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Scaphoid Fracture

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

136 citationsUpdated Sep 2026

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Overview

Scaphoid fractures are common carpal injuries where outcomes are generally favorable; virtually all fractures that unite achieve a good result regardless of malunion [219]. In pediatric populations, nonoperative management for children below the age of 10 is safe and feasible with no significant long-term morbidity [1], and pediatric scaphoid fractures overall have excellent outcomes [2]. For adults, nondisplaced fractures can be effectively treated nonoperatively with union rates approaching or exceeding those of operative intervention [55]. A comparative study did not demonstrate a true long-term benefit of internal fixation over nonoperative treatment for acute nondisplaced or minimally displaced fractures [10]. However, the definition of instability and the indications for conservative treatment must be considered carefully [21].

Operative intervention is recommended for displaced scaphoid fractures [55]. Internal fixation is indicated in certain acute situations and in chronic nonunion cases [22]. Appropriately performed acute percutaneous internal fixation is a standard treatment option for a selected group of patients with acute scaphoid fracture [24]. Early internal fixation is increasingly favored even for nondisplaced fractures [9]. Volar percutaneous fixation performed with appropriate indications in patients with subacute scaphoid fractures achieved excellent outcomes [74]. The optimal protocol for postoperative immobilization following operative treatment remains controversial [81].

Nonunion rates remain high despite improvements in diagnosis and surgical techniques [9]. The clinical outcomes of malunited scaphoids after reconstruction for nonunion did not differ significantly from well-united scaphoids at a minimum 5-year follow-up [7]. The main indication for open reduction, bone graft, and staple fixation is pseudarthrosis of the middle third of the scaphoid [14]. Patients with recent scaphoid fractures that failed treatment may be treated with distal scaphoid resection [67]. Successful treatment of scaphoid nonunions with screw fixation does not depend on the implant used but rather on careful selection of patients and precise surgical technique [77]. The procedure of double antirotation screw fixation performed with arthroscopy is considered pertinent for certain recent scaphoid nonunions [215]. Bone grafts are used in scaphoid nonunions to augment internal fixation, promote healing, and restore carpal alignment [201]. The rationale, indications, contraindications, technique, and results of bone grafting scaphoid nonunions with grafts harvested from the medial femoral condyle have been presented [63]. No prospective randomized studies comparing different operative treatments of scaphoid nonunion were found in a systematic review of 147 publications including 5,246 cases [82].

The management of scaphoid fractures remains a source of controversy with no established gold standard for immobilization, acute surgical repair, or nonunion management despite decades of study [97]. 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 [8]. Inadequate follow-up of treated scaphoid fractures results in delayed diagnosis and treatment of non-union [3]. Delayed diagnosis and treatment of non-union can lead to impaired outcomes secondary to degenerative changes [3]. Inadequate follow-up of treated scaphoid fractures can result in litigation against the surgeon [3].

Anatomy & Pathophysiology

Bony Anatomy

The scaphoid is a small, irregular S-shaped tubular bone located in the proximal carpal row on the radial aspect of the wrist [101]. It lies entirely within the wrist joint at a 45-degree plane to the longitudinal and horizontal axis of the wrist [101]. As the only carpal bone bridging the proximal and distal carpal rows, it acts as a tie-rod [150]. The bone is divided into three regions: the proximal pole, the waist, and the distal pole (tubercle) [150]. Its orientation within the carpus features an intrascaphoid angle averaging 40 ± 3 degrees in the coronal plane and 32 ± 5 degrees in the sagittal plane [150]. The scaphoid gently pronates and flexes distally, positioning the distal pole ulnarly angulated relative to the proximal pole [101].

Articulations are extensive, with over 80% of the scaphoid surface covered with articular cartilage [101]. The proximal articular surface is convex and articulates with the radius [101]. The distal articular surface features two distinct facets for the trapezium and trapezoid, forming the STT joint [101]. Medially, the scaphoid articulates with the capitate and lunate [101]. Specifically, the capitate head articulates with a sulcus on the radial articular surface of the scaphoid, providing a socket-like fit [101].

Ligamentous Anatomy

Ligamentous attachments are predominantly found on the nonarticular dorsoradial surface, and there are no tendon attachments to the scaphoid [101]. The scapholunate interosseous ligament (SLIL) is a stout ligament connecting the scaphoid to the lunate and serves as the primary stabilizer [150]. The dorsal aspect of the SLIL is composed of transverse collagen fibers, while the palmar ligament consists of oblique collagen fibers inserting to the volar capsular ligaments [150]. The dorsal portion is twice as strong as the palmar portion [150]. Functionally, the dorsal region resists palmar-dorsal translation and gap, whereas the volar portion resists rotation [150]. Only 20 to 30 degrees of motion is possible at an intact scapholunate interval [150].

The radioscaphocapitate (RSC) ligament originates from the volar radial aspect of the radius, crosses the volar concavity of the scaphoid waist, and proceeds ulnarly toward the capitate [150]. It acts as a fulcrum around which the scaphoid rotates [150]. The scaphocapitate ligament originates from the distal scaphoid and inserts into the border between the trapezoid facet and the capitate facet, specifically into the volar waist of the capitate distal to the RSC ligament [150]. Together with the scaphotrapezial ligament, the scaphocapitate ligament functions as a primary restraint of the distal pole [150].

Vascular Anatomy

The blood supply of the scaphoid is predominantly retrograde [150]. Seventy to 80% of the intraosseous and proximal pole vascular supply derives from branches of the radial artery entering distally through the dorsal ridge of the scaphoid [150]. Volar branches from the radial artery or superficial palmar arch enter in the region of the tubercle and supply 20% to 30% of the bone in the region of the distal pole [150]. The proximal pole also receives blood supply from the radioscapholunate ligament (ligament of Testut) and direct scapholunate branches from the palmar and dorsal transverse carpal arches [150]. Venous drainage from the proximal pole occurs via the dorsal ridge into the venae comitantes of the radial artery [150].

The waist of the scaphoid has minimal or no perforating vasculature [101]. No vessels perforate the proximal dorsal cartilaginous area or through the scapholunate ligament [101]. Anatomical variability exists in arterial foramina: only 67% of scaphoid bones have arterial foramina throughout their length, including the distal, middle, and proximal thirds [112]. Thirteen percent of scaphoid bones have blood supply predominantly in the distal third [112]. Twenty percent of scaphoid bones have most arterial foramina in the waist area with no more than a single foramen near the proximal third [112].

Mechanism of Injury

Scaphoid fractures usually occur after a fall onto the outstretched hand or during sports [72]. The usual mechanism is forced hyperextension of the wrist [16]. Almost 90% of patients recall a hyperextension injury [23]. Hyperextension past 95 degrees is the usual position of injury [121]. Fracture occurs when the wrist is dorsiflexed to at least 95 degrees and radially deviated to at least 10 degrees [127].

In the hyperextension mechanism, a fracture usually begins at the volar waist with tensile failure, with forces propagating to the dorsal surface with compression loading until failure occurs [121]. The proximal pole is held firmly between the radius, capitate, radioscaphocapitate ligament, and palmar capsule during hyperextension [127]. With radial deviation, the radioscaphocapitate ligament is relaxed and unable to relieve increasing force applied to the radiopalmar aspect of the scaphoid [127]. The scaphoid fractures most frequently through the waist because it is subject to maximal bending movement and has a characteristically lower trabecular volume [127]. Fractures of the waist are usually the result of shear forces across the scaphoid [127]. Tubercle fractures appear to be caused by either compression or avulsion [127]. Proximal scaphoid fractures can result from dorsal subluxation during forced hyperextension [121]. The size of a proximal pole fracture is dependent on the level of the proximal extent of the joint facet with the capitate [127]. Smaller proximal pole fractures can be caused by an avulsion of the attachment of the scapholunate ligament [127].

Fracture Epidemiology and Location

Acute scaphoid fractures account for 2% to 3% of all fractures [72]. They represent approximately 10% of all hand fractures [72] and between 60% and 80% of all carpal fractures [72]. Scaphoid fractures account for almost 75% of all carpal fractures [16]. The mean age for scaphoid fracture in the literature ranges from 25 to 35 years [72]. Males are significantly younger at the time of injury compared to females [72]. There is a male predominance with a male to female ratio of approximately 2.5:1 [72].

Fracture location distribution is as follows: * Waist: Approximately 70% to 80% of scaphoid fractures occur in the midportion or waist area [38]. Snuffbox tenderness applies predominantly to waist fractures, which represent 70% of scaphoid fractures [12]. * Proximal Pole: Proximal pole fractures are the second most common type at 20% [12]. Ten to 20% of scaphoid fractures involve the proximal third [38]. * Distal Pole: Distal pole fractures are the least common type at 10% [12]. A smattering of fractures occur in the distal scaphoid, involving the tuberosity or articular surface [38]. The vast majority of distal scaphoid fractures occur in children [38].

Pathophysiology and Kinematics

The scaphoid is critical to the coordination of normal carpal kinematics, and its fracture has significant biomechanical consequences to the wrist [100]. It acts as a midcarpal joint “bridge” linking and synchronizing the motions of the proximal and distal carpal rows as part of the key intercalated segment [101]. Motion of the scaphoid includes rotation proximally and gliding distally, while providing stability to the midcarpal joint [101].

With an unstable displaced scaphoid fracture, joint compressive forces, trapezium–scaphoid shear stress, and capitolunate rotation moments act upon the scaphoid [127]. These forces lead to a dissociation of the proximal and distal carpal rows, permitting them to collapse into a lunate-extended posture [127]. The scaphoid assumes an anteverted position, while the lunate and triquetrum may subluxate forward and rotate dorsally [127]. The capitate and hamate subluxate dorsally and proximally, producing the dorsal intercalated segment instability (DISI) deformity [127]. Chronic scaphoid nonunion presents as a DISI deformity known as scaphoid nonunion advanced collapse (SNAC) [127].

After a simulated scaphoid waist fracture, the proximal and distal segments of the scaphoid move independently [233]. The distal scaphoid assumes a relatively flexed stance and displays increased motion after fracture [233]. The proximal scaphoid fragment and lunate assume a relatively extended stance and display less motion after fracture [233]. Kinematic abnormalities from unstable scaphoid fractures produce significant interfragmentary motion that complicates normal fracture healing [233]. Spontaneous collapse of the two scaphoid fragments produces a dorsal angulation or “humpback" deformity [233]. The proximal and distal fracture fragments can collapse, giving a characteristic flexed or “humpback” position on radiographs with an intrascaphoid angle of greater than approximately 30 degrees [127].

Scaphoid nonunions have a dramatic impact on carpal kinematics, partially uncoupling the proximal and distal carpal rows [105]. Problem fractures and non-unions of the scaphoid are associated with major alterations in wrist kinematics [54]. They are also associated with a higher incidence of premature carpal collapse and degenerative arthritis [54].

Natural History and Complications

Nonunion occurs in 10% to 15% of all scaphoid fractures [121]. Risk factors for nonunion include: * Delay of treatment for more than 4 weeks [121]. * Proximal pole fractures [121]. * Fracture displacement greater than 1 mm [121]. * Osteonecrosis [121]. * Tobacco use [121]. * Associated carpal instability, specifically dorsal intercalated segmental instability (DISI) with a scapholunate angle >60 degrees and a capitolunate angle >15 degrees [121].

Nonunion rates for nondisplaced waist fractures treated with casting are 5% to 12% [121]. Nonunion rates for displaced scaphoid fractures treated nonoperatively reach 50% [121]. Untreated displaced fractures of the waist usually angulate as the volar bone is reabsorbed, yielding a “humpback” flexion deformity [121]. Humpback deformity is defined as a flexed intrascaphoid angle >45 degrees, compared to a normal intrascaphoid angle of 24 degrees [121]. Resultant radial column shortening and extension of the proximal scaphoid pole releases the lunate to rotate into DISI [121].

Untreated scaphoid nonunion predictably progresses to arthritic change known as scaphoid nonunion advanced collapse (SNAC) [121]. Arthritic change in SNAC arises at the radial styloid articulation with the distal scaphoid pole (stage I) [121]. SNAC stage II involves degeneration of the scaphocapitate joint [121]. SNAC stage III involves degeneration of the midcarpal joint [121]. Arthritic changes have been found in 97% of patients assessed at least 5 years after injury [121]. The degree of arthritic changes is proportionate to the duration of nonunion [121]. In a 30-year follow-up study, 10% of patients with scaphoid fractures treated with casts developed nonunion [121]. Sixty percent of patients with nonunion demonstrated radiographic evidence of radiocarpal osteoarthritis [121]. Only 2% of the healed group demonstrated degenerative change [121].

Proximal fractures are inexorably associated with at least temporary disruption of the interosseous blood supply to the proximal pole [101]. One third of scaphoid fractures occurring in the proximal third may be without adequate blood supply [112]. The prevalence of osteonecrosis can be 35% in fractures at the proximal pole level [112]. Fractures in the proximal pole take longer to heal and usually have higher rates of nonunion [112]. Proximal pole fractures have a reported incidence of avascular necrosis (AVN) of 13% to 50% [150]. The relative risk of nonunion for proximal pole fractures managed nonoperatively is 7.5 times higher compared with more distal fractures [45]. Temporary interruption of the blood supply to the proximal fragment is virtually certain with proximal pole fractures [45]. If stabilized, the proximal pole has the capacity to revascularize and heal [45]. Malunion or nonunion can lead to a relentless downward spiral of wear and cartilage damage [76]. Chronic pain and dysfunction of the wrist resulting from malunion or nonunion affects both hand function and the entire upper extremity [76].

Classification

General and Acute Fracture Classifications

Over a dozen classification systems for acute scaphoid fractures have been proposed, primarily based on fracture location or displacement [154]. The Herbert classification is the most popular system for acute scaphoid fractures [154]. It categorizes acute stable fractures as Type A, including tubercle fractures (A1) and undisputed "crack" fractures of the waist (A2) [229]. Acute unstable fractures are categorized as Type B, including oblique fractures of the distal third (B1), displaced or mobile waist fractures (B2), proximal pole fractures (B3), fracture dislocations of the carpus (B4), and comminuted fractures (B5) [229]. The system further categorizes delayed union as Type C and established non-union as Type D, with Type D subdivided into fibrous non-union (D1) and sclerotic non-union/pseudoarthrosis (D2) [229].

The Schernberg classification categorizes scaphoid fractures by location as proximal pole (type 1), proximal part of the body (type 2), distal part of the body (type 3), tuberosity (type 4), distal segment (type 5), or partial fractures of the tuberosity (type 6) [225]. A modified classification for distal scaphoid fractures based on Prosser includes Type I extra-articular avulsion, Type IIA radial fragment with fracture line within the trapezium articulation, Type IIB ulnar fragment with fracture line within the trapezium articulation, Type IIC Y fracture, Type III fracture line within the trapezoidal articulation, and Type IV extraarticular transverse distal fracture [94].

Acute scaphoid fractures mainly occur in the middle third of the bone and tend to divide the scaphoid in half by volumetric size of the fracture fragments [187]. There is no consensus regarding the imaging modality and measurements to use to define a scaphoid fracture as 'nondisplaced' [18].

Pediatric Fracture Classifications

The D’Arienzo classification system for pediatric scaphoid fractures is based on the age of the child and the presumed degree of ossification [65]. Type 1 lesions occur in children younger than age 8 years and may be purely chondral or involve part of the ossific nucleus [65]. Type 2 lesions are osteochondral fractures occurring in patients aged 8 to 11 years [65]. Type 3 lesions are the most common fractures, occurring in adolescents aged ≥12 years where the scaphoid is almost completely ossified [65].

Pediatric scaphoid fractures may also be classified according to anatomic location as tuberosity, transverse distal pole, avulsion distal pole, waist, and proximal pole [65]. In children, fractures of the distal third of the scaphoid are the most common [65]. The scaphoid experiences a period of maturation from age 6 to 15 years, altering its physical properties during this time [65].

Nonunion Classifications

Scaphoid nonunions have been described by anatomic location or with clinically specific terms such as stable, fibrous, sclerotic, unstable, humpback, synovial, cystic, pseudarthrosis, or avascular [227]. A revised classification of scaphoid nonunions focuses on the width of the devitalized scaphoid zone and circumstances that complicate the healing process [227]. Scaphoid nonunions can be divided roughly into two groups: early nonunions without substantial bone resorption, and older nonunions with substantial bone resorption [227]. Complicating factors in scaphoid nonunion treatment include perfusion, deformity, and instability (bony or ligamentous) [227].

The Slade and Geissler classification of scaphoid fracture nonunion includes Type 1 for delayed presentation for 4–12 weeks and Type 2 for fibrous union with minimal fracture line [231]. Type I scaphoid nonunions are defined as delayed or fibrous union with no deformity, requiring only rigid fixation to heal if there is adequate perfusion [231]. Scaphoid nonunions with minimal bone resorption of the anterior cortical bone and minimal fracture sclerosis (<2 mm confirmed by CT scan) have the potential for healing in the early stages with screw fixation alone [231].

The Vender et al. classification describes SNAC severity in stages, with stage 1 initiated between the distal scaphoid fragment and the radius, stage 2 involving narrowing of the scaphocapitate joint, and stage 3 involving degenerative change of the capitolunate joint [230]. The inter- and intra-observer reliability of the Vender et al. classification for SNAC severity is poor [230].

Other Considerations: Two different patterns of displacement of scaphoid nonunions were demonstrated: one volar and one dorsal [206]. The fracture location relative to the apex of the dorsal scaphoid ridge is a reliable landmark to determine the natural history of scaphoid nonunion [95]. There is a need for a validated prognostic classification system for scaphoid nonunions that can allow comparisons between outcome studies [124]. Several classification schemes for scaphoid nonunions have been proposed, yet they are not all-encompassing with regard to nonunion characteristics and treatment options [226].

Clinical Presentation

Epidemiology and Mechanism

The annual incidence of true radiographically confirmed acute scaphoid fractures in a defined adult population is 29 per 100,000 per year [72]. Male sex is a risk factor associated with a true scaphoid fracture [72]. Scaphoid fractures usually occur after a fall on to the outstretched hand or during sports [72]. Sports injuries are associated with a true scaphoid fracture [72]. Low-energy falls from standing height occur more frequently in females, while males are more likely to sustain fractures after high-energy injuries such as sports or motor-vehicle collisions [72]. Scaphoid fractures are increasingly documented after punching or assault-related injuries [72]. In pediatric populations, scaphoid fractures account for approximately 3% of hand and carpal fractures and 0.34% of all fractures in children [75]. In children, high-energy mechanisms, closed physes, and a high body mass index are associated with fractures of the scaphoid waist or proximal pole [199].

Symptoms and Signs

Patients classically present with wrist pain following a fall onto the outstretched hand [23]. The main complaint is radial-sided wrist pain [23]. There is usually a history of trauma, such as falling on an outstretched hand, collision of the wrist against a person or heavy obstacle, or a direct blow against an object [12]. Pain and swelling can be subtle in the anatomic snuffbox [75]. In the acute phase, pain, swelling, ecchymosis, and tenderness around the region of the scaphoid may be present [23]. Wrists with acute fractures may have swelling and bruising in the radial aspect of the wrist [12]. Wrists with chronic injury may have swelling in the dorsoradial wrist [12]. There may be limited range of motion and pain when applying extended wrist loading or positioning the wrist in extreme positions of flexion or extension [12]. Swelling obliterating the snuff-box is more often present with fractures than without after 2 weeks [35]. Patients with diffuse swelling on the dorsoradial side of the wrist are recorded as negative for snuff-box swelling [35].

Physical Examination Findings

Fractures tend to occur at the waist partly because the RSC ligament acts as a fulcrum over which the scaphoid waist fractures [12]. The full physical examination of the scaphoid bone should include the waist, distal pole, and proximal pole [12]. To palpate the anatomic snuffbox for the waist examination, palpate just distal to the radial styloid in the “soft spot” [12]. The distal pole should be palpated at the scaphoid tubercle on the palmar aspect of the wrist [12]. To palpate the distal pole, place the index finger in the anatomic snuffbox and place the thumb on the palmar aspect just distal to the anatomic snuffbox [12]. With radial deviation of the wrist, the distal pole prominence should move palmarly toward the examiner’s thumb [12]. The proximal pole is palpated dorsally in line with the second ray just distal to the dorsal radius lip [12]. The scapholunate ligament is in line between the second and third rays just distal to the dorsal radius lip and corresponds to the 3-4 wrist arthroscopy portal [12]. The proximal pole is just radial to the scapholunate ligament/3-4 portal area [12]. Pain on longitudinal compression of the thumb (scaphoid axial compression test) is a sign of scaphoid fracture [12]. If anatomic snuffbox tenderness, scaphoid tubercle tenderness, and the scaphoid axial compression test are all positive, there is 87% to 100% sensitivity and 74% specificity for scaphoid fracture [12]. There may be slight fullness in the anatomical snuffbox [16]. Precisely localized tenderness in the anatomical snuffbox is an important diagnostic sign [16]. Examination must include pressure backwards over the scaphoid tubercle, palpation over the proximal pole, and telescoping of the thumb base [16]. If any of the signs of snuffbox fullness/tenderness, scaphoid tubercle pressure, proximal pole palpation, or thumb telescoping are positive, the suspicion for a scaphoid fracture should be high [16].

No single clinical sign has been found to be adequately sensitive or specific for scaphoid fracture [23]. Anatomical snuffbox tenderness has a sensitivity of 87–100% and a specificity of 3–98% [23]. Axial compression of the thumb has a sensitivity of 48–100% and a specificity of 22–97% [23]. Scaphoid tubercle tenderness has a sensitivity of 82–100% and a specificity of 17–57% [23]. Pain on ulnar deviation has a sensitivity of 67–100% and a specificity of 17–60% [23]. Pain on radial deviation has a sensitivity of 67–90% and a specificity of 31–42% [23]. Reduced range of movement of the thumb has a sensitivity of 65–66% and a specificity of 38–59% [23]. Thumb–index finger pinch has a sensitivity of 75–79% and a specificity of 44–76% [23]. Anatomical snuffbox tenderness is oversensitive and has poor specificity [23]. In a study of 246 patients with a suspected fracture, anatomical snuffbox tenderness had a sensitivity of 90% and a specificity of 40% [23]. In the same study, scaphoid tubercle tenderness had a sensitivity of 87% and a specificity of 57% [23]. The negative predictive value of anatomical snuffbox pain on ulnar deviation of the pronated wrist was 100% in a prospective analysis of 73 patients [23]. A combination of anatomical snuffbox tenderness, scaphoid tubercle tenderness, and anatomical snuffbox pain on longitudinal compression of the thumb generated a sensitivity of 100% and a specificity of 74% in a prospective study of 215 consecutive patients [23]. The combination of anatomical snuffbox tenderness, scaphoid tubercle tenderness, and anatomical snuffbox pain on longitudinal compression of the thumb was valid only for the first 24 hours after injury [23]. Pain on thumb–index finger pinch and anatomical snuffbox pain on pronation of the forearm were most suggestive of a true scaphoid fracture in a study using MRI as the reference standard [23]. The best predictors of fracture within 72 hours of injury were the absence of pain on ulnar deviation of the wrist and pain on thumb–index finger pinch [23]. Scaphoid tubercle tenderness was most predictive at week 2 [23]. A clinical scaphoid score (CSS) of 4 or higher requires an MRI, based on a scoring system of anatomical snuffbox tenderness with wrist in ulnar deviation (3 points), tenderness over the scaphoid tubercle (2 points), and pain upon longitudinal compression of the thumb (1 point) [23]. Clinical signs are inadequate indicators of scaphoid fracture when used alone and should be combined to achieve a more accurate clinical diagnosis [30]. Most scaphoid fractures are missed due to failure to consider the possibility of the injury and search for clinical signs [33].

Diagnostic Challenges and Occult Fractures

Up to 30% to 40% of scaphoid fractures are not identified on initial assessment and investigation with standard four-view radiographs [23]. Patients with a suspected fracture who are subsequently found to have a fracture confirmed on repeated assessment and radiologic imaging, most frequently at 10 to 14 days after injury, are said to have had an occult fracture of the scaphoid [23]. 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 [13]. 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 [17]. Standard scaphoid radiographs are not reliable for the diagnosis or exclusion of a scaphoid fracture because of the low inter-observer agreement in the interpretation [56]. Plain radiographs are unable to reliably rule out subtle fractures routinely [51]. If initial radiographs are negative, a fracture of the trapezium is more likely to be present than one of the scaphoid, despite high levels of clinical suspicion for scaphoid injuries [36]. Inadequate follow-up of treated scaphoid fractures will result in delayed diagnosis and treatment of non-union with a potentially impaired outcome secondary to degenerative changes [3]. The high rates of delayed presentation and incomplete evaluation and treatment suggest a strong need for better patient and doctor education on the subject of scaphoid injuries and nonunions [60].

Investigations

Clinical Examination

Patients with scaphoid fractures classically present with pain on the radial side of the wrist, often following a fall onto an outstretched hand or hyperextension injury [12]. Approximately 90% of patients recall a hyperextension injury mechanism [23]. Physical examination includes palpation of the anatomic snuffbox, the scaphoid tubercle on the palmar aspect, and the proximal pole dorsally [12]. Pain on longitudinal compression of the thumb (scaphoid axial compression test) is a clinical sign of scaphoid fracture [12]. No single clinical sign has been found to be adequately sensitive or specific for the diagnosis of scaphoid fracture [23]. Anatomic snuffbox tenderness has a sensitivity range of 87–100% and a specificity range of 3–98% across studies [23]. Axial compression of the thumb has a sensitivity range of 48–100% and a specificity range of 22–97% across studies [23]. Scaphoid tubercle tenderness has a sensitivity range of 82–100% and a specificity range of 17–57% across studies [23]. The combination of anatomic snuffbox tenderness, scaphoid tubercle tenderness, and the scaphoid axial compression test has a sensitivity of 87% to 100% and a specificity of 74% for scaphoid fracture [12]. A clinical scaphoid score (CSS) of 4 or higher, derived from specific clinical tests, indicates the need for MRI in patients with normal radiographs [23]. Most missed scaphoid fractures are attributed to a failure to consider the possibility of the injury and search for clinical signs [33].

Plain radiography

Standard radiographic views for scaphoid fracture evaluation include posteroanterior, lateral, oblique, and scaphoid views [49]. A true scaphoid pisiform capitate (SPC) lateral radiograph allows for a true assessment of carpal alignment [49]. The scaphoid view is obtained with the wrist in ulnar deviation to extend the proximal carpal row and minimize overlap from neighboring bones [49]. A clenched pencil view is useful for assessing associated dynamic scapholunate widening and SNAC/SLAC wrist changes [49]. Radiographs are initially nondiagnostic in more than 30% of scaphoid fracture cases [129]. Plain radiography is approximately 50% sensitive for the detection of a scaphoid fracture [117]. Up to 30% to 40% of scaphoid fractures are not identified on initial assessment with standard four-view radiographs [23]. The combination of conventional radiographs and two clinical examinations identifies a true fracture in only about 40% of patients [13]. The combination of conventional radiographs and clinical reassessment does not increase diagnostic accuracy compared with conventional radiographs alone [17]. Six-week radiographs are not adequate for evaluating suspected scaphoid fractures due to low observer agreement and poor diagnostic performance [19]. Plain radiographs are unable to reliably rule out subtle scaphoid fractures [51]. If initial radiographs are negative, a fracture of the trapezium is more likely to be present than one of the scaphoid despite high clinical suspicion for scaphoid injuries [36]. Comparison views of the opposite wrist are important to distinguish subtle changes in the intercalated carpal segment from normal variants [135].

MRI

MRI has higher sensitivity and specificity than CT scan, bone scintigraphy, or ultrasound for diagnosing scaphoid fractures [68]. MRI has a sensitivity, specificity, and accuracy all greater than 95%, with high positive and negative predictive values at less than 24 hours [129]. MRI demonstrated fracture of the scaphoid in approximately one-third of patients with a negative X-ray [34]. Early MRI provides an immediate diagnosis for suspected scaphoid fractures when initial radiographs are inconclusive [62]. MRI is the optimal second test for assessing a possible scaphoid fracture after a negative radiograph [177]. Routine MRI of suspected scaphoid fractures carries a risk of overdiagnosis, with nearly 70% of MRI findings categorized as distracting and potentially misleading [193]. MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers [205]. Variation in definitions of scaphoid fracture on MRI scans exists, and better standardization is required [46].

CT

CT is preferred when the fracture is visible for further assessment and surgical planning [177]. Multidetector CT (MDCT) sensitivity was 86% and specificity was 100% for detecting occult scaphoid fractures in patients with negative radiographic examinations [173]. CT is more sensitive than radiographs for diagnosing a scaphoid fracture and is useful for confirming alignment of bone fragments if surgery is planned [16]. Scaphoid fracture displacement on CT was identified in 26 to 34% of fractures that were nondisplaced on radiograph [90]. Three-dimensional imaging should be considered when assessing scaphoid nonunions to identify the exact location of the fracture [85].

Bone scan

Bone scintigraphy is a valuable diagnostic tool when there is strong clinical suspicion of a scaphoid fracture that cannot be confirmed by conventional radiology [6]. The best diagnostic strategy for clinically suspected scaphoid fractures consists of initial radiography followed by bone scintigraphy in patients with negative radiographs [15]. Bone scintigraphy has a high sensitivity of 95% but varying specificity between 60% and 95% [37]. A normal bone scan excludes scaphoid fracture, and a positive bone scan sufficiently confirms the presence of clinically relevant scaphoid fracture [53]. Bone scintigraphy is inappropriate for evaluating specificity and sensitivity against clinical examination, with MRI recommended as the examination of choice for occult fractures [181].

Ultrasound

High-frequency ultrasound is recommended to investigate occult suspected scaphoid fractures to allow early diagnosis and eliminate the need for more invasive or expensive tests in most cases [58]. In patients with an occult scaphoid fracture confirmed by bone scan, the sensitivity of intrasound vibration was 18% [41].

Treatment

Non-Operative

Subacute scaphoid fractures presenting within 6 months of injury can be expected to heal successfully with casting alone, even when the initial diagnosis is delayed [5]. A restricted period of cast immobilisation is recommended for the initial treatment of non-displaced scaphoid fractures [66]. Non- and minimally displaced scaphoid waist fractures are best treated conservatively [110], and aggressive conservative management avoids unnecessary surgery in all acute scaphoid fractures [160]. For asymptomatic scaphoid nonunion in children, nonoperative management is recommended [161]. Clinicians should note that 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 [159].

Operative

Indications: Appropriately performed acute percutaneous internal fixation is now a standard treatment option for a selected group of patients with acute scaphoid fracture [24]. While 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 [10], surgical treatment may be slightly favourable for standardised functional outcome in the short term (within 2 years), with a significantly faster return to work (SMD of 7 weeks) [43]. There was no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively [25]. 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 [70]. The authors prefer to treat nondisplaced acute scaphoid fractures in the athlete on an individualized basis [162]. For most scaphoid nonunion, surgical treatment should be considered first, except for patients who cannot undergo surgery for any reason, because surgical treatment shows better outcome than conservative treatment [197].

Surgical Approach / Technique: Union rates are significantly greater when treatment is instituted prior to 4 weeks from injury [69]. In patients with subacute scaphoid fractures, volar percutaneous fixation performed with appropriate indications achieved excellent outcomes [74]. The dorsal percutaneous treatment of scaphoid fractures and nonunions using arthroscopy is safe and effective [109]. Minimally invasive fixation has been demonstrated to have a higher union rate than cast treatment and has relatively few complications [76]. The success of percutaneous fixation of acute fractures can be extended to the care of scaphoid nonunions [174]. Uncomplicated scaphoid nonunions that are nondisplaced and nonangulated are candidates for the minimally invasive bone grafting and compression screw fixation procedure [178]. SMS is effective in treating waist scaphoid nonunions at more than 6 months from trauma [175]. Patients with recent scaphoid fractures that failed treatment may also be treated with distal scaphoid resection [67].

Implant Selection: The proximal scaphoid fracture did not heal by conservative management in more than 30% of cases, while the operative regimen failed only once in 7 cases [78]. For all indications, the scaphoid staple has a high union rate and a low complication rate [11]. The use of 2 headless compression screws for the treatment of scaphoid nonunions is safe and effective [132].

Other Considerations: Inadequate follow-up of treated scaphoid fractures will result in delayed diagnosis and treatment of non-union with a potentially impaired outcome secondary to degenerative changes and even litigation against the surgeon [3]. Neglected scaphoid fractures seldom heal with acceptable alignment, often leading to complications in their management [4]. 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 [7]. Patients treated nonoperatively or with salvage procedures had similar long-term outcomes as those treated with a corrective scaphoid osteotomy [28]. The frequency of non-union after surgical management for closed scaphoid fractures exceeds 10% and remained consistent during the study period [47]. Treatment with LIPUS had no effect on reducing time to union in patients who underwent surgical fixation of established scaphoid nonunions [183]. The use of electrical stimulation for scaphoid nonunion may be indicated in patients who have failed previous bone grafting procedures or if surgery is refused or unsafe [191]. Real time ultrasonography is a useful adjunct in the assessment of scaphoid non-union, particularly when radiographs are inconclusive between 8 to 12 weeks of immobilization [156]. 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 [6]. The authors recommend that all acute scaphoid fractures should be assessed with MRI scans or tomography and classified as undisplaced and displaced [27]. Scaphoid fracture displacement on CT was identified in 26 to 34% of fractures that were nondisplaced on radiograph, confirming that radiographic evaluation alone underestimates displacement [90]. Approximately 70% to 80% of scaphoid fractures occur in the midportion or waist area and 10% to 20% involve the proximal third [38]. Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures [148].

Complications

Non-union and Degenerative Changes

Inadequate follow-up of treated scaphoid fractures results in delayed diagnosis and treatment of non-union, potentially leading to impaired outcomes secondary to degenerative changes [3]. Neglected scaphoid fractures seldom heal with acceptable alignment, often leading to complications in management [4]. In cases of scaphoid non-union or malunion, reconstruction of the scaphoid is exceedingly difficult and increases the chances of morbidity associated with extended hand immobilisation [4]. The prevalence of established scaphoid fracture non-union in the general population is 0.14% [211].

Scaphoid nonunion is associated with progressive degenerative changes, although the correlation of symptoms and disease is poor and the true natural history is debatable [50]. 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 [54]. Untreated symptomatic scaphoid non-unions undergo a specific sequence of degenerative changes, including cyst formation, radioscaphoid arthritis, and generalized wrist arthritis, which are likely to occur if sufficient time elapses after the non-union develops [196]. Scaphoid nonunions are unlikely to remain aligned or free of arthritis after 10 years [200].

In a review of 55 patients with untreated scaphoid non-unions, arthritis developed in 97% of patients who had been injured five years or more earlier [194]. Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop [194]. In a study of 33 patients with scaphoid non-union diagnosed 2 to 37 years following trauma, X-rays revealed a 100% incidence of progressive radio-carpal osteoarthritis at reexamination 10 to 17 years later [189]. Freedom of pain is not a reliable prognostic indicator for scaphoid non-union, and all patients with non-union are likely to benefit from surgical treatment of the pseudarthrosis, except those with advanced degenerative arthritis of the radio-carpal joint [189].

Malunion and Residual Deformity

Residual scaphoid deformity has no relevant negative impact on mid-term wrist function [26]. Patients treated nonoperatively or with salvage procedures had similar long-term outcomes as those treated with a corrective scaphoid osteotomy for scaphoid malunion [28].

Surgical Complications and Re-operation

Persistent nonunion is common after surgery for scaphoid non-union, and surgeries for persistent nonunion are even less successful [83, 84]. With every decade of a patient’s life, the odds of union after surgery for established scaphoid non-union are reduced by 1.72 times [89]. Dominant hand injury reduces the odds of union after surgery for established scaphoid non-union by 7.35 times [89]. Previous scaphoid surgery reduces the odds of union after surgery for established scaphoid non-union by 4.24 times [89].

Increased likelihood for nonunion after early open reduction and internal fixation was found when the fracture was treated greater than 31 days from injury [98]. Increased likelihood for nonunion after early open reduction and internal fixation was found when fracture volume was less than 38% of the entire scaphoid [98]. The scaphoid staple has a high union rate and a low complication rate for all indications [11].

Pediatric Complications

Delayed presentation of pediatric scaphoid fractures 21 days or more after injury predicts a greater risk of casting failure [88]. Despite delayed presentation, the union rate for pediatric scaphoid fractures remains high with comparable time in cast [88].

Other Considerations

A fractured proximal pole scaphoid documented by serial CT scanning can refracture within 7 months of documented healing [92].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for light activities such as desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a typical month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence provided does not specify a typical month range for the stabilization of pain, strength, and final functional outcomes.

Rehabilitation protocol: The evidence provided does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression, or sling/brace removal timing.

Functional milestones: No validated patient-reported outcome measure trajectories or specific outcome-measure benchmarks (e.g., Constant, ASES, WOMAC) are reported in the evidence.

Other Considerations: Pediatric and adolescent outcomes are influenced by age and sex; for every year older, the risk of true scaphoid fracture in children increased by 25% [71], and being a male was associated with a risk of true scaphoid fracture diagnosis almost 3 times higher than that of females at the same age [71]. In pediatric scaphoid fractures presenting 21 days or more after injury, the union rate remains high with comparable time in cast [88]. Good clinical outcomes can be achieved after scaphoid fractures in prospective NFL athletes [213].

Treatment timing significantly impacts healing. Union rates for acute scaphoid fractures are significantly greater when treatment is instituted prior to 4 weeks from injury [69]. Conversely, an increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury [98] or when fracture volume was less than 38% of the entire scaphoid [98]. Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union [238]. A fractured proximal pole scaphoid that was documented by serial CT scanning refractured within 7 months of documented healing [92].

Regarding operative versus nonoperative management, no difference in functional outcome at 12 months was found for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively [25]. A study did not demonstrate a true long-term benefit of internal fixation compared with nonoperative treatment for acute nondisplaced or minimally displaced scaphoid fractures [10]. However, 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) [43] and is associated with a significantly faster return to work (SMD of 7 weeks) compared to conservative treatment [43].

Nonunion and malunion outcomes present distinct challenges. Inadequate follow-up of treated scaphoid fractures may result in litigation against the surgeon [3], and neglected scaphoid fractures seldom heal with acceptable alignment [4]. The frequency of non-union after surgical management for closed scaphoid fractures exceeds 10% [47]. Scaphoid nonunion is associated with progressive degenerative changes [50], although the correlation of symptoms and disease in scaphoid nonunion is poor [50]. A symptomatic nonunion of the scaphoid is significantly likely to progress to osteoarthritis according to a predictable sequence, becoming worse both radiographically and clinically with time [241]. Persistent nonunion is common after surgery for scaphoid non-union [83, 84], and surgeries for persistent scaphoid nonunion are less successful than initial surgeries [83, 84].

Delayed presentation is a significant factor in nonunion management. A quarter (25%) of patients with established scaphoid nonunions delayed seeking medical attention for more than 6 months [240]. High rates of delayed presentation and incomplete evaluation and treatment suggest a strong need for better patient and doctor education on scaphoid injuries and nonunions [60]. Despite these challenges, a case of chronic scaphoid nonunion of 28-year duration treated with surgical fixation and bone grafting resulted in bony healing and a good clinical outcome [87]. Osseous union of the scaphoid was confirmed by X-ray in all patients treated with a vascularized bone graft based on the first dorsal metacarpal artery in an average of 2.1 months [244]. Scaphoid nonunions demonstrate findings indicative of progression to union on CT at a mean of 6 weeks and as early as 3 weeks postoperatively [243]. Although a patient with a scaphoid non-union present for more than 1 year was symptom free with no osteoarthritic changes at last visit, it is possible that osteoarthritic changes will occur in the long run [245].

Specific fracture patterns show favorable outcomes. No instances of non-union, necrosis of the proximal fragment of the scaphoid or scapholunate dissociation were noted during a mean follow-up period of 18 months for isolated scaphoid fracture with anterosuperior dislocation of the proximal fragment [91]. The fractures of the carpal scaphoid associated with radial head fracture were all united within the usual time limits with no residual disability in any of the elbows [73].

Key Evidence

• [L4] Nonoperative management of most scaphoid fractures in this age group is safe and feasible with no significant long-term morbidity. [1] (10.1055/s-0040-1713800)
• [L1] Pediatric scaphoid fractures have excellent outcomes. [2] (10.1177/1558944717735948)
• [L4] Inadequate follow-up of treated scaphoid fractures will result in delayed diagnosis and treatment of non-union with a potentially impaired outcome secondary to degenerative changes and even litigation against the surgeon. [3] (10.1016/s0020-1383(02)00162-6)
• [L4] [4] (10.1016/j.injury.2009.07.078)
• [L4] 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. [5] (10.1055/s-0035-1564983)
• [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. [6] (10.1016/j.injury.2005.02.009)
• [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. [7] (10.1016/j.otsr.2014.09.026)
• [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. [8] (10.1177/1753193420977241)
• [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. [9] (10.1016/j.jhsa.2008.04.026)
• [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. [10] (10.2106/jbjs.g.00673)
• [L4] For all indications, the scaphoid staple has a high union rate and a low complication rate. [11] (10.1177/1558944716658747)
• [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. [13] (10.1097/corr.0000000000002413)
• [L4] The main indication for this procedure is pseudarthrosis of the middle third of the scaphoid. [14] (10.1016/s0363-5023(05)80015-2)
• [L3] The best diagnostic strategy in the management of clinically suspected scaphoid fractures consists of initial radiography followed by bone scintigraphy in patients with negative radiographs. [15] (10.1016/0266-7681(93)90074-p)
• [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. [17] (10.1097/corr.0000000000002310)
• [L5] There is no consensus regarding the imaging modality and measurements to use to define a scaphoid fracture as 'nondisplaced.' [18] (10.1016/j.jhsa.2012.10.025)
• [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. [19] (10.1007/s00402-016-2438-4)
• [L5] The definition of instability of scaphoid fractures and the indications for conservative treatment must be considered carefully. [21] (10.1142/s0218810415400018)
• [L5] Internal fixation of scaphoid fractures is indicated in certain acute situations and in chronic nonunion cases. [22] (10.1016/s0749-0712(21)00118-9)
• [L4] Appropriately performed acute percutaneous internal fixation is now a standard treatment option for a selected group of patients with acute scaphoid fracture. [24] (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. [25] (10.1302/0301-620x.104b8.bjj-2022-0085.r2)
• [L4] Residual scaphoid deformity has no relevant negative impact on mid-term wrist function. [26] (10.1177/17531934221125355)
• [L3] The authors recommend that all acute scaphoid fractures should be assessed with MRI scans or tomography and classified as undisplaced and displaced. [27] (10.1016/s0363-5023(03)80355-6)
• [L4] Patients treated nonoperatively or with salvage procedures had similar long-term outcomes as those treated with a corrective scaphoid osteotomy. [28] (10.1177/1558944716643295)
• [L2] The results suggest that these clinical signs are inadequate indicators of scaphoid fracture when used alone and should be combined to achieve a more accurate clinical diagnosis. [30] (10.1016/s0266-7681(98)80050-8)
• [L4] Most scaphoid fractures were missed due to failure to consider the possibility of the injury and search for clinical signs. [33] (10.1016/j.injury.2019.05.009)
• [L3] MRI demonstrated fracture of the scaphoid in approximately one-third of the patients with a negative X-Ray. [34] (10.1097/00130911-200209000-00004)
• [L3] [35] (10.1016/0266-7681(94)90249-6)
• [L3] If initial radiographs are negative, a fracture of the trapezium is more likely to be present than one of the scaphoid, despite high levels of clinical suspicion for scaphoid injuries. [36] (10.1007/s10140-019-01702-2)
• [L4] [37] (10.1016/j.jhsb.2006.04.007)
• [L5] [38] (10.1016/s0749-0712(21)01437-2)
• [L2] In patients with an occult scaphoid fracture (evidence on the bone scan), the sensitivity was 18% and the specificity was unchanged. [41] (10.1016/s0363-5023(98)80118-4)
• [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). [43] (10.1136/jisakos-2015-000024)
• [L3] [46] (10.1177/17531934251367541)
• [L3] The frequency of non-union after surgical management for closed scaphoid fractures exceeds 10% and remained consistent during the study period. [47] (10.1016/j.jhsa.2015.06.019)
• [L5] Scaphoid nonunion is associated with progressive degenerative changes, although the correlation of symptoms and disease is poor and the true natural history is debatable. [50] (10.1016/j.jhsa.2012.03.002)
• [L4] Plain radiographs, while useful for obvious scaphoid fractures, are unable to reliably rule out subtle fractures routinely. [51] (10.1177/15589447241257705)
• [L5] A normal bone scan excludes scaphoid fracture, and a positive bone scan sufficiently confirms the presence of clinically relevant scaphoid fracture. [53] (10.1016/s0020-1383(96)00127-1)
• [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. [54] (10.2106/00004623-199274030-00014)
• [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. [55] (10.2106/jbjs.rvw.15.00073)
• [L4] The study concludes that standard scaphoid radiographs are not reliable for the diagnosis or exclusion of a scaphoid fracture because of the low inter-observer agreement in the interpretation, irrespective of the experience and training of the observer. [56] (10.1016/0020-1383(92)90035-q)
• [L3] We recommend that high-frequency ultrasound be used to investigate occult suspected scaphoid fractures because of its ability to allow early diagnosis and to eliminate the need for a more invasive or expensive diagnostic test in most cases. [58] (10.1016/j.jhsa.2003.12.012)
• [L2] The high rates of delayed presentation and incomplete evaluation and treatment suggest a strong need for better patient and doctor education on the subject of scaphoid injuries and nonunions. [60] (10.1016/j.jhsa.2011.06.016)
• [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. [62] (10.1016/j.jhsa.2013.03.055)
• [Paper] The rationale, indications, contraindications, technique and results of bone grafting scaphoid nonunions with grafts harvested from the medial femoral condyle are presented. [63] (10.1016/j.main.2010.09.009)
• [L5] [65] (10.5435/00124635-200902000-00004)
• [L4] [66] (10.1016/j.injury.2008.10.028)
• [L4] Patients with recent scaphoid fractures that failed treatment may also be treated with distal scaphoid resection. [67] (10.1016/j.jhsg.2024.03.013)
• [L2] MRI has higher sensitivity and specificity than CT scan, bone scintigraphy, or ultrasound for diagnosing scaphoid fractures. [68] (10.1055/s-0039-1693147)
• [L5] Early treatment of acute scaphoid fractures is important, with union rates significantly greater when treatment is instituted prior to 4 weeks from injury. [69] (10.1016/s0749-0712(21)00580-1)
• [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. [70] (10.5435/00124635-200007000-00003)
• [L3] For every year older, risk of true scaphoid fracture increased by 25%, and by being a man, risk of true scaphoid fracture diagnosis was almost 3 times higher than that of women at the same age. [71] (10.1177/15589447241231311)
• [L4] The fractures of the carpal scaphoid were all united within the usual time limits and there was no residual disability in any of the elbows. [73] (10.1016/s0020-1383(73)80017-8)
• [L3] In patients with subacute scaphoid fractures, volar percutaneous fixation performed with appropriate indications achieved excellent outcomes. [74] (10.1016/j.otsr.2025.104186)
• [L4] Successful treatment of scaphoid nonunions with screw fixation does not depend on the implant used but rather on careful selection of patients and precise surgical technique. [77] (10.1016/s0363-5023(09)91122-4)
• [L4] The proximal scaphoid fracture did not heal by conservative management in more than 30% of cases, while the operative regimen failed only once in 7 cases. [78] (10.1016/s0266-7681(96)80318-4)
• [L4] The optimal protocol for postoperative immobilization following operative treatment of scaphoid fractures remains controversial. [81] (10.1177/15589447221093675)
• [L4] The authors found no prospective randomized studies comparing different operative treatments of scaphoid nonunion. [82] (10.1080/00016470410001529)
• [L4] Persistent nonunion is common after surgery for scaphoid non-union, and surgeries for persistent nonunion are even less successful. [83] (10.1016/j.jhsa.2015.06.022)
• [L4] Persistent nonunion is common after surgery for scaphoid non-union, and surgeries for persistent nonunion are even less successful. [84] (10.1016/j.jhsa.2015.06.023)
• [L4] Three-dimensional imaging should be considered when assessing scaphoid nonunions to identify the exact location of the fracture. [85] (10.1016/j.jhsa.2008.05.035)
• [L4] This case represents the longest reported duration of delayed treatment of scaphoid nonunion (28 years) treated with surgical fixation and bone grafting that resulted in bony healing and a good clinical outcome. [87] (10.1055/s-0032-1326727)
• [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. [88] (10.1016/j.jhsa.2023.10.020)
• [L2] With every decade of a patient’s life, dominant hand injury, and previous scaphoid surgery, the odds of union are reduced by 1.72 times, 7.35 times, and 4.24 times, respectively. [89] (10.1177/15589447231219523)
• [L3] Scaphoid fracture displacement on CT was identified in 26 to 34% of fractures that were nondisplaced on radiograph, confirming that radiographic evaluation alone underestimates displacement. [90] (10.1055/s-0037-1604136)
• [L4] No instances of non-union, necrosis of the proximal fragment of the scaphoid or scapholunate dissociation were noted during a mean follow-up period of 18 months. [91] (10.1016/j.main.2011.06.002)
• [L5] A fractured proximal pole scaphoid that was documented by serial CT scanning refractured within 7 months of documented healing. [92] (10.1016/s0363-5023(05)80016-4)
• [L2] [94] (10.1016/j.jhsa.2017.06.016)
• [L5] The fracture location relative to the apex of the dorsal scaphoid ridge is a reliable landmark to determine the natural history of scaphoid nonunion, and evaluation using 3D CT is recommended to determine the fracture type for management strategy. [95] (10.1055/s-0038-1637739)
• [L5] The management of scaphoid fractures remains a source of controversy with no established gold standard for immobilization, acute surgical repair, or nonunion management despite decades of study. [97] (10.1016/j.hcl.2019.04.001)
• [L3] 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. [98] (10.1055/s-0039-3402769)
• [L5] The scaphoid is critical to the coordination of normal carpal kinematics, and its fracture has significant biomechanical consequences to the wrist. [100] (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. [105] (10.1016/j.jhsa.2008.03.008)
• [L4] The dorsal percutaneous treatment of scaphoid fractures and nonunions using arthroscopy is safe and effective. [109] (10.1177/145749690809700402)
• [L2] Non- and minimally displaced scaphoid waist fractures are best treated conservatively. [110] (10.1016/j.jhsa.2015.03.007)
• [L4] There is a need for a validated prognostic classification system for scaphoid nonunions that can allow comparisons between outcome studies. [124] (10.1177/1753193417739510)
• [L4] The use of 2 headless compression screws for the treatment of scaphoid nonunions is safe and effective. [132] (10.1016/j.jhsa.2014.02.030)
• [L1] Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures. [148] (10.1007/s11552-010-9276-6)
• [L4] Over a dozen classification systems for acute scaphoid fractures have been proposed, mainly based on fracture location or displacement, with the Herbert classification being the most popular. [154] (10.1055/s-0036-1571280)
• [L4] Real time ultrasonography is a useful adjunct in the assessment of scaphoid non-union, particularly when radiographs are inconclusive between 8 to 12 weeks of immobilization. [156] (10.1016/0266-7681(94)90216-x)
• [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. [159] (10.1016/j.jhsg.2026.100958)
• [L3] This aggressive conservative management also avoids unnecessary surgery in all acute scaphoid fractures. [160] (10.1142/s2424835518500029)
• [L4] The authors recommend considering nonoperative management for asymptomatic scaphoid nonunion in children. [161] (10.1055/s-0037-1602799)
• [L4] The authors prefer to treat nondisplaced acute scaphoid fractures in the athlete on an individualized basis. [162] (10.1016/s0749-0712(21)00181-5)
• [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. [173] (10.1007/s11604-010-0520-3)
• [L4] The success of percutaneous fixation of acute fractures can be extended to the care of scaphoid nonunions. [174] (10.1097/bth.0b013e3181877644)
• [L3] SMS is effective in treating waist scaphoid nonunions at more than 6 months from trauma. [175] (10.1055/s-0040-1710387)
• [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. [177] (10.1016/j.hcl.2019.03.001)
• [L4] Uncomplicated scaphoid nonunions that are nondisplaced and nonangulated are candidates for the minimally invasive bone grafting and compression screw fixation procedure described. [178] (10.1016/j.jhsa.2008.03.004)
• [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. [181] (10.1016/j.injury.2007.12.013)
• [L1] Treatment with LIPUS had no effect on reducing time to union in patients who underwent surgical fixation of established scaphoid nonunions. [183] (10.2106/jbjs.23.00783)
• [L4] Acute scaphoid fractures mainly occur in the middle third of the bone and tend to divide the scaphoid in half by volumetric size of the fracture fragments. [187] (10.1055/s-0039-1693050)
• [L4] [189] (10.1016/0266-7681(92)90204-f)
• [L5] The use of electrical stimulation for scaphoid nonunion may be indicated in patients who have failed previous bone grafting procedures or if surgery is refused or unsafe. [191] (10.1016/s0749-0712(21)01453-0)
• [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. [193] (10.1097/corr.0000000000002914)
• [L4] [194] (10.2106/00004623-198567030-00013)
• [L4] [196] (10.2106/00004623-198466040-00003)
• [L4] [197] (10.1142/s2424835518300049)
• [L4] [200] (10.1016/j.jhsa.2014.08.030)
• [L4] This review focuses on the indications and role of bone grafts in scaphoid nonunions to help augment internal fixation, promote healing, and restore carpal alignment. [201] (10.5435/jaaos-d-24-00510)
• [Paper] MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers. [205] (10.1016/s0363-5023(10)60085-8)
• [L4] Two different patterns of displacement of scaphoid nonunions were demonstrated, 1 volar and 1 dorsal. [206] (10.1053/jhsu.2000.7381)
• [L4] There was a 0.14% prevalence of established scaphoid fracture non-union in the general population, indicating that unrecognised scaphoid non-union is rare. [211] (10.1016/s0020-1383(99)00301-0)
• [L4] Good clinical outcomes can be achieved after scaphoid fractures in prospective NFL athletes. [213] (10.1016/j.arthro.2017.08.259)
• [L4] The procedure is considered pertinent for certain recent scaphoid nonunions. [215] (10.1016/j.jhsa.2014.06.089)
• [L3] Virtually all scaphoid fractures which unite have a good outcome, regardless of malunion. [219] (10.1177/1753193408093327)
• [L4] [225] (10.1016/s0266-7681(05)80048-8)
• [L4] [226] (10.2106/jbjs.rvw.m.00074)
• [L5] [227] (10.1097/01.blo.0000205886.66081.9d)
• [L4] [229] (10.1016/0266-7681(88)90178-7)
• [L3] [230] (10.1177/1753193417739519)
• [L5] [233] (10.1016/0363-5023(89)90022-1)
• [L3] Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union. [238] (10.1177/15589447221142894)
• [Paper] A quarter (25%) of patients with established scaphoid nonunions delayed seeking medical attention for more than 6 months. [240] (10.1007/s12593-015-0206-2)
• [L4] A symptomatic nonunion of the scaphoid is significantly likely to progress to osteoarthritis according to a predictable sequence, becoming worse both radiographically and clinically with time. [241] (10.1007/bf00453208)
• [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. [243] (10.1016/j.jhsa.2016.07.051)
• [L4] Osseous union of the scaphoid was confirmed by X-ray in all patients in an average of 2.1 months. [244] (10.1016/s0266-7681(97)80420-2)
• [L5] Although at his last visit the patient was symptom free and no osteoarthritic changes were seen on the radiographs, it is possible that in the long run osteoarthritic changes will occur because a non-union of the scaphoid has been present for more than 1 year. [245] (10.1016/s0266-7681(98)80228-3)

See Also

• Wrist Arthroscopy

References

[1] Scaphoid Fractures below the Age of 10: Case Series and Review of the Literature. Journal of Wrist Surgery. 2020. DOI: 10.1055/s-0040-1713800

[2] Management Modalities and Outcomes Following Acute Scaphoid Fractures in Children: A Quantitative Review and Meta-Analysis. HAND. 2017. DOI: 10.1177/1558944717735948

[3] The presentation of scaphoid non-union. Injury. 2003. DOI: 10.1016/s0020-1383(02)00162-6

[4] Management of late-diagnosed scaphoid fractures. Injury. 2010. DOI: 10.1016/j.injury.2009.07.078

[5] The Missed Scaphoid Fracture–Outcomes of Delayed Cast Treatment. Journal of Wrist Surgery. 2015. DOI: 10.1055/s-0035-1564983

[6] Outcome of routine bone scintigraphy in suspected scaphoid fractures. Injury. 2005. DOI: 10.1016/j.injury.2005.02.009

[7] Clinical outcome of scaphoid malunion as a result of scaphoid fracture nonunion surgical treatment: A 5-year minimum follow-up study. Orthopaedics & Traumatology: Surgery & Research. 2015. DOI: 10.1016/j.otsr.2014.09.026

[8] Questions regarding the evidence guiding treatment of displaced scaphoid fractures. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420977241

[9] Treatment of Scaphoid Fractures and Nonunions. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.04.026

[10] Nonoperative Compared with Operative Treatment of Acute Scaphoid Fractures. The Journal of Bone & Joint Surgery. 2008. DOI: 10.2106/jbjs.g.00673

[11] The Scaphoid Staple: A Systematic Review. HAND. 2016. DOI: 10.1177/1558944716658747

[12] Green S Operative Hand Surgery. Examination and Imaging of the Scaphoid.

[13] CORR Insights®: What Is the Diagnostic Performance of Conventional Radiographs and Clinical Reassessment Compared With HR-pQCT Scaphoid Fracture Diagnosis?. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002413

[14] Scaphoid nonunion: Treatment by open reduction, bone graft, and staple fixation. The Journal of Hand Surgery. 1995. DOI: 10.1016/s0363-5023(05)80015-2

[15] The Value of Radiographs and Bone Scintigraphy in Suspected Scaphoid Fracture. Journal of Hand Surgery. 1993. DOI: 10.1016/0266-7681(93)90074-p

[16] Apley And Solomon S Concise System Of Orthopaedics And Trauma. FRACTURES OF THE DISTAL RADIUS IN CHILDREN > FRACTURE OF THE SCAPHOID.

[17] What Is the Diagnostic Performance of Conventional Radiographs and Clinical Reassessment Compared With HR-pQCT Scaphoid Fracture Diagnosis?. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002310

[18] Diagnosis of Scaphoid Fracture Displacement. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.10.025

[19] 6-week radiographs unsuitable for diagnosis of suspected scaphoid fractures. Archives of Orthopaedic and Trauma Surgery. 2016. DOI: 10.1007/s00402-016-2438-4

[21] Scaphoid Fracture - Overview and Conservative Treatment. Hand Surgery. 2015. DOI: 10.1142/s0218810415400018

[22] INTERNAL FIXATION OF SCAPHOID FRACTURES. Hand Clinics. 1997. DOI: 10.1016/s0749-0712(21)00118-9

[23] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Signs and Symptoms of Scaphoid Fractures.

[24] Percutaneous Fixation of Scaphoid Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200708000-00004

[25] One-year outcome of surgery compared with immobilization in a cast for adults with an undisplaced or minimally displaced scaphoid fracture. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b8.bjj-2022-0085.r2

[26] Residual flexion deformity after scaphoid nonunion surgery: 7-year follow-up study. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221125355

[27] MRI assessment of scaphoid fracture displacement: Does it predict union?. The Journal of Hand Surgery. 2003. DOI: 10.1016/s0363-5023(03)80355-6

[28] Long-Term Outcomes of Scaphoid Malunion. HAND. 2016. DOI: 10.1177/1558944716643295

[30] Combining the Clinical Signs Improves Diagnosis of Scaphoid Fractures. Journal of Hand Surgery. 1998. DOI: 10.1016/s0266-7681(98)80050-8

[33] Why scaphoid fractures are missed. A review of 52 medical negligence cases. Injury. 2019. DOI: 10.1016/j.injury.2019.05.009

[34] Diagnosis of Occult Carpal Scaphoid Fracture: A Comparison of Magnetic Resonance Imaging and Computed Tomography Techniques. Techniques in Hand and Upper Extremity Surgery. 2002. DOI: 10.1097/00130911-200209000-00004

[35] Clinical Signs in Scaphoid Fractures. Journal of Hand Surgery. 1994. DOI: 10.1016/0266-7681(94)90249-6

[36] Trapezium fracture: a common clinical mimic of scaphoid fracture. Emergency Radiology. 2019. DOI: 10.1007/s10140-019-01702-2

[37] Diagnostic Strategy for Suspected Scaphoid Fractures in the Presence of Other Fractures in the Carpal Region. Journal of Hand Surgery. 2006. DOI: 10.1016/j.jhsb.2006.04.007

[38] INCIDENCE, MECHANISM, AND NATURAL HISTORY OF SCAPHOID FRACTURES. Hand Clinics. 2001. DOI: 10.1016/s0749-0712(21)01437-2

[41] Is intrasound vibration useful in the diagnosis of occult scaphoid fractures?. The Journal of Hand Surgery. 1998. DOI: 10.1016/s0363-5023(98)80118-4

[43] Surgical treatment of non- and minimally-displaced acute scaphoid fractures favours over-conservative treatment but only in the short term: an updated meta-analysis. Journal of ISAKOS. 2016. DOI: 10.1136/jisakos-2015-000024

[45] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Open Reduction and Internal Fixation of Proximal Pole Scaphoid Fractures.

[46] Variation in definitions of scaphoid fracture on MRI scans for suspected fracture: a systematic review. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251367541

[47] An Epidemiologic Perspective on Scaphoid Fracture Treatment and Frequency of Nonunion. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.06.019

[49] Green S Operative Hand Surgery. Diagnostic Imaging of Scaphoid Fractures.

[50] Management of Scaphoid Nonunion. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.03.002

[51] Inter-Rater and Intrarater Reliability of Radiographs in the Diagnosis of Pediatric Scaphoid Fractures. HAND. 2024. DOI: 10.1177/15589447241257705

[53] The diagnostic management of suspected scaphoid fracture. Injury. 1997. DOI: 10.1016/s0020-1383(96)00127-1

[54] Compression-staple fixation for fractures, non-unions, and delayed unions of the carpal scaphoid.. The Journal of Bone & Joint Surgery. 1992. DOI: 10.2106/00004623-199274030-00014

[55] Acute Scaphoid Fractures. JBJS Reviews. 2016. DOI: 10.2106/jbjs.rvw.15.00073

[56] Diagnosing scaphoid fractures: radiographs cannot be used as a gold standard!. Injury. 1992. DOI: 10.1016/0020-1383(92)90035-q

[58] Ultrasound for the early diagnosis of clinically suspected scaphoid fracture. The Journal of Hand Surgery. 2004. DOI: 10.1016/j.jhsa.2003.12.012

[60] Delays and Poor Management of Scaphoid Fractures: Factors Contributing to Nonunion. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.06.016

[62] The Role of Magnetic Resonance Imaging in Scaphoid Fractures. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.03.055

[63] Medial femoral condyle vascularized bone grafts for scaphoid nonunions. Chirurgie de la Main. 2010. DOI: 10.1016/j.main.2010.09.009

[65] Pediatric Scaphoid Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2009. DOI: 10.5435/00124635-200902000-00004

[66] Non-operative treatment of non-displaced scaphoid fractures may be preferred. Injury. 2009. DOI: 10.1016/j.injury.2008.10.028

[67] Distal Scaphoid Excision for Chronic and Nonchronic Scaphoid Fracture Nonunion. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2024.03.013

[68] Systematic Review of Diagnosis of Clinically Suspected Scaphoid Fractures. Journal of Wrist Surgery. 2019. DOI: 10.1055/s-0039-1693147

[69] MANAGEMENT OF ACUTE SCAPHOID FRACTURES. Hand Clinics. 2000. DOI: 10.1016/s0749-0712(21)00580-1

[70] Acute Fractures of the Scaphoid. Journal of the American Academy of Orthopaedic Surgeons. 2000. DOI: 10.5435/00124635-200007000-00003

[71] Predictors of True Scaphoid Fractures in Children. HAND. 2024. DOI: 10.1177/15589447241231311

[72] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Assessment of Scaphoid Fractures.

[73] Carpal scaphoid fracture associated with fracture of the radial head. Injury. 1973. DOI: 10.1016/s0020-1383(73)80017-8

[74] Does the screw trajectory affect surgical outcomes in percutaneous fixation for subacute scaphoid fracture?. Orthopaedics & Traumatology: Surgery & Research. 2025. DOI: 10.1016/j.otsr.2025.104186

[75] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Pediatric Forearm, Wrist, and Hand Trauma > Scaphoid Fractures.

[76] Green S Operative Hand Surgery. SCAPHOID FRACTURES AND NONUNION.

[77] Anterior bone grafting and conventional lag screw fixation to treat scaphoid nonunions. The Journal of Hand Surgery. 1990. DOI: 10.1016/s0363-5023(09)91122-4

[78] Pros and cons of conservative and operative treatment in fractures of the carpal scaphoid: results in 414 scaphoid fractures between 1984 and 1994. Journal of Hand Surgery. 1996. DOI: 10.1016/s0266-7681(96)80318-4

[81] Postoperative Immobilization of Scaphoid Fractures: A Comprehensive Review of the Literature. HAND. 2022. DOI: 10.1177/15589447221093675

[82] Bone grafting the scaphoid nonunionA systematic review of 147 publications including 5 246 cases of scaphoid nonunion. Acta Orthopaedica Scandinavica. 2004. DOI: 10.1080/00016470410001529

[83] Importance of Computed Tomography in Determining Displacement of Scaphoid Fractures. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.06.022

[84] Factors Associated with Re-operation after Surgery for Scaphoid Nonunion. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.06.023

[85] Relationship Between the Fracture Location and the Kinematic Pattern in Scaphoid Nonunion. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.05.035

[87] Chronic Scaphoid Nonunion of 28-Year Duration Treated with Nonvascularized Iliac Crest Bone Graft. Journal of Wrist Surgery. 2013. DOI: 10.1055/s-0032-1326727

[88] Clinically Significant Treatment Delay in Pediatric Scaphoid Fractures. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.10.020

[89] Risk Factors for the Development of Persistent Scaphoid Non-Union After Surgery for an Established Non-Union. HAND. 2024. DOI: 10.1177/15589447231219523

[90] Importance of Computed Tomography in Determining Displacement in Scaphoid Fractures. Journal of Wrist Surgery. 2017. DOI: 10.1055/s-0037-1604136

[91] Isolated scaphoid fracture with anterosuperior dislocation of the proximal fragment. Chirurgie de la Main. 2011. DOI: 10.1016/j.main.2011.06.002

[92] Refracture of a proximal pole scaphoid fracture: A case report. The Journal of Hand Surgery. 1995. DOI: 10.1016/s0363-5023(05)80016-4

[94] Long-Term Outcomes After Distal Scaphoid Fractures: A 10-Year Follow-Up. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.06.016

[95] Current Management of Scaphoid Nonunion Based on the Biomechanical Study. Journal of Wrist Surgery. 2018. DOI: 10.1055/s-0038-1637739

[97] Current Concepts and Controversies in Scaphoid Fracture Management. Hand Clinics. 2019. DOI: 10.1016/j.hcl.2019.04.001

[98] Factors Associated with Scaphoid Nonunion following Early Open Reduction and Internal Fixation. Journal of Wrist Surgery. 2020. DOI: 10.1055/s-0039-3402769

[100] EFFECTS OF SCAPHOID FRACTURES ON THE BIOMECHANICS OF THE WRIST. Hand Clinics. 2001. DOI: 10.1016/s0749-0712(21)01439-6

[101] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Pathoanatomy and Applied Anatomy Related to Scaphoid Fractures.

[105] Interfragmentary Motion in Patients With Scaphoid Nonunion. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.03.008

[109] Retrospective Review of 234 Scaphoid Fractures and Nonunions Treated with Arthroscopy for Union and Complications. Scandinavian Journal of Surgery. 2008. DOI: 10.1177/145749690809700402

[110] Conservative Treatment Versus Arthroscopic-Assisted Screw Fixation of Scaphoid Waist Fractures—A Randomized Trial With Minimum 4-Year Follow-Up. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.03.007

[112] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > FRACTURES OF THE SCAPHOID.

[117] Campbell S Operative Orthopaedics 4 Volume Set. OVERCORRECTION OSTEOTOMY AND LIGAMENTOUS REPAIR OR RECONSTRUCTION > SCAPHOID AND CARPAL FRACTURES.

[121] Green S Operative Hand Surgery. Biomechanics of Scaphoid Fractures and Implications of Nonunion.

[124] Scaphoid nonunion: what is the role of the Zaidemberg 1,2 intercompartmental supraretinacular arterial flap?. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417739510

[127] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Carpal Fractures > Fracture of the Scaphoid.

[129] Miller S Review Of Orthopaedics. 2. Scaphoid fractures > Diagnosis.

[132] Scaphoid Nonunions Treated With 2 Headless Compression Screws and Bone Grafting. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.02.030

[135] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Pigmented Villonodular Synovitis and Giant Cell Tumor of the Tendon Sheath > Fractures and Dislocations of the Wrist and Hand > Routine Scaphoid Radiographic Series.

[148] Treatment of Acute Scaphoid Fractures: A Systematic Review and Meta-Analysis. HAND. 2010. DOI: 10.1007/s11552-010-9276-6

[150] Green S Operative Hand Surgery. SCAPHOID FRACTURES AND NONUNION > PERTINENT ANATOMY OF THE SCAPHOID.

[154] Classifications of Acute Scaphoid Fractures: A Systematic Literature Review. Journal of Wrist Surgery. 2016. DOI: 10.1055/s-0036-1571280

[156] Real Time Ultrasonography in the Assessment of Movement at the Site of a Scaphoid Fracture Non-Union. Journal of Hand Surgery. 1994. DOI: 10.1016/0266-7681(94)90216-x

[159] Early Nonsteroidal Anti-Inflammatory Drug Prescriptions and Nonunion After Scaphoid Fractures: A TriNetX Matched Cohort Study. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.100958

[160] A Prospective Study of Acute Undisplaced and Minimally Displaced Scaphoid Fractures Managed by Aggressive Conservative Approach. The Journal of Hand Surgery (Asian-Pacific Volume). 2018. DOI: 10.1142/s2424835518500029

[161] Spontaneous Healing of a Pediatric Scaphoid Proximal Pole Fracture Nonunion. Journal of Wrist Surgery. 2017. DOI: 10.1055/s-0037-1602799

[162] PERCUTANEOUS AND ARTHROSCOPIC SCREW FIXATION OF SCAPHOID FRACTURES IN THE ATHLETE. Hand Clinics. 1999. DOI: 10.1016/s0749-0712(21)00181-5

[173] Diagnostic accuracy of multidetector computed tomography for patients with suspected scaphoid fractures and negative radiographic examinations. Japanese Journal of Radiology. 2011. DOI: 10.1007/s11604-010-0520-3

[174] Percutaneous Management of Scaphoid Nonunions. Techniques in Hand & Upper Extremity Surgery. 2009. DOI: 10.1097/bth.0b013e3181877644

[175] Comparison of Shape Memory Staple and Gelled Platelet-Rich Plasma versus Shape Memory Staple alone for the Treatment of Waist Scaphoid Nonunion: A Single-Center Experience. Joints. 2019. DOI: 10.1055/s-0040-1710387

[177] Imaging for Acute and Chronic Scaphoid Fractures. Hand Clinics. 2019. DOI: 10.1016/j.hcl.2019.03.001

[178] Mini-Incision Fixation of Nondisplaced Scaphoid Fracture Nonunions. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.03.004

[181] A prospective comparison for suspected scaphoid fractures: Bone scintigraphy versus clinical outcome. Injury. 2008. DOI: 10.1016/j.injury.2007.12.013

[183] Low-Intensity Pulsed Ultrasound Versus Sham in the Treatment of Operatively Managed Scaphoid Nonunions. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00783

[187] Scaphoid Fracture Patterns—Part One: Three-Dimensional Computed Tomography Analysis. Journal of Wrist Surgery. 2019. DOI: 10.1055/s-0039-1693050

[189] Natural History of Scaphoid Non-Union, with Special Reference to “Asymptomatic” Cases. Journal of Hand Surgery. 1992. DOI: 10.1016/0266-7681(92)90204-f

[191] ELECTRICAL AND ULTRASOUND STIMULATION FOR SCAPHOID FRACTURES. Hand Clinics. 2001. DOI: 10.1016/s0749-0712(21)01453-0

[193] Editor’s Spotlight/Take 5: Routine MRI Among Patients With a Suspected Scaphoid Fracture Risks Overdiagnosis. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002914

[194] The natural history of scaphoid non-union. A review of fifty-five cases.. The Journal of Bone & Joint Surgery. 1985. DOI: 10.2106/00004623-198567030-00013

[196] The natural history of scaphoid non-union.. The Journal of Bone & Joint Surgery. 1984. DOI: 10.2106/00004623-198466040-00003

[197] Surgical Strategy for Scaphoid Nonunion Treatment. The Journal of Hand Surgery (Asian-Pacific Volume). 2018. DOI: 10.1142/s2424835518300049

[199] Orthopaedic Knowledge Update. Fractures of the Forearm, Wrist, and Hand > Scaphoid Fractures.

[200] Persistent Fracture Line After Scaphoid Fracture Fixation. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.08.030

[201] Bone Graft and Fixation Options in the Surgical Management of Scaphoid Nonunion. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00510

[205] False Positive MRI's for Scaphoid Fracture in Healthy Volunteers. The Journal of Hand Surgery. 2010. DOI: 10.1016/s0363-5023(10)60085-8

[206] Scaphoid nonunions: A 3-dimensional analysis of patterns of deformity. The Journal of Hand Surgery. 2000. DOI: 10.1053/jhsu.2000.7381

[211] The prevalence of established scaphoid fracture non-union found on incidental radiography. Injury. 2000. DOI: 10.1016/s0020-1383(99)00301-0

[213] Clinical and Radiologic Outcomes After Scaphoid Fracture: Injury and Treatment Patterns in National Football League Combine Athletes Between 2009 and 2014. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.08.259

[215] Benefits of a Double Antirotation Screw Fixation Performed With Arthroscopy for Scaphoid Fractures: A Prospective Series of 9 Cases. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.089

[219] The Clinical Outcome of Scaphoid Fracture Malunion at 1 Year. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408093327

[225] Pattern of Scaphoid Fracture Union Detected by Macroradiography. Journal of Hand Surgery. 1995. DOI: 10.1016/s0266-7681(05)80048-8

[226] Evaluation and Treatment of Scaphoid Nonunions. JBJS Reviews. 2014. DOI: 10.2106/jbjs.rvw.m.00074

[227] Minimally Invasive Management of Scaphoid Nonunions. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000205886.66081.9d

[229] Scaphoid fractures treated by Herbert screw fixation. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1988. DOI: 10.1016/0266-7681(88)90178-7

[230] Radial styloidectomy for scaphoid nonunion advanced collapse – relevance of nonunion location. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417739519

[231] Scaphoid Fractures and Nonunion. 2021.

[233] The effects of simulated unstable scaphoid fractures on carpal motion. The Journal of Hand Surgery. 1989. DOI: 10.1016/0363-5023(89)90022-1

[238] Delayed Scaphoid Fracture Union in Patients With Comorbid Psychiatric Diagnoses: A Retrospective Analysis of 20 340 Patients. HAND. 2022. DOI: 10.1177/15589447221142894

[240] Factors Associated with Patient Delay in Scaphoid Nonunions. Journal of Hand and Microsurgery. 2015. DOI: 10.1007/s12593-015-0206-2

[241] The natural history of scaphoid non-union. Archives of Orthopaedic and Trauma Surgery. 1996. DOI: 10.1007/bf00453208

[243] Early Detection of Healing of Scaphoid Fracture Nonunions Using Computed Tomography. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.051

[244] Treatment of Scaphoid Nonunions with a Vascularized Bone Graft Based on the First Dorsal Metacarpal Artery. Journal of Hand Surgery. 1997. DOI: 10.1016/s0266-7681(97)80420-2

[245] Spontaneous Healing of a non-Union of the Scaphoid. Journal of Hand Surgery. 1998. DOI: 10.1016/s0266-7681(98)80228-3