- Kevin deWeber, MD, FAAFP, FACSM
Kevin deWeber, MD, FAAFP, FACSM
- Family Medicine of SW Washington Residency
- PeaceHealth SW Medical Center
- Affiliate Associate Professor of Family Medicine
- Oregon Health and Science University
- Clinical Instructor of Family Medicine
- University of Washington School of Medicine
- Section Editors
- Patrice Eiff, MD
Patrice Eiff, MD
- Section Editor — Adult Orthopedics; Sports-Related Injuries
- Professor of Family Medicine
- Oregon Health & Science University
- Chad A Asplund, MD, FACSM, MPH
Chad A Asplund, MD, FACSM, MPH
- Associate Professor of Health and Kinesiology
- Director of Athletic Medicine
- Head Team Physician
- Georgia Southern University
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Scaphoid fractures are among the most common upper extremity injuries. They frequently occur following a fall onto an outstretched hand. Plain radiographs taken soon after the injury may not reveal a fracture, but the clinician should assume one is present until definitive proof otherwise is obtained.
This topic will review the diagnosis and nonoperative management of scaphoid (navicular) fractures in adults. An overview of carpal fractures and distal radius fractures and discussions of how to evaluate wrist or thumb pain in adults are presented separately. (See "Overview of carpal fractures" and "Evaluation of the adult with acute wrist pain" and "Evaluation of the adult with subacute or chronic wrist pain" and "Evaluation of the patient with thumb pain" and "Distal radius fractures in adults" and "Anatomy and basic biomechanics of the wrist".)
Carpal fractures account for approximately 5 percent of all fractures and 18 percent of hand fractures, and scaphoid fractures are the most common carpal fracture [1-3]. Scaphoid fractures account for 10 percent of all hand fractures and 60 to 70 percent of all carpal fractures [1,4].
A study of scaphoid fractures in the military showed an unadjusted incidence of 1.21/1000 person-years. In addition, males and whites had a higher relative risk, and 20 to 24 year olds had the highest incidence at 1.64/1000 person-years . According to data from the United States National Electronic Injury Surveillance System, the estimated incidence in the population at large is 1.47 fractures/100,000 person-years .
The anatomy and biomechanics of the wrist are discussed in detail separately; anatomy of particular relevance to scaphoid injury is reviewed here. (See "Anatomy and basic biomechanics of the wrist".)
- Eiff MP, Hatch RL, Calbach WL. Carpal fractures. In: Fracture Management for Primary Care, 2nd ed, Saunders, Philadelphia 2003.
- Alshryda S, Shah A, Odak S, et al. Acute fractures of the scaphoid bone: Systematic review and meta-analysis. Surgeon 2012; 10:218.
- Duckworth AD, Jenkins PJ, Aitken SA, et al. Scaphoid fracture epidemiology. J Trauma Acute Care Surg 2012; 72:E41.
- Geissler WB. Carpal fractures in athletes. Clin Sports Med 2001; 20:167.
- Wolf JM, Dawson L, Mountcastle SB, Owens BD. The incidence of scaphoid fracture in a military population. Injury 2009; 40:1316.
- Van Tassel DC, Owens BD, Wolf JM. Incidence estimates and demographics of scaphoid fracture in the U.S. population. J Hand Surg Am 2010; 35:1242.
- Seitz WH Jr, Papandrea RF. Fractures and dislocations of the wrist. In: Rockwood and Green's Fractures in Adults, 5th ed, Bucholz RW, Heckman JD (Eds), Lippincott Williams & Wilkins, Philadelphia 2002.
- Dobyns JH, Beckerbaugh RD, Bryan RS, et al. Fractures of the hand and wrist. In: Hand Surgery, 3rd ed, Flynn JE (Ed), Williams & Wilkins, Philadelphia 1982.
- Geissler W, Slade JF. Fractures of the carpal bones. In: Operative Hand Surgery, 6th ed, Green DP (Ed), Churchill Livingstone, Philadelphia 2011. p.639.
- Carpenter CR, et al. Adult scaphoid fracture. Acad Emerg Med 2014; 21:102.
- Waeckerle JF. A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures. Ann Emerg Med 1987; 16:733.
- Mallee WH, Wang J, Poolman RW, et al. Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Cochrane Database Syst Rev 2015; :CD010023.
- Chen AC, Lee MS, Ueng SW, Chen WJ. Management of late-diagnosed scaphoid fractures. Injury 2010; 41:e10.
- Bernard SA, Murray PM, Heckman MG. Validity of conventional radiography in determining scaphoid waist fracture displacement. J Orthop Trauma 2010; 24:448.
- Lozano-Calderón S, Blazar P, Zurakowski D, et al. Diagnosis of scaphoid fracture displacement with radiography and computed tomography. J Bone Joint Surg Am 2006; 88:2695.
- Bhat M, McCarthy M, Davis TR, et al. MRI and plain radiography in the assessment of displaced fractures of the waist of the carpal scaphoid. J Bone Joint Surg Br 2004; 86:705.
- Dorsay TA, Major NM, Helms CA. Cost-effectiveness of immediate MR imaging versus traditional follow-up for revealing radiographically occult scaphoid fractures. AJR Am J Roentgenol 2001; 177:1257.
- Hauger O, Bonnefoy O, Moinard M, et al. Occult fractures of the waist of the scaphoid: early diagnosis by high-spatial-resolution sonography. AJR Am J Roentgenol 2002; 178:1239.
- Yin ZG, Zhang JB, Kan SL, Wang XG. Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis. Clin Orthop Relat Res 2010; 468:723.
- Yin ZG, Zhang JB, Kan SL, Wang XG. Diagnostic accuracy of imaging modalities for suspected scaphoid fractures: meta-analysis combined with latent class analysis. J Bone Joint Surg Br 2012; 94:1077.
- Bergh TH, Steen K, Lindau T, et al. Costs analysis and comparison of usefulness of acute MRI and 2 weeks of cast immobilization for clinically suspected scaphoid fractures. Acta Orthop 2015; 86:303.
- Patel NK, Davies N, Mirza Z, Watson M. Cost and clinical effectiveness of MRI in occult scaphoid fractures: a randomised controlled trial. Emerg Med J 2013; 30:202.
- Hansen TB, Petersen RB, Barckman J, et al. Cost-effectiveness of MRI in managing suspected scaphoid fractures. J Hand Surg Eur Vol 2009; 34:627.
- Karl JW, Swart E, Strauch RJ. Diagnosis of Occult Scaphoid Fractures: A Cost-Effectiveness Analysis. J Bone Joint Surg Am 2015; 97:1860.
- Yin ZG, Zhang JB, Gong KT. Cost-Effectiveness of Diagnostic Strategies for Suspected Scaphoid Fractures. J Orthop Trauma 2015; 29:e245.
- Tiel-van Buul MM, Broekhuizen TH, van Beek EJ, Bossuyt PM. Choosing a strategy for the diagnostic management of suspected scaphoid fracture: a cost-effectiveness analysis. J Nucl Med 1995; 36:45.
- Smith M, Bain GI, Turner PC, Watts AC. Review of imaging of scaphoid fractures. ANZ J Surg 2010; 80:82.
- Beeres FJ, Hogervorst M, Rhemrev SJ, et al. A prospective comparison for suspected scaphoid fractures: bone scintigraphy versus clinical outcome. Injury 2007; 38:769.
- Chakravarty D, Sloan J, Brenchley J. Risk reduction through skeletal scintigraphy as a screening tool in suspected scaphoid fracture: a literature review. Emerg Med J 2002; 19:507.
- Herneth AM, Siegmeth A, Bader TR, et al. Scaphoid fractures: evaluation with high-spatial-resolution US initial results. Radiology 2001; 220:231.
- Eastley N, Singh H, Dias JJ, Taub N. Union rates after proximal scaphoid fractures; meta-analyses and review of available evidence. J Hand Surg Eur Vol 2013; 38:888.
- Singh HP, Taub N, Dias JJ. Management of displaced fractures of the waist of the scaphoid: meta-analyses of comparative studies. Injury 2012; 43:933.
- Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am 2001; 83-A:483.
- Saedén B, Törnkvist H, Ponzer S, Höglund M. Fracture of the carpal scaphoid. A prospective, randomised 12-year follow-up comparing operative and conservative treatment. J Bone Joint Surg Br 2001; 83:230.
- Dias JJ, Dhukaram V, Abhinav A, et al. Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months. J Bone Joint Surg Br 2008; 90:899.
- Vinnars B, Pietreanu M, Bodestedt A, et al. Nonoperative compared with operative treatment of acute scaphoid fractures. A randomized clinical trial. J Bone Joint Surg Am 2008; 90:1176.
- Shen L, Tang J, Luo C, et al. Comparison of operative and non-operative treatment of acute undisplaced or minimally-displaced scaphoid fractures: a meta-analysis of randomized controlled trials. PLoS One 2015; 10:e0125247.
- Ibrahim T, Qureshi A, Sutton AJ, Dias JJ. Surgical versus nonsurgical treatment of acute minimally displaced and undisplaced scaphoid waist fractures: pairwise and network meta-analyses of randomized controlled trials. J Hand Surg Am 2011; 36:1759.
- Buijze GA, Doornberg JN, Ham JS, et al. Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. J Bone Joint Surg Am 2010; 92:1534.
- Fowler JR, Hughes TB. Scaphoid fractures. Clin Sports Med 2015; 34:37.
- Langhoff O, Andersen JL. Consequences of late immobilization of scaphoid fractures. J Hand Surg Br 1988; 13:77.
- Wong K, von Schroeder HP. Delays and poor management of scaphoid fractures: factors contributing to nonunion. J Hand Surg Am 2011; 36:1471.
- Buijze GA, Ochtman L, Ring D. Management of scaphoid nonunion. J Hand Surg Am 2012; 37:1095.
- Adams JE, Steinmann SP. Acute scaphoid fractures. Orthop Clin North Am 2007; 38:229.
- Ingari JV. Wrist and hand. In: DeLee and Drez's Orthopedic Sports Medicine Principles and Practice, 3rd ed, Saunders, Philadelphia 2010.
- Rettig ME, Dassa GL, Raskin KB, Melone CP Jr. Wrist fractures in the athlete. Distal radius and carpal fractures. Clin Sports Med 1998; 17:469.
- Buijze GA, Goslings JC, Rhemrev SJ, et al. Cast immobilization with and without immobilization of the thumb for nondisplaced and minimally displaced scaphoid waist fractures: a multicenter, randomized, controlled trial. J Hand Surg Am 2014; 39:621.
- Clay NR, Dias JJ, Costigan PS, et al. Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. J Bone Joint Surg Br 1991; 73:828.
- Doornberg 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.
- Gellman H, Caputo RJ, Carter V, et al. Comparison of short and long thumb-spica casts for non-displaced fractures of the carpal scaphoid. J Bone Joint Surg Am 1989; 71:354.
- CLINICAL ANATOMY
- MECHANISM OF INJURY
- SYMPTOMS AND EXAMINATION FINDINGS
- DIAGNOSTIC IMAGING
- MANAGEMENT OF SUSPECTED ACUTE FRACTURE WITH NEGATIVE PLAIN RADIOGRAPHS
- Approach to imaging and diagnosis
- Magnetic resonance imaging
- Radionuclide bone scan
- Computed tomography
- DIFFERENTIAL DIAGNOSIS
- INDICATIONS FOR SURGICAL REFERRAL
- IMMOBILIZATION (CASTING) AND GENERAL MANAGEMENT
- Initial treatment
- Casting recommendations
- FOLLOW-UP CARE
- RETURN TO SPORT OR WORK
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS