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Scaphoid Fracture

Scaphoid fractures — recognition, the high non-union risk, casting and percutaneous/open fixation.

131 citationsUpdated Sep 2026

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Overview

Scaphoid fractures are managed based on displacement status, with nondisplaced fractures healing in the vast majority of cases with strict immobilization [19]. These nondisplaced injuries achieve union faster than displaced fractures [92] and can be effectively treated nonoperatively, with union rates approaching or exceeding those of operative intervention [59]. A study comparing nonoperative and operative treatment did not demonstrate a true long-term benefit of internal fixation compared with nonoperative treatment for acute nondisplaced or minimally displaced scaphoid fractures [14]. In pediatric patients below the age of 10, nonoperative management is safe and feasible with no significant long-term morbidity [1], and cast immobilization remains a reasonable option even for fractures presenting 21 days or more after injury [37]. Pediatric scaphoid fractures generally have excellent outcomes [2].

Operative intervention is recommended for displaced scaphoid fractures, which have a propensity for nonunion due to displacement and rotation [19, 59]. Internal fixation is indicated in certain acute situations and in chronic nonunion cases [28], and appropriately performed acute percutaneous internal fixation is now a standard treatment option for a selected group of patients with acute scaphoid fracture [30]. Early internal fixation is increasingly favored even for nondisplaced fractures [13]. For all indications, the scaphoid staple has a high union rate and a low complication rate [15]. However, the optimal protocol for postoperative immobilization following operative treatment remains controversial [80].

Despite improvements in diagnosis and surgical techniques, nonunion rates remain high [13]. The clinical outcomes of malunited scaphoids after reconstruction for scaphoid fractures nonunion did not differ significantly from well-united scaphoids at a minimum 5-year follow-up [10], and virtually all scaphoid fractures which unite have a good outcome, regardless of malunion [38]. Patients with recent scaphoid fractures that failed treatment may also be treated with distal scaphoid resection [68]. Bone grafts are used in scaphoid nonunions to help augment internal fixation, promote healing, and restore carpal alignment [183], while double antirotation screw fixation performed with arthroscopy is considered pertinent for certain recent scaphoid nonunions [197]. The management of scaphoid fractures remains a source of controversy with no established gold standard for immobilization, acute surgical repair, or nonunion management despite decades of study [42]. Even some well-established and widely used principles of scaphoid fracture management are supported by an insufficient amount of evidence, with many decisions based on small case series [7]. There is insufficient evidence to support the most effective treatment for acute scaphoid fractures [63], and there are no prospective randomized studies comparing different operative treatments of scaphoid nonunion [81]. Inadequate follow-up of treated scaphoid fractures will result in delayed diagnosis and treatment of non-union with a potentially impaired outcome secondary to degenerative changes and even litigation against the surgeon [5]. The definition of instability of scaphoid fractures and the indications for conservative treatment must be considered carefully [27]. Osteopenia was not significantly associated with scaphoid nonunion in adults aged 50 years or older [92].

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 [100]. It lies entirely within the wrist joint at a 45-degree plane to the longitudinal and horizontal axis of the wrist [100]. As the only carpal bone bridging the proximal and distal carpal rows, it acts as a tie-rod and a midcarpal joint "bridge," linking and synchronizing the motions of the two rows as part of the key intercalated segment [139, 100]. The scaphoid articulates with the trapezium and trapezoid on its distal surface, the radius on its proximal/lateral surface, and the capitate and lunate on its medial surface [100]. The proximal articular surface is convex and articulates with the radius, while the capitate head fits into a sulcus on the radial articular surface, providing a socket-like fit [100]. Two distinct articular facets for the trapezium and trapezoid form the STT joint at the distal surface [100]. Over 80% of the scaphoid surface is covered with articular cartilage, a feature that limits periosteal healing capacity and increases the tendency for delayed union and nonunion [100].

The bone is divided into three regions: proximal pole, waist, and distal pole (tubercle) [139]. The intrascaphoid angle averages 40 ± 3 degrees in the coronal plane and 32 ± 5 degrees in the sagittal plane [139]. The distal pole sits ulnarly angulated relative to the proximal pole due to gentle pronation and flexion [100]. Motion of the scaphoid includes rotation proximally and gliding distally while providing stability to the midcarpal joint [100]. The nonarticular dorsoradial surface is ridged, serving as the insertion point for the dorsal component of the scapholunate and intercarpal ligaments [100]. There are no tendon attachments to the scaphoid [100].

Vascular Anatomy

The blood supply of the scaphoid is predominantly retrograde and meagre [100]. Two vascular pedicles originating from the scaphoid branches of the radial artery supply the bone [100]. The dorsal branch enters via small foramina along the spiral groove and dorsal ridge, supplying 70% to 80% of the scaphoid proximally, including the proximal pole [100]. The volar branch enters via the scaphoid tubercle and supplies the remaining 20% to 30% of the distal scaphoid [100]. Vessels enter the scaphoid from the radial artery laterovolarly, dorsally, and distally [108]. The laterovolar and dorsal systems share in the blood supply to the proximal two thirds of the scaphoid [108]. The proximal pole also receives blood supply from the radioscapholunate ligament (ligament of Testut) and direct scapholunate branches from the palmar and dorsal transverse carpal arches [139]. Venous drainage from the proximal pole is via the dorsal ridge into the venae comitantes of the radial artery [139].

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 [100]. Anatomical variability exists: only 67% of scaphoid bones have arterial foramina throughout their length, including the distal, middle, and proximal thirds [108]. In 13% of scaphoid bones, blood supply is predominantly in the distal third [108]. In 20% of scaphoid bones, most arterial foramina are in the waist area with no more than a single foramen near the proximal third [108]. Consequently, one third of scaphoid fractures occurring in the proximal third may be without adequate blood supply [108]. The more proximal the fracture, the more likely the bone is to be dysvascular and the higher the risk of nonunion [139].

Proximal fractures are associated with at least temporary disruption of the interosseous blood supply to the proximal pole [100]. Fractures in the proximal pole take longer to heal and usually have higher rates of nonunion [108]. The prevalence of osteonecrosis can be 35% in fractures at the proximal pole level [108]. Proximal pole fractures have a reported incidence of avascular necrosis (AVN) of 13% to 50% [139].

Ligamentous Anatomy

Ligamentous attachments of the scaphoid are predominantly found on the nonarticular dorsoradial surface [100]. Short intrinsic ligaments provide stability through attachments to other carpal bones, particularly the lunate, and merge with extrinsic ligaments and the wrist capsule [100]. The scapholunate interosseous ligament (SLIL) is a stout ligament connecting the scaphoid to the lunate and is the primary stabilizer [139]. The dorsal aspect of the SLIL is composed of transverse collagen fibers, while the palmar ligament is composed of oblique collagen fibers inserting to the volar capsular ligaments [139]. The dorsal portion of the SLIL is twice as strong as the palmar portion [139]. The dorsal region of the SLIL resists palmar-dorsal translation and gap, while the volar portion resists rotation [139]. Only 20 to 30 degrees of motion is possible at an intact scapholunate interval [139].

The radioscapocapitate (RSC) ligament does not attach to the bone itself but crosses the waist, acting as a sling that allows rotation [100]. It originates from the volar radial aspect of the radius, crosses the volar concavity of the scaphoid waist, and proceeds ulnarly toward the capitate [139]. The RSC ligament acts as a fulcrum around which the scaphoid rotates [139]. The scaphoid can fracture around the RSC ligament fulcrum at the waist [139]. The scaphocapitate ligament originates from the distal scaphoid and inserts into the border between the trapezoid facet and the capitate facet [139]. It inserts into the volar waist of the capitate distal to the RSC ligament [139]. The scaphocapitate ligament, along with the scaphotrapezial ligament, functions as a primary restraint of the distal pole [139].

Mechanisms of Injury

The usual mechanism of scaphoid fracture is forced hyperextension of the wrist [18]. Patients classically present with wrist pain following a fall onto the outstretched hand, with almost 90% recalling a hyperextension injury [29]. Hyperextension past 95 degrees is the usual position of injury for scaphoid fractures [115]. Other mechanisms such as axial loading and hyperflexion of the wrist have been postulated to produce scaphoid fractures [115]. In a review of 52 medical negligence cases, 41 cases had mechanisms consistent with scaphoid injury (hyperextension of wrist or fall onto outstretched hand) and 11 cases had inconsistent mechanisms [17].

Fracture of the scaphoid occurs when the wrist is dorsiflexed to at least 95 degrees and radially deviated to at least 10 degrees [120]. In this position, the proximal pole of the scaphoid is held firmly between the radius, capitate, radioscaphocapitate ligament, and the palmar capsule [120]. When the wrist is radially deviated, the radioscaphocapitate ligament is relaxed and unable to relieve increasing force applied to the radiopalmar aspect of the scaphoid [120]. Axial loading and/or dorsal compression of the scaphoid in this position causes fracture, most frequently through the waist [120]. With the hyperextension mechanism, a fracture usually begins at the volar waist with tensile failure, propagating to the dorsal surface with compression loading until failure occurs [115]. The scaphoid usually fractures on tension at the radial-palmar side during a fall on the outstretched palm resulting in severe hyperextension and slight radial deviation [108]. The proximal pole locks in the scaphoid fossa of the radius, and the distal pole moves excessively dorsal during injury [108].

The waist is subject to maximal bending movement and has a characteristically lower trabecular volume [120]. Fractures of the waist are usually the result of shear forces across the scaphoid [120]. Wrist deviation may predict the location of the fracture, with the midcarpal joint line crossing the proximal pole in radial deviation and the distal pole in ulnar deviation [120]. Tubercle fractures appear to be caused by either compression or avulsion [120]. The size of a proximal pole fracture is dependent on the level of the proximal extent of the joint facet with the capitate [120]. Smaller proximal pole fractures can be caused by an avulsion of the attachment of the scapholunate ligament [120].

Epidemiology

Scaphoid fractures account for almost 75% of all carpal fractures [18]. Acute scaphoid fractures account for 2% to 3% of all fractures, approximately 10% of all hand fractures, and between 60% and 80% of all carpal fractures [74]. The estimated incidence rate for the U.S. population is 1.47 fractures per 100,000 person-years [41]. Scaphoid fractures made up 2.36% of wrist fractures overall in the U.S. population [41].

66.4% of scaphoid fractures occur in males [41]. The incidence rate ratio for gender, using females as the referent group, is 2.04 [41]. The male to female ratio is approximately 2.5:1 [74]. Males are significantly younger at the time of injury compared to females [74]. Peak incidence of scaphoid fracture occurs in the second and third decades of life [41]. The incidence rate for persons aged 10 to 19 years is 3.38 per 100,000 person-years [41]. The incidence rate for persons aged 20 to 29 years is 2.34 per 100,000 person-years [41]. The mean age in the literature ranges from 25 to 35 years [74]. Scaphoid fractures are rare in children and in the elderly [18].

In the pediatric population, scaphoid fractures account for approximately 3% of hand and carpal fractures and 0.34% of all fractures in children [76]. In children, the most common pattern of scaphoid fracture is the distal pole fracture during early stages of ossification [95]. By early adolescence, the fracture pattern in children becomes similar to adult types of scaphoid fractures [95].

Clinical Presentation and Examination

Patients usually present with pain on the radial side of the wrist [16]. There may be swelling on the radial side of the wrist [16]. There is usually a history of trauma, such as falling on an outstretched hand, collision of the wrist against a person or heavy obstacle, or a direct blow against an object [16]. Limited range of motion and pain when applying extended wrist loading or positioning the wrist in extreme positions of flexion or extension may be present [16]. Wrists with acute fractures may have swelling and bruising in the radial aspect of the wrist [16]. Wrists with chronic injury may have swelling in the dorsoradial wrist [16]. Generally, pain, swelling, ecchymosis, and tenderness around the region of the scaphoid may be present in the acute phase [29].

Fractures tend to occur at the waist partly because the RSC ligament acts as a fulcrum over which the scaphoid waist fractures [16]. "Snuffbox tenderness" applies predominantly to waist fractures, which represent 70% of scaphoid fractures [16]. Proximal pole fractures represent 20% of scaphoid fractures [16]. Distal pole fractures represent 10% of scaphoid fractures [16]. There may be slight fullness in the anatomical snuffbox, and precisely localized tenderness in the same place is an important diagnostic sign [18].

The full physical examination of the scaphoid should include palpation of the waist, distal pole, and proximal pole [16]. The anatomic snuffbox for the waist examination is palpated just distal to the radial styloid in the "soft spot" [16]. The distal pole is palpated at the scaphoid tubercle on the palmar aspect of the wrist [16]. With radial deviation of the wrist, the scaphoid tubercle prominence moves palmarly toward the examiner’s thumb [16]. The proximal pole is palpated dorsally in line with the second ray just distal to the dorsal radius lip [16]. The scapholunate ligament is in line between the second and third rays just distal to the dorsal radius lip and corresponds to the 3-4 wrist arthroscopy portal [16]. The proximal pole is just radial to the scapholunate ligament/3-4 portal area [16]. Examination must include pressure backwards over the scaphoid tubercle, palpation over the proximal pole, and telescoping of the thumb base [18]. If any of these specific examination maneuvers are positive, the suspicion for a scaphoid fracture should be high [18].

Pain on longitudinal compression of the thumb (scaphoid axial compression test) is a sign of scaphoid fracture [16]. If anatomic snuffbox tenderness, scaphoid tubercle tenderness, and the scaphoid axial compression test are all positive, there is 87% to 100% sensitivity and 74% specificity for scaphoid fracture [16]. No single clinical sign has been found to be adequately sensitive or specific for scaphoid fracture [29]. Anatomical snuffbox tenderness has a sensitivity of 87–100% and specificity of 3–98% [29]. Axial compression of the thumb has a sensitivity of 48–100% and specificity of 22–97% [29]. Scaphoid tubercle tenderness has a sensitivity of 82–100% and specificity of 17–57% [29]. Pain on ulnar deviation has a sensitivity of 67–100% and specificity of 17–60% [29]. Pain on radial deviation has a sensitivity of 67–90% and specificity of 31–42% [29]. Reduced range of movement of the thumb has a sensitivity of 65–66% and specificity of 38–59% [29]. Thumb–index finger pinch has a sensitivity of 75–79% and specificity of 44–76% [29]. ASB tenderness is oversensitive and has poor specificity [29]. In a study of 246 patients with a suspected fracture of the scaphoid, ASB tenderness had a sensitivity of 90% and a specificity of 40% [29]. In the same study, scaphoid tubercle tenderness had a sensitivity of 87% and a specificity of 57% [29]. The negative predictive value of ASB pain on ulnar deviation of the pronated wrist was 100% in a prospective analysis of 73 patients [29]. 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% in a prospective study of 215 consecutive patients [29].

Classification

General and Acute Fracture Classifications

More than a dozen classification systems for acute scaphoid fractures have been proposed, primarily based on fracture location or displacement [143]. The Herbert classification is the most popular system for acute scaphoid fractures [143]. There is no consensus regarding the imaging modality and measurements to use to define a scaphoid fracture as 'nondisplaced' [9]. Acute scaphoid fractures mainly occur in the middle third of the bone and tend to divide the scaphoid in half by volumetric size of the fracture fragments [165].

Pediatric Fracture Classifications

Pediatric scaphoid fractures may be classified according to anatomic location: tuberosity, transverse distal pole, avulsion distal pole, waist, and proximal pole [67]. In children, fractures of the distal third of the scaphoid are the most common [67]. Patient age, degree of ossification, and fracture location are interrelated factors important for determining fracture type, classification, and treatment in pediatric scaphoid fractures [67].

D’Arienzo classification: D’Arienzo proposed a three-part classification system for pediatric scaphoid fractures based on the age of the child and the presumed degree of ossification [67]. * Type 1: Occurs in children younger than age 8 years and may be purely chondral or involve part of the ossific nucleus [67]. * Type 2: Osteochondral fractures that occur in patients aged 8 to 11 years [67]. * Type 3: The most common fractures, occurring in adolescents aged ≥12 years and behaving similarly to adult scaphoid fractures [67].

Nonunion Classifications

Several classification schemes have been proposed for scaphoid nonunion, generally based on factors such as time since injury, mobility of the fragments, cystic or flexion deformity, and degenerative change [215]. Existing classification schemes for scaphoid nonunion are not all-encompassing with regard to nonunion characteristics and treatment options [215]. There is a need for a validated prognostic classification system for scaphoid nonunions that can allow comparisons between outcome studies [117].

Slade and Geissler classification: This system classifies scaphoid fracture nonunion into two types [215]. * Type 1: Delayed presentation for 4–12 weeks [215]. * Type 2: Fibrous union with a minimal fracture line [215].

Slade and Dodds classification: This system describes scaphoid nonunion into six grades to match healing potential to a specific treatment algorithm [221]. * Grades I, II, and III: Represent delayed presentation, fibrous nonunion, and minimal sclerosis, respectively [221]. * Grades IV and V: Represent bone loss without significant flexion deformity [221]. * Grade VI: Represents nonunions with more advanced resorption [221].

Other Considerations: Scaphoid nonunions can be divided roughly into two groups: early nonunions without substantial bone resorption, and older nonunions with substantial bone resorption [212]. Complicating factors in scaphoid nonunion treatment include perfusion, deformity, and instability (bony or ligamentous) [212]. The fracture location relative to the apex of the dorsal scaphoid ridge is a reliable landmark to determine the natural history of scaphoid nonunion [40].

Clinical Presentation

Epidemiology and Demographics

Acute scaphoid fractures represent 2% to 3% of all fractures [74], approximately 10% of all hand fractures [74], and between 60% and 80% of all carpal fractures [74]. The mean age for these injuries ranges from 25 to 35 years [74]. A male predominance exists with a male-to-female ratio of approximately 2.5:1 [74]. Male gender is a risk factor for true scaphoid fractures [74], as are sports injuries [74]. Low-energy falls from standing height occur more frequently in females, whereas males are more likely to sustain fractures after high-energy injuries such as sports or motor-vehicle collisions [74]. Scaphoid fractures are increasingly documented after punching or assault-related injuries [74]. In the pediatric population, scaphoid fractures account for approximately 3% of hand and carpal fractures [76] and 0.34% of all fractures in children [76]. For every year older, the risk of a true scaphoid fracture in children increases by 25% [32]. Being male increases the risk of a true scaphoid fracture diagnosis by almost 3 times compared to women at the same age in the pediatric population [32].

Mechanism of Injury

Patients classically present with wrist pain following a fall onto the outstretched hand [29]. Almost 90% of patients recall a hyperextension injury [29], and the usual mechanism is forced hyperextension of the wrist [18]. Scaphoid fractures usually occur after a fall onto the outstretched hand or during sports [74]. Sports noted to cause increased risk include football, basketball, cycling, and skateboarding [74]. In a review of 52 medical negligence cases, 19 cases involved hyperextension of the wrist and 19 involved a fall onto an outstretched hand [17]. Other mechanisms in this review included 3 cases of punching injuries [17], 4 cases of stamping on during sport or assault [17], 1 case of hyperextension of the thumb [17], 1 case of hyperflexion of the wrist [17], and 1 case of a fall onto the shoulder [17]. Additionally, 2 cases had an unknown mechanism after sport or drinking [17], and 2 cases had no recorded mechanism [17].

Symptoms and Signs

The main complaint is radial-sided wrist pain with localized tenderness over the scaphoid in the region of the anatomical snuffbox [29]. Pain, swelling, ecchymosis, and tenderness around the region of the scaphoid may be present in the acute phase [29]. There may be slight fullness in the anatomical snuffbox [18]. Precisely localized tenderness in the anatomical snuffbox is an important diagnostic sign [18]. There may be limited range of motion and pain when applying extended wrist loading or positioning the wrist in extreme positions of flexion or extension [16]. In pediatric patients, pain and swelling can be subtle in the anatomic snuffbox, and these fractures often present late [76].

Physical Examination Findings

The full physical examination of the scaphoid bone should include the waist, distal pole, and proximal pole [16]. The second most common type of scaphoid fracture is a proximal pole fracture, at 20% [16], while the least common type is a distal pole fracture, at 10% [16]. To palpate the anatomic snuffbox for the waist examination, palpate just distal to the radial styloid in the “soft spot” [16]. The distal pole should be palpated at the scaphoid tubercle on the palmar aspect of the wrist [16]. To palpate the distal pole, place the index finger in the anatomic snuffbox and place the thumb on the palmar aspect just distal to the anatomic snuffbox [16]. With radial deviation of the wrist, the prominence of the distal pole should move palmarly toward the examiner’s thumb [16]. Examination must include pressure backwards over the scaphoid tubercle [18], palpation over the proximal pole [18], and telescoping of the thumb base [18]. If any of the signs of pressure over the scaphoid tubercle, palpation over the proximal pole, or telescoping of the thumb base are positive, the suspicion for a scaphoid fracture should be high [18].

If all three tests of anatomic snuffbox tenderness, scaphoid tubercle tenderness, and scaphoid axial compression test are positive, there is 87% to 100% sensitivity and 74% specificity for scaphoid fracture [16]. Anatomical snuffbox tenderness has a sensitivity of 87–100% and a specificity of 3–98% [29]. Axial compression of the thumb has a sensitivity of 48–100% and a specificity of 22–97% [29]. Scaphoid tubercle tenderness has a sensitivity of 82–100% and a specificity of 17–57% [29]. Pain on ulnar deviation has a sensitivity of 67–100% and a specificity of 17–60% [29]. Pain on radial deviation has a sensitivity of 67–90% and a specificity of 31–42% [29]. Reduced range of movement of the thumb has a sensitivity of 65–66% and a specificity of 38–59% [29]. Thumb–index finger pinch has a sensitivity of 75–79% and a specificity of 44–76% [29]. Anatomical snuffbox tenderness is oversensitive and has poor specificity [29]. In a study of 246 patients with a suspected fracture of the scaphoid, anatomical snuffbox tenderness had a sensitivity of 90% and a specificity of 40% [29]. In the same study, scaphoid tubercle tenderness had a sensitivity of 87% and a specificity of 57% [29]. In a prospective analysis of 73 patients with a suspected scaphoid fracture, the negative predictive value of anatomical snuffbox pain on ulnar deviation of the pronated wrist was 100% [29]. A combination of anatomical snuffbox tenderness, scaphoid tubercle tenderness, and anatomical snuffbox pain on longitudinal compression of the thumb generated a sensitivity of 100% and a specificity of 74% in the first 24 hours after injury [29]. Pain on thumb–index finger pinch and anatomical snuffbox pain on pronation of the forearm were most suggestive of a true scaphoid fracture [29]. 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 [29]. Scaphoid tubercle tenderness was most predictive at week 2 [29]. A clinical scaphoid score (CSS) using tenderness in the anatomical snuffbox with the wrist in ulnar deviation (3 points), tenderness over the scaphoid tubercle (2 points), and pain upon longitudinal compression of the thumb (1 point) identified that patients with a CSS of 4 or higher require an MRI [29]. A combination of physical examination tests including tenderness in the anatomical snuffbox, pain on palpation of the scaphoid tubercle, pain with axial compression of the thumb, and painful thumb range of motion should be used to increase the specificity to detect an occult scaphoid fracture [60].

Diagnostic Challenges and Missed Fractures

Up to 30% to 40% of scaphoid fractures are not identified on initial assessment and investigation with standard four-view radiographs and are thus classified as having a suspected fracture [29]. 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 [29]. The combination of conventional radiographs and two clinical examinations does not provide adequate diagnostic certainty for scaphoid fractures, as a true fracture was identified in only about 40% of patients [4]. The combination of conventional radiographs and clinical reassessment does not increase the accuracy of these diagnostic tests compared with the accuracy of conventional radiographs alone [20]. Standard scaphoid radiographs are not reliable for the diagnosis or exclusion of a scaphoid fracture because of the low inter-observer agreement in the interpretation, irrespective of the experience and training of the observer [12]. Plain radiographs, while useful for obvious scaphoid fractures, are unable to reliably rule out subtle fractures routinely [56]. 6-week radiographs are not adequate for evaluating suspected scaphoid fractures due to low agreement between observers for the recognition of scaphoid fractures and poor diagnostic performance [24]. Misdiagnosed and maltreated scaphoid fractures result in significant complications, primarily pseudoarthrosis, and high costs for both society and patients [140]. The high rates of delayed presentation and incomplete evaluation and treatment suggest a strong need for better patient and doctor education on the subject of scaphoid injuries and nonunions [64].

Investigations

Clinical Examination

Patients with scaphoid fractures classically present with radial-sided wrist pain, often accompanied by swelling [16]. A history of trauma, such as falling on an outstretched hand, collision of the wrist against an obstacle, or a direct blow, is usually present [16]. Limited range of motion and pain when applying extended wrist loading or positioning the wrist in extreme positions of flexion or extension are common clinical features [16]. "Snuffbox tenderness" is predominantly associated with waist fractures, which represent 70% of scaphoid fractures [16]. Proximal pole fractures account for 20% of scaphoid fractures, while distal pole fractures account for 10% [16].

No single clinical sign has been found to be adequately sensitive or specific for scaphoid fracture diagnosis [29]. In a study of 246 patients with suspected scaphoid fracture, anatomical snuffbox tenderness had a sensitivity of 90% and a specificity of 40% [29]. In the same study of 246 patients, scaphoid tubercle tenderness had a sensitivity of 87% and a specificity of 57% [29]. A negative test for ASB pain on ulnar deviation of the pronated wrist has a negative predictive value of 100% [29]. The 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% in the first 24 hours after injury [29]. If anatomic snuffbox tenderness, scaphoid tubercle tenderness, and the scaphoid axial compression test are all positive, the sensitivity for scaphoid fracture is 87% to 100% and the specificity is 74% [16].

Pain on thumb–index finger pinch and ASB pain on pronation of the forearm were the most suggestive clinical signs of a true scaphoid fracture [29]. Scaphoid tubercle tenderness was the most predictive clinical sign at week 2 [29]. A clinical scaphoid score (CSS) of 4 or higher, based on ASB tenderness with ulnar deviation, scaphoid tubercle tenderness, and pain on longitudinal thumb compression, indicates the need for an MRI [29]. Clinical examination along with early MRI scan should form the basis of diagnosing a suspected scaphoid fracture [47].

Plain radiography

Standard radiographic views for scaphoid fracture workup include posteroanterior (PA), lateral, oblique, and scaphoid views [54]. A true scaphoid pisiform capitate (SPC) lateral radiograph allows for a true assessment of carpal alignment [54]. The scaphoid view is taken with the wrist in ulnar deviation to take the scaphoid out of its usual position of flexion and pronation [54]. A clenched pencil view is useful for assessing associated dynamic scapholunate widening and shows SNAC and SLAC wrist changes better than standard PA views [54].

Standard scaphoid radiographs are not reliable for the diagnosis or exclusion of a scaphoid fracture due to low inter-observer agreement [12]. Radiographs are initially nondiagnostic in more than 30% of scaphoid fracture cases [121]. Up to 30% to 40% of scaphoid fractures are not identified on initial assessment with standard four-view radiographs [29]. Plain radiographs are unable to reliably rule out subtle scaphoid fractures [56]. The combination of conventional radiographs and two clinical examinations does not provide adequate diagnostic certainty, as a true fracture was identified in only about 40% of patients [4]. The combination of conventional radiographs and clinical reassessment does not increase the accuracy of these diagnostic tests compared with conventional radiographs alone [20]. 6-week radiographs are not adequate for evaluating suspected scaphoid fractures due to low agreement between observers and poor diagnostic performance [24].

For clinically suspected occult scaphoid fractures with negative initial radiographs, the wrist may be casted and radiographs repeated in 10 to 14 days [54]. If normal radiographic findings and high clinical suspicion exist, the arm should be immobilized and physical examination and radiographs repeated in 2 weeks, or MRI obtained immediately [121]. The usual advice for a normal X-ray with suggestive clinical features is to return for a second X-ray 2 weeks later while immobilizing the wrist in a scaphoid plaster [18]. Patients with 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 [29].

MRI

MRI is the definitive way to confirm or exclude a diagnosis of scaphoid fracture if the technique is available [18]. MRI has higher sensitivity and specificity than CT scan, bone scintigraphy, or ultrasound for diagnosing scaphoid fractures [71]. MRI has the highest sensitivity, specificity, and accuracy (all >95%), with high positive and negative predictive values, at less than 24 hours [121]. Early magnetic resonance imaging (MRI) provides an immediate diagnosis for suspected scaphoid fractures when initial radiographs are inconclusive, which is cost-effective and minimizes complications [66]. The use of early MRI in patients with clinically suspected scaphoid fracture results in the accurate and reliable identification of a significant number of radiological occult injuries and early identification of patients without acute injuries [57].

MRI is the optimal second test for assessing a possible scaphoid fracture after a negative radiograph, while CT is preferred when the fracture is visible for further assessment and surgical planning [156]. MRI is the best diagnostic radiological test for triage of suspected scaphoid fractures, but bone scanning, CT, and ultrasound may also be useful when MRI is not readily available [163]. Although MRI remains the best diagnostic tool after radiography for detecting occult scaphoid fractures, MDCT sensitivity was 86% and specificity was 100% in one study [154].

Routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment, with nearly 70% of MRI findings categorized as distracting and potentially misleading [173]. Routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment due to the high prevalence of distracting signal changes and low prevalence of true fractures [207]. MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers [187]. There is a need for a consensus definition of scaphoid fractures on MRI scans to assess the reliability and diagnostic performance of MRI [52]. Better standardization of MRI definitions for scaphoid fractures is required, but a definition may not exist to solve the potentially unsolvable issue of diagnostic uncertainty [186].

Dynamic imaging with time-intensity curve analysis does not provide additional predictive value over standard delayed enhanced imaging for acute scaphoid fracture viability [96]. Viability of scaphoid fragments should be assessed by combining MRI findings with intraoperative observation of bleeding [205]. MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion seen in over 6% despite appropriate initial immobilization [53]. Most patients with MRI-detected scaphoid nonunion require surgery to achieve union [53].

In pediatric patients, MRI, which is more sensitive than CT, is useful in making the diagnosis of scaphoid fracture [112]. A normal MRI study as early as 2 days after injury has a negative predictive value of 100% for scaphoid fracture in pediatric patients [112]. Findings suggest a low but non-zero occult scaphoid fracture rate, discordance in radiologic interpretation, and a lack of advanced imaging in pediatric populations [203].

CT

A CT scan is more sensitive for diagnosing a scaphoid fracture and is particularly useful for confirming alignment of bone fragments if surgery is planned or to confirm union [18]. Scaphoid fracture displacement on CT was identified in 26 to 34% of fractures that were nondisplaced on radiograph [89]. Computed tomography improves the reliability of detecting scaphoid fracture displacement but has a more limited effect on accuracy, which remains <80% [203]. CT is a good way to screen occult fractures but may not be any better than MRI or bone scanning in detecting scaphoid fractures without some over treatment [69].

If there is any doubt about the presence of displacement, particularly if there is fragmentation at the fracture line, a CT scan is suggested [123]. CT oriented in the longitudinal axis of the scaphoid with 1-mm cuts can be helpful to evaluate for bridging trabeculae if healing cannot be determined with certainty [45]. Routine use of a week 4 CT scan is valuable in the early management of scaphoid fractures to predict the likelihood of union with nonoperative treatment [11]. Three-dimensional imaging should be considered when assessing scaphoid nonunions to identify the exact location of the fracture [84]. Diagnosis of malreduction of a scaphoid fracture is possible with 3D modalities, and utilization may assist in operative care [21]. 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].

Bone scan

If there is a strong clinical suspicion of a scaphoid fracture which cannot be confirmed by conventional radiology, bone scintigraphy is a valuable diagnostic tool [8]. A normal bone scan excludes scaphoid fracture, and a positive bone scan sufficiently confirms the presence of clinically relevant scaphoid fracture [25]. Bone scintigraphy is inappropriate for evaluating specificity and sensitivity against clinical examination, and MRI is the recommended examination of choice for diagnosing occult scaphoid fractures [159].

Ultrasound

With a sensitivity of only 50% and five missed scaphoid fractures in a small series, ultrasonic assessment is not recommended for the early diagnosis of acute scaphoid fractures [49].

Treatment

Non-Operative

Nonoperative management is safe and feasible for most scaphoid fractures in patients below the age of 10, with no significant long-term morbidity [1]. For subacute fractures presenting within 6 months of injury, casting alone is expected to result in successful healing even if the initial diagnosis was delayed [3]. A restricted period of cast immobilisation is recommended for the initial treatment of non-displaced scaphoid fractures [31], as nondisplaced fractures heal with cast immobilization in most cases [73]. Non- and minimally displaced scaphoid waist fractures are best treated conservatively [106]. Including the thumb in a cast has not been shown to increase scaphoid union rates or accelerate time to union [60]. Among patients managed nonoperatively, those prescribed NSAIDs within 1 month of diagnosis demonstrated an increased risk of nonunion and subsequent salvage procedures [148]. The authors recommend considering nonoperative management for asymptomatic scaphoid nonunion in children [149].

Operative

Indications: Displaced fractures have a propensity for nonunion due to displacement and rotation [19], making operative intervention recommended for these injuries [59]. Operative treatment is being offered with greater frequency to active patients to reduce the period of cast immobilization [73]. Early treatment of acute scaphoid fractures is important, with union rates significantly greater when treatment is instituted prior to 4 weeks from injury [72]. Neglected scaphoid fractures seldom heal with acceptable alignment; this often leads to complications in their management [6].

Surgical Approach / Technique: Minimally invasive fixation has been demonstrated to have a higher union rate than cast treatment and has relatively few complications [77]. A single compression screw through the central axis of the scaphoid is the fixation method with the most evidence to support its routine use [60]. Dorsal percutaneous treatment of scaphoid fractures and nonunions using arthroscopy is safe and effective [105]. The use of 2 headless compression screws for the treatment of scaphoid nonunions is safe and effective [124]. Uncomplicated scaphoid nonunions that are nondisplaced and nonangulated are candidates for the minimally invasive bone grafting and compression screw fixation procedure described [157]. Arthroscopic treatment of scaphoid nonunion in adolescents shows high union rates, improved function, and low morbidity [167]. SMS is effective in treating waist scaphoid nonunions at more than 6 months from trauma [155].

Adjuncts: The use of electrical stimulation for scaphoid nonunion may be indicated in patients who have failed previous bone grafting procedures or if surgery is refused or unsafe [170]. Treatment with LIPUS had no effect on reducing time to union in patients who underwent surgical fixation of established scaphoid nonunions [162].

Other Considerations: This study did not demonstrate a true long-term benefit of internal fixation, compared with nonoperative treatment, for acute nondisplaced or minimally displaced scaphoid fractures [14]. We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively [33]. Patients treated nonoperatively or with salvage procedures had similar long-term outcomes as those treated with a corrective scaphoid osteotomy [35]. The frequency of non-union after surgical management for closed scaphoid fractures exceeds 10% and remained consistent during the study period [23]. There was a 0.14% prevalence of established scaphoid fracture non-union in the general population, indicating that unrecognised scaphoid non-union is rare [36]. Malunion or nonunion can potentially lead to a relentless downward spiral of wear and cartilage damage [77]. Chronic pain and dysfunction of the wrist results from malunion or nonunion, which affects both hand function and the entire upper extremity [77].

Diagnostic Considerations for Treatment

Scaphoid fracture displacement on CT was identified in 26 to 34% of fractures that were nondisplaced on radiograph, confirming that radiographic evaluation alone underestimates displacement [89]. Routine use of a week 4 CT scan is valuable in the early management of scaphoid fractures [11]. The outcome of non-operative treatment of undisplaced scaphoid waist fractures can be predicted with reasonable accuracy by assessing fracture union on a week 4 CT scan [169]. Early advanced imaging such as a CT or MRI within the first week of injury should be considered for high-demand patients who present with radialsided wrist pain and negative radiographs and who wish to avoid unnecessary cast immobilization [60]. A combination of physical examination tests (tenderness in the anatomical snuffbox, pain on palpation of the scaphoid tubercle, pain with axial compression of the thumb and painful thumb range of motion) should be used to increase the specificity to detect an occult scaphoid fracture [60].

Special Populations and Contexts

Scaphoid fractures are common in competitive and recreational athletes, and such patients are reluctant to submit to the long period of immobilization and restricted activity that plaster requires [86]. The authors prefer to treat nondisplaced acute scaphoid fractures in the athlete on an individualized basis [150]. One study reported a faster return to play with internal fixation compared with a playing cast alone [86]. A potential problem with plaster immobilization is compliance, as young people often will modify or remove the cast and are increasingly noncompliant with follow-up over time [86]. The goal for treating scaphoid fractures in athletes is the successful union of the scaphoid fracture regardless of the patient's athletic responsibilities [86]. This case is interesting as the child is one of the youngest patients described in the literature with a scaphoid fracture, and the fracture went on to non-union despite immediate medical attention and rigorous treatment [133]. This report documents the first case of spontaneous healing of an established proximal pole scaphoid non-union without surgical intervention or immobilization [160].

Evidence Quality and Controversies

Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures [63]. The authors found no prospective randomized studies comparing different operative treatments of scaphoid nonunion [81]. Many authors have investigated treatment options and outcomes for scaphoid fractures, but there are substantial weaknesses in the evidence [60]. The heterogeneity of management algorithms creates multiple confounding factors when comparing studies [60]. Most earlier studies are retrospective case series without randomization or control groups [60]. The lack of standardization in imaging amongst authors and the prevalence of radiographs for fracture assessment may be erroneously affecting assessments of time to union and union rates for the interventions used [60]. The scaphoid is the most frequently fractured carpal bone [6]. In cases of non-union or malunion, reconstruction of the scaphoid is exceedingly difficult, and this increases the chances of morbidity already associated with an extended period of hand immobilisation [6].

Complications

Nonunion and Degenerative Changes

The frequency of non-union after surgical management for closed scaphoid fractures exceeds 10% [23]. Scaphoid nonunion is associated with progressive degenerative changes, although the correlation of symptoms and disease is poor [55]. In a review of 56 untreated scaphoid non-unions, arthritis developed in 31 of 32 patients (97%) who had been injured five years or more earlier [175]. Problem fractures and non-unions of the scaphoid are associated with major alterations in wrist kinematics and a higher incidence of premature carpal collapse and degenerative arthritis than previously appreciated [58]. Scaphoid nonunions are unlikely to remain aligned or free of arthritis after 10 years [182]. Untreated symptomatic scaphoid non-unions undergo a specific sequence of degenerative changes, including cyst formation, radioscaphoid arthritis, and generalized arthritis of the wrist [177]. Inadequate follow-up of treated scaphoid fractures results in delayed diagnosis and treatment of non-union with potentially impaired outcomes secondary to degenerative changes [5]. The prevalence of established scaphoid fracture non-union in the general population is 0.14% [36].

Surgical Complications and Outcomes

Persistent nonunion is common after surgery for scaphoid non-union, and surgeries for persistent nonunion are less successful [82, 83]. With every decade of a patient’s life, the odds of union after surgery for established scaphoid non-union are reduced by 1.72 times [88]. Dominant hand injury reduces the odds of union after surgery for established scaphoid non-union by 7.35 times [88]. Previous scaphoid surgery reduces the odds of union after surgery for established scaphoid non-union by 4.24 times [88]. Increased likelihood for nonunion after early open reduction and internal fixation was found when the fracture was treated greater than 31 days from injury [94]. Increased likelihood for nonunion after early open reduction and internal fixation was found when fracture volume was less than 38% of the entire scaphoid [94]. The clinical outcomes of malunited scaphoids after reconstruction for scaphoid fracture nonunion did not differ significantly from well-united scaphoids at a minimum 5-year follow-up [10]. Residual scaphoid deformity has no relevant negative impact on mid-term wrist function [34]. Patients treated nonoperatively or with salvage procedures for scaphoid malunion had similar long-term outcomes as those treated with a corrective scaphoid osteotomy [35]. Late surgery for ununited scaphoid fractures can produce good results if there is no secondary wrist osteoarthritis [97]. Patient age and delay from acute scaphoid fracture to non-union surgery do not influence the outcome of bone grafting surgery, provided there is no secondary wrist osteoarthritis [97]. A 28-year duration of delayed treatment for scaphoid nonunion treated with surgical fixation and bone grafting resulted in bony healing and a good clinical outcome [87].

Diagnostic Complications

Standard scaphoid radiographs are not reliable for the diagnosis or exclusion of a scaphoid fracture due to low inter-observer agreement in interpretation [12].

Pediatric Considerations

For every year older, the risk of true scaphoid fracture in children increased by 25% [32]. Being male increases the risk of true scaphoid fracture diagnosis by almost 3 times compared to women at the same age in pediatric populations [32].

General Management and Epidemiology

Neglected scaphoid fractures seldom heal with acceptable alignment, often leading to complications in management [6]. Reconstruction of the scaphoid in cases of non-union or malunion is exceedingly difficult and increases the chances of morbidity associated with extended hand immobilisation [6]. Even some well-established principles of scaphoid fracture management are supported by an insufficient amount of evidence, with many decisions based on small case series [7]. Scaphoid fractures account for 2% of all fractures and are the most commonly injured carpal bone [26]. The estimated incidence rate for the U.S. population is 1.47 scaphoid fractures per 100,000 person-years [41]. The incidence rate ratio for scaphoid injury in persons aged 10 to 19 years is 35.3 compared to other decade groups [41].

Recovery

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

Full activity (months): The evidence provided does not specify a month range for the return to manual work, sport, or full range of motion and strength.

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

Rehabilitation protocol: The evidence provided does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression schedules, or sling and brace removal timing.

Functional milestones: From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function as well as good wrist motion and strength [39]. Good clinical outcomes can be achieved after scaphoid fractures in prospective NFL athletes [194].

Other Considerations: Neglected scaphoid fractures seldom heal with acceptable alignment due to the unique anatomical structure of the bone [6]. Inadequate follow-up of treated scaphoid fractures results in delayed diagnosis and treatment of non-union, potentially leading to impaired outcomes secondary to degenerative changes [5]. A quarter (25%) of patients with established scaphoid nonunions delayed seeking medical attention for more than 6 months [220]. High rates of delayed presentation and incomplete evaluation and treatment suggest a need for better patient and doctor education on scaphoid injuries and nonunions [64].

A symptomatic nonunion of the scaphoid is significantly likely to progress to osteoarthritis according to a predictable sequence, becoming worse both radiographically and clinically with time [222]. Scaphoid nonunion is associated with progressive degenerative changes, although the correlation of symptoms and disease is poor and the true natural history is debatable [55]. Persistent nonunion is common after surgery for scaphoid non-union, and surgeries for persistent nonunion are even less successful [82, 83]. Dominant hand injury is associated with a 7.35 times reduction in the odds of union after surgery for established scaphoid non-union [88]. Previous scaphoid surgery is associated with a 4.24 times reduction in the odds of union after surgery for established scaphoid non-union [88]. Increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury [94]. Increased likelihood for nonunion was found when fracture volume was less than 38% of the entire scaphoid [94]. Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union [218].

Union rates are significantly greater when treatment is instituted prior to 4 weeks from injury for acute scaphoid fractures [72]. There was no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively [33]. Patient age and delay from acute scaphoid fracture to non-union surgery do not influence the outcome of bone grafting surgery, provided that there is no secondary wrist osteoarthritis [97]. Late surgery for the ununited scaphoid fracture can produce good results if there is no secondary osteoarthritis [97]. CC grafts are associated with consistent deformity correction and superior Mayo wrist scores in the management of unstable scaphoid nonunion [93]. Distal scaphoid resection is a durable procedure with good long-term results, with 94% of patients remaining satisfied and no further wrist collapse or radiocarpal arthritis developing [199]. Evaluation using 3D CT is recommended to determine the fracture type for management strategy in scaphoid nonunion [40].

Scaphoid nonunions demonstrate findings indicative of progression to union on CT at a mean of 6 weeks and as early as 3 weeks postoperatively [225]. Being a male was associated with an almost 3 times higher risk of true scaphoid fracture diagnosis than being female at the same age in pediatric patients [32].

Key Evidence

• [L4] Nonoperative management of most scaphoid fractures in this age group is safe and feasible with no significant long-term morbidity. [1] (10.1055/s-0040-1713800)
• [L1] Pediatric scaphoid fractures have excellent outcomes. [2] (10.1177/1558944717735948)
• [L4] Subacute scaphoid fractures presenting within 6 months from injury can be expected to successfully heal with casting alone, even if the initial diagnosis is delayed. [3] (10.1055/s-0035-1564983)
• [L5] The combination of conventional radiographs and two clinical examinations does not provide adequate diagnostic certainty for scaphoid fractures, as a true fracture was identified in only about 40% of patients. [4] (10.1097/corr.0000000000002413)
• [L4] Inadequate follow-up of treated scaphoid fractures will result in delayed diagnosis and treatment of non-union with a potentially impaired outcome secondary to degenerative changes and even litigation against the surgeon. [5] (10.1016/s0020-1383(02)00162-6)
• [L4] [6] (10.1016/j.injury.2009.07.078)
• [L5] Even some well-established and widely used principles of scaphoid fracture management are supported by an insufficient amount of evidence, with many decisions based on small case series. [7] (10.1177/1753193420977241)
• [Paper] If there is a strong clinical suspicion of a scaphoid fracture which cannot be confirmed by conventional radiology, bone scintigraphy is a valuable diagnostic tool. [8] (10.1016/j.injury.2005.02.009)
• [L5] There is no consensus regarding the imaging modality and measurements to use to define a scaphoid fracture as 'nondisplaced.' [9] (10.1016/j.jhsa.2012.10.025)
• [L4] The clinical outcomes of malunited scaphoids after reconstruction for scaphoid fractures nonunion did not differ significantly from well-united scaphoids at a minimum 5-year follow-up. [10] (10.1016/j.otsr.2014.09.026)
• [L2] Routine use of such a scan is valuable in the early management of scaphoid fractures. [11] (10.1177/1753193411403092)
• [L4] The study concludes that standard scaphoid radiographs are not reliable for the diagnosis or exclusion of a scaphoid fracture because of the low inter-observer agreement in the interpretation, irrespective of the experience and training of the observer. [12] (10.1016/0020-1383(92)90035-q)
• [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. [13] (10.1016/j.jhsa.2008.04.026)
• [L1] This study did not demonstrate a true long-term benefit of internal fixation, compared with nonoperative treatment, for acute nondisplaced or minimally displaced scaphoid fractures. [14] (10.2106/jbjs.g.00673)
• [L4] For all indications, the scaphoid staple has a high union rate and a low complication rate. [15] (10.1177/1558944716658747)
• [L4] [17] (10.1016/j.injury.2019.05.009)
• [L5] Nondisplaced scaphoid fractures heal in the vast majority of cases with strict immobilization, whereas displaced fractures have a propensity for nonunion due to displacement and rotation. [19] (10.1016/s0749-0712(21)01437-2)
• [L2] The combination of conventional radiographs and clinical reassessment does not increase the accuracy of these diagnostic tests compared with the accuracy of conventional radiographs alone and is therefore also limited in diagnosing scaphoid fractures. [20] (10.1097/corr.0000000000002310)
• [L4] Diagnosis of malreduction of a scaphoid fracture is possible with 3D modalities, and utilization may assist in operative care. [21] (10.1016/j.otsr.2014.07.038)
• [L3] The frequency of non-union after surgical management for closed scaphoid fractures exceeds 10% and remained consistent during the study period. [23] (10.1016/j.jhsa.2015.06.019)
• [L2] Due to low agreement between observers for the recognition of scaphoid fractures and poor diagnostic performance, 6-week radiographs are not adequate for evaluating suspected scaphoid fractures. [24] (10.1007/s00402-016-2438-4)
• [L5] A normal bone scan excludes scaphoid fracture, and a positive bone scan sufficiently confirms the presence of clinically relevant scaphoid fracture. [25] (10.1016/s0020-1383(96)00127-1)
• [L5] Scaphoid fractures account for 2% of all fractures and are the most commonly injured carpal bone. [26] (10.1016/j.hcl.2017.04.003)
• [L5] The definition of instability of scaphoid fractures and the indications for conservative treatment must be considered carefully. [27] (10.1142/s0218810415400018)
• [L5] Internal fixation of scaphoid fractures is indicated in certain acute situations and in chronic nonunion cases. [28] (10.1016/s0749-0712(21)00118-9)
• [L4] Appropriately performed acute percutaneous internal fixation is now a standard treatment option for a selected group of patients with acute scaphoid fracture. [30] (10.5435/00124635-200708000-00004)
• [L4] [31] (10.1016/j.injury.2008.10.028)
• [L3] For every year older, risk of true scaphoid fracture increased by 25%, and by being a man, risk of true scaphoid fracture diagnosis was almost 3 times higher than that of women at the same age. [32] (10.1177/15589447241231311)
• [L1] We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively. [33] (10.1302/0301-620x.104b8.bjj-2022-0085.r2)
• [L4] Residual scaphoid deformity has no relevant negative impact on mid-term wrist function. [34] (10.1177/17531934221125355)
• [L4] Patients treated nonoperatively or with salvage procedures had similar long-term outcomes as those treated with a corrective scaphoid osteotomy. [35] (10.1177/1558944716643295)
• [L4] There was a 0.14% prevalence of established scaphoid fracture non-union in the general population, indicating that unrecognised scaphoid non-union is rare. [36] (10.1016/s0020-1383(99)00301-0)
• [L4] Cast immobilization for scaphoid fractures presenting 21 days or more after injury is a reasonable option. [37] (10.1016/j.jhsa.2023.10.020)
• [L3] Virtually all scaphoid fractures which unite have a good outcome, regardless of malunion. [38] (10.1177/1753193408093327)
• [L2] From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function as well as good wrist motion and strength. [39] (10.1016/j.jhsa.2017.06.016)
• [L5] The fracture location relative to the apex of the dorsal scaphoid ridge is a reliable landmark to determine the natural history of scaphoid nonunion, and evaluation using 3D CT is recommended to determine the fracture type for management strategy. [40] (10.1055/s-0038-1637739)
• [L4] [41] (10.1016/j.jhsa.2010.05.017)
• [L5] The management of scaphoid fractures remains a source of controversy with no established gold standard for immobilization, acute surgical repair, or nonunion management despite decades of study. [42] (10.1016/j.hcl.2019.04.001)
• [L3] Clinical examination along with early MRI scan should form the basis of diagnosing a suspected scaphoid fracture. [47] (10.1177/1753193420979465)
• [L4] With a sensitivity of only 50% and five missed scaphoid fractures in this small series, we can not recommend ultrasonic assessment for the early diagnosis of acute scaphoid fractures. [49] (10.1054/jhsb.2000.0432)
• [L3] This review highlights the need for a consensus definition of scaphoid fractures on MRI scans to assess the reliability and diagnostic performance of MRI scans for diagnosing true scaphoid fractures, as well as their potential harms and benefits. [52] (10.1177/17531934251367541)
• [L3] MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion seen in over 6% despite appropriate initial immobilization, with most of these patients with nonunion requiring surgery to achieve union. [53] (10.1302/0301-620x.106b4.bjj-2023-1171.r1)
• [L5] Scaphoid nonunion is associated with progressive degenerative changes, although the correlation of symptoms and disease is poor and the true natural history is debatable. [55] (10.1016/j.jhsa.2012.03.002)
• [L4] Plain radiographs, while useful for obvious scaphoid fractures, are unable to reliably rule out subtle fractures routinely. [56] (10.1177/15589447241257705)
• [L2] The use of early MRI in patients with clinically suspected scaphoid fracture results in the accurate and reliable identification of a significant number of radiological occult injuries and early identification of patients without acute injuries. [57] (10.1177/1753193412471008)
• [L5] Problem fractures and non-unions of the scaphoid are associated with major alterations in wrist kinematics and a higher incidence of premature carpal collapse and degenerative arthritis than previously appreciated. [58] (10.2106/00004623-199274030-00014)
• [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. [59] (10.2106/jbjs.rvw.15.00073)
• [L5] [60] (10.1177/1753193417735973)
• [L1] Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures. [63] (10.1007/s11552-010-9276-6)
• [L2] The high rates of delayed presentation and incomplete evaluation and treatment suggest a strong need for better patient and doctor education on the subject of scaphoid injuries and nonunions. [64] (10.1016/j.jhsa.2011.06.016)
• [L5] Early magnetic resonance imaging (MRI) provides an immediate diagnosis for suspected scaphoid fractures when initial radiographs are inconclusive, which is cost-effective and minimizes complications. [66] (10.1016/j.jhsa.2013.03.055)
• [L5] [67] (10.5435/00124635-200902000-00004)
• [L4] Patients with recent scaphoid fractures that failed treatment may also be treated with distal scaphoid resection. [68] (10.1016/j.jhsg.2024.03.013)
• [Commentary] CT is a good way to screen occult fractures but may not be any better than MRI or bone scanning in detecting scaphoid fractures without some over treatment. [69] (10.1177/1753193412446273)
• [L2] MRI has higher sensitivity and specificity than CT scan, bone scintigraphy, or ultrasound for diagnosing scaphoid fractures. [71] (10.1055/s-0039-1693147)
• [L5] Early treatment of acute scaphoid fractures is important, with union rates significantly greater when treatment is instituted prior to 4 weeks from injury. [72] (10.1016/s0749-0712(21)00580-1)
• [L5] Nondisplaced fractures of the scaphoid heal with cast immobilization in most cases, but operative treatment is being offered with greater frequency to active patients to reduce the period of cast immobilization. [73] (10.5435/00124635-200007000-00003)
• [L4] The optimal protocol for postoperative immobilization following operative treatment of scaphoid fractures remains controversial. [80] (10.1177/15589447221093675)
• [L4] The authors found no prospective randomized studies comparing different operative treatments of scaphoid nonunion. [81] (10.1080/00016470410001529)
• [L4] Persistent nonunion is common after surgery for scaphoid non-union, and surgeries for persistent nonunion are even less successful. [82] (10.1016/j.jhsa.2015.06.022)
• [L4] Persistent nonunion is common after surgery for scaphoid non-union, and surgeries for persistent nonunion are even less successful. [83] (10.1016/j.jhsa.2015.06.023)
• [L4] Three-dimensional imaging should be considered when assessing scaphoid nonunions to identify the exact location of the fracture. [84] (10.1016/j.jhsa.2008.05.035)
• [L4] This case represents the longest reported duration of delayed treatment of scaphoid nonunion (28 years) treated with surgical fixation and bone grafting that resulted in bony healing and a good clinical outcome. [87] (10.1055/s-0032-1326727)
• [L2] With every decade of a patient’s life, dominant hand injury, and previous scaphoid surgery, the odds of union are reduced by 1.72 times, 7.35 times, and 4.24 times, respectively. [88] (10.1177/15589447231219523)
• [L3] Scaphoid fracture displacement on CT was identified in 26 to 34% of fractures that were nondisplaced on radiograph, confirming that radiographic evaluation alone underestimates displacement. [89] (10.1055/s-0037-1604136)
• [L3] Nondisplaced fractures achieved union faster than displaced fractures, and osteopenia was not significantly associated with scaphoid nonunion. [92] (10.1177/15589447241235342)
• [L1] CC grafts are associated with consistent deformity correction and superior Mayo wrist scores. [93] (10.1016/j.jhsa.2014.05.009)
• [L3] Increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury and when fracture volume was less than 38% of the entire scaphoid. [94] (10.1055/s-0039-3402769)
• [L5] [95] (10.1016/j.hcl.2005.10.004)
• [L4] Our data are consistent with previously reported data supporting contrast-enhanced MRI for assessment of viability, and showing that dynamic imaging with time-intensity curve analysis does not provide additional predictive value over standard delayed enhanced imaging for acute scaphoid fracture. [96] (10.1007/s00256-014-1981-8)
• [L4] [97] (10.1016/s0020-1383(00)00059-0)
• [L4] The dorsal percutaneous treatment of scaphoid fractures and nonunions using arthroscopy is safe and effective. [105] (10.1177/145749690809700402)
• [L2] Non- and minimally displaced scaphoid waist fractures are best treated conservatively. [106] (10.1016/j.jhsa.2015.03.007)
• [L4] There is a need for a validated prognostic classification system for scaphoid nonunions that can allow comparisons between outcome studies. [117] (10.1177/1753193417739510)
• [L4] The use of 2 headless compression screws for the treatment of scaphoid nonunions is safe and effective. [124] (10.1016/j.jhsa.2014.02.030)
• [L4] This case is interesting as the child is one of the youngest patients described in the literature with a scaphoid fracture, and the fracture went on to non-union despite immediate medical attention and rigorous treatment. [133] (10.2106/00004623-198365080-00026)
• [L3] Misdiagnosed and maltreated scaphoid fractures result in significant complications, primarily pseudoarthrosis, and high costs for both society and patients. [140] (10.1530/eor-21-0108)
• [L4] Over a dozen classification systems for acute scaphoid fractures have been proposed, mainly based on fracture location or displacement, with the Herbert classification being the most popular. [143] (10.1055/s-0036-1571280)
• [L2] Among patients with nonoperatively managed scaphoid fractures, those prescribed NSAIDs within 1 month of diagnosis demonstrated an increased risk of nonunion and subsequent salvage procedures. [148] (10.1016/j.jhsg.2026.100958)
• [L4] The authors recommend considering nonoperative management for asymptomatic scaphoid nonunion in children. [149] (10.1055/s-0037-1602799)
• [L4] The authors prefer to treat nondisplaced acute scaphoid fractures in the athlete on an individualized basis. [150] (10.1016/s0749-0712(21)00181-5)
• [L2] Although MRI remains the best diagnostic tool after radiography for detecting occult scaphoid fractures, MDCT sensitivity was 86% and specificity was 100% in this study. [154] (10.1007/s11604-010-0520-3)
• [L3] SMS is effective in treating waist scaphoid nonunions at more than 6 months from trauma. [155] (10.1055/s-0040-1710387)
• [Paper] MRI is the optimal second test for assessing a possible scaphoid fracture after a negative radiograph, while CT is preferred when the fracture is visible for further assessment and surgical planning. [156] (10.1016/j.hcl.2019.03.001)
• [L4] Uncomplicated scaphoid nonunions that are nondisplaced and nonangulated are candidates for the minimally invasive bone grafting and compression screw fixation procedure described. [157] (10.1016/j.jhsa.2008.03.004)
• [L5] The authors argue that bone scintigraphy is inappropriate for evaluating specificity and sensitivity against clinical examination, and that MRI is the recommended examination of choice for diagnosing occult scaphoid fractures. [159] (10.1016/j.injury.2007.12.013)
• [L4] This report documents the first case of spontaneous healing of an established proximal pole scaphoid non-union without surgical intervention or immobilization. [160] (10.1007/s11552-011-9328-6)
• [L1] Treatment with LIPUS had no effect on reducing time to union in patients who underwent surgical fixation of established scaphoid nonunions. [162] (10.2106/jbjs.23.00783)
• [L5] According to the existing literature, MRI is the best diagnostic radiological test for triage of suspected scaphoid fractures, but bone scanning, CT, and ultrasound may also be useful, particularly when MRI is not readily available. [163] (10.1016/j.jhsa.2008.04.016)
• [L4] Acute scaphoid fractures mainly occur in the middle third of the bone and tend to divide the scaphoid in half by volumetric size of the fracture fragments. [165] (10.1055/s-0039-1693050)
• [L4] Arthroscopic treatment of scaphoid nonunion in adolescents shows high union rates, improved function, and low morbidity. [167] (10.1002/ars2.70008)
• [L2] The outcome of non-operative treatment of undisplaced scaphoid waist fractures can be predicted with reasonable accuracy by assessing fracture union on a week 4 CT scan. [169] (10.1016/s0363-5023(09)60110-6)
• [L5] The use of electrical stimulation for scaphoid nonunion may be indicated in patients who have failed previous bone grafting procedures or if surgery is refused or unsafe. [170] (10.1016/s0749-0712(21)01453-0)
• [L5] Routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment, with nearly 70% of MRI findings categorized as distracting and potentially misleading, suggesting that stopping the pursuit of occult fractures may prevent unnecessary treatment. [173] (10.1097/corr.0000000000002914)
• [L4] [175] (10.2106/00004623-198567030-00013)
• [L4] [177] (10.2106/00004623-198466040-00003)
• [L4] [182] (10.1016/j.jhsa.2014.08.030)
• [L4] This review focuses on the indications and role of bone grafts in scaphoid nonunions to help augment internal fixation, promote healing, and restore carpal alignment. [183] (10.5435/jaaos-d-24-00510)
• [L5] The authors argue that better standardization of MRI definitions for scaphoid fractures is required, but acknowledge that a definition may not exist to solve the potentially unsolvable issue of diagnostic uncertainty, suggesting patients should participate in decisions regarding diagnostic and treatment strategies. [186] (10.1177/17531934251394819)
• [Paper] MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers. [187] (10.1016/s0363-5023(10)60085-8)
• [L4] Good clinical outcomes can be achieved after scaphoid fractures in prospective NFL athletes. [194] (10.1016/j.arthro.2017.08.259)
• [L4] The procedure is considered pertinent for certain recent scaphoid nonunions. [197] (10.1016/j.jhsa.2014.06.089)
• [L4] Distal scaphoid resection is a durable procedure with good long-term results. 94% of patients remained satisfied, and no further wrist collapse or radiocarpal arthritis developed. [199] (10.1016/s0363-5023(11)60002-6)
• [L4] Findings suggest a low but non-zero occult scaphoid fracture rate, discordance in radiologic interpretation, and a lack of advanced imaging, providing an avenue for future prospective studies. [203] (10.1177/1558944720930293)
• [L4] Viability of scaphoid fragments should be assessed by combining MRI findings with intraoperative observation of bleeding. [205] (10.1007/s004020050411)
• [L4] Routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment due to the high prevalence of distracting signal changes and low prevalence of true fractures. [207] (10.1097/corr.0000000000002851)
• [L5] [212] (10.1097/01.blo.0000205886.66081.9d)
• [L3] Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union. [218] (10.1177/15589447221142894)
• [Paper] A quarter (25%) of patients with established scaphoid nonunions delayed seeking medical attention for more than 6 months. [220] (10.1007/s12593-015-0206-2)
• [L4] [221] (10.1177/1753193419841253)
• [L4] A symptomatic nonunion of the scaphoid is significantly likely to progress to osteoarthritis according to a predictable sequence, becoming worse both radiographically and clinically with time. [222] (10.1007/bf00453208)
• [L4] Scaphoid nonunions demonstrate findings indicative of progression to union on CT at a mean of 6 weeks and as early as 3 weeks postoperatively. [225] (10.1016/j.jhsa.2016.07.051)

See Also

• Wrist Arthroscopy
• Wrist Osteoarthritis

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