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Management of late-diagnosed scaphoid fractures
Injury, Int. J. Care Injured 41 (2010) e10–e14
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Management of late-diagnosed scaphoid fractures Alvin Chao-Yu Chen *, Mel S. Lee, Steve Wen-Neng Ueng, Wen Jer Chen Department of Orthopaedic Surgery, Chang Gung Memorial Hospital & University, 5, Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 13 July 2009
Background: Scaphoid fractures are among the most common types of carpal bone injury; they can be easily overlooked in the acute stage. Scaphoid fractures detected in the subacute stage require a more meticulous and prompt approach, to prevent chronicity and regain wrist function. Methods: The records of 30 patients were selected from 97 with scaphoid fractures surgically treated between 1994 and 2002. Fractures that were diagnosed between 2 weeks and 5 months (average, 2.2 months) after the injury were included. We report the fracture patterns and locations, as determined from radiographs, as well as the surgical methods used. The mean follow-up was 2.5 years. Results: Oblique fractures (60%) were the most commonly overlooked fractures. Twenty-six patients (87%) underwent open surgery, and 23 (77%) required bone grafts. Percutaneous fixation was indicated for only four patients, whose fractures were reducible via either fluoroscopic or arthroscopic guidance. Osseous unions were achieved for 29 (97%) patients; these patients returned to their pre-injury level of activity. The average union time was 10.6 weeks. Conclusion: Oblique-type scaphoid fractures are potentially unstable and may result in detrimental sequelae if overlooked in the acute stage. Accurate diagnosis is possible through critical skepticism and the meticulous scrutiny of radiographs. Prompt surgical intervention is associated with promising outcomes. ß 2009 Elsevier Ltd. All rights reserved.
Keywords: Late diagnosis Scaphoid fracture Subacute Oblique fracture
The scaphoid is the most frequently fractured carpal bone. Despite recent advances in the understanding of scaphoid fractures, a number of questions remain unanswered. Diagnosis of scaphoid fracture can be complicated, and this type of fracture can be easily overlooked in an acute injury.6 Unfortunately, owing to its unique anatomical structure, neglected scaphoid fractures seldom heal with acceptable alignment; this often leads to complications in their management.2,8,10,11 In cases of non-union or malunion, reconstruction of the scaphoid is exceedingly difficult, and this increases the chances of morbidity already associated with an extended period of hand immobilisation.9,12,14 Despite the many reports on their management, scaphoid fractures are managed largely on the basis of anecdotal evidence and traditional remedies. Few reports refer to the management of neglected scaphoid fractures in the subacute stage; these fractures theoretically require prompt but meticulous treatment to prevent chronic sequelae. The purpose of this report is to elucidate the essential elements in the diagnosis and management of scaphoid fractures detected in the subacute stage.
* Corresponding author. Tel.: +886 3 3281200x3882; fax: +886 3 3284564. E-mail address: [email protected] (A.-Y. Chen). 0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2009.07.078
Patients and methods The records of 97 scaphoid fractures treated surgically between 1994 and 2002 were reviewed. Only patients whose fractures were overlooked at the time of acute injury and subsequently detected within 5 months of the injury were included. Scaphoid non-unions that were unhealed at or after 6 months from the injury were not included. Fractures with severely sclerotic margins or midcarpal instability were excluded to rule out cases of old scaphoid nonunions that had become symptomatic through recent injury. A total of 30 fractures were included in the study (21 in men and 9 in women) (Table 1). All fractures were referred cases, and the delay in diagnosis varied. The average length of time between injury and diagnosis was 2.2 months (range, 0.5–4.5 months). The mean patient age was 33.7 years (range, 20–67 years). Routine radiographs were obtained using both standard postero-anterior views in neutral, ulnar and radial deviations and the lateral view. Oblique projections and computed tomography (CT) scans were used in equivocal cases (Fig. 1) where the fracture or fracture pattern could not be clearly defined. Of the 30 fractures, 17 involved the scaphoid waist, with 6 of these being the transverse type and 11 the oblique type, according to the Russe classification system.5 The remaining 13 fractures were localised at the distal and proximal poles in 7 and 6 cases, respectively.
A.-Y. Chen et al. / Injury, Int. J. Care Injured 41 (2010) e10–e14
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Table 1 Patient and scaphoid fracture characteristics. No.
Age (years)
Sex
Delay (months)
Fracture site
Fracture type
Surgery
Implant
Bone graft
Union (weeks)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
37 32 67 20 33 30 59 26 20 63 27 30 20 20 23 30 23 28 52 39 56 28 30 24 33 27 29 38 23 44
F M M M F M M F M F M M M M M M M M F M F M M M F M M M F F
3 3 4 3 3 3 3 3 1.5 1 1 4 1.5 1.5 1.5 0.5 2.5 1 2 2.5 2 4.5 3 2 2 0.5 4 1 1 1.5
D D D D W P P W W P W W W W P W D W P W W W P D W W W W W D
HO T HO T T VO VO VO HO T HO T HO HO VO T T T VO HO VO T VO T T VO HO VO VO T
O O O O O O O O O A O O O O O CR O O O O O O O O O CR O CR O O
K K K K K K K K K H H H H A K H H H H H H K K K K K K K K K
W W W W W W W W W No No C W C W No R No V No R R V R W No W No C C
10 10 12 12 12 10 12 10 10 12 10 10 10 10 Non-union 12 10 10 12 10 10 10 10 12 10 10 12 10 10 10
Note: D = distal pole, W = waist, P = proximal pole, HO = horizontal oblique, T = transverse, VO = vertical oblique, O = open surgery, CR = closed reduction, A = arthroscope-guided reduction, K = Kirschner wires, H = Herbert screw, A = A–O cannulated screw, W = corticocancellous wedge bone graft, C = cancellous bone graft, R = Russe bone graft, V = pedicle-vascularised bone graft.
Fig. 1. Scaphoid fracture detected 1.5 months after injury. (A) Plain radiographs showing no remarkable fracture in either the postero-anterior or lateral view. (B) CT images showing an oblique-type fracture with displacement. (C) Postoperative radiographs.
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Table 2 Algorithm for selecting treatment method.
a
Chronic changes: sclerosis, cystic change, or volar collapse. The graft type was dependent on the severity of humpback deformity and avascular necrosis.
b
All of the fractures had been treated surgically by one of the two hand surgeons at our institute. Twenty-six of the fractures (87%) were treated by open surgery and four (13%) by percutaneous fixation (closed reduction, three; arthroscopic-guided reduction, one). Successful realignment was achieved using closed reduction under the guidance of a C-arm intensifier in three cases; arthroscopic-assisted reduction was performed in one case, in which a residual fracture gap of >1 mm was noted in the C-arm image after initial closed manipulation. The four cases of percutaneous fixation included newly displaced fractures that had occurred within the previous month and were reducible with surgical management. The divergent Kirschner wire fixation technique was performed in 19 cases, and cannulated screw fixation was performed in 11 cases. Bone-grafting procedures were performed for 23 fractures (77%), including 13 wedge bone grafts that were performed using the sandwich technique previously described by us.4 We also performed four Russe grafts, four cancellous bone grafts and two pedicle-vascularised bone grafts.16 A wedge interposition bone graft was used to correct humpback deformity, while a Russe graft was chosen in cases without significant volar collapse. A cancellous bone graft was used to fill the small bone cysts at the fracture ends. Pedicle-vascularised bone grafts were used in two cases with very sclerotic and small proximal fragments. Table 2 shows the algorithm that was used to determine treatment modalities. Results Diagnoses We were able to review the radiographs of 12 patients; each radiograph had been obtained at the time of acute injury. For the other 18 patients, radiographs at the acute stage were either unavailable or had not been taken during the primary survey in other clinics. Of the 12 acute stage radiographs, 7 showed no remarkable fracture line in the postero-anterior or lateral view, while 5 showed visible fracture lines in at least one view and had been overlooked. In radiographic examinations performed after the acute stage, 26 fractures were diagnosable in at least two views, and two could be diagnosed after the addition of oblique
projections. In the remaining two cases, a CT scan along the long axis of the scaphoid in multiple directions facilitated a definitive diagnosis. Surgical options Of the 26 fractures treated with open surgery, 23 required bone grafting owing to either cystic changes at the fracture site or bone defects on the volar cortex (Fig. 2). In 13 cases, a wedge bone graft was incorporated into the volar aspect of the scaphoid fracture to maintain alignment when reduced. Pedicle-vascularised bone grafts with a dorsal approach were used in two fractures involving the very proximal portion of the scaphoid, with antegrade Herbert screw fixation used for one and multiple Kirschner wire fixations for the other. For the remaining eight fractures, cancellous bone chips and/or Russe grafts were used to fill the osseous defect to a flush level and bridge the fracture site. Time to union Radiographs were taken every 2 weeks after surgery, until an osseous union was achieved. Fracture union was defined on the basis of both clinical evidence of pain-free wrist motion and radiographic findings showing complete trabecular bridging in more than one view of a routine radiograph. The mean follow-up period was 2.5 years (range, 1.5–6 years). An osseous union was achieved in 29 (97%) of the patients in an average of 13.6 weeks (range, 12–16 weeks), after which Kirschner wires were removed to facilitate subsequent range-of-motion exercises. The remaining patient (case 15) had a proximal scaphoid fracture and underwent anterior wedge bone grafting and divergent Kirschner wire fixation. Postoperative radiographs at 3 months showed a sclerosing proximal scaphoid, and the fracture remained ununited (3%) at the most recent follow-up visit. All patients achieved painfree motion in performing daily activities, including physical work. We conducted a functional survey 6 months after the surgery using the modified Mayo wrist score. The Mayo wrist score grading was excellent in 25 (83%) patients; the score was good in the remaining five patients (17%), owing to the suboptimal recovery of grip strength and limited use of the limb.
A.-Y. Chen et al. / Injury, Int. J. Care Injured 41 (2010) e10–e14
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Fig. 2. Scaphoid fracture detected 2.5 months after injury. (A) Radiographs showing a displaced scaphoid waist fracture with an osseous defect on the volar cortex (arrow). (B) Postoperative radiograph.
Complications There were no immediate surgical complications in any patient; however, in one patient, the fracture remained ununited even 2 years after the operation. Discussion In the present study, we reviewed cases that had not been diagnosed until between 2 weeks and 4.5 months after the initial injury. Each patient presented with a displaced fracture that met the diagnostic criteria in terms of fracture gap or angulation7 and was subsequently treated with surgical intervention. Radiographs obtained at the time of acute injury were available for 12 patients; seven of these radiographs had only antero-posterior and lateral projections, and none revealed any remarkable fracture lines. Diagnoses were made after persistent symptoms indicated suspected bone fractures, which subsequently led to more detailed radiographic assessments. In cases like these, radiographs should be taken along the true axis of the scaphoid in different directional views to detect all unstable fractures, including cases overlooked initially and occult fractures with secondary displacement. Although CT scans are not always cost-effective, they may be indicative in some cases and require more scrutinising cuts up to the availability.1 The pattern of a scaphoid fracture may be classified in terms of location and obliquity.5 Russe originally classified scaphoid fractures as horizontally oblique, transverse or vertically oblique; vertically oblique fractures are more unstable than either transverse or horizontally oblique types.15 In the present study, 43% (10/23) of the scaphoid waist fractures were of the vertically oblique type. In general, the union rate for this type of fracture with cast treatment is <60%.10 Therefore, we recommend that both initial screening and serial follow-up radiographic assessments be performed for this fracture type. This will enable the early detection of vertically oblique fractures, which pose a greater risk of later displacement than other types and require prompt surgical stabilisation. There are a number of reports of favourable outcomes for acute fractures treated with recent percutaneous techniques such as cannulated screw fixation with fluoroscopic or arthroscopic control.19 This method is generally indicated for minimally displaced scaphoid fractures.3 In the present study, percutaneous screw fixation was used for only four fractures that were reducible under C-arm fluoroscopic guidance. Two of these fractures were detected within 2 weeks of the injury; the other two fractures were occult and underwent displacement between the two visits, and
they were treated surgically with closed manipulation or arthroscopic reduction. For the remaining 26 patients, open surgery was performed to restore correct alignment and explore the fracture site. In a previous report, a well-treated stable scaphoid fracture that led to cystic formation within 3 months and failed to unite was described.7 On the basis of the afore-mentioned information and clinical observations, the use of closed reduction with percutaneous fixation appears less feasible for neglected scaphoid fractures, unless the injury or displacement is recent. Therefore, scaphoid fractures detected in the subacute stage should be managed differently from acute fractures and chronic non-unions. It is important not only to treat scaphoid fractures more aggressively but also to customise the surgical options. An interpositional strut bone graft has been commonly considered an essential procedure in cases of unstable scaphoid fractures that are ununited.4,16,17 There is a significant correlation between improved wrist function and improved carpal alignment; however, there have been no relevant data published regarding fractures detected 1–5 months after injury. Reports concerning the closed management of subacute scaphoid fractures have concluded that unstable subacute middle-third and proximal-third fractures are less likely to heal.13,18 The radiographic presentations and intraoperative findings of the present study indicate that chronic changes at the fracture site, including cyst formation, volar collapse and synovial ingrowth, are common. Because of their chronic nature, neglected scaphoid fractures should be treated as scaphoid nonunions rather than acute fractures. Indications for bone grafting and the selection of graft type are based not only on perioperative radiographic assessment but also on intra-operative findings. Interpositional strut bone grafts are essential for the correction of scaphoid malalignment in cases of marked volar collapse.4 Limitations of the present study The present study was a retrospective review of clinical cases; as such, it did not include a control group against which statistical differences could be established. Nevertheless, our observational data were comprehensive; long-term follow-up studies, as part of an ongoing investigation, are required to suggest an optimal approach to this disease entity. Conclusion Oblique scaphoid fractures are among the most common type of neglected injuries; they are potentially unstable and may become
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displaced. Open reduction and rigid fixation with meticulous selection of bone grafting are effective treatment options for fractures detected at the subacute stage. Prompt surgical intervention is essential to prevent chronic sequelae and to facilitate positive outcomes. Conflict of interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject matter of our study. The authors report no conflict of interest. References 1. Adey L, Souer JS, Lozano-Calderon S, et al. Computed tomography of suspected scaphoid fractures. J Hand Surg 2007;32A:61–6. 2. Barton NJ. Apparent and partial nonunion of the scaphoid. J Hand Surg 1996;21B:496–500. 3. Chen AC, Chao EK, Hung SS, et al. Percutaneous screw fixation for unstable scaphoid fractures. J Trauma 2005;59:184–7. 4. Chen CY, Chao EK, Lee SS, Ueng SW. Osteosynthesis of carpal scaphoid nonunion with interpositional bone graft and Kirschner wires: a 3- to 6-year follow-up. J Trauma 1999;47:558–63. 5. Green DP. Operative hand surgery, 3rd ed., New York: Churchill-Livingstone; 1993. p. 806. 6. Jacobsen S, Hassani G, Hansen D, Christensen O. Suspected scaphoid fractures: can we avoid overkill. Acta Orthop Belg 1995;61:74–8.
7. Jupiter JB, Shin AY, Trumble TE, Fernandez DL. Traumatic and reconstructive problems of the scaphoid. In: Sim FH, editor. Instructional course lectures. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2001 . p. 105– 22. 8. Kim WC, Shaffer JW, Idzikowski C. Failure of treatment of ununited fractures of the carpal scaphoid: the role of non-compliance. J Bone Joint Surg 1983;65A: 985–91. 9. Kleinert JM, Zenni Jr EJ. Nonunion of the scaphoid: review of literature and current treatment. Orthop Rev 1984;13:125–41. 10. Langhoff O, Andersen JL. Consequences of late immobilization of scaphoid fractures. J Hand Surg 1988;13B:77–9. 11. Leslie IJ, Dickson RA. The fractured carpal scaphoid: natural history and factors influencing outcome. J Bone Joint Surg 1981;63B:225–30. 12. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid nonunion. J Bone Joint Surg 1984;66A:504–9. 13. Mark GR, Wilckens JH, McPherson SA. Subacute scaphoid fractures. A closer look at closed treatment. Am J Sports Med 1998;26:56–8. 14. Ruby LK, Stinson J, Belsky MR. The natural history of scaphoid non-union: a review of fifty-five cases. J Bone Joint Surg 1985;67A:428–32. 15. Russe O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg 1960;42A:759–68. 16. Shin AY, Sheetz KK, Bishop AJ, Berger RA. Vascularized pedicled bone graft from the distal radius. Arch Am Acad Orthop Surg 1999;2:94–106. 17. Tsuyuguchi Y, Murase T, Hidaka N, et al. Anterior wedge-shaped bone graft for old scaphoid fractures or nonunions: an analysis of relevant carpal alignment. J Hand Surg 1995;20B:194–200. 18. Whipple TL. Acute scaphoid fracture fixation. In: Vastamaki M, Vollo S, Raatikainen M, et al., editors. Current trends in hand surgery. Amsterdam, Netherlands: Elsevier Science; 1995. p. 75–7. 19. Wozasek GE, Moser KD. Percutaneous screw fixation for fractures of the scaphoid. J Bone Joint Surg 1991;73B:138–42.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Management of late-diagnosed scaphoid fractures Alvin Chao-Yu Chen *, Mel S. Lee, Steve Wen-Neng Ueng, Wen Jer Chen Department of Orthopaedic Surgery, Chang Gung Memorial Hospital & University, 5, Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 13 July 2009
Background: Scaphoid fractures are among the most common types of carpal bone injury; they can be easily overlooked in the acute stage. Scaphoid fractures detected in the subacute stage require a more meticulous and prompt approach, to prevent chronicity and regain wrist function. Methods: The records of 30 patients were selected from 97 with scaphoid fractures surgically treated between 1994 and 2002. Fractures that were diagnosed between 2 weeks and 5 months (average, 2.2 months) after the injury were included. We report the fracture patterns and locations, as determined from radiographs, as well as the surgical methods used. The mean follow-up was 2.5 years. Results: Oblique fractures (60%) were the most commonly overlooked fractures. Twenty-six patients (87%) underwent open surgery, and 23 (77%) required bone grafts. Percutaneous fixation was indicated for only four patients, whose fractures were reducible via either fluoroscopic or arthroscopic guidance. Osseous unions were achieved for 29 (97%) patients; these patients returned to their pre-injury level of activity. The average union time was 10.6 weeks. Conclusion: Oblique-type scaphoid fractures are potentially unstable and may result in detrimental sequelae if overlooked in the acute stage. Accurate diagnosis is possible through critical skepticism and the meticulous scrutiny of radiographs. Prompt surgical intervention is associated with promising outcomes. ß 2009 Elsevier Ltd. All rights reserved.
Keywords: Late diagnosis Scaphoid fracture Subacute Oblique fracture
The scaphoid is the most frequently fractured carpal bone. Despite recent advances in the understanding of scaphoid fractures, a number of questions remain unanswered. Diagnosis of scaphoid fracture can be complicated, and this type of fracture can be easily overlooked in an acute injury.6 Unfortunately, owing to its unique anatomical structure, neglected scaphoid fractures seldom heal with acceptable alignment; this often leads to complications in their management.2,8,10,11 In cases of non-union or malunion, reconstruction of the scaphoid is exceedingly difficult, and this increases the chances of morbidity already associated with an extended period of hand immobilisation.9,12,14 Despite the many reports on their management, scaphoid fractures are managed largely on the basis of anecdotal evidence and traditional remedies. Few reports refer to the management of neglected scaphoid fractures in the subacute stage; these fractures theoretically require prompt but meticulous treatment to prevent chronic sequelae. The purpose of this report is to elucidate the essential elements in the diagnosis and management of scaphoid fractures detected in the subacute stage.
* Corresponding author. Tel.: +886 3 3281200x3882; fax: +886 3 3284564. E-mail address: [email protected] (A.-Y. Chen). 0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2009.07.078
Patients and methods The records of 97 scaphoid fractures treated surgically between 1994 and 2002 were reviewed. Only patients whose fractures were overlooked at the time of acute injury and subsequently detected within 5 months of the injury were included. Scaphoid non-unions that were unhealed at or after 6 months from the injury were not included. Fractures with severely sclerotic margins or midcarpal instability were excluded to rule out cases of old scaphoid nonunions that had become symptomatic through recent injury. A total of 30 fractures were included in the study (21 in men and 9 in women) (Table 1). All fractures were referred cases, and the delay in diagnosis varied. The average length of time between injury and diagnosis was 2.2 months (range, 0.5–4.5 months). The mean patient age was 33.7 years (range, 20–67 years). Routine radiographs were obtained using both standard postero-anterior views in neutral, ulnar and radial deviations and the lateral view. Oblique projections and computed tomography (CT) scans were used in equivocal cases (Fig. 1) where the fracture or fracture pattern could not be clearly defined. Of the 30 fractures, 17 involved the scaphoid waist, with 6 of these being the transverse type and 11 the oblique type, according to the Russe classification system.5 The remaining 13 fractures were localised at the distal and proximal poles in 7 and 6 cases, respectively.
A.-Y. Chen et al. / Injury, Int. J. Care Injured 41 (2010) e10–e14
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Table 1 Patient and scaphoid fracture characteristics. No.
Age (years)
Sex
Delay (months)
Fracture site
Fracture type
Surgery
Implant
Bone graft
Union (weeks)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
37 32 67 20 33 30 59 26 20 63 27 30 20 20 23 30 23 28 52 39 56 28 30 24 33 27 29 38 23 44
F M M M F M M F M F M M M M M M M M F M F M M M F M M M F F
3 3 4 3 3 3 3 3 1.5 1 1 4 1.5 1.5 1.5 0.5 2.5 1 2 2.5 2 4.5 3 2 2 0.5 4 1 1 1.5
D D D D W P P W W P W W W W P W D W P W W W P D W W W W W D
HO T HO T T VO VO VO HO T HO T HO HO VO T T T VO HO VO T VO T T VO HO VO VO T
O O O O O O O O O A O O O O O CR O O O O O O O O O CR O CR O O
K K K K K K K K K H H H H A K H H H H H H K K K K K K K K K
W W W W W W W W W No No C W C W No R No V No R R V R W No W No C C
10 10 12 12 12 10 12 10 10 12 10 10 10 10 Non-union 12 10 10 12 10 10 10 10 12 10 10 12 10 10 10
Note: D = distal pole, W = waist, P = proximal pole, HO = horizontal oblique, T = transverse, VO = vertical oblique, O = open surgery, CR = closed reduction, A = arthroscope-guided reduction, K = Kirschner wires, H = Herbert screw, A = A–O cannulated screw, W = corticocancellous wedge bone graft, C = cancellous bone graft, R = Russe bone graft, V = pedicle-vascularised bone graft.
Fig. 1. Scaphoid fracture detected 1.5 months after injury. (A) Plain radiographs showing no remarkable fracture in either the postero-anterior or lateral view. (B) CT images showing an oblique-type fracture with displacement. (C) Postoperative radiographs.
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Table 2 Algorithm for selecting treatment method.
a
Chronic changes: sclerosis, cystic change, or volar collapse. The graft type was dependent on the severity of humpback deformity and avascular necrosis.
b
All of the fractures had been treated surgically by one of the two hand surgeons at our institute. Twenty-six of the fractures (87%) were treated by open surgery and four (13%) by percutaneous fixation (closed reduction, three; arthroscopic-guided reduction, one). Successful realignment was achieved using closed reduction under the guidance of a C-arm intensifier in three cases; arthroscopic-assisted reduction was performed in one case, in which a residual fracture gap of >1 mm was noted in the C-arm image after initial closed manipulation. The four cases of percutaneous fixation included newly displaced fractures that had occurred within the previous month and were reducible with surgical management. The divergent Kirschner wire fixation technique was performed in 19 cases, and cannulated screw fixation was performed in 11 cases. Bone-grafting procedures were performed for 23 fractures (77%), including 13 wedge bone grafts that were performed using the sandwich technique previously described by us.4 We also performed four Russe grafts, four cancellous bone grafts and two pedicle-vascularised bone grafts.16 A wedge interposition bone graft was used to correct humpback deformity, while a Russe graft was chosen in cases without significant volar collapse. A cancellous bone graft was used to fill the small bone cysts at the fracture ends. Pedicle-vascularised bone grafts were used in two cases with very sclerotic and small proximal fragments. Table 2 shows the algorithm that was used to determine treatment modalities. Results Diagnoses We were able to review the radiographs of 12 patients; each radiograph had been obtained at the time of acute injury. For the other 18 patients, radiographs at the acute stage were either unavailable or had not been taken during the primary survey in other clinics. Of the 12 acute stage radiographs, 7 showed no remarkable fracture line in the postero-anterior or lateral view, while 5 showed visible fracture lines in at least one view and had been overlooked. In radiographic examinations performed after the acute stage, 26 fractures were diagnosable in at least two views, and two could be diagnosed after the addition of oblique
projections. In the remaining two cases, a CT scan along the long axis of the scaphoid in multiple directions facilitated a definitive diagnosis. Surgical options Of the 26 fractures treated with open surgery, 23 required bone grafting owing to either cystic changes at the fracture site or bone defects on the volar cortex (Fig. 2). In 13 cases, a wedge bone graft was incorporated into the volar aspect of the scaphoid fracture to maintain alignment when reduced. Pedicle-vascularised bone grafts with a dorsal approach were used in two fractures involving the very proximal portion of the scaphoid, with antegrade Herbert screw fixation used for one and multiple Kirschner wire fixations for the other. For the remaining eight fractures, cancellous bone chips and/or Russe grafts were used to fill the osseous defect to a flush level and bridge the fracture site. Time to union Radiographs were taken every 2 weeks after surgery, until an osseous union was achieved. Fracture union was defined on the basis of both clinical evidence of pain-free wrist motion and radiographic findings showing complete trabecular bridging in more than one view of a routine radiograph. The mean follow-up period was 2.5 years (range, 1.5–6 years). An osseous union was achieved in 29 (97%) of the patients in an average of 13.6 weeks (range, 12–16 weeks), after which Kirschner wires were removed to facilitate subsequent range-of-motion exercises. The remaining patient (case 15) had a proximal scaphoid fracture and underwent anterior wedge bone grafting and divergent Kirschner wire fixation. Postoperative radiographs at 3 months showed a sclerosing proximal scaphoid, and the fracture remained ununited (3%) at the most recent follow-up visit. All patients achieved painfree motion in performing daily activities, including physical work. We conducted a functional survey 6 months after the surgery using the modified Mayo wrist score. The Mayo wrist score grading was excellent in 25 (83%) patients; the score was good in the remaining five patients (17%), owing to the suboptimal recovery of grip strength and limited use of the limb.
A.-Y. Chen et al. / Injury, Int. J. Care Injured 41 (2010) e10–e14
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Fig. 2. Scaphoid fracture detected 2.5 months after injury. (A) Radiographs showing a displaced scaphoid waist fracture with an osseous defect on the volar cortex (arrow). (B) Postoperative radiograph.
Complications There were no immediate surgical complications in any patient; however, in one patient, the fracture remained ununited even 2 years after the operation. Discussion In the present study, we reviewed cases that had not been diagnosed until between 2 weeks and 4.5 months after the initial injury. Each patient presented with a displaced fracture that met the diagnostic criteria in terms of fracture gap or angulation7 and was subsequently treated with surgical intervention. Radiographs obtained at the time of acute injury were available for 12 patients; seven of these radiographs had only antero-posterior and lateral projections, and none revealed any remarkable fracture lines. Diagnoses were made after persistent symptoms indicated suspected bone fractures, which subsequently led to more detailed radiographic assessments. In cases like these, radiographs should be taken along the true axis of the scaphoid in different directional views to detect all unstable fractures, including cases overlooked initially and occult fractures with secondary displacement. Although CT scans are not always cost-effective, they may be indicative in some cases and require more scrutinising cuts up to the availability.1 The pattern of a scaphoid fracture may be classified in terms of location and obliquity.5 Russe originally classified scaphoid fractures as horizontally oblique, transverse or vertically oblique; vertically oblique fractures are more unstable than either transverse or horizontally oblique types.15 In the present study, 43% (10/23) of the scaphoid waist fractures were of the vertically oblique type. In general, the union rate for this type of fracture with cast treatment is <60%.10 Therefore, we recommend that both initial screening and serial follow-up radiographic assessments be performed for this fracture type. This will enable the early detection of vertically oblique fractures, which pose a greater risk of later displacement than other types and require prompt surgical stabilisation. There are a number of reports of favourable outcomes for acute fractures treated with recent percutaneous techniques such as cannulated screw fixation with fluoroscopic or arthroscopic control.19 This method is generally indicated for minimally displaced scaphoid fractures.3 In the present study, percutaneous screw fixation was used for only four fractures that were reducible under C-arm fluoroscopic guidance. Two of these fractures were detected within 2 weeks of the injury; the other two fractures were occult and underwent displacement between the two visits, and
they were treated surgically with closed manipulation or arthroscopic reduction. For the remaining 26 patients, open surgery was performed to restore correct alignment and explore the fracture site. In a previous report, a well-treated stable scaphoid fracture that led to cystic formation within 3 months and failed to unite was described.7 On the basis of the afore-mentioned information and clinical observations, the use of closed reduction with percutaneous fixation appears less feasible for neglected scaphoid fractures, unless the injury or displacement is recent. Therefore, scaphoid fractures detected in the subacute stage should be managed differently from acute fractures and chronic non-unions. It is important not only to treat scaphoid fractures more aggressively but also to customise the surgical options. An interpositional strut bone graft has been commonly considered an essential procedure in cases of unstable scaphoid fractures that are ununited.4,16,17 There is a significant correlation between improved wrist function and improved carpal alignment; however, there have been no relevant data published regarding fractures detected 1–5 months after injury. Reports concerning the closed management of subacute scaphoid fractures have concluded that unstable subacute middle-third and proximal-third fractures are less likely to heal.13,18 The radiographic presentations and intraoperative findings of the present study indicate that chronic changes at the fracture site, including cyst formation, volar collapse and synovial ingrowth, are common. Because of their chronic nature, neglected scaphoid fractures should be treated as scaphoid nonunions rather than acute fractures. Indications for bone grafting and the selection of graft type are based not only on perioperative radiographic assessment but also on intra-operative findings. Interpositional strut bone grafts are essential for the correction of scaphoid malalignment in cases of marked volar collapse.4 Limitations of the present study The present study was a retrospective review of clinical cases; as such, it did not include a control group against which statistical differences could be established. Nevertheless, our observational data were comprehensive; long-term follow-up studies, as part of an ongoing investigation, are required to suggest an optimal approach to this disease entity. Conclusion Oblique scaphoid fractures are among the most common type of neglected injuries; they are potentially unstable and may become
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displaced. Open reduction and rigid fixation with meticulous selection of bone grafting are effective treatment options for fractures detected at the subacute stage. Prompt surgical intervention is essential to prevent chronic sequelae and to facilitate positive outcomes. Conflict of interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject matter of our study. The authors report no conflict of interest. References 1. Adey L, Souer JS, Lozano-Calderon S, et al. Computed tomography of suspected scaphoid fractures. J Hand Surg 2007;32A:61–6. 2. Barton NJ. Apparent and partial nonunion of the scaphoid. J Hand Surg 1996;21B:496–500. 3. Chen AC, Chao EK, Hung SS, et al. Percutaneous screw fixation for unstable scaphoid fractures. J Trauma 2005;59:184–7. 4. Chen CY, Chao EK, Lee SS, Ueng SW. Osteosynthesis of carpal scaphoid nonunion with interpositional bone graft and Kirschner wires: a 3- to 6-year follow-up. J Trauma 1999;47:558–63. 5. Green DP. Operative hand surgery, 3rd ed., New York: Churchill-Livingstone; 1993. p. 806. 6. Jacobsen S, Hassani G, Hansen D, Christensen O. Suspected scaphoid fractures: can we avoid overkill. Acta Orthop Belg 1995;61:74–8.
7. Jupiter JB, Shin AY, Trumble TE, Fernandez DL. Traumatic and reconstructive problems of the scaphoid. In: Sim FH, editor. Instructional course lectures. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2001 . p. 105– 22. 8. Kim WC, Shaffer JW, Idzikowski C. Failure of treatment of ununited fractures of the carpal scaphoid: the role of non-compliance. J Bone Joint Surg 1983;65A: 985–91. 9. Kleinert JM, Zenni Jr EJ. Nonunion of the scaphoid: review of literature and current treatment. Orthop Rev 1984;13:125–41. 10. Langhoff O, Andersen JL. Consequences of late immobilization of scaphoid fractures. J Hand Surg 1988;13B:77–9. 11. Leslie IJ, Dickson RA. The fractured carpal scaphoid: natural history and factors influencing outcome. J Bone Joint Surg 1981;63B:225–30. 12. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid nonunion. J Bone Joint Surg 1984;66A:504–9. 13. Mark GR, Wilckens JH, McPherson SA. Subacute scaphoid fractures. A closer look at closed treatment. Am J Sports Med 1998;26:56–8. 14. Ruby LK, Stinson J, Belsky MR. The natural history of scaphoid non-union: a review of fifty-five cases. J Bone Joint Surg 1985;67A:428–32. 15. Russe O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg 1960;42A:759–68. 16. Shin AY, Sheetz KK, Bishop AJ, Berger RA. Vascularized pedicled bone graft from the distal radius. Arch Am Acad Orthop Surg 1999;2:94–106. 17. Tsuyuguchi Y, Murase T, Hidaka N, et al. Anterior wedge-shaped bone graft for old scaphoid fractures or nonunions: an analysis of relevant carpal alignment. J Hand Surg 1995;20B:194–200. 18. Whipple TL. Acute scaphoid fracture fixation. In: Vastamaki M, Vollo S, Raatikainen M, et al., editors. Current trends in hand surgery. Amsterdam, Netherlands: Elsevier Science; 1995. p. 75–7. 19. Wozasek GE, Moser KD. Percutaneous screw fixation for fractures of the scaphoid. J Bone Joint Surg 1991;73B:138–42.