Palmar approach to the scaphoid

The palmar approach to the scaphoid is indicated for the following injuries:

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

AO teaching video

Wrist joint–Scaphoid bone – Palmar approach

Anatomical landmarks

The landmarks for this incision are:

Scaphoid tubercle
Flexor carpi radialis (FCR) tendon

Palmar approach to the scaphoid – Anatomical landmarks

Angled skin incision

The incision is in line over the distal part of the FCR tendon and then turns at the level of the palmar rim of the distal radius towards the scaphoid tubercle and scaphotrapezial joint.

Palmar approach to the scaphoid – Angled incision

Zigzag incision

Alternatively, a zigzag incision may be constructed using the same landmarks. This incision may result in better cosmetic outcome in case of very pronounced palmar crease.

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 the palmar branch of radial artery

Open the FCR sheath as far distally as possible and retract the tendon towards the ulnar side.

Palmar approach to the scaphoid – Opening the FCR sheath

Open the capsule obliquely, starting at the scaphoid tubercle towards the palmar rim of the radius.

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

Palmar approach to the scaphoid – Exposure of the wrist capsule with oblique incision

Alternatively, a zigzag incision may be used. It starts at the level of the scaphoid tubercle distally and turns in line with the radioscaphocapitate ligament. It then turns at the level of the radial styloid down to the pronator quadratus.

Palmar approach to the scaphoid – Exposure of the wrist capsule with zigzag incision

Retract the divided radioscaphocapitate ligament to expose 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 – Retracting the divided radioscaphocapitate ligament to expose the scaphoid

Expose the scaphotrapezial joint to allow optimal positioning of a screw.

Deepen the incision distally, dividing the origin of the thenar muscles in line with their fibers.

Palmar approach to the scaphoid – Exposure of scaphotrapezial joint

Identify the scaphotrapezial joint, divide the scaphotrapezial ligament in the line of its fibers, and open the joint capsule.

Palmar approach to the scaphoid – Dividing the scaphotrapezial ligament during exposure of scaphotrapezial joint

To prevent secondary carpal instability, the divided palmar ligaments (radioscaphocapitate/long radiolunate) must be repaired with fine interrupted sutures.

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.