Should Acute Scaphoid Fractures be Fixed?

Author(s): Dias J.J., Wildin C.J., Bhowal B., Thompson J.R.

Source: The Journal of Bone and Joint Surgery, 87A:2160-2168, 2005.

Summary:

This study is a prospective randomized review of the treatment of 88 non-displaced scaphoid waist fractures treated acutely.  Recruited patients had a mean age of 30 years (range 16-61 years).  There were 79 male and 9 female patients and the injured hand was dominant in 46 patients.  Operative treatment in 44 patients involved a Herbert screw with a Huene jig through a volar incision.  Nonoperative treatment in 44 patients consisted of immobilization in a short arm cast, with the thumb free.  Scaphoid fractures that showed no evidence of healing at 12 weeks on plain radiographs and a CT scans were considered probable nonunions and surgery was recommended.  In the nonperatively treated group, there was a nonunion at 12 weeks in 10 fractures.  Seven of the 10 patients underwent operative intervention.  There were no nonunions in the internal fixation group and no postoperative immobilization was used.  The grip strength was consistently higher in the group that had open reduction and internal fixation, but this difference was most marked at 8 and 12 weeks.  In addition, at each follow up visit, the operatively treated group had better results on the Patient Evaluation Measure, with the largest differences also occurring at 8 and 12 weeks.  In the operatively treated group, there were no serious complications, but 10 patients reported scar sensitivity.  Patients treated with a cast returned to work in a mean of 6 weeks, while those managed with an operation returned to work in a mean of 5 weeks and both groups were able to perform most work tasks comfortably within 2 weeks of return.

The authors of this study recommend a program of so-called aggressive conservative treatment whereby fracture healing is assessed with plain radiographs and CT scans if necessary after 6-8 weeks of cast immobilization and surgery is recommended at that time if a gap or cyst is identified at the fracture site.  They reported that there were no significant differences between the groups.  However, in the nonoperative group, there were 10 patients without evidence of healing at 3 months and ultimately surgical intervention was recommended.  In the operatively treated group, there was a 100 % union rate without any postoperative immobilization.  In addition, the operatively treated group had consistently better early grip strength, Patient Evaluation Measure scores and range of motion.  This significant difference was only sustained for grip strength until the 12 week review.  Despite the authors recommendations for initial nonoperative treatment, the faster recovery of grip strength, range of motion and satisfaction as well as the 100 % union rate for operative intervention would still make an argument for early operative intervention in these injuries.  However, this must be balanced against a healing rate in the literature of over 90% for scaphoid fractures without displacement.  Further prospective studies will be of benefit to clarify these issues.

 


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