The Mini-Open Dorsal Approach to the Scaphoid

Scaphoid fractures are a common, yet challenging, injury to treat. The mini-open dorsal approach to the scaphoid is a simple, yet effective, approach that allows for improved visualization and more accurate screw placement in the setting of scaphoid fracture fixation.

An approximately 2-cm longitudinal incision is made centered over the dorsal radiocarpal joint, just ulnar to the Lister tubercle. Blunt dissection is performed down to the extensor retinaculum. A longitudinal incision is made through the retinaculum. The tendons of the fourth and third compartments are visualized, the extensor digitorum communis is retracted ulnarly, and the extensor pollicis longus is retracted radially. A small, 1-cm longitudinal capsulotomy is made, and the scapholunate ligament and proximal pole of the scaphoid are visualized. Careful attention is paid to avoid injury to the scapholunate ligament, which lies just beneath the capsule. Next, the scaphoid fracture is reduced.

Traditionally, nondisplaced or minimally displaced scaphoid waist fractures have been treated nonoperatively. Surgical treatment has become more popular because of the faster recovery, improved range of motion, improved time to union, and decreased nonunion rates. There are several surgical approaches that can be utilized, including percutaneous fixation and traditional open techniques through a volar or dorsal approach.

Precise fracture reduction and screw fixation is biomechanically advantageous and critical in improving union rates of scaphoid fractures¹. Although percutaneous fixation has the advantage of being least invasive, it is difficult to achieve an accurate starting point and there is an increased risk of damaging the extensor tendons and blood supply about the scaphoid. Prior studies have shown a 29% complication rate associated with a dorsal percutaneous approach². When compared with the percutaneous or volar approach, the mini-open dorsal approach provides improved visualization of the starting point for more accurate screw placement³.

Precise screw placement is advantageous when stabilizing scaphoid fractures. Studies involving the use of a limited dorsal approach have shown excellent radiographic and functional results, with cadaveric studies showing that the dorsal approach can help avoid articular damage to the scaphotrapezial articulation^4,5. The mini-open dorsal approach has comparable complication rates to those shown for the dorsal percutaneous approach¹; however, the mini-open dorsal approach allows for improved visualization and thus safer and more accurate identification of the optimal starting point for screw fixation of scaphoid fractures.

Take care to lift up the capsule while making the capsulotomy in order to prevent injury to the underlying scapholunate ligament.The use of a 16-gauge needle can help assist with guidewire placement when trying to establish the starting point in the central axis of the scaphoid. Central-third guidewire placement should be confirmed on posteroanterior and lateral views before proceeding.Wrist flexion can help identify the correct starting point on the proximal scaphoid for fracture fixation.Take multiple fluoroscopic images while drilling to ensure maintenance of fracture reduction.

SL = scapholunateK-wire = Kirschner wireEDC = extensor digitorum communisEPL = extensor pollicis longusCT = computed tomography.