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Wrist News

Review of Surgery Versus Casting for Acute Scaphoid Fractures

Right now, most doctors prefer to fix an acute scaphoid fracture (fracture of the small bone on the thumb side of the wrist, where the wrist bends) with surgery if the break moves the bones, or displaces them. The chances of the bones not joining or not fusing properly are higher, so surgery's role is fairly obvious. But, in breaks where the bones aren't displaced isn't as clear cut when it comes to treatment, although surgeons who favor it say that the patients can return to their regular life more quickly and the bones still heal better with surgery.

The authors of this study examined six published randomized controlled trials that compared treatment with a cast (immobilization) with surgery. The researchers looked at the x-rays of the wrist bones, but were hampered by there not being any computer tomography scans (CT scans) and only three of the six studies reported when the bones joined or fused (called "time to union").

Five of the six studies found that the union rates were high for both groups. One study, led by Dias, found that there was a difference between the two groups and union rates. They found that 10 of the 44 casted wrists did not fuse, something that didn't happen in any of the 44 wrists that had received surgery. When looking at recovery time, one study that did report time to union, led by McQueen, found that the surgical patients recovered more quickly than the casted patients. However, another study led by Adolfsson didn't see the same results at all.

Grip strength is one way of measuring how well a wrist has healed. Most of the studies reported that there was no difference in grip strength between the two groups during their final assessment of the patients, but earlier in the study (at eight and 16 weeks), the surgery patients did have, on average, a stronger grip strength than the casted patients. All studies had similar return-to-work rates although, patients who did manual labor returned to work more quickly if they had had surgery.

When considering costs, casting is significantly less expensive than surgery but, interestingly, only in non-manual labor workers where the cost was one-third of the surgery cost. For manual workers, the cost was still cheaper for surgery, but the difference wasn't as wide as with the non-manual workers.

Treatments always have the risk of complications. With casting, complications include stiffness and weakness after the cast is removed. With surgery, complications include infection (common to all types of surgery), chronic regional pain syndrome, scar-related complications, hardware problems (breaking, movement, visible), and osteoarthritis.

The authors wrote that the six studies they examined had several shortcomings. The lack of CT scanning made it more difficult to see the fracture and healing and they felt that perhaps not all the fractures actually fell into the non-displaced category. The x-rays can't be depended on to accurately diagnose a scaphoid fracture and when it healed. As well, since most people who break the scaphoid are young, mobile and independent, many are likely not to return for follow ups if they feel that they've healed sufficiently.

They also felt that the return to work measure wasn't a precise or objective measurement because of the way that different work environments judge if someone is able to return or not. The example in this article is the U.S. Navy - someone in the navy who has a cast isn't allowed to return to active duty, which would delay the calculation of time for return to work.

Complications during surgery are sometimes the result of surgeons who don't perform the particular surgery frequently. Inexperience could result in higher complication rates for the surgical scaphoid repairs.

In conclusion, the authors feel that there needs to be reliable and valid methods to diagnose both the fracture, bone displacement, and union of the bones, such as using CT scanning. To be able to determine whether surgery or casting is best, a large, multicenter trial is needed.


Ruby Gerwal, MD, and Graham J.W. King, MD. An Evidence-Based Approach to the Management of Acute Scaphoid Fractures. In The Journal of Hand Surgery. April 2009. Vol. 34. No. 4. Pp. 732 to 734.

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