Courtesy – Dr. Esther Chow, Dr Ashok Shyam, Ortho TV

Introduction

• Scaphoid fractures are the most common carpal bone fractures of the wrist.
• Management of undisplaced scaphoid waist fractures (Herbert Type B2) remains controversial.
• Undisplaced fracture definition:
  • <1 mm displacement, step, or gap on imaging.

 

Indications for Surgical Management of Scaphoid Fractures

Common indications include:

• Perilunate fracture dislocation
• Displaced or comminuted scaphoid fractures
• Established nonunion
• Proximal pole fractures (due to poor vascularity)

 

Conservative Treatment

Method

• Immobilization in a cast
  • Long arm cast or short arm cast
  • Often with thumb immobilization (thumb spica cast)

Evidence

• Systematic reviews show insufficient evidence to determine whether long-arm or short-arm cast is superior.

 

Surgical Treatment

Current Surgical Trend

• Percutaneous screw fixation

Techniques

• Retrograde screw insertion
• Antegrade screw insertion

Proposed Advantages

• Faster return to work
• Earlier return to sports
• Earlier fracture union

 

Survey on Treatment Preference

A questionnaire survey among healthcare workers (n = 56 respondents) showed:

• 1% preferred surgical treatment
• ~32% preferred conservative treatment

Factors Affecting Treatment Choice

• Age – No significant effect
• Gender – No significant effect
• Occupation – No overall significant effect

Interesting Findings

• Male orthopaedic non-hand surgeons tended to prefer surgery
• Female hand surgeons tended to prefer conservative treatment

Other Factors

No significant influence from:

• Participation in sports
• Playing musical instruments

 

Evidence from Systematic Reviews and Meta-Analyses

2016 Systematic Review

• Screw fixation
  • Faster return to work
  • Shorter time to union
• Conservative treatment
  • Lower complication rate

2018 Meta-analysis

• Surgery shows:
  • Faster return to work
  • Slightly faster union
• No significant difference in:
  • Range of motion
  • Functional outcome
  • Complication rate

Overall Conclusion

• Insufficient evidence to conclude that surgery is superior to conservative treatment.

 

Functional Outcomes

Return to Work

• Surgery: ~6 weeks
• Conservative treatment: ~11.5 weeks

 

Range of Motion

• 8–16 weeks: Better with screw fixation
• After 16 weeks: No difference between groups
• Long-term: May be similar or slightly better in conservative group

 

Grip Strength

• Early phase (8–16 weeks): Better after surgery
• After 16 weeks: No significant difference

 

Functional Scores

• 8–12 weeks: Better in surgical group
• 1 year: No difference between treatments

 

Time to Union

• Screw fixation: ~7.4 weeks
• Conservative treatment: ~10 weeks
• Difference ? 2–3 weeks

Important considerations:

• Union detection varies depending on:
  • CT scan
  • Plain radiographs

 

Nonunion Rates

• No significant difference between surgical and conservative groups.

 

Complications

Overall Complication Rate

• Lower with conservative treatment

Surgical Complications

Can be classified into:

Implant-related

• Broken drill bits
• Broken guide wires
• Implant breakage
• Screw protrusion

Reported rates:

• Screw protrusion or prominence: ~12.5%
• Implant breakage: ~8%

 

Tendon Injuries

Volar approach

• Flexor carpi radialis (FCR) tendon injury
• Flexor pollicis longus tendon rupture

Reported FCR injury rates:

• Up to 27% in some reports

Dorsal approach

• Extensor tendon injury risk (~12.5%)

 

Nerve Injury

Possible injuries include:

• Median nerve compression due to misplaced screw

 

Vascular Injury

Risk to:

• Superficial palmar branch of the radial artery during volar approach

 

Radiation Exposure

• Percutaneous fixation requires multiple fluoroscopic images.
• Leads to increased radiation exposure compared with conservative treatment.

 

Cost Comparison

Direct Medical Cost

• Conservative treatment: ~USD 650
• Surgical fixation: ~USD 7500

Indirect Cost

Includes:

• Loss of income due to absence from work.

Even after considering indirect costs:

• Surgical treatment remains more expensive overall.

 

Clinical Example

• 28-year-old right-handed IT worker
• Sustained undisplaced scaphoid fracture
• Previously had screw fixation on opposite wrist with complications (screw protrusion)
• Chose conservative treatment with cast
• Fracture healed at 8 weeks with good outcome

 

Conclusion

For undisplaced scaphoid fractures (Herbert Type B2):

Advantages of Surgery

• Faster return to work (~6 weeks)
• Slightly earlier union

Limitations of Surgery

• Surgical complications
• Radiation exposure
• Higher cost

Advantages of Conservative Treatment

• No surgical risk
• No radiation exposure
• Lower complication rate
• Lower risk of long-term arthritis
• Lower cost

Final Consideration

• Long-term outcomes (range of motion, grip strength, function) are similar between both treatments.

Therefore, conservative treatment remains a reasonable and often preferable option for undisplaced scaphoid fractures.