The document discusses wrist instability and carpal misalignment. It notes that not all carpal misalignments are unstable, and that normal alignment does not guarantee stability. It describes the progressive perilunar instability pattern in 4 stages: stage I involves scaphoid fracture or dissociation, stage II perilunate dislocation, stage III triquetrum disruption or fracture, and stage IV lunate dislocation. Diagnosis involves history, physical exam including specific tests of motion and tenderness, and radiographic views including standard, stress, and motion views to assess stability and alignment.

1. Dr. Ahmed Suparno Bahar Moni
MS(Ortho)

2. Introduction
Wrist is one of the most complex joints
of human body.
One of its important role:
“Placing the hand in the position that
ensures maximal efficiency with minimal
effort”

3. Joint instability
• If a joint is unable to avoid subluxations or dislocations under
physiologic loads in all positions.
• Are the word “Carpal/Wrist instability” & “Carpal misalignment”
same, interchangeable?
• Confusion arises due to oversimplified interpretation of the early
surgeons which propagates the incorrect view that all carpal
misalignments are unstable.

4. Not all carpal
misalignments are
necessarily unstable
Normal alignment
does not guarantee
stability.

5. • Example ‐ Chronic unreduced perilunate dislocations ‐ malaligned, but
not unstable.
• If dislocation left unreduced, due to arthrofibrosis it becomes stiff.
• And the stiffness is the opposite of instability.

6. Radiographic
parameters

7. Radiographic parameters used to
assess the distal radius (AP view):
• Radial height:
• Distance between 2 parallel lines (perpendicular to
the long axis of the radial shaft)
• One from the tip of the radial styloid
• The other from the ulnar corner of the lunate fossa.
• Average = 12 mm.
• Radial inclination:
• Angle between 2 lines—
• One from the ulnar corner of the lunate fossa
perpendicular to the long axis of the radius
• The other between that point in the lunate fossa and the
tip of the radial styloid.
• Average = 23°.

8. Ulnar variance
(AP view): :
• The relative lengths of
radius and ulna.
• Distance between 2
parallel lines drawn
perpendicular to the long
axis of the radius-
• One from ulnar end
of lunate fossa
• The other from ulnar
corner of sigmoid
notch of the radius.
• 60% of the population are
ulnar neutral.

9. Palmar inclination
(LA view)
• Angle between 2 lines—
• One drawn
perpendicular to long
axis of the radius from
the dorsal lip of radius
• The other between the
dorsal and palmar lips
of the distal radial
articular surface.
• Average = 12°.

10. “Progressive perilunar instability,”
• Head‐on motorbike collision (where the hand gets pinned to the
handlebar while the body is violently projected forward) due to
loaded hyperextension and intracarpal rotation
• Carpal destabilization undergoes in 4 ‐ stage pattern(Mayfield et al.)

11. Stage I: SL Dissociation or Scaphoid
Fracture
Stage II: Perilunate Dislocation
Stage III: LTq Disruption or Triquetrum
Fracture
Stage IV: Lunate Dislocation

12. Stages:
• Stage I: SL Dissociation or Scaphoid Fracture
• When wrist is violently twisted into extension and intracarpal
supination, the scaphoid extends and supinates but lunate stays
behind by the RL lig.
• It may lead to progressive tearing of the SL lig. & ends into SL
dissociation.
• If the same process happens when the wrist is radially inclined
instead of SL dissociation, a scaphoid fracture is likely to occur.
• Rarely, the lunate may suffer a coronal fracture.

13. • Stage II: Perilunate Dislocation
• Once the SL joint is disrupted, if the destabilizing force continues, the
capitate leaves the lunate concavity, leads to dorsal perilunate
dislocation.
• If it occurs with scaphoid fracture – it’s trans‐scapho‐perilunate
dislocation.
• Less commonly, the capitate may undergo a fracture.

14. • Stage III: LTq Disruption or Triquetrum Fracture
• As the distal row dislocates dorsally, the TqH and TqC lig. become
extremely taut, generating an dorsal translation vector to the
triquetrum.
• This may result in separation of the triquetrum from the lunate, or a
sagittal fracture of triquetrum.

15. • Stage IV: Lunate Dislocation
• When all perilunate ligaments are torn except palmar RL lig., capitate
pushes the lunate palmarly, out of the lunate fossa, results in palmar
dislocation.

16. Diagnosis of Wrist Disorders
• A thorough medical History, with special emphasis on mechanism of
injury.
• Pain ‐ location, duration, and characteristics including aggravating ‐
relieving factors, and previous treatments.
• Deformity.
• Inquiry about patient’s jobs and hobbies (whether there has been
exposure to repetitive stress, vibrating tools, or potentially dangerous
instruments)

17. • Physical examination:
• Look:
• External appearance ‐ may not be so dramatic.
• Swelling ‐ generally moderate.
• In case of delay, swelling may be significant, visualization of the
displaced bones is more difficult.
• Skin abrasions, contusions, or ecchymosed areas is helpful in
determining the mechanism of injury and the potential areas of
damage.

18. • Feel:
• Areas of maximal tenderness is one of the most useful tools in the
diagnosis of wrist pathology.
• Move:
• Acutely, ROM is usually limited by pain, whereas it may be reduced or
normal in chronic cases.
• Passive mobilization is valuable in determining the presence of
abnormal motion or crepitus and in reproducing pain in chronic cases.

19. • Grip and pinch strength ‐ may be reduced due to muscle atrophy or
by pain.
• Careful assessment of neurovascular status is imperative, with
attention to the median and ulnar nerves, which may be injured by ‐
• Direct contusion at the moment of impact
• Compression from displaced bones or
• Swelling in the carpal canal.

20. Radiological Examination
• Routine Views: 4
• PA (Palm Down) Projection
• Lateral Projection
• Semipronated (Oblique) Projection
• Scaphoid Projection

21. PA (Palm Down) Projection
• Hand placed flat over the radiograph film,
the shoulder abducted 90°, the elbow
flexed 90°, and forearm neutral.
• True PA radiograph will show ECU groove
at radial to the axis of the ulnar styloid.
• In the PA view, the proximal and distal
outlines of the proximal row, as well as
the proximal outline of the distal row (i.e.,
“Gilula’s lines”) are smooth, without
breaks in their continuity.

22. “Gilula’s line”
• Gilula defined 3 smooth,
curved lines (1, 2, 3) joining
the proximal and distal cortical
surfaces of the carpal bones
that help assess normal carpal
relationships.
• A disruption or step‐off in
any one of these lines may
indicate a major carpal
derangement.

23. • Any overlap between the carpals suggests abnormality.
• In the PA view, the normal lunate has a trapezoidal configuration.
• So, if abnormally extended, the lunate has an ovoid configuration due
to the distal displacement of the wider anterior horn.
• And if abnormally flexed, the lunate is triangular shaped, often with a
half moon‐like configuration, with concavity facing toward the
scaphoid

24. The shape of the lunate (L) on a PA view may help differentiate a dislocated
from a mal-aligned lunate.
A, The lunate in DISI position tends to have an ovoid configuration, with a
prominent ulnar corner pointing toward ulnar side.
B, The lunate in VISI has a “C”-shaped or moonlike appearance.
C, In dorsal perilunate dislocations, the subluxed lunate appears as an
isosceles triangle pointing distally.

25. Lateral Projection
• Taken with the arm adducted to the
patient’s side, elbow 90° and the
forearm and the wrist in neutral
rotation.
• The axis of the 3rd MCB needs to be
parallel to that of the radius, and the
palmar outline of the pisiform needs to
be located between (equidistant to) the
palmar surfaces of the scaphoid
tuberosity and the capitate head.

26. Scaphoid Projection
• It’s a PA view, centered on scaphoid, with the
wrist in ulnar inclination and the fingers fully flexed.
• The best projection to confirm a scaphoid
fracture.

27. Semipronated
(Oblique) Projection
• 45° oblique view –
• Profiling the anterolateral
and posteromedial corners
of the carpus.
• Useful to investigate the
fractures of the dorsal ridge
of the triquetrum and of
the scaphoid tuberosity.

28. Additional Radiograph Views
• AP (palm up) view with a clenched fist, wrist
neutral:
• Alternatively, get radiographs with a longitudinal
compression force applied to the wrist by an assistant, which
may accentuate the gap that often appears in SL dissociation
.
• Correct positioning can be evaluated by looking at the 3rd
CMCJ.
• When the wrist is in neutral, the joint’s surfaces are parallel.

29. • PA (palm down) view with 10° of tube angulation from ulna toward
radius:
• This view is ideal to assess the SL interval.
• Measurement of SL gap is made at the midportion of the joint where its
anatomy is more consistent.
• The spacing should be compared with the opposite wrist and with the
surrounding carpal articulations.

30. Clenched‐pencil
view:
It consists of a PA view of
both wrists while the two
hands are gripping one pencil
tightly, with IF apposed, the
thumb metacarpals lying flat
on the radiographic cassette.

31. Carpal tunnel view: • By profiling the carpal concavity of the wrist, a clearer
view of the hook of the hamate, the pisiform, and the
palmar ridge of the triquetrum can be obtained.

32. • Oblique view at 20° of pronation from the lateral position:
• To visualize the dorsum of the triquetrum, where avulsion fractures
frequently occur, and to evaluate the distal tuberosity and waist of the
scaphoid.
• It is ideal for fracture–subluxations of the fifth CMC joint.
• Oblique view at 30 ° of supination from the lateral position:
• The pisotriquetral relationship is best seen with this view.
• Lateral view with the wrist radially inclined:
• The palmar outline of the hook of the hamate can be seen on a lateral view
with the wrist radially inclined and the thumb in maximal anteposition.

33. • Static motion views:
• For patients suspected of having carpal instability, a routine “motion” series
may be needed.
• It should include PA and anteroposterior views in radial and ulnar inclination,
in addition to lateral views in extension and flexion.
• Distraction Views
• In patients with acute fracture–dislocations, obtaining AP and lateral
radiographs with the hand suspended in finger traps is recommended.
• Distraction views may reveal intraarticular fracture fragments or joint
dissociations in the form of a step‐off that cannot be seen on routine films.

34. • Stress Views
• PA projections of the wrist while forcing it into maximal radial or ulnar
inclination.
• Lateral views while applying a dorsal or palmar force to the distal carpal row
(drawer test) are also helpful to identify midcarpal instabilities.
• Lateral radiographs, while extending a fully flexed wrist against resistance
(resisted extension test), may reveal dynamic dorsal subluxation of the
proximal scaphoid.

35. Carpal Bone Alignment Measurement
Axes of carpal bones on lateral
radiographs.
A. The scaphoid (S) axis - a tangential
line that connects 2 palmar convexities
of the scaphoid
B. The lunate (L) axis - is perpendicular to
a line that joins 2 distal horns of the
bone.
C. The capitate (C) axis - is determined
by the center of 2 proximal and distal
articular surfaces.
D. The axis of the radius (R).

36. SL angle:
• The angle between the scaphoid and
lunate axis.
• It’s one of the major determinants of SL
dissociation.
• Normal value ‐ 30 ‐ 60° (average, 47°).
• Although angles > 80° indicate SL lig.
disruption, lower readings do not rule
out the pathology.

37. LC angle:
• Angle between the long
axis of the lunate and
capitate.
• It quantifies midcarpal
misalignment.
• A normal LC angle ‐ 0 ±
15 degrees with the
wrist in neutral.

38. RL angle:
• This gives objective evidence of the
dorsal or palmar tilt of the lunate.
• The normal RL angle ‐ 0 ± 15 deg.

39. Ulnar variance: The
relative lengths of the
radius and ulna
Measured on PA radiographs.
It is measured by the distance
between 2 lines perpendicular to
radial axis.
‐ One is at the most distal point
of the ulnar dome
‐ the other is tangential to the
distal articular surface of the
lunate fossa of radius.
When the ulna is ‐
‐ shorter than the radius, ulnar
variance is negative.
‐ when longer, it is positive.

40. Carpal height ratio:
(carpal height ÷
length of 3rd MCB)
• The ratio is 0.54 ± 0.03
• Carpal height ‐ the distance
between the base of the 3rd MCB
and the distal articular surface of
the radius measured along the
axis of the 3rd MCB.
• As wrist radiographs often do
not include the entire 3rd MCB,
some authors have proposed
using the length of the capitate
instead (i.e., carpal height ÷
capitate length),
• Normal range ‐ 1.57 ± 0.05.

41. Ulnar translocation ratio:
• The perpendicular distance from the center of
the head of the capitate to a line from the radial
styloid, which extends distally and parallel to
the longitudinal axis of the radius or the axis of
the ulna or the axis of the radius.
• The carpal translocation ratio (the ratio of this
distance to the length of the 3rd MCB) in normal
wrists is 0.28 ± 0.03.

42. Other inv.
• Computed Tomography:
• Usually taken at 1‐2 mm intervals along the axial(transverse), sagittal, and
coronal planes.
• CT is also useful in evaluating the union of fractures or arthrodeses,
although in many instances the image can be altered by presence of
hardware.
• CT has the advantage of allowing computer manipulation to obtain 3D
image.
• By observing a sequence of 3D CT of the wrist, one can get the impression
of seeing it in motion. This is called “dynamic 3D”/“four dimensions–CT”
(4D‐CT).
• Recent introduction ‐ ultrafast CT, reduced image‐acquisition time to a
fraction of a second.

43. • Cineradiography:
• Cineradiography includes observation of active motion from a radial‐
to‐ulnar inclination in PA views; flexion and extension in lateral views,
and radial and ulnar inclination in lateral views.
• If the patient has a painful clunk, the true nature of the subluxation
can be identified by observing the moving wrist under an image
intensifier.
• Provocative stress maneuvers may be of help to document the
location of maximal dysfunction.

44. • Arthrography:
• Although long considered the gold standard, now rarely performed.
• The technique was originally introduced based on the assumption
that any flow of dye from the radiocarpal to the midcarpal space or
vice versa was pathologic.
• But asymptomatic degenerative tears of the proximal SL or LTq
membranes are not unusual, especially in elderly.
• Arthrography still has some potential, particularly in association with
high‐resolution tomography (i.e., arthroscan), to assess cartilage
defects and ligament injuries.

45. • MRI:
• Traditional MRI without dedicated wrist coils shows reduced
sensitivity and specificity.
• When iv contrast is injected, these parameters may slightly improve.
• High‐resolution non‐contrast techniques have good indications of the
evaluation of the TFCC and intrinsic ligaments, but require a
dedicated wrist coil and slice thickness of no more than 1 mm.

46. • USG:
• High‐frequency linear transducers have been shown to have great
potential.
• USG is less expensive than MRI, is real time (permitting dynamic
evaluation of kinematic instabilities), and does not require
intraarticular injection of a contrast medium or the use of ionizing
radiation.
• In many countries, USG is incorporated into clinical practice as an
inexpensive and safe method to get most of the information required
to make accurate treatment decisions.

47. • Arthroscopy:
• It provides the technical capabilities to examine and treat
intraarticular abnormalities.
• As well as allowing direct visualization of the articular surfaces,
synovial tissues, and intercarpal ligaments, arthroscopy has proved to
be a useful adjunct in the management of various acute and chronic
wrist lesions.

48. Classification
• Chronicity: Depending on the time elapsed from injury 3 categories:
• Acute injuries ‐ diagnosed within a week, the lig.‐healing potential is likely to
be optimal.
• Subacute injuries ‐ diagnosed between 1 and 6 weeks, the deformity is still
easily reducible but the lig. may have reduced healing potential because of
retraction and/or necrosis.
• Chronic – diagnosed after 6 weeks, the possibility of achieving an acceptable
reduction and primary lig. healing, although possible, is unlikely.

49. • Severity: According to the severity, 3 groups of instabilities:
• Occult ‐ partial lig. tears with no misalignment under stress
• Dynamic ‐ carpal misalignment only under certain loading conditions
• Static ‐ complete ruptures with permanent alteration of carpal alignment.
• Static reducible
• Static irreducible

50. • Etiology:
1. Congenital
2. Traumatic - Most instability are caused by trauma.
3. Inflammatory ‐ RA
4. Neoplastic
5. Iatrogenic
6. Miscel.

51. • Location:
• 1. Radiocarpal
• 2. Proximal intercarpal
• 3. Midcarpal
• 4. Distal intercarpal
• 5. CMC
• 6. Specific bones
• It is also important to consider whether the pathology affects single /
multiple joints.

52. Direction:
• The most common are:
• (1) DISI ‐ when the lunate is
regarded as an intercalated
segment and appears
abnormally extended relative
to the radius and capitate.
• (2) VISI, when the lunate
appears abnormally flexed.

53. • (3) Ulnar translocation ‐ when a portion of, or the entire proximal row,
is (or can be) displaced ulnarly beyond normal limits
• (4) Dorsal translocation ‐ when the carpal condyle, often as a result of
a dorsally malunited fracture of the radius, is (or can be) displaced in
a dorsal direction
• (5) Radial translocation ‐ when the proximal row can be passively
displaced radially beyond normal, usually in the context of a radially
malunited distal radius fracture.

54. Classification of Carpal Instability
• But none of these classifications includes all types of carpal instability
or simple enough to be easily remembered and used clinically.
• Despite its limitations, the Mayo Clinic classification is the most
commonly used and hence recommended.
• There are 3 major instability patterns of the wrist‐
• 1. Dissociative carpal instabilities
• 2. Nondissociative carpal instabilities
• 3. Carpal instability complex

55. Carpal instability complex(CIC)
• Where there are features of both CID and CIND types.
• Carpal dislocations, if treated inadequately, may generate complex
patterns of instability where the dysfunction affects both the
radiocarpal and the proximal intercarpal joint.

56. Dissociative carpal
instabilities (CID)

57. • Predominant dysfunction is between the bones of the same carpal
row.
• Results from tear of intrinsic ligament(s).
• Most common ‐ Scapholunate Dissociation
• less often ‐ Lunotriquetral dissociation
• Rarely between the bones of the distal row.

58. Scapholunate Dissociation
• Most frequent.
• Can be an isolated injury or in association with other injuries (distal
radial fracture, perilunate injury, scaphoid fracture).
• Pathomechanics of SL Dissociation:
• A fall on the outstretched hand with the wrist in extension and ulnar
inclination and associated with midcarpal supination.

59. Diagnosis
• Frequently missed at presentation, as masked by other, more obvious
injuries e. g. scaphoid or distal radius fractures.
• A high index of suspicion is needed for diagnosis.
• Iatrogenic SL injury ‐ excessive capsular excision when removing
dorsal ganglions, or after lig. attenuation from RA, metabolic, or
septic arthritis.

60. SCAPHOID SHIFT TEST/ WATSON TEST ‐
Positive test is diagnostic of SL dissociation.
Procedure:
• Place 4 fingers behind the radius, and the thumb on the scaphoid
tuberosity.
• Other hand is used to move the wrist passively from ulnar‐to‐
radial inclination.
• In ulnar inclination, the scaphoid is extended. In radial
inclination, the scaphoid is flexed.
• Pressure on the tuberosity while the wrist is moved from ulnar‐
to‐radial inclination prevents the scaphoid from flexing.
• If the SL lig. are completely ruptured or elongated, the proximal
pole subluxes dorsally out of the radius, inducing pain.
• When pressure is released, a typical clunking may occur,
indicating self‐reduction of the scaphoid.

61. • RESISTED FINGER EXTENSION TEST ‐
• Ask the patient to extend the index and middle fingers fully against resistance
with the wrist partially flexed.
• In the presence of an injury or insufficiency of the dorsal SL ligament, a sharp
pain is elicited in the SL area, due to the presence of synovitis at the RS joint.
• SL Ballottement Test ‐
• The lunate is firmly stabilized with the thumb and IF of one hand, while the
scaphoid, held with the other hand (i.e., thumb on the palmar tuberosity and
IF on the dorsal proximal pole) is displaced dorsally and palmarly.
• The test is positive when there is pain, crepitus, and excessive mobility of the
scaphoid.

62. Radiological examination
• INCREASED SL JOINT SPACE:
• The “Terry Thomas sign” ‐ named by Frankel after
the English film comedian’s dental diastema.
• Considered positive when the space between the
scaphoid and lunate appears abnormally wide.
• A unilateral gap >5 mm is diagnostic.
• If there is no history of specific trauma, and obvious
SL diastasis, it could be either a constitutionally
increased SL gap, with or without hyperlax lig.
• Other less common causes ‐ RA, gout, and calcium
pyrophosphate deposition disease.

63. SCAPHOID RING SIGN
• When scaphoid
collapsed into flexion, it
has a foreshortened
appearance in the AP
view.
• Scaphoid tuberosity is
shown in the PA
projection in the form of
a radiodense circle or
ring over the distal
2/3rd - “Ring sign”.

64. INCREASED SL ANGLE
In lateral view, if scaphoid lies
more perpendicular to the
long axis of the radius and the
lunate appears normally
aligned or abnormally
extended, SL dissociation
should be suspected.
SL angle is > 45 to 60°.

65. • PALMAR V SIGN -
• In lateral view of normal wrist, a wide “C”-shaped line can be drawn by joining
the palmar margins of the scaphoid and radius.
• When the scaphoid is abnormally flexed, the palmar outline of it intersects the
palmar margin of the radial styloid at an acute angle, forming a sharper, “V”-
shaped pattern.
• Advanced imaging -
• If history, clinical examination, and radiographs are inconclusive, MRI, computed
arthrotomography, or arthroscopy may be helpful to assess the degree of
injury to the lig.

66. Treatment
• Difficult and not always predictable.
• In partial inj., radiographs are usually normal. So, frequently missed.
• Even if diagnosed early, the lig. remnants are difficult to repair.
• As SL lig. is exposed to considerable tension, successful repairs even
deteriorate with time.
• So early diagnosis and proper treatment even don’t guarantee good
recovery.

67. 6 Questions to Consider When Evaluating SL
Injury(Garcia‐Elias)
• Is the dorsal SL lig. intact and functional? Partial
• If the lig. has ruptured, does it have good integrity for repair?
Repairable
• Is the scaphoid alignment normal? RS angle
• Is radiolunate alignment still retained?
• Are abnormal carpal alignments easily reducible?
• Is the articular cartilage normal?
• Answers to these questions categorize of the SL dissociation into 7
stages.

68. • Stage I: Partial SL lig. Injury / “occult” SL dissociation:
• No widening of the SL joint space on standard/ stress radiographs.
• Diagnosis: by arthroscopy or high‐resolution MRI.
• European Wrist Arthroscopy Society (EWAS) suggested modifying Geissler’s
classification to include subtypes of SL lig. Disruption.

69. Arthroscopic EWAS Staging of SL Lig. Ruptures
Stage Description
Arthroscopic Testing of Scapholunate Joint From the
Radial Midcarpal Portal
I Elongation No passage of the probe
II
Rupture of proximal SL
membrane
Passage of the tip of the probe in the SL space without
widening
IIIA
Rupture of proximal +
volar SL lig.
Volar SL joint widening when tested with the probe
(anterior laxity)
IIIB
Rupture of proximal +
dorsal SL lig.
Dorsal SL joint widening when tested with the probe
(posterior laxity)
IIIC
Rupture of proximal +
volar + dorsal SL lig.
Global widening of SL space, reducible with removal of
probe
IV
IIIC + SL gap (no
misalignment)
SL diastasis without radiographic abnormalities;
arthroscope may enter the radiocarpal space
V IV + carpal misalignment Wide SL gap with radiographic anomalies

70. • Recommended treatment:
• In acute phase ‐ arthroscopically guided /
PC pinning of the SL joint with two or more
K ‐ wires for 8 weeks.
• In chronic case ‐ 3 different approaches:
• Proprioception re‐education and strengthening
of the intracarpal supination muscles – ECRL,
APL
• Arthroscopic debridement of the torn lig.
• Electrothermal ligament shrinkage.

71. • Stage II: Complete SL lig. injury, repairable ‐ “Dynamic” instabilities:
• According to Andersson et al,dorsal SL lig. Ruptures are of 4 major types:
• Avulsion from the scaphoid (42%)
• Avulsion from the lunate (18%)
• Midsubstance rupture (20%)
• Partial rupture plus elongation (22%).

72. Recommended treatment : Open reduction, ligament repair, and dorsal
capsulodesis.

73. • Stage III: Complete SL lig. injury, nonrepairable, normally aligned
scaphoid and lunate, “Dynamic” instabilities.
• When the dorsal SL lig. is disrupted through mid‐substance, two ends tend to
degenerate rapidly.
• Carpal misalignment is not yet present as scaphoid is constrained by
anterolateral STT lig., volar capsule, and dorsal intercarpal lig.
• An increased SL gap may appear only under specific loading conditions.

74. • Treatment options: Dorsal SL lig. reconstruction
• Dorsal capsulodesis ‐ prevent the scaphoid to collapse into flexion and
pronation
• 3 – lig. Tenodesis ‐ recommended
• Bone lig bone graft
• Dynadesis

75. Dorsal capsulodesis
• Proximally based dorsal
capsulodesis described by
Blatt.
• Laterally based dorsal
intercarpal ligamentoplasty
(DIL).
• Medially based DIL
described by Szabo et al.

76. • SOFT TISSUE RECONSTRUCTION OF DORSAL SL LIG.:
• Reconstruction of dorsal SL lig. with a strip of either the dorsal intercarpal
ligament or the dorsal radiocarpal lig.
• The free end of the ligament flap is tightly reinserted onto the dorsal and
ulnar corner of the proximal scaphoid.
• Bone‐anchored sutures should be used to facilitate incorporation of the lig.
into denuded dorsal and distal cortices of the scaphoid and lunate.
• Very appealing in their simplicity and low local morbidity.

77. • BONE–LIGAMENT–BONE GRAFTS
• Weiss reported transferring a bone‐retinaculum–bone autograft harvested
from the region of the Lister tubercle.
• Harvey and associatesadvocated the use of the third metacarpal–capitate
dorsal lig.
• After the scaphoid and lunate are reduced and transfixed by wires, a deep
trough is carved on either side of the SL joint, and a bone–ligament–bone
graft is impacted and fixed with miniature screws, small wires, or interference
screws

78. • DYNADESIS ‐
• Dynamic ECRL tendon transfer to the distal
scaphoid plus volar FCR tenodesis ‐ passing
two‐thirds of the ECRL tendon through a 3.5‐
mm tunnel drilled across the distal pole of
the reduced scaphoid and anchoring the end
to the FCR tendon.
• The portion of FCR distal to the scaphoid
becomes a check‐rein that tightens with
contraction of the ECRL.

79. • Stage IV: Complete SL lig. injury, nonrepairable, reducible flexion
deformity of the scaphoid, static instability:
• There is complete loss of the proximal and distal scaphoid stabilizers.
• The scaphoid is flexed and subluxates dorsally, RS angle > 45°.
• The lunate extends slightly but RL lig. are normal.
• Clunking secondary to self‐reduction is a common finding.
• Treatments options:
• SL Ligamentoplasty using a tendon graft – 3 lig tenodesis (recommended)
• Reduction‐association of the SL joint (i.e., RASL procedure).

80. Brunelli and Brunelli
technique:
• A strip of FCR tendon was obtained, leaving its distal end
attached to the 2nd MCB.
• Through a separate dorsal incision, the scaphoid reduced
and neutralized with Kirschner wires.
• A 3.2-mm tunnel, perpendicular to the main axis of the
scaphoid, was drilled from the center of the scaphoid
tuberosity to the neck and the strip of FCR passed through it.
• FCR tendon was pulled taut proximally and anchored to the
dorsal rim of the distal radius.
• Adv. - excellent stabilization of the scaphoid.
• Disadv. - marked reduction in wrist flexion, and an increased
rate of RS OA.

81. Modified Brunelli
technique:
The trans‐scaphoid drill
hole was placed slightly
oblique rather than
perpendicular to the axis of
the scaphoid.
The tendon did not cross
the radiocarpal joint but
used the dorsal radiocarpal
lig. as an anchor point for
the tendon to be tensioned
before being sutured onto
itself.

82. • Three‐Ligament Tenodesis – recommended.
• Indications
• Dynamic SL dissociation, reducible, with normal cartilage (stage III)
• Static SL dissociation, reducible, with normal cartilage (stage IV)

83. Procedure
• Perform a dorsal approach centered at Lister tubercle.
• Incise the extensor retinaculum along third compartment.
• If PIN is intact, perform a proximal-based nerve-sparing
capsulotomy; if not intact, perform a dorsal capsulotomy with
the fiber-splitting technique.
• Reducibility is checked by traction or manipulation with K-
wires as joysticks.
• Enter the scaphoid with a 2.7-mm cannulated drill hole
along the axis of the scaphoid aiming at palmar tuberosity.
• Make a palmar incision over the scaphoid tuberosity,
release FCR tendon sheath. obtain a distally based 8-cm strip
of tendon (0~3 mm).
• Retrieve the tendon strip from the dorsum using a wire or a
tendon passer.

85. • Carve a trough over the dorsum of the lunate with a rongeur.
• Insert a 1.8‐mm anchor suture into the lunate.
• Localize the dorsal radial triquetrum lig., and loop the tendon strip around its
distal insertion.
• While tensioning the tendon using the radial triquetrum ligament as a pulley,
transfix the SL and SC joints (2/3, 1.5‐mm K‐wires are used)
• Without releasing the tendon tension, use the anchor suture to bury the
tendon against the lunate cancellous bone in the previously created trough.
• Suture the tendon loop onto itself.
• Close the capsule over the tendon strip carefully.
• Reconstruct the extensor retinaculum.

86. Modifications to this
technique:
• Ross et al recommend drilling 2
tunnels:
• One across the scaphoid, as for
3‐lig. Tenodesis
• Another across the lunate and
triquetrum, from the SL lig.
insertion site to medial corner
of triquetrum.
• The tendon is passed through
the tunnels and secured using
an interference screw in the
triquetrum.

87. REDUCTION‐ASSOCIATION OF THE
SL JOINT
• “Reduction‐association of the scapholunate” (RASL) procedure
was proposed as a novel approach to static SL instabilities
• Before repairing the lig. remnants, the articular cartilage
between the scaphoid and lunate is removed and the joint is
reduced and transfixed with one headless screw for 12 months or
more.
• The goal is to create a fibrous union of the SL joint and allow
loading these bones without fear of recurrent joint widening.

88. • Modifications of RASL:
• 1. To introduce a specially designed jointed screw into the SL interval
that allows some rotation of the scaphoid about the lunate (SLIC
screw, Acumed®, Hillsboro, OR).
• 2. To insert a tendon autograft along the axis of SL rotation that will
act as a flexible biological link between the two bones (SL‐axis
method, Arthrex®, Naples, FL).
• 3. RASL procedure plus tendon reconstruction of the SL lig.

89. • Stage V: Reducible carpal collapse due to chronic SL lig. injury, plus
instability of radiolunate joint and normal joint cartilage
• Rupture of both the primary and secondary lig. stabilizers of the scaphoid
• Both the scaphoid and lunate are unstable.
• Stability is only possible if the reconstruction is based on the radius.
• Recommended treatment: “Spiral tenodesis”

90. “Antipronation spiral
tenodesis”
• Reconstruction of spiral
arrangement of ligaments using
one single strip of FCR.
• The technique begins the same
as for 3‐lig. tenodesis.
• Then from dorsum of the
triquetrum, the FCR is passed
through a dorsopalmar tunnel
across triquetrum to exit at the
floor of the carpal tunnel.
• From there, it is brought under
FDP to emerge in a separate
incision over the radial styloid
where it is inserted through a
hole on it.

91. • Stage VI: Irreducible carpal collapse due to chronic SL lig. injury,
with normal joint cartilage
• If carpal misalignment cannot be reduced due to subluxed joint
surfaces, fibrosis within the empty spaces and capsular retraction but
joint cartilages are normal, it’s stage VI.
• Recommended treatment ‐ Partial Carpal Fusion.

92. RADIO‐SCAPHOID–LUNATE
FUSION & DISTAL
SCAPHOIDECTOMY
If cartilage of midcarpal joint is
normal, it is reasonable to fuse
RSL joint.
As after fusion, the STT joint
may degenerate with time due
to inability of the scaphoid to
flex during wrist flexion and
radial inclination, creating local
impingement.
Excision of distal 1/3rd of
scaphoid is suggested.

93. Scaphoid–trapezium–
trapezoid arthrodesis
• Goal ‐ reduce the proximal pole
of the scaphoid into the scaphoid
fossa, restoring RS congruency.
• Underreduction (scaphoid
flexed) fails to close the SL gap.
• Overreduction (scaphoid
extended) may result in more
restricted motion and more
severe RS impingement.

94. • Modification – to solve painful RS impingement, Watson et al.
recommended incorporating a dorsolateral Radial Styloidectomy with
STT fusion.
• Preexisting cartilage degeneration between scaphoid and radius is a
contraindication to STT joint fusion.

95. SL ARTHRODESIS
• Previously believed to be the ideal
method.
• Now proved to be one of the least
reliable option.
• Due to small area of contact and the
magnitude of forces transmitted by
capitate, make this fusion difficult to
achieve.
• After this as mutual shifting between 2
bones is no longer possible, results in
increased demands on the arthrodesis,
predisposing the fusion to refracture.

96. • SCAPHOID–CAPITATE ARTHRODESIS ‐
• In laboratory, the kinematic and kinetic carpal behavior after STT or SC fusion
is similar.
• Both cause abnormal transfer of load and significant loss of midcarpal joint
motion, especially in radial and ulnar inclinations.
• The long‐term results of this procedure are quite acceptable.
• Approx. 30% of patients develop degenerative changes at the RS joint.

97. • SCAPHOID–LUNATE–CAPITATE ARTHRODESIS:
• Adding the lunate to the scaphoid–capitate fusion can correct both the
scaphoid and the lunate misalignment at the expense of 50% reduction in
wrist motion.
• This procedure is combined with dorsoradial styloidectomy.

98. • Stage VII: Complete SL lig. injury with irreducible misalignment and
cartilage degeneration (SLAC wrist):
• The cartilage wear begins and progresses to entire RS joint.
• At a later stage, the midcarpal joint also degenerate, starting at LC joint except
at RL joint.
• Preferred treatment ‐ scaphoidectomy plus midcarpal fusion (4 corner fusion).
• Other options:
• Proximal row carpectomy.
• Total wrist arthroplasty.
• Total wrist arthrodesis.

99. 4‐corner fusion
• Scaphoidectomy and
midcarpal fusion/ SLAC
procedure – total
Scaphoid excision plus
capitate–lunate–
triquetrum–hamate
fusion

100. • Frequent complication ‐ dorsal impingement between the dorsal edge
of the radius and capitate.
• To avoid this, fully correct the extension deformity of the lunate
before stabilizing the midcarpal joint.
• Several new implants, circular or square plates, staples, and locking
screws have been designed to be countersunk below the dorsal
intersection of the four carpal bones to avoid radial impingement.
• In patients with ulnar‐positive variance or in chronic combined SL and
LTq instability, the scaphoid and triquetrum can also be excised.

101. Proximal row
carpectomy
Salvage operation.
Scaphoid, lunate, and
triquetrum are excised.
Creating a neoarticulation
between the capitate and
lunate fossa of the radius.

102. It converts a complex composite articulation into a single ball‐and‐
socket joint with nonmatching articular surfaces.
• The wrist can adjust to this if there is a good articular cartilage on the
proximal pole of the capitate and in the lunate fossa of the radius.
• It avoids long immobilization and the risk of nonunion.
• Advantage ‐ being able to be converted into a wrist arthrodesis or
arthroplasty in painful OA.
• Increased failure risk if offered to patients <35 years

103. • Radial styloidectomy:
• This is one of the oldest procedures used to relieve wrist pain caused
by an impingement between the tip of the radial styloid and a
misaligned distal scaphoid.
• Despite removing the degenerated radial styloid process, the SLAC
wrist sequence will continue to progress.
• For individuals who desire minimal surgical intervention, arthroscopic
radial styloidectomy may be an option.

104. Total wrist arthroplasty
A reasonable option for
patients who place low
demands on the wrist.
Most patients with
posttraumatic instability are
young, active or manual
laborers, for whom a joint
prosthesis is not an
acceptable choice.

105. Total wrist arthrodesis
Rarely considered.
Still the procedure of choice
for patients who perform
heavy manual work.
Most patients with total wrist
fusion can accomplish all daily
tasks by learning to
compensate for the loss of
wrist motion.

106. Lunotriquetral Dissociation
• Posttraumatic or degenerative LTq dissociations ‐ not infrequent.
• Chance of being missed or confused with other ulnar‐sided wrist
problems (e.g., midcarpal instabilities or TFCC injuries) is high.

107. Mechanism of injury:
• Backward fall onto outstretched hand, with the arm externally
rotated, the forearm supinated, and the wrist extended and radially
inclined.
• the impact is concentrated on the hypothenar area, and pisiform,
which acts as a punch against the extended triquetrum, induces its
dorsal displacement.
• The lunate does not follow the triquetrum as it is constrained by the
radius and the volar long RL ligament.
• Substantial shear stress is created at the LTq joint, causing progressive
stretching and ultimately tearing of the LTq lig. (i.e., volar, dorsal, and
proximal).

108. Diagnosis:
• Spectrum of clinical conditions ‐ ranging from asymptomatic partial tear to
a painful complete dissociation with static carpal collapse.
• Pain ‐ aggravated with ulnar inclination of the wrist and supination of the
forearm.
• Weakness and a sensation of the wrist giving way
• some may have ulnar nerve paresthesias.
• Reversed “fork‐like” or “bayonet” deformity, like the deformity seen in
volarly displaced distal radius fractures
• Painful crepitus as the patient inclines the hand ulnarly.
• Point tenderness directly over the dorsal aspect of the joint.
• Wrist motion is seldom diminished except in the more advanced cases.

109. • Ballottement test ‐ pathognomonic
• Procedure:
• The lunate is firmly stabilized with the thumb and IF
of one hand, while the triquetrum and pisiform are
displaced dorsally and palmarly with the other hand.
• A positive result elicits pain, crepitus, and abnormal
displacement of the joint.
• Shear test ‐ a variation of ballottement test, can be
done with a single hand:
• Procedure:
• By stabilizing the dorsal aspect of the lunate with the
index finger, the pisiform is loaded by the thumb in a
dorsal direction, creating a shear force at the LTq joint
that causes pain.

110. • The Derby test ‐ useful in the reducible LTq dissociation without a
fixed VISI type deformity.
• Procedure:
• This test starts by realigning the lunate and scaphoid relative to the radius.
• This is done by placing the wrist in extension and at a slight ulnar inclination.
• If, in that position, we reduce the LTq joint by pushing the pisiform dorsally,
the feeling of instability disappears immediately, and grip strength increases
as long as pressure over the pisiform is maintained.

111. Inv.
• Standard wrist views appear normal in most patients with partial
tears.
• In static VISI pattern of misalignment secondary to complete rupture
of both intrinsic and extrinsic LTq lig., radiographic diagnosis is
obvious.
• Most characteristic is disruption of the normal convex arc of the
proximal carpal row (the Gilula line) in the PA radiograph projection.
• A moon‐like lunate facing a foreshortened scaphoid is also typical of
this condition

112. In such cases, the lunate’s dorsal pole is
superimposed on the distal part of the
capitate, implying an abnormal flexion of
the bone.
Seagull sign ‐ the distal outlines of the
lunate and triquetrum adopt the form of
a flying seagull.

113. Treatment:
• Needs to be individualized ‐
• according to the patient’s age, occupation, recreational demands, and
intensity of symptoms.

114. • Acute LTq injury without carpal collapse:
• Dynamic or occult LTq instability ‐ diagnosed by arthroscopy.
• Conservative management:
• With a molded cast or splint (with a pad beneath the pisiform and over the dorsum of
the distal radius). It should be an above‐elbow cast.
• Recommended treatment:
• Percutaneous LTq joint fixation with multiple K‐ wires and below elbow cast.
• Adequate proprioceptive reeducation of ECU is recommended during
rehabilitation.

115. • Chronic LTq injury without carpal collapse:
• As two ends of the disrupted ligaments have degenerated, chances for
successful healing is less.
• No collapse means the extrinsic ligaments are still functioning.
• Recommended treatment:
• LTq lig. reconstruction with ECU tendon graft.
• Other treatment options:
• Simple arthroscopic debridement
• Electrothermal shrinkage
• LTq arthrodesis.

116. • LTq lig. Reconstruction:
• Procedure :
• A strip of ECU tendon is taken, left attached distally and passed through holes
in the lunate and triquetrum.
• By tightly looping the tendon graft around the LTq joint, immediate stability is
achieved.
• The reconstruction is further secured by transfixing the joint with one or two
K ‐ wires for 8 weeks, followed by 4 more weeks in a protective splint.

118. • LTq Arthrodesis:
• Indications ‐
• Dynamic LTq instability secondary to complete intrinsic ligament rupture in
the absence of an ulnocarpal abutment syndrome (i.e., normal TFCC) and
normal midcarpal joint
• Perilunar SL and LTq instability
• No radiographic evidence of VISI

119. • Procedure:
• Perform a dorsal (e.g., zigzag, lazy “S,” or longitudinal) incision centered at the
IV–V septum
• Perform a longitudinal incision of the extensor retinaculum along the V
compartment.
• Open the septum between IV–V; coagulate intraseptal artery.
• Perform a Z capsulotomy creating two flaps following the fiber‐splitting
concept.
• Complete section of the remnants of LTq ligaments.
• Open the LTq as a book and remove the adjacent articular surfaces with a
dental rongeur to expose cancellous bone keeping the rim of the opposing
cortical edges to preserve the normal intercarpal separation.

120. • Harvest cancellous bone from the radius through a window created under the
infratendinous sheath at the floor of compartment IV.
• Two 1.5‐mm nonparallel K‐wires are preset in the ulnar aspect of the
triquetrum.
• Bone graft is densely packed in the biconcave cavity.
• The joint is reduced, and two K‐wires are driven into the lunate and their
position verified.
• One wire is used to insert a headless cannulated compression screw.
• Cut the second wire below the skin’s surface.
• Perform standard capsular and retinacular closure.

122. • Chronic LTq dissociation with carpal collapse (i.e., VISI):
• secondary to complete disruption of LTq lig. and attenuation or disruption of
the extrinsic lig.—dorsal and palmar radiocarpal lig.
• Recommended treatment:
• RL fusion + LTq fusion.
• If there is an ulna‐plus variant ‐
• Add a wafer procedure or an ulnar shortening plus LTq fusion.
• In chronic SL and LTq dissociation:
• RSL fusion plus a distal scaphoidectomy.

123. Nondissociative Carpal
Instability(CIND)

124. • Results from a tear of the extrinsic lig.
• Dysfunction of the radiocarpal and/or the midcarpal joints
• CIND can be further subdivided into –
• Radiocarpal ‐ CIND ‐ RC
• Midcarpal ‐ CIND ‐ MC
• Combined radiocarpal–midcarpal – CIND ‐ DISI, CIND ‐ VISI.

126. Diagnosis:
• Painful clunking wrist
• Physical exam
• Inv. –
• cineradiography, stress views x‐ray.
• In doubtful case, occasionally arthroscopy.
• Recommended treatment:
• Most nondissociative disorders respond well to conservative treatment ‐
splinting, avoidance of activities plus a controlled hand therapy program
aimed to stabilize the ECU and FCU.
• Surgery is only indicated if conservative protocol fails.

127. • Surgery:
• For reducible instability with normal cartilages – ECRB tenodesis.
• In all other instances, RL arthrodesis.
• ECRB tenodesis procedure –
• It can recreate the TqC lig and augment the dorsal radiocarpal lig.
• Two longitudinal incisions (i.e., dorsal and palmar) are used.
• Two drill holes, 3.2 mm in diameter are made:
• (1) one from the dorsal aspect of the capitate into the carpal canal
• (2) another from the palmar aspect of the triquetrum into its dorsal ridge.
• A strip of ECRB tendon is passed through the capitate hole, retrieved palmarly, and passed
again through the triquetrum hole.
• The tendon is pulled taut, and sutures reinforcing the remnants of the palmar TqC and TqH
ligaments are placed.
• On the dorsum, the tendon is tightly sutured to the origin of the dorsal–radiocarpal ligament.
• K‐wires are used to stabilize the construct further.

128. Dorsal Perilunate
Dislocations (Lesser‐
Arc Injuries

129. • Emergency Management:
• Closed reduction in the
emergency department ASAP (to
urgently decompress the median
nerve and to release tension on
the vascular supply to the
displaced carpal bones)
• If dislocation has been reduced,
definitive treatment can be delayed
to several hours or days to get the
right equipment and trained
personnel.

130. • Definitive management:
• Double ‐ approach open reduction—dorsal SL and palmar LTq lig. repair—and
SL and LTq K‐wire fixation.
• Surgery is always indicated, regardless of the quality of reduction obtained by
closed means, unless an underlying medical condition contraindicates it.
• If the patient is reluctant to allow surgery, or if an unstable medical
condition persists for >1 week, closed reduction and percutaneous
fixation could be considered.

131. Palmar surgical approach – L distal surface of
lunate. After reduction, palmar LTq lig is
repaired (arrow) Post op X‐ray

132. Dorsal Perilunate Fracture–
Dislocations

133. • The most frequent is ‐ dorsal trans‐scaphoid
perilunate dislocation.
• Trans‐scaphoid Perilunate Fracture–Dislocations:
• Approx. 60% of perilunate dislocations are associated
with a displaced scaphoid fracture.
• Initial management ‐ same as dorsal perilunate
dislocation.
• Definitive management: Open reduction—dorsal SL
ligament repair—and SL and LTq K‐wire fixation plus rigid
screw fixation of the scaphoid fracture .

134. • Closed Reduction and Percutaneous Fixation
• If surgery is contraindicated, or the patient refuses open treatment, and the
dislocation has been acceptably reduced by closed means
• Two or more percutaneous K‐wires are driven across the fracture, and two
additional ones are used to stabilize the LTq joint.
• If available, arthroscopically guided percutaneous screw fixation may achieve
improved results.

135. Thank you