1 · SNAPSHOT
The most commonly missed fracture in the body, and it gets missed in exactly the room you'll be standing in.
Illness script in one line: someone fell onto an outstretched hand, thought they'd sprained their wrist, and is still sore at the base of the thumb more than 48 hours later.
Caseload frequency: you will see the presentation regularly. Read further: carpal and scaphoid fracture incidence in south-eastern Australia [1], the wider epidemiology [2].
The X-ray that comes back normal
One sentence makes this page: "X-ray may be negative initially — high index of suspicion required."
That is the entire problem. The patient goes to a GP or an ED, gets a wrist X-ray, is told it's clear, and is sent to you with "wrist sprain, please rehab."
Read further: imaging for suspected scaphoid fracture [3], early MRI in clinical scaphoid fracture [4], diagnostic characteristics and reliability of radiological methods [5], variation in how scaphoid fracture is defined on MRI [6].
Occult scaphoid fracture was called a diagnostic enigma in 1989 [7]. It still is.
A normal first X-ray does not clear a snuffbox-tender wrist. It never has.
2 · SE — THE SUBJECTIVE PATTERN
Acute and traumatic, so the UniSA order changes: MAIN PROBLEM → BODY CHART → HISTORY → BEHAVIOUR.
MAIN PROBLEM
"I sprained my wrist and it's still sore."
That sentence, plus a fall onto an outstretched hand, plus more than 48 hours, is the whole trigger. May feel "sprained wrist" but pain persists >48 hrs.
BODY CHART
- Radial wrist, at the base of the thumb. Ask them to point with one finger — the anatomical snuffbox is the answer you're listening for.
- ± into the thenar eminence and the thumb.
- Swelling is often unimpressive. The absence of a dramatic wrist is not reassurance.
HISTORY
- The mechanism. FOOSH — a fall onto the outstretched, extended, radially deviated wrist. Sport, a trip, a bike, a ladder.
- How long ago, and is it settling? The 48-hour mark is the line that matters.
- Have they been imaged, when, and what were they told? See section 1. "The X-ray was clear" is the sentence you must not accept.
- What can they not do? Gripping, pinching, pushing up out of a chair, opening a jar.
- Any previous wrist injury on that side?
BEHAVIOUR
- Aggs: gripping and pinching, pushing through the hand, wrist extension, radial deviation.
- Eases: rest, not using it. And this is the trap — it eases enough that people stop worrying.
- Irritability: often low, which is exactly why it gets dismissed.
SPECIAL / SCREENING QUESTIONS
High-energy mechanism, other injuries, any numbness or circulatory change in the hand, and whether the wrist looks or feels deformed.
Assessing this region? Download the Wrist & Hand assessment template →
3 · HYPOTHESIS RANKING
Top three, and the one feature that separates each
| Pattern | The discriminating feature |
|---|---|
| 1. Scaphoid fracture | FOOSH + snuffbox tenderness + still sore beyond 48 hours. Ranked first on consequence, not on probability. |
| 2. Wrist sprain / soft tissue injury | The default label, and the diagnosis of exclusion — not the starting point. It only becomes the answer after the scaphoid has been properly excluded. |
| 3. Distal radius fracture | More swelling, more deformity, tenderness over the distal radius rather than the snuffbox. Often obvious. Sometimes not. |
Also on the list
| Pattern | The discriminating feature |
|---|---|
| Scapholunate ligament injury / perilunate injury | Dorsal wrist pain, a clunk, a much more unstable pattern from the same mechanism. Easily missed alongside a scaphoid fracture. |
| Other carpal fractures | Triquetral, hamate hook — different tenderness locations, same mechanism. |
| De Quervain's tenosynovitis | Gradual onset, no trauma, tender over the radial styloid rather than in the snuffbox. Its own page — and the honest confusion on the radial side. |
| 1st CMC osteoarthritis | Older, gradual, pain with pinch and jar-opening, positive grind test. |
The rule that runs this page
On a radial-sided wrist after a fall, the scaphoid is ranked first until someone with imaging says otherwise. That's not clinical reasoning — it's risk management, and here they're the same thing.
4 · RED FLAGS — DON'T MISS THIS
Free forever. Safety is never behind a paywall.
On this page the fracture is the red flag. What follows is what it costs to miss it, and what else the same fall does.
| Finding | What it means |
|---|---|
| FOOSH + anatomical snuffbox tenderness, at any time point | Scaphoid fracture until imaging says otherwise. Immobilise and refer today. |
| Pain at the base of the thumb persisting beyond 48 hours after a fall | Same action. |
| A normal X-ray in a snuffbox-tender wrist | NOT A CLEARANCE. Repeat imaging or MRI is a medical decision — your job is to say so, in writing. |
| Pain settling but tenderness persisting | The most dangerous version. Avoid early loading even if pain subsides. |
| Dorsal wrist pain, a clunk, or gross instability | Scapholunate or perilunate injury. Urgent. |
| Obvious deformity, high-energy mechanism, or multiple injuries | Escalate to ED. |
| A cold, pale or discoloured hand | Vascular compromise. EMERGENCY. |
| New or progressive numbness or weakness in the hand | Possible nerve compromise. Urgent: same day. |
What missing it actually costs
Read further: outcomes of delayed cast treatment for the missed scaphoid fracture [8]. Risk factors for nonunion in acute fractures treated with cast immobilisation have been examined [9], and a small proximal-to-distal fragment ratio identified as a risk factor [10]. Read further: treatment of established nonunion [11].
Read further: the litigation cost of negligent scaphoid fracture management [12]. That paper exists for a reason, and knowing it exists is a legitimate part of the education.
The scaphoid has a retrograde blood supply. Miss a proximal pole fracture and you are not risking a slow recovery — you are risking avascular necrosis and a wrist that never works properly again.
Any red flag: stop, escalate, and check it with your educator.
5 · OE — THE OBJECTIVE
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Sign in or join free6 · MX — MANAGEMENT ESSENTIALS
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Sign in or join free7 · CLINICAL PEARLS + RETRIEVAL CHECK
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The objective exam, management and pearls, plus the six-minute lesson and the debrief. Free with an account.
Sign in or join freeMembers
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Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.
Sign in or join freeGuideline anchor
No Australian clinical practice guideline — but unusually, there are two Australian anchors.
More
Carpal and scaphoid fracture incidence has been reported in an epidemiological study in south-eastern Australia (Holloway et al. 2015, PMID 25910867) and the initial management of potential occult scaphoid fracture examined in Australasia (Kelly et al. 2010, PMID 20414381). The diagnostic anchors are a systematic review and meta-analysis of clinical diagnostic evaluation for scaphoid fractures in the Journal of Hand Surgery (Mallee et al. 2014, PMID 25091335), a systematic review of which clinical features best predict occult scaphoid fractures in the Emergency Medicine Journal (Coventry et al. 2023, PMID 37169546) and a meta-analysis of adult scaphoid fracture in Academic Emergency Medicine (Carpenter et al. 2014, PMID 24673666).
These are diagnostic systematic reviews and emergency-medicine practice studies, not a physiotherapy management guideline. There is no guideline for the physiotherapy management of this fracture — because the physiotherapy job in the acute phase is recognition and referral.
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Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.
Sign in or join freeSources · 20
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Every source on this page resolves and title-verifies against PubMed. Newest first.
- 2015Holloway et al. (2015). Carpal and scaphoid fracture incidence in south-eastern Australia: an epidemiologic study. Archives of osteoporosis, 10, 10. https://doi.org/10.1007/s11657-015-0215-6
- 2012Duckworth et al. (2012). Scaphoid fracture epidemiology. The journal of trauma and acute care surgery, 72(2), E41-5. https://doi.org/10.1097/ta.0b013e31822458e8
- 2008Ring & Lozano-Calderón (2008). Imaging for suspected scaphoid fracture. The Journal of hand surgery, 33(6), 954-7. https://doi.org/10.1016/j.jhsa.2008.04.016
- 2003Brydie & Raby (2003). Early MRI in the management of clinical scaphoid fracture. The British journal of radiology, 76(905), 296-300. https://doi.org/10.1259/bjr/19790905
- 2025Smith et al. (2025). The diagnostic characteristics and reliability of radiological methods used in the assessment of scaphoid fracture union : a systematic review. Bone & joint open, 6(3), 246-253. https://doi.org/10.1302/2633-1462.63.BJO-2024-0211.R1
- 2026van Boxel et al. (2026). Variation in definitions of scaphoid fracture on MRI scans for suspected fracture: a systematic review. The Journal of hand surgery, European volume, 51(2), 139-145. https://doi.org/10.1177/17531934251367541
- 1989Mittal & Dargan (1989). Occult scaphoid fracture: a diagnostic enigma. Journal of orthopaedic trauma, 3(4), 306-8. https://doi.org/10.1097/00005131-198912000-00008
- 2015Grewal et al. (2015). The Missed Scaphoid Fracture-Outcomes of Delayed Cast Treatment. Journal of wrist surgery, 4(4), 278-83. https://doi.org/10.1055/s-0035-1564983
- 2026Dean et al. (2026). Risk factors for scaphoid nonunion in acute fractures treated with cast immobilization. Bone & joint open, 7(8), 1001-1006. https://doi.org/10.1302/2633-1462.78.BJO-2026-0012.R1
- 2025Sugiura et al. (2025). A Small Ratio of Proximal to Distal Bone Fragments Is a Risk Factor for Scaphoid Nonunion: A Volumetric Analysis of Preoperative CT. Journal of wrist surgery, 14(3), 226-232. https://doi.org/10.1055/s-0044-1779286
- 2015Pinder et al. (2015). Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence. The Journal of hand surgery, 40(9), 1797-1805.e3. https://doi.org/10.1016/j.jhsa.2015.05.003
- 2015Harrison et al. (2015). The litigation cost of negligent scaphoid fracture management. European journal of emergency medicine : official journal of the European Society for Emergency Medicine, 22(2), 142-3. https://doi.org/10.1097/MEJ.0000000000000152
- 2014Mallee et al. (2014). Clinical diagnostic evaluation for scaphoid fractures: a systematic review and meta-analysis. The Journal of hand surgery, 39(9), 1683-1691.e2. https://doi.org/10.1016/j.jhsa.2014.06.004
- 2023Coventry et al. (2023). Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies. Emergency medicine journal : EMJ, 40(8), 576-582. https://doi.org/10.1136/emermed-2023-213119
- 2014Carpenter et al. (2014). Adult scaphoid fracture. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 21(2), 101-21. https://doi.org/10.1111/acem.12317
- 1996Grover (1996). Clinical assessment of scaphoid injuries and the detection of fractures. Journal of hand surgery (Edinburgh, Scotland), 21(3), 341-3. https://doi.org/10.1016/s0266-7681(05)80197-4
- 2020Mallee et al. (2020). Detecting scaphoid fractures in wrist injury: a clinical decision rule. Archives of orthopaedic and trauma surgery, 140(4), 575-581. https://doi.org/10.1007/s00402-020-03383-w
- 2010Kelly (2010). Initial management of potential occult scaphoid fracture in Australasia. International journal of emergency medicine, 3(1), 45-7. https://doi.org/10.1007/s12245-009-0138-3
- 2009Modi et al. (2009). Operative versus nonoperative treatment of acute undisplaced and minimally displaced scaphoid waist fractures--a systematic review. Injury, 40(3), 268-73. https://doi.org/10.1016/j.injury.2008.07.030
- 2015Tada et al. (2015). Scaphoid Fracture--Overview and Conservative Treatment. Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand, 20(2), 204-9. https://doi.org/10.1142/S0218810415400018
Mapped to this pattern
Generic measures that also apply
- Borg RPE
Borg Rating of Perceived Exertion Scale (6-20)
perceived exertion · 1 items · 1 min
- DASH
Disabilities of the Arm, Shoulder and Hand
upper limb disability · 30 items · 8 min
- GROC
Global Rating of Change Scale
perceived change since baseline · 1 items · 1 min
- NPRS
Numeric Pain Rating Scale
pain intensity · 1 items · 1 min
- PGIC
Patient Global Impression of Change
perceived change since baseline · 1 items · 1 min
- PSFS
Patient-Specific Functional Scale
patient-generated function · 3 items · 2 min
- QuickDASH
QuickDASH
upper limb disability, short form · 11 items · 4 min
- SANE
Single Assessment Numeric Evaluation
patient-rated function as a percentage of normal · 1 items · 1 min
- UEFI
Upper Extremity Functional Index
upper limb function · 20 items · 5 min
- VAS
Visual Analogue Scale
pain intensity · 1 items · 1 min
- Borg CR10
Borg Category Ratio 10 Scale
perceived exertion or symptom intensity, ratio scale · 1 items · 1 min
- GAS
Goal Attainment Scaling
individualised goal achievement · 10 min
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