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By: Mohsen Mardani Kivi M.D. Assistant Professor of Orthopedics Orthopedic Research Center

Scaphoid Fractures: A Comparison of Two Surgical Methods Using Either Herbert Screws or Multiple Pins for Internal Fixation. By: Mohsen Mardani Kivi M.D. Assistant Professor of Orthopedics Orthopedic Research Center Guilan University of Medical Sciences. What is it?.

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By: Mohsen Mardani Kivi M.D. Assistant Professor of Orthopedics Orthopedic Research Center

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  1. Scaphoid Fractures:A Comparison of Two Surgical Methods Using Either Herbert Screws or Multiple Pins for Internal Fixation By: Mohsen MardaniKivi M.D. Assistant Professor of Orthopedics Orthopedic Research Center Guilan University of Medical Sciences

  2. What is it? The most common fracture of wrist

  3. Anatomy • Links the proximal and the distal carpal rows • Waist is susceptible to fracture

  4. Mechanism of Injury • 2 mechanisms: • Hyperextension and bending • Puncher’s Scaphoid- axial force along the second metacarpal with the wrist in neutral.

  5. Classification Herbert’s Classification

  6. Symptoms • Hard to recognized because the pain improves quickly, there’s no bruising, and minimum swelling. • People usually think it’s a sprain • Some people don’t become aware of it until months or years after the event. • Tenderness directly over the scaphoid bone (which is located in the hollow at the thumb side of the wrist known as the “snuffbox”)

  7. Scaphoid Fracture Evaluation • Duration • <3 weeks old- better prognosis • If >4 weeks old drastically lower union rates when treated with cast alone • Location • Distal 1/3 (Pole) (5%) • Middle 1/3 (Waist) (80%) • Proximal 1/3 (Pole) (15%)-poor healing due to limited blood supply, osteonecrosis rate close to 100%

  8. Union rate

  9. Scaphoid Fracture Evaluation • Displacement- Nonunion rates in displaced fractures reach 92% • >1 mm step off on any view • Scapholunate angle of >60 degrees • Lunocapitate angle of greater than 15 degrees • Lateral intrascaphoid angle of more than 20 degrees

  10. Internal Fixation Herbert Screw vs. Multiple Pins Vs.

  11. Patients and methods • Cross-sectional study • From 2009 to 2011 • 23 patients in Herbert screw and 18 in multiple pins groups

  12. Inclusion and Exclusion Criteria • Inclusion criteria • Scaphoid fracture • >1mm displacement • Exclusion criteria • Herbert’s Type A • Accompanying lesions

  13. Surgical Techniques

  14. After surgery • Herbert Screw : • 4 weeks short arm cast + 4 weeks short palmar brace • Multiple Pins: • 6 weeks short arm cast + 2 weeks short palmar brace

  15. Follow up Visits: Two weeks post-surgery, Every month for six months, Every year after one year Measurements: Degree of fracture healing, Visual Analog Score (VAS) of Pain, Range of motion, Hand grip strength, Quick DASH score, Mayo Modified Wrist Score (MMWS)

  16. results • Mean follow up time 24.5 m (11-34) • 38 men (92.7%) and 3 women (7.3%) • Men age 30.6 ± 7.8 years No statistically difference between groups according to Age and Gender

  17. Fracture Types Frequencies

  18. Outcome * Flexion, Extension and grip are in comparison of contra lateral limb

  19. Outcome • VAS (satisfaction) in final visit: HS= 9.5 MP=9 p>0.05 • Osteonecrosis in final visit: HS=1(4.3%) MP=3(16.6%) p>0.05

  20. discussion RCT • Closed Reduction+Cast, • Herbert Screw, • Multiple Pins MMWS, ROM, Union time, Return to activity time, and Complications. Both surgical treatments were superior to CR+cast but were not different from each others.

  21. discussion Results of using Herbert Screw+4 weeks cast: 152/158 patients had excellent and good fixation 132/138 were completely satisfied 125/138 had normal or near normal function Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br 1984; 66:114-123.

  22. discussion • HS vs. Pins in delayed union scaphoid fractures: • Better functional outcome in HS than in MP • The complication rate was relatively high with both methods • Unsatisfactory reasons with MP Pelto-Vasenius K, Hirvensalo E, Böstman O, Rokkanen P. Fixation of scaphoid delayed union and non-union with absorbable polyglycolide pin or Herbert screw. Consolidation and functional results. Arch Orthop Trauma Surg. 1995;114(6):347-51.

  23. Conclusion The use of multiple pins for the internal fixation of scaphoid fractures proves to be a viable treatment option when compared to Herbert Screws, due to their decreased cost and increased availability.

  24. ANY QUESTIONS ?!

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