Scaphoid Fracture: Complete Guide
The most common carpal fracture (70%). Critical to diagnose early to prevent nonunion and arthritis. Expert information on diagnosis, treatment, and outcomes.
Understanding Scaphoid Fractures
The scaphoid is the most commonly fractured carpal bone, accounting for approximately 70% of all carpal fractures. It is crucial for wrist function, acting as a link between the proximal and distal carpal rows. The scaphoid's unique blood supply makes it vulnerable to nonunion and avascular necrosis.
Anatomy & Blood Supply: The scaphoid has a retrograde blood supply - blood enters through branches at the distal pole and flows proximally. The proximal 70-80% of the scaphoid depends on this single blood supply, making proximal pole fractures particularly at risk for healing problems.
Epidemiology: Scaphoid fractures most commonly occur in young adults aged 15-30 years, typically males. The classic mechanism is a fall onto an outstretched hand (FOOSH) with the wrist extended.
Herbert Classification
A1: Fracture of tubercle
A2: Incomplete fracture through waist (crack)
Typically treated with immobilization. Good prognosis.
B1: Distal oblique fracture
B2: Complete waist fracture
B3: Proximal pole fracture
B4: Trans-scaphoid perilunate fracture-dislocation
Usually require surgical fixation. Higher nonunion risk.
Nonunion Risk by Location: Distal pole <5%, Waist 10-20%, Proximal pole 30-40%. This correlates with the retrograde blood supply pattern.
Signs & Symptoms
• Mechanism: Fall onto outstretched hand (FOOSH) with wrist extended
• Anatomical snuffbox tenderness: Classic finding (sensitivity 90%, specificity 40%)
• Scaphoid tubercle tenderness: Volar wrist at base of thumb
• Axial compression: Pain with thumb compression along its axis
• Swelling: Often minimal, may be absent
• Grip weakness: Pain with gripping
Clinical Pearl: If anatomical snuffbox tenderness is present after a fall, treat as a scaphoid fracture until proven otherwise. Initial negative X-rays do not rule out fracture - obtain MRI or repeat X-rays at 10-14 days.
Diagnosis
X-rays: Standard wrist series plus scaphoid views (PA with ulnar deviation, oblique). Initial X-rays are negative in 15-20% of scaphoid fractures. If clinical suspicion is high, immobilize and re-image.
MRI: Gold standard for occult scaphoid fractures. Sensitivity and specificity approach 100%. Recommended if initial X-rays negative but clinical suspicion high. Can be done within 48 hours.
CT Scan: Better than X-rays for displacement assessment and surgical planning. Used to assess union during treatment. Essential for nonunion assessment.
Bone Scan: Highly sensitive but not specific. Rarely used now that MRI is widely available.
Treatment Options
Indications:
- Non-displaced waist fractures (<1mm displacement)
- Distal pole/tubercle fractures
- Patient preference against surgery
Protocol:
- Thumb spica cast (long arm initially for 4-6 weeks, then short arm)
- Total immobilization: 8-12 weeks
- Serial X-rays to monitor healing
- CT scan if union uncertain
Union rates: 85-95% for non-displaced waist fractures
Indications:
- Displaced fractures (>1mm gap or step-off)
- Proximal pole fractures
- Delayed presentation (>4 weeks)
- Athletes/workers needing faster return
- Associated carpal instability
- Nonunion
Surgical Technique:
Headless Compression Screw: Herbert screw or similar (Acutrack, Acutrak). Placed percutaneously or through limited incision. Provides compression across fracture site.
Approach: Volar for waist fractures, dorsal for proximal pole fractures.
Bone Grafting: Added for nonunion or significant bone loss (vascularized graft for AVN).
Union rates: >95% with screw fixation of acute non-displaced fractures
Complications
Occurs in 5-20% of fractures if not properly treated. Risk factors: proximal location, displacement, delayed diagnosis, smoking. Leads to SNAC wrist arthritis over time.
Death of bone due to disrupted blood supply. Most common with proximal pole fractures. May require vascularized bone grafting for treatment.
Recovery Timeline (After Surgery)
Evidence & References
- • Dias JJ, et al. Suspected scaphoid fractures: management algorithms and evidence-based guidelines. Bone Joint J. 2014
- • Buijze GA, et al. Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. JBJS. 2010
- • Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. JBJS Br. 1984
- • Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand Surg Am. 2008
Last Updated: January 2025 | Content reviewed by Dr. Deepthi Nandan Reddy, FRCS (Ortho)