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• W1995384512 abstract "We read with interest the article by Luria et al, “Optimal fixation of oblique scaphoid fractures: a cadaver model.”1Luria S. Lenart L. Lenart B. Peleg E. Kastelec M. Optimal fixation of oblique scaphoid fractures: a cadaver model.J Hand Surg. 2012; 37A: 1400-1404Google Scholar The authors compared the stability of a screw placed perpendicular to the fracture plane in scaphoid fractures with a screw placed in the center of the proximal fragment. Biomechanical testing demonstrated no significant difference in the load to failure. They concluded that a screw placed through the tuberosity and perpendicular to the fracture plane results in similar stability and has the advantage of avoiding the scaphotrapezial joint. We wish to bring to attention 2 issues.First, the model used in this study was that of a vertical oblique waist fracture. According to the original article by Russe,2Russe O. Fracture of the carpal navicular Diagnosis, non-operative treatment, and operative treatment.J Bone Joint Surg. 1960; 42A: 759-768Crossref Scopus (464) Google Scholar this fracture pattern results in the most shear forces across the fracture site, thus making it the most unstable type, but it accounts for only 5% of scaphoid fractures. In an epidemiological study, the annual incidence of scaphoid fractures was 23 in 100,000 inhabitants, of which 1 in 100,000 was a vertical oblique fracture (4.3% of scaphoid fractures).3Brøndum V. Larsen C.F. Skov O. Fracture of the carpal scaphoid: frequency and distribution in a well-defined population.Eur J Radiol. 1992; 15: 118-122Abstract Full Text PDF PubMed Scopus (64) Google Scholar The original study of over 200 scaphoid fractures that led to the Herbert classification did not recognize a vertical oblique fracture at the waist.4Herbert T.J. Scaphoid fractures and carpal instability.Proc R Soc Med. 1974; 67: 1080PubMed Google Scholar A more recent 3-dimensional analysis of scaphoid fracture patterns found 3 basic anatomical fracture patterns: waist, dorsal sulcus, and proximal pole. In the waist type, the fractures follow the anatomical waist at right angles to the long axis of the bone. In the dorsal sulcus type, the fractures are in the line of the dorsal sulcus and at 45° to the surgical waist, and therefore to the long axis of the bone. A vertical oblique fracture type was not encountered in this group of 91 scaphoid fractures.5Compson J.P. The anatomy of acute scaphoid fractures: a three-dimensional analysis of patterns.J Bone Joint Surg. 1998; 80B: 218-224Crossref Scopus (66) Google ScholarSecond, there is no evidence that using a transtrapezial approach or resecting part of the trapezium to achieve central screw position will lead to an increase in symptomatic scaphotrapezial osteoarthritis.6Geurts G. van Riet R. Meermans G. Verstreken F. Incidence of scaphotrapezial arthritis following volar percutaneous fixation of nondisplaced scaphoid waist fractures using a transtrapezial approach.J Hand Surg. 2011; 36A: 1753-1758Google Scholar, 7Noland S.S. Saber S. Endress R. Hentz V.R. The scaphotrapezial joint after partial trapeziectomy for trapeziometacarpal joint arthritis: long-term follow-up.J Hand Surg. 2012; 37A: 1125-1129Google Scholar Previous studies have looked at signs of degeneration at the scaphotrapezial joint with the standard volar approach and found degenerative changes at the scaphotrapezial joint in 40% to 78% of patients.8Kehoe N.J. Hackney R.G. Barton N.J. Incidence of osteoarthritis in the scapho-trapezial joint after Herbert screw fixation of the scaphoid.J Hand Surg. 2003; 28B: 496-499Google Scholar, 9Nicholl J.E. Buckland-Wright J.C. Degenerative changes at the scaphotrapezial joint following Herbert screw insertion: a radiographic study comparing patients with scaphoid fracture and primary hand arthritis.J Hand Surg. 2000; 25B: 422-426Google Scholar, 10Saedén B. Törnkvist H. Ponzer S. Höglund M. Fracture of the carpal scaphoid A prospective, randomised 12-year follow-up comparing operative and conservative treatment.J Bone Joint Surg. 2001; 83B: 230-234Crossref Scopus (132) Google Scholar Scaphotrapezial osteoarthritis is also frequently seen in patients with scaphoid fractures treated with plaster immobilization (25% to 67%).9Nicholl J.E. Buckland-Wright J.C. Degenerative changes at the scaphotrapezial joint following Herbert screw insertion: a radiographic study comparing patients with scaphoid fracture and primary hand arthritis.J Hand Surg. 2000; 25B: 422-426Google Scholar, 10Saedén B. Törnkvist H. Ponzer S. Höglund M. Fracture of the carpal scaphoid A prospective, randomised 12-year follow-up comparing operative and conservative treatment.J Bone Joint Surg. 2001; 83B: 230-234Crossref Scopus (132) Google Scholar Most of these patients were asymptomatic or had minor problems, even at long-term follow-up.Fixation of the scaphoid should not be performed in a uniform fashion. The location and type of fracture should determine which approach allows the best screw placement.11Soubeyrand M. Biau D. Mansour C. Mahjoub S. Molina V. Gagey O. Comparison of percutaneous dorsal versus volar fixation of scaphoid waist fractures using a computer model in cadavers.J Hand Surg. 2009; 34A: 1838-1844Google Scholar In most scaphoid waist fractures, a screw along the central axis is perpendicular to the fracture plane and is biomechanically superior. Only in the rare vertical oblique type could the recommendations of the authors be followed, and the screw can be placed perpendicular to the fracture plane, avoiding the scaphotrapezial joint. It might be useful for the surgeons treating these fractures to stress these points. We read with interest the article by Luria et al, “Optimal fixation of oblique scaphoid fractures: a cadaver model.”1Luria S. Lenart L. Lenart B. Peleg E. Kastelec M. Optimal fixation of oblique scaphoid fractures: a cadaver model.J Hand Surg. 2012; 37A: 1400-1404Google Scholar The authors compared the stability of a screw placed perpendicular to the fracture plane in scaphoid fractures with a screw placed in the center of the proximal fragment. Biomechanical testing demonstrated no significant difference in the load to failure. They concluded that a screw placed through the tuberosity and perpendicular to the fracture plane results in similar stability and has the advantage of avoiding the scaphotrapezial joint. We wish to bring to attention 2 issues. First, the model used in this study was that of a vertical oblique waist fracture. According to the original article by Russe,2Russe O. Fracture of the carpal navicular Diagnosis, non-operative treatment, and operative treatment.J Bone Joint Surg. 1960; 42A: 759-768Crossref Scopus (464) Google Scholar this fracture pattern results in the most shear forces across the fracture site, thus making it the most unstable type, but it accounts for only 5% of scaphoid fractures. In an epidemiological study, the annual incidence of scaphoid fractures was 23 in 100,000 inhabitants, of which 1 in 100,000 was a vertical oblique fracture (4.3% of scaphoid fractures).3Brøndum V. Larsen C.F. Skov O. Fracture of the carpal scaphoid: frequency and distribution in a well-defined population.Eur J Radiol. 1992; 15: 118-122Abstract Full Text PDF PubMed Scopus (64) Google Scholar The original study of over 200 scaphoid fractures that led to the Herbert classification did not recognize a vertical oblique fracture at the waist.4Herbert T.J. Scaphoid fractures and carpal instability.Proc R Soc Med. 1974; 67: 1080PubMed Google Scholar A more recent 3-dimensional analysis of scaphoid fracture patterns found 3 basic anatomical fracture patterns: waist, dorsal sulcus, and proximal pole. In the waist type, the fractures follow the anatomical waist at right angles to the long axis of the bone. In the dorsal sulcus type, the fractures are in the line of the dorsal sulcus and at 45° to the surgical waist, and therefore to the long axis of the bone. A vertical oblique fracture type was not encountered in this group of 91 scaphoid fractures.5Compson J.P. The anatomy of acute scaphoid fractures: a three-dimensional analysis of patterns.J Bone Joint Surg. 1998; 80B: 218-224Crossref Scopus (66) Google Scholar Second, there is no evidence that using a transtrapezial approach or resecting part of the trapezium to achieve central screw position will lead to an increase in symptomatic scaphotrapezial osteoarthritis.6Geurts G. van Riet R. Meermans G. Verstreken F. Incidence of scaphotrapezial arthritis following volar percutaneous fixation of nondisplaced scaphoid waist fractures using a transtrapezial approach.J Hand Surg. 2011; 36A: 1753-1758Google Scholar, 7Noland S.S. Saber S. Endress R. Hentz V.R. The scaphotrapezial joint after partial trapeziectomy for trapeziometacarpal joint arthritis: long-term follow-up.J Hand Surg. 2012; 37A: 1125-1129Google Scholar Previous studies have looked at signs of degeneration at the scaphotrapezial joint with the standard volar approach and found degenerative changes at the scaphotrapezial joint in 40% to 78% of patients.8Kehoe N.J. Hackney R.G. Barton N.J. Incidence of osteoarthritis in the scapho-trapezial joint after Herbert screw fixation of the scaphoid.J Hand Surg. 2003; 28B: 496-499Google Scholar, 9Nicholl J.E. Buckland-Wright J.C. Degenerative changes at the scaphotrapezial joint following Herbert screw insertion: a radiographic study comparing patients with scaphoid fracture and primary hand arthritis.J Hand Surg. 2000; 25B: 422-426Google Scholar, 10Saedén B. Törnkvist H. Ponzer S. Höglund M. Fracture of the carpal scaphoid A prospective, randomised 12-year follow-up comparing operative and conservative treatment.J Bone Joint Surg. 2001; 83B: 230-234Crossref Scopus (132) Google Scholar Scaphotrapezial osteoarthritis is also frequently seen in patients with scaphoid fractures treated with plaster immobilization (25% to 67%).9Nicholl J.E. Buckland-Wright J.C. Degenerative changes at the scaphotrapezial joint following Herbert screw insertion: a radiographic study comparing patients with scaphoid fracture and primary hand arthritis.J Hand Surg. 2000; 25B: 422-426Google Scholar, 10Saedén B. Törnkvist H. Ponzer S. Höglund M. Fracture of the carpal scaphoid A prospective, randomised 12-year follow-up comparing operative and conservative treatment.J Bone Joint Surg. 2001; 83B: 230-234Crossref Scopus (132) Google Scholar Most of these patients were asymptomatic or had minor problems, even at long-term follow-up. Fixation of the scaphoid should not be performed in a uniform fashion. The location and type of fracture should determine which approach allows the best screw placement.11Soubeyrand M. Biau D. Mansour C. Mahjoub S. Molina V. Gagey O. Comparison of percutaneous dorsal versus volar fixation of scaphoid waist fractures using a computer model in cadavers.J Hand Surg. 2009; 34A: 1838-1844Google Scholar In most scaphoid waist fractures, a screw along the central axis is perpendicular to the fracture plane and is biomechanically superior. Only in the rare vertical oblique type could the recommendations of the authors be followed, and the screw can be placed perpendicular to the fracture plane, avoiding the scaphotrapezial joint. It might be useful for the surgeons treating these fractures to stress these points. Optimal Fixation of Oblique Scaphoid Fractures: A Cadaver ModelJournal of Hand SurgeryVol. 37Issue 7PreviewAcute scaphoid fractures are commonly fixed with headless cannulated screws positioned in the center of the proximal fragment. Central placement of the screw may be difficult and may violate the scaphotrapezial joint. We hypothesize that placement of the screw through the scaphoid tuberosity will achieve perpendicular fixation of an oblique waist fracture and result in more stable fixation than a screw in the center of the proximal fragment. Full-Text PDF In ReplyJournal of Hand SurgeryVol. 37Issue 9PreviewThe aim of this cadaver study was not to describe a solution for the majority of “transverse” waist fractures. According to the literature, these may be the most common fractures, but the tools used for the classification in the past are inaccurate compared with the tools we are using today.1–3 Analysis of fractures with radiographs without a clear definition of the long axis of the scaphoid questions the use of the word “transverse.”4 The short oblique simulation of a fracture may not be as rare as suggested. Full-Text PDF" @default.
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