What is the treatment for a scaphoid fracture?

Treatment of Scaphoid Fractures

For stable, non-displaced scaphoid fractures, treat with short-arm thumb spica cast immobilization for 6-12 weeks, while displaced or unstable fractures require open reduction and internal screw fixation. 1, 2

Classification-Based Treatment Algorithm

Stable, Non-Displaced Fractures

• Cast immobilization is the standard treatment with a short-arm thumb spica cast positioned in slight volar flexion and radial deviation 1, 3
• Immobilization of the thumb interphalangeal joint is not necessary—a forearm gauntlet cast leaving the thumb free achieves equivalent union rates 4
• Duration of immobilization typically ranges from 6-12 weeks until radiographic union is confirmed 1, 2
• Percutaneous screw fixation is an alternative option for patients who wish to avoid prolonged immobilization or require early return to activities, particularly athletes 1, 2, 5

Displaced or Unstable Fractures

Operative intervention is indicated when:

• Fracture displacement exceeds 1 mm 3
• Dorsal lunate rotation (instability collapse pattern) is present on lateral radiographs 3
• Proximal pole fractures are present (higher risk of nonunion and avascular necrosis) 2

Surgical approach:

• Open reduction and internal screw fixation is the recommended treatment for all displaced fractures 1, 3, 2
• Closed reduction with percutaneous screw or pin fixation may be considered only for minimally displaced or easily reducible fractures 1
• Early mobilization is possible after secure internal fixation 1

Important Clinical Considerations

Diagnostic Confirmation

• If initial radiographs are negative but clinical suspicion remains high (positive snuffbox tenderness or axial thumb loading pain), proceed directly to MRI without IV contrast rather than presumptive casting 6, 7
• MRI has the highest diagnostic accuracy with 94.2% sensitivity and 97.7% specificity 6, 7
• If MRI is unavailable, immobilize and repeat radiographs at 10-14 days (not earlier, as premature imaging risks missing occult fractures) 8

Common Pitfalls to Avoid

• Do not delay treatment of displaced fractures—these require operative fixation to prevent nonunion, malunion, and avascular necrosis 5
• Do not use long-arm casts for stable fractures—short-arm immobilization is sufficient 1
• Avoid wrist extension positioning—volar flexion with radial deviation provides superior outcomes with 100% union rates 3
• Do not perform repeat radiographs before 10-14 days—earlier imaging has high false-negative rates for occult fractures 8