creation date: 2026-02-23 18:10
tags: Pathologies
Scaphoid Fracture
Background
Definitions
Scaphoid fractures are a common upper extremity injury, frequently occuring following a fall onto an outstretched hand (FOOSH).
Scaphoid fractures account for 60-70% of all carpal fractures and 10% of all hand fractures.
Etiology and Pathophysiology
The fracture can occur with direct axial compression or with hyperextension of the wrist (eg. FOOSH).
When the wrist is dorsiflexed greater than 95 degrees and loaded in a manner such as a fall, the indentation in the midbody of the scaphoid is forced against the dorsal lip of the distal radius, creating a mechanism for injury.
Clinical Presentation
Signs & Symptoms
Pain
- Localized to the radial aspect of the wrist, often just proximal to the thumb metacarpal
Tenderness in one of three locations:
- Volar prominence at the distal wrist crease (distal pole fractures)
- Anatomic snuffbox (waist fractures, most common)
- Distal to Lister’s tubercle, a bony prominence on the distal dorsal radius (proximal pole fracture)
Other findings include:
- Possible swelling on dorsoradial aspect of wrist
- Range of motion and grip strength slightly reduced
History & Physical Exam
History will almost always elicit an injury involving an axial load placed on the wrist or a fall onto an outstretched hand.
Physical exam alone has poor diagnostic accuracy but anatomic snuffbox tenderness has acceptable sensitivity (although specificity is limited).
Assessment of more distal and proximal joints and bones should be done in the context of traumatic injury.
Risk Factors
Diagnosis
Criteria
Diagnosis of scaphoid fractures is made with imaging.
Standard radiograph may be sufficient but sensitivity is limited, especially in the acute phase. CT and MRI can also be used for diagnosis with better diagnostic accuracy.
In the case where advanced imaging is unavailable, a presumptive diagnosis can be made if history is consistent.
Work-up
Imaging
Standard radiograph for scaphoid fractures include PA, true lateral, oblique, and scaphoid views.
If the radiographs are normal but there is clinical suspicion, CT or MRI immediately or radionuclide bone scan ≥72 hours after injury should be ordered.
Differential
The differential for traumatic wrist pain includes:
- Distal radius fracture
- Wrist sprain
- Carpal injuries (other than scaphoid fracture)
Red Flags / Complications
The major complications are:
- Nonunion if diagnosis is missed and especially if displaced
- Avascular necrosis (30-40%), affecting the proximal pole
- Scapholunate dissociation
- Delayed union
Management
Immobilization (Casting) and General Management
Initial treatment should be initiated as long as diagnosis is suspected, even if radiographs are negative.
Patients should be placed in either:
- Volar wrist splint
- Thumb spica split
- Cast
Patients are advised to cease tobacco use due to risk of nonunion.
Casting
Casting is suitable for nondisplaced fractures. The recommendations are:
- Distal scaphoid fractures or possible occult: wrist in slight extension for 4-6 weeks
- Waist or proximal (not pole) fractures: 10-12 weeks for waist, 12-20 weeks for proximal
The cast can be bivalved (cut longitudinally on opposite sides and wrapped with elastic bandage) if there are swelling concerns.
Expected recovery
Immobilization should be continued until union is documented on radiograph (or CT if radiograph does not visualize well). If healing is not evident at 3-4 months, referral to surgery should be done.
The average time to return to work is approximately 11 weeks. However, patients can return to full activity if the cast does not interfere.
Physiotherapy or occupational therapy is encouraged as prolonged casting can weaken strength and reduce ROM.
Surgical Treatment
Immediate surgical treatment is indicated for:
- Open fractures
- Fractures associated with neurovascular compromise
Surgical referral is indicated within several days for:
- Fractures of the proximal pole (ie. proximal 1/5)
- Non-waist fractures displaced >1 mm
- Waist fractures displaced >2 mm
Nonunion or osteonecrosis at any time during follow-up of non-surgical treatment is also indication for surgical referral.
The average time to return to work is approximately 6 weeks.