Snapshot A 28-year-old man trips while running and lands on his outstretched left hand. He experiences immediate-onset, severe left wrist pain and inability to flex or extend his wrist. On exam, he has point tenderness dorsally over the anatomic snuffbox. A radiograph of his left wrist demonstrates a fracture of the proximal pole of the scaphoid. Introduction Clinical definition fracture of the scaphoid bone "scaphoid" is derived from the Greek word for "boat" due to its boat-like appearance Epidemiology Incidence most common carpal fracture Demographics adolescents and young adults more common in males than females Etiology Fall from standing height on an outstretched hand High-energy trauma is less common Pathoanatomy normal anatomy the scaphoid is one of four bones in the proximal carpal row of the wrist other three are the lunate, triquetrum, and pisiform articulations radius proximally lunate medially trapezium, trapezoid, and capitate distally anatomic subdivisions proximal third middle third (waist) distal third the scaphoid tubercle is part of the distal third vascular supply dorsal carpal branch of radial artery supplies proximal 80% of the scaphoid via retrograde flow the proximal scaphoid is the most likely to undergo avascular necrosis (AVN) due to its tenuous retrograde blood supply superficial palmar branch of radial artery supplies distal 20% of the scaphoid fracture location 65% scaphoid waist 25% proximal third 10% distal third the distal third is the most common site in young children due to the ossification pattern Associated conditions ligamentous injury (wrist sprain) scaphoid attaches to many wrist ligaments which can be torn in scaphoid fractures Presentation Symptoms radial wrist pain Physical exam anatomic snuffbox tenderness dorsally scaphoid tubercle tenderness volarly pain with resisted pronation Imaging Radiography indications always indicated if the fracture is suspected standard anteroposterior (AP), lateral, and oblique views of the wrist may not demonstrate the fracture dedicated scaphoid views may be needed to visualize the fracture initial radiographs may be negative if high clinical suspicion, repeat radiographs are indicated 2-3 weeks after the injury findings fracture line through the scaphoid Computerized tomography (CT) indications can be used if initial radiographs are negative less sensitive than MRI better than radiography to demonstrate healing findings can demonstrate fracture lines, fragment sizes, and extent of bony collapse Magnetic resonance imaging (MRI) indications most sensitive imaging modality within first 24 hours can be used if initial radiographs are negative findings can best demonstrate associated ligamentous injuries allows for assessment of the vascular integrity of proximal pole of scaphoid if AVN is suspected Differential Distal radius fracture fracture will be evident on an AP and/or lateral radiograph of the wrist more likely in older patients Wrist sprain ligamentous injury in the absence of a fracture will be evident on MRI Treatment Non-operative thumb spica cast immobilization indications stable non-displaced fractures normal radiographs but a high index of suspicion for occult fracture Operative percutaneous pin fixation vs open reduction and internal fixation (ORIF) indications unstable fractures displaced fractures proximal pole fractures comminuted fractures vertical or oblique fractures Complications Avascular necrosis most common in proximal injuries due to a retrograde blood supply Non-union Scaphoid non-union advanced collapse (SNAC) progressive wrist arthritis due to chronic scaphoid non-union Prognosis Favorable stable non-displaced fracture Unfavorable unstable displaced fracture AVN