An X-ray didn’t spot my hand fracture – and now I have arthritis  

Cycling to the shops one morning, I was a few streets from home when a student driving a hatchback pulled out without looking and hit me, throwing me in the air.

As I fell, I stretched out my right arm and hand to break my fall.

I staggered to my feet, but such was the force of the impact that, within an hour, my right hand and wrist had swollen to twice their usual size and I was in great pain.

The next day, I went to my GP, who sent me to A&E. There, I was given an X-ray and told I had not sustained a break or a fracture. Just rest it, I was told — the swelling and pain will subside in time.

What happened to me next is a cautionary tale of what can go wrong when what starts as a treatable injury is misdiagnosed.

In fact, I had fractured a bone in my hand. But it took six months to get the right diagnosis and another year to get the right treatment — by which time, the bone had started to die and arthritis had set in.

For people who work with their hands, such as builders, this kind of damage can be life-changing, so it is hardly surprising misdiagnosed fractures like mine are a common reason for orthopaedic-related negligence cases.

But, blithely unaware of all this back then, I tried to tackle the pain by taking paracetamol, strapping a splint or elasticated support to my wrist and avoiding using my hand when I could.

But, after a few weeks with no improvement, I returned to my GP, only to be told again that it needed time to mend. 

Several months later, still with no improvement, I asked for another X-ray. By then, six months had passed since the accident. My worst fears were confirmed: I had indeed suffered a fracture — to my scaphoid, a small, peanut-shaped bone at the base of the thumb.

Delayed: It took six months to get the right diagnosis and a year to get the correct treatment

The scaphoid, which sits between hand and forearm on the thumb side of the wrist, is one of the most common hand bones to break. It is one of eight carpal bones between the bottom of your palm and the top of the wrist.

These bones perform a dual function, allowing free movement of the hand and wrist, while maintaining wrist stability. Not only is the scaphoid one of the most common hand bones to fracture, but the fracture is one of those most likely to be missed.

As many as one scaphoid fracture in 30 is misdiagnosed, estimates David Shewring, a consultant hand surgeon at University Hospital of Wales, in Cardiff, and president of the British Society for Surgery of the Hand.

Moreover, if a fracture is missed, the scaphoid will rarely rejoin, says Mr Shewring. In time, this can cause avascular necrosis — death of the bone, or part of the bone, due to poor blood supply — and early onset arthritis.

The scaphoid is often fractured as a result of a hyper-extension injury to the wrist, such as a fall on an outstretched hand, but you can fracture it even by hitting a funfair punchbag.

Scaphoid injuries are more common in men. ‘They are more likely to play football or rugby, more likely to get drunk and fall over and more likely to get into fights,’ says Mr Shewring.

‘Someone like me with a scaphoid non-union [fracture] with arthritis may develop a chronically painful, stiff wrist,’ writes Mr Membery

Anyone in A&E treating someone with an injury to the hand and wrist caused by something like this ‘should have a strong suspicion that a scaphoid fracture has occurred’, he adds.

Tenderness in the area around the scaphoid is another warning sign. In such cases, scaphoid-specific X-rays should always be done, says Mr Shewring. This means X-raying the hand from four different angles, which creates a much higher chance of revealing the fracture.

‘If a scaphoid-specific X-ray is undertaken, there is a 90 per cent chance of the fracture being identified,’ he says. ‘Emergency units tend to be cautious about missing a scaphoid fracture — and rightly so, because of the long-term implications.

‘So there are quite strict guidelines about what to do when one is suspected.’

Even if a fracture is not identified, Mr Shewring says that a patient with symptoms characteristic of such injuries, such as severe swelling and bruising of the wrist caused by a fall on an outstretched hand, should still be treated as if they have a scaphoid fracture.  The treatment is fairly straightforward, with the wrist put in plaster for six to eight weeks. ‘If this is done, approximately 90 per cent of scaphoid fractures will heal,’ says Mr Shewring.

If a fracture is not visible, but there is a suspicion that the scaphoid has been fractured, ‘the wrist should be supported in a cast or splint and re-examined ten days later,’ he adds.

After my fracture was diagnosed, I was referred to a specialist unit at another hospital. But it seems the initial misdiagnosis was just the beginning of my woes. By the time I eventually got my first appointment in summer 2016, scans showed that necrosis and arthritis had already set in.

Arthritis will develop in nearly 100 per cent of untreated scaphoid fractures, explains Mr Shewring. If arthritis hasn’t set in, there are two options: a vascularised graft, where a piece of bone with its blood vessel still attached (usually taken from a bone in the forearm) is used to join the break; or a non-vascularised graft, taken from the pelvis.

One doctor told me the former’s success rate was 60 per cent at best, but another told me that, in her native Australia, they would have automatically tried to reconnect the blood supply to the bone.

The months dragged on and, around 18 months after my accident, I was given a date for surgery, only for it to be cancelled at the last minute. I was given a second date two months later, only to be told on the eve of the operation that they couldn’t fit me in that day after all. So by the time I had my surgery, in late 2017, it was almost two years since my accident.

Had surgery been carried out within a few months of the fracture, a bone graft would normally have been performed. Instead, the delay meant that surgeons could only carry out a ‘salvage’ operation, removing nerve endings in the wrist to tackle the pain, but not trying to unite the fractured bone.

‘If arthritic changes have developed in the wrist, rejoining the bone may then be pointless,’ explains Mr Shewring.

Yes, the swelling has gone and I can still swim, cycle and walk the dog, but when it’s cold, my wrist hurts and I can’t lift anything heavy with that hand, even the kettle sometimes.

The surgeon who carried out the procedure said afterwards that, in time, someone like me with a scaphoid non-union [fracture] with arthritis may develop a chronically painful, stiff wrist. 

This can obviously affect one’s ability to work and result in the need for surgery to fuse the wrist using a titanium plate. This would make the wrist stiffer, resulting in the loss of up-and-down movement of the hand, but reduce the pain.

The NHS may be a marvellous institution in many respects, but, as Mr Shewring observes: ‘It’s a shame your scaphoid fracture wasn’t identified. If it had been, then you’d have been put in a plaster for six to eight weeks and you would have probably avoided all these problems.’

British Society for Surgery of the Hand, bssh.ac.uk