Description
The scaphoid is one of the small bones in the wrist (carpal bones), and the one that is most likely to break. The scaphoid is located on the thumb side of the wrist, in the area where the wrist bends (see Figure 1).When you hold your thumb in a “hitch hiking” position, the scaphoid is at the base of the depression made by your thumb tendons. Pain or tenderness in this area can be a sign that the scaphoid is injured (see Figure 2).

A fracture of the scaphoid usually happens when you fall on an outstretched hand, with your weight landing on the palm. The end of the forearm bone (radius) may also break in this type of fall, depending on the position of the hand when you land. Pain and swelling in the wrist will usually cause a person with a scaphoid fracture to see a doctor. If the wrist is not deformed, however, you might not know that you have a broken bone–people sometimes think they have just sprained the wrist.

It is important to see your doctor if you have pain on the thumb side of the wrist that starts after a fall or accident and does not go away within a few days. The doctor will probably order X-rays to look at the bone.

Sometimes, a broken scaphoid does not show up on an X-ray right away. When this is the case, the doctor may put your wrist in a splint and wait to take a new X-ray in a week or two, when the fracture may become visible. Keep the splint on and do not do any heavy lifting during the waiting time.

Your doctor might also recommend an MRI (magnetic resonance image) to see the bones and soft tissues. An MRI can sometimes show a fracture of the scaphoid before it can be seen on an X-ray.

Risk Factors/Prevention
Fractures of the scaphoid occur in people of all ages, including children. The injury often happens during sports activities or a motor vehicle accident. Men aged 20 to 30 years are most often affected.

There are no specific risks or diseases that increase the chance of having a scaphoid fracture. Some studies have shown that use of wrist guards during activities like inline skating and snowboarding can decrease the chance of breaking a bone around the wrist.

Symptoms
Scaphoid fractures usually cause pain in the base of the thumb, with swelling in the same area. You may have severe pain when you move your thumb or wrist or grip anything. Other times, the pain is not so bad, and you may mistakenly think that you just sprained your wrist.

Treatment Options
Treatment of scaphoid fractures depends on the location of the break in the bone. Sometimes, the scaphoid is broken at the end near the thumb. This part of the bone has a good blood supply. Scaphoid fractures in this location usually heal in a matter of weeks with proper protection. The time frame to healing is best determined by X-rays or other imaging studies such as a CT scan, which confirm that the bone has healed. Most fractures here heal well when they are placed in a cast. The cast will usually be below the elbow. It may or may not include the thumb.

More commonly, the scaphoid is broken in the middle (waist) or at the part closer to the forearm (proximal pole). This part of the scaphoid does not have a very good blood supply, so it is more difficult to heal. If your orthopaedist recommends that your scaphoid fracture be treated in a cast, it will probably include the thumb. Sometimes the cast will extend to above your elbow and may also include your index finger.

Treatment Options: Surgical
Often, when the scaphoid is broken at the waist or proximal pole, an orthopaedist will recommend surgery using a screw or wire to stabilize the scaphoid from the inside while the bone heals (see Figure 3). Depending on what part of the scaphoid is broken, the incision will be on the front or the back of the wrist (see Figure 4). Sometimes the screw or wire is placed with just a small incision.

Other times a bigger incision is needed to ensure that the pieces of the scaphoid are put back together well. Usually your wrist will be placed in a cast after the surgery, sometimes for a few months. Even with surgery, fractures in this area can take a long time to heal, and it is possible that a nonunion or avascular necrosis will occur.

If the scaphoid does not heal, either with or without initial surgery, your orthopaedist may recommend an operation to add bone graft to the scaphoid to help it heal. The surgeon may order an MRI or CT (computed tomography) scan to show more detail about position of the broken pieces of the scaphoid, to help plan the operation. Many kinds of bone graft can be used–your surgeon will discuss which one is best for you. Bone graft may be taken from a bone in the forearm or the pelvis or it may be manufactured. Sometimes a special kind of bone graft with its own blood supply (vascularized graft) may be used.

Nonunions, Avascular Necrosis and Arthritis
A bone that fails to heal is called a nonunion; this happens more often in scaphoid fractures than in fractures of many other bones. To heal properly, the bones need blood to carry oxygen and nutrients to the site of the fracture. The scaphoid bone has a poor blood supply. When the scaphoid is broken, especially when broken parts have moved apart (displaced), the blood supply may be disrupted.

Sometimes, the blood supply to one of the broken pieces is so poor that the piece does not get enough nutrients and the cells in the piece die. This is called avascular necrosis. Both nonunion and avascular necrosis of the scaphoid can lead to arthritis of the wrist.

Symptoms of arthritis in the wrist that results from scaphoid nonunion or avascular necrosis include:

• Aching in the wrist
• Decreased range of motion of the wrist
• Pain with activities such as lifting or gripping

If X-rays show arthritis in the wrist because of an old break in the scaphoid, treatment focuses on improving the symptoms of arthritis. At first, this may include taking anti-inflammatory medicine (such as ibuprofen) and wearing a splint when the wrist is painful. Sometimes the doctor may give you a steroid injection into the wrist to help to lessen wrist pain. If this does not work, the doctor may recommend surgery. Many types of operations can be performed for wrist arthritis. Your surgeon will discuss the risks and benefits of the surgery that will be most helpful to you.

Rehabilitation
You will have to wear a cast or splint while the scaphoid fracture is healing, perhaps for as long as six months. Your doctor will give you specific limitations.

Most commonly, you should:

• Avoid heavy lifting, carrying, pushing, pulling or throwing with the injured arm
• Not participate in contact sports
• Not climb ladders or trees
• Avoid activities with a risk of falling onto your hand (for example, inline skating, jumping on a trampoline.

Some people have stiffness in the wrist after scaphoid fractures; this is more common when a cast was needed for a long time and when surgery was done through a long incision. Your orthopaedist may recommend hand therapy to help regain the motion and strength in your wrist. Even with therapy, some people do not recover the same motion and strength in their wrist that they had before the injury.

Research on the Horizon/What’s New?
Some orthopaedists are placing a screw in the scaphoid through a very small incision–about one-fourth to one-half inch. This may decrease the chances of long-term stiffness in the wrist by decreasing the time that a full-time cast needs to be worn. This is done using a special X-ray machine during surgery to help guide the placement of the screw. Some surgeons use this method even when the broken pieces of the scaphoid are out of place. By looking directly at the scaphoid with a tiny camera (an arthroscope), the surgeon can tell when the broken pieces are lined up.

There is a lot of research being done about the best way to treat fractures of the scaphoid that are not healing well. Some of this research looks at different types of bone graft, including vascularized grafts. New types of manufactured bone graft with special bone cell components to increase healing are being tried to help bones that are not healing.

What is replantation?
Replantation refers to the surgical reattachment of a finger, hand, or arm that has been completely cut from a person’s body. The goal of replantation surgery is to give the patient back as much use of the injured area as possible. In some cases, replantation is not possible because the part is too damaged.

If the lost part cannot be reattached, a patient may have to use a prosthesis (a device that substitutes for a missing part of the body). In some cases, a prosthesis may give a person without hands or arms the ability to function.

Replantation is usually recommended when the replanted part will work at least as well as a prosthesis. Generally, a missing hand would not be replanted knowing that it would not work, be painful, or get in the way of everyday life. Before surgery the doctor, if possible, will explain the procedure and how much use is likely to return following replantation. The patient or family member must decide whether that amount of use justifies the long and difficult operation, time in the hospital, and months or years of rehabilitation.

How is the procedure done?
There are a number of steps in the replantation process. First, damaged tissue is carefully removed. Then bone ends are trimmed before they are rejoined. This makes putting together the soft tissue on either side of the wound easier. Arteries, veins, nerves, muscles, and tendons are sewn back together (Figure 1). Areas without skin are covered with skin that has been taken from other areas of the body. Uncovered nerves, tendons, and joints may be covered by a free-tissue transfer, where a piece of tissue is removed from another part of the body, along with its artery and veins.

What kind of recovery can I expect?
The patient has the most important role in the recovery process. Smoking causes poor circulation and may cause loss of blood flow to the replanted part. Allowing the replanted part to hang below heart level may also cause poor circulation. Younger patients have a better chance of their nerves growing back, they may regain more feeling, and may regain more movement in the replanted part.

Generally, the further down the arm the injury occurs, the better the return of use to the patient. Patients who have not injured the joint will get more movement back than those who have. A cleanly cut part usually works better after replantation than one that has been crushed or pulled off.

Recovery of use depends on regrowth of two types of nerves: sensory nerves that let you feel, and motor nerves that tell your muscles to move. Nerves grow about an inch per month. The number of inches from the injury to the tip of a finger gives the minimum number of months after which the patient may be able to feel something with that fingertip. The replanted part never regains 100% of its original use. Most doctors consider 60% to 80% an excellent result. Cold weather can be uncomfortable and a frequent complaint even for those with excellent recovery.

What about therapy and rehabilitation?
Complete healing of the injury and surgical wounds is only the beginning of a long process of rehabilitation. Therapy and temporary bracing are important to the recovery process. From the beginning, braces are used to protect the newly repaired tendons and allow the patient to move the replanted part. Therapy with limited motion helps keep joints from getting stiff, muscles moving, and scar tissue to a minimum.

Even after you have recovered fully, you may find that you cannot do everything you wish to do. Tailor-made devices may help many patients do special activities or hobbies. Talk to your physician or therapist to find out more about such devices. Many replant patients are able to return to the jobs they held before the injury. When this is not possible, patients can seek assistance in selecting a new type of work.

Are emotional problems common following replantation?
Replantation can affect your emotional life as well as your body. When your bandages are removed and you see the replanted part for the first time, you may feel shock, grief, anger, disbelief, or disappointment because the replanted part simply does not look like it did before. Worries about the look of a replanted part and how it will work are common. Talking about these feelings with your doctor often helps you come to terms with the outcome of the replantation.

Your doctor may also ask a counselor to assist with this process. You may find it helpful to talk about it with someone and work through your feelings so you can move on with your life.

Will additional surgery be necessary?
Some patients who have fully recovered from replantation surgery may need surgery later to reach full usage of the part.

Some of the most common procedures are:

• Tenolysis – frees tendons from scar tissue.
• Capsulotomy – releases stiff, locked joints.
• Tendon or muscle transfer – moves tendons or muscles to another spot so that they can work in an area that needs the tendon or muscle more.
• Nerve grafting – replaces a scarred nerve or a gap in the nerves to improve how the nerve works.
• Late amputation – removing the part later because it does not work or has become painful.

Stay in the flow of life. You have many great gifts. Even with the best medical care, you need to be strong during the course of recovery. Remember that quality of life is directly related to your attitude and expectations—not just regaining limb use.

What is Reflex Sympathetic Dystrophy?

Reflex sympathetic dystrophy, also known as RSD, is a condition of burning pain, stiffness, swelling, and discoloration of the hand. RSD includes other medical diagnoses such as casualgia, Sudeck’s atrophy, and shoulder-hand syndrome. RSD occurs from a disturbance in the sympathetic (unconscious) nervous system that controls the blood flow and sweat glands in the hand and arm. When the nervous system becomes overactive, burning pain is felt and swelling and warmth are left in the affected arm. If not treated, RSD can cause stiffness and loss of use of the affected part of the arm.

What causes Reflex Sympathetic Dystrophy?

In some cases, the cause of RSD is unknown. Often an injury can cause RSD, or the symptoms may appear after a surgery. Other causes include pressure on a nerve, infection, cancer, neck disorders, stroke, or heart attack. These conditions can cause pain, which sets off the sympathetic reflex causing RSD symptoms. Nerve injuries may change the way the nerve impulses are sent, causing a “short circuit” (Figure 2).

Signs and symptoms

The pain associated with reflex sympathetic dystrophy is often described as burning in nature. Swelling can cause painful joints and stiffness.

RSD has three stages:

• Stage I (acute) may last up to three months. During this stage the symptoms include pain and swelling, increased warmth in the affected part/limb, and excessive sweating. There may be faster-than-normal nail and hair growth and joint pain during movement of the affected area (Figure 1).
• Stage II (dystrophic) can last three to 12 months. Swelling is more constant, skin wrinkles disappear, skin temperature becomes cooler, and fingernails become brittle. The pain is more widespread, stiffness increases, and the affected area becomes sensitive to touch.
• Stage III (atrophic) occurs from one year on. The skin of the affected area is now pale, dry, tightly stretched, and shiny. The area is stiff, pain may decrease, and there is less hope of getting motion back.

Diagnosis

The diagnosis usually is made when at least three of the following symptoms are present: pain and tenderness, signs of changed blood flow (either increased or decreased), swelling with joint stiffness, or skin changes.

Treatment
Early diagnosis and treatment are important. Three forms of treatment may be combined: medication, physical therapy, and surgery. Medication taken by mouth can help decrease the symptoms. To reduce symptoms and provide long-term relief, local anesthetics may be injected into a nerve bundle at the base of the neck (stellate ganglion block). In some cases, a tourniquet is applied to the arm and medication can be injected into a vein along with an anesthetic.

Your hand surgeon may recommend therapy by a hand, occupational or physical therapist, or physician. Therapy is important to regain function and reduce discomfort caused by RSD. Successful treatment depends on the patient’s full and active effort in therapy. Occasionally, surgery is performed in the later stages, but the results can be disappointing. Your physician can advise you on the best treatment for your situation.