fractures and dislocations of the carpal bones

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MD Consult: Canale & Beaty: Campbell's Operative Orthopaedics

http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-0-323-0332...

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Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed.Copyright 2007 Mosby, An Imprint of Elsevier

FRACTURES AND DISLOCATIONS OF THE CARPAL BONES, INCLUDING KIENB?CK DISEASEThe diagnosis of fractures and dislocations of the carpal bones can be difficult for several reasons. The outlines of the eight bones are superimposed in most radiographic views. Even in the anteroposterior view, at least one bone overlies another. All views must be interpreted with an understanding of the normal bone contours, the relationships between the bones, and the changing relationships during the various arcs of wrist motion. Because of the difficulty in recognizing fractures in acute injuries, fractures in this region may not be seen at initial examination. Articular damage and ligament injuries are even more difficult to evaluate. The latter may permit abnormal rotations and subluxations of the various bones. Special radiographic techniques are helpful. Nakamura et al. found scaphoid fracture displacement to be more readily detected and distinct with three-dimensional CT than with plain tomography. Even though special techniques may be used, establishing a precise diagnosis can be difficult. Often prognosis is uncertain because of the peculiarities of the blood supply of these bones, especially of the scaphoid and lunate. Perlik and Guilford compared MRI with plain radiographs, tomograms, and the surgeon's operative impression in the assessment of scaphoid nonunions. They found that MRI was more accurate than the other techniques in predicting the vascularity of scaphoid nonunions.

Fractures of the ScaphoidFracture of the carpal scaphoid bone is the most common fracture of the carpus, and frequently diagnosis is delayed. A delay in diagnosis and treatment of this fracture may alter the prognosis for union. A wrist sprain that is sufficiently severe to require radiographic examination initially should be treated as a possible fracture of the scaphoid, and radiographs should be repeated in 2 weeks even though initial radiographs may be negative.

EtiologyThis fracture has been reported in individuals ranging from 10 to 70 years old, although it is most common in young men. It is caused by a fall on the outstretched palm, resulting in severe hyperextension and slight radial deviation of the wrist. Weber and Chao showed that the scaphoid usually fractures in tension with the wrist extended and concentrating the load on the radial-palmar side. The proximal pole locks in the scaphoid fossa of the radius, and the distal pole moves excessively dorsal (Fig. 66-19). Of scaphoid fractures, 60% to 80% occur at the scaphoid waist or midportion. Seventeen percent of patients have other fractures of the carpus and forearm, including transscaphoid perilunar dislocations, fractures of the trapezium, Bennett fractures, fractures of the radial head, dislocations of the lunate, and fractures at the distal end of the radius. When other injuries of carpal bones require open reduction, the fractured scaphoid also should be reduced accurately.

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Fig. 66-19 Representation of potential load-carrying structures involved in proximal carpal articulation. Four ligamentous components, cb, ed, ih, kj, potentially transmit tensile loads when wrist is in strong dorsiflexion. Dorsal ligamentous structures eliminated from analysis because in dorsiflexion structures would be lax. Articular surface between radius and scaphoid and between radius and lunate potentially transmit compressive forces Ff and Fg. These forces are related to fixed coordinate system (XYZ) and to vector representation of applied load (P). cb, radiocollateral ligament complex; ed, radiocapitate ligament; Ff, radioscaphoid contact force; Fg, radiolunate contact force; ih, radiolunate ligament; kj, ulnar capsular ligament; XYZ, cartesian coordinate system.(From Weber ER, Chao EY: An experimental approach to the mechanism of scaphoid waist fractures, J Hand Surg 3A:142, 1978.)

Anatomy and Blood Supply of the Scaphoid BoneThe unique anatomy of the scaphoid predisposes fracture of this carpal bone to delayed union or nonunion and to disability of the wrist. Because it articulates with the distal radius and with four of the remaining seven carpal bones, the scaphoid moves with nearly all carpal motions, especially volar flexion. Any alteration of its articular surface through fracture, dislocation, or subluxation or any alteration of its stability by ligamentous rupture can cause severe secondary changes throughout the entire carpus. The blood supply of the scaphoid is precarious. Obletz and Halbstein showed that only 67% of

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scaphoid bones have arterial foramina throughout their length, including the distal, middle, and proximal thirds. Of the remaining bones, 13% have blood supply predominantly in the distal third, and 20% have most of the arterial foramina in the waist area of the bone with no more than a single foramen near the proximal third. One third of scaphoid fractures occurring in the proximal third may be without adequate blood supply. This seems to be borne out clinically; the prevalence of osteonecrosis can be 35% in fractures at this level. Fractures in the proximal pole can be expected to take longer to heal and usually have higher rates of nonunion. Taleisnik and Kelly showed that vessels entered the scaphoid from the radial artery laterovolarly, dorsally, and distally. The laterovolar and dorsal systems share in the blood supply to the proximal two thirds of the scaphoid. Gelberman and Menon found that vascularity of the proximal pole and 70% to 80% of the interosseous circulation were provided through branches of the radial artery, entering through the dorsal ridge. In the distal tuberosity region, 20% to 30% of the bone receives its blood supply from volar branches of the radial artery.

Diagnosis and TreatmentTreatment of scaphoid fractures is determined by displacement and stability of the fracture. Cooney, Dobyns, and Linscheid classified scaphoid fractures as either undisplaced and stable or displaced and unstable (Fig. 66-20). Although this classification remains useful, fractures of the tuberosity, the distal articular surface, and the proximal pole may require special management decisions. For nondisplaced fractures, radiographic diagnosis can be difficult initially. A posteroanterior plain radiograph with the wrist slightly extended in ulnar deviation is helpful. Although repeating radiographs after 2 weeks of immobilization in a cast is a time-honored method for evaluation of a suspected nondisplaced scaphoid fracture, the technetium bone scan, MRI, and CT (in the sagittal plane of the scaphoid) provide diagnostic information sooner. Although bone scan has been considered the most sensitive study, Gaebler et al. reported 100% sensitivity and specificity using MRI to diagnose occult scaphoid fractures at an average of 2.8 days after injury (Fig. 66-21 A). MRI, especially with gadolinium enhancement, also is useful in assessing the vascularity of a fractured scaphoid (Fig. 66-21 B).

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Fig. 66-20 Union of scaphoid after bone grafting is influenced significantly by location of fracture and amount of displacement.(From Cooney WP, Dobyns JH, Linscheid RL: Nonunion of the scaphoid: analysis of the results from bone grafting, J Hand Surg 5A:343, 1980.)

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Fig. 66-21 MRI is useful for diagnosis of occult scaphoid fractures (A) and for evaluation of vascularity of fractured scaphoid (B).(From Segalman KA, Graham TJ: Scaphoid proximal pole fractures and nonunions, J Am Soc Surg Hand 4:233, 2004.)

Nondisplaced, Stable Scaphoid Fractures Nonoperative treatment usually is successful for acute nondisplaced, stable fractures through the scaphoid waist and in the distal pole without other bony or ligamentous injury and for scaphoid fractures in children. The prognosis is better if the fracture is diagnosed early. Controversies continue regarding the position of the wrist, the proximal and distal length of the cast, and elbow and thumb immobilization. There are clinical and experimental data to support most aspects of the controversies. In a series of 92 patients, Terkelsen and Jepsen found that the incidence of nonunion was no greater in patients treated by a removable short arm thumb spica cast than in patients treated by a long arm thumb spica cast. Conversely, Gellman et al. found that the time to union was 3 months earlier in patients treated initially for 6 weeks in a long arm thumb spica cast. Using an experimental scaphoid fracture, Kaneshiro et al. found that displacement of more than 3 mm occurred between fracture fragments during pronation and supination with the forearm in a short arm thumb spica cast. We use either a forearm cast or a Munster-type cast, from just below the elbow proximally to the base of the thumbnail and the proximal palmar crease distally (thumb spica) with the wrist in slight radial deviation and in neutral flexion. The thumb is maintained in a functional position, and the fingers are free to move from the metacarpophalangeal joints distally. Using nonoperative casting techniques, the expected rate of union is 90% to 95% within 10 to 12

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weeks. During this time, the fracture is observed radiographically for healing. If collapse or angulation of the fractured fragments occurs, surgical treatment usually is required. Singh et al. evaluated 66 patients with acute fractures of the scaphoid waist and proximal pole treated with a below-elbow cast for 8 to 12 weeks. CT scanning at 12 to 18 weeks revealed 22 partial unions and 14 delayed unions. CT scans at 23 to 40 weeks showed additional healing in nine of 12 patients with partial union of less than 75% of the fracture. Fractures at and distal to the scaphoid waist are expected to heal sooner than fractures in the proximal pole. If the diagnosis is delayed, or the fracture is in the proximal third, the prognosis is less favorable, and an initial long arm thumb spica cast for 6 weeks may be justified. If the diagnosis of an undisplaced fracture of the scaphoid has been delayed for several weeks, treatment usually begins with cast immobilization. Mack et al., reviewing scaphoid fractures diagnosed 1 to 6 months after injury, found that stable middle-third scaphoid fractures would heal with cast immobilization, but required an average of 19 weeks to heal, compared with a similar group of acute fractures that healed in an average of 10 weeks. As is reflected in the subsequent discussion of surgical treatment, there is a well-established trend toward earlier operative fixation of nondisplaced fractures. Surgery may be considered if new healing activity is not evident, and if union is not apparent after a trial of cast immobilization for about 20 weeks. Because of the potential for joint stiffness, muscle atrophy, or the inability to use the hand during and after prolonged immobilization, special nonoperative or operative treatment may be considered in certain patients (e.g., young laborers or athletes). Operative techniques, including percutaneous fixation with cannulated screws, are used with increasing frequency. The effect of early internal fixation on scaphoid fracture healing is inconclusive. Prospective, randomized studies by Bond et al. and Adolfsson et al. comparing percutaneous screw fixation with cast immobilization showed that patients in the screw fixation groups were able to regain movement and return to most activities earlier than patients in the casted groups. No harmful effects on fracture healing were seen. Dias et al., in a prospective randomized study of nondisplaced scaphoid waist fractures, compared 44 patients treated with casting with 44 patients treated with Herbert screw fixation without postoperative immobilization. There were no nonunions in the operatively treated group. In the cast treatment group, there were 10 nonunions at 12 weeks. Slade and Jaskwhich, Slade et al., and Inoue and Shionoya reported healing of all fractures treated with limited access, percutaneous, and arthroscopic percutaneous fixation. Advantages of this technique, according to its proponents, include less risk to neurovascular structures and intercarpal ligaments, earlier bone healing, and earlier return to activities. Patients considering such treatment should understand that acute, nondisplaced scaphoid fractures have a high probability of healing with cast treatment, and that complex and demanding surgical procedures may have complications. For some athletes, the use of padded casts during competition may be considered. The advantages and disadvantages of various treatment modifications should be considered in each patient. Displaced, Unstable Scaphoid Fractures A different course of treatment is required for a displaced, unstable fracture in which the6 de 69 13/10/2011 0:37

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fragments are offset more than 1 mm in the anteroposterior or oblique view, or lunocapitate angulation is greater than 15 degrees, or the scapholunate angulation is greater than 45 degrees in the lateral view (range 30 to 60 degrees). Other criteria for evaluating displacement include a lateral intrascaphoid angle greater than 45 degrees, an anteroposterior intrascaphoid angle less than 35 degrees (Amadio et al.), and a heightto-length ratio of 0.65 or greater (Bain et al.). Because the range of lunocapitate and scapholunate angulation can vary, comparison views of the opposite wrist can be helpful. Reduction can be attempted initially by longitudinal traction and slight radial compression of the carpus. If the reduction attempt is successful, percutaneous fixation with a cannulated screw or pins and application of a long arm thumb spica cast may suffice. Otherwise, open reduction and internal fixation may be required. For a displaced or unstable recent fracture of the scaphoid, the best method of fixation depends on the surgeon's experience and the equipment available. In some fractures, adequate internal fixation can be obtained with Kirschner wires. The AO cannulated screw, the Herbert differential pitch bone screw, other more recently designed screws, and staples have been used to advantage in displaced and unstable scaphoid fractures. According to a cadaver comparison study by Toby et al., the AO screw, the Acutrak screw, and the Herbert-Whipple screw showed better resistance to cyclical bending load than the noncannulated Herbert screw. In a comparison study of patients with scaphoid fractures, Trumble et al. noted 100% union in both groups, one treated with AO cannulated screws and the other with HerbertWhipple cannulated screws. Cannulated bone screws are useful because the screw can be placed accurately over a guide pin with video fluoroscopic control. The advantages of the Herbert screw, according to Sprague and Howard, are that it (1) reduces the time of external immobilization, (2) provides relatively strong internal fixation, and (3) produces compression at the fracture site. In addition, because the headless screw remains below the bone surface, removal usually is unnecessary. These screws can be used with a bone graft to correct scaphoid angulation. Use of the cannulated design can minimize the disadvantages of the noncannulated Herbert screw, which include the use of a jig for insertion and the demanding surgical technique (Fig. 66-22). Contraindications include (1) avascular fragmentation of the proximal pole of the scaphoid, (2) extensive trauma or osteoarthritis involving the adjacent carpals or articular surface of the radius, and (3) gross carpal collapse.

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Fig. 66-22 Herbert screw fixation of scaphoid. A, Jig used for volar approach to scaphoid. B, Short drill used for making screw hole. C, Long drill inserted to maximal depth. D, Herbert screw inserted.(Redrawn from Sprague HH, Howard FM: The Herbert screw for treatment of the scaphoid fracture, Contemp Orthop 16:18, 1988.)

Regardless of the fixation device used, preoperative review and practice of the details of the procedure for the planned fixation are necessary. Careful intraoperative attention to the details of the procedure, the achievement of as near an anatomical reduction as possible, and precise placement of the fixation device are of utmost importance. TECHNIQUE 66-5 Open Reduction and Internal Fixation of Acute Displaced Fractures of the Scaphoid

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Volar Approach With the patient supine and under suitable anesthesia, prepare the hand and wrist and one iliac crest, and inflate a pneumatic tourniquet. The volar approach usually gives the best exposure for scaphoid fractures at and distal to the waist. Make a longitudinal skin incision over the palmar surface of the wrist, beginning 3 to 4 cm proximal to the wrist flexion crease over the flexor carpi radialis. Extend the incision distally to the wrist flexion crease, and curve it radially toward the scaphotrapezial and trapeziometacarpal joints. Protect terminal branches of the palmar cutaneous branch of the median nerve and the superficial radial nerves. Reflect skin flaps at the level of the forearm fascia. Open the sheath of the flexor carpi radialis, retract the tendon radially, and open the deep surface of its sheath. Expose the palmar capsule of the joint over the radioscaphoid joint. Extend the wrist in ulnar deviation, and open the capsule in the longitudinal axis of the scaphoid bone, obliquely extending the incision toward the scaphotrapezial joint. With sharp dissection, expose the fracture, incise the long radiolunate and radioscaphocapitate ligaments, preserving each leaf of these capsuloligamentous structures for later repair. Inspect the fracture to determine the need for bone grafting. If comminution is absent or minimal, reduction and fixation suffice. If comminution is extensive, especially on the palmar surface, with a tendency to flexion of the scaphoid at the fracture, obtain an iliac crest bone graft. (See techniques of Stark et al. and of Fernandez in the section on scaphoid nonunions; also see Fig. 66-40.) Kirschner wires placed in the distal and proximal poles as toggle levers (joysticks) help to manipulate the fragments. Reduce the fracture, and fix it with Kirschner wires or a screw technique (e.g., cannulated screws), avoiding rotation or angulation. If a cannulated device is used, ensure that the guidewire is centered in the proximal and distal poles. Image intensification with C-arm fluoroscopy is helpful for this step. For fractures through the waist and in the distal pole, insert the fixation device through a distal portal. Create the distal portal by opening the scaphotrapezial joint with a longitudinal capsular incision. Remove a portion of the trapezium with a rongeur to allow placement of the guidewire from distal to proximal. If a noncannulated Herbert screw is used, place the tip of the alignment jig at the dorsum of the proximal pole, near the scapholunate joint (see Fig. 66-22). Stabilize the barrel of the drill guide distally against the tuberosity and the distal pole, compressing the fracture. Read the length from the calibrations on the barrel. Use C-arm fluoroscopy to monitor the jig placement

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and drill and screw location. Use the short drill for the distal pole entry site and the longer drill for the proximal pole. Insert the screw until the trailing end (head) is flush with subchondral bone, countersunk beneath the articular cartilage. Placement of Kirschner wires down the long axis of the scaphoid is made easier by gentle radial deviation of the wrist, aligning the scaphoid vertically. With the wrist in this position, direct the wires almost dorsally into the scaphoid. After stable reduction and fixation are obtained, check the position and alignment of the reduction and the placement of the internal fixation with image intensification or radiographs. Deflate the tourniquet, and obtain hemostasis. Insert a drain if needed, and close the wrist capsule with nonabsorbable sutures or long-lasting absorbable sutures. Close the skin, and apply a dressing that includes either a sugar-tong splint with a thumb spica extension or a long-arm cast incorporating the thumb.

Fig. 66-40 Technique for scaphoid nonunion. A, Excavation of scaphoid and placement of Kirschner wires; Chandler retractor is used to protect articular cartilage of radioscaphoid joint. B, Cortical graft is inserted into cavity. C, Kirschner wire is inserted to stabilize bone graft.(Redrawn from Stark HH, Rickard TA, Zemel NP, et al: Treatment of ununited fractures of the scaphoid by iliac bone grafts and Kirschner-wire fixation, J Bone Joint Surg 70A:982, 1988.)

TECHNIQUE 66-6

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Dorsal Approach For noncomminuted fractures in the proximal pole of the scaphoid, exposure of the fracture site and placement of internal fixation can be done through a dorsal approach. Make a dorsal transverse incision about 5 to 10 mm distal to the radiocarpal joint (Fig. 66-23 Protect the sensory branches of the radial and ulnar nerves. Preserve, cauterize, or ligate and divide dorsal veins. Extend the skin incision from the radial styloid to the ulnar styloid. Make parallel incisions in the extensor retinaculum on each side of the extensor digitorum communis tendons. Protect the extensor tendons, especially the extensor pollicis longus tendon as it exits the third dorsal retinacular compartment. Connect the parallel incisions proximally to create a flap to allow access to the dorsal wrist capsule. Pass a loop of Penrose drain around the extensor tendons, and retract them medially. Open the dorsal capsule by creating a radially based flap, incising along the dorsal intercarpal ligament and the dorsal radiotriquetral ligament. Retract the capsular flap radially, and expose the fracture. Insert a Kirschner wire into the proximal fragment parallel to the central axis of the scaphoid. Use this wire as a toggle lever (joystick) to manipulate the proximal fragment into a reduced position. When the fracture is reduced, pass the first wire across the fracture for temporary interfragmentary fixation. Insert an additional Kirschner wire, or screw fixation, as the fracture configuration permits. If a cannulated screw is used, center the guidewire in the proximal and distal poles, monitoring this placement with C-arm fluoroscopy. Determine the appropriate length of the screw to be used. Drill and tap the bone, according to the device being used, and insert the screw of appropriate length. Ensure that the guidewire or screw fixation is placed in the center of the long axis of the proximal and distal poles of the scaphoid, using C-arm fluoroscopy. Either leave the initial Kirschner wire as supplemental fixation, or remove it if screw fixation has been selected. Close the capsular flap, and repair the retinacular flap. Close the skin and apply a cast or sugar-tong splint that extends from above the elbow to include the thumb.

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Fig. 66-23 Dorsal approach to wrist. Transverse incision of skin. Radial-based capsular flap between dorsal radiotriquetral and dorsal intercarpal ligaments (enlargement shows proximal one third fracture of scaphoid).(Redrawn from Linscheid RL, Weber ER: Scaphoid fractures and nonunion. In Cooney WP, Linscheid RL, Dobyns JH, eds: wrist, St Louis, 1998, Mosby.)

AFTERTREATMENT The sutures are removed, and the splint or cast is changed at 2 weeks. Immobilization in an elbow-to-thumb spica cast is continued for 6 to 8 weeks. If used, Kirschner wires are removed at 6 to 8 weeks. Screw fixation can be left in place permanently, unless tender

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areas develop, or the screw loosens. At 6 to 8 weeks, a short arm thumb spica cast is applied; this cast is changed monthly for 4 to 6 months. If the patient is compliant and reliable, removable bracing can begin at 6 to 8 weeks. If healing is progressing by radiographic examination, a short arm thumb spica brace is worn until bone healing is ensured. If healing cannot be determined with certainty, CT or MRI can be helpful to evaluate for bridging trabeculae. Finger, thumb, and shoulder motion is encouraged throughout convalescence, and after cast removal, wrist motion and elbow motion are increased gradually, followed by strengthening exercises. TECHNIQUE 66-7 Percutaneous Fixation of Scaphoid Fractures

Slade et al. Slade et al. recommended the following equipment for this technique: (1) headless cannulated compression screw (standard Acutrak screw), (2) minifluoroscopy unit, (3) Kirschner wires, and (4) equipment for small joint arthroscopy. If arthroscopy is to be used to check the fracture reduction and to place internal fixation, have the operating room prepared for wrist arthroscopy. Position the patient supine, with the upper extremity extended. After the induction of appropriate anesthesia and sterile preparation and draping procedures, flex the elbow 90 degrees. Use a C-arm fluoroscopic unit or mini C-arm fluoroscope to evaluate the fracture position and alignment and to determine if there are other bone or ligament injuries. Use a skin marking pen to indicate the best surface location for a dorsal skin incision and entry of the guidewire, drills, and screw. Target the scaphoid by locating the central axis of the scaphoid on the posteroanterior view of the reduced scaphoid (Fig. 66-24 A). Gently pronate and flex the wrist until the proximal and distal poles of the scaphoid are aligned and confirmed with fluoroscopy. When the poles are aligned, the scaphoid has a ring appearance on the fluoroscopic monitor (Fig. 66-24 B and C). The center of the ring circle is the central axis of the scaphoid, the best location for screw placement (Fig. 66-25). For ease of insertion, make a skin incision at the previously marked location to allow blunt dissection to the capsule of the wrist joint. With a double-point 0.045-inch (1.14-mm) Kirschner wire in a powered wire driver, insert the wire starting in the proximal pole of the scaphoid under fluoroscopic control. If there is uncertainty about wire placement, make the previously mentioned incision distal and medial (ulnar) to Lister tubercle, opening the dorsal wrist capsule lateral (radial) to the scapholunate interval, exposing the proximal pole of the scaphoid.

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Pass the guidewire from dorsally down the central axis of the scaphoid and out through the trapezium (Fig. 66-26 A and B). Use a 12-gauge angiocatheter to assist with positioning of the guidewire. Keep the wrist flexed to avoid bending the guidewire. Advance the wire through the distal pole out the palmar surface. Check the position of the wire with the fluoroscope. Reverse the wire driver to pull the wire far enough distally to allow the dorsal, trailing end of the wire to clear the radiocarpal joint dorsally and to allow full wrist extension. With C-arm fluoroscopy, confirm scaphoid fracture alignment and correct positioning of the guidewire (Fig. 66-26 C). If a correct path cannot be created with the 0.045-inch wire, use a 0.062-inch (1.57-mm) wire to create the correct path. Exchange the larger wire for the 0.045-inch wire before drilling the scaphoid. Check for wire position and fracture alignment with the fluoroscope. If the fracture reduction is unsatisfactory, and for displaced fractures, place a 0.062-inch Kirschner wire into each fracture fragment, perpendicular to the axis of the scaphoid, as toggle levers (joysticks) to manipulate the fracture fragments (Fig. 66-27). If needed, place the proximal lever wire in the lunate. With the wire driver on the distal end of the guidewire, withdraw the wire distally across the fracture site, leaving the wire in the central axis of the distal fragment. Align the fracture fragments with the joysticks. Pass the guidewire from distal to proximal across the fracture site to hold the reduction. If needed for stability and rotational control, insert another 0.045-inch wire, entering the proximal pole of the scaphoid, from dorsal to palmar, parallel to the first guidewire to control rotation. Leave the wire levers and the antirotational wire in place during screw insertion. Confirm the reduction and wire placement with fluoroscopy. If the fracture is difficult to reduce, percutaneously insert a small curved hemostat to assist with the reduction. If the fracture cannot be reduced, or if the guidewire cannot be properly placed, abandon the percutaneous technique, and open the fracture, using either the volar or the dorsal approach (see Techniques 66-5 and 66-6). Determine the scaphoid length using two wires. To determine the scaphoid length, adjust the guidewire position so that the distal end is against the distal cortex of the scaphoid. Place a second wire of the same length as the guidewire parallel to the guidewire, so the tip of the second wire is against the cortex of the proximal scaphoid pole. The difference in length is the length of the scaphoid (Fig. 66-28). To allow for countersinking the screw fully within the scaphoid, select a screw length that is 4 mm shorter than the scaphoid length. Determine dorsal or palmar insertion of the screw depending on the fracture location. For fractures of the proximal pole, insert the screw dorsally. For fractures of the waist, insert the screw from either the dorsal or the volar side. For fractures of the distal pole, insert the screw

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from the volar side. Drill the screw channel 2 mm short of the opposite scaphoid cortex, using a cannulated hand drill, always avoiding contact with the opposite cortex (Fig. 66-29). Check the position and depth of the drill with fluoroscopy. Use a standard Acutrak screw, 4 mm shorter than the scaphoid length. Advance the screw, monitoring with fluoroscopy, until the screw is within 1 to 2 mm of the opposite cortex (Fig. 66-30 A). Verify fracture reduction and screw placement with final fluoroscopic images (Fig. 66-30 B and C) If ligament injury or other carpal injuries are suspected, add arthroscopic examination to the fracture management. Apply longitudinal traction through the fingers. Locate the midcarpal and radiocarpal portals with fluoroscopy. Insert the arthroscope into the radial midcarpal portal to inspect the fracture reduction. Remove clot and synovium with the full radius shaver. Examine the scapholunate and lunatotriquetral ligaments. Inspect the proximal pole through the 3-4 portal to confirm countersinking of the screw into the proximal pole. If ligament tears are encountered, treat them with d?bridement, intercarpal pinning, or open dorsal ligament repair.

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Fig. 66-24 Percutaneous fixation of scaphoid fracture. A, Central axis of scaphoid is located on posteroanterior view. Wrist is pronated until scaphoid poles are aligned. C, Wrist is flexed until scaphoid has ring appearance on fluoroscopy.(From Slade JF III, Gutow AP, Geissler WB: Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach, J Bone Joint Surg 84A[suppl 2]:21, 2002.)

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Fig. 66-25 Percutaneous fixation of scaphoid fracture. Guidewire in central axis of scaphoid for placement of screw.(From Slade JF III, Gutow AP, Geissler WB: Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach, J Bone Joint Surg 84A[suppl 2]:21, 2002.)

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Fig. 66-26 Percutaneous fixation of scaphoid fracture. A and B, Guidewire is placed at base of proximal pole of scaphoid (A) and driven along central axis (B). C, Wrist is extended, and fracture alignment and guidwire position are confirmed with fluoroscopy.(From Slade JF III, Gutow AP, Geissler WB: Percutaneous internal fixation of scaphoi fractures via an arthroscopically assisted dorsal approach, J Bone Joint Surg 84A[suppl 2]:21, 2002.)

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Fig. 66-27 Percutaneous fixation of scaphoid fracture. Fracture reduction with two 0.062-inch Kirschner wires used as joysticks to manipulate fracture fragments.(From Slade JF III, Gutow AP, Geissler WB: Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach, J Bone Joint Surg 84A[suppl 2]:21, 2002.)

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Fig. 66-28 Percutaneous fixation of scaphoid fracture. Determination of scaphoid length (see text).(From Slade JF III, Gutow AP, Geissler WB: Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach, J Bone Joint Surg 84A[suppl 2]:21, 2002.)

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Fig. 66-29 Percutaneous fixation of scaphoid fracture. Screw channel is created with cannulated hand drill and confirmed with fluoroscopy.(From Slade JF III, Gutow AP, Geissler WB: Percutaneous internal fixation of scaphoi fractures via an arthroscopically assisted dorsal approach, J Bone Joint Surg 84A[suppl 2]:21, 2002.)

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Fig. 66-30 Percutaneous fixation of scaphoid fracture. A, Joysticks and antiglide wires are maintained during drilling and dorsal implantation of screw. B and C, Fluoroscopy confirms placement of headless compression screw.(From Slade JF III, Gutow AP, Geissler WB: Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach, J Bone Joint Surg 84A[suppl 2]:21, 2002.)

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AFTERTREATMENT Apply a postoperative splint, depending on the extent of soft-tissue injury. If no ligament injury is present, apply a thumb spica splint. If there is ligament injury, apply a sugar-tong thumb spica splint of the Munster type, extending above the elbow. For fracture management, remove skin sutures at about 2 weeks, and change the splint to a short arm thumb spica cast. Remove any remaining pins at 6 to 8 weeks. Continue with casting or removable thumb spica splinting until radiographic healing has occurred, changing the cast monthly. CT and MRI can help in determining if bridging trabeculae are present. After healing has occurred, begin a therapist-supervised rehabilitation program. Nonunion of Scaphoid Fractures Nonunion of scaphoid fractures is influenced by delayed diagnosis, gross displacement, associated injuries of the carpus, and impaired blood supply. Of these fractures, an estimated 40% are undiagnosed at the time of the original injury. According to Eddeland et al., displaced scaphoid fractures may have a nonunion rate of 92%. The incidence of osteonecrosis is approximately 30% to 40%, occurring most frequently in fractures of the proximal third. Cystic changes in the scaphoid and the adjoining bones followed by osteonecrosis can occur after untreated fractures, but this is not an absolute indication for surgery. Mazet and Hohl and Stewart reported several patients in whom fractures of the scaphoid healed after a delay in diagnosis of 5 months when treated with cast immobilization for 8 to 12 months. Nonunion is expected more often if the scaphoid fracture is untreated for 4 or more weeks. Delayed treatment can result in a nonunion rate of 88%. Treatment options for nonunions of proximal pole fractures depend on the blood supply to the proximal pole and the size of the fragments. Nonunions involving the proximal third or more can be treated with nonvascularized bone grafts if circulation is satisfactory as determined by preoperative gadolinium-enhanced MRI and by intraoperative assessment of bone bleeding. Vascularized bone grafts are indicated when circulation to the proximal pole is poor. For very small, avascular, ununited fragments, the proximal pole can be excised. Electrical and ultrasound stimulation methods have been found to be of variable effectiveness for the treatment of scaphoid nonunions. Reports by Frykman et al. and Adams et al. suggest that bone grafting should be considered a better option than pulsed electromagnetic field treatment of scaphoid nonunions. There is no conclusive information at this time to recommend the use of low-intensity ultrasound for scaphoid nonunions. Mayr et al. compared two groups of patients with fresh scaphoid fractures, one treated with casting and ultrasound and the other treated with casting alone. Patients treated with ultrasound healed in an average of 43 days, whereas patients treated with casting alone healed in an average of 62 days. More information is needed to define further the place of these technologies in the treatment of nonunions and acute fractures. Many nonunions of the scaphoid have minimal symptoms and can be tolerated well by patients with sedentary occupations. Patients should be informed that some degenerative arthritis of the wrist probably is inevitable, but this can take years to develop, depending on the amount

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of chronic stress applied and the activity of the wrist. Radiographic findings of arthritis usually seen with scaphoid nonunion include radioscaphoid narrowing, capitolunate narrowing, cyst formation, and pronounced dorsal intercalated segment instability. This is the so-called scaphoid nonunion advanced collapse pattern described by Watson and Ballet and Watson et al. (Fig. 66-31). The radiolunate joint usually is spared in early stages, but may show degenerative changes as the arthritis becomes more diffuse. Jupiter et al. observed that ununited fractures of the scaphoid fall into three groups, depending on the extent of arthrosis: established nonunions without arthrosis, nonunions with radiocarpal arthrosis, and nonunions with advanced radiocarpal and intercarpal arthrosis. Although bone healing is needed for nonunions without arthrosis, additional procedures, including salvage operations, may be required for patients with more extensive arthrosis. The observations and experiences of Barton, Slade et al., and Cosio and Camp suggest that there may be a group of nondisplaced scaphoid nonunions that heal after rigid internal fixation without bone grafting. Knoll and Trumble proposed a scheme for scaphoid nonunion treatment, including the consideration of osteonecrosis (Fig. 66-32). In old fractures with arthritis, symptoms can be decreased by excision of the radial styloid just proximal to the fracture in middle-third fractures; however, other reconstructive surgery, especially for severe arthritic degeneration, may be indicated, and proximal row carpectomy or arthrodesis of the wrist joint may prove to be more dependable. The following operations can be useful for nonunions of the scaphoid: (1) radial styloidectomy; (2) excision of the proximal fragment, the distal fragment, and, occasionally, the entire scaphoid; (3) proximal row carpectomy; (4) traditional bone grafting; (5) vascularized bone grafting; and (6) partial or total arthrodesis of the wrist.

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Fig. 66-31 Stages of scaphoid nonunion advanced collapse. Stage I, arthritis at radial styloid. Stage II, scaphoid fossa arthritis. Stage III, capitolunate arthritis. Stage IV, diffuse arthritis of carpus.(From Knoll VD, Trumble TE: Scapholunate advanced collapse. In Trumble TE, ed: Hand surgery update 3, Rosemont, Ill., American Society for Surgery of the Hand, 2003.)

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Fig. 66-32 Algorithm for treatment of scaphoid nonunion. AVN, avascular necrosis (osteonecrosis).(From Knoll VD, Trumble TE: Scapholunate advanced collapse. In Trumble TE, ed: Hand surgery update 3, Rosemont, Ill., American Society for Surgery of the Hand, 2003.)

Preiser disease (osteonecrosis of the scaphoid) usually manifests with wrist pain. Plain radiographs, MRI, and CT may help in assessing the circulation to the scaphoid and the extent of fragmentation. If symptoms and disability are not relieved with nonoperative methods, revascularization techniques similar to those used for Kienb?ck disease may preserve the scaphoid architecture. If there is significant scaphoid collapse or radioscaphoid arthrosis, scaphoid excision combined with capitate-lunate-triquetrum-hamate fusion or with proximal row carpectomy may be required. Styloidectomy Styloidectomy alone probably is of little value in treating nonunions of the scaphoid. If arthritic changes involve only the scaphoid fossa of the radiocarpal joint, however, styloidectomy is indicated in conjunction with any grafting of the scaphoid or excision of its ulnar fragment. In older patients in whom radioscaphoid arthritis predominates, and the proximal fragment is not loose, styloidectomy alone can provide pain relief. Stewart emphasized the importance of removing adequate radial styloid when styloidectomy is performed. The distal articular surface of the radius has two concave surfaces, one articulating with the scaphoid and the other articulating with the lunate, separated by a small ridge of bone. Stewart recommended resecting enough of the styloid to remove the entire articulation with the scaphoid. To avoid ulnar translocation of the carpus, it is important to preserve the palmar radiocarpal ligaments when such a generous styloidectomy is done. TECHNIQUE 66-8

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Stewart Make a bayonet-shaped incision along the radial aspect of the wrist as follows. Begin distally over the dorsum of the first metacarpal and proceed proximally to the anatomical snuffbox, dorsally along the extensor crease of the wrist, and proximally along the dorsoradial aspect of the distal radius. Expose and carefully protect the radial artery and the sensory branches of the radial nerve, which lie in the subcutaneous tissue. Incise the joint capsule, and expose the radial styloid subperiosteally. Careful subperiosteal dissection on the dorsal and palmar surfaces helps to avoid excessive disruption of the volar radiocarpal ligaments. Locate the ridge on the radius that separates the articular fossa for the lunate from that for the scaphoid. With a sharp, thin osteotome or a thin oscillating saw blade, make the osteotomy cut perpendicular to the long axis of the radius, with its ulnar border at the ridge just located. Remove the resected styloid. Move the wrist through a full range of motion under direct vision to ensure that the irregular surfaces of the scaphoid do not impinge on the remaining radius. Reattach the reflected dorsal and palmar capsuloligamentous flaps with sutures through drill holes in the distal radius, or use suture anchors. Repair the retinaculum. Close the wound in layers, and apply an anterior splint from the palm to the elbow.

AFTERTREATMENT The sutures are removed at 10 to 14 days. At 3 weeks, the splint is removed, and active exercises are begun. A removable splint should be provided for the patient to wear until satisfactory function is restored to the hand and wrist. Excision of the Proximal Fragment Excising both fragments of the scaphoid as the only procedure is unwise; although the immediate result may be satisfactory, eventual derangement of the wrist is likely. Soto-Hall and Haldeman reported gradual migration of the capitate into the space previously occupied by the scaphoid, although disability was not apparent for 5 to 7 years. If excision of both fragments is considered, it is preferable to add some other procedure to stabilize the capitolunate joint (e.g., capitolunate or capital-lunate-triquetral-hamate fusions). When indicated, excising the proximal scaphoid fragment usually is satisfactory; the loss of

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one fourth or less of the scaphoid usually causes minimal impairment of wrist motion. Because postoperative immobilization is brief, function usually returns rapidly. Strength in the wrist usually is decreased to some extent. The following are indications for excising the proximal fragment of a scaphoid nonunion: 1. 2. The fragment is one fourth or less of the scaphoid. Regardless of its viability, grafting of such a small fragment frequently fails. The fragment is one fourth or less of the scaphoid and is sclerotic, comminuted, or severely displaced. The comminuted fragments usually should be excised early to prevent arthritic changes; a severely displaced fragment also should be excised early if it cannot be accurately replaced by manipulation. In the past, Silastic implants have been used to act as space fillers. Because of the possibility of silicone synovitis, we prefer to leave the space empty, or we use a folded or rolled tendon graft to fill the defect. The fragment is one fourth or less of the scaphoid, and grafting has failed. If a nonviable proximal fragment consists of more than one fourth of the scaphoid, some other treatment is preferable to excision alone. Arthritic changes are present in the region of the radial styloid. Styloidectomy is indicated in conjunction with excision of the proximal fragment.

3.

4.

TECHNIQUE 66-9

At the level of the styloid process of the radius, make a transverse skin incision 5 cm long on the dorsoradial aspect of the wrist, centered over the scaphoid. Protect the superficial radial nerve and its terminal branches. Release the radial side of the extensor retinaculum with a longitudinal incision along the radial border of the first dorsal compartment. Reflect the flap medially toward the second and third compartments. Protect and retract the tendons of the thumb abductors in a palmar direction and the tendon of the extensor pollicis longus in a dorsal and ulnar direction. Create a radially based triangular flap of dorsal capsule, incising along the distal border of the dorsal radiotriquetral, and dorsal intercarpal ligaments to expose the scaphoid. To avoid excising a normal carpal bone, place a Kirschner wire in the proximal fragment of the scaphoid, and identify the fragment in an anteroposterior radiograph. Grasp the fragment to be excised with a towel clip, apply traction, and remove the fragment by dividing its soft-tissue attachments. As an alternative, remove the proximal pole with a rongeur.

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If it seems that there is sufficient laxity in the wrist to allow the capitate to migrate into the defect left by proximal pole excision, proceed to a scaphocapitate fusion (see Technique 66-45). Close the capsular flap, and repair the retinaculum with absorbable sutures. Close the skin, and apply an anterior splint, extending from the palm to the elbow.

AFTERTREATMENT The wrist is immobilized in the postoperative splint for 2 weeks. Sutures are removed at 10 to 14 days. A removable splint is used while the patient transitions to a program of active exercises, which is continued until satisfactory function is restored. If a limited intercarpal arthrodesis has been done, the aftertreatment is the same as that described after Technique 66-45.

Excision of the Distal Scaphoid Malerich et al. obtained satisfactory results in 12 scaphoid nonunions with radioscaphoid arthritis treated with distal scaphoid resection an average of 14.6 years after injury. After removal of the distal scaphoid for scaphotrapeziotrapezoid arthritis, Garcia-Elias et al. found that 13 of 21 wrists were pain-free. A dorsal intercalated segment instability pattern developed in 12 of the 21 wrists. No further joint deterioration was seen in these wrists. If capitolunate arthritis is present, an additional procedure (e.g., limited intercarpal arthrodesis) should be added to distal scaphoid excision. The technique and the aftertreatment are similar to those described earlier for proximal pole excision. Proximal Row Carpectomy Proximal row carpectomy is used as a reconstructive procedure for posttraumatic degenerative conditions in the wrist, especially conditions involving the scaphoid and lunate. Reports by Stamm, Crabbe, Inglis and Jones, Jorgensen, Neviaser, Green, and Calandruccio support its use as an alternative to arthrodesis. Reports by Cohen and Kozin and Krakauer et al. comparing proximal row carpectomy with limited intercarpal fusion confirmed that satisfactory relief of pain and preservation of motion and strength can be achieved. It is considered to be a satisfactory procedure in patients who have limited requirements, desire some wrist mobility, and accept the possibility of minimal persistent pain (Fig. 66-33). If a proximal row carpectomy fails to meet the patient's needs, arthrodesis remains an option. Manual laborers usually are better candidates for a wrist arthrodesis.

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Fig. 66-33 A, Long-standing scaphoid nonunion with arthritis, osteonecrosis, collapse of proximal pole, and settling of capitate into proximal row. B, After proximal row carpectomy with radial styloidectomy.(From Neviaser RJ: Proximal row carpectomy for posttraumatic disorders of the carpus, J Hand Surg 8A:301, 1983.)

When proximal row carpectomy is done for degenerative changes, healthy articular surfaces should be present in the lunate fossa of the radius and the proximal articular surface of the capitate to allow for satisfactory articulation between these surfaces. Arthrosis at the capitolunate joint does not absolutely contraindicate proximal row carpectomy because the proximal pole of the capitate can be excised and covered with a dorsal capsular flap with satisfactory function. If significant degenerative changes on these articular surfaces can be seen radiographically or by direct vision at the time of procedure, consideration should be given to an alternative procedure, such as arthrodesis. Primary proximal row carpectomy can be useful in treating severe open carpal fracture-dislocations characterized by significant disruption of the bony architecture, comminuted fractures of the scaphoid and lunate, and disruption of the blood supply to the lunate and scaphoid. Excision of the triquetrum, lunate, and entire scaphoid usually is recommended. The distal pole of the scaphoid at its articulation with the trapezium can be left, however, to provide a more

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stable base for the thumb. If the distal scaphoid pole is left, radial styloidectomy should be done to avoid impingement of the distal scaphoid pole and trapezium on the radial styloid. When a radial styloidectomy is done during proximal row carpectomy, care should be taken to avoid injury to the volar radiocapitate ligament, as stressed by Taleisnik and Green. Excision of the pisiform is unnecessary because of its location in the flexor carpi ulnaris tendon as a sesamoid. The bones usually are removed piecemeal; threaded Kirschner wires or screws used as joysticks or handles are helpful to lever the bone out at the wrist. Two techniques are described. TECHNIQUE 66-10

Make a transverse incision on the dorsum of the wrist 5 to 10 mm distal to the radiocarpal joint and extending from the dorsal aspect of the ulnar styloid to the radial styloid. Deepen the incision to the extensor retinaculum, preserving the sensory branches of the radial and ulnar nerves. Ligate and divide the superficial veins. Divide the retinaculum longitudinally on the radial and on the ulnar sides of the extensor digitorum communis tendons; avoid damaging the extensor pollicis longus tendon as it crosses the wound diagonally. Expose the dorsum of the proximal row of carpal bones through two longitudinal incisions in the capsuleone in the interval between the extensor digitorum communis tendons and the extensor carpi ulnaris and one between the extensor carpi radialis brevis tendon and the extensor digitorum communis. If the capitate articular surface shows erosion, fashion a capsular flap, based distally, by connecting the parallel capsular incisions with a transverse incision, proximally, near the dorsum of the distal radial articular surface. (Because the extensor pollicis longus tendon crosses this area diagonally, it can be retracted medially or laterally as necessary.) Expose the lunate by elevating the capsule of the wrist beneath the extensor digitorum communis tendons; insert a threaded pin into the lunate, apply traction to the bone through the pin, and excise the bone by dividing its capsular attachments with sharp pointed scissors. A small, angled cleft palate blade also is helpful. Carefully fragment the lunate with a small bone cutter, osteotome, or saw to facilitate removal (Fig. 66-34 A). Insert the pin into the triquetrum, and excise it in a similar manner (Fig. 66-34 B). (The lunate and triquetrum are excised first to provide more space for the more difficult excision of the scaphoid.) Through the more radial of the two incisions in the capsule, excise the ulnar fragment of the scaphoid first in the manner just described and then the radial fragment, but dissect close to this fragment to avoid injuring the radial artery. Align the capitate with the lunate fossa. Use a Steinmann pin to stabilize the capitate if needed. If the palmar radiocapitate ligament is preserved, this may be unnecessary.

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Obtain hemostasis or drain the wound as needed, and close the wound in layers. Apply a sugar-tong splint with the hand and wrist in a functional position.

Fig. 66-34 Proximal row carpectomy through dorsal approach. A, Exposure and morcellization of scaphoid and lunate between second and fourth dorsal compartments. B, Exposure of triquetrum between fourth and fifth extensor compartments for triquetrum excision.(From Calandruccio JH: Proximal row carpectomy, J Am Soc Surg Hand 1:112, 2001.)

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AFTERTREATMENT The wrist is immobilized in slight extension and with the hand in the functional position in a plaster sugar-tong splint for 2 or 3 weeks. If a Steinmann pin has been used, it is removed at about 4 weeks. Active motion of the digits is encouraged soon after surgery and is continued throughout the convalescence. When the soft tissues have healed, active motion of the wrist is increased gradually. Active exercises to strengthen grip are of utmost importance. TECHNIQUE 66-11

Neviaser Make a dorsal oblique or straight dorsal longitudinal incision. Preserve the extensor retinaculum by reflecting it laterally. Make a T-shaped incision in the dorsal capsule, and dissect it from the proximal carpal row, including the scaphoid, the lunate, and the triquetrum. Excise these bones piecemeal, but leave a thin shell of cortical bone adherent to the palmar capsule if necessary. Avoid injuring the proximal articular surface of the capitate, and allow it to settle into the lunate fossa. If the trapezium abuts the radial styloid and prevents radial deviation, perform a radial styloidectomy. Cut the styloid transversely to remove the radial edge of the lunate fossa. Repair the dorsal capsule. After closure of the skin, immobilize the wrist in slight extension.

AFTERTREATMENT Immobilization is continued for 3 weeks, and then progressive exercises are begun. The wrist is supported with splints for another 3 weeks. Grafting Operations Cancellous bone grafting for scaphoid nonunion, as first described by Matti and modified by Russe, has proved to be a reliable procedure, producing bony union in 80% to 97% of patients. This technique is most useful for ununited fractures that do not have associated shortening or angulation. Of 27 patients seen an average of 12 years after surgery, Stark et al. reported that 24 were satisfied with the result, and all but one had returned to work. Mulder reported 97% bony union in 100 operations using the Matti-Russe technique.33 de 69 13/10/2011 0:37

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TECHNIQUE 66-12

Matti-Russe With the patient supine and under general anesthesia, prepare the injured limb, and prepare one iliac crest for possible bone graft harvest. Under pneumatic tourniquet control, make a longitudinal incision 3 to 4 cm long on the volar aspect of the wrist slightly to the radial side of the flexor carpi radialis tendon. Protect the palmar cutaneous branch of the median nerve and the terminal branches of the superficial radial nerve. Retract the flexor carpi radialis tendon ulnarward. Incise the wrist capsule, reflecting the radiocarpal ligaments as medial and lateral flaps to be repaired. Identify the scaphoid bone and expose the nonunion. It can be seen more clearly with dorsiflexion and ulnar deviation of the wrist. Freshen the sclerotic bone ends with a small gouge, and form a cavity that extends well into each adjacent fragment. The cavity can be formed with a high-speed burr; however, thermal bone injury can occur. As an alternative, outline a rectangular trough with drill holes and connect the holes with a thin osteotome or a powered thin saw blade (Linscheid and Weber). From the iliac crest, obtain a piece of cancellous bone, and shape it into a large lozengeshaped peg to fit into the preformed cavity, and stabilize the two fragments (Fig. 66-35). If a rectangular trough has been formed, shape the bone graft to fit the cancellous portion into the trough. Place multiple small bone chips around the peg. Use intraoperative C-arm fluoroscopy to verify filling of the cavity. Although the fragments can be stabilized by the corticocancellous bone graft, stability can be improved with a Kirschner wire inserted from distal to proximal across the fracture. Leave the wire either just beneath the skin or protruding from the palmar skin. After removing the tourniquet, suture the capsule, and close the skin. Apply a sugar-tong splint with a thumb spica extension, from above the elbow to the palm with the wrist in neutral position.

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Fig. 66-35 Matti-Russe technique of bone grafting for nonunion of carpal scaphoid.

AFTERTREATMENT The sutures are removed at 8 to 10 days, and a new cast is applied. If a Kirschner wire is used, it is removed at 4 to 6 weeks. For 12 to 16 weeks, the patient is checked every 1 to 2 weeks, and the cast is replaced when necessary.

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Malpositioned Nonunion of Scaphoid Fractures (Humpback Deformity) Established nonunions of scaphoid fractures can be seen in preoperative radiographs to have resorption or comminution, with resulting shortening and angulation, with its convexity dorsal and radial (humpback deformity). Preoperative computer-assisted tomography in the sagittal and coronal planes shows this deformity (Fig. 66-36). The deformity includes extension of the proximal pole of the scaphoid, resulting extension of the lunate, and a form of dorsal intercalated instability pattern seen on lateral plain radiographs. Fisk emphasized that interposition bone grafting allows restoration of length and correction of malalignment. Amadio et al. and Cooney et al. proposed anterior wedge grafting for angulation resulting in a scapholunate angle of more than 60 degrees or an intrascaphoid angle of more than 45 degrees. Modifications proposed by Fernandez emphasized careful preoperative planning, comparison radiographs of the uninjured side, the use of a bone graft fitted to the defect, and Kirschner wire fixation. Tomaino et al. treated persistent lunate extension after interposition grafting of the scaphoid by radiolunate pinning to stabilize the lunate in a neutral position before correcting the scaphoid humpback deformity. The cannulated Herbert-Whipple screw was found to be effective fixation. According to Manske, McCarthy, and Strecker, the doublethreaded Herbert screw was most effective in nonunions with evidence of osteonecrosis, nonunions involving the proximal third, or nonunions having had previous failed bone grafts. Stark et al. recommended Kirschner wire fixation with an iliac bone graft for all nonunions because judging stability with bone grafting alone was difficult, and because the technique was technically easy and added little to the operating time. They achieved union in 97% of 151 old ununited fractures of the scaphoid. Combining volar wedge grafting with Herbert screw fixation in 26 scaphoid nonunions, Daly et al. reported a union rate of 95%. Of the five methods he had used, Barton reported a 74% union rate, his best results, using the wedge graft and the Herbert screw. The meta-analysis of 1121 articles reported by Merrell, Wolfe, and Slade included 36 eligible reports indicating that grafting with screw fixation produced better healing rates (94% union) than Kirschner wires and wedge grafting (74%). Vascularized grafts provided a better union rate (88%) than wedge grafting and screw fixation (47%) in cases with osteonecrosis of the proximal pole.

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Fig. 66-36 A, For sagittal plane images, forearm is held pronated, and hand lies flat on table. Forearm crosses gantry at angle of approximately 45 degrees (roughly in line with abducted thumb metacarpal). B, Scout images are obtained to confirm appropriate orientation and to ensure that entire scaphoid is imaged. Sections are obtained at 1-mm intervals. Images obtained in sagittal plane are best for measuring intrascaphoid angle. D, For coronal plane images, forearm is in neutral rotation. E, Scout images show alignment of wrist through gantry of scanner. F, Interpretation of images obtained in coronal plane is straightforward.(Copyright 1999 by Jesse B. Jupiter, MD.)

TECHNIQUE 66-13

Fernandez Preoperatively, calculate the amount of resection, size of graft, and angular deformity on tracing paper by using the radiographic findings of the uninjured wrist as a guide (Fig. 66-37). Approach the scaphoid between the flexor carpi radialis and the radial artery according to the classic Russe procedure. Incise the palmar capsule of the wrist longitudinally in line with the skin incision, and extend it to the scaphoid tubercle for exposure of the nonunion, the proximal and distal fragments, and the scapholunate junction. Using an oscillating saw, carry out resection according to the preoperative plan.

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If signs of osteonecrosis of the proximal fragment are apparent, place multiple 1-mm drill holes within the sclerotic cancellous bone. Correct the flexion deformity and shortening by distracting the osteotomy site on the palmar-radial aspect with two small bone hooks or a spreader clamp. As this is done, have an assistant simultaneously correct the dorsal rotation of the lunate by pushing the palmar pole toward the radius with a fine bone spike. Shape the corticocancellous graft from the iliac crest to fit the defect. If considerable lengthening is necessary, the graft would need to be trapezoidal to bridge the defect that appears on the dorsal aspect of the navicular (see Fig 66-37). Orient the graft so that its cortical part is palmar. After insertion of the graft, shape the protruding edges flush with the proximal and distal fragments. Use image intensification to control correction of lunate rotation. Fix the scaphoid with two or three 1.2-mm Kirschner wires, which are power driven percutaneously into the palmar aspect of the distal fragment across the graft into the dorsal aspect of the proximal fragment (see Fig 66-37). Use image intensification to ensure correct placement of the internal fixation material. Carefully close the palmar capsule, and cut the Kirschner wires short, 3 mm below the palmar skin of the thenar area.

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Fig. 66-37 Preoperative planning. Top, Tracing of uninjured wrist and measurement of scaphoid length and scapholunate (SL) angle. Middle, Calculation of size of resection area and form of graft. Bottom, Definitive diagram of operation.(Redrawn from Fernandez DL: A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability, J Hand Surg 9A:733, 1984.)

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AFTERTREATMENT A palmar plaster splint that includes the thumb is applied for 2 weeks, at which time the sutures are removed. The wrist and thumb are immobilized in a short navicular cast for 6 weeks. Immobilization is discontinued after 8 weeks, and a palmar thermoplastic removable splint is applied with which the patient can perform active exercises of the wrist three times a day for 15 minutes. CT scans of the navicular are obtained at 10 weeks, and if bony union is confirmed, the internal fixation material is removed through a small incision under local anesthesia. TECHNIQUE 66-14

Tomaino et al. With the patient supine and under appropriate anesthesia, and after preparation of the skin and one iliac crest, exsanguinate the limb with an elastic wrap, and inflate the pneumatic tourniquet. Make a palmar skin incision between the flexor carpi radialis and the radial artery, extending from about 2 cm proximal to the radial styloid to about 1 cm distal to the scaphoid tuberosity. Incise the palmar capsule and radioscaphocapitate ligament longitudinally in line with the skin incision. Extend the incision distally, exposing the proximal trapezium and the scaphotrapezial joint. Correct lunate extension by maximally flexing the wrist joint to derotate the extended lunate (Figs. 66-38A and 66-39A). Fix the lunate in the flexed position by percutaneously passing a 1.1-mm (0.045-inch) Kirschner wire through the radius from its lateral surface into the lunate fossa of the articular surface of the radius (see Figs. 66-38A and 66-39A and B). Protect the superficial radial nerve during the wire passage. Use the C-arm fluoroscope to obtain a lateral image to ensure neutral alignment of the lunate (see Fig. 66-39 C). Supinate the forearm, and maximally extend the wrist to open up the scaphoid nonunion site (see Fig. 66-38 B). Using a microsagittal saw or rongeur, resect the nonunion to viable bleeding bone proximally and distally. Measure the gap in the scaphoid (length, width, and depth) to determine the dimensions of the wedge graft. Distally, notch the trapezium with a rongeur to allow for placement of a cannulated screw (Herbert-Whipple). Obtain a tricortical corticocancellous graft from the iliac crest using a microsagittal saw, irrigating with saline to avoid thermal bone injury (see Fig. 66-38 C).

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Sculpt the graft to fit the defect. Gently impact the graft into place with the inner (cancellous) surface facing the capitate (see Fig. 66-38 D). Avoid prominence of the graft on the dorsal and ulnar surfaces. Pass a single 1.1-mm (0.045-inch) Kirschner wire eccentrically down the long scaphoid axis to hold the scaphoid and graft in place. Remove the radiolunate wire to allow movement of the wrist to obtain satisfactory images of guidewire placement. Using C-arm fluoroscopic images, place the guidewire for the Herbert-Whipple screw. Ascertain with the fluoroscopic images that the guidewire is centrally placed. Insert a screw of appropriate length. Anticipate that it might be necessary to reduce the screw length 4 to 6 mm from the length obtained from the guidewire. Using the fluoroscope, ascertain central placement of the guidewire and screw. Use a small burr to remove prominent graft on the radial and volar surfaces. Assess wrist flexion and extension and radial and ulnar deviation to ensure that the graft is not impinging on the distal radius. If there is impingement, perform a limited radial styloidectomy. Repair the palmar capsule, the radioscaphocapitate ligament, and the sheath of the flexor carpi radialis. Deflate the pneumatic tourniquet, obtain hemostasis, and close the skin. Apply a short arm thumb spica splint.

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Fig. 66-38 A, Lunate extension (dorsal intercalated segment instability deformity) accompanies scaphoid nonunion with humpback deformity because of carpal collapse. B, With wrist extension, radiolunate joint is pinned, and scaphoid opens at nonunion site. Microsagittal saw is used to smooth ends of bone at nonunion. C, Tricortical iliac crest graft is harvested. D, Graft is pinned in place before insertion of Herbert-Whipple screw. Lunate transfixion pin is removed before screw placement to facilitate accurate imaging of scaphoid and guidewire.(Redrawn from Tomaino MM, King J, Pizillo M: Correction of lunate malalignment when bone grafting scaphoid nonunion with humpback deformity: rationale and results of a technique revisited, J Hand Surg 25A:322, 2000.)

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Fig. 66-39 A, Lateral radiograph of wrist with scaphoid nonunion and humpback deformity shows lunate extension because of collapse. B, Posteroanterior radiograph shows Kirschner wire that has been placed percutaneously through radial side of radius into lunate after correcting lunate extension. C, Normal radiolunate angle has been restored.(From Tomaino MM, King J, Pizillo M: Correction of lunate malalignment when bone grafting scaphoid nonunion with humpback deformity: rationale and results of a technique revisited, J Hand Surg 25A:322, 2000.)

AFTERTREATMENT The splint and sutures are removed at 2 weeks. A removable short arm thumb spica splint is provided. Activities are limited until bone union has occurred, usually at 10 to 12 weeks. For noncompliant patients, the wrist is immobilized in a thumb spica cast. TECHNIQUE 66-15

Stark et al. Expose the scaphoid through a straight or zigzag volar incision.

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After the wrist capsule is incised longitudinally, and the wrist is dorsiflexed, both parts of the scaphoid and the articular surface of the radius can be seen readily. Remove a small, rectangular window of bone from the volar aspect of the distal fragment immediately adjacent to the fracture. Through this opening, clear fragments of fibrous tissue and dead bone using a low-speed power burr or curet. As emphasized by Matti, fashion a large cavity in the proximal and distal parts of the scaphoid. Use a Chandler retractor to protect the articular cartilage of the radioscaphoid joint (Fig. 66-40 A). It also helps to correct angulation, malrotation, and displacement of the fragments. The volar part of the cortex of the scaphoid often is deficient, and this deficiency permits an exaggerated volar tilt of the distal fragment, creating the humpback deformity of the scaphoid. Realignment and reduction of the fracture and restoration of the bone to the proper length are difficult parts of the procedure. Intraoperative radiographs usually are necessary. Transfix the scaphoid with two 0.035-inch (0.9-mm) Kirschner wires by inserting them through the distal fragment into the proximal one; protect the articular cartilages of the scaphoid and radius with the retractor. Observe correct placement of the wires through the volar window. Pack cancellous bone from the ilium into the cavity (Fig. 66-40 B). The wires can be inserted after packing the cavity with bone, but it is easier to verify their location before inserting the graft. Often a cortical bone graft can be fashioned to fit snugly into the volar window; stabilize it with one additional 0.028-inch (0.7-mm) Kirschner wire (Fig. 66-40 C). Cut the wires off beneath the skin. Approximate the capsule with absorbable sutures, close the skin, and immobilize the extremity in a long arm thumb spica splint with the forearm in supination, the wrist in neutral, and the thumb in abduction.

AFTERTREATMENT The sutures are removed at 2 weeks, and a long arm thumb spica cast is applied and is worn for 6 additional weeks. The Kirschner wires are removed after the fracture has united. When immobilization is discontinued, patients are permitted to use the wrist and hand for light activities, but strenuous and forceful activity is discouraged for an additional 2 months. Vascularized Bone Grafts

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The use of vascularized bone grafts has proved to be an effective method for treating scaphoid nonunions, especially nonunions with an avascular proximal pole and those that have failed to heal after previous procedures. Since Braun's 1983 report of success with a pronator quadratus pedicle graft from the distal radius, other sources of pedicle flaps from the distal radius and ulna and the metacarpals have been described by Sheetz et al., Mathoulin and Brunelli, and Fernandez and Eggli. Kawai and Yamamoto also reported satisfactory healing using the pronator quadratus pedicle bone graft for difficult scaphoid nonunions. Lutz et al. reported success using an iliac crest free flap with microvascular techniques. Zaidemberg et al. used a vascularized bone graft from the distal dorsolateral radius to obtain healing in 11 patients with long-standing nonunions of the scaphoid. Steinmann, Bishop, and Berger also reported union in all 14 patients with established scaphoid nonunions with the use of pedicle bone grafts based on the 1,2 intercompartmental supraretinacular artery. Although vascularized pedicle grafts are useful for promoting healing, the presence of established radiocarpal arthrosis may compromise the functional outcome, as reported by Steinmann et al. and Mathoulin and Brunelli. TECHNIQUE 66-16

Kawai and Yamamoto Make a volar zigzag incision over the scaphoid tuberosity and the distal radius to expose the site of nonunion. Divide the radioscaphocapitate ligament complex, but retain it for later repair to the muscle pedicle. Excise the sclerotic bone ends, and freshen them with a power burr to form an oval cavity 10 to 20 mm long and parallel to the axis of the scaphoid. Identify the pronator quadratus, and outline a block of bone graft 15 to 20 mm long at its distal insertion on the distal radius close to the abductor pollicis longus tendon (Fig. 66-41). Outline the margin of the graft with Kirschner wire holes to facilitate separation with a fine osteotome. Ensure that the pronator quadratus is not detached from the harvested bone graft; dissect the muscle toward the ulna to secure a pedicle 20 mm thick. The anterior interosseous vessels need not be identified. If the muscle is too tight to allow easy transfer of the pedicled bone, dissect the ulnar origin of the pronator quadratus subperiosteally from the ulna through an additional incision over the distal ulna. Align the proximal and distal scaphoid segments carefully as a traction force is applied to the thumb. This maneuver corrects any intercalated segment instability and allows the grafted bone to be inserted snugly into the cavity in the scaphoid. Fix the proximal and distal scaphoid segments and the graft with two 0.045-inch (1.16-mm) Kirschner wires introduced at the scaphoid tuberosity. Do not cross the radiocarpal joint with a Kirschner wire.

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Close the skin, and apply a long arm thumb spica cast.

Fig. 66-41 Pronator quadratus pedicle bone graft for scaphoid nonunion. Graft fills excavated site of nonunion and is fixed with Kirschner wires.(Redrawn from Kawai H, Yamamoto K: Pronator quadratus pedicled bone graft for old scaphoid fractures, J Bone Joint Surg 70B:829, 1988.)

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AFTERTREATMENT The long arm thumb spica cast is worn for 1 month, followed by a short arm thumb spica cast for another month. At 2 months, union is evaluated with radiographs and, in case of doubt, tomograms. The wrist is braced in a functional position for another 1 to 2 months, and then active exercises are begun. When stable bony union is certain, the Kirschner wires are removed, usually about 4 months after surgery. TECHNIQUE 66-17

Zaidemberg et al. Place the patient supine on the operating table with the hand pronated on the hand table. Prepare the arm to use the pneumatic tourniquet. After skin preparation, draping, limb exsanguination, and tourniquet inflation, with the forearm pronated, make an oblique skin incision on the dorsoradial side of the wrist, centered on the radiocarpal joint. Avoid injury to the branches of the superficial radial nerve. Incise the extensor retinaculum of the first dorsal extensor compartment. Retract the extensor pollicis brevis and the abductor pollicis longus in a palmar direction. Retract the wrist and finger extensors toward the ulna. On the distal radial periosteum, identify the longitudinal course of the ascending irrigating branch of the radial artery (Fig. 66-42 A). Design a bone graft with the longitudinal vessel as its center. Identify and protect the branches of the superficial branch of the radial nerve (Fig. 66-42 B Expose the scaphoid nonunion, and freshen the sclerotic bone ends with curets or a power burr. Reduce the fracture. A Kirschner wire used as a joystick can be helpful. If the fracture cannot be reduced, approach the scaphoid through a second, palmar incision over the distal flexor carpi radialis, retracting its tendon and entering the wrist through the volar capsule. Make a 15- to 20-mm long trough in the scaphoid parallel to its long axis. Use narrow osteotomes or a small gouge to harvest a bone graft from the distal radius, beneath the periosteal vessel (Fig. 66-42 C). Avoid comminution of the cortex and injury to the vessel. Make the bone graft about the size of the defect in the scaphoid, and transpose it to the defect in the scaphoid (Fig. 66-42 D). Stabilize the bone graft with Kirschner wires. Obtain additional cancellous bone from the same radial donor site, if needed.

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Deflate the tourniquet, ensure hemostasis, and close the capsule; avoid strangulating the vessel. Close the skin, and apply a bulky bandage supported by a long arm thumb spica cast.

Fig. 66-42 Pedicled vascularized bone graft for scaphoid nonunion. A, Incision (solid red line) exposes scaphoid and bone graft donor site. Subcutaneous tissues are raised from extensor retinaculum, and 1,2 intercompartmental supraretinacular artery (ICSRA) is identified. R, radius; RA, radial artery; S, scaphoid. B, Branches (I, II, III) of superficial branch of the radial nerve (SBRN) are identified and protected. Dashed lines indicate incisions of first and second extensor compartments. C, With graft levered out, tourniquet is deflated, and vascularity of graft is checked. Graft is gently press-fit into scaphoid nonunion site. Supplemental fixation with Kirschner wires or placement of scaphoid screws can be done at this time.(Redrawn from Shin AY, Bishop AT: Pedicled vascularized bone grafts for disorders of the carpus: nonunion and Kienbock's disease, J Am Acad Orthop Surg 10:210, 2002. Adapted with permission from the Mayo Foundation, Rochester, Minn.)

AFTERTREATMENT

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The sutures are removed at 2 weeks, and the long arm thumb spica cast is worn for 1 month. At 1 month, a short arm thumb spica cast is applied and is worn for at least 2 weeks. At 6 weeks, bone union is evaluated with plain radiographs. Immobilization is continued until union is seen on plain radiographs or evaluation with tomograms is obtained as needed. Wrist motion and forearm rehabilitation are begun when union is established.

Arthrodesis of the Wrist Arthrodesis should be considered a salvage procedure for old ununited or malunited fractures of the scaphoid with associated radiocarpal traumatic arthritis. Wrist arthrodesis is discussed later in this chapter.

Naviculocapitate Fracture Syndrome and Capitate FracturesAlthough naviculocapitate fracture syndrome is rare, it should be considered among the associated injuries that can occur with a fracture of the scaphoid. Axial compression of a dorsiflexed wrist forces further dorsiflexion, and after the scaphoid fractures, the dorsal lip of the radius forcefully impacts the head of the capitate, causing it to fracture. As the wrist continues into further dorsiflexion, after the scaphoid and the capitate are fractured, the capitate head rotates 90 degrees. The hand, when returned to neutral position, brings the proximal fragment of the capitate into 180 degrees of rotation (Fig. 66-43). This injury can be associated with dorsal perilunate dislocation (see Fig. 66-80 B) or fractures of the distal end of the radius. Open reduction is necessary to derotate the capitate fragment. Some surgeons have excised this fragment, but others have replaced it, reduced the scaphoid and capitate fractures, and maintained them with internal fixation or cast immobilization. Osteonecrosis of the capitate may follow such injuries. If sufficiently symptomatic, osteonecrosis of the capitate may be treated with excisional-interposition arthroplasty or midcarpal or capitate-hamate arthrodesis. Isolated fractures of the capitate are unusual. Nondisplaced fractures of the body of the capitate are treated nonoperatively. Displaced fractures, especially fractures involving the joint, usually require open reduction and internal fixation with Kirschner wires or screws.

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Fig. 66-43 Mechanism of carpal fractures from falls on outstretched hand with wrist going into marked dorsiflexion. A, Wrist in marked dorsiflexion. Capitate is at 90-degree angle to radius. B, Scaphoid fractures as result of increased dorsiflexion at midcarpal joint. C, Dorsal lip of radius strikes capitate, causing it to fracture. D, Proximal fragment of capitate is rotated 90 degrees. E, Return of wrist to neutral position. Proximal fragment of capitate is now rotated 180 degrees.(From Stein F, Siegel MW: Naviculocapitate fracture syndrome, J Bone Joint Surg 51A:391, 1969.)

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Fig. 66-80 Repair of scapholunate dissociation as described by Palmer, Dobyns, and Linscheid. A, Radial view of wrist showing position of flexor carpi radialis muscle-tendon unit. B, Dorsal view of wrist with overhang of radius cut away shows tear of radioscapholunate ligament and separation of scaphoid and lunate. C, Both views show tunnels in scaphoid and lu