The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for addressing Scaphoid Fracture. These directives are designed to assist healthcare professionals in identifying appropriate therapeutic approaches within the context of a comprehensive assessment.
Healthcare professionals with expertise in managing Scaphoid Fracture can depend on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic methods for their patients.
It is crucial to emphasize that these guidelines are not meant to substitute clinical judgment or professional expertise. The final decision regarding the management of Scaphoid Fracture should involve collaboration between the patient and their healthcare provider.
Scaphoid Fracture
Scaphoid fractures, also referred to as wrist navicular fractures, rank among the most common carpal bone fractures. While many are not work-related, some are associated with occupational activities.
The predominant cause of scaphoid injury involves a fall on the outstretched hand or axial loading with a closed fist, such as during a vehicular accident. Notably, scaphoid fractures, particularly those affecting the proximal third, are prone to complications like non-union and avascular necrosis due to limited blood supply disruption by the fracture.
Diagnostic Studies
X-Rays
Recommended for diagnostic purposes, including at least 3 to 4 views, incorporating a “scaphoid view.”
X-Rays – Follow-up in two weeks
Recommended for assessing potential scaphoid fractures, especially in cases where clinical suspicion persists despite negative initial x-rays.
Evidence for the Use of X-rays for scaphoid fractures
MRI
Recommended in select patients for diagnosing occult scaphoid fractures when clinical suspicion remains high despite negative x-rays.
Indications: Clinical suspicion of scaphoid fracture with negative x-rays.
Rationale for Recommendation: While not necessary for the majority, MRI may be indicated for cases with clinical suspicion but negative x-rays.
Evidence for the Use of MRI for Scaphoid Fracture
CT Imaging
Recommended for diagnosing occult scaphoid fractures when clinical suspicion remains high, MRI is contraindicated, and x-rays are inconclusive.
Evidence for the Use of CT Imaging for Diagnosing Scaphoid Fractures
Bone Scan
Recommended for select patients to diagnose occult scaphoid fractures when clinical suspicion remains high despite negative x-rays.
Indications: At least 48 hours after the injury with continuing clinical suspicion.
Rationale for Recommendation: Bone scans assist in securing an earlier diagnosis, especially for patients with clinical suspicion but negative x-rays, potentially avoiding prolonged splinting.
Evidence for the Use of Bone Scans for Scaphoid Fractures
Medications
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Scaphoid Fractures Pain
Recommended for managing pain associated with acute, subacute, or chronic scaphoid fractures.
Indications: Acute, subacute, or chronic Scaphoid fractures pain.
Frequency/Duration: As needed use may be reasonable for many patients.
Indications for Discontinuation: Resolution of symptoms, lack of efficacy, or development of adverse effects.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
Recommended for concomitant use with cytoprotective drugs for patients at high risk of gastrointestinal bleeding.
Indications: Patients with a high-risk factor profile requiring NSAIDs.
Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers recommended.
Indications for Discontinuation: Intolerance, adverse effects, or discontinuation of NSAID.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Recommended for patients with known cardiovascular disease or multiple risk factors, with a preference for acetaminophen or aspirin as the first-line therapy.
Recommended: If needed, non-selective NSAIDs are preferred over COX-2 specific drugs.
In patients receiving low-dose aspirin, the NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin.
Acetaminophen for Treatment of Scaphoid Fractures Pain
Recommended for managing scaphoid fractures pain, particularly in patients with contraindications for NSAIDs.
Indications: All patients with scaphoid fractures pain, including acute, subacute, chronic, and post-operative.
Dose/Frequency: Per manufacturer’s recommendations; may be utilized on an as-needed basis.
Indications for Discontinuation: Resolution of pain, adverse effects, or intolerance.
Limited Use of Opioids for Acute and Post-operative Pain Management
Recommended for brief (less than seven days) and select use for acute and post-operative pain management as adjunctive therapy to more effective treatments.
Indications: Acute injury and post-operative pain management, primarily for nocturnal use.
Frequency/Duration: Prescribed as needed throughout the day, then later only at night, before weaning off completely.
Rationale for Recommendation: Opioids may be beneficial for patients with insufficient pain relief from NSAIDs, particularly for nocturnal use. Recommended for brief, select use in postoperative patients with primary use at night to achieve sleep postoperatively.
Treatment
Splinting
Wrist Splinting
Recommended for treating scaphoid tubercle fractures.
Rationale for Recommendation
Splinting may suffice, as these fractures heal well due to adequate blood supply.
Cast Immobilization
Recommended for the treatment of stable non-displaced scaphoid fractures.
Frequency/Duration
Casting should be performed for 6 to 8 weeks, with cast removal for clinical reevaluation and re-xray to determine the need for additional casting.
Thumb Immobilization with Spica Casting
Recommended for concurrent immobilization of the thumb with the wrist for treating scaphoid fractures.
Frequency/Duration
Casting should be done for 6 to 8 weeks, with cast removal for clinical reevaluation and re-xray to assess the necessity for additional casting.
Spica Splint
Recommended for patients with suspicion of scaphoid fracture but negative x-rays.
Duration
2 weeks, followed by a repeat clinical examination and x-ray. If the x-ray is negative, consider discontinuation of the splint.
Rehabilitation
Rehabilitation for work-related injuries should focus on restoring functional ability for daily and work activities, aiming to return the injured worker to pre-injury status.
Active therapy involves internal effort by the patient, while passive therapy relies on modalities delivered by a therapist. Passive interventions facilitate progress in an active therapy program, emphasizing objective functional gains. Continuing active and passive therapies at home is crucial for maintaining improvement, and assistive devices may aid in achieving functional gains.
Therapy: Active
Therapeutic Exercise – for Post-operative Scaphoid Fractures
Recommended for post-operative scaphoid fractures.
Frequency/Dose/Duration
Total visits may range from two to three for mild deficits to 12 to 15 for severe deficits, with documentation of ongoing improvement. If ongoing deficits persist, more than 12 to 15 visits may be indicated. A home exercise program should complement therapy as part of the rehabilitation plan.
Surgery
Surgical Fixation
Recommended for displaced scaphoid fractures.
Rationale for Recommendation
Displaced fractures generally require surgical treatment with fixation due to the higher risk of nonunion, malunion, or degenerative joint disease. High-risk scaphoid fractures should be promptly referred to hand or orthopedic surgical specialists for definitive treatment.
Surgical Intervention of Non-Displaced or Minimally Displaced Scaphoid Fractures
Recommended for select patients requiring earlier functional recovery.
Not Recommended
In general, non-displaced fractures are best treated with cast immobilization.
Rationale for Recommendation
Surgical intervention may be appropriate for patients with non-displaced or minimally displaced scaphoid fractures who cannot or do not wish to be treated with non-operative methods, including athletes. The decision involves a discussion between the orthopedist and patient, weighing the benefits of earlier functional recovery against the long-term risks of osteoarthrosis.
Hardware Removal
Recommended in select cases where hardware removal is indicated based on doctor/patient preference.
Indications
Cases where there is protruding hardware, pain attributed to the hardware, broken hardware on imaging, and/or a positive anesthetic injection response.
