The scaphoid is one of eight small bones in the wrist and the most commonly fractured. It is also the most commonly missed fracture in the wrist. A normal plain X-ray does not exclude a scaphoid fracture — up to 20% of scaphoid fractures are radiographically occult on initial imaging. The clinical signs — anatomical snuffbox tenderness, pain on axial loading of the thumb — should trigger clinical suspicion even when the X-ray appears normal, and should prompt further imaging with CT or MRI. When a scaphoid fracture is missed and is not immobilised or surgically fixed in time, avascular necrosis of the proximal pole (bone death from interrupted blood supply), non-union, and permanent wrist pain and dysfunction can result.
Why scaphoid fractures are missed
- Plain X-ray is normal or equivocal in a significant proportion of acute fractures
- Symptoms attributed to a wrist sprain
- Patient discharged with analgesia and no fracture clinic follow-up
- Inadequate use of clinical signs (snuffbox tenderness is highly sensitive)
- Failure to arrange CT or MRI when X-ray is normal but clinical suspicion is high
Consequences of a missed scaphoid fracture
- Avascular necrosis of the scaphoid — bone death from disrupted blood supply, which tracks through the bone proximally to distally
- Non-union — failure of the fracture to heal, causing instability and chronic pain
- Scapholunate advanced collapse (SLAC) — progressive wrist arthritis
- Permanent loss of wrist range of movement and grip strength
- Career-ending disability in manual workers
Frequently asked questions
Can I claim if my scaphoid fracture was dismissed as a sprain?
Yes — if clinical signs of a scaphoid fracture were present and a competent clinician would have arranged CT or MRI, and the failure to diagnose led to avascular necrosis or non-union.
What is the standard expected of A&E clinicians for scaphoid fractures?
British Orthopaedic Association and NICE guidance recommends that patients with snuffbox tenderness following a wrist injury should be assumed to have a scaphoid fracture until proved otherwise, immobilised, and have CT or MRI if plain X-ray is normal.