Acute scaphoid fractures: guidelines for diagnosis and treatment

Abstract

In cases of suspected scaphoid fracture where the initial radiographs are negative, a supplementary MRI, or alternatively CT, should be carried out within three to five days. Fracture classification, assessment of dislocation as well as evaluation of fracture healing is best done on CT with reconstructions in the coronal and sagittal planes, following the longitudinal axis of the scaphoid. After adequate conservative management, union is achieved at six weeks for approximately 90% of non-displaced or minimally displaced (≤ 0.5 mm) scaphoid waist fractures. Scaphoid waist fractures with moderate displacement (0.5–1.5 mm) can be treated conservatively, but require prolonged cast immobilization for approximately eight to ten weeks. Internal fixation is recommended for all scaphoid waist fractures with dislocation ≥ 1.5 mm. Distal scaphoid fractures can be treated conservatively. The majority heal uneventfully after four to six weeks of immobilization, depending on fracture type. In general, proximal scaphoid fractures should be treated with internal fixation. Cite this article: EFORT Open Rev 2020;5:96-103. DOI: 10.1302/2058-5241.5.190025

Conservative treatment for fractures of the scaphoid

“…Stable fracture patterns include nondisplaced or minimally displaced waist fractures, transverse fracture orientation, and distal pole fractures. Radiographic signs suggestive of fracture instability include displacement greater than 1 mm, lateral intra-scaphoid angle > 35°, fracture comminution, oblique or vertical fracture orientation, dorsal intercalated segment instability (scapholunate angle greater than 60°), or associated ligamentous injury [1].…”

“…These include wrist or hand stiffness, persistent pain, and cast irritation [40]. Surgical complications include protruding hardware, infection, scar tenderness, and iatrogenic injury to articular cartilage, nerves, or tendons [1]. The SWIFFT RCT documented 65 % of patients who underwent ORIF had screw penetration on CT at the 1 year mark.…”

“…These include delayed union, non-union, avascular necrosis, complex regional pain syndrome, tendon injury, and post-traumatic arthritis [41]. Scaphoid fracture non-unions left untreated may also lead to a predictable pattern of degenerative changes, known as scaphoid non-union advanced collapse (SNAC) [1].…”

“…Scaphoid fractures are the most common fractures observed within the carpus. They comprise 60 % of fractures within the carpus, and 2 % of fractures overall [1]. Scaphoid fractures are most commonly seen in young males.…”

Epidemiology of scaphoid fractures and non-unions: A systematic review

“…Furthermore, a prospective study, where MRI was used as golden standard, showed that conventional radiographs detected 54 % of acute scaphoid fractures in children [6]. In patients with clinically suspected scaphoid fracture and negative radiographs an early MRI is recommended [12]. MRI has a sensitivity of 99-100 %to detect an acute scaphoid fracture [13].…”