PassFinals
Trauma & Orthopaedics

Scaphoid Fracture

A scaphoid fracture after a fall onto an outstretched hand can be occult on initial radiographs; immobilise clinical suspicion, obtain definitive imaging promptly, and escalate proximal or displaced injuries because retrograde blood supply makes non-union and avascular necrosis clinically important.

In a nutshell

Suspect a scaphoid fracture after a forced-hyperextension injury with focal scaphoid tenderness. Initial radiographs may be normal: immobilise and arrange definitive imaging. The proximal pole and displaced fractures need urgent specialist assessment because retrograde blood supply increases the risk of non-union and avascular necrosis.

Classic presentation

A patient with thumb-side wrist pain and anatomical snuffbox tenderness after a fall onto an outstretched hand, with a normal or equivocal initial radiograph.

Key points

  • Examine the anatomical snuffbox, scaphoid tubercle and proximal pole, and assess pain on ulnar deviation and axial thumb loading.
  • Request dedicated scaphoid radiographs, but do not use a normal initial film to exclude the fracture.
  • Immobilise a clinically suspected fracture and arrange MRI or specialist review; NICE supports MRI as first-line imaging after thorough examination.
  • Use CT to measure displacement in a definite fracture and to assess union when radiographs are equivocal or symptoms persist.
  • Stable, minimally displaced waist or distal-pole fractures can be casted under specialist follow-up; displaced, unstable and proximal-pole injuries need urgent hand or orthopaedic assessment.
  • Do not end follow-up just because pain improves: union needs appropriate radiographic or CT confirmation.

First-line investigation

Thorough wrist examination followed by dedicated scaphoid radiographs; if the films are normal or equivocal but suspicion remains, arrange MRI through the urgent specialist pathway.

Management

Protect and image

  • Assess skin and neurovascular status, immobilise the wrist, obtain dedicated scaphoid radiographs and give analgesia using the current BNF and local trauma protocol.1,4

Do not dismiss a normal film

  • If suspicion persists despite normal or equivocal radiographs, keep the wrist immobilised and arrange MRI or specialist review; NICE supports MRI as first-line imaging after thorough examination.3,1

Stratify the fracture

  • Use CT for displacement in a definite fracture. Stable minimally displaced waist or distal-pole injuries may be casted, whereas displaced, unstable or proximal-pole injuries require urgent specialist assessment and may need fixation.1

Prove union

  • Arrange union imaging at the specialist-recommended interval; persistent tenderness, absent progression or cystic change requires CT and reassessment for continued immobilisation or surgery.1

Protect recovery

  • Give cast or splint care, activity and analgesia advice, and return instructions for worsening pain, numbness, colour change or cast problems; later recurrent wrist pain also needs review because non-union can present after the initial injury.1,2,4

Exam traps

  • A normal initial X-ray does not exclude a scaphoid fracture.
  • The proximal pole is higher risk for avascular necrosis because its blood supply is predominantly retrograde.
  • A definite fracture needs CT assessment of displacement; do not classify management from a single plain view alone.
  • Displaced proximal-pole fractures are an urgent specialist problem, not routine cast follow-up.
  • Persistent tenderness or a fracture gap during follow-up suggests delayed union or non-union and needs CT or specialist review.

Illustrations

Anatomical snuffboxPhotograph illustrating the borders and palpation point of the anatomical snuffbox on the radial wrist.Kayawaya, Wikimedia Commons · CC0
Retrograde blood supply of the scaphoidDiagram showing the radial artery branches entering at the distal pole and supplying the proximal pole retrogradely.PassFinals · original
X-ray of a scaphoid waist fractureRadiograph demonstrating a fracture line across the waist of the scaphoid.James Heilman, MD, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. British Society for Surgery of the Hand: Scaphoid fracture standards of care (Current BSSH acute scaphoid fracture standard for adults over 16, covering dedicated radiographs, immobilisation, MRI or CT pathways, displacement and proximal-pole referral, fixation and union follow-up; document to be revised in 2027.)
  2. Cambridge University Hospitals NHS Foundation Trust: Scaphoid fractures (NHS patient information on occult presentation, immobilisation, follow-up imaging and recovery advice for scaphoid fractures.)
  3. NICE NG38: Fractures (non-complex): assessment and management (Recommendation 1.2.3: consider MRI for first-line imaging in people with suspected scaphoid fractures after a thorough clinical examination; guideline last reviewed 23 June 2025.)
  4. BNF online: current analgesia prescribing information (Use the current BNF and local trauma protocol for age-, weight-, renal-function- and pregnancy-appropriate analgesic choice, dose, contraindications and monitoring; no fixed dose is reproduced here.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.