Authors of section

Authors

Matej Kastelec, Renato Fricker, Fiesky Nuñez, Terry Axelrod

Executive Editor

Chris Colton

Open all credits

Palmar approach to the scaphoid

1. Indications

This approach is indicated for the following injuries:

  • Irreducible, displaced scaphoid fractures, in the distal two thirds
  • Comminuted fractures

Palmar approach to the scaphoid - Indications

2. Angled skin incision

The landmarks for this incision are:

  • The scaphoid tubercle
  • The flexor carpi radialis (FCR) tendon
Palmar approach to the scaphoid - Landmarks

The incision line can be marked on the skin in line with the FCR tendon, starting at the scaphoid tubercle, and running proximally for about 2 cm. Distal of the scaphoid tubercle, the incision angles towards the base of the thumb, over the scaphotrapezial joint.

Palmar approach to the scaphoid - Incision

3. Zigzag incision

Alternatively, a zigzag incision may be constructed using the same landmarks.

Palmar approach to the scaphoid - Incision

4. Ligate superficial palmar branch of radial artery

The superficial palmar branch of the radial artery passes towards the palm, running close to the scaphoid tubercle. If necessary, it can be ligated and divided.

Palmar approach to the scaphoid – Ligation of palmar branch of radial artery

5. Open the FCR sheath

The FCR sheath is opened as far distally as possible, and the tendon retracted towards the ulnar side.

Palmar approach to the scaphoid – Opening of CFR sheath

6. Exposure of the wrist capsule

The capsule is then incised obliquely from the tubercle distally towards the palmar rim of the radius proximally.

As determined by the fracture configuration, preserve as much of the palmar ligament complex as possible, as it helps to contain the proximal pole and prevent palmar tilt of the scaphoid.

Palmar approach to the scaphoid – Exposure of the wrist capsule

7. Expose the scaphoid

Retract the divided radioscaphocapitate ligament to expose the scaphoid.

Palmar approach to the scaphoid – Exposure of the scaphoid

If it is necessary to expose the proximal part of the scaphoid, divide the long radiolunate ligament, proximally as far as the palmar rim of the radius.

Palmar approach to the scaphoid – Exposure of the scaphoid

8. Exposure of scaphotrapezial joint

The scaphotrapezial joint must be exposed to allow optimal positioning of a screw.The incision is deepened distally, dividing the origin of the thenar muscles in line with their fibres.

Palmar approach to the scaphoid – Exposure of scaphotrapezial joint

The scaphotrapezial joint is identified, the scaphotrapezial ligament divided in the line of its fibers, and the joint capsule opened.

Palmar approach to the scaphoid – Exposure of scaphotrapezial joint

9. Wound closure

The divided palmar ligaments (radioscaphocapitate/long radiolunate) must be repaired with fine interrupted sutures in order to prevent secondary carpal instability.
Approximate the soft tissues over the scaphotrapezial joint.
Test the integrity of the soft-tissue repair by passive wrist motion.
Finally, the FCR tendon sheath is repaired and covered with subcutaneous tissue.

Palmar approach to the scaphoid – Wound closure