Percutaneous screw fixation for scaphoid nonunion in skeletally immature patients: a report of two cases

Nonunion of the scaphoid waist in skeletally immature patients is rarely diagnosed. We report 2 cases of scaphoid nonunion in skeletally immature patients who underwent percutaneous screw fixation without bone graft. In stable nonunions with minimal sclerosis, percutaneous screw fixation without bone graft can be an alternative to the conventional open procedure in skeletally immature patients, with successful union and clinical outcome.     

Pediatric scaphoid nonunion

PURPOSE: To report the outcome of pediatric scaphoid nonunions treated with a Herbert screw and bone graft. METHODS: This is a retrospective review of 12 cases of scaphoid nonunion in 12 skeletally immature patients treated with a uniform approach consisting of open reduction, iliac crest bone grafting and Herbert screw fixation. All patients were boys and presented with nonunions of the scaphoid waist. The final follow-up evaluation was at a mean of 32 months, ranging from 22 to 45 months, and consisted of assessing anatomic snuffbox tenderness, wrist arc of motion, grip strength, calculation of the Modified Mayo Wrist score, and assessment of union based on plain radiographs. RESULTS: At the latest follow-up evaluation, all patients were pain free (including absence of snuffbox tenderness) except one who experienced slight discomfort during extreme activities. There was no statistically significant difference in the arc of motion between the surgically treated and healthy sides, and the average grip strength was 96% that of the contralateral extremity. Clinical and radiographic union was present in all cases at a mean of 3.4 months after surgery. The Modified Mayo Wrist score was excellent in 11 patients and good in 1. There were no complications. CONCLUSIONS: Open reduction and internal fixation with a Herbert screw reliably obtained union in all patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Surgical treatment of pediatric scaphoid fracture nonunions

Scaphoid fractures in the pediatric population are uncommon but can usually be successfully managed with standard immobilization techniques. However, nonunions of pediatric scaphoid wrist fractures have been reported. We present the treatment and outcome of 13 pediatric scaphoid fracture nonunions in 12 children treated over an 18-year period. The average time elapsed between time of fracture and time of surgery was 16.7 months. Four of the nonunions were treated by using the Matti-Russe procedure, and nine were treated with Herbert screw fixation and iliac crest bone grafting. The average time of follow-up was 6.9 years (range, 2-19 years). All cases went on to clinical and radiographic union. There was no statistically significant difference in range of motion or strength between the operative and nonoperative wrist. Eleven of 12 patients demonstrated an excellent rating based on the Mayo Modified Wrist score. The length of time for postoperative immobilization in the Herbert screw group was significantly less than that in the Matti-Russe group. Currently our standard approach to the treatment of scaphoid fracture nonunions in the skeletally immature patient is the use of the Herbert screw and iliac crest bone graft.     

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。     

Scaphoid fracture in the young athlete--therapeutic outcome of internal fixation using the Herbert screw

BACKGROUND: A fractured scaphoid is a common disabling injury occurring in contact sports. This study was designed to evaluate the therapeutic outcome of Herbert screw fixation for scaphoid fracture in young athletes. METHODS: Thirty athletes with 30 scaphoid fractures were treated. According to the Herbert classification, 10 were classified as acute fracture (group I), 6 as fibrous union (group II) and 14 as pseudoarthrosis (group III). Twenty scaphoid non-unions were due to missed diagnosis or unsuccessful immobilisation. RESULTS: Bony union was evident at an average of 9.2, 8.0 and 11.9 weeks postoperatively in groups I, II and III, respectively, and times for returning to sports were 10.7, 14.0 and 22.9 weeks. The clinical outcome assessed using the Mayo wrist score was excellent in groups I (97.5 points) and II (93.3) and good in group III (85.4). CONCLUSION: Early definitive diagnosis and treatment can allow early return to sports in young athletes. The Herbert screw technique produces an excellent clinical result for scaphoid fracture.     

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.     

3.0 mm AO空心松质骨螺钉治疗腕舟骨骨折

目的 总结应用3．0mm AO空心松质骨螺钉对9例舟骨骨折病人进行治疗的经验。方法 骨折按Herben分型，A2型5例，B2型2例，B4型1例，D1型1例。A2型及B2型7例骨折经皮穿钉进行内固定。B4型1例伴有舟月骨分离，在切开复位固定的同时进行了舟月韧带重建。D1型1例在切开复位的同时进行了骨移植。患者手术时平均年龄为33岁。结果 术后平均随访12个月。9例均获得了骨性愈合。结论 3．0mm AO窄心钉对骨折端可产牛良好的加压效果，并获得较好的治疗效果。     

Non-union of the scaphoid: Russe graft vs Herbert screw

The results of treatment in 50 consecutive patients with established non-union of the scaphoid are presented. All patients were treated under the care of a single consultant, for the same indications. Russe bone graft is compared with wedge bone graft plus Herbert screw fixation, in terms of union and function. Overall, a higher success rate was obtained by wedge graft plus Herbert screw, and a significantly better range of movement. However, Russe bone graft appears equally satisfactory for fibrous non-union.     

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.     

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.     

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.     

早期切开复位Herbert螺钉内固定治疗经舟骨月骨周围脱位

目的 评价早期切开复位、Herbert螺钉内固定治疗经舟骨月骨周围脱位的临床效果.方法 早期采用切开复位、Herbert螺钉内固定治疗新鲜经舟骨月骨周围脱位8例,术后随访X线片了解骨折愈合情况及腕关节轴线恢复情况.Cooney腕关节评分法评价术后腕关节功能恢复程度,DASH问卷调查表行术后腕关节功能自我评价.结果 术后随访时间为7～35个月,平均14个月.根据Cooney腕关节评分:优3例,良2例,中2例,差1例;平均评分值为76.DASH评分值为27.X线片检查舟骨完全愈合,腕关节轴线恢复好.结论 早期切开复位Herbert螺钉内固定能达到舟骨解剖复位、恢复腕关节轴线,术后功能恢复较好,是治疗新鲜经舟骨月骨周围脱位较好的方法.     

经皮腕掌侧入路Herbert螺钉内固定治疗非移位性舟骨骨折

目的：总结经皮腕掌侧入路Herbert螺钉内固定治疗舟骨骨折的经验。方法：自2008年4月至2012年9月,采用经皮腕掌侧入路Herbert螺钉内固定治疗舟骨骨折15例,男14例,女1例;年龄25～45岁,平均35岁;左侧10例,右侧5例。患者自受伤至就诊时间3～10 d,平均5 d.术前均行常规X线及CT检查,所有舟骨骨折提示均为B2型骨折（Herbert分型）.根据腕关节功能Krimmer评分标准对所有患者术后腕关节功能恢复情况进行评价。结果：15例患者获随访,时间5～18个月,平均10个月。术后3个月内每月复查X线1次,骨折愈合时间7～14周,平均10周,螺钉位置良好。术后参考Krimmer评分标准进行腕关节功能评定,14例为100分,1例90分。所有患者腕掌小切口Ⅰ期愈合,无感染和骨不愈合等并发症发生。结论：经皮腕掌侧入路Herbert螺钉内固定治疗舟骨骨折是一种微创、骨折愈合率高、并发症相对较少的有效治疗方法。     

The Herbert screw for fractures of the scaphoid. A review of results and technical difficulties

We have reviewed 22 patients with scaphoid fractures treated by internal fixation with the Herbert screw. Three patients had trans-scaphoid perilunar dislocations, one had an oblique displaced fracture of the waist of the scaphoid and 18 had fractures with delayed or non-union. Corticocancellous bone grafts were added in nine of the cases of non-union. Results were excellent or good in 80% of cases after a mean duration of postoperative immobilisation of four weeks. The technical difficulties are analysed and the problems of applying the jig and of operative exposure are discussed.     

Fixation of scaphoid delayed union and non-union with absorbable polyglycolide pin or Herbert screw

Internal fixation with an absorbable polyglycolide pin or a Herbert screw was used to treat 34 patients with ununited and delayed union of fractures of the carpal scaphoid. The late clinical result could be reviewed in 14 patients in the polyglycolide group and 10 in the Herbert group with an average follow-up time of 68 and 58 months, respectively. The rate of union was 64% in the polyglycolide group and 60% in the Herbert group. The functional outcome was better in the Herbert group than in the polyglycolide group. A transient local abacterial tissue reaction occurred in 5 of 20 (25%) patients in the polyglycolide group. Two Herbert screws were removed due to penetration of the screw into the radial cartilage. The complication rate was relatively high with both methods. The polyglycolide pin results were unsatisfactory in this study, and thus we do not recommend their use in delayed union of and ununited scaphoid fractures.     

经皮交叉克氏针固定、自体骨髓移植治疗Herbert Ⅰ型腕舟骨骨折的临床研究

目的观察经皮交叉克氏针固定、自体骨髓移植治疗HerbertⅠ型腕舟骨骨折的临床效果。方法随机选择36例新鲜无错位（HerbertⅠ型）腕舟骨骨折患者，采用经皮交叉克氏针固定，抽取自体红骨髓5ml，快速、加压注入舟状骨骨折部位，术后6周开始，每周拍摄计算机X线片（CR-X）1次，至骨折愈合，并记录骨折愈合及恢复工作时间。结果术后随访6周～4年，36例全部愈合，骨折愈合时间为7～12周，平均8．3周。35例腕关节活动度达到健侧腕关节活动标准，活动后无疼痛，均恢复了正常工作。1例腕关节伸屈活动术后较术前有明显改善，但仍未达健侧腕关节活动范围，且活动时疼痛。结论经皮交叉克氏针固定、自体骨髓移植治疗HerbertⅠ型腕舟骨骨折，较传统治疗方法，具有损伤小、操作简单、安全，最大限度地避免了医源性损伤，缩短了骨折愈合时间，提高了治愈率，是一种有效的治疗方法。     

Vascularised bone graft for the treatment of non-union of the scaphoid.

A 4/5 compartment pedicled vascularised bone graft from the distal radius combined with internal fixation with a Herbert type cannulated screw was used to treat non-union fractures of the proximal pole of the scaphoid in 13 patients. Non-union was identified on plain radiographs alone. Uneventful clinical and radiological healing was achieved in 11 patients. One patient had progressive signs of failure of the fixation of the screw at the proximal pole; the screw was changed and the fracture was stable at reoperation. One patient had a fall postoperatively, radiographs taken at follow-ups showed only partial healing, and he had a bone graft 12 months later. Twelve patients had clinical and radiological union of the fracture, and one patient fibrous healing alone. The technique may improve healing of non-union of fractures of the proximal pole of the scaphoid, but it is still a technical challenge.     

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.     

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。     

以第一、二伸肌腱鞘支持带上动脉为血管蒂的桡骨瓣治疗舟骨骨不连

目的 探讨以第一、二伸肌腱鞘支持带上动脉(1,2 ICSRA)为血管蒂的桡骨瓣带蒂逆行转移治疗舟骨骨不连的手术指征、技术和疗效.方法 2007年2月至2010年10月,我科对15例舟骨骨不连患者,应用以1,2 ICSRA为血管蒂的桡骨瓣远端蒂转移植骨内固定进行治疗.其中腰部骨不连9例,近端骨不连6例.9例伴有近端骨折块缺血性坏死;3例伴有舟状骨弓背畸形及嵌入体背伸不稳(DISI);2例伴有桡骨茎突关节炎表现.所有病例均采用腕桡侧纵形切口,13例予以交叉克氏针内固定,2例行单枚Herbert螺钉附加1枚克氏针固定.12例将带血管蒂植骨块从舟骨背侧嵌插植入,3例将植骨块楔形修整后自舟骨掌侧植入.术后随访骨折愈合时间、腕痛、腕关节活动度及握力等情况.结果 术后随访时间为6～ 21个月,平均13个月,2例失访.所有随访病例X线片显示舟骨均获得骨性愈合,平均愈合时间为14.2周.所有患者腕痛消失,腕关节屈曲(59.92±4.82)°,背伸(49.73±4.58)°.根据改良的Mayo腕关节功能评分标准评定:优9例,良2例,可2例;优良率为84.6％.结论 以1,2 ICSRA为血管蒂的桡骨瓣逆行转移植骨手术,能促进舟骨骨不连的愈合,特别对有近端骨块缺血性坏死的患者疗效显著.