No Benefit Found from Operative Treatment of Acute Scaphoid FractureUsually, treatment of a break in the scaphoid, the largest bone in the hand, that hasn't moved or displaced is casting. This has an 85 percent to 90 percent success rate for treatment if the casting is done quickly. However, casting takes time and is inconvenient, and recovery of strength and movement following removal of the cast can take some time.
In the mid-1980s, some researchers claimed that the success of casting was only 50 percent so they introduced a new treatment with hardware in order to stabilize the fracture. According to their study, after 12 months, all repaired fractures were still in place. Other studies have found good success with the screw repair, along with rapid return of use of the hand. The drawback, however, is that the procedure is surgery, which involves using the surgical suites, equipment, and manpower. There is also the question as to whether introducing the screw into the joint could contribute to the development of osteoarthritis.
The authors of this study looked at the long-term outcomes of patients who had either been casted or had undergone the screw implantation. Their goal was to see which treatment offered the best outcomes.
Patients were divided into two groups, 42 patients were casted and 43 underwent surgery. The mean age of all the patients was 31 years for the first group, 32 for the second.
Among the patients who were casted, their casts immobilized their hand from below the elbow. It was worn for six weeks and then removed for evaluation. Following evaluation of the bone union, it was reapplied for an extra two to four weeks if the doctor recommended.
The patients in the surgical group wore a splint on the affected hand for about two weeks after the surgery. After two weeks, for most patients, the splint was changed to a cast for an additional three weeks.
Follow-up at 10 years provided answers from 75 of the original 85 patients. The patients underwent x-rays and were assessed for sensitivity of the scar area, tenderness, joint movement, grip strength and pinch strength. Patients filled out questionnaires about their hand, including a disability questionnaire called the Disabilities of the Arm, Shoulder and Hand (DASH) and the Patient-related Wrist Evaluation (PRWE).
The researchers found that most patients in both groups had no symptoms, although two did have high scores in the DASH questionnaire. More patients who had surgery found that their wrist did not function as well as it had before the fracture and surgery, although the researchers said that the difference was not significant.
When assessing range of motion, those who did not have surgery had better range of motion than the other group. Strength, both pinch and grip, did not vary significantly between groups. The researchers looked for signs of osteoarthritis (with the x-rays) and it was found in one patient who did not have surgery and in 11 who did have surgery.
The authors conclude that the surgical procedure as treatment for treatment of scaphoid fractures did increase the risk of developing osteoarthritis, despite the appeal of the high union rate, short cast time, and quick return to work, which they felt was transient. They pointed out that such patients should be chosen with care.
Bertil Vinnars, MD, et al. Nonoperative Compared with Operative Treatment of Acute Scaphoid Fractures. In The Journal of Bone & Joint Surgery. June 2008. Volume 90. No. 6. Pp. 1176-1185.
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