TraumaUpper Extremity/Upper Extremity

SCAPHOID FRACTURES

Resident Dr. Mehmet KARAKUS· Umraniye Training and Research Hospital, Istanbul
Apr 24, 2026

SUMMARY / CORE POINTS

  • Scaphoid fractures are the most common carpal fractures, accounting for approximately 60% of all carpal fractures.

  • Despite their frequency, they are clinically critical due to:

    • Difficult early diagnosis

    • High risk of nonunion

    • Risk of avascular necrosis (AVN)

  • The unique anatomy and retrograde blood supply of the scaphoid make timely diagnosis and appropriate treatment essential.

EPIDEMIOLOGY

  • Represents:

    • ~60% of carpal fractures

    • ~11% of hand fractures

    • ~2% of all fractures

  • Annual incidence: ~30–40 per 100,000

  • Most commonly affects:

    • Young, active males (15–30 years)

  • Typical scenario:

    • Sports-related trauma

    • Fall on an outstretched hand

ANATOMY AND PATHOPHYSIOLOGY

  • The scaphoid is a three-dimensional, boat-shaped bone forming a critical link between:

    • Proximal carpal row

    • Distal carpal row

  • Approximately 75–80% of its surface is covered by articular cartilage, limiting periosteal healing.

Vascular Supply (Key Concept)

  • Dorsal carpal branch of the radial artery

    • Supplies ~70–80% of blood flow

    • Enters dorsally near the waist

    • Supplies the proximal pole via retrograde flow

  • Palmar branches

    • Supply distal pole only

  • Consequence:

    • Waist or proximal pole fractures compromise blood supply

    • High risk of ischemia and AVN

Fracture Location

  • Waist fractures (~65%)

    • Most common

  • Proximal pole fractures (~20–25%)

    • Highest risk of AVN and nonunion

  • Distal pole / tubercle fractures (~10%)

    • Best prognosis due to good vascularity

MECHANISM OF INJURY

  • Classic mechanism:

    • FOOSH (fall on an outstretched hand)

    • Wrist in:

      • Hyperextension

      • Radial deviation

  • Energy transfer through the radial column compresses the scaphoid against the distal radius.

CLINICAL PRESENTATION

Symptoms

  • Radial-sided wrist pain

  • Swelling

  • Decreased grip strength

  • Pain exacerbated by wrist motion

Physical Examination – Clinical Triad

  • Anatomic snuffbox tenderness

    • Highly sensitive

  • Scaphoid tubercle tenderness

    • Palpated volar-radially

  • Pain with axial thumb compression

    • Lower specificity alone

Key Pearl

  • Presence of ≥2 findings strongly suggests fracture, even with normal X-rays.

IMAGING

Radiographs

  • Standard scaphoid series:

    • PA

    • Lateral

    • Oblique

    • Scaphoid view (PA with ulnar deviation)

  • Sensitivity:

    • ~70%

  • Up to 20% of fractures are occult initially

MRI

  • Gold standard for early diagnosis

  • Sensitivity: ~99–100%

  • Detects:

    • Occult fractures

    • Bone marrow edema

    • Associated ligament injuries

  • Recommended within 3–5 days if X-rays are negative

CT

  • Best modality for:

    • Fracture displacement

    • Fracture morphology

    • Assessment of union

  • Essential for:

    • Surgical planning

    • Follow-up of healing

CLASSIFICATION

Herbert Classification

  • Type A – Stable acute fractures

  • Type B – Unstable acute fractures

  • Type C – Delayed union

  • Type D – Established nonunion

Classification helps guide treatment and prognosis, but fracture stability must always be assessed clinically and radiologically.

MANAGEMENT

GENERAL PRINCIPLES

  • High index of suspicion is mandatory

  • Any patient with snuffbox tenderness:

    • Treat as fracture until proven otherwise

  • Early immobilization prevents displacement and nonunion

NONOPERATIVE TREATMENT

Indications

  • Non-displaced or minimally displaced fractures (≤0.5 mm)

  • Stable waist or distal pole fractures

Method

  • Short-arm cast or thumb spica cast

  • Thumb immobilization is not always required

Duration

  • Waist fractures: ~6 weeks

  • Proximal pole fractures: 8–10 weeks

  • Distal pole fractures: 4–6 weeks

OPERATIVE TREATMENT

Indications

  • Displacement ≥1–1.5 mm

  • Proximal pole fractures

  • Fracture instability

  • High-demand patients

  • Delayed union or nonunion

Techniques

  • Headless compression screw fixation

    • Open or percutaneous

  • Approach selection

    • Volar: waist and distal fractures

    • Dorsal: proximal pole fractures

COMPLICATIONS

  • Nonunion

    • Leads to SNAC wrist

  • Avascular necrosis

    • Especially proximal pole

  • Malunion

    • Humpback deformity

    • Alters carpal kinematics

  • Secondary osteoarthritis

PROGNOSIS

  • Non-displaced waist fractures:

    • ~90% union with conservative treatment

  • Prognosis depends on:

    • Fracture location

    • Displacement

    • Timing of diagnosis

    • Compliance with immobilization

HIGH-YIELD PEARLS

  • Snuffbox tenderness + normal X-ray ≠ no fracture

  • Proximal pole fractures behave like intra-capsular femoral neck fractures

  • CT is best for union assessment

  • Loss of scaphoid integrity → carpal collapse

  • Early diagnosis prevents lifelong disability

SURGICAL TECHNIQUES

1. PERCUTANEOUS SCREW FIXATION

Indications

·       Acute, non-comminuted fractures

·       Minimally displaced waist fractures

·       Selected proximal pole fractures with intact vascularity

Advantages

·       Minimal soft tissue disruption

·       Preservation of ligamentous and vascular structures

·       Lower risk of stiffness

·       Faster rehabilitation

Approach Selection

·       Volar percutaneous approach

o   Preferred for waist and distal pole fractures

o   Allows correction of humpback tendency

·       Dorsal percutaneous approach

o   Preferred for proximal pole fractures

o   Provides direct central axis screw placement

Technique

·       Guidewire placed centrally along the long axis of the scaphoid

·       Fluoroscopic confirmation in multiple planes

·       Cannulated headless compression screw inserted

·       Screw length optimized to maximize compression without joint penetration

2. OPEN REDUCTION AND INTERNAL FIXATION (ORIF)

Indications

·       Displaced fractures

·       Comminuted fractures

·       Failed closed or percutaneous reduction

·       Fractures with carpal malalignment

·       Delayed union or early nonunion

A. Volar (Palmar) Approach

Indications

·       Waist fractures

·       Distal pole fractures

·       Humpback deformity correction

Advantages

·       Direct visualization of fracture

·       Allows correction of volar collapse

·       Facilitates bone grafting if needed

Technique

·       Incision along the radial border of FCR tendon

·       Capsulotomy performed carefully

·       Fracture reduced anatomically

·       Headless compression screw placed from distal to proximal

·       Bone graft added if instability or bone loss present

B. Dorsal Approach

Indications

·       Proximal pole fractures

·       Nonunion of proximal pole

·       Need for direct access to proximal fragment

Advantages

·       Central screw placement into proximal pole

·       Improved fixation in small proximal fragments

Risks

·       Potential injury to dorsal carpal blood supply

·       Increased risk of stiffness

Technique

·       Longitudinal dorsal incision

·       Protection of dorsal sensory branches

·       Fracture reduced and fixed with headless screw

·       Care taken to avoid over-compression

3. BONE GRAFTING TECHNIQUES

Bone grafting is indicated in:

·       Delayed union

·       Nonunion

·       Fractures with bone loss or AVN risk

A. Non-Vascularized Bone Grafting

Indications

·       Nonunion without AVN

·       Stable fracture environment

Sources

·       Distal radius

·       Iliac crest

Technique

·       Curettage of fibrous tissue

·       Packing cancellous graft

·       Screw fixation

B. VASCULARIZED BONE GRAFTING

Indications

·       Proximal pole nonunion

·       Avascular necrosis

·       Failed previous surgery

Common Techniques

·       1,2-intercompartmental supraretinacular artery (1,2-ICSRA) graft

·       Volar vascularized grafts (less common)

Advantages

·       Provides biological stimulus

·       Improves union rates in ischemic bone

4. FIXATION DEVICES

·       Headless compression screws

o   Herbert screw

o   Acutrak screw

·       Provide:

o   Interfragmentary compression

o   Minimal articular surface disruption

o   Allow early mobilization

Key Technical Principle

·       Screw must be placed centrally in both AP and lateral planes

·       Malposition leads to:

o   Nonunion

o   Screw cutout

o   Articular damage

POSTOPERATIVE MANAGEMENT

·       Immobilization in thumb spica splint:

o   1–2 weeks for percutaneous fixation

o   4–6 weeks for open procedures

·       Early finger and elbow motion encouraged

·       Wrist ROM initiated once early union is evident

·       CT scan recommended at 6–8 weeks to confirm union

OUTCOMES

·       Union rates:

o   Acute fractures: >95%

o   Nonunion with vascularized graft: 80–90%

·       Earlier return to work and sports compared to casting

·       Outcomes strongly depend on:

o   Fracture location

o   Surgical timing

o   Quality of reduction

COMPLICATIONS OF SURGICAL TREATMENT

·       Nonunion

·       Hardware failure or migration

·       AVN progression

·       Wrist stiffness

·       Donor site morbidity (bone graft)

·       Degenerative arthritis

 

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