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Scaphoid fractures are the most common carpal injury and have a high complication propensity. In particular, the unique blood supply of the scaphoid leads to an increased rate of avascular necrosis, while the geometry of the scaphoid causes relatively high rates of nonunion.
Among operative approaches, percutaneous and open reduction with internal fixation (ORIF) may both be considered, with ORIF being preferred for displaced, comminuted, proximal pole and nonunion/delayed healing fractures. With internal fixation, a dorsal or volar approach can be undertaken based on fracture alignment.
Here, we discuss the case of a proximal pole scaphoid fracture repaired with ORIF via a dorsal approach. After dissection through the joint capsule and exposure of the base of the scaphoid, a headless compression screw is placed anterograde in line with the thumb in all planes. This procedure provides increased stability and improved rate of the union in correlation with the accuracy of intraoperative reduction, leading to improved outcomes for surgical candidates over more conservative approaches.
Scaphoid fractures are a common traumatic injury, accounting for about 15% of all acute wrist injuries.1 Young, active males are the most frequently affected demographic with falling on an outstretched hand being the most common etiology.2
The scaphoid bone is prone to chronic sequelae if not appropriately managed, most notably nonunion as well as avascular necrosis (AVN), which can contribute to both chronic pain and reduced function of the wrist joint.3 Of note, the unique blood supply from the dorsal carpal branch of the radial artery, which provides retrograde perfusion to the scaphoid and is prone to damage during scaphoid fracture, predisposes to AVN of the proximal pole of the scaphoid.3
A degree of uncertainty exists in the ideal management algorithm for scaphoid fractures, with surgeon opinions on ideal operative approach varying in regard to fracture location, instability, hardware use, and more.4
History should focus on the mechanism of injury and time since the injury in order to guide treatment decision making. Additional information relevant to surgical candidacy should be gathered including past medical/surgical history, current medical conditions, current medications, and smoking history.
Pertinent findings on physical exam include:
- Inspection of the wrist for the severity of the swelling, gross deformity, and erythema/ecchymosis.
- Evaluation of any wounds about the wrist.
- Assess pain with gentle passive manipulation of the wrist and tenderness within the anatomic snuffbox.
Confirmatory imaging is most often achieved with plain radiographs including anteroposterior, lateral, and oblique views of the wrist. Special radiographs including a scaphoid view taken posteroanteriorly with the wrist in 30-degrees of ulnar deviation may occasionally be of value. Computed tomography (CT) may be helpful for preoperatively planning to assess fracture characteristics. Magnetic resonance imaging (MRI), while not routinely indicated, may be helpful if plain film radiographs are negative or inconclusive yet a high index of suspicion for scaphoid fracture exists.5 Imaging is also used to determine the Herbert, Mayo and/or Russe classifications. Based on the Mayo classification, 70% are middle scaphoid, 20% are distal scaphoid, and 10% are proximal scaphoid fractures.6
Without intervention, untreated scaphoid fractures have a high rate of nonunion or malunion, increasing the likelihood of degenerative arthritis7, as well as AVN in up to 50% of all untreated scaphoid fractures.8 The likelihood of chronic complications is related to the severity of the injury, the extent of comminution and displacement, and the location of the fracture.
Treatment is predicated based on fracture alignment, fracture characteristics and location, and patient characteristics and expectations.
Non-operative treatment with cast immobilization is indicated for acute and non-displaced fracturs of the scaphoid.
Operative treatment for isolated scaphoid fractures is indicated for displaced or comminuted fractures, proximal pole fractures, and fractures with delayed diagnosis or healing. Percutaneous fixation is preferred if the displacement of the fracture is minimal and there is no significant angulation or deformity. Open reduction with internal fixation (ORIF) is indicated in cases with more severe displacement, proximal pole fractures, humpback deformity of 15 degrees or more, comminuted fractures, or fractures with delayed diagnosis, healing, or nonunion.9, 10 While both the dorsal and volar approaches to the surgery are reasonable, distal and middle fractures are more commonly operated on via a volar approach, while proximal pole fractures are more commonly approached dorsally to allow ease of screw placement.6
Clinical management of scaphoid fractures varies based on the severity of the injury and findings on imaging. Over time, however, clinical trends have moved towards a preference for surgical intervention over conservative management as multiple studies have shown a reduction in arthritis when compared with cast immobilization.11-13
Proximal pole fractures of the scaphoid, as highlighted in the present case, are considered inherently unstable and prone to AVN; therefore, they require surgical intervention. In contrast, nondisplaced wrist fractures may be conservatively managed with cast immobilization. Among surgical approaches for proximal pole and unstable fractures, ORIF is preferred due to lower rates of malunion, arthrosis, and osteonecrosis when compared with the percutaneous approach.
Since its introduction in 1984, ORIF with headless compression screw fixation has become the favored surgical technique for the repair of unstable scaphoid fractures.9 This fixation strategy allows for internal fixation, compression, and stability while not leaving hardware prominent on the articular surface of the scaphoid. The central placement of the screw is critical to achieving a successful union and is technically easier from the dorsal approach.9 With adequate screw placement, successful union rates of scaphoid fractures can surpass 95%.9
Future considerations for operative management of scaphoid fractures include advancement in hardware options and applications—such as alternative screw types14, use of double-screw fixation15, and scaphoid plate fixation16—and improved guidelines for ideal surgical approaches to subtypes of scaphoid fractures.
Measures of surgical efficacy can vary and may include:
- Rate of the successful union on imaging follow-up
- Grip strength
- Wrist mobility and range of motion
- Return to sport/activity
- Pain experienced
- Headless compression screw
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Hayat Z, Varacallo M. Scaphoid Wrist Fracture. StatPearls. Treasure Island (FL). 2020. https://doi.org/10.1097/HTR.0000000000000351
- Brenner LA, Forster JE, Hoffberg AS, et al. Window to Hope: A Randomized Controlled Trial of a Psychological Intervention for the Treatment of Hopelessness Among Veterans With Moderate to Severe Traumatic Brain Injury. J Head Trauma Rehabil. 2018;33(2):E64-E73. https://doi.org/10.1097/HTR.0000000000000351
- Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am. 1980;5(5):508-513. https://doi.org/10.1016/s0363-5023(80)80087-6
- Suh N, Grewal R. Controversies and best practices for acute scaphoid fracture management. J Hand Surg Eur. Vol. 2018;43(1):4-12. https://doi.org/10.1177/1753193417735973
- Phillips TG, Reibach AM, Slomiany WP. Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004;70(5):879-884. https://www.ncbi.nlm.nih.gov/pubmed/15368727.
- Rhemrev SJ, Ootes D, Beeres FJ, Meylaerts SA, Schipper IB. Current methods of diagnosis and treatment of scaphoid fractures. Int J Emerg Med. 2011;4:4. https://doi.org/10.1186/1865-1380-4-4
- Seltser A, Suh N, MacDermid JC, Grewal R. The Natural History of Scaphoid Fracture Malunion: A Scoping Review. J Wrist Surg. 2020;9(2):170-176. https://doi.org/10.1055/s-0039-1693658
- Trumble TE. Avascular necrosis after scaphoid fracture: a correlation of magnetic resonance imaging and histology. J Hand Surg Am. 1990;15(4):557-564. https://doi.org/10.1016/s0363-5023(09)90015-6
- Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand Surg Am. 2008;33(6):988-997. https://doi.org/10.1016/j.jhsa.2008.04.026
- Ring D, Jupiter JB, Herndon JH. Acute fractures of the scaphoid. J Am Acad Orthop Surg. 2000;8(4):225-231. https://doi.org/10.5435/00124635-200007000-00003
- Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001;83(4):483-488. https://doi.org/10.2106/00004623-200104000-00001
- Buijze GA, Doornberg JN, Ham JS, Ring D, Bhandari M, Poolman RW. Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2010;92(6):1534-1544. https://doi.org/10.2106/JBJS.I.01214
- Symes TH, Stothard J. A systematic review of the treatment of acute fractures of the scaphoid. J Hand Surg Eur Vol. 2011;36(9):802-810.
- Loving VA, Richardson ML. Scaphoid Fracture Fixation with an Acutrak((R)) Screw. Radiol Case Rep. 2006;1(2):58-60. https://doi.org/10.2484/rcr.v1i2.13
- Yildirim B, Deal DN, Chhabra AB. Two-Screw Fixation of Scaphoid Waist Fractures. J Hand Surg Am. 2020. https://doi.org/10.1016/j.jhsa.2020.03.013
- Dodds SD, Williams JB, Seiter M, Chen C. Lessons learned from volar plate fixation of scaphoid fracture nonunions. J Hand Surg Eur Vol. 2018;43(1):57-65. https://doi.org/10.1177/1753193417743636
Cite this articleM. Grant Liska, BS, Asif M. Ilyas, MD, FACS. Scaphoid open reduction and internal fixation through dorsal approach. J Med Insight. 2022;2022(302). https://doi.org/10.24296/jomi/302
Table of Contents
- Measure Guidewire
- Drill over Guidewire
- Place Screw over Guidewire
- Confirm Screw Position
Scaphoid fractures are common fractures of the wrist that often require surgical repair with internal fixation. Common indications for internal fixation of a scaphoid fracture include: displaced or comminuted fracture of the scaphoid, proximal pole fractures of the scaphoid, scaphoids with a delayed diagnosis, or scaphoid fractures with delayed healing or non-unions. When indicated for surgery, fractures of the scaphoid can be approached volarly or dorsally. This is a case of a proximal pole scaphoid fracture treated through a dorsal approach.
After the operative limb is prepped and draped, the incision is marked. First, Lister's tubercle is identified by palpation. The incision is placed just distal and ulnar to Lister's tubercle to allow identification of the EPL tendon and the interval between the second and fourth compartments. The surgical incision site is then injected with a local anesthetic. The limb is then exsanguinated, and the tourniquet is inflated.
The incision is placed, and then blunt dissection is performed down to the level of the extensor retinaculum.
Once blunt dissection has been achieved down to the level of the extensor retinaculum, the distal aspect of the extensor retinaculum just distal to Lister's tubercle is released until the EPL tendon is in the field. Once the EPL tendon is identified and protected, the interval distal to it between the second and fourth compartments is developed.
With the EPL tendon identified and protected and the joint capsule exposed, an inverted-T arthrotomy of the capsule is performed. Care must be taken to avoid injury of the EPL tendon proximally, the ECRB tendon radially, and the EDC tendons ulnarly. Also, deep dissection with a knife should be avoided to avoid inadvertent injury to the scaphoid lunate ligament. It is typical for a joint hemarthrosis to be identified in the setting of an acute fracture as shown here. Once the arthrotomy is performed and the joint washed out, the base of the scaphoid should become readily apparent as shown here. The fracture line is also apparent.
With the fracture reduced and the base of the scaphoid exposed, the guidewire for the headless screw is placed at the center of the base of the scaphoid just radial to the scaphoid lunate ligament as shown here. The trajectory for the guidewire being placed antegrade in the scaphoid should be in line with the thumb ray in all planes. Using a wire driver, the guidewire is then advanced antegrade down the center of the scaphoid as shown here. Note how the wrist is held in a flexed posture during insertion of the guidewire. With the aid of an image intensifier, a center-center position of the guidewire within the scaphoid is confirmed on PA, oblique, and lateral views as shown here.
Once satisfied, the screw is placed following the manufacturer's guide for that headless compression screw. Here the guidewire is being measured with a cannulated depth gauge.
Next, the cannulated drill is placed over the guidewire. This creates the path for the headless compression screw. The drill is advanced in oscillation to avoid binding any tissue or tendons as well as to avoid cutting the pin within the scaphoid. It is advanced up to the distal subchondral bone of the scaphoid but does not cross into the ST joint.
Next, the cannulated headless compression screw is placed over the guidewire. Typically, the length of the screw is 16 to 24 mm based on the size of the patient or the length of the scaphoid. It is advanced slowly over the guidewire making sure to be adequately countersunk in the proximal pole of the scaphoid while not being too proud or violating the distal pole of the scaphoid or the ST joint distally.
Screw position is then confirmed on the image intensifier, again making sure that the screw is placed down the center of the scaphoid and that it is adequately countersunk proximally but not proud distally.
Once satisfied, the closure is undertaken. The wound and joint is washed out. Next, the capsule is closed. The EPL tendon is identified and retracted. Care is taken to avoid capturing any of the extensor tendons inadvertently in the capsule or closure. Finally, the skin is closed, and a bulky dressing, and/or splint, and/or cast is applied. Thank you.