Scaphoid fracture

What does scaphoid fracture of the hand mean?

The scaphoid bone is one of the carpal bones which, altogether with the other carpal bones and the two bones of the forearm, constitute the wrist joint. If this bone breaks, we refer to it as a scaphoid fracture.

Scaphoid fractures are by far the most common fracture of the wrist and also one of the most common fractures in humans, making up 2-7% of all fractures.  

Common causes of this hand injury

Typically, a scaphoid fracture results from a fall on the outstretched hand. These accidents can occur, for example, during various sports, but also at home after falling from a ladder or while riding a bicycle or motorcycle. This injury also often occurs in goalkeepers who catch a very powerful shot with their hand. 

Men are most commonly affected by scaphoid fractures, about 6 times more often than women. The age peak of the injury lies between 20 and 30 years.

How does a scaphoid fracture present?

Scaphoid fractures can be accompanied by any of the general signs of a fracture. They occur at the wrist on the thumb side. 

• Pain upon movement and pressure  

• Swelling  

• Redness 

• Restricted range of motion (or excessive mobility) 

• Palpable bone gap or palpable crepitations (crackling of the bone fragments as they move against each other) 

• Open fracture (in this case the skin is damaged, exposing bone fragments) 

How can a doctor diagnose a scaphoid fracture?

Given that the circumstances of the accident are often quite typical for this injury, an interview with the doctor, along with an examination of the affected hand, will already provide an idea of a scaphoid fracture.  

If a fracture is suspected, X-rays are obtained in three planes. A fracture line between the two bone fragments can usually be recognized in these images.  

As this fracture line cannot be seen on the X-ray image in around 30% of cases of recent scaphoid fractures, a CT scan is additionally performed if the X-ray findings are unclear or negative if this injury is suspected. Although CT imaging may also be required to plan the surgery if the findings are positive, it is not routinely done for every suspicion of a scaphoid fracture, since the radiation exposure is higher than with conventional X-rays.

Treatment of scaphoid fractures: Is a plaster cast enough or is surgery needed? Scaphoid fractures can be categorized into stable and unstable fractures and are treated differently based on this. A scaphoid fracture is considered unstable if it fulfills at least one of the following criteria: 

• Dislocated fracture (meaning that the bone fragments are displaced against each other or within the anatomy of the wrist). 

• Proximal fracture (the proximal part of the scaphoid, in other words the part facing the forearm, has less blood supply than the part facing the fingers, so fractures in this area heal worse). 

• Long oblique fracture (in this case, an elongated fracture surface extends diagonally through the oval bone). 

If the scaphoid fracture is stable, it can be treated conservatively.  

This involves symptomatic treatment in the form of resting and cooling the wrist and non-steroidal anti-inflammatory drugs and painkillers such as ibuprofen. Furthermore, the fracture is stabilized in a splint or cast for 4-8 weeks so that it can heal. Afterwards, the fracture is checked with a CT scan. According to the results, the immobilization may be extended by a few more weeks. It should not last longer than 12 weeks in total, however. 

If patients need to be able to bear weight early, for example athletes or craftsmen, then even a stable fracture can be operated on. 

Unstable scaphoid fractures always require surgery. Surgery can be carried out under general anesthesia or plexus anesthesia, which involves a temporary numbing of the nerves that carry pain impulses from the hand to the brain by injecting a drug into the armpit. Patients are therefore awake during the operation, yet feel no pain in the affected hand. 

A screw is inserted to stabilize the bone fragments and compress them against each other, which promotes bone healing. A small skin incision is enough to insert this screw in a minimally invasive manner. In dislocated fractures, however, the fragments of the scaphoid have to be moved into their original position first, meaning that an open approach with a larger incision is necessary.  

If additional ligament injuries to the wrist have occurred during the accident, they can be treated with stitches during the same operation.

Prognosis & healing period - What long-term consequences are possible? 

For scaphoid fractures that have been treated conservatively, physiotherapy and occupational therapy are provided after the splint has been removed, depending on the functional deficit. Approximately one month after immobilization, the wrist can be fully loaded again. 

After surgery to repair a fracture, the wrist can be moved on the first day after the operation as long as there is no pain. However, straining the hand and forearm, for example supporting or carrying a bag, should be avoided. Physiotherapy instructions for training the surrounding muscles are provided still in the hospital. Before the patient can be discharged from the hospital, the results of the operation are assessed with an X-ray. 

Afterwards, physiotherapy training is gradually started and increased. By the eleventh week after the operation, the hand is fully functional again in everyday life.  

Can you drive a car with a scaphoid fracture? 

Generally, it is not forbidden to drive a car with a scaphoid fracture or with a plaster cast applied to the hand.  

Nevertheless, patients may have a limited sense of touch and mobility of the hand because of the fracture itself or a cast or splint, which may lead to problems with safe steering and operating the gearshift. In the event of an accident, the driver is normally held at least partly responsible due to negligence. This can result in a loss of insurance cover. 

Which doctors & clinics specialize in the treatment of scaphoid fractures? 

Carpal bone injuries such as a scaphoid fracture are treated in a clinic specializing in hand surgery, where specialized hand surgeons as well as radiologists, physiotherapists and occupational therapists are part of the diagnostics and therapy. 

The additional specialization for hand surgery can be achieved by a specialist for surgery or orthopaedics through appropriate further training.