What is the recommended treatment for a patient with a scaphoid fracture of the wrist, assuming no significant medical history?

Treatment of Scaphoid Fracture of the Wrist

For undisplaced or minimally displaced scaphoid waist fractures, cast immobilization is the recommended first-line treatment, as it achieves excellent union rates with lower cost and avoids surgical complications, while surgical fixation should be reserved for displaced fractures, non-unions, or patients requiring rapid return to activity. 1

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis with appropriate imaging:

• Begin with standard 3-view wrist radiographs including posteroanterior, lateral, and 45° semipronated oblique "scaphoid view" 2, 3
• If radiographs are negative but clinical suspicion remains high (positive anatomical snuffbox tenderness), proceed directly to MRI without IV contrast rather than empiric casting, as MRI has 94.2% sensitivity and 97.7% specificity for occult fractures 2, 3
• CT without IV contrast is an acceptable alternative if MRI is contraindicated or unavailable, particularly useful for evaluating bone cortex detail 2, 3

Classification-Based Treatment Algorithm

Stable/Undisplaced Fractures (<1mm displacement, no carpal malalignment)

Cast immobilization is the treatment of choice:

• Apply a below-elbow thumb spica cast for 6-10 weeks with the wrist positioned in slight volar flexion and radial deviation 4, 1
• This approach achieves 100% union rates in properly selected cases with no malunions 4
• The SWIFFT trial (2020) demonstrated no clinically relevant difference in Patient-Rated Wrist Evaluation scores at 52 weeks between surgery and cast treatment (adjusted mean difference -2.1,95% CI -5.8 to 1.6, p=0.27), with surgery costing £1295 more per patient 1
• Non-union rate with cast treatment is very low (4 of 220 patients in the SWIFFT trial) 1

Unstable/Displaced Fractures (>1-2mm displacement, scapholunate angle abnormalities, carpal malalignment)

Surgical fixation with headless compression screws is indicated:

• Open reduction and internal fixation should be performed when accurate reduction cannot be obtained or maintained with casting 4
• Use CE-marked headless compression screws for fixation 1
• Displaced fractures have higher risk of non-union and avascular necrosis if not surgically stabilized 3, 4

Special Populations Requiring Surgical Consideration

Elite athletes or military personnel may benefit from percutaneous screw fixation even for undisplaced fractures:

• Percutaneous fixation achieves union in 7 weeks versus 12 weeks with casting (p=0.0003) and return to work in 8 weeks versus 15 weeks (p=0.0001) 5
• This approach allows earlier rehabilitation and return to elite play 6, 5
• However, the cost-benefit must be weighed carefully, as the SWIFFT trial confirmed cast treatment is more cost-effective for the general population 1

Follow-Up Protocol for Cast-Treated Patients

• Monitor for non-union with repeat radiographs at 6 weeks 1
• If non-union is suspected, confirm immediately with CT or MRI and proceed to urgent surgical fixation 1
• Most occult fractures become visible on radiographs by 2 weeks if initial imaging was negative 7
• Instruct patients to perform active finger motion exercises throughout cast treatment to prevent finger stiffness, which is one of the most functionally disabling complications 8

Management of Confirmed Non-Union

For scaphoid non-unions:

• Undisplaced non-unions can be treated with inlay bone graft using either dorsal or volar approach 4
• Displaced non-unions require open reduction, bone grafting, and internal fixation, particularly if radioscaphoid arthrosis is present 4
• Immobilize for minimum 4 months or until radiographic union is confirmed 4
• Avoid peg graft techniques, which have higher rates of non-union and secondary arthritis 4

Critical Pitfalls to Avoid

• Do not rely solely on anatomical snuffbox tenderness for diagnosis, as 80% of patients with this finding have no definite bony injury, leading to unnecessary immobilization 7
• Do not miss concomitant ligamentous injuries (scapholunate or lunotriquetral ligament tears), which require MRI for detection and may change management 2, 3
• Do not use inadequate radiographic views - minimum 3 views are required to avoid missed diagnosis 3, 9
• Proximal pole fractures carry higher risk of avascular necrosis due to retrograde blood supply and warrant closer monitoring 3