Herbert and Fisher described a double‑threaded screw technique for rigid fixation of every type of scaphoid fracture and proposed a classification of these fractures to define who needs operation.
Prospective series of 158 scaphoid operations from 1977 to 1981 for acute unstable fractures, delayed union and non‑union. 12 patients were lost to review and 8 had too little follow‑up.
Methods
Design
Prospective trial of a new screw technique
Operations 1977 to 1981
Patients
158 operations
22 Type B
21 Type C
115 Type D (38 D1, 77 D2)
12 lost to review, 8 with insufficient follow‑up
Basis
Acute stable vs acute unstable fracture
Delayed union vs established non‑union
Subtypes by fracture site, pattern or non‑union type
Key Findings
Union reached 100% in acute fractures and 83% overall.
The authors judged a screw alone inadequate for established non‑union and recommended resecting the pseudarthrosis and grafting before fixation, since failure to graft was the prime cause of persisting Type D1 non‑union.
Average return to work was 5 to 7 weeks even with bone grafting, 5.5 weeks after surgery for patients without compensation claims (vs 9.8 weeks off before it) and 6.7 weeks for claimants (vs 28 weeks before).
Among patients reviewed, 96% were satisfied and 91% had a satisfactory clinical result (Grades 0 and 1).
More than half of Type C fractures showed radiographic ischaemia of the proximal fragment that returned to normal after fixation and union, so the authors did not treat ischaemia as a contraindication.
Board pearl
Herbert placed proximal pole fractures (B3) among the acute unstable fractures, the same type as displaced or mobile waist fractures (B2).
Herbert classification of scaphoid fracturesHerbert, J Bone Joint Surg Br 1984
Type A
Acute stable fracture
A1
Tubercle fracture
A2
Undisplaced crack fracture of the waist
Type B
Acute unstable fracture
Indication for operation
B1
Oblique fracture of the distal third
B2
Displaced or mobile waist fracture
B3
Proximal pole fracture
B4
Carpal fracture‑dislocation
B5
Comminuted fracture
Type C
Delayed union
Indication for operation
Type D
Established non‑union
Bone graft plus screw
D1
Fibrous non‑union
D2
Sclerotic non‑union (pseudarthrosis)
Authors' conclusion
This method of treatment appears to offer significant advantages over conventional techniques in the management of the fractured scaphoid.
Herbert and Fisher described a double‑threaded screw technique for rigid fixation of every type of scaphoid fracture and proposed a classification of these fractures to define who needs operation.
Prospective series of 158 scaphoid operations from 1977 to 1981 for acute unstable fractures, delayed union and non‑union. 12 patients were lost to review and 8 had too little follow‑up.
Methods
Design
Prospective trial of a new screw technique
Operations 1977 to 1981
Patients
158 operations
22 Type B
21 Type C
115 Type D (38 D1, 77 D2)
12 lost to review, 8 with insufficient follow‑up
Basis
Acute stable vs acute unstable fracture
Delayed union vs established non‑union
Subtypes by fracture site, pattern or non‑union type
Key Findings
Union reached 100% in acute fractures and 83% overall.
The authors judged a screw alone inadequate for established non‑union and recommended resecting the pseudarthrosis and grafting before fixation, since failure to graft was the prime cause of persisting Type D1 non‑union.
Average return to work was 5 to 7 weeks even with bone grafting, 5.5 weeks after surgery for patients without compensation claims (vs 9.8 weeks off before it) and 6.7 weeks for claimants (vs 28 weeks before).
Among patients reviewed, 96% were satisfied and 91% had a satisfactory clinical result (Grades 0 and 1).
More than half of Type C fractures showed radiographic ischaemia of the proximal fragment that returned to normal after fixation and union, so the authors did not treat ischaemia as a contraindication.
Board pearl
Herbert placed proximal pole fractures (B3) among the acute unstable fractures, the same type as displaced or mobile waist fractures (B2).
Herbert classification of scaphoid fracturesHerbert, J Bone Joint Surg Br 1984
Type A
Acute stable fracture
A1
Tubercle fracture
A2
Undisplaced crack fracture of the waist
Type B
Acute unstable fracture
Indication for operation
B1
Oblique fracture of the distal third
B2
Displaced or mobile waist fracture
B3
Proximal pole fracture
B4
Carpal fracture‑dislocation
B5
Comminuted fracture
Type C
Delayed union
Indication for operation
Type D
Established non‑union
Bone graft plus screw
D1
Fibrous non‑union
D2
Sclerotic non‑union (pseudarthrosis)
Authors' conclusion
This method of treatment appears to offer significant advantages over conventional techniques in the management of the fractured scaphoid.