Non-surgical or percutaneous fixation for undisplaced scaphoids?
Should we or should we not fix scaphoid fractures acutely? This issue is controversial, and all the more so when the fractures are completely undisplaced. The definitive answer will hopefully be provided by the very large randomised SWIFFT study currently being run from Leicester (UK). There are, however, already some fairly reliable indications and a review team based in Montreal, Boston and Riyadh have nicely summarised the available literature in their systematic review.1
The authors included published articles over a 40-year period, all reporting scaphoid fractures treated either conservatively or through a ‘minimally invasive’ technique. The authors were able to find ten studies that met the inclusion criteria and were reporting sufficient demographic, treatment and outcome details to warrant inclusion in the study.
The bottom line appears to be that percutaneous fixation of undisplaced scaphoid fractures indeed leads to more rapid union (44 days vs 79 days) and return to work (46 days vs 77 days) than does plaster immobilisation, with no increase in complications. Health economics are complex, but an earlier return to taxpaying status might more than pay for the extra cost of fixation. We keenly await the reporting of the SWIFFT study which should provide a robust answer to this question.
PRC or four-corner fusion?
The differing approaches of the proximal row carpectomy (PRC) and four-corner fusion (FCF) in the treatment of scaphoid nonunion advanced collapse or scapholunate advanced collapse have created much debate over the years. Proponents of PRC argue that the potential articulation of the distal row with the radius conceivably sacrifices grip strength, however, it maintains motion compared with the four-corner fusion which potentially offers a more grip strength-preserving option but may be a motion-sacrificing approach. Or at least that’s how the proponents of each approach argue it.
The reality may, however, be different, with many papers …