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Scaphoid fracture, a few questions (Page 1)

Hello,
I broke my left scaphoid 2 months ago.
I immediately went to a hospital due to an acute pain, they x rayed my hand and casted it for 10 days.
After those 10 days I was x rayed again without the cast, the doctor said there is undisplaced fracture in scaphoid waist.
I was casted once again and 5 weeks later they x rayed my hand again without the cast.
What the doctor saw was strange, he saw that the waist fracture was almost fully healed but there was another fracture, in the proximal part.
He casted me again for another 4 weeks.
Currently, I got 10 days left until my next visit, which means I've been in a cast for 8 weeks!
The cast now is WITHOUT the thumb(the doctor said he wants me to move my thumb a lot).

The problem is that even now, in the cast I am having pain near the snuffbox when I am doing some things, my grip got strong almost like before the fracture but the pain concerns me.
I am asking for your advise or your stories about that damn scaphoid fracture.
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First Helper User Profile Gaelic
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replied November 3rd, 2011
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JohnGal.

Unfortunately, scaphoid fractures can be very difficult to treat. Even when caught early and treated properly, they still sometimes go on to nonunions, avascular necrosis (AVN) of the proximal pole, and in the long term a SNAC wrist (scaphoid nonunion advanced collapse).

Scaphoid fractures are troublesome because of the scaphoid's blood supply. Since most of the bone is covered with articular cartilage and is contained within the joints of the wrist, there is little area left for soft tissues attachments and for blood vessels to penetrate the cortex of the bone. The blood vessel to the scaphoid enters at the distal pole, and the vessels then travel back down the scaphoid to the proximal pole. So, any fracture around the waist disrupts the blood supply to the proximal pole. This is why many scaphoid fractures go on to AVN of the proximal pole.

It used to be very common to treat scaphoid fractures in long arm thumb spica casts for 6 to 8 weeks, followed by a short arm thumb spica cast for another 6 to 8 weeks (or until the fracture healed). So, is was not uncommon to see patients in casts for 3 to 5 months for scaphoid fractures.

Then, it was found that if the fracture was not healing properly within 3 months or so, then, it was time to bite the bullet and operate on the bone. But, surgery had its own set of problems, as most patients who were operated on, never regained full range of motion. They had functional ranges of motion, but usually lost motion at the extremes of flexion and extension.


Currently, in the US, except for the occult or truly totally nondisplaced fractures, most scaphoid fractures are now percutaneously pinned. This is a misnomer, because a screw is used, rather than the smooth K-wires. This has been found to allow the patient to return to work a lot faster and decreases the need for external immobilization.

But, this is not to say that all hand surgeons feel that most scaphoid fractures need to be operated on, by any means. There really is no consensus on the best way to treat nondisplaced fractures.


As to you having pain in the anatomical snuffbox (the location of the scaphoid waist on the radial side of the wrist), this is not a real good sign. Continued pain in this location, with motion of the thumb, could be signaling that there is motion at the fracture site. If the pain is a sharp, intense one you should contact your surgeon and advise him of this. If it is more of a dull, aching, work-out type pain, it may just be the soft tissues around the joint stretching out.

The other fracture in the proximal pole may be signaling that you are developing AVN. If the proximal pole collapses, then you are looking at a surgery most likely. Some times, if the proximal pole does develop AVN, but does not collapse, it is possible for the body to revascularize the pole, but it takes a long time.

Usually, if there are signs of AVN of the proximal pole, the surgeon will obtain a CT scan and on MRI. The CT scan looks at the architecture of the bone and if there is bridging callus across the fracture site. The MRI looks at the cancellous (inside, spongy type) bone and to see if AVN is developing.


Hope your fracture goes on to uneventful healing. The rehab of the arm after it comes out of the cast will still take quite a while longer though. Good luck.
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replied May 31st, 2013
i recently broke my right scaphoid bone and the ER also splinted mine twice, i went to the doctor and he said it was an undisplaced fracture and i have been in a cast for 2 months and i have to undergo surgery because it wont heal properly
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replied November 3rd, 2011
Dear Gaelic,
First of all I would like to thank you for the information and for your response.

The strange thing is that the last time I was x rayed(7 weeks after being casted) the doctor did physical checks on my hand.

When he pressed at the scaphoid bone I felt no pain, he pressed in a few spots with both of his hands and I didnt feel any pain.
When he tilted my hand the pain was unbelievable(in the snuffbox or near it).
The doctor didn't explained too much when I asked him what does this pain mean.

About how the pain right now, well its not sharp but its definitly similar to the pain I had in the first days.

I am trying to move my thumb the least I can although the doctor told me to move it.

One more thing, I asked the doctor if he sees any healing signs of the x ray, he answered "I think so".

The doctor is a hand specialist.
Will it help if I upload the last x ray?

Thank you alot and I am really sorry for all the questions, I'm just kind of confused and dont really know what else to do.
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replied November 3rd, 2011
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John,

The initial pain could have just been from the generalized radiocarpal joint, which has been immobilized for a while. Stiff joints hurt a lot when first moved.

Since you are seeing a hand surgeon, he/she should know how to examine for tenderness specifically over the scaphoid. The proximal pole can be palpated from the dorsal (back) aspect of the wrist, the waist from the anatomical snuffbox, and the distal pole can be palpated from the volar (palmar) wrist.

It is often very difficult to tell if a scaphoid fracture is healing from an x-ray. Usually, if there is a question, a CT scan and/or an MRI is obtained. Bone scanning, at this point, would not give you very much good information.


Most likely, at this point, your moving the thumb will not cause any problems with this scaphoid. Several years ago, there was a bunch of research done an what type of cast was they best for immobilizing a scaphoid fracture. Some researchers showed that to get the least movement of the scaphoid, one would have to be in a long arm, thumb spica, three fingered cast. This cast included the thumb, index, and middle finger. Talk about being tied up. This was great for the research lab, but in the real world, it was hard to show any real difference between that cast and a regular short arm cast.

So, now days, where displaced fractures are almost always operated on, long arm thumb spica casts are almost never used anymore. Thumb spicas are used instead of just a regular short arm cast, mostly for comfort of the patient, as moving the thumb usually hurts.


So, the discomfort you are feeling may just be the soft tissues and scar tissues around the joint starting to stretch out. You do not need to go whole hog on your motion, but you might want to do some range of motion.

Then you are just going to have to wait to see what happens in the next week or so. Hopefully, when you get the cast off in 10 days, the fracture will be united. If so, they the hard part starts, doing the rehab to get your motion back.

If not, then some decisions have to be made. Do you continue trying to get the thing to heal, or do you go ahead on operate on it. If you operate on it, do you try a percutaneous pinning, an open fixation, and do you need a bone graft. This is all something you will need to discuss with your hand surgeon.

Good luck. Hope your fracture heals.
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replied November 4th, 2011
Gaelic,

Thank you very much for the useful information.
The bright side about this fracture is that I gained so much information.

I will update this topic 9 days from today, hopefully it will be healed.

Last thing, I've added the last x ray:

http://i43.[image removed]/mjx2k0.jpg

Once again, I sincerely thank you.
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replied November 4th, 2011
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John,

Though there is some sclerosis around the fracture site, on this set of x-rays, the proximal pole looks like it is still viable.

When AVN sets in, the bone often become very dense, appearing like ivory on the x-ray.

But, one can still be fooled. Sometimes, a bone which looks viable on x-ray, has absolutely no punctate bleeding at surgery, and also just the opposite, some bones which you would bet money on not having any blood supply, bleed like crazy at the time of surgery.

Looking forward to your future post. Hang in there, keep working on finger motion.
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replied November 4th, 2011
Dear Gaelic,

Do you see the other fracture? that the doctor said it was almost fully healed?

When I look at the x rays, I see a small thin like an hair line, thats the fracture?

I apologise for asking so many questions, I just can't believe that I'm 20 years old and my body can't heal itself.
I got the fracture from a fall, a really idiotic fall that I could have avoided from it.

Anyway, thanks.
Will update.
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replied November 4th, 2011
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John,

I see a vertical line through the proximal pole of the scaphoid, but that really looks like an overlap shadow with the posterior edge of the lunate. If you look at the lunate, your first impression is that of a blunted triangle. But, it also has depth and there is another edge of it just to the right of the first edge you notice. And that is just about where that vertical line appears.

And I only see the line on the AP view, it is not there on the oblique. Usually, if you don't see a fracture on two different views, you have to question if it is really there. You only put up two views of the wrist, the lateral was not included. If there was a fracture in the proximal pole, it should be on the lateral view also.

This is another reason to get a CT and/or MRI, so you can make sure if that is a fracture or not.


Hey, scaphoid fractures are most commonly seen in young adult males. The young and old, tend to break the distal radius instead. It is actually a fairly common fracture. And in the vast majority of cases, it heals. But, because of the blood supply, it can sometimes take a while.

Unfortunately, our society now is very impatient and expects everything to occur at the rate of high speed internet, and sometimes, bones take their sweet old time.

Hopefully, when you get the cast off next time, the fracture will be well on its way to uniting and you will be able to get on with rehab.

Good luck.
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replied November 13th, 2011
Dear Gaelic,

I've just came back from the doctor.
Well..not great news at all.
He told me that he sees a process of healing, personally, I don't know.

I am again in a cast(without the thumb again), for another month!
That would be 3 and a half months with cast.

I am really hopeless, I've added the new X-rays.
I see the fracture, if I am not mistaken it's in the waist, don't really see any signs of "healing process".

http://i39.[image removed]/20rlmrn.jpg

http://i39.[image removed]/2e1w403.jpg
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replied November 13th, 2011
Dear Gaelic,

Don't know but its not showing my posts so I'll try again.

I've been to the doctor today.
Not good news at all, he told me to cast myself for another month(again without the thumb).
Together it will be 3 and a half months.

He said he sees a process of healing, personally, I don't.
I am really hopeless now, waiting to hear your opinion.
I've added the new X-rays, I see the fracture(if i'm not mistaken its in the waist) but I don't really see any "healing process", hope you will see.

2 views of the x-ray:
http://i39.[image removed]/20rlmrn.jpg

another 2:
http://i39.[image removed]/2e1w403.jpg


By the way, the cast is really loose, I can move the wrist inside it.
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replied November 13th, 2011
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John,

I answered your private message. The reason these posts are not showing up immediately, is that you have an outside link in them. The Forum always reviews these before allowing them to be posted. So, they will probably show up in a couple of days or so.

Look at your private messages for my reply.
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replied November 21st, 2011
Gaelic,

In the past days I've been feeling strange sharp stabs in the fracture location.

The "sharp stabs" last for 10 -30 seconds.
Does it mean anything?

I am feeling like I got no power in my left hand, thats because of the long immobilization(almost 3 months)?
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replied November 21st, 2011
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John,

Good to hear from you.

Prolonged immobilization can cause significant atrophy. So, you are going to be very weak, until you can rebuild the strength in the muscles.

It is not uncommon to have pain around the area of the fracture when you start doing a lot of motion. But, if the pain becomes persistent or gets worse, you should back off and contact your surgeon. If it just stays occasional twings, you might be able to work through it. Again, though, if it really bothers you, let your surgeon know before you stress it a lot.


Has your surgeon taken you out of the cast totally now, or are you still in a short arm cast? If you are still in a cast, that will also decrease your strength, because the wrist is not is the best biomechanical position. But, most of your loss of strength is due to the atrophy from the prolonged immobilization.

Hope you do well and your fracture heals shortly, so you can get on with life.

Good luck.
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replied November 22nd, 2011
Gaelic,

Thanks again.
Currently, I am still with the cast, 20 days left until the next check up.

The pain lasts for a few seconds and it feels like a stab, not something that really hurts that much.

I was thinking, maybe its a sign of healing?
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replied November 24th, 2011
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John,

It could be from that, basically the scar tissue giving when stretched. As long as the discomfort does not persist after a couple of seconds it is probably okay. You are going to have some pain in the area. Wait till you get the cast off. Your wrist is going to be really stiff and sore for a while.

Even if your surgeon doesn't give you one, most patients coming out of a cast after as many months as you have been in one, need a small wrist splint. A splint is really helpful in the first couple of weeks. It provides some support during activities, but allows you to do the necessary rehabilitation. And you do not sound like a guy who is going to become dependent upon a splint (the surgeons worry about this).

Hope everything goes well for you. Good luck.
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replied November 24th, 2011
Okay.

The doctor did told me to purchase a splint that will support my wrist after the cast.

However, I prefer not to, I don't mind the pain if it means that the hand will recover faster.

Another thing, I asked about physiotherapy, the doctor said that its not necessary.
Sounds strange to me, what's your opinion about physiotherapy after scaphoid fracture?
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replied November 25th, 2011
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John,

Usually, the patients I would send to occupational therapy (hand therapy) are the ones I thought would be timid and would not move the wrist on their own. Most of the time, OT is not needed by most patients. In some highly technical rehab programs, like tendon laceration recovery, supervised therapy is mandatory. But, most patients find the activities done in formal therapy boring and meaningless. They feel they can do the same thing on their own, and do more.

However, you might want to see the therapist once, just to get an idea of things to work on. But, it sounds like you are well motivated and intelligent enough to know what to do and what not to do. Some knuckle-heads have to be slowed down and some little 'ole ladies have to be prompted that is now okay to move.

So, if when you get the cast off it seems that you need some guidance, ask the surgeon for a consultation with a therapist. That way you can get the correct activities to do on your own.


Good luck. Hope you do well in the future.
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replied December 11th, 2011
Gaelic,

Hello it's been almost 3 weeks and in a couple days I'm going to the check up.

Total time I'm casted is almost 3 and a half months.
Unfortunately, I still feel pain inside the cast at the fracture position.
When I tilt my hand to the left or to the right inside the cast and the cast presses a bit on the snuffbox I feel pain in that exact location.
Does it mean that the fracture is still unhealed?
I will update you with the new x-rays and the doctor's opinion in a couple days.

Again, thanks alot Gaelic.
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replied December 11th, 2011
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John,

You will have to wait to see what the x-rays show. The pain may just be from the soft tissues.

Hope the scaphoid is healed and you can start the long soft tissue rehabilitation.

Good luck.
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