Should acute scaphoid fractures be fixed? A randomized controlled trial

Background: With the proliferation of different fixation screws, there is an increasing trend to recommend early internal fixation of the broken scaphoid even if the fracture is not displaced. The benefits and risks of early fixation of scaphoid fractures have not been established. These were investigated in eighty-eight patients who were of working age with clearly defined minimally displaced or undisplaced bicortical fractures of the waist of the scaphoid. Methods: Patients who provided informed consent were randomized to treatment with early internal fixation with use of a Herbert screw without a cast (forty-four patients) or to nonoperative treatment for eight weeks with immobilization in a below-the-elbow plaster cast with the thumb left free (forty-four patients). The patients were evaluated at two, eight, twelve, twenty-six, and fifty-two weeks with respect to the severity of pain; tenderness; swelling; wrist movement; grip strength; and symptoms and disability, which were assessed with the Patient Evaluation Measure. In addition, radiographs were made and assessed at each visit. Results: No difference was detected between the groups with respect to age, sex, hand dominance, side of injury, mechanism of injury, or the occupation of the patients. The range of motion, score on the Patient Evaluation Measure, and grip strength were significantly better in the group managed operatively than in the group managed nonoperatively at the eight-week follow-up evaluation, which corresponded with the visit when the cast was removed in that group. Patients returned to work at five to six weeks after the injury in both groups. At twelve weeks, grip strength was better in patients who had had surgery. No significant difference was detected between the two groups with respect to any other outcome measure at any other time. Ten of the forty-four fractures treated nonoperatively had not healed radiographically at twelve weeks, and, as a consequence, the treatment was altered. Complications occurred in thirteen patients who had been managed operatively. All complications were minor, and ten were related to the scar. Conclusions: This study did not demonstrate a clear overall benefit of early fixation of acute scaphoid fractures beyond the decrease in the rate of a change in treatment because of a delayed union at twelve weeks. Early internal fixation of minimally displaced or nondisplaced fractures of the scaphoid waist, which would heal in a cast, could lead to overtreatment of a large proportion of such fractures, exposing such patients to avoidable surgical risk. Thus, we have adopted a program of so-called aggressive conservative treatment, whereby we carefully assess fracture-healing with plain radiographs, and computed tomography scans if necessary, after six to eight weeks of cast immobilization and recommend surgical fixation with or without bone-grafting at that time if a gap is identified at the fracture site. Such an approach should result in fracture union in over 95% of such patients.