Surgical versus nonsurgical treatment of acute minimally displaced and undisplaced scaphoid waist fractures: pairwise and network meta-analyses of randomized controlled trials.

PURPOSE: To investigate the effectiveness of surgical treatment for minimally displaced and undisplaced scaphoid waist fractures compared with nonsurgical intervention through pairwise and network meta-analyses of randomized controlled trials.

METHODS: We searched several databases from 1990 to 2009 for randomized controlled trials that evaluated surgical and nonsurgical treatments of undisplaced or minimally displaced scaphoid waist fractures. We based the main pairwise meta-analysis comparison on the odds ratio of fracture union between patients undergoing surgical versus nonsurgical treatment. We also investigated other outcome measures including complications, range of motion, grip strength, and osteoarthritis of the scaphotrapeziotrapezoid and radiocarpal joints. We used a network meta-analysis to simultaneously synthesize trials making different intervention comparisons while modeling different surgical and nonsurgical treatments distinctly.

RESULTS: Of the 67 articles identified, 6 studies were eligible for the primary pairwise meta-analysis, with a total of 363 patients. The pooled odds ratio of fracture union between the surgical and nonsurgical groups was in favor of surgery but not statistically significant. Surgical treatment was associated with a statistically significant elevated risk of complication. Range of motion, grip strength, and osteoarthritis of the scaphotrapeziotrapezoid and radiocarpal joints did not reach statistical significance in the pairwise meta-analyses. The mixed-treatment network meta-analysis showed that open (Herbert) screw fixation had a probability of 0.73 as being the best treatment method compared with percutaneous screw fixation, short arm cast, and short thumb spica cast.

CONCLUSIONS: Although surgical treatment is favored in terms of fracture union in our pairwise meta-analysis, this did not reach statistical significance, but was associated with a significantly increased risk of complications. The cumulative evidence at present does not support routine surgical treatment, and aggressive conservative management should remain the mainstay for scaphoid waist fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.