Dorsal approach to the scaphoid

This approach is used for the following injuries:

Proximal pole fractures

Complete scapholunate (SL) ligament rupture.

Scaphoid fractures, or complete SL ligament ruptures with concomitant distal radial fractures.

Make a straight dorsal skin incision starting over Lister’s tubercle...

...and extending for about 4 cm distally.

Identify and preserve the dorsal superficial branch of the radial nerve, which runs in the radial skin flap of the wound.

Note the radial nerve.

Incise the extensor retinaculum over the extensor pollicis longus (EPL) tendon,...

...opening the distal part of the third extensor compartment.

The EPL tendon is then retracted radially together with the tendons of the second extensor compartment (extensor carpi radialis brevis and longus).
The fourth extensor compartment, containing the extensor digitorum and extensor indicis, is located on the ulnar side.

Make a longitudinal, or inverted T-shaped, incision, starting at the dorsal rim of the distal radius, extending to the dorsal intercarpal ligament.

Take care to preserve the vessels to the dorsal ridge of the scaphoid.
The capsule is not stripped from this area.

To expose the proximal pole of the scaphoid, it is necessary to flex the wrist.
The scaphoid now comes into view. Identify the SL ligament.

Close the capsule with interrupted sutures.

Close the third extensor compartment, avoiding any tension over the EPL tendon, which must glide smoothly. If this is not possible, the EPL tendon is best left superficial to the retinaculum, in the subcutaneous tissue.