Post on 16-Jul-2015
Indications for acute scaphoid fixation
Adam C WattsConsultant Upper Limb Surgeon, Wrightington, UK
Visiting Professor, Manchester University
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Best Treatment of Scaphoid Fractures
PrimaryAchieve sound union
Secondaryin the shortest time with lowest risk and disruption to patient
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Scaphoid Fractures
Common injury in young adults
Compliance challenges
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Cast immobilisation
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Cast immobilisation
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Low riskLow cost
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Cast immobilisation
InconvenientMuscle atrophyJoint stiffness
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Low riskLow cost
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Screw fixation
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Screw fixation
Early return to function
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Screw fixation
Early return to function
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Higher direct costsGreater risks
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Scaphoid Fractures
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Treatment costs
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Scaphoid Fractures
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Work Disability Costs
Treatment costs
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Scaphoid Fractures
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Work Disability Costs
Treatment costs
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Scaphoid Fractures
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Work Disability Costs
Treatment costs
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Predicting Union
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Decision Making
Scaphoid tubercle fracture
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Decision Making
Trans-scaphoid perilunate dislocation
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Decision Making
Proximal pole fracture
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Decision Making
Proximal pole fracture
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10% 70%
20%
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Assessment of displacement
Translation
Gap
Angulation
Rotation
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Assessment of displacement
Translation
Gap
Angulation
Rotation
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} >1mm
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Displaced scaphoid fractures
Relative risk of non-union displaced fractures in cast 4.4 (c.i. 2.2-8.7)
For displaced fractures odds ratio of non-union of 16.9 for cast treatment versus surgical fixation
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Assessment of displacement
MRI gold standard : X-ray sensitivity 33-47% positive predictive value 27-86% (Bhat 2004)
Arthroscopy gold standard: Xray sensitivity 75% positive predictive value 10% (Lozano-Calderon 2006)
Reliability intraobserver interobserverX-rays 0.54 0.27CT 0.65 0.43CT and X-rays 0.63 0.48
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Cadaveric model
Specificity X-ray predicting displacement 84%
CT 89%
but poor sensitivity for both (x-ray 52%, CT 49%)
However only sagittal CT imaging
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Does vascularity matter?
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Avascular
Fracture displacement measured on CT or MRI appears to be key to assessing
risk on non-union
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Displaced fractures
>2mm displacement on CT = Non-union 50% in cast
≤2mm displacement on CT = 100% union in cast
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Undisplaced fracture
Union in 4 week cast = 96%
Can surgery beat this?
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Cost analysis - undisplaced fractures
Non-manual workerscost of surgical arm significantly higher than non-surgicalaverage period off work 0 days compared to 19 days
Manual workersreturned to work more quickly after surgery (61 v 100 days)total costs higher with surgery but not statistically significant
No assessment of lost productivity
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CT/MRI
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Scaphoid fracture seen on radiograph
Tubercle fractureUnicortical fracture
Surgical fixation
Waist fracture appears undisplacedProximal poleAssociated wrist injuryObviously displaced
Displaced ≤2mm Displaced >2mm
Individual requires early wrist motion
Cast immobilisation No Yes
CT/MRI
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Scaphoid fracture seen on radiograph
Tubercle fractureUnicortical fracture
Surgical fixation
Waist fracture appears undisplacedProximal poleAssociated wrist injuryObviously displaced
Displaced ≤2mm Displaced >2mm
Individual requires early wrist motion
Cast immobilisation No Yes
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5 QuestionsAnswer ‘yes’ to any then consider surgical treatment with screw fixation
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www.wrightington.com
5 QuestionsAnswer ‘yes’ to any then consider surgical treatment with screw fixation
1.Is there an associated ipsilateral wrist injury?
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www.wrightington.com
5 QuestionsAnswer ‘yes’ to any then consider surgical treatment with screw fixation
1.Is there an associated ipsilateral wrist injury?2.Is there a proximal pole fracture?
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www.wrightington.com
5 QuestionsAnswer ‘yes’ to any then consider surgical treatment with screw fixation
1.Is there an associated ipsilateral wrist injury?2.Is there a proximal pole fracture?3.Is there a waist fracture that is displaced on
scaphoid series radiographs?
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www.wrightington.com
5 QuestionsAnswer ‘yes’ to any then consider surgical treatment with screw fixation
1.Is there an associated ipsilateral wrist injury?2.Is there a proximal pole fracture?3.Is there a waist fracture that is displaced on
scaphoid series radiographs?4.Is there a waist fracture that is shown to have
more than 2mm displacement on CT/MRI?
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www.wrightington.com
5 QuestionsAnswer ‘yes’ to any then consider surgical treatment with screw fixation
1.Is there an associated ipsilateral wrist injury?2.Is there a proximal pole fracture?3.Is there a waist fracture that is displaced on
scaphoid series radiographs?4.Is there a waist fracture that is shown to have
more than 2mm displacement on CT/MRI?5.Is there a waist fracture that is shown to have up
to 2mm displacement in an individual who requires early wrist motion?
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