Most scaphoid fractures are part of multiple injuries and multiple fractures, which often do not receive sufficient attention. It has been reported in the literature that improper initial management or delayed treatment can lead to shoulder joint and upper limb dysfunction [1-3]. From August 2002 to April 2005, 18 cases of scaphoid fracture were treated by surgery in our department, and good results were achieved. 1. Clinical data The 18 cases in this group, 12 males and 6 females, aged 23-62 years old, average 42 years old. Among them, there were 10 cases of traffic accident injury, 4 cases of fall injury, 4 cases of heavy object pressure injury; 7 cases on the left side and 11 cases on the right side. According to the anatomical part of the fracture, there were 11 cases of body fracture and 7 cases of surgical neck fracture, among which 4 cases were combined with scapular gland fracture. Combined injuries: 2 cases of clavicle fracture, 3 cases of more than 2 ribs fracture, 3 cases of hemopneumothorax, 4 cases of craniocerebral trauma. 18 cases were performed with incision and internal fixation with 1~2 reconstructed plates and screws. 2.Surgical method Surgical approach: under high epidural anesthesia or general anesthesia, in the healthy-side lying position, with the upper limb raised, along the posterior side of the lateral edge of the scapula (for combined scapular gland fractures, an oblique incision along the scapular gland was added). The incision is made from the inferior border of the deltoid muscle, along the lateral border of the scapula and obliquely to the inferior angle of the scapula. The lower posterior border of the deltoid, the infraspinatus, the teres minor, and the teres major are exposed. By separating the infraspinatus from the greater and lesser circular muscles, the scapular body, axillary margin, lower part of the neck and posterior aspect of the joint capsule can be revealed. To reveal the scapular glenoid and neck more clearly, another incision is made along the scapular gonad and the beginning of the infraspinatus muscle is cut and turned downwards. Care should be taken to protect the suprascapular nerve that extends backwards from the suprascapular incision to innervate the infraspinatus and infraspinatus muscles. When dissecting the outer edge of the scapular neck, care should be taken not to damage the axillary nerve and the posterior rotator humeral artery that travels within the foramen quadratus. In addition to avoiding injury to the suprascapular nerve and artery, care should be taken not to injure the dorsal scapular nerve and descending branch of the transverse cervical artery. Internal fixation method: The fracture is fixed by reconstructed plate and screws. 5-8 holes of reconstructed plate can be used for internal fixation of the scapular gland or neck of the scapula or the outer edge of the body. The drilling of the scapular neck should pay attention to the direction of the drill bit to prevent it from entering the humeral glenoid cavity. The fracture involving the scapular gonad is fixed with another reconstructed plate. For floating shoulder injury, clavicle fracture, proximal humerus fracture or rupture of the rostral collar ligament should be properly treated; the fracture of the acromion can be fixed with plates and screws to maintain the stability of the glenohumeral joint and prevent the fracture of the scapular neck from healing abnormally. Postoperative treatment: After the injured limb was suspended with a sling or triangular scarf for 2~4 d after surgery, arm swinging exercises were started, and the auxiliary exercises were gradually increased and active exercises were started 1 week after surgery. 3. Results The mean healing time of the fracture was 6-8 weeks at the postoperative follow-up of 6-24 months. According to Hardegger’s [1] shoulder joint scoring system: excellent, grade 5 abductor strength, no restriction in range of motion, no pain around the shoulder; good, grade 4 abductor strength, basically no restriction in range of motion, mild pain around the shoulder; acceptable, grade 3 abductor strength, moderate restriction in range of motion, moderate pain around the shoulder; poor, grade 2 abductor strength, severe restriction in shoulder joint movement, >40% restriction in shoulder abduction, severe pain around the shoulder. Severe pain around the shoulder. In this group, 13 cases were excellent and 5 cases were good. There were no complications such as plate fracture, loosening, fracture displacement, bone non-union, infection, re-fracture and neurovascular injury. 4. Discussion 4.1 Indications for surgery Most of the scaphoid fractures can be treated conservatively, but only severely displaced and unstable fractures of the scapular neck, acromion or rostral process have indications for surgery. A fracture of the articular glenoid is indicated for a fracture causing persistent subluxation of the humeral head, i.e., >3 mm dislocation of the anterior 1/4 or posterior 1/3 of the articular glenoid labrum; a fracture of the scapular neck is indicated for >5 mm separation displacement or >20° angular displacement in the transverse or coronal plane; a comminuted scapular body fracture with >1 cm displacement of the fracture fragment or entry of the fracture fragment into the glenohumeral joint; a fracture of the rostral process with acromioclavicular The fracture of the rotator cuff should be treated surgically if the fracture is significantly displaced, if the fracture is retracted and enters the subacromial space, or if there is severe fracture or dislocation that may cause rotator cuff dysfunction. 4.2 Selection of internal fixation Ye Genlin [[3]] found that the thinnest point of the outer edge of the scapula is 8.6 mm and the thickness of the scapular gland is 84.5-6.2 mm. the outer edge of the scapula and the scapular gland provide strong support for the scapula as the two sides of the fan-shaped scapula, which can be used for internal fixation of the plate. For scapular neck fractures, the outer ridge of the scapula is extremely suitable for internal fixation and is easier to reveal surgically than the inner rim. Although there are several internal fixations available for neck fractures, except for small fractures at the glenoid fossa, internal fixation with a single screw is not effective because the width of the outer ridge of the scapula is less than 0.5crn and is oblique, and the fracture is deep there. At the same time, most of the neck fractures are insertional and comminuted fractures, and the fracture fragment removal and fixation with a single screw will inevitably cause the neck to become shorter and the fracture will be difficult to be well aligned, so the plate can play a role of pulling together or supporting the fracture at this place, because the scapula is a flat bone, and there is no problem of front and back displacement after internal fixation according to the direction of the fracture line, so the porous plate can be used only to pull together or support the fracture. The reconstructed plate can be bent in all directions to fit the uneven crest of the scapula, and it is easy to drill and screw vertically after the plate is attached. For severe comminuted fractures, another plate can be pre-bent to fix the scapular gland to the scapular neck. For scaphoid fracture, scaphoid crest fracture and/or clavicle fracture, a reconstructive steel plate is also used for fixation. 4.3 Significance of imaging The scapula is located behind the chest wall, the fracture patient has less scapular outward displacement due to painful protection, the X-ray plain film is not satisfactory, CT scan and reconstruction can obtain accurate displacement relationship between the fracture blocks, the whole picture of the fracture. It facilitates the determination of treatment direction and surgical approach and guides intraoperative repositioning. Unstable scaphoid fractures occur with local adhesions and deformed healing due to loss of original shoulder joint stability with conservative treatment. This results in shoulder abduction weakness and subacromial pain [1,2]. According to Ada et al [4], rest pain occurred in 50% to 100% of patients, extension weakness in 40% to 60% of patients, and extension pain in 20% to 60% of patients, which seriously affected patients’ life and work. The fracture was stabilized and functional exercises were carried out under the guidance of 3~5 days after surgery. 4,4 Experience Ding Xianjun [5] et al. proposed Judet incision to cut and peel the infraspinatus muscle from the inner edge of the scapular gland scapula to expose the scapular neck and body. The infraspinatus muscle is one of the important dynamics of the rotator cuff, and the Judet incision strips the infraspinatus muscle from both the inner and outer upper three sides, weakening the dynamics of the rotator cuff and preventing the patient from moving early. We believe that access from the outer edge of the scapula does not require extensive stripping of the muscle, is less traumatic, has less possibility of damaging the suprascapular nerve vessels, and allows early postoperative activity. In this group of cases, functional exercises for shoulder abduction were encouraged three days after surgery, and all of them did not need external fixation, and there was no muscle atrophy and joint function limitation. The results were satisfactory.