Surgery is performed under regional nerve block and MAC anesthesia. Prophylactic antibiotics are given prior to incision. After exsanguinating the forearm, a 2-cm incision is made just ulnar to Lister’s tubercle. The extensor retinaculum is incised over the third dorsal compartment, and the EPL tendon is retracted radially. A distal radius cortical bone window proximal to Lister’s tubercle is created, and 1 mL of cancellous bone graft is harvested. The cortical window is replaced after bone graft harvest. A 1-cm longitudinal incision is then made in the dorsal proximal capsule. The wrist is brought into hyperflexion until the proximal pole of the scaphoid is visualized. In this patient, a guidewire from the Acutrak 2 (Hillsboro, OR) mini screw set was advanced from proximal to distal in a central position in both the AP and lateral planes. Once the position was confirmed radiographically, a second anti-rotation guidewire was placed. The central guidewire was over-drilled and removed. The distal radius cancellous bone graft was then packed through the drill hole into the nonunion site .

After bone grafting, the central guidewire was replaced, and the position was confirmed radiographically to ensure that the wire was in the proper path. An Acutrak 2 mini screw was then advanced over the wire to achieve fixation and compression of the fracture. AP, lateral and oblique fluoroscopic images were taken to confirm proper screw position (Fig. 8.3). After wound irrigation, the capsule and the extensor retinaculum were repaired. The subcutaneous tissue and skin were closed with Monocryl, followed by Steri-Strips. A thumb spica splint was applied .

The patient was brought back to the office in 10 days for application of a short arm thumb spica cast. Radiographs were obtained on the first postoperative visit to confirm adequate positioning of the hardware . At 2 months, a CT scan of the wrist was obtained to assess fracture healing and showed early bony bridging. The patient was placed in a second thumb spica cast. A second CT scan at 4 months demonstrated obvious fracture healing (Fig. 8.4). At this point, the patient was transitioned to a splint and began occupation therapy for range of motion and strengthening exercises. At final follow-up 8 months after surgery (Fig. 8.5), the patient exhibited wrist extension of 58°, flexion of 63°, radial deviation of 15°, and ulnar deviation 20°. His grip strength was 104 lbs compared to 120 lbs in the contralateral side. He reported no limitations in activities and had a quickDASH score of 2.3.