What is the initial approach for a scaphoid reduction maneuver?

Scaphoid Reduction Maneuver: Initial Approach

For acute scaphoid fractures, closed reduction is achieved by positioning the wrist in volar flexion with radial deviation, which provides optimal alignment of fracture fragments and maintains stability during immobilization. 1

Reduction Technique

Hand Positioning and Maneuver

• Apply longitudinal traction to the thumb and wrist to disimpact the fracture fragments 1
• Position the wrist in volar flexion (palmar flexion) combined with radial deviation - this is the preferred reduction position that achieves 100% union rates without malunions 1
• Avoid the traditional positions of wrist extension with either radial or ulnar deviation, as these have inferior outcomes 1

Assessment of Reduction Quality

• Displacement >1 mm or presence of dorsal lunate rotation (instability collapse pattern) on lateral radiograph indicates an unstable, displaced fracture that requires different management 1
• If standard radiographs show questionable alignment, obtain radial-ulnar deviation stress views, traction oblique views, or trispiral tomography to definitively assess fracture stability 1

Critical Decision Point: Stable vs Unstable Fractures

Undisplaced/Stable Fractures (≤1 mm displacement, no lunate tilting)

• Proceed with short-arm thumb spica cast in the volar flexion-radial deviation position achieved during reduction 1
• This provides adequate support for fracture union without need for surgical intervention 1

Displaced/Unstable Fractures (>1 mm displacement or dorsal lunate tilting)

• Long-arm cast immobilization is required after closed reduction in volar flexion-radial deviation 1
• If accurate reduction cannot be obtained or is lost during treatment, proceed immediately to open reduction and internal fixation rather than accepting malposition 1
• Consider percutaneous fixation for minimally displaced B1 or B2 fractures to avoid prolonged immobilization while maintaining reduction 2, 3

Common Pitfalls to Avoid

• Do not accept reduction with >1 mm residual displacement - this indicates instability and will likely fail with closed treatment alone 1
• Do not use wrist extension positions for reduction or immobilization, as these have higher failure rates 1
• Recognize that up to 25% of scaphoid fractures are radiographically occult initially - clinical examination (snuffbox tenderness, scaphoid tubercle tenderness) takes precedence over negative initial radiographs 4
• Proximal pole fractures have high risk of avascular necrosis due to retrograde blood supply and may require surgical intervention even if minimally displaced 4