Scaphoid fracture of the wrist - OrthoInfo - AAOS (2023)

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A scaphoid (scaphoid) fracture is a break in one of the small bones of the wrist (carpal bones). This type of fracture most commonly occurs after a fall onto an outstretched hand.

Symptoms of a scaphoid fracture typically include swelling and pain in the wrist just below the base of the thumb. Squeezing, grasping, pushing, and pulling often make the pain worse.

Treatment for a scaphoid fracture can vary from plaster casts to surgery. The optimal treatment may depend on the severity of the fracture (how severe the fracture is) and its location in the bone. Because portions of the scaphoid have poor blood flow and a fracture can further disrupt (slow or stop) blood flow to the bone, scaphoid fractures are more likely to complicate the healing process than fractures of other bones.

Anatomy

The wrist consists of the two bones of the forearm - the radius and ulna - and eight small carpal bones. The carpal bones are arranged in two rows at the base of the hand. There are four bones in each row.

Scaphoid fracture of the wrist - OrthoInfo - AAOS (2)

Normal anatomy of the hand and wrist. The scaphoid is one of the small carpal bones in the wrist.

Gengivet von JF Sarwark, red: Essentials of Musculoskeletal Care, ed. 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

The scaphoid is one of the carpal bones on the thumb side of the wrist, just above the radius. The bone is important for both movement and stability of the wrist.

The word "scapoid" comes from the Greek term for "boat". The navicular bone resembles a boat with its relatively long and curved shape. The scaphoid is particularly important to wrist function because it connects the proximal row of carpal bones (the bones closer to the radius and ulna) to the distal row of carpal bones (the bones closer to the fingers). Smooth and unrestricted (free) movement of the scaphoid is required for optimal wrist movement.

The navicular bone is easiest to see when your thumb is held in a "flexed" or "thumbs up" position. It is located at the bottom of the indentation created by the tendons of the thumb on the back of the wrist. This area, often referred to as the "anatomical snuffbox," is usually where you feel the most tenderness or pain with a scaphoid fracture.

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Photo and X-ray show the position of the scaphoid in the wrist. The red arrows indicate the location of the anatomical snuff box.

As mentioned above, the scaphoid is poorly supplied with blood.

Blood flows throughout the body from the heart to the extremities (arms and legs) - from near the body (proximal) to the fingers and toes (distal). This direction of flow is found in most bones of the arms and legs, where blood flows from the part of the bone closest to the body to the part of the bone closest to the fingers or toes.

However, the blood supply to the scaphoid is "backward": blood enters the part of the scaphoid closest to the thumb (distal) and flows back toward the part of the scaphoid closest to the body (proximal). For this reason, fractures of the distal scaphoid heal significantly faster than fractures of the proximal scaphoid. In fact, there is a risk that if the proximal scaphoid is fractured, the blood supply will be completely cut off and part of the scaphoid may die or die. This phenomenon, called "avascular necrosis," can cause long-term problems in the wrist.

Description

A scaphoid fracture is usually described by its location in the bone. Most commonly, the scaphoid fractures in its middle part, called the "waist." Fractures can occur at both the proximal and distal ends of the bone.

Scaphoid fractures are classified by the severity of the displacement—or how far the pieces of bone have moved from their normal position:

  • Undisplaced fracture.In this type of fracture, the bone fragments are properly aligned.
  • displaced fracture.In this type of fracture, the bone fragments have moved out of their normal position. There may be gaps between bone pieces or fragments may overlap.

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Diagram and x-ray showing a fracture in the middle portion or "waist" of the scaphoid. This is the most common site for a fracture.

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Caused

A scaphoid fracture usually occurs when you fall onto your outstretched hand and your weight lands on your palm. Depending on the position of the hand upon landing, this type of fall can also fracture the end of the large forearm bone (radius).

Injuries can also occur during sporting activities or collisions with motor vehicles.

Fractures of the scaphoid occur in people of all ages, including children. There are no specific risk factors or diseases that increase the risk of a scaphoid fracture. Some studies have shown that wearing wrist guards during high-energy activities like rollerblading, skateboarding, and snowboarding can help reduce the risk of fractures around your wrist.

symptoms

Scaphoid fractures usually cause swelling and pain at or near the anatomical snuff box and the thumb side of the wrist. The pain can be severe when you move your thumb or wrist, or when you try to pinch, grab, push, or pull something.

Unless your wrist is deformed, it may not be obvious to you that your scaphoid is fractured. With some scaphoid fractures, the pain is not severe and can be mistaken for a wrist sprain.

Pain in your wrist that doesn't go away within a day of the injury could be a sign of a fracture — so it's important to see a doctor if your pain doesn't go away. Timely treatment of a scaphoid fracture can help prevent potential complications.

Scaphoid fracture of the wrist - OrthoInfo - AAOS (5)

The symptoms of a scaphoid fracture often appear in the anatomical snuff box at the base of the thumb.

Medical examination

Physical examination

During the exam, your doctor will:

  • Can talk to you about your general health
  • I'm going to ask how you got injured
  • I will ask you to describe your symptoms

Your doctor will also examine your wrist. In most fractures, there is tenderness just above the scaphoid bone in the anatomical snuff box. Your doctor will also look for the following:

  • swelling
  • bruises
  • loss of motion

Tests

X-rays.X-rays provide images of dense structures, such as bones. Your doctor will likely order an X-ray to determine if you have a fractured scaphoid and if the broken pieces of bone are misaligned. An X-ray can also help your doctor determine if you have other fractures or dislocations.

In some cases, a scaphoid fracture is not immediately apparent on the X-ray. If your doctor suspects you have a fracture but it isn't visible on the x-ray, they may recommend that you wear a wrist splint or cast for 2 to 3 weeks and then come back for a follow-up exam. Scaphoid fractures often only become visible in the X-ray image after some time. During this waiting period, you should wear your splint or cast and avoid activities that could lead to further injury.

Magnetic resonance imaging (MRI) scan.Your doctor may order an MRI to learn more about the bones and soft tissues in your wrist. An MRI can sometimes show a scaphoid fracture before it is visible on an X-ray.

Computed tomography (CT) scan.A CT scan can be helpful in detecting a fracture of the scaphoid and also showing if the bones are misaligned. Your doctor can use the information from the CT scan to determine your treatment plan.

Treatment

The treatment recommended by your doctor depends on several factors, including:

  • The location of the fracture in the bone
  • Whether the bone fragments are displaced
  • How long has it been since you were injured?
  • Your age and general health

Non-surgical treatment

Fracture near the thumb.Nondisplaced scaphoid fractures closer to the thumb (distal pole) are likely to heal with appropriate protection and reduced activity. This part of the scaphoid has a good blood supply, which is necessary for healing.

For this type of fracture, your doctor may put your forearm and hand togetherpouror a rail. The cast or splint is usually below the elbow and encompasses your thumb.

The healing time varies from patient to patient. Your doctor will monitor your healing with X-rays or other imaging tests.

Scaphoid fracture of the wrist - OrthoInfo - AAOS (6)

For some fractures, a cast covering the forearm, wrist, and thumb (called a thumb spica cast) may be used to hold the bone fragments in place while they heal.

Fracture near the forearm.If the scaphoid is broken (but not displaced) in the center of the bone (waist) or closer to the forearm (proximal pole), healing may be more difficult. As discussed above, these areas of the scaphoid are not very well supplied with blood.

If your doctor treats this type of fracture with a cast, the cast may encompass the thumb and extend past the elbow. Typically, this type of fracture will require you to stay in a cast or splint longer than a more distal fracture near the thumb.

bone stimulator.In some cases, your doctor may recommend using a bone stimulator to help fracture healing. This small device delivers low-intensity ultrasonic waves or pulsed electromagnetic waves that stimulate healing.

surgical treatment

If your scaphoid is fractured at the waist or proximal pole and/or if the fracture is displaced, your doctor may recommend surgery. The goal of surgery is to realign and stabilize the fracture to give it a better chance of healing.

Reduction.During the surgery, your doctor will put the bone back in the right position. In some cases, this is done via a limited (smaller) incision and special guided instruments. In other cases, the operation is performed through an open incision with direct manipulation of the fracture. For some fractures, your doctor may use a small camera called aArthroskopto help with the reduction.

Internal fixation.During this part of the procedure, metal implants — including screws, plates, and/or wires — are used to hold the broken ends together and hold the scaphoid in place until the bone has fully healed.

Scaphoid fracture of the wrist - OrthoInfo - AAOS (7)

(Links)This x-ray shows a scaphoid fracture fixed with a screw.(To the right)This x-ray was taken 4 months after the operation. The fracture of the scaphoid has healed.

The location and size of the surgical incision depends on which part of the scaphoid is broken. Sometimes the implants can be inserted through a small cut in bone fragments. In other cases, a larger incision is required to ensure the fragments of the scaphoid are properly aligned before it is fixed. The incision can be made either on the palm of your hand or on the back of your wrist.

bone graft.In some cases, a bone graft can be used with or without internal fixation. A bone graft is new bone placed around the broken bone. It can stimulate bone production and healing. The bone graft can be taken from your forearm, elbow, hip, or other area. Some companies also make grafts that can be placed in the fracture so the surgeon doesn't have to harvest bone from your body.

recreation

Regardless of whether the treatment is surgical or non-surgical, you may need to wear a cast or splint for up to 6 months or until your fracture heals. Unlike most other fractures, scaphoid fractures tend to heal slowly. During this time, unless your doctor approves an advanced activity, you should avoid the following activities:

  • Lifting, carrying, pushing, or pulling more than 1 pound of weight
  • Throw with the injured arm
  • Participation in contact sports
  • Climbing ladders or trees
  • Participate in activities where there is a risk of falling on your hand, such asInlineskatingorjump on a trampoline
  • Use of heavy machinery or vibrating machinery/equipment
  • Smoking(which can delay or prevent fracture healing; it can also have repercussionshealing after an operation)

Some patients experience wrist stiffness after a scaphoid fracture. This is more common in patients who wear a cast for a long time or who require more extensive surgery.

It is important to be able to move your fingers fully throughout the recovery period. Your doctor will create an exercise program for you and may refer you to a licensed hand therapist to help restore as much range of motion and strength as possible to your wrist.

Despite hand therapy and patient exertion during home therapy, some patients may not regain the same range of motion and strength as they did before their injury.

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complications

No connection

A bone that does not heal is referred to as an anon-union. Pseudarthrosis occurs more frequently after scaphoid fractures because the blood supply to the scaphoid bone is poor. A good blood supply to a bone is very important for fracture healing, as blood carries oxygen and nutrients to the fracture site, aiding healing.

If your scaphoid fracture doesn't heal, your doctor may consider additional surgery to insert a bone graft. There are different types of bone grafts.

  • For nonunions, your doctor may use a special type of graft that has its own blood supply (vascularized graft).
  • In the case of a collapsed fracture, your doctor may use a structural graft of sufficient strength -- possibly from your hip.

Avascular necrosis

In the case of scaphoid fractures - especially those in which the bone fragments have been displaced - the blood supply to the bone can be disrupted. If the blood supply to one of the bone fragments is significantly reduced or lost altogether, that bone fragment will not receive enough nutrients and the cells in the bone will die. In this case, the bone does not heal properly. This condition is called avascular necrosis.

A vascularized bone graft may be the most effective treatment for this condition—as long as the bone hasn't collapsed significantly or arthritis hasn't developed in the wrist.

Arthritis

Over time, nonunion and avascular necrosis of the scaphoid can occurArthritis in the wrist. Arthritis occurs when the articular cartilage in the joint becomes worn and frayed — sometimes to the point that bone rubs against bone.

Symptoms of arthritis in the wrist can include:

  • pain
  • stiffness
  • Reduced range of motion in the wrist
  • Pain with activities such as lifting, grasping, or straining

Treatment for gout focuses on improving symptoms. Initially, this may include:

  • Takeanti-inflammatory drugsor over-the-counter analgesics (painkillers)
  • Wearing a splint when your wrist hurts
  • Avoid activities that put strain on the wrist
  • Possibly a steroid injection in the wrist which may help with pain relief

If conservative treatment doesn't relieve your symptoms, your doctor may recommend surgery. There are many types of procedures that can be performed for wrist arthritis.

New Developments

For certain fracture patterns, some doctors now use a very small incision—less than 1 cm long—to realign the fracture and place a screw in the navicular bone. This procedure is performed using a special x-ray machine to facilitate screw placement.

In addition, your doctor may insert a small camera called an arthroscope into your wrist to view the fracture directly. This can aid in reduction and fixation of the bone and reduce the surgical incision length required.

Various types of bone grafts and bone graft substitutes are currently being researched to accelerate bone healing. Additional agents such as bone morphogenic proteins (BMP) are also being evaluated to enhance healing potential.

Newer types of wrist braces can help prevent injury, and better imaging can lead to earlier diagnosis of these difficult fractures.

References

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