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Scaphoid Fracture

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Other Names

  • Scaphoid non union
  • Occult scaphoid fracture
  • Carpal Scaphoid Fracture
  • Wrist Scaphoid Fracture
  • Carpal Navicular Fracture
  • Navicular Fracture (hand)
  • Scaphoid Waist Fracture
  • Proximal Pole Scaphoid Fracture

Background

  • This page refers to fractures of the Scaphoid bone

History

  • The scaphoid fracture was first formally described in 1905 by the French surgeon and radiologist Destot[1]
  • Early literature referred to the scaphoid as the “navicular bone of the hand,” reflecting its boat-like shape and historical confusion with the tarsal navicular bone.[2]
  • In the 20th century, recognition of the scaphoid’s tenuous retrograde blood supply led to early understanding of complications such as nonunion and avascular necrosis[3]
  • A major advancement in management occurred in 1984 when Herbert and Fisher introduced the **headless compression (Herbert) screw**, revolutionizing surgical fixation and improving union rates.[4]

Epidemiology

  • Scaphoid is most commonly fractured carpal bone[5]
  • 10% of all hand fractures and 60% of all carpal fractures[5]
  • 15% of wrist fractures (need citation)
  • Incidence is highest in young, active males aged 15–30 years due to higher exposure to trauma.[6]
  • These injuries are relatively uncommon in children and older adults due to differences in bone structure and injury patterns.[7]

Introduction

There is a Scaphoid Fracture through the waist of the scaphoid[8]
Left palmer view of the scaphoid bone
Palpation of the (A) snuff box and (B) scaphoid tubercle[9]

General

  • Scaphoid fractures are a common cause traumatic wrist pain and are the most common carpal bone fracture
  • Retrograde blood supply makes scaphoid particular susceptible to avascular necrosis and nonunion
  • Diagnosis is made radiographically, with a high incidence of occult fractures and missed diagnosis
  • Treatment is often surgical although select cases can be treated conservatively

Location

  • 65% occur in the waist[5]
  • 25% proximal 1/3rd, which has an increased risk of AVN
  • 10% distal 1/3rd, which has a higher rate of union

Etiology

  • Traumatic injury which typically involves fall on outstretched hand[10]
    • Wrist is hyper-extended with radial deviation
  • Axial load / sports trauma
  • Rare stress fractures[6]

Anatomy of the Scaphoid

  • Boat-shaped carpal bone on radial side of the wrist[11]
  • Spans proximal & distal carpal rows
  • Articulates with radius, lunate, capitate, trapezium, trapezoid
  • The retrograde blood supply (distal → proximal) makes it particularly vulnerable[12]
  • Proximal pole has poorest vascularity (↑ AVN risk)
  • Function is to aid in movement of the wrist, forms the radial border of the carpal tunnel

Associated Injuries

Risk Factors

Patient Factors

Mechanism / Injury Factors

  • FOOSH with wrist hyperextension[16]
  • High-energy trauma (sports, MVC, falls)

Fracture-Specific Factors (Complication Risk)

  • Proximal pole fracture (↑ AVN)
  • Displacement or comminution
  • Delayed diagnosis or treatment

Anatomic / Vascular Factors

  • Retrograde blood supply
  • Limited vascularity of proximal pole

Differential Diagnosis

Carpal Bone Fractures

Differential Diagnosis Wrist Pain

Clinical Features

Predictive characteristics of index tests (click to enlarge)[17]
Clamp Sign for scaphoid fracture

History

  • Patients will some history of trauma, typically a FOOSH
  • Will complain of wrist pain or thumb pain, worse with movement or activity
  • The pain may be vague, hard to localize
  • Worse with gripping, pinching
  • Range of motion is decreased
  • Initially, patient may be able to continue activity

Physical Exam: Physical Exam Wrist

  • Mild swelling over radial wrist
  • Deformity is typically absent
  • These 3 exam findings reported to be 100% sensitive, 74% specific for scaphoid fracture in first 24 hours following injury[18]
    • Scaphoid compression test
    • Snuffbox tenderness
    • Palpation of the volar scaphoid tubercle
  • Pain with resisted pronation

Special Tests

Evaluation

Possible scaphoid fracture with subtle lucency in the waist
Chronic scaphoid fracture with severe degenerative changes
CT of chronic scaphoid fracture with nonunion

Radiographs

  • Standard Radiographs Wrist
    • 3 view radiographs often sufficient
    • If negative but suspicious, repeat in 2-3 weeks
    • Up to 16% of fractures are missed on initial radiographs[19]
    • Sensitivity is only 67%[20]
  • Scaphoid View: PA view in ulnar deviation

MRI

  • Most sensitive for occult fractures
    • Pooled sensitivity of 88% and specificity of 100% in meta-analysis[19]
  • Can evaluate for other soft tissue pathology
  • Cost-effectiveness analysis: MRI is superior to empiric cast immobilization, reducing both costs and morbidity[21]

CT

  • Diagnostic accuracy
    • Pooled sensitivity of 72%, specificity of 99%[22]
  • Useful for assessing
    • Fracture fragments
    • Extent of collapse
    • Pre-operative planning

Bone Scan

  • Falling out of favor, remains an option
  • Highest sensitivity among imaging modalities at 99%, lower specificity 86%[19]

Ultrasound

  • For radiographically occult scaphoid fractures, pooled sensitivity of 85.6% and specificity of 83.3%[23]
  • Advantages: rapid, non-invasive, point-of-care modality without radiation exposure
  • Dynamic ultrasound can also evaluate for fracture stability
  • However, operator dependendent and not widely used for scaphoid imaging

Classification

Herbert and Fisher's Classification of Scaphoid Fractures

  • Type A: Stable acute fractures
    • A1: Tubercle fracture
    • A2: Incomplete waist fracture
  • Type B: Unstable acute fractures
    • B1: Distal oblique fractures
    • B2: Complete or displaced waist fracture
    • B3: Proximal pole fracture
    • B4: Transscaphoid perilunate dislocation fracture
    • B5: Comminuted fracture
  • Type C: Delayed union
  • Type D: Established nonunion
    • D1: Fibrous union
    • D2: Pseudoarthrosis

Management

Long Thumb Spica Brace

(a) Preoperative image showing fracture at the waist of scaphoid. (b) Follow-up image three months following surgery. (c) Image taken six months after surgery. (d) Measuring grip strength at final follow-up. (e) Range of movement of the wrist six months after surgery.[24]

Nonoperative

  • Indications
    • Stable, nondisplaced (majority)
    • Normal radiographs with high index of suspicion
    • Minimally displaced scaphoid waist and distal pole fractures
    • Incomplete fractures
    • Confirmed stable fractures without displacement
  • Suspected Fracture
    • In patients with normal radiographs, but a high degree of clinical suspicion,
    • Patients should be placed in a thumb spica splint or thumb spica brace
    • Repeat radiographs in roughly 1-2 weeks
  • Confirmed Fracture
    • Management decisions should be made in consultation with an orthopedic surgeon
    • The majority of scaphoid fractures are nondisplaced or minimally displaced
    • Can be treated with immobilization for 6-10 weeks in a thumb spica cast
    • One study showed Below-elbow casting without thumb immobilization improved outcomes[5]

Operative

  • Indications[25]
    • Displaced fractures (>2 mm displacement or step-off)
    • Proximal pole fractures (prone to nonunion due to tenuous blood supply)
    • Unstable fracture patterns
    • Patient preference for faster return to activity (particularly athletes)
    • Confirmed nonunion after conservative treatment
  • Technique
    • Standard Single Screw Fixation
    • Dual Screw Fixation
    • Plate Fixation

Rehab and Return to Play

Rehab exercises for scaphoid fracture
Physical therapy exercises for scaphoid fracture

General Rehab Principles

  • Healing first: confirm union (prefer CT) before advancing
  • Early protection: strict immobilization initially
  • Imaging-guided: don’t rely on exam alone
  • Protect loading: avoid early grip, impact, weight-bearing
  • Maintain motion: keep shoulder, elbow, fingers moving
  • ROM before strength: restore motion prior to resistance
  • Criteria-based progression: healing + pain-free + functional ROM
  • Control swelling/stiffness: elevation, compression, tendon glides
  • Gradual strengthening: progress to functional/sport tasks
  • Individualize care: fracture type, location, athlete demands
  • Watch complications: nonunion, AVN, persistent pain
  • Return to activity: only after union + full painless function

Phase 1: Protection & Early Mobilization[26]

  • Nonoperative
    • Immobilization: 6–10 weeks (below-elbow cast ± thumb)
    • Thumb not required for nondisplaced waist/distal pole fractures
    • Maintain: shoulder, elbow ROM; finger motion
    • Progression: CT at ~6 weeks with ≥50% trabecular bridging
  • Operative
    • Immobilization: 0–2 weeks (variable)
    • Post-op: immediate mobilization → short splinting (surgeon dependent)
    • Maintain: early finger motion; guided wrist motion
    • Progression: wound healing, pain control, surgeon clearance

Phase 2: Active ROM & Gentle Strengthening[27]

  • Timeline: After cast removal (non-op) or per surgeon protocol (op)
  • Goals
    • Restore wrist ROM (flex/ext, radial/ulnar deviation)
    • Restore forearm rotation (pronation/supination)
    • Improve grip strength
    • Reduce edema/stiffness
  • Exercises
    • Active wrist ROM (pain-free)
    • Forearm rotation
    • Gentle grip (putty/ball)
    • Tendon gliding (fingers/thumb)
    • Edema control (elevation/compression)
  • Restrictions
    • No heavy lifting or impact
    • Avoid forceful grip or weight-bearing
    • Progress by pain tolerance
  • Duration: ~2–4 weeks

Phase 3: Strengthening & Functional Return

  • Timeline
    • Non-op: ~8–12 weeks
    • Operative: ~6–10 weeks
  • Prerequisites
    • CT: ≥50% bridging (prefer full union)
    • Minimal/no pain with ADLs
    • ≥70% ROM vs contralateral side
  • Goals
    • Full wrist ROM
    • Restore strength (wrist + grip)
    • Return to ADLs
    • Sport-specific progression
  • Exercises
    • Resistance training (wrist curls, extension, deviation)
    • Progressive grip strengthening
    • Proprioception/stability drills
    • Functional/task-specific training
    • Plyometrics (athletes)
  • Duration: ~4–6 weeks

Scaphoid Fracture Rehab PDFs

Return to play criteria

Return to play criteria for Scaphoid Fracture
  • Athletes should meet ALL of the following before unrestricted return
    • Radiographic healing: CT confirmation of at least 50% trabecular bridging (complete union preferred for contact sports)
    • Pain-free activity: No pain with sport-specific movements or loading
    • Range of motion: At least 90% of contralateral wrist in all planes
    • Strength: Grip strength at least 85-90% of contralateral side
    • Functional testing: Successful completion of sport-specific drills without pain or apprehension
    • Psychological readiness: Athlete confidence in returning to full participation

Playing Cast Option

  • Indication: in-season athletes with stable, nondisplaced mid-third fractures
  • Playing cast may allow immediate or early return (average 4.3 weeks)[28]
    • Comparable union rates to those who delay return
  • This option requires:
    • Confirmed stable fracture pattern
    • Appropriate sport (typically non-contact or limited contact)
    • Custom-fitted protective cast
    • Close monitoring for displacement or nonunion
    • Shared decision-making with athlete regarding risks

Prognosis and Complications

Stage III scapholunate advanced collapse wrist. Anteroposterior (A) and lateral views (B) show damage to the radioscaphoid and lunocapitate articular surfaces.[29]

Prognosis

  • Overall
    • Prognosis is excellent when managed correctly with union rates approaching 99%[25]
    • No significant difference in patient-reported outcomes at 52 weeks between surgical and conservative management[25]
  • Nonoperative
    • >90% of union in scaphoid fractures with <1 mm displacement (need citation)
  • Fracture Location and Healing
    • Distal pole fractures: Best prognosis, highest union rates
    • Waist fractures: Good prognosis with appropriate treatment; 10-15% fail to heal with casting alone
    • Proximal pole fractures: Poorest prognosis due to tenuous blood supply; higher rates of nonunion and avascular necrosis (AVN)
  • Displaced fractures[30]
    • Displaced fractures (>1-2 mm) have significantly worse outcomes
    • 55% incidence of nonunion and 50% rate of AVN if not anatomically reduced

Complications

  • Avascular Necrosis
    • From disruption of the scaphoid's fragile blood supply, which enters primarily from the distal pole
    • Proximal pole fractures are particularly prone to AVN
  • Non-union[31]
    • Most significant complication
    • Occurs in 10-15% of conservatively treated fractures and up to 10% after surgical treatment
    • Risk factors include displacement, instability, delayed diagnosis, smoking, inadequate treatment, AVN
  • Scaphoid Nonunion Advanced Collapse
    • Untreated nonunion almost inevitably leads to degenerative wrist arthritis, typically within 5 years
  • Malunion[32]
    • Malunion with "humpback deformity" (flexion deformity of the scaphoid) can occur
    • Leading to altered carpal mechanics and predisposing to degenerative changes

See Also

Internal

External

References

  1. ↑ Rhemrev SJ, et al. Current methods of diagnosis and treatment of scaphoid fractures. 2011.
  2. ↑ Gray’s Anatomy; historical terminology review.
  3. ↑ Rhemrev SJ, et al. 2011.
  4. ↑ Herbert TJ, Fisher WE. The Herbert screw. 1984.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Buijze, Geert A., and Jesse B. Jupiter. "Acute Scaphoid Fractures: Guidelines for Diagnosis and Treatment." Journal of the American Academy of Orthopaedic Surgeons, vol. 19, no. 6, 2011, pp. 354–365.
  6. ↑ 6.0 6.1 Duckworth, A. D., et al. "The Epidemiology of Fractures of the Scaphoid." Journal of Bone and Joint Surgery, vol. 94-B, no. 10, 2012, pp. 1305–1310.
  7. ↑ Cooney, William P. "Scaphoid Fractures: Current Treatments and Techniques." Instructional Course Lectures, vol. 52, 2003.
  8. ↑ Case courtesy of Hani M. Al Salam, Radiopaedia.org, rID: 13037
  9. ↑ Hackney, Lauren A., and Seth D. Dodds. "Assessment of scaphoid fracture healing." Current reviews in musculoskeletal medicine 4 (2011): 16-22.
  10. ↑ Fowler, J. R., and J. P. Hughes. "Scaphoid Fractures." Clinical Sports Medicine, vol. 34, no. 1, 2015, pp. 37–50.
  11. ↑ Standring, Susan, ed. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 41st ed., Elsevier, 2016.
  12. ↑ 12.0 12.1 Gelberman, Richard H., and Daniel J. Menon. "The Vascularity of the Scaphoid Bone." Journal of Hand Surgery, vol. 5, no. 5, 1980, pp. 508–513.
  13. ↑ Fowler, J. R., and J. P. Hughes. "Scaphoid Fractures." Clinical Sports Medicine, vol. 34, no. 1, 2015, pp. 37–50.
  14. ↑ Herzberg, Guillaume. "Perilunate and Axial Carpal Dislocations and Fracture-Dislocations." Journal of Hand Surgery, vol. 33, no. 9, 2008, pp. 1659–1668.
  15. ↑ Palmer, A. K. "Triangular Fibrocartilage Complex Lesions: A Classification." Journal of Hand Surgery, vol. 14, no. 4, 1989, pp. 594–606.
  16. ↑ Fowler, J. R., and J. P. Hughes. "Scaphoid Fractures." Clinical Sports Medicine, vol. 34, no. 1, 2015, pp. 37–50.
  17. ↑ Coventry, Laura, et al. "Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies." Emergency Medicine Journal (2023).
  18. ↑ Parvizi J, Wayman J, Kelly P, Moran CG. Combining the clinical signs improves diagnosis of scaphoid fractures. A prospective study with follow-up. J Hand Surg Br. 1998 Jun; 23(3):324-7
  19. ↑ 19.0 19.1 19.2 Mallee, Wouter H., et al. "Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs." Cochrane Database of Systematic Reviews 6 (2015).
  20. ↑ Daniels, Anne M., et al. "What is the diagnostic performance of conventional Radiographs and clinical reassessment compared with HR-pQCT scaphoid fracture diagnosis?." Clinical Orthopaedics and Related Research® 481.1 (2023): 97-104.
  21. ↑ Karl, John W., Eric Swart, and Robert J. Strauch. "Diagnosis of occult scaphoid fractures: a cost-effectiveness analysis." JBJS 97.22 (2015): 1860-1868.
  22. ↑ Gemme, Seth, and Robert Tubbs. "What physical examination findings and diagnostic imaging modalities are most useful in the diagnosis of scaphoid fractures?." Annals of Emergency Medicine 65.3 (2015): 308-309.
  23. ↑ Kwee, Robert M., and Thomas C. Kwee. "Ultrasound for diagnosing radiographically occult scaphoid fracture." Skeletal radiology 47.9 (2018): 1205-1212.
  24. ↑ Mohiuddin, Md, et al. "The outcome of scaphoid fracture nonunion managed by 1, 2 intercompartmental supraretinacular artery (1, 2 ICSRA) vascularized bone graft." Cureus 15.10 (2023).
  25. ↑ 25.0 25.1 25.2 Dias, Joseph J., et al. "Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial." The Lancet 396.10248 (2020): 390-401.
  26. ↑ Dunleavy, Mark L., Nicholas Pilla, and Michael Darowish. "Treatment Options, Return to Play, and Functional Performance after Operatively and Non-operatively Managed Acute Scaphoid Fractures." Current Reviews in Musculoskeletal Medicine 18.1 (2025): 17-25.
  27. ↑ Hughes, Thomas B. "Acute scaphoid waist fracture in the athlete." Clinics in sports medicine 39.2 (2020): 339-351.
  28. ↑ Rettig, Arthur C., Erich J. Weidenbener, and Robert Gloyeske. "Alternative management of midthird scaphoid fractures in the athlete." The American journal of sports medicine 22.5 (1994): 711-714.
  29. ↑ Odella, Simona, et al. "Locking dorsal plate in four-bone arthrodesis in SLAC and SNAC 3 wrist." Joints 6.01 (2018): 037-041.
  30. ↑ Szabo, Robert M., and DAVID MANSKE. "Displaced fractures of the scaphoid." Clinical Orthopaedics & Related Research 230 (1988): 30-38.
  31. ↑ Kawamura, Kenji, and Kevin C. Chung. "Treatment of scaphoid fractures and nonunions." The Journal of hand surgery 33.6 (2008): 988-997.
  32. ↑ Gray, Robert RL, et al. "Scaphoid fracture and nonunion: new directions." Journal of Hand Surgery (European Volume) 48.2_suppl (2023): 4S-10S.
Created by:
John Kiel on 10 June 2019 01:01:55
Last edited:
10 April 2026 11:40:41
Categories:
Trauma | Osteology | Wrist | Upper Extremity | Fractures | Acute | Featured
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