Acute scaphoid fractures: guidelines for diagnosis and treatment

Overview

This review provides guidance on diagnosing and treating acute scaphoid fractures, the most common carpal fractures. They are easily missed, and a delayed diagnosis increases the risk of non-union and long-term wrist problems.

Clinical suspicion

A scaphoid fracture should be suspected after a fall on the outstretched hand with pain on the thumb side of the wrist. Tenderness in the anatomical snuffbox and other provocative tests are sensitive but not specific, so a combination of findings is more useful than any single sign.

Imaging

Initial radiographs should include dedicated scaphoid views. Because early radiographs can miss a fracture, patients with ongoing clinical suspicion and normal films should have further imaging. MRI is favoured for its accuracy in excluding a fracture, and CT is useful for defining fracture displacement. Early advanced imaging avoids unnecessary prolonged immobilisation of patients who have no fracture.

Treatment

Non-displaced fractures of the scaphoid waist are usually treated with cast immobilisation, while surgical fixation is an option for patients who want a faster return to activity. Displaced, unstable or proximal pole fractures generally need surgical fixation because of a higher risk of non-union.

Follow-up

Healing should be confirmed, ideally with CT when radiographs are unclear, before immobilisation ends. Non-union and avascular necrosis are the main complications to look out for.