Scaphoid Fracture

Acute presentation: pain and swelling at the radial wrist after FOOSH, particularly in a young adult athlete. The mechanism is often dismissed as a sprain - this is the source of missed diagnoses. Pain on resisted pronation and gripping, reduced wrist range of motion, and tenderness over the radial wrist are characteristic.

Clinical signs in suspected scaphoid fracture:

• •Anatomical snuffbox tenderness: sensitive (~90%) but poorly specific. The single most important clinical finding
• •Scaphoid tubercle tenderness (volar approach, just distal to the distal radius): increases specificity when combined with snuffbox tenderness
• •Pain on axial compression of the thumb metacarpal (axial loading test): high specificity
• •Pain or weakness on resisted pronation
• •Reduced grip strength compared with the contralateral side

A combination of snuffbox tenderness, scaphoid tubercle tenderness, and pain on thumb axial load substantially increases the post-test probability of fracture. Document neurovascular status (median, ulnar, radial nerves; radial pulse, capillary refill). Late presentation (weeks to months after injury) is the SNAC-risk scenario: persistent radial-sided wrist pain after a forgotten FOOSH, often with grip weakness.

Initial imaging: dedicated scaphoid four-view radiograph series (PA, lateral, oblique, and ulnar-deviated PA "scaphoid view"). The ulnar-deviated view elongates the scaphoid and reveals waist fractures that hide on standard PA.

If radiographs are non-diagnostic but clinical suspicion remains (snuffbox tender, FOOSH mechanism), NICE NG38 permits and supports MRI as the first-line definitive investigation. This is a UK practice change from the older "splint and re-X-ray at 10-14 days" pathway, which produced delays without diagnostic benefit. Modern UK fracture clinics increasingly obtain MRI within 72 hours.

Imaging options:

• •MRI: most sensitive (>95%) and specific (>95%); detects occult fractures and bone bruising. UK gold standard when first-line films are non-diagnostic
• •CT: used for fracture displacement assessment, pre-operative planning, and detailed evaluation of the proximal pole. Better than X-ray for displacement (under 1 mm threshold)
• •Bone scan: historically used for occult fractures; now superseded by MRI (less specific, more radiation)
• •Ultrasound: not recommended for scaphoid evaluation; insufficient sensitivity

Routine bloods are not indicated. Document mechanism, hand dominance, occupation, and sport for fracture-clinic handover.

Management is driven by location, displacement, and clinical context (BSSH, NICE NG38, BOAST).

Undisplaced waist or distal pole fracture: cast immobilisation.

• •Below-elbow scaphoid cast (with or without thumb spica - the SWIFFT trial demonstrated no difference). UK practice now favours below-elbow cast without thumb spica
• •6-8 weeks of immobilisation for distal pole; 8-12 weeks for waist
• •Weekly clinical review; repeat imaging at 6 weeks (CT or repeat X-ray) to assess union
• •SWIFFT trial (Lancet 2020) demonstrated that cast and surgical fixation produced equivalent functional outcomes at 1 year for undisplaced waist fractures. Cast immobilisation is the UK first-line, with surgery reserved for displaced, proximal pole, and patient-specific scenarios

Displaced fracture (any location, displacement over 1 mm): operative fixation.

• •Percutaneous or open Herbert screw fixation
• •Cancellous bone graft may be added in delayed presentations or displacement

Proximal pole fracture: operative fixation regardless of displacement.

• •Due to AVN and non-union risk
• •Vascularised bone graft may be required for established non-union or AVN

Established non-union: surgical reconstruction.

• •Vascularised bone grafts (1,2-intercompartmental supraretinacular artery [ICSRA] graft) for proximal pole non-union with AVN
• •Bone grafting and screw fixation for waist non-union without AVN
• •Salvage procedures (scaphoid excision and four-corner fusion, or proximal row carpectomy) for established SNAC wrist arthritis

Referral pathway: all suspected scaphoid fractures go to fracture clinic at the first available appointment (24-72 hours). Refer urgently to hand surgery for displacement, proximal pole, polytrauma, or sporting timeline requirements where early fixation may shorten recovery.

Cast immobilisation pathway:

• •Weeks 0-6 (distal pole) or 0-8-12 (waist): below-elbow cast. Finger and shoulder ROM encouraged daily. No loaded gripping; document neurovascular status at each review
• •Post-cast removal: progressive wrist ROM exercises with hand therapy supervision
• •Weeks 8-12: gentle grip strengthening; pinch and grip dynamometer assessment
• •Weeks 12-16: progressive resistance training; sport-specific loading
• •Return to non-contact sport at 12-16 weeks; contact sport at 4-6 months with confirmed bony union on CT

Post-operative (Herbert screw fixation, undisplaced waist):

• •Day 0-7: bulky dressing then thumb spica or wrist splint (surgeon-specific); finger ROM from day 1
• •Week 1-6: splint or removable orthosis; progressive wrist ROM under hand therapy supervision
• •Week 6-12: strengthening; sport-specific loading once bony union confirmed (CT at 6-8 weeks)
• •Return to sport: 6-12 weeks for non-contact; 12-16 weeks for contact

Vascularised bone graft (non-union or proximal pole AVN): longer recovery, immobilisation 8-12 weeks before progressive loading. Union may take 3-6 months.

Persistent radial-sided wrist pain beyond expected union timeframe (over 3 months for waist, over 4 months for proximal pole) needs imaging reassessment for delayed union or non-union. Early identification preserves salvage options.

• •NICE NG38 Fractures (non-complex, 2016) - Permits MRI as first-line definitive imaging in suspected scaphoid fracture when initial radiographs are non-diagnostic; modernises the older "splint and re-X-ray" pathway.
• •SWIFFT trial (Dias et al., Lancet 2020) - Randomised UK multicentre trial: cast immobilisation and surgical fixation produced equivalent function and pain at 12 months for undisplaced waist scaphoid fractures. Cast is the UK first-line.
• •BSSH Scaphoid Fracture Standards - UK hand-surgery framework: aligns with SWIFFT for undisplaced waist; operative fixation for proximal pole, displaced fractures, and patient-specific factors.
• •Herbert classification (1984) - Distinguishes acute stable, acute unstable, delayed union, and established non-union; underpins operative-vs-conservative decision-making.
• •Cooney displacement criteria - Over 1 mm displacement, scapholunate angle over 60 degrees, or radiolunate angle over 15 degrees define instability and indicate fixation regardless of location.

• •Retrograde blood supply via the distal dorsal carpal branch makes the proximal pole "ischaemic by default". Proximal pole fractures require operative fixation regardless of displacement; waist and distal pole fractures may be managed in cast if undisplaced.
• •The combination of anatomical snuffbox tenderness, scaphoid tubercle tenderness, and pain on axial compression of the thumb metacarpal substantially raises pre-test probability. Tenderness in any of these warrants splinting and imaging.
• •NICE NG38 permits MRI as first-line definitive imaging when initial radiographs are non-diagnostic. The "splint and re-X-ray at 10-14 days" pathway is outdated UK practice.
• •SWIFFT trial (2020) showed cast and surgical fixation produced equivalent outcomes at 12 months for undisplaced waist fractures. Cast is the UK first-line; surgery reserved for displacement, proximal pole, or specific patient timelines.
• •The "sprained wrist" after FOOSH is the most dangerous missed diagnosis in upper limb trauma. Persistent radial-sided wrist pain 6+ weeks after a forgotten FOOSH is non-union until proven otherwise.
• •SNAC wrist (Scaphoid Non-union Advanced Collapse) is the 5-10 year sequel of missed scaphoid non-union. Pattern: scapholunate dissociation, dorsal intercalated segment instability (DISI), radial-styloid then capitate-lunate arthritis, and ultimately pancarpal salvage surgery.