Scaphoid fracture

Fixing your fracture so you are free to move

A fracture of this carpal bone is most common in adolescents and young adults. The scaphoid bone is located on the radial side (thumb) of the wrist in an area known as anatomical snuff box.

Scaphoid fractures often mistaken for sprained wrists

The scaphoid is unique in that it spans the two rows of bones that make up your wrist. Due to its position, it is the most commonly broken bone in the wrist and because symptoms can be minimal, scaphoid fractures are frequently mistaken as sprained wrists. There is often only a little swelling which usually goes away in a few days and a variable amount of pain may be present.

Unlike the forearm, hand and finger bones, fractures of the scaphoid almost never show any obvious deformity of the wrist. These factors can make it common for the diagnosis to be delayed for weeks, months or occasionally even years after the initial injury because this injury can be overlooked or thought to be a common wrist sprain. Scaphoid fractures will require casting or surgery.

Symptoms that indicate a scaphoid fracture

A scaphoid fracture causes tenderness directly over the bone and the pain may increase when you move your thumb or grip things. Your initial pain may decrease over days or weeks and because there is no significant bruising or swelling they are often mistaken for a sprained wrist.

Symptoms of a non-union of the scaphoid bone may be more subtle i.e. you may have pain when you use your wrist but this can be minimal. Still, the most common symptom of a non-union is a gradual increase in pain and over several years the non-union can lead to degenerative arthritis in the wrist joint.

Causes: How does a scaphoid fracture develop?

A scaphoid fracture most commonly results from a fall on an outstretched hand. When a scaphoid fracture is recognised on the first X-ray, treatment begins immediately. Since patients often assume that the injury is just a sprain it is often the case that they wait for it to heal on its own. In some instances, the wrist gets better however, in many cases the bone fails to heal. This can result in the scaphoid fracture developing into what surgeons call a non-union.

A non-union can occur in two ways i.e. a simple non-union, the two pieces of bone fail to heal together or the second type which is much more serious when the lower half of the fractured bone loses its blood supply and dies e.g. avascular necrosis. Only one small artery enters the bone, at the end that is closest to the thumb therefore, if the fracture tears the artery, the blood supply is lost. If a scaphoid fracture is left untreated, the bone is at risk of avascular necrosis.

Diagnosis: Find the exact causes of your symptoms

To diagnose a scaphoid fracture we begin by examining your wrist and taking specific X-rays. Sometimes scaphoid fractures do not show up on initial X-rays, particularly if specifically dedicated views are not sought. Any patient who has fallen on an outstretched hand and has swelling or tenderness on the thumb side of the wrist should be assumed to have a scaphoid fracture, until tests prove otherwise.

X-rays taken immediately after the injury may not show a fracture. If there remains a high degree of likelihood, the wrist should be immobilised in a splint and further imaging should be done by repeating dedicated X-ray views of the scaphoid at 10-14 days after the injury or performing an MRI scan.

Repeating plain X-rays after 10-14 days often will reveal a fracture that was not initially apparent, as the fracture gap widens initially as part of the normal healing process. An MRI scan is extremely sensitive and will identify a fracture, even if it still is not visible on X-ray at two weeks. An MRI however also has the advantage of identifying other injuries, for example, significant ligament injuries that may present in a similar fashion.

As part of treatment, computerised tomography (CT) scans also have a role. These can be used to assess the success of the union but also can assess the 3D anatomy of the scaphoid bone, particularly when the bone has failed to unite. The shape of the bone ultimately is also important in allowing the complex mechanics of the wrist to function well.

Our treatment is oriented to your individual case

Treatment depends on the location, fracture type, and how long ago the injury occurred. Fractures located near the thumb (distal pole) heal well with casting, others in areas with a poor blood supply and displaced fractures generally require surgery.

Surgery for scaphoid fractures can be achieved via a tiny incision when the bone fragments do not need to be reduced (manipulated). Otherwise, a relatively small incision at the base of the thumb is needed. The surgical approach is determined by the fracture location in the bone. Headless screws there are several types, are used to hold the scaphoid bone in position while it heals and a cast or splint is worn for some time following surgery.

Wearing a cast

If the fracture is identified immediately and is in good alignment, you will probably wear a cast for 9 to 12 weeks. The cast will cover your forearm, wrist and thumb which is necessary to hold the scaphoid bone very still while it heals. Your specialist will take X-rays at least once a month to check the progress of the healing and the cast will be removed once the fracture has healed. Even with this type of treatment, there is still a risk that the fracture may not heal well and could potentially become a non-union.

Electrical stimulator for non-union

A fracture that does not heal within several months is considered a non-union. If the injury is fairly recent, your specialist might recommend more time in the cast or they may also prescribe an electrical stimulator. This device sends a small electrical current to your scaphoid bone and it is worn like a large bracelet for 10 to 12 hours a day because electrical current has been shown to help bones heal.

Screw fixation

Some surgeons report good results performing surgery right away when a patient has had a recent, non-displaced scaphoid fracture. Studies have shown that this method can help people get back to activity and work faster than wearing a cast for up to 12 weeks. The procedure involves inserting a screw through the scaphoid. The screw holds the scaphoid firmly until it heals and often can be inserted through a very small incision.

Scaphoid debridement

In cases where a non-union has occurred despite appropriate treatment, surgery will likely be suggested. Depending on the exact location of the non-union the incision is made in the wrist directly over the scaphoid bone either on the palmar side of the wrist, or on the back of the wrist. The surgeon will find the old fracture line on the scaphoid bone and will remove all of the scar tissue between the two halves of the bone (debrided). This will create a fresh bone surface to allow healing to begin again. In some cases, damaged bone tissue from the scaphoid is also removed and stability and compression of the two fragments is firmly held with a screw.

Bone graft method

Your surgeon may use a bone graft which involves taking bone tissue from another spot in your wrist and inserting it into the fracture this procedure can stimulate healing on the surface of the bones. Sometimes, in order to alter the shape of the scaphoid in the presence of a longstanding non-union, a bone graft will be taken from the brim of your pelvic bone.

If the bones do not heal as planned (pseudarthrosis) and the non-union continues to cause pain, you may need a second operation. Your surgeon will probably add more bone graft and check that the pins or screws are holding the bones together.

Depending on the type of surgery you have, you may be placed in a splint for up to 12 weeks after surgery. Your surgeon will X-ray the wrist several times after surgery to make sure that the bones are healing properly. Once the two halves of the scaphoid bone have healed, you can safely begin a rehabilitation programme.

Scaphoid fracture surgery: Aftercare

You may need hand therapy or occupational therapy sessions for 6 to 8 weeks after surgery. The first few treatments will focus on controlling the pain and swelling i.e. exercises to help strengthen and stabilise the muscles around the wrist joint. Other exercises are used to improve fine motor control and dexterity of your hand. You will be given tips on ways to do your activities while avoiding extra strain on the wrist joint.

Scaphoid fracture: Our wrist specialists

With some of the world’s finest hand and wrist specialists at Schoen Clinic, treatment is in safe hands. Leaders in the field are at your disposal to ensure your hands resume normal function with great mobility.

Scaphoid fracture: Our specialised hospital

Schoen Clinic Orthopaedic and Spinal Hospital London boasts some of the most highly experienced specialists altogether in one location. From prevention to diagnosis and treatment to aftercare, a multidisciplinary team of experts puts you at the centre of your care.