Scaphoid Bone

Scaphoid Bone

Breaks or fractures of the scaphoid bone often result in significant loss of functionality, inability to work for weeks on end, and require a long-term abstinence from athletic activities. The primary difficulties with a scaphoid bone fracture are still diagnosis, and other complications, such as post-traumatic pain, loss of functionality, slow healing, and pseudoarthrosis (when the bone fails to heal). 

DIAGNOSIS

Diagnosis is carried out through a clinical examination and evaluation of the circumstances of the accident. Such accidents often involve falling onto an outstretched hand, over-stretching the wrist backwards. The area of maximum tenderness is just above the snuff-box, the hollow formed by the two extensor tendons of the thumb. After a short period of time, a hematoma, or bruise, often emerges at the site. However, symptoms are often not particularly pronounced, causing the fracture to not be noticed and symptoms simply overlooked. This is a great disadvantage, as lack of treatment often leads to pseudoarthrosis (see below), and all its unpleasant consequences.

For accurate diagnosis, an X-ray including four images of the carpus (Image 1a) is absolutely imperative. In the event that clinical symptoms of a scaphoid bone fracture are present but cannot be confirmed radiologically, Dr. Gäbler recommends an MRI (Image 1b). An alternative to the MRI would be to place the injured hand in a cast and repeat the X-ray after 10 days.

Image 1: A tiny incision is made over the joint (preferably at a fold of skin so that the small scar is no longer visible after a couple of months).
Image 1a: Images clearly show a scaphoid fracture.
Image 1b: An MRI showing the scaphoid fracture of a 20-year-old athlete who fell onto his wrist. The fracture was not visible on the initial X-ray images, however, as the patient complained of typical pain, an MRI was carried out.
Image 2: A drill wire is inserted to guide the screw using an X-ray image intensifier.

TREATMENT

Many hospitals still just put the injured wrist in a cast. The thumb is often included in the cast despite it having been proven including the thumb in a non-displaced scaphoid fracture has no benefits. A correctly positioned forearm cast suffices for a non-displaced scaphoid fracture. Immobilization by cast should last eight weeks.

Scaphoid fractures usually heal within eight weeks, however, osseous healing can take up to 12–16 weeks. Some fractures still do not heal despite extended immobilization with a cast, leading to pseudarthrosis (non-healing and formation of a false joint).

Image 3: After the scaphoid bone has been screwed back together, the fracture line is no longer visible.

Pseudarthrosis of the scaphoid is a serious problem that usually ends in severe arthrosis of the wrist, severe pain and weakness, and requires surgical procedures that go as far as stiffening the wrist. Most such cases of pseudarthrosis occur as a result of inadequate immobilization with a cast. However, pseudarthrosis also often arises when an injury to the scaphoid is not detected. Scaphoid fractures primarily occur in young active individuals as a result of falling onto the wrist (for example when cycling, in-line skating, skiing, or quite simply by falling on the street). To allow a scaphoid fracture to heal, patients must be immobilized in a cast for weeks or months, therefore often prevented from working and, of course, athletic activities.

Image 4: The tiny incision is closed with a suture. Pain after the operation is minimal.

AN ALTERNATIVE: A PERCUTANEOUS OPERATION

An alternative to this is to treat the patient using a very gentle (minimally invasive) operation method. For this procedure, a screw is inserted through a tiny incision, stabilizing the fracture. Patients operated on this way do not require a cast and are fully able to work and do sports after four weeks.

Together with the University of Edinburgh, Dr. Gäbler carried out a scientific study on the topic, which was published in a top journal:
McQueen MM, Gelbke M., Wakefield A., Will E., Gaebler C. 
Percutaneous Screw Fixation Versus Conservative Treatment for Fractures of the Wrist of the Scaphoid: A Prospective Randomized Study 
J Bone Joint Surgery Br (2008) 90: 66 – 71

This study used scientific methods to show with complete objectivity that this surgical method is far superior to long-term immobilization in a cast. There were no significant complications as a result of the operation. Patients who had been operated on were able to play sports again after only five weeks and were also fully capable of returning to work. Patients who had only been immobilized in a cast required an average of eight weeks before returning to work and an average of 14 weeks before being fully able to play sports. Moreover, three patients in the group that were not operated on contracted pseudarthrosis, which then had to be operated on after 16 weeks of wearing a cast.

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Please note that medical indications and therapies are constantly changing and evolving. Sometimes these changes occur more rapidly than Dr. Gäbler is able to update the homepage. Detailed information about the dosage, administration, and composition of medications may have changed since the last update. Reading a website is never a substitute for visiting your doctor. An examination by and discussion with your doctor can provide significant additional information for you based on your personal diagnosis and the latest scientific findings. Please note that surgeries and outpatient procedures are not performed on the premises of the Sportambulatorium Wien.