The treatment of acute undisplaced fractures of the Scaphoid: A Systematic Review Kreibich Presentation 2007 Tom Symes

Treatment of undisplaced Scaphoid #s Why is this study important? 2nd most common wrist fracture 2nd most common wrist fracture 60-70% of all carpal bone fractures Berger % of all carpal bone fractures Berger 1999 US annual incidence ~ 345,000 US annual incidence ~ 345,000 Up to 5% result in non-union Osterman and Mikulics, 1988 Up to 5% result in non-union Osterman and Mikulics, 1988 Need to establish evidence based best practice Need to establish evidence based best practice

Treatment of undisplaced Scaphoid #s Conservative treatment Controversies Controversies Position of wrist in plaster Position of wrist in plaster Inclusion of other joints Inclusion of other joints Duration of immobilisation Duration of immobilisation Traditional treatment Traditional treatment Scaphoid cast – Watson Jones 1995 Scaphoid cast – Watson Jones 1995 Inclusion of elbow Verdan, 1964, Kuhlmann 1987 Inclusion of elbow Verdan, 1964, Kuhlmann 1987 Colles cast – Clay Colles cast – Clay

Treatment of undisplaced Scaphoid #s Surgical treatment Pros Pros Quicker rehab Quicker rehab Better ROM Better ROM Higher rate of union Higher rate of union Cons Cons Complications Complications Cost Cost Resources Resources

Treatment of undisplaced Scaphoid #s Review Questions Is operative fixation of an undisplaced scaphoid fracture a more effective treatment than immobilisation in a cast? Is operative fixation of an undisplaced scaphoid fracture a more effective treatment than immobilisation in a cast? If immobilisation is the preferred treatment then: If immobilisation is the preferred treatment then: What is the ideal type of cast? What is the ideal type of cast? What is the ideal position of the wrist in plaster? What is the ideal position of the wrist in plaster? What is the ideal duration of immobilisation? What is the ideal duration of immobilisation?

Treatment of undisplaced Scaphoid #s Methods Study design Study design Systematic review Systematic review Sources Sources MEDLINE MEDLINE EMBASE EMBASE The Cochrane Library The Cochrane Library Other electronic databases Other electronic databases Search terms Search terms MeSH MeSH Cochrane search strategy for RCTs Cochrane search strategy for RCTs

Treatment of undisplaced Scaphoid #s Methods Study selection Study selection RCTs RCTs Quasi RCTs Quasi RCTs Quality assessment Quality assessment Validity Validity Applicability Applicability Importance Importance

Treatment of undisplaced Scaphoid #s Results Cast vs Surgery - 4 RCTS Cast vs Surgery - 4 RCTS Above elbow vs below elbow casts - 2 RCTs Above elbow vs below elbow casts - 2 RCTs Scaphoid vs Colles Cast – 1 RCT Scaphoid vs Colles Cast – 1 RCT Wrist Extension vs Flexion - 1 RCT Wrist Extension vs Flexion - 1 RCT 1 high quality study, 7 intermediate 1 high quality study, 7 intermediate

Treatment of undisplaced Scaphoid #s Cast vs Surgery 4 studies 4 studies Adolfsson et al 2001 Adolfsson et al 2001 Bond et al 2001 Bond et al 2001 Saeden et al 2001 Saeden et al 2001 Dias et al 2005 Dias et al 2005

Treatment of undisplaced Scaphoid #s Cast vs Surgery Considerable variation in the interventions Considerable variation in the interventions surgical surgical percutaneous in two studies percutaneous in two studies open in two studies open in two studies cast cast variation in the form and length of postoperative immobilisation. variation in the form and length of postoperative immobilisation.

Treatment of undisplaced Scaphoid #s Cast vs Surgery- Conclusions No difference No difference rate of non-union rate of non-union pain pain tenderness tenderness patient satisfaction patient satisfaction Grip strength & ROM better short term in the surgical group Grip strength & ROM better short term in the surgical group Time to union quicker in surgical group -1 study Time to union quicker in surgical group -1 study

Treatment of undisplaced Scaphoid #s Scaphoid vs Colles Clay et al (1991) Clay et al (1991) Casts identical except Scaphoid cast included the thumb to the IPJ Casts identical except Scaphoid cast included the thumb to the IPJ Rate of non-union almost identical between the groups Rate of non-union almost identical between the groups

Treatment of undisplaced Scaphoid #s Flexion vs Extension – Hambidge (1999) Casts with wrist in 20°of flexion or extension Casts with wrist in 20°of flexion or extension No difference No difference rate of non-union rate of non-union wrist flexion wrist flexion grip strength at 6months grip strength at 6months Significantly better wrist extension in the extension group at 6 months (WMD 7 degrees) Significantly better wrist extension in the extension group at 6 months (WMD 7 degrees)

Treatment of undisplaced Scaphoid #s Above vs below elbow cast 2 studies 2 studies Alho and Kankaanpaa Alho and Kankaanpaa below elbow cast resulted in a lower rate of non- union below elbow cast resulted in a lower rate of non- union Gellman Gellman above elbow cast resulted in a lower rate of non- union! above elbow cast resulted in a lower rate of non- union!

Treatment of undisplaced Scaphoid #s Recommendation Based on the available evidence, the most effective treatment for acute undisplaced fractures of the scaphoid is: Based on the available evidence, the most effective treatment for acute undisplaced fractures of the scaphoid is: Colles or Scaphoid cast Colles or Scaphoid cast wrist held in 20° of extension wrist held in 20° of extension until union is determined clinically and radiologically. until union is determined clinically and radiologically.

Treatment of undisplaced Scaphoid #s References Included trials Included trials Adolfsson L, Lindau T, Arner M, (2001) Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist fractures.Journal of Hand Surgery - British Volume. 26(3): Adolfsson L, Lindau T, Arner M, (2001) Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist fractures.Journal of Hand Surgery - British Volume. 26(3): Alho A, and Kankaanpaa, U. (1975) Management of fractured scaphoid bone. A prospective study of 100 fractures. Acta Orthopaedica Scandinavica. 46 (5): Alho A, and Kankaanpaa, U. (1975) Management of fractured scaphoid bone. A prospective study of 100 fractures. Acta Orthopaedica Scandinavica. 46 (5): Bond CD, Shin AY, McBride MT, Dao KD (2001) Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures Journal of Bone & Joint Surgery - American Volume 83-A (4): Bond CD, Shin AY, McBride MT, Dao KD (2001) Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures Journal of Bone & Joint Surgery - American Volume 83-A (4): Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ (1991) Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. Journal of Bone & Joint Surgery - British Volume. 73 (5): Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ (1991) Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. Journal of Bone & Joint Surgery - British Volume. 73 (5): Dias JJ, Wildin CJ, Bhowal B, Thompson JR (2005) Should acute scaphoid fractures be fixed? A randomized controlled trial Journal of Bone & Joint Surgery - American Volume. 87(10): Dias JJ, Wildin CJ, Bhowal B, Thompson JR (2005) Should acute scaphoid fractures be fixed? A randomized controlled trial Journal of Bone & Joint Surgery - American Volume. 87(10):

Treatment of undisplaced Scaphoid #s References Included trials Included trials Gellman H, Caputo RJ, Carter V, Aboulafia A, McKay M. (1989) Comparison of short and long thumb-spica casts for non-displaced fractures of the carpal scaphoid. Journal of Bone & Joint Surgery - American Volume 71(3): Gellman H, Caputo RJ, Carter V, Aboulafia A, McKay M. (1989) Comparison of short and long thumb-spica casts for non-displaced fractures of the carpal scaphoid. Journal of Bone & Joint Surgery - American Volume 71(3): Hambidge JE, Desai VV, Schranz PJ, Compson JP, Davis TR, Barton NJ (1999) Acute fractures of the scaphoid. Treatment by cast immobilisation with the wrist in flexion or extension? Journal of Bone & Joint Surgery - British Volume 81(1):91-92 Hambidge JE, Desai VV, Schranz PJ, Compson JP, Davis TR, Barton NJ (1999) Acute fractures of the scaphoid. Treatment by cast immobilisation with the wrist in flexion or extension? Journal of Bone & Joint Surgery - British Volume 81(1):91-92 Saeden B, Tornkvist H, Ponzer S, Hoglund M. (2001) Fracture of the carpal scaphoid. A prospective, randomised 12-year follow-up comparing operative and conservative treatment Journal of Bone & Joint Surgery - British Volume 83(2): Saeden B, Tornkvist H, Ponzer S, Hoglund M. (2001) Fracture of the carpal scaphoid. A prospective, randomised 12-year follow-up comparing operative and conservative treatment Journal of Bone & Joint Surgery - British Volume 83(2): Other refs: Other refs: Berger, R.A., Imeada, T., Berglund. L. and An, K.N. (1999) Constraint and material properties of the subregions of the scapholunate interosseous ligament. Journal of Hand Surgery (Am) 24: 953–962 Berger, R.A., Imeada, T., Berglund. L. and An, K.N. (1999) Constraint and material properties of the subregions of the scapholunate interosseous ligament. Journal of Hand Surgery (Am) 24: 953–962 Osterman, A.L. and Mikulics, M. (1988) Scaphoid nonunion. Hand Clinics of North America 4: 437–455 Osterman, A.L. and Mikulics, M. (1988) Scaphoid nonunion. Hand Clinics of North America 4: 437–455