Scaphoid fracture: cast, surgery and recovery time

The scaphoid is one of the eight small carpal bones of the wrist, on the thumb side. East Kent Hospitals says a scaphoid fracture is usually caused by an unexpected force through the wrist and hand, such as a fall onto an outstretched hand. Pain or tenderness at the base of the thumb can be a sign, although it can also occur with a wrist sprain or bone bruising.

The injury gets special attention for two reasons. First, it can be difficult to see on early X-rays: East Kent Hospitals says it may be necessary to repeat X-rays 10 to 14 days later, and sometimes an MRI scan is needed, and that clinicians may start treatment for a scaphoid fracture just in case and refer you to the fracture clinic. Second, University Hospitals Plymouth says that surgery may be needed if the bone has moved or if the blood supply is affected, and describes avascular necrosis as a rare complication of a scaphoid fracture that has disrupted the blood supply and not healed properly.

The NIHR summary of the SWIFFT trial adds that scaphoid fractures are among the most common broken bone injuries, that breaks across the midpoint (the waist) account for most, and that if the bone does not repair normally, arthritis may develop in the wrist.

East Kent Hospitals says you will be in a plaster cast for six weeks, but your treating clinician will discuss this because sometimes the length of time changes. It says fractures that occur at the end of the scaphoid may need to be immobilised for longer. University Hospitals Plymouth describes a below-elbow cast or removable Velcro wrist splint for 5 to 6 weeks, and says that during this period you may use the hand for light tasks and should move the wrist and fingers within your pain tolerance straight away. NIHR Evidence says that immobilising the wrist in a cast for 6 to 10 weeks is generally sufficient for full healing.

The sources therefore give a range rather than a single number, and which end applies depends on the position of the fracture, how it looks on X-ray and how it is healing. East Kent Hospitals asks you not to use your hand or move your wrist without the cast or brace in place during the immobilisation period, and says the cast should be kept dry, using a shower sleeve for showering or bathing.

University Hospitals Plymouth says that if there are still high levels of pain after 6 weeks, the doctor may choose to investigate further, and that you will be checked for avascular necrosis.

Surgery for a scaphoid fracture usually means fixing the break with a small screw. East Kent Hospitals says occasionally an operation is needed, due to poor blood supply to this area of the bone. University Hospitals Plymouth says surgery may be needed if the bone has moved, or if the blood supply is affected.

The large SWIFFT trial compared the two approaches for a break across the waist of the scaphoid. NIHR Evidence reports that 439 mostly male patients aged 32 to 39 were treated at 31 NHS hospitals in England and Wales, half with surgery and half with a plaster cast, and that after six months and again at a year there was no significant difference in pain, grip or wrist movement between the groups. It says very few people had a break that did not heal, medical complications leading to stiffness or numbness were more common after surgery, and the researchers concluded that a plaster cast should be used as first-line treatment, with surgery only if the fracture does not heal in a cast.

The same summary points out that the trial included mainly younger, healthy men and that remaining questions include less common types of scaphoid fracture or those with more displacement. It is a reason that the plan for your own fracture is individual and set by the fracture clinic after looking at your X-rays.

If surgery is needed, East Kent Hospitals lists the possible complications: delayed wound healing or infection, a scar that may be tender for several months, non-union (it quotes five in every 100 patients where surgery is completed within four weeks of the injury), nerve damage that often settles within a couple of months, and complex regional pain syndrome, which is very rare. It describes the operation as a day case, with up to six hours in hospital.

East Kent Hospitals says that most scaphoid fractures heal without problems, that it may take several months for swelling to go down and to feel like you have full strength and flexibility, and that gripping, full weight-bearing and repetitive work can be uncomfortable for up to a year. After removal of the cast or after an operation you may be referred to the hand therapy team, and the aim of treatment is to restore normal movement to the wrist and hand as soon as possible.

During recovery, it advises avoiding heavy lifting, pulling or pushing for the first six to eight weeks after the injury, and avoiding contact sports for eight to 12 weeks. After surgery it says to avoid significant weight-bearing activities, including pushing up from a chair or heavy gripping, for the first four weeks, while light activities such as feeding, drinking, dressing, typing and light housework can be done straight away.

Self-care advice from the same leaflet is to keep the hand raised above heart level for the first one to two weeks, to avoid a sling because it can cause discomfort in the shoulder and neck, to move all the other joints of the hand and arm, to use simple painkillers such as paracetamol or ibuprofen if you need them (checking with a pharmacist if unsure), and to stop smoking, which it says greatly reduces the risk of the fracture not healing.

University Hospitals Plymouth says that if you are a car driver you will need to take a break from driving and that guidance is available from the DVLA. East Kent Hospitals says that after surgery you cannot drive home, and that you should only return to driving when your arm feels comfortable, when you can use it for general daily activities and you can safely control your vehicle, which is not usually while it is in plaster or within six weeks of surgery.

On work, East Kent Hospitals says light duties may be possible one to two weeks after surgery, more demanding work around three to six weeks, and that heavy manual work should be avoided for eight to 12 weeks. For desk work in a cast the practical limits are the cast itself and how comfortable the hand is.

East Kent Hospitals asks you to contact your GP or local urgent treatment centre if you have loss of feeling in your hand or fingers, discoloured skin on the hand or fingers, or fingers that become hot or cold, and to contact the fracture clinic if the cast gets in the way or feels too tight. It also lists increasing pain or swelling and the signs of wound infection after surgery.

Ongoing severe pain and swelling of the whole hand after four to six weeks can be a sign of complex regional pain syndrome, according to the same leaflet, which asks you to contact the consultant or your GP for review. Continued high levels of pain after six weeks is a reason for further investigation, says University Hospitals Plymouth.