Scaphoid ORIF
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What’s the Problem?
The scaphoid is a small bone at the end of the wrist that can commonly be injured in a fall or traumatic accident. In some cases, it can be treated non operatively in a plaster, but if the fracture pattern is too severe, then surgery or internal fixation is recommended. Scaphoid fractures also often present months to years after the original injury. If this has occurred, then there could be a disruption to the blood supply to parts of the scaphoid. As a result, bone grafting may sometimes also be required.
How can you treat it?
In some instances, non-surgical treatment is appropriate. This includes:
- Taking pain relief
- A plaster around the wrist – usually for 8 weeks
- Physio or Hand Therapy to mobilise the wrist and surrounding muscles/tendons after the plaster has been removed
Ultimately, surgery is only reserved for patients whose injury is severe enough that they would have symptoms of severe wrist pain, stiffness and immobility without it.
The Operation
A scaphoid ORIF involves an incision down the front of the wrist towards the thumb. The broken bone fragments are placed back into their correct position, and then permanently held there with screws. X-rays are taken intra-operatively to confirm positioning.
The Anaesthetic
You will be asleep for the duration of the operation (ie a general anaesthetic). The anaesthetist may talk to you about a nerve block before the operation, which helps with pain relief and generally lasts 24-48 hours. Alternatively, Mr Lau can put local anaesthetic into the wound whilst you are asleep, which can also help reduce pain.
What are the Risks of this Operation?
- Infection:
Usually only a superficial wound infection to the top-most layer of the skin. In rarer cases a deep infection can develop and this is a serious complication that may require further surgery and exchange of the implants. Rare but serious, <1%. - Stiffness and ongoing pain:
It is common to have stiffness for a few months after the operation. This is because your wrist needs to be splinted to allow the bone to heal. Physio or Hand Therapy after surgery will help with improving movement, but some wrist rehabilitation will be required. Occasionally, the stiffness may be secondary to screw positioning, and a second operation may be required to remove it. - Damage to the nerves and blood vessels around the wrist.
Rare but serious, <1% - Fracture Non-Union:
The blood supply to the scaphoid can be limited, and fractures put the scaphoid at risk of dying (avascular necrosis). The longer the time between injury and surgery, the greater this chance. This has been reported in 5-10% of cases. Sometimes bone grafting may be required to improve the chances of fracture healing. If the bone does not unite, despite an operation, there are other options to utilise other bone grafts to try and help with healing.
Benefits
If Mr Lau recommends surgical fixation of your scaphoid fracture, it is because he feels you will have a better outcome with surgery. In particular, your wrist will be more pain free, have a greater range of motion and have greater functional improvements than if it was treated non surgically. It will also prevent the development of rapid onset arthritis to the whole wrist, which can occur if the scaphoid remains fractured.
What can I expect?
You will wake up with your arm in a sling after your surgery and in a half-plaster. If you have had a nerve block, you shouldn’t feel any pain till the next day. The nurses will provide you pain relief and the next morning a physio or hand therapist will see you to go through some exercises you can do to mobilise the fingers and elbow to prevent excessive stiffness in these joints. These exercises will change over the next few weeks to months but you should try to do them regularly to maximise your rehabilitation.
Most patients spend 1 day in hospital after surgery, before going home. A number of allied health staff (physios, occupational therapists) will make sure you have adequate support at home before discharge. An appointment will be made for you for a wound check at 2 weeks. At this time, the plaster will be removed and a plastic removable splint made for you. This splint is removable and allows for washing, whilst also keeping your wrist immobilised. Another appointment with Mr Lau will be at 6 weeks with repeat XRs
What should I avoid doing?
- In the first 2 weeks:
Keep your plaster/wound dry. Try to mobilise your fingers and elbow as much as possible - Between 2 and 6 weeks:
You will be placed into a moulded thermoplastic splint which allows for washing of the hand/wrist. Gentle flexion and extension of the wrist is possible, as well as continued elbow/finger exercises. You can pick up lighter objects such as a phone or cup with the affected side. You will have physio or hand therapy to help you with rehabilitation - Between 6 and 12 weeks:
Full mobilisation of the wrist, fingers and elbow. The only restriction is no heavy lifting (weights, heavy pots/pans etc) till after 12 weeks.
Return to…?
- Work
Depends what you do. Desk based work can be done from 2 weeks post operatively, if you can do these tasks single handedly. Otherwise generally 6 weeks before you can use both hands freely whilst seated.
For manual work, it depends on what kind of lifting/pushing you do, but generally not before 3 months - Drive
In Australia, you can’t drive unless you are in full control of both your arms. Therefore, whilst you’re in a sling, you cannot drive. Generally 6 weeks post operatively. - Sports/Hobbies:
- Gentle swimming: after 6 weeks
- Gardening (light tasks only): 8-12 weeks
- Bowls: after 3 months
- Golf, tennis, badminton, squash: after 4-6 months
- Weights: commence after 3 months
Concerns or questions?
If you have any concerns post operatively, or you would like further information, please contact Mr Lau through the VBJS on 03 5752 5020 or via email at admin@vbjs.com.au
If you need urgent medical help, call 000 or go to your nearest emergency department.
Rehabilitation protocols
These notes have been prepared by Mr Simon Lau. They are general overviews and information aimed for use by his patients. They reflect Mr Lau’s views, opinions and recommendations. They do not constitute medical advice. The contents are provided for information and education purposes only. Please seek Mr Lau’s specific advice with any questions regarding medical conditions and treatment.