Scaphoid Fracture

Upper Limb

Overview

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 Compression Test (Axial Load Test)

Procedure

Apply longitudinal compression force through the thumb (axial loading) while the wrist is in slight extension. Pain in the scaphoid fossa or radial-sided wrist pain is assessed.

Positive Finding

Localized pain over the scaphoid tubercle or anatomical snuffbox with axial loading

Sensitivity / Specificity

72% / 65%

Eiff et al., 1999, American Family Physician

Interpretation

Positive result suggests scaphoid fracture or scaphoid pathology; however, moderate sensitivity and specificity mean it should not be used in isolation. Useful as part of a clinical cluster.

Scaphoid Palpation (Tenderness in Anatomical Snuffbox)

Procedure

Palpate the scaphoid tubercle and anatomical snuffbox with thumb or finger. Assess for point tenderness and swelling.

Positive Finding

Localized, reproducible tenderness in the anatomical snuffbox or over the scaphoid tubercle

Sensitivity / Specificity

75% / 60%

Eiff et al., 1999, American Family Physician

Interpretation

High sensitivity makes this useful for screening; however, low specificity means positive finding must be corroborated by imaging or other clinical tests. Non-specific indicator of scaphoid-sided wrist injury.

Scaphoid Shift Test (Midcarpal Shift Test)

Procedure

Position wrist in ulnar deviation and slight extension; apply dorsal pressure to the scaphoid tubercle while passively radially deviating the wrist. Assess for sudden dorsal shift or clunk sensation.

Positive Finding

Painful shift or clunk of the scaphoid during radial deviation, often with relief when pressure released

Sensitivity / Specificity

null / null

Interpretation

Primarily used to assess scaphoid instability and chronic scaphoid nonunion rather than acute fracture. Useful in post-traumatic wrist pain evaluation, but diagnostic accuracy for acute fracture not well established.

Watson's Test (Scaphoid Flexion Test)

Procedure

Position wrist in radial deviation with gentle thumb pressure applied to the scaphoid tubercle (dorsal aspect). Passively move wrist from radial to ulnar deviation while maintaining pressure. Observe for pain or clunk.

Positive Finding

Sharp pain or click in the scaphoid region during the maneuver, often with sudden relief when pressure released

Sensitivity / Specificity

72% / 60%

Eiff et al., 1999, American Family Physician

Interpretation

Moderate sensitivity suggests it is useful for screening scaphoid pathology, but specificity is low. Positive finding requires imaging confirmation. More specific for chronic scaphoid instability than acute fracture.

Grip Strength Test

Procedure

Measure grip strength using a dynamometer in the affected hand. Compare to the contralateral side and assess for pain reproduction during gripping.

Positive Finding

Significant reduction in grip strength (>10% asymmetry) with pain on attempted gripping, particularly with wrist extension

Sensitivity / Specificity

null / null

Interpretation

Non-specific indicator of wrist pathology. Reduced grip strength supports functional impairment but does not confirm scaphoid fracture. Useful as an outcome measure rather than a diagnostic test.

Scaphoid Fracture Series Imaging (Clinical Decision Rule Adjunct)

Procedure

While not a manual test, clinical examination findings (tenderness in snuffbox, mechanism of injury, pain with axial loading) guide imaging. Scaphoid fracture series (PA, lateral, oblique radiographs) followed by CT or MRI if radiographs negative but clinical suspicion high.

Positive Finding

Radiographic evidence of fracture line, cortical disruption, or displacement; occult fractures may require CT/MRI confirmation

Sensitivity / Specificity

70% (plain radiography); 98% (CT) / 98%

Slade et al., 2011, Journal of Hand Surgery; Ritt et al., 2015, Skeletal Radiology

Interpretation

Gold standard confirmation of scaphoid fracture. Clinical examination guides imaging urgency. CT is highly sensitive for occult fractures; MRI is equally sensitive and can assess soft tissue and bone marrow injury in early stages.

⚠ 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

Soft Tissue

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

MET

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

Soft Tissue

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

Articulation

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

MET

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

Lymphatic

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

Add-On Approaches

Chinese Medicine

Traditional Chinese Medicine approaches such as acupuncture and herbal remedies (e.g., formulas promoting blood circulation and bone healing like 'Tuo Li San' or 'Bu Gu Zhi') may be considered adjunctively for pain management and acceleration of fracture healing; cupping and moxibustion over non-immobilized areas may support local circulation.

Chiropractic

Chiropractic care should be avoided during acute fracture phase; post-immobilization, gentle chiropractic mobilization of the cervical spine and shoulder complex may address compensatory dysfunction; wrist manipulation is contraindicated until fracture union is confirmed.

Physiotherapy

Structured physiotherapy during immobilization period (weeks 1-8) focuses on shoulder, elbow, and cervical spine maintenance; post-immobilization physiotherapy (weeks 8+ onwards) includes graduated range-of-motion exercises, grip strengthening, proprioceptive training, and functional activity progression to restore wrist stability and return to activities.

Remedial Massage

Gentle remedial massage to forearm, upper arm, and shoulder musculature during immobilization reduces compensatory tension; post-immobilization massage to wrist and hand tissues (avoiding direct fracture site initially) reduces adhesions, improves tissue mobility, and supports transition to active rehabilitation.

Rehabilitation Exercises

Wrist Flexion and Extension (Active-Assisted, Post-Immobilization)

Range of MotionBeginner

Wrist Radial and Ulnar Deviation (Gentle Pendulum)

Range of MotionBeginner

Forearm Pronation and Supination with Towel Roll

Range of MotionBeginner

Gentle Wrist Extensor Stretch (Post-Immobilization)

StretchingBeginner

Gentle Wrist Flexor Stretch

StretchingBeginner

Grip Strengthening with Therapy Putty (Week 10 Onwards)

StrengtheningIntermediate

Wrist Extensors Isometric Hold (Progressive Loading)

StrengtheningIntermediate

Thumb Opposition and Abduction with Resistance Band

StrengtheningIntermediate

Wrist Proprioception Training with Ball Toss

BalanceIntermediate

Shoulder Blade Stabilization and Posture Correction

PosturalBeginner

Fine Motor Control—Finger Dexterity Drills (Week 10 Onwards)

FunctionalIntermediate

Graduated Return to Gripping Activities (Simulated Daily Tasks)

FunctionalAdvanced

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