Controversies and best practices for acute scaphoid fracture management

Bilateral Scaphoid Fractures: A Systematic Literature Review

Bilateral scaphoid fractures are rare lesions, warranting a review to synthesize current knowledge, identify gaps, and suggest research directions. Two authors, adhering to PRISMA guidelines, in January 2024 identified 16 case reports (1976-2023). Data extraction included demographics, injury mechanisms, associated injuries, fracture sites, treatments, and outcomes. Among 121 initial outcomes, 16 articles met the criteria, predominantly affecting young people (93.75% males, mean age 22 years). High-energy traumas (75%) often caused associated wrist injuries (68.75%). Most fractures required surgical intervention (68.75%), primarily headless compression screws. Bilateral scaphoid fractures, which are rare but associated with high-energy traumas, commonly involve wrist injuries. Surgical management is often necessary, yielding better outcomes with fewer complications. Further research is essential to understand the epidemiology, optimal management, and long-term results. Early diagnosis and appropriate treatment are crucial for preventing complications and ensuring favorable patient outcomes.

Scaphoid fracture and nonunion: new directions

The scaphoid is the largest of the carpal bones, articulating with both proximal and distal carpal rows. If scaphoid fractures are not appropriately diagnosed and treated, there is a risk of nonunion, osteonecrosis and degenerative arthritis. Operative management of the scaphoid fracture is primarily determined by the fracture location and amount of displacement. There is increased momentum for dual screw fixation constructs, intended to provide greater stability and reduce the risk of nonunion. Our current practice is to utilize two screws without graft as a first-line treatment for scaphoid nonunion with or without humpback deformity and cyst formation. This review will discuss the management of acute scaphoid fractures and the treatment of nonunion.

Postoperative Immobilization of Scaphoid Fractures: A Comprehensive Review of the Literature

The optimal protocol for postoperative immobilization following operative treatment of scaphoid fractures remains controversial. Reports of successful management with brief postoperative immobilization suggest that earlier restoration of function may be achieved by limiting the duration of immobilization. However, the risk of nonunion and its associated complications suggest that a more conservative approach with extended immobilization could optimize fracture healing. This paper presents a thorough review of the relevant literature and summarizes the myriad postoperative immobilization protocols and their reported outcomes. Postoperative immobilization protocols and reported outcomes for displaced, comminuted, and proximal pole fractures are discussed separately. The literature is reviewed following different operative techniques, including open reduction internal fixation and percutaneous screw fixation. Vigilant postoperative care of scaphoid fractures managed surgically is warranted to monitor for signs of nonunion while attempting to regain motion and strength to the injured wrist.

A Comparison Between Robotic-Assisted Scaphoid Screw Fixation and a Freehand Technique for Acute Scaphoid Fracture: A Randomized, Controlled Trial

PURPOSE

We compared robotic-assisted scaphoid screw fixation to conventional technique in terms of accuracy, surgical times, radiation exposure, and clinical outcomes, including range of motion, grip strength, functional score, and complications.

METHODS

This study was a registered, prospective, randomized, controlled trial. From May 2019 to December 2019, 1 surgeon performed 18 robotic-assisted and 18 conventional scaphoid screw fixations and these patients were eligible for participation in this study. Surgical time, including the time of the overall procedure, set-up time, and time for ideal guidewire placement, was recorded. The number of guidewire attempts also was recorded. All patients were evaluated clinically and radiographically at follow-up with respect to the severity of pain, wrist motion, grip strength, complications, and Mayo modified wrist score.

RESULTS

The average set-up time and overall time of the procedure were longer in the robotic-assisted than in the conventional groups, while the mean guidewire insertion time and the mean guidewire attempts was less in the robotic-assisted group than that of the conventional group. The overall radiation exposure was lower in the robotic group.

CONCLUSIONS

Robotic-assisted technique provided a useful tool to improve implantation accuracy and shorten radiation exposure. Additional cost and prolonged duration of surgery without evidence of improved clinical scores may limit widespread acceptance of this technique.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Excessive Derotational K-Wire Angulation Decreases Compression by Headless Compression Screw

Background  Scaphoid fracture is the most common carpal bone fracture. Open reduction internal fixation of scaphoid fractures typically undergo stabilization by a single headless compression screw (HCS). During screw insertion, a derotational Kirschner wire (K-wire) is often placed for rotational control of the near and far fragment. Questions/Purposes  The aim of this study was to determine if there is an angle of derotational K-wire placement in relation to the axis of a HCS that compromises the amount of compression generated at a fracture site by the HCS. We hypothesize that increased off-axis angle will lead to decreased compression across the fracture site. Methods  A Cellular Block 20 rigid polyurethane foam (Sawbones, Vashon, WA) scaphoid model was created to eliminate variability in bone mineral density in cadaveric bone. MiniAcutrak HCS screws (Acumed, Hillsboro, OR) were used for testing. Three conditions were tested: (1) HCS with derotational wire inserted parallel to the HCS (zero degrees off-axis); (2) HCS with derotational wire inserted 10 degrees off-axis; and (3) HCS with derotational wire inserted 20 degrees off-axis. Results  A statistically significant difference in the mean compression of the control group (56.9 N) was found between the mean compression with the derotational K-wire placed 20 degrees off-axis (15.2 N) ( p  = 0.001). Conclusions  Compression at the fracture site could be impeded by placing an excessively angulated off-axis derotation wire prior to insertion of the HCS. Clinical Relevance  Our study adds a new detail to the optimal technique of HCS placement in scaphoid fractures to improve compression and fracture union.

10 Hypotheses in Hand Surgery

I have put together 10 topics and labeled them as hypotheses, which outline my preferred practices. The topics relate to questionable nerve compression, double crush syndrome of nerves, motion therapy after surgery, delayed primary tendon repair, proximal pole fracture of the scaphoid, short splint, and indications for postoperative hand elevation. I found no proof whether my preferred methods are better than or inferior to alternative methods that others use. The 10 hypotheses are presented to stimulate thinking, clinical observation, or investigations and highlight several areas of research. Investigation into these hypotheses may avoid unnecessary treatment or improve postsurgical comfort for patients and long-term outcomes of treatment.

A Machine Learning Algorithm to Estimate the Probability of a True Scaphoid Fracture After Wrist Trauma

PURPOSE

To identify predictors of a true scaphoid fracture among patients with radial wrist pain following acute trauma, train 5 machine learning (ML) algorithms in predicting scaphoid fracture probability, and design a decision rule to initiate advanced imaging in high-risk patients.

METHODS

Two prospective cohorts including 422 patients with radial wrist pain following wrist trauma were combined. There were 117 scaphoid fractures (28%) confirmed on computed tomography, magnetic resonance imaging, or radiographs. Eighteen fractures (15%) were occult. Predictors of a scaphoid fracture were identified among demographics, mechanism of injury and examination maneuvers. Five ML-algorithms were trained in calculating scaphoid fracture probability. ML-algorithms were assessed on ability to discriminate between patients with and without a fracture (area under the receiver operating characteristic curve), agreement between observed and predicted probabilities (calibration), and overall performance (Brier score). The best performing ML-algorithm was incorporated into a probability calculator. A decision rule was proposed to initiate advanced imaging among patients with negative radiographs.

RESULTS

Pain over the scaphoid on ulnar deviation, sex, age, and mechanism of injury were most strongly associated with a true scaphoid fracture. The best performing ML-algorithm yielded an area under the receiver operating characteristic curve, calibration slope, intercept, and Brier score of 0.77, 0.84, -0.01 and 0.159, respectively. The ML-derived decision rule proposes to initiate advanced imaging in patients with radial-sided wrist pain, negative radiographs, and a fracture probability of ≥10%. When applied to our cohort, this would yield 100% sensitivity, 38% specificity, and would have reduced the number of patients undergoing advanced imaging by 36% without missing a fracture.

CONCLUSIONS

The ML-algorithm accurately calculated scaphoid fracture probability based on scaphoid pain on ulnar deviation, sex, age, and mechanism of injury. The ML-decision rule may reduce the number of patients undergoing advanced imaging by a third with a small risk of missing a fracture. External validation is required before implementation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Arthroscopic bone graft and fixation for proximal scaphoid nonunions

AIMS

This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation.

METHODS

This was a retrospective analysis of 20 patients. All cases were delayed presentations (n = 15) or failed nonoperatively managed scaphoid fractures (n = 5). Surgery was performed at a mean duration of 27 months (7 to 120) following injury with arthroscopic debridement and arthroscopic iliac crest autograft. Fracture fixation was performed percutaneously with Kirschner (K)-wires in 12 wrists, a headless screw in six, and a combination of a headless screw and single K-wire in two. Clinical outcomes were assessed using grip strength, patient-reported outcome measures, and wrist range of motion (ROM) measurements.

RESULTS

Intraoperatively, established avascular necrosis of the proximal fragment was identified in ten scaphoids. All fractures united within 16 weeks, confirmed by CT. At a mean follow-up of 31 months (12 to 64), there were significant improvements in the Patient-Rated Wrist Evaluation, Mayo Wrist Score, abbreviated Disabilities of the Arm, Shoulder and Hand score, wrist ROM, grip strength, and the patients' subjective pain score. No peri- or postoperative complications were encountered.

CONCLUSION

Our data indicate that arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment. Cite this article: Bone Joint J 2022;104-B(8):946-952.

The influence of fracture location and comminution on acute scaphoid fracture displacement: three-dimensional CT analysis

We aimed to assess the influence of fracture location and comminution on acute scaphoid fracture displacement using three-dimensional CT. CT scans of 51 adults with an acute scaphoid fracture were included. Three-dimensional CT was used to assess fracture location, comminution and displacement. Fracture location was expressed as the height of the cortical breach on the volar and dorsal side of the scaphoid relative to total scaphoid length (%), corresponding to the fracture's entry and exit point, respectively. We found a near-linear relation between dorsal fracture location and displacement. As dorsal fracture location became more distal, translation (ulnar, proximal, volar) and angulation (flexion, pronation) of the distal fragment relative to the proximal fragment increased. Comminuted fractures had more displacement. Dorsal fracture location predictably dictates the direction of translation and angulation in displaced scaphoid fractures. Surgeon attention to dorsal fracture location can help identify displacement patterns and provide guidance in adequately reducing a displaced scaphoid fracture.Level of evidence: III.

Pediatric Scaphoid Fracture Associated with Osteopetrosis: A Case Report

CASE

A 12-year-old boy with osteopetrosis sustained a scaphoid waist fracture, which has not previously been reported with this condition. Healing was successfully achieved with percutaneous cannulated compression screw fixation, albeit with prolonged healing as is typical for this condition.

CONCLUSION

A lack of osteoclastic remodeling predisposes patients with osteopetrosis to fractures, commonly in long bones. Increased risks of infection, anesthesia, and broken hardware along with limited ability to compress bone may discourage operative management. Internal fixation should still be considered in select cases to limit displacement while allowing early range of motion.

Robot-assisted double screw fixation of minimally displaced scaphoid waist fracture nonunions or delayed unions without bone graft

We retrospectively reviewed 12 minimally displaced fractures of the scaphoid waist in 12 patients who developed delayed or nonunions with or without conservative treatment. Mean time between injury and surgery was 6 months (range 3-12). The fractures were stabilized with double screws, which were percutaneously inserted with robot assistance, and without bone grafting. All fractures united at a mean of 8 weeks (range 6-10) after surgery. The patients were followed-up at 6 months and 1 year. The patients recovered good wrist function. No major postoperative complications were reported, and the patients returned to their usual level of activity. Robot assistance gave a high degree of accuracy when placing the cannulated screws since only two attempts were needed for correct placement of the guide wires. We explain the high union incidence by patient selection, good stabilization and not disturbing the vascular supply.Level of evidence: IV.

Diagnostic and Therapeutic Approach to Acute Scaphoid Fractures

The scaphoid is the carpal bone that most often fractures, accounting for up to 70% of carpal fractures and 11% of hand fractures. It is the second most common arm fracture, only surpassed by fractures of the distal radius. Despite being so common, these fractures can be difficult to diagnose and treat due to the anatomic and physiological particularities of the bone, including its precarious vascularization, its complex three-dimensional structure, and its ligament connections, which greatly contribute to the risk of complications such as malunion, pseudoarthrosis and avascular necrosis. Although there are many published studies on the treatment of these injuries, there is still controversy over what is the most suitable one for certain fracture types. The present article is a comprehensive and updated review of the literature. Combining strategies for clinical and radiological diagnosis, we propose a complete algorithm for the diagnosis of scaphoid fractures based on the varying availability of resources, and we also describe the most appropriate therapeutic approach for the different types of acute fractures of this bone.

Artificial intelligence in orthopaedics: false hope or not? A narrative review along the line of Gartner's hype cycle

Artificial Intelligence (AI) in general, and Machine Learning (ML)-based applications in particular, have the potential to change the scope of healthcare, including orthopaedic surgery.

The greatest benefit of ML is in its ability to learn from real-world clinical use and experience, and thereby its capability to improve its own performance.

Many successful applications are known in orthopaedics, but have yet to be adopted and evaluated for accuracy and efficacy in patients’ care and doctors’ workflows.

The recent hype around AI triggered hope for development of better risk stratification tools to personalize orthopaedics in all subsequent steps of care, from diagnosis to treatment.

Computer vision applications for fracture recognition show promising results to support decision-making, overcome bias, process high-volume workloads without fatigue, and hold the promise of even outperforming doctors in certain tasks.

In the near future, AI-derived applications are very likely to assist orthopaedic surgeons rather than replace us. ‘If the computer takes over the simple stuff, doctors will have more time again to practice the art of medicine’.⁷⁶

Cite this article: EFORT Open Rev 2020;5:593-603. DOI: 10.1302/2058-5241.5.190092

Conservative treatment for fractures of the scaphoid

This review article aims to discuss the indications, techniques, outcomes, and complications of non-operative management of scaphoid fractures.

[Clinical and imaging methods in diagnostics of scaphoid fracture and non-union]

Clinical and radiological diagnostics are the base of a differentiated treatment of carpal disorders. With special regard to diagnostics of the scaphoid, not only the choice and the correct implementation of the imaging methods are crucial, but also their methodical limitations have to be taken into account. No other common fracture is more often undiagnosed, because neglected or overlooked. Concomitantly, delayed or untreated scaphoid fractures require demanding therapies in the sequel and may lead to functional restrictions in the long-term. This review article aims to discuss the clinical and imaging diagnostics for scaphoid fractures and non-union.

Compound or Specially Designed Flaps in the Lower Extremities

Novel and combined tissue transfers from the lower extremity provide new tools to combat soft tissue defects of the hand, foot, and ankle, or fracture nonunion. Flaps can be designed for special purposes, such as providing a gliding bed for a grafted or repaired tendon or for thumb or finger reconstruction. Propeller flaps can cover soft tissue defects of the leg and foot. In repairing severe bone and soft tissue defects of the lower extremity, combined approaches, including external fixators, one-stage vascularized bone grafting, and skin or muscle flap coverage of the traumatized leg and foot, have become popular.

Vascularized Small-Bone Transfers for Fracture Nonunion and Bony Defects

Vascularized small-bone grafting is an efficient and often necessary surgical approach for nonunion or necrosis of several bones in particular sites of the body, including scaphoid, lunate, distal ulna, and clavicle. The medial femoral condyle is an excellent graft source that can be used in treating scaphoid, ulna, clavicle, or lower-extremity bone defects, including nonunion. Vascularized bone grafting to the small bones, particularly involving reconstruction of damaged cartilage surfaces, should enhance subchondral vascular supply and help prevent cartilage regeneration. Vascularized osteoperiosteal and corticoperiosteal flaps are useful for treating nonunion of long bones.

Major Changes in Lymphatic Microsurgery and Microvascular Surgery in Past 20 Years

This article summarizes the major changes seen in lymphatic microsurgery and microvascular surgery in first 20 years of the 21st century. Lymphatic microsurgery is discussed first, as more advances have been seen in imaging of the lymphatic system, lymphatico-venous anastomosis, and vascularized lymph node transfers. During the past 2 decades, there have been more patient population changes than major technical evolutions in microvascular surgery, although new techniques and modifications emerged and became clinical routines, with the landscape of microvascular surgery evolving in this time period.

Acute scaphoid fractures: guidelines for diagnosis and treatment

In cases of suspected scaphoid fracture where the initial radiographs are negative, a supplementary MRI, or alternatively CT, should be carried out within three to five days.

Fracture classification, assessment of dislocation as well as evaluation of fracture healing is best done on CT with reconstructions in the coronal and sagittal planes, following the longitudinal axis of the scaphoid.

After adequate conservative management, union is achieved at six weeks for approximately 90% of non-displaced or minimally displaced (≤ 0.5 mm) scaphoid waist fractures.

Scaphoid waist fractures with moderate displacement (0.5–1.5 mm) can be treated conservatively, but require prolonged cast immobilization for approximately eight to ten weeks.

Internal fixation is recommended for all scaphoid waist fractures with dislocation ≥ 1.5 mm.

Distal scaphoid fractures can be treated conservatively. The majority heal uneventfully after four to six weeks of immobilization, depending on fracture type.

In general, proximal scaphoid fractures should be treated with internal fixation.

Cite this article: EFORT Open Rev 2020;5:96-103. DOI: 10.1302/2058-5241.5.190025

Three-dimensional-printed patient-specific Kirschner-wire guide for percutaneous fixation of undisplaced scaphoid fractures: a cadaveric study

Undisplaced scaphoid waist fractures can be managed by percutaneous fixation. The purpose of this study is to compare percutaneous fixation using a three-dimensional (3-D)-printed guide with the conventional method in a cadaveric study. Twelve wrists were divided into two groups: standard fluroscopic technique group, and a patient-specific 3-D-printed guide group. In the patient-specific group, using high resolution CT scans, we manufactured a mould-guide including a wire guide sleeve aligned with the planned ideal path, and 3-D printed it. On postoperative CT scans we measured the angular deviation of the screw axis from the ideal axis, and compared the two groups. The angular deviation was significantly lower in the patient-specific guide group. We concluded that a 3-D-printed guide for scaphoid percutaneous fixation allows a more accurate placement of the screw than a fluoroscopy guide in our cadaveric model.

Robot-assisted percutaneous scaphoid fracture fixation: a report of ten patients

This study reports the technique, efficacy and safety of robotic-assisted, computer-navigated, percutaneous fixation of scaphoid fractures. Ten males with acute undisplaced waist fractures underwent fixation with this method using a commercially available three-dimensional fluoroscopy unit and robotic navigation system. The mean total operative duration was 40 minutes, which comprised of a set-up time of 18 minutes and planning and surgical time of 22 minutes. All patients required only a single guidewire insertion attempt, and there were no screw protuberances or other complications. All fractures united at a mean of 8 weeks. At a mean follow-up of 6.5 months (range 6-8), the mean Mayo wrist score was 96, patient-rated wrist evaluation was 2, flexion-extension arc was 96% and grip strength was 91% of the contralateral side. We conclude from our patients that robotic-assisted percutaneous scaphoid fixation is feasible, safe and accurate, and is a satisfactory method for treating these injuries. Level of evidence: IV.

Comparison of SCAphoid fracture osteosynthesis by MAGnesium-based headless Herbert screws with titanium Herbert screws: protocol for the randomized controlled SCAMAG clinical trial

Background

Scaphoid fractures are the most common carpal fractures. They often need to be treated by surgery, where the use of a compression screw is the globally accepted gold standard. Surgeons may choose between different implant materials including titanium alloys, which remain in the body or are removed after healing. An alternative are biodegradable magnesium-based implants. Properties of magnesium alloys include high stability, osteoconductivity, potential reduction of infections and few artifacts in magnetic resonance imaging (MRI). The aim of this trial is to demonstrate non-inferiority of magnesium-based compression screws compared with titanium Herbert screws for scaphoid fractures.

Methods

The trial is designed as a multicenter, blinded observer, randomized controlled parallel two-group post market trial. Approximately 190 patients will be randomized (1:1) with stratification by center either to titanium or magnesium-based compression screws. Follow-up is 1 year per patient. Surgical procedures and aftercare will be performed according to the German treatment guideline for scaphoid fractures. The first primary endpoint is the patient-rated wrist evaluation (PRWE) score after 6 months. The second primary endpoint is a composite safety endpoint including bone union until 6 months, no adverse device effect (ADE) during surgery or wound healing and no serious ADE or reoperation within 1 year. The third primary endpoint is the difference in change MRI artifacts over time. Non-inferiority will be investigated for primary endpoints 1 (t-test confidence interval) and 2 (Wilson’s score interval) using both the full analysis set (FAS) and the per protocol population at the one-sided 2.5% test-level. Superiority of magnesium over titanium screws will be established using the FAS at the two-sided 5% test-level (Welch test) only if non-inferiority has been established for both primary endpoints. Secondary endpoints include quality of life.

Discussion

This study will inform care providers whether biodegradable magnesium-based implants are non-inferior to standard titanium Herbert screws for the treatment of scaphoid fractures in terms of wrist function and safety. Furthermore, superiority of magnesium-based implants may be demonstrated using MRI, which is used as surrogate endpoint for screw degradation.

Trial registration

DRKS, DRKS00013368. Registered Dec 04, 2017.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2723-9) contains supplementary material, which is available to authorized users.

The Use of the Proximal Hamate as an Autograft for Proximal Pole Scaphoid Fractures: Clinical Outcomes and Biomechanical Implications

Scaphoid proximal pole fractures remain a surgical challenge because of high propensity for nonunion, osteonecrosis, and ultimately carpal collapse. Options for management of nonsalvageable proximal pole fractures include non-vascularized bone grafts, vascularized pedicled bone grafts, free vascularized bone flaps, and rib cartilage grafts. The proximal pole of the hamate can also serve as a replacement arthroplasty in the setting of proximal pole scaphoid nonunions with collapse, bone loss, and/or osteonecrosis. This novel graft addresses shortcomings of other graft choices by providing a local structural autograft solution with minimal donor site morbidity, correcting carpal collapse, reconstructing the scapholunate ligament, and mitigating the need for microvascular anastomosis.

Wrist arthroscopy for the treatment of scaphoid delayed or nonunions and judging the need for bone grafting

This study reports outcomes of arthroscopy in the treatment of delayed or nonunions of 25 scaphoids (25 patients). The surgery was performed between 8 and 43 weeks after injury. Intraoperatively, 11 fractures were deemed stable to probing and underwent percutaneous screw fixation only; 14 were unstable and received arthroscopic bone grafting with percutaneous screw fixation. All fractures united. At a mean follow-up of 21 months (range 12-48), the mean Mayo wrist score was 96, and patient-rated wrist evaluation was 4, and the flexion-extension arc was 90% of the contralateral wrist. We conclude that arthroscopy is valuable in the treatment of scaphoid delayed or nonunions and in judging the need for bone grafting. Our data indicate that regardless of cystic formation in the scaphoid, bone grafting is not always necessary. Percutaneous fixation alone is sufficient when scaphoid delayed or nonunions are between 8 weeks and 1 year following injury, without scaphoid nonunion advanced collapse or dorsal intercalated segment instability, and when forceful probing confirms stability of the scaphoid arthroscopically. Level of evidence: IV.

Closed Limb Fractures With Compromised Vascularization: A Narrative Review

Vascular compromised fractures typically result in a high rate of healing complications, such as avascular necrosis, nonunion, delayed union, and arthritis, which severely affect a patient's function and quality of life. The purpose of this review was to identify and describe the epidemiology and available treatment options for the most well-known vascular compromised closed fractures. The injuries discussed in detail in this review were scaphoid, lunate, femoral neck, and talar fractures. Current evidence suggests that optimal treatment for vascular compromised fractures is dependent on the degree of fracture displacement and comminution, and the patient's post-injury functional demands, age, and bone quality. Conservative efforts generally include casting or splinting with a period of immobilization. Surgery is indicated for substantially displaced fractures, patients who require higher functional demands and an earlier return to activity, or if complications occur following nonoperative treatment; however, operative intervention is typically performed for femoral neck fractures regardless of the amount of displacement. Various surgical techniques exist, though internal fixation with screws is a common procedure among these injuries and can be used in combination with other implants, such as plating or Kirschner wires (k-wires), when needed. Severe fracture comminution, poor bone quality, or arthritis can contraindicate the use of screws and more invasive intervention will be required. Bone grafting is done in some cases to enhance vascularity. Salvage procedures exist for patients who develop severe complications, but these will permanently alter the anatomy of the injured area and should be considered a last resort.