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Nondisplaced distal fractures heal well with strict immobilization in a well-molded short arm thumb spica. Controversy exists over whether to use a long arm or a short arm cast. One comparison 16 found that nondisplaced fractures healed well regardless of the type of cast that was used. Current treatment for this type of fracture is a thumb spica, but some evidence suggests that the thumb could be omitted from the cast. A randomized prospective trial 17 found that immobilization of the thumb did not improve outcomes for nondisplaced fractures.
Screw fixation may speed recovery to pre-injury activities; referral for surgery may be indicated, depending on the needs of the patient.
If conservative treatment is attempted, a long arm cast with thumb immobilization is appropriate. Fractures with even small amounts of displacement are prone to nonunion, and operative treatment is recommended. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. He received his medical degree from Hahnemann Medical College in Philadelphia, and after a one-year surgical internship, completed a residency in family practice at the Wyoming Valley Family Practice Residency Program in Kingston, Pa.
Reibach holds a certificate of added qualification in adolescent medicine. He is a diplomate of the American Board of Family Practice and holds a certificate of added qualification in sports medicine. Address correspondence to T. Grant Phillips, M. Reprints are not available from the authors. The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported. Figures 1 , 3 top , and 4 provided by the authors.
Figure 2 provided by Dave Klemm. Gutierrez G. Office management of scaphoid fractures. Phys Sports Med. Greene WB. Essentials of musculoskeletal care. Rosemont, Ill. Orthopedic pitfalls in the ED: scaphoid fracture. Am J Emerg Med. Schubert HE. Scaphoid fracture. Review of diagnostic tests and treatment.
Can Fam Physician. Freeland P. Scaphoid tubercle tenderness: a better indicator of scaphoid fractures? Arch Emerg Med. Chen SC. The scaphoid compression test. J Hand Surg [Br]. New clinical test for fracture of the scaphoid.
Can J Surg. The value of radiographs and bone scintigraphy in suspected scaphoid fracture. A statistical analysis. Diagnosis of scaphoid fracture and dedicated extremity MRI. Acta Orthop Scand. Clinically suspected scaphoid fracture: a comparison of magnetic resonance imaging and bone scintigraphy.
Br J Radiol. Brydie A, Raby N. Early MRI in the management of clinical scaphoid fracture. A comparison of bone scintigraphy and MRI in the early diagnosis of the occult scaphoid waist fracture. Skeletal Radiol. Occult fractures of the waist of the scaphoid: early diagnosis by high-spatial-resolution sonography.
Choosing a strategy for the diagnostic management of suspected scaphoid fracture: a cost-effectiveness analysis. J Nucl Med. Kozin SH.. Incidence, mechanism, and natural history of scaphoid fractures. Hand Clin. Comparison of short and long thumb-spica casts for non-displaced fractures of the carpal scaphoid.
The scaphoid receives its primary blood supply from the dorsal scaphoid branches of the radial artery, which enter the scaphoid at a point near the distal pole. As such, the scaphoid is perfused in the distal to proximal direction. Because of this, the blood supply to the scaphoid is termed "retrograde. Because of this retrograde blood supply, displacement of a fracture across the scaphoid waist i.
The loss of blood supply will of course deprive the bone of oxygenation and nutrients. The standard of care for a potential scaphoid fracture is preventative immobilization for weeks followed by repeat radiographic imaging.
The logic is that if a fracture were present, either a fracture line or a healing response will be seen. In some cases, a patient will initially undergo an MRI to rule out a displaced scaphoid fracture following a negative x-ray. It can be aggravated by hand use, gardening, sport or work, but none of these are a definite cause. Simple treatment consists of painkillers and anti-inflammatory medicines, and avoiding exacerbating activities if possible.
Physiotherapy can be very helpful, although the process can be painful. I do not advocate splinting as it can lead to stiffness, but some people find respite with immobilisation of the thumb.
Steroid injection can be performed in the outpatient clinic and is often useful for patients, leading to complete resolution in some, and an improvement in most, although this is not always permanent.