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Nonoperative Compared with Operative Treatment of Acute Scaphoid FracturesA Randomized Clinical Trial
Bertil Vinnars, MD1; Mihai Pietreanu, MD1; Åke Bodestedt, MD1; Fredrik af Ekenstam, MD, PhD2; Bengt Gerdin, MD, PhD1
1 Departments of Hand Surgery (B.V. and M.P.), Radiology (Å.B.), and Plastic Surgery (B.G.), Uppsala University Hospital, SE-751 85 Uppsala, Sweden. E-mail address for B. Vinnars: bertil.vinnars@akademiska.se
2 Department of General Surgery, Central Hospital, SE-801 87 Gävle, Sweden
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Folksam research fund (Sweden) and the AFA research fund (Sweden). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
Investigation performed at the Department of Hand Surgery, Uppsala University Hospital, Uppsala, and the Centre for Clinical Research—Uppsala University, Central Hospital, Västerås, Sweden

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jun 01;90(6):1176-1185. doi: 10.2106/JBJS.G.00673
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Abstract

Background: Traditionally, acute nondisplaced scaphoid fractures have been treated nonoperatively in a cast, and the expected union rate approaches 90%. Internal fixation of nondisplaced scaphoid fractures has increased in popularity, and a union rate of 100% has been reported. The growing trend is to recommend internal fixation for the majority of acute scaphoid fractures. The true long-term benefits of this more complicated treatment modality have not yet been determined in randomized controlled trials. The purpose of this study was to compare the long-term results of operative fixation of acute scaphoid fractures with those of nonoperative treatment.

Methods: During the period between 1992 and 1997, eighty-three patients with an acute nondisplaced or minimally displaced scaphoid fracture were randomly allocated to, and received, either nonoperative treatment with a cast or internal fixation with a Herbert screw. At a median of ten years after the injury, seventy-five (93%) of the eighty-one patients who were still alive were assessed clinically and radiographically.

Results: All fractures united. A significant increase in the prevalence of osteoarthritis in the scaphotrapezial joint was found in the operatively treated group. No differences in subjective symptoms, as measured with limb-specific outcome scores, were found between the two groups. The range of motion and grip strength were greater, but not significantly greater, in the nonoperatively treated group.

Conclusions: This study did not demonstrate a true long-term benefit of internal fixation, compared with nonoperative treatment, for acute nondisplaced or minimally displaced scaphoid fractures. The long-term risks of surgery should be considered when recommending operative treatment.

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

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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