When to operate on acute scaphoid fractures
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From the American Association for Hand Surgery (ASSH) 2015 a presentation by Adam Watts from Wrightington Hospital, UK on the indication for acute scaphoid fracture fixation.
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When to operate on acute scaphoid fractures
- 1. Indications for acute scaphoid fixation Adam C Watts Consultant Upper Limb Surgeon, Wrightington, UK Visiting Professor, Manchester University 1
- 2. www.wrightington.com Best Treatment of Scaphoid Fractures Primary Achieve sound union Secondary in the shortest time with lowest risk and disruption to patient 2
- 3. www.wrightington.com Scaphoid Fractures Common injury in young adults Compliance challenges 3
- 6. www.wrightington.com Cast immobilisation Inconvenient Muscle atrophy Joint stiffness 4 Low risk Low cost
- 8. www.wrightington.com Screw fixation Early return to function 5
- 9. www.wrightington.com Screw fixation Early return to function 5 Higher direct costs Greater risks
- 15. www.wrightington.com Decision Making Scaphoid tubercle fracture 8
- 16. www.wrightington.com Decision Making Trans-scaphoid perilunate dislocation 9
- 17. www.wrightington.com Decision Making Proximal pole fracture 10
- 18. www.wrightington.com Decision Making Proximal pole fracture 10
- 24. www.wrightington.com Displaced scaphoid fractures Relative risk of non-union displaced fractures in cast 4.4 (c.i. 2.2-8.7) For displaced fractures odds ratio of non-union of 16.9 for cast treatment versus surgical fixation 15
- 26. www.wrightington.com Assessment of displacement MRI gold standard : X-ray sensitivity 33-47% positive predictive value 27-86% (Bhat 2004) Arthroscopy gold standard: Xray sensitivity 75% positive predictive value 10% (Lozano-Calderon 2006) Reliability intraobserver interobserver X-rays 0.54 0.27 CT 0.65 0.43 CT and X-rays 0.63 0.48 17
- 28. www.wrightington.com Cadaveric model Specificity X-ray predicting displacement 84% CT 89% but poor sensitivity for both (x-ray 52%, CT 49%) However only sagittal CT imaging 19
- 32. Fracture displacement measured on CT or MRI appears to be key to assessing risk on non-union 23
- 33. www.wrightington.com Displaced fractures >2mm displacement on CT = Non-union 50% in cast ≤2mm displacement on CT = 100% union in cast 24
- 34. www.wrightington.com Undisplaced fracture Union in 4 week cast = 96% Can surgery beat this? 25
- 35. www.wrightington.com Cost analysis - undisplaced fractures Non-manual workers cost of surgical arm significantly higher than non-surgical average period off work 0 days compared to 19 days Manual workers returned to work more quickly after surgery (61 v 100 days) total costs higher with surgery but not statistically significant No assessment of lost productivity 26
- 36. CT/MRI www.wrightington.com 27 Scaphoid fracture seen on radiograph Tubercle fracture Unicortical fracture Surgical fixation Waist fracture appears undisplaced Proximal pole Associated wrist injury Obviously displaced Displaced ≤2mm Displaced >2mm Individual requires early wrist motion Cast immobilisation No Yes
- 37. CT/MRI www.wrightington.com 27 Scaphoid fracture seen on radiograph Tubercle fracture Unicortical fracture Surgical fixation Waist fracture appears undisplaced Proximal pole Associated wrist injury Obviously displaced Displaced ≤2mm Displaced >2mm Individual requires early wrist motion Cast immobilisation No Yes
- 38. www.wrightington.com 5 Questions Answer ‘yes’ to any then consider surgical treatment with screw fixation 28
- 39. www.wrightington.com 5 Questions Answer ‘yes’ to any then consider surgical treatment with screw fixation 1.Is there an associated ipsilateral wrist injury? 28
- 40. www.wrightington.com 5 Questions Answer ‘yes’ to any then consider surgical treatment with screw fixation 1.Is there an associated ipsilateral wrist injury? 2.Is there a proximal pole fracture? 28
- 41. www.wrightington.com 5 Questions Answer ‘yes’ to any then consider surgical treatment with screw fixation 1.Is there an associated ipsilateral wrist injury? 2.Is there a proximal pole fracture? 3.Is there a waist fracture that is displaced on scaphoid series radiographs? 28
- 42. www.wrightington.com 5 Questions Answer ‘yes’ to any then consider surgical treatment with screw fixation 1.Is there an associated ipsilateral wrist injury? 2.Is there a proximal pole fracture? 3.Is there a waist fracture that is displaced on scaphoid series radiographs? 4.Is there a waist fracture that is shown to have more than 2mm displacement on CT/MRI? 28
- 43. www.wrightington.com 5 Questions Answer ‘yes’ to any then consider surgical treatment with screw fixation 1.Is there an associated ipsilateral wrist injury? 2.Is there a proximal pole fracture? 3.Is there a waist fracture that is displaced on scaphoid series radiographs? 4.Is there a waist fracture that is shown to have more than 2mm displacement on CT/MRI? 5.Is there a waist fracture that is shown to have up to 2mm displacement in an individual who requires early wrist motion? 28