Scaphoid fractures occur most commonly in young adults after a fall onto an outstretched hand, often during sports. Patients present with wrist pain, sometimes with swelling, and often with tenderness in the ‘anatomical snuff-box’.
The treatment of this injury presents a number of challenges:
Undisplaced fractures of the scaphoid wrist or distal pole are generally treated with cast immobilisation for a period of six to twelve weeks, depending on the progress of healing of the fracture. Usually, six to eight weeks is sufficient.
The indications for surgical fixation of isolated scaphoid fractures are:
A relative indication for surgical fixation is an active patient who does not wish to have their wrist immobilised in a below-elbow cast for between six and twelve weeks.
Percutaneous screw fixation (i.e. using only a small incision of approximately 5mm in length, rather than the conventional open technique) can be used in the majority of these situations, and the patient’s wrist is only immobilised in a cast for one to two weeks after surgery. After this time, a removable splint is worn which allows an early range of motion exercises, and unprotected use of the wrist for low-demand daily activities (e.g. washing, dressing, writing).
Percutaneous screw fixation also has a role in the treatment of selected patients with delayed or non-union of the scaphoid — although this is not always possible because of bone resorption at the fracture site and the consequent need for bone grafting, or because of significant displacement. Pre-operative CT scans are invaluable for surgical decision-making in this context.
Percutaneous screw fixation of the scaphoid — technical aspects:
It is unusual to need the screw to be removed in the medium to long-term.
A 22-year-old Masters student was pushed over during a game of five-a-side football and landed on his outstretched dominant left hand. His wrist gradually became more painful over the evening, so the following day he saw his GP who suspected be May have a scaphoid fracture. Radiographs were carried out which confirmed the diagnosis of an undisplaced scaphoid waist fracture, and he was referred to Mr Gidwani.
After a discussion of the pros and cons of cast treatment versus percutaneous fixation, the patient elected to be treated in a cast. He returned to the clinic within a week, however, having changed his mind – he was frustrated by the cast, and by the difficulties he experienced while trying to write and take notes during lectures.
A few days later, a percutaneous fixation was carried out. He was kept in a cast for two weeks, before being transferred into a removable splint. A CT scan carried out at 12 weeks postoperatively confirmed complete union of the fracture and at that stage, all restrictions were lifted on the use of the wrist for sports and leisure activities.
At four months post-op, he has recovered a full range of motion, is back to skiing and playing football, and hopes to be back on the basketball court soon.
This article was written by Mr Sam Gidwani. Find out more about his speciality as a hand and wrist surgeon here.
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