8
Scaphoid Fractures
S. Brent Brotzman, MD  |  Steven R. Novotny, MD
BACKGROUND
The scaphoid (carpal navicular) is the most commonly frac-
tured of the carpal bones, and carpal fractures often are diffi-
cult to diagnose and treat. Complications include nonunion and
malunion, which alter wrist kinematics. This can lead to pain,
decreased ROM, decrease in strength, and early radiocarpal
arthrosis.
The scaphoid blood supply is precarious. The radial artery
branches enter the scaphoid on the dorsal ridge, distal third,
and lateral-volar surfaces. The proximal third of the scaphoid
receives its blood supply from intraosseous circulation in about
one-third of scaphoids and thus is at high risk of osteonecrosis
(ON).
Scaphoid fractures usually are classified by location of frac-
ture: proximal third, middle third (or waist), distal third, or
tuberosity. Fractures of the middle third are most common, and
distal third fractures are rare. Besides the location of the frac-
ture, comminution and displacement have a dramatic impact
on the healing rate.  were proven on subsequent radiographs; if four to five qual-
CLINICAL HISTORY AND
EXAMINATION
Scaphoid fractures usually occur with hyperextension and radial
flexion of the wrist, most often in young active male patients.
Patients usually have tenderness in the anatomic snuffbox
(between the first and the second dorsal compartments), less
commonly on the distal scaphoid tuberosity volarly, and may
have increased pain with axial compression of the thumb meta-
carpal and decreased grip strength. Nondisplaced scaphoid
fractures are often difficult to evaluate radiographically because
of the bone’s oblique orientation in the wrist and the minimal
calcific disruption seen.
Initial radiographs should include posteroanterior (PA),
oblique, lateral, and ulnar deviation PA. If there is any question
clinically, an MRI is extremely sensitive in detecting scaphoid
fractures as early as 2 days after injury. A comparison of MRI
and bone scintigraphy found a sensitivity of 80% and specificity
of 100% for MRI done within 24 hours of injury and 100% and
90%, respectively, for bone scintigraphy done 3 to 5 days after
injury (Beeres et al. 2008). Bone contusion and micro fractures
will produce edematous changes that will be seen on the MRI
at this time, which could lead to an overcautious diagnosis and
unnecessarily prolonged treatment.
If an MRI is unavailable, patients with snuffbox tenderness
should be immobilized for 10 to 14 days and then return for
repeat radiographs out of the splint. If follow-up radiographs
are positive the diagnosis is certain; however if negative, clinical
exam should dictate further imaging (Low 2005). If the diagnosis
is still questionable, a bone scan is indicated (Tiel-van Buul 1993).
42
Assessment of scaphoid fracture displacement is cru-
cial for treatment and is often best assessed with thin section
(1-mm) computed tomography (CT) scans. Displacement is
defined as a fracture gap of more than 1 mm, a lateral scaph-
olunate angle greater than 60 degrees, lateral radiolunate angle
greater than 15 degrees, or intrascaphoid angle greater than
35 degrees.
Most clinically diagnosed scaphoid fractures turn out to
be nonfactual fractures. Sjolin and Andersen (1988) reported
on 108 patients with clinically diagnosed scaphoid fractures.
They report 14 days of sick time with plaster and 4 days with
a soft wrap. Two fractures were suspected radiographically,
and four had avulsion fragments from the tuberosity; how-
ever, none had verifiable complete fractures. They conclude
that since these fractures almost always heal irrespective of
treatment, soft dressing should be used. Jacobsen (1995) pro-
vides a more complete thought on this clinical question. Of
their 231 patients with clinical scaphoid fracture, only three
ity radiographs are taken and viewed by an experienced radi-
ologist almost 100% of factual fractures can be seen on the
initial radiographs. They recommend supportive bandage
during the observation period if the initial radiographs are
negative.
The question of long arm cast versus short arm cast and
thumb spica or not hasn’t been completely answered. Gellman
(1989) published a small series of long arm thumb spica versus
short arm thumb spica treated scaphoid fractures. Those treated
initially with a long system healed radiographically faster with-
out nonunion. Those treated with a short system healed slower,
with some delayed and nonunions. They recommend initial
long arm treatment. Clay (1991) randomized 392 fresh fractures
to short arm thumb spica or short arm cast treatment. Of the
292 followed for 6 months, the incidence of nonunion was inde-
pendent of which cast was used. Patients were followed every 2
weeks for cast change as needed and immobilized for 8 weeks.
Unfortunately almost 25% of enrolled patients didn’t complete
follow-up, and only 60% of proximal pole fractures were defi-
nitely healed. The small number of proximal pole fractures fol-
lowed (12, and only six definitely healed) still doesn’t answer
the question if all nondisplaced scaphoid fractures should be
treated equally. One common theme when authors report good
results with cast immobilization is frequent evaluation for cast
loosening, molding the cast into the palm, and discussion of
compliance issues.
Two meta-analysis studies with different inclusion crite-
ria recently were published. Doomberg (2011) looked mainly
at types of immobilization and functional outcome from ran-
domized trials and didn’t detect a clinical difference between
the types of treatment. Alshryda (2012) showed that the type

of immobilization wasn’t a factor as long as the wrist was not
placed in flexion, operative treatment did not produce a higher
union rate in nondisplaced fractures, and open repair trended
superior to percutaneous treatment.  delayed return to heavy labor or sports) would be intolerable
TREATMENT
Truly nondisplaced fractures can be treated closed and nearly
always heal with well molded cast immobilization. Above- or
below-elbow casting is still a subject of controversy. In proxi-
mal fractures we prefer 6 weeks of long arm thumb spica cast-
ing, followed by a minimum of 3 weeks of short arm thumb
spica casting. If radiographs do not demonstrate healing
we immobilize for another 3 weeks. Scaphoid union can be
verified with thin section CT scan if needed at this time. The
expense would only be warranted for very few. Most are con-
tinued with immobilization until radiographic union. Waist
and distal fractures are treated with a short arm system. If on
follow-up radiographs the fracture displaces or fracture line
significantly widens we revert to screw fixation.
Herbert screw jig
Clamping fractured
scaphoid bone
Trapezium bone Radius bone
Lunate bone
Fig. 8.1  Combined passive flexion and extension exercises of the
metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal
interphalangeal (DIP) joints.
REHABILITATION PROTOCOL 8.1    Rehabilitation Protocol After Treatment and Rehabilitation for
Scaphoid Fractures
For Fractures Treated Closed (Nonoperative), Treatment in
Thumb Spica Cast
0–6 Weeks
• Above elbow thumb spica cast for proximal pole, short arm
thumb spica for mid and distal poles
• Active shoulder ROM
• Active second through fifth MCP/PIP/DIP joint ROM  • Active/gentle-assisted thenar cone exercise
6–12 Weeks
• Short arm thumb spica cast
• Continue shoulder and finger exercises.
• Begin active elbow flexion/extension/supination/ pronation.  • Active/aggressive-assisted wrist flexion/extension ROM
12 Weeks or Bony Union
• CT scan to confirm union if radiographs in doubt. If not united,
continue short arm thumb spica cast.
• If cysts are forming intramedullary, reverting to screw fixation
and possible bone grafting should be considered. 
8  Scaphoid Fractures 43
Surgical treatment is indicated for the following:
• Nondisplaced fractures in which the complications of pro-
longed immobilization (wrist stiffness, thenar atrophy, and
• Scaphoid fractures previously unrecognized or untreated
• Displaced scaphoid fractures (see previous for criteria for
displacement)
• Scaphoid nonunions
For nondisplaced or minimally displaced fractures, percu-
taneous fixation with cannulated screws has become accepted
treatment. A recent meta-analysis reported that percutaneous
fixation may result in union 5 weeks earlier than cast treatment
and return to sport or work about 7 weeks earlier than with
cast treatment (Modi et  al. 2009). For fractures with marked
displacement, ORIF is mandatory (Fig. 8.1) (Rehabilitation
Protocol 8.1). Huene (Huene 1979) reported a small series
of scaphoid repairs including four athletes. All athletes were
returned to their sport within 6 to 8 weeks unprotected. Rettig
(Rettig 1994) retrospectively reviewed 30 athletes injured pre-
season or early season and those who planned on participating
in a subsequent season sport. Those who could play in a cast
were allowed to; those whose sport didn’t allow a playing cast
had screw fixation. After surgery return to sports was allowed
once range of motion was within 10% of the opposite side and
the fracture wasn’t tender. Both had comparable results. 
REHABILITATION
Once released from the cast, a standard mobilization proto-
col such as with a distal radius fracture is undertaken. Active-
assisted range of motion and progressive strengthening are the
therapy mainstays. Heat as an adjunct for joint mobilization or
cold for new rounds of swelling can be employed at home in
addition to massage and tendon and nerve glides. The overall
emphasis is on patient accountability. The therapist needs to
ensure that clients understand their home program responsibil-
ities completely. Most personal activities can be resumed once
protective range of motion is restored. Safety issues may dictate
a graduated return to previous level of function due to work-
place safety concerns.
12–14 Weeks
• Assuming union at 12 weeks, removable thumb spica splint
• Begin home exercise program.
• Active/gentle-assisted wrist flexion/extension ROM
• Active/gentle-assisted wrist radial/ulnar flexion ROM
• Active/gentle-assisted thumb MCP/IP joint ROM
 
14–18 Weeks
• Discontinue all splinting.
• Formalized physical/occupational therapy
• Active/aggressive-assisted wrist radial/ulnar flexion ROM
• Active/aggressive-assisted thumb MCP/IP joint ROM
• Active/aggressive-assisted thenar cone exercise 
Continued
44 SECTION 1  Hand and Wrist Injuries

REHABILITATION PROTOCOL 8.1    Rehabilitation Protocol After Treatment and Rehabilitation for
Scaphoid Fractures—cont’d
18 Weeks + 8–10 Weeks (Assuming Union)
• Grip strengthening, aggressive ROM • Emphasis on home exercise program
• Unrestricted activities  • Active/gentle-assisted wrist flexion and extension ROM
• Active/gentle-assisted wrist radial/ulnar flexion ROM
For Scaphoid Fractures Treated With ORIF • Active/gentle-assisted thumb MCP/IP joint ROM
0–10 Days • Active/gentle-assisted thenar cone exercise
• Elevate sugar-tong thumb spica splint, ice • Once fracture union present, progressive strengthening can be
• Shoulder ROM instituted 
• MCP/PIP/DIP joint active ROM exercises  10–14 Weeks
10 Days–4 Weeks • Discontinue all splinting.
• Suture removal • Formalized physical/occupational therapy can be discontinued
• Exos forearm-based thumb spica rigid splint to allow washing and with patient understanding of his or her responsibility and good
scar modification, or casting for a total of 3 to 4 weeks after surgery early recovery. Continue formal office program if poor progress
• Continue hand/elbow/shoulder ROM.  • Active/aggressive-assisted wrist flexion/extension ROM
• Active/aggressive-assisted wrist radial/ulnar flexion ROM
4–7 Weeks • Active/aggressive-assisted thumb MCP/IP joint ROM
• Removeable short arm thumb spica splint system • Active/aggressive-assisted thenar cone exercise 
• Elbow active/assisted extension, flexion/supination/pronation; 14 Weeks +
continue fingers 2 through 5 active ROM and shoulder active ROM
• Wrist motion is initiated active only, not passive.  • Aggressive ROM if still needed
• Unrestricted activities
  

REFERENCES Martineau PA, Berry GK, Harvey EJ. Plating for distal radius fractures. Hand
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FURTHER READING
Beeres FJ, Rhemrey SJ, den Hollander P, et al. Early magnetic resonance imag-
ing compared with bone scintigraphy in suspected scaphoid fractures. J Bone
Joint Surg Br. 2009;90:1250.
REFERENCES
Alshryda S, Shah A, Odak S, et al. Acute fractures of the scaphoid bone: system-
atic review and meta-analysis. Surgeon. 2012;10:218–219.
Beeres FJ, Rhemrev SJ, den Hollander P, et al. Early magnetic resonance imag-
ing compared with bone scintigraphy in suspected scaphoid fractures. J Bone
Joint Surg Br. 2008;90:1205–1209.
Clay NR, Dias JJ, Costigan PS, et al. Need the thumb be immobilized in scaph-
oid fractures? JBJS Br. 1991;73:828–832.
Doomberg JN, Buijze GA, Ham SJ, et  al. Nonoperative treatment for acute
scaphoid fractures: a systematic review and meta-analysis of randomized
controlled trials. J Trauma. 2011;71:1073–1081.
Gellman H, Caputo RJ, Carter V, et  al. Comparison of short or long thumb-
spica casts for non-displaced fractures of the carpal scaphoid. JBJS Am.
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