Dorsal approach to the scaphoid

Indication

Scaphoid fracture, particular for small proximal fragments to allow for antegrade passage of screw.

Volar approach is more difficult, because requires  incision through the tough volar ligaments and exposure of the scaphotrapezial joint to allow for passage of screw.

Incision of the thin dorsal ligaments gives easy access to the entire carpus.

Anatomy

Blood supply dorsal

Considerations

Consider:

• Volar approach

• Percutaneous dorsal

• Percutaneous volar

Positioning

Supine

Tourniquet

Skin Incision

4-cm dorsal incision between the second and fourth compartments.

Superficial dissection

Open wrist capsule longitudinally

Observe fracture after elevation of the wrist capsule from the scaphoid

Reduce and stabilise fracture with towel clip or similar

Flex wrist and insert guide wire for cannulated variable pitch screw (Mini-Acutrak, Herbert Whipple)

Use Intra operative fluoroscopy to check guide wire placement.

The tip of the wire should be approximately 2 mm short of the distal articular surface of the scaphoid, to ensure that the tip of the screw will not penetrate the distal cortex.

Keep the wrist flexed at all times, to avoid bending and or breaking the guide wire.

Measure using guide provided. (subtract about 4mm to ensure head buried and does not penetrate distal surface)

Hand drill, to the appropriate screw length (as indicated by markings on the drill bit).

Insert headless screw.

Deep dissection

Exposure extension

To extend exposure elevate extensor pollicis longus tendon from the third compartment.

Closure

Post operatively

Consider splinting post op depending on fixation

References

Chung, Kevin C. M.D. A Simplified Approach for Unstable Scaphoid Fracture Fixation Using the Acutrak Screw. Plastic & Reconstructive Surgery. 110(7):1697-1703, December 2002.

Page created by: Lee Van Rensburg

Last updated 11/09/2015