By: Mohsen Mardani Kivi M.D.

Assistant Professor of Orthopedics

Orthopedic Research Center

Guilan University of Medical Sciences

Scaphoid Fractures: A Comparison of Two Surgical Methods Using Either Herbert Screws or Multiple Pins for Internal Fixation

What i s i t ?

The most common fracture of wrist

Links the proximal and the distal carpal rows

Waist is susceptible to fracture

Anatomy

2 mechanisms:• Hyperextension and bending• Puncher’s Scaphoid- axial force along the second metacarpal with the wrist in neutral.

Mechan i sm o f I n ju ry

C lass ifi ca t i on

Herbert’s Classification

Hard to recognized because the pain improves quickly, there’s no bruising, and minimum swelling.

People usually think it’s a sprain

Some people don’t become aware of it until months or years after the event.

Tenderness directly over the scaphoid bone (which is located in the hollow at the thumb side of the wrist known as the “snuffbox”)

Symptoms

Duration <3 weeks old- better prognosis If >4 weeks old drastically lower union rates when

treated with cast alone

Location Distal 1/3 (Pole) (5%) Middle 1/3 (Waist) (80%) Proximal 1/3 (Pole) (15%)- poor healing due to

limited blood supply, osteonecrosis rate close to 100%

S c a p h o i d Fr a c t u re E v a l u a t i o n

Un ion ra te

Displacement- Nonunion rates in displaced fractures reach

92%

S c a p h o i d Fr a c t u re E v a l u a t i o n

>1 mm step off on any view

Scapholunate angle of >60 degrees

Lunocapitate angle of greater than 15 degrees

Lateral intrascaphoid angle of more than 20 degrees

I n te rna l Fi xa t i on

Herbert Screw vs. Multiple Pins

Vs.

Pa t i en t s and methods

• Cross-sectional study• From 2009 to 2011• 23 patients in Herbert screw and 18 in multiple

pins groups

Inclusion and Exclusion Criteria

• Inclusion criteria• Scaphoid fracture • >1mm

displacement

• Exclusion criteria• Herbert’s Type A• Accompanying

lesions

Surg i ca l Techn iques

Afte r su rgery

• Herbert Screw : • 4 weeks short arm cast + 4 weeks short

palmar brace• Multiple Pins:

• 6 weeks short arm cast + 2 weeks short palmar brace

Follow up

Visits:Two weeks post-surgery, Every month for six months, Every year after one year

Measurements: Degree of fracture healing, Visual Analog Score (VAS) of Pain, Range of motion, Hand grip strength, Quick DASH score, Mayo Modified Wrist Score (MMWS)

resu l t s

• Mean follow up time 24.5 m

(11-34)

• 38 men (92.7%) and 3 women

(7.3%)

• Men age 30.6 ± 7.8 years

Herbert Screw

20 men

3 women

Multiple Pins

18 men

-

No statistically difference between groups according to Age and Gender

Fracture Types Frequencies

B1 B2 B3 B4 B5 C D1 D20

10

20

30

40

50

60

70

80

90

100Herbert Screw

Multiple Pins

Outcome

Final Visit 6 m Post-op

P value

HS MP P value

HS MP

0.9 96.6 96.3 0.5 93.1 91.1 Flexion *

0.7 94.7 93.7 0.6 89.3 87.3 Extension *

0.8 95.6 94.9 0.7 92.6 91.3 Grip *

0.9 95.3 95.2 0.8 92.2 91.6 Quick Dash

0.2 95 93.7 0.6 92.5 90.6 MMWS

* Flexion, Extension and grip are in comparison of contra lateral limb

Outcome

VAS (satisfaction) in final visit: HS= 9.5 MP=9 p>0.05

Osteonecrosis in final visit: HS=1(4.3%) MP=3(16.6%) p>0.05

Return to previous activities

Daily activities

HS= 4±2

MP= 4±1

Sport

HS= 39±8

MP= 38±7

d i scuss ion

RCT • Closed Reduction+Cast, • Herbert Screw, • Multiple Pins

MMWS, ROM, Union time, Return to activity time, and Complications.

Both surgical treatments were superior to CR+cast but were not different from each others.Dehghani M, Teimouri M, Nekoei F, Fatahi F. [Comparative Study of Results and

Complications of Three Methods in Treatment of Scaphoid Fractures. Journal of Isfahan Medical School 2010; 28(109): 408-15.

d i scuss ion

Results of using Herbert Screw+4 weeks cast:

152/158 patients had excellent and good fixation132/138 were completely satisfied 125/138 had normal or near normal function

Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br 1984; 66:114-123.

d i scuss ion

HS vs. Pins in delayed union scaphoid fractures:

• Better functional outcome in HS than in MP• The complication rate was relatively high with

both methods• Unsatisfactory reasons with MP

Pelto-Vasenius K, Hirvensalo E, Böstman O, Rokkanen P. Fixation of scaphoid delayed union and non-union with absorbable polyglycolide pin or Herbert screw. Consolidation and functional results. Arch Orthop Trauma Surg. 1995;114(6):347-51.

The use of multiple pins for the internal fixation of scaphoid fractures proves to be a viable treatment option when compared to Herbert Screws, due to their decreased cost and increased availability.

Conc lus ion

Take home message

ANY QUESTIONS ?!