gms | German Medical Science

Objectives/Interrogation: Recent evidence suggests that a shorter period (4-6 weeks) of cast immobilisation is adequate for the treatment of nondisplaced scaphoid waist fractures [1]. This study was set out to investigate patient and surgeon factors associated with surgeon recommendation for prolonged cast immobilisation (>8-12 weeks) of a nondisplaced scaphoid waist fracture.

Methods: 218 orthopedic and upper-extremity surgeons participated in an international online survey study. Participants were presented with 16 case scenarios of patients with nondisplaced scaphoid waist fractures treated with cast immobilisation. They were asked whether they would continue or stop cast immobilisation. Patient variables included sex, age, gender, radiographic fracture consolidation, presence of fracture tenderness and duration of completed cast wear (8 or 12 weeks). Multivariable linear regression analysis was used to identify which characteristics were associated with surgeon recommendation for continued cast wear.

Results and Conclusions: Up to 84% and 49% of the surgeons recommended additional immobilization after 8 and 12 weeks, respectively. Unclear fracture healing on radiographs increased the likelihood of prolonged cast duration (>8-12 weeks) with an odds ratio (OR) of 35.0 (95% confidence-interval (CI): 4.6-262, p=0.001). The presence of fracture tenderness was associated with an OR of 9.6 (95% CI 2.1 to 36, p=0.001) for continued cast wear compared to no fracture tenderness. Female surgeons (OR 3.0, 95% CI 1.3-6.8, p=0.011) and those not specialized in trauma or upper-extremity surgery (OR 2.6, 95% CI 1.3-5.3, p=0.007) were more likely to recommend continued cast wear, while surgeons practicing in Europe were less likely to recommend additional immobilization (OR 0.15, 95%CI 0.051-0.46, p=0.001).

In this online survey study, cast duration was dictated by radiographic fracture appearance and the presence of fracture tenderness. This runs counter to good evidence that radiographs are unreliable in assessing scaphoid union. The role of fracture tenderness in assessing fracture healing merits further investigation. Considering the high union rates of this type of fracture following cast immobilisation (>90%), the use of CT may not always be justified to assess union. A clinical prediction rule to determine scaphoid fracture healing may contribute to reducing immobilisation time, or help identify patients who require a CT-scan for follow up.