Treatment Of Scaphoid Fractures Research Articles

Outcome analysis of surgical treatment for old scaphoid fractures

Objective To discuss the surgical methods and treatment effects of old scaphoid fractures.Methods From June 2005 to June 2008, 16 cases of old scaphoid waist fractures were treated by debridement of necrotic bone, autologous bone graft and Herbert screw plus Kirschner wire internal fixation through a dorsal approach. Postoperative X-rays were taken on a regular basis to observe fracture healing. Wrist function was evaluated according to Krimmer score. Results Postoperatively the 16 cases were follow-up for an average of 8.5 months. All the fractures healed and the average healing time was 16 weeks. Krimmer score determined wrist function to be excellent in 8 cases, good in 5 cases, fair in 2 cases and poor in 1 case. The overall satisfactory rate was 81.3%. Conclusion Herbert screw and K-wire internal fixation combined with autologous bone graft can attain good clinical results in the treatment of old scaphoid fiactures at the waist. Key words: Scaphoid bone; Fractures,closed; Fracture fixation,internal

Current methods of diagnosis and treatment of scaphoid fractures

Fractures of the scaphoid bone mainly occur in young adults and constitute 2-7% of all fractures. The specific blood supply in combination with the demanding functional requirements can easily lead to disturbed fracture healing. Displaced scaphoid fractures are seen on radiographs. The diagnostic strategy of suspected scaphoid fractures, however, is surrounded by controversy. Bone scintigraphy, magnetic resonance imaging and computed tomography have their shortcomings. Early treatment leads to a better outcome. Scaphoid fractures can be treated conservatively and operatively. Proximal scaphoid fractures and displaced scaphoid fractures have a worse outcome and might be better off with an open or closed reduction and internal fixation. The incidence of scaphoid non-unions has been reported to be between 5 and 15%. Non-unions are mostly treated operatively by restoring the anatomy to avoid degenerative wrist arthritis.

Die primär nicht nachweisbare Skaphoidfraktur – Eine diagnostische Herausforderung?

Scaphoid fractures represent the most common carpal bone fractures. These fractures may be overlooked due to insufficient diagnostics and lead to non-union and disability. A standardized diagnostic procedure with X-ray examinations, CT scans and/or MRI is recommended. We report on a case where a scaphoid fracture was overlooked, probably because of an incorrect technique of the computed tomography. A 42-year-old man was admitted to our emergency room after a fall on the out-stretched wrist. X-rays showed no evidence of a bony lesion. In the follow-up examination on the next day, a scaphoid fracture was still suspected clinically. Because of that a CT scan in thin slice technique with axial layers and multiplanar reconstruction was performed but showed no sign of a fracture. Six weeks after the trauma the patient presented with persistent wrist pain. X-rays and a CT scan of the wrist now demonstrated an old waist fracture of the scaphoid. -Operative treatment with iliac crest bone grafting and screw fixation was performed. Early diagnosis and a correct description of the fracture pattern are of high value in the treatment of scaphoid fractures. X-rays combined with a CT scan or an MRI scan of the affected wrist are considered as the diagnostic standard. The reported case demonstrates that even with a thin thickness layer CT scan in axial planes, a scaphoid fracture can be overlooked. Therefore we recommend after primarily inconspicuous X-rays a CT scan with primary -oblique-sagittal layers in the longitudinal axis of the scaphoid. If this shows no fracture and the clinical suspicion persists, an MRI scan should be performed.

The in vivo study of three-dimensional kinematics of fractured scaphoid

Objective To accurately quantify three-dimensional in vivo kinematics of fractured scaphoid in wrist flexion-extension and radial-ulrar deviation, and to provide the theoretic bases for clinical application. Methods The bilateral wrists of 10 adult volunteers with scaphoid fractures were imaged by spiral CT at neutral position, at 15°, 30°, 45° and 60° of wrist flexion-extension, at 10° and 20° of radial deviation and at 10°, 20°, 30° and 40° of ulnar deviation. The 3D quantitative measurement and analysis of fractured scaphoid were performed in our computer-operated simulation system. The 3D kinematic data of the proximal and distal fragments of the fractured scaphoid were measured using the center of articular surface of the distal radius as reference. The kinematic data from the healthy side scaphoid were also acquired for comparison. Results After the scaphoid was fractured, being compared with the normal scaphoid, the proximal fragment of the scaphoid did not show obvious changes of rotation and translation. The changes of the distal fragment of the scaphoid were significant. When the wrist was positioned at 10° radial deviation and 30° extension, the distance between the centroids of distal and proximal fragment models was the smallest. Conclusion In the treatment of scaphoid fractures, the wrist should be kept at 10° radial deviation and 30° extension to ensure shortest distance between the fracture fragments and hence satisfactoiy reduction. The study provided some theoretic and technical reference for treatment of scaphoid fractures. Key words: Scaphoid bone; Fractures; bone; Imaging; three-dimensional; Kinematics; In vivo

Acute scaphoid fracture: a review

The scaphoid is by far the most commonly fractured carpal bone. Occult fractures, imperceptible on initial radiographs and a reputation for non-union make diagnosis and management challenging. The past few years have seen significant advances in the assessment and surgical treatment of scaphoid fractures. This article reviews the published literature relating to acute scaphoid fractures and examines the advances that have been made in management.

Treatment of scaphoid fractures with AO double thread compression cannulated screw via a volar approach

Objective To discuss the application,operative techniques and the treatment outcome of scaphoid fractures using AO double thread compression earmulated screw via a volar approach.Methods From March 2000 to January 2008.we treated 21 patients with fresh scaphoid waist fractures by dose reduction and intemal fixation with AO double thread compression cannulated screw via a volar approach under fluoroscope guidance.Plain X-ray was taken on a regular base postoperatively to investigate fracture healing.Wrist ftmetion was evaluated according to Krimmer score.Results,The patients were followed up for an average of 15 months (range,3 to 24 months).Primary healing of the fractures was seen in all cases with an average heallng time of 10weeks.Wrist function was graded as excellent in 15 cases,good in 4 cases and fair in 2 cases according to Krimmer score evaluation.The overall excellent and good rate was 90.5%.Conclusion Close reduction and internal fixafion with AO double thread compression cannulated screw via a volar approach iixider fluoroscope guldanee is a valid treatment option for scaphoid waist fractures.It is minimally invasive and allows early postoperative rehabilitation which improves fracture healing and functional roeovery. Key words: Scaphoid bone; Fractures,closed; Fracture fixation,internal

Retrospective Review of 234 Scaphoid Fractures and Nonunions Treated with Arthroscopy for Union and Complications

The purpose of this paper is to retrospectively review 234 consecutive cases of scaphoid fractures and nonunions treated using arthroscopy with the dorsal percutaneous implantation of a headless compression screw for healing and complications. Solid union of fracture is determined by CT scan. We identified 126 acute injuries, including 65 proximal pole fractures; 67 grossly displaced fractures; 12 trans-scaphoid perilunate dislocations including four trans-scaphoid trans-capitate fractures; and ten combined scaphoid and distal radius fractures. 108 scaphoid nonunions were identified. 98 were correctly aligned and ten had a humpback deformity which was correctable using arthroscopic assisted reduction techniques at the time of surgery. 82 presented with a fracture gap 2mm or greater requiring percutaneous bone grafting. 12 cases of avascular necrosis (AVN) were identified by MRI. 20 nonunions had surgery performed at other institutions. The mean time to surgery for the nonunions was 20 months. 99% union rate of acute scaphoid fractures was obtained by 12 weeks, as determined by CT scan. Two complications were identified (3%). One case of delayed healing was identified. this delayed union was treated with percutaneous bone grafting and continued on to heal uneventfully. The other complication was a case of volar trans-scaphoid peri-lunate dislocation. While the fracture healed, the patient developed a traumatic dislocation requiring a capitate-lunate arthrodesis. Treatment of scaphoid nonunions resulted in ten cases of delayed healing, which were treated with repeat percutaneous bone grafting. This represented a 9% complication rate. of the ten cases of delayed unions that were re-bone grafted, four failed to heal by nine months. This resulted in a 96% union rate of our nonunion group by nine months. when acute fracture healing was compared to nonunions the average healing of acute fractures as determined by CT scanning measuring trabecular bridging was 12 weeks, while the average healing of non-unions was 22 weeks. We conclude that the dorsal percutaneous treatment of scaphoid fractures and nonunions using arthroscopy is safe and effective. CT scans to evaluate scaphoid healing by measuring trabecular bridging at the fracture site was determined to be an excellent modality to evaluate scaphoid healing. While not witnessed in this series, the potential for complications requires proper training.

AO 3.0mm cannulated screwを用いた舟状骨骨折の治療

AO 3.0mm cannulated screwを用いた舟状骨骨折の治療

A Biomechanical Comparison of Scaphoid Fixation With Bone Grafting Using Iliac Bone or Distal Radius Bone

Although many scaphoid fractures may be treated by immobilization, complex scaphoid fractures generally require bone grafting with internal fixation. A preferred source of bone graft for scaphoid grafting is the iliac crest. Donor site morbidity from iliac crest harvest, however, is a known complication, and the comparable strength and osteogenic properties of bone harvested from other sites are unclear. To this end, we have conducted a cadaveric comparative investigation of the strength of scaphoid nonunions with bone graft and internal fixation using either iliac crest bone or distal radius bone. Ten paired, human, fresh-frozen cadaveric wrists were used to create a standard midwaist wedge osteotomy into which identically shaped distal radius or iliac crest bone wedges were internally fixed using headless compression screws. After bone density and computed tomography assessment of the bones, benchtop biomechanical testing was conducted to compare the strength of the scaphoids after iliac and distal radius grafting, at 2-mm displacement, and at failure. Analysis of scaphoid length, width, height, weight, density, and screw placement revealed no statistical differences between both bone graft groups. Although not significant, scaphoid nonunions grafted with distal radius bone evidenced a reduced load (3.23 +/- 0.26 Nm) to 2-mm displacement compared with iliac crest bone (5.97 +/- 0.68 Nm). Similarly, though not significant, scaphoids grafted with distal radius bone showed a reduced load (4.18 +/- 0.30 Nm) to failure compared with iliac crest bone grafting (6.42 +/- 0.66 Nm). Although no significance was found between the 2 grafting methods, a trend toward greater strength in the iliac crest graft group was observed. Given the comparable biomechanical strength shown between iliac and distal radius bone in this study and the simplified surgical technique of distal radius harvesting, the data justify use of distal radius bone as a viable alternative donor source in scaphoid fracture treatment.

A prospective comparison for suspected scaphoid fractures: Bone scintigraphy versus clinical outcome

Early diagnosis and treatment of scaphoid fractures limits the number of delayed and non-unions. Bone scintigraphy proved to be a sensitive diagnostic tool for the detection of occult scaphoid fractures. However, the results have to be interpreted with care. To prospectively correlate the results of bone scintigraphy with clinical outcome. In a prospective study, we analysed 50 consecutive patients with signs of a scaphoid fracture at physical examination but no evidence of a scaphoid fracture on scaphoid radiographs. All patients had a protocolised follow up at fixed intervals. The clinical outcome was defined according to a standardised algorithm. Bone scintigraphy revealed 32% (16/50) occult scaphoid fractures and 40% (20/50) occult other fractures. Clinical outcome proved that bone scintigraphy was false positive in five patients and in one case false negative for a scaphoid fracture. Bone scintigraphy in combination with protocolised physical examination is the gold standard for patients with signs of a scaphoid fracture that cannot be proven on scaphoid radiographs.

Interfragmentary compression forces of scaphoid screws in a sawbone cylinder model

Various screws have been developed to stabilise fractures of the scaphoid. Commonly used are the Herbert, the HBS, the 3-mm AO and the Acutrak screws. Not long ago a new screw, the Twin Fix, was introduced. This is cannulated and similar in shape and appearance to the classical Herbert screw. In our test series we compared the maximum achievable compression forces of the Twin Fix screw with that of three other screws (AO, HBS and Acutrak screws). To avoid the variations of density, stiffness and rigidity in natural bone, a polyurethane sawbone-based test setup was used. The test series included 10 screws of each type. The compression force was measured using a special strain gauge. The mean compression force was significantly higher for the Twin Fix screw (8+/-1N) and the Acutrak screw (7.6+/-0.4/0.6N) in relation to the AO screw (6.8+/-1.0/1.4N) and HBS screw (2+/-1N). We found the Twin Fix and Acutrak screws to be promising in the treatment of scaphoid fractures.

Comparison of direct and indirect costs of internal fixation and cast treatment in acute scaphoid fractures: A randomized trial involving 52 patients

Background The most cost-effective treatment of scaphoid fractures has not yet been determined.Methods In a prospective trial, 52 employed or selfemployed patients with scaphoid fractures were randomized to closed (cast) or surgical treatment.Results There were 3 complications in the surgical group and 1 in the cast group. Median time off work was numerically but not statistically significantly greater after cast than after surgery (74/39 days). Manual workers (manuals) had a longer time away from work than non-manual employees/individuals who were selfemployed (non-manuals; median 84 days and 16 days, respectively; p < 0.001) and they had a longer time off work after cast than after surgery (median 100 days and 61 days; p = 0.03). Hospital costs were lower after cast than after surgery (p < 0.001). Work disability costs were numerically but not statistically significantly higher after cast than after surgery, and similarly, the total costs were lower after cast than after surgery. Work disability costs and total costs were higher in manuals than in non-manuals (p < 0.001). Non-manuals had lower total costs after cast than after surgery (p = 0.05).Interpretation There was a longer period of absence from work after cast than after surgery in manuals, but not in non-manuals. In non-manuals, total costs were lower after cast than after surgery. Socioeconomic classification had a greater influence on cost than mode of treatment.

Treatment of fresh unstable scaphoid fracture with GRAND FIX absorbable screw

目的 评价用可吸收螺钉(GRAND FIX)治疗腕舟骨骨折的临床疗效.方法应用可吸收螺钉内固定治疗不稳定腕舟骨骨折12例,骨折按Herbert分型,A2型5例,B2型3例,B4型2例,D1型2例.结果 12例术后平均随访13.3个月.11例骨折全部愈合,1例术后9个月出现骨不连.舟骨骨折愈合患者腕关节活动范围在120°～128°,未见过敏反应,也无感染发生.结论可吸收螺钉作为一种新的生物内固定材料,对治疗不稳定腕舟骨骨折,具有生物相容性好,促进骨折愈合,无需二次手术取出等优点。

Evaluation of high-resolution computed tomography in diagnosis and treatment of scaphoid fracture

目的 评价高分辨率CT在急性舟骨骨折诊断和治疗中的应用价值. 方法术前对4 6例47侧舟骨骨折患者进行腕关节常规X线片检查,其中对27例采用高分辨率CT检查.术后对全部47侧 腕关节进行X线片及CT检查.结果术前42侧腕关节X线检查显示舟骨骨折 ,5侧未能显示.C T检查明确显示27例舟骨骨折的部位、骨折移位和粉碎的情况.术后发生舟骨骨折不愈合、 畸形愈合、螺钉的位置以及创伤性关节炎等均可在CT扫描时清楚显示.结论 CT检测能提高舟骨骨折的诊断水平,为临床制定治疗方案提供可靠依据。

Current Concepts in the Treatment of Scaphoid Fractures

Fractures of the carpus are frequent injuries and typically result from of a fall onto the outstretched hand. Scaphoid fractures are the second most frequent fracture type of the hand (80%). 95% of the patients with acute scaphoid fractures are male, and the average age is approximately 25 years. Conservative treatment of acute scaphoid fractures with immobilization in a plaster cast was the therapy of choice for a long time. Surgical treatment was reserved to severe dislocated fractures only. A progress could be obtained by the principle of intramedullary fixation, whose forerunner is represented by the Herbert screw, and the introduction of cannulated screws guaranteed a continuous improvement. The decision to treat the fracture by surgery requires a clear definition of the fracture type. Therefore, precise radiologic technique is mandatory to detect the fracture and to analyze the pathomorphological circumstances. In order to get an exact classification for the decision on how to proceed, three standard X-ray projections (posteroanterior [PA], lateral and Stecher projection) and a CT scan have to be performed. The most well-known classification has been defined by Herbert & Fisher which combines fracture anatomy, stability and disease history in order to derive prognostic and therapeutic criteria. Also, delayed healings and nonunions are considered. To decide on the adequate treatment, a prerequisite for conservative therapy of acute scaphoid fractures is the anatomic position of the scaphoid. Conservative therapy should be reserved to fracture types, which are stable and heal reliably in the lower-arm plaster cast within 6 weeks. All displaced and unstable acute scaphoid fractures should be operated, and whenever possible, rigid internal fixation should be achieved because of interfragmentary compression. Therefore, several intramedullary implants are available for surgical treatment of acute scaphoid fractures, e. g., Herbert screw, Mini Herbert screw, AO screw (cannulated), Acutrac screw (cannulated), or Twin-fix screw (cannulated). With improved surgical and radiologic techniques, most scaphoid fractures are amenable to minimally invasive fixation. The dorsal approach guarantees a good overview in treating proximal pole fractures. Yet, not all types of fractures can be treated in this way. Severely displaced fractures require the classic open palmar approach. In order to prevent the development of a scaphoid nonunion or an advanced carpal collapse (SNAC-wrist), an early and sufficient diagnostic algorithm is necessary. We recommend internal fixation with a cannulated Herbert screw in B1 and B2 fractures and a Mini Herbert screw in fractures of the proximal third (B3). A2 fractures can be treated conservatively. Early diagnosis and operative treatment will shorten the time off work, minimize the risk of nonunion, and reduce the costs of health care in the long term.

Minimally invasive fixation versus conservative treatment of undisplaced scaphoid fractures: a cost-effectiveness study

This study compares the direct and indirect costs of conservative and minimally invasive treatment for undisplaced scaphoid fractures. Costs data concerning groups of non-operated and operated patients were analysed. Direct costs were higher in operated patients. Although highly variable, indirect costs were significantly smaller in operated patients and the total costs were higher in non-operated patients. In conclusion, operative treatment of scaphoid fractures is initially more expensive than conservative treatment but markedly decreases the work compensation costs.

Successful treatment of scaphoid fractures and nonunions using bioabsorbable screws: report of six cases

Purpose A variety of implants have been used for the fixation of scaphoid fractures, but we have found no reports on bioabsorbable screws used for this purpose. We report 6 cases of scaphoid fractures treated with bioabsorbable screws. Methods Six patients with scaphoid waist region fractures (3) and nonunions (3) treated using bioabsorbable self-reinforced poly-L-lactide screws. Interposition of a bone graft from the iliac crest was used in 4 cases. Immobilization in a short arm-thumb spica cast was applied after surgery for an average of 8 weeks. Results Solid union was achieved in 5 cases. Using the Mayo modified Green-O’Brien wrist score, we graded the results as excellent in 1 case, good in 4 cases, and poor in the single case of nonunion. Conclusions These results suggest that bioabsorbable self-reinforced poly- l-lactide screws might offer an alternative in the fixation of scaphoid fractures and nonunions in the future, provided that cannulated screws of appropriate size will be available.

Minimal Invasive Treatment for Scaphoid Fractures Using the Cannulated Herbert Screw System

Internal fixation of scaphoid fractures avoids the problems associated with prolonged plaster immobilization and, at the same time, allows an early return to activity for these mostly young patients.Internal fixation of the scaphoid is greatly facilitated by the use of specially designed headless bone screws, such as the Herbert bone screw, originally developed specifically for internal fixation of the scaphoid; furthermore, the advent of cannulated scaphoid screws has made closed (percutaneous fixation) stabilization of the scaphoid a reality. Indeed, this method has now become the treatment of choice for the majority of acute scaphoid fracture, bringing with it all the advantages of internal fixation without the disadvantages of open surgery.However, the success of closed treatment is also dependent on an accurate assessment of the fracture, and for this reason, we now advocate the routine use of computed tomography preoperatively. Because of the complex, 3-dimensional shape of the scaphoid, simple x-rays alone are inadequate, whereas computed tomography, parallel to the long axis of the scaphoid, allows excellent visualization of the fracture and any associated deformity, which must be corrected at the time of surgery.We describe here our method of treating acute scaphoid fractures, and we report the outcome of minimally invasive fixation.

Wrist: Current Diagnosis and Treatment of Scaphoid Fractures and Injuries of the Scapholunate Ligament

Summary: Background: Fractures of the scaphoid and injuries to the scapholunate ligament are mostly seen as causes of the acute and chronic painful wrist. Strict guidelines are necessary to precisely detect these lesions in the acute stage and to provide adequate treatment. A computed tomography bone scan parallel to the long axis of the scaphoid is best for demonstrating fractures and any associated deformities. Scapholunate ligament injuries are best staged by standard plane radiographs including stress views and by arthroscopy of the wrist. Methods: To avoid lengthy plaster immobilization and to lower the risk of nonunion, displaced and comminuted scaphoid fractures of the wrist as well as all proximal pole fractures should be internally fixed. Headless screws such as the Herbert screw, now available in a cannulated shape, allow the minimally invasive stabilization of the majority of these fractures with a high success rate under early mobilization. Undisplaced fractures can be treated conservatively with a below-elbow cast; alternatively, they can be stabilized percutaneously without the need for immobilization in a cast. Early diagnosis of scapholunate ligament injuries is most important, as anatomical healing of the injured ligaments can be expected only with primary treatment including correct realignment of the scaphoid and lunate followed by immobilization in a cast for about 8 weeks. In cases of chronic lesions, ligament reconstruction or even partial wrist fusion can be performed. In order to assess the different procedures, precise classification and staging with regard to a dynamic or static pattern are needed. Results: Early rigid fixation of scaphoid fractures promotes a union rate of up to 100 % with rapid functional recovery. Primary repair of scapholunate ligament injuries provides the best clinical outcome. Ligament reconstruction or partial wrist fusion can help to prevent rapid secondary arthrotic changes in the wrist and leads to significant pain relief, albeit with restriction of mobility and grip strength. Conclusions: Standardized diagnosis and treatment of scaphoid fractures and scapholunate ligament injuries improve clinical outcome and significantly reduce post-traumatic arthrotic changes in the wrist.

Anmerkung zur Geschichte der Kahnbeinfraktur

Die Geschichte der Diagnostik und Behandlung der Kahnbeinfraktur ist eine Geschichte der Irrtümer und Dogmen. Wurde anfänglich die Möglichkeit der Fraktur des Kahnbeines sogar geleugnet, so zeigte die Entwicklung der Röntgendiagnostik, dass dieser kleine Knochen durchaus brechen kann. Der anfänglich propagierte therapeutische Nihilismus ohne jegliche Ruhigstellung führte zu katastrophalen Ergebnissen mit häufiger Pseudarthrose, so dass die Exstirpation des Kahnbeines als Therapie der Wahl galt. Erst mit Lorenz Böhler beginnt die Ära einer effektiven Behandlung der Kahnbeinfraktur, eine Ausheilung der Kahnbeinpseudarthrose wurde erst durch die kortikospongiöse Verblockung nach Matti und Russe möglich. Die operative Stabilisierung des frakturierten, insbesondere instabilen Kahnbeines beginnt mit McLaughlin und hat sich mit Einführung der Herbert-Schraube zu einem etablierten Verfahren mit immer breiterer Anwendung entwickelt.