A scaphoid fracture is a break in the scaphoid bone, which is one of the eight small carpal bones in the wrist. It’s the most commonly fractured carpal bone, making up about 60-70% of all carpal bone breaks. These fractures often occur after a fall onto an outstretched hand, with the weight landing on the palm.
When you extend your thumb, a triangular hollow appears on the back of your wrist. This is known as the anatomical snuffbox. By pressing in this area, you will feel the scaphoid bone beneath the surface. Tenderness in the anatomical snuffbox is a common clinical indicator of a scaphoid fracture.
The Anatomy Of The Wrist
The scaphoid is one of the eight small carpal bones found in the wrist, located on the thumb side. It serves as a link between the forearm and the hand. It has a unique curved shape, resembling a boat or twisted peanut. Approximately 80% of the scaphoid’s surface is covered in articular cartilage, allowing smooth wrist movement. The scaphoid has a retrograde blood supply, meaning most of its blood flow enters the bone at the part closest to your thumb and travels down towards the part closest to your forearm. This directly influences the fractures recovery rate.
The scaphoid is divided into three parts:
- The Lower pole: The part closest to your thumb.
- The waist: The middle portion.
- Upper pole: The part closest to your forearm.
What does a scaphoid bone do?
The scaphoid bone contributes to the overall stability of the wrist and enables movements such as bending the wrist downward, upward, toward the thumb, and towards the pinky finger. When force is applied through the hand, the scaphoid helps absorb and distribute the load across the wrist joint. Additionally, it serves as an anchor point for several ligaments that contribute to the wrist’s structural stability.
How did it happen?
A scaphoid fracture primarily occurs when you fall onto an outstretched hand. As your hand hits the ground, your wrist bends backwards beyond its normal range, and the force is transmitted through your hand. This locks the scaphoid in a very vulnerable position. The scaphoid bone gets squeezed between the forearm and another carpal bone. This creates a “nutcracker” effect on the scaphoid bone, crushing it and leading to a fracture. The middle part of the scaphoid is the most common site for this break because it’s the narrowest part of the bone.
Causes of
- Falling on outstretched hand. (Most common)
- Direct blows to the wrist.
- High-energy trauma from sports injuries or motor vehicle accidents.
- Participating in activities with repetitive forceful wrist movements will lead to stress fractures of the scaphoid.
How severe is my scaphoid fracture?
Your fracture is largely influenced by the location and whether the bone fragments have moved out of place.
A fracture, located closest to your forearm, is the most serious type because of the disruption in the bone’s blood supply. This will cause delayed healing time or complete failure to heal. Waist fractures, found in the middle of the bone, have a lower risk of bone death, compared to upper pole fractures that are located closest to your thumb. Lower pole fractures, located closest to your forearm, have the best outlook and heal fastest due to better blood supply.
If your bone fragments remain correctly aligned after a fracture, it is considered stable and has a better chance of healing with just a cast. However when the fragments have shifted out of their normal position, it is considered unstable and there is a higher risk of not healing properly. Therefore these fractures require surgery to realign and stabilize the bone. A displacement of more than 1 mm is a key indicator of an unstable fracture. When your bone is broken into multiple small pieces, it can make healing more challenging. The presence of other carpal bone fractures in the wrist can prolong your healing.
If the fracture is accompanied by damage to the ligaments surrounding the scaphoid, it will significantly worsen the prognosis and lead to chronic instability and arthritis.
Diagnosis
Physiotherapy diagnosis
We as Physiotherapists play a vital role in the management of scaphoid fractures. Our primary goal is to reduce pain , swelling, restore normal movement and prevent future flare-ups. We provide the most effective treatments for wrist fractures. With a well-structured and comprehensive treatment plan, we target your recovery goals to ensure the best possible outcome. As experts, we also help you identify activities that may be contributing to your wrist pain and offer guidance on how to modify them.
X-rays
X-rays are the first-line investigation for suspected scaphoid fractures.
However, they can miss a significant percentage of fractures (5-20%) in the early stage of your injury. Therefore, we treat your condition as if it is a fracture.
Your physiotherapist will refer you for X-rays, if necessary.
MRI
MRI is considered the most sensitive modality for detecting scaphoid fractures.
MRI is also excellent for identifying associated ligamentous injuries and assessing the vascular status of the scaphoid.
Your physiotherapist will refer you to get a MRI taken, if necessary.
Why is my pain not going away?
The most common complication of a scaphoid fracture is its failure to form a solid bone. This leaves a gap between the two broken fragments. The unhealed fragments move abnormally while using the wrist, causing constant irritation and instability. The scaphoid bone may also heal in a deformed position which leads to persistent pain, especially with gripping and pinching activities. Up to 50% of scaphoid fractures lead to bone death , which compromises the bone’s weight-bearing capacity.
Problems we see with a scaphoid fracture
Waiting too long to seek medical assistance
Scaphoid fractures are often subtle on initial X-rays and can be mistaken for a wrist sprain. If the fracture goes undiagnosed or untreated for an extended period, the chances of failure to heal increase significantly. If a scaphoid fracture fails to heal, complications such as chronic pain, stiffness, weakness and arthritis occur that will severely impact your ability to perform daily activities. Therefore, accurate diagnosis and treatment is necessary to ensure proper healing and prevent long-term disability.
Resting too much or too little
Wearing a cast or splint for the appropriate duration is essential to keep the wrist properly immobilized. If not worn long enough, the condition may worsen and become more difficult to treat. However, keeping the wrist immobilized for too long can lead to joint stiffness and muscle weakness around the wrist. That’s why early diagnosis and treatment is necessary.
Physiotherapy treatment
We as Physiotherapists play a vital role in the conservative management of scaphoid fractures. Our primary goal is to reduce pain and swelling, restore normal movement, and prevent future flare-ups. We provide the most effective treatments for scaphoid fractures. With a well-structured and comprehensive treatment plan, we target your recovery goals to ensure the best possible outcome. As experts, we also help you identify activities that may be contributing to your fracture and offer guidance on how to modify them.
Phases of rehabilitation
1st Phase: Protection and Pain Management
Our primary objective is to accurately diagnose your condition and identify any factors contributing to it. With this understanding, we can advise you on activities to avoid and provide strategies to manage your symptoms effectively. In the initial stage, we recommend applying the POLICE method to manage your symptoms.
Your wrist will be immobilized in a thumb spica cast for 6 weeks to 6 months, depending on the type of fracture. During the immobilization period, it’s crucial to avoid putting any weight on your hand and refrain from any gripping activities. X-rays are taken every 2-4 weeks to monitor the healing process. These images assist in determining if the fracture is healing properly. Once the fracture is confirmed to be healed with an X-ray, the cast is removed. After the removal of the cast, it is expected for your wrist to feel weak and stiff. Therefore, it is crucial to receive physiotherapy to prevent long term complications.
2nd Phase: Restoring Movement and Early Strength
This phase typically starts 0-4 weeks after cast removal. (2-6 months post-injury). Our goal is to progressively restore full, pain-free range of motion of your wrist and improve neuromuscular control in your hand. We also aim to reduce any remaining swelling and discomfort. We will introduce progressive range-of-motion exercises to restore wrist movement. Gentle stretching of the forearm flexors and extensors will be incorporated to enhance flexibility. Low-intensity isometric contractions of the forearm muscles will be initiated to activate these muscles without placing excessive stress on the wrist. Soft tissue mobilization techniques will be applied to the surrounding muscles to alleviate muscle tension and improve circulation.
3rd Phase: Strengthening and Functional restoration
This phase typically starts 4-8 weeks after cast removal. Our objective is to rebuild full strength and endurance in the muscles surrounding the wrist and forearm. We aim to enhance functional abilities, enabling you to return to your regular activities, without pain or limitations. Isotonic exercises will be introduced in this phase of healing, using light weights or resistance bands for the wrist flexors and extensors. Continued soft tissue mobilization will be done as needed to address any muscle tightness or restrictions. Before returning to your daily activities, guidance will be provided on a safe and gradual return to sport or work activities, modifying them as necessary to avoid re-irritation.
4th Phase: Maintenance and Prevention
This phase typically starts 8-12 weeks after cast removal (4+ months post-injury). Our focus is to maintain full, pain-free range of motion and strength in the wrist and forearm muscles.
Healing time
The healing time for your scaphoid fracture treated non-surgically varies due to the factors discussed previously. Lower pole fractures heals within 4-8 weeks. Mid-portion fractures heals within 10-12 weeks. Upper pole fractures heals within 3-6months. Most scaphoid fractures take approximately 3 months to heal after surgery. Full recovery function in your hand may take 9 to 12 months after consistent rehabilitation.
Other forms of treatment
Biologic Injections (Emerging Treatments):
These are still relatively new for scaphoid fractures and are mostly used for delayed unions or non-unions, often in conjunction with surgery. They aim to deliver growth factors or cells directly to the fracture site to enhance healing.
Platelet-Rich Plasma (PRP):
Prepared from the patient’s own blood, PRP contains a concentrated amount of platelets that release growth factors important for healing. It can be injected directly into the fracture site.
Bone Marrow Aspirate Concentrate (BMAC):
This involves aspirating bone marrow, usually from the patient’s hip, and concentrating the mesenchymal stem cells and growth factors. This concentrate is then injected into the fracture site. These stem cells have the potential to differentiate into bone-forming cells.
Stem Cell Therapy:
Involves isolating specific stem cells (e.g., mesenchymal stem cells) and implanting them at the fracture site to promote regeneration. This is still largely experimental for scaphoid fractures.
Is surgery an option?
When a scaphoid fracture fails to heal after 3-6 months of conservative management, surgery is the recommended to fixate the bones together and stabilize the site. Surgery is also recommended when a fracture moves out of alignment by 1mm or more. This is because the disruption in alignment of the 2 broken fragments have a higher chance of healing in a poor position or, not at all. Surgery is also recommended to reduce the risk of bone death occurrence.
