Most common carpal fracture; high risk of nonunion and avascular necrosis given retrograde blood supply.
Also known as: scaphoid fracture, navicular fracture, wrist scaphoid
Overview
Fracture of the scaphoid bone of the proximal carpal row, typically from a fall on an outstretched hand with the wrist in extension and radial deviation. The scaphoid is the most commonly fractured carpal bone, accounting for approximately 70 percent of carpal fractures.
Epidemiology
Peak incidence in young adult men aged 15-30 from sports and high-energy trauma. Children and older adults sustain other wrist injuries (distal radius fracture) more often.
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Fall on outstretched hand with wrist extended and radially deviated
Contact and high-velocity sports (football, snowboarding, basketball)
Motor vehicle collision
Young adult male sex
Pathophysiology
The scaphoid receives its blood supply predominantly from the dorsal carpal branch of the radial artery, which enters distally and flows retrograde to the proximal pole. A fracture across the waist or proximal pole disrupts this supply, creating a high risk of nonunion and proximal pole avascular necrosis — the more proximal the fracture, the higher the risk.
Clinical presentation
Symptoms
Radial-sided wrist pain after a fall on the outstretched hand
Pain with gripping or wrist motion
Mild swelling and decreased grip strength
Signs / physical exam
Tenderness in the anatomic snuffbox (between extensor pollicis longus and extensor pollicis brevis/abductor pollicis longus)
Tenderness over the scaphoid tubercle volarly
Pain with axial loading of the thumb
Limited and painful wrist range of motion
Classic findings
Anatomic snuffbox tenderness after a fall on an outstretched hand should be presumed to be a scaphoid fracture until proven otherwise, even when initial radiographs are normal.
Differential diagnosis
Distal radius fracture — Most common adult wrist fracture; tenderness over distal radius rather than snuffbox; visible on PA and lateral wrist radiographs
Other carpal fracture (triquetrum, hamate, lunate) — Tenderness localizes to the specific carpal bone; dedicated views or CT may be needed
Scapholunate ligament injury — Pain dorsal wrist with positive scaphoid shift (Watson) test; widened scapholunate interval >3 mm on PA radiograph (Terry Thomas sign)
Wrist sprain — Diagnosis of exclusion; should not be assigned in the setting of snuffbox tenderness without further imaging
De Quervain tenosynovitis — Radial wrist pain with positive Finkelstein test, no acute trauma
Diagnostic workup
Diagnostic criteria
Diagnosis is established by radiographic visualization of the fracture line, MRI evidence of marrow edema and fracture line, or CT confirmation. Russe classification (horizontal oblique, transverse, vertical oblique) and anatomic location (proximal pole, waist, distal pole, tubercle) guide management.
Labs
None required
Imaging
PA, lateral, oblique, and dedicated scaphoid (PA wrist in ulnar deviation) views
Initial radiographs are negative in up to 25 percent of true scaphoid fractures
If clinical suspicion is high and radiographs are negative: immobilize and repeat radiographs in 7-14 days OR obtain MRI (gold standard for occult fracture) or CT
CT is most useful to assess displacement, comminution, and to plan operative fixation
Diagnostic algorithm
Location
Nonunion Risk
Typical Treatment
Tubercle / distal pole
Low
Short-arm thumb spica cast 6-8 weeks
Waist (nondisplaced)
Moderate
Thumb spica cast 8-12 weeks OR percutaneous screw
Waist (displaced >1 mm)
High
Open reduction with compression screw
Proximal pole
High (up to 30%)
Operative fixation typically recommended
Nonunion risk and management by scaphoid fracture location.
Treatment
First-line
Suspected nondisplaced fracture with negative initial radiographs: thumb spica splint or short-arm thumb spica cast, reimaging in 7-14 days
Nondisplaced distal pole or tubercle fracture: short-arm thumb spica cast for 6-8 weeks
Nondisplaced waist fracture: short-arm or long-arm thumb spica cast for 8-12 weeks total
Strict immobilization of the wrist and thumb interphalangeal joint is essential
Second-line / adjunct
Operative fixation with a headless compression screw (Herbert or Acutrak) for displaced fractures (>1 mm displacement), proximal pole fractures, comminution, scapholunate ligament injury, or established nonunion
Early operative fixation may be considered for high-demand athletes and laborers to shorten time to return to activity
Bone grafting for nonunion or established avascular necrosis (vascularized graft from distal radius for proximal pole nonunion with AVN)
Complications
Nonunion (5-15 percent of waist fractures, up to 30 percent of proximal pole fractures)
Avascular necrosis of the proximal pole
Scaphoid nonunion advanced collapse (SNAC wrist) — progressive radiocarpal and midcarpal arthrosis from chronic nonunion
Malunion with carpal instability
Chronic wrist pain and decreased grip strength
PANCE pearls
Snuffbox tenderness with a normal radiograph is treated as a scaphoid fracture — immobilize and reimage.
Proximal pole fractures have the highest rate of nonunion and avascular necrosis and are often treated surgically from the outset.
Thumb spica immobilization, not a standard short-arm cast, is required.
Untreated scaphoid nonunion leads to predictable wrist arthritis (SNAC) over years.
References
AAOS — American Academy of Orthopaedic Surgeons clinical resources on the management of scaphoid fractures
ASSH — American Society for Surgery of the Hand evidence-based guidance on scaphoid fracture management
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