Management of displaced fractures of the waist of the scaphoid: Meta-analyses of comparative studies
Injury,  Evidence Based Medicine  Clinical Article

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.

Results
  • 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.

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