The scaphoid is one of the carpal bones on the thumb side of the wrist and is the most commonly fractured carpal bone. Fractured scaphoids usually occur from a fall on an outstretched hand. There is no obvious deformity and little swelling. It often improves relatively quickly meaning it is commonly mistaken for a simple wrist sprain. To further complicate diagnosis, the fracture is often not visible on x-ray shortly after injury.
DiagnosisOn examination there is likely to be tenderness over the anatomical "snuff box", over the scaphoid tubercle and on the scaphoid compression test. Scaphoid fractures are most commonly diagnosed by x-rays of the wrist, although as mentioned above, they often do not show up for 10-14 days post injury, especially with non-displaced fractures. Also, standard x-ray views may not pick up all scaphoid fractures and a special scaphoid view (wrist in ulnar deviation and extension) may be required. After this time, if a scaphoid fracture is still suspected, a CT or MRI may be ordered to aid diagnosis. CT and MRI should pick up scaphoid fractures immediately after injury.
TreatmentUntil a definitive diagnosis is made, the patient may remain splinted to prevent movement of a possible fracture. Once diagnosis is made, it is usually treated by immobilisation in a cast for 6-12 weeks (for non-displaced fractures.) Scaphoid fractures often take a long time to heal due to its uncommon blood supply. Unlike nearly all other bones in the body, the blood supply enters the bone distally (near the hand) rather than proximally (towards the forearm.) The main blood vessel is commonly disrupted by the fracture, which slows the healing process and can even cause death of the proximal fragment of the bone (avascular necrosis.)
Displaced fractures, or fractures in the proximal third of the bone (poor blood supply) are likely to need surgery. A screw or pin is inserted to stabilise the bone, sometimes with a bone graft to help heal the bone.
ComplicationsComplications include non-union, malunion, avascular necrosis, or post-traumatic arthritis. Many people seek help many months after the initial injury with persistent pain or poor wrist function, often because the fracture is misdiagnosed or neglected in the first instance.
Physios are the Worst Patients!Read on, if you want to know how NOT to manage a scaphoid fracture...
I crashed in a Devil race on the track back in June. I fell heavily on my left side but got back on and finished the Omnium I was racing in that day. Despite not being able to move my left hand or grip the next morning, I did a 10 mile TT. I went to A&E for an x-ray 4 days later as I had quite a lot of snuff box pain, but it was clear (although a scaphoid view wasn't taken.) With the help of taping and a splint, I continued to ride my bike and work as a physio.
I didn't go back for re-x-ray after two weeks as I should have, but instead completed the Marmotte! The wrist was feeling much better, so I resumed road racing and promptly crashed again, this time falling on my right wrist. This one didn't feel like it was broken so I didn't bother with an x-ray and just continued to ride and work with taping and a splint.
A month later, my right wrist was still very painful, so I got both wrists/scaphoids x-rayed. To my surprise, my left scaphoid had been broken for 8 weeks (across the waist, plus a chip off the end) but the right wrist was clear. Even more surprising was the fact that the scaphoid fracture seemed to be healing just fine, despite pretty much no immobilisation and a lot of use. When asked what should be done, the doctor said just to continue to wear my brace and not to fall on it again. I took two weeks off road racing and then finished off the season, thankfully crash-free!
I've had a lot of bad luck with crashes this year, but extremely good luck with the healing of my scaphoid, especially since I'm a self-employed Physio! I will definitely be booking in for re-xray in a month or so, just to make sure it has healed. My best advice - Do as I say, not as I do!
Written by Nicole Oh