Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures

BACKGROUND: Nondisplaced scaphoid fractures treated with prolonged cast immobilization may result in temporary joint stiffness and muscle weakness in addition to a delay in return to sports or work. Fixation of scaphoid fractures with a percutaneous cannulated screw has resulted in a shorter time to union and to return to work or sports. The purpose of this prospective, randomized study was to compare cast immobilization with percutaneous cannulated screw fixation of nondisplaced scaphoid fractures with respect to time to radiographic union and to return to work. METHODS: Twenty-five full-time military personnel with an acute nondisplaced fracture of the scaphoid waist consented to be randomized to either cast immobilization or fixation with a percutaneous cannulated Acutrak screw (Acumed, Beaverton, Oregon) for the purpose of this study. Time to fracture union, wrist motion, grip strength, and return to work as well as overall patient satisfaction at the time of a two-year follow-up were evaluated. RESULTS: Eleven patients were randomized to percutaneous cannulated screw fixation, and fourteen were randomized to cast immobilization. The average time to fracture union in the screw fixation group was seven weeks compared with twelve weeks in the cast immobilization group (p = 0.0003). The average time until the patients returned to work was eight weeks compared with fifteen weeks in the cast immobilization group (p = 0.0001). There was no significant difference in the range of motion of the wrist or in grip strength at the two-year follow-up evaluation. Overall patient satisfaction was high in both groups. CONCLUSIONS: Percutaneous cannulated screw fixation of nondisplaced scaphoid fractures resulted in faster radiographic union and return to military duty compared with cast immobilization. The specific indications for and the risks and benefits of percutaneous screw fixation of such fractures must be determined in larger randomized, prospective studies.     

背侧入路经皮加压螺钉内固定治疗舟骨骨折的临床研究

目的介绍背侧入路经皮加压螺钉内固定治疗舟骨骨折的适应证、手术方法和疗效。方法2009年4~10月,采用背侧入路经皮加压螺钉固定小切口空心钉技术治疗6例急性舟骨骨折的患者,骨折分型为HerbertB2,B3型。术中以Lister结节为标志,于其远端0·5~1cm处触及舟骨近极,在导针引导、C型臂监视下、沿舟骨轴线打入合适长度的加压螺钉。结果6例患者均有初步随访资料,随访时间为4至6个月,平均5个月。B2型骨折平均愈合时间为8周,B3型骨折平均愈合时间为12周;恢复工作时间平均为14d;活动度达到健侧90%以上;无疼痛等不适感觉。没有并发症。结论背侧入路经皮加压螺钉技术治疗急性舟骨骨折创伤小,根据骨折类型不需外固定或外固定时间较保守治疗缩短,愈合率高,治疗结果满意。     

针头引导下经皮无头空心加压螺钉内固定治疗急性腕舟状骨非移位性骨折

目的：探讨针头引导下经皮空心加压螺钉内固定治疗急性腕舟状骨非移位骨折的疗效。方法 ：回顾性分析2014年1月至2019年1月治疗的急性舟状骨非移位性骨折患者28例,根据术中置入空心螺钉导针方法的不同分为引导组（16例）和常规组（12例）。引导组男13例,女3例,年龄20～60 (31.42±9.71)岁;Herbert A2型5例,B1型3例,B2型8例,采取针头引导下经皮空心加压螺钉内固定;常规组男11例,女1例,年龄23～61 (30.51±7.52)岁;Herbert A2型5例,B1型2例,B2型5例,采取常规经皮空心加压螺钉内固定。观察并对比两组患者的手术时间、术后正侧位X线片螺钉与舟状骨长轴夹角、腕关节功能评分。结果：28例患者获随访,时间20～45(33.00±8.72)个月。所有患者无术中并发症,无手术切口感染,术后2周逐步恢复工作,骨折12周内均愈合。在手术时间上,引导组少于常规组（P<0.05）。在术后X线片螺钉与舟状骨轴线夹角上,引导组小于常规组（P<0.05）。末次随访Mayo腕关节功能评分差异均无统计学意义（P>0.05）。随访期内28例患者...     

Open reduction and internal fixation of acute displaced scaphoid waist fractures

Fourteen consecutive patients with acute displaced scaphoid waist fractures were treated with open reduction and internal fixation. The operative technique consisted of anatomic reduction of the displaced scaphoid waist fracture, correction of carpal instability, radial bone grafting for comminution, and internal fixation with K-wires or Herbert screw. The patients were evaluated an average of 26 months (range, 4-48 months) after surgery. Thirteen of the 14 (93%) fractures united. The average time to union was 11.5 weeks (range, 8-20 weeks). Fracture union was confirmed with trispiral tomography. Final radiographic assessment consistently revealed a healed scaphoid fracture, restored intrascaphoid alignment, and no evidence of carpal instability. All patients regained functional wrist range of motion (wrist extension, 57 degrees; wrist flexion, 52 degrees ) and grip strength. Open reduction and internal fixation of acute displaced scaphoid waist fractures restores scaphoid alignment and leads to predictable union. Early operative intervention avoids malunion and carpal instability that often occurs with closed management of these complex fractures.     

闭合复位经皮Herbert螺钉内固定治疗新鲜稳定型舟骨腰部骨折

目的：观察闭合复位经皮Herbert螺钉内固定治疗新鲜稳定型舟骨腰部骨折的临床疗效。方法对采用闭合复位经皮Herbert螺钉内固定治疗的12例新鲜稳定型舟骨腰部骨折患者进行随访,采用修订后Mayo腕关节评分标准对临床效果进行评价。结果所有患者均获得随访,随访时间13~23个月（平均15个月）,无感染、螺钉松动、过敏排斥反应及关节炎的发生。所有患者骨折均愈合,骨折愈合时间为8~14周,平均10周。按修订后Mayo腕关节评分标准：优7例,良4例,可1例,优良率91.7%。结论闭合复位经皮Herbert螺钉内固定治疗新鲜稳定型舟骨腰部骨折,具有操作简单,固定可靠,并发症少及能早期进行功能锻炼等优点。     

Percutaneous fixation of scaphoid fractures.

The scaphoid proximal pole and waist fractures presented here were treated by a novel dorsal percutaneous technique with arthroscopic assistance. All fractures healed, with good final functional results and no complications. The advantages of the dorsal percutaneous approach to scaphoid fixation are: (1) the proximal-to-distal placement of the guide pin and screw allow for more precise placement along the central axis of the scaphoid, which decreases healing time and reduces risk of screw thread exposure. (2) The dorsal approach avoids injuring the vulnerable volar ligament anatomy. And (3) the insertion of the screw from the proximal to distal direction allows the more rigid fixation of proximal scaphoid fractures. Arthroscopy allows confirmation of fracture reduction and screw implantation as well as evaluation of concurrent ligament injuries not detected with standard imaging. Percutaneous K-wires act as joysticks to reduce and compress fracture fragments prior to fixation. The presented technique allows for early, rigid internal fixation with minimal associated morbidity. Patients successfully treated with this technique include those with stable and unstable acute fractures of the scaphoid at all locations, including the proximal pole. Nondisplaced fractures that present with delayed or fibrous union without evidence of avascular necrosis, cyst formation, or bony sclerosis may also be treated with this technique. This technique allows for faster rehabilitation and an earlier return to work or avocation without restriction once CT scan confirms a solid union. Some articles document extraordinary rapid healing by standard radiographs; however, we caution that scaphoid bone healing cannot accurately be determined without CT scan. Percutaneous, arthroscopically assisted internal fixation by a dorsal approach may be considered in all acute scaphoid fractures selected for surgical fixation. The dorsal guidewire permits dorsal and volar implantation of a cannulated screw along the central axis of the scaphoid. This technique permits the reduction of displaced fractures and the stable repair of fractures of the proximal pole. In addition, selected scaphoid fibrous union or delayed union may also be repaired, with realistic expectations of healing. The proven benefits of the percutaneous technique include decreased soft tissue trauma; arthroscopic visualization of the fracture, ensuring anatomic reduction; and stable fixation, allowing early physical rehabilitation. The theoretical benefits of the technique include decreased risk of interruption of the tenuous scaphoid blood supply. Percutaneous internal fixation of scaphoid fractures provides faster rehabilitation, earlier return to work, and quicker bony union in most patients.     

Minimally invasive management of scaphoid fractures

Percutaneous internal fixation of scaphoid fractures allows for more predictable union and less morbidity than cast treatment or open internal fixation. This technique is appropriate for both acute scaphoid waist and proximal pole fractures, as well as selected nonunions. A headless cannulated compression screw (standard Acutrak) is implanted via a dorsal percutaneous approach using fluoroscopy and arthroscopy to confirm position and reduction. The details of this technique are reviewed. In a consecutive series of 27 fractures treated with arthroscopic assisted dorsal percutaneous fixation, eighteen fractures were treated acutely and 9 were treated more than 1 month after injury. CT scan confirmed 100% union rate at an average of 12 weeks with no complications.     

Complications in dorsal percutaneous cannulated screw fixation of nondisplaced scaphoid waist fractures

PURPOSE: With advances in tools and techniques, percutaneous screw fixation of nondisplaced fractures of the scaphoid waist has gained increasing popularity in recent years as an alternative to prolonged cast immobilization or open reduction and internal fixation. Many reports cite low complication rates, including no complications in some series. The purpose of this study was to evaluate the complications encountered with dorsal percutaneous cannulated screw fixation of nondisplaced scaphoid waist fractures. METHODS: A retrospective chart review was performed for 24 patients who had surgery performed by a single surgeon over a 5-year period. All cases involved dorsal percutaneous cannulated screw fixation of nondisplaced (<1 mm) fractures of the scaphoid waist. Complications were rated a priori as major or minor based on modifications of established criteria. RESULTS: The overall complication rate was 29%; there were 21% (5/24) major complications and 8% (2/24) minor complications. Major complications consisted of 1 case of nonunion, 3 cases involving hardware problems, and 1 case of postoperative fracture of the proximal pole of the scaphoid. Minor complications included intraoperative equipment breakage-1 case involving a screw and 1 case involving a guide wire. CONCLUSIONS: Complications in dorsal percutaneous cannulated screw fixation of scaphoid fractures may be more common than previously reported.     

Percutaneous screw fixation versus conservative treatment for fractures of the waist of the scaphoid: a prospective randomised study

We randomly allocated 60 consecutive patients with fractures of the waist of the scaphoid to percutaneous fixation with a cannulated Acutrak screw or immobilisation in a cast. The range of movement, the grip and pinch strength, the modified Green/O'Brien functional score, return to work and sports, and radiological evidence of union were evaluated at each follow-up visit. Patients were followed sequentially for one year. Those undergoing percutaneous screw fixation showed a quicker time to union (9.2 weeks vs 13.9 weeks, p < 0.001) than those treated with a cast. There was a trend towards a higher rate of nonunion in the non-operative group, although this was not statistically significant. Patients treated by operation had a more rapid return of function and to sport and full work compared with those managed conservatively. There was a very low complication rate. We recommend that all active patients should be offered percutaneous stabilisation for fractures of the waist of the scaphoid.     

Fixation of nondisplaced scaphoid fractures: making treatment cost effective

Introduction Nondisplaced scaphoid waist fractures treated with prolonged plaster immobilisation often lead in transient joint stiffness and to a delay in return to sport and work activity. The long time off work increases the work off compensation costs. Internal fixation of scaphoid fractures has resulted in a shorter time to union and to return to work and sports. This prospective study compares cast immobilisation with screw fixation and the direct cost with indirect cost of conservative and minimally invasive treatment of undisplaced scaphoid fractures. Materials and methods Forty-seven patients with an acute nondisplaced waist fracture of the scaphoid were allocated into either cast immobilisation or internal screw fixation for this study. Cost data concerning the groups of nonoperated and operated patients were analysed. Range of wrist motion, grip strength, DASH-score, time to fracture union, return to work time and the needed physiotherapy at the final follow-up at 6 months were evaluated. Results Twenty-one patients were included in the group of screw fixation and 23 patients were included in the group of cast immobilisation. At final follow-up there was no significant difference in the range of motion of the wrist or in grip strength. The operatively treated group had a better mean DASH-score than the conservative group. Fracture union was seen in the screw fixation group at a mean of 43 days and in the cast immobilisation group at a mean of 74 days (P < 0.5). The average time of return to work was 8 days for patients who had an internal screw fixation, while those treated with a cast returned to work at a mean of 55 days (P < 0.5). In total the internal fixation of undisplaced scaphoid fractures is less expensive than conservative treatment. Conclusion Internal screw fixation of nondisplaced scaphoid fractures had a shorter time to bony union and the patients returned earlier to work compared with cast immobilisation. Although it is assumed that operative treatment is more expensive, in this study the cost was not found to be higher.     

手术治疗舟骨骨折49例结果及体会

目的报道手术治疗49例舟骨骨折的结果及体会。方法经皮或切开复位Acutrak钉/空心钉/可吸收钉/U形钉内固定舟骨骨折,陈旧性骨折及骨坏死者加做带血管蒂桡骨茎突骨瓣移植,记录术后骨折愈合时间、握力、腕关节活动度、疼痛、恢复工作时间及腕关节功能评分。结果对本组患者进行随访1～8.5年,平均3.6年;骨折愈合时间为7～12周,平均10.8周。腕关节平均评分85.2分;功能优28例,良21例,差0例。所有患者均恢复原来的工作或改为较轻的工作。结论经皮或切开复位螺钉固定、带血管蒂桡骨茎突骨瓣移植是治疗舟骨骨折的一种好方法;骨折类型不同,手术方法也需有所变化。Acutrak钉固定效果好于空心钉或可吸收钉。短期随访,未见有桡骨茎突切除的并发症。桡腕关节桡侧切口有利于显露骨折端及骨瓣制备,值得推荐。带血管蒂桡骨茎突骨瓣移植可缩短骨折愈合时间。     

Treatment of Delayed/Nonunion of Scaphoid Waist with Synthes Cannulated Scaphoid Screw and Bone Graft

Fracture of the scaphoid bone is the most common fracture of the carpus, and frequently, diagnosis is delayed. The unique anatomy and blood supply of the scaphoid itself predisposes to delayed union or nonunion. The Synthes scaphoid screw is a cannulated headed screw, which provides superior compression compared with some other devices used to internally fix scaphoid nonunions. Our aim was to conduct a retrospective study looking at the 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. This study is a review of a cohort of 30 patients treated with a cannulated Synthes scaphoid screw and corticocancellous bone grafting for scaphoid waist delayed union and nonunion at our center. We achieved 86% overall union rate. The patients with delayed union achieved a 100% union rate. Three out of four patients with persistent nonunion after surgery reported no pain and improved function. The failure rate was 75% in patients who had sustained their fracture more than 5 years previously. Our study demonstrates that delayed union of scaphoid waist fractures and scaphoid waist nonunions present for less than 5 years can be successfully treated by fracture compression and bone grafting. No support of any kind was received from anybody.     

Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach

Percutaneous internal fixation of scaphoid fractures allows for more predictable union and less morbidity than cast treatment or open internal fixation. A headless cannulated compression screw (standard Acutrak) is implanted by way of a dorsal percutaneous approach with the aid of fluoroscopy and arthroscopy to confirm screw position and fracture reduction. This technique is indicated in the correction of acute proximal pole fractures, acute waist fractures, and delayed unions that are not associated with avascular necrosis or collapse. The details of this technique are reviewed. In a consecutive series of twenty-seven fractures (seventeen waist fractures and ten proximal pole fractures) treated with arthroscopically assisted dorsal percutaneous fixation, computed tomographic scanning confirmed 100% union at an average of twelve weeks. Eighteen fractures were treated within one month after the injury, and nine were treated more than one month after the injury. In this series, the fractures that were treated early (less than one month after the injury) healed more quickly than those treated later.     

Displaced scaphoid fractures treated with open reduction and internal fixation with a cannulated screw

BACKGROUND: This study was performed to determine if the accuracy of screw placement was improved with use of the Herbert-Whipple cannulated screw compared with use of the AO/ASIF cannulated screw and also to evaluate the functional results in patients with an acute displaced fracture of the waist of the scaphoid treated with open reduction and internal fixation with a cannulated screw. METHODS: We retrospectively reviewed the results for thirty-five patients in whom an acute displaced fracture of the waist of the scaphoid had been treated with internal fixation with use of a cannulated screw. The patients were divided into two groups; Group 1 consisted of nineteen patients managed with a 3.5-millimeter cannulated AO/ASIF screw from 1990 through 1997, and Group 2 consisted of sixteen patients managed with a Herbert-Whipple screw from 1993 through 1997. RESULTS: There were no clinical or radiographic differences between the two groups. The average time to union (and standard deviation), confirmed with tomography, was 4.2 +/- 1.2 months for Group 1 and 4.0 +/- 1.2 months for Group 2. Both screws significantly improved the alignment of the scaphoid and decreased carpal collapse (p < 0.01). Importantly, the use of either cannulated screw improved the height-to-length ratio and the lateral intrascaphoid angle, which were correlated with an increase in the range of motion of the wrist (r = 0.584 and 0.625). In addition, both screws allowed for accurate placement in the central portion of the proximal pole. Regardless of the type of screw used, the time to union increased with increasing age of the patient (r = 0.665) and with increasing initial displacement of the fracture (r = 0.541). Within both groups, the time to union was longer for the patients who smoked (p < 0.01). CONCLUSIONS: Within both groups, cannulated screw fixation maintained the corrected fracture alignment and promoted healing and return of function. Our study shows cannulated screws to be a safe and effective method of treatment.     

Treatment of scaphoid nonunion with 1,2 intercompartmental supraretinacular artery vascularized graft and compression screw fixation

PurposeAim of the present study was to evaluate the clinical, functional, and radiological outcomes of 1,2-intercompartmental supraretinacular artery (1.2-ICSRA) vascularized graft technique together with compression screw fixation for the management of scaphoid nonunions.MethodsA retrospective study was designed to evaluate the medical records of the 21 patients treated with 1,2-ICSRA vascularized graft for established scaphoid nonunion of the waist or proximal pole between 2015 and 2018. Seventeen patients who met the criteria were included in the study. The retrospectively analysed demographic parameters included age, gender, injured hand (dominant/non-dominant), aetiology of the injury, delay between injury and operation, initial treatments following the fracture, tobacco use, and background diseases that may affect healing (diabetes, vasculopathy etc.). Radiological and clinical examinations were routinely performed 2 weeks, 6 weeks, 3 months and 6 months after surgery and during the final follow-up. Postoperative clinical and functional outcomes at the latest follow-up were evaluated by measuring active wrist range of motion, grip strength, Turkish version of Quick Disabilities of the Arm, Shoulder and Hand Questionnare (Quick DASH) and Mayo Wrist scores and comparing them with preoperative values.ResultsAll 17 patients were male with an average age of 26.82 ± 4.08 years (range 20–35 years). The fracture site was located in the scaphoid waist and proximal pole in 5 (29.4%) and 12 (70.6%) patients, respectively. Avascular necrosis was observed in 13 patients (2 at the waist, 11 at the proximal pole). The mean follow-up duration was 18.88 ± 11.98 months (range 6–44 months). No graft extrusion occurred, and no other complication was observed in any of the patients. Amongst the 17 patients, 15 (88.2%) achieved union. The total wrist motions of patients were better postoperatively than preoperatively. However, only improvement in wrist extension was found to be statistically significant. Quick DASH and Mayo Wrist scores of the patients and grip strength were significantly improved postoperatively.ConclusionThe 1,2-ICSRA vascularized graft technique together with compression screw fixation offers an easy and reliable option for the treatment of scaphoid nonunions with a high union rate and good functional and clinical outcomes.Level of Evidence : IV Therapautic     

Arthroscopic-assisted percutaneous reduction and screw fixation of displaced scaphoid fractures

Many scaphoid fractures can be treated with percutaneous screw insertion, but fracture displacement usually necessitates open reduction. Two surgeons treated 20 consecutive patients with displaced fractures of the scaphoid using arthroscopic-assisted percutaneous screw fixation. Thirteen patients had dorsal (antegrade) and seven had palmar (retrograde) percutaneous screw insertion. At an average follow-up of 18 (range 6-48) months, all of the fractures were healed and there were no implant problems. The early results of arthroscopic-assisted percutaneous screw fixation of displaced fractures of the scaphoid suggest that union can be obtained and good to excellent function achieved predictably without the need for open exposure. Avoidance of an open exposure limits wrist ligament injury and may preserve blood supply. Further evaluation of this procedure is merited.     

双空心螺钉内固定术治疗Herbert B型腕舟骨骨折

目的探讨采用2枚微型空心螺钉内固定术治疗腕舟骨骨折的临床疗效。方法对13例腕舟骨骨折采用双空心螺钉行切开复位内固定术,均选择掌侧入路,早期功能锻炼。术后评估腕部疼痛、腕关节活动度、手部握力及骨折愈合情况,并用Krimmer评分法评估疗效。结果 13例均获随访,随访时间12～32个月,平均15个月。骨折均一期愈合,治愈率为100%。愈合时间为4～9周,平均6周。11例活动度与健侧相同,无疼痛等不适感觉。2例桡偏和掌屈欠5°～10°,腕关节掌屈时感轻度疼痛,无其他并发症。按Krimmer评分法评估总体疗效:优11例,良2例。结论采用双空心螺钉切开复位内固定治疗腕舟骨骨折,愈合率高,功能恢复好,是治疗腕舟骨骨折的一种较好方法。     

经皮腕背入路DTJ空心螺钉内固定治疗舟骨骨折

目的 总结经皮腕背人路DTJ空心螺钉内固定治疗舟骨骨折的经验.方法 利用经皮腕背人路DTJ空心螺钉内固定治疗舟骨骨折患者12例,男10例,女2例;年龄16~39岁,平均25岁.根据改良Herbert舟骨骨折分型:A2型3例,82型5例,83型2例,D1型2例.10例新鲜骨折患者自受伤至就诊时间为1~12d,平均3.5d;2例纤维愈合患者自受伤至就诊时间分别为76d和68d.结果 骨愈合时间为术后6.5~9.5周,平均8.5周.除1例患者行体力劳动后自觉有轻度腕痛外,其余11例患者术后疼痛均消失.患者均获得随访,随访时间6~26个月,平均14个月.12例患者术后患手握力恢复至健侧的平均86.4%(82%~93%),患侧腕关节屈伸活动度恢复至健侧的平均87.5%(83%~100%).除1例患者体力劳动后自觉有轻度腕痛改变原工作外,6例患者于术后平均5.5周(4.5~8周)返回原工作岗位,5例学生患者于术后平均4.5个月(3~6个月)恢复体育运动.所有患者腕背小切口均一期愈合,无感染等并发症发生.结论 经皮腕背入路DTJ空心螺钉内固定是一种微创、骨折愈合率高、并发症相对较少的舟骨骨折的有效治疗方法.     

应用掌侧小切口空心钉技术治疗新鲜舟骨骨折

目的 探讨应用掌侧小切口空心钉技术治疗新鲜舟骨骨折的疗效. 方法 2003年1月至2007年12月期间采用小切口空心钉技术治疗16例新鲜舟骨骨折,骨折按Herbert分型:A2型11例,B2型5例,其中2例合并桡骨远端骨折.术中以舟骨结节为中心,在腕关节掌桡侧做2 am长小切口,切除大多角骨基底掌侧关节面后,在导针引导、C型臂监视下于舟骨轴线上打入AO空心加压螺钉,术后不需外固定. 结果 16例中12例获得完整随访,时间6～55个月,平均18个月.骨折平均愈合时间42 d,恢复工作时间平均10 d(3～28 d).10例活动度与健侧相同,2例桡偏和掌屈欠50°10例无疼痛等不适感觉,2例腕关节掌屈时感轻度疼痛,无其他严重并发症. 结论 掌侧小切口空心钉固定舟骨腰部骨折具有方法简单、创伤小、不需外固定、愈合率高等优点,治疗结果满意.     

Percutaneous cannulated screw fixation of acute scaphoid waist fracture

This prospective study assessed the outcome of percutaneous cannulated screw fixation in 49 of 60 acute scaphoid fractures. The union rate was 100% (mean time for radiological union at 12 weeks). There were no early or mid-term complications and all achieved an excellent functional recovery.