SCAPHOID FRACTURE OF THE WRIST
INTRODUCTION
Welcome to Hicksville Physical Therapy’s patient resource about Scaphoid Fracture of the Wrist.
Typically, if a patient falls on an outstretched hand, doctors will diagnose a sprained wrist; however, in some cases, when pain and swelling don’t go away, the cause may be something more serious than a common sprain. Falls of this nature may result in a break within the scaphoid bone. Fractures are not always recognized early or with x-rays, which can lead to poorly healed injuries.
Below, this guide will outline:
- Causes of fractures
- What nonunion of the scaphoid is
- Treatments for this type of injury
- Physical Therapy rehabilitation for Scaphoid Fracture
ANATOMY
WHERE IS THE SCAPHOID BONE OF THE WRIST?
The wrist joint is one of the most complex joints of the entire body. Due to its use, i.e the ability to have a wide range of motion and strength for gripping, the wrist is made up of multiple joints and bones. In addition, the wrist is made up or eight small bones, known as:
CARPAL BONES
The bone at the base of the thumb, aka the scaphoid bone, connects the two bones of the forearm, the radius and the ulna,to the bones within the hand. Additionally, long bones that lie within the palm, known as metacarpal bones, attach to the phalanges, the bones of the fingers and thumb.
Because of its complex nature what we know as the “wrist joint” is actually made up of many small joints joined by ligaments.
The scaphoid bone, the most commonly fractured carpal bone, is a small carpal bone on the thumb side (radial side) of the wrist.
Heavy stress on the scaphoid bone, like a fall, can cause a crack or complete separation of the bones, known as a displaced fracture.
CAUSES
almost all cases a scaphoid fracture is caused by a fall on the hand. Usually, when we fall we put our hands out to break that fall, resulting in hand and wrist injuries. Oftentimes, patients assume an injury as just a sprain and leave it to heal on its own which, typically, will heal on its own. However, this isn’t always the case, and the fracture may result in a nonunion. There are two types of nonunions:
– A simple nonunion: where the two pieces of bone fail to heal together, and
– A avascular necrosis nonunion, which is much more serious.
In an avascular necrosis nonunion, the lower half of a fractured bone loses blood supply, which results in bone death. Because there is only one small artery that enters the bone, a scaphoid fracture is highly at risk for this type of nonunion.
SYMPTOMS
Pain and tenderness within the wrist are the most common symptoms of a fresh fracture. Swelling is also a common factor of an injury, as blood from the fractured bone fills the wrist joint. Thinner people may see a bulging of the joint capsule, the watertight sac that encloses the joint.
Symptoms of a nonunion of the scaphoid bone may be more subtle, such as pain when using the wrist, although the pain may be minimal. Doctors commonly see nonunion of the scaphoid bone on X-rays, even when a patient cannot remember an injury as they chalked it up to a simple sprain, possibly years ago. A gradual increase of pain and degenerative arthritis may result from a nonunion.
DIAGNOSIS
At Hicksville Physical Therapy, our Nassau County physical therapist will first go over your medical history, such as any injuries or pain. In addition, our therapist will be prompted to do a physical exam of your wrist, examining its extension, ability and pinpoint where your pain is.
In some cases, patients may be referred for further diagnosis. Upon completion of the exam, our physical therapists in Nassau County will offer treatment options that will aid in speedy recovery, so that you can more quickly return to your active lifestyle.
OUR TREATMENT
NON-SURGICAL REHABILITATION
You may be placed in a cast if the bone is in good alignment or there are no problems regarding blood supply. These casts can range from a long-arm or a thumb-spica cast, which prevent the wrist and thumb from moving.
Typically you will be placed in a cast anywhere from 9 – 12 weeks, although this may differ depending on where the fracture lies or how the bones have healed. A cast may leave your wrist stiff or weak. In order to regain strength and motion, you may begin your Hicksville Physical Therapy rehabilitation program.
POST-SURGICAL REHABILITATION
In some cases you may be placed in a splint for upwards of 12 weeks post-surgery. In order to make sure your bones are healing properly, your surgeon will x-ray several times post-op. When the scaphoid bone is finally healed, you can then begin your physical therapy.
First, our physical therapist will focus on treatments for controlling pain and swelling.We will gradually work with you to help strengthen and stabilize the muscles, as well as improve fine motor skills and dexterity without straining your wrist.
SURGERY
Screw Fixation
Some surgeons report good results doing surgery right away when a patient has had a recent, nondisplaced scaphoid fracture. Studies have shown that this method can help people get back to activity faster than wearing a cast for up to 12 weeks. The procedure involves inserting a screw through the scaphoid. The screw holds the scaphoid firmly until it heals.
Scaphoid Debridement
In cases where a nonunion has occurred depite wearing a cast and using an electrical stimulator, surgery will likely be suggested. An incision is made in the wrist directly over the scaphoid bone. The surgeon finds the old fracture line on the scaphoid bone. All the scar tissue between the two halves of the bone must be removed (debrided). This creates a fresh bone surface to allow healing to begin again. In some cases, damaged bone tissue from the scaphoid is also removed.
Bone Graft Method
Your surgeon may use a bone graft. A bone graft involves taking bone tissue from another spot in your wrist and inserting it into the fracture. A bone graft can stimulate healing on the surface of the bones. The bone graft is usually taken through a second small incision just above the wrist. (It is sometimes taken from the pelvis, through an incision in the side of your hip.)
After the bone graft is placed between the parts of the scaphoid bone, some surgeons also insert a metal pin or screw across the bone. The goal is to hold the two pieces of bone tightly together, allowing them to fuse into one bone.
When the surgery is complete, the incision is stitched closed. The arm is placed in a large bandage or a splint. You are then awakened and taken to the recovery room.
Sometimes the bones still do not heal as planned. Surgeons call a fused bone that fails to heal a pseudarthrosis. If the nonunion continues to cause pain, you may need a second operation. Your surgeon will probably add more bone graft and check that the pins or screws are holding the bones together.
PHYSICIAN REVIEW
Although your x-ray may not show evidence of a fracture immediately after injury, your doctor will most likely put a cast on anyway and take another x-ray in 10 days. This may prevent nonunion and allow the fractured bone time to heal. If after the 10 days a fracture is still not evident, your doctor may order other imaging tests, such as a bone scan. In a bone scan, tracers are injected into the bloodstream, which will show through special x-rays how the blood flows through the bone and tissue. .
In addition, your doctor may also order a magnetic resonance imaging, or MRI, scan. An MRI scan uses magnetic waves to create pictures of your body in slices. The MRI scan will show both tendons and bones, and is pain free with no needles or injections.
FRACTURE
If immediately identified and the bone is in good alignment, you will most likely wear a cast that covers your forearm, wrist and thumb for 9 – 12 weeks, in order to hold the bone very still so it heals. Monthly x-rays will be taken to check the healing process. However, there is still risk that the fracture may not heal, even with this type of treatment.
NONUNION
If a fracture doesn’t heal within several months it is considered a nonunion. A more recent injury may require longer cast time, or electrical stimulation, a device that sends a small electrical current to the bone, which you wear around your wrist for 10 to 12 hours a day.
SCAPHOID FRACTURE SURGERY
SCREW FIXATION
In some cases of a recent, nondisplaced scaphoid fracture, doctors report good results following urgent surgery. Studies have also shown that this can aid in getting patients back to activity quicker than a cast. In this procedure, a screw is inserted through the scaphoid, holding the bone still until it heals.
SCAPHOID DEBRIDEMENT
Surgery will most likely be suggested when a nonunion has occurred, despite wearing a cast for an extended period of time, or through electrical stimulation. During surgery, an incision will be made in the wrist directly above the scaphoid bone. The surgeon will remove the scar tissue from in between the two halves of the bone, allowing a fresh bone surface to heal.
BONE GRAFT METHOD
In some instances, your surgeon may use what is called a bone graft, where bone tissue from one spot of the wrist or the pelvis, will be inserted into the fracture, stimulating healing on the surface. Following a bone graft, some surgeons may additionally insert a metal pin or screw across the bone in order to hold the two pieces of bone tightly together.
Following surgery, the arm will then be placed in a large bandage or splint.
In some instances, the bone may not heal as planned. Surgeons call a fused bone that fails to heal a pseudarthrosis, and you may need a second surgery if you continue to have pain. Most likely, your surgeon will add more bone graft to the area and check that the pins or screws are holding the bones together.
If additional room is necessary to relieve the pressure being placed on the nerve, some of the piriformis muscle may be taken out. Typically, this procedure causes no issue with strength since there are multiple muscles that are much stronger that assist the leg in turning outward.
