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Scaphoid Injuries - by Dr Esplin
10.16.14 Thursday
The school year has begun, bringing with it the excitement of another year of learning and the intensity and anticipation of athletic competition! Many young athletes have prepared for this year by honing their skills, training to defend their titles or seeking revenge for prior defeats.   Unfortunately, with such high level competition and preparation injuries often occur.  Even with protective gear and rule changes to protect the athletes, bones are broken, ligaments get torn and tendons and muscles become inflamed. In writing this article, I wish to stress the importance of listening to the coaches and trainers on the sidelines.  They are very interested in keeping their teams healthy. One significant injury may put a good player out for the entire season. Most injuries are obvious, like breaking an arm, dislocating your shoulder, or tearing knee ligaments. Your recovery may require a cast or even surgery and rehabilitation.  However, there are a few elusive but significant injuries of the wrist that are often missed.  Because the wrist structures and spaces are small, they don’t swell much or may not even be painful enough to stop play.  The original pain may improve in a few weeks only to manifest itself weeks, months or even years later after permanent damage has occurred.  If these injuries are ignored and untreated, these young athletes may suffer from impaired wrist function for the rest of their lives. The scaphoid is a peanut shaped bone on the thumb side of the wrist that serves a key role in linking the other four bones of the wrist making possible the remarkable pain free range of motion in normal wrists.  Unfortunately the scaphoid is the most commonly fractured bone in the wrist, accounting for 70% of wrist bone fractures. They are often dismissed by the patient or their parents as a sprain. In fact, they are often missed by physicians even with x-rays. I often see athletes with restricted motion and persistent wrist pain two to four months after the season is over. Although the pain caused by a scaphoid fracture will be noticeable, motivated athletes will usually continue to play.  The pain and limited swelling will be more noticeable the next day but may improve or even go away over the following weeks. However, the motion of the wrist will not return to normal. Pain will also accompany any activity that puts force across the wrist, especially when extended. Most typical fractures in children and adolescents heal within 6 weeks.  The scaphoid bone however, seldom heals without appropriate treatment.  Any bone needs a good blood supply to heal. Because the scaphoid is almost completely surrounded by cartilage, there are few places blood can get into the bone. When it breaks it has a hard time healing or may not heal. If treated early however, nearly 100% of scaphoid fractures will heal; a cast is often sufficient but surgery may be required. Unfortunately, these fractures are often missed and not treated until months or years later.  By then a “non-union” has developed, or in other words they have not healed and will not heal without surgery.  The success rate of fixing these non-unions is dependent on how long it has been since the initial injury.  In many cases part of the bone has worn away and a bone graft from the hip or pelvis is required to bridge gaps between pieces of the scaphoid.  Sometimes the bone graft must be transferred with its blood supply. If the non-union cannot be corrected, a partial fusion or other wrist limiting surgery is required. You don’t need to see a doctor every time you or your athlete has a sore wrist.  However, if you experience a forceful injury to the wrist and have the following symptoms you should see a doctor for evaluation and x-rays:
  1. Persistent pain in the wrist for over two weeks.
  2. Limited range of motion, about 50% compared to the other wrist.
  3. Significant swelling, bruising, and pain on the thumb side of the wrist. Please note, this may not be dramatic.
  4.  Wrist pain worsens with pressure applied to the thumb side of the wrist.
Scaphoid fractures are often missed on initial X-rays, which may need to be repeated a few weeks later if pain persists; an MRI may also be necessary.  If there is still a question, a referral to a Hand Specialist is a good idea. They specialize in looking at variations that can occur with this troublesome fracture and how to treat it. So good luck and I wish all the school athletes health and success with their upcoming events. If you have any questions or concerns about your upper extremity injuries come see us at the Idaho Hand Institute.
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