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Letters to the Editor to:

Scientific Articles:
J.J. Dias, C.J. Wildin, B. Bhowal, and J.R. Thompson
Should Acute Scaphoid Fractures Be Fixed? A Randomized Controlled Trial
J Bone Joint Surg Am 2005; 87: 2160-2168 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Should Acute Scaphoid Fractures Be Fixed?
Sameer Batra   (15 November 2005)
[Read Letter to the Editor] Treatment of Acute Scaphoid Fractures
Eric P. Hofmeister   (8 November 2005)

Should Acute Scaphoid Fractures Be Fixed? 15 November 2005
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Sameer Batra,
SHO
DEPARTMENT OF TRAUMA & ORTHOPAEDICS, Ysbyty Gwynedd, NW WALES NHS TRUST, Bangor, UK, LL57 2PW

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Re: Should Acute Scaphoid Fractures Be Fixed?

drbatrasameer{at}yahoo.co.uk Sameer Batra

To The Editor:

I read with interest the article ‘Should acute scaphoid fractures be fixed? A randomized controlled trial’.(1) The optimal management for undisplaced acute scaphoid fractures has been the focus of much debate. Unfortunately, this study failed in some respects to provide concrete answers.

There was a potential for observer bias in the evaluation of the radiographs because the observer could not be blinded with respect to whether the patient had had surgical treatment or cast immobilization and at the same time no mention was made to criterion for union. It has previously been reported that because of the almost complete cartilagenous surface of the scaphoid bone, fracture healing is an intraosseous process. Therefore the assessment of fracture healing by conventional radiography is very difficult. (2,3) Computed tomography imaging along the longitudinal axis of scaphoid bone is best suited for the evaluation of fractures as well as healing process.(4,5)

In the nonoperative group, the authors chose a below elbow cast with the thumb left free. Bhandari, et al,(6) in a meta-analysis on randomized controlled trials reported that use of long arm thumb spica casts with the thumb immobilized but the interphalangeal joint left free resulted in a 68% reduction in the risk of delayed or nonunion compared with short thumb spica casts.(7)

There is insufficient evidence from randomized trials to determine whether internal fixation is superior to casting in patients with undisplaced scaphoid fractures. A critical risk-benefit analysis is necessary to determine the optimal treatment of acute nondisplaced fractures of the scaphoid waist.

References:

1. J.J. Dias, C.J. Wildin, B. Bhowal, and J.R. Thompson Should Acute Scaphoid Fractures Be Fixed? A Randomized Controlled Trial J Bone Joint Surg Am 2005; 87: 2160-2168

2.Dias JJ (2001) Definition of union after acute fracture and surgery for fracture nonunion of the scaphoid. J Hand Surg; 26B, 321– 325.

3.Dias JJ, Taylor M, Thompson J, Brenkel IJ, Gregg PJ. (1988) Radiographic signs of union of scaphoid fractures: An analysis of inter-observer agreement and reproducibility. J Bone Joint Surg; 70B, 299–301.

4. Wilson AJ, Mann, FA, Gilula LA. (1990) Imaging of the hand and wrist. J Hand Surg 15B, 153–167.

5. Bain GI, Bennett JD, Richards RS, Slethaug, GP, Roth JH. (1995) Longitudinal computed tomography of the scaphoid: a new technique. Skeletal Radiol 24, 271–273.

6.Mohit Bhandari, MD, Beate P. Hanson. Acute Nondisplaced Fractures of the Scaphoid .J Orthop Trauma 2004; 18:253–255.

7. Gellman H, Caputo RJ, Carter V, et al. Comparison of short and longthumb-spica casts for non-displaced fractures of the carpal scaphoid. JBone Joint Surg Am. 1990; 72:309–310.
Treatment of Acute Scaphoid Fractures 8 November 2005
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Eric P. Hofmeister,
Physician
Naval Medical Center, San Diego, CA

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Re: Treatment of Acute Scaphoid Fractures

ephofmeister{at}nmcsd.med.navy.mil Eric P. Hofmeister

To The Editor:

In the article “Should Acute Scaphoid Fractures Be Fixed?” (2005;87:2160-2168), the authors present a very nice randomized trial between operative and nonoperative fixation of acute, nondisplaced scaphoid fractures. They concluded that at final follow up, there was not a clear overall benefit of early fixation in regard to pain, tenderness, range of motion, grip strength or the patient evaluation measure. However, the authors minimized their results in regards to delayed/nonunion.

Although each group initially consisted of 44 patients, the cast treatment group lost two patients, leaving 42 for review, and the operative group lost five patients, leaving 39 for final follow up. Ten in the cast group went on to a delayed/nonunion, for a rate of 23.8% (10/42). All fractures in the operative group healed. Utilizing a Fisher’s exact test, this gives a p-value of .001, which is highly significant.

Furthermore, in the delayed/nonunion group, six of the 10 required cancellous bone grafting, and one required a wedge graft, all which were more invasive and required longer surgery than the operative group. This “delayed” operative group then incurred an additional five to six weeks of immobilization (after an already six to eight weeks of immobilization), and 57% (4/7) continued to have minor discomfort at one year follow up.

Finally, the authors describe an “aggressive conservative treatment” with careful assessment of fracture healing on radiographs after six to eight weeks of casting. If union is not present, then additional imaging (computed tomography) is recommended, which incurs further expense, radiation exposure and inconvenience to the patient.