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PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 229
the management of scaphoid fractures have described fractures were ﬁxed via the volar approach and 22
this technique, and this approach has been advocated by the dorsal approach.
over the past few years. Since Streli’s ﬁrst report on the The study group included 39 male and 2 female
percutaneous technique in 1970,2 many reports have patients with an average age (of overall patients in the
described the percutaneous ﬁxation of scaphoid frac- dorsal or volar group) of 28 years (range, 14 –52 years).
tures. Both the volar approach3–17 and the dorsal ap- Thirty-six right hands (34 dominant) were involved.
proach18 –21 have appeared in the literature with rela- Nineteen patients were students at the time of surgery.
tively low complication rates. Slade et al.18 stressed that The remaining 22 patients included 9 manual workers,
using the dorsal approach, the screw is introduced from 7 ofﬁce workers, 3 farmers, and 3 drivers.
the narrow proximal pole to the wide distal fragment, Diagnosis of the fracture was based on physical
and therefore, it is easier to place the screw in the examination, plain radiographs, and computed tomog-
central portion of the scaphoid. Chan et al.22 conducted raphy (CT). Standard posteroanterior, lateral, and 45°
a cadaveric comparison between the proximal and distal semipronated oblique view and thin-section CT scan
techniques of percutaneous screw placement in the along the long axis of the thumb were taken in all
scaphoid and concluded that the proximal-dorsal ap- patients before the surgery to conﬁrm fracture site dis-
proach allowed more central screw placement. Al- placement, comminution, or angulation.
though good clinical results from the volar and the At the time of surgery, details of the fracture patterns
dorsal percutaneous screw ﬁxation techniques have were recorded. The average age (of each group) of the
been reported, there has been no clinical comparative patients was 30 years (range, 14 –52 years) in the dorsal
study done between the dorsal and the volar approaches group and 27 years (range, 16 –52 years) in the volar
in the literature. group. Overall, fractures were most common in patients
The purpose of this study is to evaluate the position in their twenties and thirties (32 patients). Patient details
of the screws and ﬁnd the difference of clinical and are summarized in Table 1. The most common injury
radiologic outcome between the volar approach and the was a minor fall on an outstretched hand in 33 patients,
dorsal approach groups in percutaneous screw ﬁxation and among them 15 fractures occurred during sports
for acute scaphoid fractures. activities. Five fractures were caused by a direct blow
such as a punch, and 1 fracture was due to a road trafﬁc
MATERIALS AND METHODS accident.
From January 1999 to December 2005, we prospec-
tively followed up 53 patients with an acute scaphoid Surgical technique
fracture. All fractures were classiﬁed according to the The volar approach: Under general or brachial plexus an-
modiﬁed classiﬁcation of Herbert and Fisher.23 All esthesia, patients were placed supine on the operating
fractures were classiﬁed as type B2 unstable acute frac- table and the scaphotrapezial joint was identiﬁed and
tures (22 fractures in the dorsal group and 19 fractures marked on the volar side of the skin. A trial manual
in the volar group). Mild comminution in the palmar reduction of the fractures was facilitated under an image
side was noted in 4 patients. All patients were managed intensiﬁer if necessary. A transverse stab incision was
with percutaneous screw ﬁxation by 1 hand surgeon at made at about 1 cm distal to the scaphotrapezial joint
the university hospital. under image intensiﬁer control. After blunt dissection to
Forty-one patients treated by percutaneous ﬁxation the distal end of the scaphoid, a 1.4-mm (0.045-in)
with noncannulated Herbert screw fulﬁlled the inclu- K-wire was used temporarily to facilitate fracture sta-
sion criteria: (1) type B2 acute displaced fractures of bilization along the long axis of the scaphoid directed
scaphoids, (2) a surgery within 2 weeks after initial toward the center of the proximal pole. A semipronated
injury, and (3) minimum follow-up of 2 years. oblique view was required in addition to anteroposterior
Exclusion criteria were patients with (1) a proximal and lateral views, because lateral radiograph did not
pole fracture, (2) a complicated fracture like transcaph- show the entire proximal outline of the scaphoid. The
oid perilunar dislocations, or (3) an associated fracture length of the guide wire within the scaphoid was deter-
in the distal radius or other carpal bones. mined. The drill was inserted, parallel to the guide wire
Initially, all surgeries were performed using the under ﬂuoroscopy. After tapping, a Herbert screw of
volar approach from January 1999 to June 2001, appropriate length was introduced under image intensi-
and subsequently the dorsal approach was used in ﬁer control. Compression was conﬁrmed by an image
all patients beginning July 2001. A total of 19 intensiﬁer, and the end of the screw was buried beneath
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230 PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE
TABLE 1. Comparison of Details Between the Dorsal Approach and the Volar Approach Groups
Dorsal (n 22) Volar (n 19)
Range Mean Range Mean
Variables Median (Minimum–Maximum) (SD) Median (Minimum–Maximum) (SD) p Value*
Gender (F:M), n (%) 2 (9.1):22 (90.1) 0 (0.0):9 (100) .178†
Age (y) 27 38 (14–52) 30 (12) 24 36 (16–52) 27 (9) .425
Time from injury to 10 10 (4–14) 10 (3) 10 8 (6–14) 10 (2) .766
Follow-up time (mo) 29 18 (24–42) 30 (6) 28 14 (24–38) 30 (5) .958
Statistically signiﬁcant at p .05.
*The result of the Mann-Whitney U test.
†The result of the chi-square test.
the distal surface of the scaphoid to avoid any further
damage to the scaphotrapezial joint.
The dorsal approach: Under appropriate anesthesia with
the patient in a supine position, the dorsal scapholunate
joint was marked. The wrist was pronated and ﬂexed
until the scaphoid was seen as a circle on ﬂuoroscopy.
The center of the circle was chosen as the target point
for the insertion of the guide wire into the proximal pole
of the scaphoid. After stab incision over the center of
the circle (usually over the scapholunate joint), the
guide wire was driven dorsal to volar so that it exited at
the radial base of the thumb. The reduction and place-
ment of the guide wire was conﬁrmed under an image FIGURE 1: Technique for measuring scaphoid long axis in
intensiﬁer. A pilot hole was drilled parallel to the guide plain radiographs of A posteroanterior view and B lateral view.
K-wire. After tapping, a Herbert screw was inserted The long axis of the scaphoid in the posteroanterior and
under an image intensiﬁer in a freehand manner. After semipronated oblique views was determined as a line between
the center of the distal tuberosity and the most convex point of
ﬁxation, the position of the screw could be veriﬁed
the proximal pole of the scaphoid, and it was determined as
using an image intensiﬁer.
the volar outline in the lateral view.
The wrist was supported in a volar splint for 3 weeks.
Active assisted ﬁnger exercises were encouraged im- Plain radiographs of posteroanterior, lateral, and 45°
mediately after surgery. The splint was removed and semipronated oblique views standardized by 2 radiog-
wrist exercises were initiated 3 weeks after the surgery. raphers were acquired via digital radiography and saved
Resisted or weight-bearing exercise was allowed after using a picture archiving and communications system
healing was established. Clinical and radiographic con- (PACS) (Mediface; Inﬁnitt, Seoul, Republic of Korea).
trols were performed at 4, 8, and 12 weeks and at the The axes and angles were measured using the software
end of follow-up. tool in the PACS. The long axis of the scaphoid in the
posteroanterior and semipronated oblique views was
Evaluation determined as a line between the center of the distal
Clinical evaluations as well as the pain scale, range of tuberosity and the most convex point of the proximal
motion, grip strength, and functional outcome based on pole of the scaphoid, and the long axis of the scaphoid
the Mayo wrist score system24 were performed at the was determined as the volar outline in the lateral view
end of follow-up. (Fig. 1). The relationship between (1) the long axis of
JHS Vol A, February
PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 231
TABLE 2. Clinical Results of the Dorsal Approach and the Volar Approach Groups
Dorsal (n 22) Volar (n 19)
Variables Median (Minimum–Maximum) Mean (SD) Median (Minimum–Maximum) Mean (SD) p Value*
Pain 25 10 (15–25) 23.18 (2.91) 25 5 (20–25) 23.42 (2.39) .910
Flexion (°) 65 15 (60–75) 66 (4) 65 20 (60–80) 67 (6) .989
Extension (°) 63 20 (50–70) 61 (5) 60 15 (50–65) 60 (5) .300
Radial deviation (°) 25 11 (20–31) 25 (2) 24 5 (22–27) 24 (1) .380
Ulnar deviation (°) 34 10 (26–36) 32 (3) 33 7 (31–38) 34 (2) .414
Modiﬁed Mayo wrist 100 80–100 96 (6) 95 85–100 95 (6) .446
Statistically signiﬁcant at p .05.
*The result of the Mann-Whitney U test.
the Herbert screw with respect to the long axis of the pain was reduced by internal ﬁxation of the scaphoid 2
scaphoid and (2) the fracture line with respect to the or 3 days postoperatively. The outcome measurements
angle of the long axis of the scaphoid was measured of pain, tenderness, range of motion, grip strength, and
on the posteroanterior, lateral, and semipronated Mayo wrist score are shown in Table 2. The 2 groups
oblique views. This measurement was conducted were similar at the baseline for all outcome measure-
by 1 hand surgeon who was not involved in the ments and the mean follow-up period (Table 1). Over-
treatment and 1 musculoskeletal radiologist, twice all, the ﬁnal range of motion of the wrist in both groups
by both practicioners. When there were any dis- averaged 66° (range, 60° to 80°) of ﬂexion, 61° (range,
agreements between the measurements, the measure- 50° to 65°) of extension, 25° (range, 20° to 31°) of
ments were repeated until agreement was reached. radial deviation, and 33° (range, 28° to 38°) of ulnar
Radiologic union was deﬁned as cross-trabeculation deviation. In the dorsal approach group, averages of 66°
on all radiographic views, and radiographic signs of of ﬂexion and 61° of extension were recorded, and in
arthrosis were checked. the volar approach group, averages of 67° of ﬂexion
and 60° of extension were recorded.
Statistical analyses Although the volar group demonstrated slightly
Statistical analyses were performed for comparisons greater ﬂexion and less extension, there was no statis-
between age, gender, and all clinical factors between the tically signiﬁcant difference between the 2 groups (p
volar and the dorsal groups. All variables in each group .05) (Table 2).
were described as mean, SD, median, range for quantita- According to the more stringent modiﬁed Mayo
tive variables, and frequency with a percentage for quali- wrist score system,24 the functional results in the dorsal
tative variables. To compare the 2 groups for all variables approach group were excellent for 18 patients, good for
(except gender), a Mann-Whitney U test was used, be- 3 patients, and fair for 1 patient; however, in the volar
cause a normality test was not appropriate. A chi-square approach group, 15 patients had excellent results and 4
test was performed for gender. Statistical software patients showed good results. There was no statistically
(SPSS, ver. 12.0; SPSS Inc., Chicago, IL) was used, signiﬁcant difference between the 2 groups (p .446).
and a p value .05 was considered signiﬁcant. The fracture union was diagnosed in all but 1 patient
on the visit at 12 weeks. This delayed union in the volar
RESULTS group required additional splint immobilization, and
Clinical results complete radiographic union was achieved 20 weeks
The demographics of the 2 groups were very similar after surgery. There was no statistically signiﬁcant dif-
according to age, gender, time between injury and sur- ference between the 2 groups regarding the fracture
gery, and follow-up time (Table 1). Most subjective union (p .683).
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232 PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE
FIGURE 2: A, B. The angle between the long axis of the scaphoid and the Herbert screw is measured using the standard
postoperative radiograph. The long axis of the scaphoid is marked with a dotted black line, and the long axis of the Herbert screw
is marked with a dotted red line. The Herbert screw in A the dorsal approach is placed more parallel to the long axis of the
scaphoid than in B the volar approach. C, D. The angle between the fracture site and the long axis of the Herbert screw is
measured in the standard postoperative radiograph. The fracture line of the scaphoid is marked with a dotted black line, and the
long axis of the Herbert screw is marked with a dotted red line. The Herbert screw in C the dorsal approach is placed more
vertical to the horizontal fracture line of the scaphoid than in D the volar approach.
Radiographic result of the scaphoid than that in the volar approach
group (Fig. 2A, B). The average angle between the
Radiographs made at the time of the surgery were
screw and the scaphoid in the dorsal approach
used for axis measurements. The analysis of the
group was 11° at posteroanterior view, 8° at lateral
inclination of the fracture line showed there was no
view, and 8° at semipronated oblique view. On the
statistically signiﬁcant difference between the 2
other hand, in the volar approach group, the aver-
groups at 3 different radiographic views. The mean
age angle between the screw and scaphoid was 13°
inclination angle in the dorsal approach group was
at posteroanterior view, 13° at lateral view, and
81°, and it was 82° in the volar approach group (p
16° at semipronated oblique view. Although the
.788). Radiographs at the time of the most
screws showed no signiﬁcant difference between
recent follow-up revealed that all fractures had
the 2 groups in posteroanterior and lateral views,
screws in the dorsal approach group were observed
The angle between the screw and the scaphoid long axis at 3 different to be placed more parallel to the long axis of the
views: The position of the screw in the dorsal scaphoid in the semipronated oblique view (p
approach group was more parallel to the long axis .019) (Table 3).
JHS Vol A, February
PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 233
TABLE 3. Comparison of Radiographic Results Between the Dorsal Approach and the Volar Approach
Dorsal (n 22) Volar (n 19)
Range Mean Range
Variables Median (Minimum–Maximum) (SD) Median (Minimum–Maximum) Mean (SD) p Value*
Long axis–screw 10 33 (0–33) 11 (10) 14 26 (2–28) 13 (9) .416
Long axis–screw lateral (°) 6 30 (0–30) 8 (8) 14 36 (0–36) 13 (10) .148
Long axis–screw oblique (°)‡ 40 (0–40) 8 (9) 9 19 (3–22) 10 (5) .019†
Fracture line–screw 81 30 (60–90) 80 (8) 72 30 (59–89) 74 (10) .039†
Fracture line–screw lateral (°) 85 20 (70–90) 83 (6) 72 28 (58–86) 72 (8) .000†
Fracture line–screw 82 23 (65–88) 80 (6) 77 39 (50–89) 73 (12) .023†
*The result of the Mann-Whitney U test.
†Statistically signiﬁcant at p .05.
‡Oblique: 45° inclined semipronated oblique view.
The angle between the screw and vertical to the fracture line at 3 different DISCUSSION
views: The screws in the dorsal approach group were Nondisplaced fractures of the scaphoid waist were man-
positioned more perpendicular to the fracture lines of aged with immobilization as the standard treatment;
the scaphoid compared with those of the volar approach however, unstable and displaced scaphoid fractures when
group (Fig. 2C, D). The average angle between the 2 treated with plaster immobilization are at the greatest risk
axes in the dorsal approach group was 80° at posteroan- of nonunion.25 Reports on open internal ﬁxation of scaph-
terior view, 83° at lateral view, and 80° at semipronated oid fractures have documented a high rate of union,26,27
oblique view. In the volar approach group, the average but there are risks of violating intact volar ligaments and,
angle between the 2 axes was 74° at posteroanterior subsequently, carpal instability.28,29 In addition, surgical
view, 72° at lateral view, and 73° at semipronated trauma of the soft tissue around the scaphoid, which
oblique view. There was a statistically signiﬁcant dif- has tenuous vascular supply, shows a risk of delayed
ference between the dorsal approach group and the healing or nonunion.30 Thus, recently, there has been
volar approach group for all 3 different radiographic an increased trend toward percutaneous ﬁxation for
views (p .05) (Table 3). displaced scaphoid fractures. This procedure bears
the inherent advantages of limited soft tissue dissec-
Complications tion and it hastens fracture healing.5
There were no perioperative complications. None of the Many authors have reported good or excellent func-
patients showed radiographic signs of arthrosis during tional outcome with percutaneous screw ﬁxation (Ap-
the study period. One patient sustained an injury of the pendix; this appendix may be viewed at the Journal’s
superﬁcial branch of the radial artery during the volar Web site, www.jhandsurg.org). Use of cannulated AO
approach, and there was 1 instance of a delayed union, screws,14,15,17 cannulated Acutrak screws,8,20,31,32 or
which required additional splint immobilization. One non-cannulated Herbert screws6,10,13,16 have been re-
patient in the dorsal approach group complained of a ported in previous studies. Although cannulated
painful hypertrophic scar on the dorsum of the wrist; no screws have resulted in a higher rate of central
additional procedures were necessary. There were no placement in the scaphoid with better resistance
complications related to Herbert screw (ie, migration or and compressive forces,33 in our experience we
loosening). None of the patients showed stiffness of the found that a non-cannulated Herbert screw, using the
ﬁngers or thumb, nor did they develop complex re- freehand method, is also reliable for acute scaphoid
gional pain syndrome. fractures.
JHS Vol A, February
234 PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE
Both the volar approach and the dorsal approach for proximal fragment had superior results of stiffness, load
acute fractures have been reported in the literature. at displacement, and load at failure compared with
Streli2 in 1970 ﬁrst reported a detailed surgical tech- those after eccentric positioning of the screw. The com-
nique of percutaneous screw ﬁxation for scaphoid frac- parative study by Chan and McAdams22 on 12 cadav-
ture; this was followed by Wozasek and Moser16 in eric models demonstrated that the proximal/dorsal ap-
1991. Since then, the majority of series have been proach to percutaneous screw ﬁxation of scaphoid waist
operated via the volar distal approach with successful fractures allowed for a more central placement in the
outcome; however, the dorsal approach became popular distal pole, but there was no marked difference when it
after the method was introduced by Slade et al.18 in was used in the proximal or waist regions.
2001. The reported union time in the volar approach Radiographic analysis of the 2 groups in our study
varied from 6 to 18 weeks with different screw ﬁxation conﬁrmed that screws were inserted in a more favorable
methods.3–17 The union time in the dorsal approach was position (ie, perpendicular to the fracture line) through
reported as being between 8 to 12 weeks.21,31,32 The the dorsal approach than through the volar approach.
union rate was 89% to 100%. On the other hand, This might have biomechanical advantages in terms of
complications were also reported related to both meth- fracture healing; however, this was not conﬁrmed in our
ods of ﬁxation.32 Complex regional pain syndrome, study. In addition, 45° semipronated oblique view con-
superﬁcial skin infection, and nonunion3,4,15 have been ﬁrmed that the screws were placed more parallel to the
reported in the volar approach. In the dorsal approach, long axis of the scaphoid through the dorsal approach.
only 1 extensor pollicis longus rupture and one non- In the volar approach, the guide wire tends to lead the
union (3%)31 have been reported (Appendix; this ap- screw to volar placement in the distal pole.
pendix may be viewed at the Journal’s Web site, www. Our study demonstrated that union was achieved in
jhandsurg.org). all but 1 case, with similar time to union in the volar and
Slade et al. used an arthroscopic-assisted approach in the dorsal groups. The clinical results of this study
all patients, and it allowed conﬁrmation of fracture suggest that both the volar and the dorsal approaches
reduction and screw implantation as well as an evalu- offered reliable results. There was no signiﬁcant differ-
ation of concurrent ligament injuries that could not be ence between the 2 groups in terms of union time and
detected with standard imaging. functional outcome, which included pain, range of mo-
The advantages of the dorsal approach were the tion, return to work, and grip strength. Functional result
exact targeting of the central axis of the scaphoid, more at last follow-up demonstrated that 82% of patients in
precise placement of the screw within the scaphoid, and the volar group and 79% in the dorsal group were
avoiding injury to the volar carpal ligament.18 On the graded as excellent according to the Mayo wrist score
other hand, the volar approach has easier access to the system.24 There was 1 delayed union in the volar ap-
entry because the guide wire does not cross the radio- proach group and 1 painful hypertrophic scar in the
carpal joint, there are less technically demanding, dorsal approach group. No hardware-related problems
and it is easy to maintain fracture reduction with as reported by Bushnell et al.32 were observed in our
wrist extension, so there is no risk of injuring the study. These results were comparable with those of
extensor tendons. other reports (Appendix; this appendix may be viewed
It has been shown that the technical aspects of screw at the Journal’s Web site, www.jhandsurg.org).
insertion are important for the clinical outcome after In our practice, we used exclusively the volar ap-
ﬁxation of acute fractures of the scaphoid waist.14,34 proach inﬂuenced by excellent results reported by
The study of Trumble et al.14 concluded that central Wozasek and Moser16 and Inoue and Shionoya9 from
placement of the screw in the proximal fragment of the 1999 to 2001. Since 2001, we learned that the dorsal
scaphoid with either the cannulated or Herbert screw is approach introduced by Slade et al.18 provided better
associated with a signiﬁcant reduction in the times to targeting and more precise placement. Thus, we
union (p .05). In addition, there is evidence that the changed our policy to the dorsal approach since then.
postoperative range of motion is associated with the This study is one of the largest series analyzing the
degree of scaphoid alignment achieved by internal ﬁx- outcome of percutaneous scaphoid ﬁxation.
ation; however, their study was carried out in a non- The subjects in our study are relatively uniform with
union series that had been present for more than 4 regard to age, interval between injury and surgery, and
months and not in the acute fractures. The biomechani- follow-up time. The analysis of the fracture pattern and
cal study of McCallister et al.35 in the cadaveric model characteristics are crucial in this study. In this retrospec-
conﬁrmed that the central placement of a screw in the tive study, we excluded any fracture in the distal one
JHS Vol A, February
PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 235
third or proximal one third of the scaphoid, and the Percutaneous Herbert screw ﬁxation for fractures of the scaphoid:
review of 30 cases. Chir Main 2002;21:350 –354.
collection was relatively homogenous. There was no 7. Chen AC, Chao EK, Hung SS, Lee MS, Ueng SW. Percutaneous
vertical fracture in the waist. Analysis of the inclination screw ﬁxation for unstable scaphoid fractures. J Trauma 2005;59:
of the fracture line at 3 different radiographic views 184 –187.
showed there was no statistically signiﬁcant difference 8. Haddad FS, Goddard NJ. Acute percutaneous scaphoid ﬁxation. A
pilot study. J Bone Joint Surg 1998;80B:95–99.
between the 2 groups. All surgeries were performed by 9. Inoue G, Shionoya K. Herbert screw ﬁxation by limited acess for
the same surgeon at the single institute. The patients acute fractures of the scaphoid. J Bone Joint Surg 1997;79B:
were evaluated by an independent doctor who was not 418 – 421.
10. Jeon IH, Oh CW, Park BC, Ihn JC, Kim PT. Minimal invasive
involved in the treatment. percutaneous Herbert screw ﬁxation in acute unstable scaphoid frac-
This study has the limitation of lack of assessment of ture. Hand Surg 2003;8:213–218.
intraobserver and interobserver variability for reproduc- 11. Ledoux P, Chahidi N, Moermans JP, Kinnen L. Percutaneous Her-
bert screw osteosynthesis of the scaphoid bone. Acta Orthop Belg
ible and reliable studies. The geometry of the scaphoid 1995;61:43– 47.
lacks symmetry in any single plane, thus, its true central 12. Shih JT, Lee HM, Hou YT, Tan CM. Results of arthroscopic reduc-
axis is inherently a 3-dimensional entity. Thus, this tion and percutaneous ﬁxation for acute displaced scaphoid fractures.
study has a limitation in identiﬁcation of the true long Arthroscopy 2005;21:620 – 626.
13. Taras JS, Sweet S, Shum W, Weiss LE, Bartolozzi A. Percutaneous
axis of the scaphoid, because this is based on an inter- and arthroscopic screw ﬁxation of scaphoid fractures in the athlete.
pretation of single planar imaging in 3 different planes. Hand Clin 1999;15:467– 473.
Thus, a 3-dimensional imaging technique of screw 14. Trumble TE, Clarke T, Kreder HJ. Non-union of the scaphoid.
Treatment with cannulated screws compared with treatment with
placement (such as with 3-dimensional CT reconstruc- Herbert screws. J Bone Joint Surg 1996;78A:1829 –1837.
tion) is warranted to compare the volar and the dorsal 15. Wong TC, Yip TH, Wu WC. Carpal ligament injuries with acute
techniques in the future. This measurement was con- scaphoid fractures—a combined wrist injury. J Hand Surg 2005;30B:
ducted independently by 1 hand surgeon who was not
16. Wozasek GE, Moser K. Percutaneous screw ﬁxation for fractures of
involved in the treatment and by 1 musculoskeletal radi- the scaphoid. J Bone Joint Surg 1991;73B:138 –142.
ologist. In addition, this study contains the inherent weak- 17. Yip HS, Wu WC, Chang RY, So TY. Percutaneous cannulated screw
ness of the retrospective study, a small sample size, and ﬁxation of acute scaphoid waist fracture. J Hand Surg 2002;27B:
absence of power analysis. None of the outcomes differed 18. Slade JF III, Grauer JN, Mahoney JD. Arthroscopic reduction and
signiﬁcantly between the 2 groups, but this conclusion percutaneous ﬁxation of scaphoid fractures with a novel dorsal
must be evaluated carefully given the potential of low technique. Orthop Clin North Am 2001;32:247–261.
19. Slade JF III, Jaskwhich D. Percutaneous ﬁxation of scaphoid frac-
power to detect clinically important differences. We did tures. Hand Clin 2001;17:553–574.
collect all patients who satisﬁed the inclusion criteria 20. Slade JF III, Taksali S, Safanda J. Combined fractures of the scaphoid
during the time, so all available patients were used. and distal radius: a revised treatment rationale using percutaneous and
arthroscopic techniques. Hand Clin 2005;21:427– 441.
Further, the size of the difference between the 2 groups
21. Slade JF III, Gutow AP, Geissler WB. Percutaneous internal ﬁxation
was small for each outcome variable, and good out- of scaphoid fractures via an arthroscopically assisted dorsal ap-
comes were observed in both groups, so we do not proach. J Bone Joint Surg 2002;84A:21–36.
believe clinically important differences were missed 22. Chan KW, McAdams TR. Central screw placement in percutaneous
screw scaphoid ﬁxation. A cadaveric comparison of proximal and
due to sample size limitations. Nevertheless, a prospec- distal techniques. J Hand Surg 2004;29A:74 –79.
tive controlled study with appropriate power analysis in 23. Herbert TJ, Fisher WE. Management of the fractured scaphoid using
advance is required in the future. a new bone screw. J Bone Joint Surg 1984;66B:114 –123.
24. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a
rational approach to management. Clin Orthop 1980;149:90 –97.
REFERENCES 25. Gellman H, Caputo RJ, Carter V, Aboulaﬁa A, Mckay M. Com-
1. Hove LM. Epidemiology of scaphoid fractures in Bergen, Norway. parison of short and long thumb-spica casts for non-displaced
Scand J Plast Reconstr Surg Hand Surg 1999;33:423– 426. fractures of the carpal scaphoid. J Bone Joint Surg 1989;71B:
2. Streli R. Percutaneous screwing of the navicular bone of the hand 354 –357.
with a compression drill screw (a new method). Zentralbl Chir 26. Rettig AC, Kollias SC. Internal ﬁxation of acute stable scaphoid
1970;95:1060 –1078. fractures in the athlete. Am J Sports Med 1996;2:182–186.
3. Adolfsson L, Lindau T, Arner M. Acutrak screw ﬁxation versus cast 27. Rettig ME, Kozin SH, Cooney WP. Open reduction and internal
immobilization for undisplaced scaphoid fractures. J Hand Surg ﬁxation of acute displaced scaphoid waist fractures. J Hand Surg
4. Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M. 28. Filan SL, Herbert TJ. Herbert screw ﬁxation of scaphoid fractures.
Fixation of nondisplaced scaphoid fractures: making treatment cost J Bone Joint Surg 1996;78B:519 –529.
effective. Prospective controlled trial. Arch Orthop Trauma Surg 29. Garcia-Elias M, Vall A, Salo JM, Lluch AL. Carpal alignment after
2007;127:39 – 46. different surgical approaches to the scaphoid: a comparative study.
5. Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw J Hand Surg 1988;13A:604 – 612.
ﬁxation or cast immobilization for nondisplaced scaphoid fractures. 30. Botte MJ, Mortensen WW, Gelberman RH, Rhoades CE, Gellman
J Bone Joint Surg 2001;83A:483– 488. H. Internal vascularity of the scaphoid in cadavers after insertion of
6. Brutus JP, Baeten Y, Chahidi N, Kinnen L, Moermans JP, Ledoux P. Herbert screw. J Hand Surg 1988;13A:216 –220.
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236 PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE
31. Bedi A, Jebson PJ, Hayden RJ, Jacobson JA, Martus JE. Internal 34. Adams BD, Blair WF, Reagan DS, Grundberg AB. Technical
ﬁxation of acute, nondisplaced scaphoid waist fractures via a limited factors related to Herbert screw ﬁxation. J Hand Surg 1988;13A:
dorsal approach: an assessment of radiographic and functional out- 893– 899.
comes. J Hand Surg 2007;32A:326 –333. 35. McCallister WV, Knight J, Kaliappan R, Trumble TE. Central
32. Bushnell BD, McWilliams AD, Messer TM. Complications in dorsal placement of the screw in simulated fractures of the scaphoid waist: a
percutaneous cannulated screw ﬁxation of nondisplaced scaphoid biomechanical study. J Bone Joint Surg 2003;85A:72–77.
waist fractures. J Hand Surg 2007;32A:827– 833. 36. McQueen MM, Gelbke MK, Wakeﬁeld A, Will EM, Gaebler C.
33. Toby EB, Butler TE, McCormack TJ, Jayaraman G. A comparison Percutaneous screw ﬁxation versus conservative treatment for frac-
of ﬁxation screws for the scaphoid during application of cyclical tures of the waist of the scaphoid: a prospective randomised study.
bending loads. J Bone Joint Surg 1997;79A:1190 –1197. J Bone Joint Surg 2008;90B:66 –71.
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PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 236.e1
APPENDIX. Review of the Literature on Percutaneous Fixation for Acute Scaphoid Fracture
Number of Union Time
Authors Year Patients Approach Instrument Union (%) (Mean, Weeks) Functional Outcome
Wozasek and Moser 1991 130 Volar Conventional screw 89 ND Full functional restoration
Ledoux et al.11 1995 23 Volar Herbert screw 100 ND 95% of unaffected side
Inoue and Shionoya9 1997 40 Volar Herbert screw 100 6 2.1 Satisfactory wrist function in 37
Haddad and Goddard8 1998 15 Volar Acutrak screw 100 8 13 excellent, 2 good
Taras et al.13 1999 5 Volar Herbert screw 100 8.2 ND
Adolfsson et al.3 2001 25 Volar Acutrak standard 92 16 12 of 23: 6% ROM loss
Bond et al.5 2001 11 Volar Acutrak screw 100 7 Overall satisﬁed
Slade et al.21 2002 27 Dorsal Acutrak screw 100 12 90% to 95% of ROM
Brutus et al.6 2002 30 Volar Herbert screw 90 ND 86.6% screw perpendicular to
Yip et al.17 2002 49 Volar AO/ASIF 100 12 All: excellent (no criteria)
Jeon et al.10 2003 13 Volar Herbert screw 100 9.2 93%: no or minimal loss of
function (Herbert score)
Chen et al.7 2005 11 Volar Cannulated screw 100 10.6 6 of 11: excellent 5 of 11: good
Shih et al.12 2005 15 Volar Cannulated screw 100 ND 11 of 15: excellent (Mayo
Wong et al.15 2005 52 Volar AO/ASIF 96 11 Mean 90; 75% excellent (Mayo
cannulated and score)
Arora et al.4 2007 21 Volar Cannulated screw 95 6 ND
Bedi et al.32 2007 18 Dorsal Acutrak screw 94 8 DASH score 6 of 100
Bushnell et al.32 2007 24 Dorsal Acutrak or Twinﬁx 96 ND 29% complication rate
McQueen et al.36 2008 30 Volar Acutrak 97 9.2 100% excellent/good (Green/
Author 2007 22 Volar Herbert screw 100 9.36 18 of 22: excellent 4 of 22:
good (Mayo score)
Author 2007 19 Dorsal Herbert screw 100 9.50 15 of 19: excellent 4 of 19:
good (Mayo score)
AO/ASIF, Arbeitsgemeinschaft fuer Osteosynthesefragen–Association for the Study of Internal Fixation; Arbeitsgemeinschaft fuer Osteosynthe-
sefragen–Association for the Study of Internal Fixation; ND, not described; DASH, Disabilities of the Arm, Shoulder, and Hand; ROM, range of
motion; Mayo score, Mayo wrist score system.24
Note: We searched Medline, PubMed, and Web of Science databases from 1990 to 2007 using key words “percutaneous” or “scaphoid” or
“fracture” in combination with “percutaneous scaphoid” and “percutaneous scaphoid ﬁxation” and we also examined the references lists of the
retrieved articles. We limited the publications to acute scaphoid fracture and also excluded the review articles, technical reports, and any publications
dealing with nonunion, or no description on union rate. Thus, we included only (1) English language full-length publications in peer-reviewed
journals and (2) publications with data of union (or union time) and functional outcome.
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