From the Guidelines
Scaphoid fractures should be treated with surgery when fracture fragments are large, articular, or significantly displaced, while simple immobilization is appropriate for small, nonarticular, or minimally displaced fractures. The diagnosis of a scaphoid fracture is based on a history of trauma and focal pain on palpation, and is confirmed with radiographic studies 1. When considering treatment options, it's essential to prioritize approaches that minimize morbidity, mortality, and improve quality of life.
Treatment Approaches
- For nondisplaced or minimally displaced fractures, immobilization in a thumb spica cast for an extended period may be sufficient, as it allows for proper healing while minimizing complications 1.
- However, for more complex fractures, surgical intervention may be necessary to ensure proper alignment and healing, thus reducing the risk of long-term complications such as nonunion or avascular necrosis.
- The choice between immobilization and surgery should be guided by the severity of the fracture, with a focus on preventing future complications that could impact the patient's quality of life.
Considerations for Treatment
- The unique blood supply of the scaphoid bone, which enters distally and supplies the proximal pole retrograde, plays a crucial role in determining the treatment approach, especially for proximal pole fractures 1.
- Given the potential for significant morbidity associated with scaphoid fractures, particularly those that do not heal properly, it's critical to select a treatment approach that balances the need for immobilization with the potential benefits of surgical intervention, always prioritizing the patient's long-term quality of life.
From the Research
Treatment Options for Scaphoid Fractures
- Nonsurgical treatment with cast immobilization is recommended for stable, nondisplaced or minimally displaced scaphoid fractures 2, 3, 4, 5, 6
- Immobilization of the thumb may be unnecessary for nondisplaced or minimally displaced fractures of the waist of the scaphoid 4
- Operative intervention is the recommended treatment for displaced scaphoid fractures 2, 3, 5, 6
- Early surgical intervention for nondisplaced or minimally displaced scaphoid waist fractures allows for quicker return of function, but with increased risk of surgical complications and no long-term outcomes differences compared with cast immobilization 6
Diagnostic Procedures
- Bone scans are recommended if the diagnosis cannot be established by clinical and radiographic examination 2
- Advanced imaging such as CT or MRI should be obtained if clinical suspicion is present for a scaphoid fracture with negative radiographs more than 2 weeks after the injury 3, 5, 6
- CT scan is the best method to determine union, with at least 50% continuous trabecular bridging across the fracture site deemed sufficient to begin mobilization 6
Treatment Protocols
- Treatment protocols may include:
- Bone scan or advanced imaging for early diagnosis 2, 3, 5, 6
- Percutaneous screw fixation of nondisplaced or minimally displaced scaphoid fractures as an alternative to treatment with a thumb spica cast 2
- Open reduction of displaced scaphoid fractures 2, 3, 5
- Early mobilization of stable fractures after internal fixation 2, 6
- Aggressive conservative treatment involving 6 weeks of immobilization with CT assessment to guide the need for continued casting, surgical intervention, or mobilization 6