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Scaphoid ORIF 25628

Scaphoid fracute ORIF xray

 

 

 

 

synonyms:scaphoid percutaeous screw fixation, scaphoid fracture fixation, scaphoid ORIF, scaphoid repair, carpal navicular fracture ORIF, carpal navicular percutaneous screw fixation

Scahoid Fracture CPT

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.
  • Arthrex headless compression screw
  • Acumend Acutrak headless compression screw
  • Depuy Synthes Headless compression screw
  • Stryker Cannulated compression screw

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 union not 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