Scaphoid fractures

INTRODUCTION — Scaphoid fractures are among the most common upper extremity injuries. They frequently occur following a fall onto an outstretched hand. Plain radiographs taken soon after the injury may not reveal a fracture, but the clinician should assume one is present until definitive proof otherwise is obtained.

This topic will review the diagnosis and nonoperative management of scaphoid (navicular) fractures in adults. Discussions of wrist anatomy, biomechanics, and other wrist-related injuries in adults and children are provided separately.

●Assessment of wrist pain; wrist anatomy and function: (See "Evaluation of the adult with acute wrist pain" and "Evaluation of the adult with subacute or chronic wrist pain" and "Anatomy and basic biomechanics of the wrist".)

●Adult wrist injuries: (See "Distal radius fractures in adults" and "Lunate fractures and perilunate injuries" and "Overview of carpal fractures" and "Metacarpal base fractures" and "Metacarpal shaft fractures".)

●Childhood wrist injuries: (See "Overview of acute wrist injuries in children and adolescents", section on 'Scaphoid fractures' and "Evaluation of wrist pain and injury in children and adolescents" and "Overview: Causes of chronic wrist pain in children and adolescents".)

EPIDEMIOLOGY — Carpal fractures account for approximately 5 percent of all fractures and 18 percent of hand fractures, and scaphoid fractures are the most common carpal fracture [1-3]. Scaphoid fractures account for 10 percent of all hand fractures and 60 to 70 percent of all carpal fractures [1,4].

A study of scaphoid fractures among US military personnel showed an unadjusted incidence of 1.21/1000 person-years. Male and White personnel had a higher relative risk, and 20- to 24-year-olds had the highest incidence at 1.64/1000 person-years [5]. According to data from the United States National Electronic Injury Surveillance System, the estimated incidence in the population at large is 1.47 fractures/100,000 person-years [6]. Among American collegiate athletes with hand and wrist injuries sustained between 2004 and 2014, scaphoid fractures represented 12.8 percent of all fractures and were most likely to be a season-ending injury [7].

CLINICAL ANATOMY — The anatomy and biomechanics of the wrist are discussed in detail separately; anatomy of particular relevance to scaphoid injury is reviewed here. (See "Anatomy and basic biomechanics of the wrist".)

The scaphoid is the largest bone of the proximal carpal row and is located on the radial aspect of the hand just distal to the radius itself (image 1A and figure 1 and figure 2 and figure 3 and figure 4). In lateral profile, the scaphoid is shaped like an hourglass. The scaphoid articulates with the trapezium, trapezoid, capitate, and lunate. The radioscaphoid and scapholunate ligaments anchor the scaphoid proximally (figure 5). The radial collateral ligament attaches to its lateral surface.

The palmar carpal branch of the radial artery supplies the scaphoid via the bone's distal pole and then proceeds to the proximal pole. Thus, blood supply to the proximal pole is tenuous and can be interrupted by a fracture (particularly at the waist or proximal end), thereby increasing the risk of nonunion (figure 6).

The most common classification of scaphoid fractures categorizes them by location: distal third (distal pole), central third (waist), and proximal third (proximal pole) (figure 7). Approximately 65 percent of scaphoid fractures occur at the waist, 15 percent at the proximal pole, 10 percent at the distal body, and 8 percent at the tuberosity (a protuberance at the distal palmar aspect) [8].

MECHANISM OF INJURY — Fractures of the scaphoid can occur either with direct axial compression or with hyperextension of the wrist, such as with a fall onto an outstretched hand. When the wrist is loaded in this manner and is dorsiflexed greater than 95 degrees, the indentation (waist) in the midbody of the scaphoid is forced against the dorsal lip of the distal radius, creating a mechanism for injury [9,10].

SYMPTOMS AND EXAMINATION FINDINGS — Typically, the patient with a scaphoid fracture reports sustaining an injury involving an axial load placed on the wrist or a fall onto an outstretched hand. Pain is localized to the radial aspect of the wrist, often in the area just proximal to the thumb metacarpal. Swelling may or may not be noticeable, but if present is usually on the dorsoradial aspect of the wrist.

Range of motion may be only slightly reduced unless there is a concomitant fracture dislocation. Grip strength is typically reduced.

Focal tenderness is usually present in one of three places:

●The volar prominence at the distal wrist crease for distal pole fractures (picture 1 and picture 2).

●The anatomic snuff box (see just below) for waist fractures (picture 3), which are most common.

●Just distal to Lister's Tubercle (a longitudinal bony prominence of the distal radius located just to the ulnar side of the extensor carpi radialis tendon) for proximal pole fractures (picture 4). (See 'Clinical anatomy' above.)

The anatomic snuffbox is located proximal to the base of the thumb between the extensor pollicis longus tendon medially and extensor pollicis brevis and abductor pollicis longus tendons laterally (picture 3 and figure 8). A good method for evaluating the body of the scaphoid is to gently bring the patient's wrist into ulnar deviation and slight volar flexion, and then palpate the anatomic snuffbox (picture 5).

Clinical examination alone has shown poor diagnostic accuracy for scaphoid fractures [11]. While anatomic snuffbox tenderness is the most sensitive examination finding (87 to 100 percent), its specificity is limited [12]. Combining clinical tests can improve specificity considerably [13,14], but a substantial number of fractures are still missed without diagnostic imaging. A meta-analysis of 14 studies (1940 patients) that evaluated clinical index tests showed that in patients with traumatic wrist pain, the probability of scaphoid fracture was about 60 percent in those with a combination of anatomic snuffbox tenderness, scaphoid tubercle tenderness, and pain with axial loading [14].

DIAGNOSTIC IMAGING — For suspected scaphoid fractures, standard plain radiographs include posteroanterior (PA), true lateral, oblique and scaphoid views of the wrist (image 1A-C and image 2 and image 3 and image 4 and image 5 and image 6). The scaphoid view (image 1C) is a PA picture taken with the wrist in full pronation and ulnar deviation. This view shows the scaphoid in its longitudinal axis without superimposed shadows from the distal radius.

Within two to six weeks of the injury, plain radiographs are limited in their capacity to detect scaphoid fractures. The false negative rate for radiographs taken soon after injury is 20 to 54 percent [15-17], and even six-week radiographs have limited accuracy (about 55 percent) [18]. Oblique fractures of the middle portion of the scaphoid body may be particularly difficult to detect on plain radiographs, and if missed can lead to poor outcomes [19].

In addition, the findings from multiple observational studies demonstrate that plain radiographs do not reliably show fracture detail such as displacement. Compared with computed tomography (CT) or magnetic resonance imaging (MRI), plain radiographs miss 30 to 50 percent of displaced fractures [20-23]. This has implications for treatment, as displaced fractures have a higher risk of nonunion and are more often managed surgically.

If fracture alignment is unclear on plain radiographs, a MRI or CT scan (image 7 and image 8), with images taken along the long axis, can correctly identify the degree of displacement [22].

Knowledge of normal carpal anatomy is essential for determining the presence of a fracture or dislocation, especially when interpreting the lateral view. In lateral radiographs, the distal radius, lunate, and capitate should align along a longitudinal axis (image 1B). In addition, the scapholunate angle should fall between 40 and 60 degrees. This angle is formed by a line bisecting the scaphoid in its longitudinal axis and another line bisecting the lunate (image 9). Larger or smaller angles indicate ligamentous instability or a fracture.

Plain radiographs should be evaluated for signs of ligament disruption, specifically of the scapholunate ligament. These signs include a widened space (>3 mm) between the scaphoid and the lunate. Widening can be accentuated by taking a PA view with the hand closed in a fist and the wrist in ulnar deviation (image 10). Undetected scapholunate ligament injuries can lead to disruption of the proximal carpal row and a condition known as scapholunate advanced collapse (SLAC) or scapholunate advanced collapse wrist (image 11). (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Scapholunate instability'.)

MANAGEMENT OF SUSPECTED ACUTE FRACTURE WITH NEGATIVE PLAIN RADIOGRAPHS

Approach to imaging and diagnosis — When plain radiographs are normal but patient history and examination findings are suspicious for scaphoid fracture, evidence supports obtaining early advanced imaging: magnetic resonance imaging (MRI) or computed tomography (CT) immediately, or radionuclide bone scan at least 72 hours after injury. We favor MRI due to its greater sensitivity and specificity, and its usefulness for detecting associated soft tissue injuries. However, CT or bone scan are good options, and may be preferred based on local availability and expertise, cost, and other factors.

The prevalence of occult scaphoid fracture in patients with trauma-related wrist pain but negative plain radiographs is 20 to 54 percent [15-17]. Early use of advanced imaging provides more rapid and accurate diagnosis and can markedly reduce unnecessary immobilization [11,16,24,25].

Several studies support acute MRI [26-31], CT, or bone scan [31,32] as more cost-effective strategies than empiric immobilization when initial plain radiographs are normal. While up-front imaging costs are higher using this approach, these are offset by lower costs for immobilization, follow-up visits, missed fractures and resulting nonunions, and loss of productivity.

The combination of anatomical snuffbox tenderness, scaphoid tubercle tenderness, and pain with axial loading can help to determine the need for advanced imaging. If all three findings are present, yet initial radiographs are normal, the probability of fracture is about 60 percent, so these patients are more likely to benefit from early advanced imaging [14]. In a systematic review of 8 studies (1685 patients) of occult scaphoid fractures, the most accurate clinical predictor of fracture was pain when moving from a position of pronation to supination against resistance [33]. The authors caution that this finding requires validation and that no single maneuver reliably excludes a fracture.

In locations where advanced imaging cannot be performed, it is reasonable to immobilize the injury appropriately and to either treat presumptively or to reassess, including repeat plain radiographs, at 7 to 14 days [1,8]. If the repeat radiographs are negative and there are no clinical signs of fracture, immobilization can be discontinued; if either is present, immobilization is continued for the appropriate period. However, this approach results in delayed diagnosis, and approximately 80 percent of patients will be immobilized unnecessarily for a week or longer [16,26,34]. (See 'Immobilization (casting) and general management' below and 'Follow-up care' below.)

There is no consensus on which imaging modality is the gold standard. The authors of a systematic review concluded that two such standards are reasonable: positive plain radiographs at six or more weeks post-injury, or agreement of at least two advanced imaging modalities (MRI, CT, or bone scan) [16]. Using these criteria, their review of 11 studies of moderately high quality, involving 717 patients with 719 suspected scaphoid fractures, reported the following findings:

●Bone scan has the statistically highest diagnostic accuracy due to its high sensitivity (99 percent; 95% CI 69-100), but it may not be the best test because its low specificity (86 percent; 95% CI 73-94) results on average in overtreatment of 112 of 1000 patients with negative plain radiographs.

●MRI and CT have statistically comparable diagnostic accuracy.

●MRI has a sensitivity of 88 percent (95% CI 64-97) and specificity of 100 percent (95% CI 38-100), and misses approximately 24 fractures in 1000 patients with negative plain radiographs, but results in no overtreatments. MRI also identifies soft tissue injuries in surrounding structures, and timing after injury does not affect its accuracy (image 8).

●CT has a sensitivity of 72 percent (95% CI 36-92) and specificity of 99 percent (95% CI 71-100) and would miss approximately 56 fractures in 1000 patients and overtreat only 8 patients. Timing after injury does not affect its accuracy (image 7).

The preferred approach to diagnostic imaging following negative plain radiographs depends upon a number of factors including the need for a rapid diagnosis, cost, resource availability, patient preference, and local expertise. Financial assessment should consider not only the cost of the imaging study but also the costs entailed in lost work days and repeat office visits.

Magnetic resonance imaging — Magnetic resonance imaging (MRI) is sensitive (88 percent in one review) and highly specific (100 percent in the same review) for diagnosing scaphoid fractures, and may be used when standard radiographs are inconclusive [11,16,25]. Overall, MRI is more accurate than bone scan and as accurate as CT for diagnosing a scaphoid fracture [16]. MRI also accurately identifies bony and soft tissue injuries in surrounding structures (image 8). (See 'Approach to imaging and diagnosis' above.)

When a fracture is present, the MRI shows diminished signal in T1-weighted images and increased signal in T2-weighted images [35]. Findings interpreted as "edema" can occur with fractures, microtrabecular fractures (bone bruise), or ligamentous injuries.

Several studies have reported that a protocol for evaluating suspected carpal fractures using MRI is more cost effective than the traditional approach of immobilization followed by repeat plain radiographs and allows for an earlier definitive diagnosis [26-31]. However, costs vary and local variation in cost and resources should be incorporated into decision making.

Radionuclide bone scan — In the presence of a scaphoid fracture, a radionuclide bone scan (ie, bone scintigraphy) shows focal increased uptake after 72 hours. Thus, the study must be performed at least 72 hours after injury. A negative bone scan virtually excludes a scaphoid fracture, with a negative likelihood ratio of 0.12 according to one systematic review [11]. In addition, bone scan can detect other bony injuries in cases of suspected scaphoid fracture [36]. (See 'Approach to imaging and diagnosis' above.)

Nevertheless, bone scan has limitations. It is less specific for a scaphoid fracture than either MRI or CT, and may be positive due to other injuries [8,16,25]. Bone scan also entails highest radiation dose of any of the techniques used to diagnose scaphoid fracture, and therefore may not be appropriate in children.

The authors of one systematic review of bone scintigraphy for suspected scaphoid fracture provide a diagnostic algorithm in which a bone scan is performed after three to seven days has elapsed since the initial injury [37]. According to multiple observational studies, scanning in this time frame detects all fractures and minimizes costs from additional follow-up (radiographs, office visit charges, and further diagnostic testing) and time lost from work. However, bone scintigraphy may result in unnecessary immobilization due to false positive results, and its cost is not inconsequential.

Computed tomography — Computed tomography (CT) can be used to diagnose scaphoid fractures and delineate details of the fracture pattern. As noted in the systematic review described above, CT is highly specific for detecting scaphoid fractures but less sensitive than MRI or bone scan [16]. If MRI is not available, CT can be used to rule in a scaphoid fracture but cannot definitively rule out such injury. Timing after injury does not affect its accuracy (image 7). (See 'Approach to imaging and diagnosis' above.)

Cone beam computed tomography — Cone beam CT (CBCT), a technique with higher resolution, 90 percent less radiation exposure, and faster scanning time than conventional CT, has been found to be more sensitive than plain radiographs for detecting radiocarpal fractures. Two meta-analyses of studies of patients with clinically suspected scaphoid fracture but negative plain radiographs (ie, occult fracture) reported that CBCT detected nearly all occult fractures, using MRI as a reference standard [38,39]. When available, CBCT may represent a rapid, accurate, and cost-effective imaging modality for occult wrist fracture but requires further study before it can be recommended in place of MRI, CT, or bone scan.

Ultrasonography — Abnormalities identified by ultrasound that are consistent with a scaphoid fracture include cortical disruption, hematoma, and displacement of the radial artery from the radial cortex of the scaphoid (image 12 and image 13). Two meta-analyses [11,40] and one systematic review [41] report that ultrasound (used when radiographs are normal) has a sensitivity of 80 to 89 percent and specificity of 83 to 89.5 percent for detecting scaphoid fractures. Clinicians trained in musculoskeletal ultrasound can use it to help rule in a scaphoid fracture if plain radiographs are normal. However, ultrasound, even when positive, should not supplant CT or MRI, which provide helpful information about displacement and fracture configuration that can affect treatment decisions.

Tomosynthesis — Preliminary studies report that tomosynthesis—a digital tomographic method using conventional plain radiograph systems to create multiple thin section images—has high sensitivity and specificity, and may reduce the need for advanced imaging [42-44]. However, further studies are needed to determine its role, and it is not yet widely available.

DIAGNOSIS — The diagnosis of scaphoid fracture may be made by plain radiograph if they are clearly abnormal. However, radiography is insensitive, and clinicians should assume the injury is present in patients with a consistent mechanism of injury and suggestive examination findings. A definitive diagnosis can be made using more advanced imaging techniques (eg, MRI, CT, or bone scan). (See 'Symptoms and examination findings' above and 'Approach to imaging and diagnosis' above.)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of acute, traumatic wrist pain includes distal radius fracture, wrist sprain, and carpal injuries other than scaphoid fracture. A more complete discussion of this differential diagnosis and the means for distinguishing among these diagnoses can be found separately. (See "Evaluation of the adult with acute wrist pain", section on 'Differential diagnosis by regions of the wrist'.)

INDICATIONS FOR SURGICAL REFERRAL — Open fractures and those associated with neurovascular compromise require immediate surgical consultation. Indications for referral to a hand surgeon within several days include:

●Fractures of the proximal pole (ie, proximal one-fifth of scaphoid) [45]

●Non-waist fractures displaced more than 1 mm [46]

●Waist fractures displaced more than 2 mm [47]

●Waist fractures minimally displaced (≤ 2 mm) when earlier return to work or activity is important to the patient willing to undergo surgery

●Delayed presentation of acute fractures (more than about three weeks)

●Fractures associated with scapholunate ligament rupture

●Carpal instability (eg, lunate tilt present on radiographs)

Indications for routine referral include evidence of nonunion or osteonecrosis at any time during the followup of patients being treated nonsurgically with immobilization. (See 'Diagnostic imaging' above.)

Given the risk of nonunion and the close monitoring required during treatment, it is reasonable to obtain surgical consultation for any scaphoid fracture, even acute nondisplaced injuries. Studies consistently report that surgical treatment of nondisplaced or minimally displaced fractures leads to earlier return to work by about six weeks [48-54] and earlier return to sport by about 2.5 weeks [55]. This may be especially important in persons who require earlier return to sport or occupation (athletes, military, laborers) or those who cannot tolerate prolonged casting.

If a rapid return to activity is not crucial, good outcomes may be achievable without surgery in patients with nondisplaced or minimally displaced fractures, although meta-analyses of randomized trials report mixed results concerning functional outcomes, rates of nonunion, and complications.

Delayed presentation is a risk factor for nonunion [19,56-58]. Therefore, we suggest obtaining consultation with a hand surgeon for any patient presenting more than approximately three weeks after injury. According to the authors of a series of 285 scaphoid fractures, nonunion rates can reach 40 percent when diagnosis and treatment are delayed by four weeks [56]. Thus, proper evaluation and close follow-up are crucial. Nevertheless, a review of 88 scaphoid fracture nonunions noted that initial radiographs were not obtained in 14 percent of patients who sought immediate medical attention [57].

Tobacco use, both smoking and smokeless, increases the risk for scaphoid fracture nonunion [59]. Patients who use tobacco products should be advised to quit. (See "Overview of smoking cessation management in adults".)

Evidence of nonunion necessitates referral to an orthopedic surgeon. Arterial flow to the scaphoid enters via the distal pole and travels to the proximal pole (figure 6). This blood supply is tenuous, increasing the risk of nonunion, particularly with fractures at the waist and proximal end (image 14) [46]. Nonunion may occur in as many as 5 to 10 percent of all cases [60]. Risk factors for nonunion include fracture displacement, delayed care, and proximal pole location [58,61]. (See 'Clinical anatomy' above.)

Studies comparing surgical and nonoperative management of non- or minimally displaced scaphoid waist fractures vary in important ways, including outcome measures, timing of assessments, and selection of patient self-assessment scores. Therefore, depending on the studies selected for inclusion, systematic reviews reach different inclusions [52,54,62]. Some studies report that surgical repair results in better functional outcomes (eg, grip strength, wrist mobility) than immobilization [50,53,54]; others report no significant difference [49,52,62]. Complication rates are higher for surgery in some meta-analyses [49,50,62] but equal in others [48,51,54]. As examples of this heterogeneity, in a large (408 patients), well-conducted, multicenter randomized trial, the large majority of acute scaphoid waist fractures with 2 mm of displacement or less healed well with immobilization alone, while in a small retrospective study limited to adolescents with nondisplaced scaphoid fractures, the rate of nonunion was higher and functional scores were lower with immobilization [63].

IMMOBILIZATION (CASTING) AND GENERAL MANAGEMENT

Initial treatment — When a definitive diagnosis cannot be determined at presentation and a scaphoid fracture is suspected on clinical grounds, even if radiographs are negative, the patient should be placed in a volar wrist splint or preferably a thumb spica splint or cast until a definitive imaging study can be performed [1,4,64,65]. If there is concern about swelling, the cast can be bivalved (ie, cut longitudinally on opposite sides) and wrapped with an elastic bandage.

The following figures describe how to make a thumb spica cast (picture 6A-I).

For most patients, pain is adequately managed with over-the-counter analgesics. Concerns about the effects of nonsteroidal anti-inflammatory medications on fracture healing are reviewed separately. (See "Nonselective NSAIDs: Overview of adverse effects", section on 'Possible effect on fracture healing'.)

Ice may be applied acutely to reduce swelling and pain, but if a splint is applied, the patient should be warned not to get it wet.

Casting recommendations — Displaced scaphoid fractures are referred for surgical management. Our suggested approach to the casting of nondisplaced fractures suitable for nonoperative management is as follows:

●Distal scaphoid fractures and possible occult fractures are immobilized in a cast with the wrist in slight extension for four to six weeks. Data do not support one type of cast over another (eg, short- versus long-arm, with or without thumb immobilization). Immobilization is discussed just below.

●Midbody (waist) or proximal scaphoid fractures (but not proximal pole fractures, which warrant referral) to be managed nonoperatively are immobilized initially in a cast. Duration depends on facture location. (See 'Follow-up care' below.)

No cast type has proven superior. In a systematic review and meta-analysis of seven studies, no statistically or clinically significant difference in nonunion rates was found when comparing short-arm versus long-arm casting or thumb immobilization to non-immobilization, although the number of events was small and results should be interpreted cautiously [66]. With a short-arm cast, the nonunion rate was 9.6 percent (15 of 156), and with a long-arm cast 10.5 percent (13 of 124; OR 0.79, 95% CI 0.19-3.26). With thumb-free casting, the nonunion rate was 10.1 percent (18 of 179) versus 10.3 percent (18 of 174) with the thumb immobilized (OR 0.97, 95% CI 0.49-1.94). An earlier systematic review limited to four randomized trials reached the similar conclusions [67].

While long-arm casting and thumb immobilization are preferred by some clinicians for the purpose of providing more stringent immobilization during healing, this approach leads to a slower return to full function due to increased elbow and thumb stiffness and weakness.

The duration of immobilization depends upon the location of the fracture, with distal fractures requiring the shortest period and proximal fractures the longest. (See 'Follow-up care' below.) This is due to the relative risks associated with the distal-to-proximal blood supply of the scaphoid (figure 6). (See 'Clinical anatomy' above.)

FOLLOW-UP CARE — Nondisplaced fractures are followed serially with radiographs obtained every two weeks. Guidelines for the duration of immobilization of scaphoid fractures are as follows [1,8]:

●Distal pole – 4 to 6 weeks

●Waist (midbody) – 10 to 12 weeks

●Proximal (but not proximal pole, which are referred) – 12 to 20 weeks

However, these guidelines are approximations and immobilization should be continued until fracture union is documented on radiographs. CT can be used if healing is not well visualized on plain radiographs.

Ninety to 98 percent union rates have been achieved with appropriate cast immobilization of nondisplaced distal and midbody scaphoid fractures [22,64,68]. Exercises to maintain finger, elbow, and shoulder range of motion should be performed while the wrist is immobilized.

If at three to four months radiographic healing is not evident, referral to a hand surgeon should be obtained for possible treatment with a bone stimulator or surgical correction with bone grafting.

RETURN TO SPORT OR WORK — The average time to return to work after nonsurgical treatment of a nondisplaced scaphoid fracture is about 11 weeks, and after surgical management is about six weeks [48,51,69].

Patients with nondisplaced fractures treated with a short-arm cast can be allowed to return to full activity, including non-contact sports, if the cast does not interfere with activity or sport-specific functioning [1,64]. The clinician should carefully monitor the integrity of the cast and ensure proper immobilization. After the cast is removed, the wrist should continue to be protected for two months with rigid splinting, while the patient participates in non-contact sports or other strenuous activity.

Physical or occupational therapy is strongly encouraged because of the weakness and decreased range of motion that typically results from prolonged casting. As mentioned above, during activity the wrist should continue to be protected for at least two months, until strength is at least 80 percent of the uninjured side and the range of motion has returned to near-normal.

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of definitive fracture management".)

●(See "General principles of acute fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Fractures of the skull, face, and upper extremity in adults" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Common wrist injuries (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Epidemiology and mechanism – Scaphoid fractures are the most common carpal bone fracture and typically occur from a fall onto an outstretched arm with the wrist in dorsiflexion. Suspect a scaphoid fracture in any patient with wrist pain following a fall. (See 'Epidemiology' above and 'Mechanism of injury' above.)

●Presentation and examination – Patients with a scaphoid fracture typically complain of pain localized to the radial aspect of the wrist, often in the area just proximal to the thumb metacarpal. When present, swelling is usually on the dorsoradial aspect of the wrist. Focal tenderness is usually present in one of three places:

•The volar prominence at the distal wrist crease for distal pole fractures (picture 1 and picture 2).

•The anatomic snuff box (see below) for waist fractures (picture 3), which are most common.

•Just distal to Lister's Tubercle (a longitudinal bony prominence of the distal radius located just to the ulnar side of the extensor carpi radialis tendon) for proximal pole fractures (picture 4). (See 'Symptoms and examination findings' above.)

●Diagnostic imaging – Plain radiographs should be obtained immediately after the injury, but these may not reveal evidence of a fracture. Ultrasound is a useful screening tool for ruling in occult fractures. Management of patients with negative initial radiographs but concern for scaphoid fracture based on clinical findings consists of advanced imaging if an immediate diagnosis is needed (MRI is most accurate and our preferred approach), or immobilization and repeat imaging with a bone scan (after three to five days) or plain radiographs (after 7 to 10 days). Check radiographs carefully for concomitant injury of the scapholunate ligament. (See 'Diagnostic imaging' above and 'Management of suspected acute fracture with negative plain radiographs' above.)

●Blood supply and nonunion risk – The scaphoid has a tenuous blood supply (figure 6) that runs from distal to proximal leading to the possibility of nonunion or osteonecrosis with fractures of the proximal pole. (See 'Clinical anatomy' above.)

●Indications for surgical referral – Open fractures and those associated with neurovascular compromise require immediate surgical referral. Indications for referral within several days include:

•Proximal pole (ie, proximal fifth of scaphoid) fractures (image 14)

•Fractures displaced over 1 mm

•Delayed presentation of acute fractures (more than about three weeks)

•Associated scapholunate ligament rupture (image 14)

•Carpal instability (eg, lunate tilt on radiographs)

Early consultation for nondisplaced scaphoid fractures may be preferred when a faster recovery is desired. Indications for routine referral include evidence of nonunion or osteonecrosis on follow-up during treatment with immobilization. (See 'Indications for surgical referral' above.)

●Management – Nondisplaced fractures (≤1 mm) of the distal scaphoid can be treated in a short-arm cast, with or without thumb immobilization (picture 6A-I), typically for 6 to 10 weeks. Nondisplaced fractures at the waist or proximal third (not the proximal pole) can be treated in a short-arm cast, with or without thumb immobilization, until healing is documented. These more proximal fractures require a longer period of immobilization than distal fractures. If prolonged immobilization cannot be tolerated, refer the patient for operative fixation. (See 'Immobilization (casting) and general management' above.)

●Return to activity – Athletes and workers engaged in heavy labor must continue to wear protection (rigid splint) for two months after radiographic healing is noted. (See 'Return to sport or work' above.)