The Skeptics Guide to Emergency Medicine

SGEM#475: Break on Through to the Other Side – Management of Clinical Scaphoid Fractures

May 17, 2025
Dr. Matt Schmitz, an orthopedic surgeon specializing in adolescent sports medicine at Rady Children’s Hospital, shares invaluable insights into scaphoid fracture management. He discusses the dilemmas of diagnosing these complex injuries, advocating for evidence-based approaches. Innovative research reveals that short-term bandaging may work as effectively as traditional casting. Schmitz also emphasizes the need to understand biases in clinical trials and offers alternative strategies for monitoring patients with suspected fractures, ultimately aiming for improved care outcomes.
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ANECDOTE

Typical Scaphoid Injury Case

  • A 48-year-old woman with wrist pain after a FOOSH injury presents with tenderness but normal x-rays.
  • This common ED scenario challenges clinicians to diagnose scaphoid fractures accurately and promptly.
INSIGHT

Physical Exam Limits in Scaphoid Diagnosis

  • No single physical exam maneuver reliably rules in or out an occult scaphoid fracture.
  • High clinical suspicion alone does not justify or exclude scaphoid fracture diagnosis.
ADVICE

Bandaging Plus Reassessment Alternative

  • For suspected scaphoid fractures with normal x-rays, a 3-day bandage plus reassessment is an alternative to immediate casting.
  • Casting can be avoided safely if follow-up within 10 to 14 days is assured.
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