SCIENTIFIC ARTICLE

In Vivo Scaphoid Motion During Thumb and Forearm

Motion in Casts for Scaphoid Fractures
Yohei Kawanishi, MD, PhD,* Kunihiro Oka, MD, PhD, Hiroyuki Tanaka, MD, PhD,
Kazuomi Sugamoto, MD, PhD, Tsuyoshi Murase, MD, PhD

Purpose In nonsurgical treatment for acute undisplaced or minimally displaced scaphoid waist
fractures, immobilization of both wrist and thumb can be an option. However, in vivo
scaphoid motion during forearm and thumb motion with the wrist immobilized in a cast has
not been measured. Therefore, we examined the in vivo kinematics of the scaphoid during
forearm and thumb motion with cast immobilization.
Methods Ten healthy right wrists of 10 male volunteers were included. These wrists were
immobilized in a short-arm spica cast with the thumb in a position of volar abduction and then
were scanned with the forearm in supination, neutral rotation, and pronation using computed
tomography. Next, these wrists were scanned with a forearm gauntlet cast in place with the
thumb abducted radially and opposed with the forearm positioned in neutral rotation. From
these data, the 3-dimensional position of the third metacarpal and scaphoid was analyzed.
Results From forearm supination to pronation, the scaphoid showed 0.2
radial deviation, 0.4

pronation, and 8.3
extension. The third metacarpal showed 14.6
ulnar deviation, 6.5

pronation, and 1.6
exion. During thumb opposition from radial abduction, the scaphoid
showed 2.9
radial deviation, 0.4
supination, and 7.2
extension and the third metacarpal
showed 4.5
ulnar deviation, 2.8
pronation, and 5.5
extension.
Conclusions The scaphoid was not completely immobilized by either cast. However, the
scaphoid motion during forearm and thumb motion was not signicant.
Clinical relevance Several high-quality studies have shown that undisplaced or minimally dis-
placed scaphoid waist fractures can be successfully treated with casts. Movement of scaphoid
and wrist during forearm rotation or thumb motion with a cast may not be sufcient to have a
negative impact on the outcome of scaphoid fracture using a cast. (J Hand Surg Am. 2017;-
(-):1.e1-e7. Copyright 2017 by the American Society for Surgery of the Hand. All rights
reserved.)
Key words Colles cast, scaphoid fracture, 3-dimensional analysis, thumb spica cast.

and internal xation.1,2 Despite these potential disad-

P
LASTER CAST an acute
IMMOBILIZATION FOR
scaphoid fracture can be associated with a loss vantages, acute, undisplaced or minimally displaced
of reduction over time because it does not scaphoid waist fractures can be managed with good
rigidly stabilize the fracture site like open reduction clinical outcomes using long- or short-arm thumb spica

From the *Department of Orthopedic Surgery, Itami City Hospital, Itami; the Department of This work was supported by the Japanese Society for the Promotion of Science KAKENHI
Orthopedic Surgery; and the Department of Orthopedic Biomaterial Science, Osaka University Grant Number JP15K10442.
Graduate School of Medicine, Suita, Japan. Corresponding author: Kunihiro Oka, MD, PhD, Department of Orthopedic Surgery, Osaka
Received for publication September 26, 2016; accepted in revised form March 6, 2017. University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871 Japan;
No benets in any form have been received or will be received related directly or indirectly e-mail: oka-kunihiro@umin.ac.jp.
to the subject of this article. 0363-5023/17/---0001$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2017.03.008

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1.e2 IN VIVO SCAPHOID MOTION IN CASTS

cast immobilization.3e5 Because of its 100% union

rate in 22 cases, long-arm thumb spica cast immobili-
zation for undisplaced scaphoid waist fractures has
been recommended in 1 study.5 In addition, a 100%
union rate in 28 acute, undisplaced scaphoid fractures
treated by short-arm thumb spica casting has also been
reported.4 Recently, the forearm gauntlet cast, which
allows thumb movement, has become popular for
scaphoid fractures, and favorable outcomes have been
reported with this form of immobilization as well.3,6e8
A randomized, prospective trial revealed no signicant
difference between the forearm gauntlet cast and the
short-arm thumb spica cast in terms of bone healing of
undisplaced scaphoid fractures.3
While considering the efcacy of cast immobilization
for fracture treatment, it is important to know how
effectively the cast stabilizes the fracture site. Several
researchers have conducted cadaveric studies using
scaphoid waist fracture models to clarify the inuence of
forearm rotation and thumb motion on the stability of
scaphoid waist fractures.9e13 A biomechanical cadaver
study using high-speed biplane radiographic image
sequences and stereo photogrammetric analysis showed
that motion exceeding 1 mm was observed between the
scaphoid fragments, primarily in the radial/ulnar direc-
tion, during dynamic forearm rotation when a short-arm
thumb spica cast was applied to the forearm.9 However,
in one clinical study, where intraoperative arthroscopic
evaluation was conducted, no motion at the fracture site
was identied during forearm rotation with wrist
immobilization.11 With regard to the effect of thumb
motion, it has been reported that thumb immobilization
does not contribute to fracture stability if the wrist is
mobilized.12,13 Alternatively, thumb motion increased
fracture instability when the wrist was either ulnarly
deviated or extended.13 Although these cadaveric
studies indicate that strict wrist immobilization was
necessary to obtain fracture stability, it is unclear
whether cast immobilization can accomplish such strict
immobilization in an actual clinical setting.
To our knowledge, in vivo scaphoid motion during
forearm and thumb motion with the wrist immobi-
lized in a cast has not been demonstrated. Therefore,
using a three-dimensional markerless analysis
technique,14e16 we examined the in vivo kinematics
of the scaphoid during forearm and thumb motion
with cast immobilization.
MATERIALS AND METHODS
Ten right wrists of healthy male volunteers (mean age,
34.4 years; range, 32e42 years) without a history of
trauma or disease of the right upper extremity were
FIGURE 1: A Short-arm thumb spica cast. B Forearm gauntlet cast.
studied. Our institutional review board approved
this study. To assess how effectively motion of the
scaphoid and wrist was restricted during forearm
and thumb motion under cast immobilization, their
positional changes with respect to the radius during
each motion were evaluated in terms of a radius
coordinate system.
First, each wrist was immobilized using a short-arm
thumb spica cast in which the thumb was in a position
of full volar abduction up to the interphalangeal joint
and the wrist was aligned in a neutral position with the
forearm immobilized to the proximal half (Fig. 1A).
A roll of 3-inch padding (3M, St. Paul, MN) and a roll
of 3-inch berglass cast material (3M) were used for
each wrist. A low-dose radiation computed tomogra-
phy (CT) technique (scan time, 0.5 second; slice
thickness, 1.25 mm; 10 mA; 120 kV), one-thirtieth the
normal radiation dose, provided by LightSpeed Ultra
16 (General Electric, Waukesha, WI) was used to scan
the wrists with the forearm fully supinated, neutral,
and fully pronated.14 During scanning, the subjects
were in a prone position on the CT table, and the arms
were positioned at 90
elbow exion and elevated over
the subjects head. Next, each short-arm thumb spica
cast was converted to a forearm gauntlet cast by
removing the thumb portion from the meta-
carpophalangeal joint to the interphalangeal joint,
thereby allowing carpometacarpal (CMC) joint motion
(Fig. 1B). The wrists were then rescanned in the
neutral forearm position with the thumb fully abducted
radially and fully opposed to the distal palmar crease

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 IN VIVO SCAPHOID MOTION IN CASTS 1.e3

P Value

.001

< .001
.1
.8
.7
.6
14.6  3.0*

6.5  6.1
1.6  7.0
2.7  6.5
e1.1  2.5
e9.6  4.0
Metacarpal
Supination 0 Pronation
Third
P Value
Positional Change of Scaphoid and Third Metacarpal During Forearm Rotation With Short-Arm Thumb Spica Cast

.09
.9

.9

.8
.8
.8
e0.2  3.7

0.4  3.3
e8.3  8.4
0.2  0.7
e0.9  0.7
0.3  0.3
Scaphoid
P Value

.09

.06
.7
.3
.3
.3
FIGURE 2: The orthogonal reference system of the radius.

7.6  4.6

2.7  5.7
5.0  5.6
4.7  4.7
e1.6  1.8
e5.0  5.2
Metacarpal
Neutral 0 Pronation
Third
proximal to the fth metacarpal. To reduce radiation Forearm Position
exposure of the subjects, we did not perform CT
scanning of the wrists with forearm gauntlet cast in
P Value
fully volar abducted thumb. Instead, the CT data of the

.7

.9
.9
.9
.8
.9
wrists with thumb spica cast in neutral forearm rotation
position were used because this was the same position. 2.4  2.9

e0.5  3.3
e1.0  7.4
0.04  0.7
e0.2  0.5
0.2  0.3
Data were saved in the Digital Imaging and Commu-
Scaphoid

nications in Medicine format and stored in a computer.

Contours of the radius, ulna, scaphoid, and third
metacarpal were segmented on the computer, and 3-
dimensiona surface models were constructed on the
P Value

basis of 3-dimensional surface generation of the bone .09

.1

.5
.6
.8
.9

cortex17 using commercially available software (BV;

Orthree, Osaka, Japan). The digital 3-dimensional
measurements were performed for these models us-
7.0  4.5

3.8  2.9
e3.5  3.2
e2.0  3.3
0.4  1.4
e4.6  3.7
Metacarpal
Supination 0 Neutral
Third

ing visualization software (BS; Orthree, Osaka, Japan).

The kinematic variables for the scaphoid and third
metacarpal were calculated by registering the bone in 1
position and comparisons were made relative to an
P Value

orthogonal coordinate system of the radius (Fig. 2). The

.7

.9
.1
.9
.3
.9

position of the centroid of the scaphoid and of the third

metacarpal was calculated from each volume of data.
e2.6  3.0

0.9  1.7
e7.3  4.9
0.1  0.4
e0.6  0.5
0.1  0.2

The previously reported radius coordinate system18 was

*Signicant difference, P < .05.
Scaphoid

dened as follows (Fig. 2): the y axis, indicating the

proximal ()/distal () direction, was dened as the
longitudinal radial axis. The z axis, indicating the radial
Proximal (mm)
deviation (
)

()/ulnar () direction, was dened as the line passing

Pronation (
)

Radial (mm)
Volar (mm)

through the top of the styloid process of the radius

Flexion (
)
TABLE 1.

perpendicular to the y axis. The x axis, indicating the

Ulnar

palmar ()/dorsal () direction, was dened as the line

perpendicular to the yz plane. Rotation around the z axis

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1.e4 IN VIVO SCAPHOID MOTION IN CASTS

FIGURE 3: The representative wrist motion during forearm rotation from supination (green bone models) to pronation (purple bone
models) in a short-arm thumb spica cast. View from A volar and B ulnar sides. The third metacarpal showed ulnar deviation and exion
and the scaphoid showed radial deviation and extension.

represented exion ()/extension (), rotation around
the y axis represented pronation ()/supination (), and
rotation around the x axis represented ulnar ()/radial
() deviation. The surface registration technique14 and
Euler angle method with 6 degrees of freedom and
translation parameters along the orthogonal coordinate
axes of the radius and rotation parameters around the
orthogonal coordinate axes of the radius15,18 were used
in this study. All data are expressed as the mean and SD.
Post hoc Tukey tests were performed to evaluate
the differences in each bone position during the
forearm and thumb motion. A P value less than .05
was considered to indicate statistical signicance.
RESULTS
During forearm rotation with a short-arm thumb spica
cast, the third metacarpal signicantly deviated in the
ulnar/radial directions; however, the scaphoid did not
move signicantly (Table 1; Fig. 3). The third
metacarpal signicantly deviated in the ulnar direc-
tion (P < .05) with ulnar translation of the centroid
(P < .05) from supination to pronation of the fore-
arm. During thumb opposition with the forearm
gauntlet cast, both the third metacarpal and the
scaphoid did not move signicantly (Table 2; Fig. 4).
DISCUSSION
A randomized prospective trial comparing union rates
between 143 undisplaced scaphoid waist fractures
treated with short-arm thumb spica casts and 148 frac-
tures of the same type treated with forearm gauntlet
casts showed no signicant difference between both
groups, with the nonunion rate being 10% in both
groups.3 A multicenter, randomized, controlled trial
compared undisplaced or minimally displaced scaphoid
fractures treated with forearm gauntlet casts and those
treated with short-arm thumb spica casts. The extent of
union was expressed as a percentage of the fracture
line with bridging trabeculae on CT images that were
acquired at 10 weeks. It was revealed that the forearm
gauntlet cast provided more favorable cast immobili-
zation than the short-arm thumb spica cast because of a
signicantly better extent of union in the forearm
gauntlet cast (85%) than in the short-arm thumb spica
cast (70%).6 The union rate of undisplaced or minimally
displaced scaphoid fractures treated with these casts is
extremely high, and it is important to recognize the
extent of immobilization of the target bone during
motion of the unimmobilized joints in treatment of wrist
fractures using a cast. However, in vivo kinematic var-
iables of the scaphoid in the forearm gauntlet cast during
thumb and forearm motion have never been studied.
The kinematic variables were 3-dimensionally analyzed
in the present study to elucidate the reason why the
forearm gauntlet cast is an adequate cast immobilization
method for undisplaced or minimally displaced
scaphoid waist fractures from a kinematic viewpoint.
However, the present study has some limitations.
First, the sample size was small. It is possible that a

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 IN VIVO SCAPHOID MOTION IN CASTS 1.e5

larger number of subjects may have resulted in

different ndings. Second, sex- and age-related dif-

P Value

.4

.6
.1
.2
.3
.4
ferences in thumb CMC joint kinematics could not be
evaluated in this study because only male subjects in

Radial Abduction 0 Opposition

their 30s or 40s were included. Decreased joint

4.5  3.7

2.8  2.0
e5.5  5.0
e4.6  4.6
1.9  1.6
e2.7  2.2
Metacarpal
congruence19 and increased ligamentous laxity20 of
Third the thumb CMC joints of females have been reported.
In addition, age-related differences in thumb CMC
joint kinematics have also been reported.21 Third,
although the forearm gauntlet cast allows both fore-
P Value

.6

.9
.1
.7
.4
.8
arm rotation and thumb motion, the effect of the
complex motion of the 2 joints was not been assessed
in this study. Complex motion may affect cast
e2.9  3.0

e0.4  1.2
e7.2  5.0
e0.2  0.4
e0.6  0.4
0.4  0.4
Scaphoid

immobilization of the wrist. Fourth, it is unclear

whether motion of the scaphoid and wrist during
forearm rotation is similar between the thumb spica
Positional Change of Scaphoid and Third Metacarpal During Thumb Opposition With Colles Cast

cast and the forearm gauntlet cast because we did not

P Value

perform motion analysis during forearm rotation with

.3

.9
.6
.7
.7
.1

the forearm gauntlet cast to minimize radiation

exposure of the subjects. Finally, further study using
Volar Abduction 0 Opposition

wrists with actual scaphoid waist fractures is needed

5.3  2.6

0.4  2.5
e2.9  4.7
e2.0  4.4
1.0  2.0
e3.8  2.8
Metacarpal

to determine the effect of forearm and thumb motion

Third
Thumb Position

on the stability of the fracture site of scaphoid waist

fractures.
The control of wrist motion, particularly extension
P Value

and ulnar deviation, is central to the cast treatment of

.8

.9
.3
.8
.8
.9

scaphoid waist fractures as shown in studies using

cadaveric scaphoid waist fracture models. Yanni
et al13 radiographically investigated the effect of wrist
e1.7  2.4

e0.6  1.9
e5.3  3.7
e0.1  0.3
e0.3  0.3
0.1  0.3
Scaphoid

motion on fracture stability in scaphoid waist frac-

tures. They showed an increase in fracture instability,
which included gap formation and 14.2
angulation
during 40
extension from the neutral position of the
P Value

wrist. Their study also revealed that the scaphoid was

.9

.7
.6
.6
.7
.8

locked between the trapezium and the radius when the

Radial Abduction 0 Volar Abduction

wrist was in the neutral position in the radioulnar

e0.8  4.5

2.3  2.7
e2.6  4.4
e2.6  3.5
0.9  1.5
1.1  3.8
Metacarpal

plane; however, fracture stability was decreased with

Third

a diminished locking effect when the wrist was

deviated ulnarly. Furthermore, thumb motion did not
affect fracture stability only if the wrist was immo-
bilized in a position not causing fracture instability.
P Value

Therefore, it is essential to recognize how much the

.9

.9
.8
.9
.7
.9

wrist is immobilized during motion of the unim-

mobilized joints in nonsurgical treatment of scaphoid
e1.2  2.4

0.3  1.8
e1.9  5.0
e0.05  0.2
e0.3  0.4
e0.2  0.3

waist fractures using a cast. Our study showed that

Scaphoid

wrists could move in casts during forearm and thumb

motion in spite of immobilization. Moritomo et al22
quantied in vivo interfragmentary motion of
Proximal (mm)
deviation (
)

scaphoid waist nonunions during wrist motion in 7

Pronation (
)

Radial (mm)
Volar (mm)

cases and demonstrated that the interfragmentary

Flexion (
)
TABLE 2.

motion was less than the motion of each fragment,

Ulnar

which was 33% of the global wrist motion during

wrist exion-extension and 1% of the global wrist

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1.e6 IN VIVO SCAPHOID MOTION IN CASTS
FIGURE 4: The representative wrist motion during thumb opposition from radial abduction (green bone models) to full opposition
(purple bone models) in a forearm gauntlet cast. View from A volar and B radial sides. The third metacarpal showed ulnar deviation and
extension and the scaphoid showed radial deviation and extension.
motion during wrist deviation, because both distal and
proximal fragments moved as a unit to some extent. In
the present study, the third metacarpal of the wrist
moved up to 5.0
and 5.5
in the sagittal plane and up
to 14.6
and 5.3
in the coronal plane during forearm
rotation with a short-arm thumb spica cast and during
thumb motion with a forearm gauntlet cast, respec-
tively. Based on their results, it can be assumed that
the fracture instability in the sagittal plane will be 2.8

and 1.8
, which is 33% of the wrist motion in the
sagittal plane, and the fracture instability in the
coronal plane will be 0.1
and 0.06
, which is 1% of
the wrist motion in the coronal plane, during forearm
rotation with the short-arm thumb spica cast and
during thumb motion with the forearm gauntlet cast,
respectively. Although displacement greater than 1
mm has been clinically considered as a threshold for
instability and indicative of the need for internal x-
ation,4 the relationship between scaphoid interfrag-
mentary instability and the risk of nonunion is not
precisely elucidated. However, taking the high union
rate in nonsurgical treatments for undisplaced or
minimally displaced scaphoid waist fractures3,6e8,23
and our result, in which the displacement of the
centroid of the scaphoid was less than 1 mm in all 3
directions, into consideration, fracture instability
caused by kinematic variables of the scaphoid or wrist
in a cast, as observed in the present study, may not
have an important negative impact on the course of
fracture healing. Conversely, all undisplaced or
minimally displaced scaphoid waist fractures are not
completely healed by these cast treatments.3,6 Thus,
further study is needed to elucidate a denitive
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parameter of interfragmentary instability that has a
negative impact on the course of fracture healing.
Although these casts were unable to completely
immobilize the scaphoid and wrist, these movements
of the scaphoid and wrist seem unlikely to lead to
problems with bone union in the nonsurgical treat-
ment of undisplaced or minimally displaced scaphoid
waist fractures.
ACKNOWLEDGMENT
We thank the following for their contributions to this
study: Professor Hideki Yoshikawa, MD, PhD, Ryoji
Nakao, computer programmer; and Sumika Ikemoto,
clinical assistant in the Department of Orthopedic
Surgery, Osaka University Graduate School of
Medicine.
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