The purpose of this study is to introduce our technique of free hand screw insertion for scaphoid fractures and clarify the indications of this procedure.

From 1988 to date, we performed this method in 86 cases (75 males and 11 females). Ages ranged from 11 to 73 years (av.: 29). There were 24 cases of acute stable type, 46 of acute unstable and 16 of delayed fibrous union. Screws used were original Herbert screws in 48, other cannulated type screws in 38.

Using an image intensifier, from a small skin incision over the scaphotrapezium joint, a Kirschner wire is inserted to stabilize the fracture temporarily. The wire is pulled volarward to rotate the scaphoid and a second wire is inserted along the intended line of the screw. With the original Herbert screw, after removing the wire, the screw is inserted free-hand. With the other cannulated screws, the second wire is used as guide pin.

Results of 82 cases with follow-up times over 6 months were reviewed. In one case, bony fusion was achieved but revealed symptomatic malunion. In two cases, bony fusion was not achieved. In one of them, an additional bone graft was performed, and good bony union was achieved. In the remaining 79 cases, good bony fusion and good clinical results were achieved.

The best indication for this method is an acute unstable fracture. For acute stable fractures, we recommend this method for three types of patients: those who cannot accept long term immobilization, those who desire to return to athletic activities as soon as possible, and those who also have another fracture in the forearm. It can also be used in cases of delayed fibrous union when good alignment can be achieved and a bone graft is unnecessary.

Between 1982 and 2000, 37 cases of fractures of the odontoid process were treated at Hirosaki University Hospital. There were 16 females and 21 males, with an average age of 43.9 and 37.7 respectively. Twenty-three of 37 were type II and 14 were type III by the classification of Anderson and D’Alonzo. Eight of type II were old fractures. Nineteen of them were injured in traffic accidents, 9 in accidental falls from a height, 4 by falling down, 2 in lumbering accidents and 3 by unknown causes. Severe neurological disorders were recognized in 7, mild in 12 and 22 had no neurological disorders. Neurological disorders were correlated with SAC (space available for spinal cord) at C1-2. Twenty-two of type II (95.7%) and 10 of type III (71%) were treated surgically. Surgical methods were anterior screw fixation of the odontoid process in 7, anterior atlanto-axial joint fixation in 3, posterior atlanto-axial joint fixation in 5, posterior occipito-cervical fusion in 3, anterior and posterior combined fixation of the atlanto-axial joint in 2 and others in 2. Bone union was obtained in 18 (81.8%) of type II and 10 (100%) of type III by the primary operations. There was no nonunion in anterior screw fixation cases. Nonunion occured in one of type II (100%) and 2 of type III (50%) treated nonoperatively. Two of them were operated for nonunion. One of them remained nonunion by two additional operations. No case of nonunion showed neurological deterioration for 91.8 months after treatment on average. Anterior direct screw fixation of the odontoid process is superior to the other methods in the point of immobilization of the odontoid fragment without limiting the motion of the atlanto-axial joint. We recommend anterior direct screw fixation of the odontoid process as a first choice of the surgical method for fresh fractures of the odontoid process in cases with reduced fragments.