volar approach for scaphoid fractures · volar approach for scaphoid fractures nader paksima, do,...
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Volar Approach for Scaphoid Fractures Nader Paksima, DO, MPH
Clinical Professor of Orthopaedic Surgery
NYU/Hospital for Joint Diseases
• Internal Fixation indicated for displacement >1mm
• Percutaneous fixation recommended only for non‐displaced or minimally displaced fractures
• Union rates and complication rates similar for open and percutaneous screw fixation• (94‐100%, 0‐30%)
Scaphoid fractures: Dorsal versus volar approach• Polsky et al
• Orthopedics 2002
• 16 Dorsal
• 10 Volar
• No difference in healing rates. 80 versus 81%
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Comparison of dorsal and volar percutaneous screw fixation methods in acute Type B scaphoid fractures.• Acta Orthop Traumatol Turc, 2012
• 13 Dorsal
• 14 Volar
• No difference in healing, return to work, complications
Why go volar? 7 reasons :
• Maintain vascularity
• Correct the humpback / Easy reduction
• Avoid articular injury
• Can do percutaneously
• The more distal the better ( ship to shore, screw perpendicular)
• Versatility : • Easy to add bone graft / nascent nonunion
• Have bailouts: k wires, plate, carpentry
Why not go Volar?
• Screw Trajectory less than Ideal
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Why go volar? 7 reasons :
• Maintain vascularity
• Correct the humpback / Easy reduction
• Avoid articular injury
• Can do percutaneously
• The more distal the better ( ship to shore, screw perpendicular)
• Versatility :
• Easy to add bone graft / nascent nonunion
• Have bailouts: k wires, plate, carpentry
Maintain Vascularity
Why go volar? 7 reasons :
• Maintain vascularity
• Correct the humpback / Easy reduction
• Avoid articular injury
• Can do percutaneously
• The more distal the better ( ship to shore, screw perpendicular)
• Versatility :
• Easy to add bone graft / nascent nonunion
• Have bailouts: k wires, plate, carpentry
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Humpback / reduction:
wrist extension helpsreduce the fracture
Why go volar? 7 reasons :
• Maintain vascularity
• Correct the humpback / Easy reduction
• Avoid articular injury
• Can do percutaneously
• The more distal the better ( ship to shore, screw perpendicular)
• Versatility :
• Easy to add bone graft / nascent nonunion
• Have bailouts: k wires, plate, carpentry
3‐4mm hole in the articular cartilage Retrograde vs Antegrade
Krimer , Wrist 2003
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Why go volar? 7 reasons :
• Maintain vascularity
• Correct the humpback / Easy reduction
• Avoid articular injury
• Can do percutaneously
• The more distal the better ( ship to shore, screw perpendicular)
• Versatility :
• Easy to add bone graft / nascent nonunion
• Have bailouts: k wires, plate, carpentry
Dangers of Dorsal percutaneous screw
29%
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Safe Volar Percutaneous approach
Capo et al , Techniques Hand and upper extremity Surg2009
Case example : perc screw
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Measuring tip:Supinated view
See the Piso‐triquetral joint
Kim et al JHS 2008
Why go volar? 7 reasons :
• Maintain vascularity
• Correct the humpback / Easy reduction
• Avoid articular injury
• Can do percutaneously
• The more distal the better ( ship to shore, screw perpendicular)
• Versatility :
• Easy to add bone graft / nascent nonunion
• Have bailouts: k wires, plate, carpentry
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More Distal Waist
Ship to shore, Perpendicular to fracture line
Concomitant injury
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T shaped DR fracture with scaphoid fracture
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Why go volar? 7 reasons :
• Maintain vascularity
• Correct the humpback / Easy reduction
• Avoid articular injury
• Can do percutaneously
• The more distal the better ( ship to shore, screw perpendicular)
• Versatility :
• Easy to add bone graft / nascent nonunion
• Have bailouts: k wires, plate, carpentry
6 week old injury
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8 week old injury
case from Anthony Sapienza MD
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CT Scan of wrist
• Dx: Scaphoid waist fracture with humpback deformity 2 months post injury
• Plan?
• Volar approach:
• Correct Humpback
• Preserve blood supply
• Add in bone graft support
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6 weeks post op
6 weeks post op
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6 weeks post op
Why go volar? 7 reasons :
• Maintain vascularity
• Correct the humpback / Easy reduction
• Avoid articular injury
• Can do percutaneously
• The more distal the better ( ship to shore, screw perpendicular)
• Versatility :
• Easy to add bone graft / nascent nonunion
• Have bailouts: k wires, plate, carpentry
Case Example
• 20 RHD male, left wrist pain after falling from bicycle the previous day
• Focal snuffbox tenderness
Courtesy of Dr. Anthony Sapienza
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• 25 yo longshoreman with 6 week old wrist injury
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Case Example
Courtesy of Dr. Anthony Sapienza
• Fibrous/sclerotic waist fracture site debrided
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Case Example
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• Iliac crest corticocancellous graft + plate
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Case Example
• Intraop
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Case Example
• 6 weeks postop
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Case Example
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• 12 weeks postop
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Case Example
Why not go Volar?
• Screw Trajectory less than Ideal
Screw trajectory
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Screw too Volar
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Screw trajectory
• Drill right through the trapezium
• STT arthritis?
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Trans Trapezial insertion technique
进针
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2013 Sep;27(9):1025‐7.
18 patients, all healed, no complications
Percutaneous trans trapezial volar approach
• 41 patients
• Mean of 36, range 14‐68 months) follow up
• All healed by 10 weeks
• Central placement of the screw
• No symptomatic ST arthritis
JHS European 2008 Meermans et al
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Measuring screw length suing a second Guide wire
JHS American Guerts et al , 2011
• 6 year follow up of the same group
• 34 patients available for Follow Up
• “No cases of Symptomatic ST arthritis”
• BUT:
• 6 Screw protrusions
• 2 screw removals
When should You go Dorsal ?Trans‐scaphoid peri‐lunate injuries
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Thank you
Scaphoid Fracture with SL ligamentTear
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