Fracture of the carpal scaphoid. A prospective, randomised 12-year follow-up comparing operative and conservative treatment

We compared the long-term outcome in 61 patients (62 fractures) treated operatively or conservatively for an acute fracture of the carpal scaphoid. A total of 30 fractures was randomised to conservative treatment using a cast and 32 to operative treatment using a Herbert bone screw. The duration of sick leave was shorter for patients treated by operation, but this was only significant in patients with blue-collar occupations. There were no differences between the groups in respect of function, radiological healing of the fracture, or carpal arthritis after follow-up at 12 years. Those managed by operation showed radiological signs of arthritis of the scaphotrapezial joint more often, but this finding did not correlate with subjective symptoms. Operative treatment of an acute fracture of the scaphoid allows early return of function and should be regarded as an alternative to conservative treatment in patients in whom immobilisation in a cast for three months is not acceptable for reasons related to sports, social life or work.     

Ipsilateral fractures of the distal radius and scaphoid treated by Herbert screw and external skeletal fixation. A report of two cases.

Two patients with comminuted, displaced fractures of the distal radius associated with ipsilateral, undisplaced scaphoid fractures were treated by internal fixation of the scaphoid fracture with a Herbert screw in association with external fixation of the distal radial fracture. One of the patients had a limited open reduction of the distal radius combined with bone grafting. Both patients had satisfactory results. Internal fixation of the scaphoid is indicated if distraction is applied to the carpus to treat an associated fracture of the distal radius, even if the scaphoid fracture is undisplaced.     

The scaphoid allograft: a new operation for treatment of the very proximal scaphoid nonunion or for the necrotic, fragmented scaphoid proximal pole

This is a preliminary report of eight cases in which an allograft was used to replace half of the scaphoid. The indications for the procedure include the following: (1) Severe necrosis with fragmentation of the proximal pole, (2) Very proximal pole nonunion with small (less than 20% of the bone), unreconstructable proximal fragments, and (3) One case of severely comminuted intra-articular fracture of the scaphotrapezial joint and basal joint of the thumb caused by a gunshot wound. The Herbert scaphoid screw was used to provide rigid fixation. Follow-up ranged from 8 to 30 months. The result was good in six of eight patients. It should be emphasized that this is a preliminary report of the early experience with a new operation for salvage of difficult scaphoid fracture problems.     

Incidence of osteoarthritis in the scapho-trapezial joint after Herbert screw fixation of the scaphoid

Twenty patients treated with a Herbert screw for scaphoid fractures (acute or non-union) were reviewed and X-rayed 5-10 years later to assess whether there were degenerative changes in the scapho-trapezial joint due to insertion of the screw. Six had some irregularity in the lateral part of that joint, three of which followed backing-out of the screw. Two others were described as showing irregularity all round the scaphoid but, apart from these, no radiological abnormalities were seen in the central or ulnar part of the scapho-trapezial joint, or on the proximal tip of the scaphoid.     

Flexor carpi radialis tendinitis caused by malunited trapezial ridge fracture in a professional baseball player

Flexor carpi radialis tendinitis is an uncommon cause of pain experienced over the flexor aspect of the wrist. It may be a primary condition caused by overuse syndrome, or it may be a secondary condition associated with osteoarthritis of the carpometacarpal joint of the thumb, osteoarthritis of the scaphotrapezial joint, scaphoid fracture, or scaphoid cyst. We present a case report of flexor carpi radialis tendinitis caused by a malunited trapezial ridge fracture, in a professional baseball player who was treated successfully by excision of the malunited trapezial ridge fragment. Received: May 1, 2001 / Accepted: September 16, 2001     

Internal fixation of scaphoid non-union: a comparative study of three methods

In this study we compared the results of three methods of fixation for scaphoid non-union. The implants used were the AO 2 mm mini-fragment screw, the Herbert screw and the Kirschner (K) wires. Between 1990 and 1999, 132 patients underwent surgery for scaphoid fractures. We used the modified Filan and Herbert classification. Patients with acute fractures and patients requiring vascularised bone grafts were excluded. Twenty-six non-unions were fixed with an AO mini-fragment screw, 58 with a Herbert screw, and nine with K-wires. Radiological union was achieved in 85% of cases using the AO screw, 77% using the Herbert screw and 55% using the K-wire fixation. Statistically there was no significant difference between the AO and Herbert screw groups in terms of rate and speed of radiological union. The mechanical strength of the implant and the compression achieved did not seem to influence the union rate and speed. The type of bone graft (iliac crest or distal radius) did not significantly affect the union rates. Finally, K-wire fixation, either as a primary method or as a salvage procedure, produced inferior results and required prolonged immobilisation in plaster.     

Kahnbeinfrakturen mit palmarer Trümmerzone

Two cases of acute scaphoid fractures of the middle third with palmar comminution were treated with cancellous bone transplantation and Herbert screw fixation. Despite 6 weeks of cast immobilization, secondary loss of reduction resulted in primary grade dislocation in one patient. In the other patient scaphoid dislocation led to dorsiflexed intercalated segment instability and the need for screw removal due to secondary joint irritation. As a consequence the authors recommend the use of cortical bone grafting of the iliac crest in cases where palmar defects occur after reduction of the scaphoid.     

Percutaneous transtrapezial fixation of acute scaphoid fractures

Percutaneous screw fixation of undisplaced fractures of the scaphoid waist has gained popularity but remains technically demanding. This study describes a transtrapezial modification of the volar percutaneous technique and reports the results in 41 patients. The patients were evaluated at a mean of 36 months (range 14-68 months) after surgery. All fractures healed within 10 weeks (mean 6.4 weeks). Functional ranges of wrist motion and grip strength were achieved in all patients. Radiographs showed accurate central placement of the screw in all patients and no degenerative changes were seen at the scaphotrapezial joint. In three patients, the screw was removed because it was prominent at the scaphotrapezial joint.     

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。     

The use of the Herbert bone screw by the freehand-method for osteosynthesis scaphoid fracture

Summary Scaphoid fracture is, in most cases, usually still treated conservatively. The disadvantages of long-term immobilization are stiffness of the wrist joint, loss of strength and higher costs. The osteosynthesis of the scaphoid fracture with the Herbert bone screw restores the exact form and length and the normal position of the scaphoid to the other carpal bones. It prevents non-unions, arthrosis and other late complications. The Freehand method is used as a percutaneous technique without utilization of a jig. The scaphoid fracture is treated with closed reduction and osteosynthesis is performed with the Herbert bone screw. The percutaneous technique preserves the inter- and intracarpal ligaments, the vascular supply and the articular surfaces of the scaphoid. Osteosynthesis by the Freehand method is sufficiently stable to withstand early functional moves on the first postoperative day.      

Aktueller Stand der Kahnbeinchirurgie

Conservative and various operative treatment options are available for fractures of the scaphoid. Nonunion of the scaphoid requires an operative treatment. Of the patients who underwent surgery for fractures of the scaphoid from 1999 to 2001, 74 were treated with Herbert screw fixation. Nonunion of the scaphoid in 52 cases was treated by iliac crest bone grafting and Herbert screw implantation following resection of the affected bony parts. The cannulated, self-tapping headless bone screw system (cannulated Herbert screw) was used, which allows for easier implantation of the screw. Bony consolidation was achieved in a high proportion of these cases; bony fusion was achieved in all cases of scaphoid fracture. Operative treatment was followed by healing in 47 cases of scaphoid nonunions.     

Treatment of fractures of the carpal scaphoid with Herbert's bone screw. Review of 21 clinical cases

Twenty-one patients with scaphoid fractures treated by internal fixation with the Herbert screw are reviewed. Nine patients presented acute fractures and twelve had fractures with delayed or non-union. The results of these two kinds of lesions are analyzed following the criteria established by Herbert and Fisher in 1984. This type of internal fixation gives excellent results in isolated lesions of the scaphoid provided it is correctly executed.     

The treatment of scaphoid nonunion. A review of a novel technique using precision bone grafting compared with Herbert screw fixation and bone graft

We have retrospectively reviewed the results of 40 consecutive patients with nonunion of the scaphoid treated by the senior author (PG) between 1993 and 1996. These comprised two groups of patients. Group 1 comprised 20 patients treated between 1993 and 1994, with a Herbert screw and autograft, and Group 2, which also comprised 20 patients treated with the precision bone grafting technique which we describe. The precision bone grafting technique employs simple instrumentation to harvest bone percutaneously from the iliac crest and then insert it at the scaphoid nonunion site. The evaluation consisted of a clinical and radiological assessment of union and wrist function. Our review demonstrates a higher rate of union with the precision bone grafting technique than by the Herbert screw fixation with bone grafting.     

Acute percutaneous scaphoid fixation using a non-cannulated Herbert screw

Conservative treatment of fractures of the scaphoid often leads to an important physical and economic morbidity, especially in the young and active population. Acute percutaneous scaphoid fixation is a fast technique with minimal soft tissue damage, which allows immediate mobilisation without prolonged casting. We describe our operation technique in which we always use a non-cannulated Herbert screw. We place the screw freehand and always pass through the trapezium, a technique which is in our hands the best way to place the screw in the right position. It is not technically demanding, but has a considerable learning curve and requires a three-dimensional knowledge of the scaphoid. We reviewed the results of 44 patients treated in our centre between 1996 and 2001. Comparing with literature of percutaneous scaphoid fixation, we found similar results. Although in literature this technique is only indicated for minimally and non-displaced fractures of the waist (Herbert A2 and B2), we describe some good results with proximal pole fractures. Nevertheless we found that all cases of delayed and non-union occurred with this type of fracture.     

Comparison of headless screws used in the treatment of proximal nonunion of scaphoid bone

Screws with different levels of compression force are available for scaphoid fixation and it is known that the Acutrak screw generates greater compression than the Herbert screw. We retrospectively compared two types of headless compression screw for their effectiveness in the repair of scaphoid nonunion. Twenty-nine cases of proximal scaphoid nonunion were surgically treated with non-vascularised bone graft: the Acutrak screw was used in 17 patients and the cannulated Herbert screw in 12 patients. Wrist range of motion, Mayo wrist score, grip strength and QuickDASH scores were indicators used for the functional evaluation. Radiographic findings were assessed for consolidation of nonunion and signs of arthrosis. The mean follow-up time was 49.2 months (range 12–96). Statistically, there was no significant difference between the Acutrak and Herbert screw types in terms of functional evaluation and time required for consolidation. Greater compression did not influence the functional outcome, consolidation rate or time to consolidation. The need for greater compression in the treatment of proximal scaphoid nonunions is thus questionable because it may increase the risk of proximal fragment communition.     

Symptomatic non-union of the carpal scaphoid: Matti-Russe bone grafting versus Herbert screw fixation

We have reviewed 19 patients who have had Matti-Russe bone grafting and 16 patients who have had Herbert screw fixation for symptomatic non-union of the carpal scaphoid. The success rate in both groups was similar, 74 per cent in the Matti-Russe group and 71 per cent in the Herbert screw group. Only five patients in the Herbert screw group had bone grafts. The advantages and disadvantages of both methods of treatment are discussed.     

Scaphotrapezial trapezoidal arthrosis

Scaphotrapezial trapezoidal degenerative arthritis as an isolated entity or as a preponderant part of a pantrapezial degenerative process was seen in 49 hands of 34 patients. Pain and weakness were the primary complaints. Point tenderness was present in all but two hands. Significant loss of grasp and pinch strength was noted in 18 hands, and loss of wrist motion occurred in 16 hands. Roentgenographic findings included narrowing of the scaphotrapezial trapezoidal joint space, subarticular cortical sclerosis, and cyst formation. A dorsiflexed position of the scaphoid, with a scapholunate angle of less than 45 degrees, was noted in 38 of the 45 hands. Late collapse of the intercarpal joint with dorsiflexion instability of the lunate also was noted. Twenty-nine hands were treated conservatively by protective splints, corticosteroid injections, and avoidance of exacerbating activities. Surgical treatments consisted of fibrous arthroplasty (four), silicone interposition arthroplasty (six), trapezial replacement arthroplasty (three), arthrodesis (five), joint debridement (one), and trapezial excision (one). Late results were more encouraging than were early results and were moderately satisfactory for each method. Improvement in grasp and pinch strength was most predictable for arthrodesis, although wrist motion was diminished.     

Treatment of scaphoid non-unions with a corticocancellous graft and Herbert screw fixation: results at five years follow-up

In a retrospective survey, 16 patients with 18 established nonunions of the scaphoid treated with a sandwich graft and Herbert screw fixation, were reviewed: 14 patients were very satisfied with the outcome. The mean DASH score was 17 (SD 18.4). Flexion was 76%, extension 79% and gripping force 85% of the contralateral side. Union was achieved in 13 scaphoid bones. There was a significant increase in carpal height. Despite these findings there was also an increase in osteoarthritis. However this was not related to the correction or absence of correction of the preoperatively existing DISI. There was no correlation between radiological presence of osteoarthritis and clinical outcome.     

Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months

We report the outcome at a mean of 93 months (73 to 110) of 71 patients with an acute fracture of the scaphoid who were randomised to Herbert screw fixation (35) or below-elbow plaster cast immobilisation (36). These 71 patients represent the majority of a randomised series of 88 patients whose short-term outcome has previously been reported. Those patients available for later review were similar in age, gender and hand dominance. There was no statistical difference in symptoms and disability as assessed by the mean Patient Evaluation Measure (p = 0.4), or mean Patient-Rated Wrist Evaluation (p = 0.9), the mean range of movement of the wrist (p = 0.4), mean grip strength (p = 0.8), or mean pinch strength (p = 0.4). Radiographs were available from the final review for 59 patients. Osteoarthritic changes were seen in the scaphotrapezial and radioscaphoid joints in eight (13.5%) and six patients (10.2%), respectively. Three patients had asymptomatic lucency surrounding the screw. One non-operatively treated patient developed nonunion with avascular necrosis. In five patients who were treated non-operatively (16%) there was an abnormal scapholunate angle ( > 60 degrees ), but in four of these patients this finding was asymptomatic. No medium-term difference in function or radiological outcome was identified between the two treatment groups.     

Management of trans-scaphoid perilunate dislocations

A retrospective review of 28 patients with 29 trans-scaphoid perilunate dislocations who underwent open reduction and Herbert screw fixation is presented. The majority of the patients had satisfactory results at 24 months of follow-up. A significantly better range of wrist motion was obtained in postoperative patients treated with cast immobilization for 4 weeks compared with those treated for longer than 5 weeks. The scaphoid fractures united well, with proper alignment of the carpal bones, regardless of the length of cast immobilization. We recommend open reduction, internal scaphoid fixation using a Herbert screw, carpal ligament repair and early cast removal in the management of trans-scaphoid perilunate dislocations.