STORY BYAfter Houstonian Gerre Thornhill fell 25 feet out of a tree onto concrete, he hurt almost everywhere: six broken ribs, a fractured hip, dislocated and shattered elbow and broken wrist.
It would take months to recover from all the injuries, but thanks to a newer, percutaneous (through the skin) procedure used by Idris Gharbaoui, M.D., an orthopaedic surgeon and faculty member at The University of Texas Medical School at Houston, Thornhill could use the wrist within days after the surgery.
Breaks of the scaphoid, a cashew-shaped bone located on the thumb side of the wrist, are notorious for problems in healing because of the limited blood supply to that area. There used to be only two repair options—open surgery or immobilization for up to six months.
Remarkably, the scaphoid bone in Thornhill’s wrist healed in only weeks.
The new procedure, which Gharbaoui said has a near 100 percent healing rate, provides a third alternative that gives the bone stability but spares tissue with minimal blood loss.
In the new procedure, the skin is cut and a pin is inserted into the middle of the bone with its position checked through fluoroscopy using different views. Once a perfect position is obtained, the bone is drilled, a cannulated (hollow) screw is placed over the pin and the bone is compressed.
“We use a compression screw, entirely buried into the bone, providing excellent stability of the fracture and allowing the patient to start using his hand a few days after the procedure,” Gharbaoui said. "The fixation is so stable, there's no need for a cast or splint."
According to the American Academy of Orthopaedic Surgeons, 60 percent of all wrist fractures involve the scaphoid bone. The fracture usually occurs when you try to break a fall with your hands. If the wrist is bent at a 90-degree angle or greater, the scaphoid will break; at less than 90 degrees, the lower arm bone will break.
Blood enters the scaphoid from the top of the bone. Unfortunately, most breaks occur in the center or lower portion of the bone where the blood supply is limited and thus healing is more difficult.
In a fracture, the injured cells of the bone deteriorate in seven to 10 days, making the separation more acute and in the case of the scaphoid, further threatening the needed blood supply.
The most common treatment for a broken scaphoid is to immobilize the hand, wrist and arm in a cast for six weeks to six months, depending on the location of the break within the bone. The average healing rate is three months. Spending months in a cast results in muscle atrophy, which requires physical therapy.
In up to 50 percent of cases, depending on the severity of the break, even long-term immobilization won't heal the bone and surgery including bone grafting will be required.
In cases where the fracture is unstable, immediate surgery is often recommended. Traditional surgery, which includes opening up the joint, will provide stability and has an up to 100 percent healing rate, but can adversely affect blood supply, Gharbaoui said. In addition, the patient must wear a cast for up to three months.
Other complications of open surgery include infection, soft tissue damage, wrist ligament damage and scar pain.
Because of the bone’s healing problems, patients should seek immediate treatment if they believe they may have a broken wrist.
Some people mistakenly believe that a broken scaphoid is a sprained wrist because there may be very little swelling. A fracture sometimes does not immediately show up on an X-ray, but a bone scan two to three days after the injury can confirm the break. Left untreated, the fracture can lead to severe arthritis and require future surgery to fuse or replace the joint.
Symptoms of a broken scaphoid include:
While it can still take two months for the bone to heal, Gharbaoui said Thornhill‘s break healed in a month. Although Thornhill still experiences pain in the wrist from nerve damage caused by the fall, the newer technique kept a cast from interfering with the healing of his elbow.
"My elbow might have frozen if I had to wear a cast," Thornhill said.
UPDATED: 8-01-2005
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Dr. Idris Gharbaoui is an assistant professor in the Department of Orthopaedics at the UT Medical School.
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