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Scaphoid Fractures

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Scaphoid Fractures 1 SCAPHOID FRACTURES Introduction There are two rows of small bones that comprise the wrist. The scaphoid is one of the bones in the proximal row and it sits on the thumb side (see Figure 1). Its name is derived from the Greek term for boat: Skaphos. What causes it? A fracture of the scaphoid bone usually occurs following a fall onto the outstretched hand which causes the wrist to hyper-extend and rotate towards the thumb. This position puts tremendous force on the scaphoid, and can cause it to bruise, crack or break into two or more pieces. Other common causes of scaphoid fracture include motor accidents, motor bike or cycling accidents and forceful blows to the wrist. People of all ages can sustain a scaphoid fracture but is more frequent in men between the age of 20 and 30 years. The scaphoid is the most commonly fractured bone in the wrist. What are the signs and symptoms? Pain (with or without swelling or bruising at the d within days following a fall. These symptoms may be severe at first but “thumbquickly improveside” of the and wrist) therefore can be noticethe injury is commonly interpreted as a sprain rather than a fracture, especially because there is no visible deformity. If, however, the fracture is displaced there may be a wrist is moved. painful crunching, or ‘unstable’ sensation felt when the What tests will I need? Scaphoid fractures are usually diagnosed by an x-ray of the wrist; however, an x-ray might not always show a scaphoid fracture. A break in the bone that cannot be seen on x- fracture. If there is tenderness directly over the scaphoid bone (which is located in the hollow at the thumb sideray ofyet the is wristcalled as an shown “occult” in Figure 2), you may well be recommended to wear a splint to be safe. If pain persists, a follow-up exam and x-ray in a week or two can be used to diagnose. A CT scan or MRI may also be used to diagnose the X-ray scaphoid fracture. MRI is the most sensitive modality for fractures, and can detect completely undisplaced fractures, especially in the first 24 hours following MRI scaphoid (T2 image) MRI scaphoid (T1 image) CT scaphoid injury. It is also useful in assessing for avascular necrosis. CT is though more often used, as it is more useful investigation for advising on treatment. BMI Three Shires Hospital, Northampton Ramsay Woodland Hospital, Kettering BMI Saxon Clinic, Milton Keynes 01604 633730 [email protected] www.upperlimb.co.uk 2 SCAPHOID FRACTURES What are the treatment options? Treatment depends upon whether the fracture is displaced or not displaced and where precisely in the scaphoid the fracture is located. If the fracture is non-displaced (bones aligned at the fracture site), it usually can be successfully treated with a cast. Although the fracture may heal in as little as 5-6 weeks, it may take longer for some patients. Sometimes surgery though is chosen to facilitate quicker healing this can be done percutaneously (minimally invasive surgery). If the fracture is displaced (bone ends have shifted) surgery might be the best option, with insertion – of a metal compression screw to bring the bones back into normal alignment. The precise location of the fracture within the scaphoid bone will also influence the decision as to whether surgery is required, since fractures closer to the wrist are less likely to heal without surgery (those that involve the proximal pole). What does surgery involve? Surgical treatment involves an incision over the wrist and the insertion of a metal screw into the two fragments of the scaphoid bone to hold them in a normal alignment whilst healing takes place. The type and size of scar depends upon the location of the fracture and whether an open or percutaneous approach is used. In some patients a bone graft is used to stimulate the healing process particularly where the bone is broken into multiple fragments. The bone graft may be taken from the wrist, elbow or hip. When can I return to normal activity? Whilst the bone is healing you will be wearing a cast or splint for up to 6 weeks. During this period it is essential that you do not engage in any heavy lifting or strenuous manual work involving your hands. It is also recommended that contact sports and situations that may involve a risk of falling onto your hand be avoided. What are the complications of surgery? The fractured scaphoid may not heal, this is known as non-union, and is influenced by the precise location of the fracture along the length of the scaphoid, the delay between injury and surgery, and individual factors such as other diseases the patient suffers with, including smoking. It is possible that the bone may die, this is known as avascular necrosis, and is again dependent on the precise location of the fracture, the delay to surgery and individual factors. Arthritis may occur in patients that develop non-union or avascular necrosis and this may cause pain and stiffness of the wrist in the long term. Further surgery may be performed to help prevent arthritis in patients with non-union or avascular necrosis. The risks of post-operative infection and nerve injury are small. BMI Three Shires Hospital, Northampton Ramsay Woodland Hospital, Kettering BMI Saxon Clinic, Milton Keynes 01604 633730 [email protected] www.upperlimb.co.uk .
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