The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 10

Scientific Articles | October 01, 2005

Should Acute Scaphoid Fractures Be Fixed?: A Randomized Controlled Trial

J.J. Dias, MD, FRCS¹; C.J. Wildin, FRCS(Orth)¹; B. Bhowal, FRCS(Orth)¹; J.R. Thompson, PhD²

¹ Department of Orthopaedic Surgery, Glenfield Hospital, University Hospitals of Leicester, Groby Road, Leicester LE3 9QP, United Kingdom. E-mail address for J.J. Dias: joseph.dias@uhl-tr.nhs.uk
² Department of Epidemiology, University of Leicester, 22-28 Princess Road West, Leicester LE1 6TP, United Kingdom

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A commentary is available with the electronic versions of this article, on our web site () and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity, although Herbert screws were provided by Zimmer for this study. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, United Kingdom

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Oct 01;87(10):2160-2168. doi: 10.2106/JBJS.D.02305

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Abstract

Background: With the proliferation of different fixation screws, there is an increasing trend to recommend early internal fixation of the broken scaphoid even if the fracture is not displaced. The benefits and risks of early fixation of scaphoid fractures have not been established. These were investigated in eighty-eight patients who were of working age with clearly defined minimally displaced or undisplaced bicortical fractures of the waist of the scaphoid.

Methods: Patients who provided informed consent were randomized to treatment with early internal fixation with use of a Herbert screw without a cast (forty-four patients) or to nonoperative treatment for eight weeks with immobilization in a below-the-elbow plaster cast with the thumb left free (forty-four patients). The patients were evaluated at two, eight, twelve, twenty-six, and fifty-two weeks with respect to the severity of pain; tenderness; swelling; wrist movement; grip strength; and symptoms and disability, which were assessed with the Patient Evaluation Measure. In addition, radiographs were made and assessed at each visit.

Results: No difference was detected between the groups with respect to age, sex, hand dominance, side of injury, mechanism of injury, or the occupation of the patients. The range of motion, score on the Patient Evaluation Measure, and grip strength were significantly better in the group managed operatively than in the group managed nonoperatively at the eight-week follow-up evaluation, which corresponded with the visit when the cast was removed in that group. Patients returned to work at five to six weeks after the injury in both groups. At twelve weeks, grip strength was better in patients who had had surgery. No significant difference was detected between the two groups with respect to any other outcome measure at any other time. Ten of the forty-four fractures treated nonoperatively had not healed radiographically at twelve weeks, and, as a consequence, the treatment was altered. Complications occurred in thirteen patients who had been managed operatively. All complications were minor, and ten were related to the scar.

Conclusions: This study did not demonstrate a clear overall benefit of early fixation of acute scaphoid fractures beyond the decrease in the rate of a change in treatment because of a delayed union at twelve weeks. Early internal fixation of minimally displaced or nondisplaced fractures of the scaphoid waist, which would heal in a cast, could lead to overtreatment of a large proportion of such fractures, exposing such patients to avoidable surgical risk. Thus, we have adopted a program of so-called aggressive conservative treatment, whereby we carefully assess fracture-healing with plain radiographs, and computed tomography scans if necessary, after six to eight weeks of cast immobilization and recommend surgical fixation with or without bone-grafting at that time if a gap is identified at the fracture site. Such an approach should result in fracture union in over 95% of such patients.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Nonoperative treatment of an acute scaphoid fracture with immobilization in a cast is successful in achieving union in 88% to 95% of such patients^1,2. The main disadvantages of cast treatment that have been suggested are the period of immobilization, stiffness, decreased grip strength, and delayed return to work^3,4. These factors have led to an increasing use of internal fixation, which has been reported to allow this period of immobilization to be avoided and to provide a more rapid return to athletic and work activities^5-10. It is recognized that the fixation of scaphoid fractures can be technically difficult and requires a high level of skill, but few serious complications have been reported^7-9. The role, benefits, and risks associated with fixation of an undisplaced or minimally displaced fracture of the scaphoid remain controversial and have not yet been established.

We performed a prospective, randomized controlled trial to compare the functional outcome and rates of union of acute scaphoid fractures after nonoperative treatment with immobilization in a cast and after internal fixation.

Materials and Methods

Materials and Methods | Results | Discussion | References

The study received the approval of the ethics committee of our hospital. All patients attending the Leicester Royal Infirmary, Leicester, United Kingdom, between October 1996 and November 1999, with a fracture of the scaphoid were evaluated in a special clinic. All patients of working age with a clear bicortical fracture of the waist of the scaphoid, who were seen within a week after the injury, were invited to participate in the trial. Patients with preexisting symptoms in the upper limb, associated injuries, or unicortical or tuberosity fractures were excluded. Patients with trans-scaphoid perilunate dislocations were excluded. All patients included in the trial were skeletally mature. Patients were given an information sheet, the risks and benefits of nonoperative and operative treatment were discussed, and full verbal and written consent were obtained.

A random-number sheet was generated by computer, and the random numbers were blocked to ensure equal distribution. Randomization was administered remotely by telephoning a secretary to secure the number after the patient had consented to participate in the study.

Between October 1996 and November 1999, 205 consecutive patients were assessed for eligibility. Four patients were nonresidents, thirteen refused to consent to the trial, and 100 did not meet the entry criteria (twenty-nine presented to the clinic after two weeks, twelve were less than sixteen years old, thirty-three had fractures of the tuberosity, nine had associated fractures, thirteen had arthritis in one or more joints of the wrist, and four had other serious disease). Therefore, eighty-eight patients with a bicortical fracture of the scaphoid waist were prospectively randomized to undergo early fixation or nonoperative treatment (Fig. 1). Forty-four patients were randomized to have open reduction and internal fixation, and forty-four were randomized to treatment with immobilization in a below-the-elbow cast with the thumb left free and the wrist in a functional position of slight dorsiflexion. This treatment was instituted by the doctor who initially saw the patient and was continued if the patient was allocated to nonoperative treatment after recruitment. Table I provides data on the age, sex, and occupation of the patients; hand dominance; side of injury; and mechanism of the injury. Recruited patients had a mean age of 29.5 years (range, sixteen to sixty-one years). The group included seventy-nine male and nine female patients. The injured hand was dominant in forty-six patients, the injured hand was nondominant in forty-one patients, and the left hand was injured in one patient who was ambidextrous. The most common mechanism of injury was a fall (sixty-four patients) followed by a wrenching or twisting injury (eleven), a punch (seven), and a motor-vehicle accident (five). One patient was uncertain of the mechanism. Sixty-two patients performed manual labor, eleven patients worked in an office, eight patients were students, and seven patients were unemployed.

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TABLE I Data on the Patients

	Patients Managed with Immobilization in a Cast	Patients Managed with Open Reduction and Internal Fixation	P Value^*
Age†	29.9 ± 1.6	29.0 ± 1.32	0.685‡
Sex (M/F)	39/5	40/4	1.000
Dominance§ (no. of patients) (A/L/R)	0/6/38	1/7/36	0.772
Side of injury (L/R)	24/20	25/19	1.000
Mechanism of injury (no. of patients)			0.057
Fall	32	32
Punch	5	2
Motor-vehicle accident	4	1
Wrenching	2	9
Patient uncertain as to cause	1	0
Occupation (no. of patients)			0.320
Unemployed	3	4
Student	3	5
Office	4	7
Light manual	14	10
Moderate manual	16	9
Heavy manual	4	9

^* The Fisher exact tests were done for the relevant data. †The values are given as the mean and the standard error of the mean. ‡T test. §A = ambidextrous.

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TABLE I Data on the Patients

	Patients Managed with Immobilization in a Cast	Patients Managed with Open Reduction and Internal Fixation	P Value^*
Age†	29.9 ± 1.6	29.0 ± 1.32	0.685‡
Sex (M/F)	39/5	40/4	1.000
Dominance§ (no. of patients) (A/L/R)	0/6/38	1/7/36	0.772
Side of injury (L/R)	24/20	25/19	1.000
Mechanism of injury (no. of patients)			0.057
Fall	32	32
Punch	5	2
Motor-vehicle accident	4	1
Wrenching	2	9
Patient uncertain as to cause	1	0
Occupation (no. of patients)			0.320
Unemployed	3	4
Student	3	5
Office	4	7
Light manual	14	10
Moderate manual	16	9
Heavy manual	4	9

^* The Fisher exact tests were done for the relevant data. †The values are given as the mean and the standard error of the mean. ‡T test. §A = ambidextrous.

Patients randomized to early fixation were admitted to outpatient surgery within two weeks after the injury. These patients underwent surgery at a mean of 9.2 days after the injury. Forty-one patients had the operation within two weeks after the injury, and three patients had the operation later than the time declared in the protocol, at sixteen, nineteen, and twenty-one days. The scaphoid was approached through a 4-cm longitudinal volar incision centered over the tuberosity of the scaphoid. The radioscaphocapitate ligament was incised longitudinally to expose the fracture. The broken scaphoid was fixed with a Herbert screw with use of the Huene jig (Zimmer, Swindon, United Kingdom). In nine patients, an additional or alternative method of fixation was used. In thirty-five patients, a Herbert screw was inserted with use of the Heune jig⁶. In three patients, the Herbert screw was inserted freehand, and, in one patient, it was supplemented with a Kirschner wire. In six patients, the cannulated Whipple screw system was used. It was supplemented with a Kirschner wire in two patients. Kirschner wires alone were used in two patients because the fracture was comminuted. Technical difficulty was experienced in seven patients (16%). In four of them, there was initial misplacement of either the drill or the screw. This was recognized and rectified at the time of surgery. The final screw position was checked and confirmed with use of image intensification. In two patients, some mobility persisted at the fracture site. In the remaining patient, the scaphoid tuberosity split during screw insertion. The radioscaphocapitate ligament was carefully repaired during closure. Postoperatively, forty-two patients were managed with a bulky bandage alone for two weeks and were allowed to move the wrist and hand. For two patients, the bandage was supplemented with a plaster volar splint for six weeks because of concerns about the security of fixation. The senior author (J.J.D.) was present at the time of surgery, and he performed the operation in all but sixteen patients. He assisted one of the coauthors in performing the procedure in nine patients, and another coauthor performed the operation in seven patients. The mean duration of the surgery was fifty-five minutes (range, twenty-five to 125 minutes). For the forty-four patients who underwent open reduction and internal fixation, the details of the delay to surgery, intraoperative observations of the fracture type, comminution, mobility, laxity, method of fixation, tourniquet time, and postoperative regimen were recorded. The vascularity of the two parts of the scaphoid was not assessed, as this would require disturbance of the fracture site. No fracture had bone-grafting.

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Fig. 1: Diagram showing the flow of patients through each stage of this trial (according to the Consolidated Standards of Reporting Trials²¹). Seven patients were lost to follow-up after three months, two patients did not return after recruitment, and one patient in the internal fixation group died from unrelated causes during the course of the trial. ORIF = open reduction and internal fixation.

Nonoperative treatment consisted of immobilization in a below-the-elbow cast with the thumb left free and the wrist held in slight dorsiflexion for eight weeks, after which the patient was allowed to mobilize the hand and the wrist. All patients were encouraged to resume as much activity as possible, including return to work and leisure activity that did not risk a fall on the outstretched hand or a sudden twisting of the wrist.

Routine clinical and radiographic assessments were performed at two, eight, twelve, twenty-six, and fifty-two weeks postoperatively. At each visit, the patient was assessed clinically for symptoms of pain, swelling, tenderness, range of movement, and grip strength. Pain was measured with use of a visual linear analogue scale. Range of movement was measured in a standardized manner with use of a goniometer. Grip strength was measured with the same calibrated Jamar dynamometer (Preston, Jackson, Michigan). These parameters were calculated as a percentage of the measurement on the contralateral side. Symptoms, function, and treatment satisfaction were assessed with use of the Patient Evaluation Measure Questionnaire¹⁰. The Patient Evaluation Measure is a validated written questionnaire in visual analogue form. It consists of three sections that assess patient satisfaction with the care provided, the Hand Health Profile, and the overall result. The score is calculated as a percentage of the maximum possible score, with a higher score representing worse symptoms, disability, and less satisfaction. All complications were recorded. The date of return to work and the time needed after return to work to be able to perform work tasks comfortably was documented. Standard radiographs of the scaphoid (posteroanterior, lateral, semisupinated oblique, semipronated oblique, and the view described by Ziter¹¹) were made at each visit to assess fracture union.

Two patients in the nonoperative group failed to return after recruitment. One patient did not return at any time after recruitment. The other returned at two weeks but not thereafter. Five patients who had open reduction and internal fixation did not return after the twelfth week. Of those five patients, four had returned for the eight-week visit and three had returned for the twelve-week visit. Initial and subsequent radiographs were lost for one patient in each group.

Scaphoid fractures that showed no evidence of healing at twelve weeks on plain radiographs underwent computed tomography at sixteen weeks, and, if a gap was seen, the fracture was considered a probable nonunion and surgery was recommended.

Power and Statistical Methods

The sample size calculation indicated that forty-two patients were required in each group to provide a 90% power of detecting a 10% difference with p < 0.05 in separate evaluations of grip strength, wrist movement, and disability assessed with the Patient Evaluation Measure at twelve and twenty-six weeks after injury. These three outcomes had a respective standard deviation of 15%, 14%, and 12% in our previous assessments. They were selected for the investigation of impairment and disability in the two treatment groups. As we did not have independent published data upon which to assess the sample size, an in-trial assessment of the sample size was planned and conducted after 50% of the patients had completed the twenty-six week assessment. This confirmed the initial assessment. Although a repeated-measures adjustment would have decreased the sample size required, and it was our intention to use repeated-measures assessments of the data collected, the sample size was not revised to conform to accepted practice¹².

The outcome measures were compared at baseline with use of t tests for all eighty-eight patients. At the five follow-up visits, the outcomes were compared on an intention-to-treat basis with use of a repeated-measures analysis of variance with adjustment of p values by the Greenhouse-Geisser epsilon. Subsequently, the results at each visit were compared with t tests. All calculations were performed with Stata statistical software (release 7.0; Stata, College Station, Texas).

Results

Materials and Methods | Results | Discussion | References

Eighty-eight patients were entered into the study. With the numbers available, no difference was found between the two groups with respect to age, sex, hand dominance, side of injury, mechanism of injury, or occupation (Table I).

At the time of surgery, details of the fracture pattern were recorded. The type of fracture was found to be horizontal in nine patients, transverse in thirty-one, and vertical oblique in one. In three patients, the site of the fracture could not be identified at the time of surgery. Twenty-nine fractures (66%) had no comminution. Of the remaining fractures, comminution was marked in three, moderate in four, and mild in eight. There was clear mobility at the fracture site in nine patients (20%); it was marked in four and moderate in five. In twenty-one patients, mobility was just barely appreciated, and, in the rest, no mobility was observed at the fracture site at the time of surgery. The scapholunate joint was thought to be lax in seven patients.

The outcome measures of pain, tenderness, range of motion, grip strength, and Patient Evaluation Measure score are shown in Table II. The two groups were similar at baseline for all outcome measures. Repeated-measures analysis of variance was used to test for a treatment effect, that is, for any average difference between treatments and for a treatment by visit interaction, that is, any difference between treatments in the pattern of change over time. Analysis of pain showed no treatment effect (p = 0.75) or treatment by visit interaction (p = 0.73). Similarly, tenderness showed no treatment effect (p = 0.57) or treatment by visit interaction (p = 0.10). However, although the range of motion showed no treatment effect (p = 0.24), the treatment by visit interaction was significant (p = 0.001) because the group managed with open reduction and internal fixation had a better performance at eight weeks that was no longer present at twelve weeks. Grip strength showed a significant treatment effect (p = 0.006) and a significant treatment by visit interaction (p = 0.025). The grip strength was consistently higher in the group that had open reduction and internal fixation, but this difference too was most marked at eight and twelve weeks. The consistent difference may have been due to the baseline difference between the two groups, which, although it was within the range expected by chance, did favor the open reduction and internal fixation group. The Patient Evaluation Measure was not calculated at baseline, but, at the time of follow-up, it showed a significant treatment effect (p = 0.023) but no treatment by visit interaction (p = 0.13). At each follow-up visit, the operatively treated group had better results on the Patient Evaluation Measure and the pattern resembled that found for grip strength, with the largest differences occurring at eight and twelve weeks.

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TABLE II Outcome Measures

	Follow-up Visit^*
Outcome	Initial	2 Weeks	8 Weeks	12 Weeks	26 Weeks	52 Weeks
Pain
Cast immobilization	4.45 (3.43-5.48)	3.66 (3.00-4.31)	2.29 (1.59-3.00)	3.80 (2.92-4.68)	2.35 (1.52-3.17)	1.83 (1.04-2.62)
Internal fixation	4.05 (3.49-4.61)	3.44 (2.85-4.03)	2.39 (1.65-3.13)	3.12 (2.37-3.86)	2.40 (1.61-3.19)	2.18 (1.52-2.84)
P value†	0.442	0.611	0.847	0.236	0.924	0.551
Tenderness
Cast immobilization	2.21 (1.93-2.49)	1.58 (1.09-2.06)	0.76 (0.48-1.04)	0.40 (0.21-0.60)	0.17 (0.05-0.29)	0.18 (0.02-0.34)
Internal fixation	2.14 (1.85-2.43)	1.16 (0.87-1.45)	0.55 (0.33-0.77)	0.41 (0.23-0.59)	0.26 (0.06-0.45)	0.09 (0.00-0.18)
P value†	0.752	0.379	0.239	0.967	0.443	0.325
Range of motion
Cast immobilization	42.3 (33.8-50.7)	43.2 (36.8-49.6)	54.3 (49.9-58.7)	79.9 (75.7-84.1)	89.6 (84.4-94.8)	93.4 (88.5-98.3)
Internal fixation	44.3 (38.8-49.8)	44.4 (38.9-49.9)	68.0 (62.3-73.6)	80.7 (74.9-86.5)	89.3 (85.3-93.2)	94.1 (90.5-97.8)
P value†	0.675	0.778	0.000	0.829	0.907	0.814
Grip strength
Cast immobilization	20.8 (13.3-28.4)	32.7 (22.0-43.4)	55.5 (46.3-64.5)	75.3 (69.1-81.5)	88.2 (82.3-94.1)	91.6 (85.6-97.6)
Internal fixation	29.1 (22.5-35.8)	38.1 (31.7-44.5)	75.3 (69.2-81.3)	83.9 (78.9-88.8)	93.7 (89.6-97.7)	99.1 (95.9-102.2)
P value†	0.113	0.353	0.000	0.034	0.130	0.029
Patient Evaluation Measure
Cast immobilization		35.3 (28.8-41.8)	22.9 (18.6-27.3)	14.6 (10.0-19.3)	6.8 (3.7-9.9)	5.2 (1.6-8.8)
Internal fixation		29.7 (25.4-34.1)	13.8 (10.0-17.6)	9.5 (6.1-12.9)	5.8 (3.5-8.0)	3.9 (2.0-5.9)
P value†		0.139	0.002	0.075	0.580	0.512

^*The values are given as the mean, with the 95% confidence interval in parentheses. †T test.

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TABLE II Outcome Measures

	Follow-up Visit^*
Outcome	Initial	2 Weeks	8 Weeks	12 Weeks	26 Weeks	52 Weeks
Pain
Cast immobilization	4.45 (3.43-5.48)	3.66 (3.00-4.31)	2.29 (1.59-3.00)	3.80 (2.92-4.68)	2.35 (1.52-3.17)	1.83 (1.04-2.62)
Internal fixation	4.05 (3.49-4.61)	3.44 (2.85-4.03)	2.39 (1.65-3.13)	3.12 (2.37-3.86)	2.40 (1.61-3.19)	2.18 (1.52-2.84)
P value†	0.442	0.611	0.847	0.236	0.924	0.551
Tenderness
Cast immobilization	2.21 (1.93-2.49)	1.58 (1.09-2.06)	0.76 (0.48-1.04)	0.40 (0.21-0.60)	0.17 (0.05-0.29)	0.18 (0.02-0.34)
Internal fixation	2.14 (1.85-2.43)	1.16 (0.87-1.45)	0.55 (0.33-0.77)	0.41 (0.23-0.59)	0.26 (0.06-0.45)	0.09 (0.00-0.18)
P value†	0.752	0.379	0.239	0.967	0.443	0.325
Range of motion
Cast immobilization	42.3 (33.8-50.7)	43.2 (36.8-49.6)	54.3 (49.9-58.7)	79.9 (75.7-84.1)	89.6 (84.4-94.8)	93.4 (88.5-98.3)
Internal fixation	44.3 (38.8-49.8)	44.4 (38.9-49.9)	68.0 (62.3-73.6)	80.7 (74.9-86.5)	89.3 (85.3-93.2)	94.1 (90.5-97.8)
P value†	0.675	0.778	0.000	0.829	0.907	0.814
Grip strength
Cast immobilization	20.8 (13.3-28.4)	32.7 (22.0-43.4)	55.5 (46.3-64.5)	75.3 (69.1-81.5)	88.2 (82.3-94.1)	91.6 (85.6-97.6)
Internal fixation	29.1 (22.5-35.8)	38.1 (31.7-44.5)	75.3 (69.2-81.3)	83.9 (78.9-88.8)	93.7 (89.6-97.7)	99.1 (95.9-102.2)
P value†	0.113	0.353	0.000	0.034	0.130	0.029
Patient Evaluation Measure
Cast immobilization		35.3 (28.8-41.8)	22.9 (18.6-27.3)	14.6 (10.0-19.3)	6.8 (3.7-9.9)	5.2 (1.6-8.8)
Internal fixation		29.7 (25.4-34.1)	13.8 (10.0-17.6)	9.5 (6.1-12.9)	5.8 (3.5-8.0)	3.9 (2.0-5.9)
P value†		0.139	0.002	0.075	0.580	0.512

^*The values are given as the mean, with the 95% confidence interval in parentheses. †T test.

In the operatively treated group, no serious complications were encountered but ten patients had scar problems (Table III). Patients treated with a cast returned to work at a mean of six weeks, while those managed with an operation returned to work at a mean of five weeks (p = 0.381), and both groups were able to perform most work tasks comfortably within two weeks of return.

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TABLE III Postoperative Complications

Complication	No. of Patients
Superficial wound infection	1
Sensitive scar	3
Hypertrophic scar	4
Sensitive and hypertrophic scar	3
Hypoesthesia in region of palmar cutaneous branch median nerve	1
Mild early algodystrophy	1

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TABLE III Postoperative Complications

Complication	No. of Patients
Superficial wound infection	1
Sensitive scar	3
Hypertrophic scar	4
Sensitive and hypertrophic scar	3
Hypoesthesia in region of palmar cutaneous branch median nerve	1
Mild early algodystrophy	1

Radiographic Findings

The initial radiographs for two patients, one in each group, were not available for review. The findings for the remaining eighty-six patients are presented in Table IV. No significant difference between the groups was found on the initial radiographs with respect to the fracture site, fracture type, deformity, and the degree of comminution. Lunate tilt deformity that was present initially in eleven patients (four had volar intercalated segment instability, and seven had dorsal intercalated segment instability) persisted. Deformity developed in two patients treated nonoperatively. One of them had progression to a dorsal intercalated segment instability deformity and was diagnosed as having a nonunion at six months. The other patient had a comminuted fracture that united but had a volar intercalated segment instability deformity develop at one year. In all thirty-nine fractures in the fixation group that remained in the study, union was achieved by the end of the study.

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TABLE IV Radiographic Findings

	Cast Immobilization (No. of Patients)	Internal Fixation (No. of Patients)	P Value^*
Fracture site
Distal	3	2
Low	1	1
Middle	39	40	1.000
Not known	1	1
Fracture type
Transverse	32	37
Horizontal	9	5
Vertical	1	0
Low waist	1	1	0.751
Not known	1	1
Initial displacement
None	40	35
Mild	3	7
Moderate	0	1
Severe	0	0	0.354
Not known	1	1
Initial deformity
Dorsal intercalated segment instability	3	4
None	37	38
Volar intercalated segment instability	3	1	0.890
Not known	1	1
Angular displacement	0	0
Rotational displacement	0	0
Comminution
None	31	33
Slight	6	6
Moderate	6	4	0.909
Not known	1	1
Implant position
Perfect		8
Good		26
Acceptable		8
Not known		2
Nonunion	10	0	0.001

Fisher exact test.

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TABLE IV Radiographic Findings

	Cast Immobilization (No. of Patients)	Internal Fixation (No. of Patients)	P Value^*
Fracture site
Distal	3	2
Low	1	1
Middle	39	40	1.000
Not known	1	1
Fracture type
Transverse	32	37
Horizontal	9	5
Vertical	1	0
Low waist	1	1	0.751
Not known	1	1
Initial displacement
None	40	35
Mild	3	7
Moderate	0	1
Severe	0	0	0.354
Not known	1	1
Initial deformity
Dorsal intercalated segment instability	3	4
None	37	38
Volar intercalated segment instability	3	1	0.890
Not known	1	1
Angular displacement	0	0
Rotational displacement	0	0
Comminution
None	31	33
Slight	6	6
Moderate	6	4	0.909
Not known	1	1
Implant position
Perfect		8
Good		26
Acceptable		8
Not known		2
Nonunion	10	0	0.001

Fisher exact test.

In the nonoperatively treated group, union could not be confirmed on routine scaphoid radiographs of ten fractures at twelve weeks and all appeared to have a gap on the computed tomography scan. Fracture site, pattern, displacement, and angulation were similar in these ten ununited fractures compared with those considered to be united. Of the thirty fractures that had no comminution, four did not unite. Of the five that had slight comminution, two did not unite. Of the six that had moderate comminution, three did not unite. (One patient with a nonunion did not have initial radiographs available to assess comminution, and two other patients were lost to follow-up.) With the numbers available, the difference was not significant (chi square = 5, p = 0.08).

Three of the ten fractures considered to have a nonunion at twelve weeks were managed nonoperatively. One patient had healing of the nonunion without any additional immobilization or treatment. When the patient had come in at seven months to have operative treatment, which he had delayed because of personal reasons, union was identified on radiographs. A few weeks later, union was confirmed on a subsequent computed tomography scan. Two additional patients who were offered surgery declined it and continued to have a nonunion radiographically, which was symptomatic in one. Seven patients had surgery. In three of them, the nonunion was mobile; one of them had a flexion deformity of the scaphoid, and the other two had cysts at the nonunion site. In four patients, there were no clear signs of mobility between the proximal and distal parts of the scaphoid and the fracture could not be easily identified. All seven patients had internal fixation; six were managed with a cancellous bone graft and one was managed with a wedge graft. All seven fractures that were treated surgically healed uneventfully but required immobilization for an additional five to six weeks. At one year after surgery, four patients had minor nonintrusive discomfort in the wrist without any crepitus. Data from these patients were included in the analyses on the basis of an intention to treat.

Discussion

Materials and Methods | Results | Discussion | References

There has been a proliferation of implants available for the fixation of the ununited scaphoid fracture, and they have been increasingly recommended for use in acute fractures^6-9,13-15. Proponents of early internal fixation have suggested that the principal benefits are an early return of wrist movement, a higher rate of union with an early return to work and sport, and avoidance of the need for a plaster cast in the initial six-week period. Indeed, this would be a benefit if the young person could not return to work in a cast. However, the screw is merely an internal splint, and, depending on the demands and risks of work or sport, the injured wrist still requires protection for a variable period of time even after internal fixation. Thus, most benefits of early internal fixation are transient and early.

Conversely, fractures of the scaphoid waist that are treated nonoperatively unite satisfactorily in 85% to 95% of such patients^1,2. The average reported time to union is between six and eight weeks¹⁴. After surgery, the wound may need protection for a few days to a couple of weeks. There is therefore a four to six-week period in which a cast may be avoided with operative treatment. The method of cast immobilization recommended in the literature has varied^16,17; this study used a functional below-the-elbow cast¹⁶. Casts for scaphoid fractures can be intrusive and seriously compromise hand function, especially if the thumb or elbow is immobilized. A functional cast limits the disability while still protecting the scaphoid fracture.

In this randomized controlled study, we compared the two methods of treatment to establish whether there is a difference with respect to early and late outcome, return to work, union rates, and complications. In previous prospective trials, no significant difference has been found for grip strength and range of motion at the two-year⁸ and twelve-year review⁹; no earlier outcomes have been reported as far as we know. We found that the group treated operatively had significantly better results than the nonoperatively treated group with respect to range of motion, Patient Evaluation Measure score, and grip strength at the eight-week follow-up visit, which was when the cast was removed in those treated nonoperatively. This significant difference was only sustained for grip strength until the twelve-week review. No significant difference was detected between the two groups with respect to any of the outcome measures at any other time. Therefore, it appears that the benefits of an early return of motion and strength are very transient. Moreover, at eight weeks, the difference in disability, assessed with the Patient Evaluation Measure, was small, with a rate of 14% for the group managed operatively compared with 23% for the group managed nonoperatively, but it was significant.

No significant difference was found between the two groups with respect to the time taken to return to work and to be able to perform work tasks comfortably. This is in contrast to previous studies, which have described a significant difference in return to work^8,9,13. This probably reflects our advice to patients to return to occupational and some leisure activity with care as soon as they wished. It also probably reflects our use of a functional cast with the thumb left free and the wrist in slight dorsiflexion to facilitate use of the hand while immobilizing the wrist. The time to return to work was dependent on a host of factors that included the nature of the patient's occupation and the attitudes of the patient, employer, and insurance company, making the time to return to work a questionable outcome measure in any event.

The other reported benefit of early surgery is a higher rate of union of approximately 95%^9,15. Our study confirmed that the rate of union was significantly higher for the group that had operative fixation of the fractures than for the group that had nonoperative treatment, as ten of the forty-four fractures treated with immobilization had not achieved radiographic union by twelve weeks. One reason that the rate was higher than expected was probably the definition of a nonunion, which was the presence of a gap on a computed tomography scan at twelve to sixteen weeks. One of the fractures that had a nonunion went on to unite without any intervention, and an additional four fractures that had not united had no obvious mobility between the proximal and distal parts of the scaphoid at the time of surgery. It is possible that these four also could have healed with additional immobilization. Furthermore, for this study, the period of cast immobilization was defined as eight weeks, whereas in previous studies immobilization was continued until union was seen. It is possible that prolonged immobilization would have resulted in union in at least some of these fractures that were judged to be ununited at twelve weeks.

The concern about early surgical intervention relates to the complications. The complication rate in our patients who had operative treatment was 30%. However, all of the complications were minor, and the majority were related to the scar. Percutaneous techniques could minimize scar-related problems. We did, however, experience particular technical difficulties in seven of the forty-four patients in whom the fixation technique had to be adjusted or supplemented.

The gains for the patient in having early internal fixation of an undisplaced or minimally displaced scaphoid waist fracture are slim and difficult to quantify, except for the fact that we found a higher rate of union without changing treatment with early fixation. If it were possible to confidently predict a nonunion by an examination of the different attributes of the initial injury, a clearer set of indications for early internal fixation could be suggested. However, it is difficult to predict the failure of a fracture to unite on the basis of the fracture configuration, comminution, laxity, or avascularity¹⁸. Displacement is difficult to quantify radiographically and, at best, can be used only as a relative indication for surgery¹⁵.

As a result of this study, we have adopted an alternative approach of "aggressive" conservative treatment¹⁹. The aggressive component involves identification of a delay or a failure of union at around six weeks and surgical stabilization of only these fractures. With this method, all undisplaced scaphoid fractures and those without a substantial step-off are treated with immobilization in a below-the-elbow cast with the wrist in slight dorsiflexion and the thumb left free¹⁶ for six weeks. All patients are encouraged to resume as much activity as possible early. At six to eight weeks, the cast is removed and the wrist is left free. If, at that point, there is concern about union because of the persistence of a gap, especially a clear one, or movement at the fracture on any of the radiographs²⁰ compared with previous radiographs, a computed tomography scan is performed to identify any gap at the fracture site. The patients who have a gap at the fracture site are given the option of surgery to internally fix the fracture with or without a bone graft followed by cast immobilization for an additional six weeks. Alternatively, the occasional patient who declines surgery is advised about the high probability of developing osteoarthritis because of a nonunion, is given a wrist splint to wear when performing strenuous activity, and is followed clinically and radiographically for a year.

This method of aggressive conservative treatment could, in the future, be modified as our ability to predict the failure of a fracture to unite improves. Such a method would fine-tune the current blanket indication for early internal fixation and would target early surgery for the 10% to 20% of the patients in whom a fracture union is likely to be delayed or fail. In this study, such an aggressive conservative treatment program resulted in union in forty-two (95%) of the forty-four fractures in the nonoperatively treated group in a reasonable time-period, with only two nonunions occuring in patients who had declined the use of early surgical intervention to achieve union.

The limitations of this study include the potential for bias in both the clinical and radiographic assessment, as the authors were involved in both the surgery and the assessment and could not be blinded to the treatment allocation because of the scar.

This study showed that cast treatment is a reliable, safe, and reasonably effective method of treating scaphoid waist fractures. Early fixation of acute scaphoid fractures provides an early return of grip strength and range of motion, but this benefit is not sustained. The complication rate is high, but the complications are minor. It provides no benefit in return to work, but it does have an expected impact on the union rate. However, if all acute scaphoid fractures were to be managed with internal fixation to achieve a higher union rate, operations would be performed on a large number of fractures that would heal without intervention.

Currently, we are unable to predict which fractures are at an increased risk of nonunion¹⁸, and we are therefore unable to direct the use of surgery toward fractures that would receive a more definite benefit from it. On the basis of this evidence, we believe that each fracture should be treated nonoperatively in a functional cast. Surgical intervention should be offered only to the very few patients who cannot return to work in a cast, and such patients should be made fully aware of the risks and limited gains provided by acute fixation. ?

References

Materials and Methods | Results | Discussion | References

Ford DJ, Khoury G, el-Hadidi S, Lunn PG, Burke FD. The Herbert screw for fractures of the scaphoid. A review of results and technical difficulties. J Bone Joint Surg Br.1987;69: 124-7.69124 1987 [PubMed]

Dias JJ, Brenkel IJ, Finlay DB. Patterns of union in fractures of the waist of the scaphoid. J Bone Joint Surg Br.1989;71: 307-10.71307 1989

O'Brien L, Herbert T. Internal fixation of acute scaphoid fractures: a new approach to treatment. Aust NZ J Surg.1985;55: 387-9.55387 1985

Skirven T, Trope J. Complications of immobilization. Hand Clin.1994;10: 53-61.1053 1994 [PubMed]

Rettig AC, Kollias SC. Internal fixation of acute stable scaphoid fractures in the athlete. Am J Sports Med.1996;24: 182-6.24182 1996 [CrossRef]

Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br.1984;66: 114-23.66114 1984

Bunker TD, McNamee PB, Scott TD. The Herbert screw for scaphoid fractures. A multicentre study. J Bone Joint Surg Br.1987;69: 631-4.69631 1987

Dias JJ, Bhowal B, Wildin CJ, Thompson JR. Assessing the outcome of disorders of the hand. Is the patient evaluation measure reliable, valid, responsive and without bias? J Bone Joint Surg Br.2001;83: 235-40.83235 2001 [CrossRef]

Saeden B, Tornkvist H, Ponzer S, Hoglund M. Fracture of the carpal scaphoid. A prospective, randomised 12-year follow-up comparing operative and conservative treatment. J Bone Joint Surg Br.2001;83: 230-4.83230 2001 [CrossRef]

Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am.2001;83: 483-8.83483 2001 [PubMed]

Ziter FM Jr. A modified view of the carpal navicular. Radiology.1973;108: 706-7.108706 1973 [PubMed]

Machin D, Campbell MJ, Fayers PM, Pinol APY. Sample size tables for clinical studies. 2nd ed. Oxford: Blackwell Science; 1997. p 7.7 1997

Inoue G, Shionoya K. Herbert screw fixation by limited access for acute fractures of the scaphoid. J Bone Joint Surg Br.1997;79: 418-21.79418 1997 [CrossRef]

Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop Relat Res.1980;149: 90-7.14990 1980

Rettig ME, Kozin SH, Cooney WP. Open reduction and internal fixation of acute displaced scaphoid waist fractures. J Hand Surg [Am].2001;26: 271-6.26271 2001 [PubMed][CrossRef]

Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ. Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. J Bone Joint Surg Br.1991;73: 828-32.73828 1991 [PubMed]

Thompson JS. Comparison of short and long thumb-spica casts for nondisplaced fractures of the carpal scaphoid. J Bone Joint Surg Am.1990;72: 309-10.72309 1990 [PubMed]

Desai VV, Davis TR, Barton NJ. The prognostic value and reproducibility of the radiological features of the fractured scaphoid. J Hand Surg [Br].1999;24: 586-90.24586 1999 [PubMed]

Gunal I, Barton N, Calli I, editors. Current management of scaphoid fractures: twenty questions answered. London: Royal Society of Medicine; 2002. p 30-1.30 2002

Dias JJ. Definition of union after acute fracture and surgery for fracture nonunion of the scaphoid. J Hand Surg [Br].2001;26: 321-5.26321 2001

Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet.2001;357: 1191-4.3571191 2001 [PubMed][CrossRef]

Topics

patient evaluation ; fracture ; casts, surgical ; cicatrix ; fracture fixation, internal ; immobilization ; range of motion ; scaphoid bone ; wrist fractures, navicular bone ; grip strength

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Eric P. Hofmeister

Posted on November 04, 2005

Treatment of Acute Scaphoid Fractures

Naval Medical Center, San Diego, CA

To The Editor:

In the article â€œShould Acute Scaphoid Fractures Be Fixed?â€ (2005;87:2160-2168), the authors present a very nice randomized trial between operative and nonoperative fixation of acute, nondisplaced scaphoid fractures. They concluded that at final follow up, there was not a clear overall benefit of early fixation in regard to pain, tenderness, range of motion, grip strength or the patient evaluation measure. However, the authors minimized their results in regards to delayed/nonunion.

Although each group initially consisted of 44 patients, the cast treatment group lost two patients, leaving 42 for review, and the operative group lost five patients, leaving 39 for final follow up. Ten in the cast group went on to a delayed/nonunion, for a rate of 23.8% (10/42). All fractures in the operative group healed. Utilizing a Fisherâ€™s exact test, this gives a p-value of .001, which is highly significant.

Furthermore, in the delayed/nonunion group, six of the 10 required cancellous bone grafting, and one required a wedge graft, all which were more invasive and required longer surgery than the operative group. This â€œdelayedâ€ operative group then incurred an additional five to six weeks of immobilization (after an already six to eight weeks of immobilization), and 57% (4/7) continued to have minor discomfort at one year follow up.

Finally, the authors describe an â€œaggressive conservative treatmentâ€ with careful assessment of fracture healing on radiographs after six to eight weeks of casting. If union is not present, then additional imaging (computed tomography) is recommended, which incurs further expense, radiation exposure and inconvenience to the patient.

Sameer Batra

Posted on October 27, 2005

Should Acute Scaphoid Fractures Be Fixed?

DEPARTMENT OF TRAUMA & ORTHOPAEDICS, Ysbyty Gwynedd, NW WALES NHS TRUST, Bangor, UK, LL57 2PW

To The Editor:

I read with interest the article â€˜Should acute scaphoid fractures be fixed? A randomized controlled trialâ€™.(1) The optimal management for undisplaced acute scaphoid fractures has been the focus of much debate. Unfortunately, this study failed in some respects to provide concrete answers.

There was a potential for observer bias in the evaluation of the radiographs because the observer could not be blinded with respect to whether the patient had had surgical treatment or cast immobilization and at the same time no mention was made to criterion for union. It has previously been reported that because of the almost complete cartilagenous surface of the scaphoid bone, fracture healing is an intraosseous process. Therefore the assessment of fracture healing by conventional radiography is very difficult. (2,3) Computed tomography imaging along the longitudinal axis of scaphoid bone is best suited for the evaluation of fractures as well as healing process.(4,5)

In the nonoperative group, the authors chose a below elbow cast with the thumb left free. Bhandari, et al,(6) in a meta-analysis on randomized controlled trials reported that use of long arm thumb spica casts with the thumb immobilized but the interphalangeal joint left free resulted in a 68% reduction in the risk of delayed or nonunion compared with short thumb spica casts.(7)

There is insufficient evidence from randomized trials to determine whether internal fixation is superior to casting in patients with undisplaced scaphoid fractures. A critical risk-benefit analysis is necessary to determine the optimal treatment of acute nondisplaced fractures of the scaphoid waist.

References:

1. J.J. Dias, C.J. Wildin, B. Bhowal, and J.R. Thompson Should Acute Scaphoid Fractures Be Fixed? A Randomized Controlled Trial J Bone Joint Surg Am 2005; 87: 2160-2168

2.Dias JJ (2001) Definition of union after acute fracture and surgery for fracture nonunion of the scaphoid. J Hand Surg; 26B, 321â€“ 325.

3.Dias JJ, Taylor M, Thompson J, Brenkel IJ, Gregg PJ. (1988) Radiographic signs of union of scaphoid fractures: An analysis of inter-observer agreement and reproducibility. J Bone Joint Surg; 70B, 299â€“301.

4. Wilson AJ, Mann, FA, Gilula LA. (1990) Imaging of the hand and wrist. J Hand Surg 15B, 153â€“167.

5. Bain GI, Bennett JD, Richards RS, Slethaug, GP, Roth JH. (1995) Longitudinal computed tomography of the scaphoid: a new technique. Skeletal Radiol 24, 271â€“273.

6.Mohit Bhandari, MD, Beate P. Hanson. Acute Nondisplaced Fractures of the Scaphoid .J Orthop Trauma 2004; 18:253â€“255.

7. Gellman H, Caputo RJ, Carter V, et al. Comparison of short and longthumb-spica casts for non-displaced fractures of the carpal scaphoid. JBone Joint Surg Am. 1990; 72:309â€“310.

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J.J. Dias, C.J. Wildin, B. Bhowal, J.R. Thompson; Should Acute Scaphoid Fractures Be Fixed?A Randomized Controlled Trial. The Journal of Bone & Joint Surgery. 2005 Oct;87(10):2160-2168.

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