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Clinical Question
In nonoperative management of scaphoid fractures, does using a thumb spica cast lead to superior outcomes compared with a cast that does not include the thumb?
Evidence-Based Answer
The type of cast used does not appear to impact outcomes. A short arm cast allows the patient to have better function and mobility during immobilization without compromising the healing process. (Strength of Recommendation [SOR]: B, randomized controlled trials and cross-sectional studies.) Thumb spica casts are no better than casts that do not include the thumb in fracture healing rates or long-term improvement in range of motion, strength, or pain. (SOR: B, multiple randomized controlled trials.) Testing on uninjured individuals shows no difference in the range of motion or functional movement of the wrist when immobilized in a thumb spica cast compared with a cast that does not include the thumb. (SOR: C, cross-sectional anatomic studies.) Patients wearing thumb spica casts also have more functional limitations than patients able to use their thumb while casted. (SOR: C, cross-sectional studies.)
Evidence Summary
FRACTURE UNION
A 2014 multicenter randomized controlled trial from the Netherlands compared below-elbow casting with and without inclusion of the thumb for the treatment of nondisplaced or minimally displaced fractures of the scaphoid waist (n = 55) and distal scaphoid (n = 7).1 Included patients (n = 62) were 18 years or older and presented less than four weeks after injury with a scaphoid fracture confirmed by magnetic resonance imaging or computed tomography (CT) with less than 1 mm of gapping or translation between fracture fragments and no other associated fracture or perilunate injury. Patients were treated with cast immobilization for 10 weeks, with or without the thumb included, at which time a CT scan was performed, and fracture union was measured as a percentage of the fracture line crossed by bridging bone. The primary outcome was extent of union at 10 weeks, with secondary outcomes measured at six months, including radiographic union,...