Aims

There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures.

Aims. The aim of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was to determine the optimal treatment for adults with a bicortical undisplaced or minimally displaced fracture of the waist of the scaphoid, comparing early surgical fixation with initial cast immobilization, with immediate fixation being offered to patients with nonunion. Methods. A cost-effectiveness analysis was conducted to assess the relative merits of these forms of treatment. The differences in costs to the healthcare system and quality-adjusted life years (QALYs) of the patients over the one-year follow-up of the trial in the two treatment arms were estimated using regression analysis. Results. Our base case analysis found that patients randomized to early surgical fixation had statistically significantly higher mean costs to the NHS of £1,295 more than for the cast immobilization arm (p < 0.001), primarily due to the cost of surgery. They also had a marginally better quality of life, over the period, of 0.0158 QALYs; however, this was not statistically significant (p = 0.379). The mean combined cost per additional QALY was £81,962, well above the accepted threshold for cost-effectiveness used in the UK and internationally. The probability of early surgery being cost-effective in this setting was only 5.6%. Conclusion. Consistent with the clinical findings of SWIFFT, these results indicate that initial cast immobilization of minimally displaced scaphoid fractures, with immediate fixation only offered to patients with nonunion, is the optimal form of treatment, resulting in comparable outcomes with less cost to the healthcare system. Cite this article: Bone Joint J 2021;103-B(7):1277–1283

Introduction. We investigated whether grey scale early ultrasonography could be used for the accurate initial diagnosis of non displaced occult scaphoid fractures. Methods. This is a prospective blind clinical study that includes 36 patients that came to the emergency room with suspected clinical symptoms for scaphoid fracture but negative initial X-ray's. After that, a high resolution ultrasonography (without Doppler) was performed. Both wrists of each patient were examined, for comparison. After 14 days, new X-rays were performed, which compared to the early sonographic results of the patients. Results. 25 out of the 36 patients that were included in the study found with subperiosteal hematoma, while 11 of them had also cortical discontinuity. Besides, follow-up X-rays were diagnostic of fracture in 22 patients. 7 patients were ultrasound-positive for fracture but their late X-ray's remained negative, while 4 patients were ultrasound-negative with positive X-ray's. We performed a CT scan on these 11 patients, where we found early ultrasound's sensitivity: 87.5%, specificity: 75%, positive prognostic value: 84% and negative prognostic value: 72%. On the other hand, late X-ray's had sensitivity: 87.5%, specificity: 91%, positive prognostic value: 95% and negative prognostic value: 78% in the detection of occult fractures. Conclusion. The use of early scaphoid ultrasound in the E.R. is valuable in the hands of the orthopaedic surgeon and decongests the radiology department and the national health system from further specific and expensive imaging studies. So, this examination offers the possibility to reduce the time of diagnosis of these occult fractures, so as to provide early and correct treatment. Level of Evidence. II

We hypothesised that the use of pulsed electromagnetic field (PEMF) bone growth stimulation in acute scaphoid fractures would significantly shorten the time to union and reduce the number of nonunions in a randomised, double-blind, placebo-controlled multicentre trial. A total of 102 patients (78 male, 24 female; mean age 35 years (18 to 77)) from five different medical centres with a unilateral undisplaced acute scaphoid fracture were randomly allocated to PEMF (n = 51) or placebo (n = 51) and assessed with regard to functional and radiological outcomes (multiplanar reconstructed CT scans) at 6, 9, 12, 24 and 52 weeks. The overall time to clinical and radiological healing did not differ significantly between the active PEMF group and the placebo group. We concluded that the addition of PEMF bone growth stimulation to the conservative treatment of acute scaphoid fractures does not accelerate bone healing.

Cite this article: Bone Joint J 2014; 96-B:1070–6.

The February 2014 Wrist & Hand Roundup³⁶⁰ looks at: simple debridement and ulnar-sided wrist pain; needle fasciotomy or collagenase injection; joint replacement in osteoarthritic knuckles; the Mannerfelt arthrodesis; scaphoid union rates with conservative treatment; the benefits of atorvastatin for muscle re-innervation after sciatic nerve transection; and complications of trapeziectomy.

Background. Scaphoid fractures with displacement have a higher incidence of nonunion and unite in a humpback position that can cause pain and reduced movement, strength and function. The aim of this study is to review the evidence available and establish the risk of nonunion associated with management of displaced scaphoid fractures in a plaster cast. Methods. Electronic databases were searched using the MeSH (Medical Subject Headings) controlled vocabulary (scaphoid fractures, AND'd with explode displaced, or explode nonunion, or explode non-healing or explode cast immobilisation, or explode plaster, or explode surgery). As no randomised or controlled studies were identified, the search was limited to observational studies based on consecutive cases with displaced scaphoid fractures treated in a plaster cast. The criterion for displacement was limited to gap or step of more than 1mm. The ‘random effects’ calculation was used to allow for the possibility that the results from the separate studies differ more than would be expected by chance. Results. Of the 27 articles identified, seven studies were eligible for the meta-analysis with a total of 1401 scaphoids. 93% (1311 scaphoids) of these scaphoid fractures healed in a plaster cast. 207 (15%) of all scaphoid fractures showed displacement of at least 1mm (Gap/step) between fracture fragments. Nonunion was identified in 18% (37/207) of displaced scaphoid fractures treated in a plaster cast. The pooled odds ratio of fracture nonunion between the displaced and undisplaced groups was five times higher with fracture displacement (pooled odds ratio: 5.5, 95%CI: 2.5–12.3; p=0.00, I. 2. =54.6%). The pooled relative risk of fracture nonunion was 4.4 (95%CI: 2.3–8.7; p=0.00 I. 2. =54.3%). Conclusions. Displaced fractures of scaphoid have a four times higher risk of nonunion when treated in a plaster cast and the patients should be advised of this potential risk

A displaced fracture of the scaphoid is one in which the fragments have moved from their anatomical position or there is movement between them when stressed by physiological loads. Displacement is seen in about 20% of fractures of the waist of the scaphoid, as shown by translation, a gap, angulation or rotation. A CT scan in the true longitudinal axis of the scaphoid demonstrates the shape of the bone and displacement of the fracture more accurately than do plain radiographs. Displaced fractures can be treated in a plaster cast, accepting the risk of malunion and nonunion. Surgically the displacement can be reduced, checked radiologically, arthroscopically or visually, and stabilised with headless screws or wires. However, rates of union and deformity are unknown. Mild malunion is well tolerated, but the long-term outcome of a displaced fracture that healed in malalignment has not been established.

This paper summarises aspects of the assessment, treatment and outcome of displaced fractures of the waist of the scaphoid.