Percutaneous fixation of scaphoid fractures.

The scaphoid proximal pole and waist fractures presented here were treated by a novel dorsal percutaneous technique with arthroscopic assistance. All fractures healed, with good final functional results and no complications. The advantages of the dorsal percutaneous approach to scaphoid fixation are: (1) the proximal-to-distal placement of the guide pin and screw allow for more precise placement along the central axis of the scaphoid, which decreases healing time and reduces risk of screw thread exposure. (2) The dorsal approach avoids injuring the vulnerable volar ligament anatomy. And (3) the insertion of the screw from the proximal to distal direction allows the more rigid fixation of proximal scaphoid fractures. Arthroscopy allows confirmation of fracture reduction and screw implantation as well as evaluation of concurrent ligament injuries not detected with standard imaging. Percutaneous K-wires act as joysticks to reduce and compress fracture fragments prior to fixation. The presented technique allows for early, rigid internal fixation with minimal associated morbidity. Patients successfully treated with this technique include those with stable and unstable acute fractures of the scaphoid at all locations, including the proximal pole. Nondisplaced fractures that present with delayed or fibrous union without evidence of avascular necrosis, cyst formation, or bony sclerosis may also be treated with this technique. This technique allows for faster rehabilitation and an earlier return to work or avocation without restriction once CT scan confirms a solid union. Some articles document extraordinary rapid healing by standard radiographs; however, we caution that scaphoid bone healing cannot accurately be determined without CT scan. Percutaneous, arthroscopically assisted internal fixation by a dorsal approach may be considered in all acute scaphoid fractures selected for surgical fixation. The dorsal guidewire permits dorsal and volar implantation of a cannulated screw along the central axis of the scaphoid. This technique permits the reduction of displaced fractures and the stable repair of fractures of the proximal pole. In addition, selected scaphoid fibrous union or delayed union may also be repaired, with realistic expectations of healing. The proven benefits of the percutaneous technique include decreased soft tissue trauma; arthroscopic visualization of the fracture, ensuring anatomic reduction; and stable fixation, allowing early physical rehabilitation. The theoretical benefits of the technique include decreased risk of interruption of the tenuous scaphoid blood supply. Percutaneous internal fixation of scaphoid fractures provides faster rehabilitation, earlier return to work, and quicker bony union in most patients.

Congenital scoliosis.

Congenital scoliosis is a deformity of the developing spine that results from defects in vertebral development. The developmental etiologies may be classified as either a failure of formation, a failure of segmentation, or a mixture of these two modes of maldevelopment. Early detection and close surveillance of congenital scoliosis is critical, as a rapidly progressive curve may lead to significant deformity, pulmonary restriction, and neurologic problems if not treated. Early surgical treatment is often necessary for rapidly progressive curves.

Anatomy of the posterolateral disc region.

Eighteen cadaveric dissections were performed to determine the location of the segmental vessels and the cephalad nerve root in relation to the posterolateral lumbar disc. The most lateral point of each lumbar disc was determined, and measurements were made form this reference point. Segmental vessels were found to be a mean of 10 to 13 mm from the junction of the vertebral body and the disc. The exception to this was the vessel superior to L5-S1, which was a mean of 7 mm from the disc margin. The cephalad nerve roots were consistently found to be adjacent to the disc, and were an average of 9 to 22 mm posterior to the lateral reference point.