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DOI: http://dx.doi.org/10.18535/jmscr/v4i8.21

Scaphoid Fractures Treated With Kirschner (K) Wires or Herbert Screw

Fixation Has No Difference in Fracture Healing Period
Authors
Ashutosh Kumar , Manish Ranjan2, Mukesh Kumar3, Neeraj Kumar4
1

Ravi Kumar5, Chandan Kumr6, Amarjeet Kumar7

1,3,4,5,6,
Senior Resident, Orthopedics Dept, AIIMS, Patna
2
Assistant Professor, Orthopedics Dept, PMCH, Patna
7
Senior Resident, Anesthesia Dept, AIIMS, Patna
Abstract
Background: The scaphoid is the most common fractured carpal bone. These fractures are commonly difficult to
diagnose or go undetected. Degenerative changes set in if scaphoid fracture non-union is left untreated. This
study evaluates the outcome of scaphoid fracture treated with K wires or Herbert screw and bone grafting.
Materials and Methods: 7 cases of scaphoid fracture treated from november 2014 to june 2016 were treated
with K wires or Herbert screw and bone grafting. Scaphoid nonunion was both clinically and radio graphically
diagnosed. Fractures were graded according to herbert’s classification.
Results: 7 patients could be followed up. All patients were no intra operative complications. One (1) patient
developed post-operative infection. The study contained 5 male and 2 female subjects. The average age was 29.6
years. Dominant wrist was affected in 5 patients, and non-dominant was affected in 2. Most of the patients
showed evidence of radiological union between 14 to 16 weeks. Range from 12 to 23 weeks and an average of
16.40 weeks. Most of the patients 19 (67%) recovered 80% or more of grip strength.
Conclusion: Our findings suggest that 1) Scaphoid fracture treated with Kirschner-wire or Herbert screw
fixation and iliac crest bone grafting presents a 90% healing rate at 6 months follow up. 2) Scaphoid fracture
treatment with Kirschner-wire or Herbert screw fixation and iliac crest bone grafting significantly decreases pain
and achieves 84% wrist joint motion compared to opposite side. 3) Scaphoid fracture treatment Kirschner-wire
fixation or Herbert screw and iliac crest bone grafting yields 75% of satisfactorily functional results. 4) Average
time for radiological union is 16.40% weeks.
Keywords: Scaphoid fracture, Kirschner-wire or Herbert screw fixation, iliac crest bone grafting.

Introduction scaphoid fracture treatment is controversial. The

The scaphoid is the most common fractured carpal aim of treatment is bone healing with scaphoid
bone. [1-3]. These fractures cannot diagnose easily shape restoration and ligaments preservation.
or go undetected [4]. If the patient does not take Some cases show mild symptomatic with mild
medical attention upon considering that it was a functional deficit. But most cases, has tendency
trivial wrist trauma, or if the patient is not treated for progressive arthrosis. They may be treated by
by immobilized for adequate period of time, electric or electromagnetic stimulation [6], bone
fracture healing will not occur, because of atypical grafting [7], internal fixation [8], vascularized bone
vascularity of scaphoid bone [5]. The mostly grafting [9,10], and combined methods[11]. Fracture
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healing failure rate with non-union persistence is complains like was noted. Scaphoid fracture with
also high, with prolonged immobilization [7], non-union was both clinically and
prevent patients to perform their professional radiographically diagnosed. Complain of patients
work, not only during rehabilitation period, but were wrist pain, decreased strength and inability
also during postoperative rehabilitation, leads to to perform any manual work. On physical
serious socioeconomic problem[2]. Degenerative examination, pain was reproduced during direct
changes occur if scaphoid fracture non-union is compression of the scaphoid or axial loading of
left untreated. An asymptomatic patient with an the thumb. On plain x-ray, with anterior-posterior,
undisplaced non-union fracture with no evidence lateral and oblique wrist views as well as clenched
of the wrist will also develop late degenerative fist views, taken for scaphoid non-union was
changes at their carpal bone[19]. This study focus demonstrated. Nonunion scaphoid may show
on the result of scaphoid fracture treated with K smooth round fracture edges, osteosclerosis and
wires or Herbert screw fixtation and bone bone cyst formation. Fractures were classified
grafting. according to Herberts classification. Patients were
treated with iliac crest bone grafting with open K
Methods and Materials wire or Herbert screw fixation. Post-operatively
This study was carried out at Aiims, Patna during the wrist was immobilized with plaster involving
november 2014 to june 2016. The subjects were the metacarpo-phalangeal joint of the thumb for a
patients who were established cases of displaced period of three months or till evidence of
scaphoid fracture. Patients who had taken primary radiological union was seen. All 7 patients could
treatment elsewhere were also included. be followed up. Patients were interviewed and
examined. Preoperatively patients were examined
Inclusion Criteria for range of motion using a goniometer compared
 Established cases of displaced scaphoid to opposite hand. Pre op and post op X rays
fracture. (immediate, 1 month and 3 months or till fracture
 Clinically pain and decreased ROM at united) were taken.
wrist. Post operative analysis was done: Post operatively
 Radiological signs of displaced scaphoid patient was assessed by modified scaphoid scoring
fracture, nonunion in terms of sclerosis, system for pain, range of motion at wrist, wrist
cystic changes or a vascularity of proximal strength, return to work and union of non union
fragment. site. Grip strength was compared to opposite hand
Exclusion criteria and was graded as percentage as compared to
 Other associated fractures, dislocations or opposite hand.
ligament injuries of the same wrist.
 Arthritis of the affected wrist. Technique
After proper antisepsis condition and after the
Methods pneumatic tourniquet was installed. The upper
Only cases of established displaced fracture limb was elevated for 5 minutes and then
treated during November 2014 to June 2016 with exsanguinated. The pneumatic tourniquet was
iliac crest bone grafting and K wire or Herbert then elevated to 130 mm Hg pressure.
screw fixation were selected. Dominance Hand, A 4-5 cm incision was carried out from the radial
mechanism of injury, interval of injury and edge of the flexor carpi radialis over the tip of the
treatment, anatomical location of fracture was styloid process of the radius. Flexor carpi radialis
noted. Profession of the patients abd inability to tendon and the radial artery were isolated. The
perform manual work was noted. Patient other palmar joint capsule was longitudinally divided

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and the deep palmar radio-carpal ligaments (radio- were instructed to followed a specific physical
scapho-capitae and radioluanate) were also therapy protocol immediately after the operation.
divided and repaired at the end of the operation or The physical therapy included finger, elbow and
mobilized. The fracture site were exposed- the shoulder exercise during the immobilization
proximal and distal fragments, and the period. The cast was changed every month and X
scapholunate junction. The fibrous and sclerotic rays done. If healing was satisfactory casting was
tissue were removed with the use of a small continued for additional few weeks. Most patients
currate until fresh hemorrhagic cancellous bone had wires removed at the same time as the cast
was revealed. After the making of the scaphoid removed. The K wires were removed without any
cavity, cortical bone was harvested from the iliac anesthesia. After the clinical and radiological
crest or distal radius of same wrist to restore the confirmation of bone healing (14.8 weeks) was
scaphoid height and cancellous bone was taken to done, the cast was removed and the patients were
fill the cavity. The cortical bone graft was then instructed to perform active, passive and assisted
inserted into the scaphoid cavity in a manner that active movement of the wrist and forearm. After
two scaphoid fragments get appropriate distracted regaining satisfactory range of movement the
and correcting the scaphoid height. After insertion patients followed a mild vegirous protocol. All
of the graft, the protruding edges were maintain patients were allowed to return to heavy manual
with the proximal and distal fragments. work and to sports after a period of six months or
Osteosynthesis now performed with the use of two three months after the healing. All patients were
Kirschner wires or Herbert screw which were assessed by using Modified Scaphoid outcome
inserted in parallel with the longitudinal axis of Scoring System [13]. The scoring system consisted
the scaphoid were selected. The alignment of of scores for pain, wrist strength, ROM at wrist,
scaphoid and position of K wires or Herbert screw return to work and patient satisfaction. Also the
fixation was checked in anterio-posterior and union of non-union site was assessed by x ray and
oblique views under image intensifier. The radio- time period documented. Grip strength was
carpal ligaments and the joint capsule were then recorded in operated hand with percentage of grip
repaired with vicryl. The wrist was immobilized the opposite hand. Tabulating this data, various
in a palmar slab for 2 weeks. The sutures were variables were statistically examined for their
removed after 2 weeks, and the long arm thumb importance and relevance in functional outcome
spica cast was applied for 1 month. All patients and radiological union

Fig:1

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Fig:2

Results Discussion
All 7 patients were operated between november Mechanism of injury did not seem to affect the
2014 to june 2016. There were no intra operative result. One of the patients who failed to unite after
complications. Post operatively 1 patient the operation had sustained injury as a result of
developed mild infection but healed with proper direct blow. We left the plaster on for about 2
dressing and short course of antibiotics. This weeks after we confirmed that the fracture has
study contained 5 male and 2 female subjects. The united radiographically. Mean time for
ages of the patients in the study ranged from 21 to immobilization in plaster was 16.25 weeks in the
48 years. The average age was 29.6 years. 75% of study. Stark et al.[12] kept the plaster on for 17
the patients were younger than 35 years of age. weeks in their study which shows 90% positive
Dominant wrist was affected in 5 patients, and outcome.
non-dominant was affected in 2. One of the probable advantages of screw fixation
The range of motion (Flexion, Extension, Radial over the k-wires is that it allows early
and Ulnar deviation) of the operated wrist was mobilization. A meta analysis [18] found the
compared to the opposite side. The mean loss of average union rate to be same in four studies that
flexion extension was about 14% compared to used no immobilization and other studies shows
opposite side and mean loss in radial-ulnar that used more than 6 weeks of immobilization. 4
deviation was 19%. Most of the patients showed to 12 weeks of immobilization are often reported
evidence of radiological union between 14 to 16 for non-union of the scaphoid [14,16]. It has been
weeks. Range from 12 to 23 weeks and an average seen that screw over K wire fixation the long time
of 16.40 weeks. Most of the patients returned in plaster did not seem to adversely affect the
back to there original profession. Most of the range of motion in our patients. The mean loss of
patients had little or no pain. 2 out of the 7 flexion-extension was about 14% compared to
patients had pain on exertion of the wrist and took opposite side and mean loss in radial-ulnar
occasional analgesics. 1 patient who had poor deviation was 19%. This is similar to or better
result complained of persistent pain. Grip strength than the mobility reported after screw fixation in
was subjectively assessed and compared to spite of shorter immobilization (14,15,16). The time
opposite hand by the same examiner to minimise in plaster of Paris for our patients is not quite as
bias. Most of the patients has good grip strength. long as the 4-6 months recommended after Russe
Mean grip strength at follow up was 80% operation [17]. Only 2 of the 5 patients had poor
compared to opposite hand. result. The success rate was in the region was high

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confirming the good results reported by Stark et 3. Scaphoid fracture treated with Kirschner-
al.[12]. wire or Herbert screws fixation and iliac
In a recent meta-analysis of 12 studies crest bone grafting yields 75% of
comprising of 519 patients treated with bone graft satisfactorily functional results.
and screw the union rate was 74%. Herbert screws 4. Average time for radiological union is
are less likely to impinge on adjacent bones than 16.40% weeks.
lag screws, but have been reported to be difficult 5. Scaphoid fractures treated with kirschner
to position correctly [13]. Trumble et al.[14] reported (k) wires or herbert screw fixation has no
that only 7 of their 16 Herbert screws were ideally diffrence in fracture healing peroid
placed. Inoue et al.[15] reported that 3 of their 16
Herbert screws were misplaced and according to References
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