1. by Joseph F. Slade, Andrew P. Gutow, and William B. Geissler
Percutaneous Internal Fixation of Scaphoid Fracturesvia an Arthroscopically Assisted Dorsal Approach
by Joseph F. Slade, Andrew P. Gutow, and William B. Geissler
J Bone Joint Surg Am
Volume 84(suppl 2):S21-S36
November 1, 2002
©2002 by The Journal of Bone and Joint Surgery, Inc.

2. Photograph and radiograph (inset) of the wrist of a patient in whom a scaphoid fracture was repaired with use of a dorsal percutaneous guidewire and a headless cannulated compression screw that was implanted through the proximal scaphoid pole along the cent...
Photograph and radiograph (inset) of the wrist of a patient in whom a scaphoid fracture was repaired with use of a dorsal percutaneous guidewire and a headless cannulated compression screw that was implanted through the proximal scaphoid pole along the central axis.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

3. Photograph of a scaphoid bone.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

4. Radiograph of the same scaphoid bone with a 0
Radiograph of the same scaphoid bone with a in guidewire lying along its central axis.
Radiograph of the same scaphoid bone with a in guidewire lying along its central axis.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

5. Photograph of a standard Acutrak screw, which is a headless cannulated compression screw with continuous variable-pitch threads.
Photograph of a standard Acutrak screw, which is a headless cannulated compression screw with continuous variable-pitch threads. The base of the screw has a diameter of 4.2 mm.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

6. On the posteroanterior view, scaphoid displacement is visualized as lateral displacement or a step-off.
On the posteroanterior view, scaphoid displacement is visualized as lateral displacement or a step-off.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

7. On the lateral or oblique view, scaphoid displacement appears as forward flexion of the distal fragment, displaying a "V"-separation of the dorsal cortex (future humpback deformity).
On the lateral or oblique view, scaphoid displacement appears as forward flexion of the distal fragment, displaying a "V"-separation of the dorsal cortex (future humpback deformity).
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

8. To visualize the central axis of the scaphoid, a posteroanterior view of the wrist must first be obtained.
To visualize the central axis of the scaphoid, a posteroanterior view of the wrist must first be obtained.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

9. The wrist is then pronated until the scaphoid poles are aligned and the scaphoid is viewed as a cylinder.
The wrist is then pronated until the scaphoid poles are aligned and the scaphoid is viewed as a cylinder.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

10. The wrist is then flexed until the scaphoid cylinder appears as a circle.
The wrist is then flexed until the scaphoid cylinder appears as a circle. The central axis of the scaphoid is now in the imaging beam, at the center of the scaphoid circle. The arrow in the radiograph and the dot on the dorsal part of the wrist mark the central axis of the scaphoid and the position and direction of the guidewire.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

11. Figs. 4-A and 4-B Under fluoroscopic visualization, the guidewire is placed at the base of the proximal pole of the scaphoid and is driven along the central axis.
Figs. 4-A and 4-B Under fluoroscopic visualization, the guidewire is placed at the base of the proximal pole of the scaphoid and is driven along the central axis.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

12. If the wire is correctly positioned, it must pass through the trapezium and exit at the radial base of the thumb.
If the wire is correctly positioned, it must pass through the trapezium and exit at the radial base of the thumb. The wrist must be maintained in a flexed position until the trailing end of the wire has cleared the proximal pole and the radiocarpal joint.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

13. The wrist is then extended, and minifluoroscopy is used to confirm the position of the guidewire along the central axis of the scaphoid as well as the quality of the fracture reduction.
The wrist is then extended, and minifluoroscopy is used to confirm the position of the guidewire along the central axis of the scaphoid as well as the quality of the fracture reduction.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

14. A in double-cut guidewire is passed in a dorsal-to-volar direction through the proximal fragment, past the fracture site, and along the central axis of the distal scaphoid fragment.
A in double-cut guidewire is passed in a dorsal-to-volar direction through the proximal fragment, past the fracture site, and along the central axis of the distal scaphoid fragment. The proximal fragment is ignored for now.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

15. Because these fractures tend to be unstable, a second antiglide guidewire, parallel to the first, is also placed in the scaphoid.
Because these fractures tend to be unstable, a second antiglide guidewire, parallel to the first, is also placed in the scaphoid.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

16. Fracture reduction is accomplished by the placement of two 0
Fracture reduction is accomplished by the placement of two in wire joysticks in the fracture fragments.
Fracture reduction is accomplished by the placement of two in wire joysticks in the fracture fragments. The joysticks are used to maintain fracture alignment while the volar guidewire in the distal pole is driven proximally and dorsally into the proximal pole, capturing and securing reduction.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

17. Figs. 5-D and 5-E The joysticks and antiglide wires are maintained during hand-drilling and dorsal implantation of the screw.
Figs. 5-D and 5-E The joysticks and antiglide wires are maintained during hand-drilling and dorsal implantation of the screw.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

18. Arthroscopy is used to assess the quality of the scaphoid fracture reduction.
Arthroscopy is used to assess the quality of the scaphoid fracture reduction. It is also used to document the integrity of the carpal and radiocarpal ligaments and to inspect the wrist for other occult injuries.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

19. Scaphoid length is determined by placing a second guidewire at the base of the proximal part of the scaphoid, next to the exposed dorsal guidewire.
Scaphoid length is determined by placing a second guidewire at the base of the proximal part of the scaphoid, next to the exposed dorsal guidewire. The difference between these wires is the scaphoid length.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

20. The scaphoid is prepared with a hand reamer.
The scaphoid is prepared with a hand reamer. Fluoroscopy is used to check the position and depth of the drill and screw. It is critical not to ream within 2 mm of the distal cortex.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

21. Figs. 8-B and 8-C A headless compression cannulated screw is implanted, and fluoroscopy confirms the correct position of the fixation device.
Figs. 8-B and 8-C A headless compression cannulated screw is implanted, and fluoroscopy confirms the correct position of the fixation device.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

22. vSingle sutures are used to close the arthroscopic portals.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

23. At the first office visit, the hand is placed into a removable thumb-spica splint and the patient is started on strengthening exercises.
At the first office visit, the hand is placed into a removable thumb-spica splint and the patient is started on strengthening exercises.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

24. Computed tomographic scanning of the scaphoid with 1-mm cuts in two planes (posteroanterior and lateral) is used to evaluate fracture-healing.
Computed tomographic scanning of the scaphoid with 1-mm cuts in two planes (posteroanterior and lateral) is used to evaluate fracture-healing.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

25. Arthroscopic inspection of the radiocarpal joint at the point at which the screw was inserted at the base of the scaphoid confirms that the screw has been completely implanted within bone.
Arthroscopic inspection of the radiocarpal joint at the point at which the screw was inserted at the base of the scaphoid confirms that the screw has been completely implanted within bone.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

26. Examination of radiocarpal joints after scaphoid healing demonstrates collagen overgrowth and a smooth gliding surface.
Examination of radiocarpal joints after scaphoid healing demonstrates collagen overgrowth and a smooth gliding surface.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

27. Radiograph, made fifty days after the injury, demonstrating the proximal pole fracture.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

28. Figs. 11-B, 11-C, and 11-D Healing was confirmed with computed tomographic scans and radiographs at 103 days after the operation.
Figs. 11-B, 11-C, and 11-D Healing was confirmed with computed tomographic scans and radiographs at 103 days after the operation.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

29. Figs. 11-B, 11-C, and 11-D Healing was confirmed with computed tomographic scans and radiographs at 103 days after the operation.
Figs. 11-B, 11-C, and 11-D Healing was confirmed with computed tomographic scans and radiographs at 103 days after the operation.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.

30. Figs. 11-B, 11-C, and 11-D Healing was confirmed with computed tomographic scans and radiographs at 103 days after the operation.
Figs. 11-B, 11-C, and 11-D Healing was confirmed with computed tomographic scans and radiographs at 103 days after the operation.
Joseph F. Slade III et al. J Bone Joint Surg Am 2002;84:S21-S36
©2002 by The Journal of Bone and Joint Surgery, Inc.