Clinical Example: Scaphoid fixation with more than one Herbert screw

A few years ago, I started putting in two Herbert screws for scaphoid fractures, with the thought that it would provide more rigid fixation. I think that it is helpful in some, but not all cases. Here are some of my results with a few variations...

 
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1. Nondisplaced fracture in a surgeon who declined continuous immobilization. 
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One week after screw stabilization using a limited dorsal approach, he was back operating, but splinted when not scrubbed. These films are one month post op: no visible fracture.
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Case 2. Nonunion with a large fracture cyst. After debridement, the defect, the graft, and yes, that is the capitate peeking through the defect.
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The graft, and inadequate seating of the more ulnar screw.
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Consolidation..
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The poorly placed screw remained a source of pain, and the hardware was removed along with a styloidectomy.
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Case 3. Another postop, better screw positioning.
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Case 4. Nonunion with a graft and screws placed in both directions from a single palmar approach, hyperextending the wrist for the proximal entry...
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and with the graft: 
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and with consolidation, 
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Case 5. Another,same bidirectional technique. Here, I ran the second screw too close to the first, and may have flattened the leading threads - not
ideal. The preop status:
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With intercalated iliac bone graft...
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and healing.
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Case 6. A dorsal approach for this proximal pole fracture would have been a better choice. 
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Case 7. This nonunion patient's scaphoid and iliac crest were unusually soft bone.
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After two screws, the fixation was clearly inadequate, so I put a third screw through the graft into the proximal pole. I wasn't sure whether to buy
stock in Herbert screws or Zantac. The fracture healed despite AWOL and no immobilization.
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Case 8. Transscaphoid perilunate fracture dislocation...
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Two screws put in dorsally, LT ligament reinforced with a strip of extensor retinaculum left attached to the triquetrium and anchored into the lunate; temporary capitolunate pin.
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Late, with asymptomatic partial union or nonunion, but no haloing.
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