Percutaneous Screw Fixation vs. Casting for Non-Displaced or Minimally Displaced Scaphoid Waist Fractures: A Meta-Analysis of Randomized Controlled Trials

Abstract The optimal treatment for non-displaced scaphoid waist fractures remains uncertain. This meta-analysis examined whether percutaneous screw fixation offers improved clinical and functional outcomes compared with cast immobilization, while also evaluating safety and the need for secondary procedures. A systematic review of MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane databases was conducted through May 2025. Randomized controlled trials comparing percutaneous or mini-open screw fixation to cast immobilization in adults with non-displaced or minimally displaced scaphoid waist fractures were included. Six trials (n = 639; 315 surgical and 324 nonsurgical) met the inclusion criteria. Outcomes were pooled using random-effects models when substantial heterogeneity was present; otherwise, a fixed-effect model was applied. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool, and certainty of evidence was graded with Grading of Recommendations Assessment, Development and Evaluation (GRADE). Percutaneous screw fixation was associated with a lower risk of nonunion (1.6% vs. 7.1%; risk ratio [RR] 0.22; 95% confidence interval [CI]: 0.09–0.57; p = 0.002; I 2 = 33.4%), faster time to union (mean difference −3.8 weeks; 95% CI: −5.20 to −2.44; p < 0.001), and earlier return to work (mean difference −5.3 weeks; 95% CI: −7.95 to −2.57; p < 0.001) compared with casting. Grip strength was higher (mean difference +2.2 kg; 95% CI: +2.06 to +2.36; p < 0.001), and immobilization duration was shorter (0.5 vs. 8.3 weeks; p < 0.001) with surgery. Secondary surgical intervention was less common in the fixation group (3.2% vs. 7.4%; RR 0.42; 95% CI: 0.21–0.86; p = 0.02), with similar complication rates between groups. Percutaneous screw fixation yields favorable short-term outcomes compared with cast immobilization in adults with non-displaced or minimally displaced scaphoid waist fractures. These findings support its use in appropriately selected patients, while highlighting the need for standardized imaging and follow-up protocols and further study of long-term outcomes. Level I.