Richard A. Bernstein, MD
Left: an x-ray of the wrist showing a scaphoid fracture.
Right: diagram of the wrist showing the position of the scaphoid.
Fractures of the scaphoid, a bone in your wrist, are not to be taken lightly. This is the only bone of the body that I know of that has an entire book written about how hard it is to diagnose and treat scaphoid fractures, and what to do when a fracture does not heal! Most of the time, a broken bone is obvious. The area around the break may be painful, swollen or deformed. But sometimes a bone can break without your realizing it. That ’ s can happen to the scaphoid (pronounced "skaf'-oyd"). Some doctors call this bone the "navicular", but this is an older, out of favor term. Many people with a fractured scaphoid think they have a sprained wrist instead of a broken bone because there is no obvious deformity and very little swelling. If you’ve fallen and think you’ve sprained your wrist, call Dr. Bernstein for an appointment as soon as possible. Rest your wrist until you get seen.
The scaphoid bone is located on the thumb side of your wrist, close to the lower arm bones (see the diagram and x - ray at the top of the page). It is shaped like a cashew, which makes it hard to visualize on the x - ray.
The reason scaphoid fractures have a hard time healing is due to the anatomy of the blood supply to the bone. The blood supply is what keeps the bone alive and allows it to heal. Most of the bone is covered with cartilage, the smooth shiny material that forms the joints and allows the bones to move. Blood vessels cannot enter through the cartilage; they enter only through the bone. Since the scaphoid is mostly covered in cartilage, there is a limited area for the arteries to enter the bone. In the scaphoid, the blood supply to the bone enters from the distal end, that is, the end toward your fingers. This can be a problem for healing, since most fractures occur in the middle or lower portion of the bone. The blood supply to the proximal fragment, that is, the piece that is toward your elbow, may not have any blood supply. Without a blood supply, the bone cannot heal and that fragment may die.
Scaphoid fractures account for about 60 percent of all wrist (carpal) fractures. They usually occur in men between ages 20 and 40 years, and are less common in children or in older adults. The break usually occurs during a fall on the outstretched hand. It ’ s a common injury in sports and motor vehicle accidents. The angle at which the hand hits the ground determines the injury. The following is a very rough "rule of thumb": If the wrist is bent at a 90 - degree angle or greater, the scaphoid bone will break; if the angle is less than 90 degrees, the lower arm bone (radius) will break.
The diagnosis is based on a history of trauma to the wrist (usually a fall or accident), a clinical exam that shows tenderness in the region of the scaphoid and a painful Watson test (a maneuver in which the wrist is moved back and forth, with the examiner's thumb on your scaphoid; it is just slightly painful), and x - rays that show a fracture. Sometimes, the x - ray does not show a fracture. In some cases other X - rays are needed to diagnosis the problem. Usually, with a supportive history and clinical exam, the diagnosis will be made of a probable scaphoid fracture.
Treatment is determined by the fracture site, the degree of displacement , any associated injuries, and the patient's occupation and desires.
Cast Treatment: Many scaphoid fractures are treated with immobilization in a cast that immobilizes the elbow, wrist, and thumb, for six weeks, and then only the wrist and thumb for an additional six weeks. Healing time, however, can range from six weeks for fractures in the top portion (toward the fingers) to six months or longer for fractures in the lower portion (toward the wrist). The cast must be checked regularly to make sure that it fits properly and prevents movement. After the cast is removed, a rehabilitation program helps restore range of motion and strength.
Surgical Treatment: Some fractures are displaced by 1 mm or so. These usually need surgical treatment. Scaphoid fractures that are accompanied by other injuries, usually a distal radius fracture, also need surgery. Also, with newer techniques, the risks of surgery are reasonably low that some patients choose surgery, because it usually means the patient does not need to we are a cast at all, just a splint. Over the last few years through a limited approach we can address scaphoid fractures and avoid cast immobilization. Via a small incision, I can introduce a screw into the scaphoid and minimize the time in a cast. As with any surgery there are risks with this procedure, there is still no guarantee that the scaphoid will heal and there are risks to the wrist and tendons. The pros and cons are something that we can talk about in the office.
Not all scaphoid fractures will heal properly. The usual causes are delay in treatment or too short a time in a cast that is too short. Smoking also interferes with bone healing. However, the scaphoid is rather famous for not healing, even when everything is done properly. Surgery is usually recommended when the scaphoid fails to heal (non - union). Surgery for non - union is successful in approximately 75 percent of cases.
Sometimes a bone graft is used to promote healing. There are two types of bone grafts. One is using your own bone, often times from the radius bone of the forearm. This can bring in new bone cells to help fill the gap. The other type of bone grafting is taking a segment of bone from the radius and moving it to the scaphoid attached to a microscopic blood vessel. There are certain times to do one or the other that we can discuss in the office.
Scaphoid fractures often take a long time to heal. Any delay in getting treatment increases the risk of poor healing and the probability of more problems later. An untreated scaphoid fracture can lead to severe arthritis and eventually require surgery to fuse or replace the joint.
Copyright © 2010, TOG All rights reserved.
Therapy for Wrist Fractures with Open Reduction and Internal Fixation
Co-authored: Kathy Jacobsen, PT,CHT/ Richard A.Bernstein, M.D.
Wrist fractures are often considered the most common type of fracture seen by physicians. The fractures are generally caused by a fall on the out- stretched hand. The distal portion of the radius bone is usually the affected area, and fractures vary greatly in type and severity. X-rays are used to determine proper treatment.
Simple fractures of the radius, where the bone is not displaced, can be treated with a cast for approximately 6 weeks. If the bone is not in proper alignment, we can put the bone back into position in a procedure called a closed reduction prior to being casted. In more severe fractures, or in people who need to get back using their hand sooner, there is the option of surgical fixation to obtain optimal fracture position and a better functional outcome. Fractures of the radius, that extend into the joint, called intra-articular fractures, are the type that most often require surgical fixation. When the articular surfaces of the wrist are not in good alignment this may result in significant loss of motion, strength and overall function of the wrist and hand. In addition, patients may experience long term pain and eventually develop arthritis at the joint.
Our decision and discussion regarding treatment, depends upon the x-ray and the individual patient’s needs.
There are a variety of methods available to treat displaced fractures of the distal radius. Traditionally, external fixators were the modality of choice. These metal frames involve pins within the radial shaft and metacarpals with bars spanning the wrist to hold the wrist distracted. Occasionally, this could be augmented with pin fixation. However, there has been a revolution in the treatment of wrist fractures utilizing metallic plates placed on the palm surface of the wrist. This T-shaped piece of hardware is placed on the volar surface of the distal radius. The articular surface of the distal radius can be appropriately aligned and the fracture pieces held securely in position. Ideally, the patient would have surgery within the first few days following the injury. The surgery is performed as an outpatient procedure, the is placed in a compressive dressing and then advanced to a splint in 5 days. The patient then sees a hand therapist to start their rehabilitation process. At the first therapy visit the post-op dressing is removed, a lighter dressing is applied, and a custom thermoplastic splint is fabricated. The splint allows greater freedom of movement of the fingers and thumb than a cast and is adjusted to be comfortable for the patient. The hand therapist teaches the patient active exercises for the hand, and gentle active exercises for the wrist.
The patient is instructed to continue to keep the wrist elevated to decrease the swelling and to use the hand for light daily activities. Most patients experience very little pain with this procedure and may take pain medicine for a few days following surgery. Patients are encouraged to ice the wrist and hand as needed.
At the follow-up visit, approximately a week and a half post-surgery, the sutures are removed and an x-ray is obtained to check the alignment of the fracture. The patient can then remove the splint for showering and exercise but will continue to use the splint as external support for the healing fracture for the next 4 weeks. Therapy visits now focus on steadily increasing hand and wrist range of motion and function. Heat modalities and gentle stretching and mobilization techniques are used to facilitate motion. Ice, elevation and compressive wraps control swelling, which is often resolving at this point.
The surgical scar is typically minimal.
Most patients return to light work and daily activities, however, patients with more demanding physical jobs or sports requirements will need to wait for clearance from the physician to resume these activities.
Approximately 6 weeks following surgery, patients start light strengthening of the wrist and hand and is no longer using the splint. Patients generally have functional range of motion at this time. The majority have full or close to normal motion of the wrist and good strength several months post-op. There are very minimal complications associated with this procedure and in our hands, less than 5% of patients require hardware removal.
© 2008 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author.