The scaphoid is the wrist bone that breaks most often, and it is the one most often missed. It breaks in a fall onto an outstretched hand, the same injury that produces an ordinary sprain, and in the first days it can look and feel like nothing worse. Its blood supply runs backwards through the bone, so a fracture that is not treated properly may never heal. Most scaphoid fractures heal in a cast. Some do better with a screw. The single most important thing is that it is found.
Why this bone behaves differently
The scaphoid sits on the thumb side of the wrist and bridges the two rows of carpal bones, so almost every wrist movement loads it. Its blood supply enters at the far end, nearest the thumb, and runs backwards along the bone, which means the part nearest the forearm is fed last. Break the bone across the middle and the upper fragment can lose most of its supply.
Two things follow from that. Fractures nearer the forearm, which are called proximal pole fractures, heal less reliably and take longer than fractures nearer the thumb. And a scaphoid fracture left alone does not simply hurt for a while and then settle. It may never heal, and an unhealed scaphoid changes the way the wrist moves and wears, which leads over years to a particular pattern of arthritis.
That is the whole reason a bone the size of a cashew nut is treated as carefully as it is.
Symptoms
Most people describe:
- Pain on the thumb side of the wrist after a fall onto an outstretched hand
- Tenderness in the hollow at the base of the thumb, the anatomical snuffbox, when it is pressed
- Pain on gripping, and on pushing through the wrist
- Swelling, which is often surprisingly mild for a broken bone
- Movement that is restricted but not lost, which is part of why it gets dismissed
Very often it simply feels like a bad sprain. A scaphoid fracture does not usually produce the obvious deformity people expect from a broken bone, and plenty of people carry on using the hand.
Why it gets missed, and what to do about it
A scaphoid fracture can be invisible on the first X-ray. The bone is broken, but the crack has not yet moved or widened enough to show. Meanwhile the wrist is swollen and sore in a way that is easily and reasonably called a sprain.
So the rule worth knowing is this. If you fell onto your hand, your wrist is tender in the hollow at the base of the thumb, and it has not settled within ten to fourteen days, go back and ask specifically about the scaphoid, whatever the first X-ray showed.
A repeat X-ray, a CT or an MRI will answer it. A scaphoid found late is a far larger problem than a scaphoid found early, and the cost of checking is one appointment.
How it is diagnosed
- Examination. Tenderness in the anatomical snuffbox and over the front of the scaphoid, and pain on loading the thumb. Sensitive, though not specific, which is exactly why a tender wrist after a fall is taken seriously even when the film is clear.
- X-rays. Specific scaphoid views rather than a standard wrist series, because the bone is angled and hides on ordinary projections. Normal on the first films in a significant minority of genuine fractures.
- CT. Shows the fracture, its position and how much it has displaced, and is the most useful scan for planning treatment.
- MRI. The most sensitive test in the first days, because it shows the bruising in the bone before any line is visible. Useful where the diagnosis has to be settled quickly.
Treatment in a cast
An undisplaced fracture through the waist of the scaphoid, which is the commonest pattern, heals in a cast in the great majority of cases. We use a below elbow cast that includes the thumb, a thumb spica, worn for six to eight weeks.
A fracture nearer the forearm takes longer, because of the blood supply. So does a fracture found late. Healing is followed on X-rays, with a CT where there is any doubt about whether the bone has united, and the cast stays on until it has.
The cast is the part people underestimate. Six to eight weeks with the thumb immobilised rules out a good deal of work and most sport, and you cannot drive in it. That is worth planning for at the start rather than discovering in week two.
Surgery
Fixing a scaphoid means placing a single compression screw down the length of the bone, squeezing the two halves together and holding them still while they heal. We would recommend it in three situations.
- The fracture is displaced. The two halves are out of position and will not heal correctly where they lie.
- The fracture is in the proximal pole. Nearest the forearm, where the blood supply is poorest and a cast is least reliable.
- The fracture is unstable. It will not stay in an acceptable position in a cast.
There is a fourth situation, and it is a conversation rather than a rule. Some people cannot afford six to eight weeks in a thumb spica. A self employed tradesperson, or an athlete mid season, may reasonably choose a screw for the shorter recovery even though the fracture would probably have healed in plaster. That is a decision we make with you, with the risks of an operation set against the cost of the cast, rather than one we make for you.
The operation
The screw is placed percutaneously, through a puncture rather than an open incision, and positioned under X-ray guidance. We use the arthroscope at the same time, passing a small camera into the wrist to check the fracture is properly reduced and to look at the joint surfaces and the ligaments while we are there. A scaphoid rarely breaks in isolation, and the scope shows damage that no X-ray will.
Working through punctures rather than opening the wrist matters here more than it does elsewhere, because the blood supply and the ligaments that carry it run in the tissue you would otherwise be cutting through to reach the bone.
It is a day surgery procedure under a general anaesthetic with a local anaesthetic block for comfort afterwards, and takes approximately 45 to 60 minutes.
Recovery after screw fixation, week by week
Indicative. The bone still takes around three months to heal whether or not there is a screw in it. What the screw changes is how much of that time you spend immobilised.
Timeframe
What to expect
Day of surgery
Your hand and wrist may feel numb or tingly for up to 24 hours because of the local anaesthetic block. You can move your fingers before you leave hospital.
Days 1 to 10
Keep the dressing clean and dry, and keep the hand elevated to reduce swelling. Move your fingers, elbow and shoulder regularly.
Two weeks
Your progress is reviewed and the wound is checked. A removable splint is fitted by your hand therapist, and gentle wrist and thumb movement begins out of the splint.
Two to six weeks
Splint use is reduced as comfort and healing allow, with therapy progressing movement. Light use of the hand. No loading, gripping hard or lifting.
Six weeks
Progress reviewed with new X-rays. Where healing is on track, splinting stops and strengthening begins under the guidance of your hand therapist.
Three months
Healing is confirmed before heavy use is allowed. Most people are through the bulk of their recovery at this point.
Three to six months
Strength and stamina continue to build. The wrist can remain stiff or ache at the end of a heavy day well into this period, and that continues to improve.
Driving and work
Driving at two to three weeks. Office work at one to two weeks. Light manual work six weeks. Heavy work three months, in line with when the bone has healed.
If the bone does not heal
A small number of scaphoid fractures do not unite, whether they were treated in a cast or with a screw, and the risk is higher where the fracture was found late or sits in the proximal pole. That is called a nonunion, and it is treatable. At this practice it is dealt with by arthroscopic bone grafting, which is Dr Nicholas Smith's particular interest, and it has a page of its own.
Hand therapy
A wrist immobilised for six to eight weeks stiffens, and getting that movement back is a therapy job rather than something that happens on its own. Our therapists fit and adjust the splint, keep the fingers, elbow and shoulder moving while the wrist cannot, and then restore wrist and thumb motion and grip once the bone allows it. Having them on site means that starts promptly.
Risks and complications
Scaphoid fixation is a routine operation and complications are uncommon. They can include:
- Wound healing problems or infection.
- Bleeding or bruising. Usually minor and settles on its own.
- Nerve injury. Temporary or permanent change in sensation in a small patch of skin near the puncture sites.
- Wrist stiffness, particularly in the first months.
- Failure of the bone to unite despite treatment, which may require further surgery.
- Screw position needing revision, or the screw needing removal later if it causes irritation.
- Arthritis of the wrist in the long term, particularly where the fracture was displaced or found late.
When to be seen sooner
Contact us, or see your GP, if you have:
- A wrist that has not settled ten to fourteen days after a fall, whatever the first X-ray showed
- Pain on the thumb side of the wrist that is not improving week on week
- A wrist that was treated for a sprain months or years ago and still aches with use
- Loss of grip strength, or a wrist that is losing movement
If you have had surgery with us and have questions or concerns afterwards, phone the rooms during office hours on (08) 7127 0365.
Frequently asked questions
My X-ray was normal. Can I still have broken it?
Yes, and this is the most important thing on the page. A scaphoid fracture is regularly invisible on the first X-ray, because the crack has not moved enough to show. If your wrist is tender in the hollow at the base of the thumb and has not settled in ten to fourteen days, it needs looking at again with repeat X-rays, a CT or an MRI.
Why does it take so long to heal?
Because of the blood supply. The scaphoid is fed from one end, and the blood runs backwards through the bone, so a fracture across the middle can cut off most of the supply to the upper half. Bone with a poor blood supply heals slowly, and sometimes not at all. That is also why a fracture nearer the forearm takes longer than one nearer the thumb.
Should I have a screw instead of a cast?
If the fracture is displaced, in the proximal pole, or unstable, then yes, and we would recommend it. If it is an undisplaced waist fracture, a cast will almost certainly heal it and that is the standard advice.
The exception is time. Six to eight weeks in a thumb spica, and no driving in it, is a real cost if you are self employed or mid season. Some people reasonably choose a screw for the shorter recovery. We will go through both with you rather than decide it for you.
Why use a camera as well as a screw?
Two reasons. It confirms the fracture is properly lined up before the screw goes in, which an X-ray alone does not always show. And a scaphoid rarely breaks on its own, so the scope lets us look at the ligaments and the joint surfaces at the same time and find damage that would otherwise be missed.
How long does the operation take, and will I be asleep?
Approximately 45 to 60 minutes, as a day surgery procedure under a general anaesthetic, with a local anaesthetic block given at the same time for comfort afterwards. You go home the same day.
Can I drive in the cast?
No. A thumb spica means you cannot control the wheel properly in an emergency, and most insurers will not cover you while you are driving in a cast or splint. That is one of the things worth weighing when you decide between a cast and a screw.
When can I drive and go back to work after the operation?
Driving at two to three weeks. Office work at one to two weeks. Light manual work at six weeks. Heavy work at around three months, which is when the bone has healed. There is no legislation covering surgery and driving, so the test is whether you can control the car safely, including in an emergency. Some insurers will not cover damage or liability if you had recent surgery, if you were in a splint or a cast while driving, or if you were taking pain medication that could affect your driving. We will give you a realistic estimate for your specific job, and a certificate.
What happens if it does not heal?
That is a nonunion, and it is treatable rather than a dead end. It is repaired with bone grafting and a compression screw, done arthroscopically at this practice. There is a separate page about it. The important point is that a nonunion left alone will eventually wear the wrist out, so it is worth dealing with rather than living with.
How will you know when it has healed?
X-rays at the review appointments, and a CT scan where there is any doubt. X-rays can be hard to read in a healing scaphoid, so a scan is the reliable answer rather than an extra.
Does the screw stay in?
Yes, in almost all cases. It sits inside the bone, it is not palpable and it does not set off airport scanners. It is only removed if it causes a problem, which is uncommon.
What does the surgery cost?
You will receive written informed financial consent setting out the surgeon, anaesthetist and hospital fees, your Medicare rebate and your health fund's contribution before anything is booked. Phone the rooms on (08) 7127 0365 for an estimate.
Do I need a referral?
A referral from your GP or another specialist means you can claim a Medicare rebate on the consultation. We can see you without one, but the rebate will not apply.
Written and clinically reviewed by Dr Paul van Minnen, MD, PhD, EBOPRAS, FRACS (Plast)
Last reviewed 11 September 2026