Bhat Anil K, Acharya Ashwath M, Manoh S, Kamble Vinay
* Unit of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College Hospital, Manipal Academy of Higher Education, Manipal, India.
J Hand Surg Asian Pac Vol. 2018 Mar;23(1):18-25. doi: 10.1142/S2424835518500029.
To identify acute un-displaced and minimally displaced scaphoid fractures which are unlikely to unite with non-operative treatment at six weeks with CT scan and stabilize them with percutaneous screw fixation with the aim of preventing non-union.
A scaphoid series radiographs of wrist were obtained for patients with undisplaced or minimally displaced fractures and were immobilized in a thumb spica cast for six weeks. At six weeks, CT scan was done for patients showing doubtful signs of clinical and radiographic union. Patients with a gap less than 2 mm were continued on cast for an additional two to four weeks. Those with gap more than 2 mm underwent percutaneous screw fixation. In both cases the immobilisation was discontinued when the fracture was considered to be united and mobilization was initiated.
21 out of 39 patients managed initially with cast for six weeks showed clinical and radiological evidence of union. 18 patients showed persistent tenderness of which eight showed a clear gap in radiographs and 10 patients had doubtful union. Eight of these 10 patients on CT scan showed fracture gap of more than 2 mm while two patients showed fracture gap of less than 2 mm. Hence, 16 patients underwent percutaneous fixation. Repeat radiographs showed progression to union at an average of 3.8 weeks from surgery. Remaining two eventually united on continuing the cast. All patients showed confirmed union at one year on follow up.
An objective measurement of fracture gap by CT scan at six weeks is useful in predicting cases with tendency for delayed union. Early percutaneous fixation of fractures would not further jeopardize the blood supply of fracture site. This aggressive conservative management also avoids unnecessary surgery in all acute scaphoid fractures.
通过CT扫描识别急性无移位和轻微移位的舟状骨骨折，这些骨折在六周时非手术治疗不太可能愈合，并用经皮螺钉固定使其稳定，以防止骨不连。
为无移位或轻微移位骨折的患者拍摄腕部舟状骨系列X线片，并将其固定在拇指人字形石膏中六周。六周时，对临床和影像学愈合迹象可疑的患者进行CT扫描。骨折间隙小于2mm的患者继续使用石膏固定两到四周。骨折间隙大于2mm的患者接受经皮螺钉固定。在这两种情况下，当骨折被认为愈合时停止固定，并开始活动。
最初用石膏固定六周的39例患者中，21例有临床和影像学愈合证据。18例患者持续压痛，其中8例X线片显示明显骨折间隙，10例患者愈合情况可疑。这10例患者中，8例CT扫描显示骨折间隙大于2mm，2例显示骨折间隙小于2mm。因此，16例患者接受了经皮固定。复查X线片显示，平均术后3.8周骨折进展至愈合。其余2例最终通过继续使用石膏固定而愈合。所有患者随访一年时均证实骨折已愈合。
六周时通过CT扫描对骨折间隙进行客观测量有助于预测有延迟愈合倾向的病例。早期对骨折进行经皮固定不会进一步损害骨折部位的血供。这种积极的保守治疗也避免了所有急性舟状骨骨折患者进行不必要的手术。
