Casting Doubt: The SUSPECT Trial — Bandaging Vs. Casting for Suspected Occult Scaphoid Fracture

🧭 REBEL Rundown

📌 Key Points

    • 🧠 Clinical Uncertainty: Snuffbox tenderness with normal X-rays creates a gray zone—fracture risk is low, but fear of missing one drives over-treatment.
    • 🩹 Bandage vs. Cast: The SUSPECT Trial tested whether simple bandaging could safely replace casting in patients with suspected occult scaphoid fractures.
    • 📊 Noninferior Outcomes: At 3 months, functional outcomes (QDASH) were noninferior with bandaging; ROM was better at 2 weeks, and no difference in serious events or nonunion was observed.
    • 💬 Patient-Centered Wins: Patients in the bandaging group reported higher satisfaction and regained motion faster.
    • 🔍 Practice-Changing Potential: The findings challenge reflexive casting and suggest that in many cases, less may be more.

🤕 Case

A 26-year-old woman presents to the ED after falling onto her outstretched right hand while rollerblading. She has localized wrist pain and tenderness in the anatomic snuffbox but no swelling or deformity. She retains full passive and active range of motion, albeit with discomfort. Initial wrist radiographs are negative for fracture.

Concerned about an occult scaphoid fracture, you face a common dilemma: should you place her in a thumb spica cast and refer her to ortho in 10–14 days, or is that overtreatment?

📝 Introduction

Managing patients with suspected occult scaphoid fractures and normal X-rays presents a common clinical dilemma. About 1 in 10 patients will have an occult fracture, and roughly 1 in 10 scaphoid fractures result in nonunion.1,2 However, the risk of nonunion among patients with MRI-confirmed occult fractures is much lower—around 1 in 30.3

Guidelines recommend immobilization with a thumb spica cast or splint when clinical suspicion is high.4 But that threshold is subjective, and snuffbox tenderness alone has poor specificity (48%).5 As a result, many patients without a fracture are unnecessarily immobilized, often leading to repeat imaging, follow-up visits, and added cost and inconvenience.6

The SUSPECT Trial set out to challenge this reflexive approach—examining whether simple bandaging could safely replace casting in patients with suspected occult scaphoid fractures and normal X-rays.7

🧾 Paper

Cohen A, Reijman M, Kraan GA, et al. Can we avoid casting for suspected scaphoid fractures? A multicenter randomized controlled trial. J Orthop Traumatol. 2025;26(1):14. PMID: 40044935

⚙️ What They Did

In adults with suspected scaphoid fractures and normal initial radiographs, does supportive bandaging for 3 days result in noninferior functional outcomes at 3 months compared to below-elbow casting for 2 weeks?

Study Design and Setting:

  • Pragmatic, parallel-group, multicenter, open-label, noninferiority randomized controlled trial (RCT)
  • Conducted in the Netherlands with 1-year follow-up
  • Trial registered on Feb 28, 2018 (NTR7164)

Selection of Participants:

  • Recruited from emergency departments (EDs) of 9 hospitals
  • Study enrollment period: June 2018 – January 2020

Randomization and Blinding:

  • Electronic randomization at point of care using Castor EDC software
  • 1:1 allocation to either bandaging or casting using variable block sizes (2, 4, or 6), stratified by hospital site
  • Patients, physicians, and researchers were not blinded
  • Radiograph assessment and statistical analysis were blinded to treatment allocation

Clinical Follow-Up:

  • All patients were re-examined by a physician at 2 weeks
    • Radiographs with at least three scaphoid-specific views obtained
    • Diagnosis and further treatment determined by treating physician (not researchers)
    • Patients diagnosed with scaphoid fractures were treated per hospital protocols

Inclusion Criteria:

  • Age ≥ 18 years
  • Trauma within 48 hours prior to presentation
  • Anatomical snuff box or scaphoid tubercle tenderness
  • Normal wrist radiographs with at least three scaphoid-specific views, as confirmed by both physician and radiologist

Exclusion Criteria:

  • Concomitant injury of the ipsilateral extremity requiring movement restriction by cast or bandage
  • Inability to complete study forms due to insufficient proficiency in the Dutch language
  • Retrospectively diagnosed scaphoid fracture on initial radiographs by the supervising radiologist

Intervention:

  • Supportive bandaging of the wrist (below-elbow, excluding the thumb)
    • Worn for 3 days, then removed
    • Patients were allowed to mobilize the wrist based on pain tolerance

Comparator:

  • Below-elbow cast or splint (with or without thumb inclusion, per local protocol)
    • Applied for 2 weeks, until reassessment at the outpatient clinic

Primary Outcome

  • Functional outcome at 3 months, measured by the Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) score
    • Scale: 0–100 (lower scores indicate better function)

Secondary Outcomes

  1. QDASH scores at additional time points:
    • After inclusion, 2 weeks, 6 weeks, and 1 year
  2. Patient-Rated Wrist/Hand Evaluation (PRWHE) scores
    • Collected at all follow-up points (score range: 0–100; lower is better)
  3. Visual Analog Scale (VAS) pain scores
    • At rest and during movement at all follow-up points (score range: 0–10; lower is better)
  4. Physical examination findings at 2 weeks and 1 year:
    • Comparison of injured vs. uninjured wrist
    • Components included:
      • Palmar and dorsal flexion
      • Ulnar and radial deviation
      • Supination and pronation
      • Grip strength
      • Finger-to-palm distance
      • Kapandji score (thumb opposition)
  5. Occult scaphoid fractures identified during follow-up
    • Based on treating physician’s clinical judgment and imaging (radiographs and/or advanced imaging)
  6. Patient satisfaction (at 2 weeks and 3 months):
    • “How satisfied are you with the treatment received at the ED?” (0–10 scale; higher is better)
    • “Would you have preferred the other treatment?” (Yes/No)

Serious and Other Adverse Events Monitored

  1. Treatment-related problems (e.g., discomfort, issues with bandage or cast)
  2. Complex Regional Pain Syndrome (CRPS)
    • Diagnosed by a physician
  3. Persisting wrist pain
    • Assessed at 6 weeks, 3 months, and 1 year with:
      • “Do you still have a painful wrist?” (Yes/No)
  4. Surgically treated scaphoid fractures
  5. Compartment syndrome
  6. Scaphoid nonunion
    • Evaluated via wrist radiographs at 1-year follow-up
 

📈 Results

💥 Critical Results

Primary Outcome (QDASH at 3 months):

    • Bandaging: 8.7 (95% CI 6.3–12.1) vs. Casting: 6.5 (95% CI 4.7–8.9)
    • Adjusted estimated difference (log-normal scale): 0.30 (95% CI: −0.02 to 0.62)
    • Bandaging was noninferior to casting.
    • Best possible QDASH score (0) achieved by:
      • 34 patients in the bandaging group
      • 35 patients in the casting group

Secondary Outcomes:

    • Range of Motion:
      • 2 Weeks: Significantly better in the bandaging group for palmar/dorsal flexion, supination, and ulnar deviation (p < 0.001).
      • 1 Year: No significant difference between groups.
    • Patient Satisfaction: Higher in the bandaging group at 2 weeks (p = 0.03) and 3 months (p = 0.049).

Serious Adverse Events:

    • No significant difference between groups.
    • Scaphoid Nonunion: 0 cases in either group.

💪 Strengths

    • Clearly focused clinical question: Addresses a relevant and focused clinical question and addresses—overuse of casting in suspected scaphoid fractures.
    • Multicenter RCT: Conducted across 9 hospitals, increasing external validity and generalizability to different clinical settings.
    • Broad inclusion criteria enhance generalizability: Included a wide range of patients with suspected scaphoid fractures, including older adults and those with comorbidities.
    • Randomization process adequately described and implemented: Allocation was done via electronic randomization, with variable block sizes, and stratified by hospital, minimizing selection bias.
    • Prospective trial registration and protocol publication: The study was registered prior to enrollment (NTR7164) and the protocol was published in advance, enhancing transparency and reducing risk of selective reporting.
    • Well-balanced baseline characteristics: Similar demographics and clinical variables between groups minimized the risk of confounding and strengthened internal validity.
    • Intention-to-treat (ITT) analysis was performed: All randomized patients were analyzed according to their original assignment, preserving the randomization.
    • High protocol adherence: The majority of patients followed the assigned interventions, and crossover was low (9 total patients across both groups).
    • Adequate follow-up duration: The 1-year follow-up was sufficient to detect key outcomes like nonunion.
    • Loss to follow-up was low: 93% completed 1-year PROMs; 83% underwent 1-year radiographs despite COVID-19 challenges.
    • Prespecified noninferiority margin with justification: The margin (7.5 QDASH points) was half of the minimal clinically important difference, consistent with best practices for noninferiority trials.
    • Consistent results across multiple outcomes: Similar findings in per-protocol analysis, secondary outcomes (e.g., PRWHE, VAS pain), physical function, and satisfaction support the primary result.
    • Pragmatic design reflects real-world care: Minimal interference with routine clinical decision-making after initial randomization increases external validity.
    • Intervention is simple, safe, and scalable: Supportive bandaging is low-cost and widely accessible—even in low-resource settings.

⚠️ Limitations

    • Small sample size: With only 180 patients, the study may be underpowered to detect rare outcomes.
    • Possible selection bias from convenience sampling: The number of eligible but non-enrolled patients was not reported, suggesting convenience sampling and limiting external validity.
    • Lack of blinding for participants and treating clinicians: Open-label design introduces risk of performance and detection bias, especially for subjective outcomes like QDASH and VAS pain.
    • No gold standard diagnostic confirmation of scaphoid fracture: Diagnosis of occult scaphoid fractures was based on clinical judgment, not standardized MRI or CT across all cases. 
    • No prespecified reference standard for outcome of nonunion: Scaphoid union assessed by radiographs only, not uniformly confirmed with CT or MR which may underestimate true nonunion rates.
    • Very low event rate limits power for rare outcomes (e.g., nonunion): Only 16 of 180 patients (9%) had confirmed scaphoid fractures.
    • Conducted in a single-country healthcare setting (Netherlands): Standard of care may differ in other countries, limiting generalizability to settings without similar follow-up pathways.
    • Potential Hawthorne effect: Patients were aware of their treatment group which may have altered their behavior (e.g., adherence, activity level).
    • Patient-reported outcomes are subjective and unblinded: Measures like QDASH and VAS pain are vulnerable to reporting bias in an unblinded study.

🗣️ Discussion

Imperfect Tools, Pragmatic Questions:

While the trial used patient-centered outcomes like QDASH, PRWHE, and VAS pain, these questionnaires are inherently subjective and prone to bias, especially in an unblinded study. Even the physical exam–based outcomes, such as range of motion, could have been unintentionally graded more favorably in one group by unblinded clinicians. Moreover, the diagnosis of scaphoid fracture and nonunion relied on clinical judgment rather than uniform imaging standards—CT or MRI were not required—raising concerns about diagnostic consistency.

That said, the hard outcome we care most about—scaphoid nonunion—was rare and did not occur in either group, regardless of treatment. Given how infrequent these complications are, it would be nearly impossible to power a study large enough to detect a meaningful difference between bandaging and casting. And in many ways, that’s the point: if serious adverse outcomes are this rare, is routine immobilization for everyone truly justified?

Bandaging is at least as good as casting—possibly better:

The trial met its primary endpoint, demonstrating that bandaging was noninferior to casting in terms of 3-month functional outcomes. Patient-reported outcomes (QDASH, PRWHE, VAS pain) were similar across groups at all time points, and while range of motion was significantly better in the bandage group at 2 weeks, it converged by 1 year. Likewise, patient satisfaction was higher in the bandaging group, and there were no differences in serious adverse events—including no cases of scaphoid nonunion in either group.

So where does that leave us? At worst, bandaging performs on par with casting. At best, it offers faster recovery, greater early mobility, and fewer life disruptions. Even if long-term outcomes converge, early improvements in ROM matter—they translate to fewer limitations in activities of daily living, less time off work, easier self-care, faster return to sports, and better quality of life in the short term. Moreover, the bandage approach also has the potential to save precious time typically spent by physicians making custom splints or casts.

📘 Author's Conclusion

“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.”

💬 Our Conclusion

This trial offers compelling evidence in support of bandaging as a safe and reasonable alternative to casting, for patients with suspected occult scaphoid fracture and normal X-rays. While underpowered to detect rare outcomes like nonunion, it addresses a key clinical dilemma using pragmatic, patient-centered data. Larger multicenter studies in more diverse patient populations and healthcare settings—particularly outside the Netherlands—are needed to confirm generalizability and long-term safety. Ultimately, it affirms what many physicians suspect: routinely casting all of these patients may be unnecessary.

🎯 Case Resolution​

After discussing the risks and benefits with the patient, including the low likelihood of true fracture, you apply a supportive bandage instead of a thumb spica cast. She’s advised to avoid high-impact activity, use the wrist as tolerated, and return for reassessment in 3 days if symptoms persist or worsen.

At follow-up, her pain has significantly improved, and repeat imaging remains normal. She never required a cast, avoided unnecessary immobilization, and returned to work within a week—sparing time, cost, and inconvenience.

🚨 Clinical Bottom Line

For patients with suspected occult scaphoid fractures and normal X-rays, routine casting offers no added benefit and may be unnecessary.

🔄 REBEL Recap

📚 References

    1. Coventry L, Oldrini I, Dean B, Novak A, Duckworth A, Metcalfe D.
      Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies.
      Emerg Med J. 2023;40(8):576-582.
      PMID: 37169546
    2. Kawamura K, Chung KC.
      Treatment of scaphoid fractures and nonunions.
      J Hand Surg Am. 2008;33(6):988-997.
      PMID: 18656779
    3. Dean BJF, Riley N, Little C, et al.
      The rate of nonunion in the MRI-detected occult scaphoid fracture.
      Bone Joint J. 2024;106-B(4):387-393.
      PMID: 38555933
    4. Li NY, Dennison DG, Shin AY, Pulos NA.
      Update to Management of Acute Scaphoid Fractures.
      J Am Acad Orthop Surg. 2023;31(15):e550-e560.
      PMID: 37332224
    5. Huynh KA, Yoon AP, Zhou Y, Chung KC.
      Bayesian Statistics to Estimate Diagnostic Probability of Scaphoid Fractures from Clinical Examinations: A Meta-Analysis.
      Plast Reconstr Surg. 2021;147(3):424e-435e.
      PMID: 33620933
    6. Karl JW, Swart E, Strauch RJ.
      Diagnosis of Occult Scaphoid Fractures: A Cost-Effectiveness Analysis.
      J Bone Joint Surg Am. 2015;97(22):1860-1868.
      PMID: 26582616
    7. Cohen A, Reijman M, Kraan GA, et al.
      Can we avoid casting for suspected scaphoid fractures? A multicenter randomized controlled trial.
      J Orthop Traumatol. 2025;26(1):14.
      PMID: 40044935

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter/X: @EMSwami), Mark Ramzy, DO (X: @MRamzyDO),

👤 Co Editor-In-Chief

Marco Propersi
DO

All Things REBEL EM

Meet The Team

🔎 Your Deep-Dive Starts Here

Elbow Dislocations

Elbow Dislocation Definition:  Disarticulation of the proximal radius & ulna ...

Trauma
Read More
Rosh Review EM Scholar Monthly Question

Cite this article as: Rosh Review Author Team, "Rosh Review ...

Orthopedics
Read More
REBEL Core Cast 77.0 – Pyogenic Flexor Tenosynovitis

Take Home Points Think about flexor tenosynovitis in a patient ...

Infectious Disease
Read More
REBEL Core Cast 70.0 – Open Fractures

Take Home Points: Prioritize ABCs and systematic evaluation of the ...

Orthopedics
Read More
Cauda Equina Syndrome

Definition: Syndrome characterized by dysfunction of multiple lumbar and sacral ...

Neurology
Read More
Cite this article as: Marco Propersi, "Casting Doubt: The SUSPECT Trial — Bandaging Vs. Casting for Suspected Occult Scaphoid Fracture", REBEL EM blog, July 14, 2025. Available at: https://rebelem.com/casting-doubt-the-suspect-trial-bandaging-vs-casting-for-suspected-occult-scaphoid-fracture/.
Don’t Miss a Post – Follow Us
Instagram Youtube Threads Reddit Facebook X-twitter Linkedin Tiktok Envelope
Want to support rebelem?
Ad space
Donate
Swag
Instagram Threads X-twitter Facebook-f Linkedin-in Youtube Tiktok Podcast Rss
rebelSWAG-lightbg
gsep-logo-1
Donate

Sponsored

REBEL EM is licensed under a

Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.

© 2022 REBEL EM. All rights reserved. | Disclaimer | Website by Innov8 Place.