Classifications of Acute Scaphoid Fractures: A Systematic Literature Review

Abstract

Background In the lack of consensus, surgeon-based preference determines how acute scaphoid fractures are classified. There is a great variety of classification systems with considerable controversies. Purposes The purpose of this study was to provide an overview of the different classification systems, clarifying their subgroups and analyzing their popularity by comparing citation indexes. The intention was to improve data comparison between studies using heterogeneous fracture descriptions. Methods We performed a systematic review of the literature based on a search of medical literature from 1950 to 2015, and a manual search using the reference lists in relevant book chapters. Only original descriptions of classifications of acute scaphoid fractures in adults were included. Popularity was based on citation index as reported in the databases of Web of Science (WoS) and Google Scholar. Articles that were cited <10 times in WoS were excluded. Results Our literature search resulted in 308 potentially eligible descriptive reports of which 12 reports met the inclusion criteria. We distinguished 13 different (sub) classification systems based on (1) fracture location, (2) fracture plane orientation, and (3) fracture stability/displacement. Based on citations numbers, the Herbert classification was most popular, followed by the Russe and Mayo classifications. All classification systems were based on plain radiography. Conclusions Most classification systems were based on fracture location, displacement, or stability. Based on the controversy and limited reliability of current classification systems, suggested research areas for an updated classification include three-dimensional fracture pattern etiology and fracture fragment mobility assessed by dynamic imaging.

Keywords: Herbert; classification; fracture; radiograph; scaphoid.

Fig. 1

Study flow diagram of the systematic review. ^†Included eight references ; *included four references.

Fig. 2

Cooney (Mayo) divided scaphoid fractures into fractures of the distal tubercle (1), distal intra-articular surface (2), distal third (3), waist (4), and proximal pole (5). Fracture location influenced both tendency and time frame for healing. (Reprinted, with permission covered by STM guidelines, from Cooney et al.13)

Fig. 3

Schernberg distinguished six fracture types (I–VI) ranging from the proximal pole to the distal tubercle using the lateral tuberosity and the radial and medial articular surfaces as references. Distal tubercle fractures were further divided into small (a), intermediate (b), or large (c) fragments, and were considered likely to heal successfully, contrary to proximal fractures. (Reprinted, with permission of authors, from Schernberg et al.21)

Fig. 4

Prosser divided distal fractures into avulsion fractures of the tuberosity (I), intra-articular compression fractures of the scaphotrapezial trapezoidal joint including involvement of the radial half (IIA), ulnar half (IIB), or a combination (IIC), and osteochondral fractures at the capitate border (III). All distal fractures were treated by plaster cast. (Reprinted, with permission from Sage publisher, from Prosser et al.22)

Fig. 5

In the AO/OTA classification, scaphoid fractures (registered with number 72) were separated into noncomminuted (A) and comminuted (B; more than three fragments) fractures while taking fracture location into account. (Reprinted , with permission covered by STM guidelines, from Marsh et al.6)

Fig. 6

Russe separated fractures based on fracture plane orientation into transverse (T), horizontal oblique (HO), and vertical oblique (VO) fractures. Vertical oblique fractures were most troublesome with healing, requiring longer immobilization time (10–12 weeks). (Reprinted, with permission from Elizabeth Roselius, from Taleisnik.15)

Fig. 7

Herbert divided acute scaphoid fractures into acute stable (A) and unstable (B). Stable acute fractures included fractures of the tubercle and incomplete unicortical “crack” fractures. Only this type unites relatively fast and should be treated with a cast. (Reprinted, with permission covered by STM guidelines, from Green DO, ed. Operative Hand Surgery. 3rd ed. New York, NY: Churchill Livingstone; 1993.)