Scaphoid Fracture
Classification systems
- Anatomical location: tubercle, distal third, waist, proximal pole
Mechanism
A fall onto the outstretched hand with the wrist hyperextended and radially deviated, loading the scaphoid against the dorsal rim of the radius. Sporting and motorcycling injuries in young men predominate. The retrograde blood supply entering distally means the more proximal the fracture, the poorer the blood supply to the proximal fragment.
Age considerations
- Paediatric
- Rare before the scaphoid ossifies substantially; distal pole and tubercle injuries predominate and heal reliably in a cast. Suspect a distal radial physeal injury instead in the younger child with the same mechanism.
- Young adult
- The typical patient. Early diagnosis is everything, because a missed waist fracture becomes a non-union that progresses to scaphoid non-union advanced collapse. Percutaneous fixation is attractive for early return to work and sport.
- Elderly
- Less common; a distal radius fracture is the usual result of the same fall. When it occurs, consider the functional demand and the higher likelihood of pre-existing wrist degeneration.
Management options
Cast immobilisationshowhide
Indication
Undisplaced distal pole, tubercle and stable waist fractures.
Implant design notes
No implant. Below-elbow cast; thumb inclusion is traditional but not clearly necessary, and the wrist is held in neutral rather than extremes.
Approach
Non-operative with defined radiographic and clinical review.
Steps overview
- Examine for scaphoid tubercle tenderness, tenderness in the anatomical snuffbox and pain on axial thumb compression
- Obtain dedicated scaphoid views; if negative with a strong clinical suspicion, immobilise and re-image or arrange cross-sectional imaging
- Apply a below-elbow cast with the wrist in neutral
- Review at two weeks with repeat films or advanced imaging if the initial films were normal
- Continue immobilisation for six to twelve weeks depending on site, with serial assessment of union
- Confirm union clinically and radiologically before releasing to sport or manual work
Notes
A clinically suspected scaphoid fracture with normal radiographs is treated as a fracture until proven otherwise — that is the medicolegal and exam answer.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Percutaneous or open screw fixationshowhide
Indication
Displaced fractures, proximal pole fractures, associated carpal instability, and undisplaced waist fractures in patients needing early return of function.
Implant design notes
Headless compression screw with differential thread pitch generating compression while sitting entirely below the articular cartilage. Central placement along the long axis of the scaphoid maximises stability; screw length should be slightly shorter than the measured axis so neither end protrudes.
Approach
Percutaneous volar (retrograde) route for waist fractures, or percutaneous dorsal (antegrade) route for proximal pole fractures. Open volar approach for displaced fractures needing reduction and bone graft.
Steps overview
- Supine with the hand on a radiolucent table and mini image intensifier available
- Obtain the true scaphoid axis view by positioning the wrist appropriately
- Insert the guide wire along the central axis under fluoroscopic control in multiple planes
- Confirm wire position, measure, and use a screw slightly shorter than measured
- Ream and insert the headless compression screw, checking it is buried at both ends
- For displaced fractures, open volarly, correct the humpback deformity, graft if needed and then fix
- Confirm reduction, screw position and carpal alignment on final images
- Splint briefly, then start protected motion with union assessment at six weeks
Notes
The humpback deformity with a lost scaphoid height ratio must be corrected, not fixed as it lies. Proximal pole fractures may need vascularised or non-vascularised graft if union is delayed.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Viva pearls
- State the blood supply clearly: the dorsal carpal branch of the radial artery enters distally and supplies most of the scaphoid in a retrograde fashion, so proximal pole fractures are at high risk of avascular necrosis.
- A normal radiograph never excludes a scaphoid fracture; splint, review and re-image.
- The natural history of untreated waist non-union is scaphoid non-union advanced collapse — a predictable radiocarpal and midcarpal arthritis pattern.
- Correct the humpback deformity; leaving flexion of the scaphoid produces a dorsal intercalated segment instability pattern.
- Central screw placement along the long axis is the technical point that separates a good result from a failure.
Sources for further reading
- Green's Operative Hand Surgery — scaphoid fractures and non-union
- Rockwood and Green's Fractures in Adults — carpal injuries
- Standard operative orthopaedics textbook — wrist and hand trauma
My labelled images · 0
Attach your own teaching radiographs with your own labels for pattern-recognition practice. Use anonymised study images only — never anything patient-identifiable.
No images yet for this topic.
Resident-authored study summary in original wording, not reproduced from copyrighted source text.