Scaphoid Fracture

The scaphoid bone is one of eight small bones that make up the “carpal bones” of the wrist. There are two rows of bones, one closer to the forearm (proximal row) and the other closer to the hand (distal row). The scaphoid bone is unique in that it spans the two rows (see Figure 1). This puts it at extra risk during injury, which accounts for it being the most commonly fractured carpal bone by far.

Scaphoid fracture occurs most frequently from a fall onto the outstretched hand. Typically there is pain initially, but the pain may decrease after days or weeks. Bruising is rare, and swelling may be minimal. Since there is no deformity, many people with this injury mistakenly assume that they have just sprained their wrist, leading to a delay in seeking evaluation. It is common for people who have scaphoid fracture not to become aware of it until months or years after the event. 

Figure 1. The scaphoid bone is unique in that it spans the two rows of wrist bones.

Tenderness directly over the tendons on the thumb-side of the wrist is the most common finding. A test is generally performed in which the patient makes a fist with the fingers clasped over the thumb. The wrist is then bent in the direction of the little finger (see Figure 2). This maneuver can be quite painful for the person with de Quervain’s tendonitis. 

Scaphoid Fracture Diagnosis

Pain over the thumb-side of the wrist is the main symptom. The pain may appear either gradually or suddenly, and pain is located at the first dorsal compartment at the wrist. Pain may radiate down the thumb or up the forearm. Hand and thumb motion increases pain, especially with forceful grasping or twisting. Swelling over the base of the thumb may include a fluid-filled cyst in this region. 

Figure 2. Significant tenderness directly over the scaphoid bone (which is located in the hollow at the thumb side of the wrist).

Scaphoid fracture is most commonly diagnosed by x-rays of the wrist. However, when the scaphoid fracture is not displaced, x-rays taken within the first week may not reveal the fracture. A non-displaced scaphoid fracture could thus be incorrectly diagnosed as a “sprain” because the x-ray was “negative.” Therefore a patient who has significant tenderness directly over the scaphoid bone (which is located in the hollow at the thumb side of the wrist, or “snuffbox”) should be suspected of having a scaphoid fracture and be splinted. The patient should be re-evaluated about two weeks later, and if findings are still suspicious for a scaphoid fracture, x-rays at that time will usually show the fracture due to changes in the bone at the edge of the fracture. In cases where waiting two weeks in a splint may cause undue hardship, or if the x-rays remain negative but the clinical exam is still suspicious, more sophisticated (and expensive) imaging techniques may be utilized, such as CT scan, bone scan, or MRI. 

Scaphoid Fracture Treatment

If the fracture is non-displaced, it could be treated by immobilization in a cast. The cast usually covers the forearm, hand, and thumb, and sometimes includes the elbow for the first phase of immobilization. Although the fracture may heal in as little as 6 weeks, the healing can often be delayed. One reason for this delay is the variable blood supply to different parts of the scaphoid bone. The fracture can disrupt the bone’s blood supply, impairing the healing. Part of the bone might even die after fracture due to loss of its blood supply, particularly in the proximal third of the bone, the part closest to the forearm. If the fracture is in this zone, or if it is at all displaced, surgery is more likely to be recommended. With surgery, a screw or pins are inserted to stabilize the fracture, often with a bone graft to help heal the bone (see Figure 3). Sometimes screw fixation surgery is recommended—even in non-displaced cases—so as to avoid prolonged casting. 

Scaphoid Fracture Complications

Scaphoid Non-Union

Figure 3. A screw or pins are placed to stabilize the fracture.

If a scaphoid fracture goes unrecognized, it often will not heal. Sometimes, even with treatment, it may not heal because of poor blood supply. Over time, the abnormal motion and collapse of the bone fragments may lead to mal-alignment within the wrist and subsequent arthritis. If caught before arthritis has developed, surgery may be performed to try to get the scaphoid to heal. 

Avascular Necrosis

A portion of the scaphoid may die because of lack of blood supply, leading to collapse of the bone and later arthritis. Again, if arthritis has not developed, surgery to try to restore circulation to the bone may be attempted. Post-traumatic arthritis: If arthritis has already developed, salvage-type procedures may be considered, such as removal of degenerated bone or partial or complete fusion of the wrist joint.

Reproduced with permission from the American Society for Surgery of the Hand     www.handcare.org

+Dr. Kayvon Izadi