Orthop Clin N Am 38 (2007) 229–235
Acute Scaphoid Fractures
Julie E. Adams, MD, Scott P. Steinmann, MD*
The Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
Scaphoid fractures often occur as a result of
a fall on the outstretched arm or a forced dorsi-
flexion injury of the wrist [1,2]. The traumatic in-
cident may be minimal and the injury may be
mistakenly dismissed as a sprain, especially if
a fracture is nondisplaced and radiographs are
read as negative. However, the penalty for missing
these important injuries is high. The blood supply
to the scaphoid is tenuous and, if disrupted by the
fracture, healing may be compromised. Avascular
necrosis occurs in an estimated 13% to 50% of
scaphoid fractures, and the incidence is even
higher in fractures involving the proximal one
fifth of the scaphoid [2–5].
The scaphoid receives its blood supply primar-
ily from the artery to the dorsal ridge of the
scaphoid, a branch of the radial artery. The
branches of this vessel enter the nonarticular
portion of the scaphoid through foramina at the
dorsal ridge at the level of the waist of the
scaphoid [4,6]. Subsequently, these vessels divide
and run proximally and palmarly to supply the
proximal pole of the scaphoid [4,6]. Other
branches provide 20% to 30% of the blood flow
and arise from the distal palmar area of the scaph-
oid, originating either directly from the radial ar-
tery or the superficial palmar branch [1,2]. Thus,
the vascularity of the proximal pole depends en-
tirely on intraosseous blood flow. Because of the
limited blood supply, fractures have a prolonged
healing period, with an acute proximal pole frac-
ture averaging 3 to 6 months. Nonunion may
occur (in 5% to 10% of all cases, with an even
higher incidence in displaced fractures), and nu-
merous series document progression of nonunion
* Corresponding author.
E-mail address: steinmann.scott@mayo.edu
(S.P. Steinmann).
0030-5898/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ocl.2007.02.004
to collapse and arthritis [1,2]. Because treating
the established nonunion can be challenging,
especially in the setting of progression to degener-
ative arthritis, diagnosing and appropriately treat-
ing the acute fracture and the possible sequelae of
nonunion is essential.
Diagnosis of acute scaphoid fractures
Because early radiographs are normal for
many patients, diagnosing a scaphoid fracture
can sometimes be difficult. Most patients will
experience tenderness to palpation over the ana-
tomic snuff box or the distal scaphoid tubercle,
pain with longitudinal compression of the thumb,
and limited range of motion and pain at the end
arc of motion, especially with flexion and radial
deviation [7–9]. Reduced grip strength may be
noted [7–9]. However, not all patients will experi-
ence pain over the scaphoid, even with a well-de-
fined fracture seen on radiograph [7]. Overall,
sensitivity is high for clinical examination, but
specificity approaches only 74% to 80% [8,9].
Plain-film radiographs are usually obtained
first in the acute setting when a scaphoid fracture
is suspected. The lateral radiograph is particularly
useful, and a proper study should show a colinear
capitate and radius, with the pisiform located
between the distal pole of the scaphoid and the
body of the capitate. This study allows the carpal
alignment and distal radioulnar joint alignment to
be evaluated. Classically, patients who had clinical
findings of scaphoid fracture but negative initial
radiographs were treated with 2 weeks of cast
immobilization followed by repeat examination
and radiographic studies, with the belief that the
delay allows for bony resorption adjacent to the
fracture site, making the fracture visible [7,10].
Although this approach remains an accepted
option for treatment, it may result in unnecessary
orthopedic.theclinics.com
230 ADAMS & STEINMANN
immobilization, with adverse effects on return to
work and requirement for repeat radiographs,
clinical examinations, and splint or cast changes
[11–13]. Most patients who have a suspected
scaphoid fracture have not actually injured the
scaphoid, and casting for no fracture just to pres-
ent a conservative treatment modality results in
overtreatment at the expense of office visits, radio-
graphs, and lost work.
Other options may include use of alternative
imaging techniques. Bone scan is sensitive but not
specific for diagnosing scaphoid fracture [14].
Bone scintigraphy has shown 100% sensitivity
and 98% specificity for a scaphoid fracture com-
pared with approximately 65% to 70% sensitivity
for plain-film radiographs [15–20]. MRI is supe-
rior to repeat radiographs for detecting occult
scaphoid fracture [21] and is considered by many
the gold standard for detecting scaphoid fracture,
with sensitivity of 95% to 100% and specificity
approaching 100% [22–24]. Furthermore, the
value of an MRI includes the ability to identify
and diagnose other causes of wrist pain if a scaph-
oid fracture is not present. If a scaphoid fracture is
identified, vascularity of the proximal pole can be
determined preoperatively with MRI. Acute frac-
tures may show normal or decreased T1 and in-
creased T2 intensity [7]. Nonunion and impaired
vascularity is often seen with low T1 and T2 mar-
row signal intensity, which may correlate with
poor healing [25,26].
The importance of missed diagnosis is high-
lighted by the risk for nonunion in up to 12% of
patients if an occult scaphoid fracture is not
identified and immobilized. Therefore, many
authorities recommend a highly conservative
strategy to immobilize patients who have a history
suggestive of scaphoid fracture but negative plain
films. However, this treatment using splinting and
casting can lead to loss of work and economic
implications [11,12,14]. Cost of time off from
work and serial casting and office visits easily ex-
ceeds the cost of an MRI or CT scan for definitive
diagnosis [12].
In a randomized control trial of 28 patients
who had suspected scaphoid fracture, Brooks and
colleagues [13] investigated the cost-effectiveness
of MRI for diagnosing suspected scaphoid frac-
tures. Patients were randomized to undergo
MRI scan or conservative treatment with immobi-
lization and serial clinical and radiographic evalu-
ation. Those who underwent MRI had a shorter
duration of immobilization and decreased use of
health care resources but increased cost to treat
compared with patients randomized to the non-
MRI group, who were immobilized and evaluated
with serial clinical and radiographic examination.
Cost per day of unnecessary immobilization be-
tween the groups was $44.37. However, these costs
do not consider absenteeism from work and
leisure activities [13]. Pillai and Jain [11] reported
a rate of more than 80% of unnecessary immobi-
lization when all clinically suspected scaphoid
fractures with negative radiographs were immobi-
lized in the traditional treatment algorithm. In this
series, 6.7% of 90 initially radiographic-negative
wrists were found to have a scaphoid fracture,
whereas 10 additional patients had other injuries
of the wrist not involving the scaphoid [11]. The
findings suggest that the cost of needless immobi-
lization, with further clinical and radiographic
studies, would have exceeded early alternative in-
vestigations, such as MRI or bone scan, which
were frequently required anyway [11].
Thorpe and colleagues [27] reported a series of
59 patients who had clinical symptoms suggesting
scaphoid fracture but negative radiographs. All
underwent MRI, bone scintigraphy, and clinical
follow-up, with clinical follow-up deemed the
gold standard for diagnosis. Clinically, 4 scaphoid
fractures, 10 other fractures, and 3 significant
ligamentous injuries were identified. Although all
scaphoid fractures were identified with both
MRI and bone scan, MRI was noted to have
better interobserver agreement and fewer false-
positives. Likewise, other causes of wrist pain,
including ligamentous injury or carpal instability,
could be identified with MRI, whereas these find-
ings could not be diagnosed with bone scan. These
investigators further noted that costs were similar
[27].
In a study comparing sensitivity and specificity
of MRI and bone scintigraphy in diagnosing
occult scaphoid fractures, 43 patients who had
wrist trauma and normal radiographs underwent
MRI and bone scan an average of 19 days after
injury. Of these, 6 patients (14%) ultimately were
diagnosed with a scaphoid waist fracture. Patients
were followed up for more than 1 year after
injury. MRI was noted to be more sensitive in
detecting occult scaphoid fracture, with fewer
false-positives than bone scan [28]. Dorsay and
colleagues [12] investigated the cost-effectiveness
of early MRI for detecting occult scaphoid frac-
tures. They noted that 75% of patients who had
clinical evidence of scaphoid fracture would be
immobilized unnecessarily if they underwent stan-
dard treatment with repeat radiographs after
 ACUTE SCAPHOID FRACTURES
immobilization. The cost differential between
standard follow-up and MRI was small [12].
In practice, although MRI can detect a fracture
within 4 to 6 hours, this specialized study cannot
always be obtained in the emergency department.
However, obtaining an MRI at 36 to 48 hours is
a reasonable goal. Occasionally, MRI may show
a false-positive result, but false-negative examina-
tions are rare. Thus, an early MRI can reliably
exclude patients who do not have a scaphoid
fracture and in whom immobilization may safely
be discontinued. Although CT scans can also
identify fractures and are useful for defining
incomplete or nonunions and for preoperative
planning with respect to intrascaphoid angles and
scaphoid collapse, they are not as accurate as
MRI for identifying acute occult scaphoid frac-
tures and may not reveal alternative diagnoses,
such as ligamentous injury.
Technetium bone scan is sensitive, but false-
positives may occur in patients who have arthrosis
or prior or concurrent injury. Likewise, bone
scans require a delay in performing the test and
often do not adequately elucidate alternative di-
agnoses. MRI is at least as sensitive and more
specific, involves less radiation exposure, and may
allow alternative problems to be diagnosed [13].
The authors’ algorithm in a patient who has
wrist trauma is to obtain anteroposterior, lateral,
and oblique radiographic views of the wrist. If
a scaphoid fracture is identified on the radio-
graphs, then a CT scan can be obtained for
surgical planning if necessary. If the radiographs
are negative or equivocal, then a limited MRI of
the wrist is then obtained to determine the
presence or absence of a scaphoid fracture. If
needed, a CT scan can also be obtained after the
MRI to help plan for surgical treatment.
Classification
Classification of scaphoid fractures has been
well described in the literature. Three common
classifications used for scaphoid fracture are the
Mayo classification, Russe classification, and
Herbert classification (Fig. 1).
Some series have shown limited prognostic
value and poor inter- and intraobserver reliability
of scaphoid fracture classification schemes [29];
nevertheless, the Mayo, Russe, and Herbert classi-
fications are commonly used in clinical practice
and many authorities feel they may be helpful in
determining treatment options and providing
231
prognostic information. The first two classifica-
tions are based on anatomic planes of the scaph-
oid. However, the Herbert classification defines
stable and unstable fractures [1,2,7] and therefore
may be particularly helpful in determining treat-
ment options. The type A Herbert [2] classifica-
tion fracture is a stable acute fracture and type
B is an unstable acute fracture. Stable fractures
include fractures of the tubercle (A1) and an
incomplete fracture of the waist (A2). These frac-
tures can potentially be treated nonoperatively.
The other types of fractures in the Herbert classi-
fication usually require surgical treatment. Type B
fractures (acute unstable fractures) include sub-
types B1 (oblique fractures of the distal third),
B2 (displaced or mobile fractures of the waist),
B3 (proximal pole fractures), B4 (fracture disloca-
tions), and B5 (comminuted fractures). Type C
fractures show delayed union after more than 6
weeks of plaster immobilization, whereas type D
fractures are established nonunions, either fibrous
(D1) or sclerotic (D2).
Treatment of acute scaphoid fractures
Differences of opinion exist on indications for
operative therapy in the setting of acute scaphoid
fractures. Nonoperative therapy often requires
prolonged immobilization of at least 12 weeks,
and much longer for more proximal fractures
[3,7,30,31]. Although few studies exist in the litera-
ture documenting consequences of long-term cast
immobilization, clearly this treatment can result
in significant stiffness that may require a protracted
rehabilitation period, and some series suggest
a poorer outcome after prolonged immobilization
[30,32,33]. In addition, union rates are higher
with operative management, approaching 95% or
higher in most series of all types of scaphoid frac-
tures [30,34–36]. Multiple studies of percutaneous
fixation of scaphoid fractures have documented
satisfactory outcomes and minimal complications
[2,30,34,37–44]. Comparative studies of surgery
versus casting for acute fractures have documented
better range of motion at the wrist, earlier healing
(7 weeks until union versus 12 weeks with casting),
and earlier return to work with surgical manage-
ment. Furthermore, minimal differences were seen
in these groups with respect to outcomes and
satisfaction at final follow-up and, importantly,
no increased complication rate related to surgical
treatment was observed [30,45,46]. Therefore,
percutaneous treatment of acute scaphoid fracture
232 ADAMS & STEINMANN
Fig. 1. Herbert classification of scaphoid fractures. (From Herbert TJ. The fractured scaphoid. St. Louis (MO): Quality
Medical Publishing;1990; with permission.)
seems to have a low morbidity level and, in the
hands of an experienced surgeon, will not result
in a higher complication rate than nonsurgical
treatment [2]. Furthermore, up to one third of
proximal pole fractures may result in a nonunion
even with appropriate immobilization. Several
studies showed good results with early surgical
intervention, and a careful dorsal approach does
not seem to injure the blood supply.
Authors’ preferred approach to acute scaphoid
fractures
In considering overall treatment options, per-
haps all proximal pole and displaced scaphoid
fractures are best treated with surgery (Figs. 2 and
3). Percutaneous screw fixation is preferred. The
scaphoid is reduced and preliminarily pinned dor-
sally to volarly, and then a screw introduced vol-
arly, unless the fracture is of the proximal pole, in
which case the opposite approach is taken.
Scaphoid nonunions
Despite optimal therapy, nonunion or mal-
union may ensue. Patient and nonunion character-
istics must be considered when treating the
established scaphoid nonunion. Because the bony
attachments of the dorsal intercarpal ligament and
dorsal scapholunate ligament are maintained in the
setting of a fracture of the proximal one third of the
scaphoid, these fractures rarely show instability
patterns, such as dorsal intercalated segmental
instability. Nonunion of a scaphoid fracture,
 ACUTE SCAPHOID FRACTURES
Fig. 2. This acute scaphoid fracture was identified in
a 29-year-old man who fell from a ladder injuring his
nondominant hand.
however, can result in carpal malalignment and
progressive radiocarpal arthrosis [5,7,47,48], but
the real effect of a malunion is less clearly defined.
In a series of 160 scaphoid nonunions treated
with internal fixation and bone grafting in which
90% healed, failure to achieve union was related
to a proximal fracture location, avascularity of
the proximal pole, instability of the fracture, and
delay to surgery. Residual flexion deformity of
the scaphoid did not affect the outcome, and there-
fore malunion was not believed to contribute to
Fig. 3. Treatment consisted of percutaneous screw
placement. No treatment was indicated for his chronic
ulnar styloid nonunion.
233
a poor result. This study, however, showed that
the length of immobilization negatively affects the
functional outcome [33].
Summary
Operative fixation is the authors’ preferred
treatment for acute fractures in which the fracture
is clearly visible on plain film radiographs. We
believe that a clearly visible fracture line is
evidence of a displaced fracture that should be
treated operatively. Several authors have shown
low morbidity and satisfactory outcomes after
operative fixation [2,30,34,37–44]. Surgical time
and morbidity are minimal and complications
are infrequent. In addition, acute treatment may
result in decreased risk for nonunion.
When a patient presents with clinical symp-
toms suggesting scaphoid fracture, initial radio-
graphs are obtained. A scaphoid fracture readily
identified on plain films represents displacement,
and acute operative treatment is recommended,
with the authors preferring percutaneous place-
ment of a cannulated screw. If no fracture is seen
and clinical findings suggest scaphoid fracture, an
MRI should be obtained. If the MRI shows
a fracture, nonoperative treatment may be un-
dertaken with a short-arm thumb spica cast, with
the wrist in neutral position immobilizing the
thumb to the interphalangeal joint, unless the
fracture is at the proximal pole. This cast is
maintained for 6 weeks and then a CT scan is
obtained. If the CT still suggests unhealed frac-
ture, cast immobilization is maintained for an-
other 6 weeks, except when a fracture of the
proximal pole is identified on MRI. In these cases,
percutaneous operative fixation should be un-
dertaken to lessen the chance of nonunion. After
operative fixation, the patient is placed in a volarly
based thumb spica splint. If the patient is unlikely
to comply with postoperative activity restrictions,
then a short-arm thumb spica cast is placed. If the
patient is reliable, a removable splint may be
provided. Activity is restricted to lifting no more
than 2 lb, no repetitive use, and using the hand
only for activities of daily living and personal
hygiene. At 6 weeks, a CT scan is obtained to
evaluate for evidence of union. If evidence of
healing is present, such as disappearance of the
fracture line, spot welding between fragments, or
callous formation, then immobilization is discon-
tinued and the patient allowed a gradual return to
activities. The literature suggests that partial
234 ADAMS & STEINMANN
union is often present but usually progresses to
full union without the need for additional immo-
bilization [49]. If no evidence of healing is noted,
immobilization is continued and another CT
scan obtained 4 to 6 weeks later.
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