Nonoperative Compared with Operative Treatment of Acute Scaphoid Fractures

Vinnars, Bertil; Pietreanu, Mihai; Bodestedt, Åke; Ekenstam, Fredrik af; Gerdin, Bengt

doi:10.2106/jbjs.g.00673

Cited by 146 publications

(188 citation statements)

References 40 publications

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“…While two previous reports have noted refracture after internal fixation in 2.5% (1/40) 4 and 7% (1/14) 13 of scaphoids, the exact incidence of secondary fracture is uncertain. However, the potential for this complication in young and active patients warrants discussion with potential patients and Fig.…”

Section: Discussionmentioning

confidence: 89%

“…11,12 However, we were unable to identify literature evaluating the in vivo biomechanical influence of headless screws on subsequent fracture of the healed scaphoid. Secondary fracture proximal to a Herbert compression screw 4 and secondary fracture of the proximal third of another scaphoid after screw fixation with bone grafting 13 have been reported. However, CT confirmation of initial fracture healing was not demonstrated in either report, and the shape and location of the secondary fracture fragment were not detailed.…”

Section: Discussionmentioning

confidence: 99%

“…Modern headless compression screws demonstrate high union rates, rapid recovery, and good-to-excellent outcomes in most series. 1,[3][4][5][6][7][8] We were unable to identify reports detailing the potential for secondary proximal pole fracture following scaphoid screw fixation.…”

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confidence: 99%

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Scaphoid Proximal Pole Fracture Following Headless Screw Fixation

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Nondisplaced scaphoid waist fractures may be managed nonoperatively, but require strict and prolonged immobilization. Fracture nonunion is a troublesome complication that leads to prolonged casting or secondary surgery and, if untreated, to carpal collapse and degenerative arthritis. 1,2 Unstable or displaced fractures, fracture-dislocations, and fractures involving the proximal pole require anatomic reduction with rigid fixation. Modern headless compression screws demonstrate high union rates, rapid recovery, and good-to-excellent outcomes in most series. 1,3-8 We were unable to identify reports detailing the potential for secondary proximal pole fracture following scaphoid screw fixation.In this series we describe three young men with scaphoid fracture nonunion that healed after antegrade headless compression screw fixation (Acumed, Hillsboro, OR, USA). Months later, the men presented with secondary fracture of the proximal pole (►Table 1). A consistently proximal and volar fracture pattern was observed that was contiguous with the screw insertion site. The purpose of this case series is to report our experience and raise awareness of a possible risk of retained hardware following antegrade scaphoid nonunion fixation, offer treatment strategies, and report outcomes. Case 1A 15-year-old right-handed lacrosse player presented to our institution after 3.5 months of sport-related left wrist pain had not abated. A scaphoid fracture had been treated as a AbstractBackground Headless screw fixation of scaphoid fractures and nonunions yields predictably excellent outcomes with a relatively low complication profile. However, intramedullary implants affect the load to failure and stress distribution within bone and may be implicated in subsequent fracture. Case Description We describe a posttraumatic fracture pattern of the scaphoid proximal pole originating at the previous headless screw insertion site in three young male patients with healed scaphoid nonunions. Each fracture was remarkably similar in shape and size, comprised the volar proximal pole, and was contiguous with the screw entry point. Treatment was challenging but successful in all cases. Literature Review Previous reports have posited that stress-raisers secondary to screw orientation may be implicated in subsequent peri-implant fracture of the femoral neck. Repeat scaphoid fracture after screw fixation has also been reported. However, the shape and locality of secondary fracture have not been described, nor has the potential role of screw fixation in the production of distinct fracture patterns. Clinical Relevance Hand surgeons must be aware of this difficult complication that may follow antegrade headless screw fixation of scaphoid fracture nonunion, and of available treatment strategies.

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Section: Discussionmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 99%

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Scaphoid Proximal Pole Fracture Following Headless Screw Fixation

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“…A recent study from Sweden shows a 100% union rate with either cast or screw fixation with no functional difference at 10 years [9]. However, there was an increase in scaphotrapezial arthritis in the operatively fixed group.…”

Section: Discussionmentioning

confidence: 96%

“…However, there was an increase in scaphotrapezial arthritis in the operatively fixed group. In their series, all surgeries were performed through a volar approach [9].…”

Section: Discussionmentioning

confidence: 99%