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.

Aims

We quantitatively compared the 3D bone density distributions on CT scans performed on scaphoid waist fractures subacutely that went on to union or nonunion, and assessed whether 2D CT evaluations correlate with 3D bone density evaluations.

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.

Penetration of the dorsal screw when treating distal radius fractures with volar locking plates is an avoidable complication that causes lesions of the extensor tendon in between 2% and 6% of patients. We examined axial fluoroscopic views of the distal end of the radius to observe small amounts of dorsal screw penetration, and determined the ideal angle of inclination of the x-ray beam to the forearm when making this radiological view.

Six volar locking plates were inserted at the wrists of cadavers. The actual screw length was measured under direct vision through a dorsal approach to the distal radius. Axial radiographs were performed for different angles of inclination of the forearm at the elbow.

Comparing axial radiological measurements and real screw length, a statistically significant correlation could be demonstrated at an angle of inclination between 5° and 20°. The ideal angle of inclination required to minimise the risk of implanting over-long screws in a dorsal horizon radiological view is 15°.

Cite this article: Bone Joint J 2013;95-B:1101–5.

Follow-up radiographs are usually used as the reference standard for the diagnosis of suspected scaphoid fractures. However, these are prone to errors in interpretation. We performed a meta-analysis of 30 clinical studies on the diagnosis of suspected scaphoid fractures, in which agreement data between any of follow-up radiographs, bone scintigraphy, magnetic resonance (MR) imaging, or CT could be obtained, and combined this with latent class analysis to infer the accuracy of these tests on the diagnosis of suspected scaphoid fractures in the absence of an established standard. The estimated sensitivity and specificity were respectively 91.1% and 99.8% for follow-up radiographs, 97.8% and 93.5% for bone scintigraphy, 97.7% and 99.8% for MRI, and 85.2% and 99.5% for CT. The results were generally robust in multiple sensitivity analyses. There was large between-study heterogeneity for the sensitivity of follow-up radiographs and CT, and imprecision about their sensitivity estimates.

If we acknowledge the lack of a reference standard for diagnosing suspected scaphoid fractures, MRI is the most accurate test; follow-up radiographs and CT may be less sensitive, and bone scintigraphy less specific.

Using inaccurate quotations can propagate misleading information, which might affect the management of patients. The aim of this study was to determine the predictors of quotation inaccuracy in the peer-reviewed orthopaedic literature related to the scaphoid. We randomly selected 100 papers from ten orthopaedic journals. All references were retrieved in full text when available or otherwise excluded. Two observers independently rated all quotations from the selected papers by comparing the claims made by the authors with the data and expressed opinions of the reference source. A statistical analysis determined which article-related factors were predictors of quotation inaccuracy. The mean total inaccuracy rate of the 3840 verified quotes was 7.6%. There was no correlation between the rate of inaccuracy and the impact factor of the journal. Multivariable analysis identified the journal and the type of study (clinical, biomechanical, methodological, case report or review) as important predictors of the total quotation inaccuracy rate.

We concluded that inaccurate quotations in the peer-reviewed orthopaedic literature related to the scaphoid were common and slightly more so for certain journals and certain study types. Authors, reviewers and editorial staff play an important role in reducing this inaccuracy.

This study identified variables which influence the outcome of surgical management on 126 ununited scaphoid fractures managed by internal fixation and non-vascular bone grafting. The site of fracture was defined by a new method: the ratio of the length of the proximal fragment to the sum of the lengths of both fragments, calculated using specific views in the plain radiographs. Bone healing occurred in 71% (89) of cases. Only the site of nonunion (p = 1 × 10⁻⁶) and the delay to surgery (p = 0.001) remained significant on multivariate analysis. The effect of surgical delay on the probability of union increased as the fracture site moved proximally. A prediction model was produced by stepwise logistic regression analysis, enabling the surgeon to predict the success of surgery where the site of the nonunion and delay to surgery is known.

We describe a case of osteosarcoma of the scaphoid bone, which to our knowledge is only the second reported case of osteosarcoma in the carpus. A 38-year-old man complained of intense pain in the right wrist and had curettage and a bone graft for a lesion in the scaphoid. Histological examination showed this to be an osteosarcoma. Below-elbow amputation was performed and adjuvant chemotherapy given. There has been no evidence of recurrence or metastases at 33 months after amputation

1. Bony spurs resulting from erosion of the scaphoid bone and trapezium in rheumatoid arthritis can pierce the floor of the carpal tunnel and cause attrition rupture of flexor tendons–most often the flexor pollicis longus tendon. 2. It is difficult to show these spurs on conventional radiographs, but using a special tomographic technique we have been able to explore the floor of the carpal tunnel in three planes. Using this technique we have been able to guard the flexor pollicis longus against attrition rupture by early excision of a spur from the scaphoid bone. 3. Our findings support the recommendation of free division of the flexor retinaculum in rheumatoid arthritis. When doing this the surgeon should always look for a bony spur piercing the floor of the carpal tunnel

Cancellous inlay bone grafting for delayed union or non-union of the scaphoid bone gives good results in most cases (Table IV). The operation is easy, does not require radiological control and does not damage the dorsal arterial plexus. The indications for the operation are twofold: firstly for patients complaining of disabling symptoms in the wrist joint with an established pseudarthrosis of the scaphoid bone, with neither arthritic changes nor severe avascularity of the proximal fragment; and, secondly, for delayed union in recent fractures despite adequate immobilisation. Union may still occur if conservative treatment is continued further, but because this may take up to eighteen months (during which time most patients would be unable to work), operation is a reasonable alternative. In this series two scaphoid fractures united after operation with some collapse of the proximal fragment. This probably resulted from removal of too much bone (preliminary to inlaying the graft) from an already small fragment with a poor blood supply. The operation can be performed even in the presence of a small proximal fragment and gave a satisfactory result in two out of three such cases

1. Operative treatment of scaphoid pseudarthrosis by the Matti-Russe method is a reliable procedure which in our series has given ninety-seven cases of bony union in a total of 100 operations. 2. We do not hesitate to advise operation for this condition as soon as it is discovered, except in cases with severe secondary osteoarthritis. Equally good results have been reported by Murray (1946) from a series of 100 cases treated with cortical grafts from the tibia (blind method) and by Agner (1963) from a series of twenty-four patients treated by Bentzon's operation (interposition of a pedicled soft-tissue flap). 3. In our opinion, Russe's open operation has great technical advantages over Murray's blind method. 4. We have no experience of Bentzon's operation, which seems attractive on account of its technical simplicity and as not more than two weeks' immobilisation in plaster after operation are needed. 5. It would be interesting to see Agner's results confirmed from other sources. It is true that many scaphoid pseudarthroses remain symptomless for years, as London (1961) has pointed out, but many of them sooner or later cause pain, and we do not agree with London's opinion that a few weeks of immobilisation will usually make the wrist painless. 6. Although severe osteoarthritis is very slow to develop in wrists with pseudarthrosis of the scaphoid bone it cannot be denied that these wrists are constantly threatened with suddenly developing pain and by progressive deterioration of function. 7. Therefore, early repair of pseudarthrosis of the scaphoid bone is advisable; it can be expected to save many wrists from progressive loss of function and from final development of severe degenerative change

1. Nine cases of disturbance of the relationship between the scaphoid and the radius and between the scaphoid and the lunate bones are described. 2. Persistent dislocation of the scaphoid bone may follow reduction of perilunar dislocations or of other dislocations of the proximal row of the carpus. It may be obvious, as in waist-deep dislocation, or may be solely a rotational dislocation which may be difficult to diagnose. 3. Uncorrected rotational dislocation of the scaphoid bone caused significant disability in six of seven cases. 4. Aids to the diagnosis of this condition are described and a vigorous approach to the problem of correction is advocated. 5. The experience of other workers in this field is reviewed and discussed

1. The bad reputation of fractures of the scaphoid bone is based on a) past disasters caused by inadequate splintage and premature resort to operation; and b) selection of disabling cases for publication. 2. The results obtained in five series comprising over 1,000 fractures suggest that 95 per cent of adequately studied fractures less than a month old unite if properly treated. 3. Sixty cases of established non-union have provided evidence that disability is almost always the result of further injury and that the disability is usually relieved by a short time in plaster. 4. There is no evidence to support the widely held beliefs that a) union by bone can occur only if the fracture is immobilised throughout the process; and b) union after prolonged immobilisation is due to the immobilisation. 5. A policy of treating the wrist and not merely its radiological appearances is advocated