Go Easy — Short-Arm, No-Thumb Spica for Scaphoid Fractures

What’s the Claim?

Non- or minimally displaced scaphoid fractures can be managed as effectively in a short-arm cast as a long-arm cast, and in a cast without thumb immobilization as with thumb immobilization (thumb spica casting), according to a meta-analysis pooling results from seven studies. Across the board, in all four of those treatment groups, nonunions occurred in about 10% of patients treated.

How’s It Stack Up?

Since this meta-analysis pooled the best-available evidence, its main findings necessarily are in line with that base of evidence. But we note with some reassurance that biomechanical studies have suggested short-arm casts to be adequate in terms of controlling wrist movement, whether with or without the spica add-on. Plus, the clinical findings of this nice meta-analysis should cause the sensible clinician to choose “without,” and spare the patient some misery.

What’s Our Take?

This study focused on patients with non- or minimally displaced scaphoid fractures. It did not look at patients who had scaphoid ORIFs. But with that caveat aside, if easy (short-arm cast, no thumb spica) is as good as hard (long-arm cast, with thumb spica), why not choose easy? We realize that sometimes “easy” drifts into “too good to be true,” but here the authors’ claims stand up to close scrutiny. This was a generally robust meta-analysis. The authors included one retrospective, comparative study that we think they should’ve excluded, because studies of that design don’t belong in pooled analyses like this one. Still, that’s but a quibble. It’s unlikely that one study would have changed the main finding based on our own assessment of the authors’ forest plot on short- versus long-arm casting. Although the thumb spica finding was based on only two studies (174 total patients), neither favored thumb immobilization; so, again, advantage goes to no-spica. Last words to CORRelations’ adviser in Hand Surgery, Desirae McKee MD, who thoughtfully shares, “I chose this paper to help clinicians treating this injury be able to choose more effectively. Thumb spica casts cause real thumb stiffness. So, if it doesn’t make a difference, why put on a more complicated cast?”  

Source

Siotos C, Asif M, Lee J, et al. Cast Selection and Non-union Rates for Acute Scaphoid Fractures Treated Conservatively: A Systematic Review and Meta-analysis. J Plast Surg Hand Surg. 2023;57:16-21.