Medical experts and climbers Dr Jeremy Windsor and Mr Tim Halsey share a helpful guide for a commonly occurring yet not widely discussed injury: the dreaded scaphoid fracture...
As someone who works as an anaesthetist in a busy hospital on the edge of the Peak District, I often meet climbers and mountaineers who need to be fixed. Earlier this year I anaesthetised Steve, a climber in his early 40's, who underwent an operation to fuse together the bones in his wrist. This procedure wasn't undertaken lightly - it was the final step in a long journey that had begun with a scaphoid fracture ten years before. After several operations and the onset of crippling arthritis, the decision had been made to connect the bones of the forearm and hand together with a metal plate and screws. Whilst this would eventually ease the pain and swelling, it would leave Steve with weakness and minimal movement in the wrist. In the future, any form of climbing would be very difficult.
Searching the forum pages of UKC it was clear that there were lots of climbers who had experienced scaphoid fractures. Whilst the majority had recovered completely, there were others like Steve who had experienced life changing complications. With their stories and the help of hand surgeon Tim Halsey, I'm going to try and explain how to spot a scaphoid fracture and describe what you can do to maximise your chances of recovery…
It all starts with a "bang"…
A scaphoid fracture isn't something that develops over time. It starts with a sharp, agonizing pain that follows an awkward fall onto an outstretched hand. The scaphoid is one of several small bones in the hand that form half of the wrist joint. The scaphoid is the most commonly damaged and sits below a spot called the "anatomical snuffbox" (ASB).
If you fall onto your wrist and feel pain at this site there's a risk that you've fractured your scaphoid. Medical staff will gently press here and check your response. Unfortunately, the ASB might also be painful in other injuries. Here's where an x-ray is useful, but…
Don't expect an x-ray immediately!
In many cases, an x-ray won't be taken straight away. This is not because of some fiendish attempt to save money in the NHS. Rather, it's the knowledge that a scaphoid fracture is often seen more clearly as it starts to heal. You'll be fitted instead with a splint and given an appointment at your nearest fracture clinic in a couple of weeks. Don't be tempted to assume, "I'm OK because I've not had an x-ray". You're not in the clear yet. Wear the splint for all but the most essential tasks and wait it out. Scaphoid fractures heal very slowly. They receive a very small and convoluted blood supply and any movement can delay healing or stop it altogether.
Two views of a fractured scaphoid bone in the right hand – from the side (left) and palm up (right). Both x-rays show a jagged horizontal black line through the body of the scaphoid bone.
As well as pain in the ASB, those with a scaphoid fracture can also expect discomfort when pressure is applied to the wrist (scaphoid tubercle tenderness) and when the thumb is compressed or "telescoped" (axial loading).
It takes time to heal!
If the x-ray shows a fracture you'll be faced with several weeks in plaster and the possibility of an operation. The likelihood of the operation depends upon two key factors – (1) whether the bone fragments are out of alignment (displaced) and (2) the site of the fracture. As Tim Halsey says,
"If the fracture is undisplaced and through the "waist" or middle of the scaphoid, it may heal in just six weeks."
However, if the fracture is displaced or occurs at a site close to the wrist (commonly known as the, "proximal pole") it is likely to need an operation.
Sometimes the fracture can't be seen on x-ray
Don't be put off! If you're x-ray appears normal but you still have symptoms you'll need a different test. This will vary depending upon the technology that your hospital has access to – CT, MRI or bone scan. These will normally provide a clear answer. Remember - persistence pays off! Tim's words could not be clearer:
"The bottom line is that if scaphoid fractures are missed and fail to heal then you can develop a pattern of arthritis which is likely to require further treatment and ultimately leave you with a stiff, painful wrist and limited function."
The "Worst Case" scenario
After your fracture, whether you've had surgery or not, you should be seen regularly in a fracture clinic to follow you up until the fracture is fully healed. Once the "all clear" has been given you'll be referred to a therapist for rehabilitation. Tim recommends the "Hand Therapy" App designed by therapists at the Chelsea and Westminster Hospital as a helpful reminder of some of the more useful exercises. Over time, strength and range of movement returns. Climbers often find it difficult to mantelshelf for several months after a fractured scaphoid. Tim offers some reassurance: "Further gains in extension can be made for up to a year after a scaphoid fracture – don't be put off if you can't mantel straight away!"
Following his appointment at the fracture clinic, Steve underwent an operation to join the two broken fragments together. X rays taken eight weeks after the injury showed that the bones were knitting together. The plaster cast was removed. Steve started to follow the exercises prescribed by the therapist. However a month or so later, the pain and swelling started to return. As Tim says, "It is possible to have a bone which seems to heal initially but does not fully knit back together and goes on to cause significant problems six months, a year or even longer after the initial injury."
Steve was warned that smoking might delay his recovery and he stopped immediately. Further time in a cast led to a series of further operations. However a well described pattern of arthritis started to take hold. Scaphoid Non-Union Advanced Collapse (SNAC) is a predictable pattern of arthritis that starts around the scaphoid and can eventually spread throughout the wrist. Over the course of a decade this left Steve with only one option – a wrist fusion.
The cases of Steve and Neil are rare. Most people make a complete recovery and quickly return to normal. Early diagnosis is vital. If you think you may have fractured your scaphoid seek expert help quickly and be prepared for a lay off whilst the bone heals. As the experiences of Steve and Neil demonstrate, the damage caused by a scaphoid that doesn't heal is truly life changing. If in doubt get your wrist checked out by a suitably qualified surgeon.
Erick (known to UKC members as "French Erick") fractured his scaphoid at the age of 21 whilst skiing off piste. He remembers protecting his face from the branches of an oncoming tree and taking a sharp blow to his arm. Despite the pain, he continued skiing with a scarf tied tightly around the wrist for two more days. A scaphoid fracture was eventually diagnosed. Fortunately, no surgery was required and the plaster cast was removed after eight weeks. Unfortunately it remained sore for a further six months. As Erick recently wrote, "I didn't know that such a small bone could be so painful!"
As a 19 year old student John fell whilst highballing "Life in a Radioactive Dustbin" and fell awkwardly onto an outstretched arm. He suffered a number of serious injuries, including a scaphoid fracture, which needed multiple operations. Although he was able to climb seven months after the fall, it took almost four years to return to his previous climbing standard. Pain proved to be a persistent problem. "I would estimate that it took at least five years to be pain free, although it would still feel painful whilst winter climbing for ten to twelve years". John's advice to those with a scaphoid fracture? "Patience is required. Careful and structured strengthening of the wrist seems to improve rehabilitation and any chronic pain."
Neil broke his scaphoid almost forty years ago following a fall down a flight of stairs. A second fracture a few years later led to a series of unsuccessful operations. In 1989 his orthopaedic surgeon offered Neil a wrist fusion. He declined the offer and decided to "let medicine move on a bit as there would be no way back after the fusion." Although the symptoms settled for a time, the wrist eventually began to deteriorate. Pain and swelling soon led to weakness. As a climber, his experience was as follows: "My pinch grip was always weak and I struggled with traverses that led with my bad hand. Crimping was difficult ... I had to drop right back off winter climbing grades. I had done a couple of Grade III's in the Lakes and on the Ben but found gripping an ice axe painful/weak – no longer a sensible proposition".
Speaking to Neil earlier this year it was clear that the difficulties had started to stack up: "The big thumb muscle has wasted on my bad hand and consequently the grip has weakened. I stopped being embarrassed about asking my wife for help opening jars and take off plastic sheets from the lid of milk bottles years ago! Changing a plug or putting up a new light fitting is awkward and painful. I'm not one to seek out DIY jobs! At work I spend a lot of time on a computer. Even "Ctrl Alt Delete" to unlock the screen has become painful now." This this has led Neil to return to the orthopaedic surgeon and contemplate life with a wrist fusion. Neil says: "I can't tolerate the weight of an empty cup in my bad hand now. I have sharp pains and drop things. The surgery choice is a simple one."