Feature

Scaphoid fracture:
diagnosis and management
Jim Bethel describes how fracture of the scaphoid,
one of the most common types of injury to the wrist,
should be diagnosed and managed in emergency departments

These findings should be treated with caution,

Summary
however, because several authors claim that scaphoid
Nurses working in first-contact settings commonly injuries in children can be missed.
assess and manage patients with suspected or actual Iqbal et al (2007), for example, report that an
injury to the scaphoid bone. In this article, lack of 11-year-old boy developed avascular necrosis of both
consensus on the assessment of such injuries, and poles of the scaphoid after an injury that was missed
on which treatment regimen and imaging techniques on first presentation.
should be used, is discussed. The importance Nashi et al (1998), meanwhile, describe how
of being aware of the risk of avascular necrosis of a similarly aged boy fell from a height and sustained
the bone after injury is also emphasised. a supracondylar fracture of the elbow, which was
treated, but also a fractured waist of scaphoid,
Keywords which was missed on initial presentation.
Fracture, scaphoid, immobilisation The authors acknowledge that scaphoid injury
is often missed initially in such cases because it is
Research suggests that up to 2.5 per cent unusual in young people.
of all patients attending emergency
departments (EDs) present with injured Anatomy and physiology
wrists (You et al 2007). The scaphoid bone has a proximal and a distal
The scaphoid is the most commonly injured pole joined by a narrow waist. A tubercle lies at the
of the eight bones of the wrist (Chakravarty et al medial distal aspect of the bone, in the distal pole.
2002, Kozin 2001, Powell et al 1988), accounting Between 75 and 80 per cent of scaphoid
for between 70 and almost 90 per cent of all fractures occur through the waist of the bone
carpal bone injuries (McNally and Gillespie (Hoynak and Hopson 2007, Morhart et al 2008),
2004, Schubert 2000), and about 10 per cent between 15 and 20 per cent occur at the proximal
of all fractures of the hand and wrist (Kouris pole, and between 10 and 15 per cent at the distal
and Schenck 2008). pole (Morhart et al 2008).
Most scaphoid injuries seen in EDs have been Tubercle fractures are rare and usually occur
sustained by men aged between 15 and 30. as an avulsion-type injury. They are associated with
In children, the weakness of the radius hyperflexion or forced ulnar deviation rather than
compared with the scaphoid is such that a the more common cause of such injuries, that is
buckle, or Salter Harris type II, fracture of the falls onto outstretched hands (Ritchie and Munter
distal radius is the more likely consequence of a 1999, Schubert 2000).
fall on to an outstretched hand. In older people, Fractures of the scaphoid are usually classified
such a fall more often results in Colles’ fracture using Herbert and Fisher’s (1984) system,
(Forman et al 2005, Gillon 2001, Laker et al 2008, which is based on radiological appearance of
Powell et al 1988, Schubert 2000). injury (Table 1).

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 Feature

Blood supply to the scaphoid bone is provided although this swelling can also be a feature of
by a sub-division of the radial artery and enters injuries to other structures close to the scaphoid
the bone near the tubercle and waist in a (Hunter 2005).
distal‑to‑proximal direction. Schubert (2000) points out that such swelling
The proximal pole therefore has no direct may not be evident, however, for up to four hours
vascular provision and is prone to avascular after injury, and can resolve after four days or more.
necrosis if it becomes isolated from its blood supply This should be borne in mind when patients present
by a fracture, particularly a complete fracture outside these timeframes.
of the waist or a fracture of the proximal pole, Given the possible absence of swelling in
(Grant Phillips et al 2004, Morhart et al 2008). scaphoid fractures, clinicians should be aware of the
For this reason, early surgical fixation of various techniques that can help identify the injury.
proximal pole fractures, rather than the more
conservative immobilisation in a plaster cast, which Pain over the ASB The ASB is located between the
is typical for scaphoid fractures, is advocated extensor pollicis brevis and extensor pollicis longus,
(Laker et al 2008). Some authors, however, report at the base of the thumb, and pain in this area
little benefit from internal fixation in complete is associated traditionally with scaphoid fracture
fractures of the waist (Dias et al 2005). (Begg 2005, Kouris and Schenck 2008, McNally and
There is a lack of consensus about the onset Gillespie 2004, Simon et al 2005).
of avascular necrosis. McRae and Esser (2008), Many authors point out, however, that ASB
for example, state that it can be sudden, while Hirohata tenderness indicates injury but not specifically
and Ito (1992) and Nallegowda et al (2005) have scaphoid fracture. It can indicate instead fracture
identified late-onset necrosis after scaphoid injury. of the distal radius, the radial styloid or the lunate or
Apart from arthritic-type pain and stiffness triquetral bones, or injury to the soft tissues of the
of the wrist, patients with established necrosis wrist (Grant Phillips et al 2004, Laker et al 2008,
also complain of numbness and tingling in the area. McRae and Esser 2008, Schubert 2000).
In addition, Nallegowda et al (2005) report
symptoms that are associated more usually with carpal Axial compression Much of the literature
tunnel syndrome, in particular sensory changes that describes the use of axial compression, or
are consistent with median nerve compression. telescoping, of the thumb, also known as the
scaphoid compression test (Larsen 2002, McNally
Mechanism of injury and Gillespie 2004).
A fall onto an outstretched hand, with associated During this test, the base of the proximal phalanx
hyperextension of the wrist, radial deviation and of the thumb is compressed onto the trapezium,
axial loading of the scaphoid onto the radial rim, which is then compressed onto the distal scaphoid.
is by far the most common cause of injury to the However, Powell et al (1988) assert that a positive
bone and should be confirmed during initial history scaphoid compression test is ambiguous, a claim
taking (Berdia and Wolfe 2001, Laker et al 2008, that is supported by Schubert (2000), who states
McNally and Gillespie 2004). that it indicates only that there is bony injury on the
Other, less common causes of scaphoid radial aspect of the wrist or hand.
injury include:
■■ Hyperextension associated with deceleration, Table 1 Classification of scaphoid fractures
rather than falling, in which the arm is planted Type Description
against, for example, the steering wheel of a car.
■■ ‘Kickback’ injuries from machinery.
A Acute but stable injuries such as fractures of the tubercle and
■■ Hyperflexion injuries (Ritchie and Munter 1999).
undisplaced or incomplete fractures of the waist.
■■ Avulsion fractures secondary to forced
ulnar deviation.
B Acute unstable injuries such as distal oblique fractures, complete
■■ Direct impact to the scaphoid causing fracture.
fractures of the waist, proximal pole fractures and fracture dislocation.
■■ Stress fractures in athletes (Boles 2007).
C Fractures in which there is evidence of delayed union.
Assessment
There is evidence that scaphoid fractures can
D Fractures in which non-union is established.
present with mild or moderate swelling over the
anatomical snuff box (ASB), on the radial aspect
Herbert and Fisher (1984)
of the wrist (McRae and Esser 2008, Purcell 2003),

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 Feature

Figure 1 Coloured X-ray, anteroposterior view, of the wrist showing the bones directly over the scaphoid bone, whereas they apply
of the hand including scaphoid with fracture pressure only indirectly when using other manoeuvres.
The absence of tubercle pain, particularly
in association with a lack of ASB tenderness,
indicates that scaphoid fracture is unlikely
(Laker et al 2008, Schubert 2000).
Trapezoid
Investigations
Capitate X-ray The main investigation for suspected
scaphoid injury is wrist X-ray including standard
Hamate anterioposterior (Figure 1) and lateral views, with
additional scaphoid views; that is, a pronated
oblique view and an ulnar-deviated oblique view
Trapezium Pisiform (Laker et al 2008).
Up to about 15 per cent of scaphoid fractures are
Scaphoid Triquetral undetectable on initial X-ray and there is evidence
showing that many are misdiagnosed as sprained wrist (Guly
fracture 2002, Larsen 2002).
Evidence of fracture that is invisible on X-ray
includes the presence of an abnormally elevated
Radius scaphoid fat stripe on the lateral border of the
Lunate scaphoid, as seen in the anterioposterior and
oblique wrist views.
Science Photo Library

Schubert (2000) claims that, in such cases,

Ulna the presence of abnormally elevated fat stripes in
the wrist is as significant as posterior and displaced
anterior fat pads in elbow injuries. Annamalai and
Raby (2003) dispute this claim, however.
Patients with clinical signs, but no radiological
Pain on pincer grasp Pain on pincer grasp of evidence, of scaphoid fracture are usually given
the thumb against the index finger is also cited repeat X-rays between ten and 14 days after
as indicative of scaphoid injury (Cooke et al presentation, when bony injury may have become
1998), although Purcell (2003) finds that painful apparent (Boles 2007).
opposition of the thumb to the little finger is Begg (2005) says that such evidence may be
similarly significant. invisible for up to six weeks, however, while
Chakravarty et al (2002) found evidence of bony
Pain on forced ulnar deviation Several injury in only between 10 and 36 per cent of
authors (Cooke et al 1998, Powell et al 1988, patients who had returned for repeat X-rays
Waizenegger et al 1994) have found that pain on after ten days.
forced ulnar deviation of the wrist in a pronated The challenges associated with the interpretation
forearm is suggestive of scaphoid injury. of plain X-rays of the scaphoid, coupled with the
However, Schubert (2000) finds that such inconvenience to some patients of being needlessly
manoeuvres have poor specificity for scaphoid immobilised for between ten and 14 days, have
fracture and suggests that they can be harmful prompted the use of other imaging methods to
to injured wrists and hands. identify this type of fracture.

Pressure over scaphoid tubercle Application of Computed tomography (CT) Cruickshank et al

pressure over the scaphoid tubercle, which is located (2007) found that CT scans are 94 per cent
at the junction of the distal flexor wrist crease and sensitive and 100 per cent specific for
the flexor carpi radialis, has, according to Laker et al scaphoid fracture.
(2008) and Schubert (2000), greater sensitivity You et al (2007) report similar levels of sensitivity
and specificity for scaphoid fracture than the and specificity but recommend that only patients
examination techniques described above. with suspected, occult injuries, for which there
Schubert (2000) states that this is because is no radiological evidence, should be considered
practitioners using the technique apply pressure for CT scan.

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 Feature

Other studies have identified limitations with CT, Sjolin and Andersen (1988) found that patients
however. Groves et al (2005a) describe a patient with with suspected, occult scaphoid injuries who are
negative CT results for a scaphoid fracture that was treated with supportive bandages regain function
evident on plain X-ray and conclude that CT relies and return to work more quickly than those treated
too heavily on cortical and trabecular displacement with plaster casts, and conclude that such injuries
to identify all such injuries. should be treated as soft tissue injuries.
Doust (2004) cites this and other studies to
Magnetic resonance imaging (MRI) Foex et al suggest that practice should change to reflect the
(2005) consider MRI to be a reliable investigation for evidence against casting suspected occult scaphoid
patients who can tolerate being in small spaces. fractures. Yin et al (2007) conclude, however, that
They are supported by many other authors the evidence base is too small to support such as
who have found MRI more accurate and reliable change in practice.
than other methods in detecting fractures early Schubert (2000) considers that immobilisation
(Brydie and Raby 2003, Dorsay and Helms 2001, of patients with occult fracture is unnecessary,
Mack et al 2003, Raby 2001). that the risk of complications from such injuries
The lack of consistency in imaging methods is is exaggerated and that there is no evidence
highlighted by Groves et al (2005b), who undertook that occult injuries result in non-union or
a worldwide survey of imaging preferences for avascular necrosis.
suspected scaphoid injury. Patients for whom there is radiological evidence
Using data from 105 hospitals, they found that of fracture can be immobilised in plaster for up to
only about one in five had systematic assessment six weeks, during which they should be re-assessed
guidelines, including investigative options. periodically to exclude non-union (Hunter 2005,
The second most common investigative technique, Laker et al 2008).
after X-ray, was found to be MRI, which is used in more Patients treated on the basis of clinical
than 25 per cent of hospitals, followed by CT imaging, suspicion alone, however, are often asked to attend
which is used in less than 20 per cent, and then by fracture clinics between ten and 14 days after ED
scintigraphy, which is used in less than 5 per cent. presentation for repeat X-rays.
These secondary X-rays can show callus
Bone scintigraphy Work by Groves et al (2004) formation at the sites of originally non-evident
suggests that bone scintigraphy is more reliable than fracture and the patients concerned can continue
CT to identify scaphoid fracture. to be treated for scaphoid fracture.
Scintigraphy is advocated by Boles (2007) and Patients for whom there is no radiological
Laker et al (2008). It is argued, however, that, evidence of fracture on repeat X-ray, who comprise
while scintigraphy has a low false-negative rate, most of this group, are given care for soft tissue
practitioners who use it often identify lesions injury of the wrist (Kouris and Schenck 2008,
such as haematomas, synovitis and lacerations as McNally and Gillespie 2004).
false positives, which can lead to over-treatment There is some controversy about the type of
(Boles 2007, Chakravarty et al 2002). plaster-cast immobilisation that should be used for
patients with radiological evidence of fracture.
Treatment Some authors advocate a below-elbow scaphoid
The risk of non-union and avascular necrosis cast with involvement of the distal interphalangeal
has prompted practitioners to treat all patients joint of the thumb (Hoynak and Hopson 2007,
with suspected scaphoid fracture, including Hunter 2005).
those for whom it is not radiologically evident, Other authors go further and suggest that
with immobilisation in plaster (Cooke et al 1998, casts taken to above the elbow limit pronation and
Kouris and Schenck 2008, Larsen 2002). supination, and thereby enhance fracture healing
Now, however, some authors propose that, while (Laker et al 2008, Morhart et al 2008).
patients with radiologically-confirmed scaphoid Yet others argue that the involvement of the
fracture should have their wrists immobilised in thumb can limit dexterity unnecessarily and has
plaster, those with suspected scaphoid fracture for no effect on clinical outcome (Clay et al 1991,
which there is no X-ray evidence should have their Schubert 2000), and suggest that the kind of plaster
wrists supported by removable splints or bandages, cast that is used for Colles’ fracture is suitable for
which are less incapacitating and inconvenient than scaphoid fractures.
plaster casts (Chakravarty et al 2002, Larsen 2002, Some clinicians argue that early surgical fixation
Sjolin and Andersen 1988). can be beneficial in undisplaced stable fractures

EMERGENCY NURSE July 2009 | Volume 17 | Number 4 27

 Feature

because it allows patients to return to normal with scaphoid fractures (Allen 1983), although
activities quickly (Morhart et al 2008). almost all proximal pole fractures develop a degree
However, Dias et al (2005) found no significant of necrosis (Laker et al 2008).
benefit in early fixation compared to plaster‑cast People with avascular necrosis often have
immobilisation in patients with undisplaced delayed attending EDs and attempted to self-care
scaphoid fracture, and conclude that early surgical for what they assume is a soft tissue injury (Tofferi
fixation under these circumstances is not justifiable and Gilliland 2008).
and represents over-treatment. When they do attend, they usually report the
presence of non‑resolving and worsening pain
Avascular necrosis in their wrists, sensory changes secondary to
The bones most commonly affected by avascular nerve impingement, and a weak pincer grasp
necrosis are those, such as the scaphoid, with a resulting in an inability to grip and retain objects
single source of blood supply and limited collateral (Nallegowda et al 2005).
circulation (Tofferi and Gilliland 2008). Where clinicians suspect avascular necrosis,
Patients who are undertaking steroid they should refer patients urgently to
therapy, who are pregnant, or who have orthopaedic team members for them to consider
systemic lupus erythematosus, haematological surgical fixation with or without bone grafting
disorders or renal failure, are all at high risk of (Laker et al 2008).
developing the condition. An example of the management of a patient
The incidence of avascular necrosis has been with suspected avascular necrosis is described in
estimated at between 2 and 9 per cent of patients the case study below.

Case study
A 23-year-old woman presented to the emergency department Inspection revealed no obvious deformity or swelling in her wrist,
(ED) with wrist pain. She said that, ten days previously, while on although direct palpation of the anatomical snuff box and the
holiday she had fallen down some steps and extended her right scaphoid tubercle elicited marked tenderness.
arm to break her fall.
She was asked to deviate her wrist in an ulnar direction and then
She had been reluctant to go to hospital while on holiday and, to perform a pincer grasp. Both movements exacerbated pain in
although in pain, had been reassured by the lack of obvious the radial aspect of her wrist.
swelling or deformity in her wrist. Pain had been constant since
the injury and exacerbated by pincer grasp and ulnar deviation of Pinprick sensory examination revealed that innervation of her
her wrist. fingers was normal, but there was an area of reduced sensation
over the areas she had identified already as feeling numb.
For three days before presentation she had noticed sensory
changes to the dorsum of the radial aspect of her wrist over the Her pincer grasp in the affected hand seemed weaker than that in
proximal phalanx of the thumb, the bases of the index and middle the unaffected hand, but it was difficult to determine how much
metacarpals, and the trapezium and scaphoid. this was influenced by pain. Capillary refill time was less than
two seconds in the nail beds of the distal digits.
She said that these areas were numb, that pincer grasp, apart
from being painful, lacked strength and that it was difficult to Based on this information, X-rays of the right wrist with scaphoid
pick up things or use computer keyboards. She had taken 400mg views were requested. Review of the X-rays revealed a displaced
ibuprofen or 1g paracetamol intermittently to manage pain. fracture of the proximal pole of the scaphoid bone.

She had no other associated injuries. She was usually The fracture was most evident on the anterioposterior view.
healthy with no significant medical history. She had no allergies.
She worked as a clerk who lived with her partner, had no children This result, combined with the patient’s complaint of numbness
and was right-hand dominant. and weakness, suggested that she may have developed avascular
necrosis of the displaced proximal pole of the scaphoid.
Before examination, she gave a pain score of 4/10. She had
taken 1g paracetamol about an hour previously so she was given A referral to the orthopaedic team was made, therefore, and the
50mg diclofenac orally as recommended in the pain management patient was admitted to hospital for further investigation
guidelines of the College of Emergency Medicine (2004). and treatment.

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 Feature

When patients present with scaphoid injuries,

emergency care practitioners must be aware
Implications for practice
that scaphoid fractures are not always evident on There is a lack of consensus in the literature on
plain X-ray. Other imaging techniques, such as CT, scaphoid injury, and care of patients with this
MRI and scintigraphy, can be used to confirm the injury can vary between service providers and even
presence of scaphoid fracture but many practitioners between individual clinicians. More work is needed,
have only limited access to these. therefore, to establish a robust evidence base.
As a result, many patients without fracture are Clinicians should be knowledgeable about the
immobilised needlessly. Although removable splints various assessment techniques and imaging
rather than plaster casts are often used for such methods available for scaphoid injury, as well as
immobilisation, the patients involved are to some the treatment options, and use their knowledge to
extent incapacitated. provide evidence-based care.
The rationale for such caution in treating Jim Bethel is a senior lecturer
suspected scaphoid injury is the risk it presents of Further reading and nurse practitioner at the
non‑union and avascular necrosis of the bone. In the For a useful grounding in fracture treatment, read University of Wolverhampton
and Walsall Hospitals
absence of access to CT, MRI or scintigraphy, these McRae R, Esser M (2008) Practical Fracture
NHS Trust, and chair
risks still greatly influence treatment. Treatment. Churchill Livingstone, Edinburgh. of the RCN Emergency
See Test your knowledge, page 31 Care Association

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