If you have a scaphoid fracture of your wrist, there are probably a lot of questions you

have regarding this problem. This sheet is designed to answer the most commonly
questions asked by patients.

What is the scaphoid bone or navicular bone?

The scaphoid and navicular are two names for the same bone. This small bone is
entirely within the wrist joint. (The navicular is now used almost exclusively to
describe a bone in the foot).

Who gets this fracture?

In adolescents and young adults, fracture of this bone is the most common fracture
around the wrist. Men are ten times more likely to fracture this bone than women.
Although the bone is small, it takes a lot to break it. Oddly enough, twice as much
force is required to break the scaphoid bone as to break one of the bigger forearm
bones. Because of this, most patients who have broken their scaphoid have done it
while participating in sports, such as football, basketball, riding a motorcycle or in an
automobile accident. Usually the patient falls on the outstretched hand and
hyperextends the wrist joint.

What is so special about this fracture?

Because the bone is entirely inside the joint, there are some unique things about this
fracture. The patient frequently overlooks the fracture because it feels like "just a
sprain." There is often only a little swelling and a variable amount of pain may be
present. Usually, the swelling will go away in a few days. Unlike the forearm, hand,
and finger bones, fractures of the scaphoid almost never show any obvious deformity
of the wrist. "It doesn't look broken." These factors can make it common for the
diagnosis to be delayed for weeks, months or occasionally even years after the initial
injury because the patient or his doctor thinks it is just a common wrist sprain.

How do I know it is broken?

Often, an x-ray of the wrist can detect a scaphoid fracture. The fracture may
occasionally be invisible on the first x-ray, only to show up on an x-ray examination
taken weeks or months later. Many patients with a suspected scaphoid fracture will
often require a "bone scan" to determine if the fracture is present. This test can be
performed 3 days after the injury to assist in the diagnosis, if needed.
What does the bone look like?
This little bone is about the size of a peanut shell and is almost completely covered in
articular cartilage. It functions much like a ball bearing in your wrist joint. Because of
this, its' blood supply is very fragile, and sometimes the fracture leaves part of the
bone without any blood flow. (Unfortunately, the blood supply is "backwards,"
supplying the top of the bone better than the base). This is very important. Although
our bones are as hard as wood, they are alive and need blood coursing through them in
order to function normally. Sometimes when a scaphoid bone breaks and loses its
blood flow, it undergoes a process called avascular necrosis. This may cause the bone
to crumble, and the wrist joint may be destroyed.

What happens if my scaphoid bone does not heal?

When a scaphoid fracture fails to heal, the patient may initially get better for a while
until the pieces of broken bone, which are loose inside the wrist joint, cause a
deterioration of the wrist joint called traumatic arthritis. In this condition, the joint
becomes painful and stiff, decreases grip strength and limits a person's ability to carry
out even moderate activities. The time required for the arthritis to develop is variable
depending upon how heavily the wrist is being used. Traumatic arthritis is different
from rheumatoid or osteoarthritis. This process only occurs in the injured joint and
does not spread to other joints if the body.

What about ligament injuries in addition to a scaphoid

fracture?
Since it takes such a violent injury to fracture the scaphoid bone, additional injuries to
the surrounding ligaments of the wrist often occur along with a scaphoid fracture.
When this happens, it is much more difficult to obtain healing of the scaphoid in just a
cast. If the wrist is not stabilized surgically, collapse of the wrist bones occurs causing
deterioration and permanent stiffness of the wrist joint.

What is the difference between a fresh fracture and fracture

nonunion?
The word "nonunion" means something special to an orthopedic surgeon. It means
that the bone has failed to heal. A nonunion may occur for a number of reasons.
Simple immobilization in a cast will not lead to healing of the bone. This scaphoid
bone is particularly prone to this for several reasons: there is the possibility of the
fracture being missed at the initial injury leading to a delay in treatment; secondly, the
bone has a poor blood supply. The fact that it is inside the joint and is constantly being
bathed by synovial fluid also contributes to the development of a nonunion. A
nonunion, in other words, is a failure on the part of the patient's bone to complete the
healing process. A "false joint" occurs at the nonunion since the ends of the broken
scaphoid are attached to ligaments at each end of the bone, further separating the
fracture and preventing healing. The term "fresh fracture" is used when the injury is
less than two to four weeks old. Although this is the optimum time for treating
scaphoid fractures, frequently the patient is not seen during this period.

How should my fractured scaphoid be treated?

The answer to this question depends on the type of fracture, the presence of any
associated ligament damage, and the severity of the ligament damage. The location of
the fracture in the bone is also important since fractures of some parts of the bone
statistically heal better in a cast than others.

When should the fracture be treated in a cast and when does

it need an operation?
The best results from cast treatment are in those patients who have a fracture that is
incomplete or does not extend all the way across the bone. "Nondisplaced" fractures
treated in a cast less than 28 days after the injury have a good chance of healing.
Fractures that are complete, particularly if they are displaced to any degree, take a
much longer time in a cast to heal and may not heal at all. The average time for a
fracture of the waist of the scaphoid of a bone that is not displaced is three months in a
cast. Since this is only an average, there are many patients who take much longer to
heal than this. Studies have shown improved rates of healing in a long arm cast
(thumb included), for up to 6 weeks, followed by a short arm thumb spica cast.
Approximately, 10% take over six months in a cast to heal. A careful discussion with
your orthopedic surgeon may result in a decision to operate and stabilize the bone
with a special screw. These patients usually are allowed out of a cast within three
weeks to begin flexibility exercises, but full use in sports is not allowed until motion
and strength are restored and the x-ray shows that the bone has healed (usually 8 to 12
weeks after the operation).

Are there any fractures that should not be treated in a cast?

Yes. Any fresh fracture that is displaced or unstable should be treated with an
operation to reduce and/or stabilize this type of fracture with the fixation device. If it
is not stabilized, the bone usually will not heal in a cast; and if it does, the wrist is stiff
and usually develops traumatic arthritis leading to pain and loss of use. Also,
nonunions of the bone or old fractures require special treatment.

How is a nonunion or an old fracture of the bone treated?

A nonunion of the scaphoid bone requires a bone graft to stimulate the old fracture to
begin the healing process again. This small piece of bone is taken from the patient's
pelvis. If you need to have a bone graft taken from the iliac portion of your pelvic
bone, it will be sore for a few days when you walk. Occasionally, fresh fractures
require a bone graft when they are in many pieces (comminuted).

After the bone graft, how long do I have to wear the cast?
This depends on several factors: the type of bone graft and the quality of blood flow in
your scaphoid bone.

There are two primary types of scaphoid bone grafts being used today in wrist
surgery. Both of these are named after the surgeon that invented them. The first type
is the Russe graft. Here the bone is hollowed out much like a "twice baked potato" and
then the bone graft if packed into the hollowed out scaphoid cavity. The average
healing rate is somewhere between 80 and 90% if the bone has good blood supply. If
the blood supply is poor, this method rarely, if ever, works. After a Russe type bone
graft the average time that you will have to wear a cast is between five and six
months. Some surgeons will use other types of screw fixation with bone grafting as an
alternative to the Herbert screw.

The other type of bone graft uses the Herbert scaphoid screw (or a similar device
using the same concept) and a solid block of bone between the two ends of the
scaphoid. Assuming the bone graft can be stabilized with the screw, the patient is
allowed out of the cast in three weeks. This is can be a big advantage in the ability to
rehabilitate the wrist more completely and quickly. The healing rate of this operation
is at least as good, if not better, than the Russe type graft.

Another advantage of the screw fixation of the scaphoid comes in patients whose
bones have a poor blood supply. In the Russe bone graft, if the blood supply is poor,
very few, if any, of these patients heal their scaphoid fractures after surgery. With the
Herbert screw or other devices, a significant number of these patients do obtain
healing, but the patient's cast must be kept on for a period of three months instead of
three weeks.
After surgery, when can I resume playing sports or heavy
work?
You may not resume contact sports or heavy activities until the bone has healed
completely. The screw is not a substitute for healing of the bone. It is merely a
substitute for wearing the cast and allows earlier rehabilitation of the wrist. As a rule,
after a fresh fracture is stabilized with the screw, the patient may return to sports in
eight weeks. After a nonunion and bone grafting, this period is three months unless
the blood flow is poor in which case the period of activity restriction may be longer.

If I decide to have my scaphoid operated on, how long do I

have to stay in the hospital?
If you do not have a bone graft, about half of the patients go home the same day as the
surgery and about half spend one night in the hospital. If you have a bone graft from
your pelvis, most of the patients spend the night after surgery in the hospital and are
sent home the following day.

What type of anesthesia is used?

Usually an auxillary block or local anesthesia is used to numb the arm. The patient
does not require general anesthesia unless a bone graft is required. In this case, the
patient usually has a block of the arm and then a short period of light general
anesthesia lasting approximately 20 minutes or less while obtaining the bone graft.

Summary:
In summary, getting this tiny bone healed and the wrist restored to function is the
goal. Although challenging and somewhat complicated, working together with your
hand/wrist surgeon, you have an excellent chance of maintaining a functional wrist
joint that will last you a lifetime. This is often a complicated problem and it is
important to understand the treatments thoroughly. If you have questions, do not
hesitate to ask.

Scaphoid Fractures

What are scaphoid fractures?

The scaphoid bone is one of the eight small bones that make up the “carpal bones” of the wrist. There
are two rows of bones, one closer to the forearm (proximal row) and the other closer to the hand
(distal row). The scaphoid bone is unique in that it links the two rows together (see Figure 1). This
puts it at extra risk for injury, which accounts for it being the most commonly fractured carpal bone.

How do scaphoid fractures occur?

Fractures of the scaphoid occur most commonly from a fall on the outstretched hand. Usually it hurts
at first, but the pain may improve quickly, over the course of days or weeks. Bruising is rare, and
there is usually no visible deformity and only minimal swelling. Since there is no deformity, many
people with this injury mistakenly assume that they have just sprained their wrist, leading to a delay
in seeking evaluation. It is common for people who have fractured this bone to not become aware of it
until months or years after the event.

Diagnosis of scaphoid fractures

Scaphoid fractures are most commonly diagnosed by x-rays of the wrist. However, when the fracture
is not displaced, x-rays taken early (first week) may appear negative. A non-displaced scaphoid
fracture could thus be incorrectly diagnosed as a “sprain.” Therefore a patient who has significant
tenderness directly over the scaphoid bone (which is located in the hollow at the thumb side of the
wrist, or “snuffbox”) should be suspected of having a scaphoid fracture and be splinted (see Figure
2). An X-ray a couple of weeks later may then more clearly reveal the fracture. In questionable
cases, MRI scan, CT scan, or bone scan may be used to help diagnose an acute scaphoid fracture. CT
scan and/or MRI are also used to assess fracture displacement and configuration. Until a definitive
diagnosis is made, the patient should remain splinted to prevent movement of a possible fracture.

Treatment of scaphoid fractures

If the fracture is non-displaced, it can be treated by immobilization in a cast that usually covers the
forearm, hand, and thumb, and sometimes includes the elbow for the first phase of immobilization.
Healing time in a cast can range from 6- 10 weeks and even longer. This is because the blood supply
to the bone is variable and can be disrupted by the fracture, impairing bony healing. Part of the bone
might even die after fracture due to loss of its blood supply, particularly in the proximal third of the
bone, the part closest to the forearm. If the fracture is in this zone, or if it is at all displaced, surgery
is more likely to be recommended. With surgery, a screw or pins are inserted to stabilize the fracture,
sometimes with a bone graft to help heal the bone (see Figure 3). Surgery to place a screw may also
be recommended in non-displaced cases to avoid prolonged casting.

Complications of scaphoid fractures

Non-union: If a scaphoid fracture goes unrecognized, it often will not heal. Sometimes, even with
treatment, it may not heal because of poor blood supply. Over time, the abnormal motion and collapse
of the bone fragments may lead to mal-alignment within the wrist and subsequent arthritis. If caught
before arthritis has developed, surgery may be performed to try to get the scaphoid to heal.

Avascular necrosis: A portion of the scaphoid may die because of lack of blood supply, leading to
collapse of the bone and later arthritis. Fractures in the proximal one third of the bone, the part
closest to the forearm, are more vulnerable to this complication. Again, if arthritis has not developed,
surgery to try to stabilize the fracture and restore circulation to the bone may be attempted.

Post-traumatic arthritis: If arthritis has already developed, salvage-type procedures may be

considered, such as removal of degenerated bone or partial or complete fusion of the wrist joint.
Figure 1: The scaphoid bone is unique in that it spans the two rows of wrist bones.

Figure 2: Significant tenderness directly over the scaphoid bone (which is located in the hollow at the
thumb side of the wrist).
Figure 3: A screw or pins are placed to stabilize the fracture.

© 2011 American Society for Surgery of the Hand. Developed by the ASSH Public Education
Committee

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