Percutaneous Internal Fixation of Scaphoid Fracturesvia an Arthroscopically Assisted Dorsal Approach...

Percutaneous Internal Fixation of Scaphoid Fracturesvia an Arthroscopically Assisted Dorsal Approach

by Joseph F. Slade, Andrew P. Gutow, and William B. Geissler

J Bone Joint Surg AmVolume 84(suppl 2):S21-S36

November 1, 2002

©2002 by The Journal of Bone and Joint Surgery, Inc.

Photograph and radiograph (inset) of the wrist of a patient in whom a scaphoid fracture was repaired with use of a dorsal percutaneous guidewire and a headless cannulated compression

screw that was implanted through the proximal scaphoid pole along the cent...

Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36


Photograph of a scaphoid bone.



Radiograph of the same scaphoid bone with a 0.045-in guidewire lying along its central axis.



Photograph of a standard Acutrak screw, which is a headless cannulated compression screw with continuous variable-pitch threads.



On the posteroanterior view, scaphoid displacement is visualized as lateral displacement or a step-off.



On the lateral or oblique view, scaphoid displacement appears as forward flexion of the distal fragment, displaying a "V"-separation of the dorsal cortex (future humpback deformity).



To visualize the central axis of the scaphoid, a posteroanterior view of the wrist must first be obtained.



The wrist is then pronated until the scaphoid poles are aligned and the scaphoid is viewed as a cylinder.



The wrist is then flexed until the scaphoid cylinder appears as a circle.



Figs. 4-A and 4-B Under fluoroscopic visualization, the guidewire is placed at the base of the proximal pole of the scaphoid and is driven along the central axis.



If the wire is correctly positioned, it must pass through the trapezium and exit at the radial base of the thumb.



The wrist is then extended, and minifluoroscopy is used to confirm the position of the guidewire along the central axis of the scaphoid as well as the quality of the fracture reduction.



A 0.045-in double-cut guidewire is passed in a dorsal-to-volar direction through the proximal fragment, past the fracture site, and along the central axis of the distal scaphoid fragment.



Because these fractures tend to be unstable, a second antiglide guidewire, parallel to the first, is also placed in the scaphoid.



Fracture reduction is accomplished by the placement of two 0.062-in wire joysticks in the fracture fragments.



Figs. 5-D and 5-E The joysticks and antiglide wires are maintained during hand-drilling and dorsal implantation of the screw.



Arthroscopy is used to assess the quality of the scaphoid fracture reduction.



Scaphoid length is determined by placing a second guidewire at the base of the proximal part of the scaphoid, next to the exposed dorsal guidewire.



The scaphoid is prepared with a hand reamer.



Figs. 8-B and 8-C A headless compression cannulated screw is implanted, and fluoroscopy confirms the correct position of the fixation device.



vSingle sutures are used to close the arthroscopic portals.



At the first office visit, the hand is placed into a removable thumb-spica splint and the patient is started on strengthening exercises.



Computed tomographic scanning of the scaphoid with 1-mm cuts in two planes (posteroanterior and lateral) is used to evaluate fracture-healing.



Arthroscopic inspection of the radiocarpal joint at the point at which the screw was inserted at the base of the scaphoid confirms that the screw has been completely implanted within bone.



Examination of radiocarpal joints after scaphoid healing demonstrates collagen overgrowth and a smooth gliding surface.



Radiograph, made fifty days after the injury, demonstrating the proximal pole fracture.



Figs. 11-B, 11-C, and 11-D Healing was confirmed with computed tomographic scans and radiographs at 103 days after the operation.



Percutaneous Internal Fixation of Scaphoid Fracturesvia an Arthroscopically Assisted Dorsal Approach...

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