Acute Scaphoid fracture management
Date First Published:
January 23, 2012
Last Updated:
February 15, 2012
Report by:
Jamie A'Court, Foundation doctor (Northumbria Healthcare trust)
Search checked by:
Santosh Venkatachalam, Northumbria Healthcare trust
Three-Part Question:
In [adult patients with an acute minimally displaced scaphoid fracture] is [conservative management as good as surgical management] at [treating the fracture and reducing long term complications]?
Clinical Scenario:
A 25 year old male attends the emergency department after he slipped on some ice and onto his outstretched right hand. He has attended complaining of tenderness in his wrist and a lack of function. There is also marked swelling around his right wrist.
Search Strategy:
Medline 1968 to 2nd week November 2011 using the ovid interface scah* AND (treatment OR Management OR non-operative OR conservative OR procedure, surgical) AND acute, limit to english language and abstract.
Outcome:
125 papers were returned from the search. 8 of them answered the 3 part question and were appropriate for inclusion.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist fractures Adolfsson L, Lindau T, Arner M 2001 Sweden | 53 patients. 28 patients randomised to cast immobilisation, 25 randomised to internal fixation with acutrak screw. | PRCT | Rate and time to union, Range of motion, grip strength. | Patients treated with internal fixation had better range of motion at 16 weeks. No difference found between union times and grip strength. | Small patient numbers |
| Should acute scaphoid fractures be fixed? A randomized controlled trial Dias JJ, Wildin CJ, Bhowal B, Thompson JR 2005 UK | 88 patients. 44 randomised to internal fixation with a Herbert screw, 44 randomised to immobilisation with a cast. | PRCT | Pain, tenderness, swelling, wrist movement, grip strength, symptoms and disability | Range of movement and grip strength significantly improved in the operative group of patients at 8 weeks follow up. No difference in symptoms or time to return to work overall. | Small patient numbers |
| Treatment of acute scaphoid fractures: systematic review and meta-analysis Yin ZG, Zhang JB, Kan SL, Wang P 2007 China | 7 studies (n=692) were included. Four studies (n=228) compared operative versus non-operative treatment and three (n=464) compared different types of casting. | Meta-analysis | Non-union rate, return to work, grip strength, range of wrist motion, complications, incidence of osteoarthritis | No evidence that operative treatment is superior to non-operative treatment for acute fractures of the scaphoid. | 5 studies reported the randomisation method and two used quasi-randomised methods. 5 studies reported losses to follow-up, but only one used intention-to-treat analysis. |
| Fixation of nondisplaced scaphoid fractures: making treatment cost effective. Prospective controlled trial Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M 2007 Swede | 44 patients randomized to screw fixation (21) or cast immobilization (23) | PRCT | Range of wrist motion, grip strength, time to fracture union and return to work time. | No statistical difference between either group when comparing grip strength and range of movement. Patients treated with internal fixation had a shorter time to union and returned to work sooner. | Power calculations not performed, The method used to allocate the patients to the two treatment groups was not stated |
| .Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months. Dias, J J. Dhukaram, V. Abhinav, A. Bhowal, B. Wildin, C J 2008 UK | 71 patients either treated with Herbert screw or below elbow plaster cast. Outcomes assessed a mean follow up at 93 months | PRCT | Mean grip strength, mean range of movement, Patient evaluation measure. | No medium term difference found in functional outcome between either group | Small patient numbers |
| Nonoperative compared with operative treatment of acute scaphoid fractures. A randomized clinical trial Vinnars B, Pietreanu M, Bodestedt A, Ekenstam F, Gerdin B. 2008 Sweden | 83 with non-displaced or minimally displaced scaphoid fractures. 42 randomised to non surgical, 41 to surgical | PRCT | 10 years post injury. Functional outcome, symptoms, incidence of arthritis | Surgical patients show no long term benefit when compared with conservatively treated patients and may have an increased risk of osteoarthritis | Power calculations if performed were not stated |
| Operative versus nonoperative treatment of acute undisplaced and minimally displaced scaphoid waist fractures—a systematic review Modi CS, Nancoo T, Powers D, Ho K, Boer R, Turner SM 2009 UK | 12 studies. 6 RCTS, 2 meta-analyses, 1 economic analysis and 3 retrospective series | Meta-analysis | Union rates, time to return to work, grip strength, complications | The evidence suggests that percutaneous fixation may result in faster union rates and an earlier return to sport and work by approximately 7 weeks over cast treatment | Low grade RCTs |
| Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. Buijze GA, Doornberg JN, Ham JS, Ring D, Bhandari M, Poolman RW 2010 Netherlands | 419 patients from 8 RCT trials. 207 patients were treated surgically, and 212 were treated conservatively | Meta-analysis | Standardised functional outcome, time to union, time off work, grip strength, pain, range of motion, non-union. | Better functional outcome significantly favored surgical treatment. Other outcomes that favoured surgical treatment were grip strength, time to union, and time off work All other outcomes showed no statistical difference between operative and conservative treatment. | Most studies were low evidence grade. Statistical heterogeneity was still present in many of the analyses |
Author Commentary:
Most RCTs and hence meta-analyses used small patient groups with low statistical power, it would however be impossible to blind the trials. It is difficult to ascertain solid conclusions but most show favourable short-term outcomes with surgical treatment.
Bottom Line:
The studies performed indicate that there is an earlier time to union and faster mobilisation found in patients who have surgical management of a minimally displaced acute scaphoid fracture. At short term follow up, patients treated surgically have better functional outcomes but this difference diminishes with time. With regards to long-term outcomes there is still insignificant data to provide any clear trends on the most favourable method of treatment. Most studies demonstrated an increase in complication rate in the surgical group. The decision on how to manage these patients needs careful consideration and discussion with the patient before a plan is agreed. Weighing up a faster recovery with increased surgical complications is a key decision.
References:
- Adolfsson L, Lindau T, Arner M. Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist fractures
- Dias JJ, Wildin CJ, Bhowal B, Thompson JR. Should acute scaphoid fractures be fixed? A randomized controlled trial
- Yin ZG, Zhang JB, Kan SL, Wang P. Treatment of acute scaphoid fractures: systematic review and meta-analysis
- Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M. Fixation of nondisplaced scaphoid fractures: making treatment cost effective. Prospective controlled trial
- Dias, J J. Dhukaram, V. Abhinav, A. Bhowal, B. Wildin, C J. .Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months.
- Vinnars B, Pietreanu M, Bodestedt A, Ekenstam F, Gerdin B.. Nonoperative compared with operative treatment of acute scaphoid fractures. A randomized clinical trial
- Modi CS, Nancoo T, Powers D, Ho K, Boer R, Turner SM. Operative versus nonoperative treatment of acute undisplaced and minimally displaced scaphoid waist fractures—a systematic review
- Buijze GA, Doornberg JN, Ham JS, Ring D, Bhandari M, Poolman RW. Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials.