Scaphoid fractures accounts for approximately 15% of all fractures of hand and wrist. Proximal pole fractures represent 10–20% of scaphoid fractures. Non –operative treatment shows high incidence of non-union and avascular necrosis. Surgical intervention with bone graft is associated with better outcome. The aim of this study was to evaluate the radiological and functional outcome of management of proximal pole scaphoid non-union with internal fixation and bone grafting. We included 35 patients with proximal pole scaphoid non-union (2008–2015). All patients underwent antegrade headless compression screw fixation and bone grafting at King's College Hospital, London (except one, who was fixed with Kirschner wire). 33 patients had bone graft from distal radius and two from iliac crest. Postoperatively patients were treated in plaster for 6–8 weeks, followed by splinting for 4–6 weeks and hand physiotherapy. All the patients were analysed at the final follow-up using DASH score and x-rays. Mean age of the patients was 28 years (20–61) in 32 men and 3 women. We lost three patients (9%) to follow up. At a mean follow up of 16 weeks (12–18) twenty three patients (66%) achieved radiological union. All patients but three (91%) achieved good functional outcome at mean follow up of 14 weeks (10–16). A good functional outcome can be achieved with surgical fixation and bone graft in proximal pole scaphoid fractures non-union. Pre-operative fragmentation of proximal pole dictates type of fixation (screw or k wire or no fixation). There was no difference in outcome whether graft was harvested from distal radius or iliac crest

We describe a new technique for fixing the proximal pole scaphoid fractures both in acute and chronic setting and present our preliminary results. We prospectively studied fixation of 25 proximal pole scaphoid fractures (1 acute displaced and 24 non unions) with this technique between 1999 and 2007. Mean age of patients was 25 years and mean time to the operation was 6 months. The technique involves making a transverse dorsal incision over the radius along the radio-carpal junction. The retinaculum is split in line with its fibres. Access to the radio-carpal joint is achieved through the third extensor compartment. The ligament attachment to the scaphoid is preserved by using a modified Mayo approach. A window is created initially at the proximal end of the dorsal ridge. The fracture is reduced and stabilised with an appropriate length Herbert screw. The fracture site is curetted through this window and cancellous bone graft from the distal radius is packed into the fracture site. The capsule and extensor retinaculum is then closed in layers. Radiological union was achieved in 23 cases, one case required refixation and one case was lost to follow up. Our technique is tendon sparing, capsule retaining, and ensures maintenance of articular surface congruity. So far this technique has led to excellent results

To determine union rate in complicated nonunions of the scaphoid treated with a vascularised bone graft. Vascularised bone grafting for scaphoid nonunions (1–2 ICSRA, Zaidemberg technique) has shown initial enthusiasm. Its usefulness has been challenged in cases where the proximal pole of the scaphoid is avascular. Complicated nonunions where the proximal pole is highly likely to be avascular occur in revision surgery and proximal pole nonunions. Fourteen patients were retrospectively followed up. Eight had nonunion following previous scaphoid surgery (two previous ORIF, two previous nonvascular grafting, and four with two previous surgeries). Six patients had no previous surgery for a proximal pole nonunion of 12.5 months’ duration. All patients were male with an average age of twenty-four. Delay from fracture to vascularised bone grafting was twenty months. Graft harvesting was done according to the Zaidemberg technique by two orthopaedic surgeons. CT-scan was used to confirm union in all patients except two who were lost of the follow-up. Twelve patients were followed up by an independent surgeon at a postoperative minimal period of four months. Functional status was assessed with the DASH questionnaire and follow x-rays were performed to determine the presence of degenerative changes. Union was confirmed by CT-scan in eleven of twelve followed patients (92%) at an average time of six months following vascularised graft. Radio-scaphoid osteoarthritis was seen in the one patient that didn’t achieve union. This series suggests that the Zaidemberg graft is useful and may be proposed in situations of revision surgery and proximal pole non-unions. We achieved a high union rate in these complicated nonunions even though there was high likelihood that the proximal pole was avascular. This study stresses the importance of protective immobilization until documented union by CT-scan in this difficult subset of patients

The aim of our study is to investigate the natural history of scaphoid non-union. Factors affecting the outcome of scaphoid fracture non-union surgery were assessed using data collected retrospectively from 785 cases treated at 18 centres throughout the UK. All cases had undergone this surgery before October 2014, ensuring a minimum period of 2 years between surgery and data collection from the medical records. Smoking status significantly influenced the union rate of 94 proximal pole (non-smokers = 71%, smokers = 44%, p < 0.05) but not waist (non-smokers = 73% non-unions. Type of bone graft did not affect the union rate of the 282 waist nonunions (iliac crest = 69%; non-vascular distal radius = 75% and vascularised distal radius = 70%: P=0.35), but did influence the union rate of the 98 proximal pole nonunions (iliac crest = 58%; non-vascular distal radius = 58% and vascularised distal radius = 82%: P=0.004). Time interval between fracture and non-union surgery did not affect the union rate of 121 proximal pole nonunions (3–6 months = 56%; 6–12 months = 76%; 1–2 years = 69%; 2+years = 54%: P=0.5), but did influence the union rate of 303 nonunions of the waist (3–6 months = 80%; 6–12 months = 82%; 1–2 years = 65%; 2+years = 55%: P=0.02). Non-unions of the proximal pole appear to be influenced by smoking status and bone graft type, whereas non-unions of the scaphoid are influenced by the time to non-union surgery

The authors are not aware of any research comparing computed tomography (CT) and avascular necrosis (AVN) of the scaphoid bone. The primary aim of our study was to investigate the use of longitudinal CT in predicting AVN of the proximal pole of the scaphoid, and subsequent fracture nonunion following internal fixation. Thirty-two patients operated on by the senior author for scaphoid fracture were included. Preoperative CT scans were independently assessed for deformity, comminution, fracture position, proximal pole sclerosis, and bridging trabeculae. Intra-operative biopsy of the proximal pole was assessed independently by a blinded musculoskeletal histologist. AVN was determined by histology of a proximal pole biopsy, using the criteria described by Ficat. Post-operative CT scan was utilised to determine fracture union. Preoperative CT features which significantly correlated with AVN were, increased radiodensity of the proximal pole, the absence of any bridging trabeculae comminution, dorsal cortical angle, proximal fracture and age less than 20. Features predictive of subsequent nonunion were fractures of the proximal, increased radiodensity of the proximal pole, and AVN. Preoperative CT scan findings are significantly correlated with histologically confirmed AVN and fracture union. Preoperative longitudinal CT scan is of significant prognostic value and should be considered to assist in predicting outcome and assessing treatment options

Introduction: To assess the value of MR imaging (MRI) with regard to union, graft viability and proximal pole bone marrow status, after use of vascularized bone grafts (VBG) for treating scaphoid nonunions (SN). Methods: VBG from the distal radius were used to treat 52 SN. Clinical and imaging evaluation was used for the pre- and postoperative assessment of all patients. Apart of radiographs obtained in all cases, 19 patients were also assessed postoperatively with MRI at 3 months (15 of 19 were assessed preoperatively with MRI) and 15 had serial MRI evaluations (6–12 months). The clinical follow-up time of this subgroup of 19 patients ranged from 6 to 27 months. Results: All patients showed clinical signs of union within 12 weeks from the procedure. 3-months MRI showed viability of the bone graft in all cases. At 3 months union was established with plain radiographs in 14 patients; plain MRI showed union in 13 patients but contrast-enhanced MRI revealed union in all cases. Eight patients were considered to have osteonecrosis of the proximal pole intraoperatively: 4 showed proximal pole necrosis with postoperative plain radiographs and 5 of them with plain postoperative MRI. Contrast-enhanced MRI at 3 months showed postoperative reversal of necrotic changes in all 8 scaphoids. Serial MRI at 6 and 12 months, revealed resolution of the bone marrow oedema of the surrounding bones and full graft incorporation in all cases. Conclusions: Contrast-enhanced MRI is able to assess the viability of the proximal pole and to demonstrate the early union after treatment of SN with VBG allowing thus earlier mobilisation

Treatment of scaphoid fractures continues to be a difficult problem for both acute unstable fractures and non-unions. In our study, the results of a consecutive series of symptomatic non-unions of scaphoid fractures treated with Herbert screw and bone graft during period between July 1996 and June 2000 are studied. Out of a total of 66 patients (one bilateral), 61 (91.04%) cases who had symptomatic non-unions (type D) were treated with Herbert screw plus iliac crest bone graft while 6 (8.95%) cases were treated for acute unstable fractures (type B) with Herbert screw only (these are excluded from the study). All fractures were classified according to Herbert classification. Russe approach was used in 50 patients while dorsal approach was used in 11 cases with proximal pole fracture non-union. The time interval between injury and surgery was 12.2 months (range 2–72 months). Patients were followed up for radiological evidence of union and clinically for range of movement of wrist, grip strength and outcome score. The site of fracture, type, screw placement, the time interval between the original injury and non-union surgery, and age of the patient, were investigated to assess whether they influenced outcome. Results: Total No. 61 – union 47 (77.1%), persistent non-union 14 (22.9%). We found site of fracture (p=0.044), type of fracture (p=0.028) and screw placement (p=0.019) as statistically significant factors influencing outcome. No statistically significant influence on outcome was found with patient’s age (p=0.983) and also with time interval to non-union surgery (p=0.749). Forty-six (75%) patients were available for clinical follow-up. Seven (15.2%) had persistent non-unions of which four had proximal pole fracture non-unions. Using the scaphoid outcome score, an assessment scale based on pain, occupation, wrist motion, strength and patient satisfaction, functional results were graded as excellent in 19 cases, good in 12 cases, fair in 10 cases and poor in 5 cases. We recommend axial placement of Herbert screw with bone grafting via Russe approach and for difficult proximal pole non-unions dorsal approach is recommended

This study reviews the results of the treatment of non-union of fractures of the scaphoid by the use of micro-surgical, vascular pedicle grafts (VPG). The indications for VPG included long-standing non-union of a fracture of the scaphoid, avascular necrosis of the proximal pole and failed conventional grafting. The contraindications were periscaphoid degenerative changes (scaphoid non-union advanced collapse) and vascular damage from previous surgery. The technique in each involved harvesting a vascularised bone graft from the distal radius based on a vascular pedicle with retrograde flow from one of a number of described vessels that constitute the vascular plexus over the carpus. The scaphoid was prepared to receive an inlay graft and then the graft was positioned and its stability was determined. Some were secured with a single 0.7mm diameter Kirschner wire. The wrist was then immobilised in a plaster cast until either the fracture had healed or it was evident that the procedure had failed to result in union. Fourteen patients have undergone VPG over 30 months. Of these eight have healed (four fractures of the waist and four of the proximal poles), four have failed (one waist and three proximal poles) and two are still in plaster casts. The mean time to healing was 20.6 weeks (range: 12.7–28.7 weeks). Of the eight that healed, seven were aged between 21 and 27 years. The four failures were aged between 34 and 44 years. The mean time since the fracture in the healed group was 2.9 years (range: 1.2 years to five years) and in the failed group it was 6.5 years (range: two years to 20 years). The first failure was related to deep infection and a subsequent Matte-Russe procedure has also failed. In the second failure the graft healed to the distal pole but the very small proximal pole collapsed resulting in a wrist arthrodesis. The graft in the third failure healed to the distal pole but failed to unite with the small proximal pole. No further treatment has been planned. The fourth failure was a non-union of the waist of 20 years standing. The graft became dislodged from the scaphoid but no further surgery has been carried out. One of the successful unions had a poor result because of degeneration in the scaphoid-trapezoid-trapezium (STT) joint secondary to damage done at the time of previous surgery (Herbert screw). A successful STT arthrodesis was done subsequently. VPG is technically challenging. Careful patient selection is vital as is preoperative planning and vessel selection. VPG can be used successfully to salvage obstinate non-unions of fractures of the scaphoid

Background: Fracture of the scaphoid bone is the most common fracture of the carpus and frequently diagnosis is delayed. The unique anatomy & blood supply of the scaphoid itself predisposes to delayed union or non-union. The Synthes scaphoid screw is a cannulated headed screw, which provides superior compression compared with some other devices used to internally fix scaphoid non-unions. Aim: To conduct a retrospective study looking at union rate, time to union and complications and correlating the outcome of treatment against the delay between injury and surgery and location of the fracture within the bone. Methods: 36 patients with scaphoid non-union (30 waist & 6 proximal pole) treated by a single surgeon with the cannulated Synthes screw & corticocancellous bone graft were reviewed retrospectively. Results: We achieved 78% overall union rate. Those patients operated within 6 months of injury achieved 100% union rate. Of the patients with persistent non-union after surgery, half reported no pain and increased movement in the wrist. The failure rate was high in patients whose injury was more than 5 years old, and in proximal pole non-unions. Conclusion: Our study demonstrates that cannulated screw fixation with bone grafting has high success rate for delayed union of scaphoid waist fractures and scaphoid waist nonunions present for less than 5 years. Patients who present more than 5 years after injury or with proximal pole nonunions have a high chance of persistent nonunion, but can symptomatically improve

Purpose: The purpose of this retrospective study was to detail factors influencing outcome of corticocancellous grafts for the treatment of scaphocarpal non-union and to determine ideal indications. Material and methods: Between 1984 and 1999, this grafting technique was used for 103 patients; we retained for analysis 57 wrists (58 nonunions). Mean follow-up was 106 months. Mean age was 36 years. For 45 patients, non-union occurred because of misdiagnosis. According to the Schernberg classification, eleven nonunions were in zone II, 40 in zone III, and seven in zone IV. Time from fracture to treatment was 35 months on average. The Alno classification of non-union was: stage I=13, stage IIA=20, stage IIA=22, stage IIIA=2, stage IIIB=1. The graft was harvested from the pelvis in 50 cases. Osteosynthesis was associated with a graft in 33 of the 58 cases. Postoperative immobilisation was maintained for 2.7 months on average. Bone healing was achieved within thee months. Results: Thirty-six patients were very satisfied. Twenty-seven had significant pain on the pelvic harvesting site (50 harvestings). Wrist motion was 56.2° flexion, 56° extension, 83° supination, 83° pronation, and 11° radial and 32.7° ulnar inclination. Thumb opposition was noted 9.4/10 and average contraopposition was 4. Mean index of carpal height was 0.547. The mean radiolunate angle was 4.8°. A DISI deformation was observed for 20 wrists. Thirty-six patients (62%) developed little or no osteoarthritis. The rate of bone healing was 81% but eleven nonunions did not heal, including seven cases of necrosis of the proximal pole. The absence of DISI deformation correction at the time of grafting favoured development of radiocarpal osteoarthritis. The presence of necrosis favoured persistent non-union. Concomitant osteosynthesis did not improve the healing rate. Discussion: Treatment of scaphoid non-union with a corticocancellous graft remains the choice alternative, providing 81% healing. Grafts consolidation must occur at the radial epiphysis in order to limit painful sequelae. This procedure can be performed for patients with a DISI deformation, but vascularised grafts should be preferred in the event of necrosis of the proximal pole of the scaphoid

A key component to the success of total knee replacement is the health and integrity of the extensor mechanism. While there are issues related to the patella, such as fracture, dislocation, subluxation, clunk due to peripatellar fibrosis and anterior knee pain, the overall integrity of the extensor mechanism is of tantamount importance in providing an excellent functional outcome. During total knee replacement it is of utmost importance to preserve the anatomic insertion of the patellar tendon on the tibial tubercle. However, after total knee replacement, a fall or extreme osteoporosis of the patella may cause a rupture of the patellar tendon, distally or proximally, and possibly the quadriceps tendon off of the proximal pole of the patella. Simple repairs of the patellar tendon avulsion may involve use of the semitendonosis and gracilis tendons along with primary repair of the tendon. Usually, patella infera develops after such a repair affecting overall strength and function. For severe disruptions of the extensor mechanism that are accompanied by a significant extensor lag, autologous tissue repair may not be possible. Thus, there are three techniques for reconstruction of this difficult problem: Extensor mechanism allograft with bone-patellar tendon-patella-quadriceps tendon, extensor mechanism allograft with os calcis-Achilles tendon construct and Marlex-mesh reconstruction for patellar tendon avulsion. The key to success of extensor mechanism allograft is proper tensioning of the allograft at full extensor and immobilisation for 6 weeks. Rosenberg's early experience showed that the allograft works best placed at maximum tension in extension. Rubash has described the use of the os calcis-Achilles tendon which does not utilise a patellar substitute. Hansen has recently described excellent results with the use of Marlex mesh to act as a structural reinforcement to the patellar tendon when it is avulsed

Objective. Delayed radiographs are routinely done to help in diagnosis of occult scaphoid fractures. Our aim was to determine the diagnostic value of these late x-rays. Methods. This is a radio-diagnostic study. We prospectively reviewed radiographs of 67 patients with injury to their wrists who presented with anatomical snuff box to the accident and emergency department.5 patients showed up a fracture of the scaphoid on trauma x-rays and they were excluded from the study. All patients had a radiograph on day of presentation as well as a delayed radiograph at a later date. The radiographs were standardized to include 4 scaphoid views. All the radiographs were reported independently by a consultant radiologist (JN) and a consultant orthopaedic surgeon (ML). Results. 62 radiographs of 42 males and 20 females with an average age of 25.91 were examined. The two sequential radiographs were taken at an average delay of 10.23 days. There was no difference of opinion between the radiologist and the orthopaedic surgeon with regards to reporting. Only one of the late radiographs showed up a fracture of the proximal pole. Rest of the x-rays failed to detect any bony injury. Conclusion. If a fracture is not visible on first day it is difficult to visualize the fracture in delayed x-rays and a strong clinical suspicion should be supplemented with a more specific investigation like a bone scan or MRI scan. We present our data with an up to date review of literature

The “Zemel technique” for scaphoid pseudarthrosis without major carpal collpse is a modification of the Matti-Russe procedure, using only cancelous bone graft and 2 Kirchner wires for fixation – these are introduced under direct vision after a large curetage of the pseudarthrosis, then partially withdrawn and reintroduced after tight local cancelous bone packing. We used it in 51 cases, obtaining bone union in 48. In 9 patients bone, union was not certain after 12 weeks of plaster and K wires were replaced by a screw with no further immobilization, but we still had 3 nonunions. This procedure, technically easy to perform and using current orthopaedic material, seems a good alternative to non-angulated pseudarthrosis of the scaphoid, except of its proximal pole

A key component to the success of total knee replacement is the health and integrity of the extensor mechanism. While there are issues related to the patella, such as fracture, dislocation, subluxation, clunk due to peripatellar fibrosis and anterior knee pain, the overall integrity of the extensor mechanism is of tantamount importance in providing an excellent functional outcome. During total knee replacement it is of utmost importance to preserve the anatomic insertion of the patellar tendon on the tibial tubercle. However, after total knee replacement, a fall or extreme osteoporosis of the patella may cause a rupture of the patellar tendon, distally or proximally, and possibly the quadriceps tendon off of the proximal pole of the patella. Simple repairs of the patellar tendon avulsion may involve use of the semitendonosis and gracilis tendons along with primary repair of the tendon. Usually, patella infera develops after such a repair affecting overall strength and function. For severe disruptions of the extensor mechanism that are accompanied by a significant extensor lag, autologous tissue repair may not be possible. Thus, there are three techniques for reconstruction of this difficult problem: Extensor mechanism allograft with bone-patellar tendon-patella-quadriceps tendon, extensor mechanism allograft with os calcis-Achilles tendon construct and Marlex-mesh reconstruction for patellar tendon avulsion. The key to success of extensor mechanism allograft is proper tensioning of the allograft at full extensor and immobilisation for 6 weeks. Rosenberg's early experience showed that the allograft works best placed at maximum tension in extension. Rubash has described the use of the os calsis-Achilles tendon which does not utilise a patellar substitute. Hansen has recently described excellent results with the use of Marlex mesh to act as a structural reinforcement to the patellar tendon when it is avulsed

Purpose of study. To study the effect of different shoes and orthotics have on patellar tendon tensile forces. Patellar tendinopathy is an overuse injury that affects tennis players and in high impact sports like basketball, volleyball and running has an incidence of 20%. The tensile forces in the patellar tendon can be reliably measured with an intratendinously placed fibre optic tube and wireless transmission device allows for dynamic testing. The biggest strain differentials have been confirmed in jumps from 30cm height. Tennis is played on 3 major different court surfaces and there is a variety of commercially designed tennis shoes on the market. Materials and methods. 6 male tennis players, ages 18–49 were enrolled for this study. A fibre optic cannula was placed in the middle of the proximal pole of patella tendon from lateral to medial direction in the dominant knee. The patellar tendon tensile forces deform the fibre optic cannula in turn modulating the light signal passing through the optic cannula. The drag in the fibre optic sensor signal was used to measure the tensile forces in the patellar tendon. MLTS 700 goniometer were utilized to measure and record the amount of flexion with each jump to standardize results for different shoes and orthotics. Results. The results of patellar tendon tensile forces measurements for different players, different shoes and orthotics showed no trend or statistical difference for any particular shoe or orthotic. Conclusions. Fibre optic measurements of the effect of different shoes on patellar tendon tensile forces did not show a distinct advantage for any shoe above another. 1 DISCLOSURE

Background. Fractures of the scaphoid are uncommon in the paediatric population. Despite their rarity a significant number of children are referred to the fracture clinic for a suspected scaphoid fracture. The aim of this study is to report on the incidence and pattern of injury of the paediatric scaphoid fracture and present a new classification. Methods. An analysis of all paediatric scaphoid fractures treated in the Royal Hospital for Sick Children, Edinburgh (age up to 14 years old) over a five year period. The case notes, radiographs and were applicable MRI scan for these patients were reviewed. The clinical information recorded included the dominant hand, mechanism of injury, clinical features on examination, type of cast and length of period, stiffness following cast removal and evidence of delayed or non union. Each radiograph was analysed independently and fracture classified according to a new classification system. Results. 56 patients out of the eight hundred and thirty eight (6.7%) referred were identified who had a confirmed diagnosis of a scaphoid fracture on both clinical and radiological assessment. This group consisted of 39 males (70%) and 17 females (30%). The average age of incidence in males was 12.2 years (range 11 to 13 years) and females was 10.3 years (range 9 to 10 years). There were no scaphoid fractures seen in males below the age of 11 years and in females below the age of 9 years. The commonest type of injury was a distal pole fracture (33 patients). One patient sustained a proximal pole fracture and went onto develop a non-union. Conclusions. Scaphoid fractures in children have distinct epidemiological features. The majority involve the distal third of the scaphoid and heal with conservative treatment. The use of a new classification system specific to the paediatric population is beneficial when determining the optimal management of this type of injury

Scapho-lunate Dissociation is an uncommon carpal instability, but produces significant functional loss and early post-traumatic arthritis. Traditional soft tissue reconstructions have a mixed history of success, and are associated with significant loss of range of motion making sport difficult. This study reports use of modified Brunelli reconstruction that allows return to professional contact sport. The Brunelli reconstruction tethers proximally from the lunate attachment of the FCR graft. The modification anchors the tendon graft from the lunate to the capitate across the stretched mid-carpal capsule, and ensures better correction of the DISI deformity and good range of motion. A cohort of 8 AFL level footballers was treated with this reconstruction, and retrospectively reviewed. The modified Brunelli reconstruction was used in all cases. Interestingly, 3 of the 8 cases were delayed by over 12 months, and had already suffered loss of cartilage over the scaphoid proximal pole dorsally. The same operation was performed despite this relative contra-indication. This was protected by a specific translation manouvre to lift the dorsal scaphoid away from the dorsal ridge of the radius whilst the wires holding the reduction were in situ. All players returned to professional level Australian Rules Football. Follow up examination revealed excellent maintenance of dorsiflexion and good retention of palmar flexion post reconstruction. No players complained of arthritic pain, and no further procedures were performed. This procedure is an excellent alternative to partial carpal fusion which is promoted in the literature as the only reliable treatment option for symptomatic scapho-lunate instability

50 consecutive cases of Scaphoid non-union were treated by open reduction and internal fixation. Average age of non-union was 2.8 yrs ranging fron 6 months to 6 years. Most common approach used was volar. Herbert screw was used to fix 48 non-unions while K wires were used in 2 cases. Bone graft was harvested from patient’s iliac crest and was used in nearly all cases. Wrist was immobilised in a plaster for an average duration of 12 weeks post operatively. All the cases were done by a single surgeon and the cases were recorded by an independent observer. The average follow up was 2 years ranging from 1 year to 6 years. Radiographic union was achieved in 45(80%) cases. Failure of union was seen in 10 cases out of which 5 were proximal pole fractures of which 2 went into avascular necrosis. Denervation of wrist, proximal row carpectomy and four corner fusion was used in 5 cases to salvage the wrist. This modest study carried out at a district general hospital of South East England suggests that scaphoid bone continues to be a challenge for general orthopaedic surgeon as some of these fractures are missed initially. Open reduction and internal fixation of Scaphoid non-union continues to give a predictable outcome

Acute scaphoid fractures are commonly treated with cast for 8–12 weeks. With this prolonged period of immobilisation patients can encounter joint stiffness and muscle wasting requiring extensive physiotherapy. Despite best practice, these fractures also pose a risk of non-union and suboptimal function. Fracture location, duration of time lost from work and impairment in activities of daily living are key factors in scaphoid fracture management. The aim of our study was to compare percutaneous screw fixation of the scaphoid with other operative fixation techniques. Parameters documented were length of conservative treatment, mechanism of injury, post-op complications and patient satisfaction levels with each technique using a standardised questionnaire. Economic benefit was also measured by examining time to return to work, number of x-rays and outpatient visits required per treatment group. In this study, 76 patients requiring operative scaphoid fixation were evaluated. 27 patients underwent percutaneous fixation. Waist fractures accounted for 66% (n= 18), proximal pole fractures 33% (n=8) and distal pole fractures 4% (n=1). There were 16 non-displaced fractures (59%) and 11 displaced fractures (41%). The average length of conservative treatment was 77 days (range: 2–256 days). Within the percutaneous group 2 patients developed non-union. We did not encounter any wound infection or superficial radial nerve damage. Patients treated with early percutaneous fixation had highest satisfaction levels, returned to work earlier and required less follow-up (P< 0.001). In conclusion percutaneous screw fixation provides earlier bone union and avoids the need for prolonged immobilisation when compared to other treatment modalities. The economic benefit of early percutaneous fixation must also be considered when managing patients with scaphoid fractures

Aims

Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation.