Current Concepts in the Treatment of Scaphoid Fractures

Sauerbier, Michael; Germann, Günter; Dacho, Andreas
April 2004
European Journal of Trauma;Apr2004, Vol. 30 Issue 2, p80
Academic Journal
Fractures of the carpus are frequent injuries and typically result from of a fall onto the outstretched hand. Scaphoid fractures are the second most frequent fracture type of the hand (80%). 95% of the patients with acute scaphoid fractures are male, and the average age is approximately 25 years. Conservative treatment of acute scaphoid fractures with immobilization in a plaster cast was the therapy of choice for a long time. Surgical treatment was reserved to severe dislocated fractures only. A progress could be obtained by the principle of intramedullary fixation, whose forerunner is represented by the Herbert screw, and the introduction of cannulated screws guaranteed a continuous improvement. The decision to treat the fracture by surgery requires a clear definition of the fracture type. Therefore, precise radiologic technique is mandatory to detect the fracture and to analyze the pathomorphological circumstances. In order to get an exact classification for the decision on how to proceed, three standard X-ray projections (posteroanterior [PA], lateral and Stecher projection) and a CT scan have to be performed. The most well-known classification has been defined by Herbert & Fisher which combines fracture anatomy, stability and disease history in order to derive prognostic and therapeutic criteria. Also, delayed healings and nonunions are considered. To decide on the adequate treatment, a prerequisite for conservative therapy of acute scaphoid fractures is the anatomic position of the scaphoid. Conservative therapy should be reserved to fracture types, which are stable and heal reliably in the lower-arm plaster cast within 6 weeks. All displaced and unstable acute scaphoid fractures should be operated, and whenever possible, rigid internal fixation should be achieved because of interfragmentary compression. Therefore, several intramedullary implants are available for surgical treatment of acute scaphoid fractures, e. g., Herbert screw, Mini Herbert screw, AO screw (cannulated), Acutrac screw (cannulated), or Twin-fix screw (cannulated). With improved surgical and radiologic techniques, most scaphoid fractures are amenable to minimally invasive fixation. The dorsal approach guarantees a good overview in treating proximal pole fractures. Yet, not all types of fractures can be treated in this way. Severely displaced fractures require the classic open palmar approach. In order to prevent the development of a scaphoid nonunion or an advanced carpal collapse (SNAC-wrist), an early and sufficient diagnostic algorithm is necessary. We recommend internal fixation with a cannulated Herbert screw in B1 and B2 fractures and a Mini Herbert screw in fractures of the proximal third (B3). A2 fractures can be treated conservatively. Early diagnosis and operative treatment will shorten the time off work, minimize the risk of nonunion, and reduce the costs of health care in the long term.


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