Surgery or Casting for Acute Nondisplaced Scaphoid Waist Fracture?The scaphoid bone, the small wrist bone at the base of the thumb, is easily broken, particularly if someone falls on an outstretched hand. Treatment of such a fracture is debatable among some surgeons as some prefer to do casting, while others prefer surgery for optimal healing. For casting, it's estimated that 90 percent to 95 percent of scaphoid waist fracture are healed by cast in about three months. However, for some patients, the three month wait isn't acceptable, often because it hampers their return to work. To encourage faster healing, some surgeons will do surgery to insert a screw, to stabilize the bone.
The pros of casting include that it is safe and inexpensive. The major con is that recovery time can be long. The authors of this article looked at three studies that looked at casting for scaphoid waist fractures. One, led by Gellman, followed two randomized groups of patients: those who had an above elbow thumb spica cast for a nondisplaced (bones haven't moved) fracture and those who had a below elbow spica thumb cast. A spica thumb cast holds the thumb in a "hitchiker's" position as it heals. The researchers felt that the above elbow cast could help protect the thumb better than the shorter one. The patients who had the above elbow spica cast were switched to a below elbow spica cast after six weeks and the researchers found that these patients had a quicker healing time (9.5 weeks) over patients who had only the below elbow spica cast (12.7 weeks).
Another study, led by Clay, looked at 392 fractures and the patients were divided into those who had below elbow casts that immobilized the thumb up past the joint at mid-thumb (the interphalageal joint and those that didn't involve that joint. There appeared to be no difference in the results of the two groups; both had a 10 percent non-union rate of bones that had broken clear across. Finally, a third study, by Hambridge and colleagues, randomized patients to casts that either placed the wrist bone with a slight extension (outward position) or with it flexed inward a bit, both with the thumb free. There didn't seem to be any difference in healing, but patients whose thumbs had been flexed had more problems getting the thumb straightened out afterwards.
Six other studies looked at surgery for management of the fractures. Study 1 by Saeden and colleagues, looked at 62 fractures, half of which were casted and half underwent surgery with hardware to stabilize the bone. So-called blue collar workers were off work for about six weeks if they had surgery, 15 weeks if they were casted, although all patients -casted or operated - had successful treatment. However, those who had surgery had a higher rate of developing osteoarthritis in the area later 12 years later.
Study 2, by Bond and colleagues, looked at 25 military personnel with fractures. They either were casted with long arm casts with the thumb free or the wrist operated on to insert a screw. There was no difference in the healing and outcomes, but those who had surgery did return to work more quickly. In Study 3, by Adolfsson, 28 patients were assigned to casting for 10 weeks and 25 patients had a screw inserted. Again, there was no difference in outcome between the two groups, with the exception of motion. Those who had surgery had better motion 16 weeks after the accident than those who were casted.
In Study 4, Dias and colleagues looked at 88 patients who were divided into eight weeks of casting wit the thumb free or surgery. Although there was a difference at eight and 12 weeks after surgery (better findings with the surgery group), the overall long-term outcome was the same for both. In Study 5, McQueen and colleagues found yet again the same results among 60 patients although the casted patients did take longer to return to their previous sports and work activities. Finally, in Study 6, Vinnars and colleagues also found the same results in their study of 83 fractures.
Cost-wise, the type of treatment does may a difference. The surgery provided better life quality during healing than did casting and was cheaper overall. Although the surgery itself was more costly than casting, those who were casted lost more work days and productivity than those who had surgery. However, if patients had functional casts and could return to work with the cast, the costs would turn out to be more for surgery, as those who returned to work with only casting could return more quickly.
The authors concluded that there doesn't appear to be a clear-cut superiority of one treatment over another when managing this type of fracture. The bones healed fairly equally in rate (about 90 percent) regardless of the procedure. To be able to be more specific about which patients (age, type of work, type of surgery, type of cast, as well as results over short, medium, and long term, would need to be assessed through a large multicenter trial.
Ashwin N. Ram, BS, and Kevin C. Chung, MD. Evidence-Based Management of Acute Nondisplaced Scaphoid Waist Fractures. In The Journal of Hand Surgery. April 2009. Vol. 34. No. 4. Pp. 735 to 738.
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