Fixation Of Scaphoid Fractures Research Articles

Postoperative Outcomes of Volar Plate Fixation in Cases of Scaphoid Deformity or Nonunion: A Case Series.

Background Fractures through the waist of scaphoid are a common injury, resulting in deformity or nonunion. Recently, a locking plate has been shown to fix deformity or nonunion of scaphoid, with limited observation of functional postoperative outcomes. Objectives We present a case series of 16 patients, with the disabilities of the arm, shoulder, and hand (DASH) score evaluation in primary fixation of scaphoid fractures with humpback deformity ( n = 11) and revision open reduction internal fixation (ORIF) for nonunion ( n = 5), using the Medartis TriLock 1.5 scaphoid plate and bone grafting. Patients and Methods DASH scores were obtained preoperatively and postoperatively at 3, 6, and 12 (if required) months. Patient demographics, smoking status, employment type, and grip strengths were recorded. Results Thirteen patients attended follow-up. Union was clinically and radiologically assessed with 13 achieving union. The mean preoperative DASH score was 34.0 ( n = 16) and at treatment completion (discharge or DNA) was 11.5 ( n = 13), with mean reduction of 18.5 ( p = 0.03). At treatment completion, mean reduction in DASH score of revision ORIF was 13.7 ( p = 0.27; n = 4), compared with 20.7 ( p < 0.01; n = 9) in primary fixation with plate. Conclusions Deformity correction, reduction in DASH score, and rate of union make the plate system useful in the management of scaphoid fractures with humpback deformity and revision for nonunion. Level of Evidence This is a Level IV study.

COMPARISON OF OPERATIVE FIXATION OF ACUTE SCAPHOID FRACTURES WITH THE NON-OPERATIVE TREATMENT: A PROSPECTIVE CLINICAL STUDY.

Aim: to compare the results of operative fixation of acute scaphoid fractures with those of non-operative treatment.&#x0D; Materials &amp; Method: This clinical study was carried out among 26 patients with an acute nondisplaced or minimally displaced scaphoid fracture reported to the OPD of Orthopedics, Jawaharlal Nehru Medical College and Hospital, Bhagalpur, Bihar, India. Patients were non-randomly allocated to group A (non-operative treatment with a cast) and group B (internal fixation with a Herbert screw).&#x0D; Results: mean age of the study population was 41.23 years. Majority of them were male 21 (80.7%) and rest 5 (19.3%) were female. Out of total 26 scaphoid fracture cases 16 (61.5%) were of right hand and rest 10 (38.5%) found on the left hand. Most common location of fracture was waist fracture (B2) 10 cases. 100% union was observed in group B.&#x0D; Conclusions: study proves that Cast treatment has the disadvantages of longer immobilisation time, joint stiffness, reduced grip strength, and longer time to return to work whereas the operative fixation of acute scaphoid fractures results in predictable satisfactory union rate and good functional outcome.&#x0D; Keywords: cast treatment, scaphoid fracture

Single versus double screw fixation for the treatment of scaphoid waist fractures: Finite element analysis and preliminary clinical results in scaphoid nonunion.

Objectives This study aims to compare the single versus double screw fixation of scaphoid waist fractures using finite element analysis, and to present the preliminary clinical results of double screw fixation in a consecutive series of patients with scaphoid nonunion.Patients and methods A transverse scaphoid waist fracture (Herbert type B2) model was fixed with either single or double cannulated compression screws. Displacement and rotation of the fragments were performed using three-dimensional finite element analysis in three different wrist positions. A retrospective review was performed on 13 male patients (mean age 31.6±12.8 years; range, 17 to 64 years) who underwent double screw fixation for an established scaphoid nonunion in our clinic between January 2015 and December 2017. Assessment of union was established with serial plain radiographs in eight patients and with wrist computed tomography in five patients. Clinical evaluation was performed using the Mayo wrist score and visual analog scale (VAS).Results In all wrist positions, the displacement of the fracture gap in double screw fixation in all planes (x, y, and z) was less than in single screw fixation. Similarly, rotation of the fracture fragments around the longitudinal axis of the scaphoid was lower in double screw fixation. Complete union was obtained in all patients. The mean time to union was 5±0.75 months (range, 4 to 6 months). The mean VAS was 0.8±0.9 (range, 0 to 3). Mayo wrist score was 91±6.9 (range, 80 to 100) at the final follow-up.ConclusionDouble-screw fixation technique may be a solution to reduce the rate of scaphoid nonunion in unstable type B2 scaphoid fractures or nonunion.

A Mini-Open, Dorsal Approach for Scaphoid Fracture Fixation With a Ligament Sparing Arthrotomy.

There are several surgical approaches that are currently used to address nondisplaced scaphoid waist fractures, including percutaneous fixation, limited exposure fixation, and traditional open techniques through a volar or dorsal approach. Although percutaneous fixation has some theoretical advantages, it is much more difficult to achieve an accurate starting point for a headless compression screw. The purpose of this paper is to describe a simple, dorsal, mini-open approach to the scaphoid that minimizes incision size, extensor tendon dissection, capsular trauma, and vascular disruption, while still allowing for direct visualization of the proximal pole and optimal exposure for accurate screw placement. As a case report, we retrospectively evaluated 80 consecutive patients with closed scaphoid fractures. There were 2 groups, with 44 patients (age: 24±10 y) receiving a percutaneous dorsal approach and 36 patients (age: 30±16 y) treated with a mini-open approach. All scaphoid fractures were acute or fibrous nonunions (<6 mo from injury, except for one) treated with cannulated headless compression screws. Intraoperative and postoperative complications were measured and evaluated for each group to assess for differences between the percutaneous approach and the mini-open technique. We found no significant difference in complication rate with the mini-open dorsal technique compared with the dorsal percutaneous approach (8.3% vs. 4.5%, respectively). Therefore, we suggest consideration of this mini-open dorsal approach for scaphoid fracture fixation as a useful and safe technique.

Three-Dimensional Printed Targeting Device for Scaphoid Fracture Fixation.

Background: Percutaneous guide wire insertion for scaphoid screw fixation can be challenging and often requires multiple attempts with significant radiation exposure to the surgical team. A 3-dimensional (3D) printed targeting device has the potential to reduce procedure time and intraoperative radiation exposure. Methods: Our targeting device protocol included a preprocedure computed tomography (CT) scan of a casted cadaver wrist, followed by 3D printing of a customized targeting guide. In a comparison trial, seven orthopedic surgery residents performed percutaneous scaphoid guide wire insertion on different cadaver specimens by both freehand technique and using our targeting device. Radiation exposure and procedure times were compared. All specimens underwent postprocedure CT to assess Kirschner wire (K-wire) accuracy, determined by central third placement. Pre- and postprocedure CT scans from the targeting device group were co-registered to compare planned and actual K-wire trajectories. Results: Using the freehand technique, mean fluoroscopy time was 120 seconds (standard deviation: ±53 seconds) generating 2.45 milligray of radiation. Average procedure time was 21 minutes with a mean of 6.4 (range: 3-9) insertion attempts. A single insertion attempt was made using the targeting device with an average procedure time of 30 seconds and no fluoroscopy exposure. Four K-wires were placed within the central scaphoid in both groups. Using the targeting device, average linear deviation from the planned trajectory was 2.1 mm, while the maximum linear deviation was 3.75 mm. Conclusion: When compared to freehand scaphoid guide wire insertion, our targeting device provides similar accuracy while significantly reducing intraoperative radiation exposure and procedure time.

Factors Associated with Scaphoid Nonunion following Early Open Reduction and Internal Fixation.

Background Nonunion after open reduction and internal fixation (ORIF) of scaphoid fractures is reported in 5 to 30% of cases; however, predictors of nonunion are not clearly defined. Objective The purpose of this study is to determine fracture characteristics and surgical factors which may influence progression to nonunion after scaphoid fracture ORIF. Patients and Methods We performed a retrospective case-control study of scaphoid fractures treated by early ORIF between 2003 and 2017. Inclusion criteria were surgical fixation within 6 months from date of injury and postoperative CT with minimum clinical follow-up of 6 months to evaluate healing. Forty-eight patients were included in this study. Nonunion cases were matched by age, sex, and fracture location to patients who progressed to fracture union in the 1:2 ratio. Results This series of 48 patients matched 16 nonunion cases with 32 cases that progressed to union. Fracture location was proximal pole in 15% (7/48) and waist in 85% (41/48). Multivariate regression demonstrated that shorter length of time from injury to initial ORIF and smaller percent of proximal fracture fragment volume were significantly associated with scaphoid nonunion after ORIF (63 vs. 27 days and 34 vs. 40%, respectively). Receiver operating curve analysis revealed that fracture volume below 38% and time from injury to surgery greater than 31 days were associated with nonunion. Conclusion Increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury and when fracture volume was less than 38% of the entire scaphoid. Level of Evidence This is a Level III, therapeutic study.

Dorsal percutaneous screw fixation of delayed scaphoid fractures augmented with bone marrow injection

Background The management of delayed scaphoid fractures in physically demanding patients remains ‎controversial. This article discusses a simple treatment that accelerates healing and allows early mobilization. ‎ The purpose of the study was to evaluate results of percutaneous headless compression screw fixation with bone ‎marrow injection in scaphoid delayed-union fractures, which allows early mobilization of wrist to achieve early ‎return to activities of daily living (ADL).‎ Patients and methods A total of 20 patients (22 scaphoid) with scaphoid delayed-union fractures underwent percutaneous headless screw fixation with bone marrow injection from iliac bone. The inclusion criteria in this series were scaphoid delayed-union fractures with intact cartilaginous envelope, no sclerosis, and no avascular necrosis. Results The mean follow-up period as 20.4 months (range: 12–24), the average radiographic union was 7.8 weeks (range: 6–10 weeks), and the average visual analog scale score was 0.05 (range: 0–1). Average wrist range of motion was flexion of 85° (range: 75–90), extension 76.5° (range: 70–85), radial tilt 18.5° (range: 15–20), and ulnar tilt 42.5° (range: 39–45). The average grip strength was 95% (85–100%). Conclusion Percutaneous technique fixation for scaphoid fractures is a reliable and less harmful method and helps in early return to activity. The dorsal approach allows proper screw positioning and allows the use of hook to correct minimal displacement and gain best compression at the fracture site. Refreshing of the fracture ends by k-wire and bone marrow injection help to accelerate union with the less-invasive method. The best results of the percutaneous technique in delayed-union scaphoid fractures are achieved with intact cartilaginous envelope, no sclerosis, and no avascular necrosis. Level of evidence This was a level IV therapeutic study.

Results of percutaneous fixation of Scaphoid fracture in patients with delayed presentation

Background: A scaphoid fracture is the most common type of carpal bone fracture affecting young active people. Inspite of its occurrence, many a times scaphoid fracture goes undetected. A patient presenting late, makes the line of management even more controversial. The purpose of our study is to evaluate the results of percutaneous fixation of scaphoid fracture in patients with delayed presentation. Materials and Method: We did a prospective case study. 17 cases presented to us with delayed history of scaphoid fracture. All patients were managed by percutaneous fixation of the scaphoid with Herbert screw. Post-surgery patients were evaluated clinically and radiologically. Functional outcome was assessed by functional scores. Patient were followed up for minimum of 12 months. Results: Almost all patients returned to work within one-month post-surgery. 13 patients had excellent result. N2 patient has good result, one developed AVN and one lost to follow-up. Conclusion: We suggest percutaneous fixation of the scaphoid fracture by Herbert screw in cases with delayed presentation.

Closed reduction and dorsal percutaneous screw fixation of scaphoid fracture

Closed reduction and dorsal percutaneous screw fixation of scaphoid fracture

A study of functional and radiological outcome of undisplaced scaphoid fracture treated with percutaneous Herbert screw fixation

Introduction: The management of undisplaced fractures of the scaphoid is controversial. Conventional management of these fractures has been with significant risk of scaphoid nonunion. Objectives: Our objective was to study if early per-cutaneous fixation of scaphoid fractures results in early return to work and sports activities, better union rates, better pain relief and better range of motion of wrist. Methodology: This study examined the results from 30 patients who underwent per-cutaneous screw fixation using a Herbert screw in an un-displaced scaphoid fracture. All patients in the study group were followed up for average 2 years evaluating them according to the Green & O’Brien score. Results: All had healed successfully after the index procedure. There were three complications consisting of wrist pain and decreased range of motion of wrist. These also went on to heal, resulting in better union rates. Conclusion: Thus per-cutaneous fixation of acute, un-displaced scaphoid fractures with percutaneous Herbert screws is an effective treatment which reduces the need of prolonged immobilization and helps in an early return to the routine activity.

Approach to the Perpendicular Fixation of a Scaphoid Waist Fracture—A Computer Analyzed Cadaver Model

In scaphoid fracture screw fixation, the screw is commonly placed along the long axis of the bone, without consideration of the fracture plane. This position is not perpendicular to transverse waist fractures or to the more common horizontal oblique fractures. Our aim was to examine the feasibility and describe possible approaches to, placing a screw perpendicular and in the center of the scaphoid waist fracture. Computed tomography of 12 cadaver wrists was performed in 3 positions to examine possible approaches in flexion, neutral, and extension of the wrist. The scans were evaluated using a 3-dimensional model that simulated horizontal oblique (60°) and transverse (90°) fractures. We examined all possible approaches for screw positioning and their deviation from the axis perpendicular to the fracture and in the center of its plane. The preferred approaches for a perpendicular screw in a horizontal oblique fracture were found to be proximal-dorsal in flexion or transtrapezial in the extended or neutral positions (through the volar-radial trapezium). In transverse fractures, the possible approaches were proximal-dorsal or transtrapezial in the flexed or neutral positions and distal in the extended position (volar to volar-radial trapezium). In these approaches, the screw could be placed perpendicularly (deviating by < 10°) and in the center of the fracture in all specimens. According to this model, it appears feasible to place a perpendicular screw in thecenter of a horizontal oblique waist fracture using a proximal-dorsal approach in flexion ora transtrapezial approach in neutral or extension positions of the wrist. Palpable landmarksmay be used as additional guides to direct these approaches according to the clinical setting. Perpendicular screw fixation of horizontal oblique or transverse scaphoid waist fractures is a possible option, if chosen for its biomechanical advantages.

Volar Percutaneous Fixation of Recent Fracture Scaphoid

AbstractBackground: Scaphoid fracture is the most commonly fractured carpal bone, frequently results from a fall on an outstretched hand with the wrist in extension. The principal treatment methods are cast immobilization or surgery.Aim of Study: The aim of this study is to evaluate results of volar percutaneous fixation of recent fracture scaphoid.Patients and Methods: In this prospective study, 21 cases with closed scaphoid fractures were treated with volar percu-taneous fixation by Herbert screw. Clinical and radiological data were analyzed.Results: These cases were assessed according to modified mayo scoring system. Clinical results were graded as excellent, good, fair as follows: Excellent in 17 patients (8%), good in 3 patients (14%), fair in one patients (5%) the excellent and good results were considered as satisfactory results while the unsatisfactory included the fair results. Thus, satisfactory results were found in 20 patients (95%), and the unsatisfactory results were found in one patient (5%).Conclusion: This study proves that fixation of recent scaphoid fractures result in predictable satisfactory union rate and functional outcome.

Three-dimensional-printed patient-specific Kirschner-wire guide for percutaneous fixation of undisplaced scaphoid fractures: a cadaveric study.

Undisplaced scaphoid waist fractures can be managed by percutaneous fixation. The purpose of this study is to compare percutaneous fixation using a three-dimensional (3-D)-printed guide with the conventional method in a cadaveric study. Twelve wrists were divided into two groups: standard fluroscopic technique group, and a patient-specific 3-D-printed guide group. In the patient-specific group, using high resolution CT scans, we manufactured a mould-guide including a wire guide sleeve aligned with the planned ideal path, and 3-D printed it. On postoperative CT scans we measured the angular deviation of the screw axis from the ideal axis, and compared the two groups. The angular deviation was significantly lower in the patient-specific guide group. We concluded that a 3-D-printed guide for scaphoid percutaneous fixation allows a more accurate placement of the screw than a fluoroscopy guide in our cadaveric model.

Robot-assisted percutaneous scaphoid fracture fixation: a report of ten patients.

This study reports the technique, efficacy and safety of robotic-assisted, computer-navigated, percutaneous fixation of scaphoid fractures. Ten males with acute undisplaced waist fractures underwent fixation with this method using a commercially available three-dimensional fluoroscopy unit and robotic navigation system. The mean total operative duration was 40 minutes, which comprised of a set-up time of 18 minutes and planning and surgical time of 22 minutes. All patients required only a single guidewire insertion attempt, and there were no screw protuberances or other complications. All fractures united at a mean of 8weeks. At a mean follow-up of 6.5months (range 6-8), the mean Mayo wrist score was 96, patient-rated wrist evaluation was 2, flexion-extension arc was 96% and grip strength was 91% of the contralateral side. We conclude from our patients that robotic-assisted percutaneous scaphoid fixation is feasible, safe and accurate, and is a satisfactory method for treating these injuries. Level of evidence: IV.

Scaphoid fractures with scapholunate ligament involvement: Instability or ligamentous laxity? Role of arthroscopy and pinning.

Percutaneous fixation of scaphoid fractures often does not allow the evaluation of potential ligamentous lesions. Arthroscopy is an useful tool in the management of scaphoid fractures to visualize potentially associated lesions. With arthroscopic assistance, we often found scapholunate ligament lesions. Our study's aim was to evaluate the role of arthroscopy in the treatment of scaphoid fracture and in particular if the alteration found was a real lesion causing instability or just a paraphysiologic laxity. Furthermore, we evaluated whether the scapholunate joint pinning alters the outcome. We performed a retrospective study on 39 patients (33 males and 6 females), with an average age at trauma of 31.2years (range 15-67), who underwent surgery for scaphoid fractures between 2010 and 2016 in our Center of Hand Surgery. Patients were divided into four groups based on surgical technique and finding of scapholunate lesions. Differences between the four groups analyzed, both in terms of clinical scores and ROM, were not statistically significant. This corroborates the hypothesis that all four treatments are equivalent. Based on our experience and the literature available, we believe the systematic use of arthroscopy to be useful in patients needing surgical treatment for scaphoid fractures. This is because arthroscopy allows the control of the fracture reduction, screw protrusion evaluation and ligamentous lesions assessment. In cases of partial scapholunate ligament alteration in which no sign of acute lesion is present (hemorrhage and clear rupture), pinning is not necessary since it might just be a paraphysiologic laxity. IV.

Impact of Screw Length on Proximal Scaphoid Fracture Biomechanics.

Background Proximal scaphoid fractures display high nonunion rates and increased revision cases. Waist fracture fixation involves maximizing screw length within the cortex; however, the optimal screw length for proximal scaphoid fractures remains unknown. Purpose The main purpose of this article is to compare stiffness and ultimate load for proximal scaphoid fracture fixation of various headless compression screw lengths. Methods Eighteen scaphoids underwent an osteotomy simulating a 7 mm oblique proximal fracture. Screws of three lengths (10, 18, and 24 mm) were randomly assigned for fixation. Each specimen underwent cyclic loading with stiffness calculated during the last loading cycle. Specimens that withstood cyclic loading were loaded to failure. Results No significant difference in stiffness between screw lengths was found. Ultimate load was significantly impacted by the screw length. A significant difference in ultimate load between a 10 and 24 mm screw was found; however, no significant difference occurred in ultimate load between an 18 and 24 mm screw. Conclusions No significant difference in stiffness between all groups could be due to similarities in purchase in the proximal aspect. The 10 mm screw withstanding less ultimate load compared to the 24 mm screw could be due to the 10 mm screw gaining less purchase on either side of the fracture site compared to the 24 mm screw. Lack of significant difference in ultimate load between the 18 and 24 mm screw could be occurring because the fracture site is closer to the 18 mm screw midpoint, as distal threads are engaged closer to the fracture. Clinical Relevance Maximizing screw length may not provide superior fixation biomechanically compared with fixation utilizing a 6 mm shorter screw for proximal scaphoid fractures.

Functional outcome in surgical management of scaphoid fractures with k wire and headless compression screw

Background: Achieving stable fixation of scaphoid fractures and nonunions continues to be a challenge. Compression screw fixation has been the current standard surgical procedure. Materials and Methods: A retrospective study was conducted of 8 patients having closed scaphoid fractures at our institution over a 3 year period. Out of these, 4 patients were operated with percutaneous k wire fixation and 4 patients with open reduction and fixation with Herbert’s screw. A review of clinical as well as radiographic data was undertaken. The mechanism of injury, patient demographics, timing of surgery, initial displacement, fixation method, smoking status, and lunate morphology were recorded. Functional outcome measures were recorded. Results: A total of 7 out of 8 patients (87 %) showed evidence of union at 12 weeks post-injury. Similarly, fractures sustained via low energy mechanisms had a higher rate of early union compared to high energy mechanisms. Conclusions: Initial displacement and mechanism of injury have the most significant effects on early rates of union. early fixation of these fractures is recommended to prevent further displacement. One may prefer surgery because of an earlier return to work and mobility.

Scaphoid Fracture Repair Does Not Significantly Diminish Short-Term Participation in the National Football League.

Fixation of scaphoid fractures is recommended in elite athletes to hasten healing and return-to-sport times. Complications such as nonunion negatively affect athletic performance. The purpose of this study was to examine the prevalence and impact of scaphoid repair on National Football League (NFL) participation during athletes' first season in the NFL, while identifying significant predictors for development of carpal arthritis and scaphoid nonunion. A total of 1311 football athletes invited to the NFL Scouting Combine from 2012 to 2015 were evaluated for history of scaphoid fracture repair. Athlete demographics, surgical history, and imaging and physical examination findings were recorded. Future NFL participation based on draft status, games played, and games started during athletes' first season were gathered using publicly available databases. Nineteen (1.4%) athletes underwent 24 operations for scaphoid repair. Limitations in wrist range of motion or strength were present in 47.4% of athletes with a history of repair. Arthritic changes were present in 32% of wrists, while radiographic nonunion was present in two athletes following scaphoid fracture. Defensive backs were observed to have a higher incidence for arthritic changes following repair compared to other positions. No significant difference in prospective NFL participation was found in athletes with a history of scaphoid repair than in those without. Athletes with a history of scaphoid repair are not at significant risk for diminished participation during their first season in the NFL.

Fixation du scaphoïde carpien par vissage palmaire ou dorsal : étude en éléments finis

PurposeScaphoid waist fractures may be fixed through volar or dorsal screw fixation. However, there is no consensus on which surgical fixation method should be performed. The purpose of this study was to compare volar versus dorsal screw fixation of scaphoid waist fractures under physiological loading conditions utilizing finite element analysis. MethodsA transverse scaphoid waist fracture (Herbert type B2) model was fixed with a headless cannulated compression screw using either a volar or dorsal approach. Displacement and rotation of the fragments and stress analysis on the scaphoid bone and screw were analyzed in the models using 3D finite element analysis in three different wrist positions; total extension (TE), neutral (N) and total flexion (TF). ResultsDisplacement of the fracture gap in volar fixation in all planes (x, y, z) was less than in dorsal fixation in the TF and N positions. Furthermore, rotational stability was stronger in volar fixation in all planes and wrist positions. Von Mises stress values were concentrated on the proximal fragment in all wrist positions. ConclusionsAlthough both volar and dorsal fixation techniques can be preferred in Herbert type B2 fractures, results of this finite element analysis suggest that centrally placed volar compression screw fixation may be biomechanically advantageous over dorsal screw fixation. Level of evidenceI.

Comparison of volar versus dorsal screw fixation for scaphoid waist fractures: A finite element analysis

PurposeScaphoid waist fractures may be fixed through volar or dorsal screw fixation. However, there is no consensus on which surgical fixation method should be performed. The purpose of this study was to compare volar versus dorsal screw fixation of scaphoid waist fractures under physiological loading conditions utilizing finite element analysis. MethodsA transverse scaphoid waist fracture (Herbert type B2) model was fixed with a headless cannulated compression screw using either a volar or dorsal approach. Displacement and rotation of the fragments and stress analysis on the scaphoid bone and screw were analyzed in the models using 3-D finite element analysis in three different wrist positions; total extension (TE), neutral (N) and total flexion (TF). ResultsDisplacement of the fracture gap in volar fixation in all planes (x, y, z) was less than in dorsal fixation in the TF and N positions. Furthermore, rotational stability was stronger in volar fixation in all planes and wrist positions. von Mises stress values were concentrated on the proximal fragment in all wrist positions. ConclusionsAlthough both volar and dorsal fixation techniques can be preferred in Herbert type B2 fractures, results of this finite element analysis suggest that centrally placed volar compression screw fixation may be biomechanically advantageous over dorsal screw fixation. Level of evidenceI.