The scaphoid fracture is the most common in the carpal area. In most cases, a fracture of the scaphoid bone occurs when falling onto an extended wrist.
The scaphoid fracture can be difficult to diagnose initially. In the absence of therapy, the fracture usually fails to heal, and a so-called scaphoid pseudarthrosis develops.
The scaphoid is located on the thumb side in the first row of the wrist. It belongs to the most important carpal bones. Together with the lunate bone (Os lunatum) and the radius (spoke), it forms the wrist. The scaphoid has a special blood circulation. The blood circulation is from distal, i.e., far from the wrist, to proximal (close to the wrist). Therefore, the proximal third of the scaphoid has the most critical blood supply. More anatomy can be found under the wrist.
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The typical age is between 20 and 30 years of age. The sex ratio is 5:1 male to female, and scaphoid fractures account for approximately 2% of all fractures.
The typical accident mechanism is the fall on the extended wrist. To suffer a scaphoid fracture, significant force is required. Theoretical calculations show that 400 – 800 lb of force is needed to cause a scaphoid fracture. In this case, the scaphoid is squeezed between the radius and the second row of the wrist and breaks. Sometimes a scaphoid fracture occurs and is not noticed. A second fall now causes complaints in the area of the scaphoid bone again, and the x-ray shows the old scaphoid fracture.
Pain with a scaphoid fracture is typically reported in the area of the thumb-side wrist. Pressure in the so-called tabatière is indicated as painful, as is the thumb sprain test.
In some cases, the symptoms can be very mild. The scaphoid fracture is divided into two categories:
- in terms of location
- about the course of fracture
The scaphoid is divided into three thirds.
5 % of all fractures affect the third far from the wrist (distal third), 80 % affect the middle third, and about 15 % affect the third near the wrist (proximal third). Due to the blood circulation situation, proximal fractures have the worst prognosis concerning fracture healing.
A distinction is made between horizontal, transverse, and vertically oblique fractures.
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The first measure to be taken if a scaphoid fracture is suspected is an X-ray of the scaphoid in four planes (scaphoid – quartet). If a scaphoid fracture cannot be detected initially, but the clinical symptoms indicate a scaphoid fracture, the x-rays can be repeated after 10 – 14 days.
To gain further information, a CT (computed tomography) of the carpus may be useful. A CT scan can provide an accurate assessment of the fracture.
In an MRI of the hand (magnetic resonance imaging of the hand), the bony structures cannot be assessed as well as in a computed tomography. MRI has advantages over the assessment of ligament structures. In the case of a fresh fracture, reactive water retention (bone bruise) can be detected in the MRI.
After one week, a skeletal scintigraphy shows a significantly increased bone metabolism in the scaphoid area during fracture healing.
In summary, computed tomography (CT), magnetic resonance imaging (MRI), and skeletal scintigraphy are diagnostic procedures that are only used in exceptional cases to confirm the diagnosis so that a scaphoid fracture cannot be overlooked.
Scaphoid fracture therapy
The therapy of a scaphoid fracture depends on the exact location of the fracture.
Depending on this, the therapy is also differently difficult. Since, due to the anatomical conditions, the blood supply to the scaphoid is from far away from the body – i.e., from the fingers instead of, as is usually the case, from the trunk – fractures of the scaphoid near the fingers heal much faster than fractures of the third of the scaphoid near the body.
In any case, however, a healing period of 6 weeks is to be assumed, usually in the range of 8-12 weeks. The wrist and forearm are fixed with a plaster splint for this period. Since fractures of the extremities are considered to be particularly restrictive in everyday life, there are various possibilities for shortening the duration of therapy.
The fragmented parts of the scaphoid could be fixed against each other using the so-called Herbert screw – a double-threaded screw. This is a special implant that was developed especially for the treatment of scaphoid fractures in the 1970s. One end of the screw is screwed into the part of the fractured scaphoid that is close to the body, and the other end is screwed into the part of the fractured scaphoid that is far from the body.
Since the near-body thread has a smaller pitch than the far-body thread, the far-side scaphoid fragment is screwed to the near-body fracture. The pressure that now acts on the two fragments (also called interfragmentary compression) accelerates the healing process. The Herbert screw has no head and is completely embedded in the bone. It is usually inserted through a small incision on the inside of the wrist. Its great advantage is that it significantly shortens the duration of therapy: the patient has to wear the cast for much less time, and thus has to struggle with limitations for less time. In the case of a distal scaphoid fracture, immobilization is usually only necessary for two weeks, while a fracture close to the body requires only two to four weeks. If the therapy option is chosen without a Herbert screw, other complications such as muscle slackening and joint stiffening must also be taken into account when immobilizing the patient for up to twelve weeks. Since the joint can no longer be moved for such a long period, the supplying muscles consistently lose mass. Furthermore, calcifications and movement restrictions can occur. After a 12-week immobilization, physiotherapy, or rehab should be considered, which follows the actual therapy of the scaphoid fracture as a consecutive form of treatment.
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Treat the scaphoid fracture with a splint.
A splint – as the name suggests – is necessary for splinting the scaphoid fracture. This must be done. Otherwise, there is a risk that the bone will grow together crookedly, resulting in a permanent malposition that cannot be easily reversed.
In addition to restricting movement in the long term, this can result in a shortening of tendons and muscles, nerve compression, loss of function, and even stiffening of the wrist.
There are different types of splints, but they usually differ only in their type and material, but not in their function. The classic plaster splint is often applied in the hospital. It consists of a fast hardening plaster that forms a robust framework around the fracture within 10 minutes after contact with water. The disadvantage is that it cannot be removed for washing and has to be cut open for change, i.e., it is not recyclable. For this reason, other splint systems with Velcro fasteners have been established over the last few years, although there is always the risk of misuse.
If a clumsy movement is made while the splint is too loose or not fitted at all, the unstable bone healing can be damaged, and the fracture can recur. On the other hand, this type of splint is more comfortable to wear and also more natural to change.
Healing of the scaphoid fracture
If a scaphoid fracture is detected in time and treated appropriately, sooner or later, a complete healing can be expected. The prognosis for uncomplicated fractures is usually excellent.
After immobilizing the forearm and wrist with a plaster cast for about 12 weeks, the fracture has healed entirely in most cases.
If the scaphoid is fractured very close to the wrist, surgery with screwing of the scaphoid is usually necessary.
However, the original mobility in the wrist is not yet restored at the time the plaster is removed or immediately after the operation. However, this is regained after some time with the help of consistent physiotherapy and a little patience.
Unfortunately, healing of the scaphoid conservatively with plaster or surgery tends to lead to complications.
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How long does it take to heal a scaphoid fracture?
Depending on the type, location, and treatment of the scaphoid fracture, the duration of the therapy can vary between two and twelve weeks. Scaphoid fractures of the two scaphoid thirds near the wrist are considered particularly difficult. In contrast, fractures of the third near the finger usually heal faster.
If a conservative treatment with a plaster splint is used, a fracture near the finger can be expected to heal within 6-8 weeks. The more complicated two thirds near the wrist usually heal only after 10-12 weeks of immobilization. There are also differences in the duration of surgical treatment with a Herbert screw and interfragmentary compression.
Scaphoid fractures near the finger usually only need to be immobilized with a plaster cast for two weeks after the operation. Fractures near the wrist require two to four weeks. How long the healing of the scaphoid fracture takes, in the end, depends on the age and general condition of the patient. It should also be considered that after a 12-week immobilization, follow-up treatment with physiotherapy or rehabilitation may be necessary, as the joint has not been moved for a very long period!
In addition to the restricted range of motion (which usually results directly from immobilizing the muscles and joints and not from the fracture itself), there may initially be other residual symptoms following conservative treatment. These include swelling, numbness in the arm and hand, or increased sensitivity to the weather.
Individual complaints can also occur following an operation. Because nerves running in the forearm can be irritated during the surgery, the affected areas may also experience tingling or numbness. These symptoms then disappear entirely within a few months, but ultimately in almost all cases, so that the wrist is once again as fit for use as it was before the accident.
From time to time, however, it can also happen that the healing process is somewhat unfavorable. The risk of this is particularly high if a small piece of the bone has been blasted off, which cannot be supplied with sufficient blood and therefore the healing process is slowed down and made more difficult, or if a scaphoid fracture remains undetected for a long time and thus remains untreated. Then in some cases, pseudarthrosis of the scaphoid develops. This means that the bone fragments do not grow back together properly. This ultimately leads to symptoms similar to those of osteoarthritis. Bone rubs against bone, which causes the patient pain and leads to limited mobility in the joint. In such a case, there is usually an indication for (further) surgery to prevent the complaints from becoming chronic and the hand from being misused.
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Plaster for scaphoid fracture
Surgical treatment is not always necessary in the case of a scaphoid fracture. If possible, one tries to avoid surgery. This can be tried without hesitation, usually with fractures that are quite fresh, stable, and not displaced. The classic variant of conservative therapy is the application of a plaster or plastic bandage and the resulting immobilization of the forearm and wrist.
In most cases, this cast extends over the entire forearm and also includes the thumb. Thus the wrist, thumb saddle joint, and thumb base joint are fixed so that they cannot move, and the bone can heal again without the risk of certain pieces slipping and the wrist growing together again crookedly. However, the thumb end joint and all finger joints are released so that they usually remain mobile.
Rarely a cast is put on that extends beyond the elbow, but this is a procedure that is disputed among doctors.
How long the cast must be worn depends on the extent of the injury. On average, it is assumed that it is sufficient to immobilize the wrist for about 12 weeks. When the cast is removed, the patient should be aware that although the scaphoid fracture has ideally healed completely, the hand is still not fully functional because it has not been moved at all for several weeks. For this reason, the increase in mobility and strength should take place slowly and step by step. Warm hand baths, in which the hand can be moved in all directions without significant stress, can be used to support this process. It is often advisable to do physiotherapy under the supervision of a doctor or physiotherapist. If pain occurs during certain movements, this should be interpreted as a severe warning signal from the body, which means that it is probably too early for this movement.
In addition to the plaster cast, various painkillers from the antirheumatic group (non-steroidal antirheumatic drugs, NSAIDs) such as Voltaren or Ibuprofen can be used. However, even this should only be done in consultation with a doctor.
Duration of healing
The duration of complete healing depends on the extent of the fracture. As a rule, however, fractures of the scaphoid and the carpal bones as a whole heal particularly slowly due to the often inadequate blood supply. The location of the fracture in the scaphoid also determines the healing time. As a result, especially in conservative treatment, immobilization in a plaster cast must take up to 12 weeks. If half of the scaphoid is affected, which is closer to the wrist, immobilization in a cast is particularly long. If the fracture is further down the wrist, six weeks may be sufficient. On average, weight-bearing is possible again after ten weeks. Follow-up treatment with further immobilization is advantageous, however. Complete healing with maximum resilience is often only achieved again after half a year.
If conservative therapy does not bring the desired success after many weeks, the fracture must be treated by surgery. After the bone components have been fixed in place with screws, it takes another 10-12 weeks for the fracture to heal again. At least one X-ray should be taken every six weeks to monitor the progress of the therapy.
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