Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Martin I. Boyer, MD*,
Barnes-Jewish Hospital at Washington University, St. Louis, Missouri
Posted June 2008
Decision-making regarding the "best" treatment of acute
undisplaced or minimally displaced fractures of the scaphoid waist involves
consideration of the relative benefits, risks, and complications of operative
treatment compared with the benefits and potential risks of nonoperative
treatment. In this manuscript, the authors have added to the knowledge base of
orthopaedic surgeons seeking to understand the natural history of both
operative and nonoperative treatment of scaphoid fractures. Their conclusion
that "this study did not demonstrate a true long-term benefit of internal fixation
(when) compared with nonoperative treatment" is based on the absence of any
significant measures of healing or function at the mean follow-up time of ten
years after injury, and it needs to be understood within the wider context of
choices that are available to the treating surgeon. The literature that has
been advanced within the last decade on this subject, and several important
studies bear mention in this regard.
Dias et al. performed a randomized controlled trial in which
they compared the operative treatment of acute minimally displaced or
undisplaced fractures of the scaphoid with nonoperative below-the-elbow cast
immobilization of eight weeks or longer1. They concluded that the
study "did not demonstrate a clear overall benefit of early fixation of acute
scaphoid fractures beyond the decrease in the rate of a change in treatment
because of a delayed union at twelve weeks." They advocated for an "aggressive
conservative" treatment plan, which indicated that surgical treatment should be
considered for a fracture that does not heal by the end of twelve weeks of cast
treatment. Although this treatment philosophy may be attractive initially, the
following questions remain: Are plain films sufficiently sensitive to determine
when a scaphoid has healed sufficiently? Additionally, and somewhat more
ominously, could these data support the withholding of acute surgical care for
these fractures on the basis of "cost-ineffectiveness?"
Bond et al. and Arora et al. also reported on the results of
randomized controlled trials that evaluated whether or not there was a
significant (both clinically and statistically) positive effect of operative
fixation when compared with cast immobilization2,3. Both groups of
authors found that early operative fixation with a headless screw allowed the
patients to return to work earlier, regain motion earlier, and heal more
quickly than their counterparts who had been managed with cast treatment. Both of
these studies utilized plain radiographs made at multiple time points following
the initiation of treatment, and the study by Bond et al. also made use of a computed
tomography scan that was acquired at the end of treatment to confirm union.
These authors believed that the fracture had healed when there was trabecular
bone traversing the fracture site on five separate views of the scaphoid and
when physical examination revealed no tenderness on palpation of the waist of
the scaphoid in the anatomic snuffbox. They did not report on complications
that were severe enough to dissuade them from concluding that early surgery for
minimally displaced or undisplaced scaphoid fractures would be of benefit. Bedi
et al. reported on the results of a case series wherein they utilized a small
dorsal incision for the introduction of a headless screw placed anterograde to
surgically fix the fracture acutely4. They, too, advocated for
earlier surgical treatment on the basis of a faster rate of healing and an
earlier return to function and motion.
The surgeon treating these fractures is in a quandary. The
risks associated with early operative fixation are nonunion (which is also a
risk associated with nonoperative treatment), infection, and scar tenderness. The
potential benefits are faster healing and a shorter time until the patient
regains motion and strength and can return to work. The risks associated with
nonoperative treatment are few, except for the time lost while the arm is in a
cast and the fracture is healing. In their paper, Vinnar et al. suggest that
there is also the potential risk of the development of cystic changes within
the scaphotrapeziotrapezoidal joint, although there were more frequent changes
within the subset of patients who were managed operatively with a screw placed
retrograde across the fracture site.
Is the development of radiographically evident arthritic
changes an important consideration in fractures treated operatively? The answer
to this question is not known, although the results of published series that evaluated
arthritic changes within the trapeziometacarpal joint of the thumb as well as the
results of series that evaluated posttraumatic arthritis of the radiocarpal
joint have cast doubt on whether radiographically evident arthritis necessarily
leads to clinical pain and disability. Similarly, does the anterograde passage
of headless screws for dorsal fixation of scaphoid waist fractures lead eventually
to symptomatic (clinically or radiographically evident) arthritis between the
proximal pole of the scaphoid and the scaphoid fossa of the distal part of the radius?
Data to support or refute this hypothesis are not available.
Why do the authors of this manuscript discount the "transient"
nature of the positive effect of early operative fixation in these patients? I
believe that this is due to the tendency of these authors to consider the end point
of treatment only (the so-called "final follow-up") rather than the relative
success or failure of both forms of treatment on earlier time points following
the initiation of treatment. If operative treatment leads to improved motion,
faster healing, and decreased immobilization of these fractures during the
first several months of treatment, can the measured "equivalence" of treatment
at ten years be used to argue for the unimportance of the improved results
during the early postoperative period? Isn't the "time of the long-term
follow-up" necessarily a time point that is determined arbitrarily? Some would
argue that this is so.
In summary, this study brings to the table the concept of scaphotrapeziotrapezoidal
arthritis following operative (as well as nonoperative) treatment of scaphoid
fractures. It is the role of the treating surgeon to determine, on the basis of
the knowledge of the natural history of the nonoperative treatment of this
fracture, whether or not the needs and wants of the particular patient being treated
would be better met by the "aggressive conservative" treatment advocated by
Dias et al.1 or by the "aggressive" operative treatment advocated by
Bond et al.2, Arora et al.3, and Bedi et al4.
Recall the lessons of Leslie and Dickson5, who, in 1981, reported
the results of cast immobilization for the treatment of scaphoid fractures,
concluding that "a union rate of 95% can be achieved using standard simple
treatment" consisting of a below-the-elbow plaster cast for as much as twelve
weeks. If only the surviving patients from their series could be identified,
examined, and imaged, the data obtained might settle the debate.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.
References
1. Dias JJ, Wildin CJ, Bhowal B, Thompson JR. Should acute scaphoid fractures be fixed? A randomized controlled trial. J Bone Joint Surg Am. 2005;87:2160-8.
2. Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001;83:483-8.
3. Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M. Fixation of nondisplaced scaphoid fractures: making treatment cost effective. Prospective controlled trial. Arch Orthop Trauma Surg. 2007;127:39-46.
4. Bedi A, Jebson PJ, Hayden RJ, Jacobson JA, Martus JE. Internal fixation of acute, nondisplaced scaphoid waist fractures via a limited dorsal approach: an assessment of radiographic and functional outcomes. J Hand Surg [Am]. 2007;32:326-33.
5. Leslie IJ, Dickson RA. The fractured carpal scaphoid. Natural history and factors influencing outcome. J Bone Joint Surg Br. 1981;63:225-30.
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