The scaphoid fracture was described by the American hand surgeon Barton as a fracture of an “awkward but important little bone”. Despite all the progress in hand surgery in the past few decades, little has changed: the scaphoid fracture remains the fracture of an “awkward but important little bone”, in our Caribbean hand surgery clinic at Trinidad Institute of Plastic Surgery and everywhere else.
If all bones with the exception of some in the craniofacial skeleton heal according to the same pattern, why do scaphoid fractures represent a problem of such increased difficulty ? Problems with the treatment of scaphoid fracture begin with timeliness of diagnosis, the presence of systemic and local factors affecting bone healing, the extent of the injury and the choice of treatment strategy by the initial provider of fracture care.
Bone healing is a complex process. Vital bone cells, adequate blood supply and continuous bone to bone contact with minimal shear or bending must exist at the fracture site. Fractures of all carpal bones are described, but none present as many headaches as the scaphoid. The scaphoid acts as a link between the two rows of carpal bones and has to withstand continuous shear and bending forces, which can delay or stop bone healing even after osteosynthesis. These biomechanical factors also determine the need for long and rigid immobilization in those few selected fracture patterns that are candidates for conservative treatment at all.
The development of the Herbert screw and its variants, and subsequently the headless, cannulated screws revolutionized the treatment of scaphoid fractures. Without these technologies newer percutaneous, minimally invasive and arthroscopic assisted fracture fixation procedures with the potential for shortened recovery and reduced surgical morbidity would be unthinkable.
Herbert’s book on the subject, a timeless classic and must-read for everybody involved in scaphoid fracture treatment, gives equally timeless advice: the vast majority of scaphoid fractures should undergo open reduction and internal fixation with a compression screw. In our Caribbean hand surgery clinic at Trinidad Institute of Plastic Surgery we actually prefer a headless, variable pitch, conical screw (AcuTrak headless compression screw), the best thing since sliced bread as far as scaphoid fracture treatment is concerned. The procedure is performed on an outpatient basis under regional or general anesthesia and torniquet control. The wrist is immobilized for two to four weeks, first in a splint, then a short arm cast. Subsequently, rehabilitation is begun. The procedure results in functional range of motion and load bearing characteristics of the wrist and absence of pain in the overwhelming majority of cases.
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