N. J. Barton

Twenty questions about scaphoid fractures

When I was appointed a consultant in 1971, I had no questions about fractures of the scaphoid: I had been taught all I needed to know during my training--or so I thought. However a seed of doubt had been sown by Mr Peter London who told me that, contrary to standard British practice, it is not necessary to immobilize the thumb in treating these fractures. As the years passed and my experience increased, I have come to believe that standard teaching on other aspects is, at best, unproved and often actually untrue. In the last ten years there have been over 300 publications on scaphoid fractures, including several review articles (J. Kleinert and Zenni, 1984; Gelberman et al., 1989; Herbert, 1991; Amadio, 1992) a symposium in French (Alnot, 1988) and chapters in several books on the wrist, the one by Taleisnik (1985) being particularly good. Herbert (1990) has written a whole book on scaphoid fractures and very readable it is. These are expressions of a renewal of interest in fractures of the scaphoid and a recognition of the problems posed by them. As a result, some questions can now be answered and some old teachings discarded, but at the same time new questions have emerged. I have therefore chosen to cast this article in the form of a series of questions, aiming to provoke thought and further study rather than to cover every aspect comprehensively.

Excision of the trapezium for osteoarthritis at the base of the thumb

We have assessed the results of 34 simple excisions of the trapezium, with no additional soft-tissue procedures, in 30 patients. At a median follow-up of five years (2 to 22), 16 thumbs (47%) were completely painfree and a further 10 (29%) were slightly painful after use. Nineteen thumbs (56%) had no functional disability, but thumb-pinch strength was reduced by about 20%. No patient had painful degeneration at the scaphotrapezial pseudarthrosis.

Clinical Signs in Scaphoid Fractures

In a prospective study we investigated 12 clinical features for scaphoid fractures in 52 patients: 23 in whom a fracture of the scaphoid was diagnosed radiologically and 29 patients in whom a fracture was clinically suspected but could not be confirmed by radiography or scintigraphy. The signs were tested within a few days of injury and again 2 weeks later. None was reliable in diagnosing a scaphoid fracture.

Scintigraphy in the Evaluation of the “Clinical” Scaphoid Fracture

In a prospective study we performed bone scans on 84 patients who had sustained a wrist injury and in whom a scaphoid fracture was clinically suspected but could not be confirmed on the original set of five routine “scaphoid view” radiographs. In 40 patients the bone scan was normal and in 25 there was increased uptake in areas other than the scaphoid. In 19 there was localized increased uptake in the scaphoid bone. In seven of these a scaphoid fracture was subsequently demonstrated on repeat radiographs (five cases) or a CT scan (two cases). In the remaining 12 no fracture could be demonstrated.

Long-Term Outcome of Articular Fractures of the Phalanges: An Eleven Year Follow Up

Fifty-four patients with fifty-nine intra-articular fractures of the phalanges have been followed prospectively for eleven years, at the end of which time only four had significant pain and sixteen others discomfort in cold weather. Improvement in the symptoms and in the range of motion often continued for more than a year after injury. Although 17% of joints developed minor osteophytes or cysts, only one had both radiological evidence of arthritis and persistent pain.

A Comparison of Conservative Treatment and Silicone Replacement Arthroplasty in Kienböck’s Disease

Two forms of treatment of Kienböcks disease were compared in a total of thirty-seven wrists. Sixteen had been treated conservatively and were followed-up for an average of twenty years. Twenty-one had undergone silicone replacement arthroplasty an average of five years prior to review. Clinical results of conservative treatment showed four (25%) good, six (37.5%) fair and six (37.5%) with a poor result. Radiological deterioration was seen in only a quarter of cases. After silicone replacement there were nine (43%) good and seven (33%) fair. Five (24%) cases had a very poor result associated with dislocation of the prosthesis but design improvements have made this less frequent. Radiological abnormalities were noted in more than half of cases treated by silicone replacement arthroplasty. These included carpal collapse, scapho-lunate diastasis and generalised degenerative changes in the carpus. There were two cases with cyst formation in the capitate which closely resembled previous reports of silicone synovitis.

Apparent and partial non-union of the scaphoid

Ten patients with radiological non-union of the scaphoid and four patients with suspected nonunion were explored surgically. At operation, ten scaphoids looked united; five of these went on to definite union but the other five to non-union (in one case, despite a Herbert screw). In another four patients, there appeared at operation to be partial union; all proceeded to complete union. Even with the scaphoid in front of you, it can be difficult to decide whether it has united or not.

Dupuytren's disease arising from the abductor digiti minimi

Twenty patients with Dupuytren’s disease arising from the abductor digiti minimi have been studied. The different patterns of origin, course, and termination of the diseased cord are described, and the clinical implications discussed.

Continuous Passive Motion Following Flexor Tendon Repair

A prospective study was performed of 20 consecutive patients with 35 flexor tendon lacerations, in whom post-operative mobilisation was carried out using the Toronto Mobilimb Continuous Passive Motion machine for the first 4 1/2 weeks. Overall the results assessed by Buck Gramcko criteria were 17 (85%) excellent or good, 3 (15%) fair and no poor results. Taking the 17 fingers with zone II lacerations, 14 (82%) were excellent or good, 3 (18%) fair and no poor results.

Hand injuries in cricketers

55 patients with 64 injuries of the hand sustained while playing cricket were reviewed, 46 clinically. Most of the injuries were during fielding. The peripheral digits were most frequently involved and joint injuries predominated. Though the majority of the patients had a satisfactory functional outcome, some admitted to occasional pain and persistence of swelling and/or minor deformity. The most serious injuries were eleven fractures of the base of the middle phalanx with dislocation of the P.I.P. joint.