What is the treatment for a suspected scaphoid fracture?

Treatment of Suspected Scaphoid Fracture

For suspected scaphoid fractures, initial management should include standard wrist radiographs with a dedicated scaphoid view, followed by MRI without IV contrast if radiographs are negative but clinical suspicion remains high. 1, 2

Initial Evaluation and Management

• Begin with standard wrist radiographs including a dedicated "scaphoid view" to identify fractures 1, 2
• If initial radiographs are negative but clinical suspicion remains high (based on anatomical snuffbox tenderness, pain with axial loading of the thumb), proceed directly to MRI without IV contrast rather than presumptive casting and repeat radiographs 1, 3
• MRI without IV contrast has the highest sensitivity (94.2%) and specificity (97.7%) for diagnosing scaphoid fractures and can detect associated soft tissue injuries 1, 2

Treatment Algorithm

For Radiographically Confirmed Fractures:

• Undisplaced/Stable Fractures:

  • Immobilization with a short arm-thumb spica cast for 8-12 weeks 4, 5
  • Consider percutaneous screw fixation as an alternative to casting, especially for patients who need to return to activities sooner 4, 5

• Displaced/Unstable Fractures (>1mm displacement or lunate dorsal tilt):

  • Open reduction and internal fixation with screw fixation is recommended 4, 6
  • For minimally displaced fractures, closed reduction and percutaneous screw or pin fixation may be considered 4

For Clinically Suspected Fractures with Negative Initial Radiographs:

• Preferred Approach:

  • MRI without IV contrast (highest diagnostic accuracy) 1, 2, 3
  • Treat according to MRI findings - if fracture is present, follow treatment for confirmed fractures 1

• Alternative Approach (if MRI unavailable/contraindicated):

  • CT without IV contrast (particularly useful for suspected hook of hamate fractures) 1, 3
  • Bone scan (becomes positive 1-2 weeks before radiographic changes) 3, 7
  • Immobilization with thumb spica cast and repeat radiographs after 10-14 days 3, 8

Advanced Imaging Considerations

• CT without IV contrast is particularly useful for evaluating fracture complications such as nonunion, malunion, or osteonecrosis in patients with chronic scaphoid fractures 1, 9
• Ultrasound has limited utility with moderate sensitivity (81.5%) and lower specificity (77.4%) and is not recommended for early diagnosis 1
• The use of IV contrast does not provide added benefit for suspected scaphoid fractures 1

Common Pitfalls and Caveats

• Waiting less than 10 days for repeat radiographs risks missing fractures that require treatment, potentially leading to complications including nonunion, malunion, and avascular necrosis 3
• Untreated scaphoid fractures can lead to scaphoid non-union progressing to osteoarthritis 8
• Overtreatment is common - less than 10% of patients with clinically suspected scaphoid fractures and normal initial radiographs actually have occult fractures 8
• For patients with prior scaphoid fractures and chronic pain, either CT or MRI without IV contrast should be performed to evaluate for fracture complications 9