Percutaneous fixation of scaphoid fractures

Recent advances in techniques and implants have led to renewed interest in percutaneous screw fixation of acute scaphoid fractures. The closed (cast) treatment of acute scaphoid fractures generally has good outcome, with bony union resulting; however, closed treatment can result in delayed union, nonunion, malunion, cast- induced joint stiffness, and lost time from employment and avocations. Acute percutaneous fixation of scaphoid fracture has been proposed as a means to minimize some of the complications of closed (cast) treatment. Percutaneous treatment of both nondisplaced and displaced scaphoid fractures reportedly can achieve a nearly 100% union rate with minimal complications. Fixation of scaphoid fractures with headless compression screws can be done using both volar and dorsal approaches. The fracture reduction and alignment are assessed by fluoroscopy and arthroscopy. Appropriately performed acute percutaneous internal fixation is now a standard treatment option for a selected group of patients with acute scaphoid fracture.     

Volar percutaneous transtrapezial fixation of scaphoid waist fractures: surgical technique

Percutaneous screw fixation of scaphoid fractures has gained popularity over the years. The disadvantages of a long period of cast immobilisation are avoided and this technique allows a more rapid return to work and sports activities than conservative treatment. Consequently, percutaneous screw fixation is appealing for the young and active population. Biomechanical studies showed that greater fixation strength is obtained when the screw is placed centrally than eccentrically. Central screw placement can however be technically demanding. In the use of a volar percutaneous approach, the trapezium and the shape of the scaphoid impede central screw placement. Different approaches are available to overcome this difficulty. The volar percutaneous transtrapezial approach facilitates and allows more accurate central screw placement compared to approaches that try to avoid the trapezium. The surgical technique of this approach is described.     

Percutaneous fixation of scaphoid fractures.

The scaphoid proximal pole and waist fractures presented here were treated by a novel dorsal percutaneous technique with arthroscopic assistance. All fractures healed, with good final functional results and no complications. The advantages of the dorsal percutaneous approach to scaphoid fixation are: (1) the proximal-to-distal placement of the guide pin and screw allow for more precise placement along the central axis of the scaphoid, which decreases healing time and reduces risk of screw thread exposure. (2) The dorsal approach avoids injuring the vulnerable volar ligament anatomy. And (3) the insertion of the screw from the proximal to distal direction allows the more rigid fixation of proximal scaphoid fractures. Arthroscopy allows confirmation of fracture reduction and screw implantation as well as evaluation of concurrent ligament injuries not detected with standard imaging. Percutaneous K-wires act as joysticks to reduce and compress fracture fragments prior to fixation. The presented technique allows for early, rigid internal fixation with minimal associated morbidity. Patients successfully treated with this technique include those with stable and unstable acute fractures of the scaphoid at all locations, including the proximal pole. Nondisplaced fractures that present with delayed or fibrous union without evidence of avascular necrosis, cyst formation, or bony sclerosis may also be treated with this technique. This technique allows for faster rehabilitation and an earlier return to work or avocation without restriction once CT scan confirms a solid union. Some articles document extraordinary rapid healing by standard radiographs; however, we caution that scaphoid bone healing cannot accurately be determined without CT scan. Percutaneous, arthroscopically assisted internal fixation by a dorsal approach may be considered in all acute scaphoid fractures selected for surgical fixation. The dorsal guidewire permits dorsal and volar implantation of a cannulated screw along the central axis of the scaphoid. This technique permits the reduction of displaced fractures and the stable repair of fractures of the proximal pole. In addition, selected scaphoid fibrous union or delayed union may also be repaired, with realistic expectations of healing. The proven benefits of the percutaneous technique include decreased soft tissue trauma; arthroscopic visualization of the fracture, ensuring anatomic reduction; and stable fixation, allowing early physical rehabilitation. The theoretical benefits of the technique include decreased risk of interruption of the tenuous scaphoid blood supply. Percutaneous internal fixation of scaphoid fractures provides faster rehabilitation, earlier return to work, and quicker bony union in most patients.     

Percutaneous fixation of stable scaphoid fractures

The increased awareness of scaphoid fractures and their complications has prompted early aggressive treatment to prevent the sequelae of nonunions and degenerative changes in the carpus. Despite this, many fractures require prolonged immobilization, often resulting in diminished motion and time lost in sports or employment. In an effort to diminish the time to union and decrease prolonged immobilization, percutaneous fixation techniques have been described and recently popularized by several authors. The indications and contraindications, technique, complications, and rehabilitation of treatment of both dorsally and volarly placed percutaneous screw fixation of stable scaphoid fractures will be the focus of this paper.     

Percutaneous screw fixation for scaphoid fractures

Long-term results of percutaneous treatment for 36 scaphoid fractures, types B1 and B2 according to Herbert, are reported. Outcomes were satisfactory in nearly all cases. In three patients, the screw was too long and had to be removed, and pseudoarthrosis developed in one patient. Consolidation was observed after 6–8 weeks, less than literature reports for immobilization with casts. The percutaneous approach is particularly suitable for younger patients who work or play sports.     

Percutaneous screw fixation for unstable scaphoid fractures

BACKGROUND: The technique of percutaneous screw fixation, with increasing popularity, has been successfully conducted in non-displaced, stable scaphoid fractures resulting in shortened immobilization duration and prompt functional retrieval. The purpose of this study was to evaluate the surgical technique and to explore the potential benefits of using percutaneous screw fixation in unstable scaphoid fractures. METHODS: Eleven of 97 patients with scaphoid fractures surgically treated between 1994 and 2002 were enrolled in this study. All were acute unstable fractures and underwent closed reduction and percutaneous screw fixation. All the records were meticulously reviewed and reported, including the complete radiographic examination before and after operation, time to fracture union, wrist motion, grip strength, and time of return to work, as well as overall patient satisfaction at the time of the most recent follow-up. RESULTS: Eleven fractures in an equal number of patients were followed up for a mean period of 1.6 years. All fractures acquired radiographic union in an average of 10.6 weeks. The modified Mayo Wrist score averaged 88.2. The functional result was ranked as excellent in 6 patients, and good in 5 patients. All returned to work or the pre-injury level of activity, and were satisfied with the surgical outcome. CONCLUSION: The technique of percutaneous screw fixation was successfully used to treat 11 unstable scaphoid fractures. The encouraging outcome of this treatment option and the prompt functional recovery deserve further investigation. Further randomized prospective studies to explore the specific indications and ubiquitous benefits of the technique presented herein are recommended.     

Percutaneous fixation of scaphoid fractures. An anatomical study

Percutaneous scaphoid fracture fixation has many advantages over the open method of fixation. We describe the anatomical basis for a safe percutaneous approach. Cannulated screws were inserted into 32 cadaveric scaphoids through 1 cm palmar incisions under fluoroscopic control. We then measured the distance between the entry point in the scaphoid and important local neurovascular structures. We also measured the angle of entry of the guide wire in two planes. The mean distance of the entry point from the main radial artery was 14 mm (range, 7-24 mm); from the radial nerve 19 mm (range, 7-35 mm); from the recurrent branch of the median nerve 29 mm (range, 14-45 mm); and from the superficial branch of the radial artery 5 mm (range, 0-8 mm) The mean radial angle of insertion was 34 degrees and the mean palmar angle of insertion was 58 degrees. Percutaneous fixation of scaphoid fractures puts the superficial palmar branch of the radial artery at risk. We recommend a 1 cm incision centred over the scaphotrapezial joint and dissection under direct vision to the entry point in the scaphoid rather than a completely percutaneous approach.     

Percutaneous screw fixation for fractures of the scaphoid.

We describe a percutaneous technique for screw fixation of all types of fractures of the scaphoid. During a 15-year period ending in 1984, 280 cases were treated by this method; 198 of them returned for evaluation in 1986 and comprise the material for this report. After a mean postoperative time of 82 months, 89% of the recent fractures had united as well as 81.8% of those with delayed or nonunion and 42.8% of those with sclerotic nonunion.     

Percutaneous fixation of selected scaphoid fractures by dorsal approach

The aim of our study was to evaluate clinical, radiological and functional outcomes of selected cases of percutaneous fixation of scaphoid fractures via a dorsal approach. Percutaneous fixation by dorsal approach was done in 32 patients (mean age 32.2 years) involving both fresh and late scaphoid fracture presentations (mean 17 days). Fourteen cases of B1 type, ten cases of B2 and eight cases of C type (Herbert’s classification) were treated. The patients were prospectively followed up clinically and radiologically for a minimum follow-up of 14 months (mean 16 months), and functional outcome and complications were assessed. All fractures united over an average of nine weeks. There was no avascular necrosis or screw cutout with preservation of wrist movement and grip strength. There were no injuries to any at risk anatomical structures. Percutaneous fixation of scaphoid fractures through dorsal approach gives good clinical and functional outcome in acute and chronic scaphoid fractures of B1, B2 and C types (Herbert’s classification).     

Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures

BACKGROUND: Nondisplaced scaphoid fractures treated with prolonged cast immobilization may result in temporary joint stiffness and muscle weakness in addition to a delay in return to sports or work. Fixation of scaphoid fractures with a percutaneous cannulated screw has resulted in a shorter time to union and to return to work or sports. The purpose of this prospective, randomized study was to compare cast immobilization with percutaneous cannulated screw fixation of nondisplaced scaphoid fractures with respect to time to radiographic union and to return to work. METHODS: Twenty-five full-time military personnel with an acute nondisplaced fracture of the scaphoid waist consented to be randomized to either cast immobilization or fixation with a percutaneous cannulated Acutrak screw (Acumed, Beaverton, Oregon) for the purpose of this study. Time to fracture union, wrist motion, grip strength, and return to work as well as overall patient satisfaction at the time of a two-year follow-up were evaluated. RESULTS: Eleven patients were randomized to percutaneous cannulated screw fixation, and fourteen were randomized to cast immobilization. The average time to fracture union in the screw fixation group was seven weeks compared with twelve weeks in the cast immobilization group (p = 0.0003). The average time until the patients returned to work was eight weeks compared with fifteen weeks in the cast immobilization group (p = 0.0001). There was no significant difference in the range of motion of the wrist or in grip strength at the two-year follow-up evaluation. Overall patient satisfaction was high in both groups. CONCLUSIONS: Percutaneous cannulated screw fixation of nondisplaced scaphoid fractures resulted in faster radiographic union and return to military duty compared with cast immobilization. The specific indications for and the risks and benefits of percutaneous screw fixation of such fractures must be determined in larger randomized, prospective studies.     

Percutaneous cannulated screw fixation of acute scaphoid waist fracture

This prospective study assessed the outcome of percutaneous cannulated screw fixation in 49 of 60 acute scaphoid fractures. The union rate was 100% (mean time for radiological union at 12 weeks). There were no early or mid-term complications and all achieved an excellent functional recovery.     

Percutaneous and arthroscopic screw fixation of scaphoid fractures in the athlete.

The authors prefer to treat nondisplaced acute scaphoid fractures in the athlete on an individualized basis. Percutaneous or arthroscopic-assisted fixation are valuable techniques to employ when prolonged immobilization is a concern. Return to athletic competition has been rapid using these methods. Morbidity has been minimal, and there have been no nonunions to date at the authors' institution.     

Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach

Percutaneous internal fixation of scaphoid fractures allows for more predictable union and less morbidity than cast treatment or open internal fixation. A headless cannulated compression screw (standard Acutrak) is implanted by way of a dorsal percutaneous approach with the aid of fluoroscopy and arthroscopy to confirm screw position and fracture reduction. This technique is indicated in the correction of acute proximal pole fractures, acute waist fractures, and delayed unions that are not associated with avascular necrosis or collapse. The details of this technique are reviewed. In a consecutive series of twenty-seven fractures (seventeen waist fractures and ten proximal pole fractures) treated with arthroscopically assisted dorsal percutaneous fixation, computed tomographic scanning confirmed 100% union at an average of twelve weeks. Eighteen fractures were treated within one month after the injury, and nine were treated more than one month after the injury. In this series, the fractures that were treated early (less than one month after the injury) healed more quickly than those treated later.     

Retrograde compression screw fixation of acute proximal pole scaphoid fractures

Seventeen consecutive patients with acute unstable proximal pole scaphoid fractures were managed over the past 5 years with open reduction and internal fixation. Four fractures were displaced, with greater than 1 mm of fragment offset and intercarpal malalignment. The operative technique consisted of a dorsal approach to the scaphoid, radius bone grafting, and freehand retrograde Herbert compression screw fixation. The patients were evaluated at an average of 37 months (range, 12-63 months) after surgery. All fractures healed within 13 weeks (average, 10 weeks). Functional wrist range of motion and grip strength were achieved in all patients. No patients developed osteonecrosis or radioscaphoid arthritis. Open reduction and internal fixation rather than primary casting is a better means of reducing the complications of delayed union, nonunion, and irreparable osteonecrosis that often occur after acute proximal pole scaphoid fracture treated with cast immobilization.