Precutaneous screw fixation vs cast immobilization?

[DJ Urbanovsky]

Ok, my medical professionals. Feedback needed, please.

Loved one broke her wrist on 4 July, has been in a cast since. Non-displaced scaphoid fracture. She was due to get her cast off today, but doc is not satisfied with fracture union and wants to do precutaneous screw fixation rather than further cast immobilization. Subject is early 30's and in good health. She is not sure that she is on board with the surgery.

Search query on the forum on key words turned up nothing, so I/we are interested in your experiences regarding similar injuries, and if they parallel linked study. And would you lean more towards further cast immobilization or screw fixation?

The study http://jbjs.org/content/83/4/483

Thanks in advance.

[Ambush Master]

D,

You may want to start collecting as many/all of the X-Rays as possible in Digital Format so that they can be sent with an E-mail!! Trust me,this will expedite the process even if it's local. When our oldest though that he had broken a finger, the Wife took him to her Office (She's a Dental Hygienist) and X-Rayed him with their Machine!! The Pedi-Doc said that it was the FIRST time that a Patient had come in with their own Pics!!

When I broke 11 Ribs on opening (Parachute Type) 5 years ago, having the Digital Pics helped with subsequent visits to other Docs!!

Do take care!!
Martin

[DJ Urbanovsky]

Roger that. Thank you, sir! I will see if she can provide me with radiography.

[miclo18d]

18D advice should be taken with a grain of salt here as we are not doctors.

After reading some sites non-displaced fractures generally heal well without surgical intervention but require strict immobilization.

Nondisplaced distal fractures heal well with strict immobilization in a well-molded short arm thumb spica. Controversy exists over whether to use a long arm or a short arm cast. One comparison16 found that nondisplaced fractures healed well regardless of the type of cast that was used. Current treatment for this type of fracture is a thumb spica, but some evidence suggests that the thumb could be omitted from the cast. A randomized prospective trial17 found that immobilization of the thumb did not improve outcomes for nondisplaced fractures. Screw fixation may speed recovery to pre-injury activities; referral for surgery may be indicated, depending on the needs of the patient.18 As the fracture line moves proximally, there is more risk of displacement and nonunion; therefore, it would be appropriate to refer these patients for orthopedic consultation.If conservative treatment is attempted, a long arm cast with thumb immobilization is appropriate.

Fractures with even small amounts of displacement are prone to nonunion, and operative treatment is recommended.19 Splinting and referral are indicated.

Bottom line refer to a good Ortho Doc and see what they say, or seek a 2nd opinion. Many start with conservative treatment as opposed to pulling out the shotgun (surgery) and blasting away.

[Red Flag 1]

It really is a decision she and her doctor have to agree to.

[DJ Urbanovsky]

Thanks for the assist, guys.

[DJ Urbanovsky]

You may not be doctors, but you're a wealth of real world knowledge and experience. That said, I did read the sticky up at the top of the forum about how no warranties are expressed or implied prior to posting. :)

She's got a good ortho/hand specialist, and has opted to go with the non-shotgun option first. Already floated idea of getting a second opinion to put her mind at ease. She does have a cast with full thumb imobilization.



18D advice should be taken with a grain of salt here as we are not doctors.

After reading some sites non-displaced fractures generally heal well without surgical intervention but require strict immobilization.



Bottom line refer to a good Ortho Doc and see what they say, or seek a 2nd opinion. Many start with conservative treatment as opposed to pulling out the shotgun (surgery) and blasting away.

[DJ Urbanovsky]

Of course. This is just another tool to populate the data pool.


It really is a decision she and her doctor have to agree to. We have no way of seeing the patient, doing a physical exam, or looking at the fracture. There is no way you can replace the "clinical eye" of her doc, with an internet opinion.

[Cynic]

If you trust your ortho, just be patient. (See what I did there?)
My husband (passed away) was an orthopaedic surgeon. Scaphoid fractures are notorious for slow healing because of poor blood supply. Depending on exactly where the break occured, various fixation treatments can be used. The cast with thumb immobilization is common.
Like everyone else said, get good xrays and a good orthopedic doc.
Good luck. A cast in this heat is no fun!

[Red Flag 1]

I can see why the doc is looking for a surgical repair.

[Odd Job]

Sorry I didn't see this thread earlier.

Non-union of a scaphoid means internal fixation is a must.

The scaphoid has a tenuous blood supply entering distally. If you have a non-union, especially with a fracture through the waist of the scaphoid you can get necrosis of the proximal half of that scaphoid. When that happens, the geometry and function of the whole wrist will be affected.

Some years ago I was the lead theatre radiographer at a hospital here in London where a surgeon by the name of Nick Goddard was at the forefront of innovative internal fixation operations involving the scaphoid. He would do them with the thumb suspended in a Chinese finger puzzle, whilst I X-rayed it with live fluoroscopy, orbiting the scaphoid.
Back then he was using a headless compression screw with two opposing thread pitches. We are talking at least 10 years back. I screened many cases with that team, and got to hear about the dangers of non-union and all the complications.

So, upfront I'll advise that although I am not a doctor I have enough info to declare that if it was me I would want the surgery.

I've attached two images from one of the cases, showing the finger puzzle and the X-ray set-up. The C-arm is in an orbit parallel to the floor. If you look on the X-ray monitor you can see the fractured scaphoid with the screw traversing the fracture, but not yet turned to achieve full compression (the light fracture line through the waist is still visible).
At the end of the procedure the fracture is reduced.

[UWOA (RIP)]

Agree with RedFlag on caveat pertaining to 'advice at a distance'. Nevertheless, from the studies that I've read, and given that this is a follow-on to an immobilization cast, your doctor has probably suggested this course of action to reduce temporary joint stiffness and muscle weakness associated with prolonged immobilization casting (basis for my conclusion is a study conducted at the Naval Medical Center, San Diego, CA.

This is supportive of your doctor's opinion, but, again, I'm not there ....

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