Arthroscopically Assisted Reduction and Internal Fixation of Scaphoid Fractures, Delayed Unions, and Nonunions

The unstable scaphoid fracture can be treated by a variety of different methods, including open reduction and internal fixation (ORIF), percutaneous fixation with either k-wires or cannulated screws, and arthroscopically assisted reduction and internal fixation (AARIF) with various cannulated screw systems. The drawbacks of ORIF include extensive soft-tissue dissection, disruption of the nondominant volar blood supply, division of the radioscaphocapitate and radioscapholunate ligaments and volar capsule, and prolonged rehabilitation. Percutaneous fixation avoids the aforementioned drawbacks, yet relies on fluoroscopic guidance alone to assure accurate reduction of the scaphoid fracture fragments and optimal positioning of the implant in the apex of the proximal pole. The technical limitations of plain radiography as well as fluoroscopy in detailed visualization of the oddly oriented scaphoid limit the accuracy of the percutaneous technique. AARIF avoids all the limitations of ORIF, yet allows direct visualization of the scaphoid fracture site and assures accurate reduction of the fragments before and during definitive arthroscopically assisted internal fixation. AARIF also assists in accurate targeting of the proximal pole apex or “sweet spot,” in addition to allowing detection of concurrent pathology in the radiocarpal or midcarpal joints. Delayed unions and stable nonunions with normal intrascaphoid angles, even with ischemic proximal poles, can be treated with AARIF augmented with percutaneous cancellous bone grafting from the trapezial ridge plus autologous platelet-derived growth factor gel.