This study reports the use of a combined surgical approach in 7 patients to treat “difficult” ununited scaphoid fractures that have a palmar bone deficiency and a proximal pole that is difficult to engage. The limited palmar approach incision is smaller than the standard approach, preserving some of the extrinsic palmar ligaments and avoiding arthrotomy of the scaphotrapeziotrapezoid joint. This exposure allows resection of the nonunion and intercalary grafting. The dorsal incision and arthrotomy are transverse and expose the scapholunate interval. A Kirschner wire is inserted for provisional fixation, followed by a Herbert screw. All 7 patients treated with this combined approach healed by radiographic and clinical assessment at a minimum of 1 year follow-up. Correction of carpal misalignment was obtained in 5 of the 6 patients with a dorsal intercalary instability pattern. Range of motion averaged 92% and grip strength 102% of the normal side at follow-up.
Nonunions at the junction of the proximal and middle thirds of the scaphoid are particularly difficult to treat, especially when combined with excessive lateral intrascaphoid angulation or “humpback” deformity. The selection of surgical approach creates a dilemma between a palmar approach for bony correction and dorsal exposure for visualization and internal fixation. This article introduces the concept of a combined limited approach that can allow simultaneous correction of the lateral intrascaphoid angulation and secure fixation of the proximal third of the scaphoid. It is unclear if the additional dorsal exposure changes the outcome, but this approach may be useful in selected cases. Lastly, it is yet to be determined how much intrascaphoid angulation must be corrected to achieve a satisfactory result.