Scaphoid fractures: what they are and the importance of early diagnosis

Posted: 03/03/2023

A scaphoid fracture is a break in the wrist, and specifically, the small bone near the base of the thumb. The word ‘scaphoid’ comes from the Greek term for ‘boat’. The scaphoid bone resembles a boat with its relatively long, curved shape.

A fracture of the scaphoid bone typically happens when a person falls onto an outstretched hand. Due to the mechanism of the injury, this form of fracture is often seen in patients who have sustained a fall when participating in sporting activities. It is also known that scaphoid fractures can arise from what are termed ‘kickback’ injuries – for example, from a steering wheel in a car crash or when a football goalkeeper makes a save.

The scaphoid bone plays an important role in both the motion and stability of the wrist joint and so prompt diagnosis of any injury to the bone and timely treatment is needed to ensure that a good recovery is made.

A scaphoid fracture will usually result in immediate pain and swelling in what is known as the ‘anatomical snuffbox’ (located at the boundary of the thumb and wrist) and on the thumb side of the wrist. The pain may be severe upon movement of the thumb or wrist, or when trying to pinch or grasp an object.

Usually, patients will typically first present to the accident and emergency department with a possible scaphoid fracture because of the circumstances in which the injury was sustained and the severity of the symptoms experienced. Consequently, fractures of the scaphoid bone are known to represent a relatively common diagnosis in day-to-day emergency department practice. There is a reasonable expectation that all clinicians working in emergency departments will be familiar with the mechanisms of injuries which might result in a scaphoid fracture and how to manage them.

A key part of forming a diagnosis is ensuring that an appropriate history of the circumstances of the fall is taken and documented in the medical records. If a patient reports falling on an outstretched hand or experiencing a kickback injury, as described above, this should give rise to a suspicion of a possible scaphoid injury/fracture. An examination of the wrist and hand should then be undertaken, followed by an X-ray. The radiologist should specifically be instructed to X-ray the scaphoid bone.

Whilst scaphoid fractures can be detected in an early X-ray, this is not always the case because the scaphoid bone can 'hide' behind the other carpal bones. Therefore, even with a re-assuring X-ray, if a scaphoid fracture is suspected, then arrangements should be made to follow up the patient, either with a fracture clinic assessment, and/or a repeat X-ray. Only after these investigations have been performed should a scaphoid fracture be ruled out as a possibility.

Provided that a scaphoid fracture is diagnosed promptly, then most injuries of this nature can be managed conservatively with immobilisation of the wrist in a cast for a period of six to eight weeks. A full or near full recovery is anticipated in this situation. In contrast, a delay in diagnosis and treatment can lead to complications including displacement and/or non-union of the fracture. Surgery in these circumstances is normally indicated. Unfortunately, even with surgery, injuries of this nature (if diagnosis and treatment is delayed) can lead to longer term implications with ongoing pain and tenderness, poor/restricted movement of the wrist and, in some cases, issues with degenerative wrist arthritis.

Naomi Holland, a senior associate in Penningtons Manches Cooper’s clinical negligence team, comments: “Prompt diagnosis and treatment of a scaphoid fracture is crucial to optimising the prospects of making a full recovery. However, it is well known that scaphoid fractures can be difficult to diagnose on initial X-rays. That is why it is important to appreciate this risk and ensure that an appropriate management plan is in place so that the injury is not missed and appropriate timely treatment can be initiated.

“Sadly, we have represented a number of clients who have experienced significant delays in the diagnosis of a scaphoid fracture because initial X-rays performed very soon after the injury had not incorporated the scaphoid bone. In other recent claims, clients were given an assurance that there was no fracture on X-ray, despite the known risk that fractures are not always visible immediately.

“In many cases, due to the delay in diagnosis, surgery has been the only option, and even then there have been longer term implications including pain and difficulties in the range of movement in the wrist. These symptoms can be particularly problematic in day-to-day life and with work, particularly typing and manual labour. Therefore, the importance of appropriate early management in scaphoid fractures cannot be emphasised enough.”

Penningtons Manches Cooper has a specialist team of orthopaedic negligence solicitors who deal with the full spectrum of orthopaedic related medical negligence claims. If you think you may have an orthopaedic claim, even if the type of claim has not been mentioned above, please do not hesitate to get in touch with a member of the team for an initial discussion.

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