Scaphoid Fractures

What are scaphoid fractures?
The scaphoid bone is one of the eight carpal bones of the wrist. It is located near the base of the thumb closest to the forearm.   It is the most commonly fractured carpal bone.  Scaphoid fractures can be displaced or nondisplaced.  Nondisplaced fractures are those where the bone is cracked but the fragments have not moved.  Displaced fractures are those where the bone is broken and the fragments are no longer aligned with one another.

How do scaphoid fractures occur?
Scaphoid fractures often occur from high velocity or high impact falls on the outstretched hand. Usually, there is immediate pain that may subside very quickly. There is often no bruising associated with scaphoid fractures and many people with this injury mistake it for a sprained wrist. Therefore, it is common for people who have fractured this bone to not seek treatment or become aware of the injury for months, possibly years after the incident.

Why are scaphoid fractures problematic?
The scaphoid is a bone that has limited blood supply and therefore can be very slow to heal when broken.  Additionally, the scaphoid is more prone to nonunion (never healing) than most other bones.  To minimize the problems that occur with slow or absent healing, early and appropriate treatment of scaphoid fractures is essential.
 
How are scaphoid fractures diagnosed?
X-rays of the wrist most commonly diagnose scaphoid fractures. However, when the fracture is non-displaced (has not moved), early x-rays may be negative. Therefore, for patients with an examination suspicious for a scaphoid fracture but with normal x-rays, it is beneficial to return for a new x-ray after 10 days.  X-rays occurring 10 days or more following an injury may show an injury not present on the initial x-ray.  When there is still a question as to whether there is a fracture or not or if an earlier diagnosis is needed, an MRI can obtained.  MRI's, although not always necessary, are the most accurate means of detecting nondisplaced scaphoid fractures.  When possible, patients should remain immobilized in a splint until a definitive diagnosis is made.

How are nondisplaced scaphoid fractures treated?
Nondisplaced scaphoid fractures can be treated with or without surgery and each treatment has its advantages and disadvantages. 

Casting:  Nonsurgical treatment of a nondisplaced scaphoid fracture consists of casting for 8-12 weeks after the injury.  The cast is removed when the fracture is determined to be healed based on examination, x-rays, and sometimes a CT scan. Unfortunately, there is about an 80% chance of the bone not healing while in the cast.  When a scaphoid fracture does not heal, this is called a scaphoid nonunion and surgery is required.  Surgery for nonunion can be more involved than early scaphoid surgery and therefore some patient may choose early surgery for a nondisplaced scaphoid fracture as noted in the next paragraph.

Surgery:  Surgical treatment of nondisplaced scaphoid fractures involves placing a screw within the scaphoid to compress and stabilize the fracture while it heals.  Advantages of surgery for these injuries more reliable healing and reduced time in a cast.  Disadvantages of surgery include risk of surgical complications as well as the increased expense of surgical treatment over a cast.  

The decision to treat nondisplaced scaphoid fractures with casting or surgery is very individualized and consultation with Dr. Rose or another hand surgery professional is recommended for advice.

How are  displaced scaphoid fractures treated?
Surgery is almost always recommended for displaced scaphoid fractures.  Malaligned fractures have a much higher chance of not healing (nonunion) or healing in the wrong position (malunion).  Scaphoid nonunions and malunions are common causes of wrist arthritis, chronic pain, and loss of function.  Displaced scaphoid fracture surgery involves making an incision to look at the fracture, manipulating the fragments to restore the shape of the bone, and  a screw is placed across the fragments to hold the bone in correct placement while healing. Occasionally, bone must be taken from elsewhere in the body to fill gaps in the scaphoid that may have formed.  Following surgery, the patient is generally required to wear a cast for 6-10 weeks to ensure bone healing. Even with displaced scaphoid fracture surgery, there is a 10-20 percent chance of the bone not healing which may require a second surgery.

How do I know what the best treatment option is best for me? 
Each patient with a scaphoid fracture requires individual assessment of their symptoms and radiographs prior to deciding on the optimal treatment. Dr. Rose has experience with all the above techniques and can provide an assessment and explanation of the options available to you. Please contact us to schedule an appointment