Scaphoid Fracture
Upper LimbOverview
Scaphoid fracture is the most common carpal bone fracture, typically resulting from a fall on an outstretched wrist (FOOSH injury) with dorsiflexion and radial deviation. The injury carries significant morbidity risk due to the scaphoid's tenuous blood supply, making early diagnosis and appropriate management critical to prevent nonunion, malunion, and avascular necrosis. Initial radiographs may appear normal despite clinical suspicion; advanced imaging is often required for diagnosis.
Pathophysiology
The scaphoid bone has a retrograde blood supply entering through a small nutrient foramen, making the proximal pole particularly vulnerable to avascular necrosis if blood supply is disrupted. Fractures commonly occur at the waist (70%) or proximal pole (20%), with displacement and comminution increasing nonunion risk. Immobilization is necessary to achieve bony union, typically requiring 8-12 weeks depending on fracture location and stability. Delayed diagnosis or inadequate immobilization predisposes to chronic scaphoid nonunion, which can lead to post-traumatic osteoarthritis of the radiocarpal and midcarpal joints.
Patient Education
Early diagnosis and strict immobilization are critical to prevent serious complications; avoid self-diagnosis or delayed medical review if you have persistent wrist pain after a fall, as nonunion and avascular necrosis can develop silently without proper treatment.
Typical Presentation
Site
Anatomical snuffbox (dorsal wrist, between extensor carpi radialis longus and extensor pollicis longus tendons); pain localizes to the radial side of the wrist at the base of the thumb
Quality
Dull, aching pain with occasional sharp pain on gripping or pinching; may be described as a constant nagging discomfort
Intensity
Mild to moderate initially, often underestimated by patient; typically 4-6/10 but can be severe with displacement; pain often increases with activity over days to weeks
Aggravating
Gripping, pinching, forceful thumb opposition, radial deviation of wrist, weight-bearing through extended wrist, repetitive wrist motions, compression of snuffbox
Relieving
Rest, immobilization, ice, elevation, avoiding gripping activities, NSAIDs for pain management
Associated
Swelling and bruising over snuffbox (may be subtle), weakness in grip strength, reduced wrist range of motion, tenderness to palpation in snuffbox, positive scaphoid compression test, loss of thumb opposition strength, may have minimal swelling early on
Orthopaedic Tests
Scaphoid Fracture Series Imaging (Clinical Decision Rule Adjunct)
Procedure
Scaphoid series X-rays: PA, lateral, oblique and a scaphoid view with the wrist in ulnar deviation. If these are normal but a fracture is still suspected, immobilise and arrange MRI or CT, or repeat X-rays at 10–14 days, following local pathways.
Positive Finding
A fracture line on X-ray, CT or MRI. MRI may also show bone bruising without a fracture line.
Sensitivity / Specificity
Reference: Mallee WH, Wang J, Poolman RW, Kloen P, Maas M, de Vet HC, et al. Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Cochrane Database Syst Rev. 2015;2015(6):CD010023.
Interpretation
X-rays miss some scaphoid fractures in the first days after injury, so a normal X-ray with ongoing snuffbox or tubercle tenderness is not the end of the work-up. The reference previously shown for this test could not be matched to any published paper and has been withdrawn. Figures are for CT and MRI in suspected fractures after normal initial radiographs (Cochrane review, 11 studies). Both reliably confirm a fracture; neither reliably excludes one — CT missed about 1 in 4. Confidence intervals are wide.
Scaphoid Compression Test (Axial Load Test)
Procedure
Hold the patient's thumb and push it gently along its long axis towards the wrist.
Positive Finding
Pain at the radial side of the wrist, in the snuffbox region.
Interpretation
Used together with snuffbox and scaphoid tubercle tenderness to decide whether to image and immobilise. On its own it neither confirms nor excludes a fracture. The reference previously shown for this test could not be matched to any published paper and has been withdrawn. No accuracy figure is shown because none has yet been checked against a study.
Scaphoid Palpation (Tenderness in Anatomical Snuffbox)
Procedure
With the wrist in slight ulnar deviation, palpate the anatomical snuffbox (between the extensor pollicis longus and brevis tendons), then the scaphoid tubercle on the palmar side at the distal wrist crease. Compare with the other wrist.
Positive Finding
Localised tenderness in the snuffbox or over the scaphoid tubercle, more than on the other side.
Interpretation
Snuffbox tenderness is common after wrist injuries even without a fracture, so a positive finding means image and immobilise rather than a diagnosis. No tenderness in either the snuffbox or over the tubercle makes a fracture less likely but does not rule it out. The reference previously shown for this test could not be matched to any published paper and has been withdrawn. No accuracy figure is shown because none has yet been checked against a study.
Scaphoid Shift Test (Watson's Test)
Procedure
Do not perform when a scaphoid fracture is suspected. Later, once a fracture is excluded or healed: forearm pronated, press your thumb on the palmar scaphoid tubercle and move the wrist from ulnar deviation into radial deviation, then release the pressure. Test both wrists.
Positive Finding
A painful clunk as the scaphoid shifts dorsally and reduces on release, or reproduction of dorsal wrist pain.
Interpretation
Assesses scapholunate instability after a fracture has been excluded or treated. It loads the scaphoid, so it has no place in the acute assessment of a suspected fracture. This test assesses scapholunate instability, not fracture. No study reports its accuracy for scaphoid fracture, so no figure is shown.
Grip Strength Test
Procedure
Only after a fracture has been excluded or has healed: measure grip with a hand dynamometer on both sides, three trials each, and record the mean.
Positive Finding
Weaker grip, or pain with gripping, on the injured side.
Interpretation
Tracks recovery after healing. It has no role in diagnosing a scaphoid fracture.
⚠ Red Flags
- •Severe pain disproportionate to apparent injury severity
- •Signs of neurovascular compromise (numbness, tingling, cold hand, colour changes)
- •Open fracture with wound contamination
- •Displaced fracture with angulation >20 degrees on imaging
- •Proximal pole fracture with high nonunion risk
- •Failure to achieve union after 12 weeks of appropriate immobilization
- •Progressive deformity, instability, or worsening function despite immobilization
- •Symptoms suggesting avascular necrosis (persistent pain, swelling, progressive loss of motion after union)
- •Associated injuries to other carpal bones or dorsal ligaments
⚡ Yellow Flags
- •History of previous wrist injury or chronic instability
- •Delayed presentation (>2 weeks post-injury) reducing treatment efficacy
- •Poor compliance with immobilization due to occupational or lifestyle demands
- •Catastrophizing beliefs about hand function and prognosis
- •Workplace or legal compensation issues that may delay recovery
- •Excessive pain behaviours or symptom magnification inconsistent with injury severity
- •Fear-avoidance beliefs limiting rehabilitation engagement
Osteopathic Techniques
Region
Wrist and forearm—soft tissue (after acute phase resolved, typically weeks 3-4 post-diagnosis)
Technique
Rationale
Gentle soft tissue mobilization to surrounding flexor and extensor musculature reduces muscle guarding, improves circulation to support healing, and begins restoring tissue extensibility without disrupting fracture site stability; performed with immobilization in place or as cleared by medical practitioner
Region
Cervical spine and shoulder girdle
Technique
Rationale
Muscle energy techniques address cervical and shoulder dysfunction that often accompanies compensatory patterns from wrist immobilization; restores segmental mobility and reduces upper limb muscle tension that contributes to ongoing pain perception and reduced rehabilitation tolerance
Region
Radial nerve (superficial branch) mobilization
Technique
Rationale
Gentle neural mobilization of the radial nerve pathway, particularly at the snuffbox and over dorsal wrist, reduces nerve irritation, improves neural gliding, and decreases referred pain patterns that may be present secondary to swelling and immobilization
Region
Wrist and hand—articulation (post-immobilization, weeks 8-12 onwards)
Technique
Rationale
Gentle grade I-II articulation of radiocarpal, midcarpal, and intercarpal joints during rehabilitation phase restores joint motion gradually, reduces stiffness from immobilization, and promotes synovial fluid nutrition to healing tissues without excessive load on the fracture site
Region
Forearm pronation/supination muscles
Technique
Rationale
Restores pronation and supination movement patterns often restricted by immobilization and pain; reduces compensatory strain on wrist stabilizers and prepares forearm for functional loading as fracture heals and rehabilitation progresses
Region
Lymphatic drainage—upper limb and axillary nodes
Technique
Rationale
Gentle lymphatic mobilization reduces swelling and oedema that impairs circulation to the fracture site and surrounding tissues; improves local tissue fluid exchange, accelerates resorption of inflammatory exudate, and supports optimal healing environment
Rehabilitation Exercises
Wrist Flexion and Extension (Active-Assisted, Post-Immobilization)
Wrist Radial and Ulnar Deviation (Gentle Pendulum)
Forearm Pronation and Supination with Towel Roll
Gentle Wrist Extensor Stretch (Post-Immobilization)
Gentle Wrist Flexor Stretch
Grip Strengthening with Therapy Putty (Week 10 Onwards)
Wrist Extensors Isometric Hold (Progressive Loading)
Thumb Opposition and Abduction with Resistance Band
Wrist Proprioception Training with Ball Toss
Shoulder Blade Stabilization and Posture Correction
Fine Motor Control—Finger Dexterity Drills (Week 10 Onwards)
Graduated Return to Gripping Activities (Simulated Daily Tasks)
Referral Criteria
- •Initial presentation with suspected scaphoid fracture—refer to emergency department or orthopaedic specialist for imaging confirmation and immobilization prescription
- •Radiographically confirmed displaced or comminuted fracture—refer to orthopaedic surgeon for possible operative intervention
- •Fracture involving the proximal pole—refer to orthopaedic specialist due to higher avascular necrosis risk and possible surgical management
- •Nonunion or malunion after 12 weeks of appropriate immobilization—refer to hand surgeon or orthopaedic specialist for advanced imaging and possible surgical intervention
- •Signs of avascular necrosis (persistent pain, swelling, loss of motion post-union)—refer to orthopaedic specialist or hand surgeon for imaging assessment and management
- •Associated injuries to other carpal bones, ligaments, or dorsal wrist structures—refer to hand surgeon or orthopaedic specialist for comprehensive assessment
- •Open fracture or wound contamination—refer urgently to emergency department for wound management and fracture stabilization
- •Neurovascular compromise or compartment syndrome symptoms—refer urgently to emergency department
- •Poor fracture healing progression or loss of union on serial imaging—refer to orthopaedic specialist for reassessment and possible surgical intervention
- •Persistent functional limitation or pain beyond expected healing timeline—refer to hand physiotherapist or occupational therapist for specialized rehabilitation
- •Symptoms inconsistent with fracture healing or progressive stiffness—refer to hand specialist to rule out undiagnosed complications