inestabilidad carpiana

SelectedInstructional Course Lectures

THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS*

FRANKLIN H. SIM, Editor, Vol. 50

COMMITTEE

JAMES H. BEATY, ChairmanFRANKLIN H. SIM

S. TERRY CANALE

DONALD C. FERLIC

EX OFFICIO

FRANKLIN H. SIM, Editor, Vol. 50DEMPSEY S. SPRINGFIELD, Deputy Editor of

The Journal of Bone and Joint Surgeryfor Instructional Course Lectures

JAMES D. HECKMAN

*Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as otherlectures presented at the Academy’s Annual Meeting, will be available in March 2001 in Instructional CourseLectures, Volume 50. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726(8 A.M.-5 P.M., Central time).

578 THE JOURNAL OF BONE AND JOINT SURGERY

Carpal Instability*†

BY RICHARD H. GELBERMAN, M.D.‡, WILLIAM P. COONEY, III, M.D.§,

AND ROBERT M. SZABO, M.D., M.P.H.#

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Anatomy

The intracapsular ligaments of the wrist are dividedinto intrinsic and extrinsic components1-9. The two mostimportant intrinsic (interosseous) ligaments, the scapho-lunate and lunotriquetral ligaments, are divided into dor-sal, proximal, and palmar regions (Fig. 1)1,10. The thickestand strongest region of the scapholunate ligament is lo-cated dorsally10, and that of the lunotriquetral ligament islocated palmarly10.

There are three strong palmar extrinsic radiocarpalligaments: the radioscaphocapitate, long radiolunate,and short radiolunate ligaments2. The radioscaphocapi-tate ligament, which extends from the radial styloid pro-cess through a groove in the waist of the scaphoid to thepalmar aspect of the capitate, acts as a fulcrum aroundwhich the scaphoid rotates (Fig. 2). The long radiolu-nate ligament, which lies parallel to the radioscaphocap-itate ligament, extends from the palmar rim of the distalpart of the radius to the radial margin of the palmarhorn of the lunate. The long radiolunate ligament andthe palmar region of the lunotriquetral interosseous lig-ament, thought to be in continuity in earlier studies,were previously labeled the radiotriquetral ligament7.Located between the radioscaphocapitate and long ra-diolunate ligaments, at the level of the midcarpal joint,is an area of capsular weakness known as the space of

Poirier. The short radiolunate ligament, which is con-tiguous with palmar fibers of the triangular fibrocarti-lage complex, originates from the palmar margin of thedistal part of the radius and inserts into the proximalpart of the palmar surface of the lunate. The radioscaph-olunate ligament (the ligament of Testut), previouslythought to be an important stabilizer of the scaphoid, is

now considered to be a neurovascular pedicle derivedfrom the anterior interosseous and radial arteries andfrom the anterior interosseous nerve3. The ulnolunateand ulnotriquetral ligaments arise from the volar edgeof the triangular fibrocartilage and insert into the lunateand the triquetrum, respectively. The dorsal radiocarpalligament originates from the dorsal margin of the distalpart of the radius and extends ulnarly and distally to at-tach to the lunate, the lunotriquetral interosseous liga-ment, and the dorsal tubercle of the triquetrum (Fig.

*No benefits in any form have been received or will be receivedfrom a commercial party related directly or indirectly to the subjectof this article. No funds were received in support of this study.

†Printed with permission of the American Academy of Ortho-paedic Surgeons. This article, as well as other lectures presented at theAcademy’s Annual Meeting, will be available in March 2001 in In-structional Course Lectures, Volume 50. The complete volume can beordered online at www.aaos.org, or by calling 800-626-6726 (8 A.M.-5P.M., Central time).

‡Department of Orthopaedic Surgery, Barnes-Jewish Hospital atWashington University, One Barnes Plaza, Suite 11300, St. Louis,Missouri 63110. E-mail address: [email protected].

§Department of Orthopaedic Surgery, Mayo Graduate School ofMedicine, 1085 Orchard Acres Lane S.W., Rochester, Minnesota 55902.E-mail address: [email protected].

#Division of Plastic Surgery, Department of Surgery, University ofCalifornia, Davis, School of Medicine, 4860 Y Street, Sacramento,California 95817. E-mail address: [email protected].

FIG. 1

Illustration demonstrating the scapholunate and lunotriquetral in-terosseous ligaments (arrows). S = scaphoid, L = lunate, and T = tri-quetrum. (Reproduced, with modification, from: Berger, R. A.: Thegross and histologic anatomy of the scapholunate interosseous liga-ment. J. Hand Surg., 21A: 172, 1996. Reprinted with permission.)

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3)11. The dorsal intercarpal ligament originates from thetriquetrum and extends radially to insert into the lunate,the dorsal groove of the scaphoid, and the trapezium11.

Kinematics

There are two prevailing theories, the columnar andoval ring concepts, that have been used to characterizecarpal kinematics. The columnar carpus concept, intro-duced by Navarro in 1921, describes the carpus as a se-ries of three longitudinal columns (the central [flexion-extension], lateral [mobile], and medial [rotational] col-umns) (Fig. 4)12. Taleisnik modified Navarro’s theory,adding the trapezium and trapezoid to the central col-umn and eliminating the pisiform from the medial col-

umn (Fig. 5)8. The scaphoid is considered to be thestabilizing link for the midcarpal joint, and the tri-quetrum is thought to be the pivot point for carpalrotation8,9. Flexion and extension occur through thecentral column, and radial and ulnar deviation occur byrotation of the scaphoid laterally and the triquetrummedially. With the proximal row independence and ovalring concepts, Linscheid13 and Lichtman et al.14 charac-terized the carpus as a ring that allows reciprocal mo-tion during radial and ulnar deviation and flexion andextension of the wrist (Fig. 6). Central to this concept isthe observation that radial and ulnar deviation and flex-ion and extension occur reciprocally between the radio-carpal and midcarpal joints (that is, movement by onerow is in the opposite direction from that by the other).An interruption of the proximal carpal row at any pointin the ring results in carpal instability.

Terminology

The carpus is considered clinically unstable if it ex-hibits symptomatic malalignment, is not able to bearloads, and does not have normal kinematics during anyportion of its arc of motion15. Static instability refers tocarpal malalignment that can be detected on standardposteroanterior and lateral radiographs16. Dynamic in-stability refers to carpal malalignment that is repro-duced with physical examination maneuvers and whenstress radiographs are made. With dynamic instability,there is no evidence of carpal bone malalignment onplain radiographs. The terms dorsal intercalated insta-bility and volar intercalated instability refer to the ap-pearance of the lunate, the intercalated segment, on the

FIG. 2

Illustration demonstrating the palmar wrist ligaments. UT = ulno-triquetral, UL = ulnolunate, SC = scaphocapitate, RSC = radio-scaphocapitate, LRL = long radiolunate, and SRL = short radiolunate.The space between the long radiolunate and short radiolunate liga-ments is where the ligament of Testut (or the radioscapholunate liga-ment), now known to be a neurovascular pedicle, enters the radiocar-pal joint.

FIG. 3

Illustration demonstrating the dorsal wrist ligaments. DIC = dorsalintercarpal, DRC = dorsal radiocarpal, and DRU = dorsal radioulnar.

FIG. 4

Illustration demonstrating Navarro’s columnar carpus12. The lateralcolumn comprises the scaphoid, trapezium, and trapezoid; the centralcolumn comprises the lunate, capitate, and hamate; and the medial col-umn comprises the triquetrum and pisiform. (Reproduced, with modi-fication, from: Lichtman, D. M.; Schneider, J. R.; Swafford, A. R.; andMack, G. R.: Ulnar midcarpal instability — clinical and laboratoryanalysis. J. Hand Surg., 6: 522, 1981. Reprinted with permission.)

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580 R. H. GELBERMAN, W. P. COONEY, III, AND R. M. SZABO

lateral radiograph17. In dorsal intercalated instability,the lunate is angulated dorsally in the sagittal plane andthe capitate is displaced dorsal to the radiometacarpalaxis (radiolunate angle, more than 10 degrees) (Fig. 7).In volar intercalated instability, the lunate angulatespalmarly (radiolunate angle, 10 degrees in a palmar di-rection), which causes the capitate to become displacedpalmar to the radiometacarpal axis.

Other terms have been introduced to clarify vari-

ous patterns of carpal instability. Carpal instabilitydissociative connotes an injury to one of the major in-trinsic carpal ligaments, such as that seen in scapho-lunate dissociation and perilunate dislocation. Carpalinstability nondissociative indicates an injury to a ma-jor extrinsic ligament, such as occurs in dorsal carpalsubluxation, midcarpal instability, volar carpal sublux-ation, or capitate-lunate instability. Carpal instabilityadaptive refers to carpal instability resulting from anexternal cause, such as that seen at the radiocarpal ormidcarpal joint following severe malunion of the distalpart of the radius.

Mechanisms of Injury

In an experimental study, Mayfield et al. determinedthat the mechanism of injury for most carpal dislocationsis a fall on the outstretched hand causing wrist extension,ulnar deviation, and intercarpal supination18,19. Sequentialligamentous injury, called progressive perilunar instabil-ity, was noted to be initiated on the radial aspect of thewrist and to extend across the perilunate ligaments to theulnar aspect of the wrist. Four stages of progressive per-ilunar instability were defined, including scapholunatedissociation caused by injury to the scapholunate in-terosseous and palmar radioscaphocapitate ligaments(stage I), dislocation of the capitolunate joint through thespace of Poirier (stage II), separation of the triquetrum

FIG. 5

FIG. 6

Illustration demonstrating Taleisnik’s modification of the columnarcarpus8. The trapezium and trapezoid are included in the central col-umn, and the pisiform is eliminated from the medial column. (Repro-duced, with modification, from: Lichtman, D. M.; Schneider, J. R.;Swafford, A. R.; and Mack, G. R.: Ulnar midcarpal instability — clin-ical and laboratory analysis. J. Hand Surg., 6: 522, 1981. Reprintedwith permission.)

Illustration demonstrating the oval ring concept of Lichtman et al.14.(Reproduced, with modification, from: Lichtman, D. M.; Schneider,J. R.; Swafford, A. R.; and Mack, G. R.: Ulnar midcarpal instability —clinical and laboratory analysis. J. Hand Surg., 6: 522, 1981. Reprintedwith permission.)

FIG. 7

Gilford et al. described the wrist as a link joint (Fig. 7, A), notingthat instability occurs in compression because of the intercalated seg-ment (the proximal carpal row represented by the lunate [L]) (Fig. 7,B). The scaphoid (S in Fig. 7, C) links the radius to the distal carpalrow and provides stability against compression forces during wristflexion and extension. C = capitate, and R = radius. (Reprinted, withpermission, from: Green, D. P.: Carpal dislocation and instabilities. InOperative Hand Surgery, edited by D. P. Green. Ed. 3, p. 863. NewYork, Churchill Livingstone, 1993. [Green noted that the figure wasmodified from: Gilford, W. W.; Bolton, R. H.; and Lambrinudi, C.: Themechanism of the wrist joint with special reference to fractures of thescaphoid. Guy’s Hosp. Rep., 92: 52-59, 1943.])


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from the lunate with associated injury to the lunotrique-tral and ulnotriquetral ligaments (stage III), and palmarlunate dislocation due to injury to the dorsal radiocarpalligament (stage IV). Transradial styloid, transscaphoid,and transcapitate fractures are associated with perilunateinjuries that progress from lateral to medial, ultimatelyinvolving the lunotriquetral ligament, the volar ulnocar-pal ligaments, and the ulnar styloid process20.

Radiographic andOther Diagnostic Studies

Six radiographs are made for wrists with suspectedcarpal instability. These include posteroanterior, lateral,radial and ulnar deviation, and flexion and extensionviews21. An additional posteroanterior radiograph of thewrist with a clenched and loaded fist is made to rule outscapholunate instability. The alignment of the proximaland distal carpal rows is measured with Gilula’s method.The midcarpal joint is visualized as an acetabulum orcup where the capitate and hamate articulate with theproximal carpal row. Interruption of the normal carpalarc of either the proximal or the distal carpal row indi-cates an instability pattern.

The use of radionuclide bone scans as screeningtools is indicated for the localization of the cause ofobscure wrist pain such as that due to a chondral frac-ture22. While a positive bone scan provides informationon the location of a wrist abnormality, it is rarely diag-nostic. A negative bone scan, which suggests that a seri-ous injury has not occurred, does not rule out carpalinstability, especially in the early stages when reactivebone changes have not yet taken place. Overall, bone-

scanning is not as helpful as other studies in the evalua-tion of wrists with suspected carpal instability.

Arthrography of the wrist, performed alone or withvideofluoroscopy, is a useful study in the evaluation of awrist with carpal instability23. While wrist dynamics arebest assessed with fluoroscopy, arthrography remainsthe standard study for the carpal ligaments and the tri-angular fibrocartilage complex24. Midcarpal, radiocar-pal, and distal radioulnar arthrography (triple-phaseinjection) provides valuable definitive data on the integ-

FIG. 8-A

Figs. 8-A, 8-B, and 8-C: Midcarpal arthrograms diagnostic for alunotriquetral ligament tear.

Fig. 8-A: Contrast material is injected into the midcarpal joint.

FIG. 8-B

Contrast material is noted to extend across the lunotriquetral joint(arrow).

FIG. 8-C

Contrast material fills the scapholunate interval but does not crossat this location into the radiocarpal joint.



rity of the intrinsic intercarpal ligaments. Contrast ma-terial injected into the midcarpal joint does not extendinto the radiocarpal joint unless there is either an acuteor a degenerative intrinsic ligament tear (Figs. 8-A, 8-B,and 8-C). For injuries of the triangular fibrocartilage

complex, selective injection of the distal radioulnar jointis carried out. However, in some cases, both the radio-carpal and the distal radioulnar joint must be inspectedto show a communicating defect. While false-positiveand false-negative arthrograms have been reported, ar-thrography is of considerable value as a primary studyfor intrinsic carpal ligament injury.

Tomography of the wrist (polytomography or com-puted tomography), which is useful for evaluating thealignment of the carpal bones, is most helpful for assess-ing the fractures and fracture-dislocations that are fre-quently associated with carpal instability25. Complexmotion polytomography is of special value for obtainingbiplanar images of the carpus. Computed axial tomog-raphy26, which provides useful cross-sectional images, isparticularly helpful if three-dimensional reconstructionis performed. In the evaluation of wrist injuries, tomog-raphy is generally limited to cases in which a carpal frac-ture is suspected.

Magnetic resonance imaging, used frequently forthe evaluation of wrist pain, is less helpful than otherstudies for the assessment of a wrist with carpal in-stability27,28. Magnetic resonance imaging is most usefulfor evaluating suspected cases of osteonecrosis of boneand tumors of bone or soft tissue. While it can be help-ful for visualizing the triangular fibrocartilage com-plex, it is not particularly useful for the evaluation ofcarpal ligament injuries unless gadolinium enhance-ment is performed28,29. The consistency with which boththe radiocarpal and the interosseous ligaments aredemonstrated, however, is not sufficient for this to be aprimary method of evaluation.

Arthroscopy has replaced arthrography in many cen-ters30,31 as the definitive diagnostic study for wrists with

FIG. 9

FIG. 10

Figs. 9 and 10: A wrist with acute static scapholunate dissociation.Fig. 9: Posteroanterior radiograph. The scaphoid is flexed (fore-

shortened), there is a scaphoid ring sign, the distance between theproximal aspect of the ring and the proximal pole of the scaphoid isless than seven millimeters, and there is a gap between the scaphoidand the lunate of greater than three millimeters (arrow). In addition,the lunate and the triquetrum are dorsiflexed (the lunate is quadrilat-eral in shape, and the triquetrum is displaced distally on the hamate),while the scaphoid is flexed (the ring sign), which indicates an inter-ruption in the proximal carpal row at the scapholunate interval.

Lateral radiograph demonstrating an increased scapholunate angle as measured with the tangential measurement method. The longitudi-nal axis of the scaphoid is demonstrated by creating a line that connects the proximal surfaces of the two poles of the scaphoid. The angle is90 degrees.


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suspected carpal instability. Recent reports have indi-cated that arthroscopic evaluation of the wrist is more ac-curate and specific than arthrography in detecting the siteand extent of ligament injury21,32. Diagnostic wrist arthros-copy includes an examination of both the radiocarpal and

the midcarpal joint. In the radiocarpal joint, triangulationprobing of the scapholunate interosseous ligament, thelunotriquetral interosseous ligament, and the triangularfibrocartilage complex is carried out. The volar carpal lig-aments are assessed in a radial-to-ulnar direction to de-termine whether extrinsic ligament injury has occurred.Midcarpal arthroscopy, with use of a triangulation probe,is performed routinely. The space between the scaphoidand lunate bones is assessed for evidence of ligamentouslaxity. A diagnosis of partial or complete carpal ligamentinjury is established on the basis of the ease of separationof the scaphoid from the lunate and of the lunate fromthe triquetrum. If the probe can be rotated within thejoint, a tear of the scapholunate or lunotriquetral in-terosseous ligament is suggested. If either the probe orthe arthroscope can be passed from the midcarpal to theradiocarpal joint, rotatory subluxation of the scaphoid (acomplete scapholunate ligament tear with extrinsic liga-ment laxity) is confirmed. Within the radiocarpal joint, atriangulation probe assists in the assessment of the size,location, and extent of tears of the triangular fibrocarti-lage complex. Associated osseous injuries (fractures ofthe proximal pole of the scaphoid or dorsal triquetralchip fractures) can be visualized also. Wrist arthrographyand arthroscopy may be carried out in sequence withinthe operating room. Comprehensive intraoperative as-sessment currently includes fluoroscopy of the wrist withthe patient under anesthesia in the operating room, fol-lowed by wrist arthrography and then by wrist arthros-copy, if indicated. Dynamic fluoroscopic imaging studiesand arthroscopy are particularly useful when performedsequentially in the operating room to confirm the pres-ence of a ligamentous injury and to plan the appropriateoperative approach.

Acute Static Scapholunate Dissociation

Acute static scapholunate dissociation, which mayoccur as an isolated entity or as a late sequela of a peri-

FIG. 11

FIG. 12

Figs. 11 through 14: A wrist with acute stage-III dorsal perilunatedislocation according to the system of Mayfield et al.18,19.

Fig. 11: Preoperative posteroanterior radiograph demonstratingoverlap of the carpal bones (normally only the trapezium and thetrapezoid, and the triquetrum and the pisiform, overlap on the pos-teroanterior radiograph), a triangular shape to the lunate, and ascapholunate gap of seven millimeters.

Preoperative lateral radiograph demonstrating that while the lunate is palmar flexed it rests in the lunate fossa of the radius. The scaphoidand the capitate are displaced dorsal to the longitudinal axis of the radius.



lunate dislocation, results from injury to the scapholu-nate interosseous and palmar radioscaphoid ligaments33.Depending on the extent of ligamentous injury, there iseither diffuse tenderness of the carpus or point tender-ness over the scapholunate interval. Radiographs revealall five key features of rotatory subluxation of the scaph-oid (Figs. 9 and 10). While ligamentous repair withinthree weeks after the injury34,35 is preferred, delayed re-pair can be carried out as long as four to six monthsfrom the time of the injury. Several factors govern thefeasibility of delayed ligamentous repair (repair laterthan three weeks after the time of the injury); these fac-tors include the identification of a substantial, reparablescapholunate interosseous ligament and the isolation ofa palmar flexed scaphoid that can be reduced withoutthe necessity for extensive circumferential dissection.The extent to which the scaphoid becomes fixed in pal-mar flexion is dependent on the magnitude of the initialcapsular injury, with scarring and capsular contractureincreasing over time.

Neither closed reduction alone nor closed reductionand percutaneous pin fixation is uniformly successful inmaintaining carpal alignment and in achieving satisfac-tory long-term outcomes in wrists with acute scapho-lunate instability. The preferred method of treatment isopen reduction of the carpus through a dorsal approach,pinning of the scaphoid to the lunate and to the capi-tate with two 0.045-inch (0.114-centimeter) Kirschnerwires36-40, and direct repair of the scapholunate ligament.Ligament repair is carried out either with direct suturefor ligaments torn in their midsubstance or with pull-outsutures or suture anchors for ligaments avulsed frombone. The wrist is immobilized in neutral position in anabove-the-elbow thumb-spica cast for eight weeks34, fol-lowing which time the pins are removed and active mo-tion is initiated.

Chronic Scapholunate Dissociation

For wrists in which the scapholunate interosseous lig-ament cannot be repaired primarily, attempts to recon-struct the dorsal and palmar ligaments of the scaphoidwith any combination of late ligamentous repair, tendon-grafting, and capsulodesis, while feasible41, have not pro-vided consistent pain relief and have not maintained thealignment of the carpus over the long term36,42,43. Eitherscaphotrapeziotrapezoid or scaphocapitate intercarpalarthrodesis is effective operative management. Each hasbeen shown to produce similar reductions in the globalrange of motion of the wrist and comparable effects onrelative intercarpal motion44. While some experimentalstudies have shown that these intercarpal arthrodesescause increased loads across the radioscaphoid joint45,46,increased shear stresses on the lunate, and increasedtension on the surrounding ligaments44, others have indi-cated that the long-term functional results are satisfac-tory46-51. Most authors have recommended that radialstyloidectomy be carried out at the time of scaphotrap-

eziotrapezoid and scaphocapitate arthrodeses to avoidradial styloid-scaphoid impingement. Following both ofthese limited intercarpal arthrodeses, residual flexion andextension of the wrist is 50 to 60 percent of that on thecontralateral side and residual radial and ulnar deviationis 60 to 70 percent of that on the contralateral side48,49,52-54.The most common complications are nonunion, which isseen in as many as 30 percent of patients, and radio-scaphoid impingement55-57.

Acute Perilunate Dislocation

With acute perilunate dislocation, the typical find-ings on physical examination are swelling, pain, anddeformity of the wrist and the typical finding on radio-graphic examination is gross disturbance of the inter-carpal relationships (Fig. 11). With dorsal perilunatedislocation, lateral radiographs demonstrate that thelongitudinal axis of the capitate is displaced dorsal tothe longitudinal axis of the radius (Fig. 12). With lunatedislocation, the longitudinal axis of the capitate is co-

FIG. 13

Postoperative posteroanterior radiograph demonstrating reductionof the scaphoid with fixation of the scaphoid to the lunate with two0.045-inch (0.114-centimeter) Kirschner wires. A third Kirschner wiresecures the scaphoid to the capitate. The scapholunate interosseousligament was reattached to the lunate with a suture anchor. Thelunotriquetral joint was reduced, and the triquetrum was secured tothe lunate with a 0.045-inch Kirschner wire. The lunotriquetral liga-ment was repaired by direct suture.


VOL. 82-A, NO. 4, APRIL 2000

linear with the axis of the radius and the lunate is dis-placed palmarly17. Distortion of the concentric arcs ofthe proximal and distal rows indicates that the injuryhas extended to the ulnar side of the carpus. If initial ra-diographs are confusing, it is helpful to make distractionradiographs with ten to fifteen pounds (4.5 to 6.8 kilo-grams) of fingertrap traction. Radiographs of the con-tralateral wrist in neutral alignment are made, andmeasurements are made from reference points on thelunate and scaphoid.

Previous investigators have noted that there is a lowlikelihood of achieving long-term success with closed re-

duction of an acute perilunate dislocation, with or with-out percutaneous pin fixation58. Currently, the treatmentof choice is immediate closed reduction followed by openligamentous repair through a dorsal approach. Closed re-duction is carried out in the emergency room with trac-tion (ten pounds [4.5 kilograms] for ten minutes) appliedto the hand with fingertraps. The fingertraps are re-moved, and manual longitudinal traction is applied. Asthe wrist is extended, the lunate is stabilized by the exam-iner’s thumb. With traction maintained, the wrist is grad-ually palmar flexed and the capitate is reduced into theconcavity of the lunate59. The patient is then taken to the

FIG. 15

Photograph demonstrating how point tenderness over the scapholunate interval is elicited in wrists with dynamic scapholunate instability.

FIG. 14

Postoperative lateral radiograph demonstrating that the capitate and the lunate are colinear with the radius and that the capitate is concen-tric with the articular surface of the lunate.



FIG. 16-B

FIG. 16-C

Figs. 16-A, 16-B, and 16-C: Photographs demonstrating the scaphoid shift maneuver.Figs. 16-A and 16-B: Volar and lateral views showing how the maneuver is performed by applying pressure over the scaphoid while the wrist

is held in ulnar deviation.Fig. 16-C: As the wrist is brought from ulnar to radial deviation, the scaphoid’s proximal pole returns to its position in the scaphoid fossa of

the radius. The patient notes wrist pain with the maneuver, and both the patient and the examiner note a clunking sensation.

FIG. 16-A


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operating room, and regional or general anesthesia is ad-ministered. A longitudinal dorsal incision is made fromthe base of the index and long metacarpals, over Lister’stubercle to the distal aspect of the forearm. Dissection ofthe carpus is carried out beneath the infratendinous reti-naculum of the fourth dorsal compartment. The scapho-lunate and lunotriquetral interosseous ligaments areinspected. After reduction of the scapholunate joint,three to four 0.045-inch (0.114-centimeter) Kirschnerwires are inserted, extending from the scaphoid to the lu-nate, from the scaphoid to the capitate, and on occasionfrom the radius to the lunate. If the lunotriquetral liga-ment is torn, the lunotriquetral joint is reduced andpinned with an additional 0.045-inch Kirschner wire(Figs. 13 and 14). The scapholunate and lunotriquetral in-terosseous ligaments are repaired with direct suture with4.0 braided Dacron or with suture anchors. Currently, apalmar incision is made in addition, particularly if thereis a palmar lunate (stage-IV18,19) dislocation that cannotbe reduced closed or if there are findings indicative ofacute carpal tunnel syndrome.

Postoperatively, the wrist is immobilized in an above-the-elbow plaster-reinforced compression dressing forfourteen days. A below-the-elbow thumb-spica cast isthen applied and is maintained for an additional sixweeks. Eight weeks postoperatively, the cast is removed,the pins are removed, and active motion is initiated60. In arecent multicenter study of perilunate dislocations andfracture-dislocations, the authors noted that both openinjury and a delay in treatment had adverse effects onoutcomes and that postoperative arthritis was common(seen in as many as 56 percent of cases)20,58,61.

Transscaphoid Perilunate Dislocation

Initial evaluation and treatment is similar to thatcarried out for perilunate dislocation20,58,60,61. Internal fix-

ation of the scaphoid is performed with insertion of acompression screw through a dorsal incision. Injury tothe dorsolateral branches of the radial artery, whichenter the scaphoid through the dorsal ridge, can beavoided by direct visualization and protection of thedorsolateral vascular leash. An additional Kirschner

FIG. 17

Figs. 17 and 18: Photograph and radiograph demonstrating the technique of dorsal capsulodesis.Fig. 17: Dorsal capsulodesis is performed by creating a transversely directed trough in the distal portion of the scaphoid. A one-centimeter-

wide dorsal radius-based capsular flap, aligned with the longitudinal axis of the thumb metacarpal (arrows), is attached to the scaphoid with su-ture anchors.

One or two 0.045-inch (0.114-centimeter) Kirschner wires, insertedthrough the scaphoid’s distal pole, provide stabilization to the capi-tate. The wrist is immobilized postoperatively in 20 degrees of exten-sion and ulnar deviation for six weeks.

FIG. 18



wire may be placed in the scaphoid to provide rotationalstability. Immobilization in a thumb-spica cast is main-tained until there are clinical and radiographic signs ofscaphoid union as evidenced by the absence of tender-ness in the anatomical snuffbox on physical examina-tion and the appearance of trabeculae extending acrossthe fracture site on plain radiographs.

Scaphoid Dislocation

Palmar radial displacement of the proximal pole ofthe scaphoid from the scaphoid fossa of the distal part ofthe radius is diagnostic of a scaphoid rather than a perilu-nate dislocation. The interposition of capsular or liga-mentous tissue may prevent closed reduction. Treatment,which is similar to that recommended for acute scapho-lunate dissociation, consists of open reduction of thescapholunate joint, insertion of two 0.045-inch (0.114-centimeter) Kirschner wires extending from the scaphoidto the lunate and from the scaphoid to the capitate, anddirect repair of the scapholunate interosseous ligament.Immobilization in a below-the-elbow thumb-spica cast ismaintained for eight weeks, after which time active mo-tion is initiated.

Dynamic Scapholunate Instability

Initially described by Taleisnik in 198062, dynamicscapholunate instability is the most common cause ofwrist pain and instability in adolescents and youngadults63. Although a precise anatomical cause has notbeen determined, it is likely that attenuation of the pal-mar radioscaphoid and scapholunate interosseous liga-ments is the basis for this instability pattern8,62,64-67. Whileradiographic findings are frequently normal61,64,68, con-sistent findings on physical examination confirm thediagnosis. There is point tenderness over the scapholu-nate interval (Fig. 15), and provocative tests reproducesymptoms of instability. The scaphoid shift maneuver,performed as described by Watson et al.69, is the mostuseful clinical test. To perform this maneuver, pressureis applied to the palmar tubercle of the scaphoid by theexaminer’s thumb with the wrist in ulnar deviation(Figs. 16-A and 16-B). In wrists with instability, thescaphoid is displaced dorsally over the lip of the radius.As the wrist is brought from ulnar to radial deviation,the scaphoid’s proximal pole returns to its position inthe scaphoid fossa of the radius (Fig. 16-C). As thescaphoid reduces, a clunking sensation and wrist painare noted. Although 110 (11 percent) of 1000 randomlyexamined wrists were found to have unilateral, asymp-tomatic increased scaphoid mobility on the scaphoidshift test70, patients with dynamic instability are distin-guished by their symptoms of instability and pain withthis maneuver. The unaffected wrist is examined, and anassessment for generalized ligamentous laxity is carriedout. Additional studies, such as three-portal wrist ar-thrography and wrist arthroscopy, have not been foundto be helpful in confirming the diagnosis63.

In a recent study, nineteen patients (twenty wrists)with dynamic instability were treated nonoperativelywith splinting of the wrist, oral administration of non-steroidal anti-inflammatory medication, and modifica-tion of activities63. No patient in that study, however,had a substantial reduction in symptoms, even aftertwelve weeks and longer durations of nonoperativetreatment.

For wrists with persistent incapacitating pain andinstability after a trial of nonoperative care, dorsal cap-sulodesis, as described by Blatt64,71 and as modified byWintman et al.63, is the treatment of choice (Figs. 17 and18). Results, reported in three recent studies, have beenconsistent with regard to the effectiveness of this proce-dure in eliminating symptoms of instability and pain inmore than 90 percent of patients and in the achievementof high levels of satisfaction as reported on question-naires36,63,64. Patients reported that substantial improve-ments occurred in activities such as brushing teeth,opening automobile doors, shoveling, sweeping, throw-ing, and using a screwdriver63. While dorsal capsulodesishas been shown to cause a mean loss of wrist flexion of 15

FIG. 19

Posteroanterior radiograph of the wrist, demonstrating stage-IIIscapholunate advanced collapse. There is severe narrowing of the ra-dioscaphoid joint space, from the tip of the styloid process of the ra-dius to the lateral edge of the scaphoid fossa, and narrowing of thecapitolunate joint space (arrows). The radiolunate joint is preserved.


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degrees, this procedure appears to provide superior out-comes when compared with the alternative methods thathave been used for the treatment of dynamic instability,

such as triscaphoid arthrodesis, which causes a far greaterloss of wrist motion in all planes36.

Dorsal Wrist Ganglia andDynamic Carpal Instability

Dorsal wrist ganglia, which most often originatefrom the scapholunate interosseous ligament in youngadults, have been shown to be associated with symp-toms and signs of dynamic scapholunate instability. In arecent study72 of eighteen patients (nineteen wrists) witha dorsal wrist ganglion and dynamic scapholunate insta-bility, treatment consisted of excision of the ganglion tothe level of the scapholunate interosseous ligament andpostoperative immobilization of the wrist in 20 degreesof extension for two weeks. On follow-up evaluation,two patients had continued wrist pain and one had a re-current ganglion. All but one patient in this series, in-cluding two who had signs of generalized ligamentouslaxity, had a stable nontender wrist on follow-up physi-cal examination at one year. It appears that postopera-tive dorsal capsular scarring following ganglion excisionand two weeks of wrist immobilization stabilizes thescaphoid sufficiently to alleviate symptoms and signs ofdynamic scapholunate instability.

Scapholunate Advanced Collapse

The most common form of wrist arthritis, scapholu-nate advanced collapse, evolves in a predictable se-quence73. Injury to the scapholunate interosseous andpalmar radioscaphoid ligaments has been shown to leadto a progressive shift of the pressure centroid of thescaphoid74, resulting in a change in the regions of peakintra-articular contact between the scaphoid and thedistal part of the radius. Three distinct time-related de-generative changes occur in scapholunate advanced col-lapse; these consist of joint-space narrowing betweenthe tip of the styloid process of the radius and the distalouter aspect of the scaphoid in stage I, degenerative

FIG. 20-B

FIG. 20-A

Figs. 20-A and 20-B: Posteroanterior and lateral radiographs show-ing a malunion of the distal part of the radius. Dorsal lunate sublux-ation occurs secondary to increased dorsal tilt. There is evidence of azigzag collapse pattern of the lunate and the capitate.



changes along the entire articular surface between theradius and the scaphoid in stage II, and narrowing of thecapitolunate joint space in stage III (Fig. 19). The obser-vation that the radiolunate joint is spared consistently inwrists with scapholunate advanced collapse has servedas the anatomical basis for several of the most widelyused treatment methods over the past two decades.

Initial treatment consists of oral administration ofnonsteroidal anti-inflammatory medication, applicationof a wrist splint, and modification of activities. For wristswith stage-I scapholunate advanced collapse that are re-sistant to nonoperative measures, operative treatmentdesigned to stabilize the carpus so that compressive andshear forces are transmitted through the normal radio-scapholunate articulation is recommended. As ligamentreconstruction has not proved to be consistently effectivein maintaining correction of the excessively flexed scaph-oid, intercarpal arthrodesis has become the operativeprocedure of choice. Either scaphotrapeziotrapezoid orscaphocapitate arthrodesis achieves the goal of maintain-ing the scaphoid in an alignment that is 50 to 55 degrees

to the longitudinal axis of the radius when the wrist is inneutral position, and each is effective in reducing painand slowing the progression of degenerative arthritis. Ra-dial styloidectomy, performed simultaneously and con-sisting of removal of seven millimeters of the radialstyloid process dorsally and four millimeters palmarly,consistently minimizes symptoms due to abutment andeliminates pain due to arthritis at the distal aspect of theradioscaphoid joint.

For wrists with degenerative arthritis involving theentire radioscaphoid joint (stage II) or the radioscaphoidand capitolunate joints (stage III), a motion-preservingreconstructive procedure, either capitate-lunate-hamate-triquetrum (four-corner) arthrodesis with scaphoid ex-cision or proximal row carpectomy, is recommended.

Studies by Imbriglia et al.75 and by Neviaser76 on prox-imal row carpectomy have indicated that, while high lev-els of wrist motion and grip strength are maintained,there is persistent pain, a failure to return to strenuouswork, and a recommendation for conversion to arthro-desis in as many as 15 percent of patients. While care-fully performed four-corner arthrodesis with scaphoidexcision provides levels of patient satisfaction and gripstrength that are similar to those seen with proximal rowcarpectomy, values for the range of motion of the wristare 15 to 20 degrees lower73,77. Attempts to limit thearthrodesis to the capitolunate joint in order to achieve ahigher postoperative range of motion of the wrist havebeen unsuccessful because of high rates of nonunion78.

Recent studies have confirmed that proximal rowcarpectomy maintains an arc of wrist flexion and exten-sion that is approximately 20 degrees greater than themotion arc that is achieved with four-corner arthrodesis.While grip-strength values and overall patient-satisfactionscores have been similar, specific complications havebeen noted with each procedure. Proximal row carpec-tomy appears to be particularly unpredictable in laborersand in wrists with stage-III scapholunate advanced col-lapse. Four-corner arthrodesis has been associated with

FIG. 21

FIG. 22

Schematic drawing of a wrist with midcarpal instability demon-strating flexion of the lunocapitate joint. The dotted oblique linethrough the distal part of the radius is the site of the proposed correc-tive osteotomy.

Radiograph showing a malunion of the distal part of the radius with 40 degrees of dorsiflexion of the distal part of the radius, a scapholunate an-gle of 75 degrees, and a lunocapitate angle of 15 degrees.


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failure rates of as high as 30 percent79, and isolated capi-tolunate arthrodesis has been associated with a nonunionrate of 50 percent (four of eight)80. Studies have indicatedthat either scaphotrapeziotrapezoid or scaphocapitatearthrodesis with radial styloidectomy is indicated forstage-I scapholunate advanced collapse52,73. For stage II,either four-corner arthrodesis with scaphoid excision orproximal row carpectomy is an effective reconstructiveprocedure. There is general consensus that either lim-ited wrist arthrodesis with scaphoid excision or proximalrow carpectomy with fascial interposition is the pro-cedure of choice for stage-III scapholunate advancedcollapse79-82.

Adaptive Instability

Dorsiflexion malunion after fracture of the distalpart of the radius is the most common cause of adaptive

carpal instability83,84. The osseous deformity leads to mal-alignment of the bones of the proximal carpal row, lossof wrist flexion, and radiocarpal or midcarpal instability.Biomechanical studies have shown that there is a shift ofload from the radius to the ulna (from 20 to 67 percent ofthe total load) when dorsal angulation is increased be-yond 15 degrees of dorsal tilt (a 26-degree loss of normalpalmar tilt)85,86. Fernandez observed that symptoms oc-curred most frequently when dorsal angulation of thedistal part of the radius was greater than 20 degrees87,and other authors have recommended that 15 to 30 de-grees of dorsal angulation be considered an indicationfor distal radial osteotomy.

Adaptive instability of the carpus may occur ateither the radiocarpal or the midcarpal joint88,89. Withradiocarpal instability, dorsal radiocarpal subluxationoccurs as the lunate contact area translates dorsally

FIG. 23

Schematic drawings of a corrective osteotomy, showing interposition of bone graft from the iliac crest to restore the length and tilt of the dis-tal part of the radius. The upper-left drawing shows the graft in place with temporary Kirschner-wire fixation, the lower-left drawing is a lateralview of T-plate fixation with the interposition graft, and the right drawing is a posteroanterior view of the graft and T-plate in place.

FIG. 24

Postoperative lateral radiograph showing the scapholunate angle corrected to 45 degrees and the lunocapitate angle corrected to less than 5degrees after corrective osteotomy for the treatment of malunion of the distal part of the radius.



along the inclined plane of the distal part of the radius17

(Figs. 20-A and 20-B). For the hand to become re-aligned with the forearm, flexion takes place at the ra-diolunate joint. With midcarpal instability, the angularrelationship between the articular surface of the radiusand the longitudinal axis of the lunate remains un-changed. For the hand to become realigned with theforearm, palmar flexion occurs at the lunocapitatelevel (Figs. 21 and 22). Instability occurs gradually, af-ter the fracture has united, as the midcarpal joint isstressed during loading of the wrist. With both types ofinstability, a zigzag collapse deformity of the carpus re-sults. While the condition is initially dynamic, both ra-diocarpal and midcarpal instability may become staticover time90. Adaptive carpal instability results in achange of the moment arm of the flexor and extensortendons, an alteration in carpal kinematics86, and a lossof power transmission across the wrist. With radialshortening and progressively increasing positive ulnarvariance, the proximal row of carpal bones abuts thedistal end of the ulna, either limiting rotation of the ra-

dius or causing palmar or dorsal displacement of thecarpus.

Patients with adaptive carpal instability most fre-quently present with wrist pain, which is often delayedin onset for several weeks to months after fracture-healing, and loss of wrist motion and grip strength. Ad-ditional sequelae may include median neuropathy at thewrist and tendon rupture83,84.

The preferred treatment for radial dorsiflexionmalunion in young patients (those less than fifty years ofage) who have greater than five millimeters of shorten-ing consists of operative restoration of both radiallength and palmar tilt. Recent modifications in preoper-ative planning and operative technique have improvedthe outcome of dorsal opening-wedge osteotomy, whichis the procedure of choice (Figs. 23 and 24)87,91. Postoper-atively, the adaptive instability pattern corrects sponta-neously in most cases and forearm rotation is restored.For wrists in which the adaptive instability pattern hasbecome static, either ligament reconstruction or inter-carpal arthrodesis is recommended.

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