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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 (www.jbjs.org) 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.

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    References

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    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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    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 “Should Acute Scaphoid Fractures Be Fixed?” (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 Fisher’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 “delayed” 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 “aggressive conservative treatment” 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 ‘Should acute scaphoid fractures be fixed? A randomized controlled trial’.(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, 321– 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, 299–301.

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

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

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

    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; 72:309–310.

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