Fracture of the scaphoid bone, treatment

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A fracture of the scaphoid bone of the wrist is an extremely unpleasant injury that requires long and difficult treatment. There are frequent cases of delayed access to a doctor, failure to detect a fracture during the initial examination, lack of treatment or improper treatment. I hope this article will help people with or suspected of having a similar injury.

Who is more likely to have wrist fractures? Usually these are young people aged 20 to 30 years, most often men. A typical mechanism of injury is a fall with support on the hand and hyperextension of the wrist joint.

Anatomy of the scaphoid

Any injury to the wrist joint area should be assessed by a traumatologist, since fractures of small bones may be mistakenly assessed by the patient as a bruise. But the consequences of a fracture of the scaphoid bone of the hand can be very serious (see explanation in the text).

The scaphoid bone is one of the small bones of the wrist. Of all the bones in the wrist, scaphoid fractures are the most common. The scaphoid is a small carpal bone on the thumb side (radial side).

The wrist is made up of eight small bones known as carpal bones. The carpal bones form two rows of four bones each, which are located between the metacarpal bones and the bones of the forearm (radius and ulna). The scaphoid bone can be palpated in the area of the “anatomical snuffbox”. This point is located between the tendons of the extensor pollicis longus and abductor longus muscles.

The anatomy of the wrist joint and carpal bones is extremely complex, probably the most complex of all joints in the human body. The joints and bones of the wrist allow us to perform a variety of movements in all planes. At the same time, the wrist ligaments must provide strength to the joints.

One of the reasons that the wrist is so complex is that each small bone forms a connection to adjacent bones.

The scaphoid bone has a poor blood supply. The proximal pole (closer to the forearm) during fractures remains without blood supply. In view of this, early diagnosis of such hand fractures is very important.

Consequences

Like any injury, a fracture of the scaphoid is fraught with the development of negative consequences. Complications of this type of injury may include:

Absence of callus (non-union of fracture). This complication occurs when treatment is not timely. This is the main reason why it is important to begin therapeutic intervention as soon as possible. Additional factors that prevent bone healing may include the location of the fracture, the presence of displacement, and the development of necrosis of the bone structure. If the formation of callus is slow, then it is likely to use methods such as long-term wearing of a splint or surgery to accelerate the fusion of fragments of the scaphoid bone.
Anatomically incorrect healing of the fracture. In some clinical cases, improper bone fusion is observed, usually at a slight angle. This development of events is fraught with increased pain when trying to move the hand and limited range of motion in the joint. This complication can be easily diagnosed using an x-ray.
Necrosis of bone tissue. If damage is detected to the narrow part of the scaphoid bone (waist), there is a risk of disruption of blood flow to it. Lack of proper nutrition can lead to the death of part of the bone tissue. Fortunately, this complication is quite rare and occurs in particularly advanced cases.
Arthritis. A frequent complication that occurs after a certain period of time after the onset of a fracture. The main reasons for its development are the consequences of necrotic syndrome or improper healing of the injured bone.

According to statistics, in most victims, a fracture of the scaphoid bone is considered undetected. It is this factor that contributes to problems with the hand (long, improper fusion of the bone).

Timely, competently provided trauma care, as well as the necessary rehabilitation measures, are the key to the speedy restoration of full motor function of the hand.

Such injuries should be treated with special attention, since trauma to a small and, at first glance, insignificant bone can block the movement of the entire wrist joint.

Causes of fractures of the scaphoid bone of the hand

Scaphoid fractures are typically caused by a fall on an outstretched arm. Also, with a similar fall, a fracture of the distal radius often occurs. Scaphoid fractures occur in people of all ages, including children. The injury often occurs during sports or a traffic accident. In men between the ages of 20 and 30, a fracture of the scaphoid bone of the hand most often occurs for one reason or another.

Some studies have shown that using “protection” while roller skating, snowboarding, skiing, or skating reduces the likelihood of fractures of the wrist and radius bones.

Closed fracture of the distal phalanx of the finger

A closed fracture of the distal phalanx of the finger occurs due to direct (impact) or indirect trauma (Bush avulsion fracture, that is, the dorsal edge of the base of the phalanx). If there is a subungual hematoma, which is accompanied by pain from increased pressure, it is opened, the nail is burned with a hot needle or a reciprocating cutter of a dental drill.

In case of transverse and comminuted fractures of the distal phalanx, the fragments are almost not displaced, so it is enough to fix it with several circular rounds of adhesive plaster (without interfering with blood circulation) for a period of 2 weeks.

Symptoms of scaphoid fractures

Fractures of the scaphoid are caused by:

Pain and swelling in the “anatomical snuffbox” area at the base of the thumb. The pain can be very intense when moving, palpating, or trying to grasp something;
Limitation of movements in the hand, but they can be masked by pain and upon examination it is very difficult to determine the range of movements;
Crepitation of fragments (crunching of broken bone fragments);
Bleeding around the wrist.

If the wrist is not deformed (as in displaced radius fractures), this does not mean that there is no fracture of the small bones of the wrist. In some cases, the pain is not severe and can be mistaken for a bruise or ligament damage.

Any pain in the wrist that does not go away within a day of the injury may be a sign of a fracture.

Symptoms of fractures

If your midfoot is injured, you may experience the following symptoms.

Sharp pain in the central part of the foot.
Swelling that may spread to the ankle joint.
Deformation of the upper part of the foot - the navicular bone protrudes outward.
Your leg may hurt a lot when you try to take a step. In this case, a person can only step on the heel.
With shrapnel injuries of the lower plane of the navicular bone, pain and swelling are observed on the inside of the foot.

Diagnosis of scaphoid fractures

It is very important to diagnose a fracture of the scaphoid bone as early as possible, since a significant part of the scaphoid bone has poor blood supply and the fracture may not heal, or necrosis of the bone fragment may occur (the non-blood-supplied fragment dies), and this leads to serious negative consequences (restriction of movements in the wrist joint).

The first and mandatory diagnostic point is radiography of the damaged area of the limb. Most often, x-rays clearly show the nature of the scaphoid fracture.

In some cases, when it is difficult to determine the relationship of fragments from an x-ray, a computed tomography scan of the wrist joint is prescribed. With such a study, you can see the damaged bone three-dimensionally, which will help in determining the tactics of surgical treatment of the fracture.

If a fracture of the scaphoid bone occurs without displacement of the fragments, then the fracture line may not be visible on the x-ray. Therefore, it is very important to perform splinting for 10 days for any hand injury. On day 10, repeat x-rays of the hand and, if there was a fracture, it will become clearly visible. Well, then they carry out appropriate therapeutic measures (see the section on treatment of scaphoid fractures).

Providing first aid

Essentially, treatment for a fracture begins immediately after a person receives an injury. Therefore, it is important to avoid mistakes at the stage of providing first aid to the victim, because competent actions will reduce not only the pain syndrome, but also the likelihood of a lot of complications.

Algorithm for providing assistance:

Apply cold to the damaged area for 15 – 20 minutes. This could be a product from the freezer, pre-wrapped in cotton cloth. After a break of 10–15 minutes, the cold is applied again.
If there is damage to the skin, treat the wound with hydrogen peroxide or chlorhexidine and, if possible, apply a sterile bandage.
Immobilize the wrist joint using any available means (board, ruler, thick cardboard, etc.).
Call a team of doctors or independently deliver the victim to a medical facility.

These measures prevent swelling and significantly reduce pain.

Complications of scaphoid fractures

Osteoarthritis: If a scaphoid fracture is not treated, nonunion often occurs. Sometimes, even with proper treatment, fracture nonunion may occur due to poor blood supply. Over time, unphysiological movement of bone fragments can lead to a violation of the relationship of the articular surfaces in the wrist and subsequent arthrosis.

Aseptic necrosis: Part of the scaphoid bone may necrotize (die) due to lack of blood supply, which leads to severe impairment of hand movements and pain. Fractures in the proximal one-third of the bone, the side closest to the forearm, are more susceptible to these complications. Aseptic necrosis becomes visible on x-ray only a few months after the injury, but this is already too late. This is why hand injuries should be evaluated by a doctor.

Causes

The anatomical features of the structure of the scaphoid bone, its size, curvature and narrowing in the center, attachment between massive structures and continuous static and dynamic loads are of enormous importance at the time of a fracture. Therefore, if you fall with emphasis on your hand with your arm outstretched, you can earn the above damage.

With such a blow, the damaging force is directed along the axis of the forearm, while the hand is in a position of dorsiflexion at an angle of 90 degrees with simultaneous deflection in the beam. In this position, the mechanical force is concentrated in the wrist, and it is this that predetermines the destruction of the scaphoid bone. That is, the mechanism of its fracture is indirect.

With excessive and sharp deviation of the hand towards the elbow, a tear develops in the tubercle of the scaphoid bone, on which the lateral ligament is attached, starting from the styloid process of the radius.

The combination of ulnar deviation of the hand at the wrist with the impact of traumatic force along the axis of the forearm provokes compression of the scaphoid bone by the capitate bone and the styloid process of the radius, leading to the destruction of its body.

Conservative treatment of scaphoid fractures

The treatment plan for a scaphoid fracture will depend on the severity of the fracture, the patient's health, activity level, and desire for a speedy recovery.

If the fracture is not displaced, then treatment is performed without surgery. This typically requires immobilization (casting) of the wrist and first finger in slight abduction for 2 months while the fracture heals. In some cases, patients with non-displaced fractures request surgery to reduce immobilization time and restore hand function as quickly as possible. This approach is still somewhat controversial among orthopedic surgeons.

Fracture of the lower third of the scaphoid (closer to the fingers)

Fractures of the lower third of the scaphoid usually heal within 4-6 weeks if properly immobilized (casting). This part of the scaphoid has a good blood supply, so there are usually no problems with nonunion.

Fracture of the upper third of the scaphoid (closer to the forearm)

If the scaphoid fracture occurs in the middle third (waist) or closer to the forearm (proximal pole), healing is more difficult. These areas of the scaphoid have poor blood supply.

The healing time depends on age, blood supply to the hand, and metabolism, so periodic medical supervision and stage radiographs or computed tomography are necessary to determine fracture healing.

If there is displacement of the fragments and there is a risk of avascular necrosis, then surgical treatment of the fracture is recommended.

Rehabilitation

Upon completion of the main treatment, the patient must be transferred to the rehabilitation department or given recommendations for developing the joint. Such measures will ensure the return of mobility and flexibility of the affected area of the bone.

It is important to maintain a certain period of rest between the end of treatment and restoration of mobility, observing the following conditions:

Minimizing physical activity for an injured hand;
Refusal to perform daily work with the affected limb;
Avoiding activities that may involve falling on an injured hand: cycling, skating, running.

Responsible compliance with all medical prescriptions is necessary, since violation of the activity regime can lead to re-injury and reduce to zero the efforts of the traumatologists and the victim himself.

The following are used as rehabilitation measures for this type of fracture:

Exercise therapy, which allows you to improve or even completely restore the mobility of the wrist joint after a period of prolonged immobilization (the first classes should be performed under the supervision of an instructor, and then, having received an idea of the exercises and the recommendations of a physiotherapist, you can begin independent recovery);
Paraffin and ozokerite applications to the fracture site;
Ultrasound with novocaine to reduce pain;
Electrophoresis;
Magnetic therapy.

Physiotherapeutic procedures can increase local blood circulation in the joint and in the area suffering from lack of nutrition.

The patient’s display of diligence and responsibility during the rehabilitation period will have a positive impact on overall well-being - the range of movements of the hand will be restored to its previous volume. With regular and correctly selected loads, restoration of the hand occurs 4 to 7 months after the start of classes.

Surgical treatment of scaphoid fractures

The goal of surgical treatment is to stabilize the scaphoid fracture, which contributes to the rapid restoration of blood supply to the fragment and healing of the fracture.

The surgery is usually performed on an outpatient basis using either regional anesthesia (brachial plexus nerve block) or local anesthesia. During the operation, the displacement of bone fragments is eliminated and they are fixed with an implant (screw) for stabilization. During the operation, radiographs are taken to confirm the restoration of the bone anatomy and the correct fixation of the fragments. In most cases, a single screw is used to stabilize the bone fragments.

The incision can be made on the palm or back of the wrist. Where the doctor will make the surgical incision and how large it will be depends on what part of the scaphoid bone is fractured. Most often, fresh fractures are fixed with a screw through a 3-5 mm incision, because the displacement is eliminated quite easily and there is no need to make a large incision for open access to the bone.

If the fracture is old and has healed in the wrong position, a sufficient incision is necessary to perform an osteotomy (artificial fracture) of the healed fragment to recreate the correct anatomy and secure the bone with a screw.

Basically, orthopedic surgeons fix fragments with screws:

This method of fixation is much more reliable than knitting needles, because... the screw is completely immersed in the bone;
Early development of movements in the wrist joint is possible.

In cases where the bone breaks into more than two pieces, a bone graft is used. A bone graft is a synthetic bone graft that is placed around a broken bone and used to stimulate healing of the bone tissue. It increases bone production. Or the graft can be taken from the radius bone of the forearm, the iliac crest.

Elimination of fractures

Treatment for various injuries to the navicular joint of the foot depends on the complexity of the injury. In case of a closed fracture without deformation, they are limited to the application of circulating plaster. To prevent proper healing, specialists install an instep support on the lower part of the bandage.

For lesions complicated by joint displacement and the presence of fragments, general anesthesia or local anesthesia is used. Doctors then correct the bone, returning it to its correct anatomical position. Moreover, the leg should be bent at the knees, and the foot should be parallel to the plane of the floor.

If the injury is complicated by a dislocation, a special apparatus consisting of metal spokes is used. The first is passed through the heel bone, the other is installed through the metatarsal heads. The operation is performed under general anesthesia.

The plaster is applied for 1.5-2 months, and during this period doctors conduct repeated examinations: x-rays, tomography. This is done in order to monitor the process of joint fusion. In some situations, a longer recovery period may be required.

Despite the complexity of the operation, doctors try to avoid removing the navicular joint, as this can lead to a bowed foot or other complications. In order for treatment to give a quick positive result, it is necessary to correctly follow all instructions and strict control of the recovery process.

Complications after surgery

Nonunion and avascular necrosis

Even after timely and correct fixation of fragments during surgery after a fracture of the scaphoid hand, there are non-unions; this directly depends on the characteristics of the body and the blood supply to the bone. This can also be affected by patient non-compliance with recommendations.

If the fracture does not heal, then the option of moving a bone graft is considered, as mentioned above. For example, the use of a special type of bone graft with its own blood supply (graft vascularization).

Arthrosis

Over time, nonunion, malunion, and avascular necrosis of the scaphoid can lead to arthrosis of the wrist. Symptoms of arthrosis include:

Wrist pain
Decreased range of motion of the wrist
Pain when lifting or grasping an object.