Scaphoid fractures

There are 8 bones in the wrist arranged in two rows sitting on top of each other. Then scaphoid bone is on the thumb side of the hand on the bottom row (also called proximal row). It is typically fractured (broken in two) in young men as a result of trauma such as falling on an outstretched hand. The scaphoid has a delicate blood supply and depending on the site of the fracture within the bone, blood supply can be disrupted and prevent the bone healing. In those cases when it doesn’t heal surgery is recommended in order to maximise the chance of it healing. If the scaphoid doesn’t heal, arthritis of the wrist is very likely to occur at some point in the patient’s future.

Symptoms

Patients present with a painful and swollen wrist.  The grip is weakened grip and movement reduced.

Diagnosis

History and clinical examination will be supplemented by x-rays and other imaging. An MRI or CT scan is often required. In older injuries a CT scan is useful to check the condition of the bone. Sometimes an arthroscopy is helpful if a ligament injury is suspected.

Treatment

Some fractures of the scaphoid can be treated in plaster cast for anything from 6 to 12 weeks if the bone fragments have not moved very much i.e. they are not displaced. These have a high chance of healing naturally. The surgeon will closely monitor the healing by regular follow-up and repeat x-rays and often a scan. Scaphoid fractures that do not heal by using a plaster, or in the initial assessment are deemed unsuitable for treatment with plaster (because the bone fragments are displaced) will need operative fixation.

Surgery

In most (85%) of cases the scaphoid bone will heal if the wrist is properly immobilised in a plaster cast for several weeks. In those cases when the scaphoid has failed to heal or the fracture configuration is such that it has a high risk of not healing, surgery is indicated. Scaphoid fracture fixation can be performed under regional or general anaesthesia as a day case procedure. The operation involves making a small cut on the back or front of the wrist  (depending on the fracture pattern) and insertion of a special screw. After surgery the wrist is immobilised in a plaster cast for six weeks followed by six weeks in a soft removable splint.   Hand therapists will supervise the recovery of motion and strength. Regular check x-rays  will be needed to check for adequate healing. Return to work and driving may vary between individual patients but as a rule heavy manual work is only allowed once the bone is fully healed which in most cases takes at least three months.

Complications

The complications of surgery are infection, stiffness, nerve damage and failure of the scaphoid to heal. Temporary or permanent reduction in range of motion is likely because of the injury and prolonged period of immobilisation.


Tenosynovitis

This is a painful condition affecting the tendons at several spots around the wrist. It results from an irritation of the lining of the tendons but no one is really sure how or why this happens. It is associated with repetitive usage of the hand and wrist such as when mothers are continuously lifting their new born baby, or from racket sports.

Symptoms

The main symptom is pain provoked by certain movements or when lifting heavy objects. Often there is a tender swelling.

Diagnosis

Careful history and examination with provocative tests gives the diagnosis. Occasionally imaging (MRI) is required.

Treatment

In mild cases simple analgesia, activity modification and splints can help. Hand therapy can be very useful.  Injection of steroids in the affected area provides pain relief and is often curative. However, a significant minority of patients need an operation.

Surgery

The surgery can be performed under local or general anaesthesia as a day case. Through a small incision the tendon thickening is released. The hand is dressed with a bulky bandage, which is then replaced with a small sticky plaster. Light duties and driving can commence at one week, light manual labour four weeks and heavy manual labour six weeks after the operation.

Complications

Complications are rare but include wound infection, recurrence and very rarely nerve damage.


Wrist pain

Wrist pain is a common problem that can affect patients of all ages. Every structure that makes up the wrist namely bones, nerves, cartilage, ligaments and tendons . can be a source of pain. It can be either due to variation from normal anatomy that the patient is born with, or due to a disease process such as arthritis. In young patients traumatic and sporting injuries are a common cause of wrist pain.

Symptoms

Pain especially on movement, swelling, tingling and weak grip can present as part of wrist pain. Patient may recall an injury or show early signs of conditions such arthritis.

Diagnosis

Majority of wrist pain causes can be diagnosed by taking a careful history and examination of the patient. Imaging such as X-rays, Ultrasound, CT scan, Bone scan and MRI may be necessary to aid diagnosis. In some patients direct visualisation of the wrist joint with the use of a special camera (“key hole surgery” – arthroscopy) may be required to confirm a diagnosis.

Treatment

In self-limiting sprains/strains simple analgesia, rest, ice, compression and elevation is all that might be needed. Recovery can take weeks to months. Some patients will benefit from strengthening exercises and splints under the guidance of a hand therapist. The vast majority of patients with wrist pain can be treated non-operatively including steroid injections but a minority need surgery. Operations including removing certain bones, fusing other bones, reconstructing ligaments and dividing the nerves that transmit.

Surgery

Wrist arthroscopy can be performed under regional or general anaesthesia as a day case procedure. Up to five small incisions are made at the back of the wrist to allow the insertion of the camera and other instruments in the joint. After arthroscopy, the hand is dressed with a bulky bandage, which is then replaced with a small sticky plaster over the small incisions after 48 hours. Normal activity can normally resume after one week.

Complications

Wound infection, nerve damage, tendon damage, swelling and stiffness can occur after arthroscopy.