Hard to recognized because the pain improves quickly, there’s no bruising, and minimum swelling. People usually think it’s a sprain Some people don’t become aware of it until months or years after the event. Tenderness directly over the scaphoid bone (which is located in the hollow at the thumb side of the wrist known as the “snuffbox”) Symptoms
Duration <3 weeks old- better prognosis <3 weeks old- better prognosis If >4 weeks old drastically lower union rates when treated with cast alone If >4 weeks old drastically lower union rates when treated with cast aloneLocation Distal 1/3 (Pole) (5%) Distal 1/3 (Pole) (5%) Middle 1/3 (Waist) (80%) Middle 1/3 (Waist) (80%) Proximal 1/3 (Pole) (15%)- Proximal 1/3 (Pole) (15%)- poor healing due to limited blood supply, osteonecrosis rate close to 100% Scaphoid Fracture Evaluation
Displacement- Displacement- Nonunion rates in displaced fractures reach 92% Nonunion rates in displaced fractures reach 92% Scaphoid Fracture Evaluation >1 mm step off on any view >1 mm step off on any view Scapholunate angle of >60 degrees Scapholunate angle of >60 degrees Lunocapitate angle of greater than 15 degrees Lunocapitate angle of greater than 15 degrees Lateral intrascaphoid angle of more than 20 degrees Lateral intrascaphoid angle of more than 20 degrees
Internal Fixation Herbert Screw vs. Multiple Pins Vs.
Patients and methods Cross-sectional study From 2009 to 2011 23 patients in Herbert screw and 18 in multiple pins groups
Inclusion and Exclusion Criteria Inclusion criteria Scaphoid fracture >1mm displacement Exclusion criteria Herbert’s Type A Accompanying lesions
After surgery Herbert Screw : 4 weeks short arm cast + 4 weeks short palmar brace Multiple Pins: 6 weeks short arm cast + 2 weeks short palmar brace
Follow up Visits: Two weeks post-surgery, Every month for six months, Every year after one year Measurements: Degree of fracture healing, Visual Analog Score (VAS) of Pain, Range of motion, Hand grip strength, Quick DASH score, Mayo Modified Wrist Score (MMWS)
results Mean follow up time 24.5 m (11-34) 38 men (92.7%) and 3 women (7.3%) Men age 30.6 ± 7.8 years Herbert Screw 20 men 3 women Multiple Pins 18 men - No statistically difference between groups according to Age and Gender
Outcome Final Visit6 m Post-op P valueHSMPP valueHSMP 0.996.696.30.593.191.1 Flexion * 0.794.793.70.689.387.3 Extension * 0.895.694.90.792.691.3 Grip * 0.995.395.20.892.291.6 Quick Dash 0.29593.70.692.590.6 MMWS * Flexion, Extension and grip are in comparison of contra lateral limb
Outcome VAS (satisfaction) in final visit: HS= 9.5 MP=9 p>0.05 Osteonecrosis in final visit: HS=1(4.3%) MP=3(16.6%) p>0.05
discussion RCT Closed Reduction+Cast, Herbert Screw, Multiple Pins MMWS, ROM, Union time, Return to activity time, and Complications. Both surgical treatments were superior to CR+cast but were not different from each others. Dehghani M, Teimouri M, Nekoei F, Fatahi F. [Comparative Study of Results and Complications of Three Methods in Treatment of Scaphoid Fractures. Journal of Isfahan Medical School 2010; 28(109): 408-15.
discussion Results of using Herbert Screw+4 weeks cast: 152/158 patients had excellent and good fixation 132/138 were completely satisfied 125/138 had normal or near normal function Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br 1984; 66:114-123.
discussion HS vs. Pins in delayed union scaphoid fractures: Better functional outcome in HS than in MP The complication rate was relatively high with both methods Unsatisfactory reasons with MP Pelto-Vasenius K, Hirvensalo E, Böstman O, Rokkanen P. Fixation of scaphoid delayed union and non- union with absorbable polyglycolide pin or Herbert screw. Consolidation and functional results. Arch Orthop Trauma Surg. 1995;114(6):347-51.
The use of multiple pins for the internal fixation of scaphoid fractures proves to be a viable treatment option when compared to Herbert Screws, due to their decreased cost and increased availability. Conclusion
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