Scaphoid Fracture
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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Risk factors
- 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 |
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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