Fixation of Scaphoid Fracture

Definition

Treatment of scaphoid fractures is guided by the fracture location (proximal, waist, distal), displacement (instability) of the fracture and patient tolerance for cast immobilisation. During scaphoid fixation, metal implants such as screws and wires are used to hold the fragmented bones in place until the bone is fully healed.

When your doctor makes a surgical incision the size is dependent on the site of the scaphoid affected. Sometimes, the screws and wires can be placed through small incision (percutaneously, 1-2mm).

In other cases, a larger incision is needed to ensure the fragments of the scaphoid are aligned properly. A bone graft is occasionally required when the fragmented bones are more than 2 pieces, to stimulate bone healing. This graft can be taken from the forearm bone of the same arm, or hip.

Who is this operation for? 

Indications for surgery:

  • Unstable scaphoid seen on x-ray or CT scan. This will impact the potential for healing with non-operative treatment.
  • Displacement between 2 fractured bones >1mm.
  • Angle between the wrist bone and lunate bone (radiolunate) is >15 degrees.
  • Angle between the scaphoid and lunate bone (scapholunate) is >60 degrees.

What are the benefits of the operation?

If percutaneous (small incision) fixation is used, this will reduce the likelihood of disruption of the surrounding soft tissue and blood supply around the scaphoid, allowing it to heal better and quicker than the traditional open incision.

Risks of not having the surgery

If unstable scaphoid is treated non-surgically (cast), then there’s increased risk of delayed union, malunion, non-union, cast-induced joint stiffness and lost time from employment and avocations.

Complications

The risks and complications of a Fixation of Scaphoid Fractures:

General complications:

  • Bleeding
  • Infection
  • Pain

Specific complications:

  • Nonunion
  • Malunion
  • Scaphoid shortening or subsidence due to secondary screw penetration
  • Neurovascular injury (cutaneous nerve, radial artery)
  • Incorrect placement of fixation screw
  • Failure to recognize concomitant injuries

Before the operation

Preadmission Clinic | Preparing for Surgery

Before your operation, you will be seen at the preadmission clinic to make sure you are fit for the operation and all the necessary tests are performed in preparation for the operation.

During the visit, you will be seen by a

  • Doctor
  • Nurse
  • Anaesthetist (if necessary)

Tests

Tests that may be ordered for you include:

  • blood tests
  • Xray wrist
  • Urine Test
  • ECG

Preparing Your Skin

Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for a program to improve your skin before surgery.

Medications

Our doctors will advise you which medications you should stop or can continue taking before surgery.

Tip

Carry a list of your medications with you including the name, dosage and how often you take it.

About the Operation

Incision and exposure: Skin incision is made over the scaphoid tubercle and curved into the thenar base. Scaphoid is then approached through few longitudinal incisions on the wrist. 

Debridement: Your doctor may use curettes or high-speed burr to debride the non-union site of fibrous tissue. 

Reduction: Dental picks or K-wires is then inserted to align the fragmented bones into reduction. Double-checking guidewire position is done with multiple radiographic views. 

Fixation: The K-wires serve as a guide for the screws (cannulated screw or Herbert screw). 

Wound closure: The surgical incisions are closed with stitches.

After the Operation

After the surgery, the incisions are closed with stitches and a dressing is applied. You are required to wear a cast or splint while the fracture heals. 

The duration for the cast or splint will vary depending on what the underlying scaphoid pathology was. 

Elevation of the wrist is essential to prevent excessive pain and swelling from occurring.

Recovery and Rehabilitation 

Every scaphoid fracture is different. Following surgery, if the fracture was treated early (within 4 weeks) and it was a waist fracture (stable) you’ll usually only be immobilised for a few days after surgery, and then will be placed in a removable splint. 

Proximal pole fractures are less stable, and are often casted for 6 weeks, sometimes longer. Your doctor may refer you for a physiotherapy course if necessary. 

Here are few steps to help you care for your wrist after surgery:

  • Wear your bandage or splint as directed by your doctor. Keep the dressing clean and dry.
  • Shower as necessary. Cover your wrist with plastic to keep the dressing dry.
  • Keep your hand raised above the level of your heart for first 2-3 days after surgery. This reduces swelling. 
  • Avoid gripping objects tightly or lifting with your affected arm
  • Do the exercise taught to you in hospital
  • If your job requires heavy lifting, you may not be able to return for several weeks
  • Do not participate in contact sports, climb ladders or trees
  • Take pain medication as required

F.A.Q.s | Frequently Asked Questions

What are the alternative treatments to having a Fixation of Scaphoid Fractures?

Short arm thumb spica cast / long arm thumb spica cast (closed treatment)

Are there important things I need to tell my doctors?

  • Fever and chills
  • Fingers that are pale and blue
  • Increased tenderness, swelling and redness of the incision
  • Inability to move fingers or hands
  • Any drainage from the incision
  • Severe pain with or without activity