Stuart, in Norwich, England asks:
"I broke my scaphoid bone. It's healed but I still dont have full mobility in it. Could you advise on any physio exercises I can do."
David Wales, Clinical Specialist Physiotherapist responds:
"The Scaphoid bone is the most commonly fractured of the eight wrist bones that make up the wrist complex. These fractures occur relatively commonly following a fall onto an outstretched hand. Because of the poor blood supply to the Scaphoid, there are often problems with fracture healing, but other complications related to a lack of mobility and residual stiffness are also quite common.
"The traditional management of Scaphoid fractures is to immobilise the wrist using a plaster cast. As with all cast immobilisation this produces short term stiffness around the wrist. In most patients this stiffness can benefit greatly from physiotherapy treatment such as massage, moblisation of surrounding joints and exercise, although symptoms remain in some wrists.
"Recent advances in surgical techniques have changed the management of Scaphoid fractures. In patients where conservative treatment using immobilisation has failed to produce a healed fracture, where the fracture fragments are displaced (not in close proximity) or where the patient's occupational demands require a more swift, certain outcome, then surgical treatment is indicated.
"Conventional open surgery involves a small screw being inserted into the Scaphoid in order to unite the fracture fragments. This may be followed by 6 weeks of wrist immobilisation in a cast or immediate mobilisation, depending on the preference of the surgeon.
"New surgical techniques using wrist arthroscopy are now becoming more popular. The arthroscope allows the surgeon to inspect the bones and soft tissues of the wrist, giving more useful information than x-ray films. Arthroscopy has an advantage over 'open' surgery in that it is less invasive and there is less associated soft tissue damage. This means the duration of rehabilitation is reduced.
"Recent studies have reported the findings in patients who have undergone arthroscopic surgery for the treatment of Scaphoid fractures. These findings have shown that more than a third of patients suffered wrist ligament and cartilage injuries, in addition to their Scaphoid fractures. These injuries have been described as 'Combined Wrist Injuries' (Wong et al, 2005) and would explain why wrist symptoms continue in patients who have had a Scaphoid fracture that has been shown to have healed on x-ray.
"Without arthroscopic surgery it may not be possible to diagnose Combined Wrist Injuries, even with investigations such as MRI. Once found, management of these injuries is dependent upon exactly which soft tissue is involved. Torn ligaments can be re-attached to the wrist bones using surgical wire. This is usually followed by immobilisation in a plaster cast for six to eight weeks, at which point the wires are removed and physiotherapy treatment begins.
"Another common finding in Combined Wrist Injuries was damage to the fibro-cartilage disc, which is known as the Triangular Fibro Cartilage Complex (TFCC). The TFCC sits between the Ulna (one of the forearm bones) and the bones of the wrist area and its function is to increase the stability of the wrist. Damage to the TFCC can be repaired with arthroscopic surgery, where the articular disc is either repaired using sutures or partially shaved off.
"If you are still experiencing symptoms in your wrist then you should return to your orthopaedic doctor for their opinion. If the Scaphoid is fully healed then it may be possible that you have a Combined Wrist Injury, and soft tissue lesions are producing your symptoms. Degeneration is also relatively common following Scaphoid fractures, so your doctor will have to review this.
"If you do have a Combined Wrist Injury then the latest evidence suggests that arthroscopic surgery is the most effective treatment in the long term. Physiotherapy treatments, such as hot wax baths and mobilisations may be effective in relieving the symptoms of wrist pain and stiffness in the short term, but ultimately a surgical approach may be necessary."