When to operate on acute scaphoid fractures

$Page 1: When to operate on acute scaphoid fractures$
Indications for acute scaphoid fixation

Adam C WattsConsultant Upper Limb Surgeon, Wrightington, UK

Visiting Professor, Manchester University

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Best Treatment of Scaphoid Fractures

PrimaryAchieve sound union

Secondaryin the shortest time with lowest risk and disruption to patient

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Scaphoid Fractures

Common injury in young adults

Compliance challenges

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Cast immobilisation

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Cast immobilisation

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Low riskLow cost


Cast immobilisation

InconvenientMuscle atrophyJoint stiffness

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Low riskLow cost


Screw fixation

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Screw fixation

Early return to function

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Screw fixation

Early return to function

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Higher direct costsGreater risks


Scaphoid Fractures

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Treatment costs


Scaphoid Fractures

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Work Disability Costs

Treatment costs


Scaphoid Fractures

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Treatment costs


Scaphoid Fractures

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Treatment costs


Predicting Union

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Decision Making

Scaphoid tubercle fracture

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Decision Making

Trans-scaphoid perilunate dislocation

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Decision Making

Proximal pole fracture

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Decision Making

Proximal pole fracture

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10% 70%

20%



Assessment of displacement

Translation

Gap

Angulation

Rotation

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Translation

Gap

Angulation

Rotation

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} >1mm



Displaced scaphoid fractures

Relative risk of non-union displaced fractures in cast 4.4 (c.i. 2.2-8.7)

For displaced fractures odds ratio of non-union of 16.9 for cast treatment versus surgical fixation

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MRI gold standard : X-ray sensitivity 33-47% positive predictive value 27-86% (Bhat 2004)

Arthroscopy gold standard: Xray sensitivity 75% positive predictive value 10% (Lozano-Calderon 2006)

Reliability intraobserver interobserverX-rays 0.54 0.27CT 0.65 0.43CT and X-rays 0.63 0.48

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Cadaveric model

Specificity X-ray predicting displacement 84%

CT 89%

but poor sensitivity for both (x-ray 52%, CT 49%)

However only sagittal CT imaging

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Does vascularity matter?

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Avascular

Fracture displacement measured on CT or MRI appears to be key to assessing

risk on non-union

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Displaced fractures

>2mm displacement on CT = Non-union 50% in cast

≤2mm displacement on CT = 100% union in cast

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Undisplaced fracture

Union in 4 week cast = 96%

Can surgery beat this?

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Cost analysis - undisplaced fractures

Non-manual workerscost of surgical arm significantly higher than non-surgicalaverage period off work 0 days compared to 19 days

Manual workersreturned to work more quickly after surgery (61 v 100 days)total costs higher with surgery but not statistically significant

No assessment of lost productivity

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CT/MRI


Scaphoid fracture seen on radiograph

Tubercle fractureUnicortical fracture

Surgical fixation

Waist fracture appears undisplacedProximal poleAssociated wrist injuryObviously displaced

Displaced ≤2mm Displaced >2mm

Individual requires early wrist motion

Cast immobilisation No Yes

CT/MRI


Scaphoid fracture seen on radiograph

Tubercle fractureUnicortical fracture

Surgical fixation

Waist fracture appears undisplacedProximal poleAssociated wrist injuryObviously displaced

Displaced ≤2mm Displaced >2mm

Individual requires early wrist motion

Cast immobilisation No Yes


5 QuestionsAnswer ‘yes’ to any then consider surgical treatment with screw fixation

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1.Is there an associated ipsilateral wrist injury?

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1.Is there an associated ipsilateral wrist injury?2.Is there a proximal pole fracture?

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1.Is there an associated ipsilateral wrist injury?2.Is there a proximal pole fracture?3.Is there a waist fracture that is displaced on

scaphoid series radiographs?

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scaphoid series radiographs?4.Is there a waist fracture that is shown to have

more than 2mm displacement on CT/MRI?

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scaphoid series radiographs?4.Is there a waist fracture that is shown to have

more than 2mm displacement on CT/MRI?5.Is there a waist fracture that is shown to have up

to 2mm displacement in an individual who requires early wrist motion?

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When to operate on acute scaphoid fractures

Health & Medicine

sagittal ct imaging19www

xray sensitivity

comscrew fixationearly

cast treatment

com22avascularfr displacement

cast2mm displacement

comcast immobilisation4www

comscrew fixation5www