Delays and poor management of scaphoid fractures: factors contributing to nonunion

Understanding Pediatric Clinical Scaphoid Injuries: A Prospective Radiological Study

Background: Controversy exists in the management of children presenting with clinical suspicion of a scaphoid fracture but normal radiographs. The purpose of this study was to prospectively evaluate the potential role for advanced imaging in children with suspected scaphoid fractures. Methods: Participants with clinical suspicion of a scaphoid fracture but 2 sets of radiographs negative for fracture were casted and underwent both computed tomography (CT) and magnetic resonance imaging (MRI). The primary outcome was the prevalence of scaphoid fracture and other imaging findings. Results: Twenty-five participants were enrolled. Nine participants (36%) were found to have a scaphoid fracture on either CT or MRI. Concordance of CT and MRI was found in 64% of cases. Conclusion: Future studies are required to better understand the clinical significance of these injuries, the role of advanced imaging, and the most appropriate treatment in children with suspected scaphoid fractures.

Radiological Diagnosis of Suspected Scaphoid Fractures in Children: A Systematic Review

Background: Children presenting with suspicion of a scaphoid fracture pose a diagnostic challenge. Several imaging modalities such as plain radiograph (XR), computed tomography (CT), and magnetic resonance imaging (MRI) have been previously described. Timely and accurate diagnosis is important to avoid overtreatment, and complications, and allow for an earlier return to activity. It is unclear which imaging modality is the most diagnostically accurate for detecting scaphoid fractures in this population. Methods: A systematic review was conducted in concordance with established guidelines to elucidate the diagnostic accuracy of various imaging modalities for detecting scaphoid fractures in children. A comprehensive literature search of electronic databases was developed by experienced librarians. All steps were performed independently by 2 reviewers. Results: Eight articles were included, all evaluating plain radiographs as the index test. One study evaluated CT. XR demonstrated sensitivity values ranging from 16% to 54%, with specificity of 71% to 100%. CT had 95% sensitivity with MRI as the reference standard. The included studies were limited by poor methodologic quality and heterogeneous patient populations. Conclusions: XR demonstrates a wide range of diagnostic accuracy in diagnosing scaphoid fractures in children. CT and MRI, while promising, are limited by a lack of evidence in children. More pediatric-specific prospective studies are required to guide the choice of diagnostic imaging in children with suspected scaphoid fractures.

Update on Management of Scaphoid Fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Accurately diagnose scaphoid fractures through examination and appropriate imaging selection. 2. Recognize those fractures that can be treated with nonoperative management. 3. Outline the different surgical approaches for scaphoid fractures. 4. Appreciate the surgical options for management of scaphoid nonunion.

SUMMARY

This article includes the most up-to-date information on the diagnosis, work-up, and treatment of scaphoid fractures.

What Is the Optimal Method of Fixation for Scaphoid Nonunion Relative to the Location of the Lesion?

INTRODUCTION

Scaphoid nonunion is a typical complication of scaphoid fractures, with the nonunion rate varying by the location of the scaphoid. The current widely used method for treating scaphoid nonunion, which is challenging for surgeons, is the headless compression screw (HCS). Various surgical approaches, such as the scaphoid plate, have been proposed to address the problem of screw fixation; however, no consensus exists regarding the optimal treatment method. This study focused on analyzing appropriate treatment methods based on the anatomical location of the scaphoid nonunion.

METHODS

Ninety-seven patients with scaphoid nonunion were treated between 2008 and 2023. All patients underwent treatment using 1 HCS or scaphoid volar locking plate with nonvascularized bone graft from the distal radius depending on the scaphoid's location. The scaphoid angle and bone union were confirmed using radiological examinations. The clinical evaluations included range of motion, pain, grip strength, and functional wrist scores.

RESULTS

Fifty-seven patients were included in the final analysis. In the screw group, 26 patients (26/42 [62%]) obtained a bone union, and all 15 patients (15/15 [100%]) in the plate group obtained a union ( P = 0.005). In the waist group, 16 patients with screw (16/25 [64%]) and 8 using a plate (8/8 [100%]) showed bony healing. In the proximal group, 3 patients with HCS (3/9 [33%]) and 4 using plate (4/4 [100%]) showed bone union. In the distal group, 7 patients with a screw (7/8 [87%]) and 3 with the plate (3/3 [100%]) showed bone union. Significant differences were found in the waist ( P = 0.047) and proximal groups ( P = 0.026), but not in the distal group ( P = 0.521). All groups showed improved radiological angles associated with the scaphoid and better clinical outcomes postoperatively.

CONCLUSIONS

Plate fixation was overall superior to screw fixation for scaphoid nonunion, especially in the waist and proximal poles, providing better union rates and stability. For the distal group, both methods are effective, with the choice depending on the surgeon's expertise and patient factors. The results highlight the importance of the lesion's anatomical location in selecting the appropriate fixation method.

Developing 3D-Printed Wrist Splints for Distal Radius and Scaphoid Fractures

Background  The purpose of this study is to optimize conservative treatment of distal radius and scaphoid fracture, in terms of comfort, fracture stabilization, and prevention of cast complications. Description of Technique  Advances in additive manufacturing have allowed the development of patient-specific anatomical braces (PSABs) which have the potential to fulfill this purpose. Our specific aims were to develop a model of PSAB, adapted to fracture care, to evaluate if this brace would be well tolerated by healthy volunteers and to determine its mechanical properties as compared with conventional methods of wrist immobilization. Materials and Methods  Several three-dimensional-printed splint prototypes were designed by mechanical engineers based on surgeons' and hand therapists' clinical expertise. These experimental braces underwent testing in a preclinical study involving 10 healthy volunteers, assessing comfort, satisfaction, and activities. The final prototype was mechanically compared with a conventional cast and a prefabricated splint, testing different closing systems. A mathematical algorithm was created to automatically adapt the final PSAB model to the patient's anatomy. Results  The final prototype achieved an overall satisfaction score of 79%, weighing less than 90 g, made from polyamide, and fixed using hook and loop straps. The PSAB stiffness varied between 0.64 and 0.99 Nm/degree, surpassing the performance of both conventional plaster casts and prefabricated splints. Conclusion  The final wrist PSAB model, adapted for fracture treatment, is lightweight, comfortable, and provides anatomical contention. It is currently being tested for the treatment of stable distal radius and scaphoid fractures in comparison to conventional plaster cast.

Surgical Treatment of Scaphoid Fractures: Recommendations for Management

Background: Several operative treatments exist for scaphoid fractures, varying by approach (e.g., ercutaneous, volar, or dorsal), implant type (e.g., screw or Kirschner wire), and bone raft choice (e.g., none, nonvascularized, or vascularized). Many previous systematic eviews and meta-analyses have investigated outcomes following different surgicalÚpproaches, the use of vascularized versus nonvascularized bone graft for scaphoidßracture nonunions, and treatment for specific fracture patterns. However, given the advancements n scaphoid fracture treatment in recent years, there is a need for updated treatment recommendations hat would be beneficial to hand surgeons. Purpose: We present a comprehensive review of the operative treatment of scaphoid fractures based on recent literature and propose a unified treatment algorithm for managing these fractures. Methods: The English-language literature was searched from 2002 to 2023 for high evidence level (e.g., randomized trials), review, and meta-analysis articles with the following search terms: "scaphoid, "u8220"scaphoid" AND "nonunion, " and "scaphoid" AND "malunion. " Each article was creened by the authors to determine the scaphoid fracture scenario addressed and ubsequent treatment recommendations. The findings from article reviews were then rganized by scaphoid fracture types in this manuscript. Results: A total of 95 pertinent articles were ultimately selected and used as the basis for reviewing different scaphoid fracture scenarios. A treatment algorithm was then proposed based on literature review. Conclusion: This summary of the recent literature can guide hand surgeons in addressing scaphoidßractures. Future research in scaphoid fracture treatment, particularly for nonunions, would be most beneficial n the form of systematic review, meta-analysis, or multicenter prospective randomized clinical trials. Level of Evidence: IV.

Fracture Gap Closure and Reduction Are Affected by the Orientation of the Headless Compression Screw

BACKGROUND

We evaluated the impact of a variable-pitch headless screw's angle of insertion relative to the fracture plane on fracture gap closure and reduction.

METHODS

Variable-pitch, fully threaded headless screws were inserted into polyurethane blocks of "normal" bone model density using a custom jig. Separate trials were completed with a 28-mm screw placed perpendicular and oblique/longitudinal to varying fracture planes (0°, 15°, 30°, 45°, and 60°). Fluoroscopic images were taken after each turn during screw insertion and analyzed. Initial screw push-off, residual fracture gap at optimal fracture gap reduction, and malreduction were determined in each trial. Statistical analysis was performed via a 1-way analysis of variance followed by Student t tests.

RESULTS

Malreduction was found to be significantly different between the perpendicular (1.88 mm ± 1.38) and the oblique/longitudinal (0.58 mm ± 0.23) screws. The malreduction increased for the perpendicular screw as the fracture angle increased (60° > 45°=30° > 15° > 0°). Residual fracture gap at optimal fracture gap reduction was also found to be significantly different between the perpendicular (0.97 ± 0.42) and oblique/longitudinal (1.43 ± 1.14) screws. The residual fracture gap increased for the oblique/longitudinal screw as the fracture angle increased, although the oblique/longitudinal screw with a 60° fracture angle was the only configuration significantly larger than all the other configurations. Screw push-off was not found to be significantly different between the oblique/longitudinal screw and perpendicular screw trials.

CONCLUSIONS

The perpendicular screw had a larger malreduction that increased with fracture angle, whereas the oblique/longitudinal screw had a larger residual fracture gap that increased with fracture angle.

AI in Hand Surgery: Assessing Large Language Models in the Classification and Management of Hand Injuries

Background: OpenAI's ChatGPT (San Francisco, CA, USA) and Google's Gemini (Mountain View, CA, USA) are two large language models that show promise in improving and expediting medical decision making in hand surgery. Evaluating the applications of these models within the field of hand surgery is warranted. This study aims to evaluate ChatGPT-4 and Gemini in classifying hand injuries and recommending treatment. Methods: Gemini and ChatGPT were given 68 fictionalized clinical vignettes of hand injuries twice. The models were asked to use a specific classification system and recommend surgical or nonsurgical treatment. Classifications were scored based on correctness. Results were analyzed using descriptive statistics, a paired two-tailed t-test, and sensitivity testing. Results: Gemini, correctly classifying 70.6% hand injuries, demonstrated superior classification ability over ChatGPT (mean score 1.46 vs. 0.87, p-value < 0.001). For management, ChatGPT demonstrated higher sensitivity in recommending surgical intervention compared to Gemini (98.0% vs. 88.8%), but lower specificity (68.4% vs. 94.7%). When compared to ChatGPT, Gemini demonstrated greater response replicability. Conclusions: Large language models like ChatGPT and Gemini show promise in assisting medical decision making, particularly in hand surgery, with Gemini generally outperforming ChatGPT. These findings emphasize the importance of considering the strengths and limitations of different models when integrating them into clinical practice.

Reasons for scaphoid non-union: Analysis of behavior of health care providers and patients

To assess factors related to health-system and patient behavior in scaphoid fracture non-union, a retrospective analysis of 134 patients treated by scaphoid reconstruction was performed. Mean age at the accident was 26 years (range, 9-75 years), and the mean age at surgery was 28 years (range, 13-75 years). Mean time to first consultation was 233 days (range, 0-12,136 days), and time to surgery 740 days (range, 19-12,362 days). The physician was mainly a general practitioner (52.2%), or an orthopedist/traumatologist (17.9%), general surgeon (12.7%), or hand surgeon (17.2%). The initial diagnostic procedure was X-ray in 76.9% of cases, computed tomography (CT) in 20.9%, magnetic resonance imaging (MRI) in 13.4%, and none in 11.2%. A fracture was diagnosed in 32.8% of cases, and non-union in 14.9%. Patients mainly presented late: 63% within 3 weeks, and a minority on the day of the accident (39%). In 11% of cases, healthcare providers performed either no or inadequate imaging (77%) and missed correct diagnosis in 52% of cases. 128 patients had a second consultation, and 77 a third, with the same or different physicians, before surgery, leading to increased healthcare costs due to delayed diagnosis and treatment. Delayed presentation and lack of suspicion by attending physicians were the main reasons. Speeding up diagnosis and improving physician training are vital and could significantly reduce health care costs. CT or MRI should be performed if scaphoid fracture is suspected.

3D printed guide-assisted percutaneous screw fixation for minimally displaced scaphoid waist fractures with delayed diagnosis or presentation

OBJECTIVES

To Investigate the value of 3D printed guide-assisted percutaneous management of minimally displaced scaphoid waist fractures(Herbert's B2) with delayed diagnosis or presentation.

METHODS

From October 2018 to February 2022, 10 patients with established delayed diagnoses and presentation of minimally displaced scaphoid waist fractures were treated with 3D printed guides assisted with percutaneous internal fixation without bone grafting. This technique was based on the patient's preoperative CT and imported into the software. Based on Boolean subtraction, the most centralized screw placement position was identified and a customized guide was produced. Intraoperative percutaneous insertion of the guide wire was assisted by the custom guide.

RESULTS

All 10 patients were successful in one attempt. The fractures healed at a mean of 7.7 weeks postoperatively (range 6-10 weeks). At a mean follow-up of 7.7 months (6-13 months), patients had excellent recovery of wrist function with minimal pain reduction. There were no major postoperative complications and the patients all returned to their previous activities before the injury.

CONCLUSIONS

Percutaneous internal fixation based on 3D printed guides is a safe and effective technique for delayed diagnosis or presentation of patients with minimally displaced fractures of the scaphoid waist. This method allows for easy insertion of screws and avoids multiple attempts.

Clinically Significant Treatment Delay in Pediatric Scaphoid Fractures

PURPOSE

Pediatric scaphoid fractures present to treatment in a delayed manner 8% to 29% of the time. The indications for cast immobilization in this population are not clear. The definition of a clinically important treatment delay is based only on anecdotal reports. Successful treatment with a cast may be more desirable than surgical intervention. However, it remains unclear what clinical and radiographic factors may predict success with casting.

METHODS

A retrospective analysis of all scaphoid fractures treated at a single pediatric hospital was performed to identify fracture characteristics, the presence of cystic change, treatment method, and healing rate. A cut-point analysis was performed to determine the number of days of treatment delay, predictive of casting failure. Kaplan-Meier assessments were performed to determine the differences in time in cast. Characteristics of the delayed group were described and stratified by treatment success or failure.

RESULTS

After review, 254 patients met the inclusion criteria. Cut-point analysis determined that a presentation delay of ≥21 days was associated with failure to unite with casting. The median time in the cast for the acute and delayed groups was not significantly different. The casting union rate of delayed fractures was less than acute fractures (75.0% vs 97.0%).

CONCLUSIONS

Delayed presentation of scaphoid fractures 21 days or more after injury predicts a greater risk of casting failure; however, the union rate remains high with comparable time in cast. Cast immobilization for scaphoid fractures presenting 21 days or more after injury is a reasonable option.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis IV.

Arthroscopic Bone Grafting and Robot-assisted Fixation for Scaphoid Nonunion

OBJECTIVES

Scaphoid nonunion remains a challenging problem to manage with no general consensus on its treatment recommendations. We propose a novel minimally invasive (MIS) technique of arthroscopic bone grafting (ABG) with robot-assisted fixation for the treatment of scaphoid nonunions.

METHODS

Patients with radiographically proven scaphoid nonunion treated by this novel surgical technique were included. Following arthroscopic debridement and iliac crest bone grafting, the scaphoid was fixed percutaneously using either multiple Kirschner (K)-wires or a headless compression screw using a robotic navigation system.

RESULTS

Six male patients with an average age of 29.2 years were enrolled. Four patients had scaphoid waist fractures, and the other two were proximal pole fractures. During wrist arthroscopy, punctate bleeding of the proximal scaphoid fragment was observed in four out of the six patients. Half of the patients were fixed using a headless compression screw and the other half using multiple K-wires. All the guidewires were placed with a single-attempt using the robotic navigation system. Postoperatively, all the scaphoid fractures had complete radiographic union by 16 weeks. At a mean follow-up of 18.3 months, there were significant improvements in wrist range of motion, grip strength, and patient-rated outcomes. No intraoperative or early postoperative complications were encountered in any of our patients.

CONCLUSION

Arthroscopic bone grafting with robot-assisted fixation is a feasible and promising therapeutic option for scaphoid nonunions, regardless of the vascularity of the proximal pole fragment. This novel technique allows for anatomic restoration of the scaphoid alignment and accurate, targeted placement of implants into the scaphoid nonunion site within a single-attempt using a robotic navigation system.

Two Parallel Headless Compression Screws for Scaphoid Fractures: Radiographic Analysis and Preliminary Outcome

BACKGROUND

Despite surgical fixation, the scaphoid nonunion rate remains at 3% to 5%. Recent biomechanical studies have demonstrated increased stability with 2-screw constructs. The objective of our study is to determine the preliminary union rate and anatomic feasibility of 2-screw surgical fixation for scaphoid fractures.

METHODS

This study is a retrospective case series of 25 patients (average age 32 years) with scaphoid fractures treated with 2 parallel headless compression screws (HCS). Postoperative evaluation included Mayo Wrist Score (MWS), range of motion, time to union, and return to activity. Bivariate analysis for gender and Pearson correlation coefficient for body size (height, weight, and body mass index) was conducted against radiographically measured scaphoid width, screw lengths, and the distance between the 2 screws.

RESULTS

All fractures healed with an average time to union of 9.9 weeks (median 7.6 weeks; range: 4.1-28.3). The mean MWS was 93.3 (range: 55-100), with 3 complications (12%), one of which affected the outcome of the surgery. The bivariate analysis demonstrated that the female gender was associated with significantly smaller scaphoid width (P = .004) but a similar distance between the 2 screws (P = .281). The distance between the 2 screws and the body size demonstrated a weak-to-no correlation.

CONCLUSIONS

The 2-screw construct for scaphoid fracture achieved a favorable union rate and clinical outcome. Gender was the only variable significantly associated with scaphoid width and screw length. The distance between the screws was constant regardless of gender and body size, indicating that the technique for parallel screw placement can remain consistent.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

Level IV.

The Outcome of Scaphoid Fracture Nonunion Managed by 1,2 Intercompartmental Supraretinacular Artery (1,2 ICSRA) Vascularized Bone Graft

BACKGROUND

Scaphoid fracture is most often missed and mismanaged leading to scaphoid nonunion with or without avascular necrosis. When avascular necrosis of the proximal pole is confirmed with intraoperative evaluation, conventional bone graft is not enough. The treatment modalities are evolving day by day. The current trend is vascular bone grafting, which has shown good outcomes in terms of union and wrist function.

METHODS

Fifty patients with nonunion fracture of the scaphoid were treated with vascularized pedicle bone graft from the dorsum of the distal radius using the 1st and 2nd intercompartmental supraretinacular artery, from 2014 to 2022. Preoperative and postoperative clinical evaluation included pain, range of motion, grip strength, and satisfaction. The average follow-up period was 12 months.

RESULTS

Among 18 patients, 14 were clinically improved after a mean follow-up period of eight weeks. Thirteen patients reported the absence of any discomfort, three patients reported slight discomfort after hard work, and two patients reported pain with light work. The wrist range of motion improved significantly, and the hand grip strength also improved. According to the modified Mayo wrist scoring chart, clinical results were rated as excellent in 24 cases, good in 19 cases, and poor in four cases.

CONCLUSION

1,2 intercompartmental supraretinacular artery (1,2 ICSRA) is superficial to the extensor retinaculum and is a proper pedicle of vascularized bone graft due to the ease of visibility and dissection. The functional results and union rates were satisfactory in our study.

The Effect of Derotational Kirschner Wires on Fracture Gap Reduction With Variable-Pitch Headless Screws

PURPOSE

We evaluated the impact of angled derotational Kirschner wires (K-wires) on fracture gap reduction with variable-pitch headless screws.

METHODS

Fully threaded variable-pitch headless screws (20 and 28 mm) were inserted into "normal" bone models of polyurethane blocks. In separate trials, derotational K-wires were inserted at predetermined angles of 0°, 15°, 30°, and 40° and compared with each other, with no K-wire as a control. Fluoroscopic images taken after each screw turn were analyzed. The optimal fracture gap closure, initial screw push-off, and screw back-out gap creation were determined and compared at various derotational K-wire angles.

RESULTS

Initial screw push-off due to screw insertion and screw back-out gap creation were not significantly affected by the angle of the derotational K-wire. With a 20-mm screw, only a 40° derotational K-wire led to significantly less gap closure compared with control and with 0°, 15°, and 30° derotational K-wires. It led to an approximately 60% decrease in gap closure compared with no K-wire. With the 28-mm screw, compared with no K-wire, 15° and 30° derotational K-wires led to statistically significant decreases in gap closure (approximately 25%), whereas a 40° derotational K-wire led to an approximately 60% decrease. With the 28-mm screw, the 40° derotational K-wire also led to a statistically significant smaller gap closure when compared with 0°, 15°, and 30° derotational K-wires.

CONCLUSIONS

A derotational K-wire placed in parallel to the planned trajectory of a headless compression screw does not affect fracture gap closure. With greater angulation of the derotational K-wire, the fracture gap is still closed, but less tightly.

CLINICAL RELEVANCE

Derotational K-wires can help prevent fracture fragment rotation during headless compression screw insertion. At small deviations from parallel (≤30°), fracture gap closure achieved by the screw is minimally affected. At greater angles (ie, 40°), fracture gap closure may be substantially reduced, preventing fracture compression.

Evaluation of a convolutional neural network to identify scaphoid fractures on radiographs

This study aimed to develop and evaluate a convolutional neural network for identifying scaphoid fractures on radiographs. A dataset of 1918 wrist radiographs (600 patients) was taken from an orthopaedic referral centre between 2010 to 2020. A YOLOv3 and a MobileNetV3 convolutional neural network were trained for scaphoid detection and fracture classification, respectively. The diagnostic performance of the convolutional neural network was compared with the majority decision of four hand surgeons. The convolutional neural network achieved a sensitivity of 82% and specificity of 94%, with an area under the receiver operating characteristic of 92%, whereas the surgeons achieved a sensitivity of 76% and specificity of 96%. The comparison indicated that the convolutional neural network's performance was similar to the majority vote of surgeons. It further revealed that convolutional neural network could be used in identifying scaphoid fractures on radiographs reliably, and has potential to achieve the expert-level performance.Level of evidence: III.

Clinical and Epidemiological Features of Scaphoid Fracture Nonunion: A Hospital-Based Study in Beijing, China

Objective

Studies exploring the epidemiological characteristics of scaphoid fracture nonunion are important to understand the causes and lead to effective prevention strategy. However, such knowledge is limited especially in China. This study aims to reveal the clinical and epidemiological features of scaphoid fracture nonunion in Chinese patients.

Methods

This was a retrospective study, which was based on patients with scaphoid fracture nonunion treated in a Chinese national orthopedic referral center from 1 August 2009 to 1 August 2020. The basic demographic and clinical characteristics, including gender, age at diagnosis of scaphoid fracture nonunion, dominant hand, the location of fracture, the side, the causes of the injury, age of the injury, age of the treatment for scaphoid fracture nonunion, and the delay period, were retrieved from the medical records. The patients were divided into a non‐delay group and a delay group based on whether they had visited the doctor within 1 month after the injury. Scaphoid fracture was classified into the proximal, waist, and distal fractures according to the location. The t‐test or Mann–Whitney U test was used to compare the difference between groups when the dependent variable is continuous, while a chi‐square test was used when the dependent variable is categorical.

Results

A total of 363 patients were included in this study. The mean age at the diagnosis of scaphoid fracture nonunion was 32 (ranging from 14 to 78). Waist fracture nonunion (76.5%) was most common. Among the 169 patients who sought medical care within 1 month after the injury (non‐delay group), more than half (90 cases) were misdiagnosed. 23 cases could not recall the injury, so the time of delay could not be determined. Among the 171 patients who did not seek medical care for acute injury (delay group), the average time was 52 months between the initial injury and the treatment. The proportion of waist nonunions was higher among patients in the delay group than that in the non‐delay group.

Conclusions

Nonunion of scaphoid fracture is caused mainly by delayed treatment and misdiagnosis in China, suggesting that timely treatment and improved diagnosis could lower the prevalence. The fracture location may be a factor contributing to the delaying of seeking medical care.

Pelvic Avulsion Fractures in Adolescent Athletes: Analyzing the Effect of Delay in Diagnosis

OBJECTIVE

To evaluate whether delay in the diagnosis of pelvic avulsion fractures in young athletes leads to prolonged treatment and prolonged return toward sport activities, whether fractures at certain locations are associated with a greater risk of diagnostic delay, and what reasons may exist for delay in diagnosis.

DESIGN

Retrospective chart review of young patients who presented with pelvic region avulsion fracture to a community-based sports medicine clinic over a 19-year period.

SETTING

Private practice, primary care sports medicine clinic.

PATIENTS

Patients younger than 20 years diagnosed with pelvic region avulsion fracture.

INTERVENTIONS

None, this was a retrospective study.

MAIN OUTCOME MEASURES

Clearance for return toward sport activities.

RESULTS

Two hundred twenty-five cases were reviewed for reasons for delay in diagnosis; 208 cases met criteria for the duration of treatment and return to play activities portions of the study. The mean time from date of injury diagnosis was 19.59 days, and the mean duration from date of injury to clearance for return to play advancement was 67.20 days. Duration of treatment varied slightly depending on timing of diagnosis, whereas duration from date of injury to clearance for return to play advancement varied greatly depending on diagnostic delay. Those who did not sense a "pop" at the time of injury were more likely to experience diagnostic delay, as were athletes with ischial tuberosity fractures. The most common cause of diagnostic delay was patient/family decision on when to seek care; misdiagnosis as a muscle strain was also common.

CONCLUSIONS

Diagnostic delay of adolescent pelvic avulsion fractures may unnecessarily prevent athletes from returning to play within an optimal time frame. Our observations highlight a need for educating athletes and their families on when to seek initial or follow-up medical care as well as educating medical providers regarding the diagnosis of pelvic avulsion fractures.

Assessment of the healing of conservatively-treated scaphoid fractures using HR-pQCT

Improving the clinical outcome of scaphoid fractures may benefit from adequate monitoring of their healing in order to for example identify complications such as scaphoid nonunion at an early stage and to adjust the treatment strategy accordingly. However, quantitative assessment of the healing process is limited with current imaging modalities. In this study, high-resolution peripheral quantitative computed tomography (HR-pQCT) was used for the first time to assess the changes in bone density, microarchitecture, and strength during the healing of conservatively-treated scaphoid fractures. Thirteen patients with a scaphoid fracture (all confirmed on HR-pQCT and eleven on CT) received an HR-pQCT scan at baseline and three, six, twelve, and 26 weeks after first presentation at the emergency department. Bone mineral density (BMD) and trabecular microarchitecture of the scaphoid bone were quantified, and failure load (FL) was estimated using micro-finite element analysis. Longitudinal changes were evaluated with linear mixed-effects models. Data of two patients were excluded due to surgical intervention after the twelve-week follow-up visit. In the eleven fully evaluable patients, the fracture line became more apparent at 3 weeks. At 6 weeks, individual trabeculae at the fracture region became more difficult to identify and distinguish from neighboring trabeculae, and this phenomenon concerned a larger region around the fracture line at 12 weeks. Quantitative assessment showed that BMD and FL were significantly lower than baseline at all follow-up visits with the largest change from baseline at 6 weeks (-13.6% and - 23.7%, respectively). BMD remained unchanged thereafter, while FL increased. Trabecular thickness decreased significantly from baseline at three (-3.9%), six (-6.7%), and twelve (-4.4%) weeks and trabecular number at six (-4.5%), twelve (-7.3%), and 26 (-7.9%) weeks. Trabecular separation was significantly higher than baseline at six (+13.3%), twelve (+19.7%), and 26 (+16.3%) weeks. To conclude, this explorative HR-pQCT study showed a substantial decrease in scaphoid BMD, Tb.Th, and FL during the first 6 weeks of healing of conservatively-treated scaphoid fractures, followed by stabilization or increase in these parameters. At 26 weeks, BMD, trabecular microarchitecture, and FL were not returned to baseline values.

Arthroscopic Management of Intra-articular Ligament Lesions on Distal Radius Fractures

Articular distal radius fractures (DRFs) have increased in incidence in recent years, especially among the economically active population. Most of the treatment approaches are based on plain X- rays, and do not give us any information on how to treat these fractures. In the search for solutions with greater precision in diagnosis, in reducing the joint surface of the fracture, and envolving minimally-invasive techniques, we found arthroscopy as the main tool for these patients. Therefore, an enhanced understanding of the biomechanics of the different types of fracture associated with ligamentous lesions should facilitate the right decision regarding the treatment. The present paper aims at providing a management-oriented concept to diagnose and treat ligamentous lesions associated with intra-articular DRFs based on a arthroscopy-assisted procedure, and showing the objective and patient-reported outcomes and a new classification. The objective and patient-reported outcomes were: the mean range of motion (ROM) was of 94.80% on the non-affected side; the mean score on the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) was of 3.6 (range: 1 to 12). The score on the Visual Analog Scale (VAS) was of 1.66 (range: 1 to 3). Complications were observed in 2 (13.33%) patients: extensor tendon synovitis in 1 patient, and a limitation (stiffness) in ROM in 1 patient, both treated with wrist arthroscopy release. The mean time until the return to work was of 6.4 weeks. In patients with unstable intra-articular DRFs associated with ligamentous lesions, the fixation of specific osseous-ligamentous fragments and ligamentous repair/reconstruction by wrist arthroscopy prove to be a safe and reliable treatment. The clinical and functional results predict that the patients can return to work more quickly.

Early mobilization vs delayed mobilisation following the use of a volar locking plate with non-vascularized bone graft in scaphoid non-union. A multicentred randomised controlled-trial

Purpose

This randomized clinical trial investigated the potential for early mobilization of the wrist following open reduction and internal fixation (ORIF) with a scaphoid specific volar locking plate and non-vascularized bone graft for scaphoid non-union.

Methods

16 patients with scaphoid non-union underwent internal fixation with a scaphoid-specific volar locking plate and iliac crest bone graft and were randomized to one of two treatment arms (A) The control were immobilized in a below elbow cast for 6 weeks (n = 9) and (B) The experimental arm were mobilized early with a removable wrist splint (n = 7). Outcomes were measured preoperatively, and at 3 months post operatively. These included the primary outcome of union, and secondary outcomes of grip strength and patient reported outcomes of disabilities of arm shoulder and hand (DASH) and patient reported wrist evaluation (PRWE). Discrete variables were analyzed using the chi squared test while continuous variables used the students t-test.

Results

The experimental (early mobilization) group developed metalware complications resulting in the early termination of the study. No significant difference in the demographic characteristics of age, gender, time to surgery, smoking status and handedness was found between groups. A significant difference was found in BMI, with significantly higher proportion of obese patients (p = 0.05) in the experimental group. There was no significant difference in the primary outcome measure of the rate of union between groups. The secondary outcomes of grip strength, Dash and PRWE also showed no significant difference between the immobilized and mobilized groups.

Conclusion

We recommend immobilization following scaphoid non-union ORIF using a volar locking plate due to high complication rates in our cohort with early mobilization.Type of study/level of evidence: Therapeutic 2.Trial registration.Australian New Zealand Clinical Trials Registry (ACTRN12614001050640). Date of registration, 02/10/2014.

Streamlining Definitive Care for Occult Scaphoid Fractures: A Retrospective Review of the Workup of Scaphoid Nonunions and Applying Lessons Learned

INTRODUCTION

The process for working up scaphoid fractures from frontline providers to the specialty care clinic is variable. Initial imaging can often be negative and the management algorithm is not clearly defined. Delays in diagnosis are a contributing factor to scaphoid nonunion. Fractures may not be identified by frontline providers on initial presentation because of radiographically occult injuries. If not treated promptly, scaphoid fractures may be complicated by nonunion, avascular necrosis, and osteoarthritis.

MATERIALS AND METHODS

Retrospective review of scaphoid nonunions from 2017 to 2018 in a single tertiary care institution after internal review board approval was obtained (NMCSD.QI.2019.0003). Cases were identified using an ICD 10 search for "scaphoid (navicular) fracture non-union" and subtypes. Charts were examined for time between injury and presentation, injury and diagnosis, initial radiologic workup, and limited duty (LIMDU). Nonparametric statistical analysis for linear and categorical data was conducted using SPSS. A subgroup of patients who had a delay in diagnosis of greater than 30 days upon entering the medical system was further analyzed and identified as the "delayed diagnosis" cohort.

RESULTS

In total, 30 patients with scaphoid nonunion were identified. Overall, 35% of patients had negative initial X-rays and averaged 42.1 days until diagnosis. In total, 100% of patients required at least one LIMDU period, averaging 1.4 periods, for a total of 6,404 days and 16% went on to a physical evaluation board (PEB). In 9 (30%) of these patients, injury was initially not identified upon entering the medical system resulting in average of 139.7 days until diagnosis; this became known as the delayed diagnosis subgroup. Further analysis of the delayed diagnosis subgroup demonstrated significantly more initial negative X-rays (P < .005) at a rate of 77% (7/9). A delay in diagnosis was significantly associated with PEB (R = 0.4, P = .031) with 33% of these patients going on to a PEB.

CONCLUSIONS

Delayed diagnosis of a scaphoid fracture is a contributing factor for excessive light duty, high rates of LIMDU utilization, and ultimately medical separation of service members. Overall, in all patients who had scaphoid nonunions, the average time to diagnosis was 42.1 days with 35% of patients presenting with negative initial imaging. A delayed diagnosis subgroup was identified and notable for a higher rate of initial negative X-rays, an average of 139.7 days until diagnosis, and a 33% PEB rate. In total, 77% of patients with a delay in diagnosis of more than 30 days had an initial negative X-ray. An evidence-based algorithm for diagnosing occult scaphoid fractures may prevent delays in diagnosis, thus increasing the readiness of active duty service members.

Revision surgery after vascularized or non-vascularized scaphoid nonunion repair: A national population study

HYPOTHESIS

We aimed (1) to discover the prevalence of vascularized bone grafting in the treatment of scaphoid nonunion and (2) to compare healing using vascularized bone grafting versus standard non-vascularized techniques. Secondarily, we sought to compare resource utilization between procedures and identify factors that may be associated with nonunion repair failure. We hypothesized that, despite being less common, vascularized bone grafts have greater success than non-vascularized bone grafting surgeries.

METHODS

We performed a large population analysis using the Truven MarketScan databases to identify patients from 2009 to 2017 with a diagnosis of a scaphoid nonunion undergoing repair surgery with and without the insertion of a pedicled or free vascularized bone graft. We defined any subsequent scaphoid or wrist surgery within 12 months after surgery as surgery failure. We compared success rates and post-operative resource utilization using Chi-squared tests.

RESULTS

Of 4177 eligible patients, 358 underwent nonunion repair with vascularized bone graft and 3819 patients received non-vascularized bone grafting. The failure rate requiring revision surgery was 5.0% in vascularized repair, versus 6.1% for non-vascularized surgery. Age and comorbidities did not affect bone graft type. Areas with higher median household incomes had more vascularized repairs. Vascularized bone graft patients received significantly more therapy and imaging after surgery.

CONCLUSIONS

Most scaphoid nonunion repairs are performed without vascularize bone grafting. Typical nonunions may not justify the increased time and technical demands of vascularized bone grafting, and traditional repair should remain first line treatment for scaphoid nonunions without additional risk factors. Further studies to elucidate which fractures benefit most from vascularized grafting are needed.

The role of vascularized flaps in the treatment of proximal pole avascular necrosis in scaphoid non-unions

OBJECTIVES

The purpose of this study is to evaluate the clinical and radiological outcomes of scaphoid non unions surgically treated with bone graft versus medial condyle corticoperiosteal free flaps.

MATERIALS AND METHODS

32 patients were divided in 2 groups. Group A (17 patients 12male, 5 females, mean age 35 years old) treated with bone grafts; Group B (15patients 11 male, 4 females, mean age 33 years old) treated with medial condyle cortico periosteal free flap. A radiological follow up was performed about every 30 days after surgery until the complete healing and at 12-month follow-up. The clinical follow up was performed at 6 and 12 months from surgery. Functional assessment was provided by Mayo wrist score and Visual Analogic Scale (VAS).

RESULTS

The average length of follow up was 12.52 months ± 1.36. In group A 60% of patients healed in 4.4 ± 1months with a reduction of 28.4% of healing times in group B (p<0.05).In Group B all nonunion sites healed primarily at an average time period of 3.2 ± 1 months. Statistical analysis showed a significant difference (p<0.001) about the preoperative and the postoperative VAS and Mayo Wrist Score evaluation in both groups at 6 and 12-month follow-up, moreover we recorded a statistical difference between groups at the 6-month and 12-month follow-up (p<0.05).

CONCLUSION

The present study showed that the free flaps showed better clinical and radiographic results for the surgical treatment of scaphoid nonunions. In fact, despite the good results of the bone graft, the flaps seems to be preferable in the treatment of these nonunions.

The Role of Cone-Beam Computed Tomography (CBCT) Scan for Detection and Follow-Up of Traumatic Wrist Pathologies

Emergency diagnostics demand fast, easily available, and cost-effective procedures. The higher the accuracy of radiological imaging, the better it supports the surgeon in decision-making for further treatment. Cone-beam computed tomography has been proven to be a reliable tool in diagnosing fractures of the hand and distal forearm. It can be easily installed, has a high spatial resolution, and a potentially lower radiation dose when compared with multislice computed tomography or a series of plain x-rays. This review focuses on the value of conventional radiography, cone-beam computed tomography, and multislice computed tomography for diagnosing traumatic wrist pathologies.

Managing the Athlete with a Scaphoid Fracture

Most minimally displaced scaphoid fractures and all displaced scaphoid fractures in elite athletes are treated with early fixation to maximally expedite the return to full function. Computed tomographic (CT) scans are recommended in all scaphoid fractures to facilitate a complete understanding of fracture anatomy and to allow for optimal screw placement. Screw placement is important to maximize healing capacity of the fracture and allow for return to sport. Postoperative CT scans can be helpful to evaluate the extent of healing and may allow patients to return to play sooner.

Diagnosis and Management of Acute Scaphoid Fractures

The scaphoid is the most commonly fractured carpal bone; despite its frequent injury, the diagnosis of fracture can be complicated by the presence of normal radiographs at the time of presentation. Clinical intuition can be increased by physical examination and immediately available modalities such as ultrasound within the emergency department. Definitive diagnosis should be made with computed tomography and magnetic resonance to verify the presence of displacement. This article provides an overview of the incidence and presentation of acute scaphoid fractures with a surgical focus on percutaneous dorsal screw fixation.

Primary medial femoral condyle vascularized bone graft for scaphoid nonunions with carpal collapse and proximal pole avascular necrosis

This study aimed to determine the outcome of free vascularized medial femoral condyle bone grafts in the primary treatment of scaphoid nonunions with scaphoid foreshortening or carpal collapse and intraoperatively documented avascular necrosis. Thirty-two patients (28 male, four female) met the inclusion criteria. Median time from injury to surgery was 70 weeks. Thirty of 32 patients healed at a median of 12 weeks. There was significant improvement from preoperative to postoperative lateral intrascaphoid angle, scapholunate angle, and radiolunate angle. Two scaphoids failed to unite; one patient underwent scaphoidectomy and four-corner fusion 15 months postoperatively after suffering a subsequent injury. Another patient underwent 1,2-intercompartmental supraretinacular artery-based vascularized bone grafting at 4 months postoperatively and then scaphoid excision with four-corner fusion 4 years later. The free vascularized medial femoral condyle bone graft restores scaphoid vascularity and architecture while promoting union in a subset of scaphoid nonunions that has historically been a clinical challenge. Level of evidence: IV.

Scaphoid specific volar locking plate and non-vascularised iliac crest bone graft in scaphoid non-union. A comparative cohort study

Scaphoid non-union develops in 10% of scaphoid fractures. There is sparse literature on fixation methods other than screws. We compared union rates following fixation of scaphoid non-union using screw fixation and a novel method of plate fixation. Retrospective study. Union rates were assessed at 3 months post-operatively by a musculoskeletal radiologist. 15 patients underwent screw fixation and 15 underwent plate fixation. 86% union rate with screw fixation and 72% plate fixation united. There was no significant difference. Screw fixation and plate fixation in our institution both provide union rates that are consistent with the literature.

Factors associated with union time of acute middle-third scaphoid fractures: an observational study

Background

The aim of this study was to investigate the union time of acute middle-third scaphoid fractures following treatments and to analyze the effect of different factors on late union.

Patients and methods

We retrospectively reviewed patients with acute middle-third scaphoid fracture at our institution between January 2013 and December 2017. Patient demographics, fracture characteristics, and treatment strategy, such as age, gender, body mass index, habit of smoking, sides of injury, dominant hand, ulnar variance, multiple fractures, and treatment methods, were investigated. Univariate and multivariate analyses were used to identify possible predictive factors.

Results

A total of 132 patients with scaphoid fracture were included in our study. Operation was performed in 67 patients (50.8%), and conservative treatment was performed in the other 65 patients (49.2%). The union time was 7.2±0.5 weeks. In the multivariate logistic regression analysis, late diagnosis (odds ratio, 1.247; 95% CI, 1.022–1.521) and conservative treatment method (odds ratio, 1.615; 95% CI, 1.031–2.528) were identified as 2 independent predictors of late union in scaphoid fractures patients. Other parameters were not demonstrated to be predictive factors.

Conclusion

Late diagnosis and conservative treatment were two factors associated with late union. Long time of follow-up is necessary for patient with these factors.

Percutaneous treatment for waist and proximal pole scaphoid fractures

Objective

Analyze the percutaneous fixation technique for scaphoid fractures in the waist of the scaphoid and the proximal pole, and demonstrate its result.

Methods

A retrospective cross-cohort study conducted from January 2005 to April 2015, aiming at the consolidation time, epidemiological profile, level of function, return to work, and complications.

Results

Twenty-eight patients were selected, with a mean of eight weeks of follow-up. They presented a mean age of 30.5 years, male prevalence (25 patients; 89.2%), and no differences between dominant and non-dominant sides. The mean time from diagnosis was 4.16 weeks, but in three cases of fibrous union, the pre-operative period was over one year. The most frequent mechanism of injury was a fall on the outstretched hand, in 22 cases (78.5%). Of all fractures, 24 cases were in the waist (85.8%) and four were of the proximal pole (14.2%); seven patients had displacement (25%). There was consolidation in 26 cases (92.8%) with a mean of 7.5 weeks after surgery. In cases of non-union, radiological follow-up was up to 24 weeks, requiring a new surgical intervention.

Conclusions

Percutaneous fixation is an excellent, reproducible technique that allows early active mobility of the wrist with a low complication rate, although it requires a learning curve.

Management of Scaphoid Fractures

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the epidemiology, classification, and anatomy pertinent to the scaphoid. 2. Appropriately evaluate a patient with suspected scaphoid fracture, including appropriate imaging. 3. Understand the indications for operative treatment of scaphoid fractures, and be familiar with the various surgical approaches. 4. Describe the treatment options for scaphoid nonunion and avascular necrosis of the proximal pole.

SUMMARY

The goal of this continuing medical education module is to present the preoperative assessment and the formation and execution of a surgical treatment plan for acute fractures of the scaphoid. In addition, secondary surgical options for treatment of scaphoid nonunion and avascular necrosis are discussed.

Novel Treatment of a Scapholunate Ligament Injury with Proximal Pole Scaphoid Nonunion

BACKGROUND

Nonunion of scaphoid proximal pole fractures presents a challenging management dilemma to hand surgeons. This problem is further complicated in the uncommon concurrence of scapholunate (SL) ligament disruption.

CASE DESCRIPTION

A 39-year-old male patient presented with new-onset wrist pain following a remote history of a proximal pole scaphoid fracture sustained as a teenager, which was treated nonoperatively. Six months before presentation, the patient sustained a fall while snowboarding. The patient was found to have a chronic nonunion of his scaphoid proximal pole with an associated SL ligament disruption. As the proximal fragment was too small to be amenable to fixation, the patient was treated with an arthroscopic partial scaphoid excision and SL ligament reconstruction using a scapholunateintercarpal screw placed percutaneously. At 26 months, the patient exhibited no pain, near-normal strength, and wrist motion, and expressed a high-level of satisfaction from his surgery.

LITERATURE REVIEW

Although cases of SL ligament disruption with concomitant proximal scaphoid fractures have been reported, to our knowledge, this is the first report of SL ligament rupture occurring in the setting of a preexisting proximal pole scaphoid nonunion.

CLINICAL RELEVANCE

We report the use of SL ligament reconstruction augmented with intercarpal screw fixation, and excision of the proximal pole scaphoid nonunion. This minimallyinvasive approach may be a particularly useful option in young, active patients such as our own, where a motion-sacrificing salvage procedure would be less than ideal.

Factors Associated with Patient Delay in Scaphoid Nonunions

Delay in seeking medical attention by patients, ─so-called patient delay, contributes to the relative high rate of delayed diagnosis and treatment in scaphoid nonunion cases. In this retrospective study we investigated the incidence of patients with a patient delay exceeding 6 months, thus by definition having an established nonunion. In addition to this, we investigated demographic, injury and patient related factors associated with this patient delay in scaphoid nonunion patients. We included 101 patients with established scaphoid nonunions treated surgically at our specialized hand surgery unit. Information regarding demographic and injury characteristics, and subjective patient related factors was obtained from medical records and a questionnaire-based survey. Sixty-four patients (63 %) responded to our survey. A quarter (25 %) of the patients showed a delay of more than 6 months. Demographic and injury characteristics were not related to this delay. In contrast to this, not attributing post-injury symptoms to a fracture but to e.g. a sprain instead, showed to be an independent predictor of patient delay. We report a high incidence of patients with an established scaphoid nonunion who delayed seeking medical attention. As there appears to be no demographic or injury characteristics associated with this patient delay, future developments of strategies to reduce patient delay should be targeted on all patients with a suspected scaphoid injury.

The Missed Scaphoid Fracture-Outcomes of Delayed Cast Treatment

Background The purpose of this study is to evaluate outcomes (report union rates and times based on CT) for subacute scaphoid fractures, defined as those presenting between 6 weeks and 6 months from injury. Questions 1) What are the expected union rates for subacute scaphoid fractures? 2) What are the expected union times for subacute scaphoid fractures? 3) Is it worth trialing a period of cast immobilization for these patients? Methods All isolated sub-acute scaphoid fractures that presented at our institution between 2006 and 2010 were identified. Each subject's health record, CT scans and X-rays were retrospectively reviewed. Results There were 20 males and 8 females, with a mean age of 30, treated with casting alone. There were 20 waist, 7 proximal and 1 distal pole fracture. The mean casting time was 11 (waist) and 14 (proximal pole) weeks with a union rate of 82% (23/28). Diabetes, comminution and a humpback deformity increased the non-union risk in this cohort. Exclusion of these cases resulted in a 96% union rate (23/24). Conclusion Subacute scaphoid fractures (presenting within 6 months from injury) can be expected to successfully heal with casting alone, even if the initial diagnosis is delayed. The expected time frame for union with cast treatment is shorter than previously reported. Level of Evidence IV.

Treatment of Scaphoid Waist Nonunion Using Olecranon Bone Graft and Stryker Asnis Micro Cannulated Screw: A Retrospective Study-80 Case Studies and 6 Years of Follow-Up

Background Screw fixation and bone grafting are the gold standard for scaphoid waist nonunion without avascular necrosis. Question/Purpose Assesses the scaphoid waist nonunion healing rate with use of an uncommon cancellous bone graft (olecranon) and an unusual fixation system (Asnis Micro Cannulated Screw System; Stryker Inc., Kalamazoo, MI, USA). Material and Methods A series of 102 consecutive patients were treated for scaphoid waist nonunion (without deformity). Of these, 80 patients subjected to clinical (Modified Mayo Wrist Score (MMWS), Jamar hydraulic dynamometer) and radiographic examination before and after surgery were evaluated. Ipsilateral olecranon cancellous bone graft and the ASNIS Micro 3.0-mm diameter screw, were used. The average follow up was 6 years (min 3; max 10). Results Radiographic consolidation was achieved in 90% of patients; dorsal intercalated segment instability (DISI) deformities were corrected in 71.4% of cases. Ninety percent improved the range of motion of the wrist and grip strength. All patients showed a significant reduction of peak force in the operated hand. In 6.25% we observed clinical and radiographic screw head-trapezium impingement. Twenty-six patients developed a degenerative wrist sign. The MMWS yielded 68 optimal, 8 good, and 4 bad results. Conclusions To treat scaphoid waist nonunions without misalignment, low-profile headed screw and olecranon bone graft allowed a high consolidation rate with positive results to long-term follow-up. The Asnis Micro 3.0 mm diameter screw may be a suitable option for treating scaphoid waist nonunion. Level of Evidence IV.

Low-intensity pulsed ultrasound for treating delayed union scaphoid fractures: case series

Background

The standard treatment to enhance fracture healing of scaphoid nonunions is surgery. Low-intensity pulsed ultrasound (LIPUS) is gaining in popularity as an alternative treatment to improve fracture healing; however, little is known about success rates of this treatment in scaphoid-delayed unions. The purpose of our study is to define the success rate of LIPUS treatment for delayed union of scaphoid fractures and further analyze whether initial management or fracture type influences success rate.

Methods

During the period of 2011–2013, in the central orthopedic clinic of our institution, patients diagnosed with delayed union of the scaphoid were offered with LIPUS treatment as an alternative to conventional surgical treatment. These patients were then divided into subgroups according to the time elapsed from initial injury until diagnosis of the fracture.

Results

Overall, 22 of 29 (76 %) fractures healed, 12 of 13 (92 %) of the early diagnosed group, and 10 of 16 (63 %) of the late diagnosed group. Difference in healing rate between proximal pole, waist, and distal pole fractures was not statistically significant.

Conclusion

LIPUS can help heal delayed union scaphoid fractures, especially in fractures diagnosed and treated soon after injury and may serve as an alternative to surgical treatment.

Management of scaphoid fractures in the athlete: open and percutaneous fixation

Scaphoid fractures occur commonly in the athlete and should be treated with urgency to avoid undesired late complications. Magnetic resonance imaging may be helpful to make a prompt diagnosis so that an appropriate early treatment plan can be initiated. Cast immobilization in acute, nondisplaced scaphoid fractures seems to have an equivalent union rate to surgical modalities. Despite this, limiting the immobilization and time to union period in the athlete will allow earlier restoration of preinjury level function and eventual return to play. Percutaneous techniques with or without arthroscopy assistance have been advocated as less invasive surgical approaches that may have an added benefit in the athlete. Displaced and unstable fractures should be approached with a volar or dorsal open technique to achieve and confirm an anatomic reduction before screw placement.

Suture anchor fixation for scaphoid nonunions with small proximal fragments: report of 11 cases

PURPOSE

To describe the use of 2 suture anchors as the fixation devices in the management of 11 patients with scaphoid proximal pole nonunions with small proximal fragments.

METHODS

In a prospective study, 11 patients with proximal pole scaphoid nonunions (10 with small proximal fragments and 1 with an oblique nonunion line) were evaluated before surgery by standard wrist x-rays and functional wrist scores including a visual analog scale (VAS), Mayo wrist score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH). The nonunion site was fixed with 2 suture anchors supplemented with autologous cancellous bone graft. Postoperative evaluations consisting of functional wrist scores and evaluation of radiological union were performed 9 months after surgery.

RESULTS

At the end of the study, we observed union in 10 of the 11 patients. The QuickDASH and VAS scores showed significant improvement, and 10 patients had satisfactory Mayo scores.

CONCLUSIONS

We propose the technique of suture anchor fixation for cases of proximal scaphoid nonunion in which secure internal fixation with common techniques is challenging because of the small size of the proximal fragment and the obliquity of the nonunion site.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement to assess reporting of observational trials in hand surgery

PURPOSE

To use the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist to critically evaluate the change in quality of observational trial reporting in the Journal of Hand Surgery American between 2005 and 2011.

METHODS

A cross-sectional analysis of observational studies published in the Journal of Hand Surgery American was designed to sample 2 6-month periods of publication (March 2005 to August 2005 and June 2011 to November 2011). Fifty-one items were extracted from the STROBE statement for evaluation. Overall STROBE compliance rates for articles and specific checklist items were determined. Final compliance percentages from each period were compared by Student t-testing. Changes in item compliance over time were quantified.

RESULTS

Overall compliance with the STROBE statement was 38% (range, 10%-54%) in 2005 and 58% (range, 39%-85%) for 2011 manuscripts representing a significant improvement. Seventy-five percent or greater of articles (2005/2011) provided the explicit reporting of background (100%/97%), follow-up time (85%/94%), overall interpretation of data (100%/94%), and results of similar studies (95%/89%). Twenty-five percent or less of articles provided the study design in the abstract (10%/20%), a clear description of the study's setting (10%/23%), the handling of missing data (0%/6%), the potential directions of bias (5%/11%), and the use of a power analysis (0%/17%). Eighty-six percent (44/51) of items were more frequently satisfied in 2011 articles than in 2005 publications. Absolute increases in compliance rates of 40% or greater were noted in 10 items (20%) with no worsening in compliance for an individual item over 6%.

CONCLUSIONS

The overall quality of the reporting of observational trials in the Journal of Hand Surgery American improved from 2005 to 2011. Current observational trials in hand surgery could still benefit from increased reporting of methodological details including the use of power analyses, the handling of missing data, and consideration of potential bias.

LEVEL OF EVIDENCE

Diagnostic III.

[New tendencies in hand surgery]

The author summarizes the new therapeutic tendencies in hand surgery at the past one and a half decade. He discusses the development of hand surgery, as an independent field, in a form of a short historical summary, then he reviews in detail new therapeutic methods considered important such as rehabilitation procedures after tendon injuries, present position of complete hand transplantation, new operations of regeneration of the injured skin and repair of nerve damages, as well as the conservative therapeutic options of Dupuytren's disease. Finally he outlines the modified, new operative procedures in bone and joint injuries of the hand. He concludes that constant development of hand surgical knowledge will likely result in further novel therapeutic methods.

A comparison of the rates of union after cancellous iliac crest bone graft and Kirschner-wire fixation in the treatment of stable and unstable scaphoid nonunion

This study was performed to determine whether pure cancellous bone graft and Kirschner (K-) wire fixation were sufficient to achieve bony union and restore alignment in scaphoid nonunion. A total of 65 patients who underwent cancellous bone graft and K-wire fixation were included in this study. The series included 61 men and four women with a mean age of 34 years (15 to 72) and mean delay to surgery of 28.7 months (3 to 240). The patients were divided into an unstable group (A) and stable group (B) depending on the pre-operative radiographs. Unstable nonunion was defined as a lateral intrascaphoid angle > 45°, or a radiolunate angle > 10°. There were 34 cases in group A and 31 cases in group B. Bony union was achieved in 30 patients (88.2%) in group A, and in 26 (83.9%) in group B (p = 0.439). Comparison of the post-operative radiographs between the two groups showed no significant differences in lateral intrascaphoid angle (p = 0.657) and scaphoid length (p = 0.670) and height (p = 0.193). The radiolunate angle was significantly different (p = 0.020) but the mean value in both groups was < 10°. Comparison of the dorsiflexion and palmar flexion of movement of the wrist and the mean Mayo wrist score at the final clinical visit in each group showed no significant difference (p = 0.190, p = 0.587 and p = 0.265, respectively). Cancellous bone graft and K-wire fixation were effective in the treatment of stable and unstable scaphoid nonunion.

Cite this article: Bone Joint J 2013;95-B:809–14.

Use of computed tomography to predict union and time to union in acute scaphoid fractures treated nonoperatively

PURPOSE

To use computed tomography to determine whether factors could be identified to predict union for acute scaphoid fractures treated nonoperatively.

METHODS

We used a radiology database at a tertiary care center to identify scaphoid computed tomography scans performed between 2004 and 2010. We noted fracture location, fracture orientation, translation between fragments, humpback deformity, comminution, cysts, and sclerosis. We determined the associations between imaging variables on union rates and time to achieve union with casting alone in a cohort of 219 patients (mean age, 31 y; 83% males).

RESULTS

Most fractures were scaphoid waist fractures (173 of 219; 79%), of which 178 (81% of total group) were nondisplaced. There were 28 proximal pole fractures (13%) and 18 distal pole fractures (8%). The overall union rate was 95% (207 of 219). The odds of developing a nonunion were increased in fractures with translation (odds ratio, 3.4) or with a humpback deformity (odds ratio, 6.9). The presence of sclerosis or cysts did not correlate with union rates. There was no statistical association between successful union and fracture location, although, given the small number of proximal pole fractures, we were underpowered for this finding. Time to union was longer for proximal pole fractures (113 d) versus distal pole (53 d) and waist fractures (65 d) and for fractures with sclerosis (166 vs 67 d) or comminution (103 vs 66 d).

CONCLUSIONS

We were able to identify a number of features that contributed to risk of nonunion or delayed union based on computed tomography scan. Factors such as fracture translation, comminution, and humpback were related to a higher risk of scaphoid nonunion. Factors such as sclerosis, comminution, translation, and location in the proximal pole were associated with longer times to union. These variables were independently significant in increasing the time required to achieve union and were shown to have an overall additive effect.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Ilizarov treatment of scaphoid nonunion

INTRODUCTION

This is single centre retrospective review of a consecutive series of patients with scaphoid nonunion (SNU) treated using the Ilizarov technique without bone graft. Fifteen of the original 18 patients were available for clinical and radiological examination at a minimum follow-up of 5 years (range 5-10 years). An evaluation was made of the late functional results, satisfaction scores, residual symptoms, grip strength and the presence of radiocarpal and scaphoid degenerative changes.

METHODS

The series consisted of 15 patients; 14 males; 1 female, with a mean SNU duration of 15.7 months, and a mean age of 23.6 years. Patients with carpal instability, humpback deformity, carpal collapse, avascular necrosis or marked degenerative change, were excluded from this treatment method. Following frame application the treatment consisted of three stages: distraction, compression and immobilisation. The technique is detailed herein.

RESULTS

Radiographic (CT) and clinical bony union was achieved in all 15 patients after a mean of 88 days (70-130 days). Mean modified Mayo wrist scores initially improved from 21 preoperatively to 86 at previous review, and were 96 at a mean follow-up of 81 months (62-120 months), with excellent results in 10, and good results seen in 5 patients. At latest review the mean grip strengths had returned to 96% of the uninjured hand, and 7 patients had regained full strength; mean wrist flexion/extension arc of motion had also continued to improve to 136° from 131°. All patients returned to their pre-injury occupations and levels of activity at a mean of 117 days. Three patients suffered superficial K-wire infections, which resolved with oral antibiotics. One patient continues to suffer intermittent mild aching in the wrist. No patient suffered loss of scaphoid height, humpback deformity, DISI instability or collapse of the regenerate bone.

CONCLUSION

In these selected patients this technique safely achieved bony union without the need to open the SNU site and without the need for bone graft. These patients also had the capacity to continually improve their wrist function beyond 3 years following their treatment.

Nonunion of the scaphoid distal pole

This study was undertaken to determine the incidence of and assess factors affecting nonunion of scaphoid distal pole fractures. A total of 193 established scaphoid nonunions were treated in our clinics between the years 1999 and 2004; of which, eight cases involved the distal pole of the scaphoid. These were further analyzed to determine factors that may have contributed to the development of nonunion. This study reveals that distal pole nonunions account for 4.1% of all scaphoid nonunions. We found inadequate initial treatment to be the cause for nonunion in 63% of patients. Type IIC fracture pattern according to Posser's classification was seen in 100% of patients and a persistent Dorsal Intercalated Segmental Instability (DISI) pattern in 100% patients. In addition, 100% of fractures occurred at the watershed zone between the two vascular networks of the scaphoid. We believe the key features leading to the likelihood of nonunion at the distal pole include a Type IIC fracture pattern associated with a continued deforming force that eventually leads to a DISI deformity. The watershed area between the proximal vascular network supplying the waist and the distal one supplying the distal pole is especially vulnerable to poor healing.

The scaphoid

The scaphoid is vitally important for the proper mechanics of wrist function. Its unique morphology from its boat like shape to its retrograde blood supply can present with challenges in the presence of a fracture. Almost completely covered with articular cartilage, this creates precise surface loading demands and intolerance to bony remodeling. Fracture location compounds risk of malunion and non-union. Scaphoid fractures may significantly impair wrist function and activities of daily living, with both individual and economic consequences.