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Three Part Question

In [adult patients with an acute minimally displaced scaphoid fracture] is [conservative management as good as surgical management] at [treating the fracture and reducing long term complications]?

Clinical Scenario

A 25 year old male attends the emergency department after he slipped on some ice and onto his outstretched right hand. He has attended complaining of tenderness in his wrist and a lack of function. There is also marked swelling around his right wrist.

Search Strategy

Medline 1968 to 2nd week November 2011 using the ovid interface scah* AND (treatment OR Management OR non-operative OR conservative OR procedure, surgical) AND acute, limit to english language and abstract.

Search Outcome

125 papers were returned from the search. 8 of them answered the 3 part question and were appropriate for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Adolfsson et al 2001 Sweden	53 patients. 28 patients randomised to cast immobilisation, 25 randomised to internal fixation with acutrak screw.	PRCT	Rate and time to union, Range of motion, grip strength.	Patients treated with internal fixation had better range of motion at 16 weeks. No difference found between union times and grip strength.	Small patient numbers
Dias et al 2005 UK	88 patients. 44 randomised to internal fixation with a Herbert screw, 44 randomised to immobilisation with a cast.	PRCT	Pain, tenderness, swelling, wrist movement, grip strength, symptoms and disability	Range of movement and grip strength significantly improved in the operative group of patients at 8 weeks follow up. No difference in symptoms or time to return to work overall.	Small patient numbers
Yin et al 2007 China	7 studies (n=692) were included. Four studies (n=228) compared operative versus non-operative treatment and three (n=464) compared different types of casting.	Meta-analysis	Non-union rate, return to work, grip strength, range of wrist motion, complications, incidence of osteoarthritis	No evidence that operative treatment is superior to non-operative treatment for acute fractures of the scaphoid.	5 studies reported the randomisation method and two used quasi-randomised methods. 5 studies reported losses to follow-up, but only one used intention-to-treat analysis.
Arora et al 2007 Swede	44 patients randomized to screw fixation (21) or cast immobilization (23)	PRCT	Range of wrist motion, grip strength, time to fracture union and return to work time.	No statistical difference between either group when comparing grip strength and range of movement. Patients treated with internal fixation had a shorter time to union and returned to work sooner.	Power calculations not performed, The method used to allocate the patients to the two treatment groups was not stated
Dias et al 2008 UK	71 patients either treated with Herbert screw or below elbow plaster cast. Outcomes assessed a mean follow up at 93 months	PRCT	Mean grip strength, mean range of movement, Patient evaluation measure.	No medium term difference found in functional outcome between either group	Small patient numbers
Vinnars, B et al 2008 Sweden	83 with non-displaced or minimally displaced scaphoid fractures. 42 randomised to non surgical, 41 to surgical	PRCT	10 years post injury. Functional outcome, symptoms, incidence of arthritis	Surgical patients show no long term benefit when compared with conservatively treated patients and may have an increased risk of osteoarthritis	Power calculations if performed were not stated
Modi CS et al 2009 UK	12 studies. 6 RCTS, 2 meta-analyses, 1 economic analysis and 3 retrospective series	Meta-analysis	Union rates, time to return to work, grip strength, complications	The evidence suggests that percutaneous fixation may result in faster union rates and an earlier return to sport and work by approximately 7 weeks over cast treatment	Low grade RCTs
Buijze GA et al 2010 Netherlands	419 patients from 8 RCT trials. 207 patients were treated surgically, and 212 were treated conservatively	Meta-analysis	Standardised functional outcome, time to union, time off work, grip strength, pain, range of motion, non-union.	Better functional outcome significantly favored surgical treatment. Other outcomes that favoured surgical treatment were grip strength, time to union, and time off work All other outcomes showed no statistical difference between operative and conservative treatment.	Most studies were low evidence grade. Statistical heterogeneity was still present in many of the analyses

Comment(s)

Most RCTs and hence meta-analyses used small patient groups with low statistical power, it would however be impossible to blind the trials. It is difficult to ascertain solid conclusions but most show favourable short-term outcomes with surgical treatment.

Clinical Bottom Line

The studies performed indicate that there is an earlier time to union and faster mobilisation found in patients who have surgical management of a minimally displaced acute scaphoid fracture. At short term follow up, patients treated surgically have better functional outcomes but this difference diminishes with time. With regards to long-term outcomes there is still insignificant data to provide any clear trends on the most favourable method of treatment. Most studies demonstrated an increase in complication rate in the surgical group. The decision on how to manage these patients needs careful consideration and discussion with the patient before a plan is agreed. Weighing up a faster recovery with increased surgical complications is a key decision.

References

1. Adolfsson L, Lindau T, Arner M Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist fractures J Hand Surg Br 2001;26: 192-5
2. Dias JJ, Wildin CJ, Bhowal B, Thompson JR Should acute scaphoid fractures be fixed? A randomized controlled trial J Bone Joint Surg Am 2005;87: 2160-8
3. Yin ZG, Zhang JB, Kan SL, Wang P Treatment of acute scaphoid fractures: systematic review and meta-analysis Clin Orthop Relat Res 2007;460:142-51.
4. Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M Fixation of nondisplaced scaphoid fractures: making treatment cost effective. Prospective controlled trial Arch Orthop Trauma Surg 2007;127:
39-46.
5. Dias, J J. Dhukaram, V. Abhinav, A. Bhowal, B. Wildin, C J .Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months. J Bone Surg - British Volume 90(7):899-905, 2008 Jul
6. Vinnars B, Pietreanu M, Bodestedt A, Ekenstam F, Gerdin B. Nonoperative compared with operative treatment of acute scaphoid fractures. A randomized clinical trial J Bone Joint Surg Am 2008;90:1176-85.
7. Modi CS, Nancoo T, Powers D, Ho K, Boer R, Turner SM Operative versus nonoperative treatment of acute undisplaced and minimally displaced scaphoid waist fractures—a systematic review Injury. 2009;40:268-73.
8. Buijze GA, Doornberg JN, Ham JS, Ring D, Bhandari M, Poolman RW Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. J Bone Joint Surg Am 2010 Jun;92(6):1534-44