Scaphoid stories

I call this piece "six months of scans piled on the table"

What do Nico Vouilloz, Blenkie, Katy WintonCameron Cole, Adam Brayton, Remi Gauvin, Cedric Gracia (and many, many more) have in common?

Yup, they’re faster than you*.

And they’ve all broken their scaphoid(s).

I didn't break anything here, but you get the idea, Toby on the conveniently located camera.

I also have this in common, in amongst my 20+ broken bones from head (left lower orbital) to toe (left 5th phalanges proximales) I can include my scaphoid. I might also be faster than you, but then again, mibbies no.

When I broke my scaphoid I struggled to find good information online relative to biking so there’s a content niche there to exploit, but before that, some caveats:

1) Why are you trying to diagnose and heal your wrist online? Go to a bloody doctor.
2) Stop reading about scaphoid injuries online, all you’re going to find are the bad news stories where there was non union and the hand fell off**, no one puts up the tales of when they broke their wrist, followed medical advice and returned to riding fine a couple months later.
3) I’ve dealt with the Scottish NHS and Haute Savoie medical system. Your mileage may vary.

Caveats done.

The small bolt nicely shows exactly where the scaphoid is. Handy that.

Let’s start at the beginning, what is the scaphoid? The scaphoid, or navicular if you’re American, is one of the carpal bones of the wrist, situated towards the base of the thumb where the radius (the bigger of your 2 arm bones) meets the wrist. If you put your thumb into the hitchhiking thumbs up position, then prod a finger into the triangle made by the tendons of the thumb by the junction with the arm, you’ll probably find your scaphoid. If that’s too hard, the scaphoid is the one with the small bolt in it, image above. The scaphoid is different to the majority of bones in the body in that most of the blood supply comes from the distal (finger) end of the bone then flows through the bone to the proximal (arm) end rather than having equally good connections at either end. It’s the most common bone to fracture of the wrist, and the most common fracture mechanism is a fall to outstretched wrist.

What sort of breaks are there of the scaphoid? Firstly breaks range from tiny wee cracks where the bone is still mostly intact and stable, through to completely severed bones or a ‘displaced fracture’ in medic speak. Tiny wee cracks in a stable fracture is what you want the doctor to say, displaced fracture isn’t. The location of the fracture on the scaphoid is important too. Fractures at the finger and thumb end, or ‘distal pole,’ are better news than in the middle, or ‘waist,’ of the bone. In turn, a fracture at the arm end of the bone, or ‘proximal pole’ is the slowest to heal.

Why is breaking a scaphoid bad? Normally when you break a bone it’s a fairly quick return to the bike, especially for pros who have a far better range of health care, physio and drugs available to help them bounce back. The scaphoid is generally not a quick return, pro or not. When a bone is broken it relies on a good blood supply to bring the assorted materials required for creating the callus and ultimately reuniting the bone. As the scaphoid gets most of its blood from just the one end of the bone, when you split that bone in half it leaves the proximal, or arm, end of the bone poorly provided with blood and hence not getting supplied with all the healing goodness required. To further compound matters, breaking a bone is generally the result of trauma so there’s a good chance the soft tissues of the wrist will be damaged and swollen and the blood supply further constricted.

This is my wrist about 3 hours after the crash. This is not what a wrist should look like and it was about now I was told I was probably going to have wrist permanently fused :-(

How can you tell if your scaphoid is fractured? Easy, you get off google and go to a hospital where they have a range of highly trained professionals and expensive diagnostic machinery. Admittedly even then it can be hard to diagnose immediately due to other trauma so it’s not uncommon for the wrist to be immobilized as a precautionary measure and you telt to come back 5 days or so later when the swelling’s gone down a bit for a better look.

Let’s assume you’re off to the hospital anyway.

If you’ve crashed and landed on your hands, you might have fractured something in your wrist. Pain and stiffness in the wrist is a good indication something’s wrong. Being unable to get your thumb into the hitchhiking position another sign, and pain or loss of strength when trying to pinch something between fingers and thumb is yet more indication. When I broke mine it was fairly easy to tell as I’d put my left arm bones through my wrist, snapping the scaphoid cleanly in half, breaking my ulna and fully dislocating my wrist (I’d also broken some bones in my right arm and wrist, but my attention was kinda focused on my left arm at the time, a good reminder that the bit that hurts might not be the only issue post crash) however friends have broken their scaphoid and not had it diagnosed for up to 6 weeks, in which time they’d kept riding, gone on road trips, ridden some MX… My x-rays also showed I’d previously broken several other bones in my wrists and not known. In summary, if it hurts, go to the fucking hospital.

So you’ve broken your scaphoid, what are the immediate medical options? Well, what country you’re in and what the surgeon’s experience is all have a bearing here, but generally it’s one of two things. For a non displaced wee fracture of the distal end of the scaphoid, then immobilization in a cast for at least 6 weeks is the probable outcome. A fully displaced fracture of the proximal pole will most likely require surgery. A fracture in between these extremes will receive a treatment in between. The younger, healthier and/or more active you are, the more likely it is you get surgery. Surgery is generally ‘internal fixation’ a.k.a. ‘screwing the bone back together’. This is most commonly in the form of a Herbert screw which is headless screw with two different thread pitches that tighten the two halves of the bone together as it’s inserted and gets buried in the bone forever, but other methods exist.

Four months after crash. I'm not saying one pole skiing is a good idea for the wrist, but it's a good idea for the head.

What are the secondary medical options? This is where it gets interesting. The above information is pretty easy to glean from a few hours of scrolling through the internet. Information of how to maximise your chances of getting a quick recovery is harder to find.

Firstly there’s the easy gains. Don’t use the arm. It’s been immobilized for a reason, going biking with your arm in a cast is not going to help matters.

Next, do everything you can to maximize the quantity and quality of the blood supply to the scaphoid. Ultimately it’s the blood that’s going to supply the required materials and remove the waste so you want this to be as good as it can be (a 2015 study where old mice were given blood from young mice showed a huge increase in bone fracture healing speeds, so going full vampire might help older readers…). Hence, avoid alcohol, salt and smoking. Obviously as a Scot my normal evenings activity is to sit on the sofa with a fish supper, a can of Super T and 20 benson and hedges listening to the Proclaimers*** so that had to change.

Getting more marginal in the gains, your diet can make a bit of a difference. Bone healing uses a lot of calories, a major bone fracture might need you to treble your calorie intake. The scaphoid is not a major bone, in fact it’s tiny, so you don’t need a massive increase in food, but you might as well try and improve the quality of what you’re eating to ensure that tenuous wee bugger of a bone joins. Fracture healing is a hugely complex process that’s still not completely understood, but there are assorted minerals and vitamins you can take supplements of that might improve blood supply and healing. Firstly, make sure you are eating enough protein, one of the major building blocks of bones. You don’t need to be drinking milk/steak smoothies, but bean sprouts, broccoli, spinach and the like are all high in protein and full of other useful nutrients. The generally agreed on minerals are calcium, iron and zinc whilst the alphabet of vitamins focuses on A, C, D, E & K. Beyond these there are all manner of articles proposing the myriad benefits of whatever the website happens to be selling.  By all means go for it, but do a bit of research before hand. You should get sufficient of them already from a healthy balanced diet, some supplements might help, some might make you think they’re helping, some might do nothing but some might actually hinder healing and that’s probably best avoided.

A number of anti inflammatory drugs also affect the healing process by inhibiting crucial enzymes, so unless prescribed don’t start necking ibuprofen or the like to try and help. Instead foods high in Omega 3 and Vitamins C & E help with the natural anti inflammatory mechanisms within the body and work to remove the waste products (free radicals, a band, terrorist group or medical term depending on your frame of reference) of the fracture healing process. So a nice kale and spinach salad with lemon dressing then, though the most efficient way to get omega 3 does seem to be from oily fish such as salmon or mackerel.

You might be able to get access to a bone growth stimulator. These emit electromagnetic or low powered ultrasound waves, depending on the device, and some studies have shown improved healing times with their use. Certainly there doesn’t seem to be any negative side effects, so if you have the opportunity it’s probably worth giving it a bash.

It seems an obvious solution that if you want to increase the blood supply to the wrist, you should go and exercise and increase the blood flowing round your body. Simples aye? Unfortunately there doesn’t seem to be any evidence to back this one up, although it’s likely your physio will give you some exercises that might help a little. There are plenty studies that show a considerable link between exercise and mental health however. There are also a number of studies linking mental health and healing rates. The happier you are the quicker you heal, so if the idea of weeks or months away from exercise has got you depressed, then finding some form of activity that won’t risk the delicate joining of the scaphoid but stops you going stir-crazy is probably a good idea.

Five months after fracture and the wrist is strong enough to drink a cup of tea. This is a very important moment for me!

How long is going to be before I can play out on my bike? Healing can take a long time. A very long time. If you’re lucky you can be in a cast for 4 weeks, another couple weeks of rest and you’re back on the bike. Normally it’s more like three plus months away from the bike. Eight months is not uncommon. It took me five months before my surgeon was confident that there was bone union and another 3 months before he was happy enough for me to start “light exercise” of the wrist. 12 months off the bike is still better than never riding again so if that’s what it’s taking to heal then that’s what it’s taking to heal. It’s not what you want to hear but shit happens.

For the first few months of my recovery I would be asking the surgeon roughly how long he thought it would take me to get back on the bike, then if he thought I would get back on the bike. The response centered on the phrase “gros traumatisme” and avoiding answering, however I’ve been told I wouldn’t ski at a high standard again after a leg injury and that I’d not have a working shoulder after 30, so don’t get too disheartened by any lack of enthusiasm for your return to biking. Anyways, after all this you need to start physio to get back on the bike. Listen to your physio and do what they tell you. If you’re not getting the treatment you think you need, change. Go private, whatever.

One of the first rides back after 8 months off the bike. Braces, physio and patient friends are grand!

How do I go biking again? Even once you get the all clear for returning to the bike it’s likely you’re going to need to protect the wrist for the first 12 months, or possibly forever. At first your mobility will be much restricted and the whole arm, wrist and hand will be weaker, even if you’ve done all your physio. There are a variety of wrist braces out there, ranging from the cheap and basic through to massively expensive. Within reason, you get what you pay for. The more expensive braces, particularly those that originate from motocross, allow you to regulate the range of movement you have before they kick in and can help you gradually increase the load the muscles are taking.

I use the Allsportsdynamics IMC/Sport wrist brace which I chose by looking at all the riders listed above that have broken their scaphoids and noticing that they were almost all using variations of that brace. The Mobius brace gets good reviews too. If using the Allsportsdynamics brace then get the glove pockets too as it’s much better than bodging it onto your hand with velcro.

Twenty months after I broke my scaphoid (and ulna and had 3 surgeries to dis-dislocate my wrist) and following lots of help from Janie and the rest of the team at Clinique du Sport in Chamonix, I have about 60% mobility, 75% strength and get all sorts of pain and discomfort during riding. But, with the brace, I can on a good day ride more or less as I used to and I suspect it’s my head rather than my body that’s stopping me from get fully back to where I was. It turns out after enough injuries you start to lose interest in getting hurt again. You might be lucky and don’t need a brace afterwards. I do. It’s better than not riding.

A couple weeks after my crash I was meant to be going to Whistler. 13 months later, I got to go to Whistler. I rode A-Line a bit. It's good to have a target....

This has probably been my longest post ever, and if you’ve managed to read through all that then I wish you all the best with your recovery. What I won’t do is wish you luck, luck has nothing to do with it. Ultimately YOU need to take charge of healing. The A&E team, the orthopedic surgeon, the physio will all try and help you heal, but if you don’t take control of your injury and work with them, look at what they’re doing, ask questions, see how you can heal better, then how do you expect to get back riding quickly? All those riders up there have come back from injury stronger again and again. They don’t do that by ignoring the issue, they do it for the same reasons they are better than you on a bike, because they keep trying, keep working, until they’re sorted.

I'll not lie, missing trips like this because an injury kept me off the bike forever would get me down, but I remind myself that this was so good because I shared it with friends, the bike was just the medium for it. There are other sports, there are other activities, the people are the important part.

Further reading. I canny recommend Dave MacLeod’sMake or Break‘ highly enough. Focused on climbing injuries, but the mechanisms for healing described within are valid across all injuries. Whilst I’m at it, as sporting self help books go, his ‘9 out of 10 climbers…‘ is pretty good reading too.

I’d also recommend having a look at a couple of online articles by injured mountain bikers which will hopefully help put things in perspective, namely Lorraine Truong, Tara Llane and Martyn Ashton

Twenty months later, 95% back. That'll do me.

*Unless you’re Aaron Gwin, in which case, hiya!
** I’ve not read of someone’s hand falling off, though some of the MX injuries ain’t far off.
***There is no medical evidence yet linking the Proclaimers to delayed bone union.

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