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) ix-ix Scaphoid injuries Lee Osterman xi-xii Scaphoid injuries Slade JF 1-18 Dorsal percutaneous fixation of stable, unstable, and displaced scaphoid fractures and selected nonunions Slade JF 19-28 Volar percutaneous fixation of stable scaphoid fractures Shin AY 29-35 Percutaneous scaphoid fixation: surgical technique volar approach with traction Goddard N 37-56 Arthroscopic assisted fixation of fractures of the scaphoid Geissler WB 57-66 Scaphoid fracture repair using the Herbert screw system (HBS) Krimmer H 67-76 Open treatment of transscaphoid perilunate fracture dislocations Sarris I 77-94 Percutaneous treatment of transscaphoid, transcapitate fracture-dislocations with arthroscopic assistance Slade JF 95-105 The treatment of chronic scapholunate dissociation with reduction and association of the scaphoid and lunate (RASL) Lipton CB
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17
107-116 Scaphoid nonunion: correction of deformity with bone graft and internal fixation Forthman C 117-128 Vascularized bone grafts for the repair of scaphoid nonunion Moreno R 129-138 Fixation of scaphoid nonunion with Kirschner wires and cancellous bone graft Gutow AP 139-148 Intercarpal fusion with the Spider plate for scaphoid nonunion Manuel JL 149-162 Percutaneous capitolunate arthrodesis using arthroscopic or limited approach Slade JF 163-183 Intercarpal fusion for scaphoid nonunion Sauerbier M 185-189 Proximal row carpectomy for scaphoid nonunion Leak RS
Atlas Hand Clin 8 (2003) ix
Foreword Scaphoid injuries
A. Lee Osterman, MD 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 fresh approaches to the old problems of scaphoid fracture, scaphoid nonunion, scapho-lunate dissociation, and scaphoid salvage. Dr. Slade is a pioneer in percutaneous scaphoid xation surgery, and his innovative approach shines through in this issue. New information and technical pearls on a variety of percutaneous techniques abound. This collection of articles updates the current state of scaphoid surgery and serves as a how-to primer for wrist surgeons. Five of the rst seven articles address the indications, methods, and results of percutaneous stabilization through a variety of approaches. Krimmer and Sarris emphasize the more traditional approaches. Dr. Rosenwasser presents his RASL procedure for scapho-lunate instability; this article and the three that follow it oer strategies to solve scaphoid nonunion, including those complicated by avascular necrosis. The nal four articles complete the cycle of scaphoid salvage. In this issue of the Atlas of the Hand Clinics, Dr. Slade and his collaborators present a comprehensive cradle-to-grave approach to the problems of the scaphoid. A. Lee Osterman, MD President The Philadelphia Hand Center 901 Walnut Street Philadelphia, PA 19107
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) xixii
Preface
Scaphoid injuries
Joseph F. Slade III, MD Guest Editor
Scaphoid fractures, nonunions, and their associated ligament injuries continue to challenge clinicians in the face of the changing needs and expectations of our patients. Gone are the days when patients were satised to return for their annual cast change. Failure of treatment in young active patients only results in their mid-life presentation with arthritis. These patients now 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 cuttingedge treatments for scaphoid injuries by the Masters. I have asked the authors to put their knife in your hands and demonstrate how they accomplish their magic. This issue opens with a variety of percutaneous techniques for scaphoid xation. These techniques are advocated by the authors for stable, displaced, and selected nonunions. In addition to these limited approaches, we are fortunate to have the new Herbert screw system detailed in the open repair of scaphoid fractures. Scaphoid fractures associated with major ligament injuries are vexing problems. Sotereanoss successful approach in dealing with these radiocarpal instabilities is an excellent read. Also detailed in this issue is the role of arthroscopy in the management of greater arc injuries, both scaphoid and capitate. Rosenwasser describes an extremely innovative approach for the treatment of chronic scapholunate dissociation with reduction and screw stabilization. Scaphoid nonunions continue to challenge even the most skilled 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 scaphoid necrosis with a vascularized bone graft with detailed illustration. Gutow and Stevanovic review the timed-tested classical approach to scaphoid nonunion with Kirschner wires and bone graft. The nal 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 his technique for implantation of the spider plate, a revolutionary plate that accomplishes a solid intercarpal arthrodesis while maintaining a low prole. This section is rounded out by traditional salvage procedure describing both the four-corner fusion and proximal row carpectomy. A nal article introduces a percutaneous fusion technique that some clinicians may nd useful. I am most indebted to these authors for their willingness to commit their valuable time and eort to produce these excellent articles. The comprehensive and clear fashion with which each topic was presented made my editorial responsibilities easy. I also wish to thank W.B. Saunders for the opportunity to serve as Guest Editor and their editorial sta for direction and guidance;
1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(03)00008-6
xii
J.F. Slade III / Atlas Hand Clin 8 (2003) xixii
I particularly want to thank Deb Dellapena for her advice and assistance in completing this exciting project. Most importantly, I would like to thank my family for their continued patience and support. Joseph F. Slade III, MD Department of Orthopedics and Rehabilitation Yale University School of Medicine P.O. Box 208071 New Haven, CT 06520-8071, USA E-mail address: joseph.slade@yale.edu
Atlas Hand Clin 8 (2003) 118
Dorsal percutaneous xation of stable, unstable, and displaced scaphoid fractures and selected nonunions
Joseph F. Slade III, MDa,*, Andrew E. Moore, MDb
Hand and Upper Extremity Service, Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA b Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA
a
This article describes a simple, reliable method for scaphoid fracture reduction and rigid xation using a dorsal percutaneous approach (Fig. 1). This technique uses real-time radiographic imaging and arthroscopy to reduce displaced carpal fractures, treat occult ligament injuries, and conrm 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 system 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 carpal collapse. Both of these injuries are recognized precursors of radiocarpal osteoarthritis. The benet of the percutaneous surgical approach lies in the fact that fracture reduction and xation can be accomplished without further injury to the scaphoids blood supply or further disruption 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 dicult because reported union rates range between 10% and 50% with plaster immobilization [35]. Close inspection of these fractures has permitted the authors to identify risk factors for nonunion. The most inuential factors include displaced fractures, fractures with ligament injuries, and proximal pole fractures. Even with best guessing, long-term studies conrm a 10% to 12% failure rate with plaster immobilization of presumed stable fractures [3]. This group includes incomplete fractures and fractures 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 failure rate 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 especially 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: joseph.slade@yale.edu (J.F. Slade). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(02)00019-5
J.F. Slade III, A.E. Moore / Atlas Hand Clin 8 (2003) 118
Fig. 1. Dorsal percutaneous technique. Scaphoid fracture is repaired through a dorsal percutaneous guidewire using a standard Acutrak (Acumed, Beaverton, OR) screw. This xation device is a headless cannulated compression screw implanted through the proximal pole.
surgery have a reported increased failure rate of 25% to 50% with functional results not equal to acute fracture repair [68]. The cause of scaphoid nonunions is multifactorial, but the tenuous blood supply is considered a major factor. The most important vessels are along the dorsal ridge, which enter the
Fig. 2. The technique employs a standard Acutrak (Acumed, Beaverton, OR) screw.
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 micromotion at the fracture site. Fracture healing in the scaphoid is made more dicult by its cartilage 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 is prolonged, 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 ndings conrm cadaver biomechanical studies showing that waist fractures are subjected to exion forces, which are resisted by intact scaphocarpal ligaments [911]. Scaphoid fractures also are subjected to translational forces, acting to displace the fracture fragments 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 simulating 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 displaced 1 to 4 mm. This study likely underestimates fracture site motion in a living subject because loosening of the cast with subsistence of swelling and muscle atrophy allows for even greater motion [12]. These studies only conrm the diculty of treating complete scaphoid fractures with plaster immobilization. All authors agree that unstable fractures require rigid internal xation. For an implant to be successful in providing secure xation 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 repetitive cyclic loading throughout the prolonged healing course of the scaphoid fracture. A variety of compression screws are available for xation of scaphoid fractures. Toby and colleagues [13] evaluated the time to failure of cyclically loaded screws. They found resistance to 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 dierences in xation strength. The Herbert, Whipple, and AO lag screws failed catastrophically with a resulting windshield wiper eect under these conditions. The Acutrak screw did not show catastrophic failure. It underwent gradual separation by plastic deformation of the surrounding bone, while still providing mechanical support for the fracture fragments. For proximal pole fractures, the strongest means of xation is a headless compression 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 signicantly more eective 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 stiness of xation [16,17].
Indications for percutaneous scaphoid fracture repair The goal of internal xation of scaphoid fractures is to provide secure xation 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 fractures are similar to the indications for open repair, as long as the goals of internal xation are met. Absolute indications include reducible displaced scaphoid fractures, fractures of the proximal pole, and fractures with delayed presentation. Scaphoid fractures with brous unions without displacement require only rigid xation for healing to be accomplished. This xation is
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 simple debridement and xation. Complete ligament disruptions can be detected arthroscopically and treated with a minimal incision directly over the disruption and repaired with bone anchors. Relative indications include 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 xation. Osteonecrosis of the scaphoid requires a vascularized bone graft with rigid xation.
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) [1820]. This guidewire permits the implantation of a cannulated headless compression screw along the central axis. It has been shown that screws in this position increase the rate of healing of scaphoid fractures [21] and increase the stiness of xation [16]. An additional benet 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 uoroscopy. Arthroscopy is used to conrm fracture reduction and to treat occult injuries. With fracture surfaces rmly opposed, a headless, cannulated compression screw is used to achieve rigid xation of the scaphoid fracture. Equipment required includes the headless, cannulated compression screw (standard Acutrak screw); a uoroscopy unit (preferably a mini-imaging unit); 0.045-inch and 0.062-inch, doublecut 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 exed 90, and a miniuoroscopy imaging unit is placed in a horizontal position, parallel to the hand table so that the imaging beam is perpendicular to the wrist. A uoroscopic survey of the carpus is performed for fracture displacement, ligament injury, and other occult injuries. The scaphoid is examined to conrm anatomic reduction. Lateral and oblique views of the scaphoid are particularly useful. Fractures of the waist of the scaphoid ex 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 exed (lunotriquetral interosseous) position of the lunate. Longitudinal traction of the carpus may detect a step-o 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 rst obtaining a posteroanterior view of a reduced scaphoid. The wrist is pronated and exed until the scaphoid poles are aligned in the radiographic beam. The scaphoid assumes 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 uoroscopy. The elbow is exed, and the imaging beam is perpendicular to the wrist and horizontal to the oor. Posteroanterior view of the wrist radiograph and picture (A). Using uoroscopy, the wrist is pronated until the scaphoid poles are aligned and the scaphoid is viewed as a cylinder (B). The wrist is exed 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 oor and under the table (D). A small roll is placed under the wrist, which permits the wrist to be exed approximately 45 and the scaphoid to be exed 90. The wrist is pronated until the scaphoid appears as a circle.
Fig. 4 (continued )
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 by the trapezium, obstructs this direct line of sight. Using miniuoroscopy, the guidewire is driven dorsally along the central axis of scaphoid passing through the trapezium. The wrist is maintained in a exed position to avoid bending the guidewire. As the wire is advanced, its position can be checked using uoroscopy. 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 conrm scaphoid fracture alignment 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 exion deformity of the scaphoid is corrected. This correction is conrmed best on lateral uoroscopy. With acute fractures, there is no loss of volar cortex because the volar scaphoid fails in tension, not compression with a hyperextension 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. 5. Placement of guidewire along scaphoid axis. Using uoroscopy, 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 exed 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 miniuoroscopy can be used to conrm 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).
distal fragment is driven from its volar position into the proximal fragment to capture and secure 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 uoroscopy conrms the fracture is aligned correctly and the guidewire is in the correct position along the scaphoid central axis, longitudinal traction is applied through all ngers to allow for safe entry of the small-joint arthroscope and instruments. Using miniuoroscopy, the midcarpal and radiocarpal portals are located, and 19G needles are used to mark these portal 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 conrm 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 (continued )
radiocarpal and the midcarpal joint. The 3,4 portal is used to conrm 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 xation, but also ligament repair. The appropriate 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 reduction, crossing 0.045-inch Kirschner wires also are placed. The joysticks are used to eect a reduction, and the reduction is secured with the crossing Kirschner wires. A bony trough is created at the site of ligament avulsion, and bone anchors are placed to advance the torn
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 dicult fracture can be reduced with a small curved hemostat introduced percutaneously (E and F).
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 conrmed, the screw size can be selected. First, the scaphoid length must be determined (Fig. 8). Adjust the scaphoid central axis guidewire until the distal end is in contact with the distal cortex. Place a second identical wire parallel to the rst so that the tip of the wire touches the cortex of the proximal pole. The dierence 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
10
Fig. 6 (continued )
selected is 4 mm shorter than the scaphoid length. This length permits the complete implantation 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 xation [20]. One concern about larger screws introduced dorsally is 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 fragmentation 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 tradeo is a decrease in the rigidity of the xation.
11
Fig. 7. Arthroscopy. A small joint angled arthroscope is placed in the midcarpal row (A). Although a large scaphoid step-o also would be seen with uoroscopy, a smaller step-o would be missed easily. Arthroscopy can detect these nal 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 aps are debrided back to a stable rim. Complete unstable tears are repaired open.
12
Fig. 8. Screw length. The wrist is exed, 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 dierence 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.
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 maximum fracture compression [14,15]. Fractures of the waist may be xed 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 drilling, the guidewire should be advanced so that both ends are exposed equally. This exposure permits 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 implantation of a headless compression screw completely within the scaphoid. It is crucial to use uoroscopy 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 uoroscopic guidance to within 1 to 2 mm of the opposite cortex with excellent compression. If the screw is advanced to the distal cortex, attempts to advance the screw further displace the distal fragment. 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 xation. The volar implantation of the screw is recommended for distal scaphoid fractures. Guidewire placement and length determination are accomplished in an identical manner as the dorsal
13
Fig. 9. Dorsal screw implantation. Rigid xation 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 conrm the correct position of the xation device (C).
14
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 of the 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 technique is identical to the dorsal procedure, including screw selection, drilling, and implantation. This volar technique diers 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 uoroscopy conrms screw position, fracture reduction, and rigid xation. Arthroscopy at this time can conrm 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 protected 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 conrmed 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.
15
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 intramedullary screw to stimulate healing. Heavy lifting and contact sports are restricted until computed tomography conrms 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 miniuoroscopy 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 approach can be employed. The limited open dorsal approach to the scaphoid provides a quick and easy identication of the scaphoid proximal pole and the scaphoids central axis. A small incision distal and ulnar to Listers tubercle is made exposing the extensor pollicis longus tendon, 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 guidewire is driven in a radial and distal direction, toward the scaphoid tubercle. Fluoroscopic imaging is used to conrm 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 xed, 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 brous 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 fractures also require rigid xation. Fractures not likely to heal include those with pseudarthrosis and frank motion at the fracture site. Also, nonunions with large cysts and a wide margin of sclerosis are less likely to heal with rigid xation 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 unprepared graft forces the graft to separate in the scaphoid; this risks exploding out the outer shell of scaphoid. 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 distraction at 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 uoroscope. If the scaphoid is overreamed, the selected standard Acutrak screw should be replaced with a wider 4/5 screw.
16
Fig. 11. Selected scaphoid nonunion. Although scaphoid brous unions require only rigid xation to heal, scaphoid nonunions with normal alignment and sclerosis require both rigid xation and the interposition of bone graft so that bridging healing can occur between fracture fragments (A). Preoperative magnetic resonance imaging conrms 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 xation 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.
17
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 withstand 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 xation of scaphoid fractures using headless compression screws was conducted between 1990 and 2002 [1720,22,2431]. A total of 214 acute fractures treated percutaneously resulted in a 100% healing rate. There were 39 fractures with either brous unions or late presentation treated percutaneously with rigid xation. 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 conrmed with computed tomography scan. These include stable, unstable, and displaced scaphoid fractures rigidly repaired using this dorsal percutaneous method without complication. In addition, the authors have treated brous unions and scaphoid fractures that have presented in a late fashion with percutaneous rigid xation 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 xation of the scaphoid is placement of the guidewire along the scaphoid central axis. Imaging identies this sweet spot. The wrist is pronated and exed 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 positioning of the guidewire in the scaphoid are examined using miniuoroscopy and arthroscopy. The dorsal implantation of a headless compression screw provides the greatest xation for proximal pole fractures. The early treatment of these fractures results in a faster union. Key techniques for dorsal percutaneous scaphoid xation are summarized as follows: The central position of the guidewire in the scaphoid is key. The wrist is pronated and exed 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 of the 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 miniuoroscopy and arthroscopy. Screw length is determined using two identical parallel wires. The difference in length between 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;17:52532. [2] Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am 1980;5:50813.
18
[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;76:24952. [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;71:3547. [5] Raudasoja L, Rawlins M, Kallio P, Vasenius J. Conservative treatment of scaphoid fractures: a follow up study. Ann Chir Gynaecol 1999;88:28993. [6] Barton NJ. The Herbert screw for fractures of the scaphoid. J Bone Joint Surg Br 1996;78:5178. [7] Schuind F, Haentjens P, Van Innis F, et al. Prognostic factors in the treatment of carpal scaphoid nonunions. J Hand Surg Am 1999;24:76176. [8] Shah J, Jones WA. Factors aecting the outcome in 50 cases of scaphoid nonunion treated with Herbert screw xation. J Hand Surg Br 1998;23:6805. [9] Garcia-Elias M. Kinetic analysis of carpal stability during grip. Hand Clin 1997;13:1518. [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;30:11657. [11] Smith DK, Cooney WP, An KN, Linsheid RL. The eects of simulated unstable scaphoid fractures on carpal motion. J Hand Surg Am 1989;14:28391. [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;24:98491. [13] Toby EB, Butler TE, McCormack TJ, Jayaraman A. Comparison of xation screws for the scaphoid during application of cyclic bending loads. J Bone Joint Surg Am 1997;79:11907. [14] Faran KJ, Ichioka N, Trzeciak MA, Han S, Medige J, Moy OJ. Eect of bone quality on the forces generated by compression screws. J Biomech 1999;32(8):8614. [15] Gutow A, Noonan J, Westmoreland G, Slade JF III. Biomechanical comparison of xation 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 oer biomechanical advantage in the internal xation 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;11:138. [18] Slade JF III, Grauer JN, Mahoney JD. Arthroscopic reduction and percutaneous xation of scaphoid fractures with a novel dorsal technique. Orthop Clin N Am 2001;32:24761. [19] Slade JF III, Grauer JN. Dorsal percutaneous repair of scaphoid fractures with arthroscopic guidance. Atlas Hand Clin 2001;6:30723. [20] Slade JF III, Jaskwhich J. Percutaneous xation of scaphoid fractures. Hand Clin 2001;17:55374. [21] Trumble TE, Gilbert M, Murray LW, et al. Displaced scaphoid fractures treated with open reduction and internal xation with a cannulated screw. J Bone Joint Surg Am 2000;82:63341. [22] Bond CD, Shin AY, McBride MT, et al. Percutaneous screw xation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am 2001;83:4838. [23] Salter RB, Simmonds DF, Malcolm BW, Rumble EJ, MacMichael D, Clements ND. The biological eect 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):123251. [24] Haddad FS, Goddard NJ. Acute percutaneous scaphoid xation: a pilot study. J Bone Joint Surg Br 1998;80:959. [25] Adolfsson L, Lindau T, Arner M. Acutrak screw xation versus cast immobilisation for undisplaced scaphoid waist fractures. J Hand Surg Br 2001;26:1925. [26] Inoue G, Tamura Y. Closed technique for the Herbert screw insertion in an undisplaced fracture of the scaphoid. J Orthop Surg Tech 1991;6:17. [27] Ledoux P, Chahidi N, Moermans JP, Kinnen L. Percutaneous Herbert screw osteosynthesis of the scaphoid bone. Acta Orthop Belg 1995;61:437. [28] Schadel-Hopfner M, Bohringer G, Gotzen L. Percutaneous osteosynthesis of scaphoid fracture with the HerbertWhipple screw-technique and results. Handchir Mikrochir Plast Chir 2000;32:2716. [29] Taras JS, Sweet S, Shum W, et al. Percutaneous and arthroscopic screw xation of scaphoid fractures in the athlete. Hand Clin 1999;15:46773. [30] Toh S, Nagao A, Harata S. Severely displaced scaphoid fracture treated by arthroscopic assisted reduction and osteosynthesis. J Orthop Trauma 2000;14:299302. [31] Yip HS, Wu WC, Chang RY, So TY. Percutaneous cannulated screw xation of acute scaphoid waist fracture. J Hand Surg Br 2002;27:426. [32] Haddad FS, Goddard NJ. Acute percutaneous scaphoid xation. A pilot study. J Bone Joint Surg Br 1998;80(1): 959.
Volar percutaneous xation of stable scaphoid fractures

Alexander Y. Shin, MDa,*, LCDR Eric P. Hofmeister, MC, USNb
a
Department of Orthopaedic Surgery, Division of Hand Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA b Division 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. Rigid internal xation of scaphoid fractures by percutaneous approaches have the benet of minimal soft tissue injury with rapid fracture healing and subsequently earlier return to work or sports [16]. The percutaneous approach has been described for dorsal and volar xation [16]. 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 stiness, loss of strength, and loss of economic productivity or athletic endeavors, several authors have described and reported on acute screw xation techniques for scaphoid fractures [114]. Although an open exposure of the scaphoid allows for better xation 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 xation for fractures of the scaphoid. In 1991, Wozasek and Moser [6] retrospectively evaluated the results of the volar percutaneous screw xation technique and showed an 89% healing rate of percutaneous screw xation 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 xation. Inoue and Shionoya [3] retrospectively reported on 40 patients treated with Wozasek and Mosers 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 xation 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 dorsiexed wrist and always should be suspected after this injury. Typical physical examination ndings include tenderness to palpation at the anatomic snubox and the scaphoid tuberosity volarly. There is usually some localized swelling in this area, and pain is elicited with radial and ulnar deviation. The authors prefer a ve-view scaphoid series, which includes posteroanterior views in neutral and radial and ulnar deviation, a true lateral view of the carpus, and 20 supinated oblique views [1].
* Corresponding author. E-mail address: shin.alexander@mayo.edu (A.Y. Shin). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(02)00017-1
20
A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 1928
The fracture line should be visible on at least two views to conrm 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. CT scan and trispiral tomography also may be useful in cases of known fracture to determine accurately 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 percutaneous screw xation technique described in this article is indicated primarily for minimally and nondisplaced scaphoid waist fractures (Fig. 1). Displacement of more than 1 mm and comminution is an indication for open reduction to obtain anatomic alignment. The technique can be
Fig. 1. (AC) The volar percutaneous technique for cannulated screw xation 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 xation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am 2001;83A:26377; with permission. Copyright by Journal of Bone and Joint Surgery.)
21
applied successfully to displaced fractures, however, that can be reduced easily by ulnar deviation and wrist extension. Fracture pattern and location are crucial; a transverse waist fracture is ideally suited to stable xation with a screw placed from the volar-distal direction. Conversely, this technique is contraindicated in proximal pole and oblique fractures because the screw cannot cross perpendicularly the fracture line and obtain adequate compression and purchase. Distal pole fractures can present the same technical diculties. 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 trabeculation 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 denitively. Although percutaneous screw xation 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 xation is required. Technique When anesthetized with a general or regional anesthetic, the patient is placed on the operating 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 uoroscopy 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 intensier coming from inferiorly. Two rolled towels are used under the supinated wrist to allow for adequate dorsiexion.
Fig. 2. The arm is placed on the operating table in the supine position over a towel roll. For a right-handed surgeon, the uoroscopy unit is placed inferiorly, and the surgeon sits superiorly to the arm.
22
The guidewire for the cannulated screw system is placed through the volar scaphoid tuberosity, directed proximally, dorsally, and ulnarly with the wrist hyperextended (Fig. 3). Image intensication 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 to the rst 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. Dorsiexion 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 understand 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 alternatively indirectly with a second guide pin. It is important to subtract 5 to 10 mm from the measured length of the guidewire because the screw should be buried completely within the scaphoid. We have found little variation in screw length: A 20-mm screw suces 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 uoroscopy (Fig. 5). The cannulated screw is placed with uoroscopic guidance to judge fracture reduction and screw position (Fig. 6). Final uoroscopic images are obtained and a live view of the reduction. The antirotation guidewire is removed, and the wound is irrigated and closed with a nylon suture. 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 dicult to direct 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 in proximal pole or oblique fractures, emphasizing the need for proper patient selection. The patient should be given informed consent for and the surgeon prepared to perform an open reduction 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 uoroscopic guidance and placing the drill and screw at the same depth. Failure to bury the head of the screw completely 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 technique 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 the supercial branch of the radial nerve, and 5 mm from the supercial branch of the radial artery [16]. The prudent surgeon must be knowledgeable about the anatomy, but as long as the guidewires are placed into the scaphoid under uoroscopic guidance and care is taken not to make errant passes into soft tissue, the risk of damage to the radial artery is minimal.
23
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 conrmed by multiple uoroscopic images and real-time images. (BD) Anteroposterior, oblique, and lateral uoroscopic 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 xation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am 2001;83A:26377; with permission. Copyright by Journal of Bone and Joint Surgery.)
24
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 ne hemostat. The cannulated drill is hand drilled to a depth conrmed by the image intensier. Anteroposterior (A) and lateral (B) views are shown.
25
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 uoroscopic guidance. (A) Operative view of the insertion of the screw. (BD) Anteroposterior, oblique, and lateral uoroscopic views of the inserted screw.
Rehabilitation Digital range of motion and edema control are initiated on the rst postoperative day. The hand is kept in a surgical dressing with a volar plaster splint for 10 days, at which time the splint and 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 xation 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 xation 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
26
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.)
xation cohort was 6 weeks compared with 9.7 weeks for conservatively treated fractures, with earlier return to work for the percutaneous xation cohort. The senior author reported on a prospective randomized study of nondisplaced scaphoid waist fractures treated with percutaneous screw xation versus cast immobilization and showed statistically signicant dierences in time to union and return to work status [1]. This series showed that patients who underwent percutaneous screw xation healed their fractures at an average of 7.1 weeks compared with 11.6 weeks for cast immobilization. Similarly, patients who had percutaneous screw xation
Fig. 8. Follow-up radiographs of a nondisplaced scaphoid fracture after volar percutaneous screw xation taken 6 weeks after surgery show a healed fracture in the anteroposterior (A), oblique (B), and lateral (C) radiographic views.
27
Fig. 8 (continued )
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 xation of minimally displaced or nondisplaced scaphoid fractures provides stable internal xation and allows for earlier healing, maintenance of motion and grip strength, and quicker return to work or athletics. The technique, although technically demanding, is easily mastered and can decrease signicantly the potential problems associated with prolonged cast immobilization and the hardships of time o work or athletics.
References
[1] Bond CD, Shin AY, McBride MT, et al. Percutaneous screw xation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am 2001;83:26377. [2] Haddad FS, Goddard NJ. Acute percutaneous scaphoid xation using a cannulated screw. Ann Chir Main 1998;17:11926. [3] Inoue G, Shionoya K. Herbert screw xation by limited access for acute fractures of the scaphoid. J Bone Joint Surg Br 1997;79:41821. [4] Slade JF 3rd, Grauer JN, Mahoney JD. Arthroscopic reduction and percutaneous xation of scaphoid fractures with a novel dorsal technique. Orthop Clin North Am 2001;32:24761. [5] Streli R. Perkutane Vershraubung des Handkahnbeines mit Bohrdrahtkompressionschraube. Zentralbl Chir 1970;95:106078. [6] Wozasek GE, Moser KD. Percutaneous screw xation for fractures of the scaphoid. J Bone Joint Surg Br 1991;73:13842. [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;66:11423. [8] Huene DR. Primary internal xaton of carpal navicular fractures in the athlete. Am J Sports Med 1979;7:1757. [9] Kozin SH. Internal xation of scaphoid fractures. Hand Clin 1997;13:57386. [10] OBrien L, Herbert TJ. Internal xation of acute scaphoid fractures: a new approach to treatment. Aust N Z J Surg 1985;55. [11] Rettig AC. Fractures in the hand in athletes. Instr Course Lect 1998;47:18790. [12] Rettig AC, Kollias SC. Internal xation of acute stable scaphoid fractures in the athlete. Am J Sports Med 1996;24:1826.
28
[13] Rettig AC, Weidenbener EJ, Gloyeske R. Alternative management of midthird scaphoid fractures in the athlete. Am J Sports Med 1994;22:7114. [14] Whipple TL. Stabilization of the fractured scaphoid under arthroscopic control. Orthop Clin North Am 1995;26:74954. [15] Wheeler DL, McLaughlin SW. Biomechanical assessment of compression screws. Clin Orthop 1998;350:23746. [16] Kamineni S, Lavy CBD. Percutaneous xation of scaphoid fractures: an anatomic study. J Hand Surg Br 1999;24:858.
Percutaneous scaphoid xation: 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 signicant debate [1]. There is no general consensus regarding either the duration or the ideal position for cast immobilization. It is dicult to ensure that the fracture has united, and importantly, even in the best reported series there remains a 10% failure rate. Acute open reduction and rigid internal xation of displaced intra-articular fractures is widely accepted as best practice, and the scaphoid is no exception. Herbert [2,3] introduced a reliable device and established screw xation of the scaphoid. The role of surgery for minimally displaced or undisplaced fractures remains unclear. It is, however, apparent that most scaphoid fractures occur in young men who may be manual workers or may be involved in athletic activity. The avoidance of plaster immobilization in these patients would be desirable. Early xation would provide the opportunity of early mobilization and earlier return to full function. The open procedure for xation of the scaphoid is associated with extensive soft tissue stripping and damage to the anterior radiocarpal ligaments [4]. Infection and painful scar hypertrophy in particular are also signicant postoperative problems [1], whereas sympathetic dystrophy may be catastrophic. Closed percutaneous scaphoid xation can be performed as an outpatient procedure and allows for earlier mobilization, has an increased rate of union, and has been shown to have fewer complications. Percutaneous screw xation of the scaphoid rst was reported by Streli [5] in 1970 in the German literature. In 1991, Wozacek and Moser [6] reported an adaptation of Strelis technique using cannulated 2.9-mm screws through a volar percutaneous approach with an 89% union rate. Ledoux and colleagues [7] reported 23 cases using percutaneous Herbert screw osteosynthesis of the scaphoid bone with union in all cases, 95% range of motion compared with the other side, and better key pinch than the contralateral hand. In 1996, the authors group further modied and simplied the volar percutaneous technique using the cannulated Acutrak screw (Acumed, Beaverton, OR) to stabilize minimally displaced or undisplaced B1 or B2 acute scaphoid fractures [8]. In a pilot study, the authors group reported a union rate of 100%, and current experience continues to reect this high rate of union. Encouraged by the early results, the authors group have expanded the indications to include displaced fractures, delayed unions, and some patterns of nonunions in which supplementary percutaneous bone grafting is used. The volar (distal to proximal) approach is applicable to all waist fractures and some proximal third fractures depending on the obliquity of the fracture line. Proximal pole fractures are dealt with best through a dorsal (proximal to distal) approach as described by Slade and Jaskwhich [9].
* Corresponding author. 43 Roehampton Lane, London SW15 5LT, UK. E-mail address: NJGoddardFRCS@aol.com. 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(03)00002-5
30
N. Goddard / Atlas Hand Clin 8 (2003) 2935
Operative technique The procedure of percutaneous scaphoid xation using the cannulated Acutrak screw can be done under general or regional anesthesia. Although it is feasible to perform the operation with the aected arm abducted on a hand table, the author has found it easier to use a modication of the original technique described by Wozacek and Moser [6]. The patient is placed supine on an operating table, the forearm and hand are prepared in a standard fashion, and the rest of the upper limb and body are covered with an extremity drape (Fig. 1). The hand is suspended by the thumb alone in a single Chinese nger trap with no countertraction. This position extends the scaphoid and ulnar deviates the wrist to improve access to the distal pole of the scaphoid. Importantly, it permits free rotation of the hand throughout the operation and the scaphoid remains in the center of the x-ray eld (Fig 2). The image intensier C-arm is turned to a horizontal position and positioned so that the wrist is in the central axis. With the image intensier in this position, it is possible to screen the scaphoid continuously around the axis of the radial column. In most cases, there is no need for any additional measures to reduce the fracture. If it is thought that the position of the fracture is unacceptable, however, Kirschner wires can be inserted and used as joysticks to manipulate the fragments into position. The quality of the reduction can be checked radiographically and if necessary arthroscopically without disturbing the overall setup. As with any closed fracture xation, time spent in setting up and ensuring quality of the reduction is time well spent. Having achieved an acceptable reduction, the rst, and probably most important, step is to establish the entry point of the guidewire and ultimately the position of the screw. The ulnar deviation of the wrist allows the distal half of the scaphoid to slide out from under the radial styloid. 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 anteroradial aspect of the wrist just radial to and distal to the scaphoid tuberosity. This needle serves as a trochar for the guidewire and proves to be invaluable as a direction aid. The needle is insinuated into the scaphotrapezial joint and tilted into a more vertical position, and the position is checked on the under image intensier. By gently levering on the trapezium, this maneuver brings the distal pole of the scaphoid more radial and ultimately facilitates screw insertion. It is possible to screen the wrist by simply rotating the forearm in the x-ray beam and to line up the needle along the long axis of the scaphoid in all planes. The aim should be to have the guidewire exiting the proximal pole just radial to the scapholunate junction. When the surgeon is happy with the proposed entry point and the direction of the guidewire, it is helpful to tap the needle lightly into the soft articular cartilage over the distal pole of the scaphoid so that the tip does not slip during the 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 patients upper body.
31
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.
The guidewire (0.045 inch/1.1 mm) can be passed down through the needle and drilled across the fracture, continually checking the direction on the image intensier and correcting as necessary, aiming for the radial aspect of the proximal pole. This process requires an appreciation of the obliquity of the scaphoid in anteroposterior and lateral planes. It is crucial not to bend the guidewire, and any adjustments in direction should be made using the needle as a guide 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 not breach it at this stage. The position, alignment, and length are checked one more time. If the position is thought to be satisfactory, a longitudinal incision of 0.5 cm is made at the entry point of the wire and deepened down to the distal pole of the scaphoid using a small hemostat and blunt dissection. This is a relatively safe zone. The length of the screw is determined either by using the proprietary depth gauge or by advancing a second guidewire of the same length up the distal cortex of the scaphoid and subtracting the dierence between the two. The correct screw size is 2 to 4 mm shorter than the measured length to ensure that the screw head is buried fully below the cartilage and the cortical surface. The positioning guidewire is advanced through the proximal pole of the scaphoid to exit on the dorsal aspect of the wrist. This is a precautionary measure to minimize the risk of inadvertent withdrawal of the wire during the reaming process and screw insertion. In the rare cases in which it is thought that there is a possibility of rotational instability, it is recommended that a second derotation wire be inserted parallel to the rst before drilling and reaming. Having secured the guidewire, the 12G needle is slid o, and the graduated cannulated drill is passed over the wire using either a power drill or hand reamer, stopping 1 to 2 mm short of the articular surface. It is helpful to screen this process to ensure accurate drilling and especially to ensure 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. Compression can be conrmed radiographically on the image intensier (Fig. 6).
32
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.
The skin is closed using a single Steri-strip or suture, which is covered with a sterile compressive dressing. The tourniquet is released, and the arm is elevated. Plaster immobilization is optional and is not used in the authors unit when xation appears stable. The arm is elevated immediately postoperatively, and routine postanesthetic and neurovascular monitoring is recorded.
Fig. 4. Lateral position of guidewire. This position is acceptable, but ideally should be a little more anterior.
33
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 xation. 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.
Patients are encouraged to begin active nger exercises before discharge. The patients are examined 10 days postoperatively to exclude sepsis and to ensure that early mobilization is being performed. The sutures are removed at this stage, and carpal radiographs are taken to conrm 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 to sedentary work is allowed as soon as the patient feels ready or when 75% of the contralateral range of motion is achieved. Manual work and athletic activity are deferred until there is radiographic evidence of fracture union. Patients are advised to wear a supportive splint for contact sports.
Fig. 6. (A and B) Final position of screw. Note the central axis and that both ends are buried beneath the articular surfaces.
34
Discussion The open approach to scaphoid fracture xation is technically demanding, damages the anterior radiocarpal ligaments, violates the scaphotrapezial joint, further endangers the already compromised blood supply of the scaphoid, and frequently leads to troublesome hypertrophic scars [1]. The blood supply of the scaphoid is precarious; 13% of scaphoids have a blood supply predominantly in the distal one third, and 20% have no more than a singe foramen in the proximal third [10]. This blood supply is threatened further by any open approach to the scaphoid. Garcia-Elias and colleagues [4] reported carpal instability after volar approaches to the scaphoid that damage the radiocapitate and radiolunate ligaments. The percutaneous technique minimizes operative trauma and attempts to preserve the blood supply of the scaphoid and the integrity of its surrounding ligaments. Herbert and Fisher [2] reported a far higher union rate for acutely stabilized scaphoid fractures. This rate was supported by the later work of Bunker and coworkers [11] and Wozacek and Moser [6]. Filan and Herberts [3] operative ndings supported early intervention; they almost invariably noted that the fractures were worse than suggested by radiographs and noted soft tissue interposition in 28 of 82 acute fractures. Satisfactory function after scaphoid fractures requires union in an anatomic position. This union is facilitated, although not accelerated, by stable xation with a compression screw. Scaphoid screw xation has been evaluated extensively clinically and biomechanically [1214]. Although the Herbert screw has a long and admirable clinical track record [3], it is by no means the ideal implant. Shaw [12] showed greater compression forces using ASIF screws but accepted the biologic advantages of the headless Herbert screw that can be buried within the scaphoid without disrupting its bony architecture. Rankin and colleagues [13] later conrmed Shaws ndings. The Acutrak screw is a headless, highly polished, tapered, self-tapping, fully threaded cannulated device designed to provide interfragmentary compression. Variable pitch creates gradual 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: personal communication). It could be postulated that the Acutrak screw combines some of the advantages of the Herbert or Herbert/Whipple system in being headless and having a variable pitch, while also providing improved interfragmentary compression. The economic and social cost of plaster immobilization after scaphoid fractures must not be underestimated. This is particularly the case in young working men or in young men involved in athletic and sporting pursuits. The technique described allows early intervention with a minimally invasive outpatient procedure. This technique encourages early wrist and hand mobilization, while avoiding the pitfalls of open carpal surgery. The authors group now has experience of almost 200 percutaneous scaphoid xations and is encouraged by the high rate of fracture union (>97%) in the treatment of acute fractures. Importantly, this high rate of union has been conrmed by others, and the author now routinely oers surgery as an alternative to plaster casting [8,1618].
References
[1] Barton NJ. The Herbert screw for fractures of the scaphoid. J Bone Joint Surg Br 1996;78:5178. [2] Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br 1984;66:11423. [3] Filan ST, Herbert TJ. Herbert screw xation of scaphoid fractures. J Bone Joint Surg Br 1996;78:1929. [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;13:60412. [5] Streli R. Perkutane Verscraubung des Handkahnbeines mit Bohrdrahtkompressionschraube. Zentralbi Chir 1970; 95:106078. [6] Wozacek GE, Moser KD. Percutaneous screw xation for fractures of the scaphoid. J Bone Joint Surg Br 1991; 73:13842. [7] Ledoux P, Chahidi N, Moermans JP, Kinnen L. Percutaneous Herbert screw osteosynthesis of the scaphoid bone. Acta Orthop Belg 1995;61:437.
N. Goddard / Atlas Hand Clin 8 (2003) 2935 [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18]
35
Haddad FS, Goddard NJ. Acute percutaneous scaphoid xation. J Bone Joint Surg Br 1998;80:959. Slade JF III, Jaskwhich D. Percutaneous xation of scaphoid fractures. Hand Clin 2001;17:55374. Obletz BE, Haibstein BM. Non-union of fractures of the carpal navicular. J Bone Joint Surg 1938;20:4248. Bunker TD, McNamee PB, Scott TD. The Herbert screw for scaphoid fractures: a multicentre study. J Bone Joint Surg Br 1987;69:6314. Shaw JA. A biomechanical comparison of scaphoid screws. J Hand Surg Am 1987;12:34753. 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;16:100210. Kaulesar Sukul DM, Johannes EJ, Marti RK, Kiopper PJ. Biomechanical measurements on scaphoid bone screws in an experimental model. J Biomech 1990;23:111521. Conrad G, et al. Small bone screw compression. Beaverton, OR: Acumed Inc. Adolfsson L, Lindau T, Arner M. Acutrak screw xation versus cast immobilization for undisplaced scaphoid waist fractures. J Hand Surg Br 2001;26:1925. Bond CD, Shin A, McBride MT, Dao KD. Percutaneous screw xation or cast immobilization for non-displaced scaphoid fractures. J Bone Joint Surg Am 2001;83:4838. Yip HSF, Wu WC, Chang RYP, So TYC. Percutaneous cannulated screw xation of acute scaphoid waist fracture. J Hand Surg Br 2002;27:426.
Arthroscopic assisted xation of fractures of 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 magnication. The scaphoid is well visualized with the arthroscope in the midcarpal space. This visualization allows for arthroscopic assisted xation 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 because 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 immobilization. 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 nonunion for these fractures has been reported to be 15%, however [2]. The duration of cast immobilization 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 immobilization. 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 osteopenia, and possibly nancial 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 dicult to access complete 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]. Factors 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 [710]. This approach requires signicant soft tissue dissection. Complications of open reduction have been reported, with hypertrophic scar seen as the most common complication (13%). Other possible complications include nonunion, avascular necrosis, carpal instability, donor site pain (bone graft), infection, screw protrusion, and reex sympathetic dystrophy [6]. Jigs designed to assist in fracture reduction have proved dicult to apply, requiring more extensive surgical exposure [11].
E-mail address: 3doghill@msn.com (W.B. Geissler). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(02)00023-7
38
W.B. Geissler / Atlas Hand Clin 8 (2003) 3756
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 fractures risk 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 xation of scaphoid fractures oers 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 oers many advantages over conventional techniques. These techniques reduce exposure and minimize soft tissue dissection with potential loss of 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 xation allows for detection and management of any associated intracarpal soft tissue injuries that may occur with a fracture of the scaphoid. This article reviews the indications and surgical techniques for arthroscopic assisted xation 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 prolonged periods of immobilization. Early rigid xation 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 xation to permit early motion until solid union has been achieved [16]. Surgical indications for arthroscopic assisted xation of scaphoid fractures include (1) nondisplaced unstable fractures, (2) minimally displaced but reducible fractures, (3) delayed presentation, (4) proximal pole fractures, (5) brous 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 unstable [17]. As a result, they require longer periods of immobilization and require frequent radiographic 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 associated with a nonunion rate of 50%. Internal xation 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 xation would not be indicated in a scaphoid nonunion with secondary humpback deformity and dorsal intercalated segment instability (DISI) collapse [18]. Volar wedge bone grafting to bring the scaphoid back to anatomic alignment would be required in this situation. Arthroscopically assisted xation 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 functional outcome and may result in premature radiocarpal arthritis. Delayed immobilization of greater than 6 weeks from initial injury increases the risk of nonunion [6]. Particularly in cases in which the fracture is nondisplaced, such cases are ideal for arthroscopic assisted xation. Acute proximal pole fractures, which may require a minimum of 4 to 6 months of cast immobilization, are ideal for arthroscopic assisted xation [15]. This technique allows for earlier range of motion and decreases the risk of cast disease, including muscle atrophy and joint stiness.
39
Displaced and nondisplaced acute fractures of the scaphoid may occur in association with intra-articular fractures of the distal radius. Arthroscopic assisted xation of associated scaphoid fractures is an ideal indication that the fracture of the distal radius requires internal xation. The fracture of the distal radius may be addressed arthroscopically as well, or arthroscopic assisted xation of the scaphoid may be used in combination with limited open techniques to x 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 xation include (1) contralateral hand or wrist fractures; (2) polytrauma; and (3) undue psychological, athletic, or economic hardship. Arthroscopic xation 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 scaphoid fracture 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 signicantly 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 fracture of the scaphoid in this population particularly may cause undue nancial or psychological hardship. A high school or college athletes potential to garner an athletic scholarship or obtain a professional sports contract may depend on the athletes early return to competition [1]. Obligatory demands on the athletes hands and the time constraints of a rigorous schedule may make prolonged cast immobilization intolerable. In these special situations, arthroscopic assisted xation 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 [1923]. These techniques include the volar approach (popularized 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 signicant amount of uoroscopy. As noted previously, nondisplaced or slightly displaced fractures without comminution are particularly amenable to any of these techniques. Signicantly displaced fractures with marked DISI rotation of the lunate, particularly in the chronic situation, are managed best by open reduction and internal xation. 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 nger 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 uoroscopy, 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 guidewire is introduced into the scaphotrapezium joint and advanced proximally and dorsally across the scaphoid fracture. The position of the guidewire is checked under uoroscopy in anterior posterior, oblique, and lateral planes. The length of the guidewire within the scaphoid is determined 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 nger 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 neurovascular structures from the volar entry points. The radial artery averaged 14 mm (range 7 to
40
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.
24 mm) from the entry point, and the radial nerve averaged 19 mm (range 7 to 9 mm). The structure most at risk was a supercial branch of the radial artery averaging 5 mm (range 0 to 8 mm) from the entry point. Because of risk of the supercial branch of the radial artery, Kamineni and Lavy [26] recommended making a 1-cm incision over the scaphotrapezial joint before introduction of the guidewire and screw.
Fig. 2. View of the scaphoid fracture with the arthroscope in the radial midcarpal portal. The fracture still is displaced slightly.
41
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 contralateral side at 3 months. Patients were able to return to sedentary work within 4 days and manual work within 5 weeks. Whipple [25] rst reported on arthroscopic assisted reduction screw xation of scaphoid fractures using a modied cannulated Herbert screw and jig. The modied 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. Whipple [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 to further compression of the fracture site, and the guidewire and screw are inserted with less surgical exposure. Using Whipples 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 arthroscope 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 ne tuned. When the reduction is ne tuned, the arthroscope is placed in the 3,4 portal. A working 1,2 portal is made. It is key when making a 1,2 portal to incise just the skin against the tip of the scalpel 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 snubox, this lessens 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 mm from 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 technique. 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 uoroscopic control. Under uoroscopy, the placement of the guidewires is evaluated. The primary guidewire should be surrounded by 2 mm of bone in all planes. When satisfactory reduction of the fracture and guidewire is seen under uoroscopy, 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 collapsed and required radial lunate fusion. More recently, the dorsal approach for arthroscopic assisted xation of scaphoid fractures was popularized by Slade [24,27,28]. This technique has become popular because of its
42
Fig. 3. Joysticks are placed in the proximal distal poles of the scaphoid, and the fracture reduction is adjusted.
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 oor; this makes it easier to ex the wrist and allows the x-ray beam to be perpendicular to the wrist. Under uoroscopy, the wrist is exed and pronated until the proximal distal poles of the scaphoid are aligned. The wrist is exed at approximately 45, which places the scaphoid at a 90 exed position (Fig. 8). Using this technique, the scaphoid should appear as a round cylinder (ring sign). It is helpful to use
Fig. 4. Arthroscopic view of the scaphoid fracture with anatomic reduction after adjustment by the joysticks with the arthroscope in the radial midcarpal portal.
43
Fig. 5. Fluoroscopic view of the Herbert-Whipple jig inserted on the scaphoid after the fracture has been anatomically reduced arthroscopically.
continuous uoroscopy as the wrist is exed 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, placement 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 uoroscopy, the needle is placed in the center of the ring and is parallel to the axis of the uoroscopy 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 be placed in the center of the uoroscopic 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 distal end is in contact with the distal scaphoid cortex. The position of the guidewire is checked under uoroscopy, maintaining the wrist in exion. If the wrist is extended at this point, it can bend the guidewire and cause breakage.
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.
44
Fig. 7. Radiographic view of the reduction of the scaphoid with the Herbert-Whipple screw in place.
A second guidewire is placed parallel to the rst so that its tip touches the proximal pole cortex. The dierence 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, causing articular cartilage damage [29]; 4 mm is subtracted from measurement between the guidewires, 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 the entire 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 assistants hand that is holding the wrist
Fig. 8. The wrist is pronated and exed to form a cylinder under uoroscopic 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.
45
Fig. 9. Under uoroscopic guidance, a guide pin is placed down the center of the cylinder of the scaphoid.
exed 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 ush with the proximal pole of the scaphoid. At this time, the wrist is extended. With the wrist extended, the ideal placement of the guidewire in the scaphoid is conrmed 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 arthroscope in the 3,4 portal (Fig. 14). With the arthroscope in the 3,4 portal, the ideal position of the guidewire in the proximal pole of the scaphoid can be conrmed 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 interosseous ligament and on the dorsal portion of the proximal pole of the scaphoid. It is essential
Fig. 10. Fluoroscopic view of the guide pin inserted down the center of the cylinder of the scaphoid, as formed by pronation and exion of the wrist.
46
Fig. 11. The guide pin is advanced out the volar aspect of the thumb. The pin exits along the base of the carpometacarpal joint. The pin is advanced out volarly until it is ush with the proximal pole of the scaphoid.
that the guide pin or entry point of the guide pin into the proximal pole of the scaphoid is visualized. 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 location 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. 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 uoroscopy in the posteroanterior, oblique, and lateral projections.
47
Fig. 13. Arthroscopic view of the guide pin centered within the scaphoid on the posteroanterior view.
in the center of a small proximal pole fragment. At this time, any associated intracarpal soft tissue injuries of the radiocarpal space can be identied 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 exion 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 reduce the fracture anatomically as arthroscopically conrmed, 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. 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 rst into the proposed portal location before making a skin incision.
48
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 conrm its ideal location. Although the position of the guide pin may look ideal under the posteroanterior uoroscopic view, frequently it is dicult to tell the ideal location on the lateral view under uoroscopy. Arthroscopy conrms the ideal location of the guide pin in the proximal pole of the scaphoid.
uoroscopy, when visualized arthroscopically, the fragments may be rotated. Arthroscopic visualization 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 placed back in the proximal pole of the scaphoid (Figs. 16 and 17).
Fig. 16. Anatomic reduction of the scaphoid is conrmed 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.
49
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 dicult to judge rotation of the fracture fragments in a proximal pole scaphoid fracture.
When anatomic reduction of the scaphoid is noted arthroscopically, the wrist is exed 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 the capsule around the guide pin (Fig. 19). In this manner, the guide pin can be checked so that it
Fig. 18. The wrist is exed, and the guide pin is advanced back out the dorsal aspect of the wrist. It is vital to keep the wrist in exion at this point so as not to bend the guide pin.
50
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.
does not impale any of the dorsal extensor tendons to the ngers or thumb. With the wrist in exion, the scaphoid is reamed (Fig. 20). Using Slades technique, the scaphoid is reamed no closer than 2 mm from the distal pole of the scaphoid. This detail is crucial because overreaming of the scaphoid prevents secure xation 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 important that the screw is not overly advanced to the far cortex because this can cause fracture distraction. [28] When the screw is placed, the guidewires are removed. The position of the screw is checked under uoroscopy to conrm 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 uoroscopy 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.
51
Fig. 20. The scaphoid is reamed with a cannulated reamer. The position of the reamer can be checked under uoroscopy.
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 nal union is obtained. The patient is placed in a removable wrist brace, and range-of-motion exercises of the ngers and wrist are initiated.
Fig. 21. A headless cannulated screw is inserted over the guidewire into the scaphoid.
52
Fig. 22. Posteroanterior radiograph of the headless cannulated screw inserted into the scaphoid.
Slade and Jaskwhich [28] reviewed results on arthroscopic assisted xation with a dorsal approach 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, brous 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 rst 15 patients with brous nonunions of the scaphoid treated arthroscopically. There were 12 horizontal oblique fractures, 1 transverse fracture, 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. Postoperatively the patients had excellent range of motion as a result of minimal surgical dissection. The patients in this series healed rapidly after intramedullary xation with a headless cannulated screw. This situation would be similar in principle to a long bone nonunion, treated by intramedullary rod xation, 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
53
Fig. 23. Lateral radiographic view of the cannulated screw inserted into the scaphoid.
recommended specically for brous nonunions of the scaphoid without signs of a humpback deformity and without extensive sclerosis at the fracture site. Percutaneous bone grafting may be considered in patients with a scaphoid nonunion with extensive 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 uoroscopic control at the scaphoid nonunion site through the drill hole percutaneously. After placement of the bone graft, the guidewire is replaced, 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 xation of scaphoid fractures also allows for simultaneous detection of associated intracarpal soft lesions. Braithwaite [19] initially reported on four patients with fractures 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 arthrography, 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
54
Fig. 24. Radiographic view of the scaphoid nonunion with the headless cannulated screw inserted.
to the scapholunate interosseous ligament, 17 patients with tears of the lunotriquetral ligament, and 35 patients with tears of the triangular brocartilage 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 fractures of the scaphoid. Arthroscopic assisted xation allows for early detection in management of any associated soft tissue injuries. Geissler and Hammit [19] devised an arthroscopic classication of interosseous ligament tears and proposed management. Grade I stretch injuries are managed with immobilization. Grade II and III injuries are treated with arthroscopic reduction and Kirschner wire xation. Complete grade IV injuries are managed best with open repair of the interosseous ligament (Table 1). Although it is not known whether early arthroscopic detection and management of associated soft tissue injuries with fractures of the scaphoid would improve the nal 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 xation of the scaphoid is not indicated in every patient. Cast immobilization of nondisplaced acute scaphoid fractures has a high success rate in 90% of cases. Arthroscopic assisted xation may be a viable treatment option, however, in carefully selected patients. Arthroscopic assisted reduction oers the advantages of decreased wrist stiness, 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.
55
Fig. 25. Radiographic view of the scaphoid proximal pole nonunion healed with the screw in place. No bone graft was used.
Arthroscopic evaluation allows for accurate anatomic reduction of the scaphoid as viewed from the midcarpal space. Particularly, any rotation that is dicult to detect by uoroscopy 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 cartilage because it can be dicult to conrm under uoroscopy [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.
Table 1 Arthroscopic classication of wrist interosseous ligament instability Grade I II Description Attenuation/hemorrhage of interosseous ligament as seen from the radiocarpal joint. No incongruency of carpal alignment in midcarpal space Attenuation/hemorrhage of interosseous ligament as seen from the radiocarpal joint. Incongruency/step-o of carpal space. A slight gap (less than the width of a probe) between carpals may be present Incongruency/step-o of carpal alignment is seen in the radiocarpal and midcarpal space. The probe may be passed through gap between carpals Incongruency/step-o 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
III IV
56
References
[1] Rettig AC, Kollias SC. Internal xation of acute stable scaphoid fractures in the athlete. Am J Sports Med 1996;24:1826. [2] Gellman H, Caputo RJ, Carter V, et al. Comparison of short and long thumb spica casts for nondisplaced fractures of the carpal scaphoid. J Bone Joint Surg 1989;71:3547. [3] Kaneshiro SA, Failla JM, Tashman S. Scaphoid fracture displacement with forearm rotation in a short arm thumb spica cast. J Hand Surg 1999;24:98491. [4] Skirven T, Trope J. Complications of immobilization. Hand Clin 1994;10:5361. [5] Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop 1980;149:907. [6] Gelberman RH, Wolock BS, Siegel DB. Current concepts review: fractures and nonunions of the carpal scaphoid. J Bone Joint Surg 1989;71:15605. [7] Cosio MQ, Camp RA. Percutaneous pinning of symptomatic scaphoid nonunions. J Hand Surg 1986;11:3505. [8] DeMaagd RL, Engber WD. Retrograde Herbert screw xation for treatment of proximal pole scaphoid nonunions. J Hand Surg 1989;14:9961003. [9] Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg 1984;66:11423. [10] OBrien L, Herbert TJ. Internal xation of acute scaphoid fractures: a new approach to treatment. Aust N Z J Surg 1985;55:3879. [11] Filan SL, Herbert TJ. Herbert screw xation of scaphoid fractures. J Bone Joint Surg 1996;78:51929. [12] Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg 1980;5:50813. [13] Botte MJ, Mortensen WW, Gelberman RH, et al. Internal vascularity of the scaphoid in cadavers after insertion of the Herbert screw. Am J Hand Surg 1988;13:21620. [14] Garcia-Elias M, Vall A, Salo JM, et al. Carpal alignment after dierent surgical approaches to the scaphoid: a comparative study. J Hand Surg 1988;13:60412. [15] Rettig ME, Raskin KB. Retrograde compression screw xation of acute proximal pole scaphoid fractures. J Hand Surg 1999;24:120610. [16] Toby EB, Butler TE, McCormack TJ, et al. A comparison of xation screws for the scaphoid during application of cyclic bending loads. J Bone Joint Surg 1997;79:11907. [17] Smith DK, Cooney WP, An KN, et al. The eects of simulated unstable scaphoid fractures on carpal motion. J Hand Surg 1989;14:28391. [18] Trumble TE, Clarke T, Kreder HJ. Nonunion of the scaphoid: treatment with cannulated screws compared with treatment with Herbert screws. J Bone Joint Surg 1996;78:182937. [19] Geissler WB, Hammit MD. Arthroscopic aided xation of scaphoid fractures. Hand Clin 2001;17:57588. [20] Haddad FS, Goddard NJ. Acute percutaneous scaphoid xation: a pilot study. J Bone Joint Surg 1998;80:959. [21] Shin A, Bond A, McBride M, et al. Acute screw xation versus cast immobilization for stable scaphoid fractures: a prospective randomized study. Presented at the American Society of Surgery for the Hand. Seattle, October 57, 2000. [22] Taras JS, Sweet S, Shum W, et al. Percutaneous and arthroscopic screw xation of scaphoid fractures in the athlete. Hand Clin 1999;15:46773. [23] Wozasek GE, Moser KD. Percutaneous screw xation of fractures of the scaphoid. J Bone Joint Surg 1991;73: 13842. [24] Slade JF III, Grauer JN, Mahoney JD. Arthroscopic reduction and percutaneous xation of scaphoid fractures with a novel dorsal technique. Orthop Clin N Am 2000;30:24761. [25] Whipple TL. The role of arthroscopy in the treatment of intra-articular wrist fractures. Hand Clin 1995;11:138. [26] Kamineni S, Lavy CBD. Percutaneous xation of scaphoid fractures: an anatomic study. J Hand Surg 1999;24:858. [27] Slade JF III, Grauer JN. Dorsal percutaneous repair of scaphoid fractures with arthroscopic guidance. Atlas Hand Clin 2001;6:30723. [28] Slade JF III, Jaskwhich J. Percutaneous xation of scaphoid fractures. Hand Clin 2001;17:55374. [29] Adams BD, Blair WF, Regan DS, et al. Technical factors related to Herbert screw xation. Am J Bone Joint Surg 1988;13:8939. [30] McCallister W. Knight J, Kaliappan R, Trumble T. Does central placement in the proximal pole of the scaphoid oer biomechanical advantage in the internal xation of acute fractures of the scaphoid waist? American Society for Surgery of the Hand (ASSH) Meeting. Baltimore, October 2001.
Scaphoid fracture repair using the Herbert screw system (HBS)

Hermann Krimmer, MDa,b,*
b a Surgery Department, University of Wurzburg, Wurzburg, Germany Handcenter Bad Neustadt, Salzburger Leite 1, 97616 Bad Neustadt/Saale, Germany
Traditionally, most scaphoid fractures are thought to heal uneventfully if adequately immobilized 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 nonunions resulting from wrong or failed conservative treatment still occurs. The introduction of small headless screws, rst by Herbert [1], has led to increased acceptance of internal xation. These implants have become simplied and rened in more recent years so that anyone with access to the necessary equipment should be prepared to consider internal xation as a viable alternative to immobilization in plaster.
Material The advantages of the Herbert screw for internal xation of the scaphoid are well documented. Diculties with precise placement of the screw and the need for a jig limited the application, 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 dierent from the design of the original Herbert screw [3]. The HBS (headless bone screw) system is a cannulated screw system with two dierent compression 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. Dierent compression forces are based on dierent 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.
Indications and contraindications Unstable scaphoid fractures (type B) according to Herberts classication are an absolute indication for internal xation 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 may require 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: h.krimmer@handchirurgie.de. 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(02)00021-3
58
H. Krimmer / Atlas Hand Clin 8 (2003) 5766
Fig. 1. High and low compression type of the HBS system cannulated for 1 mm.
pole fractures, whether displaced or nondisplaced, should be internally xed [4]. Nondisplaced scaphoid fractures (type A2) also should be considered for internal xation whenever treatment in a cast is not appropriate, for example, in the case of a professional athlete or anyone else in whom nancial 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 simplied greatly if the scaphoid fracture is internally xed and plaster can be avoided. Precise radiologic technique is mandatory to detect the fracture and to analyze the morphologic 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 long axis 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 xation. Not all types of fractures can be treated in this way, however, and the best approach depends rst on the conguration of the fracture, the method of xation used, and nally personal preferences [6]. Internal xation is contraindicated in the presence of osteoporosis or stiness of the wrist after immobilization in plaster. Under such circumstances, surgery should be delayed for a few weeks, and therapy is started immediately to overcome the adverse eects of immobilization. Other contraindications include sepsis, systemic disease, algodystrophy, an uncooperative patient, or lack of the necessary equipment or surgical skills to perform this type of surgery.
59
Fig. 2. (A) Suspected fracture of the scaphoid. (B) Proximal pole fracture detected with computed tomography scan.
Technique Percutaneous (minimally invasive) xationpalmar 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 dominant 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 important prerequisite for the procedure. The author prefers a permanent position of the image intensier 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 intensier to conrm 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 identied. The drill guide is positioned rmly 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 scaphoid (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 midaxis of the scaphoid in both planes and as closely perpendicular to the fracture as possible. The guidewire should enter, but not penetrate, the rm subchondral bone at the apex of the proximal pole. The intraosseous position in all planes must be checked by continuously moving the wrist from 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 rmly on the tubercle. To avoid that the guidewire is
60
Fig. 3. Setup for palmar minimally invasive approach.
removed with the drill, xation 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 suciently ne 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 intensier (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 nal position and stability of xation are controlled by screening the wrist on the image intensier (Fig. 4D). Postoperative treatment includes an elastic bandage for 2 weeks This bandage normally provides adequate support for the wrist during the period of wound healing, while allowing sucient movement to prevent adhesions and joint stiness. Heavy manual work and contact sports are avoided during the rst 6 weeks. The fracture should be healed within 6 to 10 weeks (Fig. 5). Open xationpalmar 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 exor carpi radialis tendon is incised, and the tendon is retracted ulnarward to expose 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 bers, 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
61
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 xed inside of the radius. (D) Correct positioning of the screw.
using the HBS system because there is no need for the jig (Fig. 6C). The joint between the scaphoid and trapezium is identied, 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 ne suction device can be used to aspirate the hemarthrosis. Any soft tissue attachment 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 carried out by using the cannulated screw system, as described in the previous section on closed xation (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 distally, 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.
62
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) Conrmation of healing on computed tomography scan 7 weeks postoperatively.
63
Fig. 6. Palmar approachopen 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.
Open xationdorsal approach For fractures at the proximal third of the scaphoid, which the author regards as an absolute indication, internal xation is carried out best through a dorsal approach, using an intraosseous xation device appropriate to the small size of the proximal fragment (Fig. 7A and B). The dorsal approach provides limited access with partial opening of the second and third extensor compartments 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
64
Fig. 7. (A) Mini-Herbert screw. (B) Proximal pole fracture. (C) Intraoperative view of the dorsal approach with a miniHerbert screw inserted through the proximal pole. (D) Radiograph.
65
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 freehand technique (Fig. 7C). The small size of this screw minimizes the risk of additionally disturbing the small proximal fragment and allows the screw to be buried beneath the subchondral cartilage (Fig. 7D). The wrist is immobilized postoperatively for 2 weeks in a below-elbow cast, and heavy manual activity is restricted during the rst 6 weeks. When radiographs show fracture union, full activities are resumed. This treatment regimen has a high success rate in the authors 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 abovementioned criteria [5]. Most showed unstable patternsB1 (1), B2 (22), and B3 (5)and only four showed a stable patternA2. Half of the cases were xed minimally invasively, and 11 were xed 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 xed.
66
the screw, where the proximal fragment was only partially xed. 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 xation is provided [7]. In contrast to the dorsal approach, this technique is more convenient because the wrist remains in one position during the whole surgery, and the hyperextended position of the wrist usually provides realignment at the fracture. This is not true for the palmar exed position, requiring more often manipulation of the guidewire for realignment [8]. In contrast, proximal pole fractures in general do not show humpback patterns and are xed best through the dorsal approach, preferably with a smaller implant 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. Cannulated 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 dislocation, precise placement of the screw is provided without the jig. The noncannulated miniHerbert screw, which is part of the system, is preferred for xation 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
[1] Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br 1984;66:11423. [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;26:88392. [3] Trumble TE, Gilbert M, Murray LW, et al. Displaced scaphoid fractures treated with open reduction and internal xation with a cannulated screw. J Bone Joint Surg Am 2000;82:63341. [4] Krimmer H. Management of acute fractures and nonunions of the proximal pole of the scaphoid. Br J Hand Surg 2002;27:2458. [5] Krimmer H, Schmitt R, Herbert T. Scaphoid fracturesdiagnosis, classication and therapy. Unfallchirurg 2000;103:8129. [6] Herbert T, Krimmer H. Scaphoid fractures: internal xation. In: Gelberman RH, editor. The wrist (master techniques in orthopaedic surgery). Philadelphia: Lippincott Williams & Wilkins; 2002. p. 11126. [7] Haddad FS, Goddard NJ. Acute percutaneous scaphoid xation using a cannulated screw. Chir Main 1998;17: 11926. [8] Slade JF III, Jaskwhich D. Percutaneous xation of scaphoid fractures. Hand Clin 2001;17:55374.
Open treatment of transscaphoid perilunate fracture 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 perilunate fracture-dislocation is the most common type of complex carpal dislocation [24]. Perilunate fracture-dislocations represent approximately 5% of wrist fractures and are about twice as common as pure ligamentous dislocations. Treatment of these injuries is dicult because of the extensive soft tissue, cartilaginous, and bone damage. Various nonoperative and operative treatment options have been recommended with a more recent emphasis on open reduction and internal xation.
Anatomy The wrist joint allows for articulation of the radius and the ulna in the forearm to the metacarpals 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 consists of hamate, capitate, trapezium, and trapezoid bones. Extrinsic ligaments stabilize the radiocarpal 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, lunotriquetral, 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,
* Corresponding author. E-mail address: kneiderm@wpahs.org 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(02)00015-8
68
I. Sarris, D.G. Sotereanos / Atlas Hand Clin 8 (2003) 6776
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.
taking a transosseous route through the scaphoid with usual disruption of the lunotriquetral ligament and fracture of the ulnar styloid [912]. The proximal fragment of the scaphoid and the lunate exes or stays coaxial with the radius, whereas the distal fragment of the scaphoid dislocates 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 specic 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 capitate 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 semiexed 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 paresthesia 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 should be taken for wrists with suspected carpal instability: posteroanterior, lateral, radial and ulnar
69
Fig. 2. Stages of perilunate fracture dislocations: I, radial styloid; II, scaphoid; III, capitate; IV, triquetrum; V, complete lunate dislocation.
deviation, and exion and extension views [16]. An additional posteroanterior radiograph of the wrist with a loaded st is made to rule out scapholunate instability. The presence of associated fractures may divert the attention of physicians away from the carpal subluxations or dislocations. True lateral radiographs usually show the loss of colinearity that exists between the radius, 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 with the radius, however, because the lunate is dislocated palmarly. Distraction radiographs are helpful to identify scaphocapitate syndrome or to delineate any other associated fracture or dislocation that was not apparent at the rst evaluation (Fig. 3CE). 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 performed [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 adequate for treatment of these injuries. The signicance 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 collapse 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 deformity of the scaphoid fragments are enough to indicate open reduction and internal xation in almost all cases. Open reduction, internal xation, and anatomic ligamentous repair have become the mainstays of treatment for transscaphoid perilunate dislocations [3,22]. Dierent 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 difcult to address the scaphoid fracture through this approach, however. The dorsal approach is needed to x the scaphoid fracture and repair the interosseous ligaments and the capsuloligamentous structures.
70
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).
71
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 aps for exposure of the carpus. Reduction of the lunate is assessed dorsally. Afterward, the scaphoid fracture is reduced and stabilized with a 0.045-inch Kirschner wire. A cannulated compression screw of choice is used to provide permanent xation of the fracture. The screw is placed in an antegraded direction aiming for the thumb base. Signicant comminution or bone loss at the fracture site can be bone grafted primarily by extending the incision proximally to harvest bone graft from the distal radius. Anatomic xation of the fracture is ensured using intraoperative uoroscopy. 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 o of the scaphoid, or by making drill holes through the scaphoid. Before the ligament repair, the scapholunate joint should be reduced anatomically using a 0.045-inch Kirschner wire in the scaphoid as a joystick; then it is stabilized using a 0.062-inch Kirschner wire from radial to ulnar. Intraoperative uoroscopy 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 rst. 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 dorsiexion or palmar-exion position. After attaining an anatomic reduction of the capitolunate joint, another 0.062-inch Kirschner 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 o 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 approach. 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 xed 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 exor 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 xation 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 anatomic 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 the wrist 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.
72
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 arthritic distortion of the wrist. Adequate radiographic views and careful evaluation usually prevent this complication. A transscaphoid perilunate dislocation is dened as chronic when it remains unreduced for more than 6 weeks. Despite the denition, open reduction and internal xation 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 xed 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 xation of the radial styloid and the scaphoid fractures.
73
Fig. 4 (continued )
Repair of the ligamentous structures is usually dicult, and in most cases the use of capsular aps for ligamentous reconstruction is advocated. In the case of irreducible chronic injuries resulting 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 is an indication for emergent operative intervention. Avascular necrosis of the scaphoid usually is seen with greater arc injuries and associated scaphoid fractures. The morbidity varies from 10% to 100% [13]. Treatment of the ischemic necrosis of the scaphoid includes revision open reduction and internal xation. Supplementary bone graft is usually necessary to increase the success of this procedure. Vascularized distal radius 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 Kienbocks disease [18]. The diagnosis is made based on radiographic presentation, in which the lunate is more radiopaque compared with adjacent carpal 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 xation, and supplemental bone grafting. In cases of scaphoid malunion, the normal articulation between the radial styloid and the scaphoid is lost. A dorsal humpback deformity of the scaphoid would be evident. To prevent
74
progressive arthritis, open reduction of the scaphoid with a tricortical wedge of iliac crest autograft is usually essential. Residual and chronic perilunate instability is a challenging dilemma for an experienced clinician [23]. This instability could be of a dissociative pattern; it could involve scapholunate or lunotriquetral 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 signicant morbidity. The variability of associated injuries (Fig. 5) and treatment 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 fracturedislocation. Associated injuries included ulnar artery, ulnar nerve, exor tendon lacerations, and comminuted fracture of the small nger middle phalanx. (A, B). Postoperative radiographs show realignment of the carpus, reduction of the base of the ring nger metacarpal to the hamate and xation of the scaphoid fracture (C, D).
75
Fig. 5 (continued )
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 carpal alignment gives better results [2,16,25,26]. Delay in treatment, damage of the cartilage, persistent 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 appropriate reduction and xation 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. 563678.
76
[2] Green DP, OBrien ET. Open reduction of carpal dislocations: indications and operative techniques. J Hand Surg Am 1978;3:25065. [3] Moneim MS, Hofammann III KE, Omer GE. Transscaphoid perilunate fracture-dislocation: results of open reduction and pin xation. Clin Orthop 1984;190:22735. [4] Moneim MS. Management of greater arc carpal fractures. Hand Clin 1988;4:45767. [5] Berger RA. The ligaments of the wrist: a current overview of anatomy with considerations of their potential functions. Hand Clin 1997;13:6382. [6] Norbeck Jr DE, Larson B, Blair SJ, et al. Traumatic longitudinal disruption of the carpus. J Hand Surg Am 1987;12:50914. [7] Garcia-Elias M, Cooney WP. Axial dislocations and fracture dislocations. In: Cooney WP, Linscheid RL, Dobyns JH, editors. The wrist: diagnosis and operative treatment. St. Louis: Mosby; 1998. p. 68495. [8] Kozin SH, Murphy MS, Cooney WP. Perilunate dislocations. In: Cooney WP, Linscheid RL, Dobyns JH, editors. The wrist: diagnosis and operative treatment. St. Louis: Mosby; 1998. p. 63250. [9] Garcia-Elias M, Dobyns JH, Cooney III WP, et al. Traumatic axial dislocations of the carpus. J Hand Surg Am 1989;14:44657. [10] Jasmine MS, Packer JW, Edwards GS Jr. Irreducible transscaphoid perilunate dislocation. J Hand Surg Am 1988;13:2125. [11] Johnson RP. The acutely injured wrist and its residuals. Clin Orthop 1980;149:3344. [12] Mayeld JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am 1980;5:22641. [13] Green DP, OBrien ET. Classication and management of carpal dislocations. Clin Orthop 1980;149:5572. [14] Viegas SF, Bean JW, Scham RA. Transscaphoid fracture dislocations treated with open reduction and Herbert screw internal xation. J Hand Surg Am 1987;12:9929. [15] Ruby LK. Fractures and dislocations of the carpus. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal trauma. Philadelphia: WB Saunders; 1992. p. 102562. [16] Cooney WP, Linscheid RL, Dobyns JH. Ligament repair and reconstruction. In: Neviaser RJ, editor. Controversies in hand surgery. New York: Churchill Livingstone; 1990. p. 12545. [17] Monahan PR, Galasko CS. The scapho-capitate fracture syndrome: a mechanism of injury. J Bone Joint Surg Br 1972;54:1224. [18] White RE Jr, Omer GE Jr. Transient vascular compromise of the lunate after fracture-dislocation or dislocation of the carpus. J Hand Surg Am 1984;9:1814. [19] Sanders WE. Evaluation of the humpback scaphoid by computed tomography in the longitudinal axial plane of the scaphoid. J Hand Surg Am 1988;13:1827. [20] Fenton RL. The naviculo-capitate fracture syndrome. J Bone Joint Surg Am 1956;38:6814. [21] Vance RM, Gelberman RH, Evans EF. Scaphocapitate fractures. J Bone Joint Surg Am 1980;9:3703. [22] Sotereanos DG, Mitsionis GJ, Giannakopoulos GN, et al. Perilunate dislocation and fracture dislocation: a critical analysis of the volar-dorsal approach. J Hand Surg Am 1997;22:4956. [23] Siegert JJ, Frassica FJ, Amadio PC. Treatment of chronic perilunate dislocations. J Hand Surg Am 1988;13:20612. [24] Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Dicult wrist fractures: perilunate fracture dislocations of the wrist. Clin Orthop 1987;214:13647. [25] Herzberg G, Comtet JJ, Linscheid RL, et al. Perilunate dislocation and fracture dislocations: a multicenter study. J Hand Surg Am 1993;18:76879. [26] Minami A, Ogino T, Ohshio I, Minami M. Correlation between clinical results and carpal instabilities in patients after reduction of lunate and perilunar dislocations. J Hand Surg Br 1986;11:21320.
Percutaneous treatment of transscaphoid, transcapitate fracture-dislocations with arthroscopic assistance

Joseph F. Slade III, MDa,*, Andrew E. Moore, MDb
a Hand and Upper Extremity Service, Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA b Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA
Scaphocapitate syndrome, the name for transscaphoid, transcapitate perilunate fracturedislocations, rst 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 dorsal 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 scaphoid and the capitate are perfused in a retrograde fashionfrom distal to proximal [4,5]. Displaced osseous fracture segments proximal to their blood supply risk nonunion and osteonecrosis if anatomic reduction and xation is not achieved. Carpal fracture-dislocations often are associated with ligament injuries, which require identication 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 xation of greater arc injuries, including scaphocapitate fractures (Fig. 2) [612]. 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 transscaphoid fracture-dislocation increases the risk of complications and delays initiation of rehabilitation until sucient ligament healing and results in decreased motion [14,15]. To minimize these risks, percutaneous repairs have been investigated [1618]. This article describes rst the authors minimally invasive methods for fracture reduction of greater arc injuries with radiographic imaging and arthroscopic guidance. Second, the article describes the authors technique, using a headless cannulated compression screw, for percutaneous xation of the scaphoid using a dorsal approach and the capitate using a second or third web space approach (Fig. 3). This article also presents a brief discussion of the preoperative evaluation and presents 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 of a 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.
* Corresponding author. E-mail address: joseph.slade@yale.edu (J.F. Slade III). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(02)00020-1
78
J.F Slade III, A.E. Moore / Atlas Hand Clin 8 (2003) 7794
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.
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 tunnel 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 displacement of the scaphoid and the capitate (Fig. 4). With spontaneous reduction, scaphocapitate syndrome can be dicult to detect. Boisgard and colleagues [7] reported that 30% of their cases were unrecognized at presentation after standard radiographs. Computed tomography (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 identify 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 miniuoroscopy unit and a traction tower. Although these survey studies are useful in detecting gross instabilities, the nal determination of carpal ligament stability 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 rst is acute carpal fracture displacement 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 and the 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 [2024]. In a similar manner, it may be enough to rigidly x a fracture to restore carpal stability. An
79
Fig. 2. A dorsal open approach and reduction of a transscaphoid transcapitate perilunate fracture-dislocation. Most authors advocate early open reduction and rigid xation of greater arc injuries, including scaphocapitate fractures. Open repairs risk further injury to the carpal blood supply and complications.
example is a displaced exed scaphoid waist fracture with carpal bones assuming dorsal intercalated segment instability deformity. Rigid xation of the scaphoid fracture restores carpal alignment and congruent synchronous carpal motion. The rst step in the treatment algorithm (Box 1) requires percutaneous fracture reduction using uoroscopy. 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 conrms fracture reduction 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 classication [25]. Percutaneously placed wires into carpal bones can act as joysticks permitting further evaluation of carpal stability. Partial tears with unstable aps are debrided easily, and this is sucient treatment. After carpal xation 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 xation. 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 fracture xation, require carpal reduction, pinning, and repair. Small bone anchors are most eective in restoring ligament continuity with acute injuries. Careful evaluation after the repair best determines the need for ligament repair reinforcement with a dorsal capsulodesis.
80
Box 1. Treatment Algorithm for greater Arc Injuries 1. Posteroanterior and lateral radiographs must be examined for axial carpal displacement a. Persistent carpal dislocationemergent care, to operating room for closed or open reduction to preserve neurovascular and joint function b. Reduced carpus and carpal fractures (1) Computed tomography scancarpal displacement and identify occult fractures (2) Distraction radiographsevaluate ligament integrity 2. Operating room suite evaluation with anesthesia and miniuroscopy a. Distraction radiographsevaluate the intrinsic and extrinsic ligament system for gross carpal instability b. Translational uoroscopy to identify carpal displacement, occult fractures, and ligament injury 3. Percutaneous carpal fracture reduction (scaphoid and capitate) with uoroscopic guidance a. Fracture reduction with 0.062-inch kirschner-wire placed percutaneously as joysticks b. Provision xation with 0.045-inch kirschner-wire c. Guidewire placement along central scaphoid axis and central capitate axis between the second or third web space 4. Small-joint arthroscopy with tourniquet a. Radiocarpal and midcarpal inspection b. Conrm fracture reduction c. Inspect interosseous ligament (IOL) for injury d. Grade ligament injuries e. Debride partial ligament injuries f. Debride and prepare complete ligament injury for repair with bone anchors 5. Rigid fracture xation of carpal fractures (scaphoid and capitate fractures) a. Implantation of headless compression screws b. Screw size 4 mm shorter than carpal bone length c. Carpal bone length determined by two parallel wires of equal length 6. Fluoroscopic examination with axial translation and longitudinal traction of carpus a. 12 lb of traction with four threads crossing fracture site b. If stability restored to carpus, ligament repair optional c. Continued carpal instability, miniopen ligament repair 7. Carpal ligament repair a. Carpal bone reduction with joysticks and provisional xation with 0.045-inch Kirschner wire b. Minibone anchors are used repair ligament c. Repair protected with Kirschner wires or cannulated screws to be removed later d. Consider dorsal capsulordesis
Surgical technique Overview Key steps include the percutaneous reduction of carpal fractures, provisional xation 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 cannulated headless compression screw for rigid xation. Fluoroscopy and traction are used to achieve frac-
81
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.
ture reduction and guidewire placement. Fluoroscopy and traction also are used to identify gross ligamentous injuries. Arthroscopy is used to conrm fracture reduction, grade ligamentous injury, and identify occult injuries. Fractures are treated rst. Opposing fracture surfaces are aligned and rmly opposed with joysticks, and headless cannulated compression screws are used to achieve rigid xation of carpal fractures. Incomplete ligament injuries are debrided, and carpal bones are stabilized as needed. Complete carpal disruptions require reduction, provisional wire stabilization, and direct repair with minibone 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 increase the stiness of xation [27]. An additional benet of the central axis placement of cannulated screws is the reduced risk of thread penetration and cartilage injury [28]. Required equipment includes the headless, cannulated compression screw (standard Acutrak screw); a uoroscopy 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].
82
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 exed position. With spontaneous reduction, transscaphoid transcapitate fracture-dislocation can be dicult to detect. The diagnosis now delayed, the resulting outcome is now compromised.
Surgical technique in detail Operating room setup Required equipment includes a hand table, miniuoroscopy unit, 0.045-inch and 0.062-inch Kirschner wires, Kirschner wire driver, small-joint arthroscopy setup, headless cannulated compression screw (standard size Acutrak screw set), and minibone anchors. The patient is placed in a supine position with a standard hand table attachment. After induction of anesthesia, the aected 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 miniuoroscopy unit is draped in sterile fashion and positioned perpendicular to the wrist and parallel to the oor. It is used to visualize the carpal bones under static and dynamic conditions. The characteristics of the fracture are compared with preoperative injury lms. Although complete carpal disruptions can be identied by gapping on static posteroanterior lms, malalignment of the lunate in a exed or extended position on a lateral radiograph suggests complete ligament disruption (Fig. 5A). Traction distraction radiographs are obtained with a miniuoroscopy unit and may reveal a more signicant injury (Fig. 5B). These radiographs are obtained by applying 12 lb of longitudinal traction through nger traps attached to the thumb and three ngers. This traction can be accomplished with an arthroscopic traction tower or conventional emergency department nger traps with a counterweight traction on the arm. Traction lms may reveal large carpal gaps where none were seen on standard radiograph. These studies are used to conrm carpal fractures, identify ligament injuries, and identify occult fractures. Partial injuries may be identied with traction by articular disruptions between the carpal rows and carpal bones. Percutaneous fracture reduction with uoroscopic guidance and guidewire placement The rst priority is the reduction of any remaining carpal dislocation. This reduction is accomplished 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 miniuoroscopy 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 alignment. A small hemostat can be introduced percutaneously into the fracture site to eect 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 uoroscopic imaging, a carpal reduction can be
83
Fig. 5. Standard radiographs and traction are used to dene 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 signicant ligamentous injury is revealed (B).
accomplished. After reduction is accomplished, a 0.045-inch guidewire is placed down the central 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 nal 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
84
Fig. 6. Percutaneous fracture reduction can be accomplished with uoroscopic 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 eect a direct fracture reduction (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 exed 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 dorsal-to-volar direction down the central axis of the circle. Central placement of the wire is conrmed by uoroscopy in the coronal and sagittal planes. The surgeon continues driving the Kirschner 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 rst to prevent rotation about the long axis. The wrist must be kept exed 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 nger 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 brocartilage. 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 placement of a screw along the central axis.
85
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.
Arthroscopy and soft tissue injuries After fracture reduction and guidewire placement, the tourniquet is inated for an arthroscopic survey. The hand is placed in 12 lb of linear traction using nger traps and a traction tower. The miniuoroscopy 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 outow 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 brocartilage complex are stressed with a 2-mm probe. Next the midcarpal row is entered in a similar 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 o with the capsule (Fig. 9C). Partial ligament tears are graded and debrided [25]. Complete tears with carpal instability are identied and prepared for later repair after carpal reduction with joysticks placed percutaneously, provisional Kirschner wire xation, and bone anchors. Rigid fracture xation scaphoid and capitate When the surgeon is satised 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 xed. 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 dierence 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
86
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 exed 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).
far cortex; this permits carpal reaming without loss of guidewire position. Proximal pole fractures of the scaphoid require dorsal implantation of a headless compression screw for the best xation [30]. Scaphoid waist fractures may be xed 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 exed 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 nger. This keystone joint is rigid, and penetration with the drill is tolerated easily. The surgeon always should hand ream the carpal bone and stop 2 mm from the opposite cortex. Overreaming must be avoided because it risks rigid xation. Finally, the properly measured screw (standard Acutrak screw) is inserted under compression. The screw placement and compression of the fracture site are conrmed by orthogonal views on the miniuoroscopy unit, then any remaining Kirschner wires are removed. The small portal sites are closed with interrupted 40 nylon, then sterile dressings and a volar splint are applied. Carpal ligament injury Carpal ligaments have been evaluated with standard and traction radiographs, uoroscopy, and arthroscopy. Although standard and traction radiographs identify gross disruptions, uoroscopy permits a dynamic examination of the carpus for more subtle injuries. Arthroscopy permits direct inspection and probing of the volar and intracarpal ligaments.
87
Arthroscopy permits the grading [25] and treatment of partial ligament injuries. Most of these injuries are raised aps which may lead to painful arthrosis. These may be treated satisfactorily with debridement alone. Signicant carpal ligament tears (Geissler II or III) may require debridement and temporary carpal immobilization with Kirschner wires. Carpal insta bility may result from partial or complete ligament disruptions and carpal fracture. Percutaneous carpal reduction with colinear alignment of the capitate, lunate, and radius and fracture repair may be sucient to reestablish carpal stability without open ligament repair. These injuries must be reexamined after carpal fracture xation with uoroscopy. Radial styloid 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 xed percutaneously with a cannulated screw. In a similar manner, rigid xation of the scaphoid fracture with its proximal and distal ligament attachment may be enough to reestablish wrist stability. If uoroscopy and arthroscopy conrm persistent carpal instability after fracture xation, complete disruptions of the carpal interosseous and volar capsular ligaments require direct repair (Fig. 11). In Fig. 11, the lateral radiograph documents persistent volar carpal subluxation after anatomic xation 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 miniuoroscopy 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 conrm alignment. The capitate is split at the neck (B), and the volar lunate is sheared o from the volar capsule (C).
88
Fig. 9 (continued )
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 obstructions 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
89
Fig. 10. Fracture xation 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 xation is accomplished by the implantation of headless cannulated compression screws (DF).
90
Fig. 11. Carpal instability may result from partial or complete ligament disruptions and carpal fracture. Percutaneous carpal fracture reduction and rigid xation may be sucient to reestablish carpal stability without open ligament repair. These injuries must be reexamined after carpal fracture repair with uoroscopy. If uoroscopy and arthroscopy conrm persistent carpal instability after fracture xation, 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 exed position after anatomic xation of the scaphoid. The volar displaced capitate with ligament disruption is shown in the intraoperative photograph.
lunate to assist in carpal alignment. Extending the 3,4 arthroscopic portal incision exposes the third 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 interosseous ligament. This ligament usually is avulsed o the proximal pole of the scaphoid. Minibone 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 is incised, 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 position. An ulnar to radially directed Kirschner wire secures the reduced lunate to the triquetrum. Minibone anchors or direct repair is used to reestablish ligament continuity. The lunate-triquetral 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 conrm 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 function. Complete ligament injuries require 6 weeks of immobilization in a short arm cast, followed 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 strengthening 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 restricted until CT conrms healing of fractures by bridging callus, and clinically the patient
91
is nontender. Ligament injuries require 3 months to heal followed by an intensive therapy program 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 xation 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).
92
sustaining a transscaphoid, transcapitate fracture. One week after injury, the patient was treated with an arthroscopic assisted reduction and percutaneous xation 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 ve patients died from associated injuries, two had concurrent pelvic fractures, 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 metaanalysis 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 aected. 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 unfamiliarity with 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 injury2 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 conservatively (nonoperatively) resulted in an incidence of one scaphoid nonunion, one scaphoid osteonecrosis, four capitate nonunions, one capitate malunion, and one capitate osteonecrosis. Historically, complications arising from nonunion, malunion, osteonecrosis, and degenerative joint changes in this injury pattern have been the norm regardless of the treatment modality [3,3134]. 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 scaphocapitate syndrome. This report also noted that the subset of patients that underwent open reduction without internal xation progressed to a reported 75% (four of ve) 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 xation with Kirschner wires. At the 3-year follow-up, the patient was asymptomatic and had 89% of extension and 78% of exion compared with the contralateral wrist [31]. Although the nal outcome of these high-energy injuries rests with factors involving the patient and the specic injury pattern [9,36], all investigators agree that the best outcomes are related directly to early diagnosis and treatment. Treatment delays are associated with poorer outcomes [9]. A complete examination is crucial so that all injuries are identied. 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 fractures because the blood supply to the capitate ows distal to proximal [37]. Most authors agree on the need for early open anatomic restoration of the carpus and secure xation of fractures [38]. Few agree on the surgical approach, whether dorsal [39], volar, or combined [38,40]. Most agree on the benets of headless screw for fracture xation; not all agree on the need for ligament repair after fracture xation [39,40]. Still other authors stress the importance of reevaluation 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 techniques in the reduction of displaced scaphoid fractures with and without ligament injuries [1618,41]. These minimally invasive techniques allow for the direct inspection of wrist injuries and their stable xation using a directed approach to the injury with limited incisions, while avoiding the complications of open repair. Another benet of percutaneous xation 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 dislocations has resulted increased overall hand and wrist motion [14,15].
93
Summary Percutaneous techniques using miniuoroscopy and arthroscopy can assist in fracture reduction and rigid xation of carpal fractures of scaphocapitate syndrome, while avoiding the complications of open repair. These techniques permit the identication of specic ligament injuries and occult fractures, allowing for directed repairs through mini-incisions. The theoretical benet 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.
References
[1] Fenton RL. The naviculo-capitate fracture syndrome. J Bone Joint Surg Am 1956;38:6814. [2] Wesley MS, Barenfeld PA. Trans-scaphoid, transcapitate, transtriquetral, perilunate fracture dislocation of the wrist: a case report. J Bone Joint Surg Am 1972;54:10738. [3] Adler JB, Shaftan GW. Fractures of the capitate. J Bone Joint Surg Am 1962;44:1537. [4] Barber H. The intraosseous and arterial anatomy of the adult human carpus. Orthop (Oxford) 1972;31120. [5] Gelberman RH, Gross MS. The vascularity of the wrist: identication of arterial patterns at risk. Clin Orthop 1986;202:409. [6] Sotereanos DG, Mitsionis GJ, Giannakopoulos GN, et al. Perilunate dislocation and fracture dislocation: a critical analysis of the volar-dorsal approach. J Hand Surg Am 1997;22:4956. [7] Boisgard S, Bremont JL, Guyonnet G, et al. Scapho-capitate fracture: apropos of a case, review of the literature. Ann Chir Main Memb Super 1996;15:1818. [8] El-Khoury GY, Usta HY, Blair WF. Naviculocapitate fracture-dislocation. AJR Am J Roentgenol 1982;139:3856. [9] Herzberg G, Comtet JJ, Linscheid RL, et al. Perilunate dislocation and fracture dislocations: a multicenter study. J Hand Surg Am 1993;18:76879. [10] Ipsen T, Larsen CF. A case of scapho-capitate fracture. Acta Orthop Scand 1985;56:50910. [11] Meyers MH, Wells R, Harvey JP Jr. Naviculo-capitate fracture syndrome: review of the literature and a case report. J Bone Joint Surg Am 1971;53:13836. [12] Vance RM, Gelberman RH, Evans EV. Scaphocapitate fractures: patterns of dislocation, mechanisms of injury, and preliminary results of treatment. J Bone Joint Surg Am 1980;62:2716. [13] Garcia-Elias M. Carpal instabilities and dislocations. In: Green DP, Hotchkiss RN, Pederson WC (eds). Greens operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999. p. 90928. [14] Inoue G, Imaeda T. Management of trans-scaphoid perilunate dislocations: Herbert screw xation, ligamentous repair and early wrist mobilization. Arch Orthop Trauma Surg 1997;116:33840. [15] Inoue G, Miura T. Transscaphoid perilunate dislocation with a dorsal dislocated proximal scaphoid fragment: report of 2 cases. Acta Orthop Scand 1991;62:3946. [16] Slade JFI II, Grauer JN. Dorsal percutaneous repair of scaphoid fractures with arthroscopic guidance. Atlas Hand Clin 2001;6:30723. [17] Slade JF I II, Grauer JN, Mahoney JD. Arthroscopic reduction and percutaneous xation of scaphoid fractures with a novel dorsal technique. Orthop Clin N Am 2001;32:24761. [18] Slade JF I II, Jaskwhich J. Percutaneous xation of scaphoid fractures. Hand Clin 2001;17:55374. [19] Minami A, Kaneda K. Repair and/or reconstruction of scapholunate interosseous ligament in lunate and perilunate dislocations. J Hand Surg Am 1993;18:1099106. [20] Berger RA. The gross and histologic anatomy of the scapholunate interosseous ligament. J Hand Surg Am 1996;21:1708. [21] Berger RA, Kauer JM, Landsmeer JM. Radioscapholunate ligament: a gross anatomic and histologic study of fetal and adult wrists. J Hand Surg Am 1991;16:3505. [22] Logan SE, Nowak MD. Intrinsic and extrinsic wrist ligaments: biomechanical and functional dierences. Biomed Sci Instrum 1987;23:913. [23] Mayeld JK, Williams WJ, Erdman AG, et al. Biomechanical properties of human carpal ligaments. Orthop Trans 1979;3:1434. [24] Short WH, Werner FW, Fortino MD, et al. A dynamic biomechanical study of scapholunate ligament sectioning. J Hand Surg Am 1995;20:98699. [25] Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am 1996;78:35765. [26] Trumble TE, Gilbert M, Murray LW, et al. Displaced scaphoid fractures treated with open reduction and internal xation with a cannulated screw. J Bone Joint Surg Am 2000;82:63341. [27] McCallister W, Knight J, Kaliappan R, Trumble T. Does central placement in the proximal pole of the scaphoid oer biomechanical advantage in the internal xation of acute fractures of the scaphoid waist? ASSH 56th Annual Meeting. Baltimore, October 6, 2001. [28] Tumilty JA, Squire DS. Unrecognized chondral penetration by a Herbert screw in the scaphoid. J Hand Surg Am 1996;21:668.
94
[29] Toby EB, Butler TE, McCormack TJ, et al. A comparison of xation screws for the scaphoid during application of cyclic bending loads. J Bone Joint Surg Am 1997;79:11907. [30] Faran KJ, Ichioka N, Trzeciak MA, et al. Eect of bone quality on the forces generated by compression screws. J Biomech 1999;32:8614. [31] Dinesh MKS, Kaulesar S, Johannes EJ. Transscapho-transcapitate fracture dislocation of the carpus. J Hand Surg Am 1992;17:34853. [32] Milliez PY, Dallaserra M, Thomine JM. An unusual variety of scapho-capitate syndrome. J Hand Surg 1993;18: 537. [33] Freeman BH, Hay EL. Nonunion of the capitate: a case report. J Hand Surg Am 1985;10:18790. [34] Rand JA, Linscheid RL, Dobyns JH. Capitate fractures: a long-term follow-up. Clin Orthop 1982;165:20916. [35] Sawant M, Miller J. Scaphocapitate syndrome in an adolescent. J Hand Surg 2000;25:10969. [36] Viegas SF, Bean JW, Schram RA. Transscaphoid fracture/dislocations treated with open reduction and Herbert screw internal xation. J Hand Surg Am 1987;12:9929. [37] Vander Grend R, Dell C, Glowczewskie F, et al. Intraosseous blood supply of the capitate and its correlation with aseptic necrosis. Am J Hand Surg 1984;9:67780. [38] Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Dicult wrist fractures: perilunate fracture-dislocations of the wrist. Clin Orthop 1987;214:13647. [39] Moneim MS. Management of greater arc carpal fractures. Hand Clin 1988;4:45767. [40] Green DP, OBrien ET. Classication and management of carpal dislocations. Clin Orthop 1980;149:5572. [41] Toh S, Nagao A, Harata S. Severely displaced scaphoid fracture treated by arthroscopic assisted reduction and osteosynthesis. J Orthop Trauma 2000;14:299302.
The treatment of chronic scapholunate dissociation 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,*
Department of Orthopaedic Surgery, Columbia University, College of Physicians and Surgeons, 622 West 168th Street, New York, NY 10032, USA b Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Monteore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA c Department of Hand Surgery, Orthopaedic Hand and Trauma Services, 622 West 168th Street, Columbia University, College of Physicians and Surgeons, New York, NY 10032, USA
a
Scapholunate dissociation is one of the most common types of carpal instability. For subacute or chronic dissociation, direct ligamentous repair is not possible because of a loss of anatomic integrity and substance of the ligament. Various methods have been proposed to stabilize the scaphoid, including dorsal capsulodesis [1], ligament reconstruction [28], proximal row carpectomy [9], four-bone arthrodesis (lunate, capitate, hamate, triquetrum) [9], scaphotrapezium-trapezoid [10,11], and scapholunate arthrodesis [5,12,13]. All of these procedures attempt to achieve stability at the cost of motion: composite motion between radiocarpal and midcarpal row and obligatory rotation between scaphoid and lunate. Also, all intercarpal fusions signicantly change load transmission across the radioscaphoid joint. The long-term results of limited intercarpal fusions, such as scaphotrapeziotrapezoid fusion, have shown radiocarpal arthrosis in 19% to 50% cases [10,14]. The reduction and association of the scaphoid and lunate (RASL) procedure is a new technique for subacute or chronic scapholunate dissociation when the scapholunate ligament is inadequate [15]. In contrast to salvage procedures, which limit wrist motion, the RASL technique is a motion-sparing procedure. In a cadaver study, Ruby and colleagues [16] showed there is 25 of rotational motion between the scaphoid and lunate in wrist exion and extension and 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 brous neoligament forms between the scaphoid and the lunate. The brous neoligament matures while still allowing rotation to occur at the scapholunate junction. Restoration of near-normal kinematics allows preservation of wrist motion and restoration of contact and loading pattern by correcting the dorsal intercalated segment instability (DISI). This normalization of kinematics should inhibit the progression of osteoarthritis and scapholunate advanced collapse (SLAC) wrist. Scaphoid stabilization procedures and ligament reconstruction procedures have had variable success [10,14,17]. The rate of arthrodesis between the scaphoid and lunate has been reported to be 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]
* Corresponding author. E-mail Address: mpr2@columbia.edu (M.P. Rosenwasser). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(03)00007-4
96
C.B. Lipton et al / Atlas Hand Clin 8 (2003) 95105
led to the development of the RASL procedure. Ligament reconstruction procedures correct the scapholunate diastasis in only 24% cases. The Blatt dorsal capsulodesis procedure is a checkrein that prevents volar exion of the scaphoid; however, lunate extension is not corrected, and there is continued abnormal loading across the radioscaphoid articulation. The RASL technique diers from other scapholunate ligament reconstructions [5,6,12] because the RASL procedure does not attempt ligament suture repair or reconstruction. In the RASL procedure, a transscapholunate Herbert screw is placed along the axis of rotation of the scapholunate. This placement permits the physiologic and obligatory rotation about this axis during exion and extension of the wrist, while correcting DISI deformity and scapholunate diastasis. The intended anatomic landmark that approximates the scapholunate axis of motion is the medial apex of the lunate. The smooth shank of the Herbert screw permits rotation despite the secure leading and trailing thread anchorage. Filan and Herbert [5] also reported on Herbert screw xation to augment ligament repair, but they advised screw removal. They believed the screw was a temporary xation until adequate healing of a remnant of scapholunate interosseous ligament occurred. They believed surgery on chronic cases failed expressly because inadequate tissue existed to maintain the proximal carpal alignment. In the RASL procedure, the interface between scaphoid and lunate is dechondried to expose the cancellous surface, induce punctate bleeding, and initiate a cellular response to create a neoligament or pseudoligament of scar. As the screw is inserted at the center of axis of scapholunate rotation, it allows motion and is not subjected to excessive bending stress. It is expected that leading thread loosening in the lunate will occur, but not until the brous neoligament has matured under these incremental loading conditions, which remodel the tissue as per the dictates of Wols law. For chronic scapholunate dissociation, which is greater than 12 weeks, or irreparable scapholunate interosseous ligament without signicant generalized arthritis, the RASL procedure provides a reliable restoration of near-normal carpal kinematics without precluding subsequent salvage procedures. Preoperative planning An acute injury is dened 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 of treating scapholunate instability are anatomic restoration and preservation of normal wrist biomechanics. A careful history, including antecedent wrist pain, date and mechanism of injury, and prior treatment, inuences treatment options. A careful physical examination assessing instability and associated injuries is important in planning treatment. The surgeon must recognize medical comorbidities, occupation, functional demands, and expectations before indicating treatment. It is established that untreated scapholunate dissociation leads to osteoarthritis and SLAC wrist. In most cases, scapholunate dissociation warrants a surgical procedure. Management of preoperative expectations has a signicant impact on patient satisfaction with surgery [18]. Routine radiographic investigations include the following: 1. A standard posteroanterior view is always performed. 2. A clenched-st 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 is present in chronic scapholunate injuries because of uncontrolled scaphoid exion on lunate extension. 4. Anteroposterior radial and ulnar deviation views are obtained to assess the potential for the scapholunate gap to close (ie, reducible or irreducible). 5. A contralateral wrist posteroanterior view is performed to rule out generalized ligament laxity as a possible cause of scapholunate diastasis. 6. Fluoroscopy, arthrography, magnetic resonance imaging, or arthroscopy may be necessary to diagnose scapholunate dissociation in patients with dynamic instability and normal radiographs.
97
Indications and contraindications 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 procedure because a radial styloidectomy is a routine part of the procedure. If advanced arthritic changes are noted intraoperatively, however, the RASL procedure is abandoned in favor of salvage procedures, 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 technique described by the senior author (M.P.R.) [15]. A longitudinal incision is made on the dorsum of the wrist just ulnar to Listers tubercle (Fig. 1). The interval between the third and fourth dorsal compartments is used. A longitudinal incision is made in the capsule to open the wrist joint, but the dorsal intercarpal ligament is dened and protected because it is a signicant component to carpal stability. The diastasis between the scaphoid and lunate is now clearly visible. Mild degenerative changes are not a contraindication to surgery; however, if advanced arthritis is present, 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 made centered over the radial styloid (Fig. 3). The branches of the supercial radial nerve and the radial artery are identied and protected. The rst dorsal compartment is incised, and the retinaculum 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 an in-continuity preservation of the radial collateral ligament. An osteotome is used to perform a radial styloidectomy. The osteotomy is made obliquely, and most, if not all, of the scaphoid fossa is preserved. Extreme care is taken not to injure ligaments. The radial collateral ligament is repaired in continuity with the periosteal sleeve to the transposed extensor retinaculum at the end of surgery. A 0.62-inch Kirschner wire is placed into the proximal dorsal surface of the extended lunate in a perpendicular plane, avoiding the capitolunate articulation, and another Kirschner wire is placed into the exed scaphoid at the distal pole of the scaphoid (Fig. 4). These wires serve as joysticks. The Kirschner wires should be placed so they do not interfere with subsequent Herbert screw insertion. The lunate is exed, and the scaphoid is extended to reduce the two bones. The mating articular surfaces between the two bones are exposed, and a side-cutting power burr is used to remove the articular cartilage of the scapholunate joint. The burr exposes punctate bleeding of the subchondral bone (Fig. 5). This bleeding allows cellular migration and the generation of a brous 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 conrm reduction. If the bones are reduced, the capitate articular surface is covered completely. The Herbert jig (Zimmer, Inc, Warsaw, IN) is introduced through the radial incision, and its position is conrmed under a C-arm. The goal is to have the Herbert screw pass through the center of rotation of the two bones. The end of the jig should lie at the lunate vertex. The insertion point for the screw is the midwaist of the scaphoid. The insertion angle parallels the normal radial inclination of approximately 20. Placing the Herbert screw jig over the intended lunate target, the medial apex of the lunate, aligns the screw with the axis of rotation of the lunate and allows the requisite scapholunate rotation. The Herbert screw is inserted in the standard fashion after measuring, drilling, and tapping both bones (Fig. 7). The screw should be countersunk
98
Fig. 1. AC, The location of the longitudinal dorsal incision made in the interval between the third and fourth dorsal compartments just ulnar to Listers 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;1:26372; with permission.)
slightly within the scaphoid. Imaging should be used to conrm correct screw positioning. When the Kirschner wires are removed, the scaphoid and lunate remain reduced. These two bones now have synchronous movement with slight rotational motion between them. The wound is closed in layers. The incised capsule at both incisions is closed without imbrication. No imbrication of capsule is performed, avoiding the capsulodesis eect with tethering and loss of motion. In some cases, the extensor pollicis longus may be released from its
99
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.
compartment and placed subcutaneously. The dorsal retinaculum and skin are closed in standard fashion, and a volar splint is applied. The authors have made some small but signicant changes in the technique from the earlier report. A U-shaped capsular incision no longer is used. Rather, a straight longitudinal capsular incision is used, respecting the transversely oriented dorsal intercarpal ligament. For more recent cases, the authors have used the cannulated HerbertWhipple 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 of surgery. Care must be taken during placement to avoid interference with screw insertion. Also the Kirschner wires should not violate the midcarpal or radiocarpal articular surfaces and 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 positioned securely to ensure accurate screw placement during drilling and tapping. 3. The smooth shank of the Herbert screw must cross the scapholunate interval to allow for obligatory rotation (ie, no threads at the scapholunate junction).
100
Cautions 1. The branches of the supercial radial nerve must be identied, carefully mobilized, and protected throughout the case. 2. The dorsal radial artery, which passes transversely distal to the screw insertion site, must be identied 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 xation is achieved, only 23 weeks of postoperative immobilization are required to allow capsular healing. All patients participate in a supervised hand therapy program during postoperative rehabilitation. Motion is the early goal followed by graduated strengthening. The goal 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 114 months) show that the wrist range of motion is preserved after the RASL procedure. Of patients, 95% have returned to occupational and avocational interests. DISI deformity and scapholunate gap have been corrected toward normal parameters successfully (Fig. 8). DISI deformity has been corrected from a preoperative scapholunate angle of 69 to a postoperative scapholunate angle of 40. The scapholunate gap was corrected from a mean preoperative gap of 4.1 mm to a postoperative gap of 1.4 mm. Dynamic uoroscopy in selected patients at 1 year postoperatively shows near-normal carpal kinematics in wrist exion, extension, radial and ulnar deviation, and grip. One patient failed because of secondary migration of the screw and required conversion to scaphocapitate fusion. One screw was removed at 4 years after surgery for radial impingement, but this patient exhibited excellent preservation of scapholunate stability despite screw removal.
Discussion The preservation of range of motion of the wrist after the RASL procedure is likely due to the fact that the authors do not perform a capsulodesis or capsular imbrication. Capsular closure without imbrication helps minimize the loss of wrist range of motion that may be seen with the Blatt dorsal capsulodesis. The radial styloidectomy treats early radial styloid/scaphoid arthritic changes often seen in chronic scapholunate dissociations and facilitates placement of the Herbert screw. The restored scapholunate articulation along with radial styloidectomy prevents scaphoid impingement and subsequent progression to SLAC wrist. In 1996, Filan and Herbert [5] reported on the use of a screw for treatment of scapholunate ligament rupture in 33 cases. The authors used the screw for internal xation after open reduction and ligament repair in acute and chronic injuries. The Herbert screw was intended as a temporary xation device that was removed an average of 12 months postoperatively. In this series, 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 xation for more recent injuries when ligamentous repair is more feasible. In 1997, the senior author (M.P.R.) reported on the RASL technique using the Herbert screw, not for temporary xation but for permanent reduction and association of scapholunate dissociation [15]. The scapholunate interval was dechondried to foster cellular ingrowth and salvage chronic cases when little or no ligament tissue remained at the scapholunate interval.
101
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;1:26372; with permission.)
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 exed scaphoid, and the other is placed proximally and directed distally in the dorsiexed 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;1:26372; with permission.)
102
Fig. 5. Burring of subchondral bone (A) to induce punctate bleeding (B) and generate a brous 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;1:26372; with permission.)
Other authors have attempted dierent methods to reconstruct the scapholunate ligament. Weiss [8] reported using dorsal radial bone-retinaculum-bone constructs on 19 patients with dynamic instability or static instability. He concluded that use of bone-retinaculum-bone works on patients with dynamic instability; however, patients with static scapholunate instability
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;1:26372; with permission.)
103
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;1:26372; with permission.)
require a stronger construct. In another study, the navicular/rst cuneiform ligament was isolated from cadavers, and the ligament was evaluated biomechanically [4]. This foot ligament showed similar biomechanical properties to the scapholunate interosseous ligament. Based on these ndings, the authors concluded that reconstruction using this foot ligament might restore wrist stability like bone-ligament-bone constructs used in anterior cruciate ligament reconstruction. In the authors series successful reduction of the scaphoid and lunate is achieved, while allowing the obigatory rotational motion between these two bones. Midterm to long-term follow-up radiographs show reductions without diastasis, carpal collapse, or capitate descent. Radiolucencies are visible around the Herbert screw at the lunate caused by the requisite scapholunate rotation. Two patients had complications necessitating reoperation. Placement of the 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 formation of neoligamentous structure. In direct contrast to the four-bone or scapho-trapezium-trapezoid fusion, the RASL procedure allows a continued shared load transfer on the scaphoid and lunate facets of the distal radius, which may diminish the risk of progression of osteoarthritis. The RASL procedure does not preclude later salvage procedures, including intercarpal fusions, proximal row carpectomy, or wrist arthrodesis, should xation fail or arthritis progress. Specic features of the RASL procedure make it an attractive alternative. In contrast to most procedures for treating scapholunate dissociation, the RASL procedure is motion sparing; it is
104
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 nearnormal anatomy.
not an arthrodesis. Herbert screw placement is not intended as a temporary xation device. The screw lies in the axis of scapholunate motion, and radiographic evidence of lucency around the screw indicates maintenance of obligatory rotation. The RASL procedure is not a panacea. Chronic scapholunate instability with progression of wrist joint arthrosis is a dicult problem to correct. A multitude of procedures have been designed to address this complex clinical entity. The RASL procedure has proved to be a reliable procedure to restore function and provide satisfaction to the patient with subacute or chronic scapholunate 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;3:81102. [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;16:3227. [3] Conyers DJ. Scapholunate interosseous reconstruction and imbrication of palmar ligaments. J Hand Surg Am 1990;15:690700.
105
[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;23:88492. [5] Filan SL, Herbert TJ. Herbert screw xation of scaphoid fractures. J Bone Joint Surg Br 1996;78:51929. [6] Glickel SZ, Millender LH. Ligamentous reconstruction for chronic intercarpal instability. J Hand Surg Am 1984;9:51427. [7] Howard FM, Fahey T, Wojcik E. Rotatory subluxation of the navicular. Clin Orthop 1974;104:1349. [8] Weiss AP. Scapholunate ligament reconstruction using a bone-retinaculum-bone autograft. J Hand Surg Am 1998;23:20515. [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;20:96570. [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;15:40814. [11] Watson HK, Ashmead D 4th, Makhlouf MV. Examination of the scaphoid. J Hand Surg Am 1988;13:65760. [12] Herbert TJ. Use of the Herbert bone screw in surgery of the wrist. Clin Orthop 1986;202:7992. [13] Hom S, Ruby LK. Attempted scapholunate arthrodesis for chronic scapholunate dissociation. J Hand Surg Am 1991;16:3349. [14] Fortin PT, Louis DS. Long-term follow-up of scaphoid-trapezium-trapezoid arthrodesis. J Hand Surg Am 1993;18:67581. [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;1:26372. [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;13:110. [17] Rogers WD, Watson HK. Radial styloid impingement after triscaphe arthrodesis. J Hand Surg Am 1989;14(2 Pt 1): 297301. [18] Eisler T, Svensson O, Tengstrom A, Elmstedt E. Patient expectation and satisfaction in revision total hip arthroplasty. J Arthroplasty 2002;17:45762. [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;19:13442.
Scaphoid nonunion: correction of deformity with bone graft and internal xation
Christopher Forthman, MDa, David Ring, MDb,c,*, Jesse B. Jupiter, MDb,c
a Harvard Combined Orthopaedic Residency Program, Boston, MA 02114, USA Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA c Hand and Upper Extremity Surgery Service, Massachusetts General Hospital, Boston, MA 02114, USA b
The scaphoid is the most commonly fractured bone in the carpus. Although greater than 90% of scaphoid fractures unite with cast immobilization, failure to heal remains a clinical reality, particularly when the fracture is displaced or associated with intracarpal instability [13]. Dabezies [4] reported a 55% incidence of nonunion and a 50% rate of proximal pole avascular necrosis (AVN) in scaphoid fractures with greater than 1 mm of displacement. Cooney and colleagues [2] noted a nonunion rate of 46% for 13 displaced scaphoid fractures. Scaphoid nonunion has been associated with progressive symptomatic radiocarpal and midcarpal arthrosis [57]. This arthrosis is the sequela of altered wrist kinematics [3,8,9]. The alteration of wrist kinematics reects not only motion through the nonunion site, but also the apex-dorsal malalignment of the scaphoid (the so-called humpback deformity) with associated dorsal angulation of the lunate and alteration in carpal height [10,11]. Although scaphoid deformity and its adverse eects on kinematics were recognized early on by Fisk [12], for many years the standard treatment of symptomatic scaphoid nonunion was based on gaining union without an attempt to correct the deformity of the scaphoid. It has been recognized, however, that some patients with residual bony deformity of the healed scaphoid may continue to have pain and functional limitations [1315]. As a result of a greater appreciation of carpal kinematics, many authors now believe that the approach to a scaphoid nonunion should consist of realigning the scaphoid anatomy and gaining union. Scaphoid deformity Posttraumatic scaphoid deformity is complex but predictable. Displaced scaphoid fragments lie in a so-called humpback conguration with exion of the distal fragment. The dorsal intercalary pattern of carpal instability (DISI) follows [16]. With the use of three-dimensional reconstructions of computed tomography images, the three-dimensional orientation of a fractured scaphoid has been represented more clearly. Belsole and coworkers [17] looked at a series of scaphoid nonunions and performed a detailed three-dimensional CT evaluation comparing the fractured and contralateral scaphoids. They found that the proximal scaphoid fracture component is extended, radially deviated, and supinated in relation to the distal fracture component. They also identied that the volume and conguration of missing bone is consistent. The amount of the scaphoid bone that was lost varied from 6% to 15% of bone volume. The bony defect is prismatic with a quadrilateral base facing palmarly.
* Corresponding author. Massachusetts General Hospital, ACC 525, 15 Parkman Street, Boston, MA 02114, USA. E-mail address: dring@partners.org (D. Ring). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(03)00003-7
108
C. Forthman et al / Atlas Hand Clin 8 (2003) 107116
Nakamura and colleagues [18] also analyzed scaphoid deformity by three-dimensional CT. They identied two dierent positions for the distal fragment: volar type and dorsal type (Fig. 1). In the volar type, the distal fragment was exed and overhung in the volar direction relative to the proximal fragment. This pattern was associated with fracture distal to the dorsal apex of the ridge of the scaphoid. In the dorsal type, the distal fragment moved dorsally on the proximal fragment and was associated with a more proximal and horizontal fracture line. Moritomo and colleagues [19] reproduced Nakamuras ndings. In their study, all of the distal or volar types of nonunions were associated with DISI deformity. Several techniques to quantify scaphoid malalignment have been suggested. Amadio and colleagues [20] described measuring the intrascaphoid angle on anteroposterior and lateral tomograms. A perpendicular line is drawn to the proximal and distal articular surfaces, and the angle between these lines is measured (Fig. 2). The average values for the anteroposterior and lateral intrascaphoid angles are 40 (range 32 to 46 ) and 24 (range 15 to 34 ). Bain and colleagues [21] showed that the intraobserver and interobserver variability of the lateral intrascaphoid angle and dorsal cortical angle (Fig. 3A) are high. They recommended the scaphoid height-to-length ratio as a more reliable technique (Fig. 3B). A baseline is drawn along the volar aspect of the scaphoid. The length is measured along this baseline from the most proximal to the most distal aspect of the scaphoid, the maximum height of the scaphoid is measured on a line perpendicular to the baseline, and the ratio is calculated by dividing the height 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 between scaphoid nonunion and progressive radiocarpal and midcarpal arthrosis. Mack and associates [5] reviewed 47 patients with symptomatic scaphoid nonunions 5 to 53 years after injury. Of lesions, 23 had sclerosis, cyst formation, or resorptive changes conned to the scaphoid bone; 14 had radioscaphoid arthritis; and 10 had generalized arthritis of the wrist. They observed greater arthrosis with longer duration of nonunion. Fracture displacement and carpal instability also correlated with the severity of degenerative changes. Ruby and Leslie [6] reviewed 32 patients with scaphoid nonunion followed for at least 5 years after injury. Of the 32 patients, 31 developed arthrosis, and the extent of arthrosis increased with time in a predictable pattern. Vender and coworkers [7] characterized this pattern of arthrosis in a retrospective radiographic analysis of 64 patients with symptomatic scaphoid nonunions. The pattern resembled 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;17:63146; with permission.)
109
Fig. 2. The intrascaphoid angles are dened 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;14:68797; with permission.)
occurred in the radial styloid-scaphoid, capitate-scaphoid proximal fragment, and capitatelunate articulations. The radius-proximal scaphoid fragment joint and the radiolunate joint consistently were spared from degenerative changes. This pattern has been termed the SNAC wrist for scaphoid nonunion advanced collapse. The data derived from these studies have been advocated as evidence of the natural history of scaphoid nonunion; however, use of the term natural history is inaccurate because only symptomatic patients presenting for treatment were included in these investigations [22]. To know the true natural history of scaphoid nonunion, one would have to evaluate all patients with 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 the inlay technique of bone grafting [23]. Russe [23] described a volar approach to the scaphoid with
110
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;23:7681; with permission.)
excavation of fragments and insertion of a corticocancellous bone graft from the iliac crest into the nonunion site. No attempt was made to correct deformity. Analysis of the functional and radiographic results of Russe bone grafting of the scaphoid provides some data regarding the inuence of malalignment on outcome. Jiranek and colleagues [24] reported on the results of Russe bone grafting for 25 patients with symptomatic scaphoid nonunion. Patients with severe carpal arthritis or signicant ligamentous injury were excluded. At an average of 11 years follow-up, there was an 81% union rate. Malunion, dened as a 45 lateral intrascaphoid angle, was found in 50% of patients. There was no signicant dierence between patients with malunion and patients with acceptable alignment with regard to either subjective complaints or the extent of arthrosis. Malunion was associated with a trend toward decreased motion and strength and a statistically signicant increased incidence of carpal collapse. The authors concluded that when pain was relieved, their patients seemed to adapt to the potential functional decits associated with malunion. Stark and colleagues [25] also observed a high level of patient satisfaction after Russe bone grafting. A total of 43 patients with symptomatic scaphoid nonunion were treated with the Russe technique at an average of 40 months after injury. Of patients, 27 were evaluated at an average of 12 years after the Russe grafting procedure; 22 (81%) had healed, 24 (89%) were satised, and 17 (63%) were totally pain-free. Malalignment, dened as a persistent step-o between fracture fragments of 2 mm or more, occurred in nine patients (33%). All patients with malalignment had osteoarthrosis, and ve of nine patients failed to heal. All cases of persistent nonunion and severe osteoarthrosis were associated with scaphoid malalignment. Wrist pain and functional limitations were twice as common in patients with persistent nonunion and severe osteoarthrosis. Despite overall patient satisfaction, this study suggested the importance of adequate reduction of scaphoid deformity for healing and improved functional and radiographic results. Burgess [10], in a cadaver study, found that scaphoid malalignment results in loss of radiocarpal and midcarpal extension. Burgess simulated malunion in four specimens by
111
osteotomizing the middle third of the scaphoid and xating the fragments in the humpback position. He progressively increased the angulation in 5 increments until all wrist extension was lost. With just 5 of malalignment, there was a 24% loss of extension. By 30 of intrascaphoid exion, all radiocarpal and midcarpal motion was lost. This experiment was done with intact ligaments to show the eect of scaphoid malunion alone. Amadio and colleagues [20] observed clinically that scaphoid malunion was associated with wrist dysfunction and arthrosis. They used trispiral tomographic and clinical evaluation to follow 46 patients with fractured scaphoids for an average of 3.5 years. After healing, 26 of the 46 scaphoids had malunion dened as a lateral intrascaphoid angle of more than 34 . Increasing lateral intrascaphoid angle was associated signicantly with decreasing relative grip and with decreasing total functional score. The subset of the malunions with a lateral intrascaphoid angle of 45 or greater was more likely to have fair or poor results with posttraumatic arthritis and functional wrist impairment. The authors concluded that union alone is inadequate as a criterion for success in treating scaphoid fractures and that alignment is an important determinant of functional and radiographic results. The justication for operative treatment of symptomatic scaphoid nonunions has been to relieve pain, improve function, and postpone or prevent progressive carpal arthrosis. The question remains with some as to whether or not the surgeon should attempt to correct deformity. The literature would suggest a trend toward greater pain, impaired function, and more 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 anatomy and patient functional decit would help answer this question.
Operative techniques to correct deformity When planning operative treatment for a scaphoid nonunion, the surgeon must consider the site of the fracture, the vascular supply to the fragments, bony anatomy, prior treatment, and duration of nonunion. Most techniques to correct deformity have been described for the more commonly seen scaphoid waist nonunion, the Nakamura distal or volar type, in which there is 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 and correction of the distal fragment malalignment. It also has been argued that the palmar approach is least injurious to the vascular supply of the proximal pole [26]. Before surgery, it is recommended that the surgeon evaluate for osteonecrosis using magnetic resonance (MR) imaging if necessary. The union rate of the scaphoid decreases as the vascularity decreases [27,28]. Conventional radiographic ndings of AVN, including an increase in bone density, a loss of the normal trabecular appearance, collapse of subchondral bone, and cystic changes, may be unreliable. Green [27] and Perlik and Guilford [29] showed that intraoperative and histologic ndings cannot be predicted accurately by the appearance of preoperative radiographs. Green [27] recommended that the proximal fragment vascularity be determined intraoperatively by punctate bleeding points in cancellous bone. The preoperative MR imaging nding of absent T1-weighted marrow signal may be more reliable [29]. According to Gunal and colleagues [30] study correlating intraoperative and MR imaging ndings, the diagnosis of AVN should be made only when MR imaging and intraoperative ndings indicate avascularity. In these cases, the surgeon should consider a vascularized bone graft [31] with or without an attempt to correct deformity. The rst operation to use a custom-shaped corticocancellous wedge graft for correction of deformity was the anterior interpositional wedge graft technique described by Fisk [32]. In cases of angulated or displaced nonunions of the waist or distal third, Fisk performed a radial approach, excising a wedge-shaped piece of the radial styloid and using it to ll the defect created by realignment. He claimed that by restoration of scaphoid length and correction of the exion deformity, the pathologic rotation of the lunate and carpal collapse could be corrected. No internal xation was used. Fernandez [3335] described a modication of Fisks original technique. His technique is based on careful preoperative planning using radiographs and tomograms of the contralateral
112
wrist to determine the exact bone graft shape needed to restore scaphoid anatomy (Fig. 4). The operative approach to the scaphoid is through a palmar incision and capsulotomy. A small bladed 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 the palmar pole of the lunate toward the radius. The bone graft is harvested from the iliac crest and carefully contoured based on the preoperative plan. The graft is inserted with the cortical part of the graft oriented palmarly, then secured to the scaphoid with a screw or Kirschner wires. After insertion of the graft, spontaneous derotation of the lunate usually takes place; however, in cases with long-standing DISI deformity, it may be useful to pin the lunate to the radius in anatomic position for 4 to 6 weeks after the operation. Postoperative immobilization depends on the degree of initial instability, associated carpal malalignment, and strength of the internal xation. A plaster splint or a cast may be required until union is identied on sequential radiographs. This approach has been implemented by many surgeons, occasionally with minor modications [3639]. Herbert [40] prioritized preservation of a shelf of bone or soft tissue posteriorly over exact restoration of scaphoid anatomy. Although Fernandez may have cut the dorsal bone and soft tissues, 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 brous 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;17:63146; with permission.)
113
suggested that this fulcrum enhances the stability of the graft. He recognized the potential for midcarpal 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-tting wedge. These authors perform a volar approach, core out the nonunion site, and reduce the humpback deformity. A cylindrical saw or serial trephine bone biopsy forceps are used to extract a cylindrical bone core from the iliac crest. The graft is placed and lies in compression within the nonunion bed. Maruthainar and coworkers [41] oversized the graft to avoid having to use internal xation. Leung and colleagues [42] used a cannulated Acutrak screw (Acumed, Beaverton, OR) inserted from the distal scaphoid. Postoperatively the patients are placed in a splint for at least 4 to 6 weeks. These authors claimed that the coring technique corrects scaphoid deformity, while being more mechanically stable than conventional wedge grafts to rotational and shear stress. Other authors suggested that scaphoid reduction can be maintained without custom-shaped corticocancellous grafts. Watson and colleagues [43] described a dorsal approach with scaphoid reduction, cancellous bone grafting, and Kirschner wire xation. Nagle [44] reported on a similar technique using a volar approach, packed morcellized cancellous bone graft, and Kirschner wire xation. Reduction of the fracture is aided by wrist extension, then Kirschner wires are driven from distal to proximal across the nonunion site. Cancellous graft can be harvested easily from the distal palmar radius without the need for a separate incision as required for iliac crest grafts. Nagle [44] suggested that cancellous morcellized graft can be manipulated more easily and precisely to t the scaphoid defect compared with corticocancellous graft. After surgery, the wrist is immobilized, and the Kirschner wires are left in place for 12 weeks. In cases of persistent nonunion or AVN, vascularized bone grafts have been used in conjunction with internal xation and correction of scaphoid deformity. The dorsoradial part of the distal radius is the most common donor site. Zaidemberg and coworkers [45] rst described a pedicled corticocancellous bone harvest based on the branch of the radial artery running between the rst and second dorsal compartments (1,2 ICSRA). Their original cases used a dorsoradial approach to harvest graft and to form a dorsal trough in the scaphoid for graft placement. Any correction of scaphoid deformity required a separate palmar incision. Steinmann and Bishop [46,47] subsequently described how to use the 1,2 ICSRAbased vascular graft as a wedge. Under direct visualization, the maximal dimensions of the palmar cortical defect, the dorsal-palmar width, radioulnar width, and internal defect are determined. A graft of appropriate dimension is raised and inserted, and vessels are placed palmarly to allow the cortical component of the graft to restore scaphoid length. Kirschner wires or a compression screw is used to add further stability. Trumble and Nyland [31] described a similar technique through a radiopalmar approach to the scaphoid.
Reported results and complications It is dicult to interpret the reported results of volar wedge grafting for scaphoid nonunion and compare them with alternative techniques owing to the fact that among the more than 30 scaphoid nonunion outcome studies found in the English literature reliable and consistent criteria are lacking for assessing union [48,49] and alignment [21], there is intermixing of various fracture types, there are dierences in the duration of the nonunion and the status of the carpal articulations at the time of treatment, various measures of patient outcome are used, and there is a lack of long-term follow-up. Most authors report their union rate but do not comment on the success in correcting scaphoid deformity. The comparative benchmark remains the long-term follow-up of the Russe bone graft technique provided by Jiranek and colleagues [24] and Stark and coworkers [25]. Together these authors 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 their results. Postoperative radiographic malalignment was noted for 33% and 50% of patients in the Stark and Jiranek studies. Jiranek and colleagues [24] documented functional limitations and
114
carpal collapse in these cases. Stark and coworkers [25] did not report specic results for this subpopulation of patients but noted osteoarthrosis in all patients with persistent malalignment. In their patients with signicant malalignment (lateral intrascaphoid angle of >45 ), Jiranek and colleagues [24] reported a exion arc of 78% and a grip strength of 76% compared with the uninjured side. Overall, Stark and coworkers [25] reported postoperative extension and exion arcs 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 average follow-up of 5.7 years. In 37 patients with nonunions treated with interpositional bone grafting and internal xation, 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 all patients had correction of the DISI deformity. These results seem to represent an improvement in union rate and correction of scaphoid deformity compared with conventional Russe bone grafting. Similarly, restoration of the exion arc (85%) and grip strength (88%) compares favorably with Jiranek and Starks studies. Most importantly, none of the patients in Eggli and colleagues [50] study developed severe degenerative changes after surgery. Although 81% of patients did have radiographic ndings of mild or moderate degenerative changes, there was no signicant progression of arthrosis after fracture union. Eggli and colleagues [50] postulated that anterior wedge grafting may delay or diminish the progression of arthrosis. Their complications included two persistent nonunions, three hypertrophic scars treated with scar revision, one patient who had a subsequent radial styloidectomy for impingement, and one patient treated with a subsequent radial shortening osteotomy and wrist denervation for pain. Other authors also reported high rates of union and improved carpal alignment and wrist function after anterior wedge-shaped grafting [36,38,49,51,52]. The rates of union ranged from 94% to 100%. Nakamura [51], Tsuyuguchi [52], Takami [37], and Chen [38] specically noted improvement in carpal instability and humpback deformity. In all studies, functional results and overall patient satisfaction were good. Early results of the coring technique have been reported by Leung and colleagues [42] and Maruthainar and colleagues [41]. In the Leung study [42], all 11 patients with symptomatic scaphoid nonunion went on to heal after surgery. At the average follow-up of 30 months, all patients were satised, and 10 of 11 had resolution of pain. Four of the patients had a loss of 20% to 30% of wrist motion. The single complication was a case of screw impingement requiring reoperation and screw removal. Leung and colleagues [42] also found that if the bony gap is more than 9 mm after reduction, trephine graft may exceed the width of the scaphoid. In this scenario, a wedge graft may be needed. Maruthainar and colleagues [41] documented a union rate of 80% after their similar procedure. At a mean follow-up of 8.2 months, four patients had radiocarpal arthritis. Neither the Leung study nor the Maruthainar study specically compared preoperative and postoperative scaphoid alignment or progression of arthrosis. Long-term results are needed to compare this technique further with that described by Eggli and colleagues [50]. Multiple factors have been identied that predict poor outcome despite custom-shaped bone grafting 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, the presence of AVN of the proximal fragment, and a history of prior surgery for nonunion. In studies reported by Nakamura [51], Schuind [53], Inoue [54], and Shah [28], time between injury and treatment of nonunion and AVN of the proximal fragment were recognized as poor prognostic factors. Daly and associates [36] and Shah and Jones [28] also identied a history of previous surgery in their patients with worse outcomes. In Eggli and colleagues [50] 5.7-year follow-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 revascularization procedure, and the other required a salvage SLAC wrist procedure. For these reasons, Fernandez and others suggested that patients with preoperative signs of AVN or failed prior surgery for nonunion should be treated with vascularized bone grafts. In cases of prolonged nonunion or AVN, results with vascularized grafts have shown higher rates of healing compared with the Russe and wedge grafting techniques. Zaidemberg and associates [45] had a 100% union rate in 11 cases of long-standing nonunion of the scaphoid
115
using the 1,2 ICSRA. Steinmann and colleagues [46,55] also had a 100% union rate in 14 patients with established nonunions. These authors have not reported results for restoration of scaphoid anatomy at the time of vascularized graft insertion. As with the typical scaphoid nonunions, success in these dicult cases also may depend on correction of scaphoid deformity. Patients with malunion may continue to have pain and functional limitations. For these cases, osteotomy and wedge grafting have been reported [13,15,40,56]. In the 18 patients found in the English literature, all osteotomies healed with improvement in patient function and carpal alignment. 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 on scaphoid malalignment are not yet convincing enough that the average hand surgeon is comfortable performing an osteotomy on a well-healed scaphoid fracture. References
[1] Szabo RM, Manske D. Displaced fractures of the scaphoid. Clin Orthop 1988;230:308. [2] Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop 1980;149:907. [3] Monsivais JJ, Nitz PA, Scully TJ. The role of carpal instability in scaphoid nonunion: casual or causal? J Hand Surg Br 1986;11:2016. [4] Dabezies EJ. Injuries to the carpus: fractures of the scaphoid. Orthopedics 1982;5:1510. [5] Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non-union. J Bone Joint Surg Am 1984;66:5049. [6] Ruby LK, Leslie BM. Wrist arthritis associated with scaphoid nonunion. Hand Clin 1987;3:52939. [7] Vender MI, Watson HK, Wiener BD, Black DM. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg Am 1987;12:5149. [8] Osterman AL, Mikulics M. Scaphoid nonunion. Hand Clin 1988;4:43755. [9] Berdia S, Wolfe SW. Effects of scaphoid fractures on the biomechanics of the wrist. Hand Clin 2001;17:53340. [10] Burgess RC. The effect of a simulated scaphoid malunion on wrist motion. J Hand Surg Am 1987;12(5 Pt 1):7746. [11] Smith DK, Cooney WP 3rd, An KN, et al. The effects of simulated unstable scaphoid fractures on carpal motion. J Hand Surg Am 1989;14(2 Pt 1):28391. [12] Fisk GR. Carpal instability and the fractured scaphoid. Ann R Coll Surg Engl 1970;46:6376. [13] Fernandez DL, Martin CJ, Gonzalez del Pino J. Scaphoid malunion: the signicance of rotational malalignment. J Hand Surg Br 1998;23:7715. [14] Lynch NM, Linscheid RL. Corrective osteotomy for scaphoid malunion: technique and long-term follow-up evaluation. J Hand Surg Am 1997;22:3543. [15] Nakamura P, Imaeda T, Miura T. Scaphoid malunion. J Bone Joint Surg Br 1991;73:1347. [16] Linscheid RL, Dobyns JH, Beabout JW, Bryan RS. Traumatic instability of the wrist: diagnosis, classication, and pathomechanics. J Bone Joint Surg Am 1972;54:161232. [17] Belsole RJ, Hilbelink DR, Llewellyn JA, et al. Computed analyses of the pathomechanics of scaphoid waist nonunions. J Hand Surg Am 1991;16:899906. [18] Nakamura R, Imaeda T, Horii E, et al. Analysis of scaphoid fracture displacement by three-dimensional computed tomography. J Hand Surg Am 1991;16:48592. [19] Moritomo H, Viegas SF, Elder KW, et al. Scaphoid nonunions: a 3-dimensional analysis of patterns of deformity. J Hand Surg Am 2000;25:5208. [20] Amadio PC, Berquist TH, Smith DK, et al. Scaphoid malunion. J Hand Surg Am 1989;14:67987. [21] 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;23:7681. [22] Kerluke L, McCabe SJ. Nonunion of the scaphoid: a critical analysis of recent natural history studies. J Hand Surg Am 1993;18:13. [23] Russe O. Fracture of the carpal navicular: diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg Am 1960;42:75968. [24] Jiranek WA, Ruby LK, Millender LB, et al. Long-term results after Russe bone-grafting: the effect of malunion of the scaphoid. J Bone Joint Surg Am 1992;74:121728. [25] Stark A, Brostrom LA, Svartengren G. Scaphoid nonunion treated with the matti-Russe technique: long-term results. Clin Orthop 1987;214:17580. [26] Botte MJ, Mortensen WW, Gelberman RH, et al. Internal vascularity of the scaphoid in cadavers after insertion of the Herbert screw. J Hand Surg Am 1988;13:21620. [27] Green DP. The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion. J Hand Surg Am 1985;10:597605. [28] Shah J, Jones WA. Factors affecting the outcome in 50 cases of scaphoid nonunion treated with Herbert screw xation. J Hand Surg Br 1998;23:6805. [29] Perlik PC, Guilford WB. Magnetic resonance imaging to assess vascularity of scaphoid nonunions. J Hand Surg Am 1991;16:47984.
116
[30] Gunal I, Ozelik A, Gokturk E, et al. Correlation of magnetic resonance imaging and intraoperative punctate bleeding to assess the vascularity of scaphoid nonunion. Arch Orthop Trauma Surg 1999;119:2857. [31] Trumble T, Nyland W. Scaphoid nonunions: pitfalls and pearls. Hand Clin 2001;17:61124. [32] Fisk GR. An overview of injuries of the wrist. Clin Orthop 1980;149:13744. [33] Fernandez DL. A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg Am 1984;9:7337. [34] Fernandez DL. Anterior bone grafting and conventional lag screw xation to treat scaphoid nonunions. J Hand Surg Am 1990;15:1407. [35] Fernandez DL, Eggli S. Scaphoid nonunion and malunion: how to correct deformity. Hand Clin 2001;17:63146. [36] Daly K, Gill P, Magnussen PA, Simonis RB. Established nonunion of the scaphoid treated by volar wedge grafting and Herbert screw xation. J Bone Joint Surg Br 1996;78:5304. [37] Takami H, Takahashi S, Ando M. Scaphoid nonunion treated by open reduction, anterior inlay bone grafting, and Kirschner-wire xation. Arch Orthop Trauma Surg 2000;120:1348. [38] Chen CY, Chao EK, Lee SS, Ueng SW. Osteosynthesis of carpal scaphoid nonunion with interpositional bone graft and Kirschner wires: a 3- to 6-year follow-up. J Trauma 1999;47:55863. [39] Cooney WP, Linscheid RL, Dobyns JH, Wood MB. Scaphoid nonunion: role of anterior interpositional bone grafts. J Hand Surg Am 1988;13:63550. [40] Herbert TJ. The fractured scaphoid. St. Louis: Quality Medical Publishing; 1990. [41] Maruthainar N, Rasquinha VJ, Gallagher P. The treatment of scaphoid nonunion: a review of a novel technique using precision bone grafting compared with Herbert screw xation and bone graft. J Hand Surg Br 2000;25:42730. [42] Leung YF, Ip SP, Cheuk C, et al. Trephine bone grafting technique for the treatment of scaphoid nonunion. J Hand Surg Am 2001;26:893900. [43] Watson HK, Pitts EC, Ashmead DT, et al. Dorsal approach to scaphoid nonunion. J Hand Surg Am 1993;18: 35965. [44] Nagle DJ. Scaphoid nonunion: treatment with cancellous bone graft and Kirschner-wire xation. Hand Clin 2001;17:6259. [45] Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg Am 1991;16:4748. [46] Steinmann SP, Bishop AT. A vascularized bone graft for repair of scaphoid nonunion. Hand Clin 2001;17:64753. [47] Green DP. Operative hand surgery. 4th edition. New York: Churchill Livingstone; 1999. [48] Dias JJ, Taylor M, Thompson J, et al. Radiographic signs of union of scaphoid fractures: an analysis of interobserver agreement and reproducibility. J Bone Joint Surg Br 1988;70:299301. [49] Filan SL, Herbert TJ. Herbert screw xation of scaphoid fractures. J Bone Joint Surg Br 1996;78:51929. [50] Eggli S, Fernandez DL, Beck T. Unstable scaphoid fracture nonunion: a medium-term study of anterior wedge grafting procedures. J Hand Surg Br 2002;27:3641. [51] Nakamura R, Horii E, Watanabe K, et al. Scaphoid non-union: Factors affecting the functional outcome of open reduction and wedge grafting with Herbert screw xation. J Hand Surg Br 1993;18:21924. [52] Tsuyuguchi Y, Murase T, Hidaka N, et al. Anterior wedge-shaped bone graft for old scaphoid fractures or nonunions: an analysis of relevant carpal alignment. J Hand Surg Br 1995;20:194200. [53] Schuind F, Haentjens P, Van Innis F, et al. Prognostic factors in the treatment of carpal scaphoid nonunions. J Hand Surg Am 1999;24:76176. [54] Inoue G, Shionoya K, Kuwahata Y. Herbert screw xation for scaphoid nonunions: an analysis of factors inuencing outcome. Clin Orthop 1997;343:99106. [55] Steinmann SP, Bishop AT, Berger RA. Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difcult scaphoid nonunion. J Hand Surg Am 2002;27:391401. [56] Birchard D, Pichora D. Experimental corrective scaphoid osteotomy for scaphoid malunion with abnormal wrist mechanics. J Hand Surg Am 1990;15:8638.
Fixation of scaphoid nonunion with Kirschner wires and cancellous bone graft
Andrew P. Gutow, MDa, Milan V. Stevanovic, MD, PhDb,*
Department of Orthopaedic Surgery, University of Michigan Medical School, Taubman Center, 2912 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA b Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 2025 Zonal Avenue, GNH 3900 Los Angeles, CA 90089-9312, USA
a
In the treatment of established carpal scaphoid nonunions, the most successful and reliable procedure for obtaining bone healing is an appropriately performed internal xation 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 rst half of the twentieth century [2]. For the most part, in the early twentieth century, surgeons accepted MacLennans [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 of simple excision. By the 1930s, Matti [3] in the German literature and Murray [4] in the English literature published reports of successful operative treatments of nonunion with cancellous and corticocancellous grafting without internal xation. During the middle third of the twentieth century, Russes [5] technique of xation by way of a volar approach with a structural cancellous bone graft from the iliac crest became commonly accepted. Other workers suggested the addition rst of wires and then screws for internal xation [1,6]. Indications The authors believe that all scaphoid nonunions will go on to develop radiographically apparent 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 outcome in a series of 55 patients. A review of asymptomatic scaphoid nonunions by Lindstrom and 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 develop 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 benets of surgical intervention. Previous failed internal xation and bone grafting is not a contraindication if severe arthritis has not developed. The authors do not perform internal xation and bone grafting in patients with severe radiocarpal arthritis; scaphoid excision or some other salvage procedure is preferred in these cases. Internal xation 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
* Corresponding author. E-mail address: stevanov@hsc.usc.edu (M.V. Stevanovic). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(02)00016-X
130
A.P. Gutow, M.V. Stevanovic / Atlas Hand Clin 8 (2003) 129138
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 alcohol abuse, psychiatric disease, or personality disorders that would prevent them from complying with the postoperative course of immobilization are not candidates for this procedure. For patients 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 approach using the 1,2-intercompartment supraretinacular artery graft as rst described by Zaidemberg [10,11]. Preoperative evaluation A standard physical examination, including range of motion, sensory testing, vascular status, and grip strength, should be performed. Standard radiographs of the aected 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 important to restore fully the length and alignment of the scaphoid at the time of surgery. There is a higher 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 modication of the technique of cancellous bone grafting and Kirschner wire xation 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 uoroscopy. An upper arm tourniquet is used. Approach A volar approach to the wrist is used. A straight incision is made in the distal forearm between the distal portion of the exor 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 exor carpi radialis tendon is retracted ulnarly and the radial artery radially. The wrist capsule is
131
Fig. 1. (AC) Three views of established nonunion without evidence of arthritis. On lateral view, some collapse into apex dorsal angulation (humpback deformity) is visible.
entered through a longitudinal incision from the volar lip of the radius to the proximal tubercle of the trapezium. The capsule carefully is reected sharply o of the scaphoid with a knife. The capsule needs to be preserved because it contains the radioscaphoid capitate ligament and is repaired 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 important parts of the procedure, and the authors usually spend 15 minutes on each of these steps. The wrist is dorsiexed over a bump to allow for visualization of the proximal and distal scaphoid fragments and the radial scaphoid articulation. A freer elevator is placed in the radioscaphoid 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 initial 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 exion of the distal fragment and dorsal exion of the proximal fragment. A window is made in the volar scaphoid proximal and distal to the fracture to allow for removal of brous tissue and dead bone. The authors use sharp small curets to clean out carefully
132
Fig. 2. Skin incision lies between the exor carpi radialis tendon and the radial artery.
all of the brous 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 highspeed 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 aect 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 exing the wrist, then temporarily transxing the lunate to the radius with a dorsal percutaneous Kirschner wire. Correcting the position of the lunate usually helps realign the proximal pole of the scaphoid from its dorsiexed position. The internal xation 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.
133
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.
Two 0.045-inch diameter Kirschner wires are used to internally x the scaphoid. These wires are inserted 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. 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.
134
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.
The wires should be aimed the central portion of the proximal pole. The wires are left protruding from the skin at the conclusion of the procedure (Fig. 6). After placement of the wires, uoroscopy or permanent radiographs should conrm 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 xation, a peg cancellous graft can be fashioned in the manner of Russe [5] and placed into the nonunion space with transxion 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 osteoprogenitor cells in iliac crest bone compared with bone from other sites. To minimize donor site morbidity, harvesting is with a trephine-type device (Bone Graft 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 iliac crest is split with electrocautery, and the trephine-type device is used to harvest corings of cancellous 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 lling in a tooth. It is important to morcellize the graft into small 1- to 2-mm
135
Fig. 6. The nonunion site is xed 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.
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 30 nonabsorbable polyester suture (Mersilene; 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 40 absorbable suture (PDS; Ethicon, Inc, Somerville, NJ), then reinforced with buttery-type bandages (Steristrip; 3M, Inc, St. Paul, MN). The Kirschner wires are cut short but left out of the skin and dressed with a bacteriostatic-containing gauze (Zeroform 3% bismuth tribromophenate; Kendall Inc, Manseld, 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 further 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 interphalangeal 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 rst 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 rst 24 hours postoperatively to decrease
136
Fig. 7. Length is restored, two Kirschner wires are placed, and cancellous bone graft is packed into place.
pain and swelling. The patient may remove the donor site dressing, leaving the Steristrips in place, and get the incision wet in the shower on the fth postoperative day. Postoperative management 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 6 weeks after surgery, the cast can be changed to a short arm thumb spica 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 complete ve-view scaphoid series including a maximally ulnarly deviated posteroanterior radiograph. 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 for at least 10 weeks, keeping them longer if they are still well xed, 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 patients regain motion. Patients are rechecked at 2 months after cast removal with nal radiographs and a check of motion. Patients generally need 4 to 6 months after cast removal to regain full motion.
137
Fig. 8. After appropriate immobilization, union occurs with maintenance of length and alignment.
138
References
[1] Stark HH, Rickard TA, Zemel NP, Ashworth CR. Treatment of ununited fractures of the scaphoid by iliac bone grafts and Kirschner-wire xation. J Bone Joint Surg Am 1988;70:98291. [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;663:144253. [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;42:75968. [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;47:24966. [7] Mack GR, Bosse MJ, Gelberman RH, et al. The natural history of scaphoid nonunion. J Bone and Joint Surg Am 1984;66:5049. [8] Ruby LK, Stinson K, Belsky MR. The natural history of scaphoid nonunion: a review of 55 cases. J Bone Joint Surg Am 1985;67:42832. [9] Lindstrom G, Nystrom A. Natural history of scaphoid non-union, with special references to asymptomatic cases. J Hand Surg 1992;17:687700. [10] Steinman SP, Bishop AT. A vascularized bone graft for repair of scaphoid nonunion. Hand Clin 2001;17:64753. [11] Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg Am 1991;16:4748. [12] Jiranek WA, Ruby LK, Millender LB, et al. Long-term results after Russe bone-grafting: the eect of malunion of the scaphoid. J Bone Joint Surg Am 1992;74:121728. [13] Sanders WE. Evaluation of the humpback scaphoid by computed tomography in the longitudinal axial plane of the scaphoid. J Hand Surg Am 1988;13:1827. [14] Trumble TE. Avascular necrosis after scaphoid fracture: a correlation of magnetic resonance imaging and histology. J Hand Surg Am 1990;15:55764. [15] Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am 1980;5:50813. [16] Taleisnik J, Kelly PJ. The extraosseous and intraosseous blood supply of the scaphoid bone. J Bone Joint Surg Am 1966;48:112537. [17] Garcia-Elias M, Vall A, Salo JM, Lluch AL. Carpal alignment after dierent surgical approaches to the scaphoid: a comparative study. J Hand Surg Am 1988;13:60412.
Fixation of scaphoid nonunion with Kirschner wires and cancellous bone graft
Andrew P. Gutow, MDa, Milan V. Stevanovic, MD, PhDb,*
Department of Orthopaedic Surgery, University of Michigan Medical School, Taubman Center, 2912 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA b Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 2025 Zonal Avenue, GNH 3900 Los Angeles, CA 90089-9312, USA
a
In the treatment of established carpal scaphoid nonunions, the most successful and reliable procedure for obtaining bone healing is an appropriately performed internal xation 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 rst half of the twentieth century [2]. For the most part, in the early twentieth century, surgeons accepted MacLennans [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 of simple excision. By the 1930s, Matti [3] in the German literature and Murray [4] in the English literature published reports of successful operative treatments of nonunion with cancellous and corticocancellous grafting without internal xation. During the middle third of the twentieth century, Russes [5] technique of xation by way of a volar approach with a structural cancellous bone graft from the iliac crest became commonly accepted. Other workers suggested the addition rst of wires and then screws for internal xation [1,6]. Indications The authors believe that all scaphoid nonunions will go on to develop radiographically apparent 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 outcome in a series of 55 patients. A review of asymptomatic scaphoid nonunions by Lindstrom and 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 develop 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 benets of surgical intervention. Previous failed internal xation and bone grafting is not a contraindication if severe arthritis has not developed. The authors do not perform internal xation and bone grafting in patients with severe radiocarpal arthritis; scaphoid excision or some other salvage procedure is preferred in these cases. Internal xation 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
* Corresponding author. E-mail address: stevanov@hsc.usc.edu (M.V. Stevanovic). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(02)00016-X
130
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 alcohol abuse, psychiatric disease, or personality disorders that would prevent them from complying with the postoperative course of immobilization are not candidates for this procedure. For patients 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 approach using the 1,2-intercompartment supraretinacular artery graft as rst described by Zaidemberg [10,11]. Preoperative evaluation A standard physical examination, including range of motion, sensory testing, vascular status, and grip strength, should be performed. Standard radiographs of the aected 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 important to restore fully the length and alignment of the scaphoid at the time of surgery. There is a higher 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 modication of the technique of cancellous bone grafting and Kirschner wire xation 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 uoroscopy. An upper arm tourniquet is used. Approach A volar approach to the wrist is used. A straight incision is made in the distal forearm between the distal portion of the exor 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 exor carpi radialis tendon is retracted ulnarly and the radial artery radially. The wrist capsule is
131
Fig. 1. (AC) Three views of established nonunion without evidence of arthritis. On lateral view, some collapse into apex dorsal angulation (humpback deformity) is visible.
entered through a longitudinal incision from the volar lip of the radius to the proximal tubercle of the trapezium. The capsule carefully is reected sharply o of the scaphoid with a knife. The capsule needs to be preserved because it contains the radioscaphoid capitate ligament and is repaired 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 important parts of the procedure, and the authors usually spend 15 minutes on each of these steps. The wrist is dorsiexed over a bump to allow for visualization of the proximal and distal scaphoid fragments and the radial scaphoid articulation. A freer elevator is placed in the radioscaphoid 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 initial 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 exion of the distal fragment and dorsal exion of the proximal fragment. A window is made in the volar scaphoid proximal and distal to the fracture to allow for removal of brous tissue and dead bone. The authors use sharp small curets to clean out carefully
132
Fig. 2. Skin incision lies between the exor carpi radialis tendon and the radial artery.
all of the brous 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 highspeed 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 aect 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 exing the wrist, then temporarily transxing the lunate to the radius with a dorsal percutaneous Kirschner wire. Correcting the position of the lunate usually helps realign the proximal pole of the scaphoid from its dorsiexed position. The internal xation 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.
133
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.
Two 0.045-inch diameter Kirschner wires are used to internally x the scaphoid. These wires are inserted 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. 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.
134
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.
The wires should be aimed the central portion of the proximal pole. The wires are left protruding from the skin at the conclusion of the procedure (Fig. 6). After placement of the wires, uoroscopy or permanent radiographs should conrm 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 xation, a peg cancellous graft can be fashioned in the manner of Russe [5] and placed into the nonunion space with transxion 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 osteoprogenitor cells in iliac crest bone compared with bone from other sites. To minimize donor site morbidity, harvesting is with a trephine-type device (Bone Graft 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 iliac crest is split with electrocautery, and the trephine-type device is used to harvest corings of cancellous 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 lling in a tooth. It is important to morcellize the graft into small 1- to 2-mm
135
Fig. 6. The nonunion site is xed 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.
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 30 nonabsorbable polyester suture (Mersilene; 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 40 absorbable suture (PDS; Ethicon, Inc, Somerville, NJ), then reinforced with buttery-type bandages (Steristrip; 3M, Inc, St. Paul, MN). The Kirschner wires are cut short but left out of the skin and dressed with a bacteriostatic-containing gauze (Zeroform 3% bismuth tribromophenate; Kendall Inc, Manseld, 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 further 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 interphalangeal 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 rst 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 rst 24 hours postoperatively to decrease
136
Fig. 7. Length is restored, two Kirschner wires are placed, and cancellous bone graft is packed into place.
pain and swelling. The patient may remove the donor site dressing, leaving the Steristrips in place, and get the incision wet in the shower on the fth postoperative day. Postoperative management 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 6 weeks after surgery, the cast can be changed to a short arm thumb spica 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 complete ve-view scaphoid series including a maximally ulnarly deviated posteroanterior radiograph. 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 for at least 10 weeks, keeping them longer if they are still well xed, 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 patients regain motion. Patients are rechecked at 2 months after cast removal with nal radiographs and a check of motion. Patients generally need 4 to 6 months after cast removal to regain full motion.
137
Fig. 8. After appropriate immobilization, union occurs with maintenance of length and alignment.
138
References
[1] Stark HH, Rickard TA, Zemel NP, Ashworth CR. Treatment of ununited fractures of the scaphoid by iliac bone grafts and Kirschner-wire xation. J Bone Joint Surg Am 1988;70:98291. [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;663:144253. [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;42:75968. [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;47:24966. [7] Mack GR, Bosse MJ, Gelberman RH, et al. The natural history of scaphoid nonunion. J Bone and Joint Surg Am 1984;66:5049. [8] Ruby LK, Stinson K, Belsky MR. The natural history of scaphoid nonunion: a review of 55 cases. J Bone Joint Surg Am 1985;67:42832. [9] Lindstrom G, Nystrom A. Natural history of scaphoid non-union, with special references to asymptomatic cases. J Hand Surg 1992;17:687700. [10] Steinman SP, Bishop AT. A vascularized bone graft for repair of scaphoid nonunion. Hand Clin 2001;17:64753. [11] Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg Am 1991;16:4748. [12] Jiranek WA, Ruby LK, Millender LB, et al. Long-term results after Russe bone-grafting: the eect of malunion of the scaphoid. J Bone Joint Surg Am 1992;74:121728. [13] Sanders WE. Evaluation of the humpback scaphoid by computed tomography in the longitudinal axial plane of the scaphoid. J Hand Surg Am 1988;13:1827. [14] Trumble TE. Avascular necrosis after scaphoid fracture: a correlation of magnetic resonance imaging and histology. J Hand Surg Am 1990;15:55764. [15] Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am 1980;5:50813. [16] Taleisnik J, Kelly PJ. The extraosseous and intraosseous blood supply of the scaphoid bone. J Bone Joint Surg Am 1966;48:112537. [17] Garcia-Elias M, Vall A, Salo JM, Lluch AL. Carpal alignment after dierent surgical approaches to the scaphoid: a comparative study. J Hand Surg Am 1988;13:60412.
Intercarpal fusion with the Spider plate for 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]. Approximately 345,000 scaphoid fractures occur annually in the United States [3]. Typically this fracture occurs following a forced dorsiexion 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 to many factors, including delayed diagnosis, lack of initial treatment, displacement of fracture fragments, location of fracture, improper immobilization, and wrist instability [4,611]. The scaphoid is thought to function as a stabilizer of the midcarpal joint, a bridge between the distal and proximal carpal rows [12]. In the uninjured wrist, the scaphoid is held in a exed position because it is compressed between the radius and the trapezium. The triquetrum has a tendency toward an extended position. The lunate bone through its ligamentous attachments to the scaphoid and the triquetrum acts as balance between these opposing force tendencies. A scaphoid fracture disrupts the scaphoid inuence on the force homeostasis. This eect on carpal stability was termed the concertina effect by Fisk [7] in 1970. Fracture of the scaphoid causes the lunate to assume a position under the inuence of the triquetral bony/ligamentous complex. The lunate and the proximal scaphoid still bound by the scapholunate ligament assume a more extended position, termed dorsal intercalated segmental instability (DISI) [13]. The distal scaphoid fragment, now free from the counteractive forces of the more ulnar carpal stabilizing structures, rotates in an opposite fashion to a more exed position [14]. This position causes a foreshortening of the scaphoid bone. As the scaphoid collapses, the capitate bone comes to bear an increased load and responds by displacing itself into the gap between the scaphoid and the lunate. Altered carpal kinematics secondary to a change in scaphoid shape, volume, and position 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 of scaphoid nonunion leads to a progressive degenerative arthritis of the wrist. Some studies report a 100% incidence of degenerative wrist arthritis after scaphoid nonunion [16]. The pattern of degenerative changes found after scaphoid nonunion are similar to those of a scapholunate advanced collapse deformity and have been termed scaphoid nonunion advanced collapse (SNAC). Progression and severity of the degenerative arthritis of the wrist associated with scaphoid nonunion advanced collapse vary and depend on many factors. A stable nondisplaced scaphoid fracture progresses more slowly than an unstable displaced scaphoid nonunion. It has been shown 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: apcweiss@brown.edu (A.-P.C. Weiss). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(03)00005-0
140
J.L.M. Manuel, A.-P.C. Weiss / Atlas Hand Clin 8 (2003) 139148
During the second decade, degenerative changes at the radioscaphoid joint become evident. In the 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 (radial styloid/scaphoid) joint is involved. Stage II SNAC consists of radial styloid/scaphoid and scaphocapitate degenerative changes. This degeneration leads to signicant carpal collapse. Stage III SNAC consists of radial styloid/scaphoid, scaphocapitate, and capitolunate degenerative changes. Generally the articulations between the proximal scaphoid/radius and the lunate/radius are not involved.
Treatment options Because a scaphoid nonunion has a high probability (near 100%) of triggering progressive degenerative arthritis of the wrist, all attempts should be made to correct the nonunion before the onset of this debilitating condition. Open reduction and internal xation with or without bone grafting always should be attempted before any salvage procedure. In the past, treatment for advanced degenerative disease of the wrist secondary to scaphoid nonunion consisted of total wrist arthrodesis. Although this procedure is eective in relieving the 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. Current surgical 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 the successful fusion of the scaphoid, lunate, capitate, and hamate. Until the 1960s, however, only a few reports of limited wrist arthrodesis can be found in the literature. The past 15 to 20 years have seen a great interest in the use of these motion-preserving procedures for degenerative arthritis of the wrist. Limited wrist arthrodesis of the capitate-hamate-lunate-triquetrum is called a four-corner arthrodesis. In the appropriate patient, the four-corner fusion with concomitant scaphoid excision allows motion to occur through the preserved radiolunate and ulnocarpal joints. This procedure is based on the principle that a fusion of the capitolunate joint allows the load bearing of the wrist to be borne by the preserved radiolunate articulation. By adding the hamate and triquetrum to this fusion mass, the rate of union is believed to be greater, without reducing the amount of preserved range of motion [19]. Originally a Silastic scaphoid prosthesis was implanted after scaphoid excision; however, this practice has been abandoned secondary to a tendency for implant malrotation and particulate synovitis [20].
Indications When deciding on treatment for a wrist with SNAC, many factors should be taken into consideration. The age of the patient and the activity and occupation of the patient are important in guiding surgical treatment options. A stage I SNAC wrist generally is treated best with a radial styloid excision with or without bone grafting of the scaphoid nonunion. There are several treatment options for a stage II SNAC degenerative wrist, including proximal row carpectomy, intercarpal fusion and radial styloidectomy, and intercarpal fusion and scaphoid excision. A stage III SNAC wrist may be treated 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 SNAC degenerative wrist who have failed open reduction and internal xation with or without bone grafting 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 results in a disruption of the concentric congruity of the radiolunate joint and a hastening of degeneration of this pivotal joint. Under these circumstances and in patients who have a pancarpal degenerative arthritis, a total wrist arthrodesis is indicated.
141
Preoperative radiographs should be evaluated for the extent of arthritis. Radiographs also always should be evaluated for the amount of DISI deformity, which needs to be corrected during the procedure before fusion. Typically a four-corner fusion for scaphoid nonunion entails excision of the scaphoid with xation 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 been used for intercarpal fusions (Fig. 1). The technique for implantation of this device in a fourcorner fusion is described next, and the benets of its use are discussed. Surgical technique The four-corner fusion technique, as described by Watson and Ryu [21], consists of a dorsal transverse incision distal to the radial styloid for excision of the radial styloid. Branches of the supercial radial nerve should be identied and protected throughout the procedure. The extensor pollicis longus and extensor carpi radialis longus and brevis also should be identied and protected. While protecting the volar ligaments, the scaphoid is removed. A transverse incision in the capsule is made at the level of the capitolunate joint. Using a rongeur, the cartilage is removed entirely from the adjacent surfaces of the lunate, capitate, hamate, and triquetrum. 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 and lunate, and triquetrum and hamate. Remaining bone graft is packed into place [21]. Alternatively the Spider plate is a no-prole plate, recessed below the surface of the carpal bones, with a conical shape that is ideal for use in a four-corner fusion. The placement of this plate uses a 7-cm incision centered over the dorsal wrist. As described in Watsons technique, the dorsal sensory branches of the radial nerve are protected. Next the extensor pollicis longus is released from its dorsal compartment and transposed radially. The extensor carpi radialis longus and brevis are elevated o the dorsal capsule and retracted radially. The contents of the fourth dorsal compartment (extensor digitorum communis and extensor indicis proprius) are elevated and retracted ulnarly. The dorsal capsule is incised in a T-shaped fashion. Alternatively a 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 drill is passed through the longitudinal axis of the scaphoid. A 3.5-mm tap is passed through the drill hole to allow traction in a joystick fashion, and the soft tissue attachments are released with a scalpel. 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 specically designed for four-corner fusions, allowing circumferential compression without plate/joint impingement. (Copyright Kinetikos Medical; used with permission.)
142
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;1:93111, 2001; with permission.)
Next, exposure of the lunate-capitate-hamate-triquetrum is performed. Any instability, typically DISI, is reduced temporarily with Kirschner wires. These Kirschner wires should be kept as volar as possible. Joysticks may assist in correction of the DISI deformity. An alternative method for reduction of the DISI deformity has been described by Linscheid and Rettig [23]. This method employs uoroscopy. An initial lateral view of the wrist is obtained. Reduction of the DISI deformity is accomplished by exion and ulnar deviation until neutral alignment of the radius and lunate is seen on the lateral wrist uoroscopy. A 0.0625-inch Kirschner wire is placed from the dorsal distal radius into the lunate to hold the reduction [23]. Fusion of the lunate in slight exion relative to the capitate, as described by Cohen and Kozin
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.
143
Fig. 4. The Spider rasp is used to fashion the circular recess which accepts the plate. (Copyright A-PC Weiss, 2000; used with permission.)
[24], may provide greater wrist extension. When any carpal instability is reduced, an additional Kirschner wire is placed from the capitate to the triquetrum, temporarily stabilizing the bones to be fused. An appropriately sized rongeur is used between the bones to be fused to remove all cartilage down to good cancellous bone. The Spider rasp is centered over the four-corner junction and used to rasp down to be ush with the dorsal aspect of the carpus (Fig. 4); this allows the plate to lie in a recessed fashion on the carpal bone surface. Autogenous bone graft, either from Listers tubercle or from the excised scaphoid, subsequently is packed into the interstices between the four bones (Fig. 5). Next, the Spider plate is aligned such that two screws may be placed into each of the four carpal bones. While the plate is held aligned, a 1.5-mm drill bit is used to drill one screw hole in each bone (Fig. 6). Sequentially, four 2.4-mm self-tapping cancellous screws are used to secure the plate. The remaining holes are drilled, and the screws are securely placed. Radial compression of the four bones is achieved by tightening of the screws (Fig. 7). All provisional Kirschner wires are removed. The wrist is taken through a range of motion to ensure stability of the fusion and to conrm that no dorsal impingement of the plate on the distal radius exists. Any remaining bone graft is packed into the center of the plate and arthrodesis site. Intraoperative radiographs are obtained to conrm screw lengths and placement (Fig. 8). The wound is irrigated copiously, then the capsule and retinaculum are repaired using 40 absorbable sutures. When skin is closed, a short arm splint is placed to allow for early active range of motion of the ngers and the elbow (unpublished data). Postoperative care and rehabilitation Postoperative care after the four-corner fusion performed using Watsons Kirschner wire technique involves a long arm posterior splint for 1 week followed by a long arm cast to include the thumb and index and middle ngers in an intrinsic plus position. After 4 weeks, a short arm thumb spica cast is placed for an additional 2 weeks. At 6 weeks postoperatively, radiographs are obtained. If satisfactory healing has occurred, the pins are removed, and active range of motion is begun [21].
144
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.)
The Spider plate four-corner fusion allows for earlier range of motion and less restriction throughout the postoperative period. Initially, as mentioned earlier, the patient is placed into a short arm splint. Sutures are removed at 1 week. At that time, either a removable splint or a short arm cast is placed to allow for early range of motion exercises; this is maintained for 3 to 4
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.)
145
Fig. 7. Excellent stability and intercarpal compression are noted after all the screws are fully tightened. (Copyright A-PC Weiss, 2000; used with permission.)
weeks. Subsequent strenuous activity is delayed until radiographic evidence of appropriate fusion (unpublished data).
Results and discussion In cadaver specimens, Ruby and coworkers [25] found that the mean value of total wrist motion was 112 . Similarly, Linscheid [26] found this value to be 150 . In 1984, Brumeld and Champoux [27] found that the functional range of motion of the wrist required to perform the activities of daily living was 10 of exion and 35 of extension. Palmer and associates [28] found these values to be 5 of exion and 30 of extension. Gellman and colleagues [29] studied the eect of limited intercarpal arthrodesis in an in vitro analysis. They found that 63% to 70% of wrist exion occurs at the radiocarpal joint and 30% to 36% occurs at the midcarpal joint. They also concluded that slightly more extension occurs at the radiocarpal joint than the midcarpal joint. These results predict a 64% exion-extension arc after four-corner arthodesis [29,30]. Ashmead and colleagues [20] reported a 44-month follow-up on 100 patients who underwent four-corner arthrodesis. Extension averaged 32 , and exion averaged 42 , which was 53% of the opposite wrist. Grip strength was 80% of the opposite side. Of 85 patients, 78 (91%) were satised and would choose to have the operation again. The initial nonunion rate was 3%, all of which progressed to union after a second procedure. Of 76 patients, 61 returned to their original jobs. Cohen and Kozin [24] also studied the eects of four-corner arthrodesis on wrist range of motion. They found that the average extension was 49 , and exion was 31 , a 58% exionextension arc compared with the opposite wrist. This study also found a greater amount of preserved radioulnar deviation compared with a proximal row carpectomy. Grip strength was found to be 79% of the opposite side. A review of the literature of intercarpal arthrodeses between 1924 and 1994 done by Siegel and 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 the literature results between 1946 and 1993. They found that the rate of nonunion for four-corner arthrodesis ranged from 9% (Krakauer) to 50% (McAulie), with an average of 8.4%.
146
Fig. 8. Posteroanterior (A) and lateral (B) radiographs show excellent placement of the Spider plate. (Copyright A-PC Weiss, 2000; used with permission.)
147
One of the most common complications after four-corner fusion is dorsal radiocarpal impingement in wrist extension. This problem is secondary to inadequate reduction of the capitolunate joint [33]. Ashmead and colleagues [20] found dorsal radiocarpal impingement to occur in 13% of their patients. These patients reportedly experienced pain relief after a limited resection 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%, supercial infection occurred in 3%, and reex sympathetic dystrophy occurred in 3%. The nonunion rate was found to be 2%. A failure rate of 2% required conversion to total wrist arthrodesis. This study found the most common complication, dorsal radiocarpal impingement, to occur in 4.4% of patients [34]. The rst reported series of patients undergoing a four-corner fusion using the Spider plate showed a 100% fusion rate [35].
Summary SNAC represents a spectrum of degenerative arthritis of the wrist. Various treatment options exist for diminishing pain and preventing progression. Intercarpal fusion of the wrist oers pain relief, preservation of carpal height, and maintenance of some wrist motion. The Spider plate for four-corner fusion is an eective tool, which allows for early mobilization. Studies have suggested that the Spider plate provides greater intercarpal stability over Kirschner wire xation [36].
References
[1] Brondum V, Larsen CF, Skov O. Fracture of the carpal scaphoid: frequency and distribution in a well dened population. Eur J Radiol 1992;15:11822. [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;4:43755. [4] Leslie IJ, Dickson RA. The fractured carpal scaphoid: natural history and factors inuencing outcome. J Bone Joint Surg Br 1981;63:22530. [5] London PS. The broken scaphoid bone. J Bone Joint Surg Br 1961;43:23744. [6] Barr JS, Elliston WA, Musnick H, et al. Fracture of the carpal navicular (scaphoid) bone. J Bone Joint Surg Am 1953;35:609. [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;11:2016. [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;81:8716. [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;42:75968. [12] Weber ER. Biomechanical implications of scaphoid waist fractures. Clin Orthop 1980;149:83. [13] Linscheid RL, Dobyns JH, Beabout JW, Bryan RS. Traumatic instability of the wrist. J Bone Joint Surg Am 1972;54:161232. [14] Gelberman RH, Wolock BS, Siegel DB. Fractures and nonunions of the carpal scaphoid. J Bone Joint Surg Am 1989;71:15605. [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;15:113. [16] Mack GR, Bosse MJ, Gelbermann RH, Yu E. The natural history of scaphoid nonunion. J Bone Joint Surg Am 1984;66:5049. [17] Ruby LK, Stinson J, Belsky MR. The natural history of scaphoid nonunion: a review of fty-ve cases. J Bone Joint Surg Am 1985;67:42832. [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;19:7519. [20] Ashmead D 4th, Watson HK, Damon C, et al. SLAC wrist salvage. J Hand Surg Am 1994;19:74150. [21] Watson HK, Ryu J. Degenerative disorders of the carpus. Orthop Clin N Am 1984;15:33753. [22] Berger RA, Bishop AT, Bettinger PC. New dorsal capsulotomy for surgical exposure of the wrist. Ann Plast Surg 1995;35:549. [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. 11931.
148
[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;26:94104. [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;13:110. [26] Linscheid RL. Kinematic considerations of the wrist. Clin Orthop 1986;202:2739. [27] Brumeld RH, Champoux JA. Biomechanical study of normal functional wrist motion. Clin Orthop 1984;187:235. [28] Palmer AK, Werner FW, Murphy D, Glisson R. Functional wrist motion: a biomechanical study. J Hand Surg Am 1985;10:3946. [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;13:37883. [30] Douglas DP, Peimer CA, Koniuch MP. Motion of the wrist after simulated limited intercarpal arthrodesis. J Bone Joint Surg Am 1987;69:14138. [31] Siegel JM, Ruby LK. A critical look at intercarpal arthrodesis: a review of the literature. J Hand Surg Am 1996;21: 71723. [32] Larsen CF, Jacoby RA, McCabe SJ. Nonunion rates of limited intercarpal arthrodesis: a meta-analysis of the literature. J Hand Surg Am 1997;22:6673. [33] Tomaino MM, Miller RJ, Cole I, Burton RI. Scapholunate advanced collapse wrist: proximal row carpectomy or limited wrist arthodesis with scaphoid excision. J Hand Surg Am 1994;19:13442. [34] Shin AY. Four-corner arthrodesis. J Am Soc Surg Hand 2001;1:93111. [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 xation [abstract]. American Association for Hand Surgery. San Diego, 2001.
Percutaneous capitolunate arthrodesis using arthroscopic or limited approach

Joseph F. Slade III, MDa,b,*, David A. Bomback, MDb
a Hand and Upper Extremity Service, Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA b Department 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 degenerative 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 dorsiexed position [3]. The preservation of this joint oers a unique opportunity to treat wrist arthrosis while retaining 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 performing a limited intercarpal fusion between these two carpal bones. This article describes a percutaneous 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 radioscaphoid and capitolunate joint spaces, which occurs in three stages. SLAC stage I wrist involves 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 ensuing 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 (SLAC stage 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 conrmed by Watson and Ballets [1] review of more than 4000 radiographs, is isolated radioscaphoid arthritis. The SLAC pattern of degenerative wrist arthrosis can result from a myriad of conditions; the most 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
* Corresponding author. E-mail address: joseph.slade@yale.edu (J.F. Slade III). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(02)00022-5
150
J.F. Slade III, D.A. Bomback / Atlas Hand Clin 8 (2003) 149162
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 diculty 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 exed 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.
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, Preisers disease, Kienbocks disease, and congenital preaxial hypoplasia [4]. It is common for patients with SLAC wrists to have minimal or no symptoms [7]. Patients who have signicant pain refractory to nonoperative modalities (activity modication, anti-inammatories) are candidates for surgery, regardless of SLAC stage. The goals of successful surgery are twofold: to eliminate the patients pain and to preserve as much wrist motion as possible. Surgical options include radial styloidectomy [8], proximal row carpectomy [911], distraction-resection arthroplasty [12], fascial implant arthroplasty [13], radiocarpal arthrodesis [14,15], scaphoid excision with a variety of limited intercarpal arthrodeses [1622], 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 the four-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 scaphoid 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
151
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 exion and proximal capitate migration.
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 headless 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 description of 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 identied under uoroscopic imaging. A line is drawn between the ulnar midcarpal portal and the 3,4 radiocarpal portal, delineating the intended surgical 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 identied just deep to the retracted tendons. A transverse incision is made through the dorsal capsule exposing the capitolunate joint (Fig. 4). The rst 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 exing the wrist and manually reducing the lunate to its neutral anatomic location. Elimination of the dorsal intercalated segment instability deformity (extended lunate) is conrmed on lateral uoroscopic 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 compression screw in the center of the lunate.) This Kirschner wire eectively secures the lunate in its 0 (neutral) lateral position (Fig. 5).
152
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 identied using uoroscopic imaging.
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.
153
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 exing 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 eectively secures the lunate in its 0 (neutral) lateral position.
Three additional key steps are performed in preparation for the arthrodesis. The rst step consists of resection of the capitolunate joint (Fig. 6A). This resection increases the surgeons working space but more importantly provides two beds of bleeding subchondral bone in anticipation for arthrodesis. The decortication of the distal lunate articular surface and proximal capitate 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 orice (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 ossic overgrowths (radial styloid and scaphoid), which can be impacted during radiocarpal motion (Fig. 6C). This is crucial for pain relief. 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 exed, 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 uoroscopy, 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 the capitate into the lunate, securing the reduction (Fig. 7C ).
154
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 nal 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.
155
Fig. 6 (continued )
A cannulated drill is used to prepare the capitate and lunate for screw placement. It is crucial not 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, Beaverton, OR) screw. The screw is advanced from the capitate into the lunate, taking care to stop 2 mm from the far (proximal articular surface) lunate cortex (to prevent possible distraction across the arthrodesis). Fluoroscopy conrms proper screw placement and neutral capitolunate alignment (Fig. 8C). Then the radiolunate Kirschner wire is removed. The wounds are irrigated and closed with 50 nylon sutures. As an alternative to the limited incision technique described earlier, an arthroscopic technique also can be successful (Fig. 9). A radiocarpal portal is used to conrm preservation of the radiolunate joint. Midcarpal and radiocarpal arthroscopy portals are used for the capitolunate, scaphoid, and radial styloid resections. The remainder of the procedure is identical to that described previously.
Postoperative care Postoperatively, patients are immobilized in a volar wrist splint, which is changed to a removable canvas wrist splint after suture removal. Hand therapy is started to recover nger motion. A strengthening program is started to axially load the fusion mass. This program aids in rapid recovery of hand function and stimulates bone healing. Computed tomography is used to conrm solid fusion and release to sports and heavy labor.
156
Clinical series and complications Ten patients were treated with percutaneous capitolunate arthrodesis without bone graft using a headless cannulated compression screw (Fig. 10). In this series, a standard Acutrak screw was used. Arthroscopic resection was performed on ve patients, and the remaining patients were treated with minimal exposure. At 38 months follow-up, 10 patients had solid fusions conrmed by computed tomography scan. One patient had mild occasional pain at the radial styloid but declined treatment. The remaining patients were pain-free. All patients had a functional range of motion with a 72 exion-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 [10,2628]. Pain relief aorded 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 nal exion-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 uoroscopy. Using the limited incision approach, the wrist is exed, exposing the proximal capitate. The guidewire is introduced into the capitate and driven distally into the second or third web space (B). Using uoroscopy, 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).
157
Fig. 7 (continued )
the operation is due to removal of arthritic, incongruous joints and substitution with a lax articulation 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 distributes the load on the radius, as is conrmed 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 arthrodesis, 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 proximal row 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
158
Fig. 8. The nal 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 conrms proper screw placement and neutral capitolunate alignment. After screw implantation, wrist motion is checked (C).
dierent reconstructive procedures for stages II and III SLAC wrists. Proximal row carpectomy preserved wrist mobility better (with a exion-extension arc of 71) than scaphoid excision and four-corner fusion (exion-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.
159
Fig. 9. An alternative to the limited incision technique is an arthroscopic resection. A radiocarpal portal is used to conrm 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.
Both groups had two patients who underwent revision to total wrist arthrodesis. Of the proximal row carpectomy patients, 33% had radiographic evidence of radiocapitate joint deterioration, 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. There were no specic dierences between the groups with respect to grip strength and pain relief, but range of motion was improved signicantly in the proximal row carpectomy group. Other investigators found no functional dierences [31]. Limited intercarpal arthrodesis oers several theoretical benets. 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 scaphoid 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 left intact. 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 resulting 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 benets. 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 Wyricks 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 nonunion rates and persistent pain often lead to revision surgery [17,32,33]. Kirschenbaum and associates [17] reported good pain relief, a exion-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 reex 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 oers the possibility of achieving capitolunate fusion through compression arthrodesis. The benets of this procedure are omission of the need
160
Fig. 10. (AC) 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 exion-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.
for bone graft, improved rate of fusion, avoidance of pin track infections, omission of secondary hardware 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 xation. Excising an additional carpal bone (the triquetrum) is advocated here to increase capitolunate fusion rates, although this has not been proven biomechanically. The average exion-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 xation with an Acutrak compression screw. It has been shown that the Acutrak screw has superior mechanical characteristics (eg, pull-out strength, torque, bending forces) than that of the Herbert screw [34,35].
161
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 percutaneous 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 conrm 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 access 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 reduction. 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;9:35865. [2] Watson HK, Ryu J, Akelman E. Limited triscaphoid intercarpal arthrodesis for rotary subluxation of the scaphoid. J Bone Joint Surg Am 1986;68:3459. [3] Watson HK, Weinzweig J. Intercarpal arthrodesis. In: Green DP, editor. Operative Hand Surgery. 4th edition. New York: Churchill Livingstone; 1998. p. 10830. [4] Ashmead D IV, Watson HK, Damon C, et al. Scapholunate advanced collapse wrist salvage. J Hand Surg Am 1994;19:74150. [5] Chen C, Chandnani VP, Kang HS, et al. Scapholunate advanced collapse: a common wrist abnormality in calcium pyrophosphae dihydrate crystal deposition disease. Radiology 1990;177:45961. [6] Resnick D, Niwayama G. Carpal instability in rheumatoid arthritis and calcium pyrophosphate deposition disease: pathogenesis and roentgen appearance. Ann Rheum Dis 1977;36:3118. [7] Fassler PR, Stern PJ, Kiefhaber TR. Asymptomatic SLAC wrist: does it exist? J Hand Surg Am 1993;18:6826. [8] Siegel DB, Gelberman RH. Radial styloidectomy: an anatomical study with special reference to radiocarpal intracapsular ligamentous morphology. J Hand Surg Am 1991;16:404. [9] Nervaiser RJ. Proximal row carpectomy for post-traumatic disorders of the carpus. J Hand Surg Am 1983;8:3015. [10] Imbriglia JE, Broudy AS, Hagberg WC, McKernan D. Proximal row carpectomy: clinical evaluation. J Hand Surg Am 1990;15:42630.
162
[11] 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;20:96570. [12] Fitzgerald JP, Peimer CA, Smith RJ. Distraction resection arthroplasty of the wrist. J Hand Surg Am 1989;14: 77481. [13] Eaton RG, Akelman E, Eaton BH. Fascial implant arthroplasty for treatment of radioscaphoid degenerative disease. J Hand Surg Am 1989;14:76674. [14] Bach A, Almquist E, Newman D. Proximal row fusion as a solution for radiocarpal arthrisis. J Hand Surg Am 1991;16:42431. [15] Krakauer JD, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg Am 1994;19:7519. [16] Calandruccio JH, Gelberman RH, Duncan SF, et al. Capitolunate arthrodesis with scaphoid and triquetrum excision. J Hand Surg Am 2000;25:82432. [17] Kirschenbaum D, Schneider LH, Kirkpatrick WH, et al. Scaphoid excision and capitolunate arthrodesis for radioscaphoid arthritis. J Hand Surg Am 1993;18:7805. [18] Minami A, Ogino T, Minami M. Limited wrist fusions. J Hand Surg Am 1988;13:6607. [19] Watson HK. Limited wrist arthrodesis. Clin Orthop 1980;149:12636. [20] Watson HK, Goodman ML, Johnson TR. Limited wrist arthrodesis: Part II. intercarpal and radiocarpal combinations. J Hand Surg Am 1981;6:22333. [21] Watson HK, Hempton RF. Limited wrist arthrodeses: I. the triscaphoid joint. J Hand Surg Am 1980;5:3207. [22] Watson HK, Weinzweig J, Guidera PM, et al. One thousand intercarpal arthrodeses. J Hand Surg Br 1999;24: 30715. [23] Dick HM. Wrist arthrodesis. In: Green DP, editor. Operative hand surgery. 2nd edition. New York: Churchill Livingstone; 1988. p. 15566. [24] 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;19:13442. [25] Viegas SF, Patterson RM, Peterson PD, et al. Evaluation of the biomechanical ecacy of limited intercarpal fusions for the treatment of scapho-lunate dissociation. J Hand Surg Am 1990;5:1208. [26] Jorgensen EC. Proximal row carpectomy: an end result of twenty-two cases. J Bone Joint Surg Am 1969;51:110411. [27] Crabbe WA. Excision of the proximal row of the carpus. J Bone Joint Surg Br 1964;46:70811. [28] Inglis AE, Jones EC. Proximal row carpectomy for diseases of the proximal row. J Bone Joint Surg Am 1977;59:4603. [29] Hagberg WC, Imbriglia JE, McKernan DJ, et al. Biomechanical analysis of t 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;18:1925. [31] Cohen MS, Kozin SH. Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and four-corner arthrodesis. J Hand Surg Am 2001;26:94104. [32] Siegel JM, Ruby LK. Midcarpal arthrodesis. J Hand Surg Am 1996;21:17982. [33] Larsen CF, Jacoby RA, McCabe SJ. Nonunion rates of limited carpal arthrodesis: a meta-analysis of the literature. J Hand Surg Am 1997;22:6673. [34] Wheeler DL, McLoughlin SW. Biomechanical assessment of compression screws. Clin Orthop 1998;350:23745. [35] Toby EB, Butler TE, McCormack TJ, Jayaraman G. A comparison of xation screws for the scaphoid during application of cyclic bending loads. J Bone Joint Surg Am 1997;79:11907.
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 collapse and subsequent arthrosis. Scapholunate advanced collapse (SLAC) wrist [1] after scapholunate dissociation and scaphoid nonunion advanced collapse (SNAC) wrist [2] after failed union of scaphoid fractures are the most common patterns of arthrosis in the wrist. The severity of the degenerative change is classied into three stages [3]. The primary signs of SLAC arthrosis appear between the scaphoid and the radial styloid (stage I). Later the radioscaphoid joint is narrowed, and radiocarpal arthrosis progresses (stage II). In stage III, midcarpal joint arthrosis develops between the scaphoid, lunate, and capitate head. In SNAC arthrosis, the pattern diers slightly [2,4]. Because only the distal fragment of the scaphoid exes, arthrosis arises only between it and the radial styloid (stage I). The proximal fragment, aligned with the lunate and hemispherical in shape, remains congruous with the radius and free of degenerative changes. In SNAC stage II, the cartilage between the distal scaphoid and the scaphoid fossa of the radius is involved, and occasionally scaphocapitate arthrosis develops between the proximal fragment of the scaphoid and the radial area of the head of the capitate. The presentation 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 capitolunate joint. The loaded capitate is driven o the radial side of the lunate between lunate and scaphoid, with shear loading of the capitolunate cartilage resulting in arthrosis in the midcarpal joint (stage III). The capitate migrates proximally toward the scaphoid and lunate (Fig. 1). Finally the pathomechanics also lead to advanced carpal collapse (SNAC wrist). A correct anatomic and biomechanical linkage of the scaphoid, lunate, and triquetrum is essential for maintaining the equilibrium of forces between the carpal components. Disruption of the proximal row connection upsets the normal balance and results in abnormal shifting of involved carpal bones [5]. The scaphoid exes palmarly in scapholunate dissociation, and its proximal pole translates dorsally against the dorsal rim of the radius. The lunate and triquetrum extend. Their motion is dissociated from the scaphoid. The capitate migrates proximally and radially toward the scapholunate gap, diminishing the carpal height. The extension of the lunate relative to the radius and capitate is termed dorsiexed intercalated segment instability (DISI) [68]. SNAC or SLAC patterns may cause abnormal contact of the radiolunate and ulnocarpal joint. These patterns usually do not lead to arthrosis, however, between the lunate and the radius [35,916]. In contrast to the articulations at the radioscaphoid and capitolunate joint, the corresponding surfaces of the distal radius and lunate are spherical. The loads applied to the lunate remain perpendicular to its radial surface regardless of its rotational stance, and shear forces do not develop; this allows the possibility
* Corresponding author. E-mail address: michael.sauerbier@urz.uni-heidelberg.de (M. Sauerbier). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(03)00006-2
164
M. Sauerbier et al / Atlas Hand Clin 8 (2003) 163183
Fig. 1. Pathomechanics of the scaphoid nonunion advanced collapse wrist with arthrotic stages I to III and dorsiexed 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.
of preserving wrist mobility even in stage III disease. Ulnar carpal translocation may occur in association with SLAC or SNAC arthrosis. Viegas and colleagues [17] conrmed that the contact area and pressure increase in the scaphoid fossa and decrease in the lunate fossa of the radius with progressive perilunate instability. Treatment options In the authors experience for SNAC wrist stage I, a scaphoid reconstruction with an interpositional bone graft and a screw xation should be used. In addition, a total or partial denervation 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 excision should be considered. An alternative option to a limited wrist arthrodesis in SLAC stage II may be a proximal row carpectomy (PRC) [2024]. For stage III disease (radioscaphoid and lunocapitate or midcarpal arthrosis), the procedure of choice is the four-corner fusion with scaphoid 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 severe carpal pathology, maximizing postoperative wrist motion, function, and strength and reducing
Table 1 Dierent stages and therapeutic options for scaphoid nonunion advanced collapse wrist Stage I II Severity of arthrosis Arthrosis between radial styloid and distal fragment of scaphoid Arthrosis distal fragment of scaphoid and scaphoid fossa Therapy Resection radial styloid and scaphoid reconstruction with bone graft and a screw Four-corner fusion with scaphoid excision Resection of proximal carpal row Lunocapitate fusion with scaphoid and triquetrum excision Four-corner fusion with scaphoid excision Lunocapitate fusion with scaphoid and triquetrum excision
III
Arthrosis midcarpal joint
165
pain and eliminating instability. It provides a means for load transference across normal residual joints in the wrist, provides adaptation of preserved intercarpal mobility to compensate for motion pathways lost to fusion, and provides reasonable assurance of prevention of progressing disease of other wrist joints. The experiences of Watson and others [16,913,16, 19,2535] encouraged many surgeons to begin various combinations of intercarpal arthrodeses for conditions aecting the wrist and particularly for wrist instabilities. In clinical series of intercarpal fusions, most authors have reported preserving at least 50% of wrist motion for extension-exion and ulnar/radial deviation or higher [14,913,15,16,19,2528,31,3335]. Various groups of wrist disorders, such as SLAC or SNAC patterns of wrist arthrosis, rotary subluxation of the scaphoid, carpal instabilities, degenerative disorders of special carpal units, Kienbocks disease, Preisers disease, other carpal osteonecroses, and congenital synchondrosis, can be treated with limited wrist fusions [16,917,20,2529,3143]. Depending on the stage of degenerative arthrosis, different procedures can be considered under the rubric limited wrist arthrodesis. Multiple experimental studies have described the theoretical eects of various limited wrist fusions on wrist motion [17,37,4446]. Giunta and colleagues [47] evaluated load transmission and subchondral bone mineralization after midcarpal fusion with computed tomography osteoabsorptiometry in vivo. They found peak mineralization in the radiolunate joint after midcarpal arthrodesis. Knowledge of causes of degenerative or posttraumatic arthrosis of the wrist has paralleled directly knowledge concerning the diagnosis, classication, and pathomechanics of traumatic wrist injuries. In a classic article by Linscheid and coworkers [7], it was stated that instability occurs because of either disruption of the ligamentous restraints or changes of the geometry of the osseous links. This type of disruption and instability commonly involves the scaphoid and its attachments, which mechanically provide stability to the intercarpal joint [7,8]. Carpal collapse can follow scaphoid fracture and ruptures of the scapholunate 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 treatment of SNAC arthrosis are known only anecdotally, however. When the articular surfaces of the distal radius, proximal scaphoid, or proximal lunate are compromised, the radioscapholunate arthrodesis may be considered as a reasonable option. The loss of wrist motion may be modulated in this instance by resecting the distal pole of the scaphoid, which in eect 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 a radial styloidectomy would be an ideal treatment for scapholunate dissociation, a SLAC wrist stage I, or a SNAC wrist stage I, in reality it has been a highly unpredictable procedure with marginal clinical results. It is possible that a combination of factors, including the opposing rotational moments of the scaphoid and lunate and the limited surface area available for the fusion to occur, predisposes this procedure to nonunion. The principles and indications of limited wrist arthrodesis in the treatment of scaphoid nonunion (SNAC) are addressed in this article. Limited wrist arthrodeses can be divided into procedures primarily fusing the midcarpal joint (four-corner and lunocapitate), radiocarpal joint (radioscapholunate), or intercarpal joints (scapholunate). This article includes discussions of four-corner fusion, lunocapitate arthrodesis, and PRC. Alternative salvage procedures are discussed, and a therapeutic algorithm is presented for dierent SNAC pathologies.
Indications and contraindications Four-corner arthrodesis A four-corner arthrodesis or midcarpal fusion implies the intentional fusion of the mutually articulating surfaces of the lunate, triquetrum, capitate, and hamate. The most common indications for performing a four-corner arthrodesis are advanced degenerative disease
166
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 a scaphoidectomy in patients with advanced degenerative disease resulting from scapholunate dissociation, scaphoid nonunion, or scaphoid malunion. Because the entire mass of fused bones after a four-corner fusion articulates almost entirely through the radiolunate joint, the only constant contraindication for this procedure is radiolunate arthrosis. Mechanical dissociation of the radiolunate joint and extreme positive variance of the ulna should be considered relative contraindications for a four-corner arthrodesis. Capitolunate arthrodesis The capitolunate arthrodesis has been promoted as a procedure that has the advantages of four-corner fusion and minimizes the disadvantages [31,36]. The principal advantage of the capitolunate arthrodesis compared with the four-corner arthrodesis is in the reduced fusion mass. By eliminating the lunotriquetral and triquetrohamate joints from the arthrodesis requisite, there may be a lower incidence of arthrodesis-related complications, such as delayed union, nonunion, hardware failure, and fusion malunion. The indications and contraindications for a capitolunate arthrodesis are the same as for a four-bone arthrodesis. It typically is accompanied by a complete excision of the scaphoid and the triquetrum [36]. Scapholunate arthrodesis The principal reason for attempting a scapholunate arthrodesis is to stabilize the scapholunate joint. The most common cause of scapholunate instability is scapholunate dissociation, followed by a proximal pole fracture or a nonunion of the scaphoid. The rationale is sound, but the success rate of scapholunate arthrodesis is low, regardless of technique. In published 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) the retrograde interosseous blood ow of the proximal scaphoid, (2) the small surface area available for the fusion, (3) the counterrotational tendencies of the scaphoid and lunate, and (4) the diculty in achieving compression across the fusion site without changing the arc of curvature of the midcarpal joint. Without an improvement in the results of this surgery, it will remain relatively contraindicated. Radiocarpal arthrodesis, radioscapholunate arthrodesis, and ulnar translocation of the carpus in scaphoid nonunion advanced collapse wrist Ulnar translocation of the carpus is dened as any condition in which the lunate translates ulnarly to such a degree that less than 50% of its proximal articular surface remains in contact with the lunate fossa of the distal articular surface of the radius. It may happen in exceptional or late circumstances of SNAC pathology. In these cases, it can be dicult to achieve a proper realignment of the lunate in the lunate fossa and the capitolunate axis with a four-corner fusion. Radioscapholunate fusion might be an option to treat these patients with a motion-sparing procedure instead of performing a total wrist arthrodesis. The principal contraindication for a radioscapholunate arthrodesis is the presence of signicant 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 planned procedure in the immediate perioperative period and long-term, and the surgeon must have a clear understanding of what the patients expectations and demands are.
167
Careful attention must be directed preoperatively to a functional assessment of the entire aected upper extremity, including the hand, forearm, elbow, and shoulder. A careful radiographic analysis of the aected wrist must be made to maximize the surgeons familiarity with the principal pathology of the wrist and to detect coexisting conditions [50]. It is often helpful to obtain similar imaging of the contralateral wrist to determine what the normal carpal height and angles are, in an attempt to replicate those values as much as possible in the aected wrist. Four-corner arthrodesis with complete scaphoid excision and lunocapitate arthrodesis with complete excision of the scaphoid and triquetrum After a careful clinical examination, plain radiographs with posteroanterior and lateral views are indicated. The severity of arthrosis and the stage of the SNAC wrist can be identied easily. If more information about the condition of the radioscaphoid and radiolunate joint is needed, a computed 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 radius is used. If the fusion is performed using bone graft from the iliac crest, general anesthesia is required. Radioscapholunate arthrodesis and scapholunate arthrodesis Careful assessment of the midcarpal joint is necessary before performing a radiocarpal joint arthrodesis. This assessment can be done with plain radiographs to assess the presence of typical signs of degenerative disease. Also, if a malalignment is present because of an abnormal angulation of the radius or of the lunate, it is helpful to calculate the degree of correction that will be attempted in the operating room. The normal angles can be determined easily from the contralateral wrist, if uninjured. 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], or transverse orientation. After clearing the subcutaneous tissue to expose the deep antebrachial fascia and the extensor retinaculum, care is taken to avoid injury to the terminal branches of the supercial radial nerve. The third extensor compartment is incised, allowing radial translocation of the extensor pollicis longus tendon. The fourth and second extensor compartments are elevated on ulnar-based and radial-based aps. The preservation of the synovial envelope should be attempted during dissection to avoid adhesions postoperatively. After mutual reztraction 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 radially based capsular ap is developed (Fig. 2) [52]. On the dorsal rim of the distal radius, the midpoint between Listers tubercle and the dorsal edge of the sigmoid notch is identied, as is the central point on the dorsal tubercle of the triquetrum and the sulcus of the scaphotrapezium-trapezoid joint. A full-thickness incision is made connecting these three points, longitudinally dividing the dorsal radiocarpal and intercarpal ligaments. The ap is developed further by incising the dorsal joint capsule from the dorsal rim of the radius until the distal extent of the radial styloid process is reached. Avoiding injury to the dorsal regions of the scapholunate and lunotriquetral ligaments, the ap 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 the radiocarpal and midcarpal joints as described earlier. Great care is taken during resection of the joint surfaces of the capitate, lunate, and triquetrum to decorticate the concave distal surface of
168
the lunate completely. The scaphoid is excised completely, while preserving all palmar radiocarpal ligaments. The reduction of the lunate and realignment of the bones can be performed with a Kirschner wire inserted into the lunate as a joystick (Fig. 3A). If the joint surfaces are removed with an osteotome in a straight direction, a corticocancellous strut from the anterior iliac crest can be inserted between the four bones. Two 1.5-mm Kirschner wires are inserted into the capitate in a distal-to-proximal direction and advanced until they protrude slightly at the head of the capitate, and one Kirschner wire is inserted in the same direction from the hamate through the capitate. The lunate and capitate are reduced, and a perfectly shaped bone graft is inserted between the capitate, lunate, hamate, and triquetrum. Inclusion of the triquetrum and hamate in the fusion mass improves the union rates and does not affect ultimate wrist 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 and capitate and the lunotriquetral and capitohamate joints. The Kirschner wires (1.5 mm) are advanced into the proximal row (see Fig. 3B). Another one or two Kirschner wires are inserted to xate 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 Listers 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 ap 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 ber-splitting capsulotomy technique for dorsal exposure of the wrist. Tech Hand Upper Extremity Surg 1997;1:210; with permission.)
169
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 xation of the four bones with Kirschner wires; the scaphoid has been resected (*). C, Alternative xation of the bones with the Spider plate (Kinetikos Medical, Inc, San Diego, CA).
170
Fig. 3 (continued )
171
bones and inserted Kirschner wires is conrmed with a radiograph. A radial styloidectomy may be performed optionally to avoid abutment of the wrist during radial deviation. After closing of the joint capsule, the extensor retinaculum is reconstructed leaving the extensor pollicis longus tendon subcutaneously. Several other xation devices are available for midcarpal arthrodesis, such as screws, staplers, and the Spider plate (Kinetikos Medical, Inc, San Diego, CA). The Spider plate was developed specically for four-bone arthrodesis but has been also used for other types of limited wrist fusions. This novel device is a three-dimensional, recessed plate that allows circumferential compression 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 transections of the remaining ligaments of the scapholunate and lunotriquetral joints are made, and the scaphoid and the triquetrum are removed piecemeal with a rongeur. The surfaces of the proximal capitate and distal lunate are denuded of the cartilage to the level of subchondral bone. The bony stabilization can be performed with Kirschner wires or cannulated screws. After closing of the joint capsule, the extensor retinaculum is sutured. The extensor pollicis longus tendon is left subcutaneously. Radioscapholunate arthrodesis The universal capsulotomy for exposure of the radial aspect of the wrist is used. Inspection of the 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), exion (H), radial deviation (I), and ulnar deviation (J).
172
Fig. 4 (continued )
173
Fig. 4 (continued )
174
Fig. 4 (continued )
to rule out midcarpal arthritic changes. If present, an alternative salvage procedure should be considered. The mutually articulating surfaces of the lunate fossa of the distal radius and the proximal 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 a radioscapholunate arthrodesis. The resulting void is packed with autologous or allograft cancellous bone or a bone substitute. The ideal angle for the scaphoid relative to the radius should be 50 of exion, whereas the lunate should be in neutral position. Fixation can be achieved with Kirschner wires, distally oriented obliquely angled screws from the dorsal cortex of the radial metaphysis, proximally oriented obliquely angled screws from the dorsal cortices of the scaphoid and lunate, staples, or even a small plate and screw xation system. Fixation
175
Fig. 4 (continued )
should be secure regardless of the method employed because of the tremendous loading and torque that occur across the radiocarpal joint. Screw purchase through the dorsal cortex of the distal radial metaphysis may prove to be suboptimal, resulting in loss of xation and failure to unite. As an option with the radioscapholunate arthrodesis, the distal pole of the scaphoid can be excised. This excision essentially unlocks the proximal and distal rows, enhancing midcarpal range of motion.
176
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.
177
Scapholunate fusion After opening the wrist joint with the radial-based capsular ap, the ulnar surface of the lunate is removed with a rongeur. The proximal pole of the scaphoid is resected. Cancellous bone graft or a corticocancellous strut from the iliac crest is packed between the scaphoid and lunate. The xation can be performed with Kirschner wires, staples, or cannulated screws.
Results and outcomes for each technique A general consequence of all limited wrist arthrosis procedures is that they result in less than normal global wrist range of motion. Substantial impairment of function depends on whether the resultant range of motion falls within functional limits. The condition that led to the decision to embark on a limited wrist arthrodesis more than likely already imparted such a limitation, 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 a capitohamate or lunotriquetral arthrodesis, whereas fusions that cross the radiocarpal or midcarpal joint have a more profound eect on motion. Several laboratory analyses have been performed to study the eect on range of motion with simulated limited wrist arthrodesis procedures, which provided an excellent foundation for predicting the postoperative range of motion [17,37,44,46,53]. Biologic factors in vivo, such as prolonged immobilization and scar formation, 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 the postoperative course, with no further deterioration expected. If the arthrodesis is performed for changes associated with an inammatory arthropathy, however, the patient and surgeon should be aware that the underlying disease can continue to be active, causing further deterioration of function. Few of the studies available for review regarding outcomes of surgery have employed the currently available tools for validated assessment of functional outcome; it is hoped that this situation will be rectied in future studies [5,12,15,3335,5355].
Midcarpal arthrodesis with scaphoid excision (four-corner fusion) Scaphoid excision with midcarpal fusion is designed to relieve pain while preserving sucient residual wrist mobility (Fig. 4). In Watsons series [6,16,27], pain was reduced signicantly, range of motion was preserved (33% of extension and 37% of exion), and grip strength improved. After 44 months on average, the results achieved were similar to the observations of Krimmer and associates [10] in 31 patients and Lanz and coworkers [13] in 45 patients. Nagy and Buchler [43] reported the results in 12 patients after four-corner fusion, in which the range of motion was adequate, and the average grip strength reached 79% of the opposite hand. Siegel and Ruby [56] examined 11 patients with midcarpal fusion in a series of 14 operated patients, of whom 4 nally underwent total wrist fusion because of continuous pain. Most groups exclude silicone scaphoid implants because of severe problems with siliconeinduced synovitis and dislocation of the prosthesis. In a series with 36 patients, the results of Sauerbier and colleagues [5] compared favorably with most of these groups. Krimmer and associates [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 [5355] and a modied Mayo wrist score [57], the results for the fourcorner fusion group were signicantly 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. The results of a small study suggest that this procedure may be an eective alternative method for
178
treatment of SLAC and SNAC wrist disorders. A exion-extension arc of 60 can be expected for this operation. Kirschenbaum and colleagues [31] reported in the largest series in the literature a nonunion rate of 33%, however. Viegas and coworkers [17] also reported high nonunion rates. In the series of Calandruccio and associates [36], there were 2 nonunions in 14 patients. The authors of that series used compression screws instead of Kirschner wires or staples 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 the head of the capitate is normal or near-normal, as it is in SLAC or SNAC stage II. Preliminary results are satisfying; however, long-term follow-up studies in large patient populations are not published yet.
Radioscapholunate arthrodesis and scapholunate arthrodesis Reports of radioscapholunate arthrodesis and scapholunate arthrodesis exist only anecdotally for the treatment of SNAC wrist. The results following radioscapholunate fusion for radiocarpal arthrosis after distal radius fractures are reasonable, however, and a radioscapholunate fusion always should be considered in these cases instead of a total wrist fusion. In the authors department, neither technique is used in SNAC salvage. All series reviewed show a relatively low rate of complications, but also report substantially below-normal range 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 denitive radiographic evidence that sucient bony union across the arthrodesis site has occurred; this may require special radiographic views or computed tomography. The decision about which variety of cast immobilization should be applied depends on the experience of the surgeon and the reliability of the patient, rather than on validated outcome studies, which are lacking in the literature. The authors preferred method of immobilization is a short arm cast for 8 weeks. If Kirschner wires were used for xation, they are buried underneath the skin to avoid pin track infections. If bony union is achieved after 8 weeks, physical therapy is initiated for the wrist. The Kirschner wires are removed 12 weeks postoperatively under brachial plexus anesthesia; the wrist is mobilized during the procedure. Common to all procedures is the need to initiate immediate postoperative therapy for digital range of motion and edema control. If the patient does not have a history of stomach ulcer or gastritis, oral nonsteroidal anti-inammatory drugs for pain control and edema are administered routinely. Complications Failure of a limited wrist arthrodesis may occur at several levels [28,29,31,56,58]. From a biologic standpoint, infection, delayed union, and nonunion may lead to substantial morbidity and less than ideal results. The most common complications of limited wrist fusions can be nonunion, hardware failure, persistent pain, and progression of the degenerative patterns. Pin track infection, paresthesia after inadvertent injury to a cutaneous nerve passing through the surgical site, and sympathetic reex dystrophy can occur. In the authors experience, limited wrist arthrodeses have proved to be eective and predictable. The four-corner fusion with complete scaphoid excision is an extremely reliable procedure for achieving sucient pain relief and satisfying active range of motion for the treatment of SNAC pathologies. Regarding wrist mobility, performance of activities of daily living and patient satisfaction make the results of limited wrist arthrodesis superior to total wrist fusion [12].
179
Salvage procedures Determination of the underlying cause is mandatory before a treatment plan for a failed partial fusion is designed. If the cause of failure is persistent pain, the source of the pain should be determined as denitively as possible. If the pain is resulting from a nonunion at the original arthrodesis site, treatment should be aimed at correcting the nonunion, either using further immobilization with or without external stimulation with pulsed electromagnetic elds or highenergy 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.
180
Fig. 6 (continued )
181
to try to determine what the cause of the nonunion was to avoid the frustrating experience of developing a nonunion a second time. If the pain is due to progressive degenerative disease in a previously unaected region of the wrist, treatment should be directed to that region. The surgeon could consider performing a total wrist arthrodesis, particularly if the patient would tolerate the loss of motion and is requesting the most reliable and ecacious treatment for wrist pain. Data showed, however, that a total wrist arthrodesis 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 dicult with a fused wrist [12,34,35]. If the patient is complaining of restricted motion, painful or otherwise, revision arthrodesis procedures would not be helpful and may make the situation worse. If a patient has pain after a limited wrist arthrodesis but does not want to consider a procedure that would compromise wrist motion further, a wrist denervation procedure may be considered [18,19,59]. No matter what the underlying source of the patients complaints are after a limited wrist arthrodesis, an exhaustive trial of conservative management should be considered, as long as the patients complaints stem from a progressive problem that has a solution or if the problem is life-threatening or limb-threatening [14]. Conservative measures should include splinting, anti-inammatory medications, and activity modications. Surgical options after failure of conservative measures include revision limited arthrodesis, total wrist arthroplasty, total wrist arthrodesis, and partial or complete wrist denervation. Summary Patients who have pain, weak grip strength, and limited range of motion because of SNAC can be treated operatively with established motion-sparing procedures. The authors preferably perform a four-corner fusion in patients with SNAC II and III; however, in SNAC stage II, a PRC might be a predictable alternative option. The latest data from the authors series show that 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 functional outcomes of all motion-sparing procedures are satisfying, and the DASH values and activities of daily living reports of the patients are superior to a total wrist arthrodesis. The use of a fourcorner fusion is recommended in most SNAC and SLAC patients. Total wrist arthrodesis should be used only for exceptional circumstances.
References
[1] Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am 1984;9:35865. [2] Krakauer JD, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg Am 1994;9:35865. [3] Watson HK, Ryu J. Evolution of arthritis of the wrist. Clin Orthop 1986;201:5767. [4] Krimmer H, Krapohl B, Sauerbier M, Hahn P. Posttraumatic carpal collapse (SLAC- and SNAC-wrist): stage classication and therapeutic possibilities. Handchir Mikrochir Plast Chir 1997;29:22833. [5] Sauerbier M, Trankle M, Linsner G, et al. Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): operative technique and outcome assessment. J Hand Surg Br 2000;25:3415. [6] Ashmead D, Watson HK, Damon C, et al. Scapholunate advanced collapse wrist salvage. J Hand Surg Am 1994;19:74150. [7] Linscheid RL, Dobyns JH, Beabout JW. Traumatic instability of the wrist: diagnosis, classication and pathomechanics. J Bone Joint Surg Am 1972;54:161232. [8] Linscheid RL, Dobyns JH, Beckenbaugh RD, et al. Instability patterns of the wrist. J Hand Surg Am 1983;8:6826. [9] Krimmer H, Lanz U. Post-traumatic carpal collapse: follow-up and therapeutic concept. Unfallchirur 2000;103:2606. [10] Krimmer H, Lanz U. Die mediokarpale Teilarthrodese des Handgelenkes. Operat Orthop Traumatol 1996;8: 175184. [11] Krimmer H, Sauerbier M, Vispo-Seara JL, et al. Fortgeschrittener karpaler Kollaps (Slac-wrist) bei Skaphoidpseudarthrose. Therapiekonzept: mediokarpale Teilarthrodese. Handchir Mikrochir Plast Chir 1992;24:1918. [12] Krimmer H, Wiemer P, Kalb K. A comparison of functional outcome following limited and total fusion of the wrist. Handchir Mikrochir Plast Chir 2000;32:36974.
182
[13] Lanz U, Krimmer H, Sauerbier M. Advanced carpal collapse: treatment by limited wrist fusion. In: Buchler U, ed. Wrist instability. London: M. Dunitz; 1996. p. 139145. [14] Sauerbier M, Berger RA. Limited wrist arthrodesis. In: Hastings H, Weiss APC, editors. Arthritic surgery of the hand and wrist. Philadelphia: Lippincott Williams & Wilkins; 2002. p. 12139. [15] Sauerbier M, Bickert B, Trankle M, et al. Operative Behandlungsmoglichkeiten bei fortgeschrittenem karpalen Kollaps (SNAC-/SLAC-Wrist). Unfallchirurg 2000;103:56471. [16] Watson HK, Goodman ML, Johnson TR. Limited wrist arthrodesis: Part II. intercarpal and radiocarpal combinations. J Hand Surg Am 1981;6:22333. [17] Viegas SF, Patterson RM, Peterson PD, et al. Evaluations of the biomechanical efcacy of limited intercarpal fusions for the treatment of scapholunate dissociation. J Hand Surg Am 1990;15:1208. [18] Berger RA. Partial denervation of the wrist: a new approach. Tech Hand Upper Ext Surg 1998;2:2535. [19] Wilhelm A. Die Gelenkdenervation und ihre anatomischen Grundlagen. Ein neues Behandlungskonzept in der Handchirurgie. Zur Behandlung der Spatstadien der Lunatummalazie und Navicularepseudarthrose. Hefte Unfallheilkd 1966;86:1109. [20] Baumeister S, Trankle M, Germann G, Sauerbier M. Aktuelles Therapiekonzept zur Behandlung des fortgeschrittenen karpalen Kollaps nach Skaphoidpseudarthrose (SNAC-Wrist). Akt Traumatol 2002;32:2707. [21] Neviaser RJ. On resection of the proximal carpal row. Clin Orthop 1986;202:125. [22] Saffar P, Fakhoury B. Resection de la premiere rangee contre arthrodese partielle des os du carpe dans les instabilities du carpe. Ann Chir Main Memb Super 1992;11:27680. [23] Tomaino MM, Delsignore J, Burton RI. Long-term results following proximal row carpectomy. J Hand Surg Am 1994;19:694703. [24] Trankle M, Sauerbier M, Blum K, Germann G. Die Entfernung der proximalen Handwurzelreihe als bewegungserhaltender Eingriff am Handgelenk. Unfallchirurg 2002 (in press). [25] Watson HK. Hempton RF. Limited wrist arthrodesis. I. the triscaphoid joint. J Hand Surg Am 1980;5:3207. [26] Watson HK, Ryu J, DiBella A. An approach to Kienbocks disease: triscaphe arthrodesis. J Hand Surg Am 1985;10:17987. [27] Watson HK, Weinzweig J, Guidera PM, et al. One thousand intercarpal arthrodeses. J Hand Surg Br 1999;24:30715. [28] 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;20:96570. [29] Hastings DE, Silver RL. Intercarpal arthrodesis in the management of chronic carpal instability after trauma. J Hand Surg Am 1984;9:83440. [30] Hom S, Rub LK. Attempted scapholunate arthrodesis for chronic scapholunate dissociation. J Hand Surg Am 1991;16:3349. [31] Kirschenbaum D, Schneider LH, Kirkpatrick WH, et al. Scaphoid excision and capitolunate arthrodesis for radioscaphoid arthritis. J Hand Surg Am 1993;18:7805. [32] Nagy L, Buchler U. Long term results of radioscapholunate fusion following fractures of the distal radius. J Hand Surg Br 1997;22:70510. [33] Sauerbier M, Trankle M, Erdmann D, et al. Functional outcome with scapho-trapezio-trapezoid arthrodesis in the treatment of Kienbocks disease. Ann Plast Surg 2000;44:61825. [34] Sauerbier M, Kania NM, Kluge S, et al. Erste Ergebnisse mit der neuen AO-Handgelenk-Arthrodesenplatte. Handchir Mikrochir Plast Chir 1999;31:2605. [35] Sauerbier M, Kluge S, Bickert B, Germann G. Subjective and objective outcomes after total wrist arthrodesis in patients with radiocarpal arthrosis or Kienbocks disease. Chir Main 2000;19:22331. [36] Calandruccio JH, Gelberman RH, Duncan SF, et al. Capitolunate arthrodesis with scaphoid and triquetrum excision. J Hand Surg Am 2000;25:82432. [37] Douglas DP, Peimer CA, Koniuch MP. Motion of the wrist after simulated limited intercarpal arthrodeses: an experimental study. J Bone Joint Surg Am 1987;69:14138. [38] Halikis MN, Colello-Abraham K, Taleisnik J. Radiolunate fusion: the forgotten partial arthrodesis. Clin Orthop 1997;341:305. [39] Inoue G, Tamura Y. Radiolunate and radioscapholunate arthrodesis. Arch Orthop Trauma Surg 1992;111:3335. [40] Lichtman DM, Bruckner JD, Culp RW, Alexander CE. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg Am 1993;18:30715. [41] Lichtmann DM, Martin RA. Introduction to the carpal instabilities. In: Lichtmann DM. editor. The wrist and its disorders. Philadelphia: WB Saunders; 1988. p. 24450. [42] Minami A, Kato H, Iwasaki N, Minami M. Limited wrist fusions: comparison of results 22 and 89 months after surgery. J Hand Surg Am 1999;24:1337. [43] Nagy L, Buchler U. Ist die Panarthrodese der Goldstandard der Handgelenkchirurgie? Handchir Mikrochir Plast Chir 1998;30:2917. [44] 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;13:37883. [45] Meyerdierks EM, Mosher JF, Werner FW. Limited wrist arthrodesis: a laboratory study. J Hand Surg Am 1987;12:5269. [46] Palmer AK, Werner FW, Murphy D, Glisson R. Functional wrist motion: a biomechanical study. J Hand Surg Am 1985;10:3946. [47] Giunta RE, Krimmer H, Krapohl B, et al. Pattern of subchondral bone mineralisation in the wrist after midcarpal fusion. J Hand Surg Am 1999;24:13847. [48] Berger RA. The gross and histologic anatomy of the scapholunate interosseus ligament. J Hand Surg Am 1996;21:1708.
183
[49] Berger RA, Blair WF, Crowninshield RD, Flatt AE. The scapholunate ligament. J Hand Surg Am 1982;7:8791. [50] Schmitt R, Lanz U, Lucas D, et al. Computertomographie der Hand: Untersuchungstechnik, Normalanatomie. Indikationsgebiete. Handchir Mikrochir Plast Chir 1989;21:8996. [51] Dao KD, Shin AY, Berger RA. T incision for exposure of the distal radius and wrist. J Hand Surg Br 2000;25: 5447. [52] Berger RA, Bishop AT, Bettinger PC. New dorsal capsulotomy for the surgical exposure of the wrist. Ann Plast Surg 1995;35:549. [53] Amadio PC. Outcomes assessment in hand surgery: whats new? Clin Plast Surg 1997;24:1914. [54] Germann G, Wind G, Harth A. Der DASH FragebogenEin neues Instrument zur Outcome Evaluation an der oberen Extremitat. Handchir Mikrochir Plast Chir 1999;31:14952. [55] Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder and Hand). The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29:6028. [56] Siegel JM, Ruby LK. A critical look at intercarpal arthrodesis: review of the literature. J Hand Surg Am 1996;21:71723. [57] Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difcult wrist fractures. Clin Orthop 1987;213:13647. [58] McAuliffe JA, Dell PL, Jaffe R. Complications of intercarpal arthrodesis. J Hand Surg Am 1993;18:11218. [59] Buck-Gramcko D. Denervation of the wrist joint. J Hand Surg Am 1977;2:5461.
Proximal row carpectomy for scaphoid nonunion

Robert S. Leak, MDa,b, Randall W. Culp, MDa,b,*
a b
Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA The Philadelphia Hand Center, 700 South Henderson Road, #200, King of Prussia, PA 19406, USA
Despite earlier recognition of scaphoid fractures, modern internal xation treatment methods, and the popularity of vascularized bone grafting, nonunion of the scaphoid remains a dilemma for the hand surgeon. In cases of chronic scaphoid nonunion (scaphoid nonunion advanced collapse [SNAC]), degenerative instability of the carpus may develop in a characteristic pattern leading to irreversible articular damage. Watson and Ballet [1] initially described a similar pattern for scapholunate advanced collapse in 1984. Vender and colleagues [2] reviewed radioscaphoid changes in 48 of 64 patients with untreated scaphoid nonunions of 4 years duration. The distal scaphoid exes with the distal carpal row, whereas the proximal scaphoid remains associated with the lunate in the proximal row. The proximal 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 the radius. The loss of normal articular congruency can result in arthritic changes that initially are isolated to the radial styloid. The spherical radiolunate joint remains congruent, so it usually is spared of articular damage. The degenerative changes progress to involve the scaphocapitate and capitolunate joints. As a result of this pattern, 39 patients at 9 years follow-up developed radioscaphoid and capitolunate arthritis causing wrist pain and decreased function. Proximal row carpectomy (PRC) initially was reported by Stamm [3] in 1944 as a means of providing relief for the painful, degenerative wrist without arthrodesis. This procedure removes the intercalary proximal row and creates a radiocapitate articulation, creating a simple hinge joint out of a complex link joint system. The capitate now articulates with the radius lunate fossa. This procedure has become more widespread in its use and has many indications in cases of congenital, degenerative, and traumatic disorders. Reports have conrmed its use in chronic scaphoid nonunion, scapholunate dissociation, fracture-dislocation of the carpus, and Kienbocks disease. PRC is a suitable option for the patient who prefers a motion-preserving procedure 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 just ulnar to Listers tubercle, in line with the long nger. Alternatively a transverse incision just distal to the radiocarpal joint may be used. We prefer the longitudinal incision because this allows easier conversion to another procedure based on surgical ndings, such as inadequate cartilage on the capitate or lunate fossa. Thick skin aps are developed, and sensory branches of the radial and ulnar sensory nerves are identied and preserved.
* The Philadelphia Hand Center, 700 South Henderson Road, #200, King of Prussia, PA 19406, USA. E-mail address: rwculp@handcenters.com (R.W. Culp). 1082-3131/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1082-3131(03)00004-9
186
R.S. Leak, R.W. Culp / Atlas Hand Clin 8 (2003) 185189
Fig. 1. Early carpal collapse in chronic scaphoid nonunion pattern.
The third extensor compartment is identied and opened. The extensor pollicis longus is retracted radially, and the fourth compartment is elevated o the distal radius and capsule in an ulnar direction, exposing the wrist capsule. Alternatively the wrist capsule can be exposed through a longitudinal incision through the fourth compartment with retraction of the extensor tendons with a Penrose drain. The carpal bones are exposed through a longitudinal incision in the dorsal capsule, which begins over the radius-lunate-capitate axis. A transverse incision is made over the scaphoid and triquetrum, forming an inverted T-shaped capsulotomy. Retraction of the capsular aps exposes the proximal row for evaluation of the articular surfaces. The radiolunate articulation should be free of degenerative changes, and the capitolunate articulation should have only minimal changes present. If signicant changes are present in either of these two articulations, a partial or total wrist arthrodesis should be considered. The removal of the proximal row may be more tedious than expected because of volar ligamentous attachments. The lunate can be removed in a piecemeal fashion using a rongeur, being careful to avoid damage to the articular surface of the capitate. This method facilitates exposure of the triquetrum, which can be removed using sharp dissection and a rongeur. It is important to have adequate exposure to preserve the extrinsic radiocarpal ligaments, and a freer elevator or Homan retractor helps with presentation of the carpal bones. A 3.5-mm AO (Synthes, Paoli, PA) tap or threaded Steinmann pin can be used as a joystick. The radioscaphocapitate ligament needs to be maintained to prevent ulnar translation. Removal of the volar portion of the scaphoid may be dicult and is made easier with longitudinal traction and direct palmar pressure on the distal scaphoid. If the ligamentous structures are preserved, the capitate settles into the lunate fossa, generally without the need for internal xation.
187
Fig. 2. Postoperative radiograph after proximal row carpectomy.
The range of motion of the wrist is checked in all planes. Occasionally the trapezium impinges on the radial styloid in full radial deviation, requiring styloidectomy. The authors have not found this to be a common problem. Meticulous hemostasis is achieved after deation of the tourniquet. The capsule and extensor retinaculum are repaired. After skin closure, a well-padded dressing and a short arm splint in a neutral position are applied. Thumb and nger motion are started immediately postoperatively. Active wrist motion is begun at 3 weeks postoperatively, and a protective wrist splint is worn for 6 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 salvage procedures for degenerative patterns in the wrist, making critical analysis dicult. In 1964, Crabbe reported overall successful results in 6 of 12 patients who underwent PRC for scaphoid nonunion [4]. He reported two failures. Tomaino and colleagues [5] reported the long-term results of PRC in 23 wrists with carpal degeneration treated from 1980 to 1989. Seven patients with SNAC wrists provided 3 to 8 years follow-up. In this group, ve patients returned to work without limitation. One patient had preoperative capitolunate arthritis and was dissatised with his result. Another patient required
188
a wrist fusion 6 years after an initially successful result. Average exion and extension arc was 77 , average radioulnar deviation arc was 26 , and the average grip strength was 72% of the uninjured side. These results were comparable to the overall series, which included scapholunate advanced collapse (SLAC) wrists and Kienbocks disease. The authors concluded that a high level of satisfaction was achieved with PRC at an average of 6 years follow-up and that preoperative diagnosis did not inuence outcomes. Wyrick and associates [6] compared 11 wrists in 10 patients who underwent PRC with 17 patients treated with scaphoid excision and four-corner arthrodesis at 27 and 37 months followup. 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 PRC group. All 11 PRC procedures were successful with a high degree of patient satisfaction. PRC compared favorably with four-corner fusion for SNAC wrist and was recommended if the lunate 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 reported successful results after PRC for a variety of conditions. Chronic pain and limitations of function were present because of rheumatoid arthritis, Kienbocks disease, chronic SLAC wrist, and chronic scaphoid nonunion. Overall results showed 6% excellent, 35% good, 29% fair, and 30% 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 rheumatoid arthritis had consistently poor results. Five of the patients in the study underwent PRC for advanced SNAC wrist and were followed up 2 to 3 years later. The preoperative exion-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 unaected side preoperatively and 61% postoperatively compared with 54% and 63% for the nonscaphoid fractured group. The SNAC wrist patients had one good, three fair, and one poor result after this procedure, with an average wrist score of 64. The SLAC wrist and Kienbocks disease patients had one excellent, four good, three fair, and four poor results, with an average postoperative wrist score of 67. Krakauer and colleagues [8] compared the results of 55 cases of SLAC wrists treated by various methods, including PRC, partial wrist fusion, and total wrist fusion. Eight patients in the series had a history of scaphoid fracture. Twelve patients underwent PRC, although their preoperative diagnosis was not clearly dened. Of the 12 patients who underwent PRC, 11 were stage II SLAC and 1 was stage III, with a mean follow-up of 39 months. The average exionextension arc at nal follow-up was 71 , the most of any treatment group. Grip strength improved from 62.7% of the contralateral hand preoperatively to 65.6% postoperatively. Five patients had rare or no pain at nal follow-up. Two had mild pain, two had moderate pain, and three had severe pain. Four patients had radiographic narrowing of the capitolunate joint. At follow-up, one was asymptomatic, one had moderate pain, and two had severe pain. The two patients with severe pain were converted to a total wrist arthrodesis, with one of the patients having resolution of pain. The authors concluded that PRC provides the best postoperative motion but can be associated with painful narrowing of the radiocapitate joint. PRC was recommended 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 undergone either a four-corner arthrodesis or PRC at 28 and 19 months. At follow-up, wrist examination revealed an 81 exion-extension arc in the PRC group and 80 exion-extension arc in the fourcorner athrodesis group. The four-corner group had greater radial deviation and slightly greater grip strengh (79% versus 71%). Pain relief was similar, and patient satisfaction was equivalent. The authors concluded that both procedures were motion-preserving options with minimal subjective or objective dierences in short-term follow-up evaluations. They noted the technical ease, early mobilization, and lack of nonunion risk in the PRC group. Discussion Candidates for PRC in SNAC wrists have not been dened completely in the literature. Most authors agree that the cartilage of the lunate fossa and proximal capitate must be preserved for the procedure to provide pain relief successfully. Nevaiser [10] stated that mild changes in the
189
scaphocapitate articulation did not preclude a good result. Culp and associates [7] found that mild preoperative radiographic deterioration at the lunate fossa or the proximal capitate were consistent with a successful result. In patients with moderate-to-severe arthritis, the procedure had poor results. Salomon and Eaton [11] recommended a modied PRC in patients with radiolunate and lunocapitate arthritis. They performed partial capitate resection and dorsal capsule interposition in seven patients with lunocapitate arthritis and in three patients with radiolunate disease. At 55 months follow-up, seven patients reported no pain, and three patients had occasional pain. Grip strength improved, and nal arc of motion was 111 . As a motion-sparing salvage procedure, PRC provides a pain-relieving salvage option without the functional loss of total wrist arthrodesis. Motion obtained after PRC compares favorably with other motion-preserving salvage procedures, ranging from 40% to 60% of the unaected side. The results in various studies [59] for the SNAC pattern show that greater than a 70 arc of motion can be expected when salvaging a SNAC wrist. Grip strength consistently improves from preoperative levels. Wyrick and colleagues [6] showed improved overall grip strength and motion in PRC. Several authors have advocated resection of the radial styloid to prevent impingement during full radial deviation. This is a potential problem if the distal pole of the scaphoid is excised incompletely. If the entire proximal row is excised, the trapezium should not impinge because it lies palmar to the styloid process of the radius, a relationship that has been shown by threedimensional computed tomography reconstruction [12,13]. If the radial styloid is removed at the time of surgery, care should be taken to avoid damage to the origin of the radioscaphocapitate ligament, which is important in preventing ulnar translation by stabilizing the capitate in the lunate fossa. The duration of symptoms, pin xation, and duration of postoperative immobilization do not seem to inuence the nal result in PRC. Imbriglia and coworkers [13] reported the combined results of PRC in heavy laborers, showing 25 of 32 patients returned to work without limitations. Most authors agree that nonlaborers are more likely to resume their preoperative vocations. PRC has been used for many years in patients with carpal degenerative instability caused by a variety of conditions. It is a technically simple procedure to perform with early mobilization of the wrist and no risk of nonunion or other complications related to hardware placement. The results of this procedure in patients with SNAC wrists in the literature and at our institution have been successful in terms of restoring function, range of motion, and grip strength. Improved results are obtained in patients with preserved capitolunate and radiolunate articulations. References
[1] Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am 1984;9:35865. [2] Vender MI, Watson HK, Wiener BD, et al. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg Am 1987;12:5149. [3] Stamm TT. Excision of the proximal row of the carpus. Proc R Soc Med 1944;38:745. [4] Crabbe WA. Excision of the proximal row of the carpus. J Bone Joint Surg Br 1964;46:789. [5] Tomaino MM, Delsignore J, Burton R. Long-term results following proximal row carpectomy. J Hand Surg Am 1994;19:694703. [6] Wyrick JD, Stern PJ, Kiefhaber TR. Motion-preserving procedures in the treatment of scapholunate advanced collapse wrist: proximal row carpectomy vs. four-corner athrodesis. J Hand Surg Am 1995;20:96570. [7] Culp RW, McGuigan FX, Turner MA, et al. Proximal row carpectomy: a multicenter study. J Hand Surg Am 1993;18:1925. [8] Krakauer JD, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg Am 1994;19:1519. [9] Cohen MS, Kozin SH. Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and four-corner arthrodesis. J Hand Surg Am 2001;26:94104. [10] Nevaiser RJ. On resection of the proximal carpal row. Clin Orthop 1986;202:125. [11] Salomon GD, Eaton RG. Proximal row carpectomy with partial capitate wedge resection. J Hand Surg Am 1996;21:28. [12] Fitzgerald JP, Peimer CA, Smith RJ. Distraction resection arthroplasty of the wrist. J Hand Surg Am 1989;14:77481. [13] Imbriglia JE, Broudy AS, Hagberg WC, et al. Proximal row carpectomy: clinical evaluation. J Hand Surg Am 1990;15:42630.

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

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

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

Uploaded by

Copyright:

Available Formats

Atlas of the Hand Clinics

Copyright 2006 Saunders, An Imprint of Elsevier

Volume 8, Issue 1 (March 2003)

Atlas Hand Clin 8 (2003) ix

Foreword Scaphoid injuries

A. Lee Osterman, MD Consulting Editor

Atlas Hand Clin 8 (2003) xixii

Joseph F. Slade III, MD Guest Editor

J.F. Slade III / Atlas Hand Clin 8 (2003) xixii

Atlas Hand Clin 8 (2003) 118

Atlas Hand Clin 8 (2003) 1928

Volar percutaneous xation of stable scaphoid fractures

A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 1928

A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 1928

A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 1928

A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 1928

A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 1928

A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 1928

A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 1928

A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 1928

A.Y. Shin, E.P. Hofmeister / Atlas Hand Clin 8 (2003) 1928

Atlas Hand Clin 8 (2003) 2935

Percutaneous scaphoid xation: surgical technique volar approach with traction

N. Goddard / Atlas Hand Clin 8 (2003) 2935

N. Goddard / Atlas Hand Clin 8 (2003) 2935

N. Goddard / Atlas Hand Clin 8 (2003) 2935

N. Goddard / Atlas Hand Clin 8 (2003) 2935

N. Goddard / Atlas Hand Clin 8 (2003) 2935

Atlas Hand Clin 8 (2003) 3756

Arthroscopic assisted xation of fractures of the scaphoid

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

W.B. Geissler / Atlas Hand Clin 8 (2003) 3756

Atlas Hand Clin 8 (2003) 5766

Scaphoid fracture repair using the Herbert screw system (HBS)

H. Krimmer / Atlas Hand Clin 8 (2003) 5766

H. Krimmer / Atlas Hand Clin 8 (2003) 5766

H. Krimmer / Atlas Hand Clin 8 (2003) 5766

Fig. 3. Setup for palmar minimally invasive approach.

H. Krimmer / Atlas Hand Clin 8 (2003) 5766

H. Krimmer / Atlas Hand Clin 8 (2003) 5766

H. Krimmer / Atlas Hand Clin 8 (2003) 5766

H. Krimmer / Atlas Hand Clin 8 (2003) 5766

H. Krimmer / Atlas Hand Clin 8 (2003) 5766

H. Krimmer / Atlas Hand Clin 8 (2003) 5766

Atlas Hand Clin 8 (2003) 6776

Open treatment of transscaphoid perilunate fracture dislocations

I. Sarris, D.G. Sotereanos / Atlas Hand Clin 8 (2003) 6776