Can we avoid casting for suspected scaphoid fractures? A multicenter randomized controlled trial

Cohen et al. Journal of Orthopaedics and Traumatology (2025) 26:14 https://doi.org/10.1186/s10195-025-00822-5 ORIGINAL ARTICLE Journal of Orthopaedics and Traumatology Open Access Can we avoid casting for suspected scaphoid fractures? A multicenter randomized controlled trial Abigael Cohen1* , Max Reijman1, Gerald A. Kraan2, Sara J. Baart3, Jan A. N. Verhaar1 and Joost W. Colaris1 on behalf of the SUSPECT study group Abstract Background In suspected scaphoid fractures with normal initial radiographs, the usual care is casting, but only 10% of patients have scaphoid fractures. To reduce overtreatment, we evaluated whether bandaging, instead of casting, resulted in noninferior functional outcomes. Patients and methods We included adults with suspected scaphoid fractures and normal initial radiographs at the emergency department in our multicenter randomized controlled trial. Patients were randomized to 3-day bandaging or 2-week casting. Questionnaires, physical examination, and radiographs were performed at 2 weeks and 1 year. Additional questionnaires were sent after inclusion, 6 weeks, and 3 months. Our primary outcome was the adjusted estimated difference between groups of the Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) score at 3 months (natural logarithm of the margin of noninferiority = 2.0). Secondary outcomes included the QDASH score, Patient-Rated Hand/Wrist Evaluation Score, visual analog scale pain, wrist range of motion, patient satisfaction, and complications during follow-up. Results Of the 180 patients (91 bandaging and 89 casting), 16 had scaphoid fractures and there were no scaphoid nonunions. Functional outcome in the bandaging group was noninferior at 3 months compared with the casting group [adjusted estimated difference QDASH score 0.30 (95% CI 0.02–0.62)]. All other patient-reported function and pain scores were not significantly different between groups. Range of motion at 2 weeks was better in the bandaging group, and they were more satisfied with the treatment than the casting group. Conclusions Casting for suspected scaphoid fractures but normal initial radiographs can be avoided because bandaging seems to be an alternative treatment option when patients are reevaluated after 2 weeks. Level of evidence Level II. Trial registration Trial registered at the Trialregister on 2018-02-28 on www.trialregister.nl, NTR7164 Keywords Adults, Fractures, Bone, Scaphoid bone, Wrist injuries, Patient-reported outcome measures *Correspondence: Abigael Cohen Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Cohen et al. Journal of Orthopaedics and Traumatology (2025) 26:14 Introduction Although only 10% of patients with suspected scaphoid fractures (but normal initial radiographs) actually have an occult scaphoid fracture on follow-up, the usual care is treatment with 2 weeks casting before reexamination [1]. This means that 90% of patients are overtreated [2, ]. Patients who present at the emergency department after a trauma, with pain over the scaphoid and normal initial radiographs, are suspected to have scaphoid fractures. Occult scaphoid fracture are scaphoid fractures that become visible during follow-up imaging modalities in these patients. Scaphoid fractures are the most common carpal fractures, occurring mainly in young, working adults [3]. Patients present to the family doctor or emergency department with traumatic radial-sided wrist pain. Identifying scaphoid fractures is challenging because initial radiographs can be normal and occult fractures become apparent at follow-up [4]. The rationale behind casting all patients with suspected scaphoid fractures is that untreated fractures can fail to unite. Scaphoid nonunions require surgery and can lead to wrist osteoarthritis [5]. When immobilization is started within 4 weeks of trauma there is no increase in nonunion rates [6]. To reduce unnecessary casting, patients with suspected scaphoid fractures could be treated with bandaging instead of casting. A single trial from 1988 has examined this and found no differences in healing complications or pain between the two groups [7]. Unfortunately, this study failed to report any information regarding randomization, measurement of the outcomes, a specified analysis plan, or duration of follow-up. These serious methodological shortcomings, and potential for bias, mean that these results are questionable. Therefore, we conducted a new high quality randomized controlled trial with 1-year follow-up to evaluate functional outcomes between patients with a suspected scaphoid fracture (and normal initial radiographs) treated with bandaging compared with casting. We hypothesized that bandaging results in noninferior functional outcome at 3 months compared with casting. Page 2 of 11 Patients and methods Study design and setting We performed the SUSPECT study (clinically SUSPEcted SCaphoid fracTure: treatment with supportive bandage or cast study), which was a pragmatic, parallel-group, multicenter, open-label, noninferiority randomized controlled trial conducted in the Netherlands with 1-year follow-up. The medical ethics committee of the Erasmus MC University Medical Center approved the study protocol prior to study commencement and all subsequent amendments. Local institutional review boards granted approval before study onset. Trial registered at 2018-0228 on www.trialregister.nl, NTR7164. Written informed consent from all patients was obtained prior to inclusion. The study was performed in accordance with the Declaration of Helsinki and Good Clinical Practice Guidelines. The design of the SUSPECT study was published previously [8]. Owing to Dutch privacy law, we were not allowed to screen the electronic patient reports to check the number of eligible patients not participating in our study. Selection of participants Patients were recruited at the emergency departments (ED) of nine hospitals from June 2018 to January 2020. The physicians provided study information if patients were eligible to participate. The inclusion and exclusion criteria are provided in Table (...truncated)