The scaphoid is arguably the most important of the carpal bones in the wrist. It is not uncommon to fracture your scaphoid; injury occurs when people fall heavily onto an outstretched hand. If you have a scaphoid fracture, you will suffer from pain on the thumb side of your wrist with reduced wrist function. If the fracture does not go on to heal, you will almost certainly have significant problems with your wrist, so it is important that these injuries are picked up early if possible, and treated quickly, as delayed treatment may result in reduced healing.
An x-ray will identify most scaphoid fractures but not all, and if a scaphoid fracture is suspected even after an apparently normal x-ray, further investigations with a CT or MRI scan may be required to ascertain whether a fracture is present or not.
Scaphoid fractures are most commonly in an area of the bone called the waist and less commonly at the proximal pole or distal pole. The fracture may be displaced or undisplaced and may be simple (in two pieces only) or comminuted (the bone is in several pieces).
Sometimes you will have a scaphoid fracture which has either not been diagnosed initially, or with initial treatment has not gone on to heal; this is called a scaphoid fracture non union. There will usually be displacement of the fracture, and a defect will develop at the fracture site where some bone is lost, often with a reduction in the healing capacity of the edges of the bone.
Scaphoid Fracture Treatment
Undisplaced Scaphoid Fractures
If the fracture is not displaced and is in the waist or distal pole, the treatment of the fracture by a splint or cast until the fracture heals may be suitable. The time to fracture healing varies between people and fractures and can typically be between five and fourteen weeks, and a portion of fractures will not go on to heal by themselves. Some people with an undisplaced waist fracture will choose to have it fixed with a small screw via tiny incisions, as this decreases the time to return to everyday activities, and increases the chance of the fracture healing. It does involve surgery with risks including infection, placing the screw in an incorrect position, and there is a possible risk of injury to structures in the wrist and/or wrist stiffness.
Displaced Scaphoid Fractures
If the fracture is displaced, or if it is in the proximal pole, then the chances of the break healing are much lower, and a good outcome is less likely. All good hand surgeons recommend putting the fracture back into its normal position and internally fixing the fracture.
Scaphoid fracture non unions are best treated with surgery to reduce the fracture and graft the defect in the bone, with some bone taken either from the distal radius or hip, or possibly the knee. This surgery requires a prolonged period in a splint or cast afterwards, and there is a reasonable risk that your fracture will not heal after surgery, as the blood supply to the fracture is not universally present. Mr Jarrett often takes the bone graft attached to blood vessels so that the bone is still alive (vascularised bone graft), or from the knee bone that is attached to blood vessels. It is then possible to plug into the blood vessels in the wrist to keep it alive (free vascularised bone graft), which increases the chance of the fracture healing well.
Scaphoid Fixation Postoperative Care
Following fracture fixation, patients will require a splint for many weeks and ongoing exercises supervised by hand therapists. Mr Jarrett advises keeping the splint in place while the fracture heals. The time needed in the splint will vary between fractures and patients. Giving up smoking, or reducing smoking as much as possible after scaphoid fractures, will aid recovery as smoking increases the risk that fractures will not heal, or will take longer to heal. Even with surgery, there is always a chance the fracture will not heal and may require further surgery. Please note that the risk of the fracture failing to heal increases if the surgery was for a fracture non union.