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Scaphoid Fixation

Percutaneous and open compression-screw fixation of scaphoid fractures.

81 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Scaphoid fixation addresses acute fractures, nonunions, and malunions, with management strategies dictated by fracture displacement, vascularity, and chronicity. Pediatric scaphoid fractures consistently demonstrate excellent outcomes [1]. For acute injuries, nondisplaced fractures can be effectively treated nonoperatively with union rates approaching or exceeding those of operative intervention [4], although early internal fixation is increasingly favored even in these cases [5]. Operative intervention is recommended for displaced acute scaphoid fractures [4]. Percutaneous screw fixation provides excellent and reliable results for acute scaphoid fractures [9] and serves as an attractive option for acute management [36]. While the advantages of surgical fixation for acute fractures are transient [66], its possible complications must not be underestimated, and long-term outcomes remain incompletely understood [66]. Failure of acute fixation often results from malreduction, failure to restore length, or compromised vascularity [10].

Scaphoid nonunion rates remain high despite improvements in diagnosis and surgical techniques [5]. Treatment varies based on stability and vascularity. Uncomplicated, nondisplaced, and nonangulated nonunions are candidates for minimally invasive bone grafting and compression screw fixation [15], or fixation and grafting after limited debridement without avascular necrosis [17]. Stable nonunions with minimal displacement, maintained mechanical alignment, and an intact cartilage cap can be treated by restoring mechanical stability [11], potentially via percutaneous debridement and fixation without formal bone grafting [28]. Proximal pole nonunions with avascular necrosis do not always require vascularized bone graft or formal open incision; if the distal scaphoid is well perfused and the proximal pole secured rigidly after percutaneous bone grafting, healing can proceed [2]. Autologous local bone graft with surgical fixation allows proximal pole fractures with delayed union to heal without complex vascularized procedures [7]. For unstable nonunions with cavitary bone loss, double screw fixation with autologous bone graft allows early active range of motion without compromising union rates [30]. The free medial femoral condyle vascularized graft represents a promising alternative for difficult nonunions with poor prognostic factors, demonstrating high union rates and low donor site morbidity [46].

Virtually all scaphoid fractures that unite have a good outcome, regardless of malunion [20]. Salvage procedures are reserved for specific deformities. The hybrid Russe procedure is recommended for scaphoid fracture waist nonunions with dorsal intercalated segment instability deformity, providing excellent functional results [31]. Scaphoid excision and 4-corner arthrodesis yields favorable outcomes at one year that do not deteriorate significantly between one and 10 years [19]. A validated prognostic classification system is needed to allow comparisons between outcome studies for scaphoid nonunions [25].

Anatomy & Pathophysiology

Bony Anatomy

The scaphoid is a small, irregular S-shaped tubular bone located in the proximal carpal row on the radial aspect of the wrist [68]. It is the only carpal bone that bridges the proximal and distal carpal rows, acting as a tie-rod [88]. The bone lies entirely within the wrist joint at a 45-degree plane to the longitudinal and horizontal axis of the wrist [68]. Its orientation within the carpus is defined by an intrascaphoid angle averaging 40 ± 3 degrees in the coronal plane and 32 ± 5 degrees in the sagittal plane [88], with a normal intrascaphoid angle of 24 degrees [76]. The scaphoid gently pronates and flexes distally, positioning the distal pole ulnarly angulated relative to the proximal pole [68].

The bone is divided into three regions: the proximal pole, waist, and distal pole (tubercle) [88]. Over 80% of the scaphoid surface is covered with articular cartilage [68]. The proximal articular surface is convex and articulates with the radius [68]. The distal articular surface features two distinct facets for the trapezium and trapezoid, forming the STT joint [68]. Medially, the scaphoid articulates with the capitate and lunate; specifically, the capitate head fits into a sulcus across the radial articular surface, providing a socket-like fit [68]. The nonarticular dorsoradial surface is ridged and serves as the insertion point for both the dorsal component of the scapholunate and intercarpal ligaments [68].

Vascular Anatomy

The blood supply of the scaphoid is predominantly retrograde [88]. Seventy to 80% of the intraosseous and proximal pole vascular supply derives from branches of the radial artery entering distally through the dorsal ridge [68, 88]. The volar branch of the radial artery enters via the scaphoid tubercle and supplies 20% to 30% of the distal scaphoid [68, 88]. The waist of the scaphoid has minimal or no perforating vasculature, and no vessels perforate the proximal dorsal cartilaginous area or through the scapholunate ligament [68]. Venous drainage from the proximal pole occurs via the dorsal ridge into the venae comitantes of the radial artery [88].

Anatomical variations in arterial foramina are common. Only 67% of scaphoid bones have arterial foramina throughout their length, including the distal, middle, and proximal thirds [72]. Thirteen percent of scaphoid bones have blood supply predominantly in the distal third [72]. Twenty percent of scaphoid bones have most arterial foramina in the waist area with no more than a single foramen near the proximal third [72]. Consequently, one third of scaphoid fractures occurring in the proximal third may be without adequate blood supply [72].

The proximity of the fracture to the proximal pole directly impacts vascularity. Proximal fractures are inexorably associated with at least temporary disruption of the interosseous blood supply to the proximal pole [68]. The more proximal the fracture, the more likely the bone is to be dysvascular and the higher the risk of nonunion [88]. Proximal pole fractures have been reported to have an incidence of avascular necrosis (AVN) of 13% to 50% [88], with the prevalence of osteonecrosis reaching 35% in fractures at the proximal pole level [72].

Ligamentous Anatomy

Ligamentous attachments of the scaphoid are predominantly found on the nonarticular dorsoradial surface [68]. There are no tendon attachments to the scaphoid [68]. The short intrinsic ligaments provide stability through attachments to other carpal bones, particularly the lunate, and merge with extrinsic ligaments and the wrist capsule [68].

The scapholunate interosseous ligament (SLIL) is a stout ligament connecting the scaphoid to the lunate and serves as the primary stabilizer [88]. The dorsal aspect of the SLIL is composed of transverse collagen fibers, whereas the palmar ligament is composed of oblique collagen fibers inserting to the volar capsular ligaments [88]. The dorsal portion of the SLIL is twice as strong as the palmar portion [88]. Functionally, the dorsal region resists palmar-dorsal translation and gap, while the volar portion resists rotation [88]. Only 20 to 30 degrees of motion is possible at an intact scapholunate interval [88].

The radioscaphocapitate (RSC) ligament originates from the volar radial aspect of the radius, crosses the volar concavity of the scaphoid waist, and proceeds ulnarly toward the capitate [88]. It acts as a fulcrum around which the scaphoid rotates [88]. Notably, the RSC ligament does not attach to the bone itself but crosses the waist, acting as a sling that allows rotation [68]. The scaphocapitate ligament originates from the distal scaphoid and inserts into the border between the trapezoid facet and the capitate facet [88]. It inserts into the volar waist of the capitate distal to the RSC ligament [88]. Together with the scaphotrapezial ligament, the scaphocapitate ligament functions as a primary restraint of the distal pole [88].

Pathophysiology

The scaphoid acts as a midcarpal joint “bridge” linking and synchronizing the motions of the proximal and distal carpal rows as part of the key intercalated segment [68]. Its motion includes rotation proximally and gliding distally, while providing stability to the midcarpal joint [68]. Scaphoid fractures account for almost 75% of all carpal fractures [40]. These fractures are rare in children and in the elderly [40]. The usual mechanism is forced hyperextension of the wrist [40]. Specifically, fracture occurs when the wrist is dorsiflexed to at least 95 degrees and radially deviated to at least 10 degrees [79]. Hyperextension past 95 degrees is the usual position of injury [76].

In this injury position, the proximal pole of the scaphoid is held firmly between the radius, capitate, radioscaphocapitate ligament, and the palmar capsule [79]. With radial deviation, the radioscaphocapitate ligament is relaxed and unable to relieve increasing force applied to the radiopalmar aspect of the scaphoid [79]. With the hyperextension mechanism, a fracture usually begins at the volar waist with a tensile failure; forces propagate to the dorsal surface with compression loading until failure occurs [76]. Proximal scaphoid fractures result from dorsal subluxation during forced hyperextension [76].

The scaphoid fractures most frequently through the waist as it is subject to maximal bending movement and has a characteristically lower trabecular volume [79]. Fractures of the waist are usually the result of shear forces across the scaphoid, while tubercle fractures appear to be caused by either compression or avulsion [79]. The size of a proximal pole fracture is dependent on the level of the proximal extent of the joint facet with the capitate [79]. Smaller proximal pole fractures can be caused by an avulsion of the attachment of the scapholunate ligament [79].

Some scaphoid fractures, especially distal oblique and waist fractures, are unstable, which predisposes to non-union or malunion [40]. With an unstable displaced scaphoid fracture, joint compressive forces, trapezium–scaphoid shear stress, and capitolunate rotation moments act upon the scaphoid, leading to dissociation of the proximal and distal carpal rows [79]. This dissociation permits the natural tendency of the two carpal rows to fail by collapsing, assuming a lunate-extended posture [79]. The scaphoid assumes an anteverted position, the lunate and triquetrum may subluxate forward and rotate dorsally, and the capitate and hamate subluxate dorsally and proximally, producing the dorsal intercalated segment instability (DISI) deformity [79].

Untreated displaced fractures of the waist usually angulate as the volar bone is reabsorbed, yielding a “humpback” flexion deformity of the scaphoid [76]. Humpback deformity is defined as a flexed scaphoid with an intrascaphoid angle >45 degrees [76]. The proximal and distal fracture fragments can collapse giving a characteristic flexed or “humpback” position on radiographs with an intrascaphoid angle of greater than approximately 30 degrees [79]. The degree of humpback deformity of the scaphoid correlates with the degree of carpal malalignment [115]. The resultant radial column shortening and extension of the proximal scaphoid pole releases the lunate to rotate into DISI under the influence of the attached triquetrum [76].

The reduced capacity for periosteal healing due to extensive articular cartilage coverage increases the tendency for delayed union and nonunion [68]. Nonunion occurs in 10% to 15% of all scaphoid fractures [76]. The risk of nonunion increases with: * Delay of treatment for more than 4 weeks [76] * Proximal pole fractures [76] * Fracture displacement greater than 1 mm [76] * Osteonecrosis [76] * Tobacco use [76] * Associated carpal instability, specifically dorsal intercalated segmental instability (DISI) with a scapholunate angle >60 degrees and a capitolunate angle >15 degrees [76]

A fracture of the scaphoid that is unrecognized and untreated for 4 weeks or longer is at increased risk for nonunion [12]. The incidence of nonunion with delayed immobilization of scaphoid fractures ranged from 19% to 88% in several studies [12]. Scaphoid fractures diagnosed on a delayed basis should be considered for operative treatment regardless of displacement [12].

Nonunion rates for nondisplaced waist fractures treated with casting are 5% to 12% [76]. Nonunion rates for displaced scaphoid fractures treated nonoperatively reach 50% [76]. In a review of 30-year follow-up results of scaphoid fractures treated with thumb spica short-arm casts, 10% of patients developed nonunion [76]. Of those who developed nonunion, 60% demonstrated radiographic evidence of radiocarpal osteoarthritis, while only 2% of the healed group demonstrated degenerative change [76].

Untreated scaphoid nonunion predictably progresses to arthritic change known as scaphoid nonunion advanced collapse (SNAC) [76]. Arthritic change in SNAC arises at the radial styloid articulation with the distal scaphoid pole (stage I), followed by degeneration of the scaphocapitate joint (stage II), and ultimately the midcarpal joint (stage III) [76]. Arthritic changes have been found in 97% of patients assessed at least 5 years after injury, with the degree of arthritic changes proportionate to the duration of nonunion [76].

Neglected scaphoid fractures seldom heal with acceptable alignment due to the unique anatomical structure of the bone [14]. Reconstruction of the scaphoid in cases of non-union or malunion is exceedingly difficult and increases the chances of morbidity associated with an extended period of hand immobilisation [14]. Fractures of the scaphoid are managed largely on the basis of anecdotal evidence and traditional remedies [14]. The blood supply of the scaphoid arises from the dorsal distal pole, meaning the proximal pole has a poor blood supply and is less likely to heal than the distal pole [40]. The proximal pole may actually crumble away due to avascular necrosis [40].

Classification

Epidemiology and Location

The scaphoid is the most frequently fractured carpal bone [14]. Fracture distribution is heavily weighted toward the waist, which accounts for approximately 60 to 80% of cases [13]. The distal third is involved in approximately 25% of fractures [13], while the proximal third is involved in approximately 5 to 10% [13]. The complex anatomy of the scaphoid, particularly its waist, may alter the strategy for fracture fixation [122].

Classification Systems

Cooney, Dobyns, and Linscheid: This system evaluates acute scaphoid fractures and includes additional criteria to differentiate between stable and unstable patterns [13]. Within this framework, distal pole fractures are classified as stable [13].

Herbert: This classification system for acute scaphoid fractures accounts for both fracture location and stability [13].

Alnot: This system is used specifically to classify scaphoid non-unions [43].

Stability Criteria

Stable acute scaphoid fractures are defined by a displacement of less than 1 mm and normal intercarpal alignment [13]. Unstable acute scaphoid fractures are defined as having greater than 1 mm displacement [13].

Nonunion Classification (Alnot)

Alnot Grade I: Described as a linear non-union without altered scaphoid form, instability, or intracarpal malalignment [43].

Alnot Grade IIB: Described as a more or less mobile non-union with an anterior defect and proximal pole flexion on the distal tubercle inducing DISI [43].

Alnot Grade III: Described as a more or less mobile displacement non-union with instability or reducible malalignment [43].

Alnot Grade IIIA: Described as isolated styloscaphoid arthritis [43].

Alnot Grade IIIB: Described as radial and/or intracarpal arthritis [43].

Alnot Grade IV: Described as proximal fragment necrosis with malalignment [43].

Alnot Grade IVA: Described as radioscaphoid and/or intracarpal arthritis [43].

Clinical Presentation

History and Mechanism

Patients classically present with wrist pain following a fall onto the outstretched hand, with almost 90% recalling a hyperextension injury [53]. The usual mechanism is forced hyperextension of the wrist [40], often resulting from falling on an outstretched hand, collision of the wrist against a person or heavy obstacle, or a direct blow against an object [39]. Patients may also report a history of hyperextension following sports or punch injuries [53]. It is critical to determine a history of previous trauma to the scaphoid to avoid treating a nonunion as an acute fracture [53]. In chronic injuries, athletes may complain of an inability to perform a push-up [99].

Physical Examination Findings

The main complaint is radial-sided wrist pain with localized tenderness over the scaphoid in the anatomical snuffbox region [53]. Acute fractures may present with swelling and bruising on the radial aspect of the wrist [39], while chronic injuries may exhibit swelling in the dorsoradial wrist [39]. Slight fullness in the anatomical snuffbox may be observed [40]. Generally, pain, swelling, ecchymosis, and tenderness around the scaphoid region may be present in the acute phase [53].

Precisely localized tenderness in the anatomical snuffbox is an important diagnostic sign [40]. "Snuffbox tenderness" has become synonymous with scaphoid fracture, but this applies predominantly to waist fractures, which represent 70% of scaphoid fractures [39]. The second most common type is a proximal pole fracture at 20%, and the least common is a distal pole fracture at 10% [39]. Fractures tend to occur at the waist partly because the RSC ligament acts as a fulcrum over which the scaphoid waist fractures [39].

Examination must include pressure backwards over the scaphoid tubercle, palpation over the proximal pole, and telescoping of the thumb base [40]. If any of these are positive, the suspicion for a scaphoid fracture should be high [40]. Pain on longitudinal compression of the thumb (scaphoid axial compression test) is also a sign of scaphoid fracture [39]. If all three tests—snuffbox tenderness, scaphoid tubercle tenderness, and scaphoid axial compression test—are positive, there is 87% to 100% sensitivity and 74% specificity for scaphoid fracture [39].

No single sign has been found to be adequately sensitive or specific for scaphoid fracture [53]. The diagnostic performance of individual signs varies significantly: * Anatomical snuffbox tenderness: Sensitivity of 87–100% and specificity of 3–98% [53]. * Axial compression of the thumb: Sensitivity of 48–100% and specificity of 22–97% [53]. * Scaphoid tubercle tenderness: Sensitivity of 82–100% and specificity of 17–57% [53]. * Pain on ulnar deviation: Sensitivity of 67–100% and specificity of 17–60% [53]. * Pain on radial deviation: Sensitivity of 67–90% and specificity of 31–42% [53]. * Reduced range of movement of the thumb: Sensitivity of 65–66% and specificity of 38–59% [53]. * Thumb–index finger pinch: Sensitivity of 75–79% and specificity of 44–76% [53].

ASB tenderness is oversensitive and has poor specificity [53]. In a study of 246 patients with a suspected fracture of the scaphoid, ASB tenderness was found to have a sensitivity of 90% and a specificity of 40% [53]. In the same study, scaphoid tubercle tenderness had a sensitivity of 87% and a specificity of 57% [53]. The use of one clinical sign in isolation was insufficient for the diagnosis of a fracture [53]. A combination of ASB tenderness, scaphoid tubercle tenderness, and ASB pain on longitudinal compression of the thumb generated a sensitivity of 100% and a specificity of 74% [53]. These findings were valid only for the first 24 hours after injury [53]. Pain on thumb–index finger pinch and ASB pain on pronation of the forearm were most suggestive of a true scaphoid fracture [53]. The best predictors of fracture within 72 hours of injury were the absence of pain on ulnar deviation of the wrist and pain on thumb–index finger pinch [53]. Scaphoid tubercle tenderness was most predictive at week 2 [53]. A clinical scaphoid score (CSS) of 4 or higher requires an MRI [53]. Tenderness over the anatomic snuffbox or pain with resisted pronation prevents the surgeon from ruling out a scaphoid fracture [99].

Diagnostic Challenges and Occult Fractures

Up to 30% to 40% of scaphoid fractures are not identified on initial assessment and investigation with standard four-view radiographs [53]. Patients who are subsequently found to have a fracture confirmed on repeated assessment and radiologic imaging, most frequently at 10 to 14 days after injury, are said to have had an occult fracture of the scaphoid [53]. A high index of suspicion is necessary to make the diagnosis because radiographs are often negative at initial presentation (approximately 25% of the time) [99]. Any history of wrist trauma and tenderness or decreased range of motion should increase suspicion [99]. Scaphoid fractures are a common problem encountered by orthopaedic hand surgeons and a common injury in basketball and football players [99]. Pain and swelling can be subtle in the anatomic snuffbox and often these fractures present late [96].

If the X-ray looks normal but the clinical features are suggestive of a fracture, the patient must not be discharged [40]. The diagnosis has to be confirmed one way or another [40]. The usual advice is to return for a second X-ray 2 weeks later [40]. Meanwhile, the wrist is immobilized in a cast extending from the upper forearm to just short of the metacarpophalangeal joints of the fingers, but incorporating the proximal phalanx of the thumb [40]. The wrist is held dorsiflexed and the thumb forwards in the ‘glass-holding’ position (the so-called scaphoid plaster) [40]. An alternative is to arrange an MRI scan (or, if not available, a CT scan) which will definitely detect the fracture even if it was not visible on the X-ray [40].

Patients with a suspected occult scaphoid fracture are reevaluated after 1 to 2 weeks of immobilization in a forearm cast or splint [94]. An examination by a specialist after the injury has become less painful allows for a more accurate physical examination and thus substantially increases the sensitivity of detecting a scaphoid fracture [94]. If the probability of a fracture remains unacceptable and new scaphoid specific radiographs are also normal, the patient can either continue with immobilization or advanced imaging (typically CT or MRI) can be used to attempt to exclude a fracture [94]. 6 weeks of splint immobilization with normal scaphoid radiographs is likely sufficient [94]. The higher the pretest odds of a fracture, the more likely an imaging diagnosis of a fracture will correlate with a true fracture [94]. The lower the pretest odds (i.e., “rule out” rather than “confirm”), the less likely that a radiologic diagnosis of a fracture will correspond with a true fracture [94]. Patients with more pressing needs to diagnose a fracture (some athletes and other occupations) can be considered for more sophisticated imaging early on [94].

If clinical suspicion is high for fracture, but the radiographs are negative, the athlete should be placed in a short arm-thumb spica splint, and an MRI should be obtained [99]. In the athlete, an MRI is useful if radiographs are inconclusive [99]. This can allow earlier return to play if no fracture is identified [99]. MRI is also used to assess osteonecrosis of the proximal pole of the scaphoid, a common complication of these injuries [99]. MRI can help assess for a scapholunate ligament injury, another common cause of radial-sided wrist pain in the athlete after a fall [99].

Scaphoid fractures are an often missed injury [99]. Fractures treated in less than 28 days from injury result in a 5% nonunion rate [99]. If treatment is delayed longer than 28 days, the nonunion rate increases to 28% [99]. It is imperative that the surgeon educate all trainers and other athletic staff about scaphoid fractures; any suspected injury should be promptly evaluated and managed [99]. Several studies have suggested that a fracture of the scaphoid that is unrecognized, and therefore untreated, for 4 weeks or longer is at increased risk for nonunion [12]. The incidence of nonunion with delayed immobilization of scaphoid fractures in several studies ranged from 19% to 88% [12].

The diagnosis of scaphoid fracture can be complicated, and this type of fracture can be easily overlooked in an acute injury [14]. Owing to its unique anatomical structure, neglected scaphoid fractures seldom heal with acceptable alignment [14]. This often leads to complications in their management [14]. In cases of non-union or malunion, reconstruction of the scaphoid is exceedingly difficult [14]. This increases the chances of morbidity already associated with an extended period of hand immobilisation [14]. Scaphoid fractures are managed largely on the basis of anecdotal evidence and traditional remedies [14]. Few reports refer to the management of neglected scaphoid fractures in the subacute stage [14]. These fractures theoretically require pro... [14]

Investigations

Clinical Examination

Patients with scaphoid fractures classically present with wrist pain following a fall onto the outstretched hand, with almost 90% recalling a hyperextension injury [53]. No single clinical sign has been found to be adequately sensitive or specific for the diagnosis of scaphoid fracture [53]. Anatomical snuffbox tenderness has a sensitivity of 87–100% and a specificity of 3–98% [53]. Axial compression of the thumb has a sensitivity of 48–100% and a specificity of 22–97% [53]. Scaphoid tubercle tenderness has a sensitivity of 82–100% and a specificity of 17–57% [53]. Pain on ulnar deviation has a sensitivity of 67–100% and a specificity of 17–60% [53]. Pain on radial deviation has a sensitivity of 67–90% and a specificity of 31–42% [53]. Reduced range of movement of the thumb has a sensitivity of 65–66% and a specificity of 38–59% [53]. Thumb–index finger pinch has a sensitivity of 75–79% and a specificity of 44–76% [53].

A combination of anatomical snuffbox tenderness, scaphoid tubercle tenderness, and anatomical snuffbox pain on longitudinal compression of the thumb generates a sensitivity of 100% and a specificity of 74% for scaphoid fracture within the first 24 hours after injury [53]. The absence of pain on ulnar deviation of the wrist and pain on thumb–index finger pinch are the best predictors of fracture within 72 hours of injury [53]. Scaphoid tubercle tenderness is the most predictive clinical sign at week 2 [53]. A clinical scaphoid score (CSS) of 4 or higher, based on ASB tenderness with ulnar deviation, scaphoid tubercle tenderness, and pain upon longitudinal compression of the thumb, indicates that a patient requires an MRI [53].

Plain radiography

Standard radiographic views for scaphoid fracture workup include posteroanterior (PA), lateral, oblique, and scaphoid views [52]. A true scaphoid pisiform capitate (SPC) lateral radiograph allows a true assessment of carpal alignment [52]. The scaphoid view is taken with the wrist in ulnar deviation to extend the proximal carpal row and allow a full view of the scaphoid bone with minimal overlap from neighboring bones [52]. A clenched pencil view is useful for assessing associated dynamic scapholunate widening and shows SNAC and SLAC wrist changes better than standard PA views [52].

Radiographs are initially nondiagnostic in more than 30% of scaphoid fracture cases [80]. Up to 30% to 40% of scaphoid fractures are not identified on initial assessment with standard four-view radiographs [53]. Plain radiography is approximately 50% sensitive for the detection of a scaphoid fracture [74]. If a scaphoid fracture is suggested but radiographs are negative, the wrist should be immobilized and reevaluated in 2 weeks because up to 30% of patients may have positive follow-up radiographs [74]. Conventional radiographic imaging is accurate and moderately reliable in diagnosing union of scaphoid waist fractures at 6 weeks follow-up [61]. Conventional radiographic imaging is reliable but inaccurate in diagnosing nonunion of scaphoid waist fractures at 6 weeks follow-up [61]. Radiographs and clinical examination are unreliable for determining the duration of immobilization for nondisplaced scaphoid fractures [82].

MRI

MRI has the highest sensitivity, specificity, and accuracy (all >95%) for scaphoid fracture diagnosis, with high positive and negative predictive values at less than 24 hours [80]. A normal MRI study as early as 2 days after injury has a negative predictive value of 100% for scaphoid fracture [74]. Contrast-enhanced MRI scans can provide useful information on scaphoid perfusion but cannot replace intraoperative judgment of vascularity [55]. Computed tomography or magnetic resonance imaging can be helpful as an adjunct to standard x-rays to evaluate the cartilage of the radiolunate joint and confirm the SLAC stage [50].

CT

CT scans are more sensitive than plain radiographs for diagnosing a scaphoid fracture [40]. CT scans are particularly useful for confirming the alignment of bone fragments if surgery is planned or to confirm whether a fracture has united [40]. Routine use of a week 4 CT scan is valuable in the early management of displaced scaphoid waist fractures to predict the likelihood of union with nonoperative treatment [16]. The inter-observer reproducibility of assessments of fracture translation, bone contact, overall displacement, and union on Week 4 CT scans was assessed using Cohen’s Kappa test [34]. CT oriented in the longitudinal axis of the scaphoid with 1-mm cuts can be helpful to evaluate for bridging trabeculae when healing cannot be determined with certainty by standard radiographic examination [47].

Other Considerations

All advanced imaging modalities, including bone scan, ultrasonography, CT, and MRI, are better for ruling out rather than ruling in a scaphoid fracture [80]. Failure of identification and immobilization for more than 4 weeks after a scaphoid fracture increases the nonunion rate almost 10-fold [80]. Neglected scaphoid fractures seldom heal with acceptable alignment, which often leads to complications in their management [14]. The diagnosis of a scaphoid fracture can be complicated and the fracture can be easily overlooked in an acute injury [14].

Treatment

Non-Operative Management

A restricted period of cast immobilisation is the recommended initial treatment for non-displaced scaphoid fractures [24]. Non- and minimally displaced scaphoid waist fractures are best managed conservatively [41]. Casting and surgery are reliable treatments for nondisplaced scaphoid waist fractures, yielding comparable outcomes [107]. However, scaphoid fractures diagnosed on a delayed basis, specifically those unrecognized for 4 weeks or longer, should be considered for operative treatment regardless of displacement due to the increased risk for nonunion [12]. The incidence of nonunion associated with delayed immobilization of scaphoid fractures ranges from 19% to 88% [12].

Operative Management

Indications: Operative intervention is recommended for displaced scaphoid fractures [4]. Early internal fixation is increasingly favored even for nondisplaced fractures [5]. Immediate surgical fixation avoids the need to immobilise the wrist in a cast and may accelerate return of function [67].

Surgical Approach / Technique: Surgical treatment for acute scaphoid fractures involves percutaneous or open fixation using standard CE marked headless compression screws, which avoid the pressure effects of the screw head on articular cartilage [67]. Percutaneous cannulated screw fixation of nondisplaced scaphoid fractures results in faster radiographic union and return to military duty compared with cast immobilization [21]. All fractures treated with percutaneous transtrapezial fixation healed within 10 weeks, with a mean of 6.4 weeks [42]. Functional ranges of wrist motion and grip strength were achieved in all patients treated with percutaneous transtrapezial fixation [42]. Following acute percutaneous scaphoid fixation, range of movement at the time of fracture union was 93 per cent and grip strength 90 per cent of that of the contralateral limb [32]. Complications such as screw protrusion or tendon damage can be avoided by careful adherence to described percutaneous fixation techniques [3]. Computer-aided percutaneous pinning of scaphoid waist fractures can significantly reduce radiation exposure and has the potential to improve the accuracy of this procedure [44]. The proximal/dorsal approach allows for more central screw placement in the distal pole of the scaphoid, but there is no significant difference in the proximal or waist region compared to the distal approach [57].

Nonunion Repair: Not all proximal pole scaphoid nonunions with avascular necrosis require vascularized bone graft or a formal open incision; if the distal scaphoid is well perfused and the proximal pole can be secured rigidly after percutaneous bone grafting, nonunion repair and healing can proceed [2]. Uncomplicated scaphoid nonunions that are nondisplaced and nonangulated are candidates for the minimally invasive bone grafting and compression screw fixation procedure [15]. The technique of fixation and grafting after limited debridement is an effective and efficient method of treating nondisplaced scaphoid nonunions without AVN [17]. Three-dimensional computer simulations are useful for accurate correction of scaphoid nonunions and proper screw placement, which consequently leads to good clinical results [23]. Patient-specific guides can be used to perform scaphoid reconstructions [38]. While traditional treatment for scaphoid nonunion involves open debridement and bone grafting, some publications suggest that stable nonunions may be amenable to percutaneous debridement and fixation without formal bone grafting, though well-designed clinical studies are needed to better define appropriate indications [28]. The use of double screw fixation with autologous bone graft for management of unstable scaphoid nonunions with cavitary bone loss allows for early active range of motion and does not compromise the incidence of union compared with the literature [30]. Percutaneous fixation with a headless compression screw is a feasible treatment for selected scaphoid nonunions with minimal sclerosis or resorption [33]. Using temporary external fixation to reduce and stabilize the scaphoid, combined with resection of sclerotic bone, bone grafting, and final internal fixation with the AO mini fragment screw, can be done easily [35]. Nonvascularized iliac bone grafting can be used for the surgical management of scaphoid nonunion with avascular necrosis [56]. Reported union rates and clinical outcomes for arthroscopic-assisted scaphoid nonunion repair are comparable to open approaches, with advantages including improved visualization, reduced donor site morbidity, and maintenance of wrist motion [58]. Using arthroscopic-assisted reduction, bone grafting and screw fixation across the SL joint in proximal scaphoid nonunion treatment, satisfactory functional and radiographic outcomes can be achieved [60]. Despite some loss of grip strength and motion, almost all patients were satisfied with the outcome and had regained normal function following Herbert-Screw Fixation with Bone-Grafting for the Treatment of Nonunion of the Scaphoid [62]. With stable internal screw fixation, scaphoid waist nonunion with collapse and bone loss can be successfully treated using only cancellous bone graft [65]. Arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment [109].

Implant Selection: In the case of displaced fractures or scaphoid non-union, the use of screws with higher compression forces, such as the Acutrak or Twin Fix, can be recommended [37].

Adjunctive and Diagnostic Considerations

Pulsed Electromagnetic Fields trials for fresh scaphoid fractures use number of scaphoid unions at six weeks as the primary endpoint [6]. Secondary endpoints for Pulsed Electromagnetic Fields trials include time interval to clinical and radiological consolidation, number of non-unions, functional status at 52 weeks and non-adherence to the treatment protocol [6]. Determinants of management for scaphoid fractures are based on assessment of fracture location, fracture displacement and stability, timing of presentation, and patient-specific factors [13]. Approximately 60 to 80% of scaphoid fractures involve the waist, followed by 25% in the distal third and 5 to 10% in the proximal third [13]. Distal pole scaphoid fractures healed at an average of 6 weeks, scaphoid waist fractures at 12 weeks, and proximal pole fractures at 12 weeks to 6 months [13]. Stable scaphoid fractures were noted to have a displacement of less than 1 mm, normal intercarpal alignment, and distal pole location [13]. Unstable scaphoid fractures were defined as greater than 1 mm displacement [13].

Complications

Nonunion and Delayed Union

Scaphoid fractures that remain unrecognized and untreated for four weeks or longer face an increased risk of nonunion [12]. Nonunion rates remain high despite improvements in diagnosis and surgical techniques [5]. Proximal pole fractures carry a relative risk of nonunion 7.5 times higher than more distal fractures managed nonoperatively [83], with approximately one-third of acute proximal pole fractures progressing to nonunion when treated non-operatively [125]. Delay in treatment is an independent risk factor for nonunion of proximal pole scaphoid fractures [125]. In the context of vascularized bone grafting for scaphoid non-union, injury to the dominant hand and a duration of non-union greater than 5 years significantly increased the risk of failure [64].

Surgical Failure and Complications

The advantages of surgical fixation for acute scaphoid fractures are transient [66].

Vascular and Grafting Complications

Proximal pole infarction is decidedly rare, and vascularized bone grafting is seldom required because the success of scaphoid nonunion surgery is independent of proximal pole vascularity [137]. The free medial femoral condyle vascularized graft for difficult scaphoid nonunions with poor prognostic factors demonstrates a high union rate with low donor site morbidity [46]. In a series of vascularized bone grafting for scaphoid nonunion with humpback deformity, the only notable complication was temporary mild paresthesia of the superficial branch of the radial nerve area in two patients [126], and no pin site infection occurred [126]. Both 1,2-ICSRA and MFC vascularized bone grafts can be used to treat scaphoid nonunion in adolescent patients with a low incidence of complications [127].

Malunion and Functional Outcomes

The outcome of scaphoid excision and 4-corner arthrodesis is favorable at one year and does not deteriorate significantly between one and 10 years [19].

Recovery

Light activity (weeks): The evidence provided does not specify a defined week range for the initiation of light activities such as desk work, driving, or light activities of daily living.

Full activity (months): Distal pole fractures heal at an average of 6 weeks [13]. Scaphoid waist fractures and proximal pole fractures heal at 12 weeks to 6 months [13].

Complete recovery / outcome plateau (months): The evidence provided does not specify a defined month range for the stabilization of pain, strength, and final functional outcomes.

Rehabilitation protocol: The evidence provided does not specify a rehabilitation protocol, including PT phasing, immobilisation duration, weight-bearing/ROM progression, or sling/brace removal timing.

Functional milestones: Range of movement at the time of fracture union was 93 per cent and grip strength 90 per cent of that of the contralateral limb [32]. Arthroscopic reduction and osteosynthesis of chronic unstable scaphoid nonunion has positive effects on the recovery of clinical wrist function [63]. Scaphoid and carpal alignment were improved postoperatively, and this improvement was maintained at the latest follow-up examination [18].

Other Considerations: Vascularized bone grafting for scaphoid nonunion results in the improvement of patient-derived outcomes, and high rates of return to preinjury activity levels and patient satisfaction [123]. The case series demonstrated excellent functional results and quality of life after bilateral scaphoid reconstruction [132]. Healing achieved using arthroscopically assisted bone grafting was superior to that achieved using percutaneous screw fixation alone for the treatment of scaphoid delayed unions and nonunions [130]. A fracture of the scaphoid that is unrecognized, and therefore untreated, for 4 weeks or longer is at increased risk for nonunion [12]. Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke and consider adding this to the patient's intake history to further identify patients at risk for nonunions [128].

Key Evidence

• [L1] Pediatric scaphoid fractures have excellent outcomes. [1] (10.1177/1558944717735948)
• [L5] Not all proximal pole scaphoid nonunions with avascular necrosis require vascularized bone graft or a formal open incision; if the distal scaphoid is well perfused and the proximal pole can be secured rigidly after percutaneous bone grafting, nonunion repair and healing can proceed. [2] (10.1097/01.blo.0000205886.66081.9d)
• [L5] The article describes basic and advanced techniques for percutaneous scaphoid fixation to minimize morbidity and allow early return of function, noting that complications such as screw protrusion or tendon damage can be avoided by careful adherence to the described techniques. [3] (10.1016/j.jhsa.2008.04.023)
• [L1] Nondisplaced scaphoid fractures can be effectively treated nonoperatively with union rates approaching or exceeding those of operative intervention, while operative intervention is recommended for displaced fractures. [4] (10.2106/jbjs.rvw.15.00073)
• [L5] This article reviews current concepts regarding the treatment of scaphoid fractures and nonunions, highlighting that despite improvements in diagnosis and surgical techniques, nonunion rates remain high and early internal fixation is increasingly favored even for nondisplaced fractures. [5] (10.1016/j.jhsa.2008.04.026)
• [L1] Primary endpoint is number of scaphoid unions at six weeks, secondary endpoints are time interval to clinical and radiological consolidation, number of non-unions, functional status at 52 weeks and non-adherence to the treatment protocol. [6] (10.1186/1471-2474-12-90)
• [L4] Proximal pole scaphoid fractures with delayed union and nonunion treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. [7] (10.1055/s-0040-1701512)
• [L4] Percutaneous screw fixation provides excellent and reliable results for acute scaphoid fractures. [9] (10.1016/j.hcl.2011.06.003)
• [L4] Failure of acute scaphoid fracture fixation often results from malreduction, failure to restore length, or compromised vascularity. [10] (10.1016/j.jhsa.2014.02.023)
• [L4] Scaphoid nonunions with minimal displacement, maintained mechanical alignment of the carpus, and an intact cartilage cap represent a stable pattern that can be treated by restoring mechanical stability. [11] (10.1016/j.jhsa.2025.07.019)
• [L5] [12] (10.5435/00124635-200007000-00003)
• [L5] [13] (10.5435/jaaos-d-22-01210)
• [L4] [14] (10.1016/j.injury.2009.07.078)
• [L4] Uncomplicated scaphoid nonunions that are nondisplaced and nonangulated are candidates for the minimally invasive bone grafting and compression screw fixation procedure described. [15] (10.1016/j.jhsa.2008.03.004)
• [L2] Routine use of such a scan is valuable in the early management of scaphoid fractures. [16] (10.1177/1753193411403092)
• [L4] The technique described is an effective and efficient method of treating nondisplaced scaphoid nonunions without AVN. [17] (10.1016/j.jhsa.2015.05.022)
• [L3] Scaphoid and carpal alignment were improved postoperatively, and this improvement was maintained at the latest follow-up examination. [18] (10.2106/00004623-199612000-00005)
• [L4] The outcome of scaphoid excision and 4-corner arthrodesis is favorable at one year and does not deteriorate significantly between one and 10 years. [19] (10.1016/j.jhsa.2010.01.025)
• [L3] Virtually all scaphoid fractures which unite have a good outcome, regardless of malunion. [20] (10.1177/1753193408093327)
• [L1] Percutaneous cannulated screw fixation of nondisplaced scaphoid fractures resulted in faster radiographic union and return to military duty compared with cast immobilization. [21] (10.2106/00004623-200104000-00001)
• [L4] The use of 2 headless compression screws for the treatment of scaphoid nonunions is safe and effective. [22] (10.1016/j.jhsa.2014.02.030)
• [L4] Three-dimensional computer simulations were found as useful for accurate correction of scaphoid nonunions and proper screw placement, which consequently leads to good clinical results. [23] (10.1097/01.blo.0000154204.72825.a5)
• [L4] [24] (10.1016/j.injury.2008.10.028)
• [L4] There is a need for a validated prognostic classification system for scaphoid nonunions that can allow comparisons between outcome studies. [25] (10.1177/1753193417739510)
• [L5] While traditional treatment for scaphoid nonunion involves open debridement and bone grafting, some publications suggest that stable nonunions may be amenable to percutaneous debridement and fixation without formal bone grafting, though well-designed clinical studies are needed to better define appropriate indications. [28] (10.1016/j.jhsa.2018.03.048)
• [L4] The use of double screw fixation with autologous bone graft for management of unstable scaphoid nonunions with cavitary bone loss allows for early active range of motion and does not compromise the incidence of union compared with the literature. [30] (10.1177/1753193420946656)
• [L4] The technique provides excellent functional results in patients with a challenging clinical problem, and we recommend it for scaphoid fracture waist nonunions with dorsal intercalated segment instability deformity. [31] (10.1016/j.jhsa.2015.07.028)
• [L4] Range of movement at the time of fracture union was 93 per cent and grip strength 90 per cent of that of the contralateral limb. [32] (10.1016/s0020-1383(98)00033-3)
• [L4] Percutaneous fixation with a headless compression screw is a feasible treatment for selected scaphoid nonunions with minimal sclerosis or resorption. [33] (10.2106/00004623-200300004-00003)
• [L3] [34] (10.1177/1753193409105189)
• [L4] The authors state that using temporary external fixation to reduce and stabilize the scaphoid, combined with resection of sclerotic bone, bone grafting, and final internal fixation with the AO mini fragment screw, can be done easily. [35] (10.1054/jhsb.1999.0262)
• [L3] Percutaneous scaphoid osteosynthesis is an attractive option for acute scaphoid fractures. [36] (10.1055/s-0040-1716352)
• [L5] In the case of displaced fractures or scaphoid non-union, the use of screws with higher compression forces, such as the Acutrak or Twin Fix, can be recommended. [37] (10.1016/j.injury.2006.11.002)
• [L3] Patient-specific guides can be used to perform scaphoid reconstructions. [38] (10.1016/j.jhsa.2015.10.009)
• [L2] Non- and minimally displaced scaphoid waist fractures are best treated conservatively. [41] (10.1016/j.jhsa.2015.03.007)
• [L4] All fractures healed within 10 weeks with a mean of 6.4 weeks, and functional ranges of wrist motion and grip strength were achieved in all patients. [42] (10.1177/1753193408092785)
• [L4] [43] (10.1016/j.otsr.2011.08.008)
• [L5] Computer-aided percutaneous pinning of scaphoid waist fractures can significantly reduce radiation exposure and has the potential to improve the accuracy of this procedure. [44] (10.1055/s-0033-1357760)
• [L4] The free medial femoral condyle vascularized graft represents a promising alternative for difficult scaphoid nonunions with poor prognostic factors, demonstrating a high union rate with low donor site morbidity. [46] (10.1177/1558944716661994)
• [L2] Contrast-enhanced MRI scans can provide useful information on scaphoid perfusion but cannot replace intraoperative judgment of vascularity. [55] (10.1177/1753193410375776)
• [L4] Nonvascularized iliac bone grafting can be used for the surgical management of scaphoid nonunion with avascular necrosis. [56] (10.1177/1753193417730657)
• [L5] The proximal/dorsal approach allows for more central screw placement in the distal pole of the scaphoid, but there is no significant difference in the proximal or waist region compared to the distal approach. [57] (10.1016/j.jhsa.2003.09.002)
• [L5] Reported union rates and clinical outcomes are comparable to open approaches, with advantages including improved visualization, reduced donor site morbidity, and maintenance of wrist motion. [58] (10.1016/j.jhsa.2026.01.012)
• [L4] Using arthroscopic-assisted reduction, bone grafting and screw fixation across the SL joint in proximal scaphoid nonunion treatment, satisfactory functional and radiographic outcomes can be achieved. [60] (10.1186/s12891-020-03850-w)
• [L2] Conventional radiographic imaging is accurate and moderately reliable in diagnosing union, and reliable but inaccurate in diagnosing nonunion of scaphoid waist fractures at 6 weeks follow-up. [61] (10.1007/s00402-014-2147-9)
• [L4] Despite some loss of grip strength and motion, almost all patients were satisfied with the outcome and had regained normal function. [62] (10.2106/00004623-199901000-00007)
• [L4] Arthroscopic reduction and osteosynthesis of chronic unstable scaphoid nonunion is limited for restoration of normal carpal alignment but has positive effects on the recovery of clinical wrist function. [63] (10.1016/j.arthro.2014.08.035)
• [L4] Injury to the dominant hand and duration of non-union greater than 5 years significantly increased the risk of failure. [64] (10.1177/1753193408092038)
• [L4] With stable internal screw fixation, scaphoid waist nonunion with collapse and bone loss can be successfully treated using only cancellous bone graft. [65] (10.1016/j.jhsa.2012.12.030)
• [L1] The data to date have demonstrated that the advantages of surgical fixation are transient, the possible complications must not be underestimated, and the long-term outcomes of surgical fixation are incompletely understood. [66] (10.1016/j.jhsa.2008.12.027)
• [L1] [67] (10.1186/s12891-016-1107-7)
• [L1] A meta-analysis showed that the relative risk of nonunion for these fractures is 7.5 compared with more distal fractures, also managed nonoperatively. [83] (10.1177/1753193412451424)
• [L2] Casting and surgery are reliable treatments for nondisplaced scaphoid waist fractures with comparable outcomes. [107] (10.1016/j.jhsa.2008.12.028)
• [L4] Our data indicate that arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment. [109] (10.1302/0301-620x.104b8.bjj-2022-0198.r1)
• [L4] The degree of humpback deformity of the scaphoid correlated with the degree of carpal malalignment. [115] (10.1016/j.jhsa.2010.10.011)
• [L4] The complex scaphoid anatomy with its waist might alter the strategy of fracture fixation, education and research. [122] (10.1186/s13018-021-02330-8)
• [L2] VBG for scaphoid nonunion results in the improvement of patient-derived outcomes, and high rates of return to preinjury activity levels and patient satisfaction. [123] (10.1177/1558944716643080)
• [L4] [125] (10.1177/1753193417743438)
• [L4] [126] (10.1055/s-0040-1715800)
• [L4] Both 1,2-ICSRA and MFC vascularized bone grafts can be used to treat scaphoid nonunion in adolescent patients with a low incidence of complications. [127] (10.1177/17531934241247279)
• [L3] Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke and consider adding this to the patient's intake history to further identify patients at risk for nonunions. [128] (10.5435/jaaos-d-23-00188)
• [L3] Healing achieved using arthroscopically assisted bone grafting was superior to that achieved using percutaneous screw fixation alone for the treatment of scaphoid delayed unions and nonunions. [130] (10.1055/s-0039-1693146)
• [L4] The case series demonstrated excellent functional results and quality of life after bilateral scaphoid reconstruction, providing a basis for further treatment and patient education. [132] (10.1007/s00402-012-1642-0)
• [L4] Proximal pole infarction is decidedly rare and vascularized bone grafting is seldom required, as success of scaphoid nonunion surgery is independent of proximal pole vascularity. [137] (10.1177/1753193417732003)

See Also

• Scaphoid Fracture
• Scapholunate Ligament Injury

References

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