Abstract
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INTRODUCTION
When we received the invitation from Professor Max Lange to submit an article for the yearbook “Wieder-herstellungschirurgie und Traumatologie” concerning the treatment of scaphoid fractures (SFs), we jointly drafted a plan for this work. Dr Trojan and Dr Jahna carried out the follow-up examinations and evaluated the material.
The treatment of SFs in the hand throws up numerous difficulties even today. Not infrequently, patients present for examination with old SFs that have been overlooked; healing then requires months of treatment, and the functional result is often worse than for fractures that are detected and treated in good time. Frequently, one also sees pseudarthroses with long-term impairment such as painful restrictions of movement, and arthroses. Early detection and treatment of the fresh scaphoid fracture is therefore particularly important, since it normally heals without long-term problems given the correct treatment.
FREQUENCY OF SCAPHOID FRACTURES
In the period from 1.12.1925 to 31.12.1952, 536,173 injured people were treated in the Vienna accident hospital; 74,463 as in-patients and 461,710 as out-patients. Of these, 1113 were SFs of the hand in 1104 patients, i.e. 0.2% of the total number of injured persons. The 1113 SFs that were treated were divided into groups as shown in Table 1.
Also during this period, 133 healed and 410 unhealed SFs were seen (the latter (predominantly pseudarthroses), making 543 old SFs in all: these were not treated but had just been referred for one-off examination or for an expert opinion.
In this article, we shall discuss only the 734 fresh, simple fractures of the scaphoid body that were treated in 732 patients (two cases involved fractures of both scaphoids). An SF was termed fresh if it was presented for treatment within 14 days of the injury. Up to about this time, no serious radiological changes occur at the fracture gap, and the length of time required for healing is not yet seriously lengthened.
In assembling the material, we proceeded as follows: all the series of X-rays were examined several times, the case histories were processed, and those injured patients who could still be contacted underwent clinical and radiological follow-up examinations. In order to assess the results from the most varied aspects, we made use of the Hollerith method. Thus, all the facts presented here are underpinned by figures even if, for reasons of space, a detailed breakdown of the data is not provided.
Tables 2–4 show the frequency of SF per year, and the distribution according to sex, side and age. The youngest patient was 13 years old, and the oldest 69 years old. We also saw a fracture of the tuberosity in a 10-year-old boy.
Of the 734 fresh SFs, 68 (11.72%) had collateral injuries to the same arm (radial styloid fracture, ulna styloid fracture, radius fracture at the typical site, avulsion fracture of the triquetrum bone, forearm shaft fracture, fracture of the head of the radius, etc.).
DIAGNOSIS
The precondition for effective treatment is early, correct diagnosis of the scaphoid fracture. The only sure diagnosis is provided by an X-ray image. Clinically, an SF is suspected after a corresponding accident (usually a fall onto the hand) with the presence of the following signs: swelling at the radial side of the wrist, painful restriction of movement and particularly pain caused by pressure over the scaphoid in the snuffbox.
There are sometimes considerable difficulties in X-ray diagnosis. These can be reduced or eliminated through the following three measures:
Technically perfect images
On an unclear, poorly exposed picture, or in the case of poor film material, fissures can very easily be overlooked. It is also difficult or impossible to determine whether and when the SF has knitted. We struggled with these difficulties particularly in the post-war years 1947–1950, when only poor film material was available.
Special views of the scaphoid
Many fissures are not visible on conventional images of the wrist. Since 1930, we have therefore additionally been using the special views of the scaphoid introduced by Böhler (Figs 1–3). When an SF is suspected, the following four pictures are always taken: PA wrist, lateral wrist with extended fingers, AP wrist with bent fingers, and the wrist in 25–45° supination with bent fingers. In the last two pictures, the scaphoid is represented to its full extent, and most fissures can be easily discerned here. However, there are also rare types of fracture that are clearly visible only with a greater supination of 60–80°, or in the lateral view. We cannot, therefore, dispense with the conventional lateral view of the wrist.
X-ray checks after 2 and 4 weeks
Many fissures, particularly in the central third, are not visible on the first day, even with good X-ray technology. If an SF continues to be suspected for clinical reasons, then X-ray checks must be made after 2 and 4 weeks. After this time, the hairline fracture gap will have widened somewhat, due to resorption at the fracture ends, and will have become more readily visible. We have seen a fissure in the central third that became visible on the X-ray only at 24 days. Of the 734 SFs, in 18 cases the diagnosis could not be made until the X-ray check at 10–24 days.
LOCALIZATION OF THE FRACTURE AND FRACTURE FORMS
There are two fundamentally different groups of SF: (1) the intra-articular fractures of the scaphoid body, and (2) the extra-articular fractures of the tuberosity. The fractures of the tuberosity are harmless, and the bone always heals. We have treated 139 cases. The treatment consisted of a dorsal plaster splint for 3 weeks. These cases have not been included in this article, since they never pose problems (Figs 4–6).
We have classified the fractures of the body according to two different aspects: firstly according to localization and secondly according to the fracture type (course of the fracture gap). Both classifications were made not just according to anatomical aspects. As we shall see later, the different groups yield interesting clues on treatment and prognosis. We shall therefore briefly mention these circumstances now.
We have grouped the fractures in group (b) together as a type of their own, since anatomically they belong to neither the middle nor the central third, but therapeutically they should rather be treated as for central fractures. The period required for fracture groups (a) and (b) to heal is usually longer, and the number of pseudarthroses is greater than for the other groups. They therefore need to be immobilized for longer (10–12 weeks).
Those fractures in the middle third where a wedge has been chipped out have also been classified separately, in order to establish whether the prognosis is worse as a result of a wedge. Overall, the duration of healing for the groups (c–e) is shorter than for the groups (a) and (b) in the majority of cases, immobilization for 6–8 weeks is sufficient.
However, the prognosis for all these groups depends not only on the localization of the fracture, but also quite considerably on the course of the fracture gap. On first looking through our cases, we found delayed fracture healing and pseudarthroses of fractures in the middle third which at first we could not explain. Only after looking through the X-ray series again were we able to separate out certain types of fracture that posed diagnostic as well as therapeutic difficulties. On the basis of these results, we made a new classification of the SFs according to the course of the fracture gap. Interesting parallels to fractures of the neck of the femur can be drawn here; in the past these have often been compared to SFs in respect of the difficulties involved in fracture healing.
Sketches 3a and b, 4a and b and 5a and b correspond to the special views of the scaphoid with bent fingers and slight supination. Sketch 5c corresponds to the lateral view of the wrist, since this fracture type is sometimes visible only in this view. The arrow shows the typical radial–palmar end of the peripheral fragment tapering to a point.
We have found three main types of oblique and transverse fractures regardless of location, wherein the term “oblique” or “transverse” should always be understood in relation to the scaphoid axis.
Horizontal oblique SF (Fig 7a–d, Sketch 3a, b)
These account for almost half of the SFs. The fracture gap runs from radial distal to ulnar proximal, i.e. it appears to run horizontally in the AP image. In actual fact, it runs oblique to the scaphoid axis and almost perpendicular to the forearm–hand axis. In the middle third, the course corresponds to the vessel furrow, in which the scaphoid is presumably torn open in this type of fracture. In terms of form and prognosis, this fracture form corresponds to that of the femur neck fracture type Pauwels I.
As a rule, diagnosis is not difficult, and the prognosis is very favourable. Even in the central third, fractures of this type can heal within 6 weeks. This fact can easily be explained in that, as for the femur neck fracture Pauwels I, when the fingers are moved the fragments are pressed together, with the bone being subjected only to pressure forces, and not shearing forces.
Transverse fractures (Fig 8a–i, Sketch 4a, b)
These are about as frequent as the horizontal oblique fractures. The fracture gap runs perpendicular to the scaphoid axis and correspondingly oblique to the forearm–hand axis. In terms of form and prognosis, they correspond to the femur neck fracture type Pauwels II. As a rule, diagnosis is not difficult, but the healing time can sometimes be longer, since in this case shearing and tilting forces, and not just pressure forces, can develop.
Vertical oblique SFs (Fig 9a–h, Sketch 5a–c)
This is the rarest fracture type. The fracture gap runs from radial-palmar proximal to ulnar dorsal distal, i.e. it appears to run almost vertically in the side image or supination image. In actual fact, it runs oblique to the scaphoid axis and almost parallel to the forearm–hand axis. In terms of form and prognosis, this fracture form corresponds to the femur neck fracture type Pauwels III. Diagnosis can sometimes be very difficult, particularly if the fracture gap runs in a purely radio-ulnar direction and is visible only on the lateral view. It is then also particularly difficult to tell from the X-ray image when the fracture has knitted, since the side image is often paid too little attention. Especially typical for this fracture type is, in the supination or lateral image, the radial-palmar end of the peripheral fragment that tapers to a point. Sometimes the fracture can be detected only in an image with more supination (60–80°).
The time taken for vertical oblique fractures to heal can be greatly extended, and in individual cases the bone may not heal. This fact can be explained in that, just as with the femur neck fracture type Pauwels III, it is almost exclusively shearing and tilting forces that develop, and not pressure forces.
Comparison of fracture localization and fracture type
As a rule, the fractures at the middle/central third border (Table 5b) are transverse fractures and have therefore been counted as part of group (b) in Table 6. The fractures in the middle third where a bending wedge has been chipped out (Table 5d) are partly horizontally oblique and partly transverse, and were accordingly assigned to the two groups (a) and (b) of Table 6.
Besides the three main types given in Table 6, there are transitional forms between a, b and c, and also incomplete fissures that do not run through the entire width of the scaphoid. We have seen that the horizontal oblique incomplete SFs are torn only radially, and the transverse ones only at the ulnar side. In contrast to that, there are slight primary diastases between the fragments, which considerably increase the time required for healing, and could also cause pseudarthrosis.
Another interesting feature is the localization of the fracture types of Table 6a–c. In the case of a SF in the central third, the horizontal oblique fractures account for around 2/3 of the total, the transverse fractures cover about 1/3, and the vertical oblique fractures occur only in isolated cases here. In the middle and peripheral third, the horizontal oblique and the transverse fractures are more or less equal in number. The vertical oblique fractures are more frequent here, and make up around 4% of the fractures in the middle and periphery.
TREATMENT
Historical background
Clinical practice for SFs begins with the discovery of X-rays. Prior to that, SFs had already been described by anatomists, but detection in living patients and treatment were only possible after 1895. In the years following the turn of the century, following the spirit of the times, treatment consisted of early massage and passive movements. It was not possible to achieve bone healing in this way. The first person to attempt to achieve bone healing through immobilization was Blau (1904). He described 15 SFs, which he treated by immobilization with a cardboard splint for at least 4 weeks, or longer in some cases. His work contains no reference to the osseous healing of his cases. He only reports that 6623 were fit for work again. Similar trials were carried out by Ehebald (1906), Ebermayer (1908), Kindl (1910).
Unfortunately, this development was interrupted; since evidently in the majority of cases they were unsuccessful in achieving bone healing. Many formed the opinion that it was not possible for SFs to heal, or that they did so only in exceptional cases. Numerous cases of pseudarthrosis were seen, which caused more or less severe problems. For this reason, many people came to believe that it was better to remove the broken scaphoid, in order to prevent the late effects of pseudarthrosis. The most radical representative of this direction was Hirsch (1914). He writes: “Every intra-articular scaphoid fracture should, on principle, be operated upon; moreover, it should be operated upon primarily and early, and the operation must comprise the total extirpation of the fractured bone.” However, the results of extirpation were not satisfactory, so some years later attempts at fixation returned to the fore (Blumer, 1922; Destot, 1921).
Since 1920, Böhler has carried out systematic, uninterrupted immobilization of fresh SFs for at least 6–8 weeks, and for correspondingly longer in the case of old fractures. This treatment method has been published by Schneck (1929, 1930, 1931) in several articles, and has gradually become established. In 1938, Böhler announced the treatment results on the basis of follow-up examinations by Jeschke and Perschl. Of 152 SFs of the body, 144 (94.7%) healed with bony union. Since then, the view consistently expressed by Böhler that fresh SFs do heal osseously given corresponding long, correctly carried out and uninterrupted immobilization, has become common property.
Treatment of fresh SFs in the Vienna accident hospital
Type of treatment
In the period from 1925 to 1942, immobilization of the SF was effected with a simple, unpadded dorsal plaster splint. In order to achieve better fixation and possibly a reduction in the length of time for healing, the thumb has been included in the plaster cast since 1942. It will be interesting to establish whether the fixation and treatment times are in fact shorter when the thumb is included than in the case of the simple dorsal plaster splint, and whether the number of pseudarthroses has been reduced. We have no experience of the fixation method proposed by Düben and Rehbein since 1948, which involves a forearm plaster which includes all the fingers (fist plaster), for fresh SFs (Table 7).
Fixation technique
The position of the hand in the dorsal plaster splint is the middle position between dorsal and palmar flexion, and the middle position between radial and ulnar abduction. The hand must not be set in plaster in a position of ulnar abduction, since this can lead to distraction of the fragments. Blau (1904) has already drawn attention to this.
The precise plaster technique is described in detail in the textbook by Böhler. It must be ensured that the plaster cast is checked at least once a week. In particular, it must be checked whether the bandage in the palm of the hand is in order to ensure perfect immobilization. If the plaster cast is broken, it must be replaced. Exercise therapy of the unfixed joints must be carried out regularly in the manner described by Böhler.
Particularly with the simple dorsal plaster splint, many patients can resume their work early. That is the best exercise therapy. If the thumb is included, it is not possible for many people to pursue their work, and with the fist plaster this would be possible only in exceptional cases.
Opinion of surgery
Surgical treatment of the fresh SF is almost never necessary. Out of 734 cases, only a single one had to undergo an operation after Matti, since after immobilization with a dorsal plaster splint there were still no signs of the beginnings of bone healing after 4 months. This was a vertical oblique fracture in the middle third (Fig 9, Sketch 5). Apart from that, two cases underwent operations with bolting after Geissendörfer (1941). Looking back, it must be said that these two would certainly have set even without an operation.
Fixation time
The average fixation time with the simple dorsal plaster splint was 50.72 days, and with the dorsal plaster splint with inclusion of the thumb it was 65.92 days. The overall average was 59.14 days.
These figures show that the SFs with the dorsal plaster splint with inclusion of the thumb were fixed for 15.2 days longer than those with the simple dorsal plaster splint. The cause of this difference is certainly not solely that the duration of fracture healing is longer when the thumb is included, there are also other causes. In the post-war years, with the poor quality of X-ray material, it was often not possible to determine whether an SF had healed or not after the plaster was removed. For this reason, in a number of cases further immobilization for 6 weeks was undertaken. Occasionally, the period of fixation was also lengthened by younger colleagues who did not yet have experience in determining the consolidation of the SF. But even if one excludes these cases which in our opinion had been fixed for too long, there still remains an average fixation time of 57.7 days for the dorsal plaster splint with inclusion of the thumb. It is apparent from this that in our cases, including the thumb in the dressing did not shorten the fixation time for any of them. On the contrary, in individual cases we gained the impression that they knitted more quickly with the simple dorsal plaster splint when the thumb was not included than when it was included. Nor did the inclusion of the thumb reduce the incidence of pseudarthrosis, as we shall see later.
So for how long should an SF be fixed, depending on localization and fracture type? We believe that we should follow the simple rule of immobilizing SFs in the central third for 10–12 weeks, and those in the middle and peripheral thirds for 6 weeks.
We have in fact seen horizontal oblique SFs in the central third which had knitted after 6 weeks (compression action). However, since the X-ray distinction between horizontal oblique and transverse fractures can sometimes be very difficult, and great experience is required, we recommend that all SFs in the central third should primarily undergo the longer immobilization of 10–12 weeks.
In the middle and peripheral thirds, horizontal oblique SFs almost always knit within 6 weeks. Of the transverse SFs, some are healed only after 10–12 weeks (in part, tilting and shearing forces). A healing duration of longer than 6 weeks is mostly required by the rare vertical oblique SFs (predominantly tilting and shearing forces). Determination of osseous healing is often particularly difficult in these fractures, since the fracture gap can sometimes only be seen with a supination of 60–80° or a lateral view. One must therefore remember to take these special radiographs after removal of the plaster in the case of these SFs.
Rehbein and Düben (1952) also state a fixation period of 6–8 weeks with the fist plaster for fresh SFs. However, in our experience most fresh SFs have likewise set in 6–8 weeks with the dorsal plaster splint, with or without thumb inclusion. We therefore regard the fist plaster as superfluous for most fresh SFs, particularly since it is only in exceptional cases that the patients can pursue their occupations with this type of fixation. At most, one might consider using a fist plaster in the case of the rare vertical oblique fresh fractures, in order perhaps to achieve a shorter duration of healing.
Sick leave and duration of treatment
After excluding 41 cases with severe collateral injuries, the remaining 691 patients were signed off as sick for an average of 68.28 days, and the average duration of treatment was 75.59 days. This difference shows that many injured patients resumed work even before the conclusion of treatment.
PROGRESS OF THE SCAPHOID FRACTURE
Without immobilization
Even though isolated cases of spontaneous healing of SFs have been described in the literature (Boerema, 1937), as a rule the final outcome for a SF without immobilization is a pseudarthrosis. After about 3 weeks, resorption at the fracture ends results in a widening of the fracture gap, and ultimately to the formation of a so-called traumatic cavity. This state remains for several months, sometimes even for several years, in the course of which metaplastic processes can take place (enlargement of the cavity). Later, the fragments seal themselves off with a calcium-dense cover, and a true pseudarthrosis is created. The distinction between a traumatic cavity and a pseudarthrosis is very important for therapeutic reasons: a traumatic cavity can often still be healed just through long-term immobilization, but a pseudarthrosis requires an operation (Fig 10a–e).
With immobilization
Signs of osseous healing (Fig 11a–d)
Since determination of bone healing of the SF from the X-ray image is particularly difficult, and the clinical examination does not allow certainty about consolidation either, we shall now describe in particular one sign that we were able to find in our cases that acted as a sure characteristic of healing.
Fissures that are not visible continuously are sometimes no longer visible when the plaster cast is removed. However, if one can still see the fracture gap in its full extent, it can sometimes be difficult to decide whether callous bridging-over is already present or not. In many of these cases, a densification zone occurs at the fracture surfaces, which in the X-rays assumes the appearance of one or two calcium-dense stripes. We have seen one calcium-dense stripe in 131 (17.85%) of our 734 cases, and two calcium-dense stripes in 158 (21.53%) cases. This sign of knitting of the fresh SF must not be confused with the beginnings of the formation of a pseudarthrosis, as one can sometimes read in X-ray reports. Pseudarthroses following fresh SFs generally develop via the traumatic cavity, and take months and years to form. These calcium-dense stripes can remain visible for months; they can later fuse to become a single stripe, and only then do they ultimately disappear. It is therefore not necessary to immobilize the SF until the fracture gap is no longer visible. This sign of knitting described above applies only for the fresh SF; other features apply in the case of old fractures.
Calcium density of the proximal fragment (Fig 12a–e)
One of the most striking symptoms in the progress of the SF is the calcium density of the proximal fragment. We found that in 325 (44.28%) of our 734 fresh SFs, the proximal fragment became more calcium-dense during treatment, as a rule after 2–6 weeks. This sign is the expression of a circulation disorder, triggered by tearing of the supplying vessels. It should therefore occur more frequently where more or larger vessels are torn. This is more easily possible in the case of the oblique fracture, which frequently runs in the vessel furrow, than in the case of a transverse fracture. Furthermore, the calcium density should also occur more frequently in the case of fractures in the middle third, since in the case of this fracture localization the main supplying vessel can more often be injured. We found that these two assumptions were confirmed by the figures in our cases.
In the normal course of healing following a fresh SF the calcium density of the proximal fragment gradually clears again. This is the sign of re-vascularization of the proximal fragment and can likewise be regarded as a symptom of osseous healing. A residue of calcium density in the most proximal part of the scaphoid can remain present for years. We saw such pictures in around 50% of the 580 cases we followed up.
RESULTS
Of the 734 fresh, simple SFs, we were able to follow up 580 (79.02%). Of the remaining 154, some had died, some were living abroad, some were ill, and only 15 did not attend despite several requests. We ourselves followed up 529 SFs in 528 patients from November 1953 to March 1954 (72.07%). We also had access to the X-ray images from the follow-up examinations by Jeschke and Perschl from the years 1938/1939, relating to 51 patients who could now no longer be contacted. The observation period ranged between at least 1 year to 28 years after completion of treatment; on average, 7.92 years.
Procedure in the follow-up examination
The patients were questioned about the following: change of job due to the accident, sports, subjective complaints (sensitivity to weather, intermittent pain during heavy work but not disabled, always pain during heavy work or pain during any work, loss of power).
Objective findings
Form, colour, callosities, movement of all joints in the arm, starting with the fingers up to the shoulder in comparison with the healthy side, pain on pressure and compression over the scaphoid, strength testing, comparative circumference measurements of the upper arm, forearm, and wrist joint.
Special X-ray views were then taken of the scaphoid on the injured side, and in the event of any abnormal result, comparative pictures were taken of the healthy scaphoid. In the case of work accidents, where the patient was covered by insurance, the pension file was examined, and short- and long-term pensions were broken down according to percentages.
Pseudarthroses
Out of 580 fresh, simple SFs, 557 (96.04%) healed osseously, and 23 (3.96%) developed a pseudarthrosis (Table 8).
Of the 23 pseudarthroses, four dropped out of treatment, and therefore do not count when assessing the treatment: one refused treatment altogether, two were given a plaster cast which they removed themselves prematurely and did not attend again and one had not healed after 6 weeks’ immobilization but refused further immobilization.
Accordingly, if we disregard these four cases, then of 576 SFs, 557 (96.65%) healed osseously, and 19 (3.35%) have a pseudarthrosis).
Causes of the 19 pseudarthroses are:
Overlooked fractures (three cases). Cases 1 and 2 (1927–1929): Fissure in middle and peripheral third, no special radiograph of the scaphoid, only wrist joint pictures. The fissure was not visible on these. Case 3 (1936): Horizontal oblique fissure in central third, fissure not visible with any certainty either on the special view on the day of injury or 10 days later. A further X-ray check should have been made after 4 weeks.
Cases that were fixed for too short a time as a result of faulty X-ray technique (One case). Case 4 (1927): Transverse fracture in the middle third, simple dorsal plaster splint for 6 weeks. Afterwards, no special view of the scaphoid, only wrist joint pictures. The fracture was wrongly judged to have knitted, and was not further immobilized.
Fractures that were fixed for less than 6 weeks (three cases). Cases 5–7 (1929, 1930): Immobilization of the SF for less than 6 weeks is too short for all fractures localizations and fracture types. One transverse fracture in the middle was immobilized for only 3 weeks, one transverse fracture of the middle proximal third for only 4 weeks, and a horizontal oblique fracture in the proximal third was likewise immobilized with a simple dorsal plaster splint for only 4 weeks.
Fractures in the central third which were fixed for less than 10–12 weeks (three cases). Cases 8–10 (1931, 1933, 1940): Immobilization of the SF in the central third or at the middle/central third border for less than 10–12 weeks is not sufficient as a rule. Two SFs were each immobilized for just 6 weeks, and one for just 8 weeks, with the simple dorsal plaster splint.
Vertical oblique fractures (three cases). Cases 11–13 (1949, 1950, 1951): Two in the middle and one in the peripheral third, immobilization of 7–13 weeks with dorsal plaster splint with inclusion of the thumb. Determining consolidation posed particular difficulties, since the fracture gap was not visible in the typical scaphoid pictures, but only with supination of 60–80°, or only in the lateral view. The fractures were erroneously prematurely deemed to have knitted, and no further fixation was undertaken. As has already been emphasized in the description of the fracture types, healing is often delayed in this type of fracture, since it is predominantly subjected to shearing and tilting forces, and not pressure forces. This fracture type has the highest percentage of pseudarthroses: three out of 20 cases (15%).
Other causes (six cases). Case 14 (1943): Transverse fracture at the middle/central third border, primarily slight diastasis between the fragments, simple dorsal plaster splint for 10 weeks. Case 15 (1948): Transverse fissure in the central third without diastasis, dorsal plaster splint with inclusion of the thumb for 20 weeks. Cases 16 and 17 (1948 and 1951): One transverse fracture in the central third and one at the middle/proximal third border, primarily slight diastasis between the fragments, dorsal plaster splint with inclusion of the thumb for 12 and 31 weeks. Cases 18 and 19 (1946 and 1948): Two transverse fractures in the middle third and at the middle/peripheral third border, primarily slight diastasis, dorsal plaster splints with inclusion of the thumb, 6 and 11 weeks.
It must be briefly pointed out at this point that the presence of a primary diastasis can delay consolidation, or endanger it. In 70 of the cases we followed up, there was a primary diastasis; of these, seven (10%) developed a pseudarthrosis. Interestingly, there were only two (5.7%) pseudarthroses in 35 cases that were treated with a simple dorsal plaster splint, as compared with five (14.3%) pseudarthroses out of 35 cases that were treated with a dorsal plaster splint with inclusion of the thumb. According to that, pseudarthroses were more common when the thumb was included in the cast. This could be explained thus: through the inclusion of the thumb, the thumb musculature is not allowed free play, so the compressive action on the scaphoid is absent and it is more difficult for the fragments to move together. This has a particularly harmful effect when a diastasis is primarily present.
Summary of the causes of the 19 pseudarthroses:
Faulty X-ray technique without special radiographs, therefore initial failure to detect SF, or failure to detect bone healing (cases 1–4).
Immobilization of the SF for less than 6 weeks in any fracture type (cases 5–7).
Immobilization of the SF in the central third for less than 10–12 weeks (cases 8–10).
Primary failure to detect the vertical oblique fracture, erroneous assumption of osseous healing where lateral pictures of the wrist or pictures with supination of 60–80° were omitted. This fracture type should be primarily fixed for 12 weeks, possibly with a fist plaster (cases 11–13).
Diastases. Too short a fixation in the case of primary diastases, wherein the inclusion of the thumb in the plaster cast appears to be particularly harmful. These cases too should be primarily immobilized for 12 weeks (cases 14–19).
Arthroses
From the compilation of data (Table 9), it is clear that after a fresh SF has healed, it is very rarely (1.1%) that arthrosis develops, even after decades. Of the six cases, five had a very slight arthrosis at the styloid of the radius, and one had it at the scaphoid. By contrast, in the case of the pseudarthroses, 14 (around 60%) had arthrosis: five had slight arthrosis at the styloid of the radius and three had it severely at the styloid of the radius, three had it slightly at the scaphoid, one had it slightly at the scaphoid and styloid of the radius, one had it severely at the scaphoid and styloid of the radius, and one had it severely in the wrist.
Clinical results
In the following, we shall evaluate only those 529 cases that we followed up personally in 1953/54, in order to always be able to present the results according to the same aspects.
Change of occupation: Of the 529 cases of SF that were followed up in 1953/54, 511 had healed osseously, 18 had pseudarthroses (see Table 10). Of those where the bone had healed, only two (0.39%) had to change their occupation because of the consequences of the accident, and of the pseudarthrosis cases 4 (22%), i.e. almost 14 (78%), did not do so. None of the six cases had any collateral injuries.
Subjective problems: Of the 529 cases of SF followed up in 1953/54, 29 were eliminated due to simultaneous collateral injuries to the same arm. Table 11 shows that amongst those SFs where the bone had healed, only ten patients complained of severe problems. Interestingly, all ten of these involved accidents at work that were covered by insurance, whereas amongst those SFs where the bone had healed and the patient was not insured, not a single one complained of severe pain. Of the ten, one is drawing a long-term pension (20%), one is still drawing a short-term pension, four have in the past drawn a short-term pension, and just four had not had a pension at any time. One is left with the impression that the problems that are voiced are often influenced by the desire for a pension. Some patients stated that they experienced stronger pain for up to 2 years after the SF, but that this pain later vanished completely. Of the pseudarthroses, around 1/3 have serious problems, whilst almost 2/3 are not markedly disabled.
Restrictions in movement: Of the 529 cases of SF followed up in 1953/54, 29 were once again eliminated due to simultaneous collateral injuries to the same arm, as were a further 20 cases in which the mobility of the wrist joint could not be compared due to an injury to the other side (Table 12).
The number of cases with severe restrictions of movement of the wrist joint following bone healing of fresh, simple SFs is vanishingly small. We found them to be somewhat more frequent in the palmar ulnar direction than in the dorsal radial direction. And of the pseudarthroses, not quite 1/2 had a severe restriction in the dorsal palmar direction, and not quite 1/5 in the radial-ulnar direction. We saw no cases of restricted movement in the fingers, forearm, elbow and shoulder as a result of the SF.
PENSIONS
Of the 732 patients with 734 fresh, simple SFs, 541 (73.91%) involved accidents at work covered by insurance. Of these, eight drew a pension due to collateral injuries (remainder: 533) (Table 13).
Of the four patients with long-term pensions, two had a pseudarthrosis; there were also a further 14 pseudarthroses among the 533 insured persons. Of these, ten had never drawn a pension and only four had drawn a short-term pension.
In the case of two patients drawing a long-term pension, the SF had healed osseously. In the case of one of them, on the occasion of an examination to assess eligibility for a pension, a pseudarthrosis was assumed on the basis of the clinical findings, and the pension was therefore granted. This is thus an assessment error. The other one had restricted wrist movement in the dorsal and palmar directions, each of 20–30, with an indication of arthrosis.
SUMMARY
In the period from 1.12.1925 to 31.12.1952, 734 fresh, simple fractures of the scaphoid body were treated in 732 patients at the Accident Hospital in Vienna. In order to overcome diagnostic difficulties, technically perfect radiographs were required, and special views of the scaphoid were proposed, as well as X-ray checks after 2 and 4 weeks in the case of questionable fissures. In describing the types of fracture, a new classification was used, based on the course of the fracture gap; here, attention was drawn in particular to the vertical oblique fracture, which presents diagnostic and therapeutic difficulties. Immobilization was achieved either with a simple dorsal plaster-splint or with a dorsal splint that also included the thumb. The overall average period of fixation was 59.14 days, this period being somewhat longer in cases where the thumb was included in the splint. Patients were on sick leave for an average of 68.28 days, and the duration of treatment averaged 75.79 days. In the progress of fracture healing, the occurrence of calcium-dense stripes was emphasized as a particular indication of bone healing, and the behaviour of the calcium density in the proximal bone fragment was discussed.
Follow-up examinations 1–28 years (average around 8 years) after the accident were possible in 580 (79%) of the 734 scaphoid fractures. Out of 576 usable cases, the bone had healed in 557 cases (96.65%), and 19 (3.35%) had pseudarthroses. Besides those already known to us, new causes of pseudarthroses were found to be the vertical oblique fracture and the presence of diastasis between the fragments of bone; a period of fixation lasting 10–12 weeks was proposed for these cases. Inclusion of the thumb in the plaster cast appears to delay fracture healing, particularly in the case of diastasis. Arthroses were found in 20 cases (3.54%), but only in 1.1% of healed cases. In clinical terms, change of job due to the accident, severe problems, and restricted movement of the wrist of more than 10° were found in only an insignificant percentage of the cases where the bone had healed. Of the patients with pseudarthroses, around 20% had to change their job as a result of the consequences of the accident, around 40% had serious problems, and 20–40% had restriction of movement greater than 10°. Of the 732 people injured, 533 sustained accidents at work that were covered by insurance and without serious collateral injuries: of these, only 4 (0.75%) receive a long-term 20% pension.
Footnotes
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Behandlungsergebnisse von 734 frischen einfachen Brüchen des Kahnbeinkörpers der Hand.