Clinical suspicion
A scaphoid fracture may occur after a fall onto an extended wrist.
Examine for:
- anatomical snuffbox tenderness
- scaphoid tubercle tenderness
- pain with axial thumb loading
- swelling and range restriction
No single sign is diagnostic.
Imaging
Initial radiographs include dedicated scaphoid views. When radiographs are negative but clinical suspicion remains high, early MRI is highly useful because it can confirm fracture and identify alternative injury. CT is excellent for assessing displacement, deformity and union.
Vascularity
The proximal pole has relatively vulnerable blood supply because much of the scaphoid is supplied from distal-to-proximal vessels. Proximal fractures therefore have a greater risk of nonunion and avascular necrosis.
Non-operative treatment
Stable, nondisplaced waist fractures and selected distal fractures can be immobilised.
Duration is guided by fracture site and evidence of union rather than a fixed number of weeks for every fracture.
Operative indications
Consider fixation for:
- displacement or instability
- proximal-pole fracture
- humpback deformity
- associated perilunate injury
- established nonunion
- selected patients in whom earlier mobilisation is a major priority
Nonunion
Assess:
- fracture location
- deformity
- cystic change
- vascularity of proximal pole
- carpal alignment
Treatment may require correction of deformity, stable fixation and bone grafting. Vascularised grafts are considered in selected biologically compromised cases.
Why the scaphoid matters
The scaphoid links the proximal and distal carpal rows and is critical to carpal stability. Much of its surface is articular, and vascularity is predominantly retrograde from distal branches, making the proximal pole vulnerable to avascular necrosis.
Diagnosis
Clinical suspicion arises with:
- anatomical snuffbox tenderness
- scaphoid tubercle tenderness
- pain with axial thumb loading
- mechanism involving wrist extension
Initial radiographs may be normal. If suspicion remains high, early MRI or CT strategy can avoid unnecessary prolonged immobilisation and detect occult fracture.
Fracture location
Fractures may involve:
- distal pole
- waist
- proximal pole
Proximal fractures have a higher risk of non-union and AVN because of blood supply.
Stability
Displacement, comminution, humpback deformity and carpal malalignment suggest instability.
CT is especially useful for:
- displacement
- fracture geometry
- union assessment
- preoperative planning
Treatment
Stable nondisplaced fractures may heal with cast immobilisation.
Fixation is considered for:
- displaced or unstable fractures
- proximal-pole injuries
- selected high-demand patients where early reliable union is important
- established non-union
Non-union
Non-union can lead to progressive carpal collapse and arthritis, classically described as scaphoid non-union advanced collapse.
Assessment includes:
- fracture location
- sclerosis/cysts
- deformity
- vascularity
- carpal alignment
- arthritis
Treatment may require:
- correction of deformity
- stable fixation
- bone graft
- vascularised graft in selected settings
Once advanced arthritis is present, reconstructive salvage procedures may be more appropriate than attempting union alone.
Screw principles
A headless compression screw should be positioned centrally along the scaphoid axis with secure purchase while avoiding joint penetration. The surgical approach depends on fracture location and geometry.
FRCS synthesis
The decision tree is: occult or visible? stable or unstable? proximal or waist? acute or non-union? arthritis present or absent?