What is the best approach for managing a scaphoid fracture?

Management of Scaphoid Fracture

The best approach for managing a scaphoid fracture is initial radiographic assessment followed by appropriate treatment based on fracture characteristics, with undisplaced fractures managed conservatively with cast immobilization and displaced fractures requiring surgical fixation.

Initial Diagnosis

Imaging Protocol

1. Standard Radiographs:

   • Begin with wrist radiographs as the initial imaging examination 1
   • Include specialized views such as carpal tunnel or semipronated oblique projection ("scaphoid view") to detect radiographically occult fractures 1

2. Advanced Imaging for Suspected Fractures Not Visible on X-ray:

   • MRI without IV contrast is the preferred next step when radiographs are normal but clinical suspicion remains high 1
   • CT without IV contrast is an acceptable alternative, especially for detailed bone cortex and trabecular evaluation 1
   • Bone scan can reliably exclude occult scaphoid fractures (high sensitivity) but has lower specificity than CT or MRI 1

Classification of Fractures

Scaphoid fractures should be classified into two main categories:

• Undisplaced/stable fractures: No significant displacement between fragments 2, 3
• Displaced/unstable fractures: Greater than 1mm of fracture offset or an instability collapse pattern (dorsal lunate rotation) 3

Treatment Algorithm

For Undisplaced/Stable Fractures (≤2mm displacement):

1. Conservative Management:

   • Short-arm thumb spica cast immobilization for 6-10 weeks 2, 3
   • Position of volar flexion-radial deviation is preferred 3
   • Recent high-quality evidence from the SWIFFT trial strongly supports cast immobilization as first-line treatment 4, 5

2. Follow-up Protocol:

   • Regular radiographic assessment to confirm healing
   • If non-union is suspected, confirm with advanced imaging (MRI or CT) 1
   • Proceed to urgent surgical fixation for confirmed non-union 4, 5

For Displaced/Unstable Fractures (>2mm displacement):

1. Surgical Management:

   • Open reduction and internal fixation (ORIF) with headless compression screws 2
   • For minimally displaced fractures, consider closed reduction and percutaneous screw or pin fixation 2

2. Post-surgical Protocol:

   • Early mobilization after secure internal fixation 2
   • Consider playing splint for athletes after secure fixation 2

Complications to Monitor

1. Surgery-related complications (14% in surgical group vs 1% in cast group) 4:

   • Infection
   • Nerve injury
   • Hardware problems

2. Cast-related complications (18% in cast group) 4:

   • Skin breakdown
   • Complex regional pain syndrome
   • Stiffness

3. Long-term complications:

   • Non-union (rare with appropriate treatment)
   • Avascular necrosis (especially with proximal pole fractures)
   • Osteoarthritis

Key Points for Clinical Practice

• The SWIFFT trial demonstrated no significant difference in patient-rated wrist evaluation scores at 52 weeks between surgical fixation and cast immobilization for minimally displaced fractures 4, 5
• Non-union rates are very low with appropriate treatment (1/219 in surgery group vs 4/220 in cast group) 5
• Cast immobilization followed by surgery for confirmed non-union is more cost-effective than immediate surgical fixation 5
• Fracture displacement greater than 1mm regularly leads to pseudarthrosis if not surgically addressed 6

Common Pitfalls to Avoid

1. Missed diagnosis: Ensure proper scaphoid views are obtained during initial radiographic assessment
2. Inadequate immobilization: Ensure proper cast technique and duration
3. Delayed treatment of non-union: Promptly identify and surgically fix non-unions
4. Unnecessary surgery: Avoid immediate surgical fixation for undisplaced fractures as evidence shows cast immobilization is equally effective with fewer complications 4, 5

By following this evidence-based approach, most scaphoid fractures will heal successfully with optimal functional outcomes and minimal complications.