Scaphoid fracture on X-ray

Written by the X-Ray Atlas editorial team from the sources listed below · Medical review pending · Updated 24 October 2026 · Level: Beginner

The scaphoid is the most commonly fractured carpal bone, typically in young adults after a fall onto an outstretched hand. It matters because the fracture is often invisible on the first films, and because its unusual blood supply means a missed fracture can progress to non-union and avascular necrosis (AVN), leading to wrist arthritis in a young person. The central lesson of this page: a normal scaphoid X-ray does not exclude a scaphoid fracture.

1. Anatomy and blood supply

The scaphoid bridges the proximal and distal carpal rows, which is why it takes so much force in a fall. It is described in three parts: the proximal pole, the waist and the distal pole (with the tubercle on its palmar side). Approximate distribution of fractures:

• Waist: about 65–80%
• Proximal pole: about 10–20%
• Distal pole and tubercle: the remainder

Most of the blood supply enters the bone distally and flows backwards (retrograde) to the proximal pole. A fracture across the waist or proximal pole can therefore cut off the proximal fragment's blood supply. The more proximal the fracture, the higher the risk of AVN and non-union. Distal pole and tubercle fractures usually heal well.

2. The scaphoid series

Standard wrist views are not enough when scaphoid fracture is suspected, because the scaphoid lies obliquely and is foreshortened on a plain PA. A scaphoid series typically includes:

• PA with ulnar deviation, which elongates the scaphoid and opens out the waist;
• lateral;
• oblique (often semi-pronated);
• an elongated or angled view (for example the Ziter view or a PA with tube angulation).

Exact combinations vary by department. Clinically, the clues that should trigger a scaphoid series are anatomical snuffbox tenderness, scaphoid tubercle tenderness and pain on axial compression of the thumb.

3. Signs of a fracture

• A lucent line across the waist or pole, best seen on the ulnar-deviated and oblique views. It may be visible on only one view.
• A sclerotic line, where trabeculae are impacted.
• A break or step in the cortex, particularly on the radial (lateral) border of the waist.
• Displacement or angulation: displacement of more than about 1 mm, or a "humpback" flexion deformity, suggests an unstable fracture. CT is often used to assess this.
• The scaphoid fat stripe: a thin lucent line of fat lying along the radial side of the scaphoid on the PA. If it is displaced or lost, it raises suspicion of an underlying fracture, but it is an indirect sign only.

4. The occult fracture: what next?

Initial radiographs can be normal in a significant minority of scaphoid fractures; figures of up to about 20% are often quoted, and the exact proportion varies between studies and with the views used. Clinical signs are sensitive but not specific, so most patients with snuffbox tenderness do not actually have a fracture. That combination is why pathways exist.

Approach	What it involves
MRI	NICE NG38 advises considering MRI as first-line imaging when a scaphoid fracture is suspected despite normal radiographs. MRI shows bone marrow oedema and a fracture line early and also identifies other carpal and ligament injuries.
CT	An alternative if MRI is contraindicated or unavailable. Good for fracture lines and displacement; less sensitive than MRI for bone bruising.
Immobilise and repeat X-ray	The traditional approach: a splint, then repeat films at about 10–14 days, when bone resorption at the fracture makes the line more visible. Still used where early MRI is not available, but a repeat film can remain normal.

Local pathways differ, and many UK departments run virtual fracture clinics for these patients. Follow your local pathway, and make sure the patient knows they need follow-up. NICE wording changes, so check the live version of NG38.

5. Non-union and AVN

On follow-up or late presentation films, look for:

• Non-union: a persistent gap with sclerotic, rounded fracture margins and cyst formation either side.
• AVN: a sclerotic (dense) proximal pole compared with the rest of the scaphoid and the other carpal bones, sometimes with collapse or fragmentation.
• Scaphoid non-union advanced collapse (SNAC): long-standing non-union leads to a predictable pattern of degenerative change, starting at the radial styloid and progressing through the wrist.

Mimics of AVN on a single film include Kienböck disease (AVN of the lunate, not the scaphoid) and Preiser disease (spontaneous scaphoid AVN without a fracture).

6. Other carpal injuries to check

• Gilula arcs: three smooth arcs on the PA (the proximal and distal surfaces of the proximal row, and the proximal surfaces of the capitate and hamate). A break suggests a ligament injury or dislocation.
• Scapholunate dissociation: a widened gap between the scaphoid and lunate (the "Terry-Thomas" sign). The upper limit of normal quoted varies: about 3 mm in some sources, 4 or 5 mm in others. A foreshortened scaphoid seen end-on produces the "signet ring" (cortical ring) sign.
• Perilunate dislocation: on the lateral, the lunate stays on the radius but the capitate is dislocated, usually dorsally. It is often trans-scaphoid, meaning a scaphoid fracture is part of the injury. It is frequently missed and is a surgical emergency.
• Lunate dislocation: the lunate tips volarly out of the radius on the lateral (the "spilled teacup") and looks triangular on the PA.
• Triquetral fracture: a small dorsal flake on the lateral; the second most common carpal fracture.

7. Pitfalls and mimics

• Overlapping cortices and Mach bands can create a false line across the waist. A true fracture usually crosses trabeculae and is seen on more than one view, or is confirmed on MRI or CT.
• Bipartite scaphoid is a rare developmental variant with smooth, corticated margins; it is often bilateral.
• Children: scaphoid fractures are less common and are often in the distal pole. The ossifying scaphoid can look irregular.
• Satisfaction of search: a distal radius fracture can co-exist with a scaphoid fracture. See distal radius fractures.

Red flags: act now

What to focus on, by role

Role	Priorities
Medical student	Snuffbox tenderness, retrograde blood supply, and "a normal film does not exclude it".
Nurse / ENP	Request a scaphoid series when indicated, immobilise suspected fractures, and arrange follow-up according to the local pathway.
Junior doctor	Document clinical findings, request MRI or follow-up as per NICE NG38 and local policy, and check the carpus for perilunate injury.
Radiographer	Scaphoid series positioning, especially the ulnar-deviated PA. Flag subtle fractures with preliminary clinical evaluation.
Advanced / FRCR	Displacement, humpback deformity, AVN and SNAC, and Gilula arc disruption.

Practise on real upper limb X-rays →

References

1. NICE NG38. Fractures (non-complex): assessment and management. nice.org.uk
2. Radiopaedia. Scaphoid fracture. radiopaedia.org
3. LITFL. Gilula carpal arcs. litfl.com
4. Perilunate injuries: review. ncbi.nlm.nih.gov
5. Royal College of Radiologists. iRefer. irefer.org.uk

For education only. Not a substitute for a formal report, senior review or your local policy. Never use this page to make decisions about a real patient.