Surgical Management

A contralateral radiograph of the normal scaphoid was taken to determine screw length. A CT scan confirmed proximal pole fracture, nondisplaced. Seven weeks after the initial

Table 57-2 The Herbert Classification Scheme

Type Description

Type A Acute, stable fractures; conservative management possible

A1 Fracture of tubercle

A2 Incomplete fracture through waist

Type B Acute, unstable fractures; surgical management required

B1 Distal pole oblique fracture

B2 Complete fracture of waist

B3 Proximal pole fracture

B4 Transscaphoid-perilunate fracture-dislocation of the carpus

Type C Classification no longer used; included delayed union; now part of type D

Type D All nonunions older than 6 weeks

injury, the patient was taken to the operating room for definitive management. The wrist was flexed to 90 degrees with the forearm pronated until the scaphoid was viewed down its long axis as a ring of cortical bone (Fig. 57—3). In the center of the ring, a 0.045-inch Kirschner wire (K wire) was driven from proximal to distal (dorsal wrist), exiting at the base of the thumb. From the base of the thumb (distal), the wire was withdrawn to the point that the wrist can again be extended to a neutral position. The hand and forearm were exsanguinated, and a tourniquet was used to maintain a bloodless field. The fingers are placed in finger traps, and longitudinal traction is applied (12 to 15 lb).

The scaphoid fracture was visualized arthroscopically through the midcarpal row. A minifluoroscopy unit placed in the horizontal plane and around the wrist was

Figure 57—4. Intraoperative fluoroscopic view ofcannu-latedAcutrak screw.

used to locate the entry portals. A 19-gauge needle was used to locate the joint space above the scaphoid and lunate and between the scaphoid and capitate.

The skin was longitudinally incised at the sites identified by the free 19-gauge needles. Care was taken to incise only the skin and not the underlying tissue as dorsal sensory nerves can cross through the area of the portals. Blunt dissection to the level of the joint capsule was performed with a small hemostat, and then the hemo-stat was used to carefully spread the joint capsule and enter the joint.

A 2.8-mm cannula with a blunt trocar was used to enter the joint. The trocar was removed and a 2.3-mm, 30-degree angled arthroscope was placed through the cannula. The inflow was then hooked up to the arthroscope cannula. A second portal was established in the same manner using the second 19-gauge needle as a guide. The second portal was used for instrument placement.

The fracture was then visualized. Both the arthroscope and traction were removed, and the wrist was flexed to 90 degrees. Minifluoroscopy confirmed that the scaphoid was reduced. The minifluoroscopy unit was used to confirm the position of the guidewire and the architectural alignment of the scaphoid. The arthroscope was reinserted to confirm articular fracture alignment. If the fracture were still displaced, we would have withdrawn the guidewire into the distal pole of the scaphoid and inserted two 0.062-inch K wires placed percutaneously to be used as joysticks to reduce the fracture. The guidewire was then driven back to secure both fracture fragments. Reduction was confirmed arthroscopically.

The wrist was removed from traction and flexed to 90 degrees, and the K wire was driven proximally. The scaphoid was prepared for screw placement using a cannu-lated hand tap dorsally. The cannulated screw was placed dorsally with a cannulated driver (Fig. 57—4). Skin incisions were closed with nylon sutures.

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