Hand & Wrist

Scaphoid Fracture

The scaphoid is the most commonly fractured carpal bone — and also the most commonly missed wrist fracture. Because initial X-rays are normal in up to 20–30% of scaphoid fractures, patients are frequently told they have a "wrist sprain" when they actually have a fracture that requires careful treatment. Left untreated or inadequately treated, a scaphoid fracture can lead to nonunion, avascular necrosis, and progressive wrist arthritis. At Maryland Orthopedic Specialists, our hand surgeons are experts in identifying and appropriately managing scaphoid fractures — from conservative cast treatment to minimally invasive percutaneous screw fixation.

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What is scaphoid fracture?

The scaphoid is a small, boat-shaped bone located on the thumb side of the wrist (radial side), forming a critical link between the proximal and distal rows of the carpus. It spans both rows and bears significant load during wrist motion, making it vulnerable to fracture from axial loading, particularly during a fall on an outstretched hand (FOOSH).

Fracture Location and Clinical Implications

Scaphoid fractures are classified by location along the bone's long axis:

Waist fractures (70–80%): The most common site — the middle, narrowest portion of the scaphoid. Most can be treated with casting, though displaced fractures at the waist carry a significant risk of nonunion without surgical intervention.

Proximal pole fractures (15–20%): The most dangerous location. The proximal pole has a retrograde, end-arterial blood supply — blood enters through the distal portion of the scaphoid and flows proximally. A proximal pole fracture may disrupt this supply entirely, putting the proximal fragment at high risk for avascular necrosis (AVN) — bone death due to loss of blood supply. AVN rates for untreated or delayed proximal pole fractures can reach 30–40% or higher.

Distal pole fractures (5–10%): The distal portion has a more robust blood supply and heals well with conservative treatment in most cases.

Acute vs. Chronic Fractures and Nonunion

A scaphoid nonunion occurs when a fracture fails to heal, progressing to fibrous tissue between the fragments rather than bone. Risk factors for nonunion include:

Displaced fractures (≥1 mm displacement)
Proximal pole fractures
Delayed diagnosis (common given the frequency of missed initial X-rays)
Inadequate immobilization

Without treatment, a scaphoid nonunion predictably leads to scaphoid nonunion advanced collapse (SNAC wrist) — a predictable pattern of radiocarpal and midcarpal arthritis. SNAC wrist, like SLAC wrist, represents an end-stage problem that is far more difficult and less rewarding to treat than the original fracture.

Treatment options

Non-Operative

Non-displaced fractures are treated in a thumb spica cast for 8 to 12 weeks; the longer immobilization is necessary because the scaphoid has a limited blood supply and heals slowly.

Surgical Procedure

Scaphoid Fracture Fixation

Internal fixation of a scaphoid fracture with a headless compression screw — placed percutaneously for minimally displaced acute fractures or via open approach for displaced or delayed-presentation injuries at risk for non-union.

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Frequently Asked Questions

The ER said I have a wrist sprain. Could it really be a fracture?

Yes. Up to 20–30% of scaphoid fractures are X-ray negative initially. If you have snuffbox tenderness after a FOOSH, you should be evaluated further with MRI or repeat imaging — not simply reassured based on a negative initial X-ray.

Why is the proximal pole so serious?

The proximal pole receives blood only from vessels that enter distally. A fracture through the waist or proximal pole can interrupt this supply, potentially killing the bone (AVN). This is why proximal pole fractures often require surgery even when non-displaced.

Is the screw permanent?

Yes. The headless compression screw is left in place permanently in most cases. Screw removal is rarely needed.

What is SNAC wrist?

SNAC (scaphoid nonunion advanced collapse) is the arthritis pattern that develops in the wrist when a scaphoid fracture fails to heal. It can require partial or total wrist fusion in advanced stages, highlighting the importance of early diagnosis and treatment.

How long will my wrist be in a cast, and when can I return to sport after a scaphoid fracture?

Non-displaced scaphoid waist fractures treated in a cast require immobilization for eight to twelve weeks, with healing confirmed by CT scan before the cast is removed. Surgical fixation with a headless compression screw significantly reduces healing time, and many active patients choose surgery to return to sport in as little as six to eight weeks. Proximal pole fractures take longer to heal regardless of treatment due to the tenuous blood supply in that region. Your MOS surgeon will discuss the risks and benefits of operative versus non-operative treatment based on the fracture location, your activity level, and your timeline for returning to work or sport.

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Peter G. Fitzgibbons, MD

Hand Surgery · Orthopedic Surgery

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Related conditions

Hand & Wrist Fractures Hand & Wrist Arthritis

Medically reviewed by Peter G. Fitzgibbons, MD, MD

Last reviewed May 1, 2026