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Scaphoid fracture and scaphoid non-union

What is it? 

The scaphoid bone is an important structure because it links the two rows of bone forming the wrist. It is therefore subjected to large mechanical loads and also has an unusual blood supply which can impede its ability to heal. Scaphoid fracture normally occurs as a result of a fall on an outstretched hand. Pain, swelling and limitation of movement are normally apparent, although in some cases this is not obvious and therefore this fracture is commonly missed.

What is it? 

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How is it diagnosed? 

Scaphoid fractures and non-unions (failure of bone to heal) are diagnosed on the basis of the history described above and by clinical examination. There may be pain when pressure is applied over the scaphoid bone. Other provocation tests include the Kirk-Watson manoeuvre. Special x-rays are required to make the diagnosis. Often these need to be repeated after two weeks as the fracture line is often clearer at this stage. If there is uncertainty an MRI scan usually confirms the diagnosis.

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What is my approach to treatment? 

Most scaphoid fractures can be treated with immobilisation in a cast, for an average period of nine weeks. This may not be appropriate in some individuals or with certain types of fracture, for example displaced or proximal fractures. An operation to fix the fracture may be advisable. You can discuss this at your first consultation.

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What does an operation involve? 

Surgery is normally carried out as a day case under a general anaesthetic. A tourniquet is applied to the upper limb, similar to a blood pressure cuff. This provides a clear view of the operative field for surgery. A small incision is made over the back (or front) of the wrist, exposing the fractured bone. The bone fragments are stabilised with a wire and a special screw is used to fix and compress the two broken bone ends together. The wire is removed and the screw remains buried within the bone. The joint capsule and skin are then closed with sutures. A long acting local anaesthetic is then administered to provide pain relief. Finally, dressings and bandages are applied.

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What is the recovery period? 

Once the local anaesthetic has worn off, normally 6 to 8 hours, simple analgesics and anti-inflammatory tablets may be used for pain. The hand should be kept elevated as much as possible during the first week after the operation, although finger movements are to be encouraged. A high-arm sling may be useful for this purpose. Temporary cast and sutures are removed in the clinic at two weeks and another cast applied until 6 weeks after surgery. It should then be possible to wet the hand. Prior to this it’s possible to shower by keeping the extremity dry with a plastic bag secured over the limb using an elastic band or a purpose made shower cover. Most pain and swelling will have settled within four weeks after surgery. Driving is usually possible after 3 to 4 weeks. When a patient is ready to return to work depends on their specific job role and may also vary from individual to individual. It may be possible to return to light keyboard work towards the end of the first week. Heavy manual work should be avoided until the fracture is soundly united. This is confirmed on radiographs and usually takes between 6-12 weeks.

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Are there any possible complications? 

Over 90% of patients are satisfied with the final result. However, as with any treatment, there are always risks involved: Infection: 2%, Chronic regional pain syndrome: 2%, Some loss of wrist motion may occur after fracture. Scaphoid non-union (failure to unite) is variable and dependant on the fracture pattern. It is far more common in smokers. If left untreated, the wrist bones fail to move correctly and over time wear out the wrist joint (osteoarthritis). Treatment of scaphoid non-union can be complex. In most cases a small amount of bone graft is taken from near the wrist and placed into the freshened fracture site. Surgical fixation of the non-union is very much along the lines of the procedure I describe for scaphoid fractures. However, recovery period is longer – taking anything from three months to one year. This can be discussed at your first consultation.

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