What is the recommended treatment for a scaphoid fracture, specifically regarding immobilization and splinting?

Management of Scaphoid Fractures: Immobilization and Splinting Recommendations

The recommended treatment for scaphoid fractures is immobilization with a short-arm thumb spica cast for stable, non-displaced fractures, while displaced or unstable fractures require surgical intervention with internal fixation. 1, 2

Classification and Diagnosis

• Scaphoid fractures should be classified as either:

  • Undisplaced/stable: No significant displacement (<1mm)
  • Displaced/unstable: >1mm displacement or dorsal lunate rotation 3

• If diagnosis cannot be established by clinical and radiographic examination:

  • MRI without IV contrast or CT without IV contrast is recommended 4
  • Bone scans are a reasonable alternative, especially for claustrophobic patients 4, 2

Treatment Algorithm

For Non-displaced/Stable Fractures:

1. Immobilization with short-arm thumb spica cast 2

   • Position: Volar flexion with radial deviation provides optimal results 3
   • Duration: 6 weeks minimum, with follow-up radiographs to confirm healing 5

2. Alternative approach: Percutaneous screw fixation may be considered, especially for athletes or those requiring faster return to activities 2

For Displaced/Unstable Fractures:

1. First-line treatment: Open reduction and internal fixation (ORIF) with screw fixation 2

   • For minimally displaced fractures: Consider closed reduction with percutaneous screw/pin fixation
   • For significantly displaced fractures: Open reduction is necessary

2. Post-surgical immobilization:

   • If secure fixation is achieved: Early mobilization may be possible
   • Athletes may use a playing splint after secure internal fixation 2

Important Considerations

• Thumb immobilization: Research shows that immobilizing the thumb may not be necessary for all scaphoid fractures. A randomized trial of 392 fractures found no difference in nonunion rates between forearm gauntlet casts (leaving thumb free) and conventional thumb spica casts 6

• Duration of immobilization: For vascularized bone grafting in scaphoid nonunion, immobilization for ≤7 weeks is recommended if intraoperative fixation is solid and follow-up radiographs show normal healing 7

• Emergency considerations:

  • If a fractured extremity appears blue, purple, or pale, activate emergency services immediately 4
  • Cover open wounds with clean dressing to prevent contamination and infection 4
  • Splinting can reduce pain, prevent further injury, and facilitate transport 4

Complications of Immobilization

• Excessive immobilization risks include:
  • Chronic pain
  • Joint stiffness
  • Muscle atrophy
  • Complex regional pain syndrome 1

Follow-up Care

• Radiographic follow-up should be performed at 3 weeks and at cessation of immobilization 1
• Approximately 90% of fractures unite within 12 weeks 1
• Early range of motion exercises should begin after immobilization to prevent stiffness 1

By following these guidelines, optimal outcomes for scaphoid fractures can be achieved with appropriate immobilization techniques and timely surgical intervention when indicated.