Scaphoid Wrist Fracture
Scaphoid Wrist Fracture | Denver, Colorado
A scaphoid fracture is a specific type of wrist fracture that I routinely treat in my hand surgery practice in the Denver metropolitan area.
There are eight wrist bones (or carpal bones) that make up the anatomic region we typically call the wrist. The scaphoid is a bean-shaped bone that sits near the base of your thumb (see Figure 1). A scaphoid fracture is often seen after an injury in high-impact athletic activities, but can occur from something as simple as a slip and fall.
Figure 1 - An X-ray showing an example of a subtle scaphoid fracture, a nearly imperceptible crack across the bean-shaped scaphoid bone.
Scaphoid Wrist Fracture Diagnosis
A scaphoid fracture can be elusive to diagnose. This is particularly troublesome because it also is a bone that has limited blood supply and poor healing potential. Thus, it is absolutely crucial we get this diagnosis right.
Some scaphoid fractures will be apparent on initial X-rays, but many will not. Subtle fractures without displacement of the bone ends can be invisible initially. Because of this, any patient who comes to me with pain over the scaphoid after an injury will receive a cast for two weeks. After those two weeks, we will repeat X-rays to determine if a fracture is visible. Patients with continued pain at this visit and with X-rays that still don’t show a fracture will require an MRI for final diagnosis.
Scaphoid Wrist Fracture Treatment
As with many of the other injuries I treat, some scaphoid fractures can be treated non-surgically, while others do better with surgery. As alluded to above, the blood supply to the scaphoid is poor. If your scaphoid fracture is truly non-displaced and caught early, casting for 3-4 months is an option. But if the fracture has displaced, there is a delay in diagnosis, or the end of the scaphoid nearest the forearm is broken, most of these do better with surgery. If a scaphoid goes on to not heal (termed nonunion), it can be a very big deal, requiring multiple surgeries in some cases.
If you do need surgery, the majority of scaphoid fractures will be fixed with one or two compression screws in a procedure known to surgeons as ‘open reduction, internal fixation’ (ORIF). Translated, this literally means, make an incision, put the bones back into alignment, and fix the bones in place with screws .
Additional Information
While this is an overview of scaphoid fractures, if you’d like more information on this topic, please continue reading through my patients’ frequently asked questions below. Additionally, please see my ‘deep dive’ section to the right of the FAQs where I have links to the longer-form articles I have written about various topics related to scaphoid fractures and their treatment.
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The Basics
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A scaphoid fracture is a type of broken ‘wrist.’
This is an injury in which the scaphoid bone breaks. The scaphoid is one of eight carpal bones that make up the anatomic region we call the ‘wrist.’
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A scaphoid fracture is typically caused by an impaction force directed across the hand or wrist.
This is most commonly seen in young individuals after falling in a high-impact athletic activity. But this injury can also occur after a simple fall onto an outstretched hand.
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You may be at a higher risk of experiencing a scaphoid fracture if you participate in ‘high energy’ activities, such as skateboarding, downhill skiing, mountain biking, or motorsports.
You may also be at risk if you are aging or if you have been diagnosed with osteoporosis, a condition that involves thinning of your bones.
Scaphoid Fracture Symptoms & Diagnosis
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Concern for a scaphoid fracture arises after sustaining a sizeable impaction force to the hand or wrist.
If you have suffered such an injury and have pain that doesn’t respond to basic measures (over the counter medications, bracing, icing), progressive bruising, deformity at the wrist, or numbness/tingling in the fingers, please get yourself to an emergency room right away for diagnosis and treatment.
Scaphoid-specific pain will be most acutely felt at the base of the thumb. This is where the scaphoid bone is located.
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Diagnosis of a scaphoid fracture can be tricky. This is a particular issue because the scaphoid has poor blood supply and poor healing potential. Because of this, it is absolutely critical that scaphoid fractures don’t go undetected.
Some scaphoid fractures will be obvious on the first set of X-rays. But many will not. Subtle fractures without displacement of the bone ends can be invisible initially.
Because we now know that many of these are initially undetectable, it is standard protocol for any patient who has pain over the scaphoid after an injury to receive a cast for two weeks.
After those two weeks, we will repeat X-rays, again looking for a fracture. If you have continued pain at this visit, but X-rays that still don’t show a fracture, we will escalate to getting an MRI for a final diagnosis.
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MRI imaging is typically only used if a patient has continued pain over the scaphoid after two weeks of casting, yet X-rays show no fracture. MRI can detect subtle fractures that aren’t visible on X-ray.
Scaphoid Fracture Treatment
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If you have sustained an injury to your wrist and you think it may be broken, there are several at-home treatments to start right away while waiting to get in to see a doctor. Let’s walk through how to treat your wrist (or any injury) with what is commonly known as R.I.C.E. therapy.
R - Rest. If your wrist hurts following an injury, try to stop using it as much as possible. Even better, obtain a ‘thumb spica’ wrist brace from your local pharmacy or a friend. This will immobilize the joints of your wrist and thumb and allow your injury to rest. While this may not be enough to definitively treat your injury, this will help with the initial stages of pain and inflammation.
I - Ice. It can be very helpful to use ice on the injured wrist. Be sure you have a protective layer between the ice and your skin (eg, dish towel, clothing). Do not ice the area for more than 20 minutes at a time. I typically recommend icing in a “20 minutes on, 20 minutes off” pattern.
C - Compression. Of all the stages of R.I.C.E., be the most careful with compression. Some find that some gentle compression feels good after an injury for extra stabilization. In general, we would recommend accomplishing this by using an elastic wrap bandage (Brand example: ACE wrap). However, it is crucial that you don’t stretch the elastic wrap bandage while you wrap. This will provide too much compression, and if your wrist swells, you can develop a painful or even permanently damaging condition. If you are interested in using compression, be sure to gently apply the bandage and re-evaluate frequently to ensure it is not becoming too tight with your wrist swelling. Never apply compression before going to sleep for the night.
E - Elevation. This is the most important one. I wish this were first in the mnemonic, but then it would spell E-R-I-C. Anyways, elevate, elevate, elevate. The higher the better. When you can, keep the wrist above the level of the heart. When that’s not possible, keep your hand above your elbow. Gravity is your friend! The more you elevate your injured wrist, the less swelling you will experience. The less swelling you experience, the less pain you will have. This is particularly crucial in the first few days after an injury.
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If you have wrist pain after a traumatic injury, it is essential to see a doctor immediately. A scaphoid fracture can frequently mimic a wrist sprain where it hurts initially but rapidly improves. Unfortunately, a missed scaphoid fracture often goes on to not heal, resulting in a progressive, debilitating arthritis of the wrist.
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Some scaphoid fractures do not need surgery. If your fracture fragments are completely non-displaced, cast treatment may be a reasonable option. Casting for scaphoid fractures typically lasts 3-4 months, and can even be longer in some cases.
Once bony healing is complete, we will transition you out of a cast and into a brace to begin range of motion and gentle exercises to the wrist. You can imagine it will need a period of rehab after so much time in a cast!
Some patients benefit from formal mobilization and strengthening with our Certified Hand Therapists. Other patients are able to rehab on their own with a simple home exercise program.
Scaphoid Fracture Surgery
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The decision regarding whether you need surgery for your scaphoid fracture is often a complex one. This will almost always require input from a specialist, such as an orthopedic hand and upper extremity surgeon.
In general, any scaphoid fracture that is displaced will benefit from surgery. The chances of bony healing in this case are far higher with surgery than without.
There are some specific fracture patterns that also benefit from surgery. The major category here is that of ‘proximal pole’ scaphoid fractures. That means any scaphoid fracture that occurs in the 1/3 of the bone closest to your forearm. This is the area of scaphoid with the poorest blood flow and there is a much higher rate of nonunion (failure to heal) without surgery compared to with surgery.
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There is a wide range of surgeries one could need to fix a scaphoid fracture. Ultimately, that decision will come down to the exact fracture pattern.
However, the vast majority of these fractures will be treated with one or two compression screws placed within the scaphoid bone itself. This forms an internal strut that compresses the two bone ends together. This surgery is referred to as an ORIF (open reduction internal fixation) of the scaphoid.
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As I’ve said before, ‘recovery’ is a very subjective term. In broad strokes, the bone will take 6-8 weeks to heal. However, a scaphoid can easily take 12-16 weeks to heal due to its poor blood supply. Below is the typical outline of healing following surgery to fix a scaphoid fracture. Please understand this could vary widely if your scaphoid is taking longer to heal:
Surgery - 2 weeks: Wear a post-operative splint full-time. You will work on the motion of making a fist with your fingers
Begin 2 weeks: Transition from a splint into a full-time cast. No lifting greater than 2 pounds with the hand/wrist.
6 weeks: Change the cast and obtain new x-rays. Very few scaphoid are fully healed at this point. Receive another full-time cast.
8-10 weeks: Repeat x-rays out of the cast. If any doubt as to healing, we will consider a CT scan at this point to confirm. Once healed, transition from a cast to a brace to begin range of motions.
4-5 months: Return to heavy activities and/or impact sports. Most patients feel 90% of their former selves by this point. Occasional aches and pains, or a bad day here or there are still expected.
9 months - 1 year: “Full” recovery, where you may have to stop and think about which wrist you had injured.
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Yes, the screws are carefully designed to be permanent. In rare cases, the hardware can back out over time and require removal.
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The hardware I typically use is made of a titanium alloy and thus will not set off airport or other metal detectors.
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If you have seriously injured your hand or upper extremity, please do not delay in seeking care from a trained hand and upper extremity surgeon. If you happen to be in Colorado, it would be my privilege to care for you (schedule here).
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All surgeries have risks, many of which are generic to surgery itself. I go over these in detail with you before surgery as part of the informed consent process. Examples include bleeding, infection, damage to surrounding nerves/vessels, anesthesia risks, or failure of the procedure.
The big risk to highlight with scaphoid fractures is nonunion. Nonunion occurs when the fracture ends just never heal back together. All I do in surgery is put the bones back in alignment and fix them there with hardware. Your body still has to biologically heal. This is a particular risk with scaphoid fractures given their naturally poor blood supply.
Risk factors for nonunion include tobacco use, vitamin D deficiency, diabetes, and other chronic health conditions. If you develop a nonunion, often a second, more involved surgery is required to prevent debilitating wrist arthritis.
This is by no means an exhaustive list of surgical risks, but rather highlights the more common things to be aware of prior to a scaphoid fracture surgery.