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What is a scaphoid fracture?

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University of Louisville star center Gorgui Dieng was diagnosed with a scaphoid fracture in his left wrist tonight.  He injured the wrist while breaking his fall after taking a charge in the Missouri game over the weekend.  Many people may be unfamiliar with this type of fracture so I wanted to share some information about it.

The scaphoid, also known as the carpal navicular, is one of the small carpal bones of the wrist.  It is located near the base of the thumb, and it is the most commonly fractured carpal bone.   It occurs frequently in sports when an athlete lands on an outstretched wrist.   Fractures of the scaphoid do not cause a visible deformity of the wrist, and they can commonly be misdiagnosed as a wrist sprain.  Since pure wrist sprains are not very common, it is important to get wrist X-rays of suspected sprains to rule out a fracture of the scaphoid.  If pain persists even with normal X-rays, other imaging studies such as CT scans or MRI may be ordered to avoid missing a diagnosis of scaphoid fracture.

A fracture of the scaphoid causes pain in the wrist, near the base of the thumb.  This area can be readily seen when the hand is placed in the “hitchhiker’s” position – a clenched fist with an extended thumb.  The depression formed by the two visible tendons at the base of the thumb in this position is the approximate position of the scaphoid.  If the scaphoid is fractured, this area will be tender to the touch.

Fractures of the scaphoid can be very serious because the blood supply to this bone comes primarily from one small artery and it occurs in a retrograde, or backwards, fashion.  The artery enters the bone near the base of the thumb, so when it is fractured the blood supply to the area of the bone near the wrist may be compromised.  This can lead to a painful condition called avascular necrosis in which the bone dies, leading to arthritis of the entire wrist joint.  The blood supply also affects how quickly fractures in this bone heal.  Fractures near the thumb heal well, fractures in the middle (called the waist) heal less well, and fractures near the wrist (proximal scaphoid) have the lowest healing rates.  A fracture that doesn’t heal leads to a painful condition called a non-union.

Treatment of scaphoid fractures depends on the type of fracture and the activity level of the patient.  Non-displaced fractures, where the two fragments did not move away from each other, can usually be treated in a cast.  The closer the fracture line is to the thumb, the higher the rates of healing.  The cast will usually include the thumb, and often will be below the elbow but occasionally will extend above the elbow.  Some scaphoid fractures will require up to 3 months in a cast to heal.

Displaced fractures need surgical fixation, usually performed by placing a special compression screw inside the bone.  Some proximal (near the wrist) fractures may need surgery even if they are non-displaced.  High-level athletes may benefit from surgical fixation of a scaphoid fracture, even if non-displaced.  Studies have shown that properly performed surgical fixation can lead to a faster return to sport, especially if the athlete can play in a padded cast.  Some complex fractures of the scaphoid or treatment of non-unions of the scaphoid may require bone grafting in addition to fixation with a screw.

The important thing to remember about scaphoid fractures is that if you injure your wrist and the pain does not improve quickly, make sure that you see an orthopaedic surgeon and get a wrist X-ray.  If the initial X-rays are negative and the pain still doesn’t improve, make sure that you let your orthopaedist know.  A missed scaphoid fracture can lead to severe long-term disability of the wrist that could easily be avoided with proper initial treatment.

What does this mean for Dieng?  I have no knowledge of the location of the fracture or the severity, so it is hard for me to speculate.  My guess is that even if he has surgery and everything goes well, he will be out of action for 8 weeks.  It’s a blow to the team for sure.

Update:  A review of the sports medicine studies shows two studies about scaphoid fractures in athletes, both from Dr. Art Rettig in Indianapolis.  In the first study from 1994, the return to play for surgically repaired scaphoids was 8.0 weeks.  In the second study from 1996, the return to play was 5.8 weeks for the surgical group.  Athletes in the non-surgical group returned to play faster because they played sports that allowed play in a cast, but they took a few weeks longer for the fracture to show signs of healing on X-ray than the surgically repaired group.

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Discussion

  1. James  November 25, 2012

    Thanks for taking the time to write this. I know that you are totally speculating, but if your guess turned out to be correct and he missed 6-8 weeks, would that imply that his break is the variety that is located higher up near the thumb?

    • Dr. Samuel Carter  November 25, 2012

      If it is near the thumb, he may not even need surgery, but it will still probably take at least 6 weeks to heal. If it’s lower, nearer the wrist, surgery has been shown to speed return to play. I think 6-8 weeks is a best-case scenario.