Clinical Question

Do adults with nondisplaced or minimally displaced scaphoid waist fractures have better functional outcomes after one year if they are treated surgically or nonsurgically?

Bottom Line

The research on the optimal management of nondisplaced or minimally displaced scaphoid waist fractures is sparse and of mixed quality. The nearly identical trade-off of benefits and complications presents an opportunity for shared decision-making until quality studies become available. (Level of Evidence = 1a−)

Synopsis

The authors report that the use of urgent surgery for adults with scaphoid waist fractures is increasing despite uncertain evidence. They analyzed the evidence by searching several databases, registries, and reference lists of included studies to identify randomized trials that compared surgery with nonoperative management in adults (i.e., older than 16 years) with scaphoid waist fractures that are displaced no more than 2 mm. The analysis focused primarily on functional outcomes after 12 months of intervention. The authors included seven trials that enrolled 25 to 439 participants who were an average of 30 years of age (i.e., ages ranged from 15 to 75 years), 83% were men, and 98% had scaphoid waist fractures. Three of the studies were rated as high quality and four were rated as low quality. Four of the studies assessed function at six and 12 months, and although the authors identified marked heterogeneity among the results, there was no difference at these time points on average. However, five studies reported nonunion rates at early follow-up (not defined by the authors); nonunion occurred in 1% of the surgically treated participants compared with 7.8% of the nonsurgically treated participants (number needed to treat = 15; 95% CI, 10 to 29). Four trials reported complications, and one reported that no complications occurred in either group. Nerve injuries, infections, or complex regional pain syndromes occurred in 9% of surgically treated participants and in 2.6% of those treated nonsurgically (number needed to harm = 16). The benefits and complications are nearly identical.