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Scaphoid Fracture

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

Updated Aug 20265 citations
A hand-drawn illustration of a faceless person tripping and falling forward, putting an outstretched hand down onto the ground to break the fall.
X-ray showing a fracture of the scaphoid bone in the wrist. Kieran Hirpara 4.0

What you're feeling

You might feel a sudden snap or pop in your wrist if a bone breaks. This often happens after a fall onto an outstretched hand or a direct impact. The pain usually starts right away and can be sharp. You may notice swelling and bruising appearing within hours. Many people find it difficult or painful to move their wrist or grip objects. Your hand might feel weak or unstable.

It is important to know that not all wrist pain after a fall means you have broken this small bone. In fact, most people who come in with suspected scaphoid fractures do not have one. The true incidence of these fractures is typically within the 10% to 20% range. Initial X-rays are not always accurate enough to rule out a break. They have a sensitivity of up to 64%. This means some fractures can be missed on the first scan. Your surgeon will look closely at your symptoms and may order further tests, such as an MRI, to be sure.

In the first few days and weeks, you will likely feel pain when you move your wrist or try to use your hand for daily tasks. Simple actions like turning a doorknob, typing, or lifting a cup can hurt. You might also feel discomfort at night, which can disturb your sleep. As healing begins, this pain should gradually settle. However, because this bone has a unique blood supply, healing can be slow. If a fracture is not diagnosed early, it can lead to complications like nonunion or arthritis later on. Early and accurate diagnosis helps protect your wrist function and prevents long-term issues.

What's actually happening

Your wrist contains eight small bones called carpals. The scaphoid is one of these, sitting near the base of your thumb. It acts like a bridge between your forearm and the rest of your hand. When you fall on an outstretched hand, this bone takes a lot of force. It can crack or break completely.

Think of the scaphoid as a keystone in an arch. If that stone shifts or cracks, the whole arch becomes unstable. In your wrist, this means the smooth sliding motion between bones gets disrupted. You might feel pain, stiffness, or weakness when you try to grip or twist your wrist. The bone needs blood to heal, and the scaphoid has a delicate blood supply. This makes healing slower than in other bones.

If the break is not moved out of place, the bone ends stay aligned. Your surgeon may recommend a cast to hold it still while it knits back together. Many of these fractures heal well without surgery. The bone forms new tissue across the crack, restoring strength and motion. Even if there is a small misalignment, you can still have good function in the long term.

If the break is displaced, the pieces have shifted. This changes how the wrist moves. The bones may rub against each other in abnormal ways. Over time, this can lead to wear-and-tear arthritis. This is where the cartilage cushion wears down. It causes pain and stiffness. In some cases, the bone fails to heal, known as a nonunion. This leaves the wrist unstable.

When healing is needed for a nonunion or a displaced break, surgery helps. We use screws or pins to hold the pieces together firmly. Sometimes we add bone graft to encourage healing. This restores the normal shape and movement of your wrist. The goal is to stop the abnormal rubbing and protect your joint. With proper treatment, most people regain normal use of their hand and wrist.

What we can do about it

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. We start by confirming the diagnosis. Standard X-rays and clinical checks alone miss many fractures, identifying a true break in only about 40% of cases. We often use an MRI scan to see clearly. This helps us spot hidden injuries early or confirm that no fracture is present. This avoids unnecessary treatment for misleading signals that appear on scans.

For stable fractures with little or no movement of the bone pieces, we may recommend non-operative care. This involves wearing a splint or cast to keep the wrist still while it heals. We monitor your progress with repeat imaging. Please note that taking anti-inflammatory painkillers (NSAIDs) within the first month of injury can increase the risk of the bone failing to heal. For displaced or unstable fractures, we often recommend surgery from the start. This involves placing small screws to hold the bone fragments together. This approach allows for a faster return to work, typically seven weeks sooner than casting alone. However, for some minimally displaced fractures, surgery and casting offer similar long-term function. We discuss these options with you to decide what fits your daily needs and pain tolerance.

Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment establishes the diagnosis. For acute problems like this, we may recommend surgery straight away, without a preceding non-operative trial. Both paths share common goals: managing pain in the early weeks, protecting the injury while it heals, and starting physiotherapy at the right stage to restore movement. We aim for a solid union, though non-union rates after surgery remain above 10%. We support you through every step of this process.

What to expect

Your bone needs time to knit back together. Most fractures heal within eight to eleven weeks, though scans may show early signs of healing as soon as three weeks after surgery. You will likely wear a cast or splint for several weeks to keep the wrist still. This protects the bone while it strengthens.

If your fracture is not moved out of place, you might choose surgery or a cast. Surgery often helps you return to work about seven weeks faster than casting alone. However, both paths lead to good long-term results if the bone heals correctly. Virtually all united fractures have a good outcome, even if the bone heals slightly crooked.

Healing does not always go smoothly. The frequency of nonunion after surgical management for closed scaphoid fractures exceeds 10%. This means the bone fails to join. Delayed presentation of scaphoid fractures 21 days or more after injury predicts a greater risk of casting failure. If you are from a socioeconomically deprived community, you may experience longer delays in presentation and a higher incidence of nonunion. Persistent nonunion is common after surgery for non-union, and surgeries for persistent nonunion are even less successful.

Other risks include avascular necrosis, where the bone tissue dies due to lack of blood supply. This corresponds with a worse prognosis and increases the likelihood of secondary procedures. You might also experience stiffness or pain. Scaphoid nonunion is associated with progressive degenerative changes, although the correlation of symptoms and disease is poor.

For those with arthritis secondary to scaphoid nonunion, distal scaphoid resection is an option. 94% of patients remained satisfied after this procedure. No further wrist collapse or radiocarpal arthritis developed after distal scaphoid resection for arthritis secondary to scaphoid nonunion. Good clinical outcomes can be achieved after scaphoid fractures in prospective NFL athletes. Distal scaphoid resection is a durable procedure with good long-term results.

Your surgeon will guide you through each stage. You will feel gradual improvement in wrist motion and strength. Most patients report normal self-assessed hand function from an 8- to 11-year perspective. We aim for a steady recovery, but we must be honest about the risks of slow or failed healing.

When to see someone

Seek urgent care if you have an open wound, deformity, numbness, tingling, or cannot use your hand. These signs need immediate attention. If pain is not settling, or if swelling and movement are not improving week on week, see your GP or ask for a specialist review. Initial X-rays can miss up to 40% of fractures. Do not assume a normal scan means you are fine. Persistent pain suggests the bone may not be healing correctly. Early assessment helps prevent long-term stiffness or arthritis. We recommend following up if your symptoms do not ease as expected during your recovery.

Advanced reading: the deeper science (optional)

This section goes further than you need for your own treatment decisions. Scaphoid fracture is worth the extra reading because where the break sits along the bone matters more than almost any other feature — and because the argument for operating is not the one most people assume.

Position on the bone changes the risk sevenfold

The scaphoid receives most of its blood supply through vessels entering near its far end, so blood travels backwards along the bone towards the proximal pole. A fracture across the waist interrupts that supply to everything beyond it.

The consequence is quantified. Amalgamating published series, 34% of acute proximal scaphoid fractures progress to nonunion when managed non-operatively, and the relative risk of nonunion for these fractures is 7.5 compared with more distal fractures treated the same way [1].

That is why two fractures which look similar on a film can carry entirely different recommendations. A distal fracture in a cast has a strong chance of healing. A proximal pole fracture treated identically fails to unite in about a third of cases.

Surgery lowers the nonunion rate but does not improve the destination

For the common waist fracture, comparing surgery with cast treatment produces a result worth reading carefully. Surgery gave a nonunion rate three times lower, a quicker return to function, and transiently better grip strength and range of movement — but was associated with more complications. There were no significant differences in pain, tenderness, cost or functional outcome [2].

So the operation buys reliability of union and speed of recovery, at the cost of surgical complications, and the two groups converge on the same place. That makes it a decision about how much a faster, more certain path is worth to a particular person — a manual worker or an athlete weighs those months differently from someone who can accommodate a cast.

Diagnosis is where most of the harm is avoided

Because a missed scaphoid fracture is the one that becomes a nonunion, the diagnostic pathway matters. Anatomical snuffbox tenderness was the most sensitive clinical test, and combining tests improved the post-test probability of fracture — which can be used to limit unnecessary immobilisation, hospital visits and imaging [3].

That last clause is the useful one. Combining examination findings is not only about catching fractures; it also identifies the people who can safely stop wearing a cast, which is why a structured reassessment is worth attending even when the wrist feels better.

For an established nonunion, the fancier graft is not the better graft

Where a fracture has failed to unite, the standard treatment is bone grafting, and a vascularised graft — one brought with its own blood supply — is intuitively superior.

The evidence does not support that. Current evidence suggests vascularised bone grafting does not yield significantly superior results to non-vascularised grafting in scaphoid nonunion, though the authors note potential selection bias reduces certainty [4]. The union figures are close: 84% for vascularised and 80% for non-vascularised grafts, with considerable variation between reports attributable to patient, fracture, treatment and study-design factors [5].

Since vascularised grafting is the longer and more technically demanding operation, that near-parity is worth knowing. Selection bias runs in a particular direction here — vascularised grafts tend to be used for the harder cases — so the comparison likely understates them. But it does not support choosing one as routinely better.

Reviewed by AI synthesis (v2) — pending human review · 18 May 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

References for the advanced reading
  1. Eastley N, Singh H, Dias JJ, Taub N. Union rates after proximal scaphoid fractures; meta-analyses and review of available evidence. J Hand Surg Eur Vol. 2012;38(8):888-97.
  2. Symes TH, Stothard J. A systematic review of the treatment of acute fractures of the scaphoid. J Hand Surg Eur Vol. 2011;36(9):802-10.
  3. Mallee WH, Henny EP, van Dijk CN, Kamminga SP, van Enst WA, Kloen P. Clinical diagnostic evaluation for scaphoid fractures: a systematic review and meta-analysis. J Hand Surg Am. 2014;39(9):1683-1691.e2.
  4. Duncumb JW, Robinson PG, Williamson TR, Murray IR, Campbell D, Molyneux SG, et al. Bone grafting for scaphoid nonunion surgery: a systematic review and meta-analysis. Bone Joint J. 2022;104-B(5):549-58.
  5. Ferguson DO, Shanbhag V, Hedley H, Reichert I, Lipscombe S, Davis TRC. Scaphoid fracture non-union: a systematic review of surgical treatment using bone graft. J Hand Surg Eur Vol. 2015;41(5):492-500.
Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Pediatric scaphoid fractures have excellent outcomes [1].
  • 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 [2].
  • 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 [4].
  • Internal fixation of scaphoid fractures is indicated in certain acute situations and in chronic nonunion cases [15].
  • Appropriately performed acute percutaneous internal fixation is now a standard treatment option for a selected group of patients with acute scaphoid fracture [17].
  • The definition of instability of scaphoid fractures and the indications for conservative treatment must be considered carefully [14].
  • 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 [24].
  • 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 [5].
  • For all indications, the scaphoid staple has a high union rate and a low complication rate [6].
  • Patients with recent scaphoid fractures that failed treatment may also be treated with distal scaphoid resection [25].
  • Despite improvements in diagnosis and surgical techniques, nonunion rates remain high and early internal fixation is increasingly favored even for nondisplaced fractures [28].

Anatomy & Pathophysiology

  • The scaphoid is critical to the coordination of normal carpal kinematics [34].
  • Scaphoid fracture has significant biomechanical consequences to the wrist [34].
  • Scaphoid nonunions have a dramatic impact on carpal kinematics, partially uncoupling the proximal and distal carpal rows [35].
  • Problem fractures and non-unions of the scaphoid are associated with major alterations in wrist kinematics [46].
  • Problem fractures and non-unions of the scaphoid are associated with a higher incidence of premature carpal collapse and degenerative arthritis than previously appreciated [46].
  • A foreshortened healed scaphoid will disrupt carpal kinematics [37].
  • A foreshortened healed scaphoid negatively impacts results, including decreased wrist range of motion and diminished grip strength [37].
  • Malunion or nonunion of an acute scaphoid fracture can lead to abnormal carpal kinematics and wrist arthrosis [61].
  • Radiocarpal-based lunate morphology was not associated with scaphoid fracture [74].
  • Anomalous carpal kinematics caused by lunotriquetral coalition may have predisposed both scaphoid bones to fracture, although causality cannot be proven [78].

Classification

  • 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 [2].
  • 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 [3].
  • 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].
  • 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 [9].
  • There is no consensus regarding the imaging modality and measurements to use to define a scaphoid fracture as 'nondisplaced' [10].
  • 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 [12].
  • Scaphoid fractures account for 2% of all fractures and are the most commonly injured carpal bone [13].
  • There is a need for a validated prognostic classification system for scaphoid nonunions that can allow comparisons between outcome studies [41].
  • The authors hypothesise higher union rates in scaphoid fractures using more stable fixation systems [79].
  • Scaphoid fracture and nonunion management continues to be an area of expanding evidence with opportunities to improve knowledge and familiarization with current evidence-based data [80].

Clinical Presentation

  • Most scaphoid fractures are missed due to failure to consider the possibility of the injury and search for clinical signs [19].
  • 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 [12].
  • Ultrasonic assessment is not recommended for the early diagnosis of acute scaphoid fractures, with a sensitivity of only 50% and five missed scaphoid fractures in a small series [39].
  • Clinical examination along with early MRI scan should form the basis of diagnosing a suspected scaphoid fracture [20].
  • 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 [23].
  • 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 [22].
  • The diagnosis of scaphoid and other fractures is reliable when using HRpQCT in patients with a clinically-suspected fracture [40].
  • Oblique scaphoid fractures are potentially unstable and may result in detrimental sequelae if overlooked in the acute stage [16].

Investigations

  • Conventional radiographs combined with two clinical examinations provide inadequate diagnostic certainty for scaphoid fractures, identifying a true fracture in only about 40% of patients [3].
  • The combination of conventional radiographs and clinical reassessment does not increase diagnostic accuracy compared to conventional radiographs alone [9].
  • There is no consensus on the imaging modality or measurements used to define a scaphoid fracture as nondisplaced [10].
  • Six-week radiographs are not adequate for evaluating suspected scaphoid fractures due to low inter-observer agreement and poor diagnostic performance [12].
  • Most missed scaphoid fractures result from a failure to consider the injury possibility and search for clinical signs [19].
  • Clinical examination combined with early MRI scan should form the basis for diagnosing suspected scaphoid fractures [20].
  • MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion occurring in over 6% of cases despite appropriate initial immobilization [22].
  • Most patients with nonunion of MRI-detected scaphoid fractures require surgery to achieve union [22].
  • Early MRI in patients with clinically suspected scaphoid fractures accurately and reliably identifies a significant number of radiological occult injuries [23].
  • Early MRI in patients with clinically suspected scaphoid fractures allows for the early identification of patients without acute injuries [23].
  • Early MRI provides an immediate diagnosis for suspected scaphoid fractures when initial radiographs are inconclusive [56].
  • Early MRI for suspected scaphoid fractures when initial radiographs are inconclusive is cost-effective and minimizes complications [56].
  • CT is a good way to screen for occult fractures but may not be superior to MRI or bone scanning in detecting scaphoid fractures without causing overtreatment [58].
  • Multidetector computed tomography (MDCT) has a sensitivity of 86% and specificity of 100% for detecting occult scaphoid fractures in patients with negative radiographic examinations [59].
  • MRI is the optimal second test for assessing a possible scaphoid fracture after a negative radiograph [60].
  • CT is preferred over MRI when the fracture is visible for further assessment and surgical planning [60].
  • There is variation in definitions of scaphoid fractures on MRI scans, highlighting a need for consensus to assess reliability and diagnostic performance [63].
  • Bone scintigraphy is inappropriate for evaluating specificity and sensitivity against clinical examination [64].
  • MRI is the recommended examination of choice for diagnosing occult scaphoid fractures over bone scintigraphy [64].
  • MRI is considered the best diagnostic radiological test for triage of suspected scaphoid fractures according to existing literature [67].
  • Bone scanning, CT, and ultrasound may be useful for suspected scaphoid fractures when MRI is not readily available [67].
  • Routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment [72].
  • Nearly 70% of MRI findings in suspected scaphoid fractures are categorized as distracting and potentially misleading [72].
  • Stopping the pursuit of occult fractures may prevent unnecessary treatment due to the risk of overdiagnosis with routine MRI [72].
  • Better standardization of MRI definitions for scaphoid fractures is required to address diagnostic uncertainty [76].
  • A definitive definition may not exist to solve the potentially unsolvable issue of diagnostic uncertainty in scaphoid fractures [76].
  • Patients should participate in decisions regarding diagnostic and treatment strategies for scaphoid fractures due to diagnostic uncertainty [76].
  • MRI is not 100% specific for diagnosing occult scaphoid fractures, with a specificity of 96% in healthy volunteers [77].

Treatment

Nonoperative Management

  • Early treatment of acute scaphoid fractures is important, with union rates significantly greater when treatment is instituted prior to 4 weeks from injury [26].
  • Surgical treatment for non-displaced and minimally displaced acute scaphoid fractures may be slightly favourable compared to conservative treatment for standardised functional outcome on the short term (within 2 years), with a significantly faster return to work (SMD of 7 weeks) [21].
  • 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 [18].
  • Non- and minimally displaced scaphoid waist fractures are best treated conservatively [36].
  • Non-operative treatment of non-displaced scaphoid fractures may be preferred [53].
  • A restricted period of cast immobilisation is usually adequate for the treatment of non-displaced scaphoid fractures [53].
  • 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 [57].
  • Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures [51].
  • 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 [54].

Operative Management

  • The frequency of non-union after surgical management for closed scaphoid fractures exceeds 10% and remained consistent during the study period [11].
  • The use of 2 headless compression screws for the treatment of scaphoid nonunions is safe and effective [44].
  • The optimal protocol for postoperative immobilization following operative treatment of scaphoid fractures remains controversial [62].

Special Populations and Considerations

  • The authors prefer to treat nondisplaced acute scaphoid fractures in the athlete on an individualized basis [55].
  • 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 [49].
  • The authors argue that comfort with uncertainty is key in suspected scaphoid fracture scenarios, as there is no best strategy; instead, clinicians should help patients choose a diagnostic and therapeutic course based on their individual values and risk tolerance [66].

Complications

  • Many decisions regarding scaphoid fracture management are based on small case series due to insufficient evidence for well-established principles [2].
  • 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 [4].
  • There is no true long-term benefit of internal fixation compared with nonoperative treatment for acute nondisplaced or minimally displaced scaphoid fractures [5].
  • The scaphoid staple has a high union rate and a low complication rate for all indications [6].
  • 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 [7].
  • The frequency of nonunion after surgical management for closed scaphoid fractures exceeds 10% and remained consistent during the study period [11].
  • Appropriately performed acute percutaneous internal fixation is a standard treatment option for a selected group of patients with acute scaphoid fracture [17].
  • There is no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively [18].
  • Persistent nonunion is common after surgery for scaphoid nonunion, and surgeries for persistent nonunion are even less successful [27].
  • Delayed presentation of scaphoid fractures 21 days or more after injury predicts a greater risk of casting failure, although the union rate remains high with comparable time in cast [29].
  • Nearly half of all patients with malunited acute scaphoid fractures demonstrated radiographic findings of early arthritis on CT imaging but had overall good clinical results on midterm follow-up [30].
  • 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 [32].

Recovery

  • Clinical outcomes of malunited scaphoids after reconstruction for nonunion did not differ significantly from well-united scaphoids at a minimum 5-year follow-up [4].
  • The frequency of nonunion after surgical management for closed scaphoid fractures exceeds 10% [11].
  • Surgical treatment for non-displaced and minimally displaced acute scaphoid fractures may be slightly favourable compared to conservative treatment for standardised functional outcome on the short term (within 2 years) [21].
  • Surgical treatment for non-displaced and minimally displaced acute scaphoid fractures results in a significantly faster return to work (SMD of 7 weeks) [21].
  • Union rates are significantly greater when treatment is instituted prior to 4 weeks from injury [26].
  • Persistent nonunion is common after surgery for scaphoid non-union, and surgeries for persistent nonunion are even less successful [27].
  • Delayed presentation of scaphoid fractures 21 days or more after injury predicts a greater risk of casting failure [29].
  • The union rate remains high with comparable time in cast despite delayed presentation of scaphoid fractures 21 days or more after injury [29].
  • Nearly half of all patients with malunited acute scaphoid fractures demonstrated radiographic findings of early arthritis on CT imaging [30].
  • Patients with malunited acute scaphoid fractures demonstrated overall good clinical results on midterm follow-up despite radiographic findings of early arthritis [30].
  • From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function [31].
  • From an 8- to 11-year perspective, patients with distal scaphoid fractures report good wrist motion and strength [31].
  • Increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury [32].
  • Increased likelihood for nonunion was found when fracture volume was less than 38% of the entire scaphoid [32].
  • Patients treated nonoperatively or with salvage procedures had similar long-term outcomes as those treated with a corrective scaphoid osteotomy [65].
  • Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union [83].
  • Dynamic imaging with time-intensity curve analysis does not provide additional predictive value over standard delayed enhanced imaging for acute scaphoid fracture viability assessment using contrast-enhanced MRI [84].
  • Scaphoid nonunions demonstrate findings indicative of progression to union on CT at a mean of 6 weeks [86].
  • Scaphoid nonunions demonstrate findings indicative of progression to union on CT as early as 3 weeks postoperatively [86].

Key Evidence

  • [L1] Pediatric scaphoid fractures have excellent outcomes. [1] (10.1177/1558944717735948)
  • [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. [2] (10.1177/1753193420977241)
  • [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. [3] (10.1097/corr.0000000000002413)
  • [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. [4] (10.1016/j.otsr.2014.09.026)
  • [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. [5] (10.2106/jbjs.g.00673)
  • [L4] For all indications, the scaphoid staple has a high union rate and a low complication rate. [6] (10.1177/1558944716658747)
  • [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)
  • [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. [9] (10.1097/corr.0000000000002310)
  • [L5] There is no consensus regarding the imaging modality and measurements to use to define a scaphoid fracture as 'nondisplaced.' [10] (10.1016/j.jhsa.2012.10.025)
  • [L3] The frequency of non-union after surgical management for closed scaphoid fractures exceeds 10% and remained consistent during the study period. [11] (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. [12] (10.1007/s00402-016-2438-4)
  • [L5] Scaphoid fractures account for 2% of all fractures and are the most commonly injured carpal bone. [13] (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. [14] (10.1142/s0218810415400018)
  • [L5] Internal fixation of scaphoid fractures is indicated in certain acute situations and in chronic nonunion cases. [15] (10.1016/s0749-0712(21)00118-9)
  • [L4] Oblique scaphoid fractures are potentially unstable and may result in detrimental sequelae if overlooked in the acute stage. [16] (10.1016/j.injury.2009.07.078)
  • [L4] Appropriately performed acute percutaneous internal fixation is now a standard treatment option for a selected group of patients with acute scaphoid fracture. [17] (10.5435/00124635-200708000-00004)
  • [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. [18] (10.1302/0301-620x.104b8.bjj-2022-0085.r2)
  • [L4] Most scaphoid fractures were missed due to failure to consider the possibility of the injury and search for clinical signs. [19] (10.1016/j.injury.2019.05.009)
  • [L3] Clinical examination along with early MRI scan should form the basis of diagnosing a suspected scaphoid fracture. [20] (10.1177/1753193420979465)
  • [L1] Surgical treatment for non-displaced and minimally displaced acute scaphoid fractures may be slightly favourable compared to conservative treatment for standardised functional outcome on the short term (within 2 years), with a significantly faster return to work (SMD of 7 weeks). [21] (10.1136/jisakos-2015-000024)
  • [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. [22] (10.1302/0301-620x.106b4.bjj-2023-1171.r1)
  • [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. [23] (10.1177/1753193412471008)
  • [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. [24] (10.2106/jbjs.rvw.15.00073)
  • [L4] Patients with recent scaphoid fractures that failed treatment may also be treated with distal scaphoid resection. [25] (10.1016/j.jhsg.2024.03.013)
  • [L5] Early treatment of acute scaphoid fractures is important, with union rates significantly greater when treatment is instituted prior to 4 weeks from injury. [26] (10.1016/s0749-0712(21)00580-1)
  • [L4] Persistent nonunion is common after surgery for scaphoid non-union, and surgeries for persistent nonunion are even less successful. [27] (10.1016/j.jhsa.2015.06.022)
  • [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. [28] (10.1016/j.jhsa.2008.04.026)
  • [L4] Delayed presentation of scaphoid fractures 21 days or more after injury predicts a greater risk of casting failure; however, the union rate remains high with comparable time in cast. [29] (10.1016/j.jhsa.2023.10.020)
  • [L4] Nearly half of all patients with malunited acute scaphoid fractures demonstrated radiographic findings of early arthritis on CT imaging but overall good clinical results on midterm follow-up. [30] (10.1016/j.jhsa.2020.04.002)
  • [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. [31] (10.1016/j.jhsa.2017.06.016)
  • [L5] The scaphoid is critical to the coordination of normal carpal kinematics, and its fracture has significant biomechanical consequences to the wrist. [34] (10.1016/s0749-0712(21)01439-6)
  • [L4] Scaphoid nonunions have a dramatic impact on carpal kinematics, partially uncoupling the proximal and distal carpal rows. [35] (10.1016/j.jhsa.2008.03.008)
  • [L2] Non- and minimally displaced scaphoid waist fractures are best treated conservatively. [36] (10.1016/j.jhsa.2015.03.007)
  • [L5] All scaphoid fractures that heal do not yield acceptable results, as a foreshortened healed scaphoid will disrupt carpal kinematics and negatively impact results, including decreased wrist range of motion and diminished grip strength. [37] (10.1016/s0749-0712(21)01437-2)
  • [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. [39] (10.1054/jhsb.2000.0432)
  • [L4] The diagnosis of scaphoid and other fractures is reliable when using HRpQCT in patients with a clinically-suspected fracture. [40] (10.1302/0301-620x.102b4.bjj-2019-0632.r3)
  • [L4] There is a need for a validated prognostic classification system for scaphoid nonunions that can allow comparisons between outcome studies. [41] (10.1177/1753193417739510)
  • [L4] The use of 2 headless compression screws for the treatment of scaphoid nonunions is safe and effective. [44] (10.1016/j.jhsa.2014.02.030)
  • [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. [46] (10.2106/00004623-199274030-00014)
  • [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. [49] (10.2106/00004623-198365080-00026)
  • [L1] Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures. [51] (10.1007/s11552-010-9276-6)
  • [L4] A restricted period of cast immobilisation is usually adequate for the treatment of non-displaced scaphoid fractures. [53] (10.1016/j.injury.2008.10.028)
  • [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. [54] (10.1016/j.jhsg.2026.100958)
  • [L4] The authors prefer to treat nondisplaced acute scaphoid fractures in the athlete on an individualized basis. [55] (10.1016/s0749-0712(21)00181-5)
  • [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. [56] (10.1016/j.jhsa.2013.03.055)
  • [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. [57] (10.5435/00124635-200007000-00003)
  • [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. [58] (10.1177/1753193412446273)
  • [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. [59] (10.1007/s11604-010-0520-3)
  • [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. [60] (10.1016/j.hcl.2019.03.001)
  • [L5] Early diagnosis and vigilant care of an acute scaphoid fracture are warranted to prevent malunion or nonunion, which can lead to abnormal carpal kinematics and wrist arthrosis. [61] (10.2106/00004623-200612000-00026)
  • [L4] The optimal protocol for postoperative immobilization following operative treatment of scaphoid fractures remains controversial. [62] (10.1177/15589447221093675)
  • [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. [63] (10.1177/17531934251367541)
  • [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. [64] (10.1016/j.injury.2007.12.013)
  • [L4] Patients treated nonoperatively or with salvage procedures had similar long-term outcomes as those treated with a corrective scaphoid osteotomy. [65] (10.1177/1558944716643295)
  • [L5] The authors argue that comfort with uncertainty is key in suspected scaphoid fracture scenarios, as there is no best strategy; instead, clinicians should help patients choose a diagnostic and therapeutic course based on their individual values and risk tolerance. [66] (10.1097/corr.0000000000003141)
  • [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. [67] (10.1016/j.jhsa.2008.04.016)
  • [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. [72] (10.1097/corr.0000000000002914)
  • [L3] By contrast, radiocarpal-based lunate morphology was not associated with scaphoid fracture. [74] (10.1016/j.jhsa.2025.10.018)
  • [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. [76] (10.1177/17531934251394819)
  • [Paper] MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers. [77] (10.1016/s0363-5023(10)60085-8)
  • [L4] The patient may represent two isolated coexisting conditions, or the anomalous carpal kinematics caused by the lunotriquetral coalition may have predisposed both scaphoid bones to fracture, although causality cannot be proven. [78] (10.1016/j.jhsa.2015.07.003)
  • [Paper] The authors hypothesise higher union rates in scaphoid fractures using more stable fixation systems. [79] (10.1007/s00402-016-2556-z)
  • [L5] Scaphoid fracture and nonunion management continues to be an area of expanding evidence with opportunities to improve knowledge and familiarization with current evidence-based data. [80] (10.1016/j.jhsg.2024.06.013)
  • [L3] Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union. [83] (10.1177/15589447221142894)
  • [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. [84] (10.1007/s00256-014-1981-8)
  • [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. [86] (10.1016/j.jhsa.2016.07.051)

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4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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