Scaphoid / Wrist Fracture
There are two rows of small bones that comprise the wrist. The scaphoid is one of these bones, which lies on the same side of the wrist as the thumb. Its position in relation to the other bones in the wrist make it susceptible to fracture. It is in fact the most commonly fractured bone in the wrist. Scaphoid fractures usually occur after a fall onto an outstretched hand.
A wrist fracture is the common term for a fracture of the distal (closest to hand) aspect of the radius bone. The radius along with the ulna are the two bones that make up your forearm.
Both Scaphoid and Wrist fractures are common after falls to an outstretched hand or can occur in car / industrial accidents and sports injuries. Symptoms include pain and swelling around the base of the thumb or distal forearm.
Most people will attend A & E first where X-rays of the wrist are routinely performed. Sometimes the x-rays do not detect a fracture of the scaphoid patients are treated cautiously with a splint and a repeat x-ray at 10-14 days after the initial injury. An MRI scan can sometimes be performed and can detect fractures at an earlier stage than x-rays.
Treating a Scaphoid / Wrist Fracture
Treatment depends upon whether the fracture is displaced (whether the two fragments of the scaphoid bone have lost their normal alignment) and where precisely in the scaphoid the fracture is located. Non-displaced fractures can be treated by application of a plaster cast over the wrist for between 6 to 12 weeks, in some cases minimally invasive surgery is performed to insert a metal compression screw into the bone to facilitate quicker return to work / sports.
Displaced fractures require surgery to insert a metal 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, as some fractures are less likely to heal without surgery. 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.
In some patients the scaphoid fracture is missed and the bone may not heal, this is termed a scaphoid non-union. This can have significant effects to the whole wrist. In these cases, depending on the individual case, surgery using a bone graft is required, bone graft may be taken from the wrist, elbow or pelvis.
Treatment depends upon the fracture type, including:
- The specific bones affected
- The extent of displacement (whether the bone fragments have lost their normal alignment)
- Whether the fracture is open (protrudes through the skin)
- Whether there is compromise to nerves or blood vessels in the hand
- Whether the fracture is comminuted (broken into many fragments)
Treatment also depends on a number of patient factors:
- Which is the patient’s dominant hand
- Other medical conditions of the patient
- The patient’s baseline ability and degree of independence prior to injury
- The patient’s normal daily activities including occupation and sports
Non-displaced fractures can be treated by application of a plaster cast over the wrist. Patients will attend clinic on a regular basis and x-rays will be taken to monitor the healing process. The bones normally take 6 - 8 weeks to heal and at this point the cast can be removed. The Physiotherapist will then provide exercises to attempt to restore normal wrist movement and function.
Displaced fractures may require manipulation, which means the re-alignment of the bones by reduction (pulling and pushing the bones into a normal position). Sometimes it is not possible to achieve a satisfactory reduction and surgery is needed to obtain a more stable configuration and reduce the risk of complications, such as long-term arthritis or nerve or tendon damage. Comminuted fractures (multiple fragments) usually require surgery to bring the fragments into a more stable configuration.
Open fractures require urgent care to prevent bone infections. This involves a thorough antiseptic cleaning of the wound in theatre and a surgical method of fracture fixation. Surgical treatment aims to restore the normal alignment of the wrist bones. This may be achieved with metal wires, screws, plates or external frames. In some patients a bone graft is needed to stimulate the healing process particularly where the bone is broken into multiple fragments and there are gaps between the bones, despite attempts to restore a normal alignment.
Patients usually have a bulky dressing applied to the arm and wrist after surgery. Sometimes a small plaster cast may also be applied. Follow up consults with Mr Murray will be required over the next few weeks to check the healing process and work with physiotherapy will continue.
The bones usually take 6-8 weeks to heal and so if a cast has been required, it is removed at approximately 6 weeks depending on the surgery performed, and a lightweight splint can then be used for comfort for a further 1-2 weeks. Dependent on the treatment you have received on your fracture Mr Murray will talk through a timeframe in which he may decide to remove any metalwork, if at all necessary.