AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

SCAPHOID FRACTURES: RAPID RECOVERY – THE FAST TRACK
RANDALL W. CULP, M.D.
I. Epidemiology
A. Among all wrist injuries, the incidence is second only to fractures of the distal radius fracture 6
B. Approximately 345,000 scaphoid fractures per year in the U.S. 17
C. Nearly 70% of carpal fractures involve the scaphoid 19
D. Annual incidence in Denmark: 38 per 100,000 men, 8 per 100,000 women 18
E. Average age group: 15-29 years 18
F. Nonunion rate of 92% in fractures displaced < 1 mm 9
G. Estimated that there are 17,250 to 34,500 nonunions per year despite proper treatment 20
II. Historical Perspective
A. Nonoperative Treatment
1. Closed cast immobilization for stable non-displaced fracture
a. The undisputed recommendation
b. Union rate up to 95%
c. Location of fracture determines healing time, duration immobilization10 1) Distal pole – 8 weeks
2) Waist – 12 weeks
3) Proximal pole – 5-6 months
d. 30 year follow up, 56 patients, 10% nonunion rate 8
2. Type of Immobilization: Support can be found for nearly every type of
cast and position!!!!
a. Wrist Position: volar flexion vs. dorsiflexion, ulnar deviation vs.
2, 6, 11, 16
radial deviation
1) No clinical data to support one wrist position over another
2) Typically fractures amenable to cast immboliziation are “stable”
and require protection rather than reduction – probably explains
why wrist position has little effect on union rates
3) Practially speaking – wrist position should be such that radiographs
after cast application show anatomic coaptation of fracments, with
normal carpal alignment
b. Thumb spica cast (long or short) most commonly used
1) Long arm vs. short arm (Gellman 198910 )
a) Fractures of the middle or proximal third of the
scaphoid-immobilization of the elbow resulted in
significantly shorter time to union
b) Fractures of the distal third – did well regardless of
elbow inclusion
2) Forearm rotation in short arm cast induces fracture site
motion (cadaver study) 15
c. Inclusion of additional digits
1) Dehne 7
– inclusion of the index and middle finger
2) Taleisnik 26
– include index/middle if “very unstable”
3) Clay5 – no difference in incidence of nonunion rates
with or without thumb spica component
27