CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 460, pp.

142151 2007 Lippincott Williams & Wilkins

Treatment of Acute Scaphoid Fractures

Systematic Review and Meta-analysis
Zhong-gang Yin, MD*; Jian-bing Zhang, MD*; Shi-lian Kan, MD*; and Pei Wang, MD

Whether operative treatment is a better option than nonoperative treatment for acute nondisplaced or minimally displaced fractures of the scaphoid is controversial. The type of cast that should be used for nonoperative treatment is not known. We performed a systematic review and meta-analysis of randomized and quasirandomized trials to evaluate the effect of operative versus nonoperative treatment and the effect of different casting methods for nonoperative treatment of acute scaphoid fractures on nonunion rate, return to work, grip strength, range of wrist motion, complications, patient evaluation, and incidence of osteoarthritis. Two investigators assessed trial quality and extracted data. Operative treatment of acute nondisplaced or minimally displaced fractures of the scaphoid waist does not provide greater benefits regarding nonunion rate, return to work, grip strength, range of wrist motion, or patient satisfaction than cast immobilization; however, it causes more complications and, perhaps, a higher risk of scaphotrapezial osteoarthritis. There is no evidence from randomized trials to determine whether operative treatment is superior to nonoperative treatment for an acute proximal pole fracture of scaphoid bones. There is insufficient evidence to determine which type of cast should be used in nonoperative treatment of nondisplaced scaphoid fractures. Level of Evidence: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The scaphoid, a bridge between the proximal and distal carpal bones, transfers compression loads from the hand to
Received: March 19, 2006 Revised: August 16, 2006; December 2, 2006 Accepted: January 24, 2007 From the *Department of Hand and Microsurgery, Tianjin Hospital, Tianjin, China; and the Department of Orthopaedics, General Hospital of Tianjin Medical University, Tianjin, China. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Correspondence to: Zhong-gang Yin, MD, Department of Hand and Microsurgery, Tianjin Hospital, 300211, Tianjin, China. Phone: 8610-02228336249; Fax: 8610-022-28313462; E-mail: zgyin@hotmail.com. DOI: 10.1097/BLO.0b013e31803d359a

the forearm and maintains normal wrist motion, carpal stability, and function of the wrist flexor and extensor tendon. Scaphoid fractures are the most common type of carpal fractures23 and occur most commonly in young male adults. The primary mechanism of injury is a fall on the outstretched hand with an extended, radially deviated wrist. Less common mechanisms of injury may involve forced palmar flexion of the wrist26 and axial loading of the wrist with the hand in a fisted position.14 Various classification systems based on fracture pattern, fracture stability, the status of healing, and the interval since injury often are combined to describe the features of a scaphoid fracture.16 Fractures may be considered acute when less than 3 weeks old, delayed to union between 4 and 6 months old, and nonunited when more than 6 months old.27 Fracture location can be identified as proximal pole, waist, and distal pole. Waist fractures are classified as transverse, vertical oblique, or horizontal oblique. Scaphoid fracture instability is defined as displacement greater than 1 mm in any direction, lateral intrascaphoid angulation greater than 35, substantial bone loss or comminution, and fractures associated with dorsal intercalated segment instability. Treatment of acute scaphoid fractures can be classified as nonoperative (cast immobilization) or operative (open or percutaneous internal fixation). Nonoperative treatment is indicated for acute nondisplaced scaphoid fractures. However, the length of the cast (below-elbow cast or above-elbow cast), immobilization of the thumb, and position of the hand in the cast are controversial.17 Surgical treatment usually is indicated for acute unstable scaphoid fractures. With the proliferation of fixation screws available for the scaphoid bone, there is an increasing trend toward surgical treatment for acute scaphoid fractures even if the fracture is nondisplaced.6 However, the benefits and risks associated with internal fixation of nondisplaced fractures of the scaphoid have not been established. Treatment of acute proximal pole fractures has been reported.16 Because the fracture line moves proximally, there is more risk of displacement and nonunion.23 Some
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Treatment of Scaphoid Fractures

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investigators recommend open reduction and internal fixation for proximal pole fractures involving less than 25% of the bone,16 whereas others suggest nonoperative treatment with a long arm cast incorporating the thumb.23 Given lingering questions about the choice of optimal treatment for acute scaphoid fractures, we performed a systematic review and meta-analysis of randomized and quasirandomized, controlled trials to assess the effect of operative versus nonoperative treatment of acute scaphoid fractures on rates of nonunion, return to work, grip strength, range of motion (ROM), rates of complications, patient satisfaction, and incidence of osteoarthritis. We also assessed the effect of different casting methods of acute nondisplaced scaphoid fractures on rates of nonunion, grip strength, and ROM of the wrist. MATERIALS AND METHODS
We searched PubMed and the Cochrane Controlled Trials Register4 without language restriction and hand-searched the references of relevant studies. In PubMed, all phases of the Cochrane highly sensitive search strategy for randomized, controlled trials for PubMed13 were combined with the following subject-specific search strategy: scaphoid bone[mh] OR carpal bones[mh] AND fracture[mh]. To be included, the study had to meet the following criteria regarding participants, treatment, outcomes, and type of study. The study had to report on adult patients with clinical and radiographic evidence of acute scaphoid fractures regardless of their gender, age, and type of fracture. The study had to report on operative versus nonoperative treatments or comparison between different casting methods. The main surgical treatments had to be closed reduction and percutaneous fixation or open or arthroscopic reduction and internal fixation by Kirschner wires or screws. The primary nonoperative treatments were casting immobilization. Studies had to report the outcomes of nonunion of acute scaphoid fracture. We included any randomized or quasirandomized clinical trials with results published as a full report in the English literature. Two reviewers independently selected the studies (ZGY, JBZ), and disagreements were discussed to reach a consensus. The search strategies yielded 554 citations: 523 from PubMed and 31 from the Cochrane database. Twelve studies were potentially eligible. Of these, five were excluded because one was reported in German,19 one compared different cast techniques that were not specific for treating scaphoid fracture,5 one was a study performed on human cadaveric scaphoids,30 one was not a prospective randomized trial,22 and one was a study about clinical scaphoid fracture without radiographic evidence.28 We included seven randomized, controlled trials.13,6,9,11,24 Two reviewers (ZGY, JBZ) independently used a checklist of 11 items to assess the methodologic quality of the studies (Table 1). Disagreements were resolved by discussion followed by arbitration by a third reviewer if necessary. The checklist was based on the PEDro scale,29 which has sufficient reliability for rating quality of randomized, controlled trials.18 Because it was not possible to blind the participants or the treatment providers,

TABLE 1. Checklist for Assessing the Methodologic Quality of the Randomized, Controlled Trials
1. 2. 3. 4. Eligibility criteria were specified Subjects were randomly allocated to groups Allocation was concealed The groups were similar at baseline regarding the most important prognostic indicators (eg, age, gender, affected side, mechanism of injury, type of fracture) Cointerventions were avoided or similar for all groups The outcome measures (nonunion, osteoarthritis) were clearly defined in the text with a definition of any ambiguous terms encountered There was blinding of all assessors who measured at least one key outcome Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups The investigators characterized the analysis of data as intention-to-treat analysis and there was an attempt to analyze data from all randomized participants as if each subject received the treatment or control condition as planned or there was no dropout even if the analysis was not specifically described as intention-to-treat The results of between-group statistical comparisons are reported for at least one key outcome The study provides point measures and measures of variability for at least one key outcome

5. 6.

7. 8. 9.

10. 11.

we made some modifications: Item 5 was substituted for there was blinding of all subjects and Item 6 was substituted for there was blinding of all therapists who administered the therapy. We also modified the definition of intention-to-treat analysis as stated in Item 9. There was no exclusion according to the score, and we did not define the quality of the studies from their scores because such use is controversial.15 However, low scores usually indicate poor methodology. A study was considered high quality if it fulfilled at least three of the following criteria: randomization, allocation concealment, blind assessment, and intention-to-treat analysis. All included studies had some methodologic limitations (Table 2). Five studies reported on randomized allocation,13,6,24 but three failed to describe the exact randomized procedure, which need not be specified according to the PEDro scale and does not affect the quality score, and failed to state whether the treatment allocation was concealed.1,3,24 Two studies were of quasirandomized allocation.9,11 No study adopted blinding of the outcome assessor. Dropout or lost to followup occurred in five studies,1,3,6,11,24 but only one performed intention-to-treat analysis.6 Two studies fulfilled the criteria of high methodologic quality.2,6 Two reviewers (ZGY, SLK) independently extracted data on nonunion, return to work, grip strength, ROM of the wrist, complications, patient evaluation, and incidence of osteoarthritis. Six hundred ninety-two patients and four comparisons were involved (Table 3). Four studies1,2,6,24 involving 228 patients compared operative treatment with nonoperative treatment. Two of these,1,2 involving 78 patients, compared percutaneous Acu-

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TABLE 2.
Study
2

Methodologic Quality Scores

1
+ + + + + + +

2
+ + + + +

3
+ ? ? + ?

4
+ + + + + + +

5
+ + + + + + +

6
+ + + + +

7
? ? ? ?

8
+ + + + ? +

9
+ + +

10
+ + + + + + +

11
+ + + + +

Score
10 8 7 10 5 6 7

Bond et al Saeden et al24 Adolfsson et al1 Dias et al6 Hambidge et al11 Clay et al3 Gellman et al9

All criteria were scored yes (+), no (), or unclear (?); Table 1 lists criteria

TABLE 3.

Study Characteristics
Participants
(A) n = 11, M/F: 9/2; (B) n = 14, M/F: 13/1; age: 24 years (range, 1834 years)

Study and Treatments

Bond et al2 (A) Percutaneous internal fixation; (B) Above-elbow thumb spica cast for 6 weeks followed by belowelbow cast Saeden et al24 (A) Open reduction internal fixation; (B) Below-elbow thumb spica cast Adolfsson et al1 (A) Percutaneous internal fixation; (B) Below-elbow thumb spica cast Dias et al6 (A) Open reduction internal fixation; (B) Below-elbow cast with thumb free Hambidge et al11 (A) Cast with wrist flexion; (B) Cast with wrist extension Clay et al3 (A) Cast with thumb enclosed; (B) Cast leaving thumb free Gellman et al9 (A) Long thumb spica cast; (B) Short thumb spica cast

Fracture Type
Acute waist nondisplaced fracture

Followup
25 months (range, 2427 months); none lost to followup

Outcomes
Nonunion, range of motion, grip strength, time to union, return to work, patient satisfaction, complications

(A) n = 32, M/F: 27/5, age: 29 13 years; (B) n = 30, M/F: 22/8, age: 37 20 years

(A) C2.1 (1), C2.2 (25), C2.3 (3), C3 (3); (B) C2.1 (2), C2.2 (27), C2.3 (0), C3 (1) (AO classification) Acute waist nondisplaced fracture

11.7 years (range, 10.212.8 years); 11 lost to followup

Nonunion, range of motion, grip strength, return to work, osteoarthritis, pain, complications

(A) n = 25, M/F: 20/5, age: 30 years (range, 1675 years); (B) n = 28, M/F: 19/9, age: 33 years (range, 1573 years) (A) n = 44, M/F: 40/4, age: 29 1.32 years; (B) n = 44, M/F: 39/5, age: 29.9 1.6 years (A) n = 58; (B) n = 63, M/F: 95/26, age: 30 years (range, 1676 years) (A) n =144; (B) n = 148, /F: 222/70, age: 29.7 years (range, 1671 years)

Acute waist nondisplaced or mild displaced fracture

24 weeks; 3 lost at 10 weeks, 14 lost at 24 weeks 52 weeks; 7 lost to followup

Nonunion, range of motion, grip strength, time to union, complications

Nonunion, range of motion, grip strength, return to work, patient satisfaction, pain, complications Nonunion, range of motion, grip strength, pain

(A) Waist (54), distal pole (4); (B) Waist (57), distal pole (6) (A) Waist (116), distal pole (15), proximal pole (9), unclassified (4); (B) Waist (133), distal pole (10), proximal pole (2), unclassified (3) (A) Nondisplaced waist (22), proximal pole (2), distal pole (3), tubercle (1); (B) Nondisplaced waist (18), proximal pole (3), distal pole (2)

6 months; lost to followup - not stated 6 months

Nonunion, life ability

(A) n = 28; (B) n = 23, M/F: 46/5, age: 30 years (range, 1457 years)

12 months (range, 624 months); none lost to followup

Nonunion, delayed union, time to union, avascular necrosis

M/F = male/female

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Treatment of Scaphoid Fractures

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trak screw (Acumed, Beaverton, Oregon) fixation with cast immobilization. Two studies,6,24 involving 150 patients, compared open reduction Herbert screw fixation with cast immobilization. Three of the four trials used below-elbow casts for the nonoperative group.1,6,24 One initially used an above-elbow cast for 6 weeks and then a below-elbow cast.2 Although there was heterogeneity across the trials that compared operative treatment with nonoperative treatment such as different surgical techniques (eg, percutaneous internal fixation or open reduction and internal fixation), different types of cast (eg, long arm cast or short arm cast), and different durations of external fixation, the results are presented for the basic comparison; namely, operative treatment (internal fixation) versus nonoperative treatment (cast immobilization). Three of the seven included studies (464 patients) compared different nonoperative treatment regimens and involved three different comparisons: Colles-type below-elbow cast with the wrist in flexion versus cast with the wrist in extension,11 a cast with the thumb enclosed versus a cast leaving the thumb free,3 and a long thumb spica cast for 6 weeks followed by a short thumb spica cast versus a short thumb spica cast.9 Three of the four studies comparing operative with nonoperative treatment, involving 166 patients, stated they only included acute nondisplaced or minimally displaced fractures of the scaphoid waist.1,2,6 The other study, involving 62 patients, reported fracture type according to the AO system, and the majority of fractures were Type C2.2 (52 of 62 fractures).24 We did not find randomized, controlled trials that evaluated surgical treatment of the proximal pole fracture of scaphoid bones. We calculated treatment effect sizes between groups and 95% confidence intervals for each randomized comparison for each outcome. The results of individually randomized trials were pooled whenever possible using RevMan 4.2 software (The Cochrane Collaboration, Oxford, UK). For dichotomous outcomes, relative risk and 95% confidence interval were used to summarize the effect. For continuous outcomes, effect sizes were reported as weighted mean differences or standardized mean differences if the trials measured the same outcome in various ways along with 95% confidence intervals. When the standard deviation at followup was not available, we used the standard deviation at baseline. If none was reported, we assumed the average standard deviation reported by other studies for that outcome. We used I2, which describes the percentage of total variation across studies that is from heterogeneity rather than chance and does not inherently depend on the number of studies in the meta-analysis12 to assess the heterogeneity. The quality

lies between 0% and 100%. A value of 0% indicates no heterogeneity and larger values show increasing heterogeneity. If I2 was less than 50%, we used the fixed effects model to combine the results. If I2 was greater than 50%, we used the random effects model. We performed sensitivity analysis under the following conditions: (1) changing the cutoff point of the heterogeneity to 25% and using the random effects meta-analysis model if I2 was greater than 25%; (2) for missing dichotomous data, performing best-case and worst-case scenario analysis; and (3) using only pooled results of studies with high methodologic quality. A p value less than 0.05 was considered significant.

RESULTS The pooled relative risk for nonunion was 0.26 (95% confidence interval, 0.070.91; p 0.04; homogeneity I2 47.8%) for the four studies that compared operative with nonoperative treatments,1,2,6,24 indicating a lower rate of nonunion in the operative group than in the nonoperative group (Table 4; Fig 1). If we changed the cutoff point of I2 to 25%, the results were pooled with a random effects model and the relative risk for nonunion was 0.41 (95% confidence interval, 0.053.69; homogeneity I2 47.8%), indicating no difference between the two groups. The pooled relative risk for nonunion with the best-case scenario analysis in which the missing data were considered as union was 0.40 (95% confidence interval, 0.043.87; 50.4%), whereas the pooled relative homogeneity I2 risk for nonunion with the worst-case scenario analysis was 0.63 (95% confidence interval, 0.281.40; homoge16.8%), indicating no difference between the neity I2 two groups. When the analysis was limited to the two high-quality studies,2,6 the pooled relative risk for nonunion was 0.06 (95% confidence interval, 00.94; p 0.05), which approached significance. Dias et al6 reported the highest rate of nonunion in the nonoperative group. In their trial, the period of cast immobilization was 8 weeks, and four fractures that were not united at 12 weeks had no obvious mobility at the fracture site and could not be easily identified at the time of surgery. It was possible these four fractures could have united with additional immobiliza-

TABLE 4.
Study

Relative Risk for Nonunion

Operative Number of Nonunions/Number of Participants
1/24 0/11 0/39 1/32 2/106

Nonoperative Number of Nonunions/Number of Participants

0/26 0/14 9/42 2/30 11/112

Relative Risk (fixed effect) (95% confidence interval)

3.24 (0.14 to 75.91) Not estimable 0.06 (0.00 to 0.94) 0.47 (0.04 to 4.91) 0.26 (0.07 to 0.91)

Adolfsson et al1 Bond et al2 Dias et al6 Saeden et al24 Total

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Fig 1. When the four studies comparing operative with nonoperative treatment were pooled, the operative treatment produced fewer nonunions because the pooled relative risk for nonunion was 0.26 (95% confidence interval, 0.07 to 0.91).

tion. If we assumed the four fractures had healed, the relative risk for nonunion was 0.39 (95% confidence in24.7%), indicating terval, 0.101.44; homogeneity I2 no difference between the two groups. The pooled weighted mean difference for return to work was 5.47 weeks (95% confidence interval, 9.97 0.98; p 0.02) for the three studies2,6,24 that reported this outcome, suggesting patients with surgical treatment returned to work more rapidly (Table 5; Fig 2). There was substantial heterogeneity (I2 92.7%). When the analysis was limited to the two high-quality studies,2,6 the pooled weighted mean difference for return to work was 4.10 weeks (95% confidence interval, 9.991.78), suggesting no difference between operative and nonoperative groups. However, the heterogeneity was still substantial (I2 96.2%). The weighted mean difference for grip strength of individual studies with different timing of outcome assessment was 0.05 (95% confidence interval, 0.080.18) at 16 weeks postoperatively, 0.06 (95% confidence interval, 0.010.13) at 26 weeks, 0.11 (95% confidence interval, 0.120.34) at 2 years followup, and 0.07 (95% confidence interval, 0.030.17) at 12 years followup, indicating no difference between operative and nonoperative groups; and 0.09 (95% confidence interval, 0.010.17; p 0.02) at 12 weeks postoperatively and 0.07 (95% confidence interval, 00.14; p 0.04) at 52 weeks in

favor of surgical treatment (Table 6; Fig 3). The results could not be pooled because the timing of the outcome assessment was different across studies. The weighted mean difference for ROM of the wrist in individual studies with different timing of outcome assessment was 0.01 (95% confidence interval, 0.060.08) at 12 weeks, 0.01 (95% confidence interval, 0.070.05) at 26 weeks, 0.01 (95% confidence interval, 0.050.07) at 52 weeks, 0.07 (95% confidence interval, 0.020.16) at 2 years followup, and 0.02 (95% confidence interval, 0.080.04) at 12 years followup, indicating no difference between operative and nonoperative groups; and 0.07 (95% confidence interval, 0.010.13; p 0.02) at 16 weeks in favor of surgical treatment (Table 7; Fig 4). The pooled relative risk for complications was 12.23 (95% confidence interval, 2.3264.60; p 0.003; homo0%) for the four studies1,2,6,24 comparing geneity I2 operative and nonoperative treatment, suggesting surgical treatment caused more complications (Table 8; Fig 5). The pooled relative risk for complications with the best-case scenario analysis was 11.82 (95% confidence interval, 0%), whereas 2.2063.61; p 0.004; homogeneity I2 the pooled relative risk for complications with the worstcase scenario analysis was 5.03 (95% confidence interval, 36.3%), sug1.8713.49; p 0.001; homogeneity I2 gesting surgical treatment caused more complications. When only the two high-quality studies2,6 were pooled, the

TABLE 5.

Weighted Mean Difference of Return to Work

Operative Nonoperative Number of Participants
14 42 21 77

Study
Bond et al2 Dias et al6 Saeden et al24 Total

Number of Participants
11 39 24 74

Mean (standard deviation)

8.00 (0.70) 5.00 (5.12) 6.00 (3.00)

Mean (standard deviation)

15.00 (0.70) 6.00 (5.12) 15.00 (10.00)

Weighted Mean Difference (95% confidence interval)

7.00 (7.556.45) 1.00 (3.231.23) 9.00 (13.444.56) 5.47 (9.970.98)

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Fig 2. When the three studies comparing operative with nonoperative treatment and included time of return to work as an outcome were pooled, the operative treatment performed better because the pooled weighted mean difference for return to work was 5.47 weeks (95% confidence interval, 9.97 to 0.98).

relative risk for complications was 16.90 (95% confidence interval, 2.22128.36; p 0.006; homogeneity I2 4.3%), suggesting surgical treatment resulted in more complications. The results of all four studies considered together showed an incidence of complications in 15 of 106 patients (14.2%) in the operative treatment group and 0 of 112 patients in the nonoperative treatment group. The complications included superficial infection (one patient), sensory change in the region of the palmar cutaneous branch of the median nerve (one patient), screw problem (one patient), reflex sympathetic dystrophy (two patients), and problems related to scarring (10 patients). The pooled standardized mean difference for patient satisfaction for the two studies2,6 that reported this outcome with a different scale was 1.04 (95% confidence 91.6%), indicatinterval, 2.920.84; homogeneity I2 ing no difference between the operative and nonoperative groups (Table 9; Fig 6). For one study with a 12-year followup reporting the incidence of osteoarthritis,24 the relative risk for scaphotrapezial joint osteoarthritis was 2.43 (95% confidence interval, 0.986.03), which approached significance. The incidence of scaphotrapezial joint osteoarthritis was 60.9% (14 of 23) in the operative group and 25% (four of 16) in the nonoperative group. However, the rate of symptomatic scaphotrapezial osteoarthritis was similar in the operative and nonoperative groups, 13% (three of 23) versus 18.8% (three of 16), and the relative risk for symptomatic scaphTABLE 6.

otrapezial osteoarthritis was 0.70 (95% confidence interval, 0.163.02). The relative risk for radiocarpal osteoarthritis was 1.25 (95% confidence interval, 0.523.04). The rate of radiocarpal osteoarthritis was 39.1% (nine of 23) and 31.3% (five of 16) in the operative and nonoperative groups, respectively, and the rate of symptomatic radiocarpal osteoarthritis was also similar in the two groups, 8.7% (two of 23) versus 12.5% (two of 16). When we performed the best-case scenario analysis, the relative risk for scaphotrapezial joint osteoarthritis was 3.28 (95% confidence interval, 1.228.86; p 0.02) and the relative risk for radiocarpal osteoarthritis was 1.69 (95% confidence interval, 0.644.47), suggesting surgical treatment increased scaphotrapezial joint osteoarthritis risk. When the worst-case scenario analysis was performed, the relative risk for scaphotrapezial osteoarthritis was 1.20 (95% confidence interval, 0.831.72) and the relative risk for radiocarpal osteoarthritis was 0.89 (95% confidence interval, 0.591.34), indicating no difference between the operative and nonoperative groups. Three studies that reported different comparisons between nonoperative treatments3,9,11 found no difference in nonunion rate between different casting methods. Hambidge et al11 compared the Colles-type below-elbow cast with the wrist in 20 flexion and in 20 extension; the position of the wrist did not influence the rate of nonunion (8.6% versus 12.7%; relative risk 0.68; 95% confidence interval, 0.241.96). Clay et al3 reported no difference in

Weighted Mean Difference for Grip Strength

Operative Nonoperative Number of Participants
44 21 44 44 14 30

Study
Dias et al Adolfsson et al1 Dias et al6 Dias et al6 Bond et al2 Saeden et al24
6

Timing
12 weeks 16 weeks 26 weeks 52 weeks 2 years 12 years

Number of Participants
44 12 44 44 11 32

Mean (standard deviation)

0.84 (0.16) 0.88 (0.17) 0.94 (0.13) 0.99 (0.10) 0.95 (0.29) 0.95 (0.17)

Mean (standard deviation)

0.75 (0.20) 0.83 (0.22) 0.88 (0.19) 0.92 (0.20) 0.84 (0.29) 0.88 (0.22)

Weighted Mean Difference (95% confidence interval)

0.09 (0.010.17) 0.05 (0.080.18) 0.06 (0.010.13) 0.07 (0.000.14) 0.11 (0.120.34) 0.07 (0.030.17)

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Fig 3. The weighted mean difference for grip strength of individual studies with different timing of the outcome assessment did not show a difference between the operative and nonoperative groups at 16 weeks, 26 weeks, 2 years, and 12 years followup.

nonunion rate with a below-elbow thumb spica or Collestype below-elbow cast (9.8% versus 10.1%; relative risk 0.97; 95% confidence interval, 0.481.93). Gellman et al9 compared initial use of an above-elbow thumb spica cast followed by the use of a below-elbow thumb spica cast with the use of a below-elbow thumb spica cast only; no difference was found (0% versus 8.7%; relative risk 0.17; 95% confidence interval, 0.013.28). Hambidge et al11 reported the Colles-type cast with the wrist in 20 extension resulted in greater grip strength (weighted mean difference 5.0; 95% confidence interval, 1.028.98; p 0.01) and better range of wrist extension (weighted mean difference 12; 95% confidence interval, 7.6116.39; p < 0.0001) at 6 months postoperatively. DISCUSSION This systematic review and meta-analysis of randomized, controlled trials involving the treatment of acute scaphoid fracture met most of the methodologic criteria that have
TABLE 7.

been suggested for meta-analysis,20 but some study limitations need to be considered when interpreting our findings. First, we included only studies published as a full report in English, which produces publication and language bias. Unpublished studies and studies presented only in abstract form are more likely to have nonsignificant results.7,25 Trials with significant results are more likely to be published in English.8 However, we identified only one full report not published in English, which evaluated the role of pulsed low-intensity ultrasound in accelerating healing of acute scaphoid fractures.19 Therefore, the language bias might have only limited impact on our results. Second, we assumed standard deviations to calculate treatment effect sizes of grip strength and ROM. In theory, this would not bias our estimates because the same assumption was applied to treatment and control groups. Calculating treatment effect sizes allows meaningful comparisons across studies.10 A third limitation was that few studies met the inclusion criteria, and there was heterogeneity across the studies. The small number of included studies hampered

Weighted Mean Difference for Range of Wrist Motion

Operative Nonoperative Number of Mean Number of Mean Weighted Mean Difference Participants (standard deviation) Participants (standard deviation) (95% confidence interval)
44 12 44 44 11 32 0.81 (0.19) 0.94 (0.08) 0.89 (0.13) 0.94 (0.12) 0.93 (0.12) 0.96 (0.13) 44 20 44 44 14 30 0.80 (0.14) 0.87 (0.08) 0.90 (0.17) 0.93 (0.16) 0.86 (0.12) 0.98 (0.13) 0.01 (0.060.08) 0.07 (0.010.13) 0.01 (0.070.05) 0.01 (0.050.07) 0.07 (0.020.16) 0.02 (0.080.04)

Study
Dias et al6 Adolfsson et al1 Dias et al6 Dias et al6 Bond et al2 Saeden et al24

Timing
12 weeks 16 weeks 26 weeks 52 weeks 2 years 12 years

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Fig 4. The weighted mean difference for range of wrist motion of individual studies with different timing of the outcome assessment did not show a difference between the operative and nonoperative groups at 12 weeks, 26 weeks, 52 weeks, 2 years, and 12 years followup.

specific subgroup analyses. Although different surgical techniques were used, we made only basic comparisons (eg, internal fixation versus cast immobilization). We believe percutaneous internal fixation may provide better treatment compared with open reduction and internal fixation. A fourth limitation is that the included studies, especially the three studies that compared nonoperative treatments, had a variable level of methodologic limitations. These limitations included a lack of concealed allocation, lack of blinding of outcome assessment, and lack of intention-to-treat analysis. The quality of the included study used for pooling analysis affects the results of a metaanalysis.21 Although the pooled result revealed a higher rate of nonunion in the nonoperative group, this finding was not robust because the sensitivity analysis (pooled results with
TABLE 8. Relative Risk for Complications
Operative Number of Participants with Complication/Number of Total Participants
1/24 1/11 13/39 0/32 15/106

a random effects model, best-case and worst-case scenario analysis, or pooled results of high-quality studies only) showed no difference between the operative and nonoperative group. Furthermore, if Dias et al6 had provided a slightly longer period of cast immobilization in the nonoperative group, the pooled result would have shown no difference in nonunion rate between the operative and nonoperative groups. The pooled results revealed internal fixation resulted in faster return to work, but there was substantial heterogeneity. Furthermore, the sensitive analysis with pooled results of high-quality studies only showed no difference between the operative and nonoperative groups. The time of return to work can be influenced by a host of factors such as the patients occupation and the attitude of the patient, physician, and employer, which can explain the heterogeneity. Although the results

Citation
Adolfsson et al1 Bond et al2 Dias et al6 Saeden et al24 Total

Nonoperative Number of Participants with Complication/Number of Total Participants

0/26 0/14 0/42 0/30 0/112

Relative Risk (fixed effect) (95% confidence interval)

3.24 (0.1475.91) 3.75 (0.1784.02) 29.03 (1.78472.39) Not estimable 12.23 (2.3264.60)

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Yin et al

Clinical Orthopaedics and Related Research

Fig 5. When the four studies comparing operative with nonoperative treatment were pooled, the operative treatment produced more complications because the pooled relative risk for complications was 12.23 (95% confidence interval, 2.32 64.60).

of grip strength and ROM of the wrist could not be statistically pooled because of different timing of outcome measures, there was a trend suggesting early internal fixation can provide only transient benefits compared with nonoperative treatment. However, there were more complications after operative treatment than after nonoperative treatment. The complications fell into the following categories: screw problem, reflex sympathetic dystrophy, superficial wound infection, problems related to scarring, and sensory change in the region of the palmar cutaneous branch of the median nerve. Although the majority of the surgical complications were related to the scar and minor scar-related complications could be minimized by the percutaneous technique, nonoperative treatment was a safer procedure. Only one study24 reported the incidence of osteoarthritis. The result showed internal fixation resulted in more scaphotrapezial osteoarthritis than with nonoperative treatment (60.9% versus 25%), but the effect size was not significant. The rates of symptomatic scaphotrapezial and radiocarpal osteoarthritis were similar between operative and nonoperative groups. However, the findings were not strong because radiographic followup was incomplete (23 of 32 in the operative group, 16 of 30 in the nonoperative group), and the results of the sensitivity analysis were inconsistent. Three studies3,9,11 comparing different cast treatments revealed the type of cast did not influence the union rate, but the Colles-type cast with the wrist in slight extension
TABLE 9.

resulted in better grip strength and ROM than the cast with the wrist in flexion. These studies had substantial methodologic limitations, and their results could not be pooled because they involved different comparisons. Given the large numbers involved (292 patients) and the point estimate of relative risk approaching 1.0, which means the effect would not be modified with larger numbers, the conclusion of the study comparing a below-elbow thumb spica cast with a below-elbow Colles type cast is, perhaps, the strongest among the three studies.3 Only limited conclusions can be drawn from the study comparing an aboveelbow thumb spica cast followed by a below-elbow thumb spica cast with a below-elbow thumb spica cast only because of the small numbers involved (51 patients) and the point estimate of relative risk substantially deviating from 1.0,9 which means the effect might be modified with a larger sample size. Early internal fixation of acute nondisplaced or minimally displaced fractures of the scaphoid waist does not provide greater benefits in terms of union and function than cast immobilization; however, it causes more complications and, perhaps, a higher risk of scaphotrapezial osteoarthritis. Although earlier return to work may be obtained with internal fixation, there is inconsistency across studies. Because time of return to work is influenced by many factors, it may not be a precise outcome measure for the effectiveness of treatment. Additional rigorously conducted randomized trials are needed to establish whether

Standardized Mean Difference of Patient Evaluation

Operative Nonoperative Number of Participants
14 44 58

Citation
Bond et al2 Dias et al6 Total

Number of Participants
11 44 55

Mean (standard deviation)

3.80 (0.20) 3.90 (6.40)

Mean (standard deviation)

3.10 (0.40) 5.20 (11.33)

Standardized Mean Difference (95% confidence interval)

2.06 (3.07 1.06) 0.14 (0.560.28) 1.04 (2.920.84)

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Treatment of Scaphoid Fractures

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Fig 6. When the two studies comparing operative with nonoperative treatment and included patient evaluation as an outcome were pooled, no difference was found because the pooled standardized mean difference for patient evaluation was 1.04 (95% confidence interval, 2.920.84).

operative treatment is superior to nonoperative treatment regarding acute proximal pole fractures of scaphoid bones and which type of cast should be used in nonoperative treatment of nondisplaced scaphoid fractures. Acknowledgment
We thank Ma Ning for literature collection.

14. 15. 16. 17. 18. 19. 20.

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