What is the Scaphoid?
The scaphoid is one of the eight carpal bones in the wrist. Together, the carpal bones are an important part of wrist function, movement, and stability. The scaphoid is arguably the most important carpal bone, connecting the two rows of carpal bones. It also happens to also be the most commonly fractured carpal bone. The scaphoid bone has some interesting properties, the most important being that it has a tenuous blood supply, and is often misdiagnosed.
Mechanism of Injury?
This injury most commonly occurs with a fall onto an outstretched hand (i.e. wrist fully extended). Any simple fall or motor vehicle accident can cause this injury, but we see it most commonly during contact sports.
Patients most commonly experience pain at rest, with range of motion, and when gripping objects. Pain is usually located on the thumb side of the wrist. There may or may not be much swelling. It is important to note, however, that many patients are surprisingly asymptomatic with this injury, which often prompts patients to delay seeking medical attention. Many patients just assume the wrist is sprained, only to find out they have a fracture. Unfortunately, a delay in diagnosis will often lead to a significantly compromised result. Please do not put off seeing a hand surgeon when you think you might just have minor trauma, we can't stress this enough!
Work-up usually first starts with an x-ray. However, because the scaphoid can often be fractured without it being adequately visualized on x-rays, if there is enough of a clinical suspicion, further radiologic studies such as an MRI or CAT Scan.
Many factors must be considered when deciding whether or not a scaphoid fracture can be treated non-operatively or would benefit from surgery. Important factors include whether or not the fracture is displaced (i.e. are the fracture fragments separated), the location of the fracture (certain areas of the scaphoid have poor blood supply and are unlikely to heal without surgery), the length of time since it was fractured, and whether or not the patient is a highly functioning athlete or has a physically demanding job.
While there can be exceptions to every rule, Dr. Lee believes most displaced fractures and most proximal pole fractures (even non-displaced) would benefit from surgical fixation. In addition, those patients requiring the fastest recovery period (athletes, surgeons, etc), or the smallest external protection (braces/splints) may opt to have the surgery performed to facilitate convenience and the fastest healing.
Dr. Lee will discuss various non-operative treatments if warranted. Treatment typically consists of wearing a cast for a longer period of time compared to most other fractures in the wrist. Some fractures may be amenable to a short cast below the elbow, while some may benefit from longer ones above the elbow.
Physical Therapy is started after the patient's cast is removed in order to regain back mobility and strength, which because of the lengthy period of immobilization, may require an extended period of time in physical therapy (usually 6-12 weeks).
The most common surgical treatment for a scaphoid fracture is something called an Open Reduction Internal Fixation (ORIF). During this procedure, a small screw is placed across the fracture site. The screw applies a compressive force across the fracture site and holds fracture fragments in proper position to allow for optimal healing. This screw stays within the confines of the bone and almost never needs to be removed. A bone grafting procedure may be recommended in severe cases (i.e. fracture with poor healing or bone loss).
Dr. Lee has a special interest in the scaphoid bone and has performed many research projects associated with this bone. Because of his specific expertise in this area, he has treated numerous patients with this problem, from pro athletes to other surgeons.
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During the post-operative period, patients are encouraged to take 500 mg of Vitamin C daily, to stop smoking, abstain from dieting, and to do everything possible to avoid additional trauma. We typically will encourage opening and closing of the fingers, but to refrain from any forced gripping, or lifting anything heavier than the weight of a coffee cup.
Patient's most commonly remain immobilized for 6 weeks after surgery. Whether a cast or brace is utilized will depend on the fracture stability and specific needs of the patient. Physical Therapy is usually started after the patient's cast is removed in order to regain back mobility and strength.
Immediate Post-Operative Instructions
Please refer to the following pages for more information:
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.