A fracture or break of the wrist can be a challenge. A scaphoid fracture can take it to a whole new level. The scaphoid is a small bone in the wrist and tends to have many complications when broken. Unfortunately, this type of fracture is not uncommon. Read on to learn more about scaphoid fractures. Let’s start with anatomy!
The wrist
The wrist is made up of 3 joints. These include the distal radioulnar joint, radiocarpal joint, and the mid carpal joint. The distal radioulnar joint is made up of the ends of the forearm bones, the radius and ulna, at the wrist. This joint is essential for supination and pronation. Pronation is rotating the forearm, so the palm faces downward, and supination is forearm rotation where the palm faces upward.
The radiocarpal joint is made up of the radius and the first row of carpals. Carpals are the small wrist bones in between the forearm bones and the hand bones. The first row of carpals includes the scaphoid, lunate, and triquetrum. The pisiform is also in this row of carpals, but it is not part of the joint. It sits on top of the triquetrum. This joint is the dominant joint for wrist extension. It assists in wrist flexion, radial deviation, and ulnar deviation.
Wrist extension is when the back of the hand moves toward the back of the forearm. Wrist flexion is when the palm of the hand moves toward the forearm. Radial deviation is when the hand moves to the thumb side. Ulnar deviation is when the hand moves towards the little finger side.
The mid carpal joint is the joint made up of the first and second row of carpals. The second row of carpals include the trapezium, trapezoid, capitate, and the hamate. This joint assists in wrist extension and ulnar deviation. It is the dominant joint for wrist flexion and radial deviation.
What is the scaphoid?
The scaphoid is one of the 8 carpal bones. It is a boat-shaped bone. It touches the radius, trapezium, and the capitate. It is important in wrist motion and stability. The scaphoid is easily identifiable. When the thumb is in the “thumbs-up” position, the scaphoid is located in the little hollow at the base of the thumb. This is also called the “anatomical snuff box”.
The blood supply to the scaphoid is different than most of the body. Blood flows from the heart to all the different areas of the body. It usually enters each area at the point that is closest to the heart and then flows to the point that is farthest from the heart. However, the blood supply to the scaphoid enters the bone from the part farthest from the heart and flows to the area that is closest. This affects the scaphoid’s healing time and ability to heal. The area of the scaphoid where the blood supply enters heals much faster than other areas of the scaphoid.
What is a scaphoid fracture?
A scaphoid fracture is a break of the scaphoid bone. It is most likely caused by a fall on an outstretched hand. This is called a FOOSH injury. Scaphoid fractures tend to occur in young adults with an average age of 29. The incidence is higher in young men. The majority of scaphoid fractures occur in the middle of the bone. Because of the scaphoid’s unique blood flow, this could cause limited to no blood supply to part of the bone.
What are symptoms of a scaphoid fracture?
There are several symptoms associated with a scaphoid fracture. These include:
- Wrist pain after recent fall or other trauma
- Pain on thumb side of the wrist
- Pain is worse with movements
- Difficulty and pain with gripping and pinching
- Swelling at the wrist
- Decreased wrist motion
- Tenderness in the anatomical snuff box
Special considerations
This injury can be missed on x-ray and misdiagnosed as a simple wrist sprain. If the pain does not go away or lessen after a day, then it could be a sign of a fracture. Untreated fractures can lead to wrist deformity, arthritis, and instability. This can cause significant disability to the young person who sustained the scaphoid fracture.
What are some of the potential complications?
There are several potential complications with this injury. They include:
- Nonunion – This is the most likely complication from misdiagnosed scaphoid fractures. Nonunion means that the fracture is not healing and there is little chance of it healing without surgical intervention.
- Avascular necrosis – This is caused by a lack of blood flow to an area of bone. This in turn causes that area of bone to die. Because of the blood supply to the scaphoid, the chance of avascular necrosis is 30-40%.
- Scapholunate dissociation – This is when a gap forms between the scaphoid and lunate bones when you move your wrist. This can cause pain, instability, and arthritis in the wrist.
- Delayed union – This indicates that it is taking longer than expected for the bones to heal, but it is expected to eventually heal without further medical intervention.
Will I need surgery?
The answer is possibly. This type of fracture has a tendency to not heal. If the fracture is not displaced and it is located in an area where it is expected to heal, then a cast or splint is applied. The time that you will have to wear the splint could range from 6-24 weeks. If the fracture is displaced more than 1mm or is deemed unlikely to heal, then surgery will be needed.
Who should I see?
- Physician – If you suspect that you have sustained a scaphoid fracture (or some other type of fracture), it is best to go to the emergency room. Because of the potential complications, this fracture should be treated quickly. However, if your fracture has already been treated and you suspect additional injury or complication, then it would be best to see your orthopedist or primary care physician. Additional imaging and inspection might be needed to rule out other conditions.
- Physical therapist – Physical therapy will be needed to regain mobility and strength in the wrist. This will be true whether or not surgery was needed. Because of the extended time in the cast, the wrist will be stiff and sore when trying to move or use it. Your PT can evaluate you to determine the extent of your mobility and strength deficits and use manual therapy, as well as, stretching and strengthening to help address all problems in and around the wrist.
What can I do?
- Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to allow the bones to heal. If you are not able to participate in your activity or sport, then you can supplement with non-irritating activities such as walking or jogging while your wrist is healing.
- Ice – Ice can help decrease pain and symptoms at the wrist. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or is preventing you from participating in an activity. Ice immediately after activity.
- The following are activities that you can do after the cast is removed or you are cleared by your surgeon.
- Wrist flexion and extension stretching – You will need to stretch out the wrist flexors and extensors. This will feel very tight and sore at first. Begin with a gentle stretch. You can stretch more aggressively as the soreness subsides. See the video below.
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- Wrist strengthening – It is important to strengthen the wrist after a long period of immobilization. Begin with low to no resistance and slowly increase as it becomes easier. You should have minimal pain when performing the exercise and no pain afterwards. Below is a video showing how to strengthen the wrist using resistance bands.
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- Grip strengthening – Strengthening the muscles for gripping is important since a scaphoid fracture can affect this action. Performing gripping exercises is helpful for recovering hand strength. See the video below.
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- Strengthening the muscles around the elbow and shoulder – Strengthening the muscles around the elbow and shoulder are also important in being able to return to your activity. Decrease your resistance or number of repetitions if you are having pain in the wrists. Using loop resistance bands, dumbbells, or resistance bands can increase strength and difficulty. See the videos below.
In review
- The wrist is made up of 3 joints.
- These include the distal radioulnar joint, radiocarpal joint, and the mid carpal joint.
- Carpals are the small wrist bones in between the forearm bones and the hand bones.
- The scaphoid is one of the 8 carpal bones.
- It is important in wrist motion and stability.
- A scaphoid fracture is a break of the scaphoid bone.
- Because of the scaphoid’s unique blood flow, a fracture can cause limited to no blood supply to part of the bone.
- There are several symptoms of a scaphoid fracture including pain at the wrist, tenderness at the anatomical snuff box, and decreased wrist motion.
- This is a frequently missed diagnosis which could lead to long-term disability and pain.
- There are several complications that could occur including non-union and avascular necrosis.
- Surgery might be required depending on the location and displacement of the fracture.
- There are things that you can do.
- Rest
- Ice
- After surgery or cast is removed
- Wrist flexion and extension stretching
- Wrist strengthening
- Grip strengthening
- Elbow and shoulder strengthening
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.physio-pedia.com/Scaphoid_Fracture