Skaphoid Fractures: Symptoms and Treatment for a Skaphoid Fracture

The hand consists of several bones of different shapes. The scaphoid is one of the eight carpal bones and is part of the wrist joint. Its inferior margin forms the articular surface facing the radius.

Strictly speaking, the human body has two different scaphoid bones:

• the os scaphoideum in the carpal region and
• the navicular bone in the tarsus.

However, this injury occurs much more frequently in the hand, so it is commonly referred to as a scaphoid fracture. Medical professionals also refer to it as a scaphoid fracture.

 

Anatomy of the left hand, showing the scaphoid © bilderzwerg / Fotolia

A scaphoid fracture is the most common fracture of the carpal bones. About 75% of all carpal fractures involve the scaphoid.

Athletes between the ages of 20 and 30 are particularly prone to scaphoid fractures. About 90% of them are men.

A scaphoid fracture in the hand is caused by a strong, direct impact.

When falling, people reflexively extend their arms forward to avoid landing on their face. The force transmitted through the forearm upon impact often results in a fracture of the scaphoid or the radius.

The location of the scaphoid fracture depends on

• the degree of hyperextension as well as
• the movements of the hand during the impact.

Scaphoid fractures occur particularly frequently during sports activities. Inline skating and snowboarding are considered high-risk sports because they often involve falls.

© yodiyim / Fotolia

The typical symptom of a scaphoid fracture is pain in the hand. This pain is most noticeable on the back of the hand and on the thumb side. In addition, the wrist swells and is particularly painful during movement. As a result, the affected person often adopts a protective posture.

Furthermore, there is increased tenderness on the back of the hand, at the wrist crease. This is where the two tendons responsible for abducting the thumb run. If tenderness is reported at this site, it is usually a clear sign of a scaphoid fracture. This is true even if the fracture is not clearly visible on an X-ray.

Most patients tend to hold the affected hand close to their body to protect it from jolts. The patient has difficulty gripping objects and experiences significant pain when doing so.

A scaphoid fracture therefore often has a significant impact on daily life.

To diagnose a scaphoid fracture, a physical examination of the affected hand is performed first. The doctor asks the patient to point out exactly where the pain is located. The doctor also observes whether the patient is holding the hand in a protective position.

One of the examination options is the Watson shift test. In this procedure, the patient’s hand is moved toward the thumb. If there is a scaphoid fracture, a small click can be felt above the bone, followed by a sharp pain in the wrist.

Imaging techniques, such as X-rays, are important for making a diagnosis. However, a scaphoid fracture cannot always be detected on an X-ray. In fact, fresh fractures are often overlooked on X-rays.

If the diagnosis remains unclear after the X-ray, the doctor will perform a computed tomography (CT) scan. A CT scan produces detailed cross-sectional images of the wrist. This usually allows the fracture line to be identified.

A scaphoid fracture is treated either conservatively or surgically. The specific treatment approach ultimately depends on the individual case. The treatment depends on the location of the injury within the hand.

Conservative treatment usually takes longer. On the other hand, surgical intervention carries certain risks.

Conservative Treatment: Patience and Rest

A prerequisite for the success of conservative treatment is that the fracture fragments of the scaphoid have not shifted.

Treatment of the fracture then essentially consists of immobilizing the affected hand. It is placed in a cast or a plastic splint.

After about two to three weeks, the doctor takes new X-rays to monitor the healing process.

However, a scaphoid fracture takes some time to heal. The patient should expect to have to immobilize their hand for two to three months.

Treatment should be followed by physical therapy once this period has elapsed.

Surgery

Surgery is considered necessary if

• there are displaced fracture fragments, or
• the scaphoid fracture is located in the immediate vicinity of the forearm joint surface.

The reason for this is the poor prognosis for healing in these two types of fractures.

During the surgery, the surgeon reconnects the two fracture fragments using screws (Herbert and Bold screws).

Following the surgical procedure, the hand is placed in a cast for about four weeks.

In general, healing after surgery is faster than with conservative treatment. In most patients, the screw remains in the wrist for the rest of their lives.

How long it ultimately takes for a scaphoid fracture in the hand to heal depends on the location of the fracture. Age also plays an important role; the younger the patient, the faster healing progresses.

However, it is not possible to provide a general prognosis for the healing time due to the numerous decisive individual factors.

If the fracture is uncomplicated and the patient is young, the prognosis for a scaphoid fracture is usually favorable. In some cases, however, there is a risk of pseudarthrosis, in which the fracture heals only incompletely.

How can I tell if I have a scaphoid fracture?

A scaphoid fracture is suspected if pain occurs in the wrist after a fall, especially in the area of the thumb (thumb pad). Often, slight swelling is visible on the wrist, and movements such as gripping or supporting the wrist are painful. Since the symptoms are often mild, a scaphoid fracture is frequently not recognized until later. Tenderness in the “snuff box” is a classic warning sign.

How is a scaphoid fracture diagnosed?

The diagnosis is based on a clinical examination of the affected hand and an X-ray of the wrist taken from multiple angles (Stecher view). Since a fine fracture line is often not visible on a fresh X-ray, computed tomography (CT) is considered the gold standard for diagnosis. If the findings are unclear, an MRI can also help to visualize bone edema.

When is surgery necessary for a scaphoid fracture?

Surgery is necessary if the fracture is unstable or displaced. Fractures in the proximal third of the scaphoid (proximal pole) also often heal poorly due to poor blood supply and are therefore usually treated surgically. In young, active patients between the ages of 20 and 30, surgery is often performed to shorten the long immobilization period in a cast.

How is the surgery performed?

During surgery, a special screw (Herbert screw) is inserted into the bone through a small incision in the skin. This screw fixation compresses the fracture fragments and stabilizes the scaphoid bone, allowing it to heal and grow back together. Since the screw is completely embedded in the bone, it usually does not need to be removed later. The procedure can often be performed using a minimally invasive technique.

How long does healing take?

The healing process for a scaphoid fracture is lengthy. With conservative treatment, the wrist often needs to be immobilized in a cast for 8 to 12 weeks. If the scaphoid fracture is treated surgically, a shorter period of immobilization—usually just a few weeks—is typically required, followed by physical therapy. However, it can take several months before the fracture is fully healed and the patient can resume sports activities.

What happens if the fracture doesn’t heal?

If a scaphoid fracture is overlooked or fails to heal, a pseudarthrosis (false joint) develops. This leads to chronic pain, limited range of motion, and, in the long term, premature joint wear (scaphoid pseudarthrosis). In such cases, a more complex surgical procedure involving a bone graft from the iliac crest may be necessary.

Why does the navicular bone heal so poorly?

The navicular bone is supplied with blood only via a small vascular system running from distal to proximal. In the event of a fracture, especially in the proximal third, the blood supply to the fracture fragment may be interrupted. This leads to delayed fracture healing or even the death of the bone fragment (necrosis).

Is a cast or surgery better?

That depends on the type of fracture. Stable fractures in the middle third often heal well with conservative treatment. Unstable fractures, displaced fragments, or fractures at the proximal end have a poor prognosis without surgery. The decision is made on a case-by-case basis after evaluating the CT images to ensure optimal stabilization of the scaphoid.