Fractures of the carpal bones (Scaphoid fracture)
I had a fall onto the outstretched hand (FOOSH) and injured my wrist / broke a bone (scaphoid) in my wrist
The wrist is a complex joint comprised of 15 bones. These are radius and ulna of the forearm, eight carpal bones and five metacarpal bones. Depending on the energy of the incident you might have broken one or more bones that form part of your wrist. The scaphoid is one of the eight carpal bones that frequently gets fractured at high energy accidents. Regardless, you might find yourself in an emergency department, suffering from pain and information overload and need some guidance and care. Please feel free to get in touch (07 3394 4073) and we will endeavour to look after you acutely. Should you happen to be at Greenslopes Private Hospital Emergency Centre ask your treating doctor to notify us. This is a straight forward referral process and Dr Rhau is often able to see you on short notice.
What are the symptoms of scaphoid fracture?
Pain and swelling are the key findings in scaphoid fracture. Range of motion and grip strengths are compromised by the pain. There is usually spot tenderness in the anatomical snuff box which is the groove between the tendons at the base of your thumb.
Who gets a scaphoid fracture?
Scaphoid fractures are the result of high energy trauma where the wrist is forced backwards. They typically happen in younger individuals often at sports activity. It is the same mechanism of injury that causes distal radius fractures in the elderly and also scapholunate ligament tear (please explanation above).
How is scaphoid fracture diagnosed?
The history of a sports injury or other accident where the wrist was forced backwards is typical. Combined with the symptoms as mentioned above and x-rays the diagnosis can be established. However, often x-rays don’t show hairline fractures in the scaphoid and as a doctor one has to have a high index of suspicion if clinical symptoms match. CT scan is able to image hairline fractures and MRI scan can even diagnose ‘internal’ scaphoid fractures as so called ‘bone bruise’.
Treatment of scaphoid fracture
The scaphoid has a very delicate blood supply and a fracture can cut the supply off in the fragment close to the radius. Therefore early diagnosis and adequate treatment are imperative as missed hairline fractures can displace secondarily or result in fracture non-union or worse ‘avascular necrosis’ (bone dying due to lack of blood supply). Undisplaced scaphoid fractures can be treated with cast immobilisation and even when x-rays are negative, clinical findings match and further imaging with CT scan or MRI is unavailable, the wrist should be immobilised until a fracture is excluded. The duration of cast immobilisation depends on the fracture configuration and varies between four and 12 weeks. If a scaphoid fracture is easily visible on x-rays, an unstable fracture situation is generally assumed which has a very high chance of non union or avascular necrosis. In these cases surgical fixation is recommended. Surgery can also be considered if a patient is not comfortable with cast immobilisation for up to 12 weeks. Following surgery immobilisation can be discontinued after four weeks.
Surgery for scaphoid fracture
Once a scaphoid fracture has been diagnosed as displaced or unstable surgical fixation is recommended to avoid complications such as non-union or ‘avascular necrosis’ (bone dying due to lack of blood supply). Most of these fractures can be done as day surgery and only a small incision is required to insert a special screw that stabilises the fracture internally. In cases where a non-union, severe displacement or avascular necrosis need to be addressed the surgery is more extensive and time consuming, also could require bone grafting. Therefore it is my suggestion to stay overnight where we are able to manage you pain adequately and make you feel comfortable.
Preparing for surgery for scaphoid fracture
In most cases we will refer you to a hand therapist to manage the swelling and fit a thermoplastic custom brace which will also be required after surgery. If required we will also arrange for a bulk billed pre-admission clinic at the hospital. This is run by a specialist anaesthetist who will gather information and request investigations that are required for safe anaesthesia. Our reception staff will advise of costs, hospital and admission details. Often these surgeries are carried out as emergency surgery and we will endeavour to provide as much information as possible prior to the procedure.
Recovery after surgery for scaphoid fracture
Following scaphoid fracture surgery wrist immobilisation is required for four to six week. During this time however hand therapy can commence for dressing changes, oedema management and some exercises. You will have follow up appointments with your surgeon two and six weeks after the procedure and a check x-ray at the 6 week mark. Once fracture union is confirmed hand therapy will focus on increasing range of motion and grip strength and you can expect a full recovery between three and six months after surgery. It is extremely rare that plates and screws that have been used for scaphoid fracture fixation require to be ever removed.