Nonoperative compared with operative treatment of acute scaphoid fractures. A randomized clinical trial.

BACKGROUND: Traditionally, acute nondisplaced scaphoid fractures have been treated nonoperatively in a cast, and the expected union rate approaches 90%. Internal fixation of nondisplaced scaphoid fractures has increased in popularity, and a union rate of 100% has been reported. The growing trend is to recommend internal fixation for the majority of acute scaphoid fractures. The true long-term benefits of this more complicated treatment modality have not yet been determined in randomized controlled trials. The purpose of this study was to compare the long-term results of operative fixation of acute scaphoid fractures with those of nonoperative treatment. METHODS: During the period between 1992 and 1997, eighty-three patients with an acute nondisplaced or minimally displaced scaphoid fracture were randomly allocated to, and received, either nonoperative treatment with a cast or internal fixation with a Herbert screw. At a median of ten years after the injury, seventy-five (93%) of the eighty-one patients who were still alive were assessed clinically and radiographically. RESULTS: All fractures united. A significant increase in the prevalence of osteoarthritis in the scaphotrapezial joint was found in the operatively treated group. No differences in subjective symptoms, as measured with limb-specific outcome scores, were found between the two groups. The range of motion and grip strength were greater, but not significantly greater, in the nonoperatively treated group. CONCLUSIONS: This study did not demonstrate a true long-term benefit of internal fixation, compared with nonoperative treatment, for acute nondisplaced or minimally displaced scaphoid fractures. The long-term risks of surgery should be considered when recommending operative treatment.

Comparison of direct and indirect costs of internal fixation and cast treatment in acute scaphoid fractures: a randomized trial involving 52 patients.

BACKGROUND: The most cost-effective treatment of scaphoid fractures has not yet been determined. METHODS: In a prospective trial, 52 employed or selfemployed patients with scaphoid fractures were randomized to closed (cast) or surgical treatment. RESULTS: There were 3 complications in the surgical group and 1 in the cast group. Median time off work was numerically but not statistically significantly greater after cast than after surgery (74/39 days). Manual workers (manuals) had a longer time away from work than non-manual employees/individuals who were selfemployed (non-manuals; median 84 days and 16 days, respectively; p < 0.001) and they had a longer time off work after cast than after surgery (median 100 days and 61 days; p = 0.03). Hospital costs were lower after cast than after surgery (p < 0.001). Work disability costs were numerically but not statistically significantly higher after cast than after surgery, and similarly, the total costs were lower after cast than after surgery. Work disability costs and total costs were higher in manuals than in non-manuals (p < 0.001). Non-manuals had lower total costs after cast than after surgery (p = 0.05). INTERPRETATION: There was a longer period of absence from work after cast than after surgery in manuals, but not in non-manuals. In non-manuals, total costs were lower after cast than after surgery. Socioeconomic classification had a greater influence on cost than mode of treatment.