Undisplaced Scaphoid Fractures Research Articles

Percutaneous Fixation of Scaphoid Fractures: A Systematic Review

Abstract Background percutaneous fixation of acute non-displaced or minimally displaced scaphoid fractures, especially in young active individuals in whom prolonged immobilization can be a significant burden, provides excellent results regarding functional outcome, earlier gain of motion of the wrist, earlier time to union, quicker return to activity of daily living, and a lower complication rate. Aim of the Work to assess the outcomes of acute, un-displaced scaphoid fractures managed with percutaneous or mini-open screw fixation in terms of time to return to work (RTW), time to union, morbidity, and functional evaluation of the outcome. Materials and Methods This is a systematic review done in percutaneous fixation of scaphoid fractures. Results One hundred and nine patients were included in this study who undergone percutaneous fixation of scaphoid fracture. The range of age was between 16-55 years old. There was male predominance with 79% compared to females. 60% of included patients was RT handed dominant. Regarding complications 15.6% of cases (total of 17 patients) were complicated. Complications were like screw protrusion, sympathetic dystrophy, non-union, wire breakage during fixation, breakage of screw driver, and superficial wound infection. The position of screws was central in most cases except four patients which had eccentric screw position but with good outcome in 3 of them. Regarding time to union, the average time to union was 5-18 weeks as proven by PXR and CT. Regarding return to work, the average recorded time to return to work was 2-12 weeks. Regarding range of motion 84.4% regained full range of motion as compared to the healthy side. Regarding pain assessment only 50% of patients were included in pain assessment, 51 patients had little or no pain at final follow-up. Regarding grip strength, 91 patients had the same grip strength compared to healthy side at final follow-up. The functional end result acc. to Mayo modified wrist score, 57 patients had excellent outcome. Four patients had good outcome. One patient had fair outcome. One patient had poor outcome. There were a number of different immobilization techniques and regimes used in the included studies. A clear benefit of surgical stabilization is that it reduces the requirement for post-operative immobilization, facilitating an accelerated return to work and sporting activities. Conclusion Percutaneous fixation of acute non-displaced or minimally displaced scaphoid fractures, especially in young active individuals in whom prolonged immobilization can be a significant burden, provides excellent results regarding functional outcome, earlier gain of motion of the wrist, earlier time to union, quicker return to activity of daily living, and a lower complication rate.

Functional outcome in case of surgically and conservatively treated bilateral distal end radius and scaphoid fracture: a rare case report

Bilateral fractures of the distal radius and scaphoid are extremely rare injuries. Proper preoperative evaluation is a must to know the orientation of the fracture. Treatment must be based on displacement of the fracture. If fracture is displaced, internal fixation is needed but if its stable with minimal displacement, we can conserve it. A patient with displaced distal radius fractures and displaced scaphoid fracture on one side, along with displaced distal end radius fracture and undisplaced scaphoid fracture on the other side, was treated via internal fixation of the scaphoid fractures with Herbert screws and internal fixation of the distal radius fractures with locked volar plating on the right side and below elbow cast in cup holding position on the left side which was non-dominant. The approach to treating fractures hinges on several factors: the specific location and alignment of the fracture, the patient's characteristics, and the surgeon's expertise. For fractures in the distal radius and scaphoid, employing a rigid internal fixation method allows for the early initiation of active wrist rehabilitation, eliminating the necessity for wrist immobilization using a plaster cast or external skeletal fixation. On the other hand, a conservative treatment approach involving a below-elbow cast offers certain advantages, such as minimal blood loss and fewer complications related to wound healing, particularly for undisplaced fractures, especially when they occur in the non-dominant hand.

Virtual management of clinically suspected scaphoid fractures.

The aim of this study was to describe the introduction of a virtual pathway for the management of patients with a suspected fracture of the scaphoid, and to report patient-reported outcome measures (PROMs) and satisfaction following treatment using this service. All adult patients who presented with a clinically suspected scaphoid fracture that was not visible on radiographs at the time of presentation during a one-year period were eligible for inclusion in the pathway. Demographic details, findings on examination, and routine four-view radiographs at the time of presentation were collected. All radiographs were reviewed virtually by a single consultant hand surgeon, with patient-initiated follow-up on request. PROMs were assessed at a minimum of one year after presentation and included the abbreviated version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the EuroQol five-dimension five-level health questionnaire (EQ-5D-5L), the Net Promoter Score (NPS), and return to work. A total of 221 patients were referred to the virtual pathway. Their mean age was 41 years (range 16 to 87) and there were 99 male patients (45%). A total of 189 patients (86%) were discharged with advice and 19 (9%) were recalled for clinical review: seven with an undisplaced scaphoid fracture, six with another fracture of the hand or wrist, two with a scapholunate ligament injury, and four in whom no abnormality was detected. A total of 13 patients (6%) initiated follow-up with the hand service: no fracture or ligament injury was identified in this group. PROMs were available for 179 patients (81%) at a mean follow-up of 19 months (range 13 to 33). The median QuickDASH score was 2.3 (interquartile range (IQR) 0 to 15.9), the median EQ-5D-5L was 0.85 (IQR 0.73 to 1.00), the NPS was 76, and 173 patients (97%) were satisfied with their treatment. There were no documented cases of symptomatic nonunion one year following injury. We describe the introduction of a virtual pathway for the management of patients with a suspected scaphoid fracture. We found high levels of patient satisfaction, excellent PROMs, and no detrimental effects in the vast majority of cases. Cite this article: Bone Joint J2022;104-B(6):709-714.

Percutaneous herbert screw fixation of undisplaced scaphoid fractures-evaluation of functional and radiological outcome

Background: On undisplaced scaphoid fractures treated with prolonged cast immobilisation may result in temporary joint stiffness and muscle weakness in addition to a delay in return to sports or work. Fixation of scaphoid fractures with a percutaneous screw has resulted in a shorter time to union and to return to work or sports. The purpose of this study was to evaluate the results of percutaneous screw fixation scaphoid fractures with respect to time to radiographic union and to return to work. Materials and Methods: In 20 patients with fracture of the scaphoid, fixation with a percutaneous screw was done. Time to fracture union, wrist motion, grip strength and return to work as well as overall patient satisfaction at the time of a two-year follow-up were evaluated. Results: Of the 20 patients in the study, mean radiological fracture union time was 12.2 weeks (range 8-15 weeks). Wrist function was excellent in 10 cases, good in remaining 6 cases and poor in 4 cases. Conclusion: Percutaneous herbert screw fixation is a well-documented surgical procedure. Undisplaced scaphoid fractures fixed by percutaneous headless screw fixation yield better results than patients treated conservatively. Good range of motion is achieved after fixation. It relieves pain and functional disability experienced by patients. Percutaneous screw fixation of scaphoid fractures resulted in faster radiographic union and return to function. The specific indications for and the risks and benefits of percutaneous screw fixation of such fractures must be determined in larger randomised prospective studies.

Union of Scaphoid Waist Fractures in Adults Despite No or Minimal Immobilization\u2014a Report of Five Cases

Traditionally scaphoid waist fractures have been treated with a long period, 10–12 weeks, of immobilization in a plaster cast until radiological union. The long period of immobilization sometimes infers great discomfort for the patients. To avoid this, surgical treatment with screw fixation has for the last decade been advocated as an option also for undisplaced fractures. In this report, we present five cases with undisplaced scaphoid waist fractures that have healed both radiologically and clinically without any immobilization at all or after a very short period of protection in a cast. These observations challenge the current treatment guidelines.

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.

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.

A Systematic Review and Meta-Analysis Examining the Differences Between Nonsurgical Management and Percutaneous Fixation of Minimally and Nondisplaced Scaphoid Fractures

The optimal management of undisplaced scaphoid fractures remains controversial. A systematic review was conducted to assess the outcomes of acute, undisplaced scaphoid fractures managed with cast immobilization versus percutaneous or miniopen screw fixation in terms of time to return to work (RTW), time to union, and morbidity. PubMed MEDLINE, Ovid MEDLINE, EMBASE, SCOPUS, and Cochrane electronic databases were searched over the period 1974 to 2015. Key words included "scaphoid fracture," "navicular fracture," "hand," "immobilization," "cast," "conservative," "percutaneous," "screw fixation," "mini open," and "minimally invasive." A 2-step review process was done by 2 independent reviewers (H.A. and J.K.) using the following criteria: (1) acute undisplaced scaphoid fracture, (2) English language, (3) RTW duration objectively reported, (5) age older than 15 years, and (5) studies with more than 10 patients. Patient demographics, duration of immobilization, time to RTW, time to union, and complications were extracted. The methodological quality of each study included was assessed independently. Meta-analysis was performed for comparative trials. Ten studies met the inclusion criteria: 6 comparative studies and 4 case series. Patients were divided into 2 groups: cast immobilization (group 1) and percutaneous fixation (group 2). Average time to RTW was 77 days for group 1 versus 46 days for group 2. Average time to radiographic union was 79 days for group 1 versus 44 days for group 2. There was no significant difference in complication rate between the groups (7% in group 1 vs 14% in group 2). Percutaneous fixation of acute undisplaced scaphoid fractures has union rates comparable with those of nonsurgical cast immobilization but with faster RTW and time to union without a significant difference in complication rate. Therapeutic II.

Determining scaphoid waist fracture union by conventional radiographic examination: an analysis of reliability and validity.

Conventional radiographic imaging is the first imaging tool of choice in scaphoid fractures. The majority of undisplaced scaphoid waist fractures unite after 6weeks of cast immobilization. We hypothesized that conventional radiographic imaging at 6weeks after injury can both accurately and reliably predict union in undisplaced scaphoid waist fractures. Fleiss' kappa statistics were used concerning the opinions of four observers reviewing 47 sets of good-quality scaphoid radiographs of undisplaced scaphoid waist fractures. As reference standard for union, radiographs were taken at a minimum of 6months after injury to determine validity. Overall agreement was defined as moderate. (κ=0.583) "No consolidation" (κ=0.816), "full consolidation" (κ=0.517) and "partial consolidation" (κ=0.390) were defined as good, moderate and fair agreement, respectively. The average sensitivity and specificity of diagnosing scaphoid waist fracture union on standard scaphoid radiographs were 0.65 and 0.67, respectively. The positive predictive value for diagnosing union was 0.93 and the negative predictive value was 0.22. Conventional radiographic imaging is accurate and moderately reliable in diagnosing union, and reliable but inaccurate in diagnosing nonunion of scaphoid waist fractures at 6weeks follow-up.

Wrist & Hand

The December 2014 Wrist & Hand Roundup360 looks at: ultrasound for carpal tunnel diagnosis; where we are at with management of undisplaced scaphoid fractures; ARPE for thumb metacarpals?; extravasation injuries in the hand and wrist; research and practice in hand surgery; and physio ineffective in hand osteoarthritis

Computer-assisted percutaneous scaphoid fixation: concepts and evolution.

Background The treatment for undisplaced scaphoid waist fractures has evolved from conventional cast immobilization to percutaneous screw insertion. Percutaneous fixation reduces some of the risks of open surgery, but can be technically demanding and carries the risk of radiation exposure. Recently, computer-assisted percutaneous scaphoid fixation (CAPSF) has been gaining interest. Materials and Methods Conventional percutaneous scaphoid fixation is performed under fluoroscopic guidance and involves insertion of a guide wire along the length of the scaphoid to facilitate placement of a cannulated screw. Adapting computer-assisted techniques for scaphoid fixation poses several unique challenges including patient tracking and registration. Results To date, five groups have successfully implemented systems for CAPSF. These systems have implemented wrist immobilization strategies to resolve the issue of patient tracking and have developed unique guidance techniques incorporating 2D fluoroscope, cone-beam CT, and ultrasound, to circumvent patient-based registration. Conclusions Computer-aided percutaneous pinning of scaphoid waist fractures can significantly reduce radiation exposure and has the potential to improve the accuracy of this procedure. This article reviews the rationale for, and the evolution of, CAPSF and describes the key principles of computer-assisted technology.

Surgical Versus Nonsurgical Treatment of Acute Minimally Displaced and Undisplaced Scaphoid Waist Fractures: Pairwise and Network Meta-Analyses of Randomized Controlled Trials

To investigate the effectiveness of surgical treatment for minimally displaced and undisplaced scaphoid waist fractures compared with nonsurgical intervention through pairwise and network meta-analyses of randomized controlled trials. We searched several databases from 1990 to 2009 for randomized controlled trials that evaluated surgical and nonsurgical treatments of undisplaced or minimally displaced scaphoid waist fractures. We based the main pairwise meta-analysis comparison on the odds ratio of fracture union between patients undergoing surgical versus nonsurgical treatment. We also investigated other outcome measures including complications, range of motion, grip strength, and osteoarthritis of the scaphotrapeziotrapezoid and radiocarpal joints. We used a network meta-analysis to simultaneously synthesize trials making different intervention comparisons while modeling different surgical and nonsurgical treatments distinctly. Of the 67 articles identified, 6 studies were eligible for the primary pairwise meta-analysis, with a total of 363 patients. The pooled odds ratio of fracture union between the surgical and nonsurgical groups was in favor of surgery but not statistically significant. Surgical treatment was associated with a statistically significant elevated risk of complication. Range of motion, grip strength, and osteoarthritis of the scaphotrapeziotrapezoid and radiocarpal joints did not reach statistical significance in the pairwise meta-analyses. The mixed-treatment network meta-analysis showed that open (Herbert) screw fixation had a probability of 0.73 as being the best treatment method compared with percutaneous screw fixation, short arm cast, and short thumb spica cast. Although surgical treatment is favored in terms of fracture union in our pairwise meta-analysis, this did not reach statistical significance, but was associated with a significantly increased risk of complications. The cumulative evidence at present does not support routine surgical treatment, and aggressive conservative management should remain the mainstay for scaphoid waist fractures. Therapeutic I.

Bilateral Simultaneous Fracture of the Carpal Scaphoid Successfully Treated with Conservative Cast Immobilisation: A Case Report

The scaphoid is the most prominent of the carpal bones in the first row and the most frequently fractured of all the carpal bones. Bilateral simultaneous scaphoid fractures are uncommon. To report bilateral simultaneous fractures of the carpal scaphoid bones and their successful treatment with bilateral thumb spica casts A 28-year-old medical practitioner presented with a day history of painful swollen wrists following a fall on both outstretched hands. He was fully examined and had both wrists X-rayed. He was subsequently treated with bilateral below elbow thumb spica POP cast. He had previously been healthy until this fall. Physical examination showed a healthy looking young man in pain. There were swelling and tenderness over both anatomical snuff boxes with associated limitation of movements at the wrists. X-rays revealed an undisplaced scaphoid wrist fracture and proximal pole fracture on the right and left respectively. He was successfully treated with bilateral below elbow thumb spica POP cast applied over a period of eight weeks. Although recent opinions tend to favour internal fixation for bilateral simultaneous fractures of the scaphoid bones to avoid prolonged cast immobilization and loss of man hours at work, they can be successfully treated with conservative cast immobilisation with comparatively early return to full activity.

Undisplaced scaphoid waist fractures: is 4 weeks’ immobilisation in a below-elbow cast sufficient if a week 4 CT scan suggests fracture union?

This prospective study investigated a cohort of 59 scaphoid waist fractures which were treated nonoperatively in a below-elbow plaster cast for 4 weeks and then underwent a Week 4 CT scan to assess displacement and progress to union. Forty-three were classed as undisplaced and 37 of these 43 were also classed as 'united'. All the 37 undisplaced and 'united' fractures united with up to 8 weeks' cast immobilisation, including 26 which were taken out of plaster at 4 weeks and mobilised. We conclude that scaphoid waist fractures which appear to be undisplaced and united on a week 4 CT scan will unite, and may not need to be immobilised in a plaster cast for more than 4 weeks. Such a treatment policy may reduce the period of disability and time off work associated with nonoperative treatment.

Undisplaced Scaphoid Fractures: The Use of a Week 4 CT Scan to Predict the Outcome of Non-operative Treatment and Reduce the Length of Immobilisation: Level 2 Evidence

Undisplaced Scaphoid Fractures: The Use of a Week 4 CT Scan to Predict the Outcome of Non-operative Treatment and Reduce the Length of Immobilisation: Level 2 Evidence

An Evidence-Based Approach to the Management of Acute Scaphoid Fractures

Current opinion favors operative treatment of displaced scaphoid fractures as it has been recognized that displaced fractures are at a higher risk of malunion and/or nonunion.1 The role of surgical fixation for undisplaced scaphoid waist fractures is more controversial. Proponents of operative fixation cite a quicker return to activity (work/sport) and a reduced risk of nonunion compared with that for cast treatment and with minimal additional risk.

Nonoperative Treatment for Undisplaced Scaphoid Fracture

Purpose: We wanted to evaluate the results of nonoperative treatment for acute, undisplaced, stable scaphoid fracture. Materials and Methods: We retrospectively reviewed 24 cases of acute undisplaced scaphoid fracture that were treated at our department from May 1998 to January 2008. The immobilization method was a long or short arm cast. Flexion-extension exercise was permitted during the period of the short arm cast, but pronation-supination motion was prohibited. After the removal of the cast, active and passive range of motion exercise was started immediately. The result was assessed by the Maudsley scale. Results: The twenty four cases were undisplaced or minimally displaced fracture (10 cases of Herbert type A1, 3 cases of A2 and 11 cases of B2) according to the Mayo classification. The average duration of immobilization was 7.16 weeks. According to the Maudsley scale, 19 cases had an excellent result and 4 cases had a good result. One case had a complication of scapho-lunate dissociation. Conclusion: We recommend conservative treatment with cast immobilization as the first treatment of choice for acute undisplaced scaphoid fracture.

Fixation of nondisplaced scaphoid fractures: making treatment cost effective

Nondisplaced scaphoid waist fractures treated with prolonged plaster immobilisation often lead in transient joint stiffness and to a delay in return to sport and work activity. The long time off work increases the work off compensation costs. Internal fixation of scaphoid fractures has resulted in a shorter time to union and to return to work and sports. This prospective study compares cast immobilisation with screw fixation and the direct cost with indirect cost of conservative and minimally invasive treatment of undisplaced scaphoid fractures. Forty-seven patients with an acute nondisplaced waist fracture of the scaphoid were allocated into either cast immobilisation or internal screw fixation for this study. Cost data concerning the groups of nonoperated and operated patients were analysed. Range of wrist motion, grip strength, DASH-score, time to fracture union, return to work time and the needed physiotherapy at the final follow-up at 6 months were evaluated. Twenty-one patients were included in the group of screw fixation and 23 patients were included in the group of cast immobilisation. At final follow-up there was no significant difference in the range of motion of the wrist or in grip strength. The operatively treated group had a better mean DASH-score than the conservative group. Fracture union was seen in the screw fixation group at a mean of 43 days and in the cast immobilisation group at a mean of 74 days (P < 0.5). The average time of return to work was 8 days for patients who had an internal screw fixation, while those treated with a cast returned to work at a mean of 55 days (P < 0.5). In total the internal fixation of undisplaced scaphoid fractures is less expensive than conservative treatment. Internal screw fixation of nondisplaced scaphoid fractures had a shorter time to bony union and the patients returned earlier to work compared with cast immobilisation. Although it is assumed that operative treatment is more expensive, in this study the cost was not found to be higher.

Outcome of routine bone scintigraphy in suspected scaphoid fractures

Undisplaced scaphoid fractures are easily missed on conventional scaphoid radiographs, but these occult fractures may seriously impair hand function. Routine bone scintigraphy (BS) is often advocated if there are clinical signs of a scaphoid fracture without radiological evidence. However, the results require careful therapeutic management. To determine the diagnostic value of BS in daily practice for clinically suspected scaphoid fractures. We evaluated our protocol of routine BS in suspected scaphoid fractures. In a retrospective study, we analysed 111 consecutive cases with signs of a scaphoid fracture on physical examination. Radiographs revealed 55 fractures, the remaining 56 patients all underwent BS. On average, the BS was performed after 4 days. It showed a fracture in 38/56 of the patients. The distribution of fractures was: scaphoid bone 15, distal radius 11, other carpal bones 9 and metacarpal bones 3. If there is a strong clinical suspicion of a scaphoid fracture, which cannot be confirmed by conventional radiology, BS is a valuable diagnostic tool.

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.