From the Guidelines
Scaphoid fractures require prompt diagnosis and treatment, and according to the most recent evidence, immobilization in a thumb spica splint and radiographs are the initial steps, with possible follow-up imaging such as MRI or CT scan within 1-2 weeks to confirm diagnosis. The diagnosis of scaphoid fractures is based on a history of trauma and focal pain on palpation, and is confirmed with radiographic studies 1. For nondisplaced fractures, treatment typically involves 6-12 weeks of immobilization in a short or long arm cast with the thumb included. Displaced fractures (>1mm gap or >60° scapholunate angle) generally require surgical fixation with headless compression screws. The proximal pole has a particularly high risk of avascular necrosis due to its retrograde blood supply pattern, with 60-90% of the scaphoid's blood supply entering distally.
Some key points to consider in the management of scaphoid fractures include:
- Immobilization in a thumb spica splint and radiographs as initial steps
- Possible follow-up imaging such as MRI or CT scan within 1-2 weeks to confirm diagnosis
- Treatment of nondisplaced fractures with 6-12 weeks of immobilization
- Surgical fixation with headless compression screws for displaced fractures
- High risk of avascular necrosis in the proximal pole due to its retrograde blood supply pattern
The most recent evidence from 2024 suggests that MRI without IV contrast or CT without IV contrast is usually appropriate as the next imaging study for chronic wrist pain following normal radiographs or radiographs remarkable for nonspecific arthritis 1. Additionally, either CT or MRI without IV contrast is usually appropriate in patients with suspected radiographically occult fractures or stress fractures, and in patients with prior scaphoid fractures and chronic pain to evaluate for fracture complications 1.
In terms of imaging, either MRI without IV contrast or CT without IV contrast is usually appropriate for evaluating scaphoid fractures, and only one of these tests is necessary. The use of IV contrast for MRI may be appropriate in some cases, but it is not usually necessary 1. Regular follow-up with serial radiographs is essential to monitor healing, and patients should be counseled about potential long-term complications even with appropriate treatment.
From the Research
Diagnosis of Scaphoid Fractures
- Scaphoid fractures are among the most common fractures of the bones of the wrist and usually result from a forceful extension of the wrist 2.
- If the diagnosis cannot be established by clinical and radiographic examination, bone scans are recommended and are preferred over tomography or MRI, which are more expensive diagnostic procedures 2.
- In cases of suspected scaphoid fracture where the initial radiographs are negative, a supplementary MRI, or alternatively CT, should be carried out within three to five days 3.
Classification and Treatment of Scaphoid Fractures
- Scaphoid fractures should be classified as either undisplaced, stable or displaced, unstable 2.
- Nonsurgical treatment with cast immobilization (short arm-thumb spica cast) is recommended for stable fractures; however, there is increased interest in percutaneous screw (or pin) fixation 2.
- The recommended treatment for unstable scaphoid fractures is open reduction and screw fixation 2.
- Percutaneous treatment of both nondisplaced and displaced scaphoid fractures reportedly can achieve a nearly 100% union rate with minimal complications 4.
- For most patients with nondisplaced or minimally displaced scaphoid waist fractures, consideration for aggressive conservative treatment involving 6 weeks of immobilization with CT assessment to guide the need for continued casting, surgical intervention, or mobilization is advocated 5.
Immobilization Protocols
- Immobilization protocols for nondisplaced scaphoid fractures have included the elbow, wrist, and thumb 6.
- Wrist immobilization is crucial for nondisplaced scaphoid waist fractures, and short arm casting was just as effective as thumb spica casting in preventing fracture displacement 6.
- When treating nondisplaced or minimally displaced scaphoid waist and distal pole fractures, immobilization below the elbow without inclusion of the thumb is an option 5.
Determination of Union
- Determination of union is best done with a CT scan at 6 weeks and at least 50% continuous trabecular bridging across the fracture site deemed sufficient to begin mobilization 5.
- After adequate conservative management, union is achieved at six weeks for approximately 90% of non-displaced or minimally displaced (≤ 0.5 mm) scaphoid waist fractures 3.