Elsevier

The Journal of Hand Surgery

Volume 42, Issue 9, September 2017, Pages 758.e1-758.e4
The Journal of Hand Surgery

Surgical technique
Fixation of Ultrasmall Proximal Pole Scaphoid Fractures Using Bioabsorbable Osteochondral Fixation Nails

https://doi.org/10.1016/j.jhsa.2017.06.011Get rights and content

Surgical treatment of ultrasmall proximal pole scaphoid fractures poses a number of challenges. The fragment may be too small to fix with conventional headless screw fixation owing to the high risk of fragmentation upon insertion. However, excision of the fragment risks compromising the scapholunate ligament complex and also exposes the radioscaphoid joint to potential degenerative changes. Under these circumstances, we describe the use of bioabsorbable osteochondral fixation nails that allows stable low-profile fixation while minimizing the risk of fracturing the proximal pole.

Section snippets

Indication

  • Very small proximal pole scaphoid fractures that are too small for conventional headless screw fixation.

Contraindications

  • Established AVN or fragmentation of the proximal pole of the scaphoid.

  • Scaphoid nonunion advanced collapse.

  • Large proximal pole fractures that can be fixed using conventional headless compression screws or Kirschner wires.

Surgical Technique

A dorsal approach to the wrist is performed. The incision is made longitudinally over the third/fourth dorsal compartment. Dissection is performed down to the extensor retinaculum, and subcutaneous flaps are established medially and laterally. The extensor retinaculum is divided over the extensor pollicis longus tendon. Oblique capsulotomy is performed to expose the proximal pole of scaphoid and care is taken to preserve the scapholunate ligament (Fig. 3A). If the fracture is chronic, the

Postoperative Care

A plaster thumb spica orthosis is applied for approximately 10 days after surgery. Thereafter, the patient is immobilized in a thermoplastic removable thumb spica orthosis for 8 weeks or until fracture union. Gentle range of motion is commenced and a follow-up computed tomography (CT) scan is performed to confirm union.

Pearls and Pitfalls

  • When curetting the proximal pole in cases of nonunion, care should be taken not to remove too much proximal bone from the already small proximal fragment.

  • Gentle drilling and tapping when inserting the SmartNail so as not to fragment the proximal pole.

Case Example

A healthy 45-year-old computer analyst presented with an ultrasmall proximal pole scaphoid fracture of his dominant wrist as a result of hyperextension injury when lifting weights at the gym. His initial presentation to our institution was 3 months following the initial injury with ongoing dorsal wrist pain and difficulty weight bearing. Plain radiographs and CT demonstrated fracture nonunion and early cystic changes. The thickness of subchondral bone in the proximal fragment was less than 3 mm

References (5)

There are more references available in the full text version of this article.

Cited by (3)

  • Use of biomaterials in scaphoid fracture fixation, a systematic review

    2021, Clinical Biomechanics
    Citation Excerpt :

    This is representative of the mean patient population presenting with scaphoid fractures and undergoing subsequent fixation (Van Tassel et al., 2010). Two case studies were included in this review (Ek and Wang, 2017; Wichelhaus et al., 2016). Wichelhaus et al (Wichelhaus et al., 2016) described two magnesium-based screws inserted as secondary fixation, with Ek and Wang (Ek and Wang, 2017) using a polylactic acid (PLA) co-polymer for fixation.

  • Comparative outcome analysis of internal screw fixation and Kirschner wire fixation in the treatment of scaphoid nonunion

    2020, Journal of Plastic, Reconstructive and Aesthetic Surgery
    Citation Excerpt :

    With the absence of adequate placement opportunities, fallback options are necessary, including no fixation at all, palmar plating, bioabsorbable nails, external fixation, and Kirschner wires.3,21 –23 Treatment with no fixation has several disadvantages leading to unfavorable results and should be avoided whenever possible, as investigated in 2015 by Pinder et al. in a systematic review (n = 83).1

  • Minimally Invasive Fixation of Ultra-Small Proximal Pole Scaphoid Fractures

    2021, Arthroscopy and Endoscopy of the Elbow, Wrist and Hand: Surgical Anatomy and Techniques

No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

This investigation was performed at the Melbourne Orthopaedic Group and Department of Orthopaedics, Dandenong Hospital, Monash University, Australia.

View full text