The treatment of acute The treatment of acute undisplaced fractures of undisplaced fractures of

the Scaphoid: the Scaphoid:

A Systematic ReviewA Systematic Review

Kreibich Presentation 2007 Tom Symes

Treatment of undisplaced Scaphoid #s

Why is this study Why is this study important?important?

2nd most common wrist fracture 2nd most common wrist fracture 60-70% of all carpal bone fractures 60-70% of all carpal bone fractures

Berger 1999Berger 1999

US annual incidence US annual incidence ~~ 345,000 345,000 Up to 5% result in non-union Up to 5% result in non-union Osterman and Osterman and

Mikulics, 1988Mikulics, 1988

Need to establish evidence based Need to establish evidence based best practicebest practice

Treatment of undisplaced Scaphoid #s

Conservative treatmentConservative treatment

ControversiesControversies Position of wrist in plasterPosition of wrist in plaster Inclusion of other jointsInclusion of other joints Duration of immobilisationDuration of immobilisation

Traditional treatmentTraditional treatment Scaphoid cast – Scaphoid cast – Watson Jones 1995Watson Jones 1995

Inclusion of elbow Inclusion of elbow Verdan,Verdan, 1964, Kuhlmann 19871964, Kuhlmann 1987

Colles cast – Colles cast – ClayClay

Treatment of undisplaced Scaphoid #s

Surgical treatmentSurgical treatment

ProsPros Quicker rehabQuicker rehab Better ROMBetter ROM Higher rate of unionHigher rate of union

ConsCons ComplicationsComplications CostCost ResourcesResources

Treatment of undisplaced Scaphoid #s

Review QuestionsReview Questions Is operative fixation of an Is operative fixation of an

undisplaced scaphoid fracture a undisplaced scaphoid fracture a more effective treatment than more effective treatment than immobilisation in a cast?immobilisation in a cast?

If immobilisation is the preferred If immobilisation is the preferred treatment then:treatment then: What is the ideal type of cast? What is the ideal type of cast? What is the ideal position of the wrist in What is the ideal position of the wrist in

plaster?plaster? What is the ideal duration of immobilisation?What is the ideal duration of immobilisation?

Treatment of undisplaced Scaphoid #s

MethodsMethods Study designStudy design

Systematic reviewSystematic review Sources Sources

MEDLINEMEDLINE EMBASEEMBASE The Cochrane Library The Cochrane Library Other electronic databases Other electronic databases

Search termsSearch terms MeSHMeSH Cochrane search strategy for RCTsCochrane search strategy for RCTs

Treatment of undisplaced Scaphoid #s

MethodsMethods

Study selectionStudy selection RCTsRCTs Quasi RCTsQuasi RCTs

Quality assessmentQuality assessment ValidityValidity ApplicabilityApplicability ImportanceImportance

Treatment of undisplaced Scaphoid #s

ResultsResults

Cast vs Surgery - 4 RCTS Cast vs Surgery - 4 RCTS Above elbow vs below elbow casts - Above elbow vs below elbow casts -

2 RCTs 2 RCTs Scaphoid vs Colles Cast – 1 RCT Scaphoid vs Colles Cast – 1 RCT Wrist Extension vs Flexion - 1 RCT Wrist Extension vs Flexion - 1 RCT

1 high quality study, 7 intermediate 1 high quality study, 7 intermediate

Treatment of undisplaced Scaphoid #s

Cast vs SurgeryCast vs Surgery

4 studies4 studies Adolfsson et al 2001Adolfsson et al 2001 Bond et al 2001Bond et al 2001 Saeden et al 2001Saeden et al 2001 Dias et al 2005Dias et al 2005

Treatment of undisplaced Scaphoid #s

Cast vs SurgeryCast vs Surgery

Considerable variation in Considerable variation in the interventions the interventions surgical surgical

percutaneous in two studies percutaneous in two studies open in two studies open in two studies

cast cast variation in the form and length variation in the form and length

of postoperative immobilisation. of postoperative immobilisation.

Treatment of undisplaced Scaphoid #s

Cast vs Surgery- Cast vs Surgery- ConclusionsConclusions

No difference No difference rate of non-unionrate of non-union painpain tenderness tenderness patient satisfactionpatient satisfaction

Grip strength & ROM better short Grip strength & ROM better short term in the surgical groupterm in the surgical group

Time to union quicker in surgical Time to union quicker in surgical group -1 studygroup -1 study

Treatment of undisplaced Scaphoid #s

Scaphoid vs Colles Scaphoid vs Colles

Clay et al (1991) Clay et al (1991) Casts identical Casts identical

except Scaphoid except Scaphoid cast included the cast included the thumb to the IPJthumb to the IPJ

Rate of non-union Rate of non-union almost identical almost identical between the between the groupsgroups

Treatment of undisplaced Scaphoid #s

Flexion vs Extension – Flexion vs Extension – Hambidge (1999) Hambidge (1999)

Casts with wrist in 20°of flexion or Casts with wrist in 20°of flexion or extension extension

No differenceNo difference rate of non-unionrate of non-union wrist flexionwrist flexion grip strength at 6months grip strength at 6months

Significantly better wrist extension in Significantly better wrist extension in the extension group at 6 months the extension group at 6 months (WMD 7 degrees)(WMD 7 degrees)

Treatment of undisplaced Scaphoid #s

Above vs below elbow Above vs below elbow castcast

2 studies2 studies Alho and KankaanpaaAlho and Kankaanpaa

below elbow cast resulted in a lower below elbow cast resulted in a lower rate of non-unionrate of non-union

GellmanGellman above elbow cast resulted in a lower above elbow cast resulted in a lower

rate of non-union!rate of non-union!

Treatment of undisplaced Scaphoid #s

RecommendationRecommendation

Based on the available evidence, the Based on the available evidence, the most effective treatment for acute most effective treatment for acute undisplaced fractures of the undisplaced fractures of the scaphoid is:scaphoid is: Colles or Scaphoid cast Colles or Scaphoid cast wrist held in 20° of extension wrist held in 20° of extension until union is determined clinically and until union is determined clinically and

radiologically.radiologically.

Treatment of undisplaced Scaphoid #s

ReferencesReferences Included trialsIncluded trials

Adolfsson L, Lindau T, Arner M, (2001) Acutrak screw Adolfsson L, Lindau T, Arner M, (2001) Acutrak screw fixation versus cast immobilisation for undisplaced fixation versus cast immobilisation for undisplaced scaphoid waist fractures.Journal of Hand Surgery - British scaphoid waist fractures.Journal of Hand Surgery - British Volume. 26(3):192-195Volume. 26(3):192-195

Alho A, and Kankaanpaa, U. (1975) Management of Alho A, and Kankaanpaa, U. (1975) Management of fractured scaphoid bone. A prospective study of 100 fractured scaphoid bone. A prospective study of 100 fractures. Acta Orthopaedica Scandinavica. 46 (5):737-fractures. Acta Orthopaedica Scandinavica. 46 (5):737-743743

Bond CD, Shin AY, McBride MT, Dao KD (2001) Bond CD, Shin AY, McBride MT, Dao KD (2001) Percutaneous screw fixation or cast immobilization for Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures Journal of Bone & Joint nondisplaced scaphoid fractures Journal of Bone & Joint Surgery - American Volume 83-A (4):483-488Surgery - American Volume 83-A (4):483-488

Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ (1991) Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ (1991) Need the thumb be immobilised in scaphoid fractures? A Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. Journal of Bone & Joint randomised prospective trial. Journal of Bone & Joint Surgery - British Volume. 73 (5):828-832Surgery - British Volume. 73 (5):828-832

Dias JJ, Wildin CJ, Bhowal B, Thompson JR (2005) Should Dias JJ, Wildin CJ, Bhowal B, Thompson JR (2005) Should acute scaphoid fractures be fixed? A randomized acute scaphoid fractures be fixed? A randomized controlled trial Journal of Bone & Joint Surgery - American controlled trial Journal of Bone & Joint Surgery - American Volume. 87(10):2160-2168Volume. 87(10):2160-2168

Treatment of undisplaced Scaphoid #s

ReferencesReferences Included trialsIncluded trials

Gellman H, Caputo RJ, Carter V, Aboulafia A, McKay M. Gellman H, Caputo RJ, Carter V, Aboulafia A, McKay M. (1989) Comparison of short and long thumb-spica casts for (1989) Comparison of short and long thumb-spica casts for non-displaced fractures of the carpal scaphoid. Journal of non-displaced fractures of the carpal scaphoid. Journal of Bone & Joint Surgery - American Volume 71(3):354-357Bone & Joint Surgery - American Volume 71(3):354-357

Hambidge JE, Desai VV, Schranz PJ, Compson JP, Davis TR, Hambidge JE, Desai VV, Schranz PJ, Compson JP, Davis TR, Barton NJ (1999) Acute fractures of the scaphoid. Treatment Barton NJ (1999) Acute fractures of the scaphoid. Treatment by cast immobilisation with the wrist in flexion or extension? by cast immobilisation with the wrist in flexion or extension? Journal of Bone & Joint Surgery - British Volume 81(1):91-92Journal of Bone & Joint Surgery - British Volume 81(1):91-92

Saeden B, Tornkvist H, Ponzer S, Hoglund M. (2001) Fracture Saeden B, Tornkvist H, Ponzer S, Hoglund M. (2001) Fracture of the carpal scaphoid. A prospective, randomised 12-year of the carpal scaphoid. A prospective, randomised 12-year follow-up comparing operative and conservative treatment follow-up comparing operative and conservative treatment Journal of Bone & Joint Surgery - British Volume 83(2):230-Journal of Bone & Joint Surgery - British Volume 83(2):230-234234

Other refs:Other refs: Berger, R.A., Imeada, T., Berglund. L. and An, K.N. (1999) Berger, R.A., Imeada, T., Berglund. L. and An, K.N. (1999)

Constraint and material properties of the subregions of the Constraint and material properties of the subregions of the scapholunate interosseous ligament. scapholunate interosseous ligament. Journal of Hand Surgery Journal of Hand Surgery (Am) (Am) 24: 953–96224: 953–962

Osterman, A.L. and Mikulics, M. (1988) Scaphoid nonunion. Osterman, A.L. and Mikulics, M. (1988) Scaphoid nonunion. Hand Clinics of North AmericaHand Clinics of North America 4: 437–455 4: 437–455