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Screw it? (Scaphoid)

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I crashed during a race on 4/27.  I knew I was hurt so I let the EMT check me out.  He said I was probably ok.  I then went to urgent care and got some x rays.  The doctor told me it was a sprain and to keep it wrapped and ice it.  Then He sent me on my way.  About the time I got home, my phone rang.  He said the radiologist saw a small fracture so I should come back to have it immobilized.  So I did, and he gave me a spica.  He also told me it was just a 1.3 mm fracture and it would heal fine.  I got a copy of the report and it said "fractured scaphoid with 1.3 mm displacement".  I took that to mean that it was separated 1.3mm.  apparently I was right.  I went back for my follow up on Monday, and to establish him as my primary care doctor,  and he asked if it still hurt.  I said yes so he referred me to an orthopedic doctor.  I just left there with him suggesting I get it screwed on Monday.  I have found in my research that this is a problematic bone that has poor blood flow etc.  It is my choice whether to have the procedure or just get a cast.  obviously I need a new  primary care doctor.  But is it worth it to get a screw?  I have an 80/20 plan so there will be some out of pocket, but if this is something I should do, that is fine. 

 

I have done a lot of research online about this, including on this forum, but I was hoping to get some advice on my particular case, seeing as how I have an x ray or two to show.

 

Also I already asked about getting a prescription for a nice brace, and that's cool.  He will even prescribe 2 for preventative on my right wrist.

 

Thanks for any input

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I really feel for you man.

 

I had the same fracture around 8 years ago skateboarding at a concrete skatepark in Chino, CA.  I wasn't near as diligent about getting to the bottom of the pain in my wrist, never got xrays and never really paid much attention to it.  after 3 or 4 weeks the pain went away and I was also told it was most likely a sprain... I basically moved on with my life.  that is a mistake that i will regret always.  3 years later i'm at my keyboard and my wrist starts popping and cracking and getting hung up in its range of movement.  it starts feeling like I have carpal tunnel and begins to be slightly painful on a daily basis.  So fast forward a few weeks later and I've made an appointment with the Hand and Wrist Center of Long Beach, CA.  the doctor informs me that i had broken my scaphoid and it never healed, a lot of big words were thrown around in that first meeting with an even larger number of xrays in every direction.  I had an avascular necrotic nonunion scaphoid, 3 years of those bones being loose and grinding at each other had finally severed what blood vessels may have been there at each end keeping the bones alive, or maybe they were severed during the incident I dont really know.

 

By the time I got around to surgery the doctor had recommended internal fixation with a screw.  seemed to me like the most rational choice, I am an engineer by trade and i worked in construction at the time so I felt like screws was something i could wrap my head around.  the surgery was expected to have some amount of bone marrow taken from my hip and used as an aide to get the bone back together, they apparently didnt feel they needed it because at some point through the surgery the doctor decided against it.  I went home in a cast and 6 weeks later had that replaced with a softer removable plastic cast.  8 weeks after I was told that my surgery looked like it was holding and that I should start using my wrist as much as possible.  1 week later I'm stretching my wrist out and I feel something give... oh s)*&^.  I go back to get xrays and find out I have re-separated my scaphoid...  worst feeling ever.

 

The second surgery the specialist decides to put pins in my scaphoid to re-stabilize it.  after 6 to 8 weeks in a cast we review the x-rays and those do not seem to be holding either.  he decides that he's going to go ahead and ditch the pins so he spends an hour removing them in his office using local anesthetic... that wasnt fun at all as it substantially wore off and pain came back after 40 minutes or so...

 

At this point my doctor and I needed a meeting on what was going to happen next, he said i have 3 options, completely fused wrist, 4 point fixation with plate, or a PRC (proximal row carpectomy) but his suggestion was to do the PRC route.  I thought long and hard about this and brought up multiple examples of people getting titanium scaphoid implants to which he dismissed as not a serious option for someone who uses their wrist as aggressively as you do.  He talked me into the PRC and it was one of the toughest things i've had to deal with in my life.  I am happy to say that my right wrist has come along way in the past 3 1/2 years since the surgery, in the last two years I actively took up motocross and trail riding, i completed the soboba trail ride last year and this year.  I now have very little pain to no pain at all on a day to day basis and through conditioning I have achieved 100% of my former grip strength and then some, but only around 50% of the flexibility that I once had.  it seems that no matter how much I stretch my wrist I will never get the full motion back.  The past 3 years has been a huge struggle in terms of pain management and flexibility and strength rehab, i did it all on my own.  With more and more riding ahead of me the wrist is just soaking it all up and getting stronger, rarely do I even feel it now while riding.  It may be because I bought the flexx bars, hard to say...  the PRC is your last ditch option and the worst case scenario.  i've made it work for me because i had no choice, you can overcome the issues, doing pushups on your fingers and stuff but it sucks and I wouldnt wish the recovery on my worst enemy.

 

My point in telling you all of this is:

#1 You are doing the right thing in getting your wrist the attention it needs, do not ignore it and do not take a single doctors recommendation at face value, I took a few recommendations from other doctors prior to going with the PRC (not that you are at that stage, far from it).  the success rate at fixing your scaphoid when it is caught early is very good.

#2 Be conservative in letting the bone completely heal, do not attempt to push the wrist too hard too fast or you may end up causing damage to the bone.  

#3 It costs money but do not let that weigh in your decision to not take the best possible action for your wrist.  It was pretty expensive after everything was done, I paid for each of my 3 surgeries, close to 1500 for each if i remember correctly.

#4 1.3 mm sounds to me like a good amount of a gap, this will probably not heal on its own without being in a cast and probably full arm cast to really isolate the area.  Screwing (internal fixation) that scaphoid back together may be the only way to ensure that the parts of the bone are held securely together for long enough to allow the bone to heal properly.  blood flow is also tricky, there may be a need to perform surgery based on some torn arteries.

$5 Your regular doctor does not know crap about your wrist, or rather they know very little compared to a wrist specialist.  

 

My recommendation is that you get referred to a hand and wrist specialist and that you receive expert attention on it right away.  it wouldn't surprise me that they recommend a screw.  I would go with it and make sure you take at least 3 months off from doing anything with that hand.  and then probably ask for a referral to get a CAT scan on the bone before putting any weight on it.

 

best of luck to you,

 

Sam

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Great post Sam! Sorry to hear about all the issues. This seems like a pretty common injury. Rich, you're not the only one, hang in there bud.

If you need someone to ride your bike while you're out, just let me know.

77x :)

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As I would think that you have learned now, if its not fixed now, you will be paying a lot more than 20% later.

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Thank you for the info.  I was after second opinion and I have it.  I'm going in Monday.   I wish I hadn't watched the youtube video of the procedure.  It looks downright horrific.

 

It is an Acumed brand scaphoid screw.  I really hope that they include an Acumed sticker to slap on the bike.  Great sponsor idea.  "When I crash, I only use Acumed scaphoid screws." 

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I only wished that the general practioner who handled my break referred me to a specialist from the outset.

Braaapopopop (rev limiter lol) your story gives some hope to someone like myself who at the moment is thinking

all doom and gloom(sitting at home can do that to you).

I hope I don't have to go down that road and I realize my wrist may be affected in some way for the rest of my life.

This is a real design defect of the human body.

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