A Comprehensive FESSH Exam Preparation Guide

Injury Mechanism: Most scaphoid fractures result from a fall on an outstretched hand with the wrist hyperextended and radially deviated radiologykey.com. In this position, the scaphoid is compressed between the radius and the capitate. Biomechanically, with the wrist extended, the distal scaphoid is forced against the radius – if the force is great enough, the scaphoid cracks, usually at the waist. Wrist position can influence fracture location: extension with radial deviation tends to fracture the distal waist, whereas extension with ulnar deviation can drive the force more to the proximal pole radiologykey.com. Understanding these mechanisms helps explain associated injuries; for example, a high-energy force can cause a trans-scaphoid perilunate fracture-dislocation (the scaphoid breaks and the lunate dislocates – a “greater arc” injury). Fortunately, most scaphoid fractures are isolated. However, always be vigilant for associated carpal injuries or distal radius fractures in trauma cases.

Clinical Presentation

Symptoms: Patients with a scaphoid fracture typically report wrist pain after an injury, often localized to the radial (thumb) side of the wrist. They may describe pain deep in the “snuffbox” area (the hollow at the base of the thumb) and difficulty gripping or pinching. Swelling may be present but is generally mild compared to, say, a distal radius fracture. Because initial pain and swelling can be modest, many patients do not seek immediate care, mistakenly thinking it’s a simple sprain.

Physical Exam: Classic exam findings for scaphoid injury are taught as the “hallmarks” for diagnosis:

• Anatomic Snuffbox Tenderness: The anatomical snuffbox is the depression on the dorsoradial wrist bounded by the EPL and EPB tendons. Tenderness here, especially after a FOOSH, is highly suggestive of a scaphoid fracture radiologykey.com. Snuffbox pain has a high sensitivity (upwards of 90%) for scaphoid injury, though it’s not 100% specific (other injuries can also cause snuffbox pain).
• Scaphoid Tubercle Tenderness: Pressing on the scaphoid tubercle (palmar aspect of the distal scaphoid, just distal to the distal wrist crease at the base of the thenar eminence) elicits pain if the scaphoid is fractured. This can be checked by extending the wrist and palpating deep at the thumb base.
• Axial Thumb Compression Test: Applying axial load through the thumb (by pushing the metacarpal into the wrist) causes pain at the scaphoid region when a fracture is present bssh.ac.uk. Essentially, this maneuver pinches the scaphoid fragments and will reproduce pain in a fracture scenario.
• Pain with Ulnar Deviation: Ulnar deviation of the wrist (especially when the wrist is in slight flexion) stresses the scaphoid and can cause snuffbox pain if fractured bssh.ac.uk.

Often, a combination of these exam findings increases diagnostic accuracy. One study noted that combining snuffbox tenderness, tubercle tenderness, and pain on axial load improved the clinical prediction of a fracture bssh.ac.uk. For the FESSH exam, remember that persistent snuffbox tenderness after injury = treat as a scaphoid fracture until proven otherwise.

Diagnostic Pitfalls: A major pitfall is that initial X-rays can appear normal (occult fracture) despite a true fracture. Thus, a patient might be misdiagnosed with a “wrist sprain” if the clinician relies solely on a normal X-ray and sends them home without immobilization. Pain from a scaphoid fracture can also subside after a few weeks even without treatment radiologykey.com, misleading both patient and doctor into thinking the injury was trivial – meanwhile, the bone may be failing to heal properly. This is why follow-up or advanced imaging is crucial when clinical suspicion is high. Key caution: A sprained wrist is a diagnosis of exclusion; always rule out a scaphoid fracture or ligament injury in the setting of wrist trauma radiologykey.com.

Other exam findings might include decreased grip strength and limited range of motion (especially in extension and radial deviation). However, these are non-specific. Some patients retain fairly good motion even with a fractured scaphoid, which is another reason the injury is easily missed.

Associated Injuries: While isolated scaphoid fractures are most common, it’s wise to check for other injuries. Examine for tenderness elsewhere in the wrist (to rule out carpal instability or other carpal fractures) and in the forearm (to rule out a Galeazzi fracture or distal radius fracture which can coexist). In high-energy injuries, assess for signs of perilunate dislocation (diffuse wrist swelling, deformity) or fracture-dislocations (e.g., if the mechanism was severe, a scaphoid fracture could accompany a perilunate dislocation – the so-called trans-scaphoid perilunate injury, which is a surgical emergency).

Pearl: If a patient has snuffbox tenderness but minimal swelling and near-normal motion, do not dismiss the injury. Scaphoid fractures can be very deceptive initially. The FESSH exam may present scenarios of a patient with wrist pain, normal X-rays, and ask for the next step – the safest answer is usually to treat as fracture (immobilize) and obtain advanced imaging (like MRI) rather than simply sending the patient off. We will discuss diagnosis and imaging next.

Pathophysiology of Complications: If a scaphoid fracture is not diagnosed early or remains unstable, the natural course can be troublesome. Two major complications to remember are non-union and osteonecrosis (AVN) of the proximal fragment. Non-union occurs when the fracture fails to heal – often due to inadequate immobilization, motion at the fracture site, or compromised blood flow. Over time, a fibrous union or pseudarthrosis can form, altering carpal biomechanics. This leads to the collapse of the wrist arch (a dorsal intercalated segment instability, DISI, with a characteristic “humpback” deformity of the scaphoid) radiologykey.com. Eventually, untreated non-union progresses to SNAC wrist, a pattern of wrist osteoarthritis starting at the radioscaphoid joint and advancing to involve the entire wrist. AVN, as noted, particularly affects the proximal pole when its blood supply is cut off. On imaging, AVN appears as sclerosis of the proximal fragment and can lead to fragmentation and collapse. Both non-union and AVN drastically impact wrist function, making their prevention a key goal in management.

In summary, the scaphoid’s unique anatomy – especially its retrograde blood flow – underlies the clinical urgency in treating these fractures. Even a seemingly “minor” wrist sprain that is actually a scaphoid fracture can have major consequences if missed. As you prepare for the FESSH exam, keep this anatomy and pathophysiology in mind, as it often forms the basis for exam questions (e.g., “Why do proximal pole fractures have higher non-union rates?”).

Herbert Classification: In Europe, the Herbert (Herbert-Fisher) classification is commonly referenced for scaphoid fractures, as it links fracture type with management. It divides scaphoid fractures into stable (Type A) and unstable acute fractures (Type B), plus delayed unions (Type C) and established non-unions (Type D) radiologykey.com. Knowing the subtypes is useful:

• Type A (Acute Stable Fractures):
  • A1: Fracture of the scaphoid tubercle (distal pole avulsion).
  • A2: Non-displaced or minimally displaced fracture of the scaphoid waist (middle or distal third).
    Management: These are considered stable injuries. A1 (tubercle) often heals with just short immobilization (4–6 weeks in a short cast) bssh.ac.uk. A2 can be treated non-operatively in a cast, or percutaneously fixed with a screw – both are acceptable options.
• Type B (Acute Unstable Fractures):
  • B1: Distal oblique fracture of the scaphoid.
  • B2: Displaced fracture of the waist (>1mm step or gap).
  • B3: Proximal pole fracture.
  • B4: Fracture associated with carpal subluxation or dislocation (e.g., trans-scaphoid perilunate fracture-dislocation).
    Management: By definition, unstable fractures (B types) require surgical fixation for optimal outcomes radiologykey.com. B1 often needs a screw due to the obliquity (which tends to shear). B2 (displaced waist) and B3 (proximal) almost always require internal fixation – often open reduction to achieve anatomic alignment. B4 injuries are complex and managed with open reduction of the carpus and fixation of the scaphoid (plus repair of ligaments as needed).
• Type C (Delayed Union): Fractures that have not united in the expected time (e.g., still not healed by ~8–12 weeks) but are not yet clearly a non-union. These often will need either prolonged immobilization or surgical intervention to facilitate healing.
• Type D (Established Non-Union):
  • D1: Fibrous non-union (minimal sclerosis).
  • D2: Sclerotic non-union (pseudarthrosis with clear fibrous joint, often with cystic changes).
    Non-unions (type D) frequently require surgical management with bone grafting (and fixation) to restore bony continuity.

For exam purposes, remember Type A vs B for acute: stable (A) might be treated conservatively, unstable (B) require surgery radiologykey.com. Also recall that proximal pole fractures (B3) are precarious due to blood supply and usually need prompt fixation. The Herbert classification might appear in a question asking which types are indications for surgery, for example.

Summary of Diagnosis: High suspicion + negative X-ray = immobilize and MRI. Confirmed fracture = classify it (stable vs unstable) and plan treatment accordingly. The FESSH exam may test the nuanced points: e.g., knowing that snuffbox tenderness has high sensitivity, or that MRI is the recommended next step if X-rays are normal but exam is positive, or applying the Herbert classification to decide management.

Treatment Options

Management of scaphoid fractures can be broadly divided into non-operative (conservative) and operative (surgical) approaches. The optimal treatment depends on the fracture’s stability, displacement, location, and patient factors. European guidelines emphasize individualized treatment: while many acute fractures can heal in cast immobilization, certain fracture types heal more reliably (or faster) with surgery. Below we outline the options and indications, and then provide a comparison table for quick reference.

Non-Operative Management (Casting)

Indications: Stable, non-displaced fractures of the waist or distal pole are prime candidates for conservative treatment. For example, a Herbert type A2 fracture (clean, non-displaced waist fracture) can be successfully treated in a cast radiologykey.com. Distal tubercle fractures (A1) almost always heal with simple immobilization due to abundant blood supply. Some proximal pole fractures that are truly non-displaced might be managed in cast, but many surgeons lean toward fixation given the higher risk of non-union.

Method: Traditional treatment is immobilization in a thumb spica cast, usually a below-elbow cast that incorporates the thumb (to immobilize the wrist and thumb basal joint). Contemporary practice varies; some evidence suggests including the thumb may not be strictly necessary for waist fractures once they are past acute phase, but initially a thumb spica is standard. Cast duration depends on fracture location: distal pole fractures may heal in ~4-6 weeks, waist fractures often need 8-12 weeks, and proximal fractures can require 12+ weeks of immobilization due to slower healing ncbi.nlm.nih.gov. Regular X-rays or a CT at ~6–8 weeks are used to assess healing progress bssh.ac.uk. If healing is on track (evidence of bridging bone), casting continues until union (which could be up to 3 months for some). If there are no signs of union by 6–8 weeks, this is a warning sign – one should consider switching to surgical management rather than continuing cast indefinitely bssh.ac.uk.

Outcomes: Historically, union rates for non-displaced scaphoid waist fractures in cast are high (90%+), though healing is slow. A landmark UK study (SWIFFT trial, 2020) provided high-quality evidence on cast vs surgery for minimally displaced waist fractures. It found no significant difference in functional outcome at 12 months between casting and surgical fixation ncbi.nlm.nih.gov. Union rates were high in both groups (~98% in surgery vs ~95% in cast), and the difference was not clinically significant ncbi.nlm.nih.gov. However, surgery patients healed a bit faster and returned to work sooner on average, whereas cast patients avoided surgical risks and costs ncbi.nlm.nih.gov. An even more recent meta-analysis (2023) echoed that overall functional outcomes are similar, but surgery gives some advantages in healing time and early wrist strength pubmed.ncbi.nlm.nih.gov. Essentially, for a stable fracture, cast treatment is very effective, and immediate surgery may not dramatically change long-term function – this is an important nuance that might come up in exam questions (e.g., “What did the SWIFFT trial conclude about managing undisplaced scaphoid fractures?”).

Casting considerations: The classic immobilization is long (often 8–12 weeks), which can be inconvenient. Some practitioners use a splint after a few weeks or start early range-of-motion once signs of union appear, to reduce stiffness. Complications of casting include joint stiffness, muscle atrophy, and in some cases, a reduced range of motion or grip strength even after cast removal (though these usually recover with physiotherapy). There’s also the risk of the fracture not uniting in cast (non-union), which then necessitates surgery later (delayed fixation). Patients should be counseled about symptoms of non-union (persistent pain after cast removal) and the need for follow-up.

Operative Management (Surgical Fixation)

Indications: Generally, any scaphoid fracture that is unstable or displaced, or has a high risk of non-union, is best treated surgically. Indications for acute surgical fixation include:

• Fracture displaced > 1–2 mm bssh.ac.uk (Even if only minimally displaced, many surgeons will fix 1 mm gaps, given the precision needed for joint surfaces).
• Fractures with associated carpal instability or fracture-dislocations (trans-scaphoid perilunate injuries require surgery).
• Proximal pole fractures (due to blood supply issues, many treat these with internal fixation to improve healing chances) bssh.ac.uk.
• Comminuted fractures or those with a humpback deformity visible on lateral view (the flexion of the scaphoid indicates instability).
• Patient factors: high-demand individuals (athletes, manual workers) who benefit from quicker healing, or patients who cannot tolerate long casting, often opt for surgical management even for non-displaced fractures to accelerate return to activity.

Surgical Techniques: The goal of surgery is to achieve stable internal fixation of the scaphoid, allowing early mobilization and reliable union. Key techniques include:

• Percutaneous Screw Fixation: Many acute fractures (especially waist fractures) can be fixed percutaneously with a headless compression screw. The most famous is the Herbert screw, a headless double-threaded screw that can be inserted across the fracture providing compression. Newer cannulated screws (e.g., Acutrak screws) are also commonly used. The approach can be volar (through the distal tubercle area) or dorsal depending on fracture location. Volar percutaneous fixation is often used for waist fractures; a dorsal percutaneous approach is sometimes chosen for proximal pole fractures (for better access to the small proximal fragment) radiologykey.com. The advantage of percutaneous surgery is minimal soft tissue dissection and quicker recovery.
• Open Reduction and Internal Fixation (ORIF): Required if the fracture is displaced or comminuted (you need to directly visualize and reduce it). A volar approach to the wrist exposes the scaphoid between the radial artery and FCR tendon; this is great for waist and distal fractures. A dorsal approach (often through a small incision between the third and fourth extensor compartments) may be used for proximal pole fractures to directly visualize and reduce them radiologykey.com. A headless compression screw is then placed. Sometimes K-wires are used temporarily to help with reduction or to augment fixation (especially in comminuted fractures, or to hold a small fragment).
• Bone Grafting: If there is bone loss or comminution, or if the fracture is delayed/non-union, bone graft may be added to stimulate healing. Two types exist: non-vascularized graft (often taken from the distal radius or iliac crest) and vascularized graft (e.g., a graft from the distal radius pedicled on a blood supply like the 1,2-Intercompartmental Supraretinacular Artery – a common technique for proximal pole non-unions with AVN). In acute fractures, grafting is usually not needed unless there is a gap.
• Double Screw Fixation: A newer concept in managing difficult scaphoid cases is using two screws. Recent literature suggests that in certain non-unions or very unstable fractures, dual headless compression screws can increase rotational stability and compression, potentially improving union rates researchgate.net; frontiersin.org. Some surgeons have started employing two screws in parallel for recalcitrant non-unions (with or without bone graft). Early series report good union with this technique, but it’s not yet the standard of care for routine fractures. It’s a “new direction” in scaphoid fixation that might be worth mentioning if a question asks about recent advances researchgate.net.

Post-op and Outcomes: Surgical fixation typically allows earlier wrist mobilization (sometimes within days or weeks, using a protective splint). Union is usually assessed by CT around 8–12 weeks post-op if painless, or earlier if doubt. Union rates with surgery for acute fractures are very high (95-99% in most modern series). Patients often regain motion faster than with prolonged casting. However, surgery has risks: infection, screw misplacement or prominence, irritation of tendons (especially dorsal screws can irritate extensor tendons if protruding), and need for hardware removal in some cases. There’s also a small risk of non-union even with surgery, especially in proximal pole fractures – hence some of the interest in adjuncts like bone graft or two screws. Overall, though, for unstable fractures, surgery significantly reduces the risk of non-union compared to casting radiologykey.com.

Complications Management:

• If a fracture goes on to non-union despite initial treatment, the standard solution is surgical: debridement of the non-union, bone grafting (often with a vascularized graft if AVN is present), and fixation. For fibrous non-unions without collapse, a non-vascularized graft and screw may suffice. For long-standing non-unions with collapse (humpback deformity and SNAC changes), more complex reconstruction or salvage might be needed (e.g., scaphoid excision and four-corner fusion, or proximal row carpectomy in advanced arthritis).
• Avascular Necrosis (AVN): If AVN of the proximal pole is present, options include trying a vascularized bone graft (to restore blood supply) plus fixation. If the proximal fragment is completely dead and collapsed, a salvage procedure like partial wrist fusion might be considered, but that’s usually a last resort. Early AVN detection (e.g., via MRI) and intervention can sometimes save the scaphoid.
• Malunion: If the scaphoid heals in a malaligned way (e.g., persistent humpback deformity), it can lead to chronic pain and wrist instability (DISI posture). The treatment would be an osteotomy of the scaphoid to correct alignment, with graft and fixation – a complex procedure usually beyond exam scope, but just realize malunion can cause problems too.
• SNAC Wrist: This is the end-stage consequence of chronic scaphoid non-union. Treatment is not fixation (too late for that) but rather salvage: either a limited fusion (like four-corner fusion of the midcarpal joint) or proximal row carpectomy, to alleviate pain from arthritis. The exam will likely not go deep into this, but it’s good to mention that chronic non-union has no easy fix.

Below is a comparison table summarizing key differences between non-operative and operative management of scaphoid fractures:

Both approaches have their place. A key evidence-based point: a randomized trial (SWIFFT) showed no long-term functional difference between casting vs immediate screw fixation for nondisplaced waist fractures ncbi.nlm.nih.gov, so patient values and context matter. European guidelines often suggest offering fixation for those who desire quicker recovery, but it is not mandatory for every case.

Follow-up Care: Regardless of treatment, follow-up is crucial until fracture union is confirmed. For cast-treated patients, if union is not evident by 6 weeks on X-ray, advanced imaging (CT) is done to check healing bssh.ac.uk. For surgically treated patients, one must monitor for any signs of complications (pain that could suggest hardware issues or delayed union). Typically, a CT scan or high-quality X-ray at around 8–12 weeks post-op is used to confirm union before allowing full unrestricted activity bssh.ac.uk. Patients should be educated that wrist strengthening and gradual return to loading tasks should follow only after the bone is confirmed healed.

Complication Management Recap: If a scaphoid fracture hasn’t healed by ~3–4 months, it’s a non-union – then bone grafting with fixation is indicated. If AVN is present, consider a vascularized graft. The exam may ask about “what to do next” in a scenario of a patient who still has pain 3 months after a scaphoid fracture in cast – the answer would be to get a CT/MRI to check union, and likely proceed to surgery if it’s a non-union.

Having covered these management principles, let’s summarize the high-yield points and then test our knowledge with practice questions.

Key Points Summary

• Most Common Carpal Fracture: The scaphoid is the most frequently broken carpal bone (up to 80% of carpal fractures) and typically occurs in young adults via FOOSH injuries radiologykey.com.
• Anatomy & Blood Supply: The scaphoid has a retrograde blood supply – 70–80% of blood flow enters from the distal pole and flows to the proximal pole en.wikipedia.org. Consequently, proximal pole fractures have a high risk (~30%) of avascular necrosis en.wikipedia.org and non-union.
• Clinical Exam: Anatomical snuffbox tenderness is a hallmark of scaphoid fracture (high sensitivity) radiologykey.com. Also assess for scaphoid tubercle tenderness and pain with axial thumb compression. If these signs are present, treat as a scaphoid fracture until proven otherwise.
• Imaging Strategy: Obtain dedicated scaphoid X-ray views (PA, lateral, oblique, scaphoid view). Remember that initial X-rays can miss fractures. If clinical suspicion is high and X-ray is normal, immobilize the wrist and arrange advanced imaging (preferably MRI within 1–2 weeks) pubmed.ncbi.nlm.nih.gov. MRI is the most sensitive test for occult scaphoid fractures; pubmed.ncbi.nlm.nih.gov; CT is excellent for assessing fracture detail and union (and is an alternative if MRI unavailable).
• Herbert Classification: Know the difference between stable (Type A) fractures that can often be casted (A1 = tubercle, A2 = nondisplaced waist) and unstable (Type B) fractures that usually require surgery (B1 = distal oblique, B2 = displaced waist, B3 = proximal pole, B4 = fracture-dislocation) radiologykey.com. Delayed unions (C) and non-unions (D) often need surgical intervention with bone graft.
• Non-Operative vs Operative: Casting (typically thumb spica) for ~6–12 weeks is effective for stable fractures, achieving ~90%+ union in undisplaced cases. Surgical fixation (usually with a headless compression screw) is indicated for displaced or unstable fractures and allows faster mobilization. Outcomes at 1 year are similar for displaced waist fractures whether treated with cast or surgery in many cases ncbi.nlm.nih.gov, but surgery gives quicker healing and less immobilization time pubmed.ncbi.nlm.nih.gov.
• Complications: Non-union and AVN are the dreaded complications. Proximal pole fractures are most prone. Non-union can lead to SNAC wrist arthritis if untreated frontiersin.org. Prevent these by early diagnosis and appropriate treatment (fixation of unstable fractures, and ensuring even stable ones are immobilized adequately).
• Management of Non-union: Scaphoid non-unions often require ORIF with bone graft. Vascularized grafts (e.g., from distal radius) are used especially if there’s AVN of the proximal fragment. In recent developments, double-screw fixation has been explored to enhance stability in difficult non-union cases researchgate.net.
• FESSH Exam Tips: Be prepared for questions on specifics like “snuffbox tenderness significance,” “best next step with normal X-ray but high suspicion,” or interpreting a Herbert classification scenario. Also, know current evidence (e.g., the SWIFFT trial result that casting is not inferior to surgery for certain fractures ncbi.nlm.nih.gov) as exams may reference these to test if candidates stay up-to-date.

Keep these points in mind for quick recall – they encapsulate the fundamentals of scaphoid fractures relevant to both clinical practice and exam vignettes.

Visual Aids and Additional Resources

Effective preparation for the FESSH exam can be enhanced with visual learning. Here are some suggested visual aids and open-access resources related to scaphoid fractures:

• Anatomical Diagrams: A diagram of the scaphoid highlighting its blood supply is useful to visualize why the proximal segment is vulnerable. For example, Wikimedia Commons hosts an illustration of scaphoid vascular supply (as described earlier) which labels the dorsal and volar arterial branches. Such images reinforce the concept of retrograde perfusion. Textbook figures or hand-drawn diagrams in review articles (e.g., in Journal of Hand Surgery or EFORT Open Reviews) also depict this well.
• X-ray and MRI Images: Viewing radiographs of scaphoid fractures at various stages can be very helpful. Open-access databases like Radiopaedia and Wikimedia Commons have clinical images. For instance, Radiopaedia has case examples of scaphoid waist fractures on X-ray and MRI. You can see how a hairline fracture on X-ray becomes obvious with bone edema on MRI. Wikimedia Commons contains a category “X-rays of human scaphoid fractures” with images of subtle fractures, displaced fractures, and even non-union cases (some of which were referenced for the embedded X-ray description above). Reviewing these can train you to spot a scaphoid break on exam images.
• Fixation Technique Illustrations: Many surgical textbooks or online resources have diagrams of how a headless compression screw is inserted in the scaphoid. Understanding the difference between a volar percutaneous approach vs. dorsal approach can be aided by such illustrations. Videos or animations (for example, by AO Foundation or orthopedic surgery education sites) often show the technique step-by-step. While the FESSH exam won’t ask you to perform a surgery, they may ask about which approach is used for a proximal pole fixation (answer: usually dorsal) or similar – a mental picture helps.
• Comparison Tables & Charts: The comparison table provided in this article is an example of how to summarize key info. Creating your own quick-reference chart for, say, “Herbert classification vs treatment” or “Imaging modalities vs sensitivity” could be useful study tools. Some review articles provide summary tables – for instance, EFORT Open Reviews (2020) had guidelines with tables on when to do MRI or CT bssh.ac.uk. Utilizing these in your study notes can solidify the decision pathways.

When studying, make use of these visual aids to complement the text. The combination of seeing an X-ray, feeling the anatomical snuffbox on yourself, and recalling the patient scenarios will make it much easier to answer exam questions confidently. Resources like Wikimedia Commons, Radiopaedia, and open-access journals are invaluable since they provide quality images that you can legally use for study and even teaching. Always ensure that any image you reference is from a reputable source and accurately represents the concept you’re learning.

References (2023 and Latest Evidence)

1. Clementson M, Björkman A, Thomsen NOB. Acute Scaphoid Fractures: Guidelines for Diagnosis and Treatment. EFORT Open Rev. 2020;5(2):96-103. doi:10.1302/2058-5241.5.190025 (See also radiologykey.com for Herbert classification details mentioned in the review).
2. Sahu A, Kuek DK, et al. MRI vs CT in Diagnosing Occult Scaphoid Fractures. Acta Radiol. 2023;64(1):201-207. doi:10.1177/02841851211064595 (pubmed.ncbi.nlm.nih.gov – Prospective study supporting MRI as the preferred modality for suspected fractures with normal X-rays).
3. Dias JJ et al. SWIFFT Trial – Surgery versus Cast for Scaphoid Waist Fractures. Lancet. 2020;396:390-401. doi:10.1016/S0140-6736(20)30932-4 (ncbi.nlm.nih.gov – Landmark RCT showing no long-term difference in outcome between casting and surgical fixation for minimally displaced fractures).
4. Chen S, Zhang C, et al. Conservative vs Surgical Treatment for Acute Scaphoid Fracture: Meta-Analysis of RCTs. World J Surg. 2023;47(3):611-620. doi:10.1007/s00268-022-06833-1 (pubmed.ncbi.nlm.nih.gov – Meta-analysis finding surgery yields faster union and grip strength, but similar final outcomes to casting).
5. Gray RRL et al. Scaphoid Fracture and Nonunion: New Directions. J Hand Surg Eur. 2023;48(2_suppl):4S-10S. doi:10.1177/17531934231165419 (researchgate.net – Recent review discussing advanced concepts like dual-screw fixation and current management trends for nonunions).
6. Ma W, Yao J, Guo Y. Double-Screw Fixation with Bone Graft for Scaphoid Nonunions. Front Surg. 2023;10:1096684. doi:10.3389/fsurg.2023.1096684 (frontiersin.org – Study demonstrating excellent union rates using two screws plus graft in difficult scaphoid nonunions – exemplifies evolving surgical techniques).
7. NICE Guideline NG38: Fractures (Non-Complex) – Scaphoid Fracture Section. NICE, 2016. (UK National guidance recommending MRI for suspected scaphoid fracture when initial X-ray is normal, among other management points).
8. Duckworth AD et al. Predictors of Fracture Following Suspected Injury to the Scaphoid. J Bone Joint Surg Br. 2012;94(7):961-8. doi:10.1302/0301-620X.94B7.28504 (Useful data on clinical exam accuracy – combining tests improves predictive value).
9. Eastley N, Singh H, Dias JJ. Union Rates After Proximal Scaphoid Fractures: A Meta-analysis. J Hand Surg Eur. 2013;38(9):889-894. doi:10.1177/1753193413481307 (Evidence of higher non-union in proximal fractures, reinforcing the need for fixation in those).
10. Radiopaedia.org – Scaphoid Fracture Case Studies. (Online radiology resource with images of scaphoid fractures on X-ray and MRI, illustrating occult fracture detection and SNAC wrist changes. See also pubs.rsna.org for comparison of imaging modalities).

Practice Questions (FESSH-Style True/False)

These questions illustrate the kind of knowledge the FESSH exam expects: an understanding of anatomy and blood supply, evidence-based management decisions, imaging algorithms, and classification systems as they apply to scaphoid fractures. Be sure to review both the “classic” teachings and the latest evidence, as both can appear on the exam.

Disclaimer

This content is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider for medical concerns.