The scaphoid bone is a small, boat-shaped bone in the wrist, which, along with 7 other bones, forms the wrist joint. It is present on the thumb side of the wrist causing it to be at a high risk for fractures. A scaphoid fracture is usually seen in young men aged 15 – 30 years.
Causes
Scaphoid fracture occurs due to a fall on an outstretched hand with complete weight falling on the palm. This fracture usually occurs during motor accidents or sporting activities.
Symptoms
Symptoms of a scaphoid fracture include pain and swelling at the site of injury (base of the thumb and forearm). There is often no deformity at the site of fracture, hence it may be mistaken for just a sprain. Bruising is also a very rare symptom of the fracture. There are chances that the patient might not be aware of the fracture for months or even years after the fall as the pain generally improves in a few days. If you have been seen by a GP or a general orthopaedic surgeon and continue to have pain after your injury Dr Bala can help to ensure you do not have a missed injury.
Diagnosis
Scaphoid fractures are diagnosed by X-rays. However, a non-displaced fracture is often not visible on an X-ray in the first week. Hence, Dr Bala will test for tenderness at the site of the scaphoid bone to detect the fracture. You will be placed in a splint and must avoid lifting anything heavy for a few weeks. Another stress X-ray, MRI scan, CT scan or bone scan will also be ordered to confirm the diagnosis of the scaphoid fracture or associated ligament injuries.
Treatment
Treatment for scaphoid fracture is based on the site of the fracture i.e., the fracture near the thumb or near the forearm.
Non-surgical Treatment: Non-surgical treatment is used when the scaphoid fracture is not displaced. Non-surgical treatment involves immobilisation of the forearm, wrist in a cast. The time taken for the fracture to heal ranges from 8 – 12 weeks. Fractures near the thumb take relatively less time to heal when compared to fractures near the forearm as the blood supply necessary for healing is better near the thumb.
Surgical Treatment:Surgical treatment may be suggested when the fracture is displaced or is present closer to the forearm. In surgical treatment, an incision is made either in the front or back of the wrist. The procedure may also be done with a very small incision (percutaneous). One or two titanium headless screws are usually used to hold the scaphoid bone in place as it heals.
If the bone is broken into more than 2 pieces, or has not healed after a trial of conservative treatment in a cast, bone graft (graft usually taken from the forearm or waist bone) may be used to help in the healing process. Dr Bala approaches this fracture from the back of the wrist.
Sometimes in high velocity injuries, scaphoid fractures can be associated with dislocation of other hand bones, ligament injuries etc which can be quite complex to treat by non-upper limb surgeons.
If you are a professional athlete and you have injured this bone during season, or are a professional who needs to use his dominant hand to get back to work early, Dr Bala may use a minimally invasive percutaneous technique even for undisplaced fractures to facilitate early return to work.
Dr Bala uses special magnification loupes to visualize and protect structures to minimize complications when operating in this area. In the event you may have a tattoo on the wrist Dr Bala is well versed in suturing tattoos back accurately with absorbable sutures.
Following surgery, your hand will be placed in a splint or cast until it completely heals. Until then, you will be advised to avoid contact sports and not to lift, throw, push or pull heavy weights with the injured arm. During recovery, you will be given physiotherapy and taught certain exercises to help you regain strength and range of motion in your wrist.
Complications
The diagnosis and treatment of scaphoid fractures can be complicated. The complications involved in the treatment of scaphoid fracture include:
- Scaphoid Non-union: when a bone fails to heal after non-surgical or surgical treatment. This is caused due to limited blood supply in the scaphoid region. Bone graft from the back of the lower end of the outer forearm bone with or without its blood supplying vessel pedicle, or from the waist bone of the same side, or from one of the small bones of the outer end of the wrist itself (hemi-hamate autograft) can be used when fixing this fracture. Dr Bala prefers to approach this fracture from the back of the wrist (unless it is collapsed volarly) and prefers to use headless titanium screws to fix this fracture.
- Avascular necrosis (AVN) of scaphoid: This is a complication in which cells of the scaphoid bone die due to lack of blood supply, causing bone collapse and arthritis. This usually happens in case of displaced fractures, as the displaced bone fails to get proper nutrients. Surgical treatment with removing the dead bone and partial wrist fusion surgery (four corner fusion) or removal of the proximal 4 small carpal bones of the wrist (proximal row carpectomy) may be suggested by Dr Bala to treat this complication. Dr Bala prefers to use a disc type plate and screws for this surgery and uses bone graft harvested from the patient’s own waist.
- Post-traumatic arthritis: Persistent non-union and avascular necrosis of the scaphoid can cause arthritis of the wrist. This can be treated with splits, anti-inflammatory medications, steroid injections or surgically removing the scaphoid bone and partial wrist fusion (four corner fusion). Dr Bala prefers to use a disc type plate and screws for this surgery and uses bone graft harvested from the patient’s own waist.
Conclusion
Scaphoid fractures can prove to be a permanent disability if not treated appropriately and with full care. The patient must take proper care to wear the cast until complete recovery of the fracture has occurred. It is also very important to maintain complete motion of the fingers and avoid lifting or pushing heavy weights during the recovery period. Exercise programs and physiotherapy should be strictly followed until the same motion and strength in the wrist is restored.
Dr Bala also deals with suboptimally treated scaphoid fractures.
