Scaphoid – Dorsal Approach

Modern Study Review (AI-Generated)

High-Yield Summary

The dorsal approach to the scaphoid is the gold standard for accessing the proximal pole and radial styloid, especially when proximal scaphoid fixation or styloid excision is required. It provides excellent dorsal visualization but carries risks to the superficial branch of the radial nerve and the dorsal carpal branch of the radial artery, which is critical for scaphoid vascularity. Although arthroscopic and volar approaches are increasingly used for mid-waist fractures, the dorsal approach remains indispensable for proximal pole exposure and complex reconstructions.

Applied Anatomy & Intervals

Internervous Interval

• No true internervous plane.
• Dissection proceeds between the Extensor Pollicis Brevis (EPB) (radial side) and Extensor Pollicis Longus (EPL) (ulnar side) tendons.

Anatomic Landmarks

• Anatomic Snuffbox: Radially bordered by Abductor Pollicis Longus (APL) and EPB; ulnarly bordered by EPL.
• Radial Styloid: Palpable distal landmark guiding incision orientation.
• Scaphoid: Palpable by ulnar deviation of the wrist, making it prominent within the snuffbox.

Patient Positioning & Setup

• Table Type: Standard operating table with arm board attachment.
• Patient Position: Supine with the arm abducted on an arm board.
• Specialized Equipment:
• Proximal arm tourniquet.
• Hand table or padded support for wrist positioning.
• Optional C-arm fluoroscopy placed contralaterally for unobstructed imaging.

Surgical Technique (The “Vital Steps”)

Incision & Superficial Dissection

• Make a gently curved longitudinal incision centered over the anatomic snuffbox.
• Identify and protect branches of the superficial branch of the radial nerve during skin and subcutaneous dissection.
• Confirm tendon identity by passive thumb movement.

Deep Dissection & Exposure

• Incise the fascia between EPL (ulnar side) and EPB (radial side).
• Retract EPL ulnarly and EPB radially to expose the dorsal capsule.
• Identify and protect the radial artery and its dorsal carpal branch beneath the fascia; mobilize the artery radially and volarly.
• Longitudinally incise the dorsal capsule to expose the scaphoid.
• Retract capsule ulnarly/dorsally and radially/volarly to maximize exposure.

The “Danger Zone”

Post-Operative Pearl

Limit wrist extension and radial deviation initially to protect the dorsal capsule repair and preserve scaphoid blood supply. Early controlled mobilization can begin after 2–3 weeks once soft tissue healing is confirmed.

Classic Clinical Notes

Dorsal Approach

Surgical Approaches – Dorsal Approach to Scaphoid

• Provides good exposure of the scaphoid, particularly proximally, but endangers the superficial branch of the radial nerve and the dorsal blood supply of the scaphoid.
• Can get good access to the proximal pole, and to the radial styloid for excision.

Approach

• Supine, arm board; prep the crest or olecranon for graft.
• Landmark the anatomic snuffbox, bordered radially by APL and EPB and ulnarly by EPL. If you ulnar deviate the wrist, you can feel the scaphoid slide out from under the radial styloid and become prominent in the snuffbox.
• Make the incision gently curved through the snuffbox.
• The dissection is anatomic – there is no internervous plane. Basically, you want to go through the snuffbox, between EPB and EPL.
• Superficially, there are branches of the superficial radial nerve – watch out for these and try to protect them.
• Pull on the thumb to ensure that you know which tendons are which.
• Incise the fascia between the two tendons and retract EPL ulnarly, EPB radially.
• Watch out for the radial artery and its dorsal carpal branch just beneath the fascia. The radial artery is crossing through the snuffbox to dip though the first interspace into the volar aspect of the hand.
• Incise the capsule longitudinally and retract it ulnarly/dorsally and radially/volarly; the radial artery gets mobilized radially/volarly.
• Again – don’t fuck up the dorsal carpal branch – this provides the main supply to the scaphoid!

Last Updated on January 25, 2026 by orthonet