2. 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

3. What is it?
The most common fracture of wrist

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

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

6. Classification
Herbert’s Classification

7. 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”)

8. 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%

9. Union rate

10. 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

11. Internal Fixation
Herbert Screw vs. Multiple Pins
Vs.

12. Patients and methods Cross-sectional study From 2009 to 2011
23 patients in Herbert screw and 18 in multiple pins groups

13. Inclusion and Exclusion Criteria
Inclusion criteria
Scaphoid fracture
>1mm displacement
Exclusion criteria
Herbert’s Type A
Accompanying lesions

14. Surgical Techniques

15. 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

16. 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)

17. - 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

18. Fracture Types Frequencies

19. 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

20. 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

21. 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):

22. 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:

23. 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):

24. 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.

25. ANY QUESTIONS ?!