Management of displaced fractures of the waist of the scaphoid: Meta-analyses of comparative studies
Evidence Based Medicine
Singh HP et al. – Displaced fractures of scaphoid have a four times higher risk of nonunion than undisplaced fractures when treated in a plaster cast, and the patients should be advised of this risk. Nonunion is more likely if a displaced fracture of the scaphoid is treated in a plaster cast.Methods
- Electronic databases were searched using the Medical Subject Headings (MeSH) controlled vocabulary (scaphoid fractures, AND’d with displaced, or nonunion, or non–healing or cast immobilisation, or plaster or surgery).
- At present, there are no randomised, controlled trials or studies comparing fixation to plaster cast treatment of displaced fractures of the scaphoid.
- The search was therefore limited to observational studies of displaced fractures of the scaphoid treated in a plaster cast (non–operative group) or fixed surgically (operative group).
- The criterion for displacement was limited to gap or step of more than mm.
- In the non–operative group, the authors compared the outcome of displaced and undisplaced fractures of the waist of the scaphoid treated in a plaster cast.
- In the operative group, contingency table analysis was used to calculate the odds ratio of nonunion with plaster treatment compared to surgery.
- In the non–operative group, seven studies were included in a meta–analysis with a total of 1401 scaphoids.
- Ninety–three percent (1311 scaphoids) of these scaphoid fractures healed in a plaster cast.
- A total of 207 (15%) of all scaphoid fractures showed displacement of at least 1mm (gap/step) between fracture fragments.
- Nonunion was identified in 18% (37/207) of displaced scaphoid fractures treated in a plaster cast.
- The pooled relative risk of fracture nonunion was 4.4 (95% confidence interval (CI): 2.3–8.7; p=0.00; I2=54.3%).
- In the surgical group, they identified six observational studies in which 157 ‘displaced’ fractures of the scaphoid were surgically fixed.
- Only two of these fractures did not heal. The odds of nonunion were 17 times higher with plaster cast treatment than surgery.