Dear Sir, The standard approaches for exploration and fixation of scaphoid fractures are the anterior distal (Matte-Russe) approach and the dorsal proximal approach (for small proximal pole fractures). We describe an approach to the scaphoid from dorsal and distal. This alternative approach is made through a dorsal incision overlying the crossing of extensor pollicis longus and extensor carpi radialis longus (Fig. 1), which is easily found 1-2 cm proximal to the trapeziometacarpal joint. The superficial radial nerve and veins are identified and retracted and the radial artery identified and protected. Only a thin layer of subcutaneous tissue then covers the 'bare' area on the scaphoid. A short proximal extension of the incision exposes the radial convex surface of the scaphoid. Inserting an instrument such as a MacDonald's elevator enhances the view of the scaphoid back to the proximal pole. This allows for additional surgery, e.g. radioscaphoid debridement, radial styloidectomy, scapholunate ligament reconstruction and scaphoid bone grafting. Placing the intended internal fixation device such as a cannulated screw is more direct, without requiring as much wrist manipulation as the anterior approach. The screw has more bone mass to grip and the likelihood of breaching the cortex, especially on the concave (capitate) side, is much less (Figs 2-A).
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