A scaphoid nonunion is a fracture of the scaphoid that has failed to heal. It happens because the bone has a limited blood supply, and it happens far more often where the original fracture was missed or treated late. Left alone it does not settle. It gradually wears the wrist out. It is repaired by clearing the old fracture, packing it with bone graft and holding it with a compression screw, and at this practice that is done arthroscopically, through punctures of about five millimetres, which preserves the very blood supply the bone is short of.
What a nonunion is
The scaphoid is one of the eight small bones that make up the wrist, and it is the one most commonly broken, usually after a fall onto an outstretched hand. It has a limited blood supply, which makes healing difficult. In a small number of cases a scaphoid fracture fails to heal, and that is a nonunion.
Nonunions also occur when the original fracture was missed or treated late, which is common, because a scaphoid fracture can be invisible on the first X-ray and can feel like an ordinary sprain. A good number of the nonunions we see belong to people who were told years ago that they had sprained their wrist.
A malunion is a related problem. There the bone has healed, but in the wrong position, usually bent forwards, and the altered shape changes how the wrist carries load. It is assessed and treated along similar lines, and the decision turns on the position of the bone and on what the wrist is doing as a result.
Why it matters, and what happens if it is left
An unhealed scaphoid does not hold the two rows of wrist bones together as it should. The wrist gradually collapses into an abnormal position, the load falls where the joint surfaces were never designed to carry it, and arthritis follows. That end point has a name, scaphoid nonunion advanced collapse, usually shortened to SNAC wrist, and by the time it arrives the options are salvage operations rather than repair of the scaphoid.
This is the argument for treating a nonunion rather than living with one. The wrist may not be troubling you much now. The reason to act is the twenty years after now.
Symptoms
Symptoms of a scaphoid nonunion include:
- Pain at the base of the thumb or on the thumb side of the wrist
- Weakness of grip
- Reduced wrist movement
- Swelling
- A history of a wrist injury, often years earlier, that was treated as a sprain
Some nonunions cause remarkably little. People present having been told their wrist is simply stiff, or having noticed only that they cannot push up out of a chair comfortably.
How it is diagnosed
Diagnosis is confirmed with X-rays and a CT or MRI scan. The CT shows the position of the fragments, whether the bone has collapsed, and how much of it is left to work with, all of which decide what the operation needs to achieve. An MRI is used to assess the blood supply to the proximal fragment, because a fragment with no blood supply behaves differently and is more difficult to heal.
The operation
The nonunion is treated with arthroscopic bone grafting and fixation with a compression screw. The whole operation is performed through small puncture wounds of approximately five millimetres, which preserves the delicate blood supply to the scaphoid and the surrounding ligaments rather than cutting through them to reach the bone.
A small camera is inserted into the wrist through two or three puncture sites. The nonunion is identified and cleaned of scar tissue through the scope. A small amount of bone graft is taken from the end of the forearm, or from the hip where more is required, and packed into the nonunion through a thin cannula. A compression screw is then placed across the scaphoid under X-ray guidance, compressing the graft and stabilising the bone while it heals. The puncture sites are closed with a single suture each, and a tape bandage covers them under a soft dressing and a plaster backslab.
It is a day surgery or overnight procedure under a general anaesthetic with a local anaesthetic block for comfort afterwards, and takes approximately 90 to 120 minutes.
Doing this through the scope rather than open is the point of the technique. A nonunion is a blood supply problem, and the conventional open approach reaches the bone by dividing the tissues that carry that blood supply. Working through punctures leaves them intact.
Recovery, week by week
Indicative. The scaphoid itself takes about three months to heal in most cases, and sometimes longer.
Timeframe
What to expect
Day of surgery
Your arm may feel numb or tingly for up to 24 hours because of the local anaesthetic block. You can move your fingers and shoulder before you leave hospital. Your wrist is supported in a plaster backslab.
Days 1 to 10
Keep the plaster clean and dry. Elevate your hand to reduce swelling. Move your fingers, elbow and shoulder regularly. If bone graft was taken from the hip, the donor site may feel tender or bruised for two to six weeks.
Days 10 to 14
Your progress is reviewed by the doctor, hand therapist or practice nurse, and the sutures are removed. The plaster is replaced with a custom made removable thumb spica splint fitted by your hand therapist. Gentle wrist and thumb exercises begin out of the splint.
Six weeks
Your progress is reviewed and new X-rays are taken. If healing is progressing as expected, splint use is gradually reduced and hand therapy progresses to include light use of the hand.
Three months
A CT scan is obtained to confirm that the scaphoid has healed. Once union is confirmed, splinting stops and heavier activities are introduced under the guidance of your hand therapist.
Six months
Graded return to sport and heavy manual tasks, guided by your hand therapist. Follow up appointments continue as required.
Six to twelve months
A useful return of strength and motion is typically achieved by four to six months, and recovery can continue up to twelve months. The wrist may remain stiff, tender or swollen for three to six months, and this continues to improve.
Skin wounds heal in two to three weeks.
Hand therapy
A wrist that has been splinted for months needs work to get moving again, and the therapy here runs longer than for most hand operations. Our therapists make the thumb spica at the two week visit, progress movement in step with the healing rather than ahead of it, and rebuild grip once the CT has confirmed union. Having them on site matters over a recovery measured in months.
Risks and complications
Arthroscopic bone grafting for scaphoid nonunion is a safe, specialised procedure and complications are uncommon. They can include:
- Wound healing problems or infection.
- Bleeding or bruising.
- Nerve injury.
- Stiffness of the wrist.
- Tenderness at the graft donor site.
- Slower than expected recovery.
- Failure of the scaphoid to heal despite treatment, in a small number of cases, which may require further surgery.
- Arthritis of the wrist in the long term, even after successful healing, which may need further treatment.
- Rarely, the compression screw may need to be removed in the future if it causes irritation.
When to be seen sooner
Contact us, or see your GP, if you have:
- A wrist injured years ago that still aches, particularly on the thumb side
- Grip strength that is dropping away, or a wrist that is losing movement
- A scaphoid fracture that was treated and has not been confirmed as healed
- Pain that is waking you at night, or that has changed in character
If you have had surgery with us and have questions or concerns afterwards, phone the rooms during office hours on (08) 7127 0365.
Frequently asked questions
My wrist was injured years ago. Is it too late?
Usually not. Nonunions are repaired years after the original injury as a matter of routine. What decides it is not how long ago it happened, it is the state of the bone and whether the wrist has already developed arthritis. A CT scan answers that. The sooner it is assessed the more options there are.
What happens if I leave it?
The wrist gradually collapses and wears, and arthritis follows. That end point is called SNAC wrist, and once it arrives the scaphoid can no longer simply be repaired. The operations available then are salvage procedures. This is the main reason we recommend treating a nonunion even when it is not causing much trouble yet.
Why do it through a camera rather than opening the wrist?
Because the problem is the blood supply. The scaphoid failed to heal in the first place because it is poorly supplied, and the conventional open approach reaches the bone by dividing the tissues that carry that supply. Working through punctures of about five millimetres leaves them intact, which is the whole argument for the technique.
Where does the bone graft come from?
Usually from the end of your own forearm, just above the wrist, through the same puncture technique. Where more graft is needed it is taken from the hip. If the hip is used, that site can feel tender or bruised for two to six weeks afterwards.
How long does the operation take, and will I be asleep?
Approximately 90 to 120 minutes, under a general anaesthetic with a local anaesthetic block for comfort afterwards. It is usually a day surgery procedure, occasionally an overnight stay.
How will you know it has healed?
A CT scan at three months. X-rays are taken along the way, at the six week review, but a healing scaphoid is genuinely difficult to judge on plain films and a CT is the reliable answer. Splinting continues until union is confirmed.
How long is the recovery?
Longer than most hand operations, and it is better to know that at the start. A plaster for ten to fourteen days, then a removable splint until the CT at three months confirms healing. Useful strength and movement by four to six months, with recovery continuing up to twelve months.
Will it definitely heal?
Most do, but not all. A nonunion is by definition a bone that has already failed to heal once, and in a small number of cases it fails again despite grafting and fixation, which may mean further surgery. The risk is higher where the fragment nearest the forearm has lost its blood supply, which is one of the things the MRI is for.
What does the surgery cost?
You will receive written informed financial consent setting out the surgeon, anaesthetist and hospital fees, your Medicare rebate and your health fund's contribution before anything is booked. Phone the rooms on (08) 7127 0365 for an estimate.
Do I need a referral?
A referral from your GP or another specialist means you can claim a Medicare rebate on the consultation. We can see you without one, but the rebate will not apply.
Written and clinically reviewed by Dr Nicholas Smith, MBBS, FRACS (Plast), PFET
Last reviewed 11 September 2026