Atlas Hand Clin Volume 8 Issue 1 March 2003 - Scaphoid Injuries

Atlas of the Hand Clinics Copyright © 2006 Saunders, An Imprint of Elsevier Volume 8, Issue 1 (March 2003) Issue Contents: (Pages ix-189)

1 ix-ix Scaphoid injuries Lee Osterman

2 xi-xii Scaphoid injuries Slade JF

3 1-18 Dorsal percutaneous fixation of stable, unstable, and displaced scaphoid fractures and selected nonunions Slade JF

4 19-28 Volar percutaneous fixation of stable scaphoid fractures Shin AY

5 29-35 Percutaneous scaphoid fixation: surgical technique volar approach with traction Goddard N

6 37-56 Arthroscopic assisted fixation of fractures of the scaphoid Geissler WB

7 57-66 Scaphoid fracture repair using the Herbert screw system (HBS) Krimmer H

8 67-76 Open treatment of transscaphoid perilunate fracture dislocations Sarris I

9 77-94 Percutaneous treatment of transscaphoid, transcapitate fracture-dislocations with arthroscopic assistance Slade JF

10 95-105 The treatment of chronic scapholunate dissociation with reduction and association of the scaphoid and lunate (RASL) Lipton CB

11 107-116 Scaphoid nonunion: correction of deformity with bone graft and internal fixation Forthman C

12 117-128 Vascularized bone grafts for the repair of scaphoid nonunion Moreno R

13 129-138 Fixation of scaphoid nonunion with Kirschner wires and cancellous bone graft Gutow AP

14 139-148 Intercarpal fusion with the Spider plate for scaphoid nonunion Manuel JL

15 149-162 Percutaneous capitolunate arthrodesis using arthroscopic or limited approach Slade JF

16 163-183 Intercarpal fusion for scaphoid nonunion Sauerbier M

17 185-189 Proximal row carpectomy for scaphoid nonunion Leak RS

Foreword

Scaphoid injuries

Consulting Editor

Scaphoid problems account for much of the disability associated with wrist injury. Dr.Joseph Slade III has organized an issue of the Atlas of the Hand Clinics that provides freshapproaches to the old problems of scaphoid fracture, scaphoid nonunion, scapho-lunatedissociation, and scaphoid salvage.

Dr. Slade is a pioneer in percutaneous scaphoid fixation surgery, and his innovative approachshines through in this issue. New information and technical pearls on a variety of percutaneoustechniques abound. This collection of articles updates the current state of scaphoid surgery andserves as a how-to primer for wrist surgeons.

Five of the first seven articles address the indications, methods, and results of percutaneousstabilization through a variety of approaches. Krimmer and Sarris emphasize the moretraditional approaches. Dr. Rosenwasser presents his RASL procedure for scapho-lunateinstability; this article and the three that follow it offer strategies to solve scaphoid nonunion,including those complicated by avascular necrosis. The final four articles complete the cycle ofscaphoid salvage.

In this issue of the Atlas of the Hand Clinics, Dr. Slade and his collaborators present acomprehensive cradle-to-grave approach to the problems of the scaphoid.

A. Lee Osterman, MDPresident

The Philadelphia Hand Center901 Walnut Street

Philadelphia, PA 19107

A. Lee Osterman, MD

1082-3131/03/$ - see front matter � 2003, Elsevier Inc. All rights reserved.

doi:10.1016/S1082-3131(03)00009-8

Atlas Hand Clin 8 (2003) ix

Preface

Scaphoid injuries

Guest Editor

Scaphoid fractures, nonunions, and their associated ligament injuries continue to challengeclinicians in the face of the changing needs and expectations of our patients. Gone are the dayswhen patients were satisfied to return for their ‘‘annual’’ cast change. Failure of treatment inyoung active patients only results in their mid-life presentation with arthritis. These patientsnow demand of their surgeons the ‘‘simple request’’ to return to their chosen avocation(eg, tennis or golf) without pain and with improved play!

It is a great pleasure to present this issue of the Atlas of the Hand Clinics, of the latest cutting-edge treatments for scaphoid injuries by the ‘‘Masters.’’ I have asked the authors to put theirknife in your hands and demonstrate how they accomplish their magic.

This issue opens with a variety of percutaneous techniques for scaphoid fixation. Thesetechniques are advocated by the authors for stable, displaced, and selected nonunions. Inaddition to these limited approaches, we are fortunate to have the new Herbert screw systemdetailed in the open repair of scaphoid fractures. Scaphoid fractures associated with majorligament injuries are vexing problems. Sotereanos’s successful approach in dealing with theseradiocarpal instabilities is an excellent read. Also detailed in this issue is the role of arthroscopyin the management of greater arc injuries, both scaphoid and capitate. Rosenwasser describes anextremely innovative approach for the treatment of chronic scapholunate dissociation withreduction and screw stabilization. Scaphoid nonunions continue to challenge even the mostskilled surgeon. Jupiter describes his technique for the correction of the scaphoid deformity,which is based on 20 years of experience. Gupta elegantly describes his approach to scaphoidnecrosis with a vascularized bone graft with detailed illustration. Gutow and Stevanovic reviewthe timed-tested classical approach to scaphoid nonunion with Kirschner wires and bone graft.The final articles detail our authors’ selected approach to salvaging the arthritic wrist.

The best ideas are often the simplest ones. I am most fortunate to have Weiss describe histechnique for implantation of the ‘‘spider plate,’’ a revolutionary plate that accomplishes asolid intercarpal arthrodesis while maintaining a low profile. This section is rounded out bytraditional salvage procedure describing both the four-corner fusion and proximal rowcarpectomy. A final article introduces a percutaneous fusion technique that some clinicians mayfind useful.

I am most indebted to these authors for their willingness to commit their valuable time andeffort to produce these excellent articles. The comprehensive and clear fashion with which eachtopic was presented made my editorial responsibilities easy. I also wish to thank W.B. Saundersfor the opportunity to serve as Guest Editor and their editorial staff for direction and guidance;

Joseph F. Slade III, MD


doi:10.1016/S1082-3131(03)00008-6

Atlas Hand Clin 8 (2003) xi–xii

I particularly want to thank Deb Dellapena for her advice and assistance in completing thisexciting project. Most importantly, I would like to thank my family for their continued patienceand support.

Joseph F. Slade III, MDDepartment of Orthopedics and Rehabilitation

Yale University School of MedicineP.O. Box 208071

New Haven, CT 06520-8071, USA

E-mail address: [email protected]

xii J.F. Slade III / Atlas Hand Clin 8 (2003) xi–xii

Dorsal percutaneous fixation of stable, unstable, anddisplaced scaphoid fractures and selected nonunions

Joseph F. Slade III, MDa,*, Andrew E. Moore, MDb

aHand and Upper Extremity Service, Department of Orthopaedics and Rehabilitation,

Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USAbDepartment of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071,


This article describes a simple, reliable method for scaphoid fracture reduction and rigid

fixation using a dorsal percutaneous approach (Fig. 1). This technique uses real-time radio-

graphic imaging and arthroscopy to reduce displaced carpal fractures, treat occult ligament

injuries, and confirm correct placement of implants (ie, headless compression screws).

The carpal bones are aligned in two rows of matching concave and convex gliding surfaces.

These carpal rows are supported by stout intrinsic ligaments and reinforced by a complex sys-tem of volar and dorsal extrinsic ligaments [1]. Because most of the carpal surface is composed

of cartilage, the blood supply is tenuous [2]. The scaphoid, the keystone to wrist stability, links

the proximal to the distal row. Injury to this bone or its attachments has recognized long-term

consequences. Forces that result in carpal fractures also can disrupt the carpal blood supply,

leading to nonunion or avascular necrosis. Failure of key stabilizing ligaments can result in car-

pal collapse. Both of these injuries are recognized precursors of radiocarpal osteoarthritis.

The benefit of the percutaneous surgical approach lies in the fact that fracture reduction and

fixation can be accomplished without further injury to the scaphoid’s blood supply or furtherdisruption to the stabilizing ligaments of the wrist. The technique employs a standard Acutrak

(Acumed, Beaverton, OR) screw (Fig. 2). This is a cannulated, headless screw with variable

thread, which compresses the fracture fragments as the screw is advanced. A detailed description

of the technique, indications, and convalescence program follows.

Understanding scaphoid fracture healing

Predicting successful scaphoid healing after a fracture can be difficult because reported union

rates range between 10% and 50% with plaster immobilization [3–5]. Close inspection of these

fractures has permitted the authors to identify risk factors for nonunion. The most influential

factors include displaced fractures, fractures with ligament injuries, and proximal pole fractures.

Even with best guessing, long-term studies confirm a 10% to 12% failure rate with plaster im-

mobilization of presumed stable fractures [3]. This group includes incomplete fractures and frac-

tures of the distal scaphoid pole or tubercle that would be expected to unite. The data suggest a

possibly higher nonunion rate for stable fractures of the scaphoid waist. Although the failurerate of stable fractures is not as high as the at-risk fracture patterns, one must balance the odds

of fracture union against 3- to 6-month cast immobilization treatment. This consideration is es-

pecially important because scaphoid injury typically occurs in a young patient population that

is active and the least tolerant of prolonged immobilization. The results of scaphoid nonunion

* Corresponding author.

E-mail address: [email protected] (J.F. Slade).


doi:10.1016/S1082-3131(02)00019-5

Atlas Hand Clin 8 (2003) 1–18

surgery have a reported increased failure rate of 25% to 50% with functional results not equal to

acute fracture repair [6–8].

The cause of scaphoid nonunions is multifactorial, but the tenuous blood supply is consid-ered a major factor. The most important vessels are along the dorsal ridge, which enter the

Fig. 1. Dorsal percutaneous technique. Scaphoid fracture is repaired through a dorsal percutaneous guidewire using a

standard Acutrak (Acumed, Beaverton, OR) screw. This fixation device is a headless cannulated compression screw

implanted through the proximal pole.

Fig. 2. The technique employs a standard Acutrak (Acumed, Beaverton, OR) screw.

2 J.F. Slade III, A.E. Moore / Atlas Hand Clin 8 (2003) 1–18

scaphoid distally and travel proximally. At the waist level, most of these vessels are endosteal.

Fractures proximal to the waist risk disruption of these nutrient vessels. Another factor is micro-

motion at the fracture site. Fracture healing in the scaphoid is made more difficult by its carti-

lage shell. Because of the surrounding articular surface, there is no primary callus formation to

stabilize the scaphoid while healing progresses. Without callus formation, the healing process isprolonged, and any micromotion at the fracture site risks nonunion and avascular necrosis.

Given the risk of motion with a complete fracture, one must understand the forces acting on

the fracture site. The forces acting to displace a complete fracture depend on the location and

the direction of the fracture plane. Untreated fractures of the waist are subjected to bending

forces and are recognized clinically as a ‘‘humpback’’ nonunion deformity.

These clinical findings confirm cadaver biomechanical studies showing that waist fractures

are subjected to flexion forces, which are resisted by intact scaphocarpal ligaments [9–11].

Scaphoid fractures also are subjected to translational forces, acting to displace the fracturefragments laterally. These forces may have a greater impact on proximal pole fractures and

fractures with intact ligaments.

A cadaver study of plaster immobilization for scaphoid fractures evaluated motion by sim-

ulating a fracture with an osteotomy, then measuring displacement with transducers. A short

arm cast was applied, and the forearm was rotated. Motion recordings showed all fractures dis-

placed 1 to 4 mm. This study likely underestimates fracture site motion in a living subject be-

cause loosening of the cast with subsistence of swelling and muscle atrophy allows for even

greater motion [12]. These studies only confirm the difficulty of treating complete scaphoid frac-tures with plaster immobilization.

All authors agree that unstable fractures require rigid internal fixation. For an implant to be

successful in providing secure fixation of scaphoid fractures, it must be able to resist the cyclic

forces that are placed on the carpus during normal functional loading. These devices must be

able to maintain compression and resist displacement while being subjected to constant repeti-

tive cyclic loading throughout the prolonged healing course of the scaphoid fracture.

A variety of compression screws are available for fixation of scaphoid fractures. Toby and

colleagues [13] evaluated the time to failure of cyclically loaded screws. They found resistanceto cyclic loading was proportional to the radius of the screw to the fourth power (r4). They

found the cannulated Acutrak screw was the strongest headless compression screw, giving the

highest number of cycles to failure. The introduction of volar comminution greatly reduced

the number of cycles required for displacement of the Herbert and the AO screws but did

not alter the relative differences in fixation strength. The Herbert, Whipple, and AO lag screws

failed catastrophically with a resulting ‘‘windshield wiper’’ effect under these conditions. The

Acutrak screw did not show catastrophic failure. It underwent gradual separation by plastic de-

formation of the surrounding bone, while still providing mechanical support for the fracturefragments. For proximal pole fractures, the strongest means of fixation is a headless compres-

sion screw introduced and advanced through the smaller fracture fragment (eg, the proximal

pole) [14]. The dorsal introduction of a headless compression screw in the proximal pole also

has been shown to be significantly more effective in resisting lateral displacement than volarly

placed screws [15]. Finally, it has been shown that screws placed along the central scaphoid axis

decrease healing time and increase the stiffness of fixation [16,17].

Indications for percutaneous scaphoid fracture repair

The goal of internal fixation of scaphoid fractures is to provide secure fixation to permit early

motion until a solid union has been achieved. Objectives include neutralization of forces acting

on the scaphoid, compression between the fracture fragments, and central placement of a screw

along the long axis of the scaphoid. The indications for percutaneous repair of scaphoid frac-

tures are similar to the indications for open repair, as long as the goals of internal fixation

are met.Absolute indications include reducible displaced scaphoid fractures, fractures of the proximal

pole, and fractures with delayed presentation. Scaphoid fractures with fibrous unions with-

out displacement require only rigid fixation for healing to be accomplished. This fixation is

3J.F. Slade III, A.E. Moore / Atlas Hand Clin 8 (2003) 1–18

accomplished without bone graft. Scaphoid nonunions with minimal sclerosis may be treated in

a similar manner if secure compression can be achieved at the nonunion site. Combined injuries

of the scaphoid, including the distal radius or other carpal bones (ie, capitate fracture), may be

treated percutaneously. Fractures with partial ligament injuries may be addressed with simpledebridement and fixation.

Complete ligament disruptions can be detected arthroscopically and treated with a minimal

incision directly over the disruption and repaired with bone anchors. Relative indications in-

clude patients with stable scaphoid fractures desiring an early return to work or hobby. These

fractures are expected to heal with simple immobilization.

Contraindications for percutaneous repair include scaphoid nonunions with severe sclerosis,

cystic changes, and pseudarthrosis. For these fractures to have an opportunity to heal, a fresh

biologic surface with bleeding needs to be established with a bone graft before rigid fixation.Osteonecrosis of the scaphoid requires a vascularized bone graft with rigid fixation.

Overview of surgical technique

The most important steps are scaphoid fracture reduction and the percutaneous placement of

a 0.045-inch, double-cut guidewire along the central axis of the reduced scaphoid (Fig. 3)

[18–20]. This guidewire permits the implantation of a cannulated headless compression screwalong the central axis. It has been shown that screws in this position increase the rate of healing

of scaphoid fractures [21] and increase the stiffness of fixation [16]. An additional benefit is that

screws placed in this position reduce the risk of thread penetration and cartilage injury [20].

Fracture reduction and guidewire placement are achieved using fluoroscopy. Arthroscopy is

used to confirm fracture reduction and to treat occult injuries. With fracture surfaces firmly op-

posed, a headless, cannulated compression screw is used to achieve rigid fixation of the scaphoid

fracture.

Equipment required includes the headless, cannulated compression screw (standard Acutrakscrew); a fluoroscopy unit (preferably a mini-imaging unit); 0.045-inch and 0.062-inch, double-

cut Kirschner wires; a wire driver; and a small joint arthroscopy setup including a traction

Fig. 3. Central axis of scaphoid. The most important step is the percutaneous placement of a 0.045-inch double-cut

guidewire along the central axis of the reduced scaphoid.


tower. The authors prefer screws of standard size with their larger core shaft because of their

increased ability to resist lateral displacement forces [13].

Surgical technique in detail

Imaging

The patient is supine and the arm is extended on an arm table with a tourniquet. The elbow is

flexed 90�, and a minifluoroscopy imaging unit is placed in a horizontal position, parallel to

the hand table so that the imaging beam is perpendicular to the wrist. A fluoroscopic survey

of the carpus is performed for fracture displacement, ligament injury, and other occult injuries.

The scaphoid is examined to confirm anatomic reduction. Lateral and oblique views of thescaphoid are particularly useful. Fractures of the waist of the scaphoid flex and on imaging are

seen as a dorsal v-shaped defect. The lunate assumes an extended position on lateral imaging.

Gross ligament disruption also may be suggested by an extended (scapholunate interosseous) or

flexed (lunotriquetral interosseous) position of the lunate. Longitudinal traction of the carpus

may detect a step-off between the carpal bones on a posteroanterior view.

On completion of this study, the central axis of the scaphoid must be located (Fig. 4). This

can be accomplished by first obtaining a posteroanterior view of a reduced scaphoid. The wrist is

pronated and flexed until the scaphoid poles are aligned in the radiographic beam. The scaphoidassumes a ‘‘ring’’ shape now, and the center of the circle is the central axis of the scaphoid. This

is also the precise location for screw placement.

Fig. 4. Targeting scaphoid with fluoroscopy. The elbow is flexed, and the imaging beam is perpendicular to the wrist and

horizontal to the floor. Posteroanterior view of the wrist radiograph and picture (A). Using fluoroscopy, the wrist is

pronated until the scaphoid poles are aligned and the scaphoid is viewed as a cylinder (B). The wrist is flexed until the

scaphoid cylinder appears as a circle (C). The central axis of the scaphoid is now in the imaging beam and is the center of

the scaphoid circle. The arrow in C marks the central axis of the scaphoid in a radiograph and the position and direction

of the guidewire. An alternative method of viewing can be obtained by extending the forearm on a radiolucent arm table

and positioning either a mini or standard imaging unit perpendicular to the floor and under the table (D). A small roll is

placed under the wrist, which permits the wrist to be flexed approximately 45� and the scaphoid to be flexed 90�. Thewrist is pronated until the scaphoid appears as a circle.


Dorsal guidewire placement in reduced scaphoid fracture

The starting position for the guidewire is the proximal pole of the scaphoid (Fig. 5). The base

of the scaphoid is covered only by soft tissue. This dorsal percutaneous approach permits easy

access to the central scaphoid axis for the guidewire. The distal scaphoid, which is covered bythe trapezium, obstructs this direct line of sight. Using minifluoroscopy, the guidewire is driven

dorsally along the central axis of scaphoid passing through the trapezium. The wrist is main-

tained in a flexed position to avoid bending the guidewire. As the wire is advanced, its position

can be checked using fluoroscopy. The wire is advanced from a dorsal to volar position until the

dorsal trailing end of the wire clears the radiocarpal joint, permitting full extension of the wrist.

The volar end of the wire exits from the radial base of the thumb, a safe zone devoid of tendons

and neurovascular structures. When the dorsal trailing end of guidewire has been buried into

the proximal scaphoid pole, the wrist can be extended for imaging to confirm scaphoid fracturealignment and to correct positioning of the guidewire.

Dorsal guidewire placement in displaced scaphoid fracture

Fractures may be reduced percutaneously using dorsally placed 0.062-inch Kirschner wires as

joysticks in each fracture fragment and a small hemostat through an arthroscopic portal (Fig. 6).

When the dorsal joysticks are brought together, the flexion deformity of the scaphoid is cor-

rected. This correction is confirmed best on lateral fluoroscopy. With acute fractures, there isno loss of volar cortex because the volar scaphoid fails in tension, not compression with a hyper-

extension injury. Older or impacted displaced fractures may require the direct introduction of

a small hemostat at the fracture site to achieve reduction. The hemostat is introduced through

a midcarpal or accessory portal. When reduction is achieved, a previously placed wire in the

Fig. 4 (continued )


distal fragment is driven from its volar position into the proximal fragment to capture and se-

cure reduction. These fractures are often unstable and require the placement of a second parallel

antiglide wire during reaming and screw implantation.

Arthroscopy and soft tissue injuries

After fluoroscopy confirms the fracture is aligned correctly and the guidewire is in the correct

position along the scaphoid central axis, longitudinal traction is applied through all fingers to

allow for safe entry of the small-joint arthroscope and instruments. Using minifluoroscopy,

the midcarpal and radiocarpal portals are located, and 19G needles are used to mark these por-

tal sites. After a small longitudinal incision is made, a small hemostat is used to dissect bluntly

the soft tissue down to the joint capsule. A blunt trochar is used to enter the joint. An angled,

small-joint arthroscope is placed in the radial midcarpal portal to confirm fracture reduction(Fig. 7). Next, an aggressive shaver is used to clear blood clot and the dorsal synovium. The

integrity of the scapholunate and lunotriquetral interossei ligaments can be assessed from the

Fig. 5. Placement of guidewire along scaphoid axis. Using fluoroscopy, the guidewire is placed at the base of the

proximal pole of the scaphoid (A). This is the key to the central axis of the scaphoid. A 12G or 14G needle can be placed

at the scaphoid base and used as a guide for wire placement (B and C). When the wire is introduced at the scaphoid base,

its position can be checked by imaging as the wire is advanced (D and E). It is crucial that the wrist be maintained in a

flexed position until the distal end of the wire clears the radiocarpal joint or the guidewire may be bent (F). The scaphoid

is covered distally by the trapezium. If the wire is positioned correctly, it must pass through the trapezium and exit at the

radial base of the thumb (G). The wire is withdrawn from the thumb base until the wrist can be extended, and

minifluoroscopy can be used to confirm the guidewire position along the central axis of the scaphoid and fracture

reduction (H and I). An alternate method of wire placement is a volar percutaneous approach, which also passes through

the trapezium (J).


radiocarpal and the midcarpal joint. The 3,4 portal is used to confirm complete seating of the

screw after implantation in the scaphoid proximal pole.

These joints are explored with a probe. Partial tears can be treated with simple debridement.

Complete disruptions require not only fracture fixation, but also ligament repair. The appropri-

ate portal incision is extended (ie, 4,5 portal for scapholunate interosseous ligament), exposing

the ligament tear. Joysticks, 0.062 inch, are placed into the disrupted carpal bones. Before reduc-

tion, crossing 0.045-inch Kirschner wires also are placed. The joysticks are used to effect a re-

duction, and the reduction is secured with the crossing Kirschner wires. A bony troughis created at the site of ligament avulsion, and bone anchors are placed to advance the torn

Fig. 5 (continued )


ligament. This repair is reinforced with dorsal capsulodesis. These soft injuries require 6 weeks

of immobilization, followed by 6 weeks of protected motion with a splint.

Scaphoid length and screw size

After scaphoid fracture reduction and guidewire position are confirmed, the screw size can be

selected. First, the scaphoid length must be determined (Fig. 8). Adjust the scaphoid central axisguidewire until the distal end is in contact with the distal cortex. Place a second identical wire

parallel to the first so that the tip of the wire touches the cortex of the proximal pole. The differ-

ence in length between these two wires is the exact length of the scaphoid. The most common

complication of percutaneous screw implantation is implantation of a too-long screw [22].

In the authors’ experience, to avoid this complication, the screw selected should provide for

2 mm clearance between the end of the screw end and the scaphoid cortex. The screw length

Fig. 6. Displaced fracture reduced percutaneously. Longitudinal traction provides for general alignment of the fracture

fragments (A). The central axis wire is withdrawn across the fracture site. The displaced fracture fragments now can be

manipulated with stout percutaneous wires constructed from 0.062-inch guidewires, which are placed dorsally into each

pole and perpendicular to the body of the fracture fragments (B and C). When reduction has been achieved, joysticks

maintain fracture alignment, while the volar guidewire in the distal pole is driven proximally and dorsally into the

proximal pole to capture and secure reduction (D). A difficult fracture can be reduced with a small curved hemostat

introduced percutaneously (E and F).


selected is 4 mm shorter than the scaphoid length. This length permits the complete implanta-

tion of a headless compression screw in bone without exposure. Now that the length of the screw

has been determined, the width must be selected. Biomechanical studies suggest that the widest

screws provide the strongest fixation [20]. One concern about larger screws introduced dorsallyis the consequences of the resulting cartilage defect, but these defects have been shown to heal

over with cartilage in time without degenerative changes [18,23].

With extremely small proximal pole fractures or avulsions, there is a possible risk of fragmen-

tation with implantation of a large screw. Under these circumstances, a smaller screw is inserted

to decrease the risk of fracture fragmentation with the understanding that the tradeoff is a

decrease in the rigidity of the fixation.

Fig. 6 (continued )


Fig. 7. Arthroscopy. A small joint angled arthroscope is placed in the midcarpal row (A). Although a large scaphoid

step-off also would be seen with fluoroscopy, a smaller step-off would be missed easily. Arthroscopy can detect these final

fracture displacements, which now can be corrected (B). Ligament tears with carpal fractures are common. A

scapholunate interosseous ligament tear is seen (C). These tears can be graded using a small probe (D). Small tears and

flaps are debrided back to a stable rim. Complete unstable tears are repaired open.


Screw implantation

Dorsal implantation of a headless compression screw is recommended for scaphoid fractures

of the proximal pole and volar implantation for distal pole fractures because this permits max-

imum fracture compression [14,15]. Fractures of the waist may be fixed from a dorsal or volar

approach as long as the screw is implanted along the central scaphoid axis. Blunt dissection

along the guidewire exposes a tract to the dorsal wrist capsule and scaphoid base. Before drill-

ing, the guidewire should be advanced so that both ends are exposed equally. This exposure per-mits the wire from becoming dislodged during reaming. The scaphoid is prepared by drilling a

path 2 mm short of the opposite scaphoid cortex with a cannulated hand drill (Fig. 9). Under no

circumstances should the scaphoid be reamed up to the opposite cortex; this permits the implan-

tation of a headless compression screw completely within the scaphoid. It is crucial to use fluo-

roscopy to check the position and depth of the drill. Overdrilling the scaphoid reduces fracture

compression and increases the risk of motion at the fracture site. A standard Acutrak screw,

4 mm shorter than the scaphoid length, is selected. The screw is advanced under fluoroscopic

guidance to within 1 to 2 mm of the opposite cortex with excellent compression. If the screwis advanced to the distal cortex, attempts to advance the screw further displace the distal frag-

ment. With unstable fractures, a joystick is left in the distal scaphoid fragment for reaming and

screw implantation. As the screw is implanted, a counterforce is exerted through the joystick,

compressing both fracture fragments and ensuring rigid fixation.

The volar implantation of the screw is recommended for distal scaphoid fractures. Guide-

wire placement and length determination are accomplished in an identical manner as the dorsal

Fig. 8. Screw length. The wrist is flexed, and the guidewire is advanced to the distal pole of the scaphoid. Scaphoid

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

guidewire. The difference between these wires is the scaphoid length. Screw length is determined by reducing by 4 mm the

scaphoid length. This permits 2 mm of clearance of the screw at each end of the scaphoid and complete implantation

without screw exposure to cartilage.


Fig. 9. Dorsal screw implantation. Rigid fixation of proximal and waist scaphoid fractures is accomplished with dorsal

implantation of a headless cannulated compression screw. The scaphoid is prepared with a hand reamer (A).

Fluoroscopy is used to check the position and depth of the drill. It is crucial not to ream beyond 2 mm of the opposite

cortex. A small curved hemostat or a joystick placed in the distal fragment can be used to compress the fracture

fragments during screw implantation (B). Fluoroscopy is used to confirm the correct position of the fixation device (C).


technique. A small incision is made at the volar site of wire penetration, and blunt dissection

is carried down to the cortex of the trapezium, not the distal scaphoid pole. To prepare the

scaphoid for screw placement, the trapezium and the scaphoid are reamed with the cannulated

hand drill; this ensures the screw is implanted along the central scaphoid axis. This violation ofthe scaphotrapezial joint is minimal and certainly less than prior techniques, which recommend

a volar osteotomy of the trapezium for application of a drill guide. The remainder of the tech-

nique is identical to the dorsal procedure, including screw selection, drilling, and implantation.

This volar technique differs from other volar techniques, which advocate entry to the scaphoid

at the edge of the scaphotrapezial joint, a starting point that risks eccentric screw placement

[24]. After screw placement, the guidewire is removed, and wrist fluoroscopy confirms screw

position, fracture reduction, and rigid fixation. Arthroscopy at this time can confirm reduction

and complete seating of the screw.

Postoperative care

Postoperative care is dictated by soft tissue injuries associated with the scaphoid fracture (Fig.

10). Complete ligament injuries require 6 weeks of immobilization, followed by 6 weeks of a pro-

tected motion program. Fractures of the waist without complete ligament injuries are started on

an immediate range-of-motion protocol, whereas proximal pole fractures are protected for

Fig. 10. Postoperative care. Portals are closed with a single suture, and the wrist is placed in a removable thumb-spica

splint. Hand therapy is initiated to recover hand function along with a strengthening program. Wrist motion is not the

focus of the rehabilitation program. With proximal pole fractures, wrist motion is delayed until healing is confirmed on

computed tomography scan, usually at 1 month. Computed tomography scan of the scaphoid with 1-mm cuts in two

planes is used to evaluate fracture healing. If hand function and strengthening are started early, wrist motion follows

quickly.


1 month before initiation of therapy. All fractures are started on a strengthening program. The

purpose of strengthening exercises is to axially load the fracture site now secured with an intra-

medullary screw to stimulate healing. Heavy lifting and contact sports are restricted until com-

puted tomography confirms healing by bridging callus and clinically the patient is nontender.

Special circumstances

Failure to pass a guidewire

If multiple attempts are made at positioning the 0.045-inch double-cut wire in the scaphoid,

an incorrect path in the scaphoid is established. It is necessary to use a larger 0.062-inch wire

to establish the correct path. When the correct path has been established, the larger wire is

exchanged for the 0.045-inch wire before scaphoid drilling.The minifluoroscopy units provide only 14 inches of clearance between the transmitter and

receiving units. This narrow space provides for a small work area and can block guidewire

placement. A 12G angiocatheter placed at the scaphoid base impales the proximal pole. The

wrist now can be removed from the imaging beam because the catheter maintains the correct

path for the 0.045-inch guidewire to travel.

If any uncertainty about the starting position of the guidewire remains, a limited open ap-

proach can be employed. The limited open dorsal approach to the scaphoid provides a quick

and easy identification of the scaphoid proximal pole and the scaphoid’s central axis. A smallincision distal and ulnar to Lister’s tubercle is made exposing the extensor pollicis longus ten-

don, which is retracted radially. The dorsal capsule is incised, exposing the proximal scaphoid

pole. A drill guide is placed on the scaphoid proximal pole, and a 0.045-inch, double-cut guide-

wire is driven in a radial and distal direction, toward the scaphoid tubercle. Fluoroscopic imag-

ing is used to confirm the correct course of the wire in the scaphoid.

Scaphoid nonunions

Selected scaphoid nonunions have failed to heal solely because of the lack of stabilization. If

rigidly fixed, these fractures proceed to union but more slowly than fractures treated acutely.

These include fractures that present in a delayed fashion for treatment and fractures with fibrous

union but no evidence of bridging bone. Also, nonunions without displacement and minimal

sclerosis have been shown to heal more slowly than fresh fractures. These fractures also can

be percutaneously bone grafted using a standard bone marrow biopsy kit (Fig. 11). These frac-

tures also require rigid fixation. Fractures not likely to heal include those with pseudarthrosisand frank motion at the fracture site. Also, nonunions with large cysts and a wide margin of

sclerosis are less likely to heal with rigid fixation alone because the zone of healing bone has

been reduced greatly. Deformed nonunions and nonunions with avascular necrosis require open

reduction and bone grafting with or without augmentation with a vascularized pedicle. A sharp

drill always must be used when reaming bone, but particularly when drilling the hardened bone

of a nonunion. Also, after the introduction of bone graft into the scaphoid, a second drilling

must be performed before screw implantation. To insert the screw and advance it into an unpre-

pared graft forces the graft to separate in the scaphoid; this risks exploding out the outer shell ofscaphoid. This situation is avoided by reaming with a sharp drill before screw implantation.

Failure of technique

Overdrilling of the scaphoid reduces fracture compression and increases the risk of motion at

the fracture site. When the screw is advanced to the distal cortex, further advancement is

blocked. Any further attempts at advancement push the distal fragment, leading to distractionat the fracture site. To prevent overdrilling, reaming always should be done by hand, not by

power. The depth of the drill should be checked frequently with the fluoroscope. If the scaphoid

is overreamed, the selected standard Acutrak screw should be replaced with a wider 4/5 screw.


Fig. 11. Selected scaphoid nonunion. Although scaphoid fibrous unions require only rigid fixation to heal, scaphoid non-

unions with normal alignment and sclerosis require both rigid fixation and the interposition of bone graft so that bridging

healing can occur between fracture fragments (A). Preoperative magnetic resonance imaging confirms the presence of

viable bone fragments. The authors presently use an 8G Jamshidi bone marrow/biopsy needle (Allegiance Healthcare

Corporation, McGaw Park, IL) to harvest and introduce iliac crest bone graft using a dorsal approach (B). Goddard [32]

used this needle for volar bone grafting of scaphoid fractures. Treatment of scaphoid nonunions by percutaneous bone

grafting requires the placement of a guidewire along the central axis. The scaphoid is reamed with a standard Acutrak

(Acumed, Beaverton, OR) reamer, and the nonunion site is curetted using the cannulated reamer portal. After harvesting

bone graft, the biopsy cannula is introduced over the guidewire, engaging the base of the scaphoid (C). The wire is

withdrawn, and bone graft is introduced into the scaphoid canal and nonunion site. This is done under imaging, and as

the graft is introduced into the scaphoid the radiolucent site becomes radiopaque (D). Once this is completed, the

guidewire is advanced dorsal, and rigid fixation is achieved with implantation of a headless compressing screw (E). If

there is any concern about stability, a second parallel wire is placed to maintain scaphoid reduction.


This wider screw grips and compresses the fracture. If too long a screw is selected, attempts to

seat the screw lead to stripping of the bone in the distal fragment and increasing the fracture gap

with each turn of the driver. The solution is to remove the screw and size down. Wire shearing

and breakage can be avoided if drilling is performed by hand and care is taken not to bend the

wire. Driver breakage is uncommon with the standard Acumed driver. It is designed to with-stand 28 lb of torque before failing at the tip. If it does break, a small hemostat easily retrieves

the cannulated driver tip, which remains trapped on the guidewire.

Clinical results of percutaneous technique

A 12-year review of articles reporting on percutaneous fixation of scaphoid fractures using

headless compression screws was conducted between 1990 and 2002 [17–20,22,24–31]. A totalof 214 acute fractures treated percutaneously resulted in a 100% healing rate. There were 39

fractures with either fibrous unions or late presentation treated percutaneously with rigid fixa-

tion. All 39 fractures healed without open bone grafting. The only complications reported in

these articles were the implantation of four screws too long, for a complication rate of 1.5%.

The authors have treated more than 50 scaphoid fractures with 100% union as confirmed

with computed tomography scan. These include stable, unstable, and displaced scaphoid frac-

tures rigidly repaired using this dorsal percutaneous method without complication. In addition,

the authors have treated fibrous unions and scaphoid fractures that have presented in a latefashion with percutaneous rigid fixation alone without bone graft. These all have healed, but

more slowly than the fractures treated acutely.

Summary

Treatment of scaphoid fractures and selected nonunions using an arthroscope and the dorsal

percutaneous approach is straightforward with a high rate of union and minimal complications.

The key to percutaneous fixation of the scaphoid is placement of the guidewire along the sca-phoid central axis. Imaging identifies this ‘‘sweet spot.’’ The wrist is pronated and flexed until

the scaphoid is seen as a circle. The center of the circle is the target point for insertion of the

guidewire into the proximal pole of the scaphoid. The guidewire is driven dorsal to volar,

through the trapezium, and exits at the radial base of the thumb. Fracture reduction and posi-

tioning of the guidewire in the scaphoid are examined using minifluoroscopy and arthroscopy.

The dorsal implantation of a headless compression screw provides the greatest fixation for prox-

imal pole fractures. The early treatment of these fractures results in a faster union. Key tech-

niques for dorsal percutaneous scaphoid fixation are summarized as follows:

• The central position of the guidewire in the scaphoid is key.

• The wrist is pronated and flexed until the scaphoid is seen as a circle, the ‘‘ring sign.’’ The

center of the circle is the target point for insertion of the guidewire into the proximal pole ofthe scaphoid.

• The guidewire is driven dorsal to volar so that the wire exits at the radial base of the thumb.

• The reduction of the fracture and position of the guidewire in the scaphoid are examined

using minifluoroscopy and arthroscopy.

• Screw length is determined using two identical parallel wires. The difference in length be-

tween these two wires is the length of the scaphoid. The screw length is 4 mm shorter than

this calculated scaphoid length.

• Reaming is stopped 2 mm from the distal cortex of the scaphoid.• The screw is implanted in the scaphoid to the level that the scaphoid has been drilled.

References

[1] Berger RA. The anatomy of the scaphoid. Hand Clin 2001;17:525–32.

[2] Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am 1980;5:508–13.


[3] Duppe H, Johnell O, Lundborg G, et al. Long-term results of fracture of the scaphoid: a follow-up study of more

than thirty years. J Bone Joint Surg Am 1994;76:249–52.

[4] Gellman H, Caputo RJ, Carter V, et al. Comparison of short and long thumb-spica casts for non-displaced fractures

of the carpal scaphoid. J Bone Joint Surg Am 1989;71:354–7.

[5] Raudasoja L, Rawlins M, Kallio P, Vasenius J. Conservative treatment of scaphoid fractures: a follow up study.

Ann Chir Gynaecol 1999;88:289–93.

[6] Barton NJ. The Herbert screw for fractures of the scaphoid. J Bone Joint Surg Br 1996;78:517–8.

[7] Schuind F, Haentjens P, Van Innis F, et al. Prognostic factors in the treatment of carpal scaphoid nonunions.

J Hand Surg Am 1999;24:761–76.

[8] Shah J, Jones WA. Factors affecting the outcome in 50 cases of scaphoid nonunion treated with Herbert screw

fixation. J Hand Surg Br 1998;23:680–5.

[9] Garcia-Elias M. Kinetic analysis of carpal stability during grip. Hand Clin 1997;13:151–8.

[10] Kobayashi M, Garcia-Elias M, Nagy L, et al. Axial loading induces rotation of the proximal carpal row bones

around unique screw-displacement axes. J Biomech 1997;30:1165–7.

[11] Smith DK, Cooney WP, An KN, Linsheid RL. The effects of simulated unstable scaphoid fractures on carpal

motion. J Hand Surg Am 1989;14:283–91.

[12] Kaneshiro SA, Failla JM, Tashman S. Scaphoid fracture displacement with forearm rotation in a short-arm thumb

spica cast. J Hand Surg Am 1999;24:984–91.

[13] Toby EB, Butler TE, McCormack TJ, Jayaraman A. Comparison of fixation screws for the scaphoid during

application of cyclic bending loads. J Bone Joint Surg Am 1997;79:1190–7.

[14] Faran KJ, Ichioka N, Trzeciak MA, Han S, Medige J, Moy OJ. Effect of bone quality on the forces generated by

compression screws. J Biomech 1999;32(8):861–4.

[15] Gutow A, Noonan J, Westmoreland G, Slade JF III. Biomechanical comparison of fixation methods for proximal

pole scaphoid fractures. Presented at American Society for Surgery of the Hand (ASSH). Seattle, WA, 2000.

[16] McCallister W, Knight J, Kaliappan R, Trumble T. Does central placement in the proximal pole of the scaphoid

offer biomechanical advantage in the internal fixation of acute fractures of the scaphoid waist? ASSH 56th Annual

Meeting. Baltimore, October 6, 2001.

[17] Whipple TL. The role of arthroscopy in the treatment of intra-articular wrist fractures. Hand Clin 1995;11:13–8.

[18] Slade JF III, Grauer JN, Mahoney JD. Arthroscopic reduction and percutaneous fixation of scaphoid fractures with

a novel dorsal technique. Orthop Clin N Am 2001;32:247–61.

[19] Slade JF III, Grauer JN. Dorsal percutaneous repair of scaphoid fractures with arthroscopic guidance. Atlas Hand

Clin 2001;6:307–23.

[20] Slade JF III, Jaskwhich J. Percutaneous fixation of scaphoid fractures. Hand Clin 2001;17:553–74.

[21] Trumble TE, Gilbert M, Murray LW, et al. Displaced scaphoid fractures treated with open reduction and internal

fixation with a cannulated screw. J Bone Joint Surg Am 2000;82:633–41.

[22] Bond CD, Shin AY, McBride MT, et al. Percutaneous screw fixation or cast immobilization for nondisplaced

scaphoid fractures. J Bone Joint Surg Am 2001;83:483–8.

[23] Salter RB, Simmonds DF, Malcolm BW, Rumble EJ, MacMichael D, Clements ND. The biological effect of

continuous passive motion on the healing of full-thickness defects in articular cartilage. An experimental

investigation in the rabbit. J Bone Joint Surg Am 1980;62(8):1232–51.

[24] Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation: a pilot study. J Bone Joint Surg Br 1998;80:95–9.

[25] Adolfsson L, Lindau T, Arner M. Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist

fractures. J Hand Surg Br 2001;26:192–5.

[26] Inoue G, Tamura Y. Closed technique for the Herbert screw insertion in an undisplaced fracture of the scaphoid.

J Orthop Surg Tech 1991;6:1–7.

[27] Ledoux P, Chahidi N, Moermans JP, Kinnen L. Percutaneous Herbert screw osteosynthesis of the scaphoid bone.

Acta Orthop Belg 1995;61:43–7.

[28] Schadel-Hopfner M, Bohringer G, Gotzen L. Percutaneous osteosynthesis of scaphoid fracture with the Herbert-

Whipple screw-technique and results. Handchir Mikrochir Plast Chir 2000;32:271–6.

[29] Taras JS, Sweet S, ShumW, et al. Percutaneous and arthroscopic screw fixation of scaphoid fractures in the athlete.

Hand Clin 1999;15:467–73.

[30] Toh S, Nagao A, Harata S. Severely displaced scaphoid fracture treated by arthroscopic assisted reduction and

osteosynthesis. J Orthop Trauma 2000;14:299–302.

[31] Yip HS, Wu WC, Chang RY, So TY. Percutaneous cannulated screw fixation of acute scaphoid waist fracture.

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[32] Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation. A pilot study. J Bone Joint Surg Br 1998;80(1):

95–9.


Volar percutaneous fixation of stablescaphoid fractures

Alexander Y. Shin, MDa,*, LCDR Eric P. Hofmeister, MC, USNb

aDepartment of Orthopaedic Surgery, Division of Hand Surgery, Mayo Clinic,

200 First Street Southwest, Rochester, MN 55905, USAbDivision of Hand and Microsurgery, Department of Orthopaedic Surgery,

Naval Medical Center San Diego, San Diego, CA 92134-5000, USA

Since the 1990s, there has been an emphasis on minimally invasive surgical techniques. Rigidinternal fixation of scaphoid fractures by percutaneous approaches have the benefit of minimal

soft tissue injury with rapid fracture healing and subsequently earlier return to work or sports

[1–6]. The percutaneous approach has been described for dorsal and volar fixation [1–6]. The

indications, contraindications, technique, rehabilitation, complications, and results of treatment

for the volar percutaneous technique are discussed.

Historical perspective

In an attempt to decrease immobilization with the subsequent wrist stiffness, loss of strength,

and loss of economic productivity or athletic endeavors, several authors have described and re-

ported on acute screw fixation techniques for scaphoid fractures [1–14]. Although an open ex-

posure of the scaphoid allows for better fixation and more rapid healing, it requires division of

the important volar radiocarpal ligaments or dorsal capsular structures. A percutaneously

placed compression screw would avoid these potential pitfalls and allow for earlier motion

and rehabilitation. In 1970, Streli [5] reported the technique of percutaneous screw fixationfor fractures of the scaphoid. In 1991, Wozasek and Moser [6] retrospectively evaluated the re-

sults of the volar percutaneous screw fixation technique and showed an 89% healing rate of per-

cutaneous screw fixation of acute scaphoid fracture healing in 146 patients after an average of

4.2 months. These authors concluded that good results could be anticipated with percutaneous

screw fixation. Inoue and Shionoya [3] retrospectively reported on 40 patients treated with

Wozasek and Moser’s technique and showed a union time of 6 weeks compared with a cohort

of conservatively treated fractures that averaged 9.7 weeks and recommended percutaneous

fixation because it allowed for earlier return to work and 100% union rate.

History and physical examination

Scaphoid fractures occur commonly after a fall on the outstretched dorsiflexed wrist and al-

ways should be suspected after this injury. Typical physical examination findings include tender-

ness to palpation at the anatomic snuffbox and the scaphoid tuberosity volarly. There is usually

some localized swelling in this area, and pain is elicited with radial and ulnar deviation. The au-

thors prefer a five-view ‘‘scaphoid series,’’ which includes posteroanterior views in neutral andradial and ulnar deviation, a true lateral view of the carpus, and 20� supinated oblique views [1].


E-mail address: [email protected] (A.Y. Shin).


doi:10.1016/S1082-3131(02)00017-1


The fracture line should be visible on at least two views to confirm the diagnosis. Occasionally

the diagnosis remains in question (ie, the mechanism and physical examination are consistent

with fracture, but radiographs are negative); a computed tomography (CT) scan or tomogram

can assist in identifying a fracture, and a bone scan can be positive 72 hours after injury. CTscan and trispiral tomography also may be useful in cases of known fracture to determine ac-

curately fracture type, location, and degree of displacement.

Indications and contraindications

The goals of surgery include early motion and return to activity while ensuring a high union

rate and avoiding the problems associated with prolonged immobilization. The volar percuta-

neous screw fixation technique described in this article is indicated primarily for minimally and

nondisplaced scaphoid waist fractures (Fig. 1). Displacement of more than 1 mm and comminu-

tion is an indication for open reduction to obtain anatomic alignment. The technique can be

Fig. 1. (A–C) The volar percutaneous technique for cannulated screw fixation is indicated primarily for nondisplaced or

minimally displaced scaphoid waist fractures as depicted in this 20-year-old man. (From Bond CD, Shin AY, McBride

MT, et al. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg

Am 2001;83A:263–77; with permission. Copyright by Journal of Bone and Joint Surgery.)

20 A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 19–28

applied successfully to displaced fractures, however, that can be reduced easily by ulnar devia-

tion and wrist extension. Fracture pattern and location are crucial; a transverse waist fracture is

ideally suited to stable fixation with a screw placed from the volar-distal direction. Conversely,

this technique is contraindicated in proximal pole and oblique fractures because the screw can-

not cross perpendicularly the fracture line and obtain adequate compression and purchase. Dis-tal pole fractures can present the same technical difficulties. These are considered relative

contraindications to the technique and are subject to patient and surgeon preferences.

Another relative contraindication is the ‘‘occult’’ scaphoid fracture (ie, when the patient has a

mechanism and examination consistent with fracture but negative radiographic studies). After 2

weeks of immobilization, the fracture line becomes visible where resorption and new bony tra-

beculation have occurred. Although this technique could be used, the authors have managed

these patients nonoperatively because the healing process already has begun when the diagnosis

is made definitively.Although percutaneous screw fixation is highly successful, the surgeon and the patient must

be aware that if the fracture is displaced further or reduced inadequately intraoperatively, an

open reduction technique is required. As such, a thorough preoperative discussion regarding

the potential for displacement of a nondisplaced fracture requiring formal open reduction

and internal fixation is required.

Technique

When anesthetized with a general or regional anesthetic, the patient is placed on the operat-

ing table in the supine position with the arm abducted on a radiolucent arm board (Fig. 2).

Although a tourniquet is placed on the brachium, it is not used routinely. Placement of the fluo-

roscopy unit depends on the handedness of the surgeon. A right-handed surgeon operating on

a right scaphoid feels most comfortable placing the guidewires seated superiorly to the arm, with

the image intensifier coming from inferiorly. Two rolled towels are used under the supinated

wrist to allow for adequate dorsiflexion.

Fig. 2. The arm is placed on the operating table in the supine position over a towel roll. For a right-handed surgeon, the

fluoroscopy unit is placed inferiorly, and the surgeon sits superiorly to the arm.

21A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 19–28

The guidewire for the cannulated screw system is placed through the volar scaphoid tuber-

osity, directed proximally, dorsally, and ulnarly with the wrist hyperextended (Fig. 3). Image

intensification is used in multiple planes to ensure that the wire is placed along the longitudinal

axis of the scaphoid and across the fracture site. Next, a second guidewire is placed parallel tothe first guidewire for antirotation control. This wire must cross the fracture and be far enough

away from the initial guidewire as not to interfere with the drill or screw. Dorsiflexion of the

wrist assists in translating the trapezium out of the path of the wire, making placement easier

and avoiding disrupting the scaphotrapeziotrapezoid joint (Fig. 4). It also is important to under-

stand that the position of the screw within the scaphoid is not along the long axis of the

scaphoid, but is slightly diagonal to it (Fig. 4).

Screw length can be measured with the measuring device available in the screw set or alter-

natively indirectly with a second guide pin. It is important to subtract 5 to 10 mm from themeasured length of the guidewire because the screw should be buried completely within the sca-

phoid. We have found little variation in screw length: A 20-mm screw suffices in almost all cases,

with a 17.5-mm or 22.5-mm screw being used in the remaining cases.

A 3-mm incision is made around the guide pin to allow drill and screw passage. The scaphoid

is hand drilled with the graduated cannulated drill, with the depth monitored by fluoroscopy

(Fig. 5). The cannulated screw is placed with fluoroscopic guidance to judge fracture reduction

and screw position (Fig. 6). Final fluoroscopic images are obtained and a live view of the reduc-

tion. The antirotation guidewire is removed, and the wound is irrigated and closed with a nylonsuture. A well-padded, short arm thumb spica splint is applied.

The authors have used the Accutrak screw system (Acumed, Beaverton, OR) exclusively for

this procedure (Fig. 7); however, other cannulated compression screw systems are available that

likely also would be suitable for this procedure. The Accutrak screw is a headless, tapered, fully

threaded and variable pitched implant that is technically simple to use and provides excellent

compression strength by biomechanical studies [15]. The mini-Accutrak has been unsuitable

for this application because of the smaller guidewire (0.028 inch), which is more difficult to di-

rect in the scaphoid and much more susceptible to bending during the positioning of the wrist.

Complications

This is a safe surgical procedure, but there are some potential pitfalls. One is the possibility of

displacing the fracture. Displacement usually is caused by inaccurate placement of the guidewire

and a drill or screw crossing the fracture at an oblique angle. Displacement is especially likely inproximal pole or oblique fractures, emphasizing the need for proper patient selection. The pa-

tient should be given informed consent for and the surgeon prepared to perform an open reduc-

tion in such a case. Placing a screw with inadequate purchase or in a malreduced fracture can

lead to potentially disastrous consequences. For this reason, patient and fracture selection for

this technique are crucial.

One problem unique to this technique is that of obtaining accurate drill depth. Overdrilling

can lead to a loose screw with poor purchase, and underdrilling potentially could split the bone

when the screw is placed. This problem can be avoided by drilling under fluoroscopic guidanceand placing the drill and screw at the same depth. Failure to bury the head of the screw com-

pletely within the scaphoid can lead to scaphotrapeziotrapezoid arthrosis and may require the

subsequent removal of the screw. This complication can be avoided by selecting a screw length

approximately 5 to 10 mm shorter than measured.

Although the radial artery is a concern in scaphoid fractures, it is in no danger if this tech-

nique is done properly. The artery branches proximal to the scaphoid, and there are no vascular

or neural structures overlying the tuberosity. Anatomic studies have shown the guidewire placed

into the scaphoid through the tuberosity to be 14 mm from the radial artery, 19 mm from thesuperficial branch of the radial nerve, and 5 mm from the superficial branch of the radial artery

[16]. The prudent surgeon must be knowledgeable about the anatomy, but as long as the guide-

wires are placed into the scaphoid under fluoroscopic guidance and care is taken not to make

errant passes into soft tissue, the risk of damage to the radial artery is minimal.


Fig. 3. (A) A guidewire from the cannulated screw set or a 0.035-inch Kirschner wire is placed percutaneously onto the

distal pole of the scaphoid while the wrist is extended over a towel roll. The guidewire is directed proximally, dorsally,

and ulnarly. After the initial guidewire is placed properly along the axis of the scaphoid and perpendicular to the

fracture, a second antirotation wire is placed. Placement is confirmed by multiple fluoroscopic images and real-time

images. (B–D) Anteroposterior, oblique, and lateral fluoroscopic images. The screw length is calculated by subtracting 5

to 10 mm from the actual measured length of the screw. (From Bond CD, Shin AY, McBride MT, et al. Percutaneous

screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am 2001;83A:263–77; with

permission. Copyright by Journal of Bone and Joint Surgery.)


Fig. 4. Extending the wrist on a towel roll translates the trapezium dorsal to the scaphoid, allowing the guidewire to be

placed in the proper location in the distal volar aspect of the scaphoid (open circle on the distal pole of the scaphoid).

Without extension of the wrist, the trapezium blocks the proper starting point on the distal volar scaphoid. The actual

position of the screw within the scaphoid is not along the long axis of the scaphoid, but is slightly diagonal to it (inset).

Fig. 5. After the guidewires are placed, a 3-mm incision is made next to the primary guidewire. The soft tissues are

spread bluntly with a fine hemostat. The cannulated drill is hand drilled to a depth confirmed by the image intensifier.

Anteroposterior (A) and lateral (B) views are shown.


Rehabilitation

Digital range of motion and edema control are initiated on the first postoperative day. The

hand is kept in a surgical dressing with a volar plaster splint for 10 days, at which time the splintand sutures are removed. The patient is placed into a molded orthoplast short arm thumb spica

splint for 3 additional weeks. During this time, the splint is removed for gentle wrist motion and

hygiene. When radiographic and clinical union are achieved (usually 6 to 7 weeks), the splint is

discontinued, and all previous activities are resumed as tolerated (Fig. 8).

Results of surgery

The results of percutaneous screw fixation of scaphoid fractures have been promising.Wozasek and Moser [6] had an 89% healing rate with this technique in a variety of scaphoid

fracture types, with an average healing time of 4.2 months. Inoue and Shionoya [3] showed

that percutaneous screw fixation had a more rapid time to union compared with a cohort of

conservatively treated scaphoid fractures. The average time to union in the percutaneous screw

Fig. 6. Typically a 20-mm Accutrak screw is used, with a 17.5-mm or 22.5-mm screw occasionally being used. The screw

is placed over the guidewire and is advanced across the fracture site under fluoroscopic guidance. (A) Operative view of

the insertion of the screw. (B–D) Anteroposterior, oblique, and lateral fluoroscopic views of the inserted screw.


fixation cohort was 6 weeks compared with 9.7 weeks for conservatively treated fractures, with

earlier return to work for the percutaneous fixation cohort. The senior author reported on a

prospective randomized study of nondisplaced scaphoid waist fractures treated with percuta-

neous screw fixation versus cast immobilization and showed statistically significant differences

in time to union and return to work status [1]. This series showed that patients who underwent

percutaneous screw fixation healed their fractures at an average of 7.1 weeks compared with

11.6 weeks for cast immobilization. Similarly, patients who had percutaneous screw fixation

Fig. 7. The Accutrak screw is a cannulated, headless, tapered, fully threaded, variable pitched implant. The screw is

technically simple to use and provides excellent compression strength. (Courtesy of Acumed, Beaverton, OR.)

Fig. 8. Follow-up radiographs of a nondisplaced scaphoid fracture after volar percutaneous screw fixation taken 6

weeks after surgery show a healed fracture in the anteroposterior (A), oblique (B), and lateral (C) radiographic views.


returned to work at an average of 8.2 weeks versus 15.3 weeks for cast immobilization. There were

no nonunions and only one case of a prominent painful screw that required subsequent removal.

Summary

Percutaneous screw fixation of minimally displaced or nondisplaced scaphoid fractures pro-

vides stable internal fixation and allows for earlier healing, maintenance of motion and grip

strength, and quicker return to work or athletics. The technique, although technically demand-

ing, is easily mastered and can decrease significantly the potential problems associated with pro-

longed cast immobilization and the hardships of time off work or athletics.

References

[1] Bond CD, Shin AY, McBride MT, et al. Percutaneous screw fixation or cast immobilization for nondisplaced


[2] Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation using a cannulated screw. Ann Chir Main

1998;17:119–26.

[3] Inoue G, Shionoya K. Herbert screw fixation by limited access for acute fractures of the scaphoid. J Bone Joint Surg

Br 1997;79:418–21.

[4] Slade JF 3rd, Grauer JN, Mahoney JD. Arthroscopic reduction and percutaneous fixation of scaphoid fractures

with a novel dorsal technique. Orthop Clin North Am 2001;32:247–61.

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1970;95:1060–78.

[6] Wozasek GE, Moser KD. Percutaneous screw fixation for fractures of the scaphoid. J Bone Joint Surg Br

1991;73:138–42. [published erratum appears in J Bone Joint Surg Br 1991;73:524].

[7] Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br

1984;66:114–23.

[8] Huene DR. Primary internal fixaton of carpal navicular fractures in the athlete. Am J Sports Med 1979;7:175–7.

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[10] O’Brien L, Herbert TJ. Internal fixation of acute scaphoid fractures: a new approach to treatment. Aust N Z J Surg

1985;55.

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[12] Rettig AC, Kollias SC. Internal fixation of acute stable scaphoid fractures in the athlete. Am J Sports Med

1996;24:182–6.

Fig. 8 (continued )


[13] Rettig AC, Weidenbener EJ, Gloyeske R. Alternative management of midthird scaphoid fractures in the athlete. Am

J Sports Med 1994;22:711–4.

[14] Whipple TL. Stabilization of the fractured scaphoid under arthroscopic control. Orthop Clin North Am

1995;26:749–54.

[15] Wheeler DL, McLaughlin SW. Biomechanical assessment of compression screws. Clin Orthop 1998;350:237–46.

[16] Kamineni S, Lavy CBD. Percutaneous fixation of scaphoid fractures: an anatomic study. J Hand Surg Br

1999;24:85–8.


Percutaneous scaphoid fixation:surgical technique volar approach with traction

Nicholas Goddard, MB, FRCS*

Department of Orthopaedics, Royal Free Hospital, London NW3 2QG, UK

The management of scaphoid fractures generates significant debate [1]. There is no generalconsensus regarding either the duration or the ideal position for cast immobilization. It isdifficult to ensure that the fracture has united, and importantly, even in the best reported seriesthere remains a 10% failure rate.

Acute open reduction and rigid internal fixation of displaced intra-articular fractures iswidely accepted as best practice, and the scaphoid is no exception. Herbert [2,3] introduced areliable device and established screw fixation of the scaphoid. The role of surgery for minimallydisplaced or undisplaced fractures remains unclear. It is, however, apparent that most scaphoidfractures occur in young men who may be manual workers or may be involved in athleticactivity. The avoidance of plaster immobilization in these patients would be desirable. Earlyfixation would provide the opportunity of early mobilization and earlier return to full function.

The open procedure for fixation of the scaphoid is associated with extensive soft tissuestripping and damage to the anterior radiocarpal ligaments [4]. Infection and painful scarhypertrophy in particular are also significant postoperative problems [1], whereas sympatheticdystrophy may be catastrophic. Closed percutaneous scaphoid fixation can be performed as anoutpatient procedure and allows for earlier mobilization, has an increased rate of union, and hasbeen shown to have fewer complications.

Percutaneous screw fixation of the scaphoid first was reported by Streli [5] in 1970 in theGerman literature. In 1991, Wozacek and Moser [6] reported an adaptation of Streli’s techniqueusing cannulated 2.9-mm screws through a volar percutaneous approach with an 89% unionrate. Ledoux and colleagues [7] reported 23 cases using percutaneous Herbert screw osteo-synthesis of the scaphoid bone with union in all cases, 95% range of motion compared with theother side, and better key pinch than the contralateral hand.

In 1996, the author’s group further modified and simplified the volar percutaneous techniqueusing the cannulated Acutrak screw (Acumed, Beaverton, OR) to stabilize minimally displacedor undisplaced B1 or B2 acute scaphoid fractures [8]. In a pilot study, the author’s groupreported a union rate of 100%, and current experience continues to reflect this high rateof union. Encouraged by the early results, the author’s group have expanded the indicationsto include displaced fractures, delayed unions, and some patterns of nonunions in whichsupplementary percutaneous bone grafting is used.

The volar (distal to proximal) approach is applicable to all waist fractures and some proxi-mal third fractures depending on the obliquity of the fracture line. Proximal pole fractures aredealt with best through a dorsal (proximal to distal) approach as described by Slade andJaskwhich [9].

* Corresponding author. 43 Roehampton Lane, London SW15 5LT, UK.

E-mail address: [email protected].


doi:10.1016/S1082-3131(03)00002-5


Operative technique

The procedure of percutaneous scaphoid fixation using the cannulated Acutrak screw can bedone under general or regional anesthesia. Although it is feasible to perform the operation withthe affected arm abducted on a hand table, the author has found it easier to use a modificationof the original technique described by Wozacek and Moser [6]. The patient is placed supine onan operating table, the forearm and hand are prepared in a standard fashion, and the rest of theupper limb and body are covered with an extremity drape (Fig. 1).

The hand is suspended by the thumb alone in a single Chinese finger trap with nocountertraction. This position extends the scaphoid and ulnar deviates the wrist to improveaccess to the distal pole of the scaphoid. Importantly, it permits free rotation of the handthroughout the operation and the scaphoid remains in the center of the x-ray field (Fig 2).

The image intensifier C-arm is turned to a horizontal position and positioned so that the wristis in the central axis. With the image intensifier in this position, it is possible to screen thescaphoid continuously around the axis of the radial column. In most cases, there is no need forany additional measures to reduce the fracture. If it is thought that the position of the fracture isunacceptable, however, Kirschner wires can be inserted and used as joysticks to manipulate thefragments into position. The quality of the reduction can be checked radiographically and ifnecessary arthroscopically without disturbing the overall setup. As with any closed fracturefixation, time spent in setting up and ensuring quality of the reduction is time well spent.

Having achieved an acceptable reduction, the first, and probably most important, step is toestablish the entry point of the guidewire and ultimately the position of the screw. The ulnardeviation of the wrist allows the distal half of the scaphoid to slide out from under the radialstyloid. The scaphoid tuberosity is easily palpable and is the key to the insertion point.

The entry point is located using a 12G intravenous needle introduced on the anteroradialaspect of the wrist just radial to and distal to the scaphoid tuberosity. This needle serves as atrochar for the guidewire and proves to be invaluable as a direction aid. The needle is insinuatedinto the scaphotrapezial joint and tilted into a more vertical position, and the position is checkedon the under image intensifier. By gently levering on the trapezium, this maneuver brings thedistal pole of the scaphoid more radial and ultimately facilitates screw insertion. It is possible toscreen the wrist by simply rotating the forearm in the x-ray beam and to line up the needle alongthe long axis of the scaphoid in all planes. The aim should be to have the guidewire exiting theproximal pole just radial to the scapholunate junction. When the surgeon is happy with theproposed entry point and the direction of the guidewire, it is helpful to tap the needle lightly intothe soft articular cartilage over the distal pole of the scaphoid so that the tip does not slip duringthe insertion of the guidewire.

Fig. 1. Overall setup. The thumb is suspended by a single trap, placing the wrist in slight ulnar deviation and extension.

The C-arm is brought across the patient’s upper body.

30 N. Goddard / Atlas Hand Clin 8 (2003) 29–35

The guidewire (0.045 inch/1.1 mm) can be passed down through the needle and drilled acrossthe fracture, continually checking the direction on the image intensifier and correcting asnecessary, aiming for the radial aspect of the proximal pole. This process requires an ap-preciation of the obliquity of the scaphoid in anteroposterior and lateral planes. It is crucial notto bend the guidewire, and any adjustments in direction should be made using the needle as aguide rather than attempting to alter the line of the guidewire alone (Figs. 3 and 4).

The guidewire should be advanced to stop just short of the articular surface and should notbreach it at this stage. The position, alignment, and length are checked one more time. If theposition is thought to be satisfactory, a longitudinal incision of 0.5 cm is made at the entry pointof the wire and deepened down to the distal pole of the scaphoid using a small hemostat andblunt dissection. This is a relatively safe zone.

The length of the screw is determined either by using the proprietary depth gauge or byadvancing a second guidewire of the same length up the distal cortex of the scaphoid andsubtracting the difference between the two. The correct screw size is 2 to 4 mm shorter than themeasured length to ensure that the screw head is buried fully below the cartilage and the corticalsurface. The positioning guidewire is advanced through the proximal pole of the scaphoid to exiton the dorsal aspect of the wrist. This is a precautionary measure to minimize the risk of in-advertent withdrawal of the wire during the reaming process and screw insertion. In the rarecases in which it is thought that there is a possibility of rotational instability, it is recommendedthat a second derotation wire be inserted parallel to the first before drilling and reaming.

Having secured the guidewire, the 12G needle is slid off, and the graduated cannulated drill ispassed over the wire using either a power drill or hand reamer, stopping 1 to 2 mm short of thearticular surface. It is helpful to screen this process to ensure accurate drilling and especially toensure that the guidewire has not inadvertently been bent and driven on through the scaphoid(Fig. 5).

The self-tapping screw is advanced over the guidewire and the wire removed. Compressioncan be confirmed radiographically on the image intensifier (Fig. 6).

Fig. 2. Close-up of the entry point. The entry point is more proximal than normally might be assumed. It is helpful to

use a 12G or 14G intravenous cannula as a trochar and aiming device, initially bringing it in virtually horizontally at the

scaphotrapezial joint, then swinging it upward and anteriorly to line up the proposed direction of the guidewire.

31N. Goddard / Atlas Hand Clin 8 (2003) 29–35

The skin is closed using a single Steri-strip or suture, which is covered with a sterilecompressive dressing. The tourniquet is released, and the arm is elevated. Plaster immobilizationis optional and is not used in the author’s unit when fixation appears stable. The arm is elevatedimmediately postoperatively, and routine postanesthetic and neurovascular monitoring isrecorded.

Fig. 3. Anteroposterior position of the guidewire. The entry point is at the lateral border of the scaphoid tuberosity, and

the 14G needle is being used as an aiming device and trochar. The guidewire should be directed to the radial aspect of the

scapholunate joint.

Fig. 4. Lateral position of guidewire. This position is acceptable, but ideally should be a little more anterior.


Patients are encouraged to begin active finger exercises before discharge. The patients areexamined 10 days postoperatively to exclude sepsis and to ensure that early mobilization isbeing performed. The sutures are removed at this stage, and carpal radiographs are taken toconfirm that screw position is satisfactory. At this stage, patients are allowed to mobilize gently,but no heavy carrying or weight-bearing activity is permitted.

Patients are examined again 4 weeks later, and more radiographs are taken. Return tosedentary work is allowed as soon as the patient feels ready or when 75% of the contralateralrange of motion is achieved. Manual work and athletic activity are deferred until there isradiographic evidence of fracture union. Patients are advised to wear a supportive splint forcontact sports.

Fig. 5. After measuring the length of the screw, the guidewire is advanced through the articular surface so as to prevent

inadvertent withdrawal during reaming and screw fixation. The chosen screw must be 2 to 4 mm shorter than the

measured length. The reamer has stopped 2 to 3 mm short of the proximal pole.

Fig. 6. (A and B) Final position of screw. Note the central axis and that both ends are buried beneath the articular

surfaces.


Discussion

The open approach to scaphoid fracture fixation is technically demanding, damages theanterior radiocarpal ligaments, violates the scaphotrapezial joint, further endangers the alreadycompromised blood supply of the scaphoid, and frequently leads to troublesome hypertrophicscars [1]. The blood supply of the scaphoid is precarious; 13% of scaphoids have a blood supplypredominantly in the distal one third, and 20% have no more than a singe foramen in theproximal third [10]. This blood supply is threatened further by any open approach to thescaphoid. Garcia-Elias and colleagues [4] reported carpal instability after volar approaches tothe scaphoid that damage the radiocapitate and radiolunate ligaments. The percutaneoustechnique minimizes operative trauma and attempts to preserve the blood supply of thescaphoid and the integrity of its surrounding ligaments.

Herbert and Fisher [2] reported a far higher union rate for acutely stabilized scaphoidfractures. This rate was supported by the later work of Bunker and coworkers [11] and Wozacekand Moser [6]. Filan and Herbert’s [3] operative findings supported early intervention; theyalmost invariably noted that the fractures were worse than suggested by radiographs and notedsoft tissue interposition in 28 of 82 acute fractures.

Satisfactory function after scaphoid fractures requires union in an anatomic position. Thisunion is facilitated, although not accelerated, by stable fixation with a compression screw.Scaphoid screw fixation has been evaluated extensively clinically and biomechanically [12–14].Although the Herbert screw has a long and admirable clinical track record [3], it is by no meansthe ideal implant. Shaw [12] showed greater compression forces using ASIF screws but acceptedthe biologic advantages of the headless Herbert screw that can be buried within the scaphoidwithout disrupting its bony architecture. Rankin and colleagues [13] later confirmed Shaw’sfindings.

The Acutrak screw is a headless, highly polished, tapered, self-tapping, fully threadedcannulated device designed to provide interfragmentary compression. Variable pitch createsgradual compression with each turn of the screw. In a ‘‘bone-foam’’ biomechanical study,Acutrak and AO screws had higher peak compressive forces than the Herbert/Whipple screw,and the Acutrak screw had the greatest push-out resistance [15] (Wheeler, et al: personalcommunication). It could be postulated that the Acutrak screw combines some of the ad-vantages of the Herbert or Herbert/Whipple system in being headless and having a variablepitch, while also providing improved interfragmentary compression.

The economic and social cost of plaster immobilization after scaphoid fractures must not beunderestimated. This is particularly the case in young working men or in young men involved inathletic and sporting pursuits. The technique described allows early intervention with aminimally invasive outpatient procedure. This technique encourages early wrist and handmobilization, while avoiding the pitfalls of open carpal surgery.

The author’s group now has experience of almost 200 percutaneous scaphoid fixations and isencouraged by the high rate of fracture union (>97%) in the treatment of acute fractures.Importantly, this high rate of union has been confirmed by others, and the author now routinelyoffers surgery as an alternative to plaster casting [8,16–18].

References

[1] Barton NJ. The Herbert screw for fractures of the scaphoid. J Bone Joint Surg Br 1996;78:517–8.


1984;66:114–23.

[3] Filan ST, Herbert TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg Br 1996;78:19–29.

[4] Garcia-Elias M, Vall A, Salo JM, Lluch AL. Carpal alignment after different surgical approaches to the scaphoid:

comparative study. J Hand Surg Am 1988;13:604–12.

[5] Streli R. Perkutane Verscraubung des Handkahnbeines mit Bohrdrahtkompressionschraube. Zentralbi Chir 1970;

95:1060–78.

[6] Wozacek GE, Moser KD. Percutaneous screw fixation for fractures of the scaphoid. J Bone Joint Surg Br 1991;

73:138–42.

[7] Ledoux P, Chahidi N, Moermans JP, Kinnen L. Percutaneous Herbert screw osteosynthesis of the scaphoid bone.

Acta Orthop Belg 1995;61:43–7.


[8] Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation. J Bone Joint Surg Br 1998;80:95–9.

[9] Slade JF III, Jaskwhich D. Percutaneous fixation of scaphoid fractures. Hand Clin 2001;17:553–74.

[10] Obletz BE, Haibstein BM. Non-union of fractures of the carpal navicular. J Bone Joint Surg 1938;20:424–8.

[11] Bunker TD, McNamee PB, Scott TD. The Herbert screw for scaphoid fractures: a multicentre study. J Bone Joint

Surg Br 1987;69:631–4.

[12] Shaw JA. A biomechanical comparison of scaphoid screws. J Hand Surg Am 1987;12:347–53.

[13] Rankin G, Kuschner SH, Orlando C, et al. A biomechanical evaluation of a cannulated compressive screw for use in

fractures of the scaphoid. J Hand Surg Am 1991;16:1002–10.

[14] Kaulesar Sukul DM, Johannes EJ, Marti RK, Kiopper PJ. Biomechanical measurements on scaphoid bone screws

in an experimental model. J Biomech 1990;23:1115–21.

[15] Conrad G, et al. Small bone screw compression. Beaverton, OR: Acumed Inc.

[16] Adolfsson L, Lindau T, Arner M. Acutrak screw fixation versus cast immobilization for undisplaced scaphoid waist

fractures. J Hand Surg Br 2001;26:192–5.

[17] Bond CD, Shin A, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for non-displaced


[18] Yip HSF, Wu WC, Chang RYP, So TYC. Percutaneous cannulated screw fixation of acute scaphoid waist fracture.

J Hand Surg Br 2002;27:42–6.


Arthroscopic assisted fixation of fracturesof the scaphoid

William B. Geissler, MD

Section of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery and Rehabilitation,

University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA

Wrist arthroscopy has revolutionized the practice of orthopedics by providing the technical

capability to examine and treat intra-articular abnormalities. Wrist arthroscopy allows direct

visualization of cartilage surfaces, synovial tissue, and the interosseous ligament under bright

light and magnification. The scaphoid is well visualized with the arthroscope in the midcarpal

space. This visualization allows for arthroscopic assisted fixation of the scaphoid.The scaphoid is the carpal bone that most often sustains a fracture and accounts for 70% of

carpal fractures. This injury typically occurs in young men between the ages of 15 and 30 years.

Scaphoid fractures are also a common athletic injury, particularly in basketball and football be-

cause aggressive play frequently causes impact injuries to the wrist. It is estimated that incidence

of scaphoid fractures in college football players is approximately 1 out of 100 [1].

Acute nondisplaced scaphoid fractures traditionally have been managed with cast immobili-

zation. Nondisplaced scaphoid fractures have been reported to heal in 8 to 12 weeks when

immobilized in long and short arm thumb spica casts [2,3]. However, The rate of nonunionfor these fractures has been reported to be 15%, however [2]. The duration of cast immobiliza-

tion varies dramatically according to the fracture site. A fracture of the scaphoid tubercle may

heal within 6 weeks, whereas a fracture of the waist may take 3 months or more of immobiliza-

tion. Fractures of the proximal third of the scaphoid may take 6 months or longer to heal with

cast immobilization because of the distal vascularity of the scaphoid.

Although cast immobilization may be successful in 90% of cases, it must be asked at what

cost to the patient, who may not be able to tolerate a lengthy course of cast immobilization.

Prolonged cast immobilization leads to muscle atrophy, possible joint contracture, disuse osteo-penia, and possibly financial hardship [4]. An athlete or worker may be inactive for 6 months or

longer as the fracture heals. Patient dissatisfaction secondary to prolonged immobilization and

frequent clinic visits and radiographic monitoring is common. Also, it is difficult to access com-

plete healing of the scaphoid with plain radiographs. Approximately 10% to 15% of all scaphoid

fractures progress to nonunion, even under the most ideal circumstances.

A nonunion rate of approximately 50% has been reported with displaced fractures [5]. Fac-

tors that worsen the prognosis for healing included displacement, delayed presentation of

greater than 4 to 6 weeks, and the presence of associated carpal instability [5,6]. Traditionally,displaced fractures of the scaphoid have been managed by an open surgical approach [7–10].

This approach requires significant soft tissue dissection. Complications of open reduction have

been reported, with hypertrophic scar seen as the most common complication (13%). Other pos-

sible complications include nonunion, avascular necrosis, carpal instability, donor site pain

(bone graft), infection, screw protrusion, and reflex sympathetic dystrophy [6]. Jigs designed

to assist in fracture reduction have proved difficult to apply, requiring more extensive surgical

exposure [11].

E-mail address: [email protected] (W.B. Geissler).


doi:10.1016/S1082-3131(02)00023-7


Successful union of scaphoid fractures depends on vascular ingrowth because the scaphoid

is surrounded by cartilage and has a limited blood supply. The major blood supply is through

the radial artery. Of the intraosseous vascularity in the entire proximal pole, 70% to 80% arises

from the branch of the radial artery entering through the dorsal ridge [12]. Scaphoid fracturesrisk necrosis of the proximal fracture unless vascularity can be reestablished. An open surgical

approach can place at risk the vascular blood supply to the scaphoid, particularly through an

extensive dorsal approach [13].

Arthroscopic or percutaneous assisted fixation of scaphoid fractures offers a middle ground

between the traditional recommendations of cast immobilization for nondisplaced fractures and

open reduction for displaced fractures of the scaphoid. The application of arthroscopic wrist

techniques to scaphoid fracture management offers many advantages over conventional tech-

niques. These techniques reduce exposure and minimize soft tissue dissection with potential lossof vascularity to the fracture fragments. These techniques avoid the division of the important

radioscaphocapitate ligament and volar capsule, which requires subsequent repair and healing

[14]. Arthroscopic assisted reduction avoids potential scar formation over the volar radial aspect

of the wrist. In addition, arthroscopic fixation allows for detection and management of any as-

sociated intracarpal soft tissue injuries that may occur with a fracture of the scaphoid.

This article reviews the indications and surgical techniques for arthroscopic assisted fixation

of scaphoid fractures. These techniques are particularly amenable to a young, active population,

in which scaphoid fractures are seen most commonly and the group least likely to tolerate pro-longed periods of immobilization. Early rigid fixation of scaphoid fractures has been advocated

for fractures at increased risk of nonunion, such as proximal pole fractures and for patients

whose work or avocation prohibits traditional plaster immobilization [15]. These techniques

have been applied to nondisplaced scaphoid nonunions in the young, active population without

signs of carpal collapse or instability.

Surgical indications

The goal of internal stabilization of scaphoid fractures is to provide secure fixation to permit

early motion until solid union has been achieved [16]. Surgical indications for arthroscopic

assisted fixation of scaphoid fractures include (1) nondisplaced unstable fractures, (2) minimally

displaced but ‘‘reducible’’ fractures, (3) delayed presentation, (4) proximal pole fractures, (5) fib-

rous nonunions with avascular necrosis and signs of carpal instability, (6) scaphoid and ipsilateral

displaced distal radius fractures, and (7) scaphoid fractures with associated ligamentous injury.

Vertical oblique fractures have a high longitudinal share component and are relatively un-stable [17]. As a result, they require longer periods of immobilization and require frequent radio-

graphic monitoring. This fracture pattern is ideal for arthroscopic management to decrease the

duration of immobilization and, particularly, frequent radiographic monitoring.

Scaphoid fractures are considered displaced if there is 1 mm or more of displacement or

greater than 15� of angulation [6]. A displaced scaphoid fracture is considered unstable and as-

sociated with a nonunion rate of 50%. Internal fixation is indicated to achieve union in greater

than 90% of these fracture patterns [6]. The key to application of arthroscopic techniques is that

the fracture pattern must be reducible. Arthroscopic assisted fixation would not be indicated in ascaphoid nonunion with secondary humpback deformity and dorsal intercalated segment insta-

bility (DISI) collapse [18]. Volar wedge bone grafting to bring the scaphoid back to anatomic

alignment would be required in this situation. Arthroscopically assisted fixation of a scaphoid

fracture that is not reducible may result in fracture healing but may result in a scaphoid

malunion. The natural history of scaphoid malunion is uncertain, but malunion decreases func-

tional outcome and may result in premature radiocarpal arthritis.

Delayed immobilization of greater than 6 weeks from initial injury increases the risk of non-

union [6]. Particularly in cases in which the fracture is nondisplaced, such cases are ideal for ar-throscopic assisted fixation. Acute proximal pole fractures, which may require a minimum of 4

to 6 months of cast immobilization, are ideal for arthroscopic assisted fixation [15]. This tech-

nique allows for earlier range of motion and decreases the risk of cast disease, including muscle

atrophy and joint stiffness.

38 W.B. Geissler / Atlas Hand Clin 8 (2003) 37–56

Displaced and nondisplaced acute fractures of the scaphoid may occur in association with

intra-articular fractures of the distal radius. Arthroscopic assisted fixation of associated

scaphoid fractures is an ideal indication that the fracture of the distal radius requires internal

fixation. The fracture of the distal radius may be addressed arthroscopically as well, or arthro-

scopic assisted fixation of the scaphoid may be used in combination with limited open tech-niques to fix the distal radius fracture if the capsule is not open. This approach also allows

for the detection and management of any associated intracarpal soft tissue injuries that can

occur with a fracture of the distal radius or scaphoid.

Relative indications for arthroscopic fixation include (1) contralateral hand or wrist frac-

tures; (2) polytrauma; and (3) undue psychological, athletic, or economic hardship. Arthro-

scopic fixation of nondisplaced or displaced fractures of the scaphoid may be indicated when

severe hand or wrist fracture occurs on the opposite extremity. This is a situation when the

contralateral hand trauma would require prolonged immobilization. In this way, the scaphoidfracture may be stabilized with minimal morbidity and may allow the patient to continue to take

care of himself or herself when the opposite hand is involved. A similar indication would be in a

case of polytrauma, in which multiple extremities are involved. Stabilization of the scaphoid

fracture with minimal surgical morbidity may help the patient significantly with immobilization,

personal hygiene, and the use of the hand to help in ambulation.

Fractures of the scaphoid typically occur in young men between the ages of 15 and 30. A frac-

ture of the scaphoid in this population particularly may cause undue financial or psychological

hardship. A high school or college athlete’s potential to garner an athletic scholarship or obtaina professional sports contract may depend on the athlete’s early return to competition [1].

Obligatory demands on the athlete’s hands and the time constraints of a rigorous schedule may

make prolonged cast immobilization intolerable. In these special situations, arthroscopic assisted

fixation of a nondisplaced scaphoid fracture may be indicated, and this should factor into the

treatment decision.

Surgical technique

Various arthroscopic assisted and percutaneous techniques for fractures of the scaphoid have

been described in the literature [19–23]. These techniques include the volar approach (popular-

ized by Haddad and Goddard [20]), the dorsal approach (more recently popularized by Slade

and colleagues [24]), and the use of the Herbert-Whipple jig (as described by Whipple [25]).

In general, all these techniques include the use of a small amount of wrist arthroscopy and a

significant amount of fluoroscopy. As noted previously, nondisplaced or slightly displaced frac-

tures without comminution are particularly amenable to any of these techniques. Significantlydisplaced fractures with marked DISI rotation of the lunate, particularly in the chronic situa-

tion, are managed best by open reduction and internal fixation.

The percutaneous volar approach was popularized by Haddad and Goddard [20]. Using this

technique, the patient is placed supine, and the thumb is suspended in a Chinese finger trap

while the patient is under general or regional anesthesia. Placing the thumb in suspension causes

ulnar deviation of the wrist, which gives access to the distal pole of the scaphoid. Under fluoro-

scopy, a longitudinal 0.5-cm incision is made at the most distal radial aspect of the scaphoid.

Blunt dissection is used to expose the distal pole of the scaphoid. A percutaneous guidewireis introduced into the scaphotrapezium joint and advanced proximally and dorsally across

the scaphoid fracture. The position of the guidewire is checked under fluoroscopy in anterior

posterior, oblique, and lateral planes. The length of the guidewire within the scaphoid is deter-

mined with a depth gauge, and a drill is inserted using a guide to protect the soft tissues.

A headless, cannulated Acutrak screw (Acumed, Beaverton, OR) is placed over the guidewire

after drilling [16]. A secondary guidewire is helpful to protect against rotation of the fracture

fragments while the screw is being inserted. Skin closure requires the use of a single suture,

and patients are encouraged to begin active finger exercises before discharge.Kamineni and Lavy [26] reviewed the anatomic basis regarding the safety of the percutaneous

volar approach in 32 cadaver wrists. In this study, the authors evaluated the distance of the neu-

rovascular structures from the volar entry points. The radial artery averaged 14 mm (range 7 to

39W.B. Geissler / Atlas Hand Clin 8 (2003) 37–56

24 mm) from the entry point, and the radial nerve averaged 19 mm (range 7 to 9 mm). The struc-

ture most at risk was a superficial branch of the radial artery averaging 5 mm (range 0 to 8 mm)

from the entry point. Because of risk of the superficial branch of the radial artery, Kamineni and

Lavy [26] recommended making a 1-cm incision over the scaphotrapezial joint before introduc-

tion of the guidewire and screw.

Fig. 1. Arthroscopic view with the arthroscope in the 3,4 portal of the Herbert-Whipple jig inserted through the 1,2

portal. The spike of the jig is placed on the dorsal aspect of the scaphoid 1 to 2 mm radial to the scapholunate

interosseous ligament.

Fig. 2. View of the scaphoid fracture with the arthroscope in the radial midcarpal portal. The fracture still is displaced

slightly.


Haddad and Goddard [20] reported their initial results in a pilot study of 15 patients. Union

was achieved in all patients at a mean of 57 days (range 38 to 71 days). The range of motion

after union was equal to that of the contralateral limb, and grip strength was 98% of the con-

tralateral side at 3 months. Patients were able to return to sedentary work within 4 days and

manual work within 5 weeks.Whipple [25] first reported on arthroscopic assisted reduction screw fixation of scaphoid frac-

tures using a modified cannulated Herbert screw and jig. The modified Herbert-Whipple screw

allowed for more accurate installation over a preliminary guidewire, incorporating self-tapping

threads, and provided a larger cross-sectional diameter of the unthreaded portion of the screw

for increased bending strength at the fracture site without changing the thread diameter. Whip-

ple [25] noted the advantage of the Herbert-Whipple jig included the fact that the jig eliminates

the need for the division of the volar radioscaphocapitate ligament to expose the proximal pole

of the scaphoid. The guide barrel of the jig is pressed against the distal pole of the scaphoid tofurther compression of the fracture site, and the guidewire and screw are inserted with less sur-

gical exposure.

Using Whipple’s technique, a 12- to 15-mm volar incision is made over the scaphoid tubercle

to expose the scaphotrapezial joint. The joint capsule is opened transversely. The scaphoid

tubercle of the trapezium is excised to expose the volar aspect of the articular surface of the

scaphoid distal pole. This amount of bony resection measures approximately 3 · 4 · 5 mm.

The wrist is suspended in a traction tower, and the arthroscope is introduced with a blunt trocar

into the radial midcarpal portal. A fracture of the scaphoid is assessed best with the arthro-scope in the midcarpal portals rather than the radial carpal space. A fracture of the waist of

the scaphoid is visualized best with the arthroscope in the radial midcarpal portal, whereas

a fracture of the proximal pole of the scaphoid is visualized best with the arthroscope in the

ulnar midcarpal portal as it looks across the wrist. The reduction of the scaphoid fracture is

assessed from the midcarpal space. If the fracture is anatomic, the arthroscope is placed

in the 3,4 portal of the radiocarpal space. If the fracture is still displaced, joysticks may be

placed in the proximal distal poles of the scaphoid, and the reduction is fine tuned. When

the reduction is fine tuned, the arthroscope is placed in the 3,4 portal. A working 1,2 portalis made. It is key when making a 1,2 portal to incise just the skin against the tip of the scal-

pel blade. The tip of the blade is inserted in the skin, and using the thumb, the skin is pulled

against the tip of the blade to avoid potential injury to either the radial artery or the branches

of the dorsal sensory branch of the radial nerve. By staying dorsal in the snuffbox, this les-

sens the risk of injury to the radial artery. Blunt dissection is continued with a small hemostat to

the level of the joint capsule, and the joint capsule is opened and spread with the hemostat.

The Herbert-Whipple compression jig is advanced through the 1,2 portal and placed on the

dorsal aspect of the scaphoid. The ideal location for the target point is approximately 2 mmfrom the scapholunate ligament in the radioulnar plane just dorsal to the most proximal contour

of the scaphoid in the sagittal plane (Fig. 1). This is the most important factor using this tech-

nique. When the target hook is placed, the guide barrel of the jig is placed midway between the

radial and ulnar edges of the distal pole of the scaphoid. The jig is compressed. The reduction of

the scaphoid may be checked further by placing the arthroscope back in the radial midcarpal

space (Figs. 2, 3, and 4). When the anatomic reduction of the scaphoid is obtained, primary

and secondary guidewires are placed to the jig across the fracture site.

At this point, the remainder of the procedure is performed under fluoroscopic control. Underfluoroscopy, the placement of the guidewires is evaluated. The primary guidewire should be sur-

rounded by 2 mm of bone in all planes. When satisfactory reduction of the fracture and guide-

wire is seen under fluoroscopy, the primary guidewire is overreamed with a cannulated step drill.

The appropriate length Herbert-Whipple screw is placed over the primary guidewire, and the jig

is removed (Figs. 5, 6, and 7).

Whipple [25] reviewed his original results on arthroscopic reduction on 20 consecutive

scaphoid fractures. Of the 20 patients, 19 healed without complication at 1-year follow-up.

The single complication was an occult fracture of the proximal pole of the lunate that collapsedand required radial lunate fusion.

More recently, the dorsal approach for arthroscopic assisted fixation of scaphoid frac-

tures was popularized by Slade [24,27,28]. This technique has become popular because of its


simplicity for further arthroscopic evaluation and reduction of the fractures. The patient is

placed supine on the table with the arm extended. It is helpful to place several towels under

the elbow to support the forearm so that it is parallel to the floor; this makes it easier to flex

the wrist and allows the x-ray beam to be perpendicular to the wrist. Under fluoroscopy, the

wrist is flexed and pronated until the proximal distal poles of the scaphoid are aligned. The wrist

is flexed at approximately 45�, which places the scaphoid at a 90� flexed position (Fig. 8). Using

this technique, the scaphoid should appear as a round cylinder (‘‘ring sign’’). It is helpful to use

Fig. 3. Joysticks are placed in the proximal distal poles of the scaphoid, and the fracture reduction is adjusted.

Fig. 4. Arthroscopic view of the scaphoid fracture with anatomic reduction after adjustment by the joysticks with the

arthroscope in the radial midcarpal portal.


continuous fluoroscopy as the wrist is flexed to obtain the true ring sign. It can be confusing

with the overlying thumb metacarpal to create the ring of the scaphoid. If this happens, place-

ment of the guide pin would not be down the center of the cylinder of the scaphoid and would

need to be replaced. A 14G needle with a needle driver is used as a drill guide for a 0.045-inch

guidewire. Under fluoroscopy, the needle is placed in the center of the ring and is parallel to the

axis of the fluoroscopy unit (Fig. 9). When this position is obtained, the needle is inserted into

the proximal pole of the scaphoid. It is essential in the particular technique that the needle beplaced in the center of the fluoroscopic ring sign (Fig. 10). When this position is obtained,

the guidewire is driven across the central axis of the scaphoid from dorsal to volar until the dis-

tal end is in contact with the distal scaphoid cortex. The position of the guidewire is checked

under fluoroscopy, maintaining the wrist in flexion. If the wrist is extended at this point, it

can bend the guidewire and cause breakage.

Fig. 5. Fluoroscopic view of the Herbert-Whipple jig inserted on the scaphoid after the fracture has been anatomically

reduced arthroscopically.

Fig. 6. The Herbert-Whipple cannulated screw is inserted over the primary guidewire. A secondary guidewire has been

placed to protect against rotation of the fracture fragments as the screw is inserted.


A second guidewire is placed parallel to the first so that its tip touches the proximal pole cor-

tex. The difference in length between the two wires is the resulting length of the scaphoid.

The tendency in this technique is to insert a screw too long. If a screw is inserted too long, this

potentially can distract the fracture as it is inserted or can violate the scaphotrapezial joint, caus-

ing articular cartilage damage [29]; 4 mm is subtracted from measurement between the guide-

wires, which provides the ideal length of the scaphoid. In this way, the compression screw

can be buried fully in the bone without exposure. If the fracture involves the proximal third,

more than 4 mm of bone may be subtracted because it is not essential to have the screw theentire length of the scaphoid.

The primary guidewire is advanced volarly through the trapezium next along the radial side

of the thumb base (Fig. 11). It is key to protect the assistant’s hand that is holding the wrist

Fig. 7. Radiographic view of the reduction of the scaphoid with the Herbert-Whipple screw in place.

Fig. 8. The wrist is pronated and flexed to form a cylinder under fluoroscopic view. It is helpful to place a large bump

underneath the elbow to support the forearm so that it is parallel with the arm table.


flexed so that the guidewire does not impale the assistant as it advances from dorsal to volar.

The guidewire is advanced volarly until the proximal end of the pin is flush with the proximal

pole of the scaphoid. At this time, the wrist is extended. With the wrist extended, the ideal place-

ment of the guidewire in the scaphoid is confirmed in the anteroposterior, oblique, and lateral

planes (Figs. 12 and 13).

The wrist is suspended in the traction tower. The radiocarpal space is evaluated with the ar-

throscope in the 3,4 portal (Fig. 14). With the arthroscope in the 3,4 portal, the ideal positionof the guidewire in the proximal pole of the scaphoid can be confirmed further (Fig. 15). Similar

to the position of the target hook using the Herbert-Whipple jig, the location of the guide pin on

the proximal scaphoid should be approximately 1 or 2 mm radial to the scapholunate inter-

osseous ligament and on the dorsal portion of the proximal pole of the scaphoid. It is essential

Fig. 9. Under fluoroscopic guidance, a guide pin is placed down the center of the cylinder of the scaphoid.

Fig. 10. Fluoroscopic view of the guide pin inserted down the center of the cylinder of the scaphoid, as formed by

pronation and flexion of the wrist.


that the guide pin or entry point of the guide pin into the proximal pole of the scaphoid is vi-

sualized. Although it is relatively easy to determine the position of the guidewire in the scaphoid

on the oblique and anteroposterior views, sometimes it is confusing to note the most ideal loca-tion of the guidewire in the proximal pole of the scaphoid on the lateral view, particularly in

proximal pole fractures. In small proximal pole fractures, the tip of the guidewire may look ideal

on the anteroposterior view but may transverse proximal or distal to the proximal pole fracture

on the lateral view. By using arthroscopy, the position of the guidewire can be visualized directly

Fig. 11. The guide pin is advanced out the volar aspect of the thumb. The pin exits along the base of the carpo-

metacarpal joint. The pin is advanced out volarly until it is flush with the proximal pole of the scaphoid.

Fig. 12. When the Kirschner wire is advanced out the volar aspect of the wrist, the wrist can be extended. The position of

the guidewire can be evaluated under fluoroscopy in the posteroanterior, oblique, and lateral projections.


in the center of a small proximal pole fragment. At this time, any associated intracarpal soft

tissue injuries of the radiocarpal space can be identified and managed.

The arthroscope is placed in the radial midcarpal portal to assess reduction of the scaphoid

fracture. One concern with this technique is that flexion of the wrist would cause displacement

of the fracture. At this stage, fracture reduction is visualized directly with the arthroscope.Kirschner wire joysticks may be placed in the dorsum of the scaphoid into the proximal distal

fragments if the reduction of the scaphoid is not anatomic. The previously placed guidewire is

advanced volarly until it is only in the distal pole of the scaphoid. The joysticks are used to re-

duce the fracture anatomically as arthroscopically confirmed, then the guide pin is advanced

back proximally from volar to dorsal into the proximal pole fragment of the scaphoid. Just

as in distal radius fractures, in which the reduction of the fracture may look anatomic under

Fig. 13. Arthroscopic view of the guide pin centered within the scaphoid on the posteroanterior view.

Fig. 14. The wrist is suspended in the traction tower with approximately 10 lb of traction. It is helpful to locate the

precise location of the 3,4 and radial midcarpal portals by placing a needle first into the proposed portal location before

making a skin incision.


fluoroscopy, when visualized arthroscopically, the fragments may be rotated. Arthroscopic vi-

sualization of the fracture surface is particularly sensitive to view malrotation of the fragments.

This rotation can be corrected under direct view of the arthroscope, and the guide pin is placedback in the proximal pole of the scaphoid (Figs. 16 and 17).

Fig. 15. Arthroscopic view of the guide pin in the proximal pole of the scaphoid with the arthroscope in the 3,4 portal.

The guide pin, similar to the Herbert-Whipple jig, should be 1 to 2 mm radial to the scapholunate interosseous ligament

and dorsal on the proximal pole of the scaphoid. It is vital to see the entrance of the guide pin to confirm its ideal

location. Although the position of the guide pin may look ideal under the posteroanterior fluoroscopic view, frequently it

is difficult to tell the ideal location on the lateral view under fluoroscopy. Arthroscopy confirms the ideal location of the

guide pin in the proximal pole of the scaphoid.

Fig. 16. Anatomic reduction of the scaphoid is confirmed with the arthroscope in the radial midcarpal portal. Here a

fracture of the waist of the scaphoid is seen best with the arthroscope in the radial midcarpal space.


When anatomic reduction of the scaphoid is noted arthroscopically, the wrist is flexed again,

and the guidewire is advanced dorsally so that it protrudes from the skin (Fig. 18). The guide pin

also is left protruding in the volar aspect of the hand so that if the guidewire breaks or bends, it

can be removed easily from either the volar or the dorsal aspect. A small dorsal incision is made

over the guidewire, and blunt dissection is continued down with the hemostat to the level of thecapsule around the guide pin (Fig. 19). In this manner, the guide pin can be checked so that it

Fig. 17. A fracture of the proximal pole of the scaphoid is seen best with the arthroscope placed in the ulnar midcarpal

portal and allows the surgeon to view the fracture across the wrist. This gives a better view of the reduction of the

fracture and its rotation. With the arthroscope in the radial midcarpal portal, it is difficult to judge rotation of the

fracture fragments in a proximal pole scaphoid fracture.

Fig. 18. The wrist is flexed, and the guide pin is advanced back out the dorsal aspect of the wrist. It is vital to keep the

wrist in flexion at this point so as not to bend the guide pin.


does not impale any of the dorsal extensor tendons to the fingers or thumb. With the wrist in

flexion, the scaphoid is reamed (Fig. 20). Using Slade’s technique, the scaphoid is reamed no

closer than 2 mm from the distal pole of the scaphoid. This detail is crucial because overreamingof the scaphoid prevents secure fixation of the fracture fragments. It is also important at this

point to have a secondary guide pin placed to help prevent rotation of the fracture fragments

during reaming of the scaphoid and placement of the screw. A headless cannulated Acutrak

screw is inserted over the guidewire to the depth previously reamed (Fig. 21). It is again im-

portant that the screw is not overly advanced to the far cortex because this can cause frac-

ture distraction. [28] When the screw is placed, the guidewires are removed. The position of

the screw is checked under fluoroscopy to confirm a central location with the scaphoid (Figs.

22 and 23).At this point, it is important to reevaluate the position of the screw in the proximal pole of

the scaphoid arthroscopically. The wrist is suspended again in the traction tower, and the

arthroscope with a blunt trocar is placed in the 3,4 portal; this is to monitor that the screw

has been inserted fully below the articular cartilage in the proximal pole of the scaphoid because

under fluoroscopy the screw may look fully inserted. At arthroscopy, however, a portion of

the screw still may be seen. If this is the case, the screw is advanced further in the scaphoid

entirely beneath the level of the articular cartilage.

Fig. 19. A small 5- to 10-mm skin incision is made around the guide pin. Blunt dissection is carried down to the level of

the capsule, which is open around the guide pin. This protects the dorsal extensor tendon.


The small dorsal incision may be closed with a single nylon stitch, and a temporary volar

wrist splint is applied. Slade [27] recommended a computed tomography (CT) scan of the wrist

with 1-mm cuts to evaluate fracture healing at approximately 4 to 6 weeks postoperatively. The

CT scan is repeated every 4 weeks until final union is obtained. The patient is placed in a remov-

able wrist brace, and range-of-motion exercises of the fingers and wrist are initiated.

Fig. 20. The scaphoid is reamed with a cannulated reamer. The position of the reamer can be checked under

fluoroscopy.

Fig. 21. A headless cannulated screw is inserted over the guidewire into the scaphoid.


Slade and Jaskwhich [28] reviewed results on arthroscopic assisted fixation with a dorsal ap-

proach in 27 consecutive patients. There were 18 waist fractures and 9 fractures of the proximal

pole. Of patients, 17 were treated within 1 month of injury, and 10 were treated late. All patients

healed their fractures as documented by CT scan.Nondisplaced, fibrous nonunions of the scaphoid also may be stabilized arthroscopically.

The key to this technique is that the scaphoid does not have a humpback deformity and that

the lunate is neutral and there are no signs of carpal collapse. Open reduction and bone grafting

should be considered if there is a humpback deformity of the scaphoid with signs of DISI to the

lunate or if there is dense sclerosis at the nonunion site.

Geissler and Hammit [19] reported on their first 15 patients with fibrous nonunions of the

scaphoid treated arthroscopically. There were 12 horizontal oblique fractures, 1 transverse frac-

ture, and 2 proximal pole fractures. All fractures healed in their series at an average of 3 months(Figs. 24 and 25). Of the 15 patients, 8 underwent CT evaluation that documented healing. Post-

operatively the patients had excellent range of motion as a result of minimal surgical dissection.

The patients in this series healed rapidly after intramedullary fixation with a headless cannulated

screw. This situation would be similar in principle to a long bone nonunion, treated by intrame-

dullary rod fixation, which heals readily. By not stripping any of the soft tissues and preserving

the blood supply, this allows the fracture to heal with stabilization. This technique is

Fig. 22. Posteroanterior radiograph of the headless cannulated screw inserted into the scaphoid.


recommended specifically for fibrous nonunions of the scaphoid without signs of a humpback de-

formity and without extensive sclerosis at the fracture site.Percutaneous bone grafting may be considered in patients with a scaphoid nonunion with ex-

tensive cystic formation. The bone graft may be harvested with a graft harvester from the iliac

crest or the distal radius. This harvester is the same size as the cannulated reamer, and the bone

graft may be placed percutaneously under fluoroscopic control at the scaphoid nonunion site

through the drill hole percutaneously. After placement of the bone graft, the guidewire is re-

placed, and the headless cannulated screw is placed. This is a potential option in patients with

a nonunion of the scaphoid with extensive cystic changes at the nonunion site.

Arthroscopic assisted fixation of scaphoid fractures also allows for simultaneous detection ofassociated intracarpal soft lesions. Braithwaite [19] initially reported on four patients with frac-

tures of the scaphoid with complete scapholunate disassociation in his series. Ho [19] reported

on his series of scaphoid fractures in which associated soft tissue injuries were evaluated by wrist

arthroscopy and arthrograms. In 69 patients with a scaphoid fracture evaluated by wrist ar-

thrography, 38 patients (55%) had positive arthrograms. In his series, 53 patients with fracture

of the scaphoid underwent arthroscopic evaluation. Of patients, 46 (89%) had associated

intracarpal soft tissue injuries, as detected arthroscopically. Ho noted 22 patients with injuries

Fig. 23. Lateral radiographic view of the cannulated screw inserted into the scaphoid.


to the scapholunate interosseous ligament, 17 patients with tears of the lunotriquetral ligament,and 35 patients with tears of the triangular fibrocartilage complex. He also noted 23 patients to

have chondral defects or loose bodies in the joint.

Similar to fractures of the distal radius, associated soft tissue injuries may occur with frac-

tures of the scaphoid. Arthroscopic assisted fixation allows for early detection in management

of any associated soft tissue injuries. Geissler and Hammit [19] devised an arthroscopic classi-

fication of interosseous ligament tears and proposed management. Grade I stretch injuries

are managed with immobilization. Grade II and III injuries are treated with arthroscopic reduc-

tion and Kirschner wire fixation. Complete grade IV injuries are managed best with open repairof the interosseous ligament (Table 1). Although it is not known whether early arthroscopic de-

tection and management of associated soft tissue injuries with fractures of the scaphoid would

improve the final outcome, it is well documented that the success rate of management of acute

interosseous ligament injuries is far better than management of chronic tears.

Summary

Arthroscopic assisted fixation of the scaphoid is not indicated in every patient. Cast immo-

bilization of nondisplaced acute scaphoid fractures has a high success rate in 90% of cases. Ar-throscopic assisted fixation may be a viable treatment option, however, in carefully selected

patients. Arthroscopic assisted reduction offers the advantages of decreased wrist stiffness, less

muscle atrophy from prolonged immobilization, reduced cartilage deterioration, preservation of

the volar radioscaphocapitate ligament, and early return to function for the patient. These

advantages result in reduced overall economic consequences for the patient and potential early

return to competition for the athlete.

Fig. 24. Radiographic view of the scaphoid nonunion with the headless cannulated screw inserted.


Arthroscopic evaluation allows for accurate anatomic reduction of the scaphoid as viewed

from the midcarpal space. Particularly, any rotation that is difficult to detect by fluoroscopy

is easily viewed arthroscopically and can be corrected with joysticks. Arthroscopic evaluation

also allows for ideal placement of the guidewire and visualization of the scaphoid after screw

placement to ensure the headless cannulated screw is seated underneath the articular cartilagebecause it can be difficult to confirm under fluoroscopy [30]. It also allows for detection and

management of any acute soft tissue lesions that have been known to occur with fractures of

the scaphoid.

Fig. 25. Radiographic view of the scaphoid proximal pole nonunion healed with the screw in place. No bone graft

was used.

Table 1

Arthroscopic classification of wrist interosseous ligament instability

Grade Description

I Attenuation/hemorrhage of interosseous ligament as seen from the radiocarpal joint.

No incongruency of carpal alignment in midcarpal space

II Attenuation/hemorrhage of interosseous ligament as seen from the radiocarpal joint.

Incongruency/step-off of carpal space. A slight gap (less than the width of a probe) between

carpals may be present

III Incongruency/step-off of carpal alignment is seen in the radiocarpal and midcarpal space.

The probe may be passed through gap between carpals

IV Incongruency/step-off of carpal alignment is seen in the radiocarpal and midcarpal space.

Gross instability with manipulation is noted. A 2.7-mm arthroscope may be passed through

the gap between carpals


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treatment with Herbert screws. J Bone Joint Surg 1996;78:1829–37.

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Scaphoid fracture repairusing the Herbert screw system (HBS)

Hermann Krimmer, MDa,b,*aSurgery Department, University of Wurzburg, Wurzburg, Germany

bHandcenter Bad Neustadt, Salzburger Leite 1, 97616 Bad Neustadt/Saale, Germany

Traditionally, most scaphoid fractures are thought to heal uneventfully if adequately immo-

bilized in plaster, and this remains the most common method of treatment. The problem with

this approach is that treatment often is prolonged for many months, and a high rate of nonun-

ions resulting from wrong or failed conservative treatment still occurs. The introduction of small

headless screws, first by Herbert [1], has led to increased acceptance of internal fixation. Theseimplants have become simplified and refined in more recent years so that anyone with access to

the necessary equipment should be prepared to consider internal fixation as a viable alternative

to immobilization in plaster.

Material

The advantages of the Herbert screw for internal fixation of the scaphoid are well docu-

mented. Difficulties with precise placement of the screw and the need for a jig limited the appli-

cation, however, at least for minimally invasive techniques [2]. The new generation of

cannulated headless screws facilitated accurate positioning within the scaphoid by the use of

a guidewire, which can be inserted percutaneously without need for a jig. Size and shape of these

implants have to be examined precisely because the Herbert-Whipple screw is quite different

from the design of the original Herbert screw [3].

The HBS (headless bone screw) system is a cannulated screw system with two different com-pression sizes, including the noncannulated mini-Herbert screw (Fig. 1; see Fig. 7A). The normal

and the high compression screw have the same size as the original Herbert screw (3.9 mm at the

head, 2 mm at the shaft, 3 mm at the distal thread) and are cannulated for a 1-mm guidewire.

Different compression forces are based on different pitch thread distally leading to an increased

compression of about 30% for the high compression type. The miniscrew has a 3.2-mm diameter

at the head, 1.5-mm diameter at the shaft, and 2.5-mm diameter at the distal thread appropriate

for the small proximal pole fragment.


Unstable scaphoid fractures (type B) according to Herbert’s classification are an absolute in-

dication for internal fixation because they are known to have a poor prognosis with conservative

treatment (Fig. 6A). This is especially true for proximal pole fractures (type B3), which, because

of their precarious vascularity, have a particularly high rate of nonunion. These fractures mayrequire 4 to 5 months of casting, and there is still a risk of nonunion. As a result, all proximal

* Handcenter Bad Neustadt, Salzburger Leite 1, 97616 Bad Neustadt/Saale, Germany.

E-mail address: [email protected].


doi:10.1016/S1082-3131(02)00021-3


pole fractures, whether displaced or nondisplaced, should be internally fixed [4]. Nondisplaced

scaphoid fractures (type A2) also should be considered for internal fixation whenever treatment

in a cast is not appropriate, for example, in the case of a professional athlete or anyone else inwhom financial pressures dictate an early return to work that would not be possible in a plaster

cast. Similarly the management of patients with coexisting or multiple injuries is simplified

greatly if the scaphoid fracture is internally fixed and plaster can be avoided.

Precise radiologic technique is mandatory to detect the fracture and to analyze the morpho-

logic aspect. High-quality radiographs should include, as a minimum, posteroanterior views

with the wrist in full radial and ulnar deviation together with true lateral views, with the wrist

in neutral position. If a fracture is suspected but cannot be shown on the initial radiograph, a

computed tomography (CT) bone scan should be ordered [5]. A sagittal cut, parallel to the longaxis of the scaphoid, is the best way to show the fracture and any associated deformity (Fig. 2).

With improved surgical and radiologic techniques, most scaphoid fractures are amenable for

percutaneous fixation. Not all types of fractures can be treated in this way, however, and the

best approach depends first on the configuration of the fracture, the method of fixation used,

and finally personal preferences [6]. Internal fixation is contraindicated in the presence of osteo-

porosis or stiffness of the wrist after immobilization in plaster. Under such circumstances, sur-

gery should be delayed for a few weeks, and therapy is started immediately to overcome the

adverse effects of immobilization. Other contraindications include sepsis, systemic disease, algo-dystrophy, an uncooperative patient, or lack of the necessary equipment or surgical skills to per-

form this type of surgery.

Fig. 1. High and low compression type of the HBS system cannulated for 1 mm.

58 H. Krimmer / Atlas Hand Clin 8 (2003) 57–66

Technique

Percutaneous (minimally invasive) fixation—palmar approach

The great advantage of this technique is that no palmar ligaments are damaged, and routinely

no immobilization in plaster is necessary. Indications are all fractures through the waist that are

undisplaced or that can be reduced by closed manipulation. It is not suitable for any fracture

that needs bone graft to restore stability or length.

For a palmar approach, whether open or closed, the surgeon should be seated with the dom-

inant hand at the outer end of the table. For a dorsal approach, this position is reversed. A

radiolucent, hinged hand-holding device is extremely useful, but failing this, a large, rolled-up

towel is used to aid extension of the wrist. The continuous availability of x-ray control is an im-portant prerequisite for the procedure. The author prefers a permanent position of the image

intensifier opposite to the surgeon with the assistant at the top of the table (Fig. 3). This setup

allows vertical x-ray control at any time.

First the scaphoid is screened with the image intensifier to confirm that the fracture is suitable

for closed treatment, and if necessary, carefully closed reduction is performed sometimes with

the help of the joystick technique. Most fractures are realigned in extension of the wrist. Next

the prominence of the scaphoid tubercle is marked, which is more prominent with the wrist in

radial deviation. A short incision is carried out, and the scaphotrapeziotrapezoid joint is iden-tified. The drill guide is positioned firmly on the distal pole of the scaphoid toward its radial

side, and the 1-mm guidewire is inserted through the sleeve (Fig. 4A). The correct entry point

should be checked with the C-arm. Then, aiming the guide toward the proximal pole of the sca-

phoid (approximately 45� dorsally and 45� ulnarly in relation to the neutral plain), the guidewire

is inserted slowly under x-ray control (Fig. 4B). The optimal position should be along the mid-

axis of the scaphoid in both planes and as closely perpendicular to the fracture as possible. The

guidewire should enter, but not penetrate, the firm subchondral bone at the apex of the proximal

pole. The intraosseous position in all planes must be checked by continuously moving the wristfrom pronation into supination.

When the guidewire is in the correct position, the length is measured using the depth gauge,

ensuring that the tip of the guide remains firmly on the tubercle. To avoid that the guidewire is

Fig. 2. (A) Suspected fracture of the scaphoid. (B) Proximal pole fracture detected with computed tomography scan.

59H. Krimmer / Atlas Hand Clin 8 (2003) 57–66

removed with the drill, fixation inside of the radius is preferable (Fig. 4C). Then the stop on the

cannulated drill is set to the appropriate length, and the drill is passed over the wire and slowly

inserted. Drilling may be carried out by hand, using the handle provided, or preferably by

power, provided that the driver has a sufficiently fine speed control. It is important to ensure

that the drill follows the same line as the guidewire, to avoid jamming or bending. When it is

fully inserted, the position is checked on the image intensifier (see Fig. 4C).Depending on the appearance of the fracture, a normal or high compression cannulated

screw is selected and placed over the guidewire. When the trailing threads start to engage in

the bone, the guidewire is removed, before fully tightening the screw. The threads are well buried

beneath the surface of the tubercle, and the final position and stability of fixation are controlled

by screening the wrist on the image intensifier (Fig. 4D).

Postoperative treatment includes an elastic bandage for 2 weeks This bandage normally pro-

vides adequate support for the wrist during the period of wound healing, while allowing sufficient

movement to prevent adhesions and joint stiffness. Heavy manual work and contact sports areavoided during the first 6 weeks. The fracture should be healed within 6 to 10 weeks (Fig. 5).

Open fixation—palmar approach

In the case of severe dislocation or comminution at the fracture site, in which a bone graft

might be necessary for reconstruction, the open approach is used (Fig. 6A and B). The incision

is centered over the tubercle of the scaphoid, palpable with the wrist in full radial deviation. The

sheath of the flexor carpi radialis tendon is incised, and the tendon is retracted ulnarward to ex-pose the anterior capsule of the wrist over the scaphoid bone. The incision is deepened distally,

dividing the origin of the thenar muscles in line with their fibers, over the palmar surface of the

trapezium. The capsule is incised longitudinally from the tubercle distally to the tip of the radius

proximally. At the proximal end of the incision, a condensation of the capsule (the radiolunate

ligament) appears as a labrum to the radiocarpal joint. This part usually can be preserved when

Fig. 3. Setup for palmar minimally invasive approach.


using the HBS system because there is no need for the jig (Fig. 6C). The joint between the sca-

phoid and trapezium is identified, and the joint capsule is incised by sweeping the knife blade

radially around the tubercle of the scaphoid. This dissection is not carried too proximally or

deeply (maximum 1 cm) to avoid damage to the blood vessels entering the scaphoid along

the spiral groove. A fine suction device can be used to aspirate the hemarthrosis. Any soft tissueattachment to the fracture site and any synovium that may have become trapped between the

bone fragments should be removed. The scapholunate ligament always should be checked for

possible associated tears. Accurate reduction of the fracture is then carried out, taking care

to correct any angulatory, rotary, or translocation deformity. A Kirschner wire may be used

to hold the reduction. This wire is inserted into the tip of the tubercle at its ulnar border, directed

proximally and dorsally toward the apex of the proximal pole. If there is a defect at the fracture

site or any tendency for the fragments to collapse under compression, all loose fragments of bone

are removed, and an adequate bone graft is inserted (Fig. 6D). Fixation of the fracture is carriedout by using the cannulated screw system, as described in the previous section on closed fixation

(Fig. 6E and F). The palmar wrist capsule is repaired using interrupted mattress sutures. Starting

proximally at the radius, the cut ends of the radiolunate ligament are reapposed. Proceeding dis-

tally, the capsule is closed over the scaphoid, and a single suture is used to approximate the soft

tissues over the scaphotrapeziotrapezoid joint. Postoperative treatment includes immobilization

in a short arm cast for 2 weeks and another 4 weeks avoiding heavy loading.

Fig. 4. Minimally invasive technique. (A) Insertion of the guidewire by power drill. (B) Correct position on lateral

projection. (C) Drill passes the whole length of the scaphoid, Kirschner wire fixed inside of the radius. (D) Correct

positioning of the screw.


Fig. 5. Clinical example. (A) Slight deformity at the radial cortex. (B) Computed tomography scan shows dislocation

of the fracture (A2). (C and D) Correct positioning of the screw in both planes. (E) Confirmation of healing on

computed tomography scan 7 weeks postoperatively.


Open fixation—dorsal approach

For fractures at the proximal third of the scaphoid, which the author regards as an absolute

indication, internal fixation is carried out best through a dorsal approach, using an intraosseousfixation device appropriate to the small size of the proximal fragment (Fig. 7A and B). The dor-

sal approach provides limited access with partial opening of the second and third extensor com-

partments and the wrist capsule over the scapholunate joint. It does not cause any further

compromise to the blood supply of the proximal fragment and allows clear visualization of

the fracture and exact placement of the screw. There is no advantage to percutaneous insertion

because no ligaments are incised with the open technique, and the risk of incorrect positioning of

the screw increases with the closed technique. If a realignment must be done, a 1-mm Kirschner

Fig. 6. Palmar approach—open technique. (A) Unstable scaphoid fracture (A2) with slight dorsal intercalated segment

instability deformity after 5 weeks of conservative treatment. (B) Computed tomography scan shows humpback

deformity. (C) Intraoperative view. (D) Situation after realignment and bone graft. (E) Insertion of the screw. (F)

Postoperative radiographs show realignment of the scaphoid and the lunate.


Fig. 7. (A) Mini-Herbert screw. (B) Proximal pole fracture. (C) Intraoperative view of the dorsal approach with a mini-

Herbert screw inserted through the proximal pole. (D) Radiograph.


wire is inserted. By using the special hand holder, the drill is inserted by a length, which

crosses the fracture side at least with the same distance as from proximally. The mini-Herbert

screw can be inserted easily under direct vision into the small proximal fragment using a free-

hand technique (Fig. 7C). The small size of this screw minimizes the risk of additionally disturb-

ing the small proximal fragment and allows the screw to be buried beneath the subchondralcartilage (Fig. 7D). The wrist is immobilized postoperatively for 2 weeks in a below-elbow cast,

and heavy manual activity is restricted during the first 6 weeks. When radiographs show fracture

union, full activities are resumed. This treatment regimen has a high success rate in the author’s

hands, even for proximal pole fractures that present 4 months after the injury.

Complications

The use of the cannulated screw system carries a risk of the guidewire becoming bent or

broken, and this part of the procedure demands extra caution. In particular, if the guidewire

penetrates the bone or the radius as mentioned earlier, unless it is removed, the joint must not

be moved because this almost certainly would cause the wire to bend or break (Fig. 8). When

drilling, one always should examine under x-ray control that the tip of the drill has reached

the opposite cortex. Otherwise, despite the self-cutting design, the screw may impinge against

the bone, and fracture displacement occurs.

Results

The author published a series of 32 patients who were treated according to the above-

mentioned criteria [5]. Most showed unstable patterns—B1 (1), B2 (22), and B3 (5)—and only

four showed a stable pattern—A2. Half of the cases were fixed minimally invasively, and 11

were fixed through a palmar open and 5 through a dorsal open approach. All fractures united.

Meanwhile, in another series of 68 minimally invasive procedures, there were 2 nonunions.On analysis, one of the nonunions showed a technical failure with incorrect positioning of

Fig. 8. Risk for breakage of the Kirschner wire if the wrist is not fixed.


the screw, where the proximal fragment was only partially fixed. The other patient had a severe

second wrist trauma 3 weeks after surgery.

Discussion

For fractures of the waist of the scaphoid, there might be a disadvantage of the palmar

approach because the entry point of the screw is not central but more palmar. If the screw

penetrates the center of the proximal fragment, however, rigid fixation is provided [7]. In contrast

to the dorsal approach, this technique ismore convenient because thewrist remains in one position

during thewhole surgery, and the hyperextendedposition of thewrist usually provides realignment

at the fracture. This is not true for the palmar flexed position, requiringmore oftenmanipulation ofthe guidewire for realignment [8]. In contrast, proximal pole fractures in general do not show

humpback patterns and are fixed best through the dorsal approach, preferably with a smaller im-

plant because the cannulated design is not necessary when a limited access is used.

Summary

The HBS system is a cannulated screw device based on the original Herbert screw. Cannu-lated for a 1-mm guidewire, it facilitates the minimally invasive technique by insertion of the

guidewire from a palmar approach. When using the open technique in the case of severe dislo-

cation, precise placement of the screw is provided without the jig. The noncannulated mini-

Herbert screw, which is part of the system, is preferred for fixation of proximal pole fragments

through a dorsal limited open approach. These techniques have a high success rate for healing of

the fractured scaphoid, allowing early mobilization.

References


1984;66:114–23.

[2] Menapace KA, Larabee L, Arnoczky SP, et al. Anatomic placement of the Herbert-Whipple screw in scaphoid

fractures: a cadaver study. Am J Hand Surg 2001;26:883–92.



[4] Krimmer H. Management of acute fractures and nonunions of the proximal pole of the scaphoid. Br J Hand Surg

2002;27:245–8.

[5] Krimmer H, Schmitt R, Herbert T. Scaphoid fractures—diagnosis, classification and therapy. Unfallchirurg

2000;103:812–9.

[6] Herbert T, Krimmer H. Scaphoid fractures: internal fixation. In: Gelberman RH, editor. The wrist (master techniques

in orthopaedic surgery). Philadelphia: Lippincott Williams & Wilkins; 2002. p. 111–26.

[7] Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation using a cannulated screw. Chir Main 1998;17:

119–26.

[8] Slade JF III, Jaskwhich D. Percutaneous fixation of scaphoid fractures. Hand Clin 2001;17:553–74.


Open treatment of transscaphoid perilunatefracture dislocations

Ioannis Sarris, MD, Dean G. Sotereanos, MD*

Department of Orthopaedic Surgery, West Penn Allegheny Health System,

490 E. North Avenue, Suite 500, Pittsburgh,

PA 15212, USA

Acute fracture-dislocations of the carpus are uncommon injuries [1]. Transscaphoid perilu-

nate fracture-dislocation is the most common type of complex carpal dislocation [2–4]. Perilu-

nate fracture-dislocations represent approximately 5% of wrist fractures and are about twice ascommon as pure ligamentous dislocations. Treatment of these injuries is difficult because of the

extensive soft tissue, cartilaginous, and bone damage. Various nonoperative and operative treat-

ment options have been recommended with a more recent emphasis on open reduction and in-

ternal fixation.

Anatomy

The wrist joint allows for articulation of the radius and the ulna in the forearm to the meta-

carpals in the hand. The carpus itself consists of two transversely oriented rows of bone. The

proximal row consists of scaphoid, lunate, triquetrum, and pisiform bones. The distal row con-

sists of hamate, capitate, trapezium, and trapezoid bones. Extrinsic ligaments stabilize the radio-

carpal and the ulnocarpal articulations. These ligaments primarily exist on the palmar side of

the wrist and include radioscaphocapitate, long radiolunate, short radiolunate, ulnolunate,

and ulnotriquetral ligaments. The aforementioned ligaments form an inverted V on the volar

side [5] of the radiocarpal and the ulnocarpal joints (Fig. 1).Intrinsic ligaments stabilize the midcarpal articulation and the articulations between osseous

structures of the same row. The important intrinsic ligaments include the scapholunate, lunotri-

quetral, scaphocapitate, and triquetrocapitate ligaments.

On the palmar side, the lunocapitate articulation is devoid of any substantial ligamentous

stability. This space is referred to as the space of Poirier [20] and is the primary site of weakness

and tear in perilunate fracture-dislocations.

Dorsally the extrinsic and the intrinsic ligaments are not as distinguishable. They primarily

are considered as thickening of the dorsal capsule.

Mechanism of injury

These injuries are usually due to high-energy [6] trauma that occurs in situations involving

motor vehicle accidents, a fall from a height, or contact sports [7,8]. The mechanism of injury

characteristically involves forceful wrist extension, ulnar deviation, and intercarpal supination,

which leads to palmar capsuloligamentous disruption starting radially and propagating ulnarly,


E-mail address: [email protected]


doi:10.1016/S1082-3131(02)00015-8


taking a transosseous route through the scaphoid with usual disruption of the lunotriquetral lig-

ament and fracture of the ulnar styloid [9–12]. The proximal fragment of the scaphoid and the

lunate flexes or stays coaxial with the radius, whereas the distal fragment of the scaphoid dis-

locates dorsally, and the distal carpal row migrates on the dorsum of the lunate. Occasionally

the distal scaphoid fragment and the distal carpal row dislocate palmarly to the lunate [2,13,14].

Variations of perilunate fracture-dislocations include fractures of the capitate or triquetrum(or both) and presence or absence of radial or ulnar styloid fractures. A few staging systems

have been used to accommodate these variations (Fig. 2) [8,15].

A specific variation of the perilunate fracture-dislocation is the scaphocapitate syndrome

[16,17]. In this uncommon injury, there is osseous disruption of the scaphoid and the capitate,

with the injury force passing through the neck of the capitate. The proximal portion of the cap-

itate usually is rotated 90� to 180� with the articular surface of the head of the capitate directed

distally [2,18]. The injury to the capitate could be missed on plain radiographs, and additional

views must be taken if this injury is suspected.

Diagnosis

Patients with perilunate fracture-dislocations usually present with wrist pain, swelling, and

crepitus. The digits often are held in a semiflexed position (Fig. 3B), and passive extension is

painful. There also is abnormal wrist alignment with the capitate displaced dorsally, which

can be apparent on clinical examination (Fig. 3A). These patients usually also complain of par-

esthesia in the median nerve distribution.

Radiographic evaluation is important to evaluate the extent of injury. Of perilunate injuries,

20% are misdiagnosed with the initial radiographic evaluation [2]. Six radiographic views shouldbe taken for wrists with suspected carpal instability: posteroanterior, lateral, radial and ulnar

Fig. 1. Anatomy of the wrist volarly. Bones: C, capitate; H, hamate; L, lunate; P, pisiform; R, radius; S, scaphoid;

TC, triquetrum; Td, trapezoid; Tm, trapezium; U, ulna. Arteries: AIA, anterior interosseous artery; RA, radial artery.

Ligaments: CH, capitohamate; LRL, long radiolunate; PRU, palmar radioulnar ligament; RSC, radioscaphocapitate;

SC, scaphocapitate; SRL, short radiolunate; STT, scaphotrapeziotrapezoid; TC, trapezocapitate; TC, triquetrocapitate;

TH, triquetrohamate; TT, trapeziotrapezoid; UC, ulnocapitate; UL, ulnolunate; UT, ulnotriquetral.

68 I. Sarris, D.G. Sotereanos / Atlas Hand Clin 8 (2003) 67–76

deviation, and flexion and extension views [16]. An additional posteroanterior radiograph of the

wrist with a loaded fist is made to rule out scapholunate instability. The presence of associated

fractures may divert the attention of physicians away from the carpal subluxations or disloca-

tions. True lateral radiographs usually show the loss of colinearity that exists between the ra-

dius, lunate, and capitate. In earlier stages of perilunate fracture-dislocation, the lunate is colinear

with the radius because the capitate is subluxed dorsally. The capitate can remain colinear withthe radius, however, because the lunate is dislocated palmarly. Distraction radiographs are help-

ful to identify scaphocapitate syndrome or to delineate any other associated fracture or disloca-

tion that was not apparent at the first evaluation (Fig. 3C–E).

Tomography of the wrist is useful for evaluating the alignment of the carpal bones and for

assessing fractures and fracture-dislocations. Complex motion tomography is of special value

for obtaining biplanar images of the carpus. Computed tomography also provides useful

cross-sectional images and is particularly helpful if three-dimensional reconstruction is per-

formed [19].

Treatment

Unsuccessful closed reduction is more common with perilunate fracture-dislocations than

with pure ligamentous injuries [10]. Most authors agree that mere closed reduction is not ad-

equate for treatment of these injuries. The significance of immediate closed reduction is there

would be less pressure on the median nerve. Inability to achieve closed reduction, progressive

paresthesia within the median nerve distribution, subsequent displacement, and fracture col-lapse are indications for emergent open reduction and operative treatment [2,13,16,20,21].

The authors believe that the advanced instability produced by this injury and the rotational de-

formity of the scaphoid fragments are enough to indicate open reduction and internal fixation in

almost all cases.

Open reduction, internal fixation, and anatomic ligamentous repair have become the main-

stays of treatment for transscaphoid perilunate dislocations [3,22]. Different surgical approaches

have been described to address this injury. The palmar approach usually is needed to repair the

rent in the volar capsule at the lunocapitate joint and release the carpal tunnel. It would be dif-ficult to address the scaphoid fracture through this approach, however. The dorsal approach is

needed to fix the scaphoid fracture and repair the interosseous ligaments and the capsuloliga-

mentous structures.

Fig. 2. Stages of perilunate fracture dislocations: I, radial styloid; II, scaphoid; III, capitate; IV, triquetrum; V, complete

lunate dislocation.

69I. Sarris, D.G. Sotereanos / Atlas Hand Clin 8 (2003) 67–76

Fig. 3. A 27-year-old man after a motor vehicle accident. Clinical pictures show a malaligned wrist (A) and an open

injury (B). Posteroanterior (C) and lateral (D) radiographs show a transstyloid perilunate fracture-dislocation with

avulsion fracture of the triquetrum. A distraction radiograph was obtained to assess the injury further (E). The

postoperative radiographs show realignment of the carpus (F, G).


The dorsal approach begins with a longitudinal midline incision dorsally, and the extensor

retinaculum is divided between the third and fourth compartments. The extensor pollicis longus

is released and retracted radially. The capsule tear is extended longitudinally with elevation of

the capsular flaps for exposure of the carpus. Reduction of the lunate is assessed dorsally. After-

ward, the scaphoid fracture is reduced and stabilized with a 0.045-inch Kirschner wire. A can-nulated compression screw of choice is used to provide permanent fixation of the fracture. The

screw is placed in an antegraded direction aiming for the thumb base. Significant comminution

or bone loss at the fracture site can be bone grafted primarily by extending the incision proxi-

mally to harvest bone graft from the distal radius. Anatomic fixation of the fracture is ensured

using intraoperative fluoroscopy.

The scapholunate interosseous ligament is repaired next. This repair can be done either by

using a bone anchor in the scaphoid, because the ligament usually avulses off of the scaphoid,

or by making drill holes through the scaphoid. Before the ligament repair, the scapholunatejoint should be reduced anatomically using a 0.045-inch Kirschner wire in the scaphoid as a joy-

stick; then it is stabilized using a 0.062-inch Kirschner wire from radial to ulnar. Intraoperative

fluoroscopy should be used to check this reduction. On the lateral projection, the angle between

the scaphoid and the lunate should be 45� to 60�.The capitolunate and the lunotriquetrum articulations should be addressed next. The capitate

is reduced to the lunate first. This reduction also should be checked radiographically. On the

lateral projection, there should be a colinear relationship between the capitate, the lunate,

and the radius. It is crucial that the lunate will not be in a dorsiflexion or palmar-flexion posi-tion. After attaining an anatomic reduction of the capitolunate joint, another 0.062-inch Kirsch-

ner wire is placed from scaphoid into the capitate.

The triquetrum is reduced to the lunate and stabilized with another 0.062-inch Kirschner

wire. At this time, by using a volar approach, the rent in the volar capsule at the level of the

lunocapitate joint can be repaired with nonabsorbable suture. If the radioscaphocapitate or long

radiolunate ligaments have avulsed off of the radial styloid, they can be repaired to the radius

using bone anchors.

In the case of a scaphocapitate syndrome, the capitate is addressed through the dorsal ap-proach. Usually the proximal portion of the capitate is rotated 180� and is stripped free from

the surrounding ligamentous attachments. The fracture needs to be reduced anatomically and

stabilized with a compression screw. The tip of this screw, as with any other screw within the

carpus, should be buried under the articular surface. Associated radial or ulnar styloid fractures

also can be fixed through the dorsal approach using a compression screw or Kirschner wires

(Fig. 3E,G).

The authors believe that the transscaphoid perilunate fracture-dislocation can be assessed

from a dorsal approach, unless there is median nerve compression or lunate palmar dislocation(Fig. 4), in which case a volar approach also is used. The standard carpal tunnel incision is made

to release the flexor retinaculum. Then the lunate is reduced in the lunate fossa so that on the

lateral radiograph there is colinear alignment of the radius and the lunate. Provisional pin fix-

ation is made from the radius into the lunate.

Other authors prefer to use a volar scaphoid approach to reduce the dislocation, assess the

scaphoid fracture, and pin the lunotriquetrum joint if involved. They use the dorsal approach

only if the capitolunate joint is irreducible from the volar side.

Postoperative care

At the conclusion of the case, intraoperative radiographs should be obtained to ensure ana-

tomic reduction of the carpus. The wrist and the forearm should be placed in a sugar-tong

splint. Patients should be encouraged to start active and passive range of motion of digits early.

In 2 weeks, the stitches are removed, and a short arm cast is applied. The cast is maintained

for 8 weeks. After the short arm cast is removed, active and passive range of motion of thewrist is allowed. Kirschner wires are removed at 10 to 12 weeks postoperatively. Patients are

allowed unrestricted use of the wrist after they have gained adequate grip strength. Full recovery

usually takes 8 to 12 months.


Complications

One of the most common complications of this injury is an inaccurate or missed diagnosis

(20%) [2,13], which leads to chronic transscaphoid perilunate dislocation and later on to ar-thritic distortion of the wrist. Adequate radiographic views and careful evaluation usually pre-

vent this complication. A transscaphoid perilunate dislocation is defined as chronic when it

remains unreduced for more than 6 weeks. Despite the definition, open reduction and internal

fixation always should be attempted even 6 or 8 months after the initial injury if the cartilage is

well preserved [23]. In this case, the scaphoid fracture is treated as a scaphoid nonunion with the

use of bone graft (cancellous, tricortical, or vascularized) and is fixed with a compression screw.

Fig. 4. Transstyloid, transscaphoid lunate dislocation in a 34-year-old man after a biking accident. The scaphoid is

fractured at its waist. There is also a mildly displaced radial styloid fracture (A). The lunate is rotated and dislocated into

the carpal tunnel (B). The median nerve was compressed by the dislocated lunate (C). Postoperative radiographs (D, E)

show good alignment of the wrist, with adequate fixation of the radial styloid and the scaphoid fractures.


Repair of the ligamentous structures is usually difficult, and in most cases the use of capsular

flaps for ligamentous reconstruction is advocated. In the case of irreducible chronic injuries re-

sulting from soft tissue contracture or cartilage damage, salvage procedures, such as proximal

row carpectomy or wrist fusion (limited or complete), usually address the problem [1,4,8,23].

Median nerve paresthesia usually is related to the initial injury. The subluxed or dislocated

lunate is pressing against the carpal tunnel and causes this complication. Early closed reduction

and decompression of the carpal tunnel during surgical treatment is recommended. In cases of

closed injuries, inability to obtain closed reduction and progressive median nerve neuropathy isan indication for emergent operative intervention.

Avascular necrosis of the scaphoid usually is seen with greater arc injuries and associated sca-

phoid fractures. The morbidity varies from 10% to 100% [13]. Treatment of the ischemic ne-

crosis of the scaphoid includes revision open reduction and internal fixation. Supplementary

bone graft is usually necessary to increase the success of this procedure. Vascularized distal ra-

dius autograft would be an excellent choice of bone graft. The initial trauma may have injured

the blood supply to the appropriate portion of the distal radius, however.

Avascular necrosis of the lunate, although rare, if present, is usually a transient phenomenon.This entity should not be confused with Kienbock’s disease [18]. The diagnosis is made based on

radiographic presentation, in which the lunate is more radiopaque compared with adjacent car-

pal bones. The treatment for transient ischemia of the lunate is usually observation.

Nonunion and malunion of the scaphoid are complications seen with greater arc injuries.

Nonunion of the scaphoid, if not treated, can lead to avascular necrosis of proximal pole of

the scaphoid or scaphoid nonunion advanced collapse. This complication usually is treated with

revision open reduction, internal fixation, and supplemental bone grafting.

In cases of scaphoid malunion, the normal articulation between the radial styloid and thescaphoid is lost. A dorsal humpback deformity of the scaphoid would be evident. To prevent

Fig. 4 (continued )


progressive arthritis, open reduction of the scaphoid with a tricortical wedge of iliac crest auto-

graft is usually essential.

Residual and chronic perilunate instability is a challenging dilemma for an experienced clini-

cian [23]. This instability could be of a dissociative pattern; it could involve scapholunate or lu-notriquetral articulations. It also could be of a nondissociative pattern, in which there is

instability of the midcarpal or radiocarpal joints. Radiocarpal instability is evident by ulnar

translocation of the carpus on the radius.

Outcome

Transscaphoid perilunate dislocations have received much attention in the literature because

they have led to significant morbidity. The variability of associated injuries (Fig. 5) and treat-ment techniques has produced controversial results in the literature. In one series, only 43%

good results [1] were achieved, whereas in other series, 80% [14] and 83% [3] good results were

achieved with open treatment. A 50% loss of wrist motion and 60% diminished grip strength

Fig. 5. A 36-year-old man after a crush injury to the wrist. He sustained a complex transscaphoid perilunate fracture-

dislocation. Associated injuries included ulnar artery, ulnar nerve, flexor tendon lacerations, and comminuted fracture of

the small finger middle phalanx. (A, B). Postoperative radiographs show realignment of the carpus, reduction of the base

of the ring finger metacarpal to the hamate and fixation of the scaphoid fracture (C, D).


also have been reported after open treatment [24], whereas in another study, only 28% and 25%

of wrist motion and grip strength were lost [15]. In our series of 23 patients, 70% had a good

result. The overall loss in grip strength was 23%, and the overall loss in wrist motion was

29% compared with the contralateral wrist [22]. Most authors agree that restoration of the car-

pal alignment gives better results [2,16,25,26]. Delay in treatment, damage of the cartilage, per-sistent instability, and fracture nonunion are the main causes of failure of open treatment of the

transscaphoid perilunate dislocation [23,25].

Summary

Open treatment of transscaphoid perilunate dislocations attains good results if appropriatereduction and fixation is achieved. A combined volar and dorsal approach provides excellent

exposure and enables restoration of ligamentous and skeletal anatomy. Closed treatment for

this injury is not advocated unless it is used for temporary relief of median nerve symptoms.

The outcome of open treatment is related closely to the extent of the initial injury (ie, cartilage

damage), the time of surgery, and the restoration of anatomic alignment of the wrist. Diagnosis

of the injury requires careful clinical and radiologic evaluation.

References

[1] Cooney WP, Linscheid RL, Dobyns JH. Fractures and dislocations of the wrist. In: Rockwood CA Jr, Green DP,

Bucholtz RW, editors. Fractures in adults. 3rd edition, volume 1. Philadelphia: JB Lippincott; 1991. p. 563–678.

Fig. 5 (continued )


[2] Green DP, O’Brien ET. Open reduction of carpal dislocations: indications and operative techniques. J Hand Surg

Am 1978;3:250–65.

[3] Moneim MS, Hofammann III KE, Omer GE. Transscaphoid perilunate fracture-dislocation: results of open

reduction and pin fixation. Clin Orthop 1984;190:227–35.

[4] Moneim MS. Management of greater arc carpal fractures. Hand Clin 1988;4:457–67.

[5] Berger RA. The ligaments of the wrist: a current overview of anatomy with considerations of their potential

functions. Hand Clin 1997;13:63–82.

[6] Norbeck Jr DE, Larson B, Blair SJ, et al. Traumatic longitudinal disruption of the carpus. J Hand Surg Am

1987;12:509–14.

[7] Garcia-Elias M, Cooney WP. Axial dislocations and fracture dislocations. In: Cooney WP, Linscheid RL, Dobyns

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Percutaneous treatment of transscaphoid, transcapitatefracture-dislocations with arthroscopic assistance

Joseph F. Slade III, MDa,*, Andrew E. Moore, MDb


Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USAbDepartment of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071,


Scaphocapitate syndrome, the name for transscaphoid, transcapitate perilunate fracture-dislocations, first was described in 1956 [1]. The path this fracture travels through the scaphoid

and capitate during extreme wrist hyperextension describes an incomplete greater arc injury.

Rarely the fracture plane is extended to include the triquetrum and completes the injury pattern

(Fig. 1) [2]. Adler and Shaftan [3] determined that capitate fractures were a result of extreme

hyperextension and ulnar deviation of the wrist, with the capitate directly impacting on the dor-

sal radius. It is believed that continued hyperextension after fracture is the initiating mechanism

by which the fractured proximal capitate pole has been observed to rotate 180� [1]. The scaphoidand the capitate are perfused in a retrograde fashion—from distal to proximal [4,5]. Displacedosseous fracture segments proximal to their blood supply risk nonunion and osteonecrosis if

anatomic reduction and fixation is not achieved. Carpal fracture-dislocations often are associ-

ated with ligament injuries, which require identification and treatment [6]. Ultimately the rate,

magnitude, and direction of the force applied to the carpus determine the structural failure in

the wrist. The key to successful treatment of these injuries is early recognition. Most authors

advocate early open reduction and rigid fixation of greater arc injuries, including scaphocapitate

fractures (Fig. 2) [6–12]. Open repairs risk further injury to a tenuous carpal blood supply, and

transient ischemia to the proximal fractured poles is common [13]. Open repair of transscaphoidfracture-dislocation increases the risk of complications and delays initiation of rehabilitation

until sufficient ligament healing and results in decreased motion [14,15].

To minimize these risks, percutaneous repairs have been investigated [16–18]. This article de-

scribes first the authors’ minimally invasive methods for fracture reduction of greater arc inju-

ries with radiographic imaging and arthroscopic guidance. Second, the article describes the

authors’ technique, using a headless cannulated compression screw, for percutaneous fixation

of the scaphoid using a dorsal approach and the capitate using a second or third web space ap-

proach (Fig. 3). This article also presents a brief discussion of the preoperative evaluation andpresents a treatment algorithm for greater arc injuries including transscaphoid, transcapitate

perilunate fracture-dislocations.

Preoperative evaluation

A detailed history and physical examination are always performed. Although perilunate

fracture-dislocations comprise only 10% of all carpal injuries [19], they are usually a result ofa high-energy impact either from a fall from an elevated position or a motor vehicle accident.

It is important to assess the integrity of the carpal ligaments and the gross articular alignment.


E-mail address: [email protected] (J.F. Slade III).


doi:10.1016/S1082-3131(02)00020-1


Careful palpation and manipulation of the wrist are performed to identify potential injuries and

instabilities. Particular attention is focused on the neurovascular examination. These injuries

commonly involve the medium nerve. One study reported a 25% occurrence of acute carpal tun-

nel syndrome [9]. Persistent carpal dislocation with increased neural pressure risks permanent

injury to the nerve. High-quality standard radiographic views must be examined for axial dis-

placement of the scaphoid and the capitate (Fig. 4). With spontaneous reduction, scaphocapi-tate syndrome can be difficult to detect. Boisgard and colleagues [7] reported that 30% of

their cases were unrecognized at presentation after standard radiographs. Computed tomogra-

phy (CT) scans can be useful to identify cortical disruptions with these injuries and the presence

of other occult fractures. To assess the ligamentous integrity, distraction radiographs can iden-

tify carpal disruptions not readily apparent on standard radiographs [13].These studies, if not

done in the emergency department, can be done in the operating room after the administration

of a suitable anesthetic using a minifluoroscopy unit and a traction tower. Although these sur-

vey studies are useful in detecting gross instabilities, the final determination of carpal ligamentstability can be made only at the completion of an arthroscopic examination.

Treatment algorithm for greater arc injuries

A treatment protocol must address two problems. The first is acute carpal fracture displace-

ment with the potential risks of necrosis and nonunion. The second is carpal instability resulting

from carpal fracture or ligamentous disruption with long-term associated risks of arthrosis.

Static stability is conferred by the matching congruent articular surfaces of carpal bones andthe stout intrinsic and extrinsic ligaments system. These systems are complementary such that

an isolated ligament injury or carpal fracture does not always lead to carpal instability. This

‘‘belt-and-suspenders’’ arrangement has been supported by cadaver cutting studies [20–24].

In a similar manner, it may be enough to rigidly fix a fracture to restore carpal stability. An

Fig. 1. Transscaphoid transcapitate perilunate fracture-dislocations are incomplete greater arc injuries. Rarely the

fracture plane extends to include the triquetrum and completes the injury pattern as shown here in this radiograph.

78 J.F Slade III, A.E. Moore / Atlas Hand Clin 8 (2003) 77–94

example is a displaced flexed scaphoid waist fracture with carpal bones assuming dorsal inter-

calated segment instability deformity. Rigid fixation of the scaphoid fracture restores carpal

alignment and congruent synchronous carpal motion.The first step in the treatment algorithm (Box 1) requires percutaneous fracture reduction

using fluoroscopy. When this reduction has been accomplished, provisional guidewires are

placed to stabilize fracture reduction and later implantation of headless compression screws.

With fractures provisionally stabilized with Kirschner wires, a small-joint angled arthroscope

is introduced into the radiocarpal and the midcarpal joints. A survey confirms fracture reduc-

tion and permits an opportunity to inspect suspected intracarpal ligaments for injuries. A

small-joint probe is 2 mm in diameter and is a useful tool for determining the degree of ligament

disruption, which is graded using the Geissler classification [25]. Percutaneously placed wiresinto carpal bones can act as joysticks permitting further evaluation of carpal stability. Partial

tears with unstable flaps are de�brided easily, and this is sufficient treatment.

After carpal fixation with a standard Acutrak (Acumed, Beaverton, OR) screw, longitudinal

traction is applied again to the wrist to evaluate further the presence of continued ligamentous

instability. It is important not to apply more than 12 lb of traction and risk fracture fixation.

Pull-out studies of standard Acutrak screws suggest that four threads crossing the fracture site

have 20 to 30 lb of pull-out strength (J.F. Slade: unpublished data). In addition to longitudinal

traction, the wrist is subjected to gentle axial translation. Complete tears, detected after fracturefixation, require carpal reduction, pinning, and repair. Small bone anchors are most effective in

restoring ligament continuity with acute injuries. Careful evaluation after the repair best deter-

mines the need for ligament repair reinforcement with a dorsal capsulodesis.

Fig. 2. A dorsal open approach and reduction of a transscaphoid transcapitate perilunate fracture-dislocation. Most

authors advocate early open reduction and rigid fixation of greater arc injuries, including scaphocapitate fractures. Open

repairs risk further injury to the carpal blood supply and complications.

79J.F Slade III, A.E. Moore / Atlas Hand Clin 8 (2003) 77–94

Surgical technique

Overview

Key steps include the percutaneous reduction of carpal fractures, provisional fixation with a

Kirschner wire, and placement of a 0.045-inch, double-cut Kirschner guidewire along the central

axis of the scaphoid and capitate. This guidewire permits the later implantation of a cannulatedheadless compression screw for rigid fixation. Fluoroscopy and traction are used to achieve frac-

Box 1. Treatment Algorithm for greater Arc Injuries

1. Posteroanterior and lateral radiographs must be examined for axial carpaldisplacementa. Persistent carpal dislocation—emergent care, to operating room for closed

or open reduction to preserve neurovascular and joint functionb. Reduced carpus and carpal fractures

(1) Computed tomography scan—carpal displacement and identifyoccult fractures

(2) Distraction radiographs—evaluate ligament integrity2. Operating room suite evaluation with anesthesia and minifluroscopy

a. Distraction radiographs—evaluate the intrinsic and extrinsic ligamentsystem for gross carpal instability

b. Translational fluoroscopy to identify carpal displacement, occultfractures, and ligament injury

3. Percutaneous carpal fracture reduction (scaphoid and capitate) withfluoroscopic guidancea. Fracture reduction with 0.062-inch kirschner-wire placed percutaneously

as joysticksb. Provision fixation with 0.045-inch kirschner-wirec. Guidewire placement along central scaphoid axis and central capitate axis

between the second or third web space4. Small-joint arthroscopy with tourniquet

a. Radiocarpal and midcarpal inspectionb. Confirm fracture reductionc. Inspect interosseous ligament (IOL) for injuryd. Grade ligament injuriese. De�bride partial ligament injuriesf. D�eebride and prepare complete ligament injury for repair with bone anchors

5. Rigid fracture fixation of carpal fractures (scaphoid and capitate fractures)a. Implantation of headless compression screwsb. Screw size 4 mm shorter than carpal bone lengthc. Carpal bone length determined by two parallel wires of equal length

6. Fluoroscopic examination with axial translation and longitudinal tractionof carpusa. 12 lb of traction with four threads crossing fracture siteb. If stability restored to carpus, ligament repair optionalc. Continued carpal instability, mini–open ligament repair

7. Carpal ligament repaira. Carpal bone reduction with joysticks and provisional fixation with 0.045-inch

Kirschner wireb. Mini–bone anchors are used repair ligamentc. Repair protected with Kirschner wires or cannulated screws to be removed

laterd. Consider dorsal capsulordesis


ture reduction and guidewire placement. Fluoroscopy and traction also are used to identify

gross ligamentous injuries. Arthroscopy is used to confirm fracture reduction, grade ligamen-

tous injury, and identify occult injuries.

Fractures are treated first. Opposing fracture surfaces are aligned and firmly opposed with

joysticks, and headless cannulated compression screws are used to achieve rigid fixation of car-pal fractures. Incomplete ligament injuries are de�brided, and carpal bones are stabilized as

needed. Complete carpal disruptions require reduction, provisional wire stabilization, and direct

repair with mini–bone anchors. These ligamentous repairs are protected with Kirschner wires or

cannulated screws until healing is accomplished.

Screws in the central position increase the rate of healing of scaphoid fractures [26] and in-

crease the stiffness of fixation [27]. An additional benefit of the central axis placement of cannu-

lated screws is the reduced risk of thread penetration and cartilage injury [28]. Required

equipment includes the headless, cannulated compression screw (standard Acutrak screw); a flu-oroscopy unit (preferably a mini-imaging unit); 0.045-inch and 0.062-inch, double-cut Kirschner

wires; a wire driver; and a small-joint arthroscopy setup including a traction tower. The

authors prefer screws of standard size with their larger core shaft because of their increased

stability [29].

Fig. 3. Percutaneous repairs have been investigated to reduce the risks of open repair and assist in the early recovery of

hand function. With the assistance of imaging, the second and third web spaces provide a percutaneous approach for the

repair of capitate fractures.


Surgical technique in detail

Operating room setup

Required equipment includes a hand table, minifluoroscopy unit, 0.045-inch and 0.062-inch

Kirschner wires, Kirschner wire driver, small-joint arthroscopy setup, headless cannulated com-

pression screw (standard size Acutrak screw set), and mini–bone anchors. The patient is placed

in a supine position with a standard hand table attachment. After induction of anesthesia, the

affected upper extremity is prepared and draped in sterile fashion to allow for free movement at

the elbow and distally.

Imaging and traction with anesthesia

The minifluoroscopy unit is draped in sterile fashion and positioned perpendicular to the

wrist and parallel to the floor. It is used to visualize the carpal bones under static and dynamic

conditions. The characteristics of the fracture are compared with preoperative injury films.

Although complete carpal disruptions can be identified by gapping on static posteroanterior

films, malalignment of the lunate in a flexed or extended position on a lateral radiograph sug-

gests complete ligament disruption (Fig. 5A). Traction distraction radiographs are obtainedwith a minifluoroscopy unit and may reveal a more significant injury (Fig. 5B). These radio-

graphs are obtained by applying 12 lb of longitudinal traction through finger traps attached

to the thumb and three fingers. This traction can be accomplished with an arthroscopic traction

tower or conventional emergency department finger traps with a counterweight traction on the

arm. Traction films may reveal large carpal gaps where none were seen on standard radiograph.

These studies are used to confirm carpal fractures, identify ligament injuries, and identify occult

fractures. Partial injuries may be identified with traction by articular disruptions between the

carpal rows and carpal bones.

Percutaneous fracture reduction with fluoroscopic guidance and guidewire placement

The first priority is the reduction of any remaining carpal dislocation. This reduction is ac-

complished with longitudinal traction. If carpal alignment cannot be reestablished in a closed

manner, open reduction is required through a dorsal or volar approach. Using a minifluoros-

copy unit, fracture alignment is assessed. If fracture reduction is not satisfactory through a

closed manipulation, 0.062-inch Kirschner wires may be inserted percutaneously into the carpal

fracture fragments to serve as joysticks to manipulate the fracture fragments into correct align-ment. A small hemostat can be introduced percutaneously into the fracture site to effect a direct

fracture reduction (Fig. 6). This method can be particularly useful in the reduction of the rotated

proximal pole capitate fracture. With transscaphoid perilunate dislocations, a hemostat can be

introduced into the midcarpal portals, and with fluoroscopic imaging, a carpal reduction can be

Fig. 4. Standard radiographs in the posteroanterior and lateral views must be examined for axial displacement. The

lateral views show a transscaphoid fracture with a volar carpal dislocation and the lunate in a flexed position. With

spontaneous reduction, transscaphoid transcapitate fracture-dislocation can be difficult to detect. The diagnosis now

delayed, the resulting outcome is now compromised.


accomplished. After reduction is accomplished, a 0.045-inch guidewire is placed down the cen-

tral axis of the carpal bone and is driven across the fracture site to capture and retain reduction.

These wires are introduced into the distal fragment before final reduction. When reduction is

accomplished, the guidewire is driven proximally to capture the proximal fragment and retain

reduction. With grossly unstable fractures, a second parallel antiguidewire is introduced to

maintain fracture alignment (Fig. 7). The scaphoid wire is introduced dorsally at the proximal

Fig. 5. Standard radiographs and traction are used to define fracture and ligament injury. Standard posteroanterior

radiographs suggest fractures to the scaphoid, capitate, and triquetrum. Lateral radiographs show a dorsal displacement

of the carpus (A). With traction, a more significant ligamentous injury is revealed (B).


scaphoid pole, whereas the capitate wire is introduced between the second or third web space. It

is important that these wires be placed down the central carpal bone axis to decrease healing

time [26] and reduce the risk of thread penetration [18].

Guidewire placement in scaphoid fracture. To place the 0.045-inch guidewire along the central

scaphoid axis, the wrist is flexed and the forearm is pronated to view the scaphoid along its

long axis (Fig. 8A). With this view, the scaphoid silhouette appears as a dense circle, which

corresponds to the cortex around the long axis. A 0.045-inch Kirschner wire is inserted in a dor-

sal-to-volar direction down the central axis of the circle. Central placement of the wire is con-

firmed by fluoroscopy in the coronal and sagittal planes. The surgeon continues driving theKirschner wire through the trapezium until it penetrates the skin at the radial base of the thumb.

A second 0.045-inch Kirschner wire may be needed parallel to the first to prevent rotation about

the long axis. The wrist must be kept flexed until the wire clears to the radiocarpal joint so as not

to bend the Kirschner wire; this would impair reaming with a cannulated reamer and screw

implantation.

Guidewire placement in capitate fracture between the second or third web space. To place the

0.045-inch guidewire along the central capitate axis, the wire must be introduced between the

second or third web space through the base of the long finger carpometacarpal joint (Fig.

8B). This keystone joint is rigid, and violation of this joint with a drill leaves only a level joint

surface, which heals with fibrocartilage. The guidewire passes through the carpometacarpal joint

into the capitate to secure fracture reduction and to provide a path for hand drilling and screw

implantation. The introduction of the screw through the web space is crucial for proper place-ment of a screw along the central axis.

Fig. 6. Percutaneous fracture reduction can be accomplished with fluoroscopic guidance. First, longitudinal traction is

applied. If fracture reduction is not satisfactory, Kirschner wires are inserted percutaneously into the carpal bones to

serve as joysticks to manipulate the fracture fragments into correct alignment (A). A small hemostat can be introduced

percutaneously into the fracture site to effect a direct fracture reduction (B).


Arthroscopy and soft tissue injuries

After fracture reduction and guidewire placement, the tourniquet is inflated for an arthro-

scopic survey. The hand is placed in 12 lb of linear traction using finger traps and a tractiontower. The minifluoroscopy unit is used to identify the radiocarpal and midcarpal portal sites,

and 19G needles are inserted to mark the location. Small longitudinal skin incisions are made at

the needle entry points. A small, curved hemostat is used to spread the subcutaneous tissue away

from the capsule and enter the joint. A blunt trochar is placed into the 3,4 portal, and a 19G

needle remains as outflow for the 6R portal. A small-joint angled arthroscope is inserted, and

a shaver is placed in the 4,5 or 6R portal to clear blood clot and hyperplastic synovial tissue

(Fig. 9A). The volar carpal ligaments, the interosseous ligaments (IOLs), and the triangular fi-

brocartilage complex are stressed with a 2-mm probe. Next the midcarpal row is entered in asimilar manner at the radial and ulnar midcarpal portals. The radial midcarpal portal is the best

portal for viewing scaphoid and capitate fracture alignment. The capitate is split at the neck

(Fig. 9B), and the volar lunate is sheared off with the capsule (Fig. 9C). Partial ligament tears

are graded and de�brided [25]. Complete tears with carpal instability are identified and prepared

for later repair after carpal reduction with joysticks placed percutaneously, provisional Kirsch-

ner wire fixation, and bone anchors.

Rigid fracture fixation scaphoid and capitate

When the surgeon is satisfied with fracture reduction, the length of the screw to be implanted

must be selected; this is determined by establishing the length of the carpal bone to be fixed. The

central axis guidewire is advanced to the distal cortex of the carpal bone (Fig. 10). The carpal

length is determined by placing a second guidewire at the base of that carpal bone, next to the

exposed guidewire. The difference between these wires is the carpal length. The screw length is

determined by reducing by 4 mm the carpal length. This reduction permits 2 mm of clearance of

the screw at each end and complete implantation without screw exposure to cartilage. Having

established the appropriate screw length, the central axis guidewire is advanced well past the

Fig. 7. After fracture reduction is accomplished, a guidewire is driven across the fracture site to capture and retain

reduction. This wire is along the central axis of the carpal bone. With grossly unstable fractures, a second parallel

antiguidewire is introduced to maintain fracture alignment.


far cortex; this permits carpal reaming without loss of guidewire position. Proximal pole frac-

tures of the scaphoid require dorsal implantation of a headless compression screw for the best

fixation [30]. Scaphoid waist fractures may be fixed from either a dorsal or a volar position as

long as the screw is along the central axis. Dorsal implantation of the scaphoid screw requires

that the wrist be maintained in a flexed position during driving and screw placement to avoid

bending the wire. The capitate guidewire located between the second or third web space passes

through the carpometacarpal joint of the long finger. This keystone joint is rigid, and penetra-

tion with the drill is tolerated easily. The surgeon always should hand ream the carpal bone andstop 2 mm from the opposite cortex. Overreaming must be avoided because it risks rigid fixa-

tion. Finally, the properly measured screw (standard Acutrak screw) is inserted under compres-

sion. The screw placement and compression of the fracture site are confirmed by orthogonal

views on the minifluoroscopy unit, then any remaining Kirschner wires are removed. The small

portal sites are closed with interrupted 4–0 nylon, then sterile dressings and a volar splint are

applied.

Carpal ligament injury

Carpal ligaments have been evaluated with standard and traction radiographs, fluoroscopy,

and arthroscopy. Although standard and traction radiographs identify gross disruptions,

fluoroscopy permits a dynamic examination of the carpus for more subtle injuries. Arthroscopy

permits direct inspection and probing of the volar and intracarpal ligaments.

Fig. 8. Scaphoid fractures are repaired with a Kirschner wire introduced dorsally at the proximal scaphoid pole (A). The

guidewire is placed along the central axis of the scaphoid with the wrist flexed and the forearm pronated. In this position,

the scaphoid is viewed along its central axis as a circle. The center of the circle is the exact location for guidewire.

Capitate fractures are repaired with guidewires introduced between the second or third web space. It is important that

these wires be placed down the central carpal bone axis (B).


Arthroscopy permits the grading [25] and treatment of partial ligament injuries. Most of

these injuries are raised flaps which may lead to painful arthrosis. These may be treated

satisfactorily with de�bridement alone. Significant carpal ligament tears (Geissler II or III) may

require de�bridement and temporary carpal immobilization with Kirschner wires. Carpal insta-

bility may result from partial or complete ligament disruptions and carpal fracture. Percutane-ous carpal reduction with colinear alignment of the capitate, lunate, and radius and fracture

repair may be sufficient to reestablish carpal stability without open ligament repair.

These injuries must be reexamined after carpal fracture fixation with fluoroscopy. Radial sty-

loid avulsion with its volar attachments of the radial scaphocapitate ligament and long radial

lunate ligament can be stabilized provisionally with a 0.045-inch guidewire and rigidly fixed per-

cutaneously with a cannulated screw. In a similar manner, rigid fixation of the scaphoid frac-

ture with its proximal and distal ligament attachment may be enough to reestablish wrist

stability.If fluoroscopy and arthroscopy confirm persistent carpal instability after fracture fixation,

complete disruptions of the carpal interosseous and volar capsular ligaments require direct re-

pair (Fig. 11). In Fig. 11, the lateral radiograph documents persistent volar carpal subluxation

after anatomic fixation of the scaphoid. Using radiographic imaging, stout Kirschner wires

(0.062 inch) are placed percutaneously as joysticks, and the disrupted carpal bones are realigned

Fig. 9. An arthroscopic survey is conducted after fracture reduction and guidewire placement (A). The minifluoroscopy

unit is used to identify the radiocarpal and midcarpal portal sites. The volar carpal and the intracarpal ligaments are

probed. The midcarpal portals are entered for scaphoid and capitate fracture viewing to confirm alignment. The capitate

is split at the neck (B), and the volar lunate is sheared off from the volar capsule (C).


and provisionally secured with additional Kirschner wires. If persistent carpal gapping is viewed

on imaging after attempting ligament repair, soft tissue interposition is suggested. These ob-

structions can be removed with an arthroscopic instrument and an aggressive shaver. Additional

provisional Kirschner wires may be placed from the radius into a reduced and correctly aligned

Fig. 9 (continued )


Fig. 10. Fracture fixation is initiated by fracture reduction and introduction of guidewires. The scaphoid wire is

introduced at the proximal pole and driven volar (A and B). The capitate wire is introduced through the second web

space (C). Rigid fixation is accomplished by the implantation of headless cannulated compression screws (D–F).


lunate to assist in carpal alignment. Extending the 3,4 arthroscopic portal incision exposes thethird dorsal compartment, which is opened, and the extensor pollicis longus is retracted radially.

The dorsal capsule is incised and retracted, exposing the disrupted dorsal scapholunate inteross-

eous ligament. This ligament usually is avulsed off the proximal pole of the scaphoid. Mini–bone

anchors are placed in the proximal scaphoid pole and the scapholunate interosseous ligament is

reattached. This repair is protected by securing the scaphoid to the lunate and the capitate with

0.062-inch Kirschner wires or cannulated screws. Similarly, disruption of the lunotriquetral

interosseous ligament is addressed by extending the 4,5 arthroscopic portal incision distally,

exposing the fourth dorsal compartment. Tendons are retracted, and the dorsal capsule isincised, exposing the disrupted lunotriquetral ligament. The lunate and triquetrum are reduced

using joysticks. Kirschner wires, 0.062 inch, direct from the radius into the lunate lock it in po-

sition. An ulnar to radially directed Kirschner wire secures the reduced lunate to the triquetrum.

Mini–bone anchors or direct repair is used to reestablish ligament continuity. The lunate-trique-

tral wire can be replaced with a cannulated screw protecting the lunotriquetral interosseous

ligament repair. If this repair needs fortifying, a dorsal capsulodesis can be applied by extending

the dorsal longitudinal incision radially into a proximally based rectangular base.

Postoperative care and rehabilitation

Before leaving the operating room, radiographs confirm restored carpal alignment and

screw and wire position. The patient is placed in a bulky hand dressing with a sugar tong

placement. The dressings and sutures are removed at 7 to 10 days postoperatively, a short

arm cast is applied, and a supervised hand therapy program is initiated to restore hand func-

tion. Complete ligament injuries require 6 weeks of immobilization in a short arm cast, fol-lowed by 6 weeks of a protected motion program with a thumb spica splint. Kirschner

wires are removed at 2 to 3 months. Fractures of the waist without complete ligament injuries

are started on an immediate range-of-motion protocol. All fractures are started on a strength-

ening program. The purpose of strengthening is to axially load the fracture site now secured

with an intramedullary screw to stimulate healing. Heavy lifting and contact sports are re-

stricted until CT confirms healing of fractures by bridging callus, and clinically the patient

Fig. 11. Carpal instability may result from partial or complete ligament disruptions and carpal fracture. Percutaneous

carpal fracture reduction and rigid fixation may be sufficient to reestablish carpal stability without open ligament repair.

These injuries must be reexamined after carpal fracture repair with fluoroscopy. If fluoroscopy and arthroscopy confirm

persistent carpal instability after fracture fixation, carpal interosseous and volar capsular ligaments require direct repair.

The lateral radiograph documents persistent volar carpal subluxation of the capitate with the lunate in a flexed position

after anatomic fixation of the scaphoid. The volar displaced capitate with ligament disruption is shown in the

intraoperative photograph.


is nontender. Ligament injuries require 3 months to heal followed by an intensive therapy pro-

gram to recover wrist functions.

Clinical results of treatment

The presence of scaphocapitate syndrome has a strong correlation with high-energy trauma

in a young patient population. A typical case involves a 34-year-old man who fell from a roof,

Fig. 12. A 34-year-old man fell from a roof sustaining a transscaphoid and transcapitate fracture. The patient was

treated in the emergency department with a closed reduction. One week after his injury, he was treated with an

arthroscopic assisted reduction and percutaneous fixation of the scaphoid and capitate fracture (A). The patient was

treated with a removable splint and a strengthening program. Full healing of the scaphoid and capitate was documented

at 3 months by computed tomography scan without bone necrosis or complication (B).


sustaining a transscaphoid, transcapitate fracture. One week after injury, the patient was treated

with an arthroscopic assisted reduction and percutaneous fixation of the scaphoid and capitate

fracture, and full healing was documented at 3months by CT scan (Fig. 12). In the study from

the Netherlands, one of five patients died from associated injuries, two had concurrent pelvicfractures, and only one patient had no other injuries [31]. All of the patients had fallen from

a height of at least 6 m (range 6 to 10 m), and the average age of the patients was 23 years (range

19 to 34 years). Milliez and colleagues [32] showed similar patient demographics in their meta-

analysis of 56 years of data. In this study, all of the patients were men with an average age of 22

years (range 13 to 31 years). Most of the injuries were from falls or motor vehicle accidents, and

there was an even distribution of sides affected. These authors also found a pattern of multiple

concurrent injuries secondary to high-energy trauma.

The diagnosis of scaphocapitate syndrome frequently is missed secondary to unfamiliaritywith radiographic carpal anatomy on the part of the initial examiner, an overemphasis of focus

on the scaphoid injury at the expense of missing the capitate injury, or distracting injuries (eg,

pelvic fracture). The literature abounds with delayed diagnosis of the injury—2 months in one

instance [12]. Milliez and colleagues [32] found one third of their 25 cases to have been delayed

in diagnosis by at least 15 days.

Nonoperative management has a high incidence of nonunion and malunion of the capitate.

Milliez and colleagues [32] reported that six cases of scaphocapitate syndrome treated conserva-

tively (nonoperatively) resulted in an incidence of one scaphoid nonunion, one scaphoid osteo-necrosis, four capitate nonunions, one capitate malunion, and one capitate osteonecrosis.

Historically, complications arising from nonunion, malunion, osteonecrosis, and degenera-

tive joint changes in this injury pattern have been the norm regardless of the treatment modality

[3,31–34]. Milliez and colleagues [32] found that only 64% (9 of 14) of the scaphoid fractures and

47% (7 of 15) of the capitate fractures progressed to union after operative intervention in sca-

phocapitate syndrome. This report also noted that the subset of patients that underwent open

reduction without internal fixation progressed to a reported 75% (four of five) fusion rate in the

scaphoid and 100% (three of three) fusion rate in the capitate.Of the patients reported by Dinesh and coworkers [31], 100% (four of four) went on to develop

signs of degenerative arthritis at the wrist, with 50% being symptomatic. Sawant and Miller [35]

reported a good outcome in a case report on a 12-year-old boy with scaphocapitate syndrome

treated by open reduction and internal fixation with Kirschner wires. At the 3-year follow-up,

the patient was asymptomatic and had 89% of extension and 78% of flexion compared with the

contralateral wrist [31].

Although the final outcome of these high-energy injuries rests with factors involving the

patient and the specific injury pattern [9,36], all investigators agree that the best outcomes arerelated directly to early diagnosis and treatment. Treatment delays are associated with poorer

outcomes [9]. A complete examination is crucial so that all injuries are identified. The successful

treatment of scaphoid fracture while neglecting the rotated neck fracture of the capitate would

result in long-term carpal arthrosis. CT is valuable in assessing the carpus for additional osseous

injuries. Avascular necrosis and nonunion are observed commonly after displaced capitate frac-

tures because the blood supply to the capitate flows distal to proximal [37]. Most authors agree

on the need for early open anatomic restoration of the carpus and secure fixation of fractures

[38]. Few agree on the surgical approach, whether dorsal [39], volar, or combined [38,40]. Mostagree on the benefits of headless screw for fracture fixation; not all agree on the need for liga-

ment repair after fracture fixation [39,40]. Still other authors stress the importance of reevalua-

tion of carpal stability after fracture repair; concurrent ligament injuries are well documented

[9,14,15]. Open repair is not without risk, including osteonecrosis, nonunion, malunion, and

causalgia [38]. Investigators have shown the usefulness of arthroscopy and percutaneous tech-

niques in the reduction of displaced scaphoid fractures with and without ligament injuries

[16–18,41]. These minimally invasive techniques allow for the direct inspection of wrist injuries

and their stable fixation using a directed approach to the injury with limited incisions, whileavoiding the complications of open repair. Another benefit of percutaneous fixation is the early

recovery of hand function, which normally would be delayed until ligaments violated during an

open approach had healed. Early motion after treatment of transscaphoid perilunate disloca-

tions has resulted increased overall hand and wrist motion [14,15].


Summary

Percutaneous techniques using minifluoroscopy and arthroscopy can assist in fracture reduc-

tion and rigid fixation of carpal fractures of scaphocapitate syndrome, while avoiding the com-

plications of open repair. These techniques permit the identification of specific ligament injuriesand occult fractures, allowing for directed repairs through mini-incisions. The theoretical benefit

of minimizing further injury to the stabilizing ligaments of the carpus and the tenuous blood

supply of the carpal bones is restoration of early hand function with possible improved

outcome.

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The treatment of chronic scapholunatedissociation with reduction and association

of the scaphoid and lunate (RASL)

Carter B. Lipton, MDa, Obinwanne F. Ugwonali, MDa,Vishal Sarwahi, MDb, Jerome D. Chao, MDa,

Melvin P. Rosenwasser, MDc,*aDepartment of Orthopaedic Surgery, Columbia University, College of Physicians and Surgeons,

622 West 168th Street, New York, NY 10032, USAbDepartment of Orthopaedic Surgery, Albert Einstein College of Medicine, Montefiore Medical Center,

111 East 210th Street, Bronx, NY 10467, USAcDepartment of Hand Surgery, Orthopaedic Hand and Trauma Services, 622 West 168th Street,

Columbia University, College of Physicians and Surgeons, New York, NY 10032, USA

Scapholunate dissociation is one of the most common types of carpal instability. Forsubacute or chronic dissociation, direct ligamentous repair is not possible because of a loss ofanatomic integrity and substance of the ligament. Various methods have been proposed tostabilize the scaphoid, including dorsal capsulodesis [1], ligament reconstruction [2–8], proximalrow carpectomy [9], four-bone arthrodesis (lunate, capitate, hamate, triquetrum) [9], scapho-trapezium-trapezoid [10,11], and scapholunate arthrodesis [5,12,13]. All of these proceduresattempt to achieve stability at the cost of motion: composite motion between radiocarpal andmidcarpal row and obligatory rotation between scaphoid and lunate. Also, all intercarpalfusions significantly change load transmission across the radioscaphoid joint. The long-termresults of limited intercarpal fusions, such as scaphotrapeziotrapezoid fusion, have shownradiocarpal arthrosis in 19% to 50% cases [10,14].

The reduction and association of the scaphoid and lunate (RASL) procedure is a newtechnique for subacute or chronic scapholunate dissociation when the scapholunate ligamentis inadequate [15]. In contrast to salvage procedures, which limit wrist motion, the RASLtechnique is a motion-sparing procedure. In a cadaver study, Ruby and colleagues [16] showedthere is 25� of rotational motion between the scaphoid and lunate in wrist flexion and extensionand 10� of motion with radial and ulnar deviation. The Herbert screw (Zimmer, Inc, Warsaw,IN) used in the RASL procedure stabilizes the reduction while a fibrous neoligament formsbetween the scaphoid and the lunate. The fibrous neoligament matures while still allowingrotation to occur at the scapholunate junction. Restoration of near-normal kinematics allowspreservation of wrist motion and restoration of contact and loading pattern by correcting thedorsal intercalated segment instability (DISI). This normalization of kinematics should inhibitthe progression of osteoarthritis and scapholunate advanced collapse (SLAC) wrist.

Scaphoid stabilization procedures and ligament reconstruction procedures have had variablesuccess [10,14,17]. The rate of arthrodesis between the scaphoid and lunate has been reported tobe 70% using the Herbert screw and iliac crest bone graft and 13% with Kirschner wires.Fibrous union may be stable, and this recognition by Ruby and colleagues [16] and Herbert [12]


E-mail Address: [email protected] (M.P. Rosenwasser).


doi:10.1016/S1082-3131(03)00007-4


led to the development of the RASL procedure. Ligament reconstruction procedures correct thescapholunate diastasis in only 24% cases. The Blatt dorsal capsulodesis procedure is a checkreinthat prevents volar flexion of the scaphoid; however, lunate extension is not corrected, and thereis continued abnormal loading across the radioscaphoid articulation.

The RASL technique differs from other scapholunate ligament reconstructions [5,6,12]because the RASL procedure does not attempt ligament suture repair or reconstruction. In theRASL procedure, a transscapholunate Herbert screw is placed along the axis of rotation of thescapholunate. This placement permits the physiologic and obligatory rotation about this axisduring flexion and extension of the wrist, while correcting DISI deformity and scapholunatediastasis. The intended anatomic landmark that approximates the scapholunate axis of motionis the medial apex of the lunate. The smooth shank of the Herbert screw permits rotation despitethe secure leading and trailing thread anchorage. Filan and Herbert [5] also reported on Herbertscrew fixation to augment ligament repair, but they advised screw removal. They believed thescrew was a temporary fixation until adequate healing of a remnant of scapholunate inter-osseous ligament occurred. They believed surgery on chronic cases failed expressly because inad-equate tissue existed to maintain the proximal carpal alignment.

In the RASL procedure, the interface between scaphoid and lunate is dechondrified to exposethe cancellous surface, induce punctate bleeding, and initiate a cellular response to create aneoligament or pseudoligament of scar. As the screw is inserted at the center of axis ofscapholunate rotation, it allows motion and is not subjected to excessive bending stress. It isexpected that leading thread loosening in the lunate will occur, but not until the fibrousneoligament has matured under these incremental loading conditions, which remodel the tissueas per the dictates of Wolff’s law. For chronic scapholunate dissociation, which is greater than12 weeks, or irreparable scapholunate interosseous ligament without significant generalizedarthritis, the RASL procedure provides a reliable restoration of near-normal carpal kinematicswithout precluding subsequent salvage procedures.

Preoperative planning

An acute injury is defined as one presenting at fewer than 3 weeks from the time of injury,subacute is between 3 and 12 weeks, and chronic is greater than 12 weeks. The basic principles oftreating scapholunate instability are anatomic restoration and preservation of normal wristbiomechanics. A careful history, including antecedent wrist pain, date and mechanism of injury,and prior treatment, influences treatment options. A careful physical examination assessinginstability and associated injuries is important in planning treatment. The surgeon mustrecognize medical comorbidities, occupation, functional demands, and expectations beforeindicating treatment. It is established that untreated scapholunate dissociation leads toosteoarthritis and SLAC wrist. In most cases, scapholunate dissociation warrants a surgicalprocedure. Management of preoperative expectations has a significant impact on patientsatisfaction with surgery [18].

Routine radiographic investigations include the following:

1. A standard posteroanterior view is always performed.2. A clenched-fist posteroanterior view with wrist in ulnar deviation view accentuates the

scapholunate gap, if present.3. A lateral view shows the scapholunate angle. The normal scapholunate angle is 30� to 60�,

which is measured by drawing lines along the long axis of the two bones. A DISI pattern ispresent in chronic scapholunate injuries because of uncontrolled scaphoid flexion on lunateextension.

4. Anteroposterior radial and ulnar deviation views are obtained to assess the potential for thescapholunate gap to close (ie, reducible or irreducible).

5. A contralateral wrist posteroanterior view is performed to rule out generalized ligamentlaxity as a possible cause of scapholunate diastasis.

6. Fluoroscopy, arthrography, magnetic resonance imaging, or arthroscopy may be necessaryto diagnose scapholunate dissociation in patients with dynamic instability and normalradiographs.

96 C.B. Lipton et al / Atlas Hand Clin 8 (2003) 95–105


Indications for the RASL procedure are as follows:

1. Subacute scapholunate injury (>3 weeks to <3 months)2. Chronic scapholunate injury (>3 months) without advanced degenerative arthritis

Relative contraindications are as follows:

1. Acute Injury (<3 weeks)2. Advanced arthritis (scaphotrapeziotrapezoid, capitolunate, or radiocarpal)

Focal radial styloid/scaphoid arthritis is not a contraindication to the RASL procedurebecause a radial styloidectomy is a routine part of the procedure. If advanced arthritic changesare noted intraoperatively, however, the RASL procedure is abandoned in favor of salvageprocedures, such as a proximal row carpectomy or wrist arthrodesis [9,19].

Surgical technique

Surgery is performed on an outpatient basis under regional anesthesia, using the techniquedescribed by the senior author (M.P.R.) [15]. A longitudinal incision is made on the dorsum ofthe wrist just ulnar to Lister’s tubercle (Fig. 1). The interval between the third and fourth dorsalcompartments is used. A longitudinal incision is made in the capsule to open the wrist joint, butthe dorsal intercarpal ligament is defined and protected because it is a significant component tocarpal stability. The diastasis between the scaphoid and lunate is now clearly visible. Milddegenerative changes are not a contraindication to surgery; however, if advanced arthritis ispresent, the RASL procedure is abandoned for salvage options (Fig. 2).

Attention now is turned to the radial side of the wrist. A second longitudinal incision is madecentered over the radial styloid (Fig. 3). The branches of the superficial radial nerve and theradial artery are identified and protected. The first dorsal compartment is incised, and theretinaculum is preserved for later repair and imbrication of the radial collateral ligament.The capsule is incised longitudinally to expose the radial styloid subperiosteally to allow for anin-continuity preservation of the radial collateral ligament. An osteotome is used to performa radial styloidectomy. The osteotomy is made obliquely, and most, if not all, of the scaphoidfossa is preserved. Extreme care is taken not to injure ligaments. The radial collateral ligament isrepaired in continuity with the periosteal sleeve to the transposed extensor retinaculum at theend of surgery.

A 0.62-inch Kirschner wire is placed into the proximal dorsal surface of the extended lunatein a perpendicular plane, avoiding the capitolunate articulation, and another Kirschner wire isplaced into the flexed scaphoid at the distal pole of the scaphoid (Fig. 4). These wires serve asjoysticks. The Kirschner wires should be placed so they do not interfere with subsequentHerbert screw insertion. The lunate is flexed, and the scaphoid is extended to reduce the twobones. The mating articular surfaces between the two bones are exposed, and a side-cuttingpower burr is used to remove the articular cartilage of the scapholunate joint. The burr exposespunctate bleeding of the subchondral bone (Fig. 5). This bleeding allows cellular migration andthe generation of a fibrous neoligament.

A Kocher clamp is applied to the two Kirschner wires to hold the reduction in place(Fig. 6). The scapholunate joint is inspected to confirm reduction. If the bones are reduced, thecapitate articular surface is covered completely. The Herbert jig (Zimmer, Inc, Warsaw, IN) isintroduced through the radial incision, and its position is confirmed under a C-arm. The goalis to have the Herbert screw pass through the center of rotation of the two bones. The endof the jig should lie at the lunate vertex. The insertion point for the screw is the mid-waist of the scaphoid. The insertion angle parallels the normal radial inclination ofapproximately 20�. Placing the Herbert screw jig over the intended lunate target, the medialapex of the lunate, aligns the screw with the axis of rotation of the lunate and allows therequisite scapholunate rotation. The Herbert screw is inserted in the standard fashion aftermeasuring, drilling, and tapping both bones (Fig. 7). The screw should be countersunk

97C.B. Lipton et al / Atlas Hand Clin 8 (2003) 95–105

slightly within the scaphoid. Imaging should be used to confirm correct screw positioning.When the Kirschner wires are removed, the scaphoid and lunate remain reduced. These twobones now have synchronous movement with slight rotational motion between them. Thewound is closed in layers. The incised capsule at both incisions is closed without imbrication.No imbrication of capsule is performed, avoiding the capsulodesis effect with tethering andloss of motion. In some cases, the extensor pollicis longus may be released from its

Fig. 1. A–C, The location of the longitudinal dorsal incision made in the interval between the third and fourth dorsal

compartments just ulnar to Lister’s tubercle. A shows the U-shaped capsular incision previously used by the author, and

B shows the currently used straight longitudinal capsular incision. (Adapted from Rosenwasser MP, Strauch RJ,

Miyasaka KC. The RASL procedure: reduction and association of the scaphoid and lunate using the herbert screw.

Techniques in Hand and Upper Extremity 1997;1:263–72; with permission.)


compartment and placed subcutaneously. The dorsal retinaculum and skin are closed instandard fashion, and a volar splint is applied.

The authors have made some small but significant changes in the technique from the ear-lier report. A U-shaped capsular incision no longer is used. Rather, a straight longitudinalcapsular incision is used, respecting the transversely oriented dorsal intercarpal ligament. Formore recent cases, the authors have used the cannulated Herbert–Whipple screw (Zimmer,Inc, Warsaw, IN) to facilitate accurate screw placement without the use of a jig.

Pearls

1. Proper placement of Kirschner wires as joysticks is probably the most crucial part ofsurgery. Care must be taken during placement to avoid interference with screw insertion.Also the Kirschner wires should not violate the midcarpal or radiocarpal articular surfacesand should be placed bicortically to avoid cutout in the bone when reduction is performed.

2. The midwaist scaphoid entry site is at an oblique angle, and the jig must be positionedsecurely to ensure accurate screw placement during drilling and tapping.

3. The smooth shank of the Herbert screw must cross the scapholunate interval to allow forobligatory rotation (ie, no threads at the scapholunate junction).

Fig. 2. Focal radial styloid/scaphoid osteoarthritis as seen here is not a contraindication to performing the reduction and

association of the scaphoid and lunate procedure because radial styloidectomy is performed.


Cautions

1. The branches of the superficial radial nerve must be identified, carefully mobilized, andprotected throughout the case.

2. The dorsal radial artery, which passes transversely distal to the screw insertion site, must beidentified and protected.

3. Instability may result if excessive radial styloid is removed and the ligaments are injured.Only a nonarticular portion of the styloid should be osteotomized.

Postoperative management

After secure fixation is achieved, only 2–3 weeks of postoperative immobilization are requiredto allow capsular healing. All patients participate in a supervised hand therapy program duringpostoperative rehabilitation. Motion is the early goal followed by graduated strengthening. Thegoal is unrestricted activity at 4 to 6 months, including avocational activities and sports.

Results

The authors’ results in 21 patients at a mean of 32.4 months of follow-up (range 8 to 114months) show that the wrist range of motion is preserved after the RASL procedure. Ofpatients, 95% have returned to occupational and avocational interests. DISI deformity andscapholunate gap have been corrected toward normal parameters successfully (Fig. 8). DISIdeformity has been corrected from a preoperative scapholunate angle of 69� to a postoperativescapholunate angle of 40�. The scapholunate gap was corrected from a mean preoperative gapof 4.1 mm to a postoperative gap of 1.4 mm. Dynamic fluoroscopy in selected patients at 1 yearpostoperatively shows near-normal carpal kinematics in wrist flexion, extension, radial andulnar deviation, and grip. One patient failed because of secondary migration of the screw andrequired conversion to scaphocapitate fusion. One screw was removed at 4 years after surgeryfor radial impingement, but this patient exhibited excellent preservation of scapholunatestability despite screw removal.

Discussion

The preservation of range of motion of the wrist after the RASL procedure is likely due to thefact that the authors do not perform a capsulodesis or capsular imbrication. Capsular closurewithout imbrication helps minimize the loss of wrist range of motion that may be seen with theBlatt dorsal capsulodesis. The radial styloidectomy treats early radial styloid/scaphoid arthriticchanges often seen in chronic scapholunate dissociations and facilitates placement of theHerbert screw. The restored scapholunate articulation along with radial styloidectomy preventsscaphoid impingement and subsequent progression to SLAC wrist.

In 1996, Filan and Herbert [5] reported on the use of a screw for treatment of scapholunateligament rupture in 33 cases. The authors used the screw for internal fixation after openreduction and ligament repair in acute and chronic injuries. The Herbert screw was intended as atemporary fixation device that was removed an average of 12 months postoperatively. In thisseries, results were superior in patients with index surgery performed within 1 year of injury(mean 8.8 months). Filan and Herbert [5] recommended Herbert screw fixation for more recentinjuries when ligamentous repair is more feasible. In 1997, the senior author (M.P.R.) reportedon the RASL technique using the Herbert screw, not for temporary fixation but for permanentreduction and association of scapholunate dissociation [15]. The scapholunate interval wasdechondrified to foster cellular ingrowth and salvage chronic cases when little or no ligamenttissue remained at the scapholunate interval.


Fig. 4. Anteroposterior (A) and lateral (B) views of the Kirschner wires in the scaphoid and lunate that are used as

joysticks to perform the reduction maneuver. Kirschner wires should be placed to avoid interference with the Herbert

screw. One Kirschner wire is placed distally and directed proximally in the palmar flexed scaphoid, and the other is

placed proximally and directed distally in the dorsiflexed lunate. (Adapted from Rosenwasser MP, Strauch RJ, Miyasaka

KC. The RASL procedure: reduction and association of the scaphoid and lunate using the herbert screw. Techniques in

Hand and Upper Extremity 1997;1:263–72; with permission.)

Fig. 3. A and B, The location of the second axial incision. This incision is centered over the radial styloid. Care is taken

to protect the radial artery and radial sensory nerve. (Adapted from Rosenwasser MP, Strauch RJ, Miyasaka KC. The

RASL procedure: reduction and association of the scaphoid and lunate using the herbert screw. Techniques in Hand and

Upper Extremity 1997;1:263–72; with permission.)


Other authors have attempted different methods to reconstruct the scapholunate ligament.Weiss [8] reported using dorsal radial bone-retinaculum-bone constructs on 19 patients withdynamic instability or static instability. He concluded that use of bone-retinaculum-bone workson patients with dynamic instability; however, patients with static scapholunate instability

Fig. 5. Burring of subchondral bone (A) to induce punctate bleeding (B) and generate a fibrous response. (Adapted from

Rosenwasser MP, Strauch RJ, Miyasaka KC. The RASL procedure: reduction and association of the scaphoid and

lunate using the herbert screw. Techniques in Hand and Upper Extremity 1997;1:263–72; with permission.)

Fig. 6. A and B, Kocher clamp holding the Kirschner wires to maintain reduction before insertion of the Herbert screw.

(Adapted from Rosenwasser MP, Strauch RJ, Miyasaka KC. The RASL procedure: reduction and association of the

scaphoid and lunate using the herbert screw. Techniques in Hand and Upper Extremity 1997;1:263–72; with permission.)


require a stronger construct. In another study, the navicular/first cuneiform ligament wasisolated from cadavers, and the ligament was evaluated biomechanically [4]. This foot ligamentshowed similar biomechanical properties to the scapholunate interosseous ligament. Based onthese findings, the authors concluded that reconstruction using this foot ligament might restorewrist stability like bone-ligament-bone constructs used in anterior cruciate ligamentreconstruction.

In the authors’ series successful reduction of the scaphoid and lunate is achieved, whileallowing the obigatory rotational motion between these two bones. Midterm to long-termfollow-up radiographs show reductions without diastasis, carpal collapse, or capitate descent.Radiolucencies are visible around the Herbert screw at the lunate caused by the requisitescapholunate rotation. Two patients had complications necessitating reoperation. Placement ofthe Herbert screw at the center of rotation axis of both the bones is crucial.

The goal of this surgery is to restore the scaphoid and lunate relationships and allow formationof neoligamentous structure. In direct contrast to the four-bone or scapho-trapezium-trapezoidfusion, the RASL procedure allows a continued shared load transfer on the scaphoid and lunatefacets of the distal radius, whichmay diminish the risk of progression of osteoarthritis. The RASLprocedure does not preclude later salvage procedures, including intercarpal fusions, proximal rowcarpectomy, or wrist arthrodesis, should fixation fail or arthritis progress.

Specific features of the RASL procedure make it an attractive alternative. In contrast to mostprocedures for treating scapholunate dissociation, the RASL procedure is motion sparing; it is

Fig. 7. Herbert screw is placed parallel to the angle of inclination of the dorsal radius starting at the midwaist of the

scaphoid with a target of the apex of the lunate. The smooth shank of the screw must cross the scapholunate interval to

allow obligatory motion between the scaphoid and lunate. (Adapted from Rosenwasser MP, Strauch RJ, Miyasaka KC.

The RASL procedure: reduction and association of the scaphoid and lunate using the herbert screw. Techniques in Hand

and Upper Extremity 1997;1:263–72; with permission.)


not an arthrodesis. Herbert screw placement is not intended as a temporary fixation device. Thescrew lies in the axis of scapholunate motion, and radiographic evidence of lucency around thescrew indicates maintenance of obligatory rotation.

The RASL procedure is not a panacea. Chronic scapholunate instability with progression ofwrist joint arthrosis is a difficult problem to correct. A multitude of procedures have beendesigned to address this complex clinical entity. The RASL procedure has proved to be a reliableprocedure to restore function and provide satisfaction to the patient with subacute or chronicscapholunate dissociation.

References

[1] Blatt G. Capsulodesis in reconstructive hand surgery: dorsal capsulodesis for the unstable scaphoid and volar

capsulodesis following excision of the distal ulna. Hand Clin 1987;3:81–102.

[2] Almquist EE, Bach AW, Sack JT, et al. Four-bone ligament reconstruction for treatment of chronic complete

scapholunate separation. J Hand Surg Am 1991;16:322–7.

[3] Conyers DJ. Scapholunate interosseous reconstruction and imbrication of palmar ligaments. J Hand Surg Am

1990;15:690–700.

Fig. 8. Preoperative anteroposterior (A) and lateral (B) radiographs of a patient with chronic scapholunate diastasis

show a widened scapholunate gap and dorsal intercalated segment instability deformity. Anteroposterior (C) and lateral

(D) radiographs 3.5 years after reduction and association of the scaphoid and lunate procedure show restoration of near-

normal anatomy.


[4] Davis CA, Culp RW, Hume EL, Osterman AL. Reconstruction of the scapholunate ligament in a cadaver model

using a bone-ligament-bone autograft from the foot. J Hand Surg Am 1998;23:884–92.

[5] Filan SL, Herbert TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg Br 1996;78:519–29.

[6] Glickel SZ, Millender LH. Ligamentous reconstruction for chronic intercarpal instability. J Hand Surg Am

1984;9:514–27.

[7] Howard FM, Fahey T, Wojcik E. Rotatory subluxation of the navicular. Clin Orthop 1974;104:134–9.

[8] Weiss AP. Scapholunate ligament reconstruction using a bone-retinaculum-bone autograft. J Hand Surg Am

1998;23:205–15.

[9] Wyrick JD, Stern PJ, Kiefhaber TR. Motion-preserving procedures in the treatment of scapholunate advanced

collapse wrist: proximal row carpectomy versus four-corner arthrodesis. J Hand Surg Am 1995;20:965–70.

[10] Kleinman WB, Carroll CT. Scapho-trapezio-trapezoid arthrodesis for treatment of chronic static and dynamic

scapho-lunate instability: a 10-year perspective on pitfalls and complications. J Hand Surg Am 1990;15:408–14.

[11] Watson HK, Ashmead D 4th, Makhlouf MV. Examination of the scaphoid. J Hand Surg Am 1988;13:657–60.

[12] Herbert TJ. Use of the Herbert bone screw in surgery of the wrist. Clin Orthop 1986;202:79–92.

[13] Hom S, Ruby LK. Attempted scapholunate arthrodesis for chronic scapholunate dissociation. J Hand Surg Am

1991;16:334–9.

[14] Fortin PT, Louis DS. Long-term follow-up of scaphoid-trapezium-trapezoid arthrodesis. J Hand Surg Am

1993;18:675–81.

[15] Rosenwasser MP, Strauch RJ, Miyasaka KC. The RASL procedure: reduction and association of the scaphoid and

lunate using the Herbert screw. Techniques Hand Upper Extremity 1997;1:263–72.

[16] Ruby LK, Cooney WP 3rd, An KN, et al. Relative motion of selected carpal bones: a kinematic analysis of the

normal wrist. J Hand Surg Am 1988;13:1–10.

[17] Rogers WD, Watson HK. Radial styloid impingement after triscaphe arthrodesis. J Hand Surg Am 1989;14(2 Pt 1):

297–301.

[18] Eisler T, Svensson O, Tengstrom A, Elmstedt E. Patient expectation and satisfaction in revision total hip

arthroplasty. J Arthroplasty 2002;17:457–62.

[19] Tomaino MM, Miller RJ, Cole I, Burton RI. Scapholunate advanced collapse wrist: proximal row carpectomy or

limited wrist arthrodesis with scaphoid excision? J Hand Surg Am 1994;19:134–42.


Scaphoid nonunion: correction of deformitywith bone graft and internal fixation

Christopher Forthman, MDa, David Ring, MDb,c,*,Jesse B. Jupiter, MDb,c

aHarvard Combined Orthopaedic Residency Program, Boston, MA 02114, USAbDepartment of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA

cHand and Upper Extremity Surgery Service, Massachusetts General Hospital, Boston, MA 02114, USA

The scaphoid is the most commonly fractured bone in the carpus. Although greater than90% of scaphoid fractures unite with cast immobilization, failure to heal remains a clinicalreality, particularly when the fracture is displaced or associated with intracarpal instability [1–3].Dabezies [4] reported a 55% incidence of nonunion and a 50% rate of proximal pole avascularnecrosis (AVN) in scaphoid fractures with greater than 1 mm of displacement. Cooney andcolleagues [2] noted a nonunion rate of 46% for 13 displaced scaphoid fractures.

Scaphoid nonunion has been associated with progressive symptomatic radiocarpal andmidcarpal arthrosis [5–7]. This arthrosis is the sequela of altered wrist kinematics [3,8,9]. Thealteration of wrist kinematics reflects not only motion through the nonunion site, but also theapex-dorsal malalignment of the scaphoid (the so-called humpback deformity) with associateddorsal angulation of the lunate and alteration in carpal height [10,11].

Although scaphoid deformity and its adverse effects on kinematics were recognized early onby Fisk [12], for many years the standard treatment of symptomatic scaphoid nonunion wasbased on gaining union without an attempt to correct the deformity of the scaphoid. It has beenrecognized, however, that some patients with residual bony deformity of the healed scaphoidmay continue to have pain and functional limitations [13–15]. As a result of a greater ap-preciation of carpal kinematics, many authors now believe that the approach to a scaphoidnonunion should consist of realigning the scaphoid anatomy and gaining union.

Scaphoid deformity

Posttraumatic scaphoid deformity is complex but predictable. Displaced scaphoid fragmentslie in a so-called humpback configuration with flexion of the distal fragment. The dorsalintercalary pattern of carpal instability (DISI) follows [16]. With the use of three-dimensionalreconstructions of computed tomography images, the three-dimensional orientation of afractured scaphoid has been represented more clearly.

Belsole and coworkers [17] looked at a series of scaphoid nonunions and performed a detailedthree-dimensional CT evaluation comparing the fractured and contralateral scaphoids. Theyfound that the proximal scaphoid fracture component is extended, radially deviated, andsupinated in relation to the distal fracture component. They also identified that the volume andconfiguration of missing bone is consistent. The amount of the scaphoid bone that was lost variedfrom 6% to 15% of bone volume. The bony defect is prismatic with a quadrilateral base facingpalmarly.

* Corresponding author. Massachusetts General Hospital, ACC 525, 15 Parkman Street, Boston, MA 02114, USA.

E-mail address: [email protected] (D. Ring).


doi:10.1016/S1082-3131(03)00003-7


Nakamura and colleagues [18] also analyzed scaphoid deformity by three-dimensional CT.They identified two different positions for the distal fragment: volar type and dorsal type (Fig. 1).In the volar type, the distal fragment was flexed and overhung in the volar direction rela-tive to the proximal fragment. This pattern was associated with fracture distal to the dorsalapex of the ridge of the scaphoid. In the dorsal type, the distal fragment moved dorsally onthe proximal fragment and was associated with a more proximal and horizontal fracture line.Moritomo and colleagues [19] reproduced Nakamura’s findings. In their study, all of the distalor volar types of nonunions were associated with DISI deformity.

Several techniques to quantify scaphoid malalignment have been suggested. Amadio andcolleagues [20] described measuring the intrascaphoid angle on anteroposterior and lateraltomograms. A perpendicular line is drawn to the proximal and distal articular surfaces, and theangle between these lines is measured (Fig. 2). The average values for the anteroposterior andlateral intrascaphoid angles are 40� (range 32� to 46�) and 24� (range 15� to 34�). Bain andcolleagues [21] showed that the intraobserver and interobserver variability of the lateralintrascaphoid angle and dorsal cortical angle (Fig. 3A) are high. They recommended thescaphoid height-to-length ratio as a more reliable technique (Fig. 3B). A baseline is drawn alongthe volar aspect of the scaphoid. The length is measured along this baseline from the mostproximal to the most distal aspect of the scaphoid, the maximum height of the scaphoid ismeasured on a line perpendicular to the baseline, and the ratio is calculated by dividing theheight by the length. The normal ratio is less than 0.65.

Consequences of nonunion and deformity of the scaphoid

Studies by Mack and associates [5] and Ruby and Leslie [6] suggested an association betweenscaphoid nonunion and progressive radiocarpal and midcarpal arthrosis. Mack and associates[5] reviewed 47 patients with symptomatic scaphoid nonunions 5 to 53 years after injury. Oflesions, 23 had sclerosis, cyst formation, or resorptive changes confined to the scaphoid bone; 14had radioscaphoid arthritis; and 10 had generalized arthritis of the wrist. They observed greaterarthrosis with longer duration of nonunion. Fracture displacement and carpal instability alsocorrelated with the severity of degenerative changes. Ruby and Leslie [6] reviewed 32 patientswith scaphoid nonunion followed for at least 5 years after injury. Of the 32 patients, 31developed arthrosis, and the extent of arthrosis increased with time in a predictable pattern.

Vender and coworkers [7] characterized this pattern of arthrosis in a retrospectiveradiographic analysis of 64 patients with symptomatic scaphoid nonunions. The pattern re-sembled that of scapholunate advanced collapse (SLAC). Successive degenerative changes

Fig. 1. (A) In the volar type of scaphoid nonunion, the distal fragment is displaced volarly, and the proximal fragment is

rotated dorsally. (B) In the dorsal type of scaphoid nonunion, the distal fragment translates dorsally. (From Fernandez

DL, Eggli S. Scaphoid nonunion and malunion: how to correct deformity. Hand Clin 2001;17:631–46; with permission.)

108 C. Forthman et al / Atlas Hand Clin 8 (2003) 107–116

occurred in the radial styloid-scaphoid, capitate-scaphoid proximal fragment, and capitate-lunate articulations. The radius-proximal scaphoid fragment joint and the radiolunate jointconsistently were spared from degenerative changes. This pattern has been termed the SNACwrist for ‘‘scaphoid nonunion advanced collapse.’’

The data derived from these studies have been advocated as evidence of the natural historyof scaphoid nonunion; however, use of the term natural history is inaccurate because onlysymptomatic patients presenting for treatment were included in these investigations [22]. Toknow the true natural history of scaphoid nonunion, one would have to evaluate all patientswith scaphoid nonunion, including patients who do not seek medical attention.

Results of treatment of scaphoid nonunions without deformity correction

For many years, the most common treatment for symptomatic scaphoid nonunion was theinlay technique of bone grafting [23]. Russe [23] described a volar approach to the scaphoid with

Fig. 2. The intrascaphoid angles are defined as the angle between perpendiculars to the proximal and distal articular

surfaces in the posteroanterior (A) and lateral (B) planes. (From Amadio PC, Berquist TH, Smith DK, et al. Scaphoid

malunion. J Hand Surg Am 1989;14:687–97; with permission.)

109C. Forthman et al / Atlas Hand Clin 8 (2003) 107–116

excavation of fragments and insertion of a corticocancellous bone graft from the iliac crest intothe nonunion site. No attempt was made to correct deformity. Analysis of the functional andradiographic results of Russe bone grafting of the scaphoid provides some data regarding theinfluence of malalignment on outcome.

Jiranek and colleagues [24] reported on the results of Russe bone grafting for 25 patients withsymptomatic scaphoid nonunion. Patients with severe carpal arthritis or significant ligamentousinjury were excluded. At an average of 11 years’ follow-up, there was an 81% union rate.Malunion, defined as a 45� lateral intrascaphoid angle, was found in 50% of patients. There wasno significant difference between patients with malunion and patients with acceptable alignmentwith regard to either subjective complaints or the extent of arthrosis. Malunion was associatedwith a trend toward decreased motion and strength and a statistically significant increasedincidence of carpal collapse. The authors concluded that when pain was relieved, their patientsseemed to adapt to the potential functional deficits associated with malunion.

Stark and colleagues [25] also observed a high level of patient satisfaction after Russe bonegrafting. A total of 43 patients with symptomatic scaphoid nonunion were treated with theRusse technique at an average of 40 months after injury. Of patients, 27 were evaluated at anaverage of 12 years after the Russe grafting procedure; 22 (81%) had healed, 24 (89%) weresatisfied, and 17 (63%) were totally pain-free. Malalignment, defined as a persistent step-offbetween fracture fragments of 2 mm or more, occurred in nine patients (33%). All patients withmalalignment had osteoarthrosis, and five of nine patients failed to heal. All cases of persistentnonunion and severe osteoarthrosis were associated with scaphoid malalignment. Wrist painand functional limitations were twice as common in patients with persistent nonunion andsevere osteoarthrosis. Despite overall patient satisfaction, this study suggested the importance ofadequate reduction of scaphoid deformity for healing and improved functional andradiographic results.

Burgess [10], in a cadaver study, found that scaphoid malalignment results in loss ofradiocarpal and midcarpal extension. Burgess simulated malunion in four specimens by

Fig. 3. (A) The dorsal cortical angle is measured by drawing lines parallel to the dorsal cortices of the proximal and distal

halves of the scaphoid and measuring the angle between them. (B) The ratio of the height of the scaphoid to its length

measured along its axis is recorded as a percentage. (From Bain GI, Bennett JD, MacDermid JC, et al. Measurement of

the scaphoid humpback deformity using longitudinal computed tomography: intra- and interobserver variability using

various measurement techniques. J Hand Surg Am 1998;23:76–81; with permission.)


osteotomizing the middle third of the scaphoid and fixating the fragments in the humpbackposition. He progressively increased the angulation in 5� increments until all wrist extension waslost. With just 5� of malalignment, there was a 24% loss of extension. By 30� of intrascaphoidflexion, all radiocarpal and midcarpal motion was lost. This experiment was done with intactligaments to show the effect of scaphoid malunion alone.

Amadio and colleagues [20] observed clinically that scaphoid malunion was associated withwrist dysfunction and arthrosis. They used trispiral tomographic and clinical evaluation tofollow 46 patients with fractured scaphoids for an average of 3.5 years. After healing, 26 of the46 scaphoids had malunion defined as a lateral intrascaphoid angle of more than 34�. Increasinglateral intrascaphoid angle was associated significantly with decreasing relative grip and withdecreasing total functional score. The subset of the malunions with a lateral intrascaphoid angleof 45� or greater was more likely to have fair or poor results with posttraumatic arthritis andfunctional wrist impairment. The authors concluded that union alone is inadequate as acriterion for success in treating scaphoid fractures and that alignment is an important de-terminant of functional and radiographic results.

The justification for operative treatment of symptomatic scaphoid nonunions has been torelieve pain, improve function, and postpone or prevent progressive carpal arthrosis. Thequestion remains with some as to whether or not the surgeon should attempt to correct de-formity. The literature would suggest a trend toward greater pain, impaired function, andmore severe arthrosis in cases of scaphoid nonunion that have healed but still have deformity.Additional outcome studies using precise and consistent methods to assess scaphoid anatomyand patient functional deficit would help answer this question.

Operative techniques to correct deformity

When planning operative treatment for a scaphoid nonunion, the surgeon must consider thesite of the fracture, the vascular supply to the fragments, bony anatomy, prior treatment, andduration of nonunion. Most techniques to correct deformity have been described for the morecommonly seen scaphoid waist nonunion, the Nakamura ‘‘distal or volar type,’’ in which thereis a humpback deformity, a scaphoid bone defect, and a DISI pattern of carpal malalignment.For these cases, the palmar approach allows easier grafting of the prismatic bone defect andcorrection of the distal fragment malalignment. It also has been argued that the palmarapproach is least injurious to the vascular supply of the proximal pole [26].

Before surgery, it is recommended that the surgeon evaluate for osteonecrosis using magneticresonance (MR) imaging if necessary. The union rate of the scaphoid decreases as the vas-cularity decreases [27,28]. Conventional radiographic findings of AVN, including an increasein bone density, a loss of the normal trabecular appearance, collapse of subchondral bone, andcystic changes, may be unreliable. Green [27] and Perlik and Guilford [29] showed that intra-operative and histologic findings cannot be predicted accurately by the appearance of pre-operative radiographs. Green [27] recommended that the proximal fragment vascularity bedetermined intraoperatively by punctate bleeding points in cancellous bone. The preoperativeMR imaging finding of absent T1-weighted marrow signal may be more reliable [29]. Accordingto Gunal and colleagues’ [30] study correlating intraoperative and MR imaging findings, thediagnosis of AVN should be made only when MR imaging and intraoperative findings indicateavascularity. In these cases, the surgeon should consider a vascularized bone graft [31] with orwithout an attempt to correct deformity.

The first operation to use a custom-shaped corticocancellous wedge graft for correction ofdeformity was the anterior interpositional wedge graft technique described by Fisk [32]. In casesof angulated or displaced nonunions of the waist or distal third, Fisk performed a radialapproach, excising a wedge-shaped piece of the radial styloid and using it to fill the defectcreated by realignment. He claimed that by restoration of scaphoid length and correction of theflexion deformity, the pathologic rotation of the lunate and carpal collapse could be corrected.No internal fixation was used.

Fernandez [33–35] described a modification of Fisk’s original technique. His technique isbased on careful preoperative planning using radiographs and tomograms of the contralateral


wrist to determine the exact bone graft shape needed to restore scaphoid anatomy (Fig. 4). Theoperative approach to the scaphoid is through a palmar incision and capsulotomy. A smallbladed saw cleanly removes the sclerotic, avascular margin on either side of the nonunion.Reduction is achieved by wrist hyperextension, distraction of the fragments, and pushing thepalmar pole of the lunate toward the radius. The bone graft is harvested from the iliac crest andcarefully contoured based on the preoperative plan. The graft is inserted with the cortical part ofthe graft oriented palmarly, then secured to the scaphoid with a screw or Kirschner wires. Afterinsertion of the graft, spontaneous derotation of the lunate usually takes place; however, incases with long-standing DISI deformity, it may be useful to pin the lunate to the radius inanatomic position for 4 to 6 weeks after the operation. Postoperative immobilization dependson the degree of initial instability, associated carpal malalignment, and strength of the internalfixation. A plaster splint or a cast may be required until union is identified on sequentialradiographs. This approach has been implemented by many surgeons, occasionally with minormodifications [36–39].

Herbert [40] prioritized preservation of a shelf of bone or soft tissue posteriorly over exactrestoration of scaphoid anatomy. Although Fernandez may have cut the dorsal bone and softtissues, Herbert left a dorsal hinge as a fulcrum around which the fragments may open. Herbert

Fig. 4. (A) The dimensions of the interposition bone graft are estimated based on comparison of preoperative

radiographs of the involved and uninvolved scaphoids. The sclerotic fracture ends are debrided of fibrous tissue and

evened with a saw. The sclerotic fracture surfaces are opened by perforating with a Kirschner wire. (B) The size and

shape of the structural corticocancellous bone graft obtained from the iliac crest are planned preoperatively.

Rectangular, triangular, and trapezoidal grafts may be used. (C) The interposed graft is stabilized with Kirschner wires

or a screw. (From Fernandez DL, Eggli S. Scaphoid nonunion and malunion: how to correct deformity. Hand Clin

2001;17:631–46; with permission.)


suggested that this fulcrum enhances the stability of the graft. He recognized the potential formidcarpal arthrosis without exact restoration of the scaphoid anatomy.

Maruthainar and coworkers [41] and Leung and colleagues [42] described a ‘‘coring’’technique as a way to maintain a good stable reduction without having to trim a well-fittingwedge. These authors perform a volar approach, core out the nonunion site, and reduce thehumpback deformity. A cylindrical saw or serial trephine bone biopsy forceps are used toextract a cylindrical bone core from the iliac crest. The graft is placed and lies in compressionwithin the nonunion bed. Maruthainar and coworkers [41] oversized the graft to avoid having touse internal fixation. Leung and colleagues [42] used a cannulated Acutrak screw (Acumed,Beaverton, OR) inserted from the distal scaphoid. Postoperatively the patients are placed in asplint for at least 4 to 6 weeks. These authors claimed that the coring technique correctsscaphoid deformity, while being more mechanically stable than conventional wedge grafts torotational and shear stress.

Other authors suggested that scaphoid reduction can be maintained without custom-shapedcorticocancellous grafts. Watson and colleagues [43] described a dorsal approach with scaphoidreduction, cancellous bone grafting, and Kirschner wire fixation. Nagle [44] reported on asimilar technique using a volar approach, packed morcellized cancellous bone graft, andKirschner wire fixation. Reduction of the fracture is aided by wrist extension, then Kirschnerwires are driven from distal to proximal across the nonunion site. Cancellous graft can beharvested easily from the distal palmar radius without the need for a separate incision asrequired for iliac crest grafts. Nagle [44] suggested that cancellous morcellized graft can bemanipulated more easily and precisely to fit the scaphoid defect compared with cortico-cancellous graft. After surgery, the wrist is immobilized, and the Kirschner wires are left in placefor 12 weeks.

In cases of persistent nonunion or AVN, vascularized bone grafts have been used inconjunction with internal fixation and correction of scaphoid deformity. The dorsoradial part ofthe distal radius is the most common donor site. Zaidemberg and coworkers [45] first describeda pedicled corticocancellous bone harvest based on the branch of the radial artery runningbetween the first and second dorsal compartments (1,2 ICSRA). Their original cases useda dorsoradial approach to harvest graft and to form a dorsal trough in the scaphoid forgraft placement. Any correction of scaphoid deformity required a separate palmar incision.Steinmann and Bishop [46,47] subsequently described how to use the 1,2 ICSRA–based vasculargraft as a wedge. Under direct visualization, the maximal dimensions of the palmar corticaldefect, the dorsal-palmar width, radioulnar width, and internal defect are determined. A graft ofappropriate dimension is raised and inserted, and vessels are placed palmarly to allow thecortical component of the graft to restore scaphoid length. Kirschner wires or a compressionscrew is used to add further stability. Trumble and Nyland [31] described a similar techniquethrough a radiopalmar approach to the scaphoid.

Reported results and complications

It is difficult to interpret the reported results of volar wedge grafting for scaphoid nonunionand compare them with alternative techniques owing to the fact that among the more than 30scaphoid nonunion outcome studies found in the English literature reliable and consistentcriteria are lacking for assessing union [48,49] and alignment [21], there is intermixing of variousfracture types, there are differences in the duration of the nonunion and the status of the carpalarticulations at the time of treatment, various measures of patient outcome are used, and there isa lack of long-term follow-up. Most authors report their union rate but do not comment on thesuccess in correcting scaphoid deformity.

The comparative benchmark remains the long-term follow-up of the Russe bone grafttechnique provided by Jiranek and colleagues [24] and Stark and coworkers [25]. Together theseauthors followed more than 50 patients for an average of greater than 10 years. In both studies,the average union rate was 81%, and at least 80% to 90% of patients were happy with theirresults. Postoperative radiographic malalignment was noted for 33% and 50% of patients in theStark and Jiranek studies. Jiranek and colleagues [24] documented functional limitations and


carpal collapse in these cases. Stark and coworkers [25] did not report specific results for thissubpopulation of patients but noted osteoarthrosis in all patients with persistent malalignment.In their patients with significant malalignment (lateral intrascaphoid angle of >45�), Jiranekand colleagues [24] reported a flexion arc of 78% and a grip strength of 76% compared with theuninjured side. Overall, Stark and coworkers [25] reported postoperative extension and flexionarcs of 70% and 80%. The average postoperative grip strength was 82% of the uninjured side.

Eggli and colleagues [50] reported on the success of anterior wedge grafting at an averagefollow-up of 5.7 years. In 37 patients with nonunions treated with interpositional bone graftingand internal fixation, solid radiographic union was achieved in 35 cases (95%). Of patients, 26(70%) had excellent or good results according to the Mayo Wrist Score. Of patients, 33 (89%)had restoration of scaphoid length to within 2 mm compared with the uninjured side, and allpatients had correction of the DISI deformity. These results seem to represent an improvementin union rate and correction of scaphoid deformity compared with conventional Russe bonegrafting. Similarly, restoration of the flexion arc (85%) and grip strength (88%) comparesfavorably with Jiranek and Stark’s studies. Most importantly, none of the patients in Eggli andcolleagues’ [50] study developed severe degenerative changes after surgery. Although 81% ofpatients did have radiographic findings of mild or moderate degenerative changes, there was nosignificant progression of arthrosis after fracture union. Eggli and colleagues [50] postulatedthat anterior wedge grafting may delay or diminish the progression of arthrosis. Their com-plications included two persistent nonunions, three hypertrophic scars treated with scar re-vision, one patient who had a subsequent radial styloidectomy for impingement, and one patienttreated with a subsequent radial shortening osteotomy and wrist denervation for pain.

Other authors also reported high rates of union and improved carpal alignment and wristfunction after anterior wedge-shaped grafting [36,38,49,51,52]. The rates of union ranged from94% to 100%. Nakamura [51], Tsuyuguchi [52], Takami [37], and Chen [38] specifically notedimprovement in carpal instability and humpback deformity. In all studies, functional results andoverall patient satisfaction were good.

Early results of the ‘‘coring’’ technique have been reported by Leung and colleagues [42] andMaruthainar and colleagues [41]. In the Leung study [42], all 11 patients with symptomaticscaphoid nonunion went on to heal after surgery. At the average follow-up of 30 months, allpatients were satisfied, and 10 of 11 had resolution of pain. Four of the patients had a lossof 20% to 30% of wrist motion. The single complication was a case of screw impingementrequiring reoperation and screw removal. Leung and colleagues [42] also found that if the bonygap is more than 9 mm after reduction, trephine graft may exceed the width of the scaphoid. Inthis scenario, a wedge graft may be needed. Maruthainar and colleagues [41] documented aunion rate of 80% after their similar procedure. At a mean follow-up of 8.2 months, fourpatients had radiocarpal arthritis. Neither the Leung study nor the Maruthainar studyspecifically compared preoperative and postoperative scaphoid alignment or progression ofarthrosis. Long-term results are needed to compare this technique further with that described byEggli and colleagues [50].

Multiple factors have been identified that predict poor outcome despite custom-shaped bonegrafting and correction of scaphoid deformity. Although there is some disparity among studies,these factors include the time between the initial fracture and the treatment of nonunion, thepresence of AVN of the proximal fragment, and a history of prior surgery for nonunion. Instudies reported by Nakamura [51], Schuind [53], Inoue [54], and Shah [28], time between injuryand treatment of nonunion and AVN of the proximal fragment were recognized as poorprognostic factors. Daly and associates [36] and Shah and Jones [28] also identified a history ofprevious surgery in their patients with worse outcomes. In Eggli and colleagues’ [50] 5.7-yearfollow-up study, the two nonunions that failed to heal had intraoperative signs of avascularity.Each patient required at least one additional operation; one patient united with a re-vascularization procedure, and the other required a salvage SLAC wrist procedure. For thesereasons, Fernandez and others suggested that patients with preoperative signs of AVN or failedprior surgery for nonunion should be treated with vascularized bone grafts.

In cases of prolonged nonunion or AVN, results with vascularized grafts have shown higherrates of healing compared with the Russe and wedge grafting techniques. Zaidemberg andassociates [45] had a 100% union rate in 11 cases of long-standing nonunion of the scaphoid


using the 1,2 ICSRA. Steinmann and colleagues [46,55] also had a 100% union rate in 14patients with established nonunions. These authors have not reported results for restoration ofscaphoid anatomy at the time of vascularized graft insertion. As with the typical scaphoidnonunions, success in these difficult cases also may depend on correction of scaphoid deformity.

Patients with malunion may continue to have pain and functional limitations. For thesecases, osteotomy and wedge grafting have been reported [13,15,40,56]. In the 18 patients foundin the English literature, all osteotomies healed with improvement in patient function and carpalalignment. There have been no reports of iatrogenic AVN or other complications. Nevertheless,although most hand surgeons are willing to try to correct a deformed nonunion, the studies onscaphoid malalignment are not yet convincing enough that the average hand surgeon iscomfortable performing an osteotomy on a well-healed scaphoid fracture.

References

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Fixation of scaphoid nonunion with Kirschner wiresand cancellous bone graft

Andrew P. Gutow, MDa, Milan V. Stevanovic, MD, PhDb,*aDepartment of Orthopaedic Surgery, University of Michigan Medical School, Taubman Center,

2912 1500 East Medical Center Drive, Ann Arbor, MI 48109, USAbDepartment of Orthopaedic Surgery, Keck School of Medicine, University of Southern California,

2025 Zonal Avenue, GNH 3900 Los Angeles, CA 90089-9312, USA

In the treatment of established carpal scaphoid nonunions, themost successful and reliable pro-cedure for obtaining bone healing is an appropriately performed internal fixation with Kirschner

wires and cancellous iliac crest bone graft. In a series of 151 patients treated with this technique,

Stark and colleagues [1] reported a 97% success rate, with only 4 patients failing to heal.

The diagnosis and treatment of scaphoid fractures and scaphoid nonunions began with the

widespread use of radiography in the first half of the twentieth century [2]. For the most part,

in the early twentieth century, surgeons accepted MacLennan’s [2] statement that ‘‘The wiring of

the fragments is seldom practicable; it takes time and really causes considerable interference

with surrounding structures.’’ Following this philosophy, the earliest treatments consisted ofsimple excision.

By the 1930s, Matti [3] in the German literature and Murray [4] in the English literature pub-

lished reports of successful operative treatments of nonunion with cancellous and corticocancel-

lous grafting without internal fixation. During the middle third of the twentieth century, Russe’s

[5] technique of fixation by way of a volar approach with a structural cancellous bone graft from

the iliac crest became commonly accepted. Other workers suggested the addition first of wires

and then screws for internal fixation [1,6].

Indications

The authors believe that all scaphoid nonunions will go on to develop radiographically ap-

parent arthritis in time. The natural history of symptomatic scaphoid nonunion was well studied

by Mack and coworkers [7], who found an inevitable progression to arthritis in a series of 46

patients with symptomatic scaphoid nonunions. Ruby and associates [8] found a similar out-

come in a series of 55 patients. A review of asymptomatic scaphoid nonunions by Lindstromand Nystrom [9] showed a 100% development of radiographic arthritis at 12 to 43 years after

the fracture. From these studies, one can conclude that scaphoid nonunions over time will de-

velop radiographic changes consistent with arthritis, and patients will have varying degrees of

symptoms with these. The authors recommend surgical treatment of all symptomatic nonunions

and asymptomatic nonunions in younger patients who understand the risks and benefits of sur-

gical intervention.

Previous failed internal fixation andbone grafting is not a contraindication if severe arthritis has

not developed. The authors do not perform internal fixation and bone grafting in patients with se-vere radiocarpal arthritis; scaphoid excision or some other salvage procedure is preferred in these

cases. Internal fixation and bone grafting is indicated in patients with mild arthritis isolated to the

scaphoid and radial styloid. For mild radioscaphoid arthritis, a styloidectomy is performed in


E-mail address: [email protected] (M.V. Stevanovic).


doi:10.1016/S1082-3131(02)00016-X


these patients at the time of the bone grafting. Osteonecrosis of the proximal fragment is not an

absolute contraindication to this technique; Stark and colleagues [1] achieved union in 21 (84%)

of 25 cases in which avascular necrosis was noted on preoperative standard radiographs.

Contraindications

This surgery is contraindicated in patients who are actively smoking. Patients with active al-

cohol abuse, psychiatric disease, or personality disorders that would prevent them from comply-

ing with the postoperative course of immobilization are not candidates for this procedure. Forpatients who have failed one attempt at union with appropriately performed conventional bone

grafting, the authors recommend pedicled vascularized graft from the radius by a dorsal ap-

proach using the 1,2-intercompartment supraretinacular artery graft as first described by

Zaidemberg [10,11].


A standard physical examination, including range of motion, sensory testing, vascular status,

and grip strength, should be performed. Standard radiographs of the affected side should be

obtained, including posteroanterior, true lateral, and posteroanterior in ulnar deviation views

(Fig. 1). Comparison views of the opposite side should be obtained to help assess scaphoid length

and alignment and to help in restoring this anatomic alignment at the time of surgery. It is impor-

tant to restore fully the length and alignment of the scaphoid at the time of surgery. There is ahigher rate of development of radiographic evidence of arthritis in wrists in which the scaphoid

alignment has not been fully restored [12], so the authors attempt to correct the deformity as

fully as possible.

In addition to standard radiographs, if further information on deformity or bone loss is needed,

a computed tomography (CT) scan of the wrist aligned in the long axis of the scaphoid should be

obtained [13]. The CT scan is obtained by having the patient lie prone on the scanner table, then

place the arm above the head with the long axis of the abducted thumb parallel to the gantry. If

there is concern about osteonecrosis, magnetic resonance imaging should be obtained [14].

Anatomy

The volar approach used avoids the primary blood supply to the scaphoid, which enters by

way of dorsal ridge perforators [5,15,16]. The volar approach risks damage to the stout volar

wrist ligaments [17], but the period of postoperative immobilization and careful closure should

prevent subsequent rotatory instability of the scaphoid.

Technique

The authors use a modification of the technique of cancellous bone grafting and Kirschner

wire fixation described by Stark and colleagues [1]. The procedure is performed as outpatient

surgery, under general anesthesia to allow for harvesting of cancellous bone graft from the iliac

crest. Occasionally, patients need to be admitted for 23-hour observation for control of donor

site pain. Prophylactic antibiotics are administered preoperatively. A radiolucent hand table is

used to allow for intraoperative fluoroscopy. An upper arm tourniquet is used.

Approach

A volar approach to the wrist is used. A straight incision is made in the distal forearm be-

tween the distal portion of the flexor carpi radialis and the radial artery, then carried out across

the distal wrist crease, jogging slightly radial toward the base of the thumb (Fig. 2). The flexor

carpi radialis tendon is retracted ulnarly and the radial artery radially. The wrist capsule is

130 A.P. Gutow, M.V. Stevanovic / Atlas Hand Clin 8 (2003) 129–138

entered through a longitudinal incision from the volar lip of the radius to the proximal tubercle

of the trapezium. The capsule carefully is reflected sharply off of the scaphoid with a knife. The

capsule needs to be preserved because it contains the radioscaphoid capitate ligament and is re-

paired at the close of the procedure (Fig. 3).

Preparation of nonunion site

Preparation of the nonunion site and the packing in of the graft are among the most impor-

tant parts of the procedure, and the authors usually spend 15 minutes on each of these steps.

The wrist is dorsiflexed over a bump to allow for visualization of the proximal and distal sca-

phoid fragments and the radial scaphoid articulation. A freer elevator is placed in the radiosca-phoid joint around the radial aspect of the scaphoid to protect the radial cartilage and to lever

the fracture out of its humpback (apex dorsal angulation) deformity (Fig. 4). Although the ini-

tial mechanism of scaphoid fracture is usually an extension load with tension failure of the volar

cortex, over time with a nonunion the muscle forces across the wrist lead to progressive loss of

volar cortex with relative volar flexion of the distal fragment and dorsal flexion of the proximal

fragment.

A window is made in the volar scaphoid proximal and distal to the fracture to allow for re-

moval of fibrous tissue and dead bone. The authors use sharp small curets to clean out carefully

Fig. 1. (A–C) Three views of established nonunion without evidence of arthritis. On lateral view, some collapse into apex

dorsal angulation (humpback deformity) is visible.

131A.P. Gutow, M.V. Stevanovic / Atlas Hand Clin 8 (2003) 129–138

all of the fibrous tissue and dead bone at the nonunion site. A low-speed bur also can be used in

this process, but the authors use curets because the damage to the living bone is less. A high-

speed bur should not be used because it can result in bone necrosis from the heat. If intact,the dorsal cortex should be preserved (Fig. 5).

Styloidectomy

If there is arthritis evident between the scaphoid and radial styloid, a styloidectomy can be

performed at the time of the bone grafting procedure. No more than 4 mm of the radial styloid

should be removed so as to preserve the radioscaphoid capitate ligament.

Restoration of alignment and insertion of wires

The humpback collapse of the scaphoid nonunion can affect the intrascaphoid angle and

create a dorsal intercalated segment instability deformity of the wrist as the lunate and the

proximal pole rotate dorsally because of loss of the link to the distal pole and distal carpal

row. The humpback deformity can be corrected by use of the freer elevator behind the scaphoid.

If the lunate is in an adaptive dorsal intercalated segment instability deformity, an attempt

should be made to correct this by volar flexing the wrist, then temporarily transfixing the

lunate to the radius with a dorsal percutaneous Kirschner wire. Correcting the position of thelunate usually helps realign the proximal pole of the scaphoid from its dorsiflexed position.

The internal fixation Kirschner wires are placed before packing the graft into place because

the wires hold the nonunion site in correct position while the bone graft is packed into place.

Fig. 2. Skin incision lies between the flexor carpi radialis tendon and the radial artery.


Two 0.045-inch diameter Kirschner wires are used to internally fix the scaphoid. These wires areinserted parallel to each other from distally to proximally. The wires should enter the distal pole

at the volar aspect of the scaphoid trapezial joint. They can be inserted percutaneously through

the skin just radial to the thenar eminence. The wires are visible in the nonunion site, then enter

the proximal pole. The position of the wires in the nonunion site can help guide their placement.

Fig. 3. Deep incision opens the volar wrist capsule longitudinally from the volar lip of the distal radius distally to the

scaphoid trapezoid joint. The volar capsule is preserved for repair at the end of the case because it includes the

radioscaphoid capitate ligament.

Fig. 4. The scaphoid can be shortened from collapse at the fracture site. The scaphoid needs to be opened up to restore

its original length. The original length can be determined from radiographs of the opposite side. Because the collapse is

often apex dorsal, the dorsal cortex may be in continuity, whereas the volar cortex opens up as the alignment is restored.

The nonunion site needs to be cleaned out of soft tissue and necrotic bone going back to the level of good bone in both

the proximal and distal fragments.


The wires should be aimed the central portion of the proximal pole. The wires are left protrud-

ing from the skin at the conclusion of the procedure (Fig. 6). After placement of the wires, fluo-

roscopy or permanent radiographs should confirm restoration of length and alignment and

appropriate position of the wires (Fig. 7).

In cases in which the proximal pole is thought to be sclerotic and too small to hold wire fix-

ation, a peg cancellous graft can be fashioned in the manner of Russe [5] and placed into thenonunion space with transfixion by one of the Kirschner wires. Additional cancellous graft

should be packed around this peg as detailed subsequently.

Harvesting and packing of graft

The graft is harvested from the iliac crest because of the greater concentration of active osteo-

progenitor cells in iliac crest bone compared with bone from other sites. To minimize donor site

morbidity, harvesting iswith a trephine-type device (BoneGraft Set;Acumed, Inc,Hillsboro,OR).A 2-cm incision is marked just superior or just inferior to the anterior iliac crest starting 6 cm

proximal to the anterior superior iliac spine. Being this far proximal to the iliac spine decreases

risk of injury to the lateral femoral cutaneous nerve of the thigh and places the incision over the

iliac tubercle. Moving the actual skin incision above or below the crest helps prevent pressure by

clothing or a belt on a sensitive scar. Before incising the skin, the proposed incision is injected

down to the level of the iliac crest periosteum with 10 mL of 0.25% bupivacaine with epinephrine.

This combination of a long-acting anesthetic with a vasoconstrictive agent gives preemptive

analgesia and helps decrease bleeding and hematoma formation. The periosteum over the iliaccrest is split with electrocautery, and the trephine-type device is used to harvest corings of cancel-

lous iliac crest bone. The donor site can be packed with Gelfoam (Pharmacia, Piscataway, NJ) to

control bleeding. The fascia over the iliac crest can be closed with 0 absorbable suture (Vicryl;

Ethicon, Inc, Somerville, NJ). No drain is needed unless unusual bleeding is encountered.

The graft is packed around the Kirschner wires into the created cavity with a dental tamp, such

as used to pack in a filling in a tooth. It is important to morcellize the graft into small 1- to 2-mm

Fig. 5. The area of nonunion has been cleaned out and a cavity created in which to pack the bone graft. One of the

Kirschner wires can be seen traversing the fracture site from the distal aspect (left) to the proximal aspect (right).

Visualizing the wires in the fracture site is helpful to their correct positioning.


pieces with a bone cutter before implantation so that it can be packed tightly into both poles of

the scaphoid and around the wires. One should take care and not rush during this process.

Closure of joint and wound

The volar capsule must be closed securely with a 3–0 nonabsorbable polyester suture (Mer-

silene; Ethicon, Inc, Somerville, NJ) on a noncutting taper (eg, cardiac) needle. The sutures all

should be placed in the capsule, then tied down as a group to obtain the best closure possible.

This closure reconstitutes the radioscaphoid capitate ligament.

The skin incisions are closed with a subcuticular 4–0 absorbable suture (PDS; Ethicon, Inc,Somerville, NJ), then reinforced with butterfly-type bandages (Steristrip; 3M, Inc, St. Paul,

MN). The Kirschner wires are cut short but left out of the skin and dressed with a bacterio-

static-containing gauze (Zeroform 3% bismuth tribromophenate; Kendall Inc, Mansfield,

MA). Additional bupivacaine may be injected into the hip and wrist wound for postoperative

pain relief. The hip wound usually can be covered by a folded 4 · 4-inch gauze and covered fur-

ther by a plastic waterproof dressing to allow immediate showering.

The initial operative splint is a long arm sugar tong thumb spica. The interphalangeal joint of

the thumb should be included in the operative splint and all following casts. If the interphal-angeal joint is left free, each time the patient bends the distal phalanx of the thumb over the

cast, the nonunion site is moved. The initial splint is worn for 1 week, then changed at the first

postoperative visit. The patient is instructed to avoid any lifting or twisting with the operated

hand. The iliac crest donor site is treated with ice for the first 24 hours postoperatively to decrease

Fig. 6. The nonunion site is fixed with two parallel 0.045-inch diameter Kirschner wires inserted percutaneously distally

to proximally. The wires can be visualized in the fracture site during insertion as they cross into the proximal fragment.

After the wires are placed, the cancellous iliac crest bone graft is morcellized into small pieces and packed tightly around

the wires and into both ends of the fracture site.


pain and swelling. The patient may remove the donor site dressing, leaving the Steristrips inplace, and get the incision wet in the shower on the fifth postoperative day.


The patient needs to understand before surgery the need for 4 months of cast immobilization

until healing is achieved. The cast needs to be changed every 3 weeks because it can become

loose with time. The exposed Kirschner wires should be cleansed and redressed at each visit.

The initial postoperative splint is removed at 1 week, and the wounds are checked. The splint is

replaced by a long arm thumb spica cast. If the hand is still too swollen for a case, the splint can be

reapplied for another week. At 6weeks after surgery, the cast can be changed to a short arm thumbspica cast for the remainder of the treatment course. This cast must be well molded and extend up

the forearm almost to the elbow and include the interphalangeal joint of the thumb distally.

Nonstress posteroanterior and lateral radiographs are taken at the initial postoperative visit

and thereafter. Starting at 10 weeks after surgery, one can start assessing for union with a com-

plete five-view scaphoid series including a maximally ulnarly deviated posteroanterior radio-

graph. If one is unsure of healing, a CT scan can be obtained with the hand still in a cast

before ceasing casting and removal of the Kirschner wires. The authors’ average time to union

has been 16 to 18 weeks, and union can require 33 weeks [1]. The authors maintain the wires forat least 10 weeks, keeping them longer if they are still well fixed, without local erythema, and

union has not occurred. If union has not occurred but the wires are loose, they can be removed

and casting continued until union (Fig. 8).

After removal of the cast, patients are encouraged to use the hand for daily activities. Patients

are given a removable wrist splint for strenuous activity. Hand therapy is instituted to help pa-

tients regain motion. Patients are rechecked at 2 months after cast removal with final radio-

graphs and a check of motion. Patients generally need 4 to 6 months after cast removal to

regain full motion.

Fig. 7. Length is restored, two Kirschner wires are placed, and cancellous bone graft is packed into place.


Fig. 8. After appropriate immobilization, union occurs with maintenance of length and alignment.


References

[1] Stark HH, Rickard TA, Zemel NP, Ashworth CR. Treatment of ununited fractures of the scaphoid by iliac bone

grafts and Kirschner-wire fixation. J Bone Joint Surg Am 1988;70:982–91.

[2] MacLennan A. The treatment of fracture of the carpal scaphoid and indications for operation. BMJ 1911;Oct:1089.

[3] Matti H. Technik und Resultate meiner Pseudarthrosenoperation. Zentralbl Chir 1936;663:1442–53.

[4] Murray G. Bone graft for non-union of the carpal scaphoid. Surg Gynecol Obstet 1935;60:529.

[5] Russe O. Fracture of the carpal navicular: diagnosis, non-operative treatment, and operative treatment. J Bone Joint

Surg Am 1960;42:759–68.

[6] Gasser H. Delayed union and pseudarthrosis of the carpal navicular: treatment by compression screw

osteosynthesis: a preliminary report of twenty fractures. J Bone Joint Surg Am 1965;47:249–66.

[7] Mack GR, Bosse MJ, Gelberman RH, et al. The natural history of scaphoid nonunion. J Bone and Joint Surg Am

1984;66:504–9.

[8] Ruby LK, Stinson K, Belsky MR. The natural history of scaphoid nonunion: a review of 55 cases. J Bone Joint Surg

Am 1985;67:428–32.

[9] Lindstrom G, Nystrom A. Natural history of scaphoid non-union, with special references to ‘‘asymptomatic’’ cases.

J Hand Surg 1992;17:687–700.

[10] Steinman SP, Bishop AT. A vascularized bone graft for repair of scaphoid nonunion. Hand Clin 2001;17:647–53.


1991;16:474–8.





[14] Trumble TE. Avascular necrosis after scaphoid fracture: a correlation of magnetic resonance imaging and histology.

J Hand Surg Am 1990;15:557–64.


[16] Taleisnik J, Kelly PJ. The extraosseous and intraosseous blood supply of the scaphoid bone. J Bone Joint Surg Am

1966;48:1125–37.


a comparative study. J Hand Surg Am 1988;13:604–12.


Fixation of scaphoid nonunion with Kirschner wiresand cancellous bone graft

Andrew P. Gutow, MDa, Milan V. Stevanovic, MD, PhDb,*aDepartment of Orthopaedic Surgery, University of Michigan Medical School, Taubman Center,

2912 1500 East Medical Center Drive, Ann Arbor, MI 48109, USAbDepartment of Orthopaedic Surgery, Keck School of Medicine, University of Southern California,

2025 Zonal Avenue, GNH 3900 Los Angeles, CA 90089-9312, USA

In the treatment of established carpal scaphoid nonunions, themost successful and reliable pro-cedure for obtaining bone healing is an appropriately performed internal fixation with Kirschner

wires and cancellous iliac crest bone graft. In a series of 151 patients treated with this technique,

Stark and colleagues [1] reported a 97% success rate, with only 4 patients failing to heal.

The diagnosis and treatment of scaphoid fractures and scaphoid nonunions began with the

widespread use of radiography in the first half of the twentieth century [2]. For the most part,

in the early twentieth century, surgeons accepted MacLennan’s [2] statement that ‘‘The wiring of

the fragments is seldom practicable; it takes time and really causes considerable interference

with surrounding structures.’’ Following this philosophy, the earliest treatments consisted ofsimple excision.

By the 1930s, Matti [3] in the German literature and Murray [4] in the English literature pub-

lished reports of successful operative treatments of nonunion with cancellous and corticocancel-

lous grafting without internal fixation. During the middle third of the twentieth century, Russe’s

[5] technique of fixation by way of a volar approach with a structural cancellous bone graft from

the iliac crest became commonly accepted. Other workers suggested the addition first of wires

and then screws for internal fixation [1,6].

Indications

The authors believe that all scaphoid nonunions will go on to develop radiographically ap-

parent arthritis in time. The natural history of symptomatic scaphoid nonunion was well studied

by Mack and coworkers [7], who found an inevitable progression to arthritis in a series of 46

patients with symptomatic scaphoid nonunions. Ruby and associates [8] found a similar out-

come in a series of 55 patients. A review of asymptomatic scaphoid nonunions by Lindstromand Nystrom [9] showed a 100% development of radiographic arthritis at 12 to 43 years after

the fracture. From these studies, one can conclude that scaphoid nonunions over time will de-

velop radiographic changes consistent with arthritis, and patients will have varying degrees of

symptoms with these. The authors recommend surgical treatment of all symptomatic nonunions

and asymptomatic nonunions in younger patients who understand the risks and benefits of sur-

gical intervention.

Previous failed internal fixation andbone grafting is not a contraindication if severe arthritis has

not developed. The authors do not perform internal fixation and bone grafting in patients with se-vere radiocarpal arthritis; scaphoid excision or some other salvage procedure is preferred in these

cases. Internal fixation and bone grafting is indicated in patients with mild arthritis isolated to the

scaphoid and radial styloid. For mild radioscaphoid arthritis, a styloidectomy is performed in


E-mail address: [email protected] (M.V. Stevanovic).


doi:10.1016/S1082-3131(02)00016-X


these patients at the time of the bone grafting. Osteonecrosis of the proximal fragment is not an

absolute contraindication to this technique; Stark and colleagues [1] achieved union in 21 (84%)

of 25 cases in which avascular necrosis was noted on preoperative standard radiographs.

Contraindications

This surgery is contraindicated in patients who are actively smoking. Patients with active al-

cohol abuse, psychiatric disease, or personality disorders that would prevent them from comply-

ing with the postoperative course of immobilization are not candidates for this procedure. Forpatients who have failed one attempt at union with appropriately performed conventional bone

grafting, the authors recommend pedicled vascularized graft from the radius by a dorsal ap-

proach using the 1,2-intercompartment supraretinacular artery graft as first described by

Zaidemberg [10,11].


A standard physical examination, including range of motion, sensory testing, vascular status,

and grip strength, should be performed. Standard radiographs of the affected side should be

obtained, including posteroanterior, true lateral, and posteroanterior in ulnar deviation views

(Fig. 1). Comparison views of the opposite side should be obtained to help assess scaphoid length

and alignment and to help in restoring this anatomic alignment at the time of surgery. It is impor-

tant to restore fully the length and alignment of the scaphoid at the time of surgery. There is ahigher rate of development of radiographic evidence of arthritis in wrists in which the scaphoid

alignment has not been fully restored [12], so the authors attempt to correct the deformity as

fully as possible.

In addition to standard radiographs, if further information on deformity or bone loss is needed,

a computed tomography (CT) scan of the wrist aligned in the long axis of the scaphoid should be

obtained [13]. The CT scan is obtained by having the patient lie prone on the scanner table, then

place the arm above the head with the long axis of the abducted thumb parallel to the gantry. If

there is concern about osteonecrosis, magnetic resonance imaging should be obtained [14].

Anatomy

The volar approach used avoids the primary blood supply to the scaphoid, which enters by

way of dorsal ridge perforators [5,15,16]. The volar approach risks damage to the stout volar

wrist ligaments [17], but the period of postoperative immobilization and careful closure should

prevent subsequent rotatory instability of the scaphoid.

Technique

The authors use a modification of the technique of cancellous bone grafting and Kirschner

wire fixation described by Stark and colleagues [1]. The procedure is performed as outpatient

surgery, under general anesthesia to allow for harvesting of cancellous bone graft from the iliac

crest. Occasionally, patients need to be admitted for 23-hour observation for control of donor

site pain. Prophylactic antibiotics are administered preoperatively. A radiolucent hand table is

used to allow for intraoperative fluoroscopy. An upper arm tourniquet is used.

Approach

A volar approach to the wrist is used. A straight incision is made in the distal forearm be-

tween the distal portion of the flexor carpi radialis and the radial artery, then carried out across

the distal wrist crease, jogging slightly radial toward the base of the thumb (Fig. 2). The flexor

carpi radialis tendon is retracted ulnarly and the radial artery radially. The wrist capsule is


entered through a longitudinal incision from the volar lip of the radius to the proximal tubercle

of the trapezium. The capsule carefully is reflected sharply off of the scaphoid with a knife. The

capsule needs to be preserved because it contains the radioscaphoid capitate ligament and is re-

paired at the close of the procedure (Fig. 3).

Preparation of nonunion site

Preparation of the nonunion site and the packing in of the graft are among the most impor-

tant parts of the procedure, and the authors usually spend 15 minutes on each of these steps.

The wrist is dorsiflexed over a bump to allow for visualization of the proximal and distal sca-

phoid fragments and the radial scaphoid articulation. A freer elevator is placed in the radiosca-phoid joint around the radial aspect of the scaphoid to protect the radial cartilage and to lever

the fracture out of its humpback (apex dorsal angulation) deformity (Fig. 4). Although the ini-

tial mechanism of scaphoid fracture is usually an extension load with tension failure of the volar

cortex, over time with a nonunion the muscle forces across the wrist lead to progressive loss of

volar cortex with relative volar flexion of the distal fragment and dorsal flexion of the proximal

fragment.

A window is made in the volar scaphoid proximal and distal to the fracture to allow for re-

moval of fibrous tissue and dead bone. The authors use sharp small curets to clean out carefully

Fig. 1. (A–C) Three views of established nonunion without evidence of arthritis. On lateral view, some collapse into apex

dorsal angulation (humpback deformity) is visible.


all of the fibrous tissue and dead bone at the nonunion site. A low-speed bur also can be used in

this process, but the authors use curets because the damage to the living bone is less. A high-

speed bur should not be used because it can result in bone necrosis from the heat. If intact,the dorsal cortex should be preserved (Fig. 5).

Styloidectomy

If there is arthritis evident between the scaphoid and radial styloid, a styloidectomy can be

performed at the time of the bone grafting procedure. No more than 4 mm of the radial styloid

should be removed so as to preserve the radioscaphoid capitate ligament.

Restoration of alignment and insertion of wires

The humpback collapse of the scaphoid nonunion can affect the intrascaphoid angle and

create a dorsal intercalated segment instability deformity of the wrist as the lunate and the

proximal pole rotate dorsally because of loss of the link to the distal pole and distal carpal

row. The humpback deformity can be corrected by use of the freer elevator behind the scaphoid.

If the lunate is in an adaptive dorsal intercalated segment instability deformity, an attempt

should be made to correct this by volar flexing the wrist, then temporarily transfixing the

lunate to the radius with a dorsal percutaneous Kirschner wire. Correcting the position of thelunate usually helps realign the proximal pole of the scaphoid from its dorsiflexed position.

The internal fixation Kirschner wires are placed before packing the graft into place because

the wires hold the nonunion site in correct position while the bone graft is packed into place.

Fig. 2. Skin incision lies between the flexor carpi radialis tendon and the radial artery.


Two 0.045-inch diameter Kirschner wires are used to internally fix the scaphoid. These wires areinserted parallel to each other from distally to proximally. The wires should enter the distal pole

at the volar aspect of the scaphoid trapezial joint. They can be inserted percutaneously through

the skin just radial to the thenar eminence. The wires are visible in the nonunion site, then enter

the proximal pole. The position of the wires in the nonunion site can help guide their placement.

Fig. 3. Deep incision opens the volar wrist capsule longitudinally from the volar lip of the distal radius distally to the

scaphoid trapezoid joint. The volar capsule is preserved for repair at the end of the case because it includes the

radioscaphoid capitate ligament.

Fig. 4. The scaphoid can be shortened from collapse at the fracture site. The scaphoid needs to be opened up to restore

its original length. The original length can be determined from radiographs of the opposite side. Because the collapse is

often apex dorsal, the dorsal cortex may be in continuity, whereas the volar cortex opens up as the alignment is restored.

The nonunion site needs to be cleaned out of soft tissue and necrotic bone going back to the level of good bone in both

the proximal and distal fragments.


The wires should be aimed the central portion of the proximal pole. The wires are left protrud-

ing from the skin at the conclusion of the procedure (Fig. 6). After placement of the wires, fluo-

roscopy or permanent radiographs should confirm restoration of length and alignment and

appropriate position of the wires (Fig. 7).

In cases in which the proximal pole is thought to be sclerotic and too small to hold wire fix-

ation, a peg cancellous graft can be fashioned in the manner of Russe [5] and placed into thenonunion space with transfixion by one of the Kirschner wires. Additional cancellous graft

should be packed around this peg as detailed subsequently.

Harvesting and packing of graft

The graft is harvested from the iliac crest because of the greater concentration of active osteo-

progenitor cells in iliac crest bone compared with bone from other sites. To minimize donor site

morbidity, harvesting iswith a trephine-type device (BoneGraft Set;Acumed, Inc,Hillsboro,OR).A 2-cm incision is marked just superior or just inferior to the anterior iliac crest starting 6 cm

proximal to the anterior superior iliac spine. Being this far proximal to the iliac spine decreases

risk of injury to the lateral femoral cutaneous nerve of the thigh and places the incision over the

iliac tubercle. Moving the actual skin incision above or below the crest helps prevent pressure by

clothing or a belt on a sensitive scar. Before incising the skin, the proposed incision is injected

down to the level of the iliac crest periosteum with 10 mL of 0.25% bupivacaine with epinephrine.

This combination of a long-acting anesthetic with a vasoconstrictive agent gives preemptive

analgesia and helps decrease bleeding and hematoma formation. The periosteum over the iliaccrest is split with electrocautery, and the trephine-type device is used to harvest corings of cancel-

lous iliac crest bone. The donor site can be packed with Gelfoam (Pharmacia, Piscataway, NJ) to

control bleeding. The fascia over the iliac crest can be closed with 0 absorbable suture (Vicryl;

Ethicon, Inc, Somerville, NJ). No drain is needed unless unusual bleeding is encountered.

The graft is packed around the Kirschner wires into the created cavity with a dental tamp, such

as used to pack in a filling in a tooth. It is important to morcellize the graft into small 1- to 2-mm

Fig. 5. The area of nonunion has been cleaned out and a cavity created in which to pack the bone graft. One of the

Kirschner wires can be seen traversing the fracture site from the distal aspect (left) to the proximal aspect (right).

Visualizing the wires in the fracture site is helpful to their correct positioning.


pieces with a bone cutter before implantation so that it can be packed tightly into both poles of

the scaphoid and around the wires. One should take care and not rush during this process.

Closure of joint and wound

The volar capsule must be closed securely with a 3–0 nonabsorbable polyester suture (Mer-

silene; Ethicon, Inc, Somerville, NJ) on a noncutting taper (eg, cardiac) needle. The sutures all

should be placed in the capsule, then tied down as a group to obtain the best closure possible.

This closure reconstitutes the radioscaphoid capitate ligament.

The skin incisions are closed with a subcuticular 4–0 absorbable suture (PDS; Ethicon, Inc,Somerville, NJ), then reinforced with butterfly-type bandages (Steristrip; 3M, Inc, St. Paul,

MN). The Kirschner wires are cut short but left out of the skin and dressed with a bacterio-

static-containing gauze (Zeroform 3% bismuth tribromophenate; Kendall Inc, Mansfield,

MA). Additional bupivacaine may be injected into the hip and wrist wound for postoperative

pain relief. The hip wound usually can be covered by a folded 4 · 4-inch gauze and covered fur-

ther by a plastic waterproof dressing to allow immediate showering.

The initial operative splint is a long arm sugar tong thumb spica. The interphalangeal joint of

the thumb should be included in the operative splint and all following casts. If the interphal-angeal joint is left free, each time the patient bends the distal phalanx of the thumb over the

cast, the nonunion site is moved. The initial splint is worn for 1 week, then changed at the first

postoperative visit. The patient is instructed to avoid any lifting or twisting with the operated

hand. The iliac crest donor site is treated with ice for the first 24 hours postoperatively to decrease

Fig. 6. The nonunion site is fixed with two parallel 0.045-inch diameter Kirschner wires inserted percutaneously distally

to proximally. The wires can be visualized in the fracture site during insertion as they cross into the proximal fragment.

After the wires are placed, the cancellous iliac crest bone graft is morcellized into small pieces and packed tightly around

the wires and into both ends of the fracture site.


pain and swelling. The patient may remove the donor site dressing, leaving the Steristrips inplace, and get the incision wet in the shower on the fifth postoperative day.


The patient needs to understand before surgery the need for 4 months of cast immobilization

until healing is achieved. The cast needs to be changed every 3 weeks because it can become

loose with time. The exposed Kirschner wires should be cleansed and redressed at each visit.

The initial postoperative splint is removed at 1 week, and the wounds are checked. The splint is

replaced by a long arm thumb spica cast. If the hand is still too swollen for a case, the splint can be

reapplied for another week. At 6weeks after surgery, the cast can be changed to a short arm thumbspica cast for the remainder of the treatment course. This cast must be well molded and extend up

the forearm almost to the elbow and include the interphalangeal joint of the thumb distally.

Nonstress posteroanterior and lateral radiographs are taken at the initial postoperative visit

and thereafter. Starting at 10 weeks after surgery, one can start assessing for union with a com-

plete five-view scaphoid series including a maximally ulnarly deviated posteroanterior radio-

graph. If one is unsure of healing, a CT scan can be obtained with the hand still in a cast

before ceasing casting and removal of the Kirschner wires. The authors’ average time to union

has been 16 to 18 weeks, and union can require 33 weeks [1]. The authors maintain the wires forat least 10 weeks, keeping them longer if they are still well fixed, without local erythema, and

union has not occurred. If union has not occurred but the wires are loose, they can be removed

and casting continued until union (Fig. 8).

After removal of the cast, patients are encouraged to use the hand for daily activities. Patients

are given a removable wrist splint for strenuous activity. Hand therapy is instituted to help pa-

tients regain motion. Patients are rechecked at 2 months after cast removal with final radio-

graphs and a check of motion. Patients generally need 4 to 6 months after cast removal to

regain full motion.

Fig. 7. Length is restored, two Kirschner wires are placed, and cancellous bone graft is packed into place.


Fig. 8. After appropriate immobilization, union occurs with maintenance of length and alignment.


References

[1] Stark HH, Rickard TA, Zemel NP, Ashworth CR. Treatment of ununited fractures of the scaphoid by iliac bone

grafts and Kirschner-wire fixation. J Bone Joint Surg Am 1988;70:982–91.

[2] MacLennan A. The treatment of fracture of the carpal scaphoid and indications for operation. BMJ 1911;Oct:1089.

[3] Matti H. Technik und Resultate meiner Pseudarthrosenoperation. Zentralbl Chir 1936;663:1442–53.

[4] Murray G. Bone graft for non-union of the carpal scaphoid. Surg Gynecol Obstet 1935;60:529.

[5] Russe O. Fracture of the carpal navicular: diagnosis, non-operative treatment, and operative treatment. J Bone Joint

Surg Am 1960;42:759–68.

[6] Gasser H. Delayed union and pseudarthrosis of the carpal navicular: treatment by compression screw

osteosynthesis: a preliminary report of twenty fractures. J Bone Joint Surg Am 1965;47:249–66.

[7] Mack GR, Bosse MJ, Gelberman RH, et al. The natural history of scaphoid nonunion. J Bone and Joint Surg Am

1984;66:504–9.

[8] Ruby LK, Stinson K, Belsky MR. The natural history of scaphoid nonunion: a review of 55 cases. J Bone Joint Surg

Am 1985;67:428–32.

[9] Lindstrom G, Nystrom A. Natural history of scaphoid non-union, with special references to ‘‘asymptomatic’’ cases.

J Hand Surg 1992;17:687–700.

[10] Steinman SP, Bishop AT. A vascularized bone graft for repair of scaphoid nonunion. Hand Clin 2001;17:647–53.


1991;16:474–8.





[14] Trumble TE. Avascular necrosis after scaphoid fracture: a correlation of magnetic resonance imaging and histology.

J Hand Surg Am 1990;15:557–64.


[16] Taleisnik J, Kelly PJ. The extraosseous and intraosseous blood supply of the scaphoid bone. J Bone Joint Surg Am

1966;48:1125–37.


a comparative study. J Hand Surg Am 1988;13:604–12.


Intercarpal fusion with the Spider platefor scaphoid nonunion

Jennifer L.M. Manuel, MD, Arnold-Peter C. Weiss, MD*

Department of Orthopedic Surgery, Brown Medical School, Rhode Island Hospital,

593 Eddy Street, Providence, RI 02903, USA

The scaphoid bone is the most commonly fractured bone in the carpus [1,2]. Approximately345,000 scaphoid fractures occur annually in the United States [3]. Typically this fracture occursfollowing a forced dorsiflexion of the wrist after a fall onto an outstretched upper extremity [4].Approximately 5% to 10% of all scaphoid fractures (34,500 annually) progress to nonunion [5].Fracture of the scaphoid and its tendency toward nonunion and malunion are attributable tomany factors, including delayed diagnosis, lack of initial treatment, displacement of fracturefragments, location of fracture, improper immobilization, and wrist instability [4,6–11].

The scaphoid is thought to function as a stabilizer of the midcarpal joint, a bridge betweenthe distal and proximal carpal rows [12]. In the uninjured wrist, the scaphoid is held in a flexedposition because it is compressed between the radius and the trapezium. The triquetrum has atendency toward an extended position. The lunate bone through its ligamentous attachments tothe scaphoid and the triquetrum acts as balance between these opposing force tendencies. Ascaphoid fracture disrupts the scaphoid influence on the force homeostasis. This effect on carpalstability was termed the concertina effect by Fisk [7] in 1970. Fracture of the scaphoid causes thelunate to assume a position under the influence of the triquetral bony/ligamentous complex. Thelunate and the proximal scaphoid still bound by the scapholunate ligament assume a moreextended position, termed dorsal intercalated segmental instability (DISI) [13]. The distalscaphoid fragment, now free from the counteractive forces of the more ulnar carpal stabilizingstructures, rotates in an opposite fashion to a more flexed position [14]. This position causesa foreshortening of the scaphoid bone. As the scaphoid collapses, the capitate bone comes tobear an increased load and responds by displacing itself into the gap between the scaphoid andthe lunate. Altered carpal kinematics secondary to a change in scaphoid shape, volume, andposition lead to progressive degenerative changes at the radial styloid/distal scaphoid fragment,the capitolunate, and the scaphocapitate articulations [15].

Mack and colleagues [16] and Ruby and coworkers [17] showed that the natural history ofscaphoid nonunion leads to a progressive degenerative arthritis of the wrist. Some studies reporta 100% incidence of degenerative wrist arthritis after scaphoid nonunion [16]. The pattern ofdegenerative changes found after scaphoid nonunion are similar to those of a scapholunateadvanced collapse deformity and have been termed scaphoid nonunion advanced collapse(SNAC).

Progression and severity of the degenerative arthritis of the wrist associated with scaphoidnonunion advanced collapse vary and depend on many factors. A stable nondisplaced scaphoidfracture progresses more slowly than an unstable displaced scaphoid nonunion. It has beenshown that typically 1 decade after fracture, cystic lesions at the site of nonunion are found.

* University of Orthopedics, 2 Dudley Street, Suite 200, Providence, RI 02905, USA.

E-mail address: [email protected] (A.-P.C. Weiss).


doi:10.1016/S1082-3131(03)00005-0


During the second decade, degenerative changes at the radioscaphoid joint become evident. Inthe third decade after initial fracture, a pancarpal arthritis is usually apparent [16,17].

SNAC has been categorized into three stages. In stage I SNAC, the radioscaphoid (radialstyloid/scaphoid) joint is involved. Stage II SNAC consists of radial styloid/scaphoid andscaphocapitate degenerative changes. This degeneration leads to significant carpal collapse.Stage III SNAC consists of radial styloid/scaphoid, scaphocapitate, and capitolunate de-generative changes. Generally the articulations between the proximal scaphoid/radius and thelunate/radius are not involved.

Treatment options

Because a scaphoid nonunion has a high probability (near 100%) of triggering progressivedegenerative arthritis of the wrist, all attempts should be made to correct the nonunion beforethe onset of this debilitating condition. Open reduction and internal fixation with or withoutbone grafting always should be attempted before any salvage procedure.

In the past, treatment for advanced degenerative disease of the wrist secondary to scaphoidnonunion consisted of total wrist arthrodesis. Although this procedure is effective in relievingthe pain associated with the SNAC wrist, the pain relief is at the expense of all wrist motion.More recently, motion-preserving procedures have been used with greater frequency. Currentsurgical options for degenerative arthritis of the wrist include total or partial wrist arthrodesis,proximal row carpectomy, distraction arthroplasty, and total wrist arthroplasty.

The earliest report of limited wrist arthrodesis was by Thorton [18] in 1924. He reported thesuccessful fusion of the scaphoid, lunate, capitate, and hamate. Until the 1960s, however, only afew reports of limited wrist arthrodesis can be found in the literature. The past 15 to 20 yearshave seen a great interest in the use of these motion-preserving procedures for degenerativearthritis of the wrist.

Limited wrist arthrodesis of the capitate-hamate-lunate-triquetrum is called a four-cornerarthrodesis. In the appropriate patient, the four-corner fusion with concomitant scaphoidexcision allows motion to occur through the preserved radiolunate and ulnocarpal joints. Thisprocedure is based on the principle that a fusion of the capitolunate joint allows the load bearingof the wrist to be borne by the preserved radiolunate articulation. By adding the hamate andtriquetrum to this fusion mass, the rate of union is believed to be greater, without reducing theamount of preserved range of motion [19]. Originally a Silastic scaphoid prosthesis was im-planted after scaphoid excision; however, this practice has been abandoned secondary to atendency for implant malrotation and particulate synovitis [20].

Indications

When deciding on treatment for a wrist with SNAC, many factors should be taken intoconsideration. The age of the patient and the activity and occupation of the patient areimportant in guiding surgical treatment options.

A stage I SNAC wrist generally is treated best with a radial styloid excision with or withoutbone grafting of the scaphoid nonunion. There are several treatment options for a stage IISNAC degenerative wrist, including proximal row carpectomy, intercarpal fusion and radialstyloidectomy, and intercarpal fusion and scaphoid excision. A stage III SNAC wrist may betreated with an intercarpal fusion and scaphoid excision or a total wrist arthrodesis.

Four-corner fusion is indicated in symptomatic patients with a stage II or III SNACdegenerative wrist who have failed open reduction and internal fixation with or without bonegrafting as long as the radiolunate articulation is not involved in the degenerative process. Also,patients with ulnar translation are not considered candidates for four-corner arthrodesis.Typically, ulnar translation results from disruption of the long radiolunate ligament and resultsin a disruption of the concentric congruity of the radiolunate joint and a hastening of de-generation of this pivotal joint. Under these circumstances and in patients who have a pancarpaldegenerative arthritis, a total wrist arthrodesis is indicated.

140 J.L.M. Manuel, A.-P.C. Weiss / Atlas Hand Clin 8 (2003) 139–148

Preoperative radiographs should be evaluated for the extent of arthritis. Radiographs alsoalways should be evaluated for the amount of DISI deformity, which needs to be correctedduring the procedure before fusion.

Typically a four-corner fusion for scaphoid nonunion entails excision of the scaphoid withfixation of the fusion mass with Kirschner wires. More recently, a newly designed recessed,three-dimensional plate, the Spider plate (Kinetikos Medical, Inc, San Diego, CA), has beenused for intercarpal fusions (Fig. 1). The technique for implantation of this device in a four-corner fusion is described next, and the benefits of its use are discussed.

Surgical technique

The four-corner fusion technique, as described by Watson and Ryu [21], consists of a dorsaltransverse incision distal to the radial styloid for excision of the radial styloid. Branches of thesuperficial radial nerve should be identified and protected throughout the procedure. Theextensor pollicis longus and extensor carpi radialis longus and brevis also should be identifiedand protected. While protecting the volar ligaments, the scaphoid is removed. A transverseincision in the capsule is made at the level of the capitolunate joint. Using a rongeur, thecartilage is removed entirely from the adjacent surfaces of the lunate, capitate, hamate, andtriquetrum. Cancellous bone subsequently is packed in between the joints to facilitate fusion.Pins (or staples) are placed between the capitate and lunate, triquetrum and lunate, hamate andlunate, and triquetrum and hamate. Remaining bone graft is packed into place [21].

Alternatively the Spider plate is a no-profile plate, recessed below the surface of the carpalbones, with a conical shape that is ideal for use in a four-corner fusion. The placement of thisplate uses a 7-cm incision centered over the dorsal wrist. As described in Watson’s technique, thedorsal sensory branches of the radial nerve are protected. Next the extensor pollicis longus isreleased from its dorsal compartment and transposed radially. The extensor carpi radialislongus and brevis are elevated off the dorsal capsule and retracted radially. The contents of thefourth dorsal compartment (extensor digitorum communis and extensor indicis proprius) areelevated and retracted ulnarly. The dorsal capsule is incised in a T-shaped fashion. Alternativelya ligament-sparing dorsal capsulotomy by Berger and colleagues [22] may be used (Fig. 2).

The scaphoid is removed with a rongeur. To facilitate removal of the scaphoid, a 3.2-mm drillis passed through the longitudinal axis of the scaphoid. A 3.5-mm tap is passed through the drillhole to allow traction in a joystick fashion, and the soft tissue attachments are released with ascalpel. During the removal of the scaphoid, care must be taken to protect the volar ligaments.The long radiolunate must be protected to prevent ulnar translation of the carpus (Fig. 3).

Fig. 1. The Spider plate (Kinetikos Medical, Inc, San Diego, CA) is a unique, three-dimensional, recessed plate

specifically designed for four-corner fusions, allowing circumferential compression without plate/joint impingement.

(Copyright Kinetikos Medical; used with permission.)

141J.L.M. Manuel, A.-P.C. Weiss / Atlas Hand Clin 8 (2003) 139–148

Next, exposure of the lunate-capitate-hamate-triquetrum is performed. Any instability,typically DISI, is reduced temporarily with Kirschner wires. These Kirschner wires should bekept as volar as possible. Joysticks may assist in correction of the DISI deformity. An alter-native method for reduction of the DISI deformity has been described by Linscheid and Rettig[23]. This method employs fluoroscopy. An initial lateral view of the wrist is obtained. Re-duction of the DISI deformity is accomplished by flexion and ulnar deviation until neutralalignment of the radius and lunate is seen on the lateral wrist fluoroscopy. A 0.0625-inchKirschner wire is placed from the dorsal distal radius into the lunate to hold the reduction [23].Fusion of the lunate in slight flexion relative to the capitate, as described by Cohen and Kozin

Fig. 2. The dorsal ligament-sparing approach advocated by Berger provides excellent exposure. (From Shin AY. Four

corner arthrodesis. J Am Soc Surg Hand 2001;1:93–111, 2001; with permission.)

Fig. 3. The long radiolunate ligament must not be injured while removing the scaphoid. This ligament prevents

progressive ulnar translation of the partial fusion mass.


[24], may provide greater wrist extension. When any carpal instability is reduced, an additionalKirschner wire is placed from the capitate to the triquetrum, temporarily stabilizing the bones tobe fused.

An appropriately sized rongeur is used between the bones to be fused to remove all cartilagedown to good cancellous bone. The Spider rasp is centered over the four-corner junction andused to rasp down to be flush with the dorsal aspect of the carpus (Fig. 4); this allows the plateto lie in a recessed fashion on the carpal bone surface. Autogenous bone graft, either fromLister’s tubercle or from the excised scaphoid, subsequently is packed into the intersticesbetween the four bones (Fig. 5).

Next, the Spider plate is aligned such that two screws may be placed into each of the fourcarpal bones. While the plate is held aligned, a 1.5-mm drill bit is used to drill one screw hole ineach bone (Fig. 6). Sequentially, four 2.4-mm self-tapping cancellous screws are used to securethe plate. The remaining holes are drilled, and the screws are securely placed. Radialcompression of the four bones is achieved by tightening of the screws (Fig. 7). All provisionalKirschner wires are removed. The wrist is taken through a range of motion to ensure stabilityof the fusion and to confirm that no dorsal impingement of the plate on the distal radiusexists. Any remaining bone graft is packed into the center of the plate and arthrodesis site.Intraoperative radiographs are obtained to confirm screw lengths and placement (Fig. 8).

The wound is irrigated copiously, then the capsule and retinaculum are repaired using 4–0absorbable sutures. When skin is closed, a short arm splint is placed to allow for early activerange of motion of the fingers and the elbow (unpublished data).

Postoperative care and rehabilitation

Postoperative care after the four-corner fusion performed using Watson’s Kirschner wiretechnique involves a long arm posterior splint for 1 week followed by a long arm cast to includethe thumb and index and middle fingers in an intrinsic plus position. After 4 weeks, a short armthumb spica cast is placed for an additional 2 weeks. At 6 weeks postoperatively, radiographsare obtained. If satisfactory healing has occurred, the pins are removed, and active range ofmotion is begun [21].

Fig. 4. The Spider rasp is used to fashion the circular recess which accepts the plate. (Copyright A-PC Weiss, 2000; used

with permission.)


The Spider plate four-corner fusion allows for earlier range of motion and less restrictionthroughout the postoperative period. Initially, as mentioned earlier, the patient is placed into ashort arm splint. Sutures are removed at 1 week. At that time, either a removable splint or ashort arm cast is placed to allow for early range of motion exercises; this is maintained for 3 to 4

Fig. 5. After rasping, excellent denuded bone surfaces of the capitate, lunate, triquetrum, and hamate are seen. A small

curet is used to denude the joint surfaces further. Autogenous bone graft, usually obtained from the distal radius, is

packed into the joints being fused. (Copyright A-PC Weiss, 2000; used with permission.)

Fig. 6. A special drill guide is used simultaneously to hold the Spider plate in optimal position while drilling the initial

screw hole. (Copyright A-PC Weiss, 2000; used with permission.)


weeks. Subsequent strenuous activity is delayed until radiographic evidence of appropriatefusion (unpublished data).

Results and discussion

In cadaver specimens, Ruby and coworkers [25] found that the mean value of total wristmotion was 112�. Similarly, Linscheid [26] found this value to be 150�. In 1984, Brumfield andChampoux [27] found that the functional range of motion of the wrist required to perform theactivities of daily living was 10� of flexion and 35� of extension. Palmer and associates [28] foundthese values to be 5� of flexion and 30� of extension. Gellman and colleagues [29] studied theeffect of limited intercarpal arthrodesis in an in vitro analysis. They found that 63% to 70% ofwrist flexion occurs at the radiocarpal joint and 30% to 36% occurs at the midcarpal joint. Theyalso concluded that slightly more extension occurs at the radiocarpal joint than the midcarpaljoint. These results predict a 64% flexion-extension arc after four-corner arthodesis [29,30].

Ashmead and colleagues [20] reported a 44-month follow-up on 100 patients who underwentfour-corner arthrodesis. Extension averaged 32�, and flexion averaged 42�, which was 53% ofthe opposite wrist. Grip strength was 80% of the opposite side. Of 85 patients, 78 (91%) weresatisfied and would choose to have the operation again. The initial nonunion rate was 3%, all ofwhich progressed to union after a second procedure. Of 76 patients, 61 returned to their originaljobs.

Cohen and Kozin [24] also studied the effects of four-corner arthrodesis on wrist range ofmotion. They found that the average extension was 49�, and flexion was 31�, a 58% flexion-extension arc compared with the opposite wrist. This study also found a greater amount ofpreserved radioulnar deviation compared with a proximal row carpectomy. Grip strength wasfound to be 79% of the opposite side.

A review of the literature of intercarpal arthrodeses between 1924 and 1994 done by Siegeland Ruby [31] found that the rate of nonunion for four-corner fusion was approximately 4.3%,the lowest rate of all intercarpal fusions. Larsen and colleagues [32] similarly reviewed theliterature results between 1946 and 1993. They found that the rate of nonunion for four-cornerarthrodesis ranged from 9% (Krakauer) to 50% (McAuliffe), with an average of 8.4%.

Fig. 7. Excellent stability and intercarpal compression are noted after all the screws are fully tightened. (Copyright A-PC

Weiss, 2000; used with permission.)


Fig. 8. Posteroanterior (A) and lateral (B) radiographs show excellent placement of the Spider plate. (Copyright A-PC

Weiss, 2000; used with permission.)


One of the most common complications after four-corner fusion is dorsal radiocarpalimpingement in wrist extension. This problem is secondary to inadequate reduction of thecapitolunate joint [33]. Ashmead and colleagues [20] found dorsal radiocarpal impingement tooccur in 13% of their patients. These patients reportedly experienced pain relief after a limitedresection of the dorsal distal radius and abutting dorsal capitate.

In 2001, Shin [34] reviewed the results of 431 four-corner arthrodeses, compiled from 8 series.The overall complication rate was 13.5%. Deep infection occurred in 0.5%, superficial infectionoccurred in 3%, and reflex sympathetic dystrophy occurred in 3%. The nonunion rate wasfound to be 2%. A failure rate of 2% required conversion to total wrist arthrodesis. This studyfound the most common complication, dorsal radiocarpal impingement, to occur in 4.4% ofpatients [34]. The first reported series of patients undergoing a four-corner fusion using theSpider plate showed a 100% fusion rate [35].

Summary

SNAC represents a spectrum of degenerative arthritis of the wrist. Various treatment optionsexist for diminishing pain and preventing progression. Intercarpal fusion of the wrist offers painrelief, preservation of carpal height, and maintenance of some wrist motion. The Spider plate forfour-corner fusion is an effective tool, which allows for early mobilization. Studies have suggestedthat the Spider plate provides greater intercarpal stability over Kirschner wire fixation [36].

References

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[2] Eddeland A, Eiken O, Hellgren E. Fractures of the scaphoid. Scand J Plast Reconstr Surg 1975;9:234.

[3] Osterman AL, Mikulics M. Scaphoid nonunion. Hand Clin N Am 1988;4:437–55.

[4] Leslie IJ, Dickson RA. The fractured carpal scaphoid: natural history and factors influencing outcome. J Bone Joint

Surg Br 1981;63:225–30.

[5] London PS. The broken scaphoid bone. J Bone Joint Surg Br 1961;43:237–44.

[6] Barr JS, Elliston WA, Musnick H, et al. Fracture of the carpal navicular (scaphoid) bone. J Bone Joint Surg Am

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[7] Fisk GR. Carpal instability and fractured scaphoid. Ann R Coll Surg Engl 1970;46:63.

[8] Monsivais JJ, Nitz PA, Scully TJ. The role of carpal instability in scaphoid nonunion: casual or causal? J Hand Surg

Br 1986;11:201–6.

[9] Morimoto H, Tada K, Yoshida T, Masatomi T. The relationship between the site of nonunion of the scaphoid and

scaphoid nonunion advanced collapse (SNAC). J Bone Joint Surg Br 1999;81:871–6.

[10] Obrien ET. Acute fractures and dislocations of the carpus. Orthop Clin N Am 1984;15:237.

[11] Russe O. Fracture of the carpal navicular: diagnosis, non-operative treatment, and operative treatment. J Bone

Joint Surg Am 1960;42:759–68.

[12] Weber ER. Biomechanical implications of scaphoid waist fractures. Clin Orthop 1980;149:83.

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[14] Gelberman RH, Wolock BS, Siegel DB. Fractures and nonunions of the carpal scaphoid. J Bone Joint Surg Am

1989;71:1560–5.

[15] Lindstrom G, Nystrom A. Incidence of post-traumatic arthrosis after primary healing of scaphoid fractures: a

clinical and radiological study. J Hand Surg Br 1990;15:11–3.

[16] Mack GR, Bosse MJ, Gelbermann RH, Yu E. The natural history of scaphoid nonunion. J Bone Joint Surg Am

1984;66:504–9.

[17] Ruby LK, Stinson J, Belsky MR. The natural history of scaphoid nonunion: a review of fifty-five cases. J Bone Joint

Surg Am 1985;67:428–32.

[18] Thornton L. Old dislocation of os magnum: open reduction and stabilization. South Med J 1924;17:430.

[19] Krakauer JK, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg Am

1994;19:751–9.

[20] Ashmead D 4th, Watson HK, Damon C, et al. SLAC wrist salvage. J Hand Surg Am 1994;19:741–50.

[21] Watson HK, Ryu J. Degenerative disorders of the carpus. Orthop Clin N Am 1984;15:337–53.

[22] Berger RA, Bishop AT, Bettinger PC. New dorsal capsulotomy for surgical exposure of the wrist. Ann Plast Surg

1995;35:54–9.

[23] Linscheid RL, Rettig ME. The treatment of displaced scaphoid nonunion with trapezoidal bone graft. In:

Gelberman RH, editor. Masters techniques in orthopedic surgery. New York: Raven Press; 1984. p. 119–31.


[24] Cohen MS, Kozin SH. Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and

four corner arthrodesis. J Hand Surg Am 2001;26:94–104.

[25] Ruby LK, Cooney WP, An KN, et al. Relative motion of selected carpal bones: a kinematic analysis of the normal

wrist. J Hand Surg Am 1988;13:1–10.

[26] Linscheid RL. Kinematic considerations of the wrist. Clin Orthop 1986;202:27–39.

[27] Brumfield RH, Champoux JA. Biomechanical study of normal functional wrist motion. Clin Orthop 1984;187:23–5.

[28] Palmer AK, Werner FW, Murphy D, Glisson R. Functional wrist motion: a biomechanical study. J Hand Surg Am

1985;10:39–46.

[29] Gellman H, Kauffman D, Lenihan M, et al. An in vitro analysis of wrist motion: the effect of limited intercarpal

arthrodesis and the contributions of the radiocarpal and midcarpal joints. J Hand Surg Am 1988;13:378–83.

[30] Douglas DP, Peimer CA, Koniuch MP. Motion of the wrist after simulated limited intercarpal arthrodesis. J Bone

Joint Surg Am 1987;69:1413–8.

[31] Siegel JM, Ruby LK. A critical look at intercarpal arthrodesis: a review of the literature. J Hand Surg Am 1996;21:

717–23.

[32] Larsen CF, Jacoby RA, McCabe SJ. Nonunion rates of limited intercarpal arthrodesis: a meta-analysis of the

literature. J Hand Surg Am 1997;22:66–73.


limited wrist arthodesis with scaphoid excision. J Hand Surg Am 1994;19:134–42.

[34] Shin AY. Four-corner arthrodesis. J Am Soc Surg Hand 2001;1:93–111.

[35] Farvarger N, Jovanovic B, Piaget F, Egloff DV. Four corner arthrodesis using the Spider plate [abstract].

European Federation of Surgical Societies of the Hand. Amsterdam, 2002.

[36] Izzi J, Weiss APC. The intercarpal stability of a simulated four corner arthrodesis model: Kwires versus plate

fixation [abstract]. American Association for Hand Surgery. San Diego, 2001.


Percutaneous capitolunate arthrodesis usingarthroscopic or limited approach

Joseph F. Slade III, MDa,b,*, David A. Bomback, MDb


Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USAbDepartment of Orthopaedics and Rehabilitation, Yale University School of Medicine,

PO Box 208071, New Haven, CT 06520-8071, USA

The scapholunate advanced collapse (SLAC) pattern is the most common form of degener-ative arthrosis in the human wrist. Degenerative changes are a result of the repetitive cycling of a

malaligned carpus through its functional arc of motion with altered loads unevenly distributed

between the carpus and distal radius [1,2]. The radiolunate joint is protected because of the

spherical lunate fossa of the distal radius as the lunate itself assumes a dorsiflexed position

[3]. The preservation of this joint offers a unique opportunity to treat wrist arthrosis while re-

taining radiocarpal joint motion. This treatment is accomplished by removing only the arthritic

changes of the wrist, restoring the carpal alignment between the capitate and lunate, and per-

forming a limited intercarpal fusion between these two carpal bones. This article describes a per-cutaneous technique for capitolunate arthrodesis using a headless compression screw without

bone graft that yields a high union rate with minimal complications as a surgical option for

managing an arthritic wrist.

Indications

Watson and Ballet [1] described SLAC of the wrist (Fig. 1) as the destruction of the radio-scaphoid and capitolunate joint spaces, which occurs in three stages. SLAC stage I wrist in-

volves early degenerative change within the radioscaphoid joint at the level of the radial

styloid. With progression of disease, the entire scaphoid fossa of the distal radius is involved,

yielding complete destruction of the radioscaphoid joint (SLAC stage II). The resulting collapse

and often malrotation of the scaphoid forces shear loading of the capitolunate joint. With ensu-

ing interosseous ligament attenuation and eventual scapholunate separation, the capitate

migrates proximally, abutting against the vulnerable lunate (Fig. 2). Destruction of the

capitolunate joint and resultant midcarpal arthosis is the culmination of the SLAC wrist (SLACstage III) [3].

The radiolunate joint is protected because of the spherical lunate fossa of the distal radius.

Such geometry allows for a perpendicular and joint-protecting cartilage-loading mechanism

[3]. This mechanism is in stark contrast to the more elliptical scaphoid fossa of the distal radius,

which is a clear setup for incongruent joint loading. The end result at the radiocarpal joint, as

confirmed by Watson and Ballet’s [1] review of more than 4000 radiographs, is isolated radio-

scaphoid arthritis.

The SLAC pattern of degenerative wrist arthrosis can result from a myriad of conditions; themost common are rotary subluxation of the scaphoid and scaphoid nonunion [4]. Arthritic

changes from the latter entity may be referred to more correctly as a scaphoid nonunion advanced


E-mail address: [email protected] (J.F. Slade III).


doi:10.1016/S1082-3131(02)00022-5


collapse (SNAC) wrist. Untreated scaphoid nonunions progress to degenerative wrist disease

with a pattern of collapse and should be treated early [3]. Other causes of SLAC wrist include

but are not limited to calcium pyrophosphate deposition disease [5,6], primary degenerative

arthritis related to scapholunate ligament attenuation, distal radius fractures involving the

radioscaphoid fossa, chronic perilunate dislocation, Preiser’s disease, Kienbock’s disease, and

congenital preaxial hypoplasia [4]. It is common for patients with SLAC wrists to have minimal

or no symptoms [7]. Patients who have significant pain refractory to nonoperative modalities(activity modification, anti-inflammatories) are candidates for surgery, regardless of SLAC

stage.

The goals of successful surgery are twofold: to eliminate the patient’s pain and to preserve as

much wrist motion as possible. Surgical options include radial styloidectomy [8], proximal row

carpectomy [9–11], distraction-resection arthroplasty [12], fascial implant arthroplasty [13], ra-

diocarpal arthrodesis [14,15], scaphoid excision with a variety of limited intercarpal arthrodeses

[16–22], total wrist arthroplasty, and total wrist arthrodesis [23]. The two most popular surgical

procedures performed for SLAC/SNAC wrists today are proximal row carpectomy and thefour-corner fusion. Proximal row carpectomy requires the preservation of the capitolunate joint

and is appropriate for the treatment of SLAC stage I and II. Four-corner fusion with sca-

phoid excision and capitate-lunate-triquetrum-hamate arthrodesis requires only the restoration

of carpal alignment and is appropriate for treatment of SLAC stages I, II, and III. These two

procedures are not without their problems, however. Reports comparing these two surgeries

indicate that complications may occur in 35% of patients, and failure (often requiring a second

Fig. 1. The goal of scaphoid lunate advanced collapse wrist reconstruction is the restoration of capitate lunate alignment

and removal of arthritic bone. Pictured here is a successful reconstruction using a limited carpal arthrodesis of the

capitate and lunate. In the past, the isolated capitolunate arthrodesis was abandoned because of the difficulty in

achieving successful fusion. With the advent of headless compression screws, fusion results; improved but correct

alignment of the fusion mass was problematic with the capitate flexed on the lunate. New techniques allow for proper

carpal alignment, while taking full advantage of these compression devices to achieve solid arthrodesis without bone

graft.

150 J.F. Slade III, D.A. Bomback / Atlas Hand Clin 8 (2003) 149–162

operation) may occur in 30% [10,24]. To avoid the complications of the four-corner fusion and

improve union rates for isolated carpal fusion, a limited approach was developed using a head-

less compression screw. The key to optimal functional outcome is the restoration of the capitate

lunate alignment [25]. A limited incision (or arthroscopic) capitolunate arthrodesis that restores

carpal alignment is presented for the treatment of radioscaphoid arthritis. A detailed descriptionof the surgical procedure is provided followed by clinical results.

Technique

The patient is placed in a supine position with the arm outstretched on a hand table. After the

operative extremity is prepared and draped in standard surgical fashion, the radiocarpal and

midcarpal (capitolunate) joints are identified under fluoroscopic imaging. A line is drawn be-tween the ulnar midcarpal portal and the 3,4 radiocarpal portal, delineating the intended surgi-

cal incision (Fig. 3).

This oblique incision (approximately 2 cm in length) is made, and the tendons of the fourth

dorsal extensor compartment are exposed and retracted. The capitate lunate joint interval is

identified just deep to the retracted tendons. A transverse incision is made through the dorsal

capsule exposing the capitolunate joint (Fig. 4).

The first key step is the reduction of the lunate from its current extended position (dorsal

intercalated segment instability deformity) to a neutral position. This reduction is done by flexingthe wrist and manually reducing the lunate to its neutral anatomic location. Elimination of the

dorsal intercalated segment instability deformity (extended lunate) is confirmed on lateral fluo-

roscopic imaging. A 0.062-inch Kirschner wire is placed through the dorsal aspect of the distal

radius and advanced into the reduced lunate. (The Kirschner wire should not be directly in the

center of the lunate but rather in a more ulnar position to permit later placement of a compres-

sion screw in the center of the lunate.) This Kirschner wire effectively secures the lunate in its 0�(neutral) lateral position (Fig. 5).

Fig. 2. The initiating mechanism for the scaphoid lunate advanced collapse wrist is the attenuation and eventual

separation of the interosseous ligament of the scapholunate joint, resulting in scaphoid flexion and proximal capitate

migration.

151J.F. Slade III, D.A. Bomback / Atlas Hand Clin 8 (2003) 149–162

Fig. 4. Surgical resection of the carpal pathology can be accomplished arthroscopically using these portals, or limited

incision between portals exposes the capitate lunate and scaphoid lunate joint. Pictured here is the capitate base as

viewed using a limited incision approach.

Fig. 3. Arthroscopic portals are also the landmarks for the surgical approach using a limited incision. The ulnar

midcarpal joint portal and the 3,4 radiocarpal joint portal are identified using fluoroscopic imaging.


Three additional key steps are performed in preparation for the arthrodesis. The first step

consists of resection of the capitolunate joint (Fig. 6A). This resection increases the surgeon’s

working space but more importantly provides two beds of bleeding subchondral bone in antici-

pation for arthrodesis. The decortication of the distal lunate articular surface and proximal cap-itate articulation is performed using a cutting bur or small osteotomes. Step two consists of

removing the dysfunctional scaphoid (either partial scaphoid resection [SNAC wrist] or total

scaphoid resection [SLAC wrist]) (Fig. 6B). This resection is accomplished using a rongeur that

allows penetration through a small orifice (sinus surgery rongeur), 1-mm and 2-mm osteotomes,

and a bur. All these instruments can be introduced through an arthroscopic portal to perform

carpal excision. The third step employs these same instruments for a radial styloidectomy. The

goal of arthritic debridement is the removal of diseased ossific overgrowths (radial styloid and

scaphoid), which can be impacted during radiocarpal motion (Fig. 6C). This is crucial for painrelief. Care is taken, however, to preserve the radioscaphocapitate ligament. Failure to preserve

this ligament results in ulnar migration of the carpus.

Next, a guidewire is introduced percutaneously in between the second or third web space

(Fig. 7A). The wrist is flexed, exposing the base of the proximal capitate, previously decorticated.

The guidewire is introduced into the capitate and driven through the base of the metacarpal into

the second or third web space (Fig. 7B). Using fluoroscopy, the capitate is reduced on the lunate

into a neutral position. Care must be taken to ensure that the capitate and lunate are aligned in

the same plane on the posteroanterior and lateral images. The guidewire is advanced from thecapitate into the lunate, securing the reduction (Fig. 7C ).

Fig. 5. The key step to any limited carpal fusion is the correction of the malposition of the lunate to a neutral position.

Most commonly the lunate is in an extended position, and flexing the wrist reduces the lunate to its neutral anatomic

location. When this reduction is accomplished, a Kirschner wire is introduced through the distal radius and advanced

into the lunate. This effectively secures the lunate in its 0� (neutral) lateral position.


Fig. 6. In preparation for arthrodesis, there are three key steps. First is the resection of the capitolunate (C-L) joint (A).

The decortication is complete when bleeding bone surfaces are exposed between the capitate and the lunate. Next is the

removal of the dysfunctional proximal scaphoid (B). The entire scaphoid need not be removed, but enough must be

removed so that there is no impingement. The final step in resection includes debridement of diseased and arthritic

surfaces, including the radial styloid, which can be impacted during radiocarpal motion (C). Special attention is paid not

to detach or divide the volar capsular ligaments and risk ulna carpal translation.


A cannulated drill is used to prepare the capitate and lunate for screw placement. It is crucialnot to drill closer than 2 mm to the proximal lunate cortex. Before reaming, the combined length

of the lunate and capitate is measured using a second guidewire. When the length is determined,

the guidewire is driven through the lunate into the radius; this prevents the wire from dislodging

when the cannulated drill is removed. The screw selected is 4 mm shorter than the length of

carpal fusion.

Finally, a headless compression screw is implanted in a retrograde fashion over the guidewire

between the web space (Fig. 8A and B). The authors prefer a standard Acutrak (Acumed, Bea-

verton, OR) screw. The screw is advanced from the capitate into the lunate, taking care to stop2 mm from the far (proximal articular surface) lunate cortex (to prevent possible distraction

across the arthrodesis). Fluoroscopy confirms proper screw placement and neutral capitolunate

alignment (Fig. 8C). Then the radiolunate Kirschner wire is removed. The wounds are irrigated

and closed with 5–0 nylon sutures.

As an alternative to the limited incision technique described earlier, an arthroscopic tech-

nique also can be successful (Fig. 9). A radiocarpal portal is used to confirm preservation of

the radiolunate joint. Midcarpal and radiocarpal arthroscopy portals are used for the capitolu-

nate, scaphoid, and radial styloid resections. The remainder of the procedure is identical to thatdescribed previously.

Postoperative care

Postoperatively, patients are immobilized in a volar wrist splint, which is changed to a remov-

able canvas wrist splint after suture removal. Hand therapy is started to recover finger motion.

A strengthening program is started to axially load the fusion mass. This program aids in rapidrecovery of hand function and stimulates bone healing. Computed tomography is used to con-

firm solid fusion and release to sports and heavy labor.

Fig. 6 (continued )


Clinical series and complications

Ten patients were treated with percutaneous capitolunate arthrodesis without bone graft us-

ing a headless cannulated compression screw (Fig. 10). In this series, a standard Acutrak screwwas used. Arthroscopic resection was performed on five patients, and the remaining patients

were treated with minimal exposure. At 38 months’ follow-up, 10 patients had solid fusions con-

firmed by computed tomography scan. One patient had mild occasional pain at the radial sty-

loid but declined treatment. The remaining patients were pain-free. All patients had a functional

range of motion with a 72� flexion-extension arc, 70� radial-ulnar deviation arc, and 92�supination-pronation arc. Grip strength was 90% of the opposite normal uninjured wrist. There

were no complications. All patients returned to their prior work and avocations, including

weight training, tennis, baseball, and recreational golf.

Discussion

Many surgical options for the SLAC wrist have been described with varied success rates; the

two most commonly performed procedures are limited intercarpal arthrodesis and proximal row

carpectomy. Proximal row carpectomy has been used successfully to treat wrist arthrosis with

follow-up intervals of greater than 10 years in some series [10,26–28]. Pain relief afforded by

Fig. 7. After carpal resection, the next steps address guidewire placement and carpal reduction in preparation for

compression screw implantation. Reduction of the capitate directly over the lunate allows for the creation of a fusion

mass in a neutral position. This position maximizes the final flexion-extension arc of motion. To accomplish this, the

guidewire must be introduced percutaneously in between the second or third web space (A); this is accomplished using

fluoroscopy. Using the limited incision approach, the wrist is flexed, exposing the proximal capitate. The guidewire is

introduced into the capitate and driven distally into the second or third web space (B). Using fluoroscopy, the capitate is

reduced on the lunate into a neutral position. The guidewire is advanced from the capitate into the lunate, securing the

reduction (C).


the operation is due to removal of arthritic, incongruous joints and substitution with a lax ar-

ticulation between the lunate fossa of the distal radius and the capitate. Imbriglia and colleagues

[10] characterized the translational and rotational motion that occurs at the new radiocapitate

articulation as a hinge plus roll joint. This combination of a ball-and-socket/hinge joint distrib-utes the load on the radius, as is confirmed by pressure distribution studies [29].

Wyrick and associates [11] compared scaphoid exision and four-corner fusion with proximal

row carpectomy and found that grip strength averaged 74% of the opposite wrist in the fusion

group versus 94% in the proximal row carpectomy group. Of 17 patients, 3 failed a limited ar-

throdesis, whereas there were no failures in the proximal row carpectomy group. This was not a

randomized, prospective study, and there were only 11 wrists in the proximal row carpectomy

group (compared with 17 in the fusion group).

A multicenter study reported 4-year follow-up on 17 nonrheumatoid wrists after proximalrow carpectomy. Three patients had severe postoperative pain, and two of these were converted

to total wrist arthrodesis [30]. Krakauer and coworkers [15] reported the outcome of several

Fig. 7 (continued )


different reconstructive procedures for stages II and III SLAC wrists. Proximal row carpectomy

preserved wrist mobility better (with a flexion-extension arc of 71�) than scaphoid excision and

four-corner fusion (flexion-extension arc of 54�). Of 23 wrists in the fusion group, 22 were stage

III SLAC, however, whereas only 1 of 12 in the proximal row carpectomy group was stage III.

Fig. 8. The final steps involve implantation of a headless compression screw. A hand-driven cannulated drill is used to

ream the capitate and lunate. Drilling ceases 2 mm distal to the proximal lunate cortex (A). The screw selected is 4 mm

shorter than the length of carpal fusion. The headless compression screw is implanted over the guidewire in the second or

third web space (B). We prefer a standard Acutrak screw. The capitate is compressed against the lunate, and the screw is

advanced from the capitate into the lunate, compressing the decorticated surfaces. Fluoroscopy confirms proper screw

placement and neutral capitolunate alignment. After screw implantation, wrist motion is checked (C).


Both groups had two patients who underwent revision to total wrist arthrodesis. Of the prox-

imal row carpectomy patients, 33% had radiographic evidence of radiocapitate joint deteriora-

tion, and all but one of these were symptomatic.

Tomaino and associates [24] presented a series of SLAC wrists treated by either proximal row

carpectomy or limited intercarpal arthrodesis with scaphoid excision. There was a 20% failure

rate in the proximal row carpectomy group and a 0% failure rate in the arthrodesis group. Therewere no specific differences between the groups with respect to grip strength and pain relief, but

range of motion was improved significantly in the proximal row carpectomy group. Other inves-

tigators found no functional differences [31].

Limited intercarpal arthrodesis offers several theoretical benefits. Intercarpal fusion stabilizes

the midcarpal joint against further loss of carpal height often seen several years after proximal

row carpectomy. The fusion eliminates painful midcarpal arthrosis. Scaphoid excision (or sca-

phoid proximal pole nonunion excision) directly addresses the radiocarpal arthrosis seen in

SLAC II and III wrists. Motion is preserved because an anatomic radiolunate articulation is leftintact. The theoretical result is a painless functional wrist [4].

Ashmead and colleagues [4] reported a 3% nonunion rate in their 100-case series of SLAC

wrists. All patients were managed operatively with scaphoid excision and four-corner fusion.

Despite this low nonunion rate, 13% of patients required revision surgery for persistent pain re-

sulting from dorsal impingement between the capitate and radius. This impingement was due to

fusion of the capitolunate joint with the lunate in an extended position. Failure to reduce the

lunate to neutral accurately resulted in an inferior range of motion and pain in these patients.

Radiographs revealed only two instances of radiolunate destruction [4].Proximal row carpectomy often is preferred over scaphoid excision and four-corner fusion

because of its motion-preserving benefits. Krakauer and coworkers [15] reported a wrist range

of motion 17� higher for patients having undergone proximal row carpectomy compared with

four-corner fusion. Similarly the total arc of motion in Wyrick’s study [11] averaged 95� for

four-corner arthrodesis versus 115� for proximal row carpectomy. In an attempt to maintain

as much wrist range of motion as possible, isolated capitolunate arthrodesis has been proposed

for SLAC/SNAC wrists [32]. Early attempts with this technique had limited success. High non-

union rates and persistent pain often lead to revision surgery [17,32,33]. Kirschenbaum and as-sociates [17] reported good pain relief, a flexion-extension arc of 60�, and grip strength of 25 kg

in 12 of 18 patients who successfully achieved solid fusion of the capitolunate joint. The 33%

nonunion rate and 62% complication rate (including reflex sympathetic dystrophy, scaphoid

implant dislocation, pseudarthrosis, pin track infection, broken Kirschner wires, prominent

staples, and progressive arthritis) are troublesome, however.

The advent of headless compression screws offers the possibility of achieving capitolunate fu-

sion through compression arthrodesis. The benefits of this procedure are omission of the need

Fig. 9. An alternative to the limited incision technique is an arthroscopic resection. A radiocarpal portal is used to

confirm preservation of the radiolunate joint. Midcarpal and radiocarpal arthroscopy portals are used for the

capitolunate, scaphoid, and radial styloid resections. The carpal reduction and screw implantation are identical to the

previously described open technique.


for bone graft, improved rate of fusion, avoidance of pin track infections, omission of secondaryhardware removal procedures, shorter operative time, and earlier return to work. Calandruccio

and associates [16] described a technique of scaphoid and triquetrum excision and capitolunate

arthrodesis using compression screw fixation. Excising an additional carpal bone (the trique-

trum) is advocated here to increase capitolunate fusion rates, although this has not been proven

biomechanically. The average flexion-extension arc in their series was 53�, and grip strength was

71% of the opposite side. The pseudarthrosis rate of 14% (2 of 14 wrists failed to achieve solid

fusion) and the percentage of patients with persistent wrist pain (21%) are comparable to those

reported in previous studies.The authors’ technique of capitolunate arthrodesis involved fixation with an Acutrak com-

pression screw. It has been shown that the Acutrak screw has superior mechanical characteris-

tics (eg, pull-out strength, torque, bending forces) than that of the Herbert screw [34,35].

Fig. 10. (A–C) Ten patients were treated with percutaneous capitolunate arthrodesis without bone graft using a headless

cannulated compression screw. In this series, solid fusion was obtained in all patients using a standard Acutrak screw

(Acumed, Beaverton, OR) without bone graft. One patient, shown here, had mild occasional pain at the radial styloid

but declined treatment. She resumed her previous recreational activities and is shown supporting her full weight on both

wrists. The remaining patients were pain-free. All had a functional range of motion with a 72� flexion-extension arc, 70�radial-ulnar deviation arc, and 92� supination-pronation arc. Grip strength was 90% of the opposite normal uninjured

wrist. There were no other complications.


Theoretically, these characteristics may account for the authors’ high fusion rate. In addition,

this technique achieved successful fusion rates without the need to excise the triquetrum as other

studies have proposed, decreasing operative time and morbidity [16]. Finally, the relatively per-

cutaneous nature of this approach leads to an overall decreased morbidity and a more cosmetic

appearance.

Summary of Key Steps

Key steps for the percutaneous technique for capitolunate arthrodesis without bone graft are

as follows:

1. Image wrist joint to confirm lunate mobility.

2. Establish arthroscopic portals at ulnar midcarpal joint and radial to 3,4 radiocarpal portal

or limited incision between portals exposing capitate-lunate joint.

3. Reduce lunate to neutral position and secure with a Kirschner wire.

4. Resect capitate-lunate joint with bur or osteotome. This increases joint space and allows ac-cess to radiocarpal joint.

5. Resect dysfunctional scaphoid, proximal pole, or entire scaphoid.

6. Perform a radial styloidectomy as needed to debride arthritis.

7. Place guidewire in second or third web space through capitate (retrograde direction).

8. Reduce capitate and lunate to neutral position; advance guidewire into lunate to secure re-

duction.

9. Screw length is 4 mm shorter than fusion mass. Carpal fusion mass length is determined

with second guidewire.10. Drive guidewire through lunate into radius to prevent migration during drilling.

11. Hand ream no closer than 2 mm to lunate cortex.

12. Compress capitate and lunate and implant one or two standard Acutrak compression

screws.

Summary

Percutaneous capitate-lunate fusion using a headless compression screw without bone graft

yields a high fusion rate with minimal morbidity. Elimination of pain and the preservation of

a functional range of motion and grip strength can be expected with this procedure.

References

[1] Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand

Surg Am 1984;9:358–65.

[2] Watson HK, Ryu J, Akelman E. Limited triscaphoid intercarpal arthrodesis for rotary subluxation of the scaphoid.

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[4] Ashmead D IV, Watson HK, Damon C, et al. Scapholunate advanced collapse wrist salvage. J Hand Surg Am

1994;19:741–50.

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pyrophosphae dihydrate crystal deposition disease. Radiology 1990;177:459–61.

[6] Resnick D, Niwayama G. Carpal instability in rheumatoid arthritis and calcium pyrophosphate deposition disease:

pathogenesis and roentgen appearance. Ann Rheum Dis 1977;36:311–8.

[7] Fassler PR, Stern PJ, Kiefhaber TR. Asymptomatic SLAC wrist: does it exist? J Hand Surg Am 1993;18:682–6.

[8] Siegel DB, Gelberman RH. Radial styloidectomy: an anatomical study with special reference to radiocarpal

intracapsular ligamentous morphology. J Hand Surg Am 1991;16:40–4.

[9] Nervaiser RJ. Proximal row carpectomy for post-traumatic disorders of the carpus. J Hand Surg Am 1983;8:301–5.

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[15] Krakauer JD, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg Am

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[16] Calandruccio JH, Gelberman RH, Duncan SF, et al. Capitolunate arthrodesis with scaphoid and triquetrum

excision. J Hand Surg Am 2000;25:824–32.

[17] Kirschenbaum D, Schneider LH, Kirkpatrick WH, et al. Scaphoid excision and capitolunate arthrodesis for

radioscaphoid arthritis. J Hand Surg Am 1993;18:780–5.

[18] Minami A, Ogino T, Minami M. Limited wrist fusions. J Hand Surg Am 1988;13:660–7.

[19] Watson HK. Limited wrist arthrodesis. Clin Orthop 1980;149:126–36.

[20] Watson HK, Goodman ML, Johnson TR. Limited wrist arthrodesis: Part II. intercarpal and radiocarpal

combinations. J Hand Surg Am 1981;6:223–33.

[21] Watson HK, Hempton RF. Limited wrist arthrodeses: I. the triscaphoid joint. J Hand Surg Am 1980;5:320–7.

[22] Watson HK, Weinzweig J, Guidera PM, et al. One thousand intercarpal arthrodeses. J Hand Surg Br 1999;24:

307–15.

[23] Dick HM. Wrist arthrodesis. In: Green DP, editor. Operative hand surgery. 2nd edition. New York: Churchill

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limited wrist arthrodesis with scaphoid excision? J Hand Surg Am 1994;19:134–42.

[25] Viegas SF, Patterson RM, Peterson PD, et al. Evaluation of the biomechanical efficacy of limited intercarpal fusions

for the treatment of scapho-lunate dissociation. J Hand Surg Am 1990;5:120–8.

[26] Jorgensen EC. Proximal row carpectomy: an end result of twenty-two cases. J Bone Joint Surg Am 1969;51:1104–11.

[27] Crabbe WA. Excision of the proximal row of the carpus. J Bone Joint Surg Br 1964;46:708–11.

[28] Inglis AE, Jones EC. Proximal row carpectomy for diseases of the proximal row. J Bone Joint Surg Am

1977;59:460–3.

[29] Hagberg WC, Imbriglia JE, McKernan DJ, et al. Biomechanical analysis of fit of the capitate in the lunate fossa

after proximal row carpectomies. American Society for Surgery of the Hand. Baltimore, 1988.

[30] Culp RW, McGuigan FX, Turner MA, et al. Proximal row carpectomy: a multicenter study. J Hand Surg Am

1993;18:19–25.


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[32] Siegel JM, Ruby LK. Midcarpal arthrodesis. J Hand Surg Am 1996;21:179–82.

[33] Larsen CF, Jacoby RA, McCabe SJ. Nonunion rates of limited carpal arthrodesis: a meta-analysis of the literature.

J Hand Surg Am 1997;22:66–73.

[34] Wheeler DL, McLoughlin SW. Biomechanical assessment of compression screws. Clin Orthop 1998;350:237–45.

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application of cyclic bending loads. J Bone Joint Surg Am 1997;79:1190–7.


Intercarpal fusion for scaphoid nonunion

Michael Sauerbier, MD, PhD*, Markus V. Kuntscher, MD,Gunter Germann, MD, PhD

Department of Hand, Plastic, and Reconstructive Surgery, Burn Center, BG-Trauma Center, Ludwigshafen,

Plastic and Hand Surgery of the University of Heidelberg, Ludwig-Guttmann-Strasse 13,

67071 Ludwigshafen, Germany

Historical perspective and pathomechanics of scaphoid nonunion

Long-standing scaphoid nonunion and scapholunate ligament injury result in carpal collapseand subsequent arthrosis. Scapholunate advanced collapse (SLAC) wrist [1] after scapholunatedissociation and scaphoid nonunion advanced collapse (SNAC) wrist [2] after failed union ofscaphoid fractures are the most common patterns of arthrosis in the wrist. The severity of thedegenerative change is classified into three stages [3]. The primary signs of SLAC arthrosisappear between the scaphoid and the radial styloid (stage I). Later the radioscaphoid joint isnarrowed, and radiocarpal arthrosis progresses (stage II). In stage III, midcarpal joint arthrosisdevelops between the scaphoid, lunate, and capitate head.

In SNAC arthrosis, the pattern differs slightly [2,4]. Because only the distal fragment of thescaphoid flexes, arthrosis arises only between it and the radial styloid (stage I). The proximalfragment, aligned with the lunate and hemispherical in shape, remains congruous with the radiusand free of degenerative changes. In SNAC stage II, the cartilage between the distal scaphoid andthe scaphoid fossa of the radius is involved, and occasionally scaphocapitate arthrosis developsbetween the proximal fragment of the scaphoid and the radial area of the head of the capitate. Thepresentation depends on the degree of arthrotic process and the amount of carpal instability.Further shift and collapse of the scaphoid occur, resulting in an increasing load on the capitolunatejoint. The loaded capitate is driven off the radial side of the lunate between lunate and scaphoid,with shear loading of the capitolunate cartilage resulting in arthrosis in the midcarpal joint (stageIII). The capitate migrates proximally toward the scaphoid and lunate (Fig. 1). Finally thepathomechanics also lead to advanced carpal collapse (SNAC wrist).

A correct anatomic and biomechanical linkage of the scaphoid, lunate, and triquetrum isessential for maintaining the equilibrium of forces between the carpal components. Disruptionof the proximal row connection upsets the normal balance and results in abnormal shiftingof involved carpal bones [5]. The scaphoid flexes palmarly in scapholunate dissociation, andits proximal pole translates dorsally against the dorsal rim of the radius. The lunate andtriquetrum extend. Their motion is dissociated from the scaphoid. The capitate migratesproximally and radially toward the scapholunate gap, diminishing the carpal height. Theextension of the lunate relative to the radius and capitate is termed dorsiflexed intercalatedsegment instability (DISI) [6–8]. SNAC or SLAC patterns may cause abnormal contact of theradiolunate and ulnocarpal joint. These patterns usually do not lead to arthrosis, however,between the lunate and the radius [3–5,9–16]. In contrast to the articulations at theradioscaphoid and capitolunate joint, the corresponding surfaces of the distal radius andlunate are spherical. The loads applied to the lunate remain perpendicular to its radial surfaceregardless of its rotational stance, and shear forces do not develop; this allows the possibility


E-mail address: [email protected] (M. Sauerbier).


doi:10.1016/S1082-3131(03)00006-2


of preserving wrist mobility even in stage III disease. Ulnar carpal translocation may occur inassociation with SLAC or SNAC arthrosis. Viegas and colleagues [17] confirmed that thecontact area and pressure increase in the scaphoid fossa and decrease in the lunate fossa ofthe radius with progressive perilunate instability.

Treatment options

In the authors’ experience for SNAC wrist stage I, a scaphoid reconstruction with aninterpositional bone graft and a screw fixation should be used. In addition, a total or partialdenervation of the wrist can be performed as a pain-relieving and motion-sparing procedure[5,18,19]. In stage II disease, a midcarpal arthrodesis (four-corner fusion) with scaphoid excisionshould be considered. An alternative option to a limited wrist arthrodesis in SLAC stage II maybe a proximal row carpectomy (PRC) [20–24]. For stage III disease (radioscaphoid andlunocapitate or midcarpal arthrosis), the procedure of choice is the four-corner fusion withscaphoid excision (Table 1). A second choice is scaphoid excision and lunocapitate arthrodesis.PRC is not appropriate when the head of the capitate shows arthrotic changes.

Historical perspective of intercarpal fusions

Limited wrist arthrodesis is an established and time-proven method of treatment for severecarpal pathology, maximizing postoperative wrist motion, function, and strength and reducing

Fig. 1. Pathomechanics of the scaphoid nonunion advanced collapse wrist with arthrotic stages I to III and dorsiflexed

intercalated segment instability (DISI) position of the lunate. The arthrosis involves the distal scaphoid fragment in the

radioscaphoid joint in stages I and II and the midcarpal joint in stage III. There are degenerative changes between the

proximal fragment of the scaphoid and the radial side of the head of the capitate but not between the proximal pole of

the scaphoid and the distal radius. The lunate extends and the capitate migrates proximally, resulting in a DISI

deformity.

Table 1

Different stages and therapeutic options for scaphoid nonunion advanced collapse wrist

Stage Severity of arthrosis Therapy

I Arthrosis between radial

styloid and distal fragment of scaphoid

Resection radial styloid and scaphoid reconstruction

with bone graft and a screw

II Arthrosis distal fragment of scaphoid

and scaphoid fossa

Four-corner fusion with scaphoid excision

Resection of proximal carpal row

Lunocapitate fusion with scaphoid and triquetrum

excision

III Arthrosis midcarpal joint Four-corner fusion with scaphoid excision

Lunocapitate fusion with scaphoid and triquetrum

excision

164 M. Sauerbier et al / Atlas Hand Clin 8 (2003) 163–183

pain and eliminating instability. It provides a means for load transference across normalresidual joints in the wrist, provides adaptation of preserved intercarpal mobility to compensatefor motion pathways lost to fusion, and provides reasonable assurance of prevention of pro-gressing disease of other wrist joints. The experiences of Watson and others [1–6,9–13,16,19,25–35] encouraged many surgeons to begin various combinations of intercarpal arthro-deses for conditions affecting the wrist and particularly for wrist instabilities. In clinical seriesof intercarpal fusions, most authors have reported preserving at least 50% of wrist motion forextension-flexion and ulnar/radial deviation or higher [1–4,9–13,15,16,19,25–28,31,33–35].

Various groups of wrist disorders, such as SLAC or SNAC patterns of wrist arthrosis, rotarysubluxation of the scaphoid, carpal instabilities, degenerative disorders of special carpal units,Kienbock’s disease, Preiser’s disease, other carpal osteonecroses, and congenital synchondrosis,can be treated with limited wrist fusions [1–6,9–17,20,25–29,31–43]. Depending on the stage ofdegenerative arthrosis, different procedures can be considered under the rubric limited wristarthrodesis.

Multiple experimental studies have described the theoretical effects of various limited wristfusions on wrist motion [17,37,44–46]. Giunta and colleagues [47] evaluated load transmissionand subchondral bone mineralization after midcarpal fusion with computed tomographyosteoabsorptiometry in vivo. They found peak mineralization in the radiolunate joint aftermidcarpal arthrodesis. Knowledge of causes of degenerative or posttraumatic arthrosis ofthe wrist has paralleled directly knowledge concerning the diagnosis, classification, andpathomechanics of traumatic wrist injuries. In a classic article by Linscheid and coworkers [7], itwas stated that instability occurs because of either disruption of the ligamentous restraints orchanges of the geometry of the osseous links. This type of disruption and instability commonlyinvolves the scaphoid and its attachments, which mechanically provide stability to theintercarpal joint [7,8]. Carpal collapse can follow scaphoid fracture and ruptures of thescapholunate interosseous ligament and lead to degenerative arthrosis if not treated [1,5,48,49].

Other limited arthrodesis procedures for scaphoid nonunion include radioscapholunate,radiolunate, and scapholunate arthrodesis. Reports of these operations for the treatmentof SNAC arthrosis are known only anecdotally, however. When the articular surfaces ofthe distal radius, proximal scaphoid, or proximal lunate are compromised, the radio-scapholunate arthrodesis may be considered as a reasonable option. The loss of wrist motionmay be modulated in this instance by resecting the distal pole of the scaphoid, which in effect‘‘unlocks’’ the midcarpal joint. An intact midcarpal joint is a requisite for this procedure,however. Finally, for completeness, the scapholunate arthrodesis should be mentioned.Although in theory, it would appear that the scapholunate arthrodesis in combination with aradial styloidectomy would be an ideal treatment for scapholunate dissociation, a SLAC wriststage I, or a SNAC wrist stage I, in reality it has been a highly unpredictable procedure withmarginal clinical results. It is possible that a combination of factors, including the opposingrotational moments of the scaphoid and lunate and the limited surface area available for thefusion to occur, predisposes this procedure to nonunion.

The principles and indications of limited wrist arthrodesis in the treatment of scaphoidnonunion (SNAC) are addressed in this article. Limited wrist arthrodeses can be divided intoprocedures primarily fusing the midcarpal joint (four-corner and lunocapitate), radiocarpaljoint (radioscapholunate), or intercarpal joints (scapholunate). This article includesdiscussions of four-corner fusion, lunocapitate arthrodesis, and PRC. Alternative salvageprocedures are discussed, and a therapeutic algorithm is presented for different SNACpathologies.


Four-corner arthrodesis

A four-corner arthrodesis or midcarpal fusion implies the intentional fusion of the mutuallyarticulating surfaces of the lunate, triquetrum, capitate, and hamate. The most commonindications for performing a four-corner arthrodesis are advanced degenerative disease

165M. Sauerbier et al / Atlas Hand Clin 8 (2003) 163–183

involving the radioscaphoid joint, arthrosis involving the ulnar half of the midcarpal joint,and midcarpal instability. A four-corner arthrodesis always should be combined with ascaphoidectomy in patients with advanced degenerative disease resulting from scapholunatedissociation, scaphoid nonunion, or scaphoid malunion.

Because the entire mass of fused bones after a four-corner fusion articulates almost entirelythrough the radiolunate joint, the only constant contraindication for this procedure isradiolunate arthrosis. Mechanical dissociation of the radiolunate joint and extreme positivevariance of the ulna should be considered relative contraindications for a four-cornerarthrodesis.

Capitolunate arthrodesis

The capitolunate arthrodesis has been promoted as a procedure that has the advantages offour-corner fusion and minimizes the disadvantages [31,36]. The principal advantage of thecapitolunate arthrodesis compared with the four-corner arthrodesis is in the reduced fusionmass. By eliminating the lunotriquetral and triquetrohamate joints from the arthrodesisrequisite, there may be a lower incidence of arthrodesis-related complications, such as delayedunion, nonunion, hardware failure, and fusion malunion. The indications and contraindicationsfor a capitolunate arthrodesis are the same as for a four-bone arthrodesis. It typically isaccompanied by a complete excision of the scaphoid and the triquetrum [36].

Scapholunate arthrodesis

The principal reason for attempting a scapholunate arthrodesis is to stabilize thescapholunate joint. The most common cause of scapholunate instability is scapholunatedissociation, followed by a proximal pole fracture or a nonunion of the scaphoid. The rationaleis sound, but the success rate of scapholunate arthrodesis is low, regardless of technique. Inpublished series, the rates of nonunion and clinical failure have been unacceptably high [30].Anecdotally the use of vascularized bone grafts has not resulted in a lower nonunion rate.Although the reason for the high nonunion incidence is unknown, it may be related to (1) theretrograde interosseous blood flow of the proximal scaphoid, (2) the small surface area availablefor the fusion, (3) the counterrotational tendencies of the scaphoid and lunate, and (4) thedifficulty in achieving compression across the fusion site without changing the arc of curvatureof the midcarpal joint. Without an improvement in the results of this surgery, it will remainrelatively contraindicated.

Radiocarpal arthrodesis, radioscapholunate arthrodesis, and ulnar translocationof the carpus in scaphoid nonunion advanced collapse wrist

Ulnar translocation of the carpus is defined as any condition in which the lunatetranslates ulnarly to such a degree that less than 50% of its proximal articular surfaceremains in contact with the lunate fossa of the distal articular surface of the radius. It mayhappen in exceptional or late circumstances of SNAC pathology. In these cases, it can bedifficult to achieve a proper realignment of the lunate in the lunate fossa and the capi-tolunate axis with a four-corner fusion. Radioscapholunate fusion might be an option to treatthese patients with a motion-sparing procedure instead of performing a total wrist arthro-desis. The principal contraindication for a radioscapholunate arthrodesis is the presenceof significant arthrosis of the midcarpal joint.

Preoperative planning

Several preoperative planning steps are common to all limited wrist arthrodesis procedures.First, the patient needs to have a clear understanding about what to expect from the plannedprocedure in the immediate perioperative period and long-term, and the surgeon must have aclear understanding of what the patient’s expectations and demands are.


Careful attention must be directed preoperatively to a functional assessment of the entireaffected upper extremity, including the hand, forearm, elbow, and shoulder. A carefulradiographic analysis of the affected wrist must be made to maximize the surgeon’s familiaritywith the principal pathology of the wrist and to detect coexisting conditions [50]. It is oftenhelpful to obtain similar imaging of the contralateral wrist to determine what the normal carpalheight and angles are, in an attempt to replicate those values as much as possible in the affectedwrist.

Four-corner arthrodesis with complete scaphoid excision and lunocapitate arthrodesiswith complete excision of the scaphoid and triquetrum

After a careful clinical examination, plain radiographs with posteroanterior and lateral viewsare indicated. The severity of arthrosis and the stage of the SNAC wrist can be identified easily.If more information about the condition of the radioscaphoid and radiolunate joint is needed, acomputed tomography scan might be helpful. Usually, wrist arthroscopy is not necessary.

The procedure can be performed with regional anesthesia if bone graft from the distal radiusis used. If the fusion is performed using bone graft from the iliac crest, general anesthesia isrequired.

Radioscapholunate arthrodesis and scapholunate arthrodesis

Careful assessment of the midcarpal joint is necessary before performing a radiocarpal jointarthrodesis. This assessment can be done with plain radiographs to assess the presence of typicalsigns of degenerative disease.Also, if amalalignment is present because of an abnormal angulationof the radius or of the lunate, it is helpful to calculate the degree of correction thatwill be attemptedin the operating room. The normal angles can be determined easily from the contralateral wrist, ifuninjured. Plain radiographs also provide information regarding ulnar variance.

Techniques

Universal dorsal approaches to the wrist

Many skin incisions can be used, including a longitudinal, curvilinear, T-shaped [51], ortransverse orientation. After clearing the subcutaneous tissue to expose the deep antebrachialfascia and the extensor retinaculum, care is taken to avoid injury to the terminal branches of thesuperficial radial nerve. The third extensor compartment is incised, allowing radial translocationof the extensor pollicis longus tendon. The fourth and second extensor compartments areelevated on ulnar-based and radial-based flaps. The preservation of the synovial envelopeshould be attempted during dissection to avoid adhesions postoperatively. After mutual re-ztraction of the digital and wrist extensor tendons, the dorsal wrist joint capsule is exposed.

To expose the midcarpal joint and the radial two thirds of the radiocarpal joint, a radiallybased capsular flap is developed (Fig. 2) [52]. On the dorsal rim of the distal radius, the midpointbetween Lister’s tubercle and the dorsal edge of the sigmoid notch is identified, as is the centralpoint on the dorsal tubercle of the triquetrum and the sulcus of the scaphotrapezium-trapezoidjoint. A full-thickness incision is made connecting these three points, longitudinally dividing thedorsal radiocarpal and intercarpal ligaments. The flap is developed further by incising the dorsaljoint capsule from the dorsal rim of the radius until the distal extent of the radial styloid processis reached. Avoiding injury to the dorsal regions of the scapholunate and lunotriquetralligaments, the flap is elevated from the carpus on a radial base.

Four-corner arthrodesis with complete scaphoid excision

The carpus is exposed using the universal approach to expose the radial aspect of theradiocarpal and midcarpal joints as described earlier. Great care is taken during resection of thejoint surfaces of the capitate, lunate, and triquetrum to decorticate the concave distal surface of


the lunate completely. The scaphoid is excised completely, while preserving all palmarradiocarpal ligaments. The reduction of the lunate and realignment of the bones can beperformed with a Kirschner wire inserted into the lunate as a joystick (Fig. 3A). If the jointsurfaces are removed with an osteotome in a straight direction, a corticocancellous strut fromthe anterior iliac crest can be inserted between the four bones. Two 1.5-mm Kirschner wires areinserted into the capitate in a distal-to-proximal direction and advanced until they protrudeslightly at the head of the capitate, and one Kirschner wire is inserted in the same direction fromthe hamate through the capitate. The lunate and capitate are reduced, and a perfectly shapedbone graft is inserted between the capitate, lunate, hamate, and triquetrum. Inclusion of thetriquetrum and hamate in the fusion mass improves the union rates and does not affect ultimatewrist motion (Fig. 3B) [6,9,10,15,16,35].

Corticocancellous chips can be used alternatively, if the cartilage is removed with a rongeur.During the reduction maneuver, care is taken to align the radial borders of the lunate andcapitate and the lunotriquetral and capitohamate joints. The Kirschner wires (1.5 mm) areadvanced into the proximal row (see Fig. 3B). Another one or two Kirschner wires are insertedto fixate the hamate to the triquetrum (Fig. 4C, D). The correct position of the fused carpal

Fig. 2. A, Drawing of the dorsal wrist outlining the landmarks for the radial-based capsulotomy. The dorsal radiocarpal

ligament (DRC) attaches to the distal radius (R) between Lister’s tubercle (LT) and the sigmoid notch. Distally, it

attaches to the dorsal tubercle of the triquetrum, the same location as the proximal attachment of the dorsal intercarpal

ligament (DIC). The bold lines show the incision lines for splitting the DRC and DIC ligaments and continuing the

proximal capsulotomy along the dorsal rim of the radius to the radial styloid process. B, After elevating the radial-based

capsular flap created with the incisions in A, the radial half of the radiocarpal joint and the entire midcarpal joint are

exposed and the scaphoid (S), lunate (L), capitate (C), and hamate (H). (From Berger RA, Bishop AT. A fiber-splitting

capsulotomy technique for dorsal exposure of the wrist. Tech Hand Upper Extremity Surg 1997;1:2–10; with

permission.)


Fig. 2 (continued )

Fig. 3. Operative technique of four-corner fusion. A, Intraoperative view after removal of cartilage of the lunate (L),

triquetrum (T), capitate (C), and hamate (H). A 1.5-mm Kirschner wire is used as a joystick for reduction of the lunate.

B, Intraoperative picture with fixation of the four bones with Kirschner wires; the scaphoid has been resected (*). C,

Alternative fixation of the bones with the Spider plate (Kinetikos Medical, Inc, San Diego, CA).


Fig. 3 (continued )


bones and inserted Kirschner wires is confirmed with a radiograph. A radial styloidectomy maybe performed optionally to avoid abutment of the wrist during radial deviation. After closing ofthe joint capsule, the extensor retinaculum is reconstructed leaving the extensor pollicis longustendon subcutaneously.

Several other fixation devices are available for midcarpal arthrodesis, such as screws, staplers,and the Spider plate (Kinetikos Medical, Inc, San Diego, CA). The Spider plate was developedspecifically for four-bone arthrodesis but has been also used for other types of limited wristfusions. This novel device is a three-dimensional, recessed plate that allows circumferentialcompression and has a central hole for the placement of additional bone graft (Fig. 5).

Lunocapitate fusion

A standard approach to the dorsal wrist as described earlier can be used. Sharp transectionsof the remaining ligaments of the scapholunate and lunotriquetral joints are made, and thescaphoid and the triquetrum are removed piecemeal with a rongeur. The surfaces of theproximal capitate and distal lunate are denuded of the cartilage to the level of subchondralbone. The bony stabilization can be performed with Kirschner wires or cannulated screws. Afterclosing of the joint capsule, the extensor retinaculum is sutured. The extensor pollicis longustendon is left subcutaneously.

Radioscapholunate arthrodesis

The universal capsulotomy for exposure of the radial aspect of the wrist is used. Inspection ofthe midcarpal joint, either through the capsulotomy or through prior arthroscopy, is mandatory

Fig. 4. Scaphoid nonunion advanced collapse wrist stage III. Preoperative radiographs: Posteroanterior (A) and lateral

(B) views. Postoperative radiographs: Posteroanterior (C) and lateral (D) views. Four-year follow-up radiographs show

no signs of arthrosis in the radiolunate joint in the posteroanterior (E) and lateral (F) views. Four-year follow-up

clinically: Extension (G), flexion (H), radial deviation (I), and ulnar deviation (J).


Fig. 4 (continued )


to rule out midcarpal arthritic changes. If present, an alternative salvage procedure should beconsidered. The mutually articulating surfaces of the lunate fossa of the distal radius and theproximal surface of the lunate are debrided to cancellous bone for a radiolunate arthrodesis,whereas the scaphoid fossa and proximoradial surface of the scaphoid are added for aradioscapholunate arthrodesis. The resulting void is packed with autologous or allograftcancellous bone or a bone substitute. The ideal angle for the scaphoid relative to the radiusshould be 50� of flexion, whereas the lunate should be in neutral position. Fixation can beachieved with Kirschner wires, distally oriented obliquely angled screws from the dorsal cortexof the radial metaphysis, proximally oriented obliquely angled screws from the dorsal cortices ofthe scaphoid and lunate, staples, or even a small plate and screw fixation system. Fixation

Fig. 4 (continued )


should be secure regardless of the method employed because of the tremendous loading andtorque that occur across the radiocarpal joint. Screw purchase through the dorsal cortex of thedistal radial metaphysis may prove to be suboptimal, resulting in loss of fixation and failure tounite. As an option with the radioscapholunate arthrodesis, the distal pole of the scaphoid canbe excised. This excision essentially ‘‘unlocks’’ the proximal and distal rows, enhancing mid-carpal range of motion.

Fig. 4 (continued )


Fig. 5. Radiographs 6 months postoperatively after performing a four-corner fusion with a Spider plate. A good

realignment of the carpus and bony union were achieved. A, Posteroanterior view. B, Lateral view.


Scapholunate fusion

After opening the wrist joint with the radial-based capsular flap, the ulnar surface of thelunate is removed with a rongeur. The proximal pole of the scaphoid is resected. Cancellousbone graft or a corticocancellous strut from the iliac crest is packed between the scaphoidand lunate. The fixation can be performed with Kirschner wires, staples, or cannulatedscrews.

Results and outcomes for each technique

A general consequence of all limited wrist arthrosis procedures is that they result in less thannormal global wrist range of motion. Substantial impairment of function depends on whetherthe resultant range of motion falls within functional limits. The condition that led to thedecision to embark on a limited wrist arthrodesis more than likely already imparted such alimitation, however. The more bones that are fused, the more restriction in motion will occur.Generally, fusions performed within a carpal row have a minimal impact on motion, such as acapitohamate or lunotriquetral arthrodesis, whereas fusions that cross the radiocarpal ormidcarpal joint have a more profound effect on motion. Several laboratory analyses have beenperformed to study the effect on range of motion with simulated limited wrist arthrodesisprocedures, which provided an excellent foundation for predicting the postoperative range ofmotion [17,37,44,46,53]. Biologic factors in vivo, such as prolonged immobilization and scarformation, make the laboratory values optimistic, however. A study by Minami and coworkers[42] showed that the results seen 22 months postoperatively represent a stable point in thepostoperative course, with no further deterioration expected. If the arthrodesis is performed forchanges associated with an inflammatory arthropathy, however, the patient and surgeon shouldbe aware that the underlying disease can continue to be active, causing further deterioration offunction. Few of the studies available for review regarding outcomes of surgery have employedthe currently available tools for validated assessment of functional outcome; it is hoped that thissituation will be rectified in future studies [5,12,15,33–35,53–55].

Midcarpal arthrodesis with scaphoid excision (four-corner fusion)

Scaphoid excision with midcarpal fusion is designed to relieve pain while preserving sufficientresidual wrist mobility (Fig. 4). In Watson’s series [6,16,27], pain was reduced significantly,range of motion was preserved (33% of extension and 37% of flexion), and grip strengthimproved. After 44 months on average, the results achieved were similar to the observations ofKrimmer and associates [10] in 31 patients and Lanz and coworkers [13] in 45 patients. Nagyand Buchler [43] reported the results in 12 patients after four-corner fusion, in which the rangeof motion was adequate, and the average grip strength reached 79% of the opposite hand. Siegeland Ruby [56] examined 11 patients with midcarpal fusion in a series of 14 operated patients, ofwhom 4 finally underwent total wrist fusion because of continuous pain.

Most groups exclude silicone scaphoid implants because of severe problems with silicone-induced synovitis and dislocation of the prosthesis. In a series with 36 patients, the results ofSauerbier and colleagues [5] compared favorably with most of these groups. Krimmer andassociates [12] compared the results of four-corner fusion (97 patients) versus total wrist fusion(41 patients) for SNAC and SLAC pathologies. Based on the Disabilities of the Arm, Shoulder,and Hand (DASH) score [53–55] and a modified Mayo wrist score [57], the results for the four-corner fusion group were significantly better than those of the total wrist group [12].

Capitolunate fusion with scaphoid and triquetrum excision

Few data are available for capitolunate fusion with scaphoid and triquetrum excision. Theresults of a small study suggest that this procedure may be an effective alternative method for


treatment of SLAC and SNAC wrist disorders. A flexion-extension arc of 60� can be expectedfor this operation. Kirschenbaum and colleagues [31] reported in the largest series in theliterature a nonunion rate of 33%, however. Viegas and coworkers [17] also reported highnonunion rates. In the series of Calandruccio and associates [36], there were 2 nonunions in 14patients. The authors of that series used compression screws instead of Kirschner wires orstaples for the capitolunate fusion.

PRC is another popular operative procedure for treating SLAC or SNAC wrist in stage II(Fig. 6). It converts a mechanical link system into a simple hinge. PRC may be indicated if thehead of the capitate is normal or near-normal, as it is in SLAC or SNAC stage II. Preliminaryresults are satisfying; however, long-term follow-up studies in large patient populations are notpublished yet.

Radioscapholunate arthrodesis and scapholunate arthrodesis

Reports of radioscapholunate arthrodesis and scapholunate arthrodesis exist onlyanecdotally for the treatment of SNAC wrist. The results following radioscapholunate fusionfor radiocarpal arthrosis after distal radius fractures are reasonable, however, and aradioscapholunate fusion always should be considered in these cases instead of a total wristfusion. In the authors’ department, neither technique is used in SNAC salvage. All seriesreviewed show a relatively low rate of complications, but also report substantially below-normalrange of motion.

Rehabilitation

Any attempt to establish a rigid rule of postoperative cast immobilization should be avoided.The decision to remove the cast should be based on definitive radiographic evidence thatsufficient bony union across the arthrodesis site has occurred; this may require specialradiographic views or computed tomography. The decision about which variety of cast im-mobilization should be applied depends on the experience of the surgeon and the reliability ofthe patient, rather than on validated outcome studies, which are lacking in the literature. Theauthors’ preferred method of immobilization is a short arm cast for 8 weeks. If Kirschner wireswere used for fixation, they are buried underneath the skin to avoid pin track infections. If bonyunion is achieved after 8 weeks, physical therapy is initiated for the wrist. The Kirschner wiresare removed 12 weeks postoperatively under brachial plexus anesthesia; the wrist is mobilizedduring the procedure.

Common to all procedures is the need to initiate immediate postoperative therapy for digitalrange of motion and edema control. If the patient does not have a history of stomach ulceror gastritis, oral nonsteroidal anti-inflammatory drugs for pain control and edema areadministered routinely.

Complications

Failure of a limited wrist arthrodesis may occur at several levels [28,29,31,56,58]. From abiologic standpoint, infection, delayed union, and nonunion may lead to substantial morbidityand less than ideal results. The most common complications of limited wrist fusions can benonunion, hardware failure, persistent pain, and progression of the degenerative patterns. Pintrack infection, paresthesia after inadvertent injury to a cutaneous nerve passing through thesurgical site, and sympathetic reflex dystrophy can occur.

In the authors’ experience, limited wrist arthrodeses have proved to be effective andpredictable. The four-corner fusion with complete scaphoid excision is an extremely reliableprocedure for achieving sufficient pain relief and satisfying active range of motion for thetreatment of SNAC pathologies. Regarding wrist mobility, performance of activities of dailyliving and patient satisfaction make the results of limited wrist arthrodesis superior to total wristfusion [12].


Salvage procedures

Determination of the underlying cause is mandatory before a treatment plan for a failedpartial fusion is designed. If the cause of failure is persistent pain, the source of the pain shouldbe determined as definitively as possible. If the pain is resulting from a nonunion at the originalarthrodesis site, treatment should be aimed at correcting the nonunion, either using furtherimmobilization with or without external stimulation with pulsed electromagnetic fields or high-energy ultrasound or returning to the operating room for a second attempt. It is also important

Fig. 6. Scaphoid nonunion advanced collapse wrist stage II. Preoperative radiograph (A) and computed tomography

scan (B) show the palmar tilt of the distal part of the scaphoid and the osteophytes at the radial styloid. Posteroanterior

(C) and lateral (D) postoperative radiographs 1 year after resection of the proximal carpal row. There are no signs of

arthrosis between the capitate and the lunate fossa.


Fig. 6 (continued )


to try to determine what the cause of the nonunion was to avoid the frustrating experience ofdeveloping a nonunion a second time.

If the pain is due to progressive degenerative disease in a previously unaffected region of thewrist, treatment should be directed to that region. The surgeon could consider performing a totalwrist arthrodesis, particularly if the patient would tolerate the loss of motion and is requesting themost reliable and efficacious treatment for wrist pain. Data showed, however, that a total wristarthrodesis does not always lead to complete pain relief [34,35] and that activities of daily living,such as personal hygiene or washing the back, may be difficult with a fused wrist [12,34,35].

If the patient is complaining of restricted motion, painful or otherwise, revision arthrodesisprocedures would not be helpful and may make the situation worse. If a patient has pain after alimited wrist arthrodesis but does not want to consider a procedure that would compromisewrist motion further, a wrist denervation procedure may be considered [18,19,59].

No matter what the underlying source of the patient’s complaints are after a limited wristarthrodesis, an exhaustive trial of conservative management should be considered, as long asthe patient’s complaints stem from a progressive problem that has a solution or if the problemis life-threatening or limb-threatening [14]. Conservative measures should include splinting,anti-inflammatory medications, and activity modifications. Surgical options after failure ofconservative measures include revision limited arthrodesis, total wrist arthroplasty, total wristarthrodesis, and partial or complete wrist denervation.

Summary

Patients who have pain, weak grip strength, and limited range of motion because of SNACcan be treated operatively with established motion-sparing procedures. The authors preferablyperform a four-corner fusion in patients with SNAC II and III; however, in SNAC stage II, aPRC might be a predictable alternative option. The latest data from the authors’ series showthat patients after four-corner arthrodesis have better grip strength than after PRC; however,the range of motion and pain relief seem to be similar in both groups [20]. The functionaloutcomes of all motion-sparing procedures are satisfying, and the DASH values and activities ofdaily living reports of the patients are superior to a total wrist arthrodesis. The use of a four-corner fusion is recommended in most SNAC and SLAC patients. Total wrist arthrodesisshould be used only for exceptional circumstances.

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Proximal row carpectomy for scaphoid nonunion

Robert S. Leak, MDa,b, Randall W. Culp, MDa,b,*aDepartment of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USAbThe Philadelphia Hand Center, 700 South Henderson Road, #200, King of Prussia, PA 19406, USA

Despite earlier recognition of scaphoid fractures, modern internal fixation treatmentmethods, and the popularity of vascularized bone grafting, nonunion of the scaphoid remainsa dilemma for the hand surgeon. In cases of chronic scaphoid nonunion (scaphoid nonunionadvanced collapse [SNAC]), degenerative instability of the carpus may develop in acharacteristic pattern leading to irreversible articular damage. Watson and Ballet [1] initiallydescribed a similar pattern for scapholunate advanced collapse in 1984.

Vender and colleagues [2] reviewed radioscaphoid changes in 48 of 64 patients with untreatedscaphoid nonunions of 4 years’ duration. The distal scaphoid flexes with the distal carpal row,whereas the proximal scaphoid remains associated with the lunate in the proximal row. Theproximal scaphoid and lunate articulate with the spherical aspect of the radius lunate fossa,whereas the distal scaphoid becomes incongruent with the elliptical lateral scaphoid fossa of theradius. The loss of normal articular congruency can result in arthritic changes that initially areisolated to the radial styloid. The spherical radiolunate joint remains congruent, so it usually isspared of articular damage. The degenerative changes progress to involve the scaphocapitateand capitolunate joints. As a result of this pattern, 39 patients at 9 years’ follow-up developedradioscaphoid and capitolunate arthritis causing wrist pain and decreased function.

Proximal row carpectomy (PRC) initially was reported by Stamm [3] in 1944 as a means ofproviding relief for the painful, degenerative wrist without arthrodesis. This procedure removesthe intercalary proximal row and creates a radiocapitate articulation, creating a simple hingejoint out of a complex link joint system. The capitate now articulates with the radius lunatefossa. This procedure has become more widespread in its use and has many indications incases of congenital, degenerative, and traumatic disorders. Reports have confirmed its use inchronic scaphoid nonunion, scapholunate dissociation, fracture-dislocation of the carpus, andKienbock’s disease. PRC is a suitable option for the patient who prefers a motion-preservingprocedure to a partial or total wrist fusion in the treatment of scaphoid nonunion (Figs. 1 and 2).

Surgical technique

A dorsal longitudinal incision is made centered over the radiocarpal joint and located justulnar to Lister’s tubercle, in line with the long finger. Alternatively a transverse incision justdistal to the radiocarpal joint may be used. We prefer the longitudinal incision because thisallows easier conversion to another procedure based on surgical findings, such as inadequatecartilage on the capitate or lunate fossa. Thick skin flaps are developed, and sensory branches ofthe radial and ulnar sensory nerves are identified and preserved.

* The Philadelphia Hand Center, 700 South Henderson Road, #200, King of Prussia, PA 19406, USA.

E-mail address: [email protected] (R.W. Culp).


doi:10.1016/S1082-3131(03)00004-9


The third extensor compartment is identified and opened. The extensor pollicis longus isretracted radially, and the fourth compartment is elevated off the distal radius and capsule in anulnar direction, exposing the wrist capsule. Alternatively the wrist capsule can be exposedthrough a longitudinal incision through the fourth compartment with retraction of the extensortendons with a Penrose drain.

The carpal bones are exposed through a longitudinal incision in the dorsal capsule, whichbegins over the radius-lunate-capitate axis. A transverse incision is made over the scaphoid andtriquetrum, forming an inverted T-shaped capsulotomy. Retraction of the capsular flaps exposesthe proximal row for evaluation of the articular surfaces. The radiolunate articulation shouldbe free of degenerative changes, and the capitolunate articulation should have only minimalchanges present. If significant changes are present in either of these two articulations, a partialor total wrist arthrodesis should be considered.

The removal of the proximal row may be more tedious than expected because of volarligamentous attachments. The lunate can be removed in a piecemeal fashion using a rongeur, beingcareful to avoid damage to the articular surface of the capitate. Thismethod facilitates exposure ofthe triquetrum, which can be removed using sharp dissection and a rongeur. It is important to haveadequate exposure to preserve the extrinsic radiocarpal ligaments, and a freer elevator or Homanretractor helps with presentation of the carpal bones. A 3.5-mm AO (Synthes, Paoli, PA) tap orthreaded Steinmann pin can be used as a joystick. The radioscaphocapitate ligament needs to bemaintained to prevent ulnar translation. Removal of the volar portion of the scaphoid may bedifficult and is made easier with longitudinal traction and direct palmar pressure on the distalscaphoid. If the ligamentous structures are preserved, the capitate settles into the lunate fossa,generally without the need for internal fixation.

Fig. 1. Early carpal collapse in chronic scaphoid nonunion pattern.

186 R.S. Leak, R.W. Culp / Atlas Hand Clin 8 (2003) 185–189

The range of motion of the wrist is checked in all planes. Occasionally the trapezium im-pinges on the radial styloid in full radial deviation, requiring styloidectomy. The authors havenot found this to be a common problem.

Meticulous hemostasis is achieved after deflation of the tourniquet. The capsule and extensorretinaculum are repaired. After skin closure, a well-padded dressing and a short arm splint in aneutral position are applied. Thumb and finger motion are started immediately postoperatively.Active wrist motion is begun at 3 weeks postoperatively, and a protective wrist splint is worn for6 weeks. Strengthening begins at 8 weeks postoperatively and continues for several months.Active motion and strengthening continue to improve for 12 to 18 months postoperatively.

Results

The results of PRC reported in the literature generally are reported with other salvageprocedures for degenerative patterns in the wrist, making critical analysis difficult. In 1964,Crabbe reported overall successful results in 6 of 12 patients who underwent PRC for scaphoidnonunion [4]. He reported two failures.

Tomaino and colleagues [5] reported the long-term results of PRC in 23 wrists with carpaldegeneration treated from 1980 to 1989. Seven patients with SNAC wrists provided 3 to 8 years’follow-up. In this group, five patients returned to work without limitation. One patient hadpreoperative capitolunate arthritis and was dissatisfied with his result. Another patient required

Fig. 2. Postoperative radiograph after proximal row carpectomy.

187R.S. Leak, R.W. Culp / Atlas Hand Clin 8 (2003) 185–189

a wrist fusion 6 years after an initially successful result. Average flexion and extension arc was77�, average radioulnar deviation arc was 26�, and the average grip strength was 72% of theuninjured side. These results were comparable to the overall series, which included scapholunateadvanced collapse (SLAC) wrists and Kienbock’s disease. The authors concluded that a highlevel of satisfaction was achieved with PRC at an average of 6 years’ follow-up and thatpreoperative diagnosis did not influence outcomes.

Wyrick and associates [6] compared 11 wrists in 10 patients who underwent PRC with 17patients treated with scaphoid excision and four-corner arthrodesis at 27 and 37 months’ follow-up. The total arc of motion in the PRC patients was 115� and in the four-corner group was 95�.Grip strength averaged 74% of the opposite side in the four-corner group and 94% in the PRCgroup. All 11 PRC procedures were successful with a high degree of patient satisfaction. PRCcompared favorably with four-corner fusion for SNAC wrist and was recommended if thelunate facet of the radius and the head of the capitate are free of arthritic change.

A multicenter study of 20 PRC procedures by Culp and coworkers [7] in 1993 reportedsuccessful results after PRC for a variety of conditions. Chronic pain and limitations of functionwere present because of rheumatoid arthritis, Kienbock’s disease, chronic SLAC wrist, andchronic scaphoid nonunion. Overall results showed 6% excellent, 35% good, 29% fair, and30% poor outcomes using a wrist function scale. The average motion decreased slightly to 52%and the average grip strength improved to 67% of the opposite side. Patients with rheumatoidarthritis had consistently poor results.

Five of the patients in the study underwent PRC for advanced SNAC wrist and werefollowed up 2 to 3 years later. The preoperative flexion-extension arc of motion was 70�

compared with 79� in the others. Postoperative motion was 64� in both nonrheumatoid groups.Grip strength was 58% of the unaffected side preoperatively and 61% postoperatively comparedwith 54% and 63% for the nonscaphoid fractured group. The SNAC wrist patients had onegood, three fair, and one poor result after this procedure, with an average wrist score of 64. TheSLAC wrist and Kienbock’s disease patients had one excellent, four good, three fair, and fourpoor results, with an average postoperative wrist score of 67.

Krakauer and colleagues [8] compared the results of 55 cases of SLAC wrists treated byvarious methods, including PRC, partial wrist fusion, and total wrist fusion. Eight patients inthe series had a history of scaphoid fracture. Twelve patients underwent PRC, although theirpreoperative diagnosis was not clearly defined. Of the 12 patients who underwent PRC, 11 werestage II SLAC and 1 was stage III, with a mean follow-up of 39 months. The average flexion-extension arc at final follow-up was 71�, the most of any treatment group. Grip strengthimproved from 62.7% of the contralateral hand preoperatively to 65.6% postoperatively. Fivepatients had rare or no pain at final follow-up. Two had mild pain, two had moderate pain, andthree had severe pain. Four patients had radiographic narrowing of the capitolunate joint. Atfollow-up, one was asymptomatic, one had moderate pain, and two had severe pain. The twopatients with severe pain were converted to a total wrist arthrodesis, with one of the patientshaving resolution of pain. The authors concluded that PRC provides the best postoperativemotion but can be associated with painful narrowing of the radiocapitate joint. PRC wasrecommended for stage II SLAC wrist with uninvolved capitate head and lunate fossa.

Cohen and Kozin [9] compared two cohort populations of 19 patients who had undergoneeither a four-corner arthrodesis or PRC at 28 and 19 months. At follow-up, wrist examinationrevealed an 81� flexion-extension arc in the PRC group and 80� flexion-extension arc in the four-corner athrodesis group. The four-corner group had greater radial deviation and slightly greatergrip strengh (79% versus 71%). Pain relief was similar, and patient satisfaction was equivalent.The authors concluded that both procedures were motion-preserving options with minimalsubjective or objective differences in short-term follow-up evaluations. They noted the technicalease, early mobilization, and lack of nonunion risk in the PRC group.

Discussion

Candidates for PRC in SNAC wrists have not been defined completely in the literature. Mostauthors agree that the cartilage of the lunate fossa and proximal capitate must be preserved forthe procedure to provide pain relief successfully. Nevaiser [10] stated that mild changes in the

188 R.S. Leak, R.W. Culp / Atlas Hand Clin 8 (2003) 185–189

scaphocapitate articulation did not preclude a good result. Culp and associates [7] found thatmild preoperative radiographic deterioration at the lunate fossa or the proximal capitate wereconsistent with a successful result. In patients with moderate-to-severe arthritis, the procedurehad poor results. Salomon and Eaton [11] recommended a modified PRC in patients withradiolunate and lunocapitate arthritis. They performed partial capitate resection and dorsalcapsule interposition in seven patients with lunocapitate arthritis and in three patients withradiolunate disease. At 55 months’ follow-up, seven patients reported no pain, and threepatients had occasional pain. Grip strength improved, and final arc of motion was 111�.

As a motion-sparing salvage procedure, PRC provides a pain-relieving salvage optionwithout the functional loss of total wrist arthrodesis. Motion obtained after PRC comparesfavorably with other motion-preserving salvage procedures, ranging from 40% to 60% of theunaffected side. The results in various studies [5–9] for the SNAC pattern show that greater thana 70� arc of motion can be expected when salvaging a SNAC wrist. Grip strength consistentlyimproves from preoperative levels. Wyrick and colleagues [6] showed improved overall gripstrength and motion in PRC.

Several authors have advocated resection of the radial styloid to prevent impingement duringfull radial deviation. This is a potential problem if the distal pole of the scaphoid is excisedincompletely. If the entire proximal row is excised, the trapezium should not impinge because it liespalmar to the styloid process of the radius, a relationship that has been shown by three-dimensional computed tomography reconstruction [12,13]. If the radial styloid is removed at thetime of surgery, care should be taken to avoid damage to the origin of the radioscaphocapitateligament,which is important in preventing ulnar translationby stabilizing the capitate in the lunatefossa.

The duration of symptoms, pin fixation, and duration of postoperative immobilization donot seem to influence the final result in PRC. Imbriglia and coworkers [13] reported thecombined results of PRC in heavy laborers, showing 25 of 32 patients returned to work withoutlimitations. Most authors agree that nonlaborers are more likely to resume their preoperativevocations.

PRC has been used for many years in patients with carpal degenerative instability caused by avariety of conditions. It is a technically simple procedure to performwith early mobilization of thewrist and no risk of nonunion or other complications related to hardware placement. The resultsof‘ this procedure in patients with SNAC wrists in the literature and at our institution have beensuccessful in terms of restoring function, range of motion, and grip strength. Improved results areobtained in patients with preserved capitolunate and radiolunate articulations.

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Atlas Hand Clin Volume 8 Issue 1 March 2003 - Scaphoid Injuries

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