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

The role of surgical timing in 124 scaphoid nonunion surgical procedures

A total of 124 scaphoid nonunion surgical procedures performed between 2002 and 2020 were analyzed to investigate the potential impact of delayed diagnosis on time to union. The primary outcome was the correlation between the time from injury to surgery and the time to union. Secondary outcomes included identifying risk factors for delayed union and persistent nonunion following scaphoid nonunion surgery. The analysis revealed that time to union was similar for surgeries performed between 6 months and over 2 years post-injury. However, nonunion persisted in 12 cases, five of which involved surgeries conducted more than 2 years after the injury. Further investigation into secondary outcomes showed that fractures in the proximal third of the scaphoid took 1.4-1.5 times longer to unite compared to fractures in the middle and distal thirds. Additionally, fractures without trabecular bone required approximately twice as long to heal. In conclusion, surgical intervention performed between 6 months and over 2 years after injury generally offers a favorable outcome for healing. However, when surgery is delayed beyond 2 years, the risk of persistent nonunion increases.

Treatment Options, Return to Play, and Functional Performance after Operatively and Non-operatively Managed Acute Scaphoid Fractures

PURPOSE OF REVIEW

Scaphoid fractures are commonly encountered injuries in the athletic population. Conservative management is pursued for incomplete fractures and those involving the distal pole. Operative management is indicated for displaced fractures, unstable fractures, and those involving the proximal pole. Complete non-displaced scaphoid waist fractures can be treated operatively or non-operatively based on patient and surgeon preference. The purpose of this article is to discuss the treatment, rehabilitation, and return to play guidelines for scaphoid injuries.

RECENT FINDINGS

CT scan is critically important to determine fracture displacement (which influences treatment choices) and healing (which influences return to activity determination). Nondisplaced scaphoid waist fractures can be treated with casting with 99.4% healing rate. Surgical treatment can hasten return to activities; newer surgical constructs have been suggested including dual screw fixation, plating, and staples. Outcomes of scaphoid fractures are generally favorable, as long as the selected treatment achieves a united, well-aligned scaphoid. In the athletic population specifically, there are high return to play rates and functional performances seen after these injuries. Each athlete is unique with regard to chosen sport, level of play, fracture type, and timing of the injury. Treatment options and return-to-play must be determined in a case-by-case manner to ensure an optimal clinical outcome.

Inter- and Intraobserver Reliability for the Computed Tomography Scan Assessment of Union After Surgery for Scaphoid Fractures and Nonunion

Purpose

Assessment of scaphoid union after operative treatment might be associated with uncertainty, disagreement, and misinterpretation. Union is defined as consolidation on three of four X-ray views. Computed tomography (CT) scans are increasingly used to evaluate union of scaphoid fractures and nonunion. It allows multiplanar assessment of the scaphoid. Reliability in CT scan assessment of union after operative intervention is limited. We hypothesized that inter- and intraobserver reliability of the CT scan assessment of union after operative treatment for scaphoid fracture and nonunion are substantial and better in fracture cases.

Methods

An institutional search identified 230 patients with operative intervention. According to the sample size, we randomly selected 60 patients (30 fractures and 30 nonunion), with age above 18 years and CT scans 6-26 weeks after surgery, when uncertainty about healing status is most pronounced. Three observers evaluated the CT scans on two occasions 6 weeks apart. Observers classified the scaphoid into two categories: No/partial/full union and >/<50% union.

Results

Interrater agreement in no/partial/full union was overall substantial, substantial in fractures, and moderate for nonunion cases. Interobserver agreement for >/<50% union was overall moderate and moderate for both fractures and nonunion groups. The interrater agreement of no/partial/full union with CT scans ≥12 weeks after surgery was substantial versus fair for the cases below. Intrarater agreement was overall better in cases with CT scans ≥12 weeks postoperative versus earlier.

Conclusions

CT scans show substantial agreement in the assessment of no/partial/full union after operative intervention, although the presence of metal artifacts and bone grafts potentially impair visibility among observers. The agreement was better in scaphoid fractures. CT scan assessment of >/<50% union is with overall moderate agreement. Inter- and intrarater agreement is improved when CT scans are taken 12 weeks or later after operative treatment, blinded to the clinical information.

Level of Evidence

Diagnostic, III.

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.

A review of scaphoid fracture, treatment outcomes, and consequences

PURPOSE

Scaphoid fractures are the most common carpal fracture and can lead to severe complications like carpal collapse and osteoarthritis. This study reviewed scaphoid fracture patterns, outcomes, and consequences in conservative and surgical management.

METHODS

Sixty-four patients with scaphoid fracture who attended the hand clinic at King Hussein Medical City from January 2022 to December 2022 were included and reviewed regarding the anatomical fracture site, the associated injury, the treatment modality (conservative versus surgical), the healing time, and fracture sequelae such as nonunion and scaphoid nonunion advanced collapse.

RESULTS

Most patients were males (62 patients, 96.9%), and most (47, 73.4%) fell within 25 to 40 years. Scaphoid waist fracture was the most common location (40, 52.5%). Most patients (47, 73.4%) received conservative treatment and 17 (26.6%) were fixed acutely. However, nonunion complicated 53 fractures (82.8%). Notably, there were no differences in the union rate or time between cases of scaphoid nonunion treated with vascularized or nonvascularized grafts. Furthermore, there were no variations in union rates among genders, extremities, age, fracture locations, or among smokers. However, a higher union rate was noted in office workers and those who received conservative treatment.

CONCLUSION

Nonunions were higher in our study than in the literature, as our department is a referral center for established nonunion cases. For conservative treatment, we recommend aggressive management and follow-up with a clinical and CT scan at three months and early referral of non-united fractures to the hand clinic to avoid the advanced collapse of the scaphoid.

Principles and Evaluation of Bony Unions

Nonunion is a common and costly problem. Unfortunately, there is no widely agreed upon and standardized definition for nonunion. The evaluation of bony union should start with a thorough history and physical examination. The clinician should consider patient-dependent as well as patient-independent characteristics that may influence the rate of healing and evaluate the patient for physical examination findings suggestive of bony union and infection. Radiographs and clinical examination can help confirm a diagnosis of union. When the diagnosis is in doubt, however, advanced imaging modalities as well as laboratory studies can help a surgeon determine when further intervention is necessary.

The corticocancellous press fit iliac crest bone dowel for recalcitrant scaphoid nonunion: analysis of union rate and clinical outcome

INTRODUCTION

Scaphoid nonunion after failed primary treatment remains challenging particularly when entailed by bone loss, avascular necrosis or deformity. We describe a scaphoid augmentation and fixation technique for cases of recalcitrant nonunion after screw placement by autologous press fit corticocancellous dowel. This study aims to provide reliable data on clinical and radiological outcomes and to contextualize in the face of other treatment options.

MATERIAL AND METHODS

The study included 16 patients with recalcitrant nonunion of the scaphoid. All patients received screw removal and scaphoid reconstruction by a dowel shaped non-vascularized corticocancellous bone graft from the iliac crest facilitating packing of the screw channel. Bone union, the scapholunate, radiolunate and intrascaphoidal angles were evaluated on X-ray and CT images, range of motion noted. Additionally grip strength, DASH and Green O'Brien scores were obtained from eight patients.

RESULTS

A union rate of 73% was noted after mean follow-up of 54 months. After revisional reconstruction of the scaphoid an extension-flexion rate of 84% of the healthy side was noted while pronation-supination reached 101%. DASH score averaged at 2.9, rest pain on a numeric rating scale was 0.43 with 99% peak grip force of the healthy side.

CONCLUSION

In complex cases of revisional scaphoid nonunion after screw placement, the corticocancellous iliac crest pressfit dowel is an option for augmentation and stabilization of the scaphoid by preserving the articular surface.

LEVEL OF EVIDENCE

IV, retrospective case series.

Scaphoid and Carpal Bone Fracture: The Difficult Cases and Approach to Management

Scaphoid and carpal bone fractures are challenging injuries to manage and have significant functional implications. Prompt diagnosis is important and relies on systematic evaluation via history, examination, and imaging. Cross-sectional imaging is often helpful for diagnosis and treatment planning. Treatment for nondisplaced fractures is often closed but these injuries typically require prolonged immobilization and may still result in nonunion or avascular necrosis. Displaced carpal bone fractures, and those associated with carpal instability, typically require open reduction internal fixation.

Update to Management of Acute Scaphoid Fractures

The scaphoid is the most commonly fractured carpal bone. With high clinical suspicion and negative radiographs, expedient evaluation by CT or MRI has been recommended. When treating nondisplaced or minimally displaced scaphoid waist and distal pole fractures, immobilization below the elbow without inclusion of the thumb is an option. Comparatively, early surgical intervention for nondisplaced or minimally displaced scaphoid waist fractures allows for quicker return of function, but with increased risk of surgical complications and no long-term outcomes differences compared with cast immobilization. For most patients with such fractures, consideration for aggressive conservative treatment involving 6 weeks of immobilization with CT assessment to guide the need for continued casting, surgical intervention, or mobilization is advocated. Determination of union is best done with a CT scan at 6 weeks and at least 50% continuous trabecular bridging across the fracture site deemed sufficient to begin mobilization. Nonsurgical and surgical management of scaphoid fractures requires a thorough understanding of fracture location, fracture characteristics, and patient-specific factors to provide the best healing opportunity of this notoriously difficult fracture and return the patient to full function.

Arthroscopic versus open cancellous bone grafting for scaphoid delayed/nonunion in adults (SCOPE-OUT): study protocol for a randomized clinical trial

BACKGROUND

Scaphoid non-union results in pain and decreased hand function. Untreated, almost all cases develop degenerative changes. Despite advances in surgical techniques, the treatment is challenging and often results in a long period with a supportive bandage until the union is established. Open, corticocancellous (CC) or cancellous (C) graft reconstruction and internal fixation are often preferred. Arthroscopic assisted reconstruction with C chips and internal fixation provides minimal trauma to the ligament structures, joint capsule, and extrinsic vascularization with similar union rates. Correction of deformity after operative treatment is debated with some studies favouring CC, and others found no difference. No studies have compared time to union and functional outcomes in arthroscopic vs. open C graft reconstruction. We hypothesize that arthroscopic assisted C chips graft reconstruction of scaphoid delayed/non-union provides faster time to union, by at least a mean 3 weeks difference.

METHODS

Single site, prospective, observer-blinded randomized controlled trial. Eighty-eight patients aged 18-68 years with scaphoid delayed/non-union will be randomized, 1:1, to either open iliac crest C graft reconstruction or arthroscopic assisted distal radius C chips graft reconstruction. Patients are stratified for smoking habits, proximal pole involvement and displacement of > / < 2 mm. The primary outcome is time to union, measured with repeated CT scans at 2-week intervals from 6 to 16 weeks postoperatively. Secondary outcomes are Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH), visual analogue scale (VAS), donor site morbidity, union rate, restoration of scaphoid deformity, range of motion, key-pinch, grip strength, EQ5D-5L, patient satisfaction, complications and revision surgery.

DISCUSSION

The results of this study will contribute to the treatment algorithm of scaphoid delayed/non-union and assist hand surgeons and patients in making treatment decisions. Eventually, improving time to union will benefit patients in earlier return to normal daily activity and reduce society costs by shortening sick leave.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05574582. Date first registered: September 30, 2022. Items from the WHO trial registry are found within the protocol.

The influence of partial union on the mechanical strength of scaphoid fractures: a finite element study

Assessment of scaphoid fracture union on computed tomography scans is not currently standardized. We investigated the extent of scaphoid waist fracture union required to withstand physiological loads in a finite element model, based on a high-resolution CT scan of a cadaveric forearm. For simulations, the scaphoid waist was partially fused at the radial and ulnar sides. A physiological load of 100 N was transmitted to the scaphoid and the minimal amount of union to maintain biomechanical stability was recorded. The orientation of the fracture plane was varied to analyse the effect on biomechanical stability. The results indicate that the scaphoid is more prone to re-fracture when healing occurs on the ulnar side, where at least 60% union is required. Union occurring from the radial side can withstand loads with as little as 25% union. In fractures more parallel to the radial axis, the scaphoid seems less resistant on the radial side, as at least 50% union is required. A quantitative CT scan analysis with the proposed cut-off values and a consistently applied clinical examination will guide the clinician as to whether mid-waist scaphoid fractures can be considered as truly united.

Arthroscopic Bone Graft and Internal Fixation of Non-Union of the Proximal Pole of the Scaphoid: Surgical Technique and Outcomes

Background  Fractures of the proximal pole of the scaphoid have been associated with delayed union, non-union, and avascular necrosis. This has been attributed to avascularity of the proximal pole of the scaphoid. While proximal pole non-unions can be successfully treated using open techniques, there is little information in the literature regarding arthroscopic bone graft and internal fixation of proximal pole non-unions. Description of Technique  After insertion of a 1.2-mm radiolunate K-wire, the scaphoid non-union was arthroscopically excised, bone grafted with iliac crest cancellous bone, and internally fixed with 3 × 1.2 mm K-wires. Patients and Methods  This is a retrospective study of patients who had arthroscopic bone graft of non-union of the proximal pole of the scaphoid between 2009 and 2021. Results  There were 30 cases in this study; 29 cases united. The one case that did not unite was caused by inadequate fixation of the proximal pole. The size of the proximal pole did not influence the outcome. Conclusion  Arthroscopic bone graft and internal fixation is a reliable technique for the treatment of non-union of the proximal pole of the scaphoid.

Arthroscopic bone graft and fixation for proximal scaphoid nonunions

AIMS

This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation.

METHODS

This was a retrospective analysis of 20 patients. All cases were delayed presentations (n = 15) or failed nonoperatively managed scaphoid fractures (n = 5). Surgery was performed at a mean duration of 27 months (7 to 120) following injury with arthroscopic debridement and arthroscopic iliac crest autograft. Fracture fixation was performed percutaneously with Kirschner (K)-wires in 12 wrists, a headless screw in six, and a combination of a headless screw and single K-wire in two. Clinical outcomes were assessed using grip strength, patient-reported outcome measures, and wrist range of motion (ROM) measurements.

RESULTS

Intraoperatively, established avascular necrosis of the proximal fragment was identified in ten scaphoids. All fractures united within 16 weeks, confirmed by CT. At a mean follow-up of 31 months (12 to 64), there were significant improvements in the Patient-Rated Wrist Evaluation, Mayo Wrist Score, abbreviated Disabilities of the Arm, Shoulder and Hand score, wrist ROM, grip strength, and the patients' subjective pain score. No peri- or postoperative complications were encountered.

CONCLUSION

Our data indicate that arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment. Cite this article: Bone Joint J 2022;104-B(8):946-952.

Clinical and Patient-Reported Outcomes After Hybrid Russe Procedure for Scaphoid Nonunion

Background: Hybrid Russe technique for the treatment of scaphoid nonunion with humpback deformity has been described with a reported 100% union rate. We sought to evaluate the reproducibility of this technique. Methods: We completed a retrospective chart review of patients with a scaphoid waist nonunion and humpback deformity treated with the hybrid Russe technique from 2015 to 2019 with a minimum of 3-month follow-up. Twenty patients with 21 nonunions were included (mean follow-up: 7.0 months). Scapholunate angle was the primary outcome measure. Secondary outcomes included: intrascaphoid angle, radiolunate angle, pain on the visual analog scale (VAS), and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Other variables included: time to computed tomography (CT) union, range of motion, and complications. Descriptive statistics were presented. Pre- and postoperative angles, VAS, and QuickDASH scores were evaluated with Wilcoxon signed rank tests. Results: The mean scapholunate angle improved -17.6° ± 6.4°. The mean intrascaphoid angle improved 28.2° ± 6.3°. The mean radiolunate angle improved 12.8° ± 8.8°. Of the 21 scaphoids, 20 (95%) demonstrated union on a CT scan. One patient was diagnosed with a nonunion. In total, 90% of patients noted symmetric range of motion compared with the contralateral side. The mean VAS pain score improved 6 ± 3 points. The mean QuickDASH score improved 10 ± 8 points. Complications (aside from nonunion) included 1 patient with persistent wrist pain that resolved with removal of hardware. Conclusions: The hybrid Russe technique for the treatment of scaphoid nonunions with humpback deformity demonstrates a 95% union rate. This technique is effective, reproducible, and may serve as an alternative to techniques that include structural grafts from distant sites.

Acute scaphoid fractures: making decisions for treating a troublesome bone

Seven aspects of the management of acute scaphoid fractures are open to debate: Diagnosis of true fractures among suspected fractures, assessment of fracture displacement, cast immobilization strategies, the role of surgical fixation, proximal pole fractures, assessment of union, and the underlying objective of treatment. We reviewed current evidence, and our varied interpretations of it, to highlight areas of uncertainty where more evidence might be helpful.

The influence of fracture location and comminution on acute scaphoid fracture displacement: three-dimensional CT analysis

We aimed to assess the influence of fracture location and comminution on acute scaphoid fracture displacement using three-dimensional CT. CT scans of 51 adults with an acute scaphoid fracture were included. Three-dimensional CT was used to assess fracture location, comminution and displacement. Fracture location was expressed as the height of the cortical breach on the volar and dorsal side of the scaphoid relative to total scaphoid length (%), corresponding to the fracture's entry and exit point, respectively. We found a near-linear relation between dorsal fracture location and displacement. As dorsal fracture location became more distal, translation (ulnar, proximal, volar) and angulation (flexion, pronation) of the distal fragment relative to the proximal fragment increased. Comminuted fractures had more displacement. Dorsal fracture location predictably dictates the direction of translation and angulation in displaced scaphoid fractures. Surgeon attention to dorsal fracture location can help identify displacement patterns and provide guidance in adequately reducing a displaced scaphoid fracture.Level of evidence: III.

The role of arthroscopy in the diagnosis of concomitant soft tissue injuries in scaphoid fractures and the effect of concomitant soft tissue injuries and fracture comminution on outcomes: A case-control study

Objectives

This study aims to evaluate the role of arthroscopy in the diagnosis of concomitant injuries, to investigate the relationship between comminution and concomitant injuries, and to analyze the effect of concomitant injuries on functional outcomes in acute and subacute scaphoid fracture.

Patients and methods

Between January 2011 and September 2018. A total of 32 acute scaphoid fracture patients (29 males, 3 females; mean age: 30±12 years; range, 18 to 65 years) were retrospectively analyzed. None of them had an obvious ligament injury in the radiological assessment. Functional outcomes were compared between concomitant and non-concomitant injuries and between comminuted and non-comminuted injuries. The percentage of range of motion (ROM), grip, and pinch strength were recorded according to the contralateral extremity to detect the restriction rate. The Mayo Wrist Score (MWS), the Turkish version of the Quick Disability of the Arm, Shoulder, and Hand (Q-DASH) and Patient-Rated Wrist Evaluation (PRWE) questionnaires were used to evaluate the functional results. Subjective pain was assessed using the Visual Analog Scale (VAS). The relationship between concomitant injuries and comminution was investigated.

Results

There were 13 patients with comminuted fractures. Concomitant injuries were diagnosed in 17 patients. The presence of concomitant injuries was higher in comminuted fractures than in non-comminuted fractures. There was no significant difference between the groups in ROMs. The final follow-up Q-DASH, PRWE, MWS, and VAS scores and the pinch strength of non-comminuted fractures were found to be statistically better than those of comminuted fractures. There were statistically worse Q-DASH, PRWE, MWS, and VAS scores in patients with concomitant injuries.

Conclusion

Arthroscopic scaphoid fracture surgery allows the diagnosis and treatment of concomitant lesions. The functional outcomes of concomitant lesions and comminuted fractures seem to be worse than those of others, while the ROM is comparable.

Can CT-Scan Measurements of Humpback Deformity, Dislocation, and the Size of Bony Cysts Predict Union after Surgery for Scaphoid Nonunion?

Objective  Scaphoid fractures are associated with high rates of late- or nonunion after conservative treatment. Nonunion is reported to occur in approximately 10% of all scaphoid fractures. It is known that the union of scaphoid fractures is affected by factors such as location at proximal pole, tobacco smoking, and the time from injury to treatment. Same factors seem to affect the healing after surgery for scaphoid nonunion. While the impact of preoperative humpback deformity on the functional outcome after surgery has been previously reported, the impact of humpback deformity, displacement, and the presence of bony cysts on union rate and time to healing after surgery has not been studied. Purpose  The primary purpose of this study is to assess the association of humpback deformity, fragment displacement, and the size of cysts along the fracture line with the union rate and union time, following surgery of scaphoid nonunion. The second purpose of the study is to investigate the interobserver reliability in the evaluation of computed tomography (CT) scans of scaphoid nonunion. Patients and Methods  From January 2008 to December 2018, 178 patients were surgically treated in our institution. After exclusion criteria were met, 63 patients with scaphoid delayed- or established nonunion, and preoperative CT scans of high quality (<2mm./ slice), were retrospectively analyzed. There was 58 men and 5 women with a mean age of 30 years (range: 16-72 years). Four orthopaedic surgeons and one radiologist independently analyzed the CT scans. The dorsal cortical angle (DCA), lateral intrascaphoid angle (LISA), the height-to-length ratio, the size of the cysts, and displacement of the fragments were measured. Healing was defined by CT scan, or by conventional X-ray, and status of no pain at clinical examination. Thirty-two of the patients had developed nonunion (>6 months postinjury), while 31 were in a stage of delayed union (3-6 months postinjury). Results  Open surgery with cancellous or structural bone graft was the treatment of choice in 49 patients, 8 patients were treated with arthroscopic bone grafting, and 6 patients with delayed union were operated with percutaneous screw fixation, without bone graft. Overall union rate was 86% (54/63) and was achieved after 84 days (12 weeks) (mean). The failure rate and time to healing were not associated with the degree of the humpback deformity, size of the cysts, or displacement of the nonunion in general. However, greater dislocation, and the localization of the nonunion at the scaphoid waist, showed significant influence on the union rate. Dislocation at nonunion site, in the group of the patients who united after surgery, was 2.7 mm (95% confidence interval [CI]: 1.5-3.7), and in the group who did not unite was 4.2 mm (95% CI: 2.9-5.7); p  = 0.048). Time from injury to surgery was significantly correlated with time to union ( p  < 0.05), but not associated with the union rate ( p  < 0.4). Patients treated arthroscopically achieved faster healing (42 days), (standard deviation [SD]: 22.27) as compared with patients treated by open techniques (92 days; SD: 70.86). Agreement among five observers calculated as intraclass correlation coefficient was for LISA: 0.92; for height-to-length ratio: 0.73; for DCA: 0.65; for size of cysts: 0.61; and for displacement in millimeters: 0.24, respectively. Conclusions  The degree of humpback deformity and the size of cysts along the fracture line of scaphoid nonunion have no predictive value for the result, neither for the union rate nor the union time after surgery for the scaphoid nonunion. However, larger dislocation of the fragments measured at the scaphoid waist showed lower union rate. Time to healing following surgery is mainly influenced by the time from injury to the surgical treatment and may be influenced by the choice of the surgical technique. Interrater reliability calculation was best with LISA measurements, and worse with the measurements of the dislocation. Level of Evidence  This is a Level III, observational, case-control study.

A meta-analysis of union rate after proximal scaphoid fractures: terminology matters

Heterogeneity in the anatomical definition of 'proximal' affects the comparison of outcomes of these scaphoid fractures. This study aims to review published outcomes of all variants to determine both, differences in terminology, and union rate based upon definition. A literature search was conducted to identify articles that reported descriptions and union rate of all acute (<8 weeks of injury) proximal scaphoid fractures in adult patients (>16 years old). Proximal fractures were grouped as reported ('third', 'pole', 'fifth' or 'undefined'). The data were pooled using a fixed-effects method, and a meta-analysis was conducted to compare relative risk (RR) of non-union against non-proximal fractures. Qualitative analysis of 12 articles included three main definitions: 'proximal' (1 article), 'proximal third' (3 articles), and 'proximal pole' (8 articles). Only 6 articles adopted a specific anatomical or ratio description. In a pooled meta-analysis of union rates (15 articles), 'proximal third' and 'proximal pole' fractures demonstrated a relative risk (RR) of non-union of 2.3 and 3.4 in comparison to non-proximal fractures, respectively. Operative management yielded lower non-union rates than non-operative for all fracture types (6% vs. 18%). In conclusion, non-union risk varies depending on definition, with non-standardised classifications adding heterogeneity to reported outcomes. We recommend an approach utilizing fixed anatomical landmarks on plain radiographs (referencing scaphoid length and scapho-capitate joint) to standardise reporting of proximal fracture union in future studies. Abbreviations: CI: confidence intervals; CT: computer tomography; Df: degrees of freedom; DL: dersimonian and laird estimator; MRI: magnetic resonance imaging; NICE: national institute for health and care excellence; OTA: orthopaedic trauma association; PA: posterior-anterior; PRISMA: preferred reporting items for systematic reviews and meta analyses; RCT: randomised controlled trial; RR: relative risk; SNAC: scaphoid non-union advanced collapse; UK: United Kingdom.

Bone Morphogenetic Protein in Scaphoid Nonunion: A Systematic Review

Background  Scaphoid nonunion can lead to carpal collapse and osteoarthritis, a painfully debilitating problem. Bone morphogenetic protein (BMP) has been successfully implemented to augment bone healing in other circumstances, but its use in scaphoid nonunion has yielded conflicting results. Case Description  The purpose of this study is to assess the outcomes and complications of scaphoid nonunion treated surgically with BMP. Literature Review  A literature review of all available journal articles citing the use of BMP in scaphoid nonunion surgery from 2002 to 2019 was conducted. We included studies that used BMP as an adjunct to surgical treatment for scaphoid nonunions in both the primary and revision settings with computed tomography determination of union. Demographic information, dose of BMP, tobacco use, outcomes, and complications were recorded. A total of 21 cases were included from four different studies meeting inclusion criteria. Clinical Relevance  The union rates were 90.5% overall, 100% for primary surgeries, and 77.8% for revision surgeries. Five patients (24%) experienced 11 complications, including four cases (19%) of heterotrophic ossification. Use of BMP in scaphoid nonunion surgery resulted in a 90.5% overall union rate but was also associated with complications such as heterotopic ossification. All included studies used BMP to augment bone graft, screw or wire fixation, or a combination of methods. The efficacy of BMP in scaphoid nonunion is unclear, and a sufficiently powered, randomized controlled trial is needed to determine optimal fixation methods, dosing, and morbidity of the use of BMP. Level of Evidence  This is a Level IC, therapeutic interventional study.

Volar Plating versus Headless Compression Screw Fixation of Scaphoid Nonunions: A Meta-analysis of Outcomes

Background  Headless compression screw fixation with bone grafting has been the mainstay of treatment for scaphoid nonunion for the past several decades. Recently, locked volar plate fixation has gained popularity as a technique for scaphoid fixation, especially for recalcitrant or secondary nonunions. Purpose  The purpose of this meta-analysis was to compare union rates and clinical outcomes between locked volar plate fixation and headless compression screw fixation for the treatment of scaphoid nonunions. Methods  A literature search was performed for studies documenting treatment outcomes for scaphoid nonunions from 2000 to 2020. Inclusion criteria consisted of (1) average age > 18 years, (2) primary study using screw fixation, plate fixation, or both, with discrete data reported for each procedure, and (3) average follow-up of at least 3 months. Exclusion criteria consisted of studies with incomplete or missing data on union rates. Data from each study was weighted, combined within treatment groups, and compared across treatment groups using a generalized linear model or binomial distribution. Results  Following title and full-text review, 23 articles were included for analysis. Preoperatively, patients treated with plate fixation had significantly longer time from injury to surgery and were more likely to have failed prior surgical intervention. There was no significant difference between union rates at 92 and 94% for screw and plate fixation, respectively. However, plate fixation resulted in longer time to union and lower modified Mayo wrist scores. Conclusion  Patients treated with locked volar plate fixation were more likely to be used for recalcitrant or secondary nonunions. There was no statistically significant difference in union rates between screw and plate fixation. The results from this meta-analysis support the select use of locked volar plate fixation for scaphoid nonunion, especially recalcitrant nonunions and those that have failed prior surgical repair.

An Evidence-Based Approach to Casting and Orthosis Management of the Pediatric, Adolescent, and Young Adult Population for Injuries of the Upper Extremity: A Review Article

OBJECTIVE

Review the use of upper-extremity orthoses and casts after injuries to the wrist and hand in the pediatric, adolescent, and young adult population. The common injuries reviewed include pediatric distal radius fractures, scaphoid fractures, metacarpal fractures, mallet fingers, volar plate injuries of the proximal interphalangeal (PIP) joint, and ulnar collateral ligament (UCL) tears of the thumb metacarpophalangeal (MCP) joint.

DATA SOURCES

We conducted a literature review from 1985 to 2016 of upper-extremity orthotic interventions. Non-English language citations and animal studies were excluded. Citations from retrieved studies were used to identify other relevant publications. This review included cases of common injuries to the upper extremity, which required orthotic intervention.

MAIN RESULTS

Immobilization recommendations for nonsurgical pediatric distal radius fractures, nonsurgical metacarpal fractures, mallet fingers, and UCL tears of the thumb MCP include a removable orthosis. Nondisplaced scaphoid fracture orthosis recommendations include initial immobilization in a nonremovable short-arm thumb spica cast. Volar plate injuries of the PIP joint require buddy straps for healing.

CONCLUSIONS

The literature demonstrates the effectiveness of removable orthoses in healing, patient satisfaction, and time to return to activity after many common upper-extremity injuries. Removable orthoses should be considered an equal or superior treatment method to cast immobilization, immobilization of additional joints, or longer periods of immobilization.

Diagnostic and Therapeutic Approach to Acute Scaphoid Fractures

The scaphoid is the carpal bone that most often fractures, accounting for up to 70% of carpal fractures and 11% of hand fractures. It is the second most common arm fracture, only surpassed by fractures of the distal radius. Despite being so common, these fractures can be difficult to diagnose and treat due to the anatomic and physiological particularities of the bone, including its precarious vascularization, its complex three-dimensional structure, and its ligament connections, which greatly contribute to the risk of complications such as malunion, pseudoarthrosis and avascular necrosis. Although there are many published studies on the treatment of these injuries, there is still controversy over what is the most suitable one for certain fracture types. The present article is a comprehensive and updated review of the literature. Combining strategies for clinical and radiological diagnosis, we propose a complete algorithm for the diagnosis of scaphoid fractures based on the varying availability of resources, and we also describe the most appropriate therapeutic approach for the different types of acute fractures of this bone.

Wrist function recovery course in patients with scaphoid nonunion treated with combined volar bone grafting and a dorsal antegrade headless screw

Background

Surgical treatment is necessary for scaphoid nonunion. Open surgery with a combined volar and dorsal approach is thought to have poor functional outcomes and a prolonged recovery course. However, the detailed recovery course for this approach is rarely reported. The aim of this study was to investigate the recovery course and radiographic outcome for patients with scaphoid nonunion who underwent a combined volar bone grafting and dorsal antegrade headless screw approach.

Material and methods

Eighteen patients with scaphoid nonunion who underwent combined volar bone grafting and dorsal antegrade headless screw fixation were enrolled in this retrospective study. Preoperative and serial postoperative wrist functional and radiographic outcomes were collected and analysed.

Results

All 18 patients achieved bone union at a mean time of 14.3 weeks. Compared to the preoperative status, the grip strength, wrist motion arc, and Mayo Wrist score were improved significantly 6 months after surgery, whilst the Disabilities of the Arm, Shoulder, and Hand (DASH) score did not recover until 12 months after surgery. Significant improvements were found in all scaphoid radiographic parameters.

Conclusion

The surgical outcomes for scaphoid nonunion treated with a combined volar bone grafting and dorsal antegrade headless screw achieved a high union rate, with great wrist functional and radiographic outcomes. The earliest recovered wrist functional parameters were grip strength, motion arc, Mayo Wrist score and finally the DASH score at postoperative 6 months and 12 months, respectively.

Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT

BACKGROUND

Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased.

OBJECTIVE

To compare the clinical effectiveness and cost-effectiveness of surgical fixation with cast treatment and early fixation in adults with scaphoid waist fractures that fail to unite.

DESIGN

Multicentre, pragmatic, open-label, parallel two-arm randomised controlled trial with an economic evaluation and a nested qualitative study.

SETTING

Orthopaedic departments of 31 hospitals in England and Wales recruited from July 2013, with final follow-up in September 2017.

PARTICIPANTS

Adults (aged ≥ 16 years) presenting within 2 weeks of injury with a clear, bicortical fracture of the scaphoid waist on plain radiographs.

INTERVENTIONS

Early surgical fixation using Conformité Européenne-marked headless compression screws. Below-elbow cast immobilisation for 6-10 weeks and urgent fixation of confirmed non-union.

MAIN OUTCOME MEASURES

The primary outcome and end point was the Patient-Rated Wrist Evaluation total score at 52 weeks, with a clinically relevant difference of 6 points. Secondary outcomes included Patient-Rated Wrist Evaluation pain and function subscales, Short Form questionnaire 12-items, bone union, range of movement, grip strength, complications and return to work.

RESULTS

The mean age of 439 participants was 33 years; 363 participants were male (83%) and 269 participants had an undisplaced fracture (61%). The primary analysis was on 408 participants with valid Patient-Rated Wrist Evaluation outcome data for at least one post-randomisation time point (surgery, n = 203 of 219; cast, n = 205 of 220). There was no clinically relevant difference in the Patient-Rated Wrist Evaluation total score at 52 weeks: the mean score in the cast group was 14.0 (95% confidence interval 11.3 to 16.6) and in the surgery group was 11.9 (95% confidence interval 9.2 to 14.5), with an adjusted mean difference of -2.1 in favour of surgery (95% confidence interval -5.8 to 1.6; p = 0.27). The non-union rate was low (surgery group, n = 1; cast group, n = 4). Eight participants in the surgery group had a total of 11 reoperations and one participant in the cast group required a reoperation for non-union. The base-case economic analysis at 52 weeks found that surgery cost £1295 per patient more (95% confidence interval £1084 to £1504) than cast treatment. The base-case analysis of a lifetime-extrapolated model confirmed that the cast treatment pathway was more cost-effective. The nested qualitative study identified patients' desire to have a 'sense of recovering', which surgeons should address at the outset.

LIMITATION

There were 17 participants who had initial cast treatment and surgery for confirmed non-union, which in 14 cases was within 6 months from randomisation and in three cases was after 6 months. Three of the four participants in the cast group who had a non-union at 52 weeks were not offered surgery.

CONCLUSIONS

Adult patients with an undisplaced or minimally displaced scaphoid waist fracture should have cast immobilisation and suspected non-unions immediately confirmed and urgently fixed. Patients should be followed up at 5 years to investigate the effect of partial union, degenerative arthritis, malunion and screw problems on their quality of life.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN67901257.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 52. See the NIHR Journals Library website for further project information.

3D mapping of scaphoid fractures and comminution

OBJECTIVE

Acute and subacute scaphoid fractures were assessed using 3D computer tomography (CT). The aims were to describe fracture morphology, to map fractures onto a 3D scaphoid model and to correlate this to scaphoid anatomy.

MATERIALS AND METHODS

A retrospective, multicentre database search was performed to identify CT studies of acute and subacute scaphoid fractures. CT scans of scaphoid fractures less than 6 weeks from time of injury were included in this retrospective, multicentre study. CTs were segmented and converted into three-dimensional models. Following virtual fracture reduction, fractures were mapped onto a three-dimensional scaphoid model.

RESULTS

Seventy-five CT scans were included. The median delay from injury to CT was 29 days. Most studies were in male patients (89%). Most fractures were comminuted (52%) or displaced (64%). A total of 73% of displaced fractures had concomitant comminution. Waist fractures had higher rates of comminution and displacement when compared with all other fractures. Comminution was located along the dorsal ridge and the volar scaphoid waist.

CONCLUSION

Our study is the first to describe acute fracture morphology using 3D CT and to correlate comminution and displacement to fracture types. The dorsal ridge and volar waist need prudent assessment, especially in waist fractures.

Conservative treatment for fractures of the scaphoid

This review article aims to discuss the indications, techniques, outcomes, and complications of non-operative management of scaphoid fractures.

How Long Should We Immobilize the Wrist after Vascularized Bone Grafting for the Treatment of Scaphoid Nonunion?

Background: Although vascularized bone grafting can effectively treat scaphoid nonunion, the optimal duration of the immobilization period after bone grafting is unclear. Therefore, we aimed to examine the difference in the union rate and range of motion between short and long immobilization periods and infer the optimal post-immobilization period after pedicled vascularized bone grafting for scaphoid nonunion treatment. Methods: A total of 23 wrists (21 men and 1 woman) with scaphoid nonunion treated using an intercompartmental supraretinacular artery pedicled vascularized bone graft were analyzed. We examined the difference in the union rate and range of motion between patients immobilized for less than 49 days (short immobilization group) and those immobilized for more than 49 days (long immobilization group). The range of motion of the wrist joint was measured before and after surgery. Patient outcomes were also assessed. Results: The overall union rate was 95.6%. A significant difference was found in postoperative extension and flexion between the two groups, but not in terms of the functional outcome. If the intraoperative fixation is solid, intraoperative proximal pole bleeding is confirmed, and the follow-up radiograph shows a normal healing process, we propose immobilization of the wrist for ≤ 7 weeks. Conclusions: The immobilization duration should depend on the solidity of intraoperative fixation and a satisfactory appearance on follow-up radiography: absence of a gap at the graft interface, surrounding lucency, or movement of the implant and displacement of the graft. If there are no signs of graft failure and fixation is solid, immobilization of the wrist for 7 weeks or less is recommended.

Comparison of Fracture Location and Extent of Comminution in Isolated Scaphoid Fractures Versus Transscaphoid Fracture-Dislocations

Background: Isolated scaphoid fractures (ISFs) are common, whereas transscaphoid fracture-dislocations (TSFDs) are not. Scaphoid fracture location and the extent of comminution are factors that affect treatment and outcome. The purpose of this study is to compare the radiographic characteristics of ISFs with TSFDs associated with greater arc injury. Methods: This study is a retrospective review of all ISFs and TSFDs that presented to our institution during a 5-year period. Fracture location (along the long axis of the scaphoid) was calculated by dividing the distance from the proximal pole to the fracture by the entire length of the scaphoid. The extent of comminution was measured in millimeters along the mid-axis of the scaphoid and divided by the entire length of the scaphoid. Results: One-hundred thirty-eight scaphoid fractures in 137 patients were identified. One-hundred twelve fractures (81%) were ISFs, and 26 (19%) were associated with a TSFD. The mean fracture location was more proximal in TSFDs than in ISFs. However, fractures occurred in the distal third of the scaphoid in 12% of ISFs compared with 0% of TSFDs. Nine percent of ISFs demonstrated comminution as compared with 12% of TSFDs. Extent of comminution was 16% and 28% for ISFs and TSFDs, respectively. Conclusion: Scaphoid fractures associated with greater arc injuries are located more proximally and are more comminuted than ISFs, and distal pole fractures rarely occur in the setting of TSFDs. The increased incidence and extent of comminution in TSFDs may be suggestive of a higher energy injury mechanism.

Acute scaphoid fractures: guidelines for diagnosis and treatment

In cases of suspected scaphoid fracture where the initial radiographs are negative, a supplementary MRI, or alternatively CT, should be carried out within three to five days.

Fracture classification, assessment of dislocation as well as evaluation of fracture healing is best done on CT with reconstructions in the coronal and sagittal planes, following the longitudinal axis of the scaphoid.

After adequate conservative management, union is achieved at six weeks for approximately 90% of non-displaced or minimally displaced (≤ 0.5 mm) scaphoid waist fractures.

Scaphoid waist fractures with moderate displacement (0.5–1.5 mm) can be treated conservatively, but require prolonged cast immobilization for approximately eight to ten weeks.

Internal fixation is recommended for all scaphoid waist fractures with dislocation ≥ 1.5 mm.

Distal scaphoid fractures can be treated conservatively. The majority heal uneventfully after four to six weeks of immobilization, depending on fracture type.

In general, proximal scaphoid fractures should be treated with internal fixation.

Cite this article: EFORT Open Rev 2020;5:96-103. DOI: 10.1302/2058-5241.5.190025

Clinical and radiological results of the vascularized medial femoral condyle graft for scaphoid non-union

INTRODUCTION

This study evaluated the use of a free vascularized bone graft with and without cartilage from the medial femoral condyle (MFC) in patients with recalcitrant scaphoid non-union, with a special focus on union rates and the osteochondral graft for proximal pole destruction.

MATERIALS AND METHODS

Thirty-eight avascular scaphoid non-unions in 37 patients who were treated with a free osteoperiosteal or osteochondral MFC graft were retrospectively evaluated (mean follow-up 16 months). Bone union, the scapholunate and the radiolunate angles were evaluated on X-ray images. The range of motion, grip strength, VAS, DASH and PRWE scores were evaluated clinically.

RESULTS

The overall union rate was 95%. Bone union was achieved in 27 out of 29 (93%) scaphoids treated with a free osteoperiosteal MFC grafts and in 9 out of 9 (100%) scaphoids treated with a free osteochondral MFC graft. The range of motion remained almost unchanged, while grip strength increased significantly (34 kg vs. 44 kg) and the VAS (22-5), DASH (59-19) and PRWE (62-30) score decreased significantly. The scapholunate (71°-65°) and radiolunate (28°-18°) angle decreased. No major donor site morbidity was observed. Postoperative complications were observed in eight cases (21%).

CONCLUSIONS

The vascularized medial femoral bone graft leads to a good functional outcome in the treatment of scaphoid non-unions. The graft provides adequate blood supply and structural stability to the scaphoid. A proximal pole destruction can be replaced using an osteochondral graft with promising short-term results preventing carpal osteoarthritis and collapse.

Scaphoid Fracture Patterns-Part Two: Reproducibility and Demographics of a Simplified Scaphoid Fracture Classification

Objective  To analyze the reproducibility, reliability, and demographics of a simplified anatomical scaphoid fracture classification based on posteroanterior radiographs using a large database of scaphoid fractures. Methods  The study consisted of a retrospective review of electronic medical records of 871 consecutive patients. All patients presented between 2003 and 2014 at two centers. Patient- and surgeon-related factors were analyzed. Additionally, interobserver reliability of the Herbert and simplified scaphoid fracture classifications were tested. Results  Proximal pole fractures were defined as fractures in which the center of the fracture line was proximal to the distal scapholunate interval (n = 30), waist fractures (n = 802) were defined as fractures involving the scaphocapitate interval, and distal tubercle fractures (n = 39) were defined as fractures involving the scaphotrapeziotrapezoid (STT) interval. The interobserver reliability of the simplified classification was fair (κ = 0.37) as for the Herbert classification (κ = 0.31). The average doubt of the answers of the observers was 2.1 on a scale from 0 to 10 for the simplified classification and 3.6 for the Herbert classification ( P  < 0.05). Conclusions  All complete fractures across the entire scaphoid distal to the scapholunate articulation and proximal to the STT joint can be classified as waist fractures; nonwaist scaphoid fractures are uncommon (6%) and have somewhat different presentations compared to waist fractures. Simplifying the fracture classification slightly improves interobserver reliability, although remaining fair, and significantly reduces doubt. Level of Evidence  This is a Level III, prognostic study.

Multiplanar reformation computed tomography for carpal malalignment

Correct interpretation of scaphoid axial length and carpal malalignment is difficult owing to the complex geometry of the scaphoid. Traditional measurements, such as the scapholunate angle and radiolunate angle, have shown limited reproducibility. To improve the assessment of these measurements, we used multiplanar reformation computed tomography with added average intensity projection. Four measurements for scaphoid morphology and carpal alignment were independently measured by four observers on computed tomography scans of 39 consecutive patients who were treated conservatively for scaphoid fracture. Fleiss's kappa for categorical results showed substantial agreement for the measurements of the scapholunate and radiolunate angles. Intraclass correlation coefficients were significant for measurements of the axial length, scapholunate angle and radiolunate angle. Our results suggest that multiplanar reformation computed tomography with added average intensity projection is a reliable technique for assessment of scaphoid morphology and carpal alignment. Level of evidence: II.

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.

Biomechanical Strength of Scaphoid Partial Unions

Background  It remains unknown how much force a partially united scaphoid can sustain without refracturing. This is critical in determining when to discontinue immobilization in active individuals. Purpose  The purpose of this study was to test the biomechanical strength of simulated partially united scaphoids. We hypothesized that no difference would exist in load-to-failure or failure mechanism in scaphoids with 50% or more bone at the waist versus intact scaphoids. Materials and Methods  Forty-one cadaver scaphoids were divided into four groups, three experimental osteotomy groups (25, 50, and 75% of the scaphoid waist) and one control group. Each was subjected to a physiologic cantilever force of 80 to 120 N for 4,000 cycles, followed by load to failure. Permanent deformation during physiologic testing and stiffness, max force, work-to-failure, and failure mechanism during load to failure were recorded. Results  All scaphoids survived subfailure conditioning with no significant difference in permanent deformation. Intact scaphoids endured an average maximum load to failure of 334 versus 321, 297, and 342 N for 25, 50, and 75% groups, respectively, with no significant variance. There were no significant differences in stiffness or work to failure between intact, 25, 50, and 75% groups. One specimen from each osteotomy group failed by fracturing through the osteotomy; all others failed near the distal pole loading site. Conclusion  All groups behaved similarly under physiologic and load-to-failure testing, suggesting that inherent stability is maintained with at least 25% of the scaphoid waist intact. Clinical Relevance  The data provide valuable information regarding partial scaphoid union and supports mobilization once 25% union is achieved.

Simultaneous Fractures of the Ipsilateral Scaphoid and Distal Radius

Background  Ipsilateral fractures of the distal radius and scaphoid are rare, with few reports describing mechanisms of injury, fracture patterns, and treatment approaches. Purpose  This article describes the clinical and radiographic features of ipsilateral distal radius and scaphoid fractures occurring simultaneously. Materials and Methods  Electronic databases from 2007 to 2017 at a single Level 1 trauma center were reviewed for patients with concurrent fractures of the distal radius and scaphoid. Patient demographics, injury mechanism, scaphoid and distal radius fracture pattern, treatment approach, and radiographic healing were studied. Results  Twenty-three patients were identified. Nineteen of the 23 (83%) were males, and 19 of 23 (83%) of the injury mechanisms were considered high energy. Twenty-two of the 23 (96%) scaphoid fractures were nondisplaced, all treated with screw fixation. Most distal radius fractures were displaced and comminuted, 17 of 23 (74%) were intra-articular. All distal radius fractures were treated surgically with internal and/or external fixation. Three patients were lost to follow-up. Average follow-up of the remaining 20 was to 19.8 weeks. Nineteen of the 20 (95%) scaphoids healed, one scaphoid went on to nonunion with avascular necrosis. All 20 radius fractures healed, 16 of 20 (80%) in anatomic alignment. Conclusion  Ipsilateral fractures of the distal radius and scaphoid are rare and are usually result of high-energy mechanisms. The scaphoid fracture is usually a nondisplaced fracture at the waist. The distal radius fracture pattern varies but most are displaced and comminuted. The union rate of the scaphoid is high, even if subjected to radiocarpal distraction required for distal radius management. Level of Evidence  Therapeutic level IV study.

Reliability of Diagnosis of Partial Union of Scaphoid Waist Fractures on Computed Tomography

Computed tomography (CT) is increasingly used not just to diagnose union but also to estimate the percentage of the fracture gap that is bridged by healing bone. This study tested the primary null hypothesis that there is no agreement between observers on the extent of union of a scaphoid waist fracture on CT. CT scans of 13 nondisplaced scaphoid waist fractures treated nonoperatively were rated by 145 observers. CT scans were done 10 to 12 weeks after injury. Observers were asked to "eyeball" measure percentage of union. We found that there was a moderate agreement on the categorical degree of partial union of a scaphoid waist fracture on CT (k = 0.34). Agreement on the location of bony bridging was slight (k = 0.31). We concluded that there is limited reliability of diagnosis of partial union of a scaphoid waist fracture on CT and that this should be taken into account in both patient care and research. This is a Level III, diagnostic study.

The clinical result of arthroscopic bone grafting and percutaneous K-wires fixation for management of scaphoid nonunions

The purpose of this study is to analyze the clinical results of patients with scaphoid nonunion treated with arthroscopic bone grafting and K (Kirschner)-wires fixation.We retrospectively reviewed the records of 27 patients with scaphoid nonunion who had been treated with arthroscopic bone grafting and K-wires fixation method from November 2008 to February 2014. The average patient age was 35 years. The time from injury to treatment averaged 45 months. The average follow-up period was 18 months. Bone union was assessed using serial plain radiographs. The functional outcome was evaluated by comparing the modified Mayo wrist score with the visual analog scale (VAS) for pain, which were measured at the time of preoperation and at final follow-up.Union was achieved in 26 of the 27 nonunions (96.29%). The average radiologic union time was 10 weeks. The average VAS score decreased from 6.38 (range, 3-10) preoperatively to 1.59 (range, 0-3) at the final follow-up. The average modified Mayo wrist score improved from 60.19 preoperatively to 83.46 at the final follow-up. According to this score, there were 12 excellent, 6 good, and 9 fair results at the final follow-up.Arthroscopic bone grafting and percutaneous K-wires fixation is an effective treatment method for a scaphoid nonunion and has the advantages of allowing thorough assessment, enabling a comprehensive management approach for scaphoid nonunion in a minimally invasive manner, and this method can also be used for the scaphoid nonunion with SNAC stage I.

Angular Stable Miniplate Fixation of Chronic Unstable Scaphoid Nonunion

Background  Around 5 to 15% of all scaphoid fractures result in nonunion. Treatment of long-lasting scaphoid nonunion remains a challenge for the treating surgeon. Healing of scaphoid nonunion is essential for prevention of scaphoid nonunion advanced collapse and the subsequent predictable pattern of radiocarpal osteoarthritis. Purpose  The purpose of this study was to investigate the feasibility of fixation of the scaphoid nonunion with a volar angular stable miniplate and cancellous bone grafting. We hypothesized that this technique could be successful, even in patients with previous surgery for nonunion and in patients with a long duration of nonunion. Patients and Methods  A total of 21 patients enrolled in a single-center prospective cohort study. Healing of nonunion was assessed on multiplanar computed tomography scan of the wrist at a 3-month interval. Functional outcome was assessed by measuring grip strength, range of motion, and by means of the patient-rated wrist and hand evaluation (PRWHE) questionnaire. Results  During follow-up, 19 out of 21 patients (90%) showed radiological healing of the nonunion. The range of motion did not improve significantly. Postoperative PRWHE scores decreased by 34 points. Healing occurred regardless of the length of time of the nonunion (range: 6-183 months) and regardless of previous surgery (38% of patients). Conclusion  Volar angular stable miniplate fixation with autologous cancellous bone grafting is a successful technique for the treatment of chronic unstable scaphoid nonunion, even in patients with long-lasting nonunion and in patients who underwent previous surgery for a scaphoid fracture. Rotational interfragmentary stability might be an important determining factor for the successful treatment of unstable scaphoid nonunion. Level of Evidence  Level IV.

Controversies and best practices for acute scaphoid fracture management

Acute scaphoid fractures are common wrist injuries that continue to elicit debate from surgeons regarding the most appropriate diagnostic and management algorithms. This review will examine the current literature and trends, in an attempt to provide the reader with an evidence-based discussion regarding current controversies of interest to clinicians. In addition, an attempt will be made to provide recommendations for the best treatment practices for acute scaphoid fractures.

Scaphoid Union: The Role of Wrist Arthroscopy

There are times when clinical examinations, radiographs, and computed tomography scans do not provide sufficient information to know whether a scaphoid fracture or scaphoid bone graft has united, partially united, or not united. When this problem arises, arthroscopic examination of the scaphoid fracture or scaphoid bone graft provides additional information to solve the problem and plan further management in an evidence-based manner. The indications for the use of arthroscopy and surgical technique are described.

Is Casting for Non-Displaced Simple Scaphoid Waist Fracture Effective? A CT Based Assessment of Union

OBJECTIVE

The purpose of this study is to report the union rate and time to union for acute non-displaced scaphoid waist fractures treated with a short arm thumb spica cast.

METHODS

A database was searched (2006-2013) to identify acute undisplaced scaphoid waist fractures. Cases that were not given a trial of casting were excluded (n=33). X-rays, CT scans and health records for each patient were reviewed to extract data.

RESULTS

172 patients met inclusion criteria. There were 138 males, 34 females, the mean age was 30 ± 16 years. The union rate was 99.4% (1 nonunion/172 subjects). The mean time to union was approximately 7.5 weeks (53 ± 37 days). Energy of injury, age or gender did not affect union rates or time to union. Cysts did not affect the union rate (p=0.73) but patients with cystic resorption along the fracture line required approximately 10 weeks for union (69 ± 60 days) compared to 7 weeks (51 ± 34 days) for those without cysts (p=0.05). Diabetes did not affect the union rate (p=0.81) but was found to increase the risk of delayed union (p=0.05). There was a weak, but statistically significant correlation between the number of days before the fracture was casted and the length of time needed to achieve union (r=0.27, p=0.001).

CONCLUSION

Non-displaced scaphoid waist fractures have a high healing rate with appropriate identification and immobilization. Follow-up CT scans to assess healing can identify union within a shorter time frame (~7 weeks) than previously reported in the literature.

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.