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Nonoperative compared with operative treatment of acute scaphoid fractures: A randomized clinical trial
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
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2008 (English)In: Journal of Bone and Joint Surgery. American volume, ISSN 0021-9355, E-ISSN 1535-1386, Vol. 90, no 6, 1176-1185 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

Traditionally, acute nondisplaced scaphoid fractures have been treated nonoperatively in a cast, and the expected union rate approaches 90%. Internal fixation of nondisplaced scaphoid fractures has increased in popularity, and a union rate of 100% has been reported. The growing trend is to recommend internal fixation for the majority of acute scaphoid fractures. The true long-term benefits of this more complicated treatment modality have not yet been determined in randomized controlled trials. The purpose of this study was to compare the long-term results of operative fixation of acute scaphoid fractures with those of nonoperative treatment.

METHODS:

During the period between 1992 and 1997, eighty-three patients with an acute nondisplaced or minimally displaced scaphoid fracture were randomly allocated to, and received, either nonoperative treatment with a cast or internal fixation with a Herbert screw. At a median of ten years after the injury, seventy-five (93%) of the eighty-one patients who were still alive were assessed clinically and radiographically.

RESULTS:

All fractures united. A significant increase in the prevalence of osteoarthritis in the scaphotrapezial joint was found in the operatively treated group. No differences in subjective symptoms, as measured with limb-specific outcome scores, were found between the two groups. The range of motion and grip strength were greater, but not significantly greater, in the nonoperatively treated group.

CONCLUSIONS:

This study did not demonstrate a true long-term benefit of internal fixation, compared with nonoperative treatment, for acute nondisplaced or minimally displaced scaphoid fractures. The long-term risks of surgery should be considered when recommending operative treatment.

Place, publisher, year, edition, pages
2008. Vol. 90, no 6, 1176-1185 p.
National Category
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-97266DOI: 10.2106/JBJS.G.00673ISI: 000256456400002PubMedID: 18519309OAI: oai:DiVA.org:uu-97266DiVA: diva2:172126
Available from: 2008-05-07 Created: 2008-05-07 Last updated: 2015-08-18Bibliographically approved
In thesis
1. Scaphoid fractures: Studies on diagnosis and treatment
Open this publication in new window or tab >>Scaphoid fractures: Studies on diagnosis and treatment
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Scaphoid fracture is most common in young individuals of working age. Without adequate diagnosis and treatment, long-term results are poor. Operative treatment is being recommended increasingly often instead of a long time in cast, although there is no evidence-based support for its superiority.

The present thesis focuses on diagnostic problems and therapeutic consequences of acute scaphoid fractures and of scaphoid reconstruction when other treatments have failed.

Simultaneous plain radiographs and computed tomography were done in 97 injured wrists. Structural assessments of plain radiography images were highly predictive with respect to the risk of having a displaced or comminute fracture as diagnosed on computed tomography. Any finding of a gap or step-off > 0.5 mm, the presence of an intermediate fragment or a dorsal lunate tilt of ≥ 15° identified 81 % of fractures that were displaced or comminuted when investigated with computed tomography.

Eighty-three patients were randomly allocated to and received either nonoperative treatment in cast or operative treatment with the aim of assessing long-term outcome of the two treatment options. Fifty-two of the patients were occupationally active. From an occupational perspective with an early return to work, surgical treatment was superior in individuals with manual employment, and from a health economic perspective conservative treatment was superior in non-manual workers.

Patients treated for scaphoid fractures generally do well up to 13 years after the injury based on limb-specific outcome scores. No benefits were identified with operative treatment compared to non-operative treatment in cast. On the contrary, there was an increased risk for osteoarthritis in the scaphotrapezial joint in those who were operated.

The patient-rated long-term results of silicone implant arthroplasty were good, with pain relief and reasonable hand function in many patients up to 20 years after surgery.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2008. 54 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 358
Keyword
Surgery, Scaphoid Bone, Wrist Joint, Wrist Injuries, Fracture Healing, Cost of Illness, Health Care Costs, Outcome Assessment (Health Care), Arthroplasty, Radiography, Health status, Kirurgi
Identifiers
urn:nbn:se:uu:diva-8845 (URN)978-91-554-7214-6 (ISBN)
Public defence
2008-05-28, Robergsalen, Ing 40, Akademiska sjukhuset, Uppsala, 13:15
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Available from: 2008-05-07 Created: 2008-05-07Bibliographically approved

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Vinnars, BertilGerdin, Bengt

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