Scaphoid

ORIF volar (most fractures)

Curvilinear incision centred over FCR
- Longitudinal incision for 3cm proximal to wrist along line of FCR then at wrist crease curve radially toward ST joint
- More proximal than you think

Blunt dissection to protect palmar branch of median N
Open FCR sheath & retract ulnarly
Carefully dissect distally
- Identifying & Ligating the superficial palmar branch of the radial artery
Extension & ulnar deviation of wrist
Incise through the bed of FCR
- volar radioscaphoid joint capsule
- radio-scapho-capitate ligaments
- NOT
  - SL ligament
exposures volar surface of scaphoid
- insert self retaining retractor
Identify the fracture site
- Extend the incision sharply slightly into the origin of thenar muscles & over the scaphoid tubercle
- Peel the ligaments off radially & ulnar
  - But preserve radially group of vessels entering scaphoid

Identify fracture & assess. ? needs bone graft if comminuted or tending into flexion
Mobilise the scapho – trapezium joint
- Allowing the distal pole to be elevated (with elevator) enough to allow proper placement of guide wire
Pulling on index & long finger will aid in exposure
Fracture assessment & reduction
- ? need for bone graft
  - infuse area with Marcaine & adrenalin
  - harvest from iliac crest
Reduce Fracture, hold with Herbert-Whipple screw clamp, pass guidewire, II in 2 planes, measure, drill, tap, screw. (or use K wires for fixation)
Release tourniquet, haemostasis, close, POP