Whether your scaphoid fracture just happened or you've been told a wrist injury from months or years ago never fully healed — both situations are treated here. The scaphoid is the most unforgiving bone in the wrist to fracture. Getting it right the first time matters enormously. And when it wasn't gotten right the first time, the reconstruction is still possible.
Scaphoid fractures are notorious for being dismissed as "wrist sprains" at initial presentation. If your wrist pain after a fall has not fully resolved, the scaphoid is worth evaluating.
Why the Scaphoid Is Different
The scaphoid is a small, oblong carpal bone at the base of the thumb side of the wrist — the first bone you feel when you move your thumb toward your wrist. It bridges the proximal and distal rows of the carpus, acting as a critical link that transmits load across the wrist and coordinates carpal motion. Disrupting it disrupts wrist mechanics.
What makes scaphoid fractures uniquely treacherous is the bone's blood supply. The scaphoid receives its blood primarily through vessels that enter at its distal pole and travel proximally — meaning the proximal pole, where many fractures occur, is at the end of the blood supply chain. Fracture disrupts this supply to the proximal fragment. Without blood flow, the proximal pole can undergo avascular necrosis — the bone dies. A dead proximal pole cannot heal, cannot accept a screw, and eventually collapses, dragging the entire wrist into degenerative arthritis.
The second problem is diagnosis. Scaphoid fractures are frequently invisible on plain X-ray immediately after injury — particularly non-displaced waist and proximal pole fractures. The patient presents with wrist pain after a fall, X-rays look normal, they are diagnosed with a wrist sprain, and sent home. Six months later they have a nonunion. This sequence is one of the most common preventable failures in hand and wrist care. If your wrist is still painful weeks after a fall and your X-rays were normal, a scaphoid fracture needs to be ruled out with MRI or CT.
The scaphoid's blood supply enters at the distal pole (green arrow) and travels proximally. A fracture at the waist or proximal pole interrupts this supply to the fragment above the fracture line. Without blood flow the proximal pole is at risk of avascular necrosis — a complication that dramatically changes the surgical approach required.
Scaphoid fractures are invisible on X-ray in roughly 20% of cases at initial presentation — the fracture line is too fine or the projection too oblique to see. The patient is diagnosed with a wrist sprain, given a brace or buddy tape, and told to follow up if it doesn't improve. Weeks pass. The fracture is healing poorly or not at all. By the time a nonunion is diagnosed, what could have been fixed with a single percutaneous screw now requires open surgery with bone graft.
The rule is simple: wrist pain on the thumb side after a fall, especially with tenderness in the anatomic snuffbox or over the scaphoid tubercle, is a scaphoid fracture until proven otherwise. MRI is the most sensitive early study. CT scan better characterizes displacement and fracture pattern for surgical planning. Neither of these should require an extended wait — prompt diagnosis determines treatment options.
If you were told your wrist sprain should have healed by now and it hasn't, come in. Dr. Graham will evaluate the scaphoid specifically.
Acute Fracture — Treatment Decision
Non-displaced scaphoid waist fractures can be treated with a thumb spica cast for 8 to 12 weeks — and that is a legitimate option that Dr. Graham presents honestly to every patient. Cast treatment works in most non-displaced cases, but it has a meaningful nonunion rate, requires months of immobilization, and carries a small but real risk of the fracture shifting during healing.
Percutaneous headless compression screw fixation — placing a headless screw across the fracture through a small stab incision under fluoroscopic guidance — is technically more involved, but produces faster healing, faster return to activity, and a lower nonunion rate. For active patients, manual workers, and anyone who cannot tolerate 3 months in a cast, surgery is the stronger choice.
Dr. Graham discusses both options fully and lets the patient decide. He does not push surgery on patients who prefer to try the cast — but he also does not minimize the real advantages of fixation. The conversation is honest, and the decision is the patient's.
Displaced scaphoid fractures are a different matter. Any significant displacement, angulation, or associated carpal instability is an indication for surgery — the fracture is not stable and will not heal reliably in a cast regardless of patient preference.
Surgical Approach
The surgical approach to scaphoid fixation is not one-size-fits-all. Dr. Graham selects the approach based on fracture location, displacement pattern, and whether deformity correction or bone grafting is required.
Access to the scaphoid from the back of the wrist. Allows optimal screw trajectory for proximal pole and waist fractures, and provides the most direct access to the proximal pole when avascular necrosis or proximal pole pathology is present.
Access to the scaphoid from the palm side of the wrist. Provides the best visualization for correction of volar flexion deformity and humpback deformity, where the distal fragment has flexed relative to the proximal pole. Essential when corticocancellous graft needs to be interposed on the volar surface to restore scaphoid length and alignment.
All bone graft for scaphoid surgery is autograft harvested from the distal radius through the same surgical incision — no hip, no separate donor site. The distal radius provides an excellent volume of cancellous bone (for small defects) or corticocancellous bone (for structural defects requiring shape restoration). Vascularized graft from the distal radius is used when proximal pole viability is compromised.
Nonunion — When the Fracture Didn't Heal
A scaphoid nonunion occurs when the fracture fails to achieve bony union — typically because it was missed at initial injury, inadequately treated, or simply because the biology of the scaphoid's blood supply made healing unreliable. The two fragments develop a fibrous pseudarthrosis — scar tissue fills the gap rather than bone. Over time, the distal fragment progressively flexes relative to the proximal pole, creating a humpback deformity that alters wrist mechanics. Untreated, this leads to predictable SNAC wrist arthritis — scaphoid nonunion advanced collapse.
The surgical goal in nonunion is to achieve union — solid bone healing across the fracture — by correcting any deformity, grafting the defect, and fixing the fragments with a screw. The specific approach and graft type depend on how long the nonunion has been present, whether a humpback deformity exists, and critically, whether the proximal pole has maintained its blood supply.
MRI is used to assess proximal pole vascularity before surgery. An enhancing proximal pole on contrast MRI indicates viable bone — non-vascularized graft is appropriate. A non-enhancing proximal pole indicates avascular necrosis — the dead bone cannot support healing through normal graft, and a vascularized bone graft is required to bring a new blood supply to the proximal fragment.
Dr. Graham accepts scaphoid nonunion cases regardless of chronicity. The reconstruction is more complex than acute fixation but remains possible in most cases, and the alternative — untreated nonunion progressing to SNAC wrist — is a far worse outcome than the surgery required to correct it.
Scaphoid nonunion advanced collapse (SNAC wrist) is the predictable end-stage of an untreated scaphoid nonunion. As the deformed scaphoid alters carpal mechanics over years, the articular surfaces begin to wear in a characteristic pattern — radioscaphoid first, then the entire wrist. SNAC wrist is a progressive, irreversible arthritis. It cannot be reversed once established — only managed. The urgency of treating a known nonunion comes from this trajectory. There is no stable plateau. An untreated nonunion is a slow countdown to a destroyed wrist.
Call (904) 241-1204Recovery
Acute fracture fixation heals faster than nonunion reconstruction — the biology is more favorable and the surgery less complex. Both require patience and hand therapy.
"I was told my wrist was just sprained after a fall. A year later it still hurt. Dr. Graham took one look and ordered the right scan. I had a scaphoid nonunion the whole time. He fixed it with a bone graft and I finally have my wrist back. He was thorough, direct, and clearly knew exactly what he was doing."
Common Questions
Questions from patients who just fell and hurt their wrist — and from patients who fell a long time ago and are still waiting for it to get better.