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).
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 is 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.
Symptoms — do you recognize these?
- Wrist pain on the thumb side following a fall on an outstretched hand
- Anatomical snuffbox tenderness: Pain when pressing in the triangular depression between the extensor pollicis longus and extensor pollicis brevis/APL tendons on the back of the thumb-side wrist — a highly sensitive clinical sign for scaphoid fracture
- Scaphoid tubercle tenderness: Tenderness on the volar (palm) side of the wrist at the scaphoid tubercle
- Pain with axial compression of the thumb
- Wrist swelling, often minimal
- Reduced wrist range of motion
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How we diagnose it
X-rays: The starting point for evaluation, with four views of the wrist (PA, lateral, oblique, and scaphoid view, a PA in ulnar deviation). However, plain X-rays are negative in 20–30% of acute scaphoid fractures and cannot be relied upon to rule out fracture in a clinically suspicious case.
MRI (the gold standard for acute occult fracture): MRI is the most sensitive and specific modality for detecting acute scaphoid fractures not visible on X-ray. It detects bone marrow edema within hours of injury. MRI also identifies associated ligamentous injuries (scapholunate ligament). An MRI obtained within 24–48 hours of injury can definitively confirm or exclude fracture and eliminate unnecessary prolonged casting for patients who in fact have only a sprain.
CT scan: Provides excellent bony detail for:
- Characterizing fracture displacement and angulation (a key determinant of treatment)
- Pre-operative planning for screw placement
- Assessing fracture healing (preferable to X-ray for monitoring union)
- Evaluating nonunion morphology
Bone scan (isotope scintigraphy): Highly sensitive but non-specific; largely replaced by MRI.
Clinical Protocol for Suspected Scaphoid Fracture
If a patient presents with anatomical snuffbox tenderness after a FOOSH and initial X-rays are negative:
- MRI within 3–7 days is the preferred approach to confirm or exclude fracture
- Alternatively, the wrist may be splinted and X-rays repeated at 10–14 days (union lines may become visible as fracture line widens with resorption), though this approach risks delayed diagnosis
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.
Scaphoid Fracture Fixation
Internal fixation of a scaphoid fracture with a headless compression screw. The screw is placed percutaneously for minimally displaced acute fractures or via open approach for displaced or delayed-presentation injuries at risk for non-union.
Click for moreRecovery & rehabilitation
- Casting: Thumb spica cast for 8–12 weeks; hand therapy after cast removal to restore grip strength and range of motion. Return to sport/heavy labor at 3–4 months.
- Percutaneous fixation: Light wrist use at 2 weeks; progressive activities over 6–8 weeks; return to sport as early as 6–10 weeks with confirmed healing on CT.
- Open ORIF/bone graft: More extended recovery. Cast for 6–8 weeks post-op; return to full activities at 4–6 months.
Frequently Asked Questions
The ER said I have a wrist sprain. Could it really be a fracture?
Why is the proximal pole so serious?
Is the screw permanent?
What is SNAC wrist?
How long will my wrist be in a cast, and when can I return to sport after a scaphoid fracture?
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References
- Yin ZG, Zhang JB, Kan SL, Wang XG. Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis. Clinical Orthopaedics and Related Research. 2010;468(3):723–734. doi:10.1007/s11999-009-1106-9
- Buijze GA, Doornberg JN, Ham JS, Ring D, Bhandari M, Poolman RW. Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. Journal of Bone and Joint Surgery (American). 2010;92(6):1534–1544. doi:10.2106/JBJS.I.01214
- Clementson M, Björkman A, Thomsen NOB. Acute scaphoid fractures: guidelines for diagnosis and treatment. EFORT Open Reviews. 2020;5(2):96–103. doi:10.1302/2058-5241.5.190025
- Shen L, Tang J, Luo C, et al. Surgical versus non-surgical interventions for treating scaphoid fractures: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2015;10:68. doi:10.1186/s13018-015-0212-3
- Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. Journal of Hand Surgery (American Volume). 2008;33(6):988–997. doi:10.1016/j.jhsa.2008.04.026