Scaphoid Fracture

Scaphoid fracture

The scaphoid is one of the small groups of bones in the wrist called the carpal bones. It is the most common carpal bone to fracture among athletes, often caused by falling onto an outstretched hand. Here we explain the symptoms, causes, treatment, surgery, and complications of a scaphoid fracture

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Scaphoid fracture symptoms

  • Pain in the wrist at the time of injury.
  • Rapid swelling, particularly at the back of the wrist.
  • Pain may settle down soon after the fall.
  • Later though, you will have difficulty gripping things.
  • Pressing in on your wrist will be tender when compared to the other side.

Imaging

  • A scaphoid fracture may show up on an X-ray, but not in all cases. It is the most common missed fracture resulting in legal claims.
  • A CT scan is better for a recent acute injury if this type of fracture needs to be ruled out.
  • An MRI scan is also suitable, however, a scaphoid fracture may not show up during the first 24 hours following injury.

The exact area of tenderness is called the anatomical snuff box and is located between two tendons on the thumb side of the wrist.

Scaphoid fracture treatment

  • Initially, treatment of a scaphoid bone fracture would be to apply ice or cold therapy, protect the wrist with bandaging or strapping and seek medical attention.
  • A doctor will X-ray the wrist to confirm a diagnosis of a scaphoid bone fracture. However, the injury may not always show up on an X-ray.
  • If the doctor suspects a fracture but the X-ray is normal then it cannot be ruled out. In this case, an MRI (24 hours post-injury) or bone scan will reveal the fracture.
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Cold therapy

Stable fractures

  • If your fracture is stable it wrist will be immobilized for 8 weeks in a plaster cast extending from just below the elbow, over the wrist, and at the base of the thumb.
  • A scaphoid fracture cast of this size is needed to properly immobilize the wrist and allow the bone to heal.
  • After 8 weeks the scaphoid fracture is re-assessed and rehabilitation exercises can begin along with a gradual return to sport. It is important to fully strengthen the wrist following so many weeks in a cast as the muscles will waste away.

Scaphoid fracture surgery & complications

Scaphoid fractures have a risk of not healing properly due to the poor blood supply. If this happens then in some cases the fracture is immobilized again for a further 4 to 6 weeks. Immobilizing beyond this time is unlikely to be beneficial so in this case, surgery is often required and many surgeons would do this sooner rather than opt for a further period of immobilization.

The bones in the wrist need to move in a perfect arc and if there is any disruption to this movement then pain and stiffness are the results. A scaphoid fracture typically affects young adults in their 20’s and 30’s. It is caused by a fall onto an outstretched hand, or sometimes in punching sports such as boxing.

Why is the Scaphoid bone so important?

The scaphoid bone is particularly important and if it does not heal properly this can lead to progressive stiffness and pain in the wrist possibly leading to arthritis or wear and tear in the joint known as post-traumatic arthritis of the wrist which is particularly debilitating.

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What happens if it is misdiagnosed?

If your scaphoid fracture is not identified and treated early enough then it may not heal. This is more likely with a Scaphoid fracture because it does not always show up initially on an X-ray. Therefore, it is often diagnosed as a sprained wrist.

If you have had a fall onto an outstretched hand, pain in the wrist with specific tenderness at the base of your thumb, it could be a fractured Scaphoid.

A scaphoid fracture should be treated aggressively. The majority, if they are picked up early enough, can be treated in a plaster cast for between 6 and 8 weeks. In most cases, the fracture will heal. However, more problematic and severe fractures will need to be operated on. The blood supply to the scaphoid bone will be so compromised that even with 8 weeks in plaster it is unlikely to heal.

Percutaneous technique

A more modern technique called a percutaneous technique means the wrist is operated on without having to open up the wrist surgically but by inserting a screw through the bone to immobilize it via a tiny hole. This is attractive for the self-employed or professional sportspeople who do not want to have the long recovery time required for a long operation.

If a scaphoid fracture is picked up early enough and treated aggressively then it is possible to get reunion of the bone and good results. If the bone does not heal either because of a cyst on the bone or a collapse of the bone then more complicated techniques are required such as a bone graft where a piece of bone from elsewhere in the wrist is transferred.

However, if a scaphoid fracture is picked up early and treated with a plaster cast or percutaneous screw then the need to avoid invasive open surgery can be avoided.

References & further reading

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