Treatment of acute scaphoid fractures - Systematic review and meta-analysis
Whether operative treatment is a better option than nonoperative treatment for acute nondisplaced or minimally displaced fractures of the scaphoid is controversial. The type of cast that should be used for nonoperative treatment is not known. We performed a systematic review and meta-analysis of randomized and quasirandomized trials to evaluate the effect of operative versus nonoperative treatment and the effect of different casting methods for nonoperative treatment of acute scaphoid fractures on nonunion rate, return to work, grip strength, range of wrist motion, complications, patient evaluation, and incidence of osteoarthritis. Two investigators assessed trial quality and extracted data. Operative treatment of acute nondisplaced or minimally displaced fractures of the scaphoid waist does not provide greater benefits regarding nonunion rate, return to work, grip strength, range of wrist motion, or patient satisfaction than cast immobilization; however, it causes more complications and, perhaps, a higher risk of scaphotrapezial osteoarthritis. There is no evidence from randomized trials to determine whether operative treatment is superior to nonoperative treatment for an acute proximal pole fracture of scaphoid bones. There is insufficient evidence to determine which type of cast should be used in nonoperative treatment of nondisplaced scaphoid fractures.
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ABSTRACT: Traditionally, acute nondisplaced scaphoid fractures have been treated nonoperatively in a cast, and the expected union rate approaches 90%. Internal fixation of nondisplaced scaphoid fractures has increased in popularity, and a union rate of 100% has been reported. The growing trend is to recommend internal fixation for the majority of acute scaphoid fractures. The true long-term benefits of this more complicated treatment modality have not yet been determined in randomized controlled trials. The purpose of this study was to compare the long-term results of operative fixation of acute scaphoid fractures with those of nonoperative treatment.
During the period between 1992 and 1997, eighty-three patients with an acute nondisplaced or minimally displaced scaphoid fracture were randomly allocated to, and received, either nonoperative treatment with a cast or internal fixation with a Herbert screw. At a median of ten years after the injury, seventy-five (93%) of the eighty-one patients who were still alive were assessed clinically and radiographically.
All fractures united. A significant increase in the prevalence of osteoarthritis in the scaphotrapezial joint was found in the operatively treated group. No differences in subjective symptoms, as measured with limb-specific outcome scores, were found between the two groups. The range of motion and grip strength were greater, but not significantly greater, in the nonoperatively treated group.
This study did not demonstrate a true long-term benefit of internal fixation, compared with nonoperative treatment, for acute nondisplaced or minimally displaced scaphoid fractures. The long-term risks of surgery should be considered when recommending operative treatment.
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ABSTRACT: The purpose of this study was to describe chondral/osteochondral and ligamentous injuries associated with scaphoid fractures treated with arthroscopically assisted reduction and percutaneous fixation.
The study consisted of 8 patients with stable scaphoid fractures and 16 with unstable scaphoid fractures. The mean age was 32 +/- 14 years (range, 17 to 75 years). The arthroscopic findings were recorded, including intrinsic and extrinsic ligamentous injuries as well as osteochondral injuries. Percutaneous screw fixation through a dorsal approach was performed. In all patients with associated soft-tissue injuries, a short-arm thumb spica cast was used for a 3- to 6-week period. Follow-up included clinical evaluation with the Mayo Modified Wrist Score and plain radiographs. The mean follow-up time was 27 +/- 16 months, with a minimum of 1 year. The mean healing time was 7 +/- 4 weeks (range, 6 to 24 weeks).
Associated soft-tissue and/or chondral/osteochondral injuries were diagnosed arthroscopically in 15 of 24 cases in this series. The result was scored as good or excellent in 23 patients and poor in 1. Complications included 1 case with partial necrosis of the proximal scaphoid pole and 2 patients with loss of wrist flexion and grip strength that improved after hardware removal.
In this series, 15 of 24 patients with acute scaphoid fractures presented with associated ligamentous and/or chondral/osteochondral injuries.
Level IV, therapeutic case series.
Available from: Tamara Nancoo
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ABSTRACT: Undisplaced and minimally displaced scaphoid waist fractures can be managed either operatively (percutaneous or ORIF) or non-operatively with both methods obtaining high rates of fracture union and subsequent return of function. The aim of this systematic review is to identify and evaluate the best available evidence to determine whether they should be managed operatively or non-operatively.
A Medline and journal hand search was performed with strict eligibility criteria to obtain the highest quality evidence from meta-analyses, randomised controlled trials (RCT) and comparative studies. Included studies were critically appraised using levels of evidence and RCTs were further appraised using a scoring tool.
The search found 112 studies, of which 12 met the eligibility criteria for inclusion. Three level 1 RCTs, three level 2 RCTs, two meta-analyses, one economic analysis, and three retrospective studies were critically appraised. The evidence suggests that percutaneous fixation may result in faster union rates by approximately 5 weeks and an earlier return to sport and work by approximately 7 weeks over cast treatment. This difference is not seen when comparing ORIF with cast treatment. Although cast treatment results in a higher non-union rate than ORIF, this needs to be balanced with the 30% minor complication rate. Manual workers require significantly longer time off work than non-manual workers regardless of the method of treatment, although they did return to work sooner after ORIF than after cast treatment.
The majority of these injuries can be treated in a cast with good results. Operative treatment should be reserved for patients unable to work in a cast and considered for most manual workers and high-level athletes.
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