From the Guidelines
The most appropriate initial step in management for this 15-year-old boy with suspected scaphoid fracture is immobilization with a thumb spica splint. This recommendation is based on the clinical presentation of tenderness in the anatomical snuffbox and pain on active range of motion of the thumb, which strongly suggests a scaphoid fracture given the mechanism of injury (fall onto an outstretched hand) 1. The thumb spica splint specifically immobilizes the wrist and the thumb, which is crucial for protecting the scaphoid bone while awaiting definitive diagnosis.
Key considerations for immobilization include:
- Immobilizing the wrist and thumb to prevent further injury and reduce pain
- Applying the splint with the wrist in slight extension and the thumb partially abducted in a functional position
- Referring the patient for follow-up imaging, either repeat X-rays in 10-14 days or preferably an MRI when available, to confirm the diagnosis
- Advising the patient to keep the wrist elevated and apply ice to reduce swelling
The evidence from 1 supports the importance of fracture immobilization as an essential part of definitive fracture treatment, and splinting as a first aid measure may be helpful to reduce pain, prevent further injury, and facilitate transport. Although there is a lack of evidence demonstrating clear benefits from fracture splinting in the prehospital first aid setting, the clinical presentation and potential risks of complications such as avascular necrosis or nonunion justify the use of a thumb spica splint in this case.
From the Research
Immobilization for Scaphoid Fracture
- The most appropriate type of splint for immobilization in a 15-year-old boy with suspected scaphoid fracture is a short arm-thumb spica cast 2.
- This type of cast is recommended for stable fractures, which are classified as undisplaced or minimally displaced 2.
- The use of a short arm-thumb spica cast allows for immobilization of the wrist and thumb, while also permitting some movement of the fingers.
- In cases where the fracture is unstable, or displaced, open reduction and screw fixation may be necessary 2.
Alternative Splint Options
- A forearm-based thumb-spica splint or a hand-based thumb-spica splint may also be used for immobilization, particularly in cases where early mobilization is desired 3, 4.
- These types of splints can be custom-made to fit the individual's hand and wrist, and can be adjusted to allow for varying degrees of movement.
- However, the use of these alternative splints may not provide the same level of immobilization as a short arm-thumb spica cast, and may not be suitable for all types of scaphoid fractures.
Considerations for Immobilization
- The choice of splint will depend on the specific characteristics of the fracture, as well as the individual's overall health and activity level 2, 4.
- It is important to follow a treatment protocol that includes regular follow-up appointments and monitoring to ensure proper healing and to prevent complications 2, 4.
- The use of a splint should be combined with other treatments, such as pain management and physical therapy, to promote optimal recovery 3, 4.