Herbert and Fisher's 1984 prospective study of 158 operations introduces the headless double-threaded compression screw for rigid internal fixation of scaphoid fractures. The paper proposes the Herbert Classification (Types A–D) to guide operative versus conservative management across the full spectrum of scaphoid pathology.
Before this paper, scaphoid fracture management meant prolonged casting — with true non-union rates the authors estimate as high as 50% after conservative treatment, and up to 6 months of immobilization even after Matti-Russe bone grafting for non-union. Internal fixation had been abandoned because standard screws either protruded into the joint, pushed fragments apart, or failed to achieve rigid fixation in small cancellous bone.
The Herbert screw changed the operative calculus. When you see a Type B (acute unstable) scaphoid fracture. Displaced waist, proximal pole, fracture-dislocation, or comminuted pattern. Early fixation with a headless compression screw is the standard of care, with 100% union and return to work in weeks rather than months.
When you see established non-union (Type D), do not offer screw fixation alone. The paper is unambiguous: pseudarthrosis resection and anterior wedge grafting must come first, or screw loosening is almost inevitable. Sclerotic bone at the non-union site simply lacks the regenerative capacity to unite with fixation alone.
One pearl worth knowing: proximal pole ischaemia on plain films does not mean the fragment is dead. Over half of Type C fractures in this series showed radiographic ischaemia preoperatively and revascularized after union. True avascular necrosis requiring Silastic replacement was reserved for cases where the fragment was soft and fragmented at surgery.
Herbert and Fisher's 1984 prospective study of 158 operations introduces the headless double-threaded compression screw for rigid internal fixation of scaphoid fractures. The paper proposes the Herbert Classification (Types A–D) to guide operative versus conservative management across the full spectrum of scaphoid pathology.
Before this paper, scaphoid fracture management meant prolonged casting — with true non-union rates the authors estimate as high as 50% after conservative treatment, and up to 6 months of immobilization even after Matti-Russe bone grafting for non-union. Internal fixation had been abandoned because standard screws either protruded into the joint, pushed fragments apart, or failed to achieve rigid fixation in small cancellous bone.
The Herbert screw changed the operative calculus. When you see a Type B (acute unstable) scaphoid fracture. Displaced waist, proximal pole, fracture-dislocation, or comminuted pattern. Early fixation with a headless compression screw is the standard of care, with 100% union and return to work in weeks rather than months.
When you see established non-union (Type D), do not offer screw fixation alone. The paper is unambiguous: pseudarthrosis resection and anterior wedge grafting must come first, or screw loosening is almost inevitable. Sclerotic bone at the non-union site simply lacks the regenerative capacity to unite with fixation alone.
One pearl worth knowing: proximal pole ischaemia on plain films does not mean the fragment is dead. Over half of Type C fractures in this series showed radiographic ischaemia preoperatively and revascularized after union. True avascular necrosis requiring Silastic replacement was reserved for cases where the fragment was soft and fragmented at surgery.