BackgroundScaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased, in spite of insufficient evidence of improved outcomes over non-surgical management. We compared the clinical effectiveness of surgical fixation with cast immobilization and early fixation of those that fail to unite, for ≤2 mm displaced scaphoid waist fractures in adults. MethodsThis pragmatic, multicentre, open-label, parallel-group, two-arm randomised clinical trial included adults who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear, bicortical fracture of the scaphoid waist on radiographs. Participants were randomly assigned to early surgical fixation or below-elbow cast immobilization followed by immediate fixation of confirmed non-union. The primary outcome was the Patient Rated Wrist Evaluation (PRWE) total score at 52 weeks post-randomisation. Registration ISRCTN67901257. FindingsOf 439 randomised patients (mean age 33 years, 363 [83%] men), 408 (93%) were included in the primary analyses. There was no difference in PRWE score at 52 weeks (adjusted mean difference -2•1 points, 95% CI -5•8 to 1•6, p=0•27). There were no differences at 52 weeks for the PRWE pain or function subscales. More participants in the surgery group experienced a surgery-related potentially serious complication than in the cast group (n=31, 14% vs n=3, 1%), but fewer had cast-related complications (n=5, 2% vs n=40, 18%). The number experiencing a medical complication (n=4, 2% vs n=5, 2%) was similar in the two groups." InterpretationAdult patients with ≤2 mm displaced scaphoid waist fracture should have initial cast immobilization and suspected non-unions confirmed and immediately fixed. This will help avoid risks of surgery and mostly limit its use to fixing non-union.

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Abstract Background Although the performance of total wrist arthroplasty systems has improved, failure is encountered and is a major challenge to manage. Questions Does physical function improve with surgical management of the failed wrist arthroplasty? Is there an improvement in secondary outcome measures including pain, grip strength, and range of motion? What are the reasons for failure in primary total wrist arthroplasty? What are the complications associated with revision of the failed total wrist arthroplasty? What are the survival profiles of the different revision strategies? Methods A systematic review of available literature was performed. Studies were systematically assessed, and data extracted from suitable studies for review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were adhered to. The study protocol was modified from a previous protocol published on the PROSPERO database. Results Fourteen studies were identified considering 218 patients/214 index operations with a follow-up duration following revision surgery of 2 months to 21 years (silicone wrist arthroplasty—42 cases; nonsilicone wrist arthroplasty—172 cases). The functional outcome of revision surgery was infrequently recorded and documented with only short-term assessments undertaken. Complications were seen in 1:2 revision procedures, with re-revision surgeries required in 21.6% of revised primary nonsilicone arthroplasties. Re-revision rate following a revision arthrodesis was 21.4% (15/70 cases) compared with revision arthroplasty of 34.8% (32/92 cases). Revision arthrodesis nonunion rate was 17.5% (22 cases). Conclusion This review has confirmed the high level of surgical complexity and the likelihood of a complicated postoperative outcome when salvaging a failed wrist replacement. Level of Evidence This is a Level 3, systematic review study.

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In order to evaluate the effectiveness of interventions for Background: osteoarthritis of the wrist in adults we performed a systematic review and meta-analysis.The MEDLINE and EMBASE via OVID, CINAHL and Methods: SPORTDiscus via EBSCO databases were searched from inception to 25 April 2018.All randomised controlled clinical trials (RCTs) and any prospective studies of adults with wrist osteoarthritis investigating any intervention with a comparator were included. Data were extracted and checked for accuracy and completeness by pairs of reviewers. Primary outcomes were pain and function. Comparative treatment effects were analysed by random effects at all time points.Three RCTs were identified for inclusion after screening and all Results: had a high risk of bias. Two compared proximal row carpectomy (PRC) with four corner fusion (4CF) for post-traumatic osteoarthritis, while the other compared leather with commercial wrist splints in patients with chronic wrist pain, of which a small group had wrist osteoarthritis.There is no prospective study comparing operative to Conclusion: non-operative treatment for wrist osteoarthritis, while there is a paucity of prospective studies assessing the effectiveness of both non-operative and operative interventions. Further research is necessary in order to better define which patients benefit from which specific interventions.The review protocol was registered with PROSPERO under Registration: the registration number . CRD42018094799

Scaphoid fractures in the pediatric population are rare. The majority of nondisplaced fractures tend to unite; however, there is an increased risk of nonunion in proximal pole fractures. Limited evidence exists in their outcomes, owing to the scarcity of the fracture pattern. A 13-year-old boy who presented late after developing a traumatic proximal pole scaphoid fracture developed nonunion. He was treated conservatively owing to it being asymptomatic and developed union at 18 months. No previous case of proximal pole pediatric scaphoid fractures with established nonunion that has developed union with conservative management has been described. The authors highlight a unique case of an established proximal pole scaphoid nonunion in a child progressing to union with nonoperative intervention. Owing to its rarity and difficulty in obtaining research, we recommend consideration of nonoperative management of asymptomatic nondisplaced proximal pole fractures in children.