Nonunion in displaced scaphoid fractures more likely when treated with plaster cast

Singh HP. Injury. 2012. doi:10.1016/j.injury.2012.02.012

  • Orthopedics Today, June 2012

Nonunion in a displaced fracture of the scaphoid is four times more likely than nonunion in an undisplaced fracture of the scaphoid if treated in a plaster cast, according to the results of this study.

According to the study abstract, the researchers searched electronic databases for scaphoid fractures either treated in a plaster cast or fixed operatively. For the purposes of the study, displacement was defined as a gap or step larger than 1 mm. Outcomes between displaced and undisplaced scaphoid waist fractures treated in a plaster cast were compared within the nonoperative group, and the researchers determined the odds ratio of nonunion when comparing plaster cast treatment to operative treatment.

The authors reported a total of 1,401 scaphoid fractures from 7 studies — 93% of which were treated with a plaster cast. Of these fractures, 207 (15%) exhibited displacement. According to the abstract, nonunion was found in 18% (37 of 207) of displaced scaphoid fractures treated with a plaster cast.

“The pooled relative risk of fracture nonunion was 4.4,” the authors wrote. “In the surgical group, we identified six observational studies in which 157 ‘displaced’ fractures of the scaphoid were surgically fixed. Only two of these fractures did not heal.” 

Perspective

  • This retrospective electronic database “research” assesses fracture union in displaced scaphoid fractures treated in casts vs. those treated operatively. Pooling all studies, the authors found increased an increased nonunion rate in the non-operative cohort (37/207) vs. the operative group (2/157). This information is not original, as the standard treatment for displaced scaphoid fractures is surgery. In essence, the authors pooled previous studies that demonstrated the same findings into a larger study. I encourage the authors to research the more vexing question, which is the treatment of displaced fractures with reference to union, risks, benefits, and costs. 

    • Scott H. Kozin, MD
    • Chief of Staff
      Shriners Hospital for Children
      Professor, Orthopaedic Surgery
      Temple University
  • Disclosures: Kozin has no relevant financial disclosures.
Perspective

  • The role of scaphoid fragment displacement in the development of nonunion has long been a clinical assumption and an indication for operative scaphoid fixation. This meta-analysis supports that indication. It does not, however, prove it, as the data is drawn from multiple studies that did not rely on a uniform method of determining displacement. Plain X-ray has 84% sensitivity in detecting 1 mm displacement. Other studies argue that a CT scan is the only valid way to detect a mm shift. Lastly, some argue that any fracture line on a plain X-ray is a sign of displacement.

    Suffice it to say that if there is scaphoid displacement, optimal treatment does include operative fixation — which can, in many cases, be performed percutaneously.

    • A. Lee Osterman, MD
    • Professor Hand and Orthopedic Surgery
      Thomas Jefferson University Hospital
      Philadelphia, PA
  • Disclosures: Osterman has no relevant financial disclosures.

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