I fell on my hand and my wrist still hurts. How do I know if it is broken or sprained?

You probably cannot tell from the outside, and the clinical exam only takes you so far. Rhemrev and colleagues' 2011 review in the International Journal of Emergency Medicine makes the point that the classic bedside tests, snuffbox tenderness, pain with axial loading of the thumb, and scaphoid compression, are sensitive but not specific. They are good at raising suspicion, but they cannot rule a fracture in or out on their own. If snuffbox pain, thumb-loading pain, or persistent wrist pain are still there a week after a fall on an outstretched hand, I want imaging before I accept a sprain diagnosis.

Why do people worry so much about scaphoid fractures compared with other wrist injuries?

Two reasons. First, the scaphoid has an unusual blood supply that runs from distal to proximal, so a fracture near the proximal pole can disrupt blood flow to the bone fragment, which raises the risk of avascular necrosis. Second, the non-union rate is higher than for most other wrist bones, particularly for displaced or proximal fractures. A missed or undertreated scaphoid fracture can become a long-term wrist problem, so the threshold for imaging should stay low.

What tests will a clinician actually do at the bedside?

I am looking to build a hypothesis rather than tick boxes. Steinmann and colleagues (2006) described three bedside manoeuvres that together raise or lower suspicion: tenderness in the anatomical snuffbox, tenderness over the scaphoid tubercle on the palm side, and pain with axial compression through the thumb. None of them is diagnostic on its own, but combined with the story of the fall and the pattern of pain, they tell me whether imaging is urgent or whether a cautious watchful period is reasonable. I still send for imaging when the picture fits, because the cost of missing a scaphoid fracture is much higher than the cost of an X-ray.

The X-ray was clear but my wrist still hurts. What now?

Early X-rays miss a meaningful share of scaphoid fractures. The practical approach in many settings is to treat as a suspected scaphoid fracture, immobilise, and re-image at around 10 to 14 days, or move to MRI or CT earlier if symptoms are severe or the person cannot tolerate waiting. I would not accept a single clear X-ray as the final word when snuffbox tenderness and thumb-loading pain are still clearly present.

Do I need surgery, or will a cast be enough?

For undisplaced waist fractures of the scaphoid, the 2020 SWIFFT trial published in The Lancet (Dias et al.) compared cast immobilisation with surgical fixation and found no meaningful difference in patient-rated wrist scores at one year, with more surgery-related serious complications in the surgery group and more cast-related complications in the cast group. For undisplaced fractures, cast management is a reasonable first choice. Displaced fractures, proximal pole fractures, and non-unions are a different conversation and generally move toward surgical consultation because the non-union risk is higher.

How long will I be in a cast?

Typical non-operative treatment for an undisplaced scaphoid waist fracture is around 6 to 12 weeks of cast immobilisation, with repeat imaging to confirm healing before the cast comes off. Proximal pole fractures often heal more slowly and may need longer. Exact timing depends on fracture location, imaging findings, and the surgeon or sports medicine physician overseeing care.

What does physiotherapy look like after the cast comes off?

The wrist is usually stiff, the forearm muscles are deconditioned, and people are understandably cautious about loading the hand. My early work is gentle range of motion for the wrist, forearm, and thumb, gradually rebuilding grip strength, restoring proprioception, and introducing loading progressions that respect the healing tissue. I do not rush axial loading through the hand and I keep a close eye on any return of snuffbox pain, because that would prompt a conversation with the treating physician before pushing forward.

Will my wrist ever feel normal again?

Most undisplaced fractures that are recognised early and managed appropriately heal and return close to normal function. Stiffness and grip weakness usually resolve with structured rehabilitation. The cases that struggle are often the ones that were missed initially, that went on to non-union, or that involved the proximal pole. That is why I take the initial picture seriously and do not shortcut the diagnosis.

Scaphoid Fractures

Wrist bone fracture after a fall on the outstretched hand

Treating scaphoid fractures at my Burlington clinic. Convenient for Waterdown and Flamborough residents.

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Scaphoid Fractures

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