The radiograph and CT scan show a displaced scaphoid waist fracture. Optimal treatment is ORIF with screw fixation.
The usual mechanism of injury to the scaphoid is axial load across a hyperextended wrist. Pain with resisted pronation, snuffbox tenderness and scaphoid tuberosity tenderness should all raise suspicion for a scaphoid fracture. AP and lateral X-rays, as well as PA view with the hand in ulnar deviation and an oblique 45 degree view with the hand in pronation can help to identify the fracture. Bone scan, CT and MRI can also be used to make the diagnosis if radiographs are indeterminate. ORIF is recommended for any fracture displaced more than 1mm, with a radiolunate angle greater than 15 degrees, with intrascaphoid angle greater than 35 degrees, associated with perilunate dislocation or with a proximal pole fracture. Optimal treatment is ORIF with screw fixation. For minimally displaced fractures, percutaneous or mini-open fixation allows minimal dissection and preservation of extrinsic ligaments.
Answer 1,2,3: Nonoperative management is not indicated in displaced scaphoid fractures
Answer 5: Vascularized bone grafting is reserved for cases of scaphoid nonunion.
Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow and Shoulder. Rosemont, IL, American Society for Surgery of the hand, 2003, pp 161-73.