Dorsal exposure of the schaphoid specific

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The dorsal approach to the scaphoid provides better access to the proximal scaphoid, and is indicated in the fixation of proximal scaphoid fractures. There is a concern with injury to the vascular supply of the scaphoid; however, recent reports have not shown a significant difference in the union rates when compared with the volar approach [31].

Lunate Blood Supply Images

Fig. 14. (A) Perilunate fracture dislocation injury (Mayfield Stage IV) demonstrating lunate dislocation on lateral radiograph. (B) The lunate is seen lying in the carpal tunnel following an extended carpal tunnel exposure. The distal articular surface of the lunate is visualized. (C) The transverse rent in the space of Poirier following reduction of the lunate. Often a combined volar and dorsal approach is required. Once surgical reduction and repairs are completed, the space of Poirier should be repaired.

Fig. 14. (A) Perilunate fracture dislocation injury (Mayfield Stage IV) demonstrating lunate dislocation on lateral radiograph. (B) The lunate is seen lying in the carpal tunnel following an extended carpal tunnel exposure. The distal articular surface of the lunate is visualized. (C) The transverse rent in the space of Poirier following reduction of the lunate. Often a combined volar and dorsal approach is required. Once surgical reduction and repairs are completed, the space of Poirier should be repaired.

Skin incision

The dorsal approach to the scaphoid is performed through a transverse or longitudinal incision over the scapholunate interval and radiocarpal joint. A longitudinal incision is least likely to injure branches of the superficial radial nerve compared with a transverse incision, although it is less cosmetic.

Retinaculum

After skin flaps are elevated and the superficial branch of the radial nerve is identified and protected, the extensor retinaculum over the third dorsal compartment is opened and the extensor policis longus (EPL) tendon is retracted radially. The septum between the third and fourth compartments is opened as described in the dorsal approach to the carpus, and the extensor tendons are retracted ulnarward.

Capsule

Radial to the insertion of the dorsal radio-carpal ligament, there are no true ligamentous structures; only capsule is present. The capsule can be opened between the radius and scaphoid radial to the border of the dorsal radiocarpal ligament. If further exposure is necessary, the ligament can be divided longitudinally along its fibers, creating a distally based flap.

Exposure

The entire proximal two thirds of the scaphoid, the radial styloid, and the scaphoid fossa in the distal radius can be exposed.

Closure

The capsule is easily closed with sutures irrespective of the type of capsulotomy used. The EPL tendon is transposed dorsal to the repaired retinaculum.

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