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Scaphoid bone

Breaks (= fractures) of the scaphoid bone commonly end in significant losses of function, inability to work for weeks and long-term abstinence from compensatory sporting activities. The main problems surrounding the scaphoid bone fracture are still the diagnosis, as well as other complications, such as posttraumatic pain, loss of function, delayed fracture healing and pseudarthrosis (= non-healing of the bone).

Diagnosis 

Diagnosis is carried out by means of a clinical examination and evaluation of the circumstances of the accident. This often involves a fall onto the outstretched hand, in which the wrist is overstretched backwards. The point of maximum tenderness is over the snuff box, the hollow that is formed by the two extensor tendons of the thumb. After a short period of time, there is often a haematoma at the site (= sanguineous effusion). However, symptoms are often not very severely pronounced which means that the fracture is sometimes not noticed or the symptoms are simply overlooked. This is a disadvantage, however, because a lack of treatment often leads to pseudarthrosis (see below), with its unpleasant consequences.

An X-ray is absolutely imperative for diagnosis, during which four images are taken of the carpus (image 1a). In the event that the clinical symptoms of a scaphoid bone fracture exist, but it cannot be confirmed radiologically, I recommend an MRI examination (image 1b). The alternative to this would be to plaster the injured hand and repeat the X-ray images again after 10 days.

Image 1a: The scaphoid fracture is clearly visible on the images of the scaphoid bone.
Image 1b: The MRI image shows the scaphoid fracture in a 20-year-old athlete, following a fall onto his wrist. The fracture was not visible on the initial X-ray images, however the patient complained of typical pain, therefore an MRI examination was arranged.
Image 1: The joint is opened using a scalpel via a mini stab incision (which is best placed in a skin fold so that the small scar is usually no longer visible after a couple of months).
Image 2: A drill wire is then inserted as a guide for the screw with an X-ray image intensifier.

 

Treatment 

In many hospitals, the injured wrist is still simply plastered. The thumb is often still included in the plastering although it has since been proven that the inclusion of the thumb in the non-displaced scaphoid fracture is not advantageous. For a non-displaced scaphoid fracture, a correctly positioned forearm plaster suffices. The duration of immobilisation in plaster is eight weeks.

It is generally recognised that scaphoid fractures usually heal within eight weeks, however osseous healing can take 12 to 16 weeks and some fractures are still not healed despite this long fixation in plaster and pseudarthrosis occurs (= non-healing with the formation of a false joint)

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 ranging as far as stiffening of the wrist. It is clear that most cases of pseudarthrosis occur as a result of inadequate immobilisation in a cast. However, pseudarthrosis often occurs because an injury to the scaphoid has not been detected. Scaphoid fractures primarily occur in young and active people as a result of a fall onto the wrist (for example when cycling, in-line skating, skiing, or quite simply by falling in the street). To allow the scaphoid fracture to heal, these people are immobilised in plaster for weeks and months, and they are therefore taken away from their work and naturally from their sporting life too.

 

Alternative --> percutaneous operation 

The alternative to this is to treat the patient with a very gentle (minimally-invasive) operation method. For this, a screw is inserted through a mini incision, which stabilises the fracture. The patients do not require a cast and are fully able to carry out sport and work again after four weeks.

This was our main approach. Together with the University of Edinburgh, we carried out a scientific study relating to this:
Percutaneous Screw Fixation versus conservative treatment for fractures of the waist of the scaphoid: A Prospective Randomized Study 
J Bone Joint Surgery Br (2008) 90: 66 – 71

This study using scientific methods showed completely objectively that the surgical method is far superior to long-term immobilisation in plaster. There were no significant complications as a result of the operation. Patients who had been operated on were able to play sport again after five weeks and were then also fully capable of returning to work. Patients who had only been immobilised in plaster needed an average of eight weeks to be able to return to work and an average of 14 weeks until they were fully able to play sport. Moreover, there were three patients in the group that had not been operated on with pseudarthrosis, who had to be operated on in any case after 16 weeks of treatment in a cast.

 

Please note that medical indications and treatments change constantly. Sometimes these changes occur more rapidly than I am able to update on my homepage. Some information regarding dosage, prescription and compositions of medications may have changed in the meantime. Reading an internet page cannot replace visiting a doctor - it may be that during an examination and subsequent discussion with your doctor, other information is also communicated as a result of new scientific knowledge.