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Casting of Scaphoid Fractures

- See: Work Up for Scaphoid Frx

- Discussion:
    - w/ proper casting nearly 100% of tubercle & distal third frxs will heal;
    - in addition to healing considerations, the surgeon should note the position of healing (malunion);
    - approximately 80-90% of scaphoid frx at the waist will heal, but only 60-70% of proximal pole frxs will heal;
           - even when healing does occur, there will is a relatively high incidence of malposition & late collapse;
    - healing by location:
           - times to union increasing for more proximal fractures;
           - distal third frx heal in approx 6-8 weeks;
           - middle third frx heal in 8-12 weeks;
           - proximal third frx heal in 12-23 weeks;

- Casting Technique:
    - non diagnostic radiograph (w/ positive snuff box tenderness);
           - if initial x-rays are negative, but suspicion is high, cast is applied in radial deviation & 10 deg of flexion w/ immobilization of thumb;
           - consider position of neurtral flexion / extension & slight ulnar deviation;
           - Weber notes that neutral flexion & slight radial deviation allows maximum opposition of frx frags;
    - non-displaced fractures
           - cast includes the proximal phalanx of thumb w/ wrist in 10 deg flexion and radial deviation to provide compression & radial deviation of the fragments;
                   - volar upward pressure is applied on the distal pole of the scaphoid
                   - dorsal downward pressure is applied on the capitate;
                          - displacement of the capitate volarly rotates the lunate and proximal pole into flexion and closes the dorsal scaphoid gap;
           - most surgeons leave the IP joint free;
           - tubercle frxs are suitable for short arm cast, while pts w/ w/ proximal pole fractures are candidates for a long arm cast;

- Post Injury Care:
    - long thumb-spica cast is used for six weeks, followed by short thumb- spica cast until clinical and radiographic signs of union are seen;
    - immobilization for 16 weeks to 6 months is sometimes required;
    - undisplaced fractures unite in 8 to 12 weeks
    - consider changing the cast every 10-14 days for the first 6 weeks so that it remains firm around forearm muscles and the wrist;
    - many surgeons will cast for an additional 4-6 weeks once trabeculation is seen crossing the frx site (on radiographs), since the same frx seen on CT scanning may demonstrate a persistent frx gap;
    - if x-rays fail to clearly demonstrate trabeculae crossing site of frx, CT scan along axis of carpal scaphoid is performed;
            - this allows assessment of possible scaphoid nonunion

Comparison of short and long thumb-spica casts for non-displaced fractures of the carpal scaphoid

Clinical fracture of the carpal scaphoid--supportive bandage or plaster cast immobilization.

Early mobilisation of Colles' fractures. A prospective trial.

Consequences of late immobilization of scaphoid fractures.

Nonoperative Compared with Operative Treatment of Acute Scaphoid Fractures

Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months

Management of displaced fractures of the waist of the scaphoid: meta-analyses of comparative studies.