Commentary & Perspective

Commentary & Perspective on
"Should Acute Scaphoid Fractures Be Fixed? A Randomized Controlled Trial"
by J.J. Dias, MD, FRCS, et al.

Commentary & Perspective by
Christina Kuo, MD, and Andrew J. Weiland, MD*,
Hospital for Special Surgery, New York, NY

Nondisplaced fractures of the scaphoid have been shown to have a high rate of union when treated conservatively with cast immobilization for eight to twelve weeks. The long-term morbidity of this treatment is low, and it has been the traditional standard of care. On the other hand, as the population has grown more active and as the amount of time that it takes to return to work, sports, or duty has become increasingly important, the indications for fixation of acute nondisplaced or minimally displaced scaphoid fractures has become a topic of some interest and debate.

In this paper, Dias et al. report on a total of eighty-eight patients with nondisplaced or minimally displaced fractures of the scaphoid waist. Half of these were treated with early internal fixation and half with cast immobilization for eight weeks followed by full mobilization of the hand and wrist. They used a less constricting and more functional below-the-elbow cast with the thumb left free, instead of the traditional long-arm thumb-spica cast. Both groups returned to work at five to six weeks. The overall conclusion of the authors was that there was no clear benefit to early operative treatment over cast immobilization with use of their cast technique except for an earlier return of strength. From this, they recommend what they termed “‘aggressive’ conservative treatment,” which advocates evaluation for delayed union at six-to-eight weeks with computed tomographic scan and subsequent operative treatment at that time for indicated fractures.

A closer look at their data, however, yields additional points of interest. The operatively treated fractures resulted in 100% union, whereas the conservatively treated fractures resulted in a 23% (ten of forty-four patients) delayed union rate as determined by radiographs and computed tomographic scan at twelve weeks. All seven of the delayed unions that underwent open reduction and internal fixation healed but required bone-grafting in all cases. Thus, the delayed unions in the conservatively treated group not only required a more involved operative procedure than the one offered acutely, they also were subjected to an additional five to six weeks of immobilization. The authors advocate evaluating fracture-healing in casted scaphoids at six weeks instead of twelve. This earlier assessment could lead to an even larger proportion of fractures undergoing delayed open reduction and internal fixation.

Another point of interest is that this study grouped two potentially different fractures—the stable scaphoid fracture and the unstable scaphoid fracture. The majority of fractures were categorized as nondisplaced, but eleven fractures were described as having mild or moderate displacement. Moreover, there were at least twenty-two fractures with comminution, eleven fractures that demonstrated lunate tilt at presentation, and two that demonstrated tilt after conservative management. Again, this tilt was not quantified, but does imply a more extensive injury than a nondisplaced fracture.

We believe that a distinction should be made between stable fractures and unstable fractures. Cooney et al. stated that scaphoid fractures with >1 mm of displacement as defined on radiographs or computed tomographic scan or a scapholunate angle >45° or a lunocapitate angle >15° should be considered unstable¹. We would recommend reducing such fractures with internal fixation rather than risking the consequences of nonunion or malunion with nonoperative management.

For the nondisplaced or stable fracture, percutaneous screw placement has increasingly been offered as an option to patients, citing earlier return to work and sports and possible gains in range of motion and grip strength. In 2001, Bond et al. compared the percutaneous Acutrak screw to thumb-spica cast treatment in a prospective, randomized study of nondisplaced fractures of the scaphoid waist². All the fractures healed, but the operatively treated fractures achieved earlier union by five weeks and earlier return to military duty by seven weeks, although there were no significant differences in grip strength or range of motion at the two-year follow-up. In the paper by Dias et al., the complications related to early operative intervention were, for the most part, related to the volar incision and could be minimized with percutaneous techniques.

This is a well-performed randomized controlled trial that offers necessary information on the question of which scaphoid fractures should be addressed operatively. Although the differences did not reach statistical significance, more of the comminuted fractures went on to delayed union with cast treatment. Alternatively, when considering cast treatment, this paper demonstrated a 77% union rate with a more functional below-the-elbow cast with the thumb left free, a number that might have been higher if it did not include several comminuted, displaced, and possibly unstable fractures.

We believe that with good technique, percutaneous fixation for nondisplaced fractures of the scaphoid waist is a reliable method of treatment leading to earlier return to function with low morbidity and few downsides. A thorough discussion must be undertaken with the patient regarding the relative risks and benefits of operative treatment for a fracture that would likely have the same long-term outcome with cast treatment. Minimally displaced fractures that meet the criteria for instability, however, should be considered as operative candidates and treated with arthroscopic or open reduction and internal fixation. 

*The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

References

1. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop Relat Res. 1980;149:90-7.
2. Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001;83:483-8.

Copyright © 2005 by the The Journal of Bone and Joint Surgery, Inc.