Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months

Department of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Groby Road, Leicester, LE3 9QP, UK.
The Bone & Joint Journal (Impact Factor: 3.31). 07/2008; 90(7):899-905. DOI: 10.1302/0301-620X.90B7.20371
Source: PubMed


We report the outcome at a mean of 93 months (73 to 110) of 71 patients with an acute fracture of the scaphoid who were randomised to Herbert screw fixation (35) or below-elbow plaster cast immobilisation (36). These 71 patients represent the majority of a randomised series of 88 patients whose short-term outcome has previously been reported. Those patients available for later review were similar in age, gender and hand dominance. There was no statistical difference in symptoms and disability as assessed by the mean Patient Evaluation Measure (p = 0.4), or mean Patient-Rated Wrist Evaluation (p = 0.9), the mean range of movement of the wrist (p = 0.4), mean grip strength (p = 0.8), or mean pinch strength (p = 0.4). Radiographs were available from the final review for 59 patients. Osteoarthritic changes were seen in the scaphotrapezial and radioscaphoid joints in eight (13.5%) and six patients (10.2%), respectively. Three patients had asymptomatic lucency surrounding the screw. One non-operatively treated patient developed nonunion with avascular necrosis. In five patients who were treated non-operatively (16%) there was an abnormal scapholunate angle ( > 60 degrees ), but in four of these patients this finding was asymptomatic. No medium-term difference in function or radiological outcome was identified between the two treatment groups.

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    • "These findings are relevant for younger active patients who sustain the majority of scaphoid fractures [1]. Studies comparing the Herbert screw to cast immobilization did not identify any long term radiographic or clinical benefits to surgical fixation versus casting [14] and longer term follow up did not demonstrate significant benefits with surgical treatment [15]. Given the controversy that exists around operative fixation of the acute minimally displaced scaphoid fracture, surgeons must look closely at patient factors prior to recommending surgery or selecting a screw system. "
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    ABSTRACT: The purpose of this study was to compare the interfragmentary compression force across a simulated scaphoid fracture by two commonly used compression screw systems; the Acutrak 2 Standard and the 3.0 mm Synthes headless compression screw. Sixteen (8 pairs; 6 female, 2 male) cadaver scaphoids were randomly assigned to receive either the Acutrak 2 or Synthes screw with the contralateral scaphoid designated to receive the opposite. Guide wires were inserted under fluoroscopic control. Following transverse osteotomy, the distal and proximal fragments were placed on either side of a custom load cell, to measure interfragmentary compression. Screws were placed under fluoroscopic control using the manufacturer's recommended surgical technique. Compressive forces were measured during screw insertion. Recording continued for an additional 60s in order to measure any loss of compression after installation was complete. The peak and final interfragmentary compression were recorded and paired t-tests performed. The mean peak compression generated by the Acutrak 2 Standard was greater than that produced by the Synthes compression screw (103.9 ± 33.2 N vs. 88.7 ± 38.6 N respectively, p = 0.13). The mean final interfragmentary compression generated by the Acutrak 2 screw (68.6 ± 36.4 N) was significantly greater (p = 0.04) than the Synthes screw (37.2 ± 26.8 N). Specimens typically reached a steady state of compression by 120-150s after final tightening. Peak interfragmentary compression observed during screw installation was similar for both screw systems. However, the mean interfragmentary compression generated by the Acutrak 2 Standard was significantly greater. Our study demonstrates that the Synthes headless compression screw experienced a greater loss of interfragmentary compressive force from the time of installation to the final steady state compression level. The higher post-installation compression of the Acutrak 2 Standard may be attributable to the greater number of threads throughout the entire length of the screw. The clinical significance of these results, are, at this point uncertain. We do demonstrate that a fully threaded design offers a more reliable compression that may translate to more predictable bony union.
    Full-text · Article · Jun 2011 · Journal of Orthopaedic Surgery and Research
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    ABSTRACT: Introduction We present a retrospective study on different treatment options for scaphoid nonunion. The results are compared to the literature and a treatment algorithm is proposed. Materials and methods Based on a retrospective case-control study, 208 patients suffering from scaphoid nonunion were treated between 2000 and 2006. The patients were grouped depending on the localization of the nonunion: proximal (n=10), middle (n=105), or distal (n=93) third. In the presence of a small avascular proximal fragment, a vascularized bone graft from the distal radius was added (n=53). The determination of scaphoid healing was achieved by conventional radiographs or CT scans. Results Overall scaphoid healing occurred in 89.9% (n=187). For small proximal scaphoid fragments (n=93), we could show healing rates up to 83% (n=77). Using a vascularized bone graft from the distal radius, scaphoid consolidation was achieved in 81% for avascular proximal fragments and recurrent scaphoid nonunion (n=53). Conclusion Using sophisticated treatment options, the prognosis of scaphoid nonunions is very good.
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