Scaphoid Fractures: Evaluation and Treatment
For suspected scaphoid fractures with negative initial radiographs, obtain MRI or CT within 3-5 days to confirm or exclude the diagnosis, then treat based on fracture displacement: non-displaced or minimally displaced fractures (≤0.5-1.5 mm) can be managed with cast immobilization for 6 weeks with CT confirmation of healing, while fractures with ≥1.5 mm displacement or any proximal pole fractures require surgical fixation.
Initial Evaluation
Imaging Protocol
Start with three-view radiographs (posteroanterior, lateral, and 45° semipronated oblique) as the initial imaging study 1. Two views are inadequate for detecting scaphoid fractures.
When clinical suspicion is high but radiographs are negative:
- Obtain MRI or CT within 3-5 days 2, 3
- MRI detects occult fractures and can change diagnosis in 55% of cases and management in 66% 1
- CT is essential for fracture classification and treatment planning 2, 4
- Ultrasound is NOT suitable (only 47% sensitivity) 1
Critical pitfall: Do not rely on bone scan—it is not indicated 1. Avoid ultrasound for diagnosis due to poor sensitivity.
Initial Immobilization
For suspected fractures pending advanced imaging:
- Recent evidence supports bandaging instead of casting for 3 days until definitive imaging, with noninferior outcomes and better patient satisfaction 5
- Traditional approach uses 2-week casting, but this overtreats 90% of patients who don't have fractures 5
Treatment Algorithm Based on CT Classification
Non-Displaced or Minimally Displaced Waist Fractures (≤0.5 mm)
Conservative management is appropriate 6, 2:
- Immobilize for 6 weeks (below-elbow cast without thumb inclusion is acceptable) 6
- Approximately 90% achieve union at 6 weeks 2, 3
- Obtain CT at 6 weeks to assess healing—look for at least 50% continuous trabecular bridging 6
- If healed on CT, begin mobilization; if not healed, continue casting or consider surgery
Surgical option: Early operative fixation allows quicker return to function but carries surgical risks with no long-term outcome differences compared to casting 6. Reserve for athletes or patients requiring rapid return to activity 7.
Moderately Displaced Waist Fractures (0.5-1.5 mm)
These can be treated conservatively but require prolonged immobilization for 8-10 weeks 2, 3. Consider surgical fixation for patients who cannot tolerate extended immobilization.
Displaced Waist Fractures (≥1.5 mm)
Internal fixation is mandatory 2, 3, 4, 8. Use cannulated headless compression screws as the preferred implant 4, 8. Approach (volar vs. dorsal) depends on fracture geometry determined by CT 9.
Distal Pole Fractures
Conservative treatment is appropriate 2:
- Immobilize for 4-6 weeks depending on fracture type
- Majority heal uneventfully
- Incomplete fractures can also be managed conservatively 7
Proximal Pole Fractures
Surgical fixation is recommended for all proximal fractures 2, 3, particularly any with displacement 10. These have higher nonunion risk due to retrograde blood supply.
Monitoring Healing
CT is the gold standard for assessing union 6, 2, 3:
- Obtain at 6 weeks for initial assessment
- Look for at least 50% continuous trabecular bridging across fracture site 6
- Plain radiographs are insufficient for determining union
Special Considerations
Associated Injuries
Surgical fixation is indicated when scaphoid fractures occur with 10:
- Distal radius fractures
- Perilunate injuries
- Suspected ligamentous injuries (MRI shows concomitant scapholunate ligament tears in many cases) 1
Complications to Avoid
The primary goal is preventing nonunion and scaphoid nonunion advanced collapse (SNAC) 8, 10, which leads to painful osteoarthritis. This requires:
- Accurate initial diagnosis (hence the importance of MRI/CT for negative radiographs)
- Appropriate treatment selection based on displacement
- CT confirmation of healing before mobilization
Key pitfall: Do not rely on radiographs alone to determine healing—they miss occult fractures initially and cannot reliably confirm union 6, 2.