Patients › Hand

Distal Scaphoid Excision

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Why this operation has been suggested¶

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, including your history, examination and imaging where needed, establishes the diagnosis.

This operation removes the worn end of the scaphoid, one of the small bones deep in your wrist. It is offered when wear-and-tear arthritis affects the joint between that bone and its two neighbours on its own. When the base of your thumb joint is also badly worn, we use a different operation instead. Non-operative care usually comes first: activity change, hand therapy and splinting. Surgery follows when that has not given enough improvement. The aim is to stop the rough, worn surfaces grinding against each other, which relieves pain and improves grip and pinch strength.

Before the operation¶

Your surgeon will confirm the plan with X-rays, and sometimes an MRI or ultrasound, to map the worn joint before anything is booked. Most people need nothing more than that. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. Stop eating and drinking seven hours before your operation; this leaves room in the theatre list in case your time is brought forward. Bring a list of every medicine you take, including anything that thins your blood, as some medicines may need to pause beforehand. Your surgeon will give you exact instructions. Arrange a lift home, since you will not be driving. Wear loose, comfortable clothing with sleeves that slide easily over your wrist.

On the day¶

You arrive at the hospital's surgical admissions unit, where staff check you in and prepare you for theatre. You then meet the anaesthetist, the doctor who puts you to sleep and looks after you during the operation. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances.

You are then taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area. Nurses watch over you while the anaesthetic wears off. Once you are stable, you either move to a ward or go home, depending on the procedure and how your recovery is going.

What the operation involves¶

The operation removes only the worn end of the scaphoid, the small bone deep in your wrist. This is the part that grinds against its two neighbours, the trapezium and the trapezoid. Once that rough surface is gone, the bones no longer rub.

Your surgeon will choose between two ways of reaching the joint. One is a small open incision at the base of your thumb. The other is keyhole surgery, where the surgeon works through a few tiny portals. Either way, only a few millimetres of the worn end of the bone are taken away. Removing just this small amount matters, because taking more bone than needed can let the other wrist bones tilt out of line.

The surgeon works carefully around nearby structures. Small nerves that give feeling to the back of your hand are identified and protected. Care is also taken with the remaining part of the scaphoid and the tendons close to it.

When the worn bone has been removed, the wound is closed with stitches. A dressing goes over the top, and it stays in place for about 10 days.

Afterwards, your wrist and thumb rest in a splint for about two weeks. You cannot drive while the splint is on. Then gentle movement begins, usually with a hand therapist.

On X-rays taken later, the wrist bones often settle into a slightly tilted position. This is expected and is one reason only a small amount of bone is removed.

After the operation¶

You wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Your wrist and thumb rest in a splint, and a dressing covers the wound. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. You may go home the same day or stay one night in hospital after this operation. Both are common, and your team will talk with you about which suits you. Someone should stay with you for the first 24 hours. Pain relief is provided, and your team will help keep you comfortable. You can move around as soon as you feel able, but no driving while the splint is on.

Recovery¶

For the first few days your wrist and thumb will be sore and swollen. This settles gradually. Keeping your hand raised on pillows, above the level of your heart, helps ease the swelling. The pain relief your team gives you keeps you comfortable while the worst passes.

You will wear a splint on your wrist and thumb for about two weeks. It protects the area while the raw surfaces settle. You cannot drive while the splint is on. Once it comes off, gentle movement begins, usually with your hand therapist, Ruby Doolan at Extend Rehabilitation. She will guide your exercises and make any splint you need along the way.

At home, you can use your hand for light tasks as soon as it feels comfortable. Desk work and light daily tasks usually come back first. Heavier work, sport and gym sessions wait until your grip is strong and your wrist moves freely without pain. Driving resumes once the splint is off, you can grip and turn the wheel comfortably, and your surgeon has cleared you. See Driving after upper-limb surgery for more detail.

The final result builds slowly. Pain and strength keep improving for some months, and grip strength in particular can take time to return. Your timeline may differ from others; your surgeon and your therapist will guide you at each step.

What can go wrong¶

Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.

Removing bone from the wrist can let the small bones settle into a more tilted position than expected. If this is severe, the wrist can become unstable, where the bones no longer line up and move together smoothly. You might notice a wrist that feels weak, gives way, or clicks and grinds when you use it. Pain that is different from your original arthritis pain, or that keeps getting worse instead of better, is worth flagging. If this happens, your surgeon will see you and discuss what comes next. In severe cases, further surgery to join some of the wrist bones together may be needed. Call the clinic if pain keeps getting worse despite your pain medicines.

The tendons that bend your fingers and thumb run close to the operated area. One of these can occasionally be damaged or rupture, meaning the tendon tears. You might notice sudden weakness, or a finger or thumb that will not bend the way it used to, sometimes with a snap or pop. Call the clinic if this happens, as a torn tendon usually needs attention.

The wrist bones can also tilt out of line on X-rays taken later. This is expected in many cases and is one reason only a small amount of bone is removed. It usually does not change the result, but your surgeon will keep an eye on it at your reviews.

The complications table on this page lists typical rates if you want the specifics.

When to call us¶

Some problems need quick attention. Go to the emergency department if you have swelling or pain in your calf, shortness of breath, or chest pain. These can be signs of a blood clot. Go to the emergency department if your fingers, hand or thumb turn pale, cold, white, blue or dark.

Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Call us the same day too if pain keeps getting worse despite your pain medicines.

Numbness or not being able to move your arm, hand or fingers is expected in the first 24 hours while the nerve block wears off. Call the clinic once the block has worn off if this does not settle.

If you cannot reach us out of hours or on a weekend, go to your nearest emergency department.

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