Scaphoid Fracture of the Wrist: 8 Points You Need to Know [+ Clinical Cases]

The scaphoid fracture in the wrist is the most common bone injury among all carpal bones, posing a significant challenge for both healthcare services and affected patients.

Another added challenge is the complexity of diagnosing these fractures. High rates of false negatives (cases where fractures go unnoticed) are common in imaging tests such as X-rays. This not only can lead to short-term complications but may also have long-term consequences if not properly addressed such as non-union or SNAC.

That’s why in this blog, we summarize in 8 points everything you need to know to properly assess and treat patients who come to the clinic with a scaphoid bone fracture.

🧐 What is the scaphoid bone? How common are scaphoid fractures? What types of fractures exist? What is better, surgical treatment or casting? What role does hand therapy play in scaphoid bone fractures?

Let´s start!

1️⃣ The Scaphoid Bone in the Wrist

The scaphoid is an obliquely oriented bone located on the radial side of the wrist. It is a crucial carpal bone that connects the proximal and distal carpal rows, playing a significant role in the stability and biomechanical function of the wrist. Its movement influences the mobility of the Semilunar Bone (through its connection to the scapholunar interosseous ligament) and the mobility of the distal carpal row.

The scaphoid is primarily intra-articular, with 80% of the bone covered by cartilage, forming an articular surface. Most of the proximal half of the scaphoid is covered with articular cartilage, allowing only a small superficial area for vascular flow. Arterial foramina span the non-articulating palmar and dorsal surfaces.

The blood supply to the bone is provided through its ligamentous attachments. Previous studies have shown that in 75% of scaphoid specimens, two arteries branch off from the radial artery to supply blood to the scaphoid on the dorsal and proximal surfaces; these branches are the dorsal carpal branch and the superficial palmar branch, respectively. In 20% of scaphoids, most arterial foramina exist in the waist region. Due to this interosseous arterial anatomy, the proximal articular pole of the scaphoid receives its blood supply retrogradely, which may explain the high incidence of avascular necrosis and non-union in untreated fractures involving this region.

It is common for a scaphoid fracture to go unnoticed or be misdiagnosed as a “sprain” due to false negatives that may appear in tests. This can lead to Avascular Necrosis, Pseudoarthrosis, or Wrist in SNAC or Advanced Collapse due to Pseudoarthrosis of the Scaphoid.

Specifically, there is an estimated 25% rate of false negatives in X-rays. Therefore, if the patient meets key criteria in the medical history and clinical assessment but no signs are observed in the X-ray, they are diagnosed with a Clinical Scaphoid Fracture (Sabbagh MD et al., 2019).

2️⃣ Epidemiology and Characteristics of Carpal Scaphoid Fracture

The scaphoid is the carpal bone most commonly fractured. It accounts for 60% of carpal fractures, 11% of hand fractures, and 2% of all fractures. The estimated annual incidence of scaphoid fractures ranges between 29 and 43 fractures per 100,000 people, primarily affecting young males aged 15 to 25 years.

The typical patient reports pain on the radial side of the wrist after a sports-related trauma, such as a fall on an outstretched hand, causing some degree of wrist hyperextension. Fractures in the waist area account for two-thirds of all scaphoid fractures, with the majority (60–85%) being non-displaced. Fractures in the distal third of the scaphoid represent 25% of scaphoid fractures, while 5–10% occur in the proximal third (Clementson M et al., 2020).

👉 Everything you need to know about Distal Radius Fractures

3️⃣ Classification of Carpal Scaphoid Fractures

The goal of classifying a fracture is to guide injury management for prompt healing with minimal complications and to allow a quick return to work or sports. Consequences of failed healing include loss of wrist movement, decreased grip strength, wrist pain, and premature joint degeneration. It is particularly important to identify which scaphoid fractures require surgical intervention for proper healing. Failure to identify and appropriately treat unstable scaphoid fractures is likely to result in 6 months or more of additional treatment and restricted activities.

A. Russe Classification of Scaphoid Fractures

One of the initial efforts to identify unstable fractures involved examining the fracture plane of the scaphoid. Russe in 1960 recognized that oblique fractures were unstable, challenging to control with immobilization, and led to an increased rate of non-union.

B. Herbert and Fisher Classification of Scaphoid Fractures

Herbert and Fisher in 1990 classified scaphoid fractures based on their stability. Stable fractures, classified as type A, included incomplete fractures (A1) or fractures of the scaphoid tubercle (A2). The authors asserted that these fractures could be safely treated with immobilization, expecting a high union rate. All other fractures were considered potentially unstable and warranted rigid fixation, a point of some controversy.

🔶Scaphoid Fracture Herbert A: Acute Stable Fractures
A1: Fracture of the Scaphoid Tubercle
A2: Incomplete Fracture of the Waist

🔶Scaphoid Fracture Herbert B:
B1: Distal Oblique Fracture
B2: Complete Waist Fracture
B3: Proximal Pole Fracture
B4: Perilunate Transescafoid Perilunar Dislocation

🔶Scaphoid Fracture Herbert C:
C: Delayed Union

🔶Scaphoid Fracture Herbert D:
D1: Fibrous Union
D2: Pseudarthrosis

4️⃣ Clinical and Radiographic Diagnosis of Scaphoid Fractures

Clinical assessment always begins by comparing the affected hand with the contralateral side.

For scaphoid fractures, clinical tests include examining tenderness in the anatomical snuffbox and the scaphoid tubercle, as well as pain with axial compression of the thumb. While these tests are sensitive (100%), their specificity increases to 74% when positive together.

Learn to differentiate pathologies and injuries with similar clinical presentation to scaphoid fractures.👉​Differential Diagnosis of Radial-Side Wrist Pain

Regarding imaging tests, conventional X-rays are commonly used, but their sensitivity is limited to 70%, which may lead to unnecessary treatments. Magnetic Resonance Imaging (MRI), with a sensitivity of 99-100%, is recommended for immediate diagnosis and appropriate treatment, although it may generate false positives.

In cases of negative X-rays, some studies suggest early MRI. Computed Tomography (CT) provides detailed reconstructions and quantitative measurements, being recommended when displacement or instability is suspected. Instability is associated with prolonged healing time and a higher risk of non-union. Fracture displacement is categorized, and a correlation has been demonstrated between fracture comminution and instability, although instability can also occur in non-displaced fractures.

5️⃣ Acute Medical Treatment for Scaphoid Fracture

Depending on the type of fracture in this carpal bone, the emergency treatment applied should be adapted. It is not the same for a minimal crack as it is for a displaced fracture.

An example would be for patients with suspected scaphoid fracture where initial X-rays are negative, and significant displacement or instability of the fracture is not expected. Consequently, we rely on immobilization with a dorsal wrist cast until additional MRI is performed.

We present you with three options based on the type of injury, as proposed by Clementson M et al., 2020.

A. Algorithm for Waist Fractures of the Scaphoid

Internal fixation for scaphoid fractures with displacement ≥ 1.5 mm. Fractures with moderate displacement (0.5–1.5 mm) may require prolonged casting, but surgical intervention is considered if signs of instability are present.

B. Algorithm for Proximal Pole Fractures

Proximal pole fractures present inherent instability due to the small size of the fragment and its unbalanced connection with the scapholunate ligament. Computed Tomography is recommended for all fractures, and internal fixation is advised in case of displacement + instability.

C. Algorithm for Distal Region Fractures

Fractures of the distal scaphoid are well-vascularized, and they are often non-displaced or minimally displaced fractures, which favors uncomplicated healing through conservative treatment. Avulsion of the radial-volar tip of the tuberosity is the most common.

6️⃣ Surgical Fixation or Cast Immobilization in Scaphoid Waist Fractures? A Study!

Immediate surgical fixation has always been advocated for promoting early recovery and return to work or sports, although the data in the evidence are not clear on this matter. Therefore, Dias, J. J. et al. (2020) designed the “Scaphoid Waist Internal Fixation for Fractures Trial” (SWIFFT) where a total of 439 patients with Bicortical Fractures of the scaphoid waist were included. These fractures had to present displacement of < 2 mm as an inclusion criterion. These patients were randomly assigned to two groups: Surgery (220) or Plaster Cast (219), and they were followed up for 2 weeks, recording:

🔸Function with the Patient-Rated Wrist Evaluation (PRWE) scale
🔸Grip Strength
🔸Range of Motion (ROM)
🔸Associated Complications

The results showed the absence of significant differences in function, pain, strength, or ROM at 52 weeks of follow-up between both groups. On the other hand, complications such as infections, nerve injuries, or Complex Regional Pain Syndromes were 10 times more frequent in the surgery group. Reinterventions were also more common in the surgery group (4%) than in the cast group (<1%).

With these data, it becomes clear that the current trend of favoring surgical fixation as the first option for any scaphoid fracture is not supported by this study, as long as the displacement is <2 mm and there is no suspicion of pseudoarthrosis. With these findings, we can affirm that immobilization with casts is equally effective as surgical fixation.

7️⃣ Non-Surgical Conservative Treatment of the Scaphoid

Non-surgical conservative treatment, through immobilization, remains a valid option for managing stable and non-displaced fractures, including those in the waist and distal pole of the scaphoid. The definition of displacement, according to Cooney et al., involves a fracture gap of 1 mm or less on anteroposterior and oblique radiographs, along with specific angles on lateral views. To accurately assess displacement, a computed tomography (CT) scan is recommended for all fractures, with 3D CT images being a promising method to determine the type and stability of the fracture.

For fractures in the middle waist or distal pole, stable and non-displaced immobilization is considered appropriate. Although there has been historical debate about the extent of combined immobilization to achieve successful union, studies on cadavers have revealed displacement of the proximal and distal poles in simulated scaphoid fractures when moving the arm between pronation and supination. However, current meta-analyses and systematic reviews have not shown a significant benefit from immobilizing the forearm, elbow, or thumb. Therefore, it is suggested that immobilization be done only distal to the elbow, keeping the wrist in a functional position.

Despite studies supporting non-surgical management in most stable waist fractures, early surgical intervention has been shown to reduce total costs and decrease immobilization times. A recent meta-analysis suggests that surgical fixation results in better mobility, decreased rates of delayed union, and less time off work. However, surgery carries more risks and complications, and the long-term risks and benefits should be carefully considered when deciding on the optimal management of a stable waist fracture.

8️⃣ Hand Therapy and Rehabilitation in Scaphoid Fracture

A. Immobilization Period for the Fracture

It is worth noting the importance of starting exercise programs even during the immobilization period of the fracture. This statement goes against what is traditionally stipulated for fractures and acute injuries.

The most current evidence supports early mobilization, citing its impact on the cortical representation of the hand, anti-edema effects, prevention of stiffness, and maintenance of muscle mass.

👉 Do you know why finger exercises during immobilization are important?

B. Early Treatment after Fracture

After a hand fracture, various phases of rehabilitation have been described. During the initial phase, movement is restricted, and activities that may aggravate the condition, such as dynamic joint loading, gripping, and pinching, are avoided to minimize pain and control inflammation and swelling. As the fracture shows radiographic signs of healing or after early surgical fixation, the restoration of active and passive range of motion can begin.

Among the techniques, it is worth highlighting thermotherapy and cryotherapy, which produce anti-inflammatory and analgesic effects on the affected region. Additionally, other techniques such as electrotherapy for pain control with TENS or electrical stimulation with NMES can be utilized.

Strategies for edema control should include early mobilizations of the region, even when immobilized, elevation of the limb with compressive bandages, or scar management.

In addition to elevation and direct compression, early mobility work is one of the most effective therapeutic modalities for reducing edema in the extremities. Several studies demonstrate the benefits of early rehabilitation and range of motion, especially in high-energy fractures and open fractures.

Active movement is under the direct control of the patient through cortical processing and activation of musculotendinous units. Active range of motion exercises generate tendon gliding, promote strength and endurance, and improve lymphatic drainage. In the fingers, active range of motion generates a local compressive effect on the surrounding skin, subcutaneous tissues, and the lymphatic system.

Active-assisted movement combines the active recruitment of muscles with movement assisted by the patient or therapist. This type of exercise is particularly useful for hesitant or cautious patients. Passive-assisted movement involves a short, high external load through a joint. Flexion bands can be used to place and maintain flexion in the affected joint.

It will also be relevant to include tendon gliding strategies that promote tendon mobility and prevent the development of adhesions and joint stiffness.

C. Late Phases of Treatment after Fracture

With increased fracture stability and soft tissue healing, patients progress to the strength and endurance phase. Finally, the functional phase of therapy prepares patients for a return to work and recreational activities, with exercises aimed at integrating specific work or life skills into the rehabilitation program.

⭕​CLINICAL CASES of Scaphoid Fractures

A. Fracture in a Gym goer Patient

We are discussing a clinical case in which a scaphoid fracture occurs during a bench press. The case was published in the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) in 2015, where they present images of the fracture.

A 21-year-old military academy cadet comes to the clinic after experiencing severe pain following exercise, specifically during a bench press. The patient mentions that during the exercise, the bar slipped from his hand, causing:

🔸Forced flexion and radial deviation
🔸Forced abduction of the thumb

At the same time, there is swelling at the dorsolateral level and significant limitation of wrist and thumb range of motion (ROM). Additionally, compression on the thumb causes pain, along with tenderness in the anatomical snuffbox region.

Due to the inability to use X-rays initially, they performed a wrist fluoroscopy. Here is an example image:

Subsequently, they managed to perform the X-ray, revealing an scaphoid waist fracture. The patient underwent conservative treatment with immobilization for 6 weeks and a gradual return to his usual activities. Here is the evolution at 3 months:

B. Clinical Fracture with Bone Edema

This patient experiences a fall, following which they are referred to the Emergency Department. Despite not observing any apparent injury on the X-ray, a preventive splint is prescribed.

Two weeks later, her symptoms worsen, and she returns to the hospital. This time, she is diagnosed with a Clinical Fracture and Bone Edema of the Scaphoid. Subsequently, she spends another month immobilized. Here is an example image of a similar fracture:

After removing the immobilization, she was directly referred to the Physiotherapy service, where various parameters are assessed.

🔸Grip strength of 0.5 kg and Pinch strength of 1 kg.

🔸Pain Visual Analog Scale (VAS) at 9/10.

🔸ROM in Flexion-Extension: 18°-34°.

🔸PRWE (Patient-Rated Wrist Evaluation) Questionnaire 88/100, indicating significant limitation.

With this information, the patient began her exercise programme using ReHand, focusing on wrist and thumb mobility.

After two months of home-based exercise therapy, a significant improvement in clinical outcomes were observed:

🔸Grip strength of 6.8 kg, and Pinch strength 1 kg.
🔸Wrist Flexion-Extension ROM: 52°-62°.
🔸PRWE at 55/100.

Learn most-important hand & wrist questionnaires such as PRWE !!👉​🔥 7 Essential Questionnaires for Hand, Wrist and Finger Injuries

However, her pain has significantly increased in recent weeks, and her progress has plateaued. But… what does the evidence tell us?

According to various authors, although the majority of Bone Edemas resolve on their own without major consequences, their appearance can affect the course of the pathology, slowing it down and increasing perceived pain.

Some authors suggest that complete recovery may extend up to 6-12 months post-injury (Ghasemi, R. A. et al, 2019).

In light of this, it is crucial to rely on four main pillars:

1) Continue with her Exercise program using ReHand, along with strength exercises and Manual Therapy.
2) Periodic use of orthoses in her daily activities.
3) Medical or pharmacological treatment to control symptoms.
4) EDUCATION: Clearly explain: The normal course of scaphoid non-union and teach self-management techniques to enhance function and joint-protection in her affected hand.

🖥️ReHand in Scaphoid Fractures Rehabilitation

Thanks to the tele-rehabilitation system with artificial intelligence, ReHand, patients can receive an individualized rehabilitation exercise program early on, either during immobilization or once the splint is removed. This early intervention helps combat edema, promotes motor relearning, exercises hand muscles, and prevents muscle mass loss.

ReHand combines the latest evidence in sensorimotor system intervention with artificial intelligence to facilitate the prescription of therapeutic exercise and optimize health outcomes for patients. ReHand has proven to be effective in the rehabilitation of bone and soft tissue injuries in the wrist, hand, and fingers, accelerating clinical recovery and reducing the number of referrals and in-person physiotherapy sessions. This was demonstrated in one of the most significant clinical trials of tele-rehabilitation in Europe.

ReHand is not just an application with exercises. ReHand is a tool for us, healthcare professionals, consisting of three systems:

🔸 Prescription System (Dashboard): Allows prescribing a therapeutic exercise program to our patient based on their pathology.

🔸 Treatment System (ReHand App): Provides access to our patient to self-treat with the prescribed program.

🔸 Monitoring System (Reports): Allows receiving weekly information on treatment adherence and the patient’s progress.

Pathologies such as thumb osteoarthritis, Carpal Tunnel Syndrome, Wrist and Hand Fractures, Scaphoid Fractures, Sudeck or Complex Regional Pain Syndrome, Carpal Instabilities, and many others, can be recovered thanks to this tool.

Learn to prescribe Hand and Wrist Exercises with Technology! ⭕

References

1) Clementson M, Björkman A, Thomsen NOB. Acute scaphoid fractures: Guidelines for diagnosis and treatment. EFORT Open Rev. 2020;5(2):96–103.

2) Dareez, N. M., Dahlslett, K. H., Engesland, E., & Lindland, E. S. (2017). Scaphoid fracture: Bone marrow edema detected with dual-energy CT virtual non-calcium images and confirmed with MRI. Skeletal radiology, 46(12), 1753–1756. https://doi.org/10.1007/s00256-017-2730-6.

3) Eriksen E. F. (2015). Treatment of bone marrow lesions (bone marrow edema). BoneKEy reports, 4, 755. https://doi.org/10.1038/bonekey.2015.124.

4) Ghasemi, R. A., Sadeghi, S., Rahimee, N., & Tahmasebi, M. (2019). Technologies in the Treatment of Bone Marrow Edema Syndrome. Orthopedic Clinics of North America, 50(1), 131-138. https://doi.org/10.1016/j.ocl.2018.08.008

5) Mason, J. S., Crowell, M. S., & Goss, D. L. (2015). Fracture of the Scaphoid During a Bench-Press Exercise. The Journal of orthopaedic and sports physical therapy, 45(8), 642. https://doi.org/10.2519/jospt.2015.0408

6) Sabbagh MD, Morsy M, Moran SL. Diagnosis and Management of Acute Scaphoid Fractures. Hand Clin [Internet]. 2019;35(3):259–69. Available from: https://doi.org/10.1016/j.hcl.2019.03.002

Pablo Rodríguez Sánchez-Laulhé

PhD Candidate | PT, Hand Therapy & eHealth Researcher