What is the recommended treatment for a scaphoid fracture?

Treatment for Scaphoid Fracture

The recommended treatment for scaphoid fractures depends primarily on fracture displacement, with non-displaced fractures typically managed conservatively using cast immobilization for 6 weeks, while displaced fractures (>1mm offset) require surgical intervention with open reduction and internal fixation to optimize healing and functional outcomes. 1

Fracture Assessment and Classification

• First determine if the fracture is:

  • Non-displaced/minimally displaced (<1mm offset)
  • Displaced (>1mm offset or instability collapse pattern with dorsal lunate rotation)
  • Location: proximal pole, waist, or distal pole

• When radiographs are inconclusive:

  • Obtain CT scan or MRI for definitive diagnosis
  • Consider stress views, traction oblique views, or tomography if needed 2

Treatment Algorithm

Non-displaced/Minimally Displaced Fractures

1. Conservative Management (First-line)

   • Short-arm thumb spica cast for 6 weeks 2, 1
   • Wrist position of volar flexion with radial deviation provides optimal results 2
   • CT assessment at 6 weeks to evaluate healing (≥50% trabecular bridging indicates sufficient healing) 1
   • If healing is progressing, begin mobilization
   • If healing is inadequate, continue immobilization or consider surgical intervention

2. Surgical Option (Alternative)

   • Consider for patients who need quicker return to function
   • Note: Provides faster functional recovery but with increased surgical complications
   • No difference in long-term outcomes compared to conservative treatment 1

Displaced Fractures (>1mm offset)

1. Initial Attempt at Closed Reduction

   • Long-arm cast with wrist in flexion and radial deviation 2
   • Radiographic confirmation of reduction

2. Surgical Management (Recommended)

   • Open reduction and internal fixation if:
     • Reduction cannot be achieved or maintained
     • Fracture displacement >1mm
     • Proximal pole fractures (higher risk of non-union)
   • Surgical approach based on fracture characteristics 3

Special Considerations

• Proximal Pole Fractures: Higher risk of non-union; surgical fixation often preferred even if non-displaced 3
• Distal Pole Fractures: Good blood supply; conservative treatment often successful 1
• Patient Factors: Consider activity level, occupation, and compliance with immobilization

Follow-up Protocol

• CT scan at 6 weeks to assess healing 1
• Continue immobilization if healing is incomplete
• For conservatively managed fractures that show delayed healing:
  • Consider extending immobilization up to 8-12 weeks 4
  • If no progression toward union after extended immobilization, consider surgical intervention

Complications and Management

• Non-union (occurs in 5-15% of cases) 5

  • Surgical treatment recommended
  • Options include bone grafting with internal fixation
  • Undisplaced non-unions: inlay bone graft via dorsal or volar approach
  • Displaced non-unions: dorsal approach with internal fixation (especially with radioscaphoid arthrosis) or volar approach with fixation 2

• Avascular Necrosis: More common in proximal pole fractures due to tenuous blood supply

  • May require vascularized bone grafting

Key Pitfalls to Avoid

• Failing to obtain adequate imaging for diagnosis
• Underestimating the importance of fracture displacement in treatment decision
• Premature discontinuation of immobilization before adequate healing
• Delaying surgical intervention when indicated by displacement or location
• Not recognizing proximal pole fractures as higher risk for complications

Remember that early appropriate treatment leads to better outcomes and reduces the risk of non-union and subsequent degenerative wrist arthritis 5.