Question: In patients with fracture of the carpal scaphoid,
how do the long-term effects of surgical treatment with fixation
by a Herbert screw compare with those of conservative treatment
with a short-arm plaster cast?
Design: Randomized (allocation concealed), unblinded,
controlled trial with a 12-year follow-up.
Setting: A hospital in Stockholm, Sweden.
Patients: 61 patients (mean age, 33 years) who had
an acute fracture at the first radiographic examination were included
(62 fractures; 79% of fractures were in men). Exclusion
criteria were fractures through the tuberosity of the scaphoid or
radiographic signs of delayed union or pseudarthrosis. 82% of
patients (82% of fractures) were followed at 12 years.
Intervention: Fractures were allocated to surgery with
use of a Herbert screw (n = 32) or to conservative treatment
with a short-arm plaster cast (from below the elbow to the metacarpophalangeal
joints of the fingers and to the interphalangeal joint of the thumb)
(n = 30). In the operative group, two surgeons used a volar approach
with a tourniquet (mean operating time, 54 min).
Main outcome measures: Duration of sick leave, pain
and discomfort at 12 years, and functional ability of the wrist.
Radiography was done in <70% of patients at 12
years.
Main results: Patients in the operative group had
a shorter duration of sick leave than those in the conservative
treatment group (6 vs. 15 wk; P = 0.002). At 12 years,
the groups did not differ with regard to reported pain or discomfort
in the wrist (table), the grip strength of the injured wrist relative
to that of the uninjured wrist (95% for the operative group
and 88% for the conservative treatment group), or range
of movement (96% for the operative group and 98% for
the conservative treatment group).
Conclusions: In patients with a fracture of the
carpal scaphoid, surgery with use of a Herbert screw was as effective
as conservative treatment with a short-arm plaster cast for decreasing
pain and discomfort. Surgery shortened the duration of sick leave.