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Dorsal or Volar? CT Evaluation of Distal Oblique Scaphoid Fractures Treated with Percutaneous Screw Fixation
Daniel Lorenzana, MD1, Christopher Klifto, MD2, Robert J French, MD3, Tyler S. Pidgeon, MD1, Marc J Richard, MD4 and David S Ruch, MD3, (1)Duke University Medical Center, Durham, NC, (2)Duke Univeristy Hospital, Durham, NC, (3)Duke University, Durham, NC, (4)Orthopedic Surgery, Duke University Medical Center, Durham, NC

Hypothesis: Both volar and dorsal percutaneous approaches are described for screw fixation of distal oblique (B1) scaphoid fractures (Figure 1). This study hypothesized that dorsal screw fixation of B1 fractures is associated with (1) a more anatomic reduction and (2) a screw trajectory that is closer to perpendicular relative to volar screw fixation.
Methods: All patients who underwent percutaneous screw fixation for acute B1 scaphoid fractures between 2009 and 2019 were retrospectively identified in a tertiary care center database. Distal oblique (B1) fractures were defined as an oblique fracture from proximal to the dorsal ridge exiting in the distal volar third. In all cases where a postoperative CT scan was available for review, radiographic measurements were performed by a fellowship-trained musculoskeletal radiologist, including height-to-length (HL) ratio, intrascaphoid angle (ISA), dorsal cortical angle (DCA), fracture obliquity relative to scaphoid axis, screw obliquity relative to the fracture, and fracture gap (if applicable). Patient demographics and clinical outcomes were also documented, including wrist range of motion and visual analogue scale score at final follow up.
Results: There were a total of 20 B1 scaphoid fractures treated by percutaneous screw fixation with postoperative CT scan available for review. Of these, 9 were performed via a volar approach and 11 via a dorsal approach. The mean height-to-length ratio of the dorsal group was significantly less than the volar group (0.64 vs 0.71, p=0.02), consistent with a more anatomic reduction (Table 1). The mean intrascaphoid angle was lower and dorsal cortical angle was higher in dorsally reduced fractures but these did not reach significance. Screw trajectory for the dorsal group was slightly closer to perpendicular but this did not reach significance (53.6 vs 49.9 deg, p=0.29). There were no significant differences between group demographics, range of motion or visual analog scale score at final follow up.
Summary:

  • Percutaneous fixation of distal oblique (B1) scaphoid fractures through a dorsal approach was associated with a greater height-to-length ratio on postoperative CT, which suggests that a dorsal approach may achieve more anatomic reduction.
  • Both volar and dorsal approaches otherwise had equivalent outcomes and can be successfully used for the management of B1 scaphoid fractures.
  • There were no significant differences in final wrist range of motion or visual analogue scale score between these groups.



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