Kreibich Scaphoid 3 by linzhengnd

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									The treatment of acute undisplaced
    fractures of the Scaphoid:
       A Systematic Review




        Kreibich Presentation 2007
               Tom Symes
      Why is this study important?
   2nd most common wrist fracture
   60-70% of all carpal bone fractures Berger 1999
   US annual incidence ~ 345,000
   Up to 5% result in non-union Osterman and Mikulics, 1988
   Need to establish evidence based best
    practice



                      Treatment of undisplaced Scaphoid #s
           Conservative treatment
   Controversies
     Position of wrist in plaster
     Inclusion of other joints

     Duration of immobilisation

   Traditional treatment
     Scaphoid cast – Watson Jones 1995
     Inclusion of elbow Verdan, 1964, Kuhlmann 1987

     Colles cast – Clay


                        Treatment of undisplaced Scaphoid #s
             Surgical treatment
   Pros
     Quicker rehab
     Better ROM

     Higher rate of union

   Cons
     Complications
     Cost

     Resources


                      Treatment of undisplaced Scaphoid #s
           Review Questions
   Is operative fixation of an undisplaced
    scaphoid fracture a more effective treatment
    than immobilisation in a cast?
   If immobilisation is the preferred treatment
    then:
       What is the ideal type of cast?
       What is the ideal position of the wrist in plaster?
       What is the ideal duration of immobilisation?



                  Treatment of undisplaced Scaphoid #s
                            Methods
   Study design
       Systematic review
   Sources
       MEDLINE
       EMBASE
       The Cochrane Library
       Other electronic databases
   Search terms
       MeSH
       Cochrane search strategy for RCTs


                        Treatment of undisplaced Scaphoid #s
                           Methods
   Study selection
       RCTs
       Quasi RCTs
   Quality assessment
       Validity
       Applicability
       Importance




                        Treatment of undisplaced Scaphoid #s
                        Results
   Cast vs Surgery - 4 RCTS
   Above elbow vs below elbow casts - 2 RCTs
   Scaphoid vs Colles Cast – 1 RCT
   Wrist Extension vs Flexion - 1 RCT

   1 high quality study, 7 intermediate



                   Treatment of undisplaced Scaphoid #s
                Cast vs Surgery
   4 studies
     Adolfsson et al 2001
     Bond et al 2001

     Saeden et al 2001

     Dias et al 2005




                    Treatment of undisplaced Scaphoid #s
                      Cast vs Surgery
   Considerable variation in the
    interventions
       surgical
          percutaneous in two studies
          open in two studies

       cast
            variation in the form and length of
             postoperative immobilisation.



                          Treatment of undisplaced Scaphoid #s
     Cast vs Surgery- Conclusions
   No difference
     rate of non-union
     pain

     tenderness

     patient satisfaction

   Grip strength & ROM better short term in the
    surgical group
   Time to union quicker in surgical group -1 study

                     Treatment of undisplaced Scaphoid #s
             Scaphoid vs Colles
   Clay et al (1991)
   Casts identical except
    Scaphoid cast included
    the thumb to the IPJ
   Rate of non-union
    almost identical between
    the groups


                  Treatment of undisplaced Scaphoid #s
           Flexion vs Extension –
              Hambidge (1999)
   Casts with wrist in 20°of flexion or extension
   No difference
     rate of non-union
     wrist flexion

     grip strength at 6months

   Significantly better wrist extension in the
    extension group at 6 months (WMD 7 degrees)


                    Treatment of undisplaced Scaphoid #s
         Above vs below elbow cast
   2 studies
   Alho and Kankaanpaa
       below elbow cast resulted in a lower rate of non-
        union
   Gellman
       above elbow cast resulted in a lower rate of non-
        union!



                      Treatment of undisplaced Scaphoid #s
               Recommendation
   Based on the available evidence, the most
    effective treatment for acute undisplaced
    fractures of the scaphoid is:
     Colles or Scaphoid cast
     wrist held in 20° of extension

     until union is determined clinically and radiologically.




                     Treatment of undisplaced Scaphoid #s
                            References
   Included trials
        Adolfsson L, Lindau T, Arner M, (2001) Acutrak screw fixation versus
         cast immobilisation for undisplaced scaphoid waist fractures.Journal of
         Hand Surgery - British Volume. 26(3):192-195
        Alho A, and Kankaanpaa, U. (1975) Management of fractured scaphoid
         bone. A prospective study of 100 fractures. Acta Orthopaedica
         Scandinavica. 46 (5):737-743
        Bond CD, Shin AY, McBride MT, Dao KD (2001) Percutaneous screw
         fixation or cast immobilization for nondisplaced scaphoid fractures
         Journal of Bone & Joint Surgery - American Volume 83-A (4):483-488
        Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ (1991) Need the
         thumb be immobilised in scaphoid fractures? A randomised prospective
         trial. Journal of Bone & Joint Surgery - British Volume. 73 (5):828-832
        Dias JJ, Wildin CJ, Bhowal B, Thompson JR (2005) Should acute
         scaphoid fractures be fixed? A randomized controlled trial Journal of
         Bone & Joint Surgery - American Volume. 87(10):2160-2168


                            Treatment of undisplaced Scaphoid #s
                              References
   Included trials
        Gellman H, Caputo RJ, Carter V, Aboulafia A, McKay M. (1989) Comparison of
         short and long thumb-spica casts for non-displaced fractures of the carpal
         scaphoid. Journal of Bone & Joint Surgery - American Volume 71(3):354-357
        Hambidge JE, Desai VV, Schranz PJ, Compson JP, Davis TR, Barton NJ (1999)
         Acute fractures of the scaphoid. Treatment by cast immobilisation with the wrist
         in flexion or extension? Journal of Bone & Joint Surgery - British Volume
         81(1):91-92
        Saeden B, Tornkvist H, Ponzer S, Hoglund M. (2001) Fracture of the carpal
         scaphoid. A prospective, randomised 12-year follow-up comparing operative and
         conservative treatment Journal of Bone & Joint Surgery - British Volume
         83(2):230-234
   Other refs:
        Berger, R.A., Imeada, T., Berglund. L. and An, K.N. (1999) Constraint and
         material properties of the subregions of the scapholunate interosseous ligament.
         Journal of Hand Surgery (Am) 24: 953–962
        Osterman, A.L. and Mikulics, M. (1988) Scaphoid nonunion. Hand Clinics of North
         America 4: 437–455




                               Treatment of undisplaced Scaphoid #s

								
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