Scaphoid Fractures: A Comparison of Two Surgical Methods Using Either Herbert Screws or Multiple Pins for Internal Fixation By: Mohsen Mardani Kivi M.D. Assistant Professor of Orthopedics Orthopedic Research Center Guilan University of Medical Sciences

What is it? The most common fracture of wrist

Anatomy Links the proximal and the distal carpal rows Waist is susceptible to fracture

Mechanism of Injury 2 mechanisms: Hyperextension and bending Puncher’s Scaphoid- axial force along the second metacarpal with the wrist in neutral.

Classification Herbert’s Classification

Symptoms 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”)

Scaphoid Fracture Evaluation Duration <3 weeks old- better prognosis If >4 weeks old drastically lower union rates when treated with cast alone Location Distal 1/3 (Pole) (5%) Middle 1/3 (Waist) (80%) Proximal 1/3 (Pole) (15%)- poor healing due to limited blood supply, osteonecrosis rate close to 100%

Union rate

Scaphoid Fracture Evaluation Displacement- Nonunion rates in displaced fractures reach 92% >1 mm step off on any view Scapholunate angle of >60 degrees Lunocapitate angle of greater than 15 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

Surgical Techniques

After surgery Herbert Screw : Multiple Pins: 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: Measurements: 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

Fracture Types Frequencies

Outcome Final Visit 6 m Post-op P value HS MP 0.9 96.6 96.3 0.5 93.1 91.1 Flexion * 0.7 94.7 93.7 0.6 89.3 87.3 Extension * 0.8 95.6 94.9 92.6 91.3 Grip * 95.3 95.2 92.2 91.6 Quick Dash 0.2 95 92.5 90.6 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 previous activities Return to Daily activities HS= 4±2 MP= 4±1 Sport HS= 39±8 MP= 38±7

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.

Conclusion 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.

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