Management of distal radial fractures. J Bone Joint Surg Am. Combined fractures of the distal radius and scaphoid. J Hand Surg Eur Vol. Dr Jeffrey N. Lawton and Dr John R.
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Two hundred questionnaires were distributed during the 36 th Brazilian Hand Surgery Congress In stable fractures the preference was for treatment with plaster cast. Most surgeons treat waist nonunion with a nonvascularized bone graft.
More experienced surgeons are more likely to request tests in occult fractures We have provided an overview of treatment preferences for scaphoid fractures. It should be noted that more experienced surgeons are more likely to request additional tests for occult fractures and to recommend surgical treatment of distal third fractures.
Level of Evidence IV, Cross-sectional survey. The scaphoid is the most commonly fractured carpal bone. Fractures occur mainly in young adults, an economically active population, after low-energy trauma or in association with sports practice. Increased risk of non-union is associated with fractures of the proximal pole, fractures with an associated carpal ligament injury, delay in diagnosis, inadequate immobilization, 2 and smoking.
The diagnosis is suggested when there is a fracture of the wrist with hyperextension trauma in young adults who present with pain and volume increase in the anatomical snuff-box. More specific examinations such as magnetic resonance imaging MRI must be performed in order to shorten the time for diagnosis, thus decreasing the direct and indirect costs of treatment.
It is estimated that among every 5 patients, 4 are immobilized unnecessarily until a more precise diagnosis is made. Classically, the treatment of acute fracture without scaphoid displacement is conservative.
However, some authors advocate surgical treatment with percutaneous fixation. This enables a shorter time for immobilization and functional restriction.
Although this procedure requires a reasonable learning curve, the low surgical morbidity supports this treatment trend. Pseudarthroses are traditionally treated via a surgical approach with the use of bone grafts and fixation. We have witnessed an evolution in the concepts of treatment of scaphoid fractures and their complications, with less invasive methods that enable more rapid rehabilitation.
This evolution in the therapeutic approach to fractures of the scaphoid, coupled with their prevalence in young and productive populations, motivated us to conduct a study. Herein we aimed to verify how experts in hand surgery certified by the Brazilian Society of Hand Surgery-SBCM plan the treatment of these fractures and manage their complications. The study was approved by the ethics committee protocol number CAAE: A structured questionnaire with 15 objective questions was devised, with focus on therapeutic planning for scaphoid fractures and management of complications, and was applied with the consent of the Scientific Commission of the Congress.
To participate in the study, a physician was required to be certified as a hand surgeon by the SBCM, complete the questionnaire, and be enrolled and present at the 36 th CBCM. A questionnaire was developed Annex a priori, with dichotomous questions relating to the management of scaphoid fractures diagnosis, treatment, and complications.
The questionnaire was initially applied as a pilot survey to the coauthors of the study, and showed good reproducibility and clarity. Of questionnaires distributed in a convenience sample, were completed, with 5 excluded due to incomplete answers, 14 because they were completed by resident physicians, and 2 because they were completed by non-Brazilians, resulting in a total of for this study. In displaced fractures of the scaphoid waist, the vast majority For pseudarthrosis with advanced arthrosis of the wrist, i.
When comparing the responses of less and more experienced surgeons, there was a difference in preferences for 2 scenarios: more experienced surgeons are more likely to request additional examinations for occult fractures Regarding other items in the questionnaire, there were no differences in management preferences between more and less experienced surgeons Table 1.
P1: Clinical suspicion of fracture, without confirmation on radiography. P2: Stable and non-displaced fractures of the distal third. P3: Stable and non-displaced fractures of the waist.
P4: Non-displaced fractures of the proximal pole. P5: Acute displaced fractures of the waist. P6: Waist pseudarthrosis with gaps in a non-displaced fracture focus of less than 3 mm. This work is unprecedented and addresses one of the most important and prevalent subjects in the practice of orthopedics and traumatology.
The results aim to show how this condition is treated in Brazil, and thus to provide guidance for management protocols and a basis for research projects. Our sample was representative, as proven by the distribution of respondents from different states, and the results were similar to those reported by the Brazilian Society of Hand Surgery.
In relation to the initial approach to wrist trauma without diagnostic confirmation, 2 possible scenarios are well established in the literature: immobilization for up to 15 days 8 and subsequent reevaluation, or early order for an MRI. Despite being commonly used in clinical practice, we believe that serial radiography does not have good inter-observer concordance and is not safe for management. Herbert's classification was the method used most by our interviewees, as it discusses and guides treatment of both acute fractures and pseudarthrosis.
Other specific classification systems for pseudarthrosis are available, enabling treatment planning for this complication in accordance with the evolution, location, and degree of bone failure, with the objective of providing less invasive treatment options and a possibility of faster rehabilitation.
In relation to stable and non-displaced fractures of the distal pole of the scaphoid, our results are in agreement with the literature; there is consensus about conservative treatment with immobilization for weeks. Although only one clinical trial studied use of a plaster cast with or without thumb immobilization, there is no evidence for a difference in the rate of consolidation between these 2 methods.
This trend is supported by the literature, as a systematic review reported that after months, patients treated operatively had significantly better functional outcomes than those treated non-operatively; further improvement was not observed after 6 months of follow-up. In a systematic review, a 4-fold increased risk of pseudarthrosis was reported when a displaced fracture was treated with cast immobilization, compared to the risk for an undetected fracture and the risk of non-consolidation was 17 times greater if a displaced fracture was treated without surgery.
There is a trend in the literature for less invasive treatment as early as possible to avoid non-union of the scaphoid. Studies have reported a higher rate of consolidation in less time and with less morbidity, in addition to shorter time of immobilization, with the use of percutaneous techniques compared to open techniques.
Iliac or distal radial grafts have similar consolidation rates, although the approach using another surgical site can result in further complications. In addition, rigid fixation allowed for early mobilization. There was no difference in relation to the dorsal or volar approach. With absorption or displacement greater than 4 mm at the focus of the pseudarthrosis, all interviewees preferred an open approach, using non-vascularized grafts, with a large preference for the ilium, although there is no evidence in the literature that there is a higher incidence of consolidation; however, there is a higher likelihood of complications.
According to a systematic review, there is no difference in the rate of consolidation with or without the use of a vascularized graft, but the time to union of the pseudarthrosis decreases from With progression to SNAC, the most common surgeries were carpectomy and four-corner arthrodesis, in accordance with the evidence in the literature.
There is no consensus on the need for inclusion of the thumb and elbow in the treatment of non-displaced fractures of the scaphoid waist and distal pole, or in the technique for treatment of pseudarthrosis with small bone failure and the technique of choice for treatment of SNAC.
The majority of respondents were found to have a consensus regarding the treatment of non-displaced fractures of the waist and distal pole with plaster casts; surgical treatment of displaced fractures of the waist and all fractures of the proximal pole; the use of bone grafts for pseudarthrosis with any degree of bone failure; and the use of vascularized bone grafts for pseudarthrosis of the proximal pole, even with poor prognosis. The more experienced surgeons tend to request tests with greater accuracy for occult fractures and perform surgery for fractures of the distal third of the scaphoid.
There is a need for additional comparative studies to assess the cost-effectiveness of MRI for early diagnosis, as well as the use of percutaneous fixation of non-displaced fractures of the waist with use of percutaneous fixation technique for treatment of pseudarthrosis with small bone failure.
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PLoS One. Percutaneous internal fixation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach. J Bone Joint Surg Am. Statistical Methods for Rates and Proportions. Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med. Scaphoid bone waist fractures, acute and chronic: imaging with different techniques.
Murthy NS. The role of magnetic resonance imaging in scaphoid fractures. J Hand Surg Am. Diagnosing scaphoid fractures: radiographs cannot be used as a gold standard!
Cost-effectiveness of immediate MR imaging versus traditional follow-up for revealing radiographically occult scaphoid fractures. Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. J Bone Joint Surg Br. Acute fractures of the scaphoid bone: Systematic review and meta-analysis. Union rates after proximal scaphoid fractures; meta-analyses and review of available evidence. J Hand Surg Eur. Management of displaced fractures of the waist of the scaphoid: meta-analyses of comparative studies.
Percutaneous screw fixation for fractures of the scaphoid. Comparison between proximal row carpectomy and four-corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study. Clinics Sao Paulo. Correspondence: Gustavo Chaves Nacif. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Services on Demand Journal. Methods: Two hundred questionnaires were distributed during the 36 th Brazilian Hand Surgery Congress Conclusions: We have provided an overview of treatment preferences for scaphoid fractures. Intervention A questionnaire was developed Annex a priori, with dichotomous questions relating to the management of scaphoid fractures diagnosis, treatment, and complications. More experienced Less experienced P-value Comparison P1 Received: August 29, ; Accepted: June 19, How to cite this article.
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Objective: To verify how hand surgeons manage scaphoid fractures and their complications. Methods: Two hundred questionnaires were distributed during the 36 th Brazilian Hand Surgery Congress In stable fractures the preference was for treatment with plaster cast. Most surgeons treat waist nonunion with a nonvascularized bone graft. More experienced surgeons are more likely to request tests in occult fractures Conclusions: We have provided an overview of treatment preferences for scaphoid fractures.
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Two hundred questionnaires were distributed during the 36 th Brazilian Hand Surgery Congress In stable fractures the preference was for treatment with plaster cast. Most surgeons treat waist nonunion with a nonvascularized bone graft. More experienced surgeons are more likely to request tests in occult fractures We have provided an overview of treatment preferences for scaphoid fractures. It should be noted that more experienced surgeons are more likely to request additional tests for occult fractures and to recommend surgical treatment of distal third fractures.
HOW SCAPHOID FRACTURES ARE TREATED IN BRAZIL