| Abstract|| |
Background : Conservative management of fracture scaphoid with cast is still the most common modality of management, but the results following this protocol are not always satisfactory.
Methods : Twenty five patients with fracture scaphoid were treated with a below elbow scaphoid cast and were followed up for minimum duration of one year. On follow up patients were examined clinicoradiologically and functional results were evaluated using the modification of the Mayo wrist scoring chart.
Results : Nineteen fractures showed union, two were malunited and five went for nonunion. Two fractures developed avascular necrosis and three patients had wrist arthritis on follow up. Nineteen patients had excellent functional results, one had good results and six patients had poor results. Patients with delayed diagnosis had nonunion and poor functional results. Patients with premature removal of cast had comparatively inferior results
Conclusion : For displaced unstable fracture, open reduction and internal fixation should be the preferred modality of treatment as cast treatment gives unacceptably high rate of malunion and nonunion with poor functional results.
Keywords: Scaphoid; Fracture.
|How to cite this article:|
Mittal V K. Conservative management of fracture scaphoid. Indian J Orthop 2006;40:255-8
| Introduction|| |
Scaphoid , the most common bone to be fractured in the carpus, has been a topic of concern for years due to its anatomical and functional peculiarities. Beginning from its normal anatomical position in the wrist, variation in its position with different wrist movements upto its peculiar blood supply, all add to the problems of diagnosing and managing the fracture. Many a times the fracture is undiagnosed and disposed off as a wrist sprain and may lead to problems of nonunion and wrist arthritis in future. Due to the peculiar blood supply, a properly treated fracture may also end up in avascular necrosis. Various treatment modalities have been tried for management of this fracture each having their own indications and limitations, out of which in India cast immobilization is still of foremost importance as the operative procedures all require considerable experience, expertise, special equipment and sophisticated instrumentation. But the results are not always satisfactory after cast treatment
The aim of the study has been to evaluate the results of scaphoid fracture after conservative treatment of fracture scaphoid with cast the factors which affect the outcome after cast management and the indications for operative intervention.
| Materials and methods|| |
The study included 25 patients having fracture scaphoid who were treated initially in a below elbow scaphoid cast extending from the elbow to the metacarpophalangeal joint of the medial four fingers and upto the interphalangeal joint of the thumb. The wrist was kept in slight dorsiflexion and slight radial deviation and the thumb in mid abduction.
On follow up at 1 ½ months patients were assessed clinico-radiologically. If radigraphs showed union and trabeculae of bone crossing the fracture site and there was no scaphoid tenderness, cast was discontinued and mobilization begun. If radiographs showed no union with persistent fracture line and / or persistent tenderness on the scaphoid, cast immobilization was further continued for a period of 1 month. After this, at total 2 ½ months follow up, again the patient was reassessed using the same criteria and cast continued or discontinued or operative intervention considered .
All patients were called for follow up at minimum one year after the date of injury and the functional and radiological assessment was done. The criteria for functional assessment and scoring were adopted from the Modification of the Mayo Wrist scoring chart. Radiologically, the following things were noted - fracture status (united, nonunion, malunion), presence of avascular necrosis, presence of arthritis and presence of instability.
| Results|| |
The study included 25 patients with an age range of 16 - 55 years (mean 31 years). There were 18 males and 7 females. There were 2 proximal pole, 12 body and 11 distal pole fractures. Nineteen fractures were stable and 6 unstable. Four patients had associated fracture of lower end radius with or without ulnar styloid fractures.
Twenty three patients reported for treatment within one day of injury. Two patients were originally undiagnosed and took no treatment initially. They were diagnosed and treated later at 15 days postinjury.
The duration of cast immobilization ranged from 15 days to 3 ½ months. (mean 1 month 3 weeks with standard deviation of 2 weeks). Six patients had removed cast themselves within one month - two fractures united, one malunited and three had nonunion. The mean duration of cast immobilization in distal pole fractures was 1 ½ months (standard deviation of 2 weeks). The mean duration of cast immobilisation in body fractures was 2 months (standard deviation of 2 weeks). The mean duration of cast immobilization in proximal pole fractures was 1 ½ months (standard deviation of 3 weeks).
Two patients had plaster sores during cast treatment. One patient removed cast himself at 1 month and in one patient cast was reapplied after sore healing in 1 week.
Twenty one patients could be followed for a minimum of one year. There were 4 patients with 4 years, 7 year and 15 years follow up who had persistent symptoms and one patient with 2 ½ years follow up had come for visit for unrelated complaint. On follow up evaluation, 16 patients had no pain, 17 patients were very satisfied, 16 patients had full range of movements and 19 patients had full grip strength. The results based on the Modification of Mayo wrist scoring chart showed that 18 patients had excellent results, one patient had good result and 6 patients had poor results.
Eighteen fractures had united at followup [Figure - 1] Two patients developed malunion. Both had an unstable body fracture and one patient out of them was inadequately immobilized. Five patients went for nonunion. Two out of 5 patients were undiagnosed and untreated initially, followed by short duration of cast immobilization. Two out of 5 patients had failed bone grafting procedures (Zaidemberg technique one [Figure - 2]a,b,c and Matti Russe technique one [Figure - 3]a,b 1 ,b 2 ,c
Two patients developed AVN in the followup [Figure - 4]. One patient had an unstable body fracture. The other patient had an unstable proximal pole fracture which later on developed AVN with nonunion with collapse of proximal fragment and finally total wrist arthritis.
Three patients developed arthritic changes. One patient had midcarpal arthritis and 2 patients had total wrist arthritis. All had nonunion with poor functional results.
Fifteen patients with excellent results had fracture united. One patient with good result had fracture united. Both patients with malunion had excellent results. Two patients with poor results had nonunion. Four patients with nonunion had poor results. Thus united fractures have more excellent /good functional results than fair/poor functional results compared to fractures with malunion/ nonunion ( but statistically insignificant by the chisquare test with Yates' correction at p < 0.05 and df=1 ).
| Discussion|| |
Cast is the most common form of management of scaphoid fractures in India. But frequently the results are not entirely satisfactory and patients end up with nonunion and avascular necrosis and poor functional results. The problem with associated lower end radius fractures is that the cast is given in ulnar deviation which may put distractive forces on the scaphoid fracture leading to nonunion.
The average duration of cast immobilization is reported as 2-9 months,,. In the present series the average duration is 1¾ months which is less compared to other series. This difference is partly due to the fact that 6 patients had removed cast themselves within one month. Another probable reason might be interobserver variation in judging the union of fracture and discontinuing the cast. Also , looking into different series, it is found that on an average the duration of cast immobilization for proximal pole fractures is more than that required for body fractures which in turn is more than that required for distal pole fractures.
The rate of union in scaphoid fractures is reported as 59 97%,,,,. Our union rate is low (80%) compared to other series. One patient had not come for regular follow up and had removed cast himself earlier than the stipulated time. Two patients were undiagnosed initially, treated with shorter duration of immobilization as they had removed cast themselves and later went for nonunion. The remaining two patients had developed AVN during the treatment and subsequently went for nonunion.
In the present series it is seen that, union chances increase and malunion/nonunion chances decrease as the fracture location proceeds distally from proximal pole to body to distal pole ( statistically significant by chisquare test at p < 0.05 and df=2 ).
In the stable fractures, a high union rate (about 90%) is observed consistently,,,,. There is a low rate of malunion and nonunion ( about 10%). In the unstable fractures, union rate ranges from 7% to 45% in different series, which is much less compared to undisplaced fractures. The rate of malunion ranges between 17% to 40% which is once again much high compared to the undisplaced fractures. The rate of nonunion ranges between 46% to 66% which is much higher than the undisplaced fractures. Thus there are increased chances of malunion / nonunion than union in unstable fractures compared to stable fractures (statistically significant by chi- square test with Yates' correction at p< 0.01 and df =1)
All unstable fractures should preferably undergo open reduction and internal fixation to obtain better results. Cast treatment for unstable fractures results in more malunion/nonunions than unions compared to open reduction and internal fixation ( statistically significant by chi-square test with Yates' correction at p< 0.05 and df=1). For stable fractures, cast treatment yields good satisfactory results and operative treatment can be avoided.
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V K Mittal
Paras Society - 2, Plot No. 50, Near Panchvati, Jamnagar 361002.
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1], [Table - 2]