Scaphoid Percutaneous Fixation 25628

synonyms:

Percutaneous Scaphoid Fixation CPT

• 25628 (Open treatment of carpal scaphoid fracture)

Percutaneous Scaphoid Fixation Indications

• Nondisplaced scaphoid waist fracture
• Acute unstable scaphoid waist fractures which can be reduced closed.
• Proximal pole fractures
• Fibrous nonunions without avascular necrosis

Percutaneous Scaphoid Fixation Contraindications

• Fractures in which adequate reduction cannot be achieved via a closed manner.
• Scaphoid nonunions with sclerosis, cystic changes, pseudarthrosis, avascular necrosis, and humpback deformities.

Percutaneous Scaphoid Fixation Alternatives

• Short arm thumb spica cast / long arm thumb spica cast
• ORIF

Percutaneous Scaphoid Fixation Planning / Special Considerations

• Screws must be placed in the central third of both poles of the scaphoid for greatest stability, and rapidity of fracture healing.
• Proximal pole fractures should be approached dorsally.
• Waist fractures may be approached dorsally or volarly.
• Distal fractures are best approached volarly.
• Displaced fractures may be reduced via: volar traction-assisted approach; the dorsal minimal incision approach, with manual reduction as the guidewire is advanced; or the dorsal approach with arthroscopy-assisted reduction.
• Proximal approach: distal aiming point is the center of the scaphotrapezial joint or the base of the thumb. Starting point = just radial to the ulnar proximal corner of the scaphoid at the insertion of the scapholunate ligament
• Distal approach: proximal aiming point is the ulnar proximal corner of the scaphoid at the insertion of the scapholunate ligament.
• Scaphoid Case card.

Percutaneous Scaphoid Fixation Technique

• Sign operative site.
• Pre-operative antibiotics, +/- regional block.
• General endotracheal anesthesia
• Supine position. All bony prominences well padded.
• C-arm positioned on opposite side of the patient. Pronation and suppination of the forearm allows complete 180° fluorscopic visualization of the scaphoid.
• Perfrom fluoroscopic exam of the wrist.  Evaluate for occult carpal fracture, great arc injury, scapolunate instability. 
• Prep and drape in standard sterile fashion.
• Wrist suspended from the thumb finger trap.
• Insert 12-gauge needle into the scaphotrapezial joint and then pass guidewire down the needle.
• Double-checking guidewire position with multiple radiographic views.
• Ensure screw is fully buried beneath the articular cartilage. Screw lenght should be 4mm shorter than the measured length of the scaphoid.
• Irrigate.
• Close in layers.

Percutaneous Scaphoid Fixation Complications

• Nonunion
• Malunion
• Scaphoid subsidence or shortening with secondary screw penetration
• Neurovascular injury (cutaneous nerve, radial artery)
• Incorrect placement of a fixation screw
• Failure to recognize concomitant injuries.

Percutaneous Scaphoid Fixation Follow-up care

• Post-op: Place in volar thumb spica splint.
• 7-10 Days: If rigid fixation in good bone was achieved start controlled motion program with a removable splint and range-of-motion and gripping exercises.
• 6 Weeks: Consider CT to determine when union has occurred. Unprotected activity is not allowed until bridging bone is seen
• 3 Months: Consider bone stimulator if unionnot confimed
• 6 Months: assess ROM
• 1Yr: follow-up xrays, assess outcome

Percutaneous Scaphoid Fixation Outcomes

• 100% union at an average of twelve weeks. Fractures treated earlier heal more quickly than those treated later. (Slade JF, Gutow AP, Geissler WB: JBJS 2002; 84A (suppl 20): 21-36).
• Screw fixation: 7wks to union, 8 weeks return to work. Cast: 12 weeks to union, 15 weeks return to work. No significant difference in wrist ROM or grip strength at 2 years. (Bond CD, JBJS 2001; 83A: 483-488).

Percutaneous Scaphoid Fixation Review References

Greens Hand Surgery