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Abstract Scaphoid bone fracture is the most common fracture of the carpal bones accounting for about 60% of all carpal bone fractures. Clinical evaluation and management of scaphoid fractures depends on its classification. Complete fracture waist of scaphoid classified as B2 according to Herbert classification can be managed by conservative or operative management. Various procedures may be used to restore alignment and anatomic fracture reduction to preserve intercarpal joint motion. These procedures may be volar or dorsal, open or percutaneous. Open volar approach to the scaphoid is most often utilized for waist, distal third fractures and for correction of a flexed scaphoid deformity. The entire volar surface of the scaphoid can be visualized allowing reduction confirmation which is useful in cases of volar bone loss, comminution, or the need to correct a scaphoid humpback deformity. Percutaneous approaches have been used as a method to decrease soft tissue injuries to the radiocarpal ligaments and dorsal capsular structures. It also limits the damage to the surrounding blood supply that theoretically may improve fracture union. Decreased surgical trauma and improved fracture healing ultimately led authors to advocate earlier return to work in patients treated with these less invasive approaches. So, percutaneous techniques have been used as less invasive surgical approaches that may have an added benefit in the nondisplaced fractures meanwhile displaced and unstable fractures should Summary 89 be approached with a volar or dorsal open technique to achieve and confirm an anatomic reduction before screw placement. The aim of this study was to compare between volar open approach and volar percutaneous fixation by Herbert screw for recent scaphoid waist fractures. A prospective study on 34 patients with recent scaphoid fractures underwent open reduction and internal fixation or percutaneous fixation by Herbert screw in the Department of orthopaedic surgery in Menoufia University Hospital and Elamrya General Hospital with equal distribution of patients between the two procedures. The inclusion criteria were: Adult age group (18-60 years old), isolated non-comminuted scaphoid middle third waist fracture, recent fractures within 3 weeks, closed fractures. The exclusion criteria were: old and non-united scaphoid fractures, concomitant injuries to the ipsilateral hand, wrist or forearm, neurovascular problems and compartmental syndrome, open fractures and any pathological wrist condition as (osteoarthritis, stiff wrist, Kienböck’s Disease). They were evaluated clinically and radiologically which was made by plain x-rays in three views (postero-anterior view, lateral view and scaphoid view) pre-operative and post-operative. The mean age was 33.65 ± 9.14 (range, 20 - 51) years and 29.24 ± 7.21 (range, 18 - 42) years in group A and B respectively. All patients in this study were males except two female patients who were treated using volar percutaneous fixation. The main mechanism of injury was falling down on outstretched hand with 29 patients divided Summary 90 as 15 patients in group A and 14 patients in group B. Ten patients were injured in their non-dominant hand with four patients in group A and six patients in group B. On the other hand, 13 patients in the group A were injured in their dominant hand with 10 patients in group B. Nineteen patients were smokers with 10 patients in group A and nine patients in group B. Twelve patients in the group A were right sided while five patients were left sided. In group B, nine patients were right sided while eight patients were left sided. Fracture union was not affected by patient age, gender, mechanism of injury, domination, smoking or side. The mean postoperative pain score according to MMWS for group A was 16.76 ± 4.98 (range, 10 - 25) but for group B it was 18.24 ± 3.03 (range, 15 - 25). The mean postoperative range of motion score according to MMWS for group A was 15.88 ± 5.07 (range, 10 - 20) but for group B it was 19.41 ± 4.96 (range, 10 - 25). The mean postoperative hand grip strength score according to MMWS for group A was 15.88 ± 4.76 (range, 10 - 25) but for group B it was 17.94 ± 4.70 (range, 15 - 25). The mean postoperative time from injury to surgery for group A was 7.41 ± 5.53 (range, 1 - 18) days but for group B it was 5.29 ± 3.44 (range, 1 - 14) days. The mean postoperative radiological fracture union score according to scaphoid fracture union grading scale for group A was 2.24 ± 0.75 (range, 1 - 3) but for group B it was 1.53 ± 0.72 (range, 1 - 3). The mean postoperative patient satisfaction score according to MMWS for group A was 21.18 ± 3.76 (range, 10 - 25) but for group B it was 21.76 ± 2.46 (range, 20 - 25). The mean postoperative final score according to MMWS for group A was 69.71 ± 15.26 (range, 40 - 90) but for group B it was 77.35 ± 10.33 (range, 60 - 95). Summary 91 At the end of postoperative follow up our results showed that both procedures are reliable options to decrease the incidence of scaphoid nonunion/malunion with residual carpal instability; however percutaneous fixation technique leads to early union and early return to functional activity with lesser complications as compared to open technique. Postoperative complications were few. There were two patients with wound dehiscence on the volar open reduction and internal fixation, three patients with superficial infection on the open surgical wound, one patient in each procedure showed Herbert screw protrusion and lastly twelve patients showed postoperative wrist joint stiffness with eight of them had done open reduction and internal fixation and four patients had done volar percutaneous fixation. |