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.

Purpose. Knowing the morphology of any fracture, including scaphoid fractures, is important in order to determine the fracture stability and the appropriate fixation technique. Scaphoid fractures are classified according to their radiographic appearance, and simple transverse waist fractures are considered the most common. There is no description in the literature of the 3-dimensional morphology of scaphoid fractures. Our hypothesis was that most scaphoid fractures are not perpendicular to its long axis, i.e. they are not simple transverse fractures. Methods. A 3-dimensional analysis was performed of CT scans of acute scaphoid fractures, conducted at two medical centres during a period of 6 years. A total of 124 scans were analysed (Amira Dev 5.3, Visage Imaging Inc). Thirty of the fractures were displaced and virtually reduced. Anatomical landmarks were marked on the distal radius articular surface in order to orient the scaphoid in the wrist. Shape analysis of the scaphoids and a calculation of the best fitted planes to the fractures were carried out implementing principal component analysis. The angles between the scaphoid's first principal axis to the fracture plane, articular plane and to the palmar-dorsal direction were measured. The fractures were analysed both for location (proximal, waist and distal) and for displacement. Results. There were 86 fractures of the waist (76 percent), 13 of the distal third and 25 of the proximal third. The average angle between the first principal axis of the scaphoid and the fracture plane was 52.6 degrees (SD 17) for all fractures, 55.6 degrees (SD 17.2) for the waist fractures, both differing significantly from a right angle (p<0.001). The majority of fractures were found to be horizontal oblique. We found no difference between the angles of the waist fractures which were displaced and those that were not displaced. In contrast, a significant difference was found between the displaced and non-displaced fractures when evaluating the orientation of the scaphoid long axis in relation to the articular plane (139.8 degrees with reduction versus 148.2 without; p=0.036). Conclusions. Most waist fractures were found to be horizontal oblique in relation to the long axis of the scaphoid and not transverse. Although the fracture angle could not explain displacement of the fracture, we found that the orientation of the scaphoid's long axis in relation to the radial articular surface was correlated with fracture displacement. According to these findings, fixation of all fractures along the long axis of the scaphoid should not be the optimal mode of fixation. Optimal fixation of acute scaphoid fractures may call for better analysis of each fracture configuration and the fixation should be guided by this analysis

Purpose. Knowing the morphology of any fracture, including scaphoid fractures, is important in order to determine the fracture stability and the appropriate fixation technique. Scaphoid fractures are classified according to their radiographic appearance, and simple transverse waist fractures are considered the most common. There is no description in the literature of the 3-dimensional morphology of scaphoid fractures. Our hypothesis was that most scaphoid fractures are not perpendicular to its long axis, i.e. they are not simple transverse fractures. Methods. A 3-dimensional analysis was performed of CT scans of acute scaphoid fractures, conducted at two medical centers during a period of 6 years. A total of 124 scans were analysed (Amira Dev 5.3, Visage Imaging Inc). Thirty of the fractures were displaced and virtually reduced. Anatomical landmarks were marked on the distal radius articular surface in order to orient the scaphoid in the wrist. Shape analysis of the scaphoids and a calculation of the best fitted planes to the fractures were carried out implementing principal component analysis. The angles between the scaphoid's first principal axis to the fracture plane, articular plane and to the palmar-dorsal direction were measured. The fractures were analysed both for location (proximal, waist and distal) and for displacement. Results. There were 86 fractures of the waist (76 percent), 13 of the distal third and 25 of the proximal third. The average angle between the first principal axis of the scaphoid and the fracture plane was 52.6 degrees (SD 17) for all fractures, 55.6 degrees (SD 17.2) for the waist fractures, both differing significantly from a right angle (p<0.001). The majority of fractures were found to be horizontal oblique. We found no difference between the angles of the waist fractures which were displaced and those that were not displaced. In contrast, a significant difference was found between the displaced and non-displaced fractures when evaluating the orientation of the scaphoid long axis in relation to the articular plane (139.8 degrees with reduction versus 148.2 without; p=0.036). Conclusions. Most waist fractures were found to be horizontal oblique in relation to the long axis of the scaphoid and not transverse. Although the fracture angle could not explain displacement of the fracture, we found that the orientation of the scaphoid's long axis in relation to the radial articular surface was correlated with fracture displacement. According to these findings, fixation of all fractures along the long axis of the scaphoid should not be the optimal mode of fixation. Optimal fixation of acute scaphoid fractures may call for better analysis of each fracture configuration and the fixation should be guided by this analysis

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