CME plus+
This article has been certified for continuing professional development purposes by the North Rhine Academy. The questions on this article may be found at http://daebl.de/RY95. The closing date for entries is 5 September 2025.
Participation is possible at cme.aerztebatt.de
Fractures of the carpal bones, especially scaphoid fractures, can have serious consequences for the function of the human hand as a tactile and grasping organ (1, 2). Furthermore, the majority of them affect people of working age, which is why these fractures are of such socio-economic relevance (3, 4).
Carpal fractures account for around eight percent of all hand fractures and, with an incidence of around 30 to 60 per 100 000 population, are among the least common fractures in humans (1, 5, 6). In 2022, 43 625 outpatient cases of carpal fractures were registered in Germany by the Central Research Institute of Ambulatory Health Care (Zi) and 871 cases by the German Statutory Accident Insurance (DGUV). The Zi found that slightly more than one half (53.1%) of these were scaphoid fractures, while the literature states the proportion of scaphoid fractures to be 51 to 90% (7, 8). The majority of carpal fractures (71.3%) are sustained by men, with 71 to 86% of patients affected being younger than 60 years of age (7, 8). In around 85% of cases, the cause is a fall on the outstretched hand (4). Because of the complex anatomy, carpal fractures are also commonly overlooked during conventional diagnostic investigations: The proportion of missed scaphoid fractures is estimated at up to 30% (eBox 1) (9).
eBox 1. Characteristics common to carpal fractures according to Garcia-Elias (34).
young age (18–30 years), high functional demands
easily missed at initial presentation
surgical reduction difficult due to small size of the fractured carpal bone
this potentially compromises its vascular supply
secondary osteoarthritis due to posttraumatic incongruent joint surfaces
unstable carpal fractures frequently associated with adjacent ligamentous injury
causes secondary entrapment neuropathies and tendon ruptures due to close relationship of the carpus to nerves and tendons
For this reason, the current review article is focused on the elements of the diagnosis and treatment of fractures of the carpal bones. Given their functional relevance, it is also essential that colleagues who do not specialize in hand surgery are familiar with carpal fractures.
Methods
After registration (PROSPERO: ID CRD42023479061), this review article began with a literature search. It was based on the PICO framework and the PRISMA criteria and included meta-analyses and randomized controlled trials (RCTs) published from 2013 to 2023 (Table, eTable) (7, 8, 10–22).
Table. RCTs and meta-analyses on the treatment of carpal fractures.
| First author (study type, reference) | Type of scaphoid fracture | Intervention | Results/primary outcome *[95% confidence interval] | Comments/interpretation | |
| 1 | Dias (RCT) (7) |
Minimally displaced (≤ 2 mm) | Surgical fixation vs. cast immobilization (+ surgical fixation for nonunion) | PRWE score after 52 weeks: 11.9 [9.2; 14.5] vs. 14.0 [11.3; 16.6] Surgery vs. cast-related complications 31 [14%] vs. 40 [18%] |
General complication rate: 4 (2%) vs. 5 (2%); cast immobilization for adults, minimally (≤ 2 mm) displaced scaphoid fractures; surgery if nonunion suspected |
| 2 | Siotos (MA) (14) |
Acute, undisplaced or minimally displaced | 1) Below-elbow cast vs. above-elbow cast 2) With thumb immobilization cast vs. without thumb immobilization cast |
1) Nonunion: 9.6% vs. 10.5%; OR = 0.79 [0.19; 3.26]; p = 0.74 2) Nonunion: 10.3% vs. 10.1%; OR = 0.97 [0.49; 1.94]; p = 0.69 |
Comparable results for: 1) Below-elbow cast vs. above-elbow cast; 2) With thumb immobilization cast vs. without thumb immobilization cast |
| 3 | Clementson (RCT) (19) |
Acute, undisplaced or minimally displaced | Conservative treatment vs. arthroscopic-assisted screw fixation (acute, undisplaced or minimally displaced) | Range of wrist motion: (10 weeks: 63% vs. 80%; p = 0.28; 26 weeks: 97% vs. 88%; p = 0.004); DASH score: (6 weeks: 27 vs. 10; p = 0.01; 10 weeks: 18 vs. 9; p = 0.025; more than 10 weeks: p >0.05); patient satisfaction: (p = 0.25) |
Screw removed in 2 patients |
| 4 | Alnaeem (MA) (16) |
Acute, undisplaced or minimally displaced | Conservative treatment vs. percutaneous fixation | Time to return to work: 11 vs. 6 weeks, p <0.05; time to bony union: 79 vs. 44 days, p <0.05; complication rate: 7% vs. 14%, p = 0.2 | Faster recovery after surgical treatment; complications, on the other hand, usually more serious, e.g. 16% screw misplacement |
| 5 | Eastley (MA) (21) |
Proximal | Union rate of proximal vs. distal scaphoid fracture (treated nonoperatively) | Nonunion rate for nonoperative treatment of proximal fractures (34%), vs. more distal fractures (<5%) (pooled or = 7.4 [3.8; 14.4]) | Term “proximal” defined inconsistently in 9 of the 11 assessed studies; result after operative fixation assessed in only 3 studies |
Randomized controlled trials and meta-analyses considered particularly relevant by the authors during the period of the conducted review (01.01.2013–01.11.2023), (overview of all studies provided in eTable 1).
*Results of the primary endpoint and key findings of the article; no claim to completeness; the order of the compared values refers to the order of the column “Intervention”; some of the results are only presented graphically in the publications; “return to work/sports” in weeks, if not otherwise stated
DASH score, disability of the arm, shoulder and hand (0–100); grip strength, 30–60 kg; MA: meta-analysis;
MD, mean difference; OR: Odds Ratio; PRWE score, total patient-rated wrist evaluation (0–50);
RCT, randomized controlled trial; ROM, range of motion (dorsal extension/palmar flexion: 60/80; radial abduction/ulnar abduction: 20/40);
SMD, standardized mean difference; vs, versus
eTable. Included studies*1.
| First author (study type, reference) | Study size | Intervention (type of scaphoid fracture) | Primary outcome/data analysis*1 | |
| 1 | Al-Ajmi (MA) (15) | 8 studies, 378 fractures |
Surgical vs. conservative treatment (acute, undisplaced or minimally displaced) | After surgical treatment: earlier return to work: weighted SMD = –6.01 [–9.16; –2.87]; functional scores after 2 months 73/100 vs. 73/100; MD = –0.77 [–1.11; –0.34]; after 4 months 69/100 vs. 71/100 SMD = –0.63 [–1.16; –0,11]; ROM using treatment score 73/100 vs. 73/100 SMD = 25.01 [–1.39; 51.38]; complication rate (p = 0.754) |
| 2 | Alnaeem (MA) (16) | 10 studies, 376 patients |
Conservative treatment vs. percutaneous fixation (undisplaced and minimally displaced) | Time to return to work: 11 vs. 6 weeks, p <0.05; time to bony union: 79 vs. 44 days, p <0.05; complication rate: 7% vs. 14%, p = 0.2 |
| 3 | Buijze (RCT) (17) | 62 patients | Cast immobilization with vs. without immobilization of the thumb (undisplaced or minimally displaced) | Bony union after 10 weeks: 84% [35; 100], vs. 70% [7; 100]; p = 0.099 |
| 4 | Chen (MA) (18) | 12 studies, 1075 patients |
Surgical vs. conservative treatment (acute, undisplaced or minimally displaced) | Nonunion rate: OR = 0.71 [0.24; 2.10]; effect strength after surgical treatment: shorter healing time: MD = 9.03 [7.43; 10.64]; earlier return to work: MD = 9.68 [8.61; 10.76]; better grip strength: MD = –1.70 [-2.25; –1.15]; better range of wrist motion: āMD = –1.84 [–2.40; –1.27]; (MD calculated from effect sizes, therefore no unit) |
| 5 | Clementson (RCT)*2 (19) | 38 patients | Conservative treatment vs. arthroscopic-assisted screw fixation (acute, undisplaced or minimally displaced) | Range of wrist motion (10 weeks 63% vs. 80%; p = 0.28; 26 weeks 97% vs. 88%; p = 0.004); DASH score (6 weeks 27 vs. 10; p = 0.01; 10 weeks 18 vs. 9; p = 0.025, later than 10 weeks; p >0.05); patient satisfaction (p = 0.25) |
| 6 | Dias (RCT)*3 (7) | 1047 patients | Surgical fixation vs. cast immobilization (+ early surgical fixation if nonunion) (minimally displaced, ≤ 2 mm) | PRWE score after 52 weeks: 11.9 [9.2; 14.5] vs.14.0 [11.3; 16.6]; nonunion rate after 52 weeks: OR = 0.40 [0.12; 1.33]; days off sick: 15.6 days vs. 18.2 days; p >0.05 |
| 7 | Drac (RCT) (20) | 76 patients | Palmar vs. dorsal mini-invasive approach for surgery (undisplaced or minimally displaced) | Nonunion rate: 1 vs. 0; range of motion: no significant differences at any level; grip strength: 93.8 vs. 94.1; p = 0.626; patient satisfaction (binary): 97.3 vs. 97.3; p = 1.0; DASH score: 3.89 vs. 3.70; p = 0.740; complication rate: 5 vs. 6; p = 1.00 |
| 8 | Eastley (MA) (21) | 11 studies, 1147 fractures |
Union rate after proximal vs. distal scaphoid fracture (treated nonoperatively) | Nonunion rate of proximal fractures treated conservatively (34%), comparison with more distal fractures (<5%) (or = 7.4 [3.8; 14.4]) |
| 9 | Johnson (MA) (22) | 7 studies with 772 patients |
Surgical vs. conservative treatment (undisplaced or minimally displaced) | Patient reported wrist function 12 months after injury (using various PROMs) (Hedges’ g 0.15 [–0.02; 0.32]; p = 0.082) |
| 10 | Kang (MA) (10) | 7 studies with 141 patients |
Dorsal vs. palmar percutaneous approach (acute, not specified in detail) | Nonunion rate: dorsal 4/128 vs. palmar 6/134, OR = 0.74 [0.21; 2.54]; postoperative complications dorsal 12/141 vs. palmar 16/142, OR = 1.05 [0.45; 2.44]; overall functional outcome score 0–100 (dorsal 91 vs. palmar 89; SMD = –0.09 [–0.39; 0.22]); postoperative pain score 0–100 (dorsal 38 vs. palmar 28; SMD: –0.03 [–0.52; 0.46]); grip strength (dorsal 104 vs. palmar 103 SMD = –1.77 [–4.56; 1.02]); ROM flexion: dorsal 139 vs. palmar 128; SMD = –0.86 [–2.86; 1.13]; extension: dorsal 139 vs. palmar 128; SMD = 0.75 [–1.27; 2.67], radial deviation: dorsal 126 vs. palmar 121; SMD = 0.32 [–1.94; 2.58]; ulnar deviation: dorsal 126 vs. palmar 121; SMD = –3.71 [–7.48; 0.05] |
| 11 | Lee (MA) (11) | 43 studies with 880 patients |
Complications and open vs. closed surgical treatment (perilunate injuries) | Pooled complication rate (osteoarthritis 30%, carpal instability 15%, avascular necrosis of the lunate 12%, CRPS 11%, scaphoid nonunion 9%) and functional outcome (scapholunate gap 2.3 mm vs. 1.7 mm, p <0.001; mmw score: 74.2 vs. 81.6, p = 0.024) |
| 12 | Li (MA) (8) | 14 studies with 765 patients | Surgical vs. conservative treatment (undisplaced or minimally displaced, middle third) | Surgical treatment: shorter time to bony union (SMD = –5.01 [–7.4; –2.58]; p = 0.000); shorter time until return to work (SMD = –2.09 [–3.08; –1.11]; p = 0.00); lower nonunion rate (RR = 0.47 [0.24; 0.90]; p = 0.23) |
| 13 | Prabowo (RCT) (12) | 36 patients | Navigated vs. conventional percutaneous screw fixation (undisplaced) | Operating time: 83.2 vs. 42.1 minutes; p <0.0001; radiation dose: 106.5 ± 19.9 vs. 45.6 ± 8.0 cGy/cm²; p = 0.016; screw length; Krimmer score: 83.6 vs. 95.0; DASH score: 5.6 vs. 8.0 |
| 14 | Shen (MA) (13) | 340 fractures | Surgical vs. conservative treatment (undisplaced or minimally displaced) | Functional outcome using PRWE, patient evaluation, Green and O‘Brien score: (2 months SMD = –0.77 [–1.11; –0.43]; 6 months SMD = –0.42 [–10.4; –0.21]); NNT = 20 (to prevent delayed bony union); total complication rate: RR = 0.91 [0.51, 1.62]; risk for delayed union: RR = 0.25 [0.07; 0.99], (i.e. 74.6% reduction with surgical treatment) |
| 15 | Siotos (MA) (14) | 7 studies, 1) 280 patients 2) 353 patients |
1) Below-elbow cast vs. above-elbow cast 2) With thumb immobilization cast vs. without thumb immobilization cast |
1) Nonunion rate: 9,6% vs. 10,5%; OR = 0.79 [0.19; 3.26] 2) Nonunion rate: 10.3% vs. 10.1%; OR = 0.97 [0.49; 1.94] |
*1 Results of the primary endpoint and key findings of the article; no claim to completeness; return to work/sports in weeks, if not otherwise stated
Duplication of individual studies in meta-analyses/reviews: *2 used in No. 1; No. 4; No. 9; No. 12; *3 used in No. 4; No. 9
CRPS, complex regional pain syndrome; DASH score, disability of the arm, shoulder and hand (0–100); grip strength: 30–60 kg; MA, meta-analysis; MMW-Score, modified Mayo wrist score (0–100);
NNT, number needed to treat; OR, Odds Ratio; MD, mean difference; PROM, patient-reported outcome measure; PRWE score, total patient-rated wrist evaluation (0–50);
RCT, randomized controlled trial; ROM, range of motion (dorsal extension/palmar flexion: 60/80; radial abduction/ulnar abduction: 20/40); RR, relative risk; SMD, standardized mean difference;
vs, versus
Enquiries were made to the Central Research Institute of Ambulatory Health Care (Zi) and the DGUV to establish the current number of cases in Germany.
A detailed presentation of the literature searches can be found in the supplementary section (eFigure, eMethods).
eFigure.
Identification of studies via databases
Flow diagram showing the process of the systematic literature search in accordance with PRISMA criteria
*1 Automatic program analysis used, individually reviewed by reviewers
*2 Automatic program analysis not used
eMethods.
MeSh-terms of the search codes used during literature search
carpal OR carpal bones OR wrist OR capitate bone OR hamate bone OR lunate bone OR pisiform bone OR scaphoid bone OR trapezium bone OR trapezoid bone OR triquetrum bone AND fracture OR fractures OR fractures, bone
Complete search code
6,#2 AND #3,,"Meta-Analysis, Randomized Controlled Trial, from 2013 - 2023","((""carpals""[All Fields] OR ""wrist joint""[MeSH Terms] OR (""wrist""[All Fields] AND ""joint""[All Fields]) OR ""wrist joint""[All Fields] OR ""carpal""[All Fields] OR ""carpal bones""[MeSH Terms] OR (""carpal""[All Fields] AND ""bones""[All Fields]) OR ""carpal bones""[All Fields] OR (""carpal bones""[MeSH Terms] OR (""carpal""[All Fields] AND ""bones""[All Fields]) OR ""carpal bones""[All Fields]) OR (""capitate bone""[MeSH Terms] OR (""capitate""[All Fields] AND ""bone""[All Fields]) OR ""capitate bone""[All Fields]) OR (""hamate bone""[MeSH Terms] OR (""hamate""[All Fields] AND ""bone""[All Fields]) OR ""hamate bone""[All Fields]) OR (""lunate bone""[MeSH Terms] OR (""lunate""[All Fields] AND ""bone""[All Fields]) OR ""lunate bone""[All Fields]) OR (""pisiform bone""[MeSH Terms] OR (""pisiform""[All Fields] AND ""bone""[All Fields]) OR ""pisiform bone""[All Fields]) OR (""scaphoid bone""[MeSH Terms] OR (""scaphoid""[All Fields] AND ""bone""[All Fields]) OR ""scaphoid bone""[All Fields]) OR (""trapezium bone""[MeSH Terms] OR (""trapezium""[All Fields] AND ""bone""[All Fields]) OR ""trapezium bone""[All Fields]) OR (""trapezoid bone""[MeSH Terms] OR (""trapezoid""[All Fields] AND ""bone""[All Fields]) OR ""trapezoid bone""[All Fields]) OR (""triquetrum bone""[MeSH Terms] OR (""triquetrum""[All Fields] AND ""bone""[All Fields]) OR ""triquetrum bone""[All Fields])) AND (""meta analysis""[Publication Type] OR ""randomized controlled trial""[Publication Type]) AND ((""fractur""[All Fields] OR ""fractural""[All Fields] OR ""fracture s""[All Fields] OR ""fractures, bone""[MeSH Terms] OR (""fractures""[All Fields] AND ""bone""[All Fields]) OR ""bone fractures""[All Fields] OR ""fracture""[All Fields] OR ""fractured""[All Fields] OR ""fractures""[All Fields] OR ""fracturing""[All Fields] OR (""fractur""[All Fields] OR ""fractural""[All Fields] OR ""fracture s""[All Fields] OR ""fractures, bone""[MeSH Terms] OR (""fractures""[All Fields] AND ""bone""[All Fields]) OR ""bone fractures""[All Fields] OR ""fracture""[All Fields] OR ""fractured""[All Fields] OR ""fractures""[All Fields] OR ""fracturing""[All Fields]) OR (""fractures, bone""[MeSH Terms] OR (""fractures""[All Fields] AND ""bone""[All Fields]) OR ""bone fractures""[All Fields] OR ""fractures bone""[All Fields])) AND (""meta analysis""[Publication Type] OR ""randomized controlled trial""[Publication Type]))) AND ((meta-analysis[Filter] OR randomizedcontrolledtrial[Filter]) AND (2013:2023[pdat]))",163,04:48:48
3,"(fracture) OR (fractures) OR (fractures, bone)",,"Meta-Analysis, Randomized Controlled Trial","(""fractur""[All Fields] OR ""fractural""[All Fields] OR ""fracture s""[All Fields] OR ""fractures, bone""[MeSH Terms] OR (""fractures""[All Fields] AND ""bone""[All Fields]) OR ""bone fractures""[All Fields] OR ""fracture""[All Fields] OR ""fractured""[All Fields] OR ""fractures""[All Fields] OR ""fracturing""[All Fields] OR (""fractur""[All Fields] OR ""fractural""[All Fields] OR ""fracture s""[All Fields] OR ""fractures, bone""[MeSH Terms] OR (""fractures""[All Fields] AND ""bone""[All Fields]) OR ""bone fractures""[All Fields] OR ""fracture""[All Fields] OR ""fractured""[All Fields] OR ""fractures""[All Fields] OR ""fracturing""[All Fields]) OR (""fractures, bone""[MeSH Terms] OR (""fractures""[All Fields] AND ""bone""[All Fields]) OR ""bone fractures""[All Fields] OR ""fractures bone""[All Fields])) AND (meta-analysis[Filter] OR randomizedcontrolledtrial[Filter])","11,270",04:26:02
2,(carpal) OR (carpal bones) OR (capitate bone) OR (hamate bone) OR (lunate bone) OR (pisiform bone) OR (scaphoid bone) OR (trapezium bone) OR (trapezoid bone) OR (triquetrum bone),,"Meta-Analysis, Randomized Controlled Trial","(""carpals""[All Fields] OR ""wrist joint""[MeSH Terms] OR (""wrist""[All Fields] AND ""joint""[All Fields]) OR ""wrist joint""[All Fields] OR ""carpal""[All Fields] OR ""carpal bones""[MeSH Terms] OR (""carpal""[All Fields] AND ""bones""[All Fields]) OR ""carpal bones""[All Fields] OR (""carpal bones""[MeSH Terms] OR (""carpal""[All Fields] AND ""bones""[All Fields]) OR ""carpal bones""[All Fields]) OR (""capitate bone""[MeSH Terms] OR (""capitate""[All Fields] AND ""bone""[All Fields]) OR ""capitate bone""[All Fields]) OR (""hamate bone""[MeSH Terms] OR (""hamate""[All Fields] AND ""bone""[All Fields]) OR ""hamate bone""[All Fields]) OR (""lunate bone""[MeSH Terms] OR (""lunate""[All Fields] AND ""bone""[All Fields]) OR ""lunate bone""[All Fields]) OR (""pisiform bone""[MeSH Terms] OR (""pisiform""[All Fields] AND ""bone""[All Fields]) OR ""pisiform bone""[All Fields]) OR (""scaphoid bone""[MeSH Terms] OR (""scaphoid""[All Fields] AND ""bone""[All Fields]) OR ""scaphoid bone""[All Fields]) OR (""trapezium bone""[MeSH Terms] OR (""trapezium""[All Fields] AND ""bone""[All Fields]) OR ""trapezium bone""[All Fields]) OR (""trapezoid bone""[MeSH Terms] OR (""trapezoid""[All Fields] AND ""bone""[All Fields]) OR ""trapezoid bone""[All Fields]) OR (""triquetrum bone""[MeSH Terms] OR (""triquetrum""[All Fields] AND ""bone""[All Fields]) OR ""triquetrum bone""[All Fields])) AND (meta-analysis[Filter] OR randomizedcontrolledtrial[Filter])","1,438",04:25:15
Filters:
Time frame: 2013-2023
Study designs included: meta-analyses and RCTs
Basic anatomical principles
The proximal row of eight carpal bones comprises from radial to ulna the scaphoid, the lunate, the triquetrum, and the pisiform as a sesamoid, while the distal row consists of the trapezium, the trapezoid, the capitate, and the hamate. The carpal bones are located between the bases of the five metacarpal bones and the radius and ulna and form the radiocarpal and ulnocarpal joints, the midcarpal and the intercarpal joints as well as the basal joint of the thumb. This kinetic chain is stabilized by a total of around 33 ligaments. Not only does it allow a stable transfer of power from the forearm to the metacarpus and a high degree of mobility of the wrist but also mobility of the thumb, which is fundamental for the grasping function of the human hand (23). The scaphoid has a special position, as it acts as a mobile connection between the proximal and distal carpal rows and as such plays a key role in stabilizing the midcarpal joint. It preserves the “carpal height”, which is the distance between the base of the third metacarpal (MC) and the distal articular surface of radius (1, 4, 5, 24, 25). Furthermore, 70 to 80% of the scaphoid is covered by cartilage. This bone has a special blood supply situation, especially to its proximal part. Blood flow is only present in the waist from distal to palmar, as only here does the scaphoid possess a periosteal covering. This is why the scaphoid is at an increased risk of non-union and posttraumatic avascular necrosis (Figure 1) (3, 26, 27).
Figure 1.
Vascularity of the scaphoid, shown from dorsal, with branches of the radial artery
Courtesy of © M.F. Langer. All rights reserved
Diagnostic investigations
Taking an appropriate case history includes, in particular, noting symptoms and mechanism of the accident (Figures 2 and 3). Clinical examination will reveal swelling and tenderness, both on palpation and movement, corresponding to the fracture site. The proximity of adjacent vessels, nerves, and tendons renders essential an additional assessment of circulation, sensory and motor function (CSM) (1, 5). With palpatory accuracy of the landmarks of the carpal bones being only 30 to 88%, the “polyarticular mosaic” of the carpus renders it difficult to precisely narrow down the localization of the fracture, even for the expert. For this reason, additional radiological diagnostic assessment becomes indispensable (2). X-ray examination of the wrist in two planes is fundamental for assessing the carpal structures (sensitivity: 70%, specificity 70 to 85%) (9). In addition, Stecher’s view in ulnar deviation with a closed fist is recommended when a scaphoid fracture is suspected. Additional special radiographic images, however, are not necessary, considering that computed tomography (CT) is readily available nowadays (9, 28). A thin-slice CT scan demonstrates the carpal bones exactly, not only to verify a clinically suspected fracture, but is also recommended once a carpal fracture has been confirmed for purposes of classification, assessment of associated injuries and degree of displacement, as well as for exact planning of treatment (sensitivity: 85 to 95%, specificity 95 to 100%) (9, 25, 28). With the arm positioned above the head, radiation exposure for CT is 0.03 mSi. This is equivalent to about one week of background radiation (29).
Figure 2.
Fall on the hyperextended wrist. The distal pole of the scaphoid is firmly fixed to the trapezium on contact of the hand with the ground and by the ligamentous system; dorsally, the radial margin acts like a chisel, while on the palmar side the radioscaphocapitate ligaments push the proximal pole in a dorsal direction.
Courtesy of © M.F. Langer. All rights reserved
Figure 3.
Different fracture sites on the scaphoid for different positions of the wrist during a fall. Arrows indicating the force vector.
Courtesy of © M.F. Langer. All rights reserved
Intraspongious fractures and ligament injuries which are occult on CT imaging, however, can be demonstrated with the aid of magnetic resonance imaging (MRI); on the other hand, MRI is inferior to thin-slice CT scan for assessing fractures (3).
Treatment and results
A search of the literature (level of evidence II to IV) shows that, in addition to a national guideline, several RCTs and meta-analyses are also available for scaphoid waist fractures comparing a surgical with a conservative approach (5, 9–22). As regards the other carpal bones, there is only one meta-analysis available on acute perilunate injuries, while the others refer to retrospective cohort studies and case reports (eTable) (11).
Scaphoid fractures
In 60 to 69% of cases, the fracture is located in the middle third (the waist) of the scaphoid, followed by the distal third (17 to 32%), and lastly the proximal third (3 to 16%) (3, 30). Herbert’s classification as modified by Krimmer is currently the most common classification for scaphoid fractures. It is based on CT morphological criteria and is fundamental for deciding treatment (Figure 4). The decision between operative and conservative management is based on fracture site, displacement, degree of comminution, associated instability, acceptance by the patient of the required period of immobilization, and functional demand (3).
Figure 4.
Krimmer’s computed tomography-based classification of scaphoid fractures based on Herbert (3, 28): stable fractures (type A) and unstable fractures (type B)
A1: fractures of the tubercle
A2: undisplaced transverse fractures in the middle or distal third
B1: long oblique fractures
B2: displaced or mobile fractures
B3: proximal pole fractures
B4: trans-scaphoid perilunate fracture dislocation
Courtesy of © M.F. Langer. All rights reserved.
Conservative management
Only type A stable scaphoid fractures, which account for 31.1%, are suitable for conservative management (31). A splint or a split plaster cast should be applied for primary immobilization until soft tissue swelling has resolved. This is followed by definitive immobilization in a circumferential cast with slight dorsal extension of the wrist (3). Whereas the metacarpophalangeal joints should be spared immobilization, there is some controversy concerning inclusion or exclusion of the thumb: Recent meta-analyses show that inclusion of the thumb offers no advantage for fracture consolidation (14, 17).
Depending on the fracture site, immobilization for four weeks is sufficient for type A1 fractures, while type A2 fractures should be immobilized for six to eight weeks. Before the immobilization period is over and depending on the clinical assessment, yet after four to eight weeks at the latest, fracture consolidation should be verified radiologically (9, 28). Immobilization should not exceed 12 weeks to avoid stiffness and associated imminent loss of wrist function. If the fracture persistently fails to heal, the alternative of surgical treatment should be planned. This will result in healing of minimally displaced fractures in over 90% of cases (3, 14, 17).
Surgical treatment
Surgical treatment is indicated for Krimmer type B scaphoid fractures and above, due to the instability of the fracture (28). Standard care comprises minimally invasive anatomical reconstruction with a cannulated double-threaded screw which is fully buried in the cancellous bone. In principle, the screw may be inserted antegrade from dorsal or retrograde from palmar for fractures of the middle third, whereas fractures of the proximal third should be managed with an antegrade approach (eFigures 1 and 2) (28). Recent data show no superiority between the different access routes with regard to nonunion rates (non-consolidation rates) (3 to 4%), functional outcome, and complications (eTable) (10, 20). Navigated management to optimize screw placement has so far brought no improvement to outcome results. Indeed, operating time is significantly longer, and radiation exposure is increased (12). If a bone defect or cystic changes within the scaphoid are present, a corticocancellous or cancellous bone graft should be inserted after debriding the fracture site (28).
eFigure 1.
40-year old (male) patient with a proximal scaphoid fracture (Krimmer type B3) (3, 28)
Indication for surgical management due to fracture located at the proximal third
Top row from left to right: preoperative X-rays AP, lateral, Stecher’s view
Bottom row from left to right: postoperative X-rays (AP, lateral, Stecher’s view) after minimally invasive management using an antegrade 2.2 mm double-threaded screw (dorsal approach to the scaphoid).
eFigure 2.
21-year-old (male) patient with a scaphoid waist fracture (Krimmer type B2) (3, 28)
Displacement as the indication for surgical management
Top row from left to right: preoperative X-rays AP, lateral, Stecher’s view, and coronal and sagittal computed tomography
Bottom row from left to right: intraoperative fluoroscopic images (AP and lateral) after minimally invasive management using a retrograde 3.0 mm double-threaded screw (palmar approach to the scaphoid).
There is international consensus on the recommendation of conservative treatment for distal fractures and recommendation of surgical treatment for proximal scaphoid fractures. However, there is some controversy concerning to what extent middle-third scaphoid fractures with a displacement of less than one to two millimeters benefit from surgical management or aggressive non-surgical treatment as with type A2 fractures. Surgical treatment can indeed result in a more rapid return to work and faster time to union, the functional outcome and nonunion rates are comparable, while the minor complication rates are increased (7, 8, 13, 15, 16, 18, 19, 21, 22, 32). Shen et al. demonstrated that the number needed to treat (NNT) in order to prevent one delayed union is 20 (13). From the patient’s perspective, a potentially more rapid return to work due to an operative approach can be highly relevant.
Complications
Apart from general perioperative complications such as infection, soft-tissue damage, bleeding, adhesions, and the development of complex regional pain syndrome (CRPS), scaphoid fractures carry in particular the risk of nonunion and avascular bone necrosis (32, 33). A detailed presentation of the complications can be found in the supplement section (eBox 2).
eBox 2. Complications.
According to the meta-analyses and RCTs on which the present review is based, nerve injury is known to occur in one to two percent of cases of undisplaced middle-third scaphoid fractures, while infection rates are around one percent. Chronic regional pain syndrome (CRPS) can also develop in one to two percent of cases (7, 15, 16, 19).
Furthermore, scaphoid fractures carry the risk of nonunion and avascular bone necrosis (32). The current incidence of nonunion is one percent for undisplaced scaphoid fractures of the middle third under adequate therapeutic care, while the rate for conservatively treated proximal scaphoid fractures is reported to be 34% (16, 21). The nonunion rate for more severely displaced scaphoid fractures, regardless of their exact site, is 10 to 15% (33).
Avascular bone necrosis develops in undisplaced scaphoid fractures of the middle third in one percent of cases, while in proximal fractures avascular bone necrosis can result in nonunion in 20 to 40% due to the retrograde blood supply (16, 21). Screw misplacements have been observed in two percent of cases of undisplaced scaphoid fractures of the middle third (16). Finally, radiocarpal osteoarthritis can develop in two to 39% of these types of fracture, a figure which increases with the observation period of the study in question (15, 19).
Due to the intrinsic ligamentous system and the rotational load, scaphoid fractures of the middle third can also result in palmar tilt of the distal fragment, with the proximal fragment tilting dorsally together with the lunate. This dorsal intercalated segment instability (DISI) malalignment promotes the development of nonunion (3, 28, 32).
If the scaphoid heals despite the instability, malalignment can result in the formation of a dorsal humpback deformity, which in turn carries the risk of extension restriction of the wrist associated with functional impairment and the development of osteoarthritis (3, 28, 32). In the long term, this leads to scaphoid nonunion advanced collapse (SNAC wrist) with potential loss of hand function (3, 21). In summary, scaphoid fractures in particular, but also triquetral body fractures and complex fractures of the carpus, have a high potential for complications, with sometimes grave consequences for the patients if diagnosis is delayed or treatment is inadequate (1, 24, 28). The majority of carpal fractures, other than scaphoid fractures, however, consist of minor avulsions, often with little or no displacement, which usually heal without complication.
Fractures of the triquetrum
Fractures of the triquetrum are the second most common carpal fractures at 10 to 15% (1, 5, 34). A distinction is made between fractures of the dorsal and palmar cortex as well as triquetral body fractures. Ninety-three percent are due to chip fractures which are the result of either a bony avulsion of the dorsal V-ligament (dorsal intercarpal ligament) or a forced dorsal extension of the wrist which produces a chisel action of the ulnar styloid upon the dorsum of the triquetrum (1, 5, 35, 36). Palmar fractures are an indication of an avulsion of the lunotriquetral (LT) ligament, which can result in functional malalignment of the proximal carpal row with palmar rotation of the lunate (palmar intercalated segment instability, PISI). As with DISI malalignment, this can lead to carpal collapse (scapholunate advanced collapse, SLAC wrist) (1, 37). Triquetral body fractures are the consequence of high-energy trauma. They can result in a clinically relevant dislocation and therefore require exclusion of associated ligament and dislocation injuries (1, 36).
Therapy focusses on restoring carpal stability, particularly with palmar fractures. Small dorsal and undisplaced fractures may be immobilized with a splint for three to six weeks, while displaced and unstable fractures as well as large dorsal fragments should be surgically stabilized. This is usually accomplished by minimally invasive Kirschner (K-) wire fixation or with an open approach and fracture fixation using a mini-screw (36).
Fractures of the trapezium
Fractures of the trapezium are the third most common carpal fractures at less than five percent (38). Their cause is commonly a fall on the outstretch thumb associated with an axial transmission of force through the first metacarpal bone (1). Walker distinguishes between axial transarticular, transversal, dorsoradial, and palmar tuberosity fractures, and comminuted fractures (39). Undisplaced fractures are immobilized in a plaster splint with inclusion of the proximal phalanx of the thumb for four to six weeks. Regular radiological reviews are required due to the risk of secondary displacement. Displaced fractures may be managed percutaneously by K-wire fixation or by open reduction and screw fixation (1). Congruent reduction is decisive in order to prevent secondary basal thumb osteoarthritis (40). Painful nonunion or troublesome bone fragments/bony edges can produce secondary carpal tunnel syndrome and tendinitis, even ruptures of the flexor carpi radialis (FCR) tendon, and should therefore be removed in due course (1, 38, 40).
Fractures of the hamate
The incidence of fractures of the hamate is around two percent (38, e1). A distinction is made between body and hook fractures (eFigure 3) (e2). Apart from acute traumatic events, causes of hook fractures also include repetitive microtrauma injury, for example during racket sports (1). In addition to paresthesia in the territory of the ulnar nerve, pain on flexion of the ring and small fingers against resistance in a wrist held in ulnar deviation (hook of hamate pull test) is diagnostically suggestive (e2). Undisplaced fractures of the hamate are immobilized for four to six weeks. Screw fixation should be performed initially for displaced fractures, and in particular before deciding to excise the hook of hamate, bearing in mind the function of the hook as a fulcrum for the ulnar-sided flexor tendons. It is possible that these tendons are restricted in their function after hook resection (eFigure 3) (1, e2). Excision is therefore primarily recommended for established nonunion (e3, e4).
eFigure 3.
48-year-old (female) patient with a hamate fracture close to the base
Top row from left to right: preoperative X-rays AP and lateral views and sagittal computed tomography
Bottom row from left to right: postoperative X-rays AP and lateral views and preoperative axial computed tomography.
The hook fracture close to its base is well recognizable on the section images (top and bottom right). Because of the recognizable bone defect, the fracture was treated with a cancellous bone graft taken from the ipsilateral distal radius and a double-threaded screw.
Fractures of the pisiform
Two percent of all carpal fractures involve the pisiform. They arise from direct trauma. The indication for operative treatment is displacement and consists of internal fixation or excision (1). Despite being located in the flexor carpi ulnaris tendon, in the insertions of the pisohamate ligament, and the abductor digiti minimi tendon, removal of the pisiform does not appear to have any functional consequences (e5).
Fractures of the capitate
One to two percent of all carpal bone fractures involve the capitate. Usually, transverse body fractures are sustained by a fall on the outstretched hand and the subsequent impaction of the distal radius, resulting in complete detachment of the proximal pole of the capitate (38). This is often associated with a fracture of the middle third of the scaphoid (scapho-capitate fracture). If the proximal pole of the capitate rotates by 180 degrees, then this is referred to as Fenton syndrome (e6, e7). As with the scaphoid, perfusion of the capitate is from distal, which increases the risk of delayed union, nonunion, and necrosis for fractures of the proximal pole (e1, e8–e10). Undisplaced transverse fractures may be treated non-operatively, although some of them require months of immobilization until the bone has fully united. For this reason, the indication for surgery should be considered, even in the presence of only slight displacement. As a rule, displaced fractures should be managed with screw or miniplate fixation to restore the anatomical carpal height and thus avoid overloading the adjacent joints (1, 37, e2).
Fractures of the lunate
Isolated lunate fractures are rare because of its protected position in the lunate facet of the distal radius. A fracture can develop in the late stage of avascular necrosis of the lunate (Kienbock’s disease) – this should be included in the differential diagnosis, especially in the absence of trauma. For this reason, an MRI scan should be obtained for diagnostic purposes, in addition to a CT scan (1, e2). Ligament instability should be excluded in every case of lunate fracture. Undisplaced fractures with no sign of instability can be managed conservatively in a forearm splint for four to six weeks. On the other hand, open reduction and internal fixation with mini-screws, double-threaded screws, or K-wires are indicated for displaced fractures. Reconstruction with bone anchor sutures and K-wire fixation are required for avulsion fractures. Proximal row carpectomy may be necessary for unreconstructable comminuted fractures and nonunion.
Fractures of the trapezoid
With fewer than one percent, these are the least common fractures of the carpal bones and are often part of a multiple traumatic injury secondary to high-velocity trauma (5, 38). Here too, displacement will require surgery with K-wires or screws. Excision is not advised on the other hand because of the risk of painful proximal metacarpal migration (MC 2) (1). Second carpometacarpal joint fusion (CMC 2) should be undertaken for comminuted fractures or osteoarthritis (5, 38).
Conclusion
Guidelines, RCTs, and meta-analyses are only available for scaphoid fractures. There is unanimous recommendation for surgical treatment of fractures of the proximal third. Bicortical displaced fractures of the middle third should undergo surgery. However, the authors’ personal opinion is that an individualized approach in the spirit of “informed consent” should be considered for undisplaced fractures – with a shorter immobilization period of two to four weeks for surgical treatment, compared with up to 12 weeks for conservative management. The currently available data do not allow a general therapeutic recommendation for fractures of the other carpal bones.
Questions on the article.
The Conservative and Operative Treatment of Carpal Fractures
The submission deadline is 5 September 2025. Only one answer is possible per question.
Please select the answer that is most appropriate.
Question No. 1
What approximate incidence is stated in the article for fractures of the carpus?
3–6/100 000 population
9–13/100 000 population
30–60/100 000 population
100–150/100 000 population
200–300/100 000 population
Question No. 2
Which of the following statements on fractures of the carpal bones is most appropriate?
The trapezium is the most commonly fractured carpal bone.
Fractures of the carpal bones are more common in women than in men.
Over 70% of those who sustain a fracture of the carpal bones are older than 60 years.
The most common cause of fractures of the carpal bones is a fall on the outstretched hand.
No fractures have ever been reported for the capitate bone.
Question No. 3
Which of the following bones is not part of the proximal row of carpal bones?
The scaphoid
The capitate
The lunate
The triquetrum
The pisiform
Question No. 4
How high is the radiation exposure of thin-layer computed tomography for detecting fractures of the carpal bones with the arm positioned above the head?
is equivalent to about three hours of background radiation
is equivalent to about one day of background radiation
is equivalent to about one week of background radiation
is equivalent to about one month of background radiation
is equivalent to about three months of background radiation
Question No. 5
Kienbock’s disease is the term used to describe which condition?
avascular necrosis of the hamate
radiocarpal osteoarthritis
fusion of the components of the radiocarpal joint
chronic inflammation of the pisiform
avascular necrosis of the lunate
Question No. 6
According to the statements in the article, which fractures have sound treatment recommendations based on guidelines, randomized controlled trials, and meta-analyses?
Fractures of the lunate
Fractures of the pisiform
Fractures of the scaphoid
Fractures of the trapezium
Fractures of the triquetrum
Question No. 7
According to the information in the article, which of the following descriptions applies to a bony ligament tear?
Atrusion
Aversion
Confraction
Afraction
Avulsion
Question No. 8
Immobilization of the wrist is commonly recommended for scaphoid fractures. According to the article, how long should immobilization be maintained at the utmost?
4 weeks
6 weeks
8 weeks
12 weeks
18 weeks
Question No. 9
Pain on flexion of the ring and small fingers against resistance with the wrist in ulnar deviation is an indication of a fracture of which carpal bone?
The pisiform
The hamate
The trapezoid
The lunate
The capitate
Question No. 10
According to the Krimmer’s classification of scaphoid fractures as described in the article, which type of scaphoid fracture involves tubercle fractures and undisplaced transverse fractures in the middle or distal third?
Types A1 and A2
Types A2 and B2
Types B1 and B2
Types B2 and C1
Types B3 and B4
Acknowledgments
Translated from the original German by Dr. Grahame Larkin
Footnotes
Conflict of interest statement
MFL is a member of the advisory boards of the AO Hand Expert Group and KLS Martin Group as well as the Executive Committee of the German Society for Hand Surgery. He has received payments for lectures and has been reimbursed for travel expenses and congress fees from AO, Johnson & Johnson, Medartis, IBRA, KLS Martin Group, and BIRG.
FU has received consulting fees from Medartis. He has been reimbursed for congress fees and travel expenses by IBRA. He is Editor in Chief of the journal “Archives of Orthopaedic and Trauma Surgery” (Springer Publishing Company), publisher of the journal “Operative Orthopädie und Traumatologie” (Springer Publishing Company), and is on the scientific advisory board of the journal “Handchirurgie Scan” (Thieme Publishing Company).
The other authors declare that there are no conflicts of interest.
References
- 1.Ayache A, Schmitt R, Unglaub F, Langer MF, Müller LP, Spies CK. Frakturen der Handwurzel ohne Os scaphoideum. Unfallchirurg. 2021;124:59–73. doi: 10.1007/s00113-020-00929-w. [DOI] [PubMed] [Google Scholar]
- 2.Catalano LW 3rd, Minhas SV, Kirby DJ. Evaluation and management of carpal fractures other than the scaphoid. J Am Acad Orthop Surg. 2020;28:e651–e661. doi: 10.5435/JAAOS-D-20-00062. [DOI] [PubMed] [Google Scholar]
- 3.Schädel-Höpfner M, Windolf J, Lögters T, Pillukat T, Jung M, Bickert B. Skaphoidfrakturen: Aktuelle diagnostische und therapeutische Konzepte. Unfallchirurgie. 2023;126:799–811. doi: 10.1007/s00113-023-01364-3. [DOI] [PubMed] [Google Scholar]
- 4.Boeddrich O, Sander AL, Lustenberger T, et al. Epidemiology of carpal fractures: is it only about the scaphoid? Eur J Trauma Emerg Surg. 2023;49:1499–1503. doi: 10.1007/s00068-022-02213-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Richter M. Handwurzelfrakturen ohne Kahnbein. Tl 1—Frakturen von Triquetrum, Pisiforme und Lunatum. www.thieme-connect.de/products/ejournals/abstract/10.1055/a-0877-8537 (last accessed on 20 February 2023) 2019;08:129–139. [Google Scholar]
- 6.Rupp M, Walter N, Pfeifer C, et al. The incidence of fractures among the adult population of Germany—an analysis from 2009 through 2019. Dtsch Arztebl Int. 2021;118:665–669. doi: 10.3238/arztebl.m2021.0238. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Dias JJ, Brealey SD, Fairhurst C, et al. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial. Lancet. 2020;396:390–401. doi: 10.1016/S0140-6736(20)30931-4. [DOI] [PubMed] [Google Scholar]
- 8.Li H, Guo W, Guo S, Zhao S, Li R. Surgical versus nonsurgical treatment for scaphoid waist fracture with slight or no displacement: a meta-analysis and systematic review. Medicine. 2018;97 doi: 10.1097/MD.0000000000013266. e13266. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Schmitt H, Rosenthal H. Bildgebende Diagnostik der Skaphoidfraktur nach der aktuellen S3-Leitlinie. Handchirurgie Scan. www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0042-108426 (last accessed on 20 February 2023) 2016;05:243–258. [Google Scholar]
- 10.Kang KB, Kim HJ, Park JH, Shin YS. Comparison of dorsal and volar percutaneous approaches in acute scaphoid fractures: a meta-analysis. PLoS One. 2016;11 doi: 10.1371/journal.pone.0162779. e0162779. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Lee CH, Lee BG, Kim JH, Yoon HS, Han KJ, Choi WS. Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review. J Hand Surg Eur Vol. 2023;48:625–629. doi: 10.1177/17531934221150331. [DOI] [PubMed] [Google Scholar]
- 12.Prabowo KA, Lopatta E, Lenz M, et al. Vergleich der navigierten und konventionellen perkutanen Verschraubung undislozierter Kahnbeinfrakturen. Handchir Mikrochir Plast Chir. 2021;53:47–54. doi: 10.1055/a-1276-1364. [DOI] [PubMed] [Google Scholar]
- 13.Shen L, Tang J, Luo C, Xie X, An Z, Zhang C. Comparison of operative and non-operative treatment of acute undisplaced or minimally-displaced scaphoid fractures: a meta-analysis of randomized controlled trials. PLoS One. 2015;10 doi: 10.1371/journal.pone.0125247. e0125247. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Siotos C, Asif M, Lee J, et al. Cast selection and non-union rates for acute scaphoid fractures treated conservatively: a systematic review and meta-analysis. J Plast Surg Hand Surg. 2023;57:16–21. doi: 10.1080/2000656X.2021.2024439. [DOI] [PubMed] [Google Scholar]
- 15.Al-Ajmi TA, Al-Faryan KH, Al-Kanaan NF, et al. A systematic review and meta-analysis of randomized controlled trials comparing surgical versus conservative treatments for acute undisplaced or minimally-displaced scaphoid fractures. Clin Orthop Surg. 2018;10:64–73. doi: 10.4055/cios.2018.10.1.64. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Alnaeem H, Aldekhayel S, Kanevsky J, Neel OF. A systematic review and meta-analysis examining the differences between nonsurgical management and percutaneous fixation of minimally and nondisplaced scaphoid fractures. J Hand Surg Am. 2016;41:1135–1144.e1. doi: 10.1016/j.jhsa.2016.08.023. [DOI] [PubMed] [Google Scholar]
- 17.Buijze GA, Goslings JC, Rhemrev SJ, et al. Cast immobilization with and without immobilization of the thumb for nondisplaced and minimally displaced scaphoid waist fractures: a multicenter, randomized, controlled trial. J Hand Surg Am. 2014;39:621–627. doi: 10.1016/j.jhsa.2013.12.039. [DOI] [PubMed] [Google Scholar]
- 18.Chen S, Zhang C, Jiang B, Mi Y, Zhu Y, Jia X. Comparison of conservative treatment and surgery treatment for acute scaphoid fracture: a meta-analysis of randomized controlled trials. World J Surg. 2023;47:611–620. doi: 10.1007/s00268-022-06833-1. [DOI] [PubMed] [Google Scholar]
- 19.Clementson M, Jørgsholm P, Besjakov J, Thomsen N, Björkman A. Conservative treatment versus arthroscopic-assisted screw fixation of scaphoid waist fractures—a randomized trial with minimum 4-year follow-up. J Hand Surg Am. 2015;40:1341–1348. doi: 10.1016/j.jhsa.2015.03.007. [DOI] [PubMed] [Google Scholar]
- 20.Drac P, Cizmar I, Manak P, et al. Comparison of the results and complications of palmar and dorsal miniinvasive approaches in the surgery of scaphoid fractures. A prospective randomized study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2014;158:277–281. doi: 10.5507/bp.2012.060. [DOI] [PubMed] [Google Scholar]
- 21.Eastley N, Singh H, Dias JJ, Taub N. Union rates after proximal scaphoid fractures; meta-analyses and review of available evidence. J Hand Surg Eur Vol. 2013;38:888–897. doi: 10.1177/1753193412451424. [DOI] [PubMed] [Google Scholar]
- 22.Johnson NA, Fairhurst C, Brealey SD, et al. One-year outcome of surgery compared with immobilization in a cast for adults with an undisplaced or minimally displaced scaphoid fracture: a meta-analysis of randomized controlled trials. Bone Joint J. 2022;104-B(8):953–962. doi: 10.1302/0301-620X.104B8.BJJ-2022-0085.R2. [DOI] [PubMed] [Google Scholar]
- 23.Cavalcanti Kußmaul A, Kühlein T, Langer MF, Ayache A, Unglaub F. The treatment of closed finger and metacarpal fractures. Dtsch Arztebl Int. 2023;120(15):855–862. doi: 10.3238/arztebl.m2023.0226. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Langer MF, Unglaub F, Breiter S, Ueberberg J, Wieskötter B, Oeckenpöhler S. Anatomie und Pathobiomechanik des Skaphoids. Unfallchirurg https://doi.org/10.1007/s00113-018-0597-1 (last accessed on 21 December 2023) 2019;122:170–181. doi: 10.1007/s00113-018-0597-1. [DOI] [PubMed] [Google Scholar]
- 25.Schmitt R, Lanz U. Bildgebende Diagnostik der Hand. Thieme https://books.google.de/books?id=vdXRBQAAQBAJ (last accessed on 21 December 2023) 2014 [Google Scholar]
- 26.Morsy M, Sabbagh MD, van Alphen NA, Laungani AT, Kadar A, Moran SL. The vascular anatomy of the scaphoid: new discoveries using micro-computed tomography imaging. J Hand Surg Am. 2019;44:928–938. doi: 10.1016/j.jhsa.2019.08.001. [DOI] [PubMed] [Google Scholar]
- 27.Berger RA. The anatomy of the scaphoid. Hand Clin www.sciencedirect.com/science/article/pii/S0749071221014384 (last accessed on 21 December 2023) 2001;17:525–532. [PubMed] [Google Scholar]
- 28.Schädel-Höpfner M, Bickert B, Dumont C. Leitlinie Skaphoidfraktur AWMF-Registernummer 012-016 2015. www.awmf.org/leitlinien/detail/ll/012-%0D016.html (last accessed on 7 December 2023) [Google Scholar]
- 29.Biswas D, Bible JE, Bohan M, Simpson AK, Whang PG, Grauer JN. Radiation exposure from musculoskeletal computerized tomographic scans. J Bone Joint Surg Am. 2009;911:882–889. doi: 10.2106/JBJS.H.01199. [DOI] [PubMed] [Google Scholar]
- 30.Jørgsholm P, Ossowski D, Thomsen N, Björkman A. Epidemiology of scaphoid fractures and non-unions. Handchir Mikrochir Plast Chir. 20205;2:374–381. doi: 10.1055/a-1250-8190. [DOI] [PubMed] [Google Scholar]
- 31.Duckworth AD, Jenkins PJ, Aitken SA, Clement ND, Court-Brown CM, McQueen MM. Scaphoid fracture epidemiology. J Trauma Acute Care Surg. 2012;72:E41–E45. doi: 10.1097/ta.0b013e31822458e8. [DOI] [PubMed] [Google Scholar]
- 32.Warwick D, Miller C, Das A, et al. Giddins G, Leblebiciogl G, editors. Scaphoid fracture—the evidence. Evidence based data in hand surgery and therapy. iris publications. 2017:283–354. [Google Scholar]
- 33.Yeo JH, Kim JY. Surgical strategy for scaphoid nonunion treatment. J Hand Surg Asian-Pacific Vol. 2018;23:450–462. doi: 10.1142/S2424835518300049. [DOI] [PubMed] [Google Scholar]
- 34.Garcia-Elias M. Carpal bone fractures (excluding scaphoid fractures) Wrist. (Ist ed) 2001;1:173–186. [Google Scholar]
- 35.Levy M, Fischel RE, Stern GM, Goldberg I. Chip fractures of the os triquetrum: the mechanism of injury. J Bone Joint Surg Br. 1979;61-B(3):355, 357. doi: 10.1302/0301-620X.61B3.479259. [DOI] [PubMed] [Google Scholar]
- 36.Guo RC, Cardenas JM, Wu CH. Triquetral fractures overview. Curr Rev Musculoskelet Med. 2021;14:101–106. doi: 10.1007/s12178-021-09692-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Smith DK, Murray PM. Avulsion fractures of the volar aspect of triquetral bone of the wrist: a subtle sign of carpal ligament injury. AJR Am J Roentgenol. 1996;166:609–614. doi: 10.2214/ajr.166.3.8623636. [DOI] [PubMed] [Google Scholar]
- 38.Wolfe SW, Pedersen WC, Hotchkiss R, et al. Green’s operative hand surgery. Handchirurgie Mikrochirurgie Plast Chir. (7th edition) 2016;48:383–383. [Google Scholar]
- 39.Walker JL, Greene TL, Lunseth PA. Fractures of the body of the trapezium. J Orthop Trauma. 1988;2:22–28. doi: 10.1097/00005131-198802000-00006. [DOI] [PubMed] [Google Scholar]
- 40.Palmer AK. Trapezial ridge fractures. J Hand Surg Am. 1981;6:561–564. doi: 10.1016/s0363-5023(81)80132-3. [DOI] [PubMed] [Google Scholar]
- E1.Price MB, Vanorny D, Mitchell S, Wu C. Hamate body fractures: a comprehensive review of the literature. Curr Rev Musculoskelet Med. 2021;14:475–484. doi: 10.1007/s12178-021-09731-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- E2.Vigler M, Aviles A, Lee SK. Carpal fractures excluding the scaphoid. Hand Clin. 2006;22:501–516. doi: 10.1016/j.hcl.2006.07.007. abstract vii. [DOI] [PubMed] [Google Scholar]
- E3.Burleson A, Shin S. Return to play after hook of hamate excision in baseball players. Orthop J Sport Med. 2018;6 doi: 10.1177/2325967118803090. 2325967118803090. [DOI] [PMC free article] [PubMed] [Google Scholar]
- E4.Smith P 3rd, Wright TW, Wallace PF, Dell PC. Excision of the hook of the hamate: a retrospective survey and review of the literature. J Hand Surg Am. 1988;13:612–615. doi: 10.1016/s0363-5023(88)80107-2. [DOI] [PubMed] [Google Scholar]
- E5.Carroll RE, Coyle MPJ. Dysfunction of the pisotriquetral joint: treatment by excision of the pisiform. J Hand Surg Am. 1985;10:703–707. doi: 10.1016/s0363-5023(85)80212-4. [DOI] [PubMed] [Google Scholar]
- E6.Strohm PC, Laier P, Müller CA, Gutorski S, Pfister U. “Scapho-capitate fracture syndrome” an beiden Händen. Erstbeschreibung des beidseitigen Auftretens einer seltenen Verletzung. Unfallchirurg. 2003;106:339–342. doi: 10.1007/s00113-002-0556-7. [DOI] [PubMed] [Google Scholar]
- E7.Fenton RL. The naviculo-capitate fracture syndrome. J Bone Joint Surg Am. 1956;38-A(3):681–684. [PubMed] [Google Scholar]
- E8.Panagis JS, Gelberman RH, Taleisnik J, Baumgaertner M. The arterial anatomy of the human carpus. Part II: The intraosseous vascularity. J Hand Surg Am. 1983;8:375–382. doi: 10.1016/s0363-5023(83)80195-6. [DOI] [PubMed] [Google Scholar]
- E9.Gelberman RH, Panagis JS, Taleisnik J, Baumgaertner M. The arterial anatomy of the human carpus. Part I: the extraosseous vascularity. J Hand Surg Am. 1983;8:367–375. doi: 10.1016/s0363-5023(83)80194-4. [DOI] [PubMed] [Google Scholar]
- E10.Gelberman RH, Gross MS. The vascularity of the wrist. Identification of arterial patterns at risk. Clin Orthop Relat Res. 1986;202:40–49. [PubMed] [Google Scholar]