Surgery was performed under regional anesthesia with tourniquet. A volar approach was chosen based on the location of the fracture as well as the humpback deformity. A hockey-stick incision was made over the distal flexor carpi radialis (FCR) tendon and angled radially and distally over the thenar eminence at the distal wrist flexion crease. Angling the incision in this direction avoids injury to the palmar sensory branch of the median nerve and exposes the scaphotrapezial joint for proper screw placement (Fig. 4.2). The FCR tendon was released and retracted in an ulnar direction to expose the volar capsule. The palmar branch of the radial artery was identified and efforts were made to protect it. The vessel occasionally needs to be tied off if preservation proves impossible. The scaphoid was palpated to direct the incision through the volar capsule and directly down onto the volar scaphoid tubercle. Starting distally and cutting proximally, we only released the tissue necessary to expose the fracture. Occasionally with this approach, we are able to preserve the important radioscaphocapitate ligament though in this case that was not possible. Still, we incised this ligament as cleanly as possible and maintained two stumps to facilitate later repair. The capsule was lifted off the distal pole of the scaphoid and the scaphotrapezoid joint opened to gain access to our screw “starting point.” The soft tissues were released radially to expose the fracture though the dorsal radial blood supply was (and must always be) preserved. Wrist extension across a towel bump extends the scaphoid offering improved access to the volar scaphoid cortex. Hematoma and soft tissue were gently debrided from the fracture site using a combination of curettes, rongeurs, and bulb irrigation (applied under pressure). The fracture was assessed and preliminary reduction was attempted. The proximal pole and fracture line were stabilized by inserting a freer elevator around the radial aspect of the fracture and into the radioscaphoid articulation. Gentle volar–ulnar-directed pressure was applied to correct the extension deformity of the proximal pole (as it follows the lunate into an extended posture). The distal pole was reduced using a dental pick. Joystick Kirschner wires (K-wires) may be placed in the proximal and distal fragments if necessary to aid with reduction as well. Alignment was assessed along the radial and ulnar cortices of the scaphoid since the volar cortex in this case was comminuted. While maintaining the reduction, a guide pin was placed from the distal pole, down the scaphoid medullary canal across the fracture, and into the proximal pole. Because of the relative instability, we chose to place two (2.3 mm) screws and the guide pins were purposely placed to allow the insertion of two screws within the medullary canal. Alternatively, one guide pin can be placed down the center of the medullary canal for single-screw fixation. The guide pins were placed as dorsally as possible on the distal scaphoid at the scaphotrapezial articulation. The trapezium prevents this point from being too dorsal and, though it was not necessary in this case, the volar aspect of the trapezium may sometimes be rongeured off to facilitate pin placement. Sometimes several passes are necessary to place the pins into an acceptable position, but this is the essential step and poor screw placement will compromise scaphoid alignment and stability. Additionally, while repositioning a pin is relatively easy, gaining adequate purchase with a repositioned screw is challenging due to the limited amount of bone stock in the scaphoid.

Once pin placement and reduction were confirmed under direct vision as well as fluoroscopy imaging as acceptable, the appropriate screw length was obtained using the measuring guide. The guide pins were adjusted so that they were just abutting the inner cortex of the proximal scaphoid pole. 3–5 mm was subtracted from the measured length to account for cartilage thickness and compression at the fracture site (typically 2 mm for cartilage on either side and 1–2 mm for compression). The guide wires were overdrilled and cannulated screws placed one at a time though final tightening was performed by alternating between the two screws to ensure symmetrical compression. The guide pins were removed, and final live fluoroscopy imaging was used to evaluate screw placement, fracture reduction, and bone alignment (Fig. 4.3a–c).

The radioscaphocapitate ligament, followed by the volar capsule, was repaired using 3-0 braided polyester suture. The tourniquet was deflated and bipolar electrocautery was used for hemostasis before closing skin with 4-0 nylon sutures. A thumb spica splint was placed over a dry sterile dressing.