A Patient’s Guide to Scaphoid (Navicular) Fracture with Animated Surgical Video

Introduction

The scaphoid (navicular) is one of the proximal carpal bones and may be injured in a fall.  These fractures are often associated with tenderness on the top of the wrist.  These injuries often masquerade as wrist sprains—and initial radiographs may not reveal the fracture.

Treatment of these fractures spans from nonoperative treatment in a cast or brace to surgical management.  The scaphoid has a particularly poor blood supply and gaining healing of this bone can be difficult—complications with treatment and healing are common.

Anatomy

The ligaments of the wrist are external to the wrist and internal to the wrist.  The wrist is made up of eight carpal bones connecting the forearm to the hand.

The eight bones of the right wrist (carpus) viewed from the front.

These bones are interconnected with a series of ligaments.  Since these ligaments are inside the wrist—they are called intrinsic ligaments.

The intrinsic ligaments of the wrist from the top right A and bottom B.  The most important intrinsic ligaments are the SL (scapholunate) and LT (lunotriquetral)

The next layer of ligaments lying more superficial than the intrinsic ligaments are the extrinsic ligaments.  These ligaments are not as dense or as strong as the intrinsic ligaments.

The extrinsic ligaments, note these ligaments may span 2 or more joints.

Diagnosis

Symptoms

Patients with a scaphoid fracture typically complain of pain, bruising, and swelling.  Typically the injury occurs after a traumatic event—like a fall.  These symptoms are typically worse with gripping and wrist motion.

Hand Surgeon Examination

After taking note of the symptoms, the surgeon inquiries regarding any pertinent family or medical history.  A physical exam centers on the injured limb.  Although unlikely, injuries to the adjacent shoulder and elbow are determined via checking for pain and motion.

An examination of the sensation to the hand is performed.  Sometimes patients with scaphoid fractures may have injured the nerves associated with the hand.  The most common nerve injured is the median nerve, resulting in numbness in the radial three digits of the hand.

The blood flow to the digits is checked.  Swelling from the sprains may cause compression of vascular structures leading to changes in blood supply to the hand.  Any deformity of the hand or wrist is also noted.

Tenderness to palpation is typically elicited over the base of the thumb—often called the anatomic snuff box.

Imaging

X-rays of the wrist are obtained and if there is suspicion of injury to the hand, elbow or shoulder these may be obtained as well.   Although x-rays do not image soft tissues, such as ligaments, they are the first line evaluation in looking for fractures of the limb.  X-rays help delineate the type of fracture, displacement and if the fracture extends within a joint.  Typically routine x-rays are sufficient, although they may be taken from many angles.

As noted above, initial radiographs for scaphoid fractures may be negative.  These films may be repeated in two weeks to assure there is not an occult scaphoid fracture. At times, enhanced imaging including CT scans or MRI is a helpful adjuvant.  Both of these imaging studies will show fractures earlier—if there is no displacement versus plain radiographs.

MRI imaging can be helpful as it can image soft tissues and detect tears of both intrinsic and extrinsic ligaments.  MRI can also uncover occult fractures of wrist bones—particularly the scaphoid.  MRI examination may also be helpful in determining blood flow to the scaphoid—an important consideration in fracture healing.

A right wrist frontal image showing a fracture of the scaphoid (yellow circle) The fracture is not displaced

A radiograph of a left wrist from the front which shows a displaced scaphoid fracture (red arrow).

A frontal image of a CT scan showing a nondisplaced scaphoid fracture (white arrow).

Treatment

Scaphoid fractures are classified according to the severity of displacement–or how far the pieces of bone have moved out of their normal position:

• Non-displaced fracture.In this type of fracture, the bone fragments line up correctly.
• Displaced fracture. In this type of fracture, the bone fragments have moved out of their normal position. There may be gaps between the pieces of bone or fragments may overlap each other.

Nonoperative

Fracture near the thumb. Scaphoid fractures that are closer to the thumb (distal pole) usually heal in a matter of weeks with proper protection and restricted activity. This part of the scaphoid bone has a good blood supply, which is necessary for healing.

For this type of fracture, your doctor may place your forearm and hand in a cast or a splint. The cast or splint will usually be below the elbow and include your thumb.

A thumb spica cast—typically utilized for distal scaphoid fractures which are not displaced.

Healing time varies from patient to patient. Your doctor will monitor your healing with periodic x-rays or other imaging studies.

Therapy for wrist and hand is common after these injuries even without surgical treatment and may require the utilization of a hand therapist.

Operative

If your scaphoid is broken at the waist or proximal pole or if pieces of bone are displaced, your doctor may recommend surgery. The goal of surgery is to realign and stabilize the fracture, giving it a better chance to heal.

Reduction. During this procedure, your doctor will administer an anesthetic or anesthesia and manipulate the bone back into its proper position. In some cases, this is done using a limited incision and special guided instruments. In other cases, it is performed through an open incision with direct manipulation of the fracture.

Internal fixation. During this procedure, metal implants—including screws and/or wires—are used to hold the scaphoid in place until the bone is fully healed.

A right wrist fracture treated with a scaphoid headless screw

WATCH AN ANIMATION VIDEO OF TREATING SCAPHOID FRACTURES WITH
HEADLESS SCREWS

Most scaphoid fracture surgery can be completed as an outpatient surgery and the majority done under regional anesthesia.  The typical incision is on the bottom side of the wrist approximately 2 inches in length.  Some fractures may be treated percutaneously with only small “poke holes” to introduce the fixation using an x-ray camera.

For most patients, blood loss is minimal and unless there are medical indications—prophylaxis for deep vein thrombosis is not necessary.  Other risks of surgery are small and include infection, bone healing, tendon rupture, and stiffness.

Patients are placed into a splint after surgery and typically return in two weeks for suture removal.  Patients who receive regional anesthesia report less pain after surgery, but all patients should follow instructions regarding pain medications to improve their postoperative experience.

Rehabilitation

After surgery patients are instructed in elevation of the extremity and work on range of motion for the digits.  By six weeks to 8ght weeks after surgery, most patients will have pins removed and transition into bracing.  Work on range of motion for the wrist can be with the help of a hand therapist.  Strengthening of the hand, wrist, and arm are emphasized and most patients should gain improved use of their wrist and hand—especially with diligent work on motion and strength.

Outcomes

Modern fracture treatment has greatly improved the results for patients.  However, patients can still expect some degree of stiffness with any fracture care.  Return to sports after injury typically requires 4-6 months.  Patients report continuing improvement for up to one year after injury.  Complications because of the poor blood supply to the scaphoid are common.