Elsevier

The Journal of Hand Surgery

Volume 34, Issue 2, February 2009, Pages 228-236.e1
The Journal of Hand Surgery

Scientific article
Percutaneous Screw Fixation for Scaphoid Fracture: A Comparison Between the Dorsal and the Volar Approaches

https://doi.org/10.1016/j.jhsa.2008.10.016Get rights and content

Purpose

To evaluate the position of the screws and find the difference of clinical and radiologic outcome between the volar approach and the dorsal approach groups in percutaneous screw fixation for acute scaphoid fractures.

Methods

Forty-one consecutive patients with an acute scaphoid fracture, who had percutaneous fixation via either the volar approach or the dorsal approach, were evaluated at an average of 30 months after the surgery. The volar approach was used in 19 patients and the dorsal approach in 22 patients. By using a computerized digital image program, angles between the Herbert screw with respect to the long axis of the scaphoid and the fracture line were measured with plain radiographs in the posteroanterior, lateral, and the 45° semipronated oblique views.

Results

The screws showed no significant difference between the 2 groups in posteroanterior and lateral views; however, screws in the dorsal approach group were observed to be placed more parallel to the long axis of the scaphoid in the semipronated oblique view. The screws in the dorsal approach group were positioned more perpendicular to the fracture lines of the scaphoid compared with those of the volar approach group for all 3 different radiographic views. There was no statistically significant difference between the 2 treatment groups regarding fracture healing. According to the Mayo wrist score system, excellent results were recorded in 18 patients in the dorsal approach group and 15 patients in the volar approach group.

Conclusions

This study suggests that screws are placed more parallel to the long axis of the scaphoid and perpendicular to the fracture line via the dorsal approach; however, there was no significant difference with regard to functional outcome and bone union.

Type of study/level of evidence

Therapeutic IV.

Section snippets

Materials and Methods

From January 1999 to December 2005, we prospectively followed up 53 patients with an acute scaphoid fracture. All fractures were classified according to the modified classification of Herbert and Fisher.23 All fractures were classified as type B2 unstable acute fractures (22 fractures in the dorsal group and 19 fractures in the volar group). Mild comminution in the palmar side was noted in 4 patients. All patients were managed with percutaneous screw fixation by 1 hand surgeon at the university

Clinical results

The demographics of the 2 groups were very similar according to age, gender, time between injury and surgery, and follow-up time (Table 1). Most subjective pain was reduced by internal fixation of the scaphoid 2 or 3 days postoperatively. The outcome measurements of pain, tenderness, range of motion, grip strength, and Mayo wrist score are shown in Table 2. The 2 groups were similar at the baseline for all outcome measurements and the mean follow-up period (Table 1). Overall, the final range of

Discussion

Nondisplaced fractures of the scaphoid waist were managed with immobilization as the standard treatment; however, unstable and displaced scaphoid fractures when treated with plaster immobilization are at the greatest risk of nonunion.25 Reports on open internal fixation of scaphoid fractures have documented a high rate of union,26, 27 but there are risks of violating intact volar ligaments and, subsequently, carpal instability.28, 29 In addition, surgical trauma of the soft tissue around the

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