Treatment Of Acute Scaphoid Fractures Research Articles

Bone Morphogenic Protein-2 Use for the Surgical Treatment of Acute Scaphoid Fractures and Scaphoid Nonunions.

Bone morphogenic protein-2 has demonstrated promise as an adjunct to surgically treating fractures. Its reported use in the upper extremity is limited. This study reports union rates, outcomes, and complications of scaphoid fractures treated with adjunctive bone morphogenic protein-2 to further characterize bone morphogenic protein-2 use in the hand and wrist. Retrospective review of scaphoid fractures treated surgically in one region of the Military Health System from 2009 to 2019 was conducted to identify cases using bone morphogenic protein-2. Fracture healing was determined by computed tomography. Primary outcomes were union rate, time to union, and complications. Secondary outcomes included union rates for prior nonunions, union rates at 4 and 6 weeks, and functional outcomes. Fourteen patients met inclusion criteria. Nonunions accounted for 50 percent of included fractures. The total union rate was 93 percent. Mean time to union was 6.2 weeks. All acute fractures healed with a mean time to union of 4.8 weeks. Nonunions had a union rate of 86 percent, with a mean time to union of 7.7 weeks. Four patients (29 percent) developed radiographic heterotopic ossification; however, no significant decrease in motion was appreciated. Thirteen patients (93 percent) resumed the push-ups portion of the military fitness test. No major complications were identified during follow-up. Adjunctive use of bone morphogenic protein-2 in operative fixation of scaphoid fractures resulted in desirable union rates without major complications. Larger, prospective studies are needed to assess whether adjunctive bone morphogenic protein-2 use in scaphoid fractures provides significant benefit compared with other treatments. Therapeutic, IV.

To compare the effectiveness of conservative and surgical approach in the management of scaphoid fracture: A prospective tertiary care centre clinical study

Aim: The aim of the present study was to evaluate the role of conservative vs operative treatment for acute scaphoid fractures. Material and Methods: This prospective comparative research was conducted in the Department of Orthopaedics, Maharishi Markandeshwar Medical College and Hospital, Solan for the period of 1 year, after obtaining the permission of the protocol review committee and institutional ethics committee. Total 50 acute scaphoid fractures (< 3 weeks) irrespective of the location and all scaphoid fractures as a component of other acute injuries including peri-lunate instabilities were included in this research.Results: During the research period, there were 50 instances of acute scaphoid fracture (< = 3 weeks) 37.5 was the average age at which a patient presented to us in our research.Road traffic accidents were the most prevalent cause of injury. Sport injuries, workplace injuries, home-related injuries and assault injuries were all common causes of injury. The most frequent site of fracture was the waist, followed by distal oblique fractures, in that order (7 cases). CRIF/ORIF with K-Wire / Herbert screw were used to treat 16 cases, whereas 34 patients were handled conservatively. Every patient's Mayo wrist score was determined as part of the follow-up process. A 12-month follow-up duration was the average. Nine patients had poor outcome (< 65), 3 patients had moderate results (65-79), 14 patients had good results (80-89), and 8 patients had outstanding results (>/=90) out of 34 conservatively treated patients. Patients who underwent surgical management; 2 patients had poor outcome, 3 patients had moderate results, 5 patients had good results and 6 patients had great results. After operational treatment (ORIF/per cutaneous - screw or k-wire fixation), all fractures were successfully repaired. With conservative management, there were eight incidents of non-union.Conclusion: We've come to the conclusion that each patient's treatment options should be discussed and weighed against one another before a decision is made about undergoing surgery or not.

A prospective study of radiological and functional outcome of non union scaphoid fractures treated by pronator quadratus muscle pedicle bone graft

Scaphoid fractures are common, but present unique challenges because of the particular geometry of the fractures and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures can lead to nonunions and subsequent degenerative wrist arthritis. Scaphoid nonunions can present with or without avascular necrosis of the proximal pole, and may show a humpback deformity on the radiograph. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis. Surgical treatment is directed at correcting the deformity with open reduction and internal fixation with bone grafting. Recently, vascularized bone grafts have gained popularity in the treatment of scaphoid nonunions, particularly in cases with avascular necrosis. This study gives us a radiological and functional outcome of 10 cases operated by pronator quadratus based muscle pedicle bone graft for scaphoid non unions at waist level.

Percutaneous Scaphoid Fixation: Experience Value among Different Approaches.

Background Percutaneous scaphoid osteosynthesis is an attractive and increasingly popular option, as a treatment for acute scaphoid fractures in selected cases, and as an alternative to conservative treatment. The purpose of this study is to assess the radiographic positioning of the screw in percutaneous scaphoid fixation, taking into consideration the surgeons' experience, and the difference between volar and dorsal approaches. Methods We retrospectively assessed patients undergoing percutaneous scaphoid fixation from 2013 to 2019. Inclusion criteria are as follows: (1) scaphoid waist fractures (Herbert's B2), (2) a minimum of 18 years of age and a maximum of 55 years of age, (3) dominant hand, (4) manual work, (5) minimum follow-up time of 6 months, and (6) without associated lesions. Criteria for correct positioning are as follows: (1) on the axis or parallel to the scaphoid axis with a maximum deviation of 1.5 mm volar/dorsal, (2) without proximal/dorsal prominence, (3) correct scaphoid alignment/reduction, and (4) absence of threads in the fracture site. Radiographs were evaluated separately by a hand surgeon, a general orthopaedic surgeon, and an orthopaedic resident. Results With a total of 39 patients, a dorsal approach was performed in 10 patients and a palmar approach in 29 patients. We verified a very good interobserver reliability. The hand surgeon's team correctly positioned 15 (83.3%, 15/18), while the other team did 9 correctly (42.9%, 9/21). Comparing teams according to the approach used, the dorsal approach did not show a statistical difference, while the same was not true for the volar approach ( p < 0.05). Conclusion This points to a positive impact on the team's experience in the positioning of the screws, and therefore in the benefit of treatment by teams dedicated to the area, while daring to suggest that less-experienced surgeons should utilize the dorsal approach.

Role of conservative vs operative treatment for acute scaphoid fractures

Scaphoid fracture is a difficult fracture to deal with. This tiny twisted bone, 80% covered with joint cartilage and lying angulated by 45° in both planes deep in the wrist, has caused great frustrations among wrist surgeons. Diagnosis is difficult, classification is controversial & there is never ending debate on appropriate treatment protocol. Firstly, scaphoid fracture is prone to be missed in clinical assessment & is usually neglected as simple wrist injuries. Adding to that, this notorious fracture is often missed in first x-ray immediately after injury. Second line of investigation is a matter of debate & varies from doctor to doctor & centre to centre. This does not end here. Once diagnosed, there is no clear-cut protocol for deciding appropriate treatment technique. There is controversy regarding whether to be managed conservatively or operatively. Both have their own pros & cons. If managed conservatively, there is again no agreement in the literature as to the optimum position of immobilization (extension, ulnar deviation, neutral) or type of cast (thumb-spica, interphalangeal [IP] free/IP included, long arm/short arm). Last but the most nuisant are the complications. Scaphoid fracture is known for its complications like AVN, Non-union, arthritis owing to its peculiar blood supply, position in wrist & shape. Management of these complications are again not free of confusions & controversies. In this study we have tried our best to address these dilemmas & study this notorious bone in further detail. Keywords: Acute scaphoid fracture, Treatment options.

Advances in diagnosis and treatment of acute scaphoid fractures

To review the advances in diagnosis and treatment of acute scaphoid fractures. The characteristic, classification, diagnosis, and treatment of acute scaphoid fractures were reviewed and summarized. As one of the common fracture in hand, scaphoid fractures are generally classified as either undisplaced and stable or displaced and unstable. CT and MRI has best diagnostic specificity and sensitivity respectively. Most undisplaced and stable fractures can be treated successfully by plaster immobilization, whereas the displaced and unstable fractures have great prognosis after open reduction and internal fixation. Acute scaphoid fractures should be diagnosed and treated at an early stage, and choose the appropriate treatment according to the location and stability of the fracture.

Diagnostics and treatment of acute scaphoid fractures

Fractures of the scaphoid bone are common but can easily be overlooked in standard X‑rays. Inadequate diagnostics and therefore inappropriate treatment of scaphoid fractures often leads to problems in healing with formation of non-union and painful osteoarthritis of the wrist. This review summarizes the current practical recommendations in the diagnostics and treatment of acute scaphoid fractures. An analysis and review of selected literature including the current S3 guidelines were performed. The main statements are that in cases of aclinically suspected scaphoid fracture, staged diagnostics including radiographs, computed tomography (CT) and when necessary magnetic resonance imaging (MRI) should be applied to confirm or exclude afracture. Further treatment in the case of afracture is planned according to aCT-based classification. There are fracture types that can be treated either conservatively or operatively and there are other fracture types that always require operative fixation. The operative technique depends on the exact fracture geometry. For osteosynthesis, cannulated headless compression screws are mostly used.

Acute Fractures of the Carpal Scaphoid-Literature Review

Background/Methods: Scaphoid fracture is the most common fracture in carpal bone of the wrist and represents 11% of all upper extremity fractures and between 70% and 80% of all carpal fractures. In most cases, the mechanism of injury is a fall with an outstretched hand. Although closed treatment of stable fractures of the scaphoid is associated with a high rate of healing, this method requires prolonged cast immobilization, which may lead to muscle atrophy, possible joint contracture, disuse osteopenia, and potential financial hardship. Because of this, internal fixation of fractures of the scaphoid has become popular. The purpose of this review was to assess the current evidence supporting operative fixation versus casting for acute scaphoid fractures through a systematic review of the literature. Also assess if the final recommendations could be extrapolate to amateur or professional athletes. Results: Our search yielded 69 articles that met our inclusion criteria with ten studies achieving level of evidence 1 according to Oxford Center for Evidence-based Medicine, 2 achieving level 2, and 57 levels 3 and 4. Conclusion: This systematic review reveals that significant weaknesses exist in the literature with respect to the level of evidence and quality of published studies on this topic. Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures. We do not find randomized control trials about treatment of acute scaphoid fractures in athletes. Therefore, it is not possible to report treatment recommendations with adequate evidence-based support.

Percutaneous Fixation for Scaphoid Nonunion with Bone Grafting Through the Distal Insertion Hole of a Fully Threaded Headless Screw.

Percutaneous scaphoid screw fixation is a popular treatment for acute scaphoid fractures with no or minimal displacement. For treating scaphoid nonunions, however, open reduction and internal fixation with bone grafting is still the most popular treatment. Percutaneous fixation with bone grafting through the screw insertion hole has received little attention, although it minimizes damage to the surrounding tissues. We report excellent results of six scaphoid nonunions treated by retrograde percutaneous fixation with curettage and bone grafting through the distal insertion hole of a fully threaded headless screw. Six scaphoid nonunions with substantial bone loss were treated, including one revision case. All nonunions were located at the middle third of the scaphoid. The mean patient age at operation was 26 years, and the mean interval between fracture and surgery was 7 months. In the revision case, the interval between the primary and revision surgery was 6 months. In one case, curettage alone was performed before retrograde insertion of the headless screw. In the other cases including the revision, curettage and bone grafting with a bone biopsy needle was required through a distal insertion hole. The mean follow-up was 11.3 months. Radiologically, union was achieved at averaged 12 weeks postoperatively. At the final follow-up, there was significant improvement in the wrist extension range of movement (from 65.8° to 80.8°) and grip strength (from 69.5% to 93.0% of the unaffected side). Five patients were free of pain, and one experienced mild pain only during heavy manual labor. The mean VAS, DASH, and Cooney wrist scores were 0.3, 1 and 99, respectively. All patients returned to their work or athletic activities. Retrograde percutaneous fixation with bone grafting through the distal insertion hole of a fully threaded headless screw is a promising option for surgical treatment of scaphoid nonunions.

Percutaneous Fixation for Scaphoid Nonunion With Bone Grafting Through the Distal Insertion Hole of a Fully Threaded Headless Screw

Objective: Percutaneous scaphoid screw fixation is a popular treatment for acute scaphoid fractures with no or minimal displacement. For treating scaphoid nonunions, however, open reduction and internal fixation with bone grafting is still the most popular treatment. Percutaneous fixation with bone grafting through the screw insertion hole has received little attention, although it minimizes damage to the surrounding tissues. We report excellent results of 10 scaphoid nonunions treated by retrograde percutaneous fixation with curettage and bone grafting through the distal insertion hole of a fully threaded headless screw. Materials and Methods: Ten scaphoid nonunions with substantial bone loss were treated, including 1 revision case. All nonunions were located at the middle third of the scaphoid. The mean patient age at operation was 24.7 years, and the mean interval between fracture and surgery was 8.8 months. In the revision case, the interval between the primary and revision surgery was 6 months. Surgery was performed under general anesthesia or an axillary brachial plexus block with local anesthesia at the iliac crest donor site. A 1.1-mm guidewire was percutaneously inserted into the scaphoid tuberosity and advanced to the proximal pole of the scaphoid with the wrist in an extended and ulnar-deviated position. A 1.2-mm second derotation wire was also inserted radial or ulnar to the original guidewire. A 2.0-mm cannulated drill was passed over the guidewire, stopping at the distal end of the cystic lesion. The guidewire was then removed. The 1.2-mm second derotation wire maintained the reduction of the scaphoid. Curettage inside the cystic lesion was performed using a small curette inserted through the distal insertion hole. Bone graft was harvested percutaneously from the iliac crest with an 11-gauge bone biopsy needle and inserted into the cystic lesion through the drill hole of the distal scaphoid fragment. The removed guidewire was reinserted into the previously drilled hole followed by insertion of a selected fully threaded headless screw (Acutrak 2 mini; Acumed, Hillsboro, OR, USA). After the operation, the wrist was immobilized in a thumb spica cast for the initial 6 weeks, followed by splinting until bone union was confirmed. In one case, curettage alone was performed before retrograde insertion of the headless screw. In the other cases including the revision, curettage and bone grafting with a bone biopsy needle was required through a distal insertion hole. Results: The mean follow-up was 12.1 months. Radiologically, union was achieved at averaged 12 weeks postoperatively. At the final follow-up, there was significant improvement in the wrist extension range of movement (from 65.8° to 80.8°) and grip strength (from 65.5% to 87.8% of the unaffected side). Nine patients were free of pain, and 1 experienced mild pain only during heavy manual labor. The mean visual analogue scale (VAS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Cooney wrist scores were 0.1, 1.75, and 98.5, respectively. All patients returned to their work or athletic activities. Conclusions: Retrograde percutaneous fixation with bone grafting through the distal insertion hole of a fully threaded headless screw is a promising option for surgical treatment of scaphoid nonunions.

Current concepts for the treatment of acute scaphoid fractures.

Fractures of the scaphoid are common injuries, accounting for approximately 80 % of carpal fractures. Differentiation between stable and unstable fractures (Herbert classification) cannot be made with conventional X-rays, so evaluation by computed tomography should additionally be performed. Under most circumstances, minimally invasive surgery with cannulated screws is the treatment of choice. A longer cast immobilization after minimal-invasive surgery is not necessary. Conservative treatment still has a place if the fracture is not dislocated nor unstable, but operative treatment can be offered to reduce the period of cast immobilization. Displaced fractures have a greater risk for nonunion and therefore should be treated operatively. Proximal pole fractures are definitely unstable, requiring treatment with screw fixation. The surgical approach depends on the location of the fracture and the preference of the surgeon.

Operative Treatment of Acute Scaphoid Fractures.

Optimal treatment of acute scaphoid fractures is a necessary goal for many reasons. One is that the scaphoid is the most commonly fractured carpal bone. Another is that a missed diagnosis of an acute scaphoid fracture leads to the more challenging situation of a delayed union, non-union and risk for premature radiocarpal arthrosis. Because the scaphoid has an inherent risk for nonunion due to its the tenuous blood supply, timely diagnosis and appropriate treatment are considered critical to achieving acceptable results and to avoiding the consequences of failed union.

Functional outcome and cost-effectiveness of pulsed electromagnetic fields in the treatment of acute scaphoid fractures: a cost-utility analysis.

BackgroundPhysical forces have been widely used to stimulate bone growth in fracture repair. Addition of bone growth stimulation to the conservative treatment regime is more costly than standard health care. However, it might lead to cost-savings due to a reduction of the total amount of working days lost. This economic evaluation was performed to assess the cost-effectiveness of Pulsed Electromagnetic Fields (PEMF) compared to standard health care in the treatment of acute scaphoid fractures.MethodsAn economic evaluation was carried out from a societal perspective, alongside a double-blind, randomized, placebo-controlled, multicenter trial involving five centres in the Netherlands. One hundred and two patients with a clinically and radiographically proven fracture of the scaphoid were included in the study and randomly allocated to either active bone growth stimulation or standard health care, using a placebo. All costs (medical costs and costs due to productivity loss) were measured during one year follow up. Functional outcome and general health related quality of life were assessed by the EuroQol-5D and PRWHE (patient rated wrist and hand evaluation) questionnaires. Utility scores were derived from the EuroQol-5D.ResultsThe average total number of working days lost was lower in the active PEMF group (9.82 days) compared to the placebo group (12.91 days) (p = 0.651). Total medical costs of the intervention group (€1594) were significantly higher compared to the standard health care (€875). The total amount of mean QALY’s (quality-adjusted life year) for the active PEMF group was 0.84 and 0.85 for the control group. The cost-effectiveness plane shows that the majority of all cost-effectiveness ratios fall into the quadrant where PEMF is not only less effective in terms of QALY’s but also more costly.ConclusionThis study demonstrates that the desired effects in terms of cost-effectiveness are not met. When comparing the effects of PEMF to standard health care in terms of QALY’s, PEMF cannot be considered a cost-effective treatment for acute fractures of the scaphoid bone.Trial registrationNetherlands Trial Register (NTR): NTR2064

CT scan-evaluated outcome of pulsed electromagnetic fields in the treatment of acute scaphoid fractures: a randomised, multicentre, double-blind, placebo-controlled trial.

We hypothesised that the use of pulsed electromagnetic field (PEMF) bone growth stimulation in acute scaphoid fractures would significantly shorten the time to union and reduce the number of nonunions in a randomised, double-blind, placebo-controlled multicentre trial. A total of 102 patients (78 male, 24 female; mean age 35 years (18 to 77)) from five different medical centres with a unilateral undisplaced acute scaphoid fracture were randomly allocated to PEMF (n = 51) or placebo (n = 51) and assessed with regard to functional and radiological outcomes (multiplanar reconstructed CT scans) at 6, 9, 12, 24 and 52 weeks. The overall time to clinical and radiological healing did not differ significantly between the active PEMF group and the placebo group. We concluded that the addition of PEMF bone growth stimulation to the conservative treatment of acute scaphoid fractures does not accelerate bone healing.

The clinical and radiological outcome of pulsed electromagnetic field treatment for acute scaphoid fractures

The use of pulsed electromagnetic fields (PEMF) to stimulate bone growth has been recommended as an alternative to the surgical treatment of ununited scaphoid fractures, but has never been examined in acute fractures. We hypothesised that the use of PEMF in acute scaphoid fractures would accelerate the time to union by 30% in a randomised, double-blind, placebo-controlled, multicentre trial. A total of 53 patients in three different medical centres with a unilateral undisplaced acute scaphoid fracture were randomly assigned to receive either treatment with PEMF (n = 24) or a placebo (n = 29). The clinical and radiological outcomes were assessed at four, six, nine, 12, 24 and 52 weeks. A log-rank analysis showed that neither time to clinical and radiological union nor the functional outcome differed significantly between the groups. The clinical assessment of union indicated that at six weeks tenderness in the anatomic snuffbox (p = 0.03) as well as tenderness on longitudinal compression of the scaphoid (p = 0.008) differed significantly in favour of the placebo group. We conclude that stimulation of bone growth by PEMF has no additional value in the conservative treatment of acute scaphoid fractures.

Review of treatment of acute scaphoid fractures: R1

Scaphoid fractures are common. Clinical suspicion and early diagnosis and treatment are vital in order to avoid complications such as avascular necrosis. The management of these fractures depends on fracture characteristics, specifically the degree of displacement. With consideration of patient factors, such as occupation, the treatment can be non-operative or operative. There has been much debate in the recent literature regarding the best management of these fractures. The purpose of this review was to identify the current evidence for non-operative and operative treatment. Undisplaced and minimally displaced fractures can be managed non-operatively with a scaphoid cast. Surgical treatment is used for fractures with displacement of >1 mm.

Nonoperative Treatment for Acute Scaphoid Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Nonoperative Treatment for Acute Scaphoid Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Nonoperative Treatment for Acute Scaphoid Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Recommendations for cast immobilization of acute scaphoid fractures vary substantially. We reviewed data from randomized controlled trials comparing nonoperative treatment methods for acute scaphoid fractures to determine the best available evidence. A systematic search of the medical literature from 1966 to 2010 was performed. Two authors independently screened titles and abstracts, reviewed articles, assessed methodological quality according to the Grading of Recommendations Assessment Development and Evaluation system, and extracted data. The primary outcome parameter was nonunion. Data were pooled using random-effects models with standard mean differences for continuous and risk ratios for dichotomous variables, respectively. Heterogeneity across studies was assessed with calculation of the I statistic. The search resulted in five potentially eligible trials of which four met our inclusion criteria. In total, 523 patients were included in four trials including two evaluating below-elbow casting versus above-elbow casting; one trial comparing below-elbow casting including the thumb versus excluding the thumb; and one trial comparing fractures with a below-elbow cast with the wrist in 20-degrees flexion to 20-degrees extension, with both types excluding the thumb. There were no significant differences in union rate, pain, grip strength, time to union, or osteonecrosis for the various nonoperative treatment methods. There is no evidence from randomized controlled trials on physician-based or patient-based outcome to favor any nonoperative treatment method for acute scaphoid fractures.

Treatment of Acute Scaphoid Fractures: A Systematic Review and Meta-Analysis

The purpose of this review was to assess the current evidence supporting operative fixation versus casting for acute scaphoid fractures through a systematic review and meta-analysis of the literature. Our search yielded 59 articles that met our inclusion criteria with five studies achieving high, 22 moderate, and 32 low Structured Effectiveness Quality Evaluation Scale scores. Pooled results of the four Sackett level 1 evidence studies showed no significant difference between the operative (114/115, 99%) versus non-operative group (106/112, 95%) (p = 0.07) when the definition of nonunion was based on more definitive criterion versus plain radiographs that may be insufficient to assess bony union. Similar results were found for the Sackett level 2 and 4 articles. This systematic review reveals that significant weaknesses exist in the literature with respect to the level of evidence and quality of published studies on this topic. Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures.

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

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