Epidemiology
- systematic review of scaphoid fractures
- majority in males
- peak incidence 20 - 29 years
- 70% in the mid third of the scaphoid
Etiology
FOOSH
Herbert Classification
Type A: Stable acute fractures
- A1: tubercle
- A2: incomplete waist fracture
Type B: Unstable fractures
- B1: distal oblique
- B2: complete waist
- B3: proximal pole fractures
- B4: trans-scaphoid perilunate fracture
- B5: comminuted
Type C: Delayed union
Type D: Nonuion
| A1: Tubercle fracture | A2: Incomplete waist fracture |
|---|---|
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| B1: Distal oblique | B2: Complete waist | B3: Proximal pole | B5: Comminuted |
|---|---|---|---|
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Anatomy
Scaphoid is greek for boat
- shaped more like a twisted peanut
- majority is articular cartilage except for dorsal ridge
- dorsal ridge is site of entry of majority of blood supply
Blood supply
1. Dorsal ridge artery
- branch of radial artery
- supplies 70- 80% scaphoid including proximal pole
- enters through the non articular dorsal ridge
2. Distal tubercle
- palmar & superficial palmar branches of radial artery
- distal 20% to 30% of scaphoid
Fracture patterns
Waist 65%
Proximal third 25%
Distal third 10%
Complications
| Nonunion | Avascular necrosis | Malunion |
|---|---|---|
|
Undisplaced < 5% Displaced 50% |
Displacement 50% Proximal pole 50% |
Flexion / increased intra-scaphoid angle Humback deformity DISI |
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Clinical
Tender anatomical snuffbox
Swelling
Reduced ROM
X-ray
5 images
- PA / lateral
- PA in 45° oblique pronation / PA 45o oblique supination
- PA in ulna deviation
Increased intra-scaphoid angle / humpback deformity
- > 35o abnormal
- > 45o associated with poor outcome i.e. DISI
- also demonstrated to lead to loss of extension
Occult scaphoid fracture
Issue
Tender in anatomical snuffbox with normal xrays
Occult fracture on delayed xrays / CT / MRI
Incidence
Cohen et al J Orthop Traumatol 2025
- 180 patients with normal xrays and suspected scaphoid fractures
- xrays at 2 weeks and 1 year
- 9% incidence of occult fracture
CT
Indication: any potential displacement
Position: patient prone with fully pronated hand over head
Instability
- displacement > 1mm on any film
- intra-scaphoid angle > 35o
- comminution
- proximal pole fracture
- perilunate trans-scaphoid dislocation
Scaphoid waist fracture 1 mm displaced
Scaphoid fracture with significant displacement
Scaphoid proximal pole fracture
MRI
Indications
- occult fractures
- diagnosis of AVN
Occult scaphoid fracture on MRI
- 67 patients with normal xray and suspected scaphoid fracture
- 10% had scaphoid fracture on MRI
Dean et al Bone Joint Open 2021
- 258 patients with normal xray and suspected scaphoid fracture
- 13% had scaphoid fracture on MRI, 6% scaphoid contusion
Non operative Management
Indications
Minimally displaced stable fractures
- incomplete fractures
- tuberosity fracture
- displaced < 1mm
Management
Thumb spica versus colles cast
Harper et al Hong Kong Occ 2025
- systematic review of 4 RCT
- no benefit of thumb spica with regards outcomes or union rates
Results
Occult scaphoid fractures
- 250 patients with scaphoid fracture diagnosed on MRI
- 3% delayed union
- 4% nonunion
Cohen et al J Orthop Traumatol 2025
- 180 patients with normal xrays and suspected scaphoid fractures
- randomized to 2 weeks cast versus bandage
- 9% incidence of occult fracture on xray at 2 weeks and 1 year
- no nonunions either group
Distal scaphoid fractures
Clementson et al J Hand Surg Am 2017
- 41 cases of distal scaphoid fracture
- nonoperative treatment followed up for 10 years with CT scan
- good functional outcomes
- asymptomatic STT OA in 17% on CT
Operative versus nonoperative minimally displaced complete scaphoid fractures
- RCT of operative v non operative 439 patients
- bicortical scaphoid fractures 2 mm displaced or less
- 1 year follow up
- surgery: 72% united, 3% nonunion, 25% unknown
- cast: 62% united, 9% nonunion, 32% unknown
- RCT 83 minimally displaced scaphoid fractures
- cast versus screw fixation
- 10 year follow up
- all fractures united
- increased STT OA in the operative group
- meta-analysis of 7 RCTs
- operative v nonoperative < 1 mm displaced scaphoid fractures
- surgery faster time to union
- no difference in nonunion rates or outcomes
Operative Management
Indications for Surgery
| Instability | Proximal pole fractures | Manual worker / athlete | Delayed diagnosis / treatment |
|---|---|---|---|
|
Displacement > 1 mm Comminution Flexion - intra-scaphoid > 35o
|
High risk of nonunion High risk of AVN |
Avoid cast Percutaneous screw |
Increased risk of nonunion |
| Perilunate fractures / dislocatons |
ORIF with screw
Volar approach / waist fractures
- preserves dorsal blood supply
Dorsal approach / proximal 1/3 fractures
Waist fractures
Open technique
Volar approach
- volar along FCR
- deviate along thenar edge to STT joint
- elevate thenar muscles
- FCR ulna, deep branch radial artery radially with APL
- divide superficial branch radial artery
- open capsule in line with FCR
- transverse opening at STT
- will divide RSC ligament
Clean and reduce fracture
- K wires as joysticks
- pass cannulated screw wire central third of scaphoid
- can remove volar beak of trapezium
- pass screw, bury head
- +/- bone graft
Bone graft (distal radius / iliac crest)
- comminuted fracture / unstable fractures
- humpback deformity
Percutaneous fixation
Indications
Minimally displaced fracture in acceptable position
Manual workers / athletes - limit time in case
Technique
Traction on thumb
- ulna deviation
- flex wrist over roll of drapes
- fluoroscopy shows long axis of scaphoid
- volar stab incision over scaphoid tuberosity
- insert K wire in long axis / central third scaphoid
- check wire position AP / lateral / 45o obliques
- insert cannulated screw
Results
Proximal pole fractures
Technique
Dorsal approach
- incision centered on Lister's tubercle
- 3/4 extensor compartment
- reflect EPL radially, reflect EDC ulnarly
- open capsule
- flex wrist and reduce fracture
- insert K wire
- proximal fragment into distal fragment
- entry point is just radial to SL ligament
- drive into trapezium
- check position on multiple views
Insert screw
Results