During the 7 days before surgery, a splint was applied and the upper extremity maximally elevated to reduce swelling. Operative procedures included open reduction and internal fixation of the scaphoid with an antegrade screw and 0.054-inch Kirschner wire, closed reduction and pinning of the distal radial fracture with Kirschner wires, repair of the scapholunate interosseous ligament, intercarpal pin stabilization, and open carpal tunnel release (Fig. 59—2).
The scaphoid was exposed through a longitudinal dorsal incision. The proximal pole of the scaphoid was found to be completely detached from the scapholunate inter-osseous ligament. Secure fixation of the scaphoid fracture was accomplished with an antegrade Herbert screw. Direct visualization of the intraarticular radial styloid fracture assisted reduction before percutaneous Kirschner pin fixation. Maintenance of the proper capitolunate orientation was achieved with a retrograde Kirschner wire from the capitate to the lunate (Fig. 59—3). The scapholunate joint was then reduced and two 0.054-inch Kirschner wires were used to maintain the normal scapholunate relationship.
The carpal tunnel release was performed through an incision that crossed the distal wrist skin flexion crease obliquely before terminating at the distal end of the ligament in line with the third web space.
The sequence of operative procedures chosen in this case illustrates consideration of all the sustained injuries. Repair of the scaphoid fracture first permits more fracture fragment mobility and makes anatomic reduction easier. Following
Figure 59—3. Lateral (A) and posteroanterior (B) roentgenograms of wrist injury in Figures 59—1 and 59—2 at 12-month follow-up.
secure fixation of the scaphoid, the distal radial intraarticular fracture is reduced and rigidly fixed. Derotation of the extended lunate and flexed scaphoid with provisional Kirschner-wire joysticks assists in Kirschner-wire fixation of the scapholunate complex. The dorsal surgical approach to the acutely fractured scaphoid permits clear visualization of the scaphoid fracture and further allows appropriate access to repair of the rare intercarpal ligament disruption as well as reduction of the radial styloid fragment. A volar approach to the scaphoid could have been chosen; however, the additional volar incision for the carpal tunnel release in the face of moderate swelling might compromise wound closure. It is the author's preference to approach displaced fresh scaphoid fractures dorsally in the presence of acute carpal tunnel syndrome. Arthroscopic management of the bone and ligament injuries in this case might have been possible but was not attempted. Moreover, when intercarpal pathology requires an arthrotomy, the radial styloid fragment reduction is simplified by direct visualization, which obviates the need for arthroscopic assistance.
This case of a transradial styloid, transscaphoid perilunar injury is exemplary of the potential greater arc injury pattern associated with a radial styloid fracture. Two such cases have been treated in the author's practice and no cases of proximal scaphoid pole avascular necrosis or scapholunate instability have been observed. Rigid fixation of the styloid body with Kirschner wires and the scaphoid fracture with an antegrade Herbert screw and immobilization of the wrist for 10 weeks have been routinely used in these injuries.
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