Operative Technique in Plastic Surgery – Kevin C.Chung

■ Basic radiographic imaging (including anteroposterior and lateral radiographs)
of both the affected digit and the hand is necessary.
■ Lateral imaging of the PIP joint allows evaluation of the amount of articular
surface that must be replaced (FIG 4A).
■ Wrist radiographs confirm that the hamate bone is intact and may serve as
potential bone graft donor (FIG 4B,C).
■ In patients with prior injuries to the base of the ring or small finger
carpometacarpal joints, the distal dorsal articular surface should be carefully
inspected, and the contralateral hand should be considered for harvest of the
hamate bone graft.
■ In addition to radiographs, advanced imaging with a CT scan may be helpful
in determining the three-dimensional nature of the middle phalanx defect.
■ Subtle radioulnar bony deficits, such as impaction and/or comminution may
be visualized that are not apparent on radiographs (FIG 4D).
NONOPERATIVE MANAGEMENT
■ Nonoperative management for PIP joint fracture dislocations may be
considered in those patients with stable injury patterns (less than 30% articular
surface involvement).
■ Stability may be confirmed with a lateral radiograph of the PIP joint in full
extension to ensure the absence of any dorsal subluxation.
■ Treatment options include dorsal blocking splint, buddy taping to a
neighboring digit, and early motion.
■ For those PIP joint fracture dislocations that are unstable but reducible with
PIP joint flexion of less than 30 degrees, nonsurgical management may be
considered.
■ A dorsal blocking splint may be used to maintain reduction, and frequent
radiographic follow-up is required to ensure the PIP joint remains congruent.
■ A figure-eight splint or silver ring splint may also be used.
SURGICAL MANAGEMENT
■ Hemihamate arthroplasty is indicated for the treatment of unstable dorsal PIP
joint fracture dislocations that are either acute or not amenable to
ligamentotaxis or internal fixation, or subacute/chronic dislocations.
■ Contraindications of this technique include any fractures involving the dorsal
cortex, since the integrity of the dorsal cortex of the middle phalanx is
necessary for hamate autograft fixation.

■ Other considerations include those fractures with significant extension into the
middle phalangeal shaft, as this can affect the positioning and recontouring of
the articular surface.
Preoperative Planning
■ Lateral radiographs of the PIP joint should be reviewed to estimate the size of
the volar articular fragment that needs to be reconstructed.
■ CT imaging may be useful in confirming the three-dimensional nature of the
fractured volar rim and ensure there is no dorsal cortical fracture or significant
distal fracture extension along the volar cortex.
Positioning
■ The patient is positioned supine on the operating table with the upper
extremity on a radiolucent hand table.
■ A malleable lead/aluminum hand may be used to help retract the nonoperative
digits.
■ The position of the surgeon should take into account the position of the
fluoroscopic machine that most easily gives a perfect lateral radiograph of the
PIP joint to be taken.
■ One configuration is with the surgeon sitting at the head of the patient with
the fluoroscopic C-arm coming from the end of the hand table in the
horizontal position and the image intensifier closer to the surgeon. (See Pearls
and Pitfalls, below.)
Approach
■ A volar “shotgun” approach of the PIP joint is most commonly used and
provides excellent exposure. Various skin flaps have been described to
accomplish exposure of the volar aspect of the PIP joint.
T E C H N I Q U E S
■ Exposure
■ We use a V-shaped Bruner incision, centered at the PIP joint flexion crease
with the apex at the radial (the ulnar border could be used too), extending
from the palmar digital crease to the DIP flexion crease.

■ Raise skin flaps to expose the underlying flexor tendon sheath, and carefully
identify both the radial and ulnar neurovascular bundles.
■ Create an ulnar-based flap of the flexor tendon sheath by making transverse
incisions distal to the A2 pulley and proximal to the A4 pulley, and also
along the radial border.
■ Retraction of this flap ulnarly with a proximal and distal retraction suture
helps to protect the neurovascular bundle just superficial to it.
■ A Penrose drain can be used to retract the flexor tendons, exposing the
underlying volar plate.
■ Incise both radial and ulnar margins of the volar plate and elevate it from its
distal attachment to the proximal phalanx to allow proximal retraction.
■ If the volar plate is still attached to the volar articular fragment, the
fragment should be excised.
■ Release both collateral ligaments off the proximal phalanx sharply, which
may be done by using a knife at the level of the joint and cutting proximally
along the contour of the proximal phalangeal head so that the incised
collateral ligaments can be redraped over the proximal phalanx to enhance
healing.
■ Now, the PIP joint may be fully hyperextended (“shotgunned”) open,
exposing the entirety of both articular surfaces (TECH FIG 1).
TECH FIG 1 • Shotgun exposure of the PIP joint of the
ring finger with a PIP fracture dislocation exposing the

head of the proximal phalanx and the fractured base
of the middle phalanx. A small Penrose drain can be
used to safely retract the flexor tendon system.
■ Middle Phalanx Preparation
■ The base of the middle phalanx should be carefully inspected and correlated
with preoperative radiographs and imaging.
■ Use a rongeur or oscillating microsagittal saw on the middle phalanx to
create a smooth articular interface to accept the hamate autograft.
■ A slow and careful approach during this step is recommended to avoid any
excess removal of bone and to prevent fracture of the remaining dorsal
bony cortex.
■ If possible, leaving a radial or ulnar bony articular lip may help to provide
further stability of the hamate autograft.
■ An ideal bone defect is one that begins at the articular surface and slopes
toward the remaining intact volar cortex, which helps to cant the hamate graft
and ultimately recreate the concave contour of the articular surface (TECH
FIG 2A).
■ The bone defect should be measured in preparation for hamate graft
harvesting using either calipers or a small cut piece of a ruler.
■ Dimensions that should be noted include the total width, the proximal to
distal length, and finally the approximate amount of articular surface that
must be recreated (TECH FIG 2B,C).

TECH FIG 2 • A. Illustration of the lateral PIP joint
demonstrating the preferred bone defect to accept a
hemihamate graft, with sloping at the articular surface
toward the remaining intact volar cortex. B,C. Careful
measurement of the dimensions of the missing volar
phalangeal base with a caliper or ruler—including the
total width, the proximal to distal length, and the
amount of articular surface that must be reconstituted
from the donor hamate graft—allows for a close match
of the graft to its recipient site.
■ Hamate Autograft Harvest
■ Identify the ring and small finger carpometacarpal joints using fluoroscopic
guidance so the incision may be accurately positioned.

■ Use either a transverse or longitudinal incision centered on the
carpometacarpal joints.
■ Retract and protect any cutaneous branches of the dorsal ulnar nerve as well
as the extensor tendons to the ring and small fingers.
■ Expose the CMC joints subperiosteally by incising the dorsal capsule
longitudinally (TECH FIG 3A).
■ Find the bony ridge between the ring and small finger CMC facets on the
hamate. This will be used as the center of the graft.
■ Using the previously measured dimensions of the PIP joint defect, mark the
hamate using an indelible sterile marker, erring on the side of harvesting a
slightly larger graft than necessary.
■ Note that the central ridge on the hamate actually runs at an oblique angle
from dorsal to volar. A previous cadaveric study has shown that the hamate
has a central ridge and bicondylar facet with articular contours similar to the
base of the middle phalanx.6
■ To ensure that the ridge remains central and in the correct orientation on
the graft, make sure the hand is sufficiently pronated on the table before
making any cuts (see Pearls and Pitfalls, below).
■ With an oscillating saw or osteotome, make the sagittal and axial plane cuts
first, remembering to take into account the loss of bone that can be expected,
depending on the thickness of the instrument used.
■ Make the coronal plane cut last with a curved osteotome, as this is usually
the most difficult cut to make and contributes directly to the concavity of the
reconstructed articular surface. Two primary techniques can be used,
antegrade or retrograde.
■ In the antegrade approach, a curved osteotome is used transversely along
the proximal dorsal surface of the hamate and aimed into the ring and small
finger CMC joint blindly. To ensure adequate thickness of the autograft
using the antegrade approach, a small slice of bone is removed just
proximal to the axial plane cut (TECH FIG 3B). This extra bone excision
will provide room for the curved osteotome to obtain the correct depth of
coronal plane cut (TECH FIG 3C–E).
■ In the retrograde approach,10 the ring and small finger metacarpals are
forcefully volarly subluxated to reveal the distal articular surface of the
hamate, and the saw or osteotome is aimed volar and proximal to make a
retrograde coronal cut.

■ Alternatively, a modification to this retrograde approach has been
proposed11 that exposes the distal articular surface of the hamate by
resecting a portion of the ring and small finger metacarpal bases.
■ Once excised, the hamate autograft can be further contoured and shaped to
fit the recipient site with a fine rongeur.
TECH FIG 3 • A. The donor site between the base of
the fourth and fifth metacarpal and the dorsal aspect
of the hamate can be exposed via either a longitudinal
or transverse incision. The graft can be visualized
after careful subperiosteal elevation. B. The coronal
cut of the autograft harvest. To ensure adequate
thickness of the autograft using the antegrade
approach, a small slice of bone is removed just

proximal to the axial plane cut (indicated in pink). C–E.
This extra bone excision will provide room for the
curved osteotome to obtain the correct depth of
coronal plane cut.
■ Hamate Graft Fixation and Closure
■ Provisionally fix the graft to the middle phalanx using a central 0.028-in. or
0.035-in. K-wire in a volar to dorsal direction (TECH FIG 4A).
■ If the visual contour of the graft is satisfactory, use two 0.035-in. K-wires to
secure both the radial or ulnar aspects of the graft to prevent any rotation
(TECH FIG 4B).
■ If 1.3-mm screws are used, there is no need to redrill, and the 0.035-in. K-
wires may simply be replaced with screws.
■ Depending on the size of the graft, a combination of two or three 1.0-, 1.3-,
or 1.5-mm screws may be used (TECH FIG 4C,D).
■ Visually verify the concavity of the articular surface, and fluoroscopically
verify screw lengths and overall graft positioning. Ideally, screws will be
bicortical such that no more than 1 thread length is visible beyond the dorsal
cortex to avoid prominence of the screw tips dorsally (TECH FIG 4E).
■ Because of the discrepancy of cartilage thickness, a bony step-off
visualized on fluoroscopy is not unusual despite visual confirmation of
articular congruency; this may be ignored.
■ If there is any prominence along the volar cortical surface, the graft may be
contoured to match the volar cortex of the middle phalanx using a bur or a
rongeur.
■ Reattach the volar plate distally, and the flexor tendon sheath flap maybe
placed underneath the flexor tendons as an additional layer.

TECH FIG 4 • A. Provisional fixation of the
hemihamate graft with a 0.035-in. K-wire. This K-wire
hole can later be used for one of the screw holes if
appropriately positioned. B. Using a shotgun
approach, the surgeon can align the articular contour
between the donor hemihamate graft and the
remaining articular surface of the recipient dorsal
phalangeal base. Because of slight mismatch in the

width of the articular cartilage of the hemihamate graft
and the phalangeal base, which may appear as a
step-off on a radiograph or fluoroscopic image, it is
more important to visually align the contour of the graft
than it is to align the fluoroscopic contour of the
underlying subchondral bone. C. AP intraoperative
fluoroscopic view of final fixation of the hemihamate
graft with one 1.0-mm and two 1.3-mm bicortical
screws to form an inverted triangle demonstrates
correction of preoperative ulnar deviation and good
medial to lateral size match of the graft with the native
middle phalanx. D. Lateral fluoroscopic view shows
restoration of PIP joint stability. E. Screw fixation of the
graft should ideally be bicortical but without more than
one thread length of the screws beyond the dorsal
cortex of the middle phalanx to avoid dorsal
prominence.
PEARLS AND PITFALLS
Autograft
contour
■ Reconstructing the proper concavity of the articular surface of the
base of the proximal phalanx is crucial. Cancellous autograft may
be used distally to aid in tilting the graft to create a more concave
articular surface.
Hamate
autograft
anatomy
■ The central ridge separating the ring and small finger metacarpal
facets on the hamate may not be purely perpendicular to the dorsal
surface.
■ There are two methods to ensure graft harvest does not result in
asymmetry:
■ Be sure to pronate the hand as much as possible such that the
central ridge is as perpendicular to the floor as possible. This will
help guide your cuts.
■ Fluoroscopy can help verify that the hamate ridge is indeed

positioned perpendicular to the cut you make.
■ If you do an antegrade osteotomy, first use the saw to remove a
very small section of hamate proximal to the graft so that you can
harvest a deep enough graft with a curved osteotome when making
your final cut in the coronal plane.
Hamate
autograft
coronal cut
■ The last cut, or the coronal plane cut, of the hamate autograft is the
cut that determines the amount of volar-dorsal articular surface
harvested.
Radioulnar
asymmetry
■ A CT scan may be helpful in determining radioulnar asymmetry of
the fracture fragment. When preparing the proximal phalanx,
keeping this asymmetry can be helpful, as the hamate autograft
may also be asymmetric.
Checking for
passive
motion
■ After the proximal phalanx recipient site is prepared, make sure
passive ROM of the reduced PIP joint is full. If necessary, an
extensor tenolysis or joint contracture release should be performed.
■ If this passive motion is not checked until after the autograft is
secured, a joint contracture could lead to undue force on the graft
and risk graft fixation failure.
C-arm
fluoroscopy
positioning
■ Obtaining a lateral radiograph of the PIP joint is critical for
evaluating the reconstructed joint bony anatomy. Using a C-arm
from the end of the hand table in the horizontal position facilitates
manipulation and imaging.
■ The shoulder is abducted to 90 degrees, and the elbow is flexed at
90 degrees. With the XR beam horizontal to the floor, the forearm
may be easily pronated and supinated until a perfect lateral of the
PIP joint is obtained.
■ If a lead hand is used, the other fingers may be fully extended and
the shotgunned surgical finger flexed at the MP joint.
■ Alternatively, an elastic bandage may be used to hold all the
nonoperative fingers flexed in a fist with the shotgunned surgical
finger extended at the MP joint.
Proximal
phalanx
preparation
■ In order to reconstruct the concavity of the articular surface, it is
important to prepare the proximal phalanx such that the graft will
be tilted to recreate the cup shape of the volar lip.
■ Creating a slope, rather than a right angle, from the articular
surface down to the volar cortex will help with this.
Collateral
ligaments
■ The collateral ligament may be repaired to the volar plate for soft
tissue coverage and a gliding surface over the bone graft for the
flexor tendons.

Postoperative
splinting
■ A dorsal blocking splint may be used in about 20 degrees of PIP
flexion as described in previous published reports, although they
may be placed in closer to full extension if the reconstruction leads
to a stable joint.
Graft
disasters
■ Should the graft that was obtained from the ipsilateral hamate be
catastrophically contaminated or dropped, consider using the
contralateral hamate.
POSTOPERATIVE CARE
■ Authors have described various postoperative immobilization protocols
including:
■ Use of a 15-degree dorsal blocking splint to protect volar plate repair and
avoid postoperative instability8
■ Alternately, initial immobilization of the wrist and digit in extension for 3 or
4 days followed by a thermoplast extension splint to avoid a flexion
contracture11
■ We prefer to utilize a wrist-based (to protect the hamate graft harvest site)
intrinsic-plus splint to include the affected finger and border digits for 1 week
until sutures are removed. We then transition to a 15-degree dorsal blocking
digital splint vs figure-eight splint initiating active wrist and digital range of
motion under the supervision of a hand therapist 1 week after surgery with a
home exercise program focusing on active range of motion techniques out of
the splint.
■ Protective splints are generally discontinued at 6 weeks, followed by initiation
of passive range of motion.
■ Full unprotected use for heavy lifting and sports is not allowed until bony
union is verified by radiographs and clinical exam, which is anticipated at 3 to
4 months.
OUTCOMES
■ A prior cadaveric study comparing the biomechanical characteristics of
hemihamate arthroplasty vs volar plate arthroplasty found that although both
techniques could adequately restore PIP joint stability, use of volar plate
arthroplasty led to an increasing flexion contracture as the middle phalanx
palmar base deficit increased.12
■ Williams and coauthors followed 13 consecutive patients with unstable dorsal
PIP fracture dislocations treated with hemihamate autograft for 16 months.13

On average, 60% of the articular surface was involved on lateral radiographs.
Average arc of motion of the PIP joint postoperatively was 85 degrees, VAS
pain score was 1.3, grip strength averaged 80% of the contralateral side, and
eleven patients were very satisfied with their function.
■ Calfee et al. reported on a cohort of 33 patients with a combination of acute
and chronic injuries with 4.5-year follow-up.8 The average arc of postoperative
PIP joint motion was 70 degrees, VAS score rating was 1.4, and grip strength
averaged 95% of the contralateral grip strength. Outcomes were modestly
better in injuries treated acutely (within 6 weeks of injury) compared to chronic
injuries (injuries treated 6 weeks or later from injury).
■ Afendras and coauthors reviewed the clinical outcomes of eight consecutive
patients who underwent hemihamate arthroplasty at a minimum follow-up of 4
years.14 The average arc of motion was 67 degrees at the PIP joint, and the
VAS rating was 10 (on a 100-point scale), with 91% grip strength compared to
the uninjured side.
COMPLICATIONS
■ Williams and coauthors reported two patients with recurrent dorsal subluxation
out of a total 13 consecutive patients.13 The authors postulated the subluxation
was due to failure of the volar plate repair and inadequate angulation of the
graft such that the articular concave geometry was not sufficiently recreated.
■ Others have suggested that adequate restoration of the middle phalangeal base
provides sufficient osseous stability to prevent such subluxation and that
extension block pinning and formal volar plate repair are rarely needed.8,15
■ Two series with long-term follow-up found no instances of subluxation or
dislocation.8,14
■ One series reported intraoperative fracture of the dorsal cortex of the middle
phalanx as a possible complication.8
■ Flexor tendon pulley insufficiency is another reported complication if the
critical A2 or A4 pulley systems that are repaired at the conclusion of the case
become incompetent.8
■ PIP joint flexion contracture has been reported and may potentially be avoided
by adherence to a closely supervised postoperative hand therapy protocol.8
■ Donor site pain in the wrist is an infrequent complication reported in 5% of
cases,15 and cadaveric studies have shown minimal evidence of instability of
the fourth or fifth carpometacarpal joints following graft harvest.6

■ Previous series have shown that radiographic signs of degenerative joint
disease of the PIP joint have occurred in close to 50% of cases with long-term
follow-up, but this has been observed in the absence of pain or other symptoms
with no correlation between loss of joint space and functional outcomes.8
■ In the patient series by Afendras, two of eight patients developed severe
symptomatic arthritis, and two of eight developed mild degenerative changes.14
The authors speculated that this may be due to nonanatomical mismatch of the
joint surface and consequent abnormal load bearing, biologic failure of the
graft, or chondral damage from the initial injury.
REFERENCES
1. Kiefhaber TR, Stern PI. Clinical perspective fracture dislocations of the
proximal interphalangeal joint. J Hand Surg [Am]. 1998;23A:368-380.
2. Mangelson JJ, Stern PJ, Abzug JM, et al. Complications following
dislocations of the proximal interphalangeal joint. Instr Course Lect.
2014;63:123-130.
3. Light T. Buttress pinning techniques. Orthop Rev. 1981;10:49-55.
4. Hastings H, Carroll C. Treatment of closed articular fractures of the
metacarpophalangeal and proximal interphalangeal joints. Hand Clin.
1988;4:503-527.
5. Leibovic SJ, Bowers WH. Anatomy of the proximal interphalangeal joint.
Hand Clin. 1994;10:169-178.
6. Capo JT, Hastings H, Choung E, et al. Hemicondylar hamate replacement
arthroplasty for proximal interphalangeal joint fracture dislocations: an
assessment of graft suitability. J Hand Surg [Am]. 2008;33:733-739.
7. Elfar J, Mann T. Fracture-dislocations of the proximal interphalangeal joint. J
Am Acad Orthop Surg. 2013;21:88-98.
8. Calfee RP, Kiefhaber TR, Sommerkamp TG, Stern PJ. Hemi-hamate
arthroplasty provides functional reconstruction of acute and chronic proximal
interphalangeal fracture-dislocations. J Hand Surg [Am]. 2009;34:1232-1241.
9. Deitch M, Kiefhaber TR, Comisar BR, Stern PJ. Dorsal fracture dislocations
of the proximal interphalangeal joint: surgical complications and long-term
results. J Hand Surg [Am]. 1999;24:914-923.
10. Yang DS, Lee SK, Kim KJ, Choy WS. Modified hemihamate arthroplasty
technique for treatment of acute proximal interphalangeal joint fracture-
dislocations. Ann Plast Surg. 2014;72:411-416.
11. DeNoble PH, Record NC. A modification to simplify the harvest of a hemi-

hamate autograft. J Hand Surg [Am]. 2016;41:e99-e102.
12. Tyser AR, Tsai M, Parks BG, Means KR. Biomechanical characteristics of
hemi-hamate reconstruction versus volar plate arthroplasty in the treatment of
dorsal fracture dislocations of the proximal interphalangeal joint. J Hand Surg
[Am]. 2015;40:329-332.
13. Williams RMM, Kiefhaber TR, Sommerkamp TG, Stern PJ. Treatment of
unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-
hamate autograft. J Hand Surg [Am]. 2003;28:856-865.
14. Afendras G, Abramo A, Mrkonjic A, et al. Hemi-hamate osteochondral
transplantation in proximal interphalangeal dorsal fracture dislocations: a
minimum 4 year follow-up in eight patients. J Hand Surg Eur Vol.
2010;35:627-631.
15. McAuliffe JA. Hemi-hamate autograft for the treatment of unstable dorsal
fracture dislocation of the proximal interphalangeal joint. J Hand Surg [Am].
2009;34:1890-1894.

13
CHAPTER
Thumb Carpometacarpal
Joint Fusion With Locking
Plates
John M. Felder and Amy M. Moore
DEFINITION
■ Arthritis of the thumb trapeziometacarpal (TMC) joint is common and leads to
weakness, deformity, limitation of motion, and pain, particularly with pinch.
■ Fusion of the TMC joint produces reliable relief of arthritic pain and a stable
position of the thumb for pinch.
■ Adequate postoperative thumb motion is maintained through movement at the
thumb metacarpophalangeal (MCP) and scaphotrapezial joints.
ANATOMY
■ The articular surface of the trapezium with the thumb metacarpal is saddle
shaped, permitting a wide range of motion and palmar abduction (abduction
perpendicular to the plane of the palm).
■ The capsule of the TMC joint must be sufficiently lax to allow the wide range
of motion of the thumb but contains key stout ligaments, such as the volar
oblique and dorsoradial ligaments, that are critical for joint stability.
Attenuation of these ligaments leads to joint incongruity and arthritis.
PATHOGENESIS
■ In typical TMC joint osteoarthritis, progressive ligamentous laxity, intrinsic
osseous instability, overuse patterns, and articular wear may all contribute to
subluxation of the thumb metacarpal from the trapezium with resultant
incongruous articulation, cartilage loss, and osteoarthritis.
■ TMC joint arthritis may also result from prior fracture of the thumb metacarpal
base or trapezium, typically in younger men.

■ Fusion of the thumb TMC joint may also be desirable as an alternative to
opponensplasty for positioning of the thumb in nerve palsies or brachial plexus
injuries affecting thumb opposition.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Any history of nontraumatic radial-sided hand pain, particularly pain
localizing to the base of the thumb, may suggest TMC joint arthritis.
■ Classically, this disease is most commonly encountered in postmenopausal
women.
■ Physical examination begins with inspection, which may show enlargement of
the thumb TMC joint and prominence of the joint due to subluxation of the
base of the metacarpal.
■ In advanced disease, metacarpal adduction due to TMC joint subluxation may
lead to compensatory hyperextension of the MCP joint, creating the so-called
zigzag deformity.
■ Maneuvers to elicit joint crepitus or tenderness at the joint include the grind
test, palpation of the joint, and the thumb adduction or extension tests (and
related tests),1 which create sheer stress across the joint.
■ The CMC grind test is performed by applying an axially directed loading
force to the thumb metacarpal and circumducting the thumb. Crepitus or
reproduction of pain is considered a positive result.
■ For the adduction stress maneuver, the examiner is seated facing the patient.
The patient places the affected hand on the examination table with the elbow
flexed 90 degrees and the forearm in neutral rotation. The examiner places his
or her ipsilateral hand such that the examiner’s thumb rests dorsally over the
head of the thumb metacarpal. The examiner’s contralateral hand supports the
ulnar side of the patient’s hand to maintain the patient’s wrist in neutral
position to prevent ulnar deviation of the patient’s wrist. The examiner firmly
directs an adduction force downward onto the patient’s metacarpal head until
the patient’s thumb metacarpal lies parallel to the midaxis of the index
metacarpal or until a firm end point is reached. The re-creation of pain at the
TMC joint is considered a positive test.
■ The thumb extension test is performed from the same starting position. The
examiner places his or her ipsilateral thumb along the radial aspect of the
distal thumb metacarpal, 5 to 10 mm proximal to the thumb MCP joint, and
extends the thumb until the thumb metacarpal comes to lie in a plane parallel
to the palm or until a firm end point is reached. Re-creation of pain at the

TMC joint is considered a positive test.
IMAGING
■ Standard PA, lateral, oblique, and Roberts view radiographs of the hand should
be obtained. Roberts view of the thumb profiles the articular surface of the
thumb TMC joint and provides optimal visualization of the thumb CMC joint.
This view requires position of the forearm in maximal pronation with the
dorsum of the thumb resting on the film cassette.
■ Radiographic staging of thumb TMC joint arthritis2 distinguishes between the
following:
■ Stage I: Normal radiographs or TMC joint widening with symptomatic pain
and laxity
■ Stage II: Mild joint space narrowing, osteophyte formation less than 2 mm
■ Stage III: Significant joint space narrowing or total loss of joint space,
osteophyte formation more than 2 mm
■ Stage IV: Stage III also including scaphotrapeziotrapezoid (STT) joint
arthritis
■ Note that this staging system is useful for description of radiographic findings
but is not used for prognosis or to guide treatment. Rather, clinical symptoms
(eg, pain) direct treatment.
DIFFERENTIAL DIAGNOSIS
■ First dorsal compartment (de Quervain) tenosynovitis
■ Carpal tunnel syndrome
■ Fracture
■ STT joint arthritis
■ Rheumatoid arthritis
NONOPERATIVE MANAGEMENT
■ In the case of the TMC joint osteoarthritis, nonoperative management should
always be attempted and consists of hand-based thumb spica splinting,
nonsteroidal anti-inflammatory medications, and intra-articular steroid
injections.
■ In the case of nerve palsy requiring arthrodesis for thumb pinch stability,
nonoperative management is not indicated and TMC joint fusion may be
elected as a planned part of the reconstructive algorithm.3
■ In either case, the patient’s tolerance for joint fusion should be tested

preoperatively with a period of immobilization of the TMC joint by rigid
splinting before proceeding with arthrodesis.
SURGICAL MANAGEMENT
■ Pain interfering with daily activities despite a period of nonoperative
management and lack of ability to stabilize the thumb in space for opposition
are indications for TMC joint fusion.
■ For painful TMC joint osteoarthritis, resection and/or interposition
arthroplasty is a reasonable alternative to fusion with similar outcomes.
■ Many authors favor TMC joint fusion for younger, higher-demand patients
who require greater pinch strength and arthroplasty for older, less active
patients.4,5
■ Because TMC joint arthroplasty with resection of the trapezium requires a
prolonged period of postoperative splinting and therapy and may weaken the
thumb for up to 6 months postoperatively, our preference is to perform TMC
joint fusion for manual laborers who require a rapid return to work and hand
strength.
Preoperative Planning
■ Preoperatively, the patient must understand the implications of joint fusion on
mobility; this is best demonstrated with a period of preoperative splinting.
■ The thumb MCP joint should be assessed for stability prior to proceeding with
TMC joint fusion. An unstable MCP joint will preclude stable pinch and, if
arthrodesis of the MP joint is required for stability, this in combination with
TMC arthrodesis may restrict thumb mobility so greatly as to interfere with
thumb function.
■ Radiographs should be assessed for osteopenia and be recognized when
proceeding with the bony fixation required for arthrodesis. Disuse osteopenia is
found with paralytic limbs.
■ Radiographs should also be assessed for degenerative changes in adjacent
joints such as the STT joint. Severe STT arthritis is a relative contraindication
for CMC arthrodesis.5
■ Surgery may be performed under general, local, or regional anesthesia. We
prefer general anesthesia supplemented by local or regional blocks.
■ Bone grafting is recommended for successful fusion; bone graft is taken from
the distal radius or iliac crest in case of suboptimal contact between prepared
bony surfaces.

■ Fluoroscopy should be available.
■ Power tools and a hand fixation set with locking plates should be requested for
this case. We prefer the use of rigid locking plate fixation to traditional plates
and K-wires in this procedure as often the bone is of poor quality. Locking
plates provide inherent stability for bony fusion.
Positioning
■ The patient is positioned supine on the operating room table, with the hand
centered on a hand table.
■ An upper arm tourniquet and exsanguination should be used for better
visualization of neurovascular structures in the field, such as the radial artery
and branches of the radial sensory nerve.
Approach
■ A volar approach, a modified Wagner approach, or a dorsoradial approach to
the TMC joint can be used.
■ We prefer the dorsal approach, which requires identification and protection of
the radial sensory nerve branches and radial artery but offers better
visualization of the joint space and metacarpal, particularly if plate fixation is
planned.
T E C H N I Q U E S
■ Dorsoradial Approach to Thumb TMC Joint
Arthrodesis with Plate and Screw Fixation
Exposure
■ A longitudinal incision is made from the midpoint of the dorsal surface of
the thumb metacarpal to the proximal aspect of the radial styloid (TECH FIG
1).
■ Superficial branches of the lateral antebrachial cutaneous (LABC) nerve and
radial sensory nerve (RSN) are identified and protected (TECH FIG 1B).
■ The abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
tendons are identified, and the interval between them is opened to create
access to the joint (TECH FIG 1C).

■ The radial artery is protected within the proximal field of dissection.
■ The TMC joint capsule is identified in the depths between the APL and EPB
tendons. At this point, it is useful to insert a Freer elevator at the presumed
TMC joint space (TECH FIG 1D) and use fluoroscopy to verify correct
position (TECH FIG 1E).

TECH FIG 1 • A. Incision is marked between midpoint
of thumb metacarpal and radial styloid. B. The
branches of the radial sensory and lateral antebrachial
cutaneous nerves are identified and protected. C. The
abductor pollicis longus and extensor pollicis brevis
tendons are identified, and the interval between them
is planned for exposure. D. A Freer elevator is used to
identify the location of the TMC joint before making a

capsular incision. E. Fluoroscopy confirms the correct
location of the joint. F. The capsule of the TMC joint is
incised, and capsular tissue is circumferentially
elevated from the thumb metacarpal and trapezium.
■ A longitudinal incision is made full thickness through the capsule to elevate
the capsule from the metacarpal and the trapezium. An attempt should be
made to preserve the edges of the capsule neatly for later closure (TECH FIG
1F).
■ Elevation of the capsule circumferentially from the metacarpal may cause
detachment of the APL tendon insertion and it does not need to be
reattached.
Fitting the Metacarpal Base to the Trapezium
■ The thumb metacarpal base is delivered into the wound using two small
Hohmann retractors.
■ Using a rongeur or a slow-running bur, the metacarpal base is denuded of
cartilage and subchondral bone, and the proximal medullary bone is
fashioned into a ball or cone shape (TECH FIG 2A,B).

B

TECH FIG 2 • A. The metacarpal base is delivered
into the wound, and a rongeur is used to fashion the
medullary bone into a cone shape. B. Healthy
cancellous bone is visualized. C. In preparing the
trapezium surface, an option to allow for adequate
bony contact is to use a K-wire to drill multiple holes
into the trapezium at a 45-degree angle directed
toward the center of the bone. D. A small osteotome is
then used to excavate the central bone to allow the
cone-shaped metacarpal base to fit into the trapezium.
E. The metacarpal is fit onto the prepared surface of
the trapezium.
■ The articular surface of the trapezium is then removed and the medullary
bone of the trapezium is fashioned into a cup shape to accommodate the cone
of the metacarpal base. This can be done with a low-speed power bur or by
using an awl.
■ Another option is to use a K-wire to drill multiple holes angled at 45
degrees toward the center of the trapezium (TECH FIG 2C). The holes are
drilled sequentially at 2- to 3-mm intervals to create a circle, and the
circumscribed cone-shaped fragment is then excavated with a small straight
osteotome (TECH FIG 2D).6
■ Attention to detail is important when shaping the surface of the trapezium,
as it may be a thin and degenerated bone with relatively little volume to
allow for error. It is essential to be certain that the center of the “cone” has
been denuded of cartilage or cortical bone and contains exposed medullary
bone.
■ The metacarpal is fit onto the prepared surface of the trapezium (TECH
FIG 2E).
Positioning the Thumb and Fixation
■ At this point, attention is turned to proper positioning of the thumb. Ideal
position is approximately 45 degrees from the coronal and sagittal planes of
the hand. Slight pronation of the thumb tip may assist with pinch to the more
ulnar digits.

■ Proper position is confirmed by seeing that the pulp of the thumb rests on
the radial aspect of the index middle phalanx with the fingers in a relaxed,
closed fist (TECH FIG 3A).
■ Positioning should be secured using a K-wire for provisional fixation. This
can initially be driven antegrade through the base of the thumb metacarpal
toward the MCP joint and then reversed and driven retrograde to secure the
base of the metacarpal to the trapezium.
■ Once position is visually adequate, bony apposition is checked with
fluoroscopy. Any areas of inadequate bony contact should be supplemented
with cancellous bone autograft.
■ Provisional K-wire fixation is maintained while placing a plate. Our
preference is to use a locking 2.3-mm T-plate with the wings of the T placed
over the trapezium and the long aspect of the plate extending onto the
metacarpal shaft (TECH FIG 3B).
■ Fluoroscopy should be used liberally to ensure that screws do not penetrate
nearby joints (eg, STT) or the FPL tendon sheath. Once fixation is achieved,
the K-wire is removed (TECH FIG 3C,D).

TECH FIG 3 • A. The thumb is positioned with it
resting on the radial aspect of the index middle
phalanx with fingers in gentle flexion. A K-wire is used
to secure the position prior to plate fixation. B–D. A
locking T-plate is used to maintain the position of the
thumb, and multiple fluoroscopic images are obtained
to evaluate the plate position, the contact of the bony
surfaces, and the length of the screws to avoid
unwanted penetration into the STT joint or flexor
pollicis longus.
■ The capsule of the TMC joint should ideally be closed with buried suture.
■ Supplement general anesthesia with local anesthetic injection before skin
closure.
■ The skin is closed with horizontal mattress sutures. Take care to avoid

branches of the RSN during closure.
■ The hand is dressed with short-arm thumb spica splint, leaving the IP joint
free.
■ Dorsoradial Approach to Thumb TMC Joint
Arthrodesis With K-Wire Fixation
■ This procedure is identical to the above technique except that in place of a
plate and screws, three 0.045-in. K-wires are used for fixation.
■ This technique is most appropriate for patients with soft bone that will not
accommodate a locking plate, such as patients with rheumatoid arthritis. We
do not recommend use of K-wire fixation for fusion in patients with
osteoarthritis.
■ The first wire should follow the planned axis of bone fusion and may be
driven using the antegrade (via the exposed TMC joint) followed by
retrograde technique.
■ The remaining two wires should be driven retrograde through the metacarpal
into the trapezium at a divergence of 10 to 20 degrees from the axis of the
first wire.
■ Wires should not penetrate the STT joint.
■ Pins are capped and left outside the skin for office removal at 6 to 8 weeks.
■ Closure and dressings are as above.
PEARLS AND PITFALLS
Simulate
fusion
preoperatively
■ Place the patient in a hand-based thumb spica splint for several
weeks preoperatively to ensure the patient understands what
postoperative motion and hand function will be like.
Preparation of
the bone
■ Careful preparation of the bone surfaces is essential for
positioning and improved bony contact. This involves complete
removal of articular cartilage and subchondral bone while
maintaining the cup and cone formation of the joint.
Bone graft
■ Be prepared to harvest bone graft if needed to ensure excellent

bony contact between fused surfaces. Our preference is to
augment the fusion site with distal radius bone graft.
Nerve
branches
■ Take great care to avoid damage to branches of the radial sensory
nerve to prevent postoperative pain syndromes.
Position
■ Discuss positioning of the thumb preoperatively with the patient.
Ideal position can be estimated by placing the thumb pulp over the
index middle phalanx with the fingers resting in a flexed position.
POSTOPERATIVE CARE
■ The short-arm thumb spica splint placed in the operating room is maintained
for 2 weeks.
■ Sutures are removed at 2 weeks, and the patient is placed into a short-arm
thumb spica cast.
■ If plate fixation is used, the cast is removed at 4 to 6 weeks postoperatively.
■ If Kirschner wire fixation is used, the cast and pins are removed at 8 weeks.
■ After cast removal, patients are given a custom-fabricated, removable forearm-
based thumb spica splint leaving the interphalangeal joint free until definitive
signs of bony healing are seen on x-ray.
■ Typically, bony healing on x-ray appears between 12 and 14 weeks (FIG
1A–C).
■ A CT scan can be performed to confirm union at 8 to 10 weeks (FIG 1D).
■ Range of motion is initiated after cast removal with the help of a certified hand
therapist (FIG 1E,F).
OUTCOMES
■ Functional outcomes are typically excellent following thumb TMC joint
arthrodesis. Clinically, it may be difficult to tell the difference between the
thumb operated upon and the normal thumb.6
■ Patients and surgeons should expect the operation to relieve the pain of
arthritis, improve grip, and restore good stability to the thumb ray.4
■ With proper positioning of the TMC joint in arthrodesis, compensatory motion
of the MCP and STT joints typically allows patients to adduct the thumb to
touch the base of the proximal phalanx of the index finger and to oppose the
thumb to the tips of all fingers.5
■ Thumb retropulsion and abduction from the plane of the palm will be
decreased when compared with the unoperated side but are adequate to allow

grasp around relatively large objects such as jar lids. Pinch strength is typically
equal to the contralateral side.7

FIG 1 • Radiographs (A–C) and CT image (D) confirm
healed arthrodesis at 10 weeks. E,F. Postoperative
photos of patient with left thumb CMC locking plate
arthrodesis.
COMPLICATIONS
■ Nonunion is the most concerning complication and occurs at a reported rate of

13%.8 Nonunion can be minimized by ensuring excellent apposition of
cancellous bony surfaces, using bone graft and careful fixation technique.
Careful attention to shaping of the cup and cone surfaces and avoiding the use
of high-speed, heat-generating power saws may also help to prevent nonunion.
Rigid stabilization with plate and screws may shorten casting time, but
definitive increased overall union rate over K-wire fixation has not been
shown.5 Nonetheless, it is our preference to use locking plate fixation over K-
wire fixation.
■ Hardware-related pain or hardware prominence is a potential complication
when using plate and screw fixation that may require return to the operating
room.
■ Hardware malposition (eg, within the STT joint) is a potential complication
that is best avoided by intraoperative use of fluoroscopy in multiple planes.
■ Radial nerve neuritis and complex regional pain syndrome are potential
complications of this operation that are best avoided by careful identification
and protection of nerve branches intraoperatively. However, the surgery should
be approached with the knowledge that these complications may occur even
despite careful surgical technique.
■ Patients may complain of an inability to place the palm flat on a table or with
difficulty in placing the hand in a pocket. These concerns are best addressed
with thorough preoperative education and splinting.
REFERENCES
1. Gelberman RH, Boone S, Osei DA, et al. Trapeziometacarpal arthritis: a
prospective clinical evaluation of the thumb adduction and extension
provocative tests. J Hand Surg [Am]. 2015;40(7):1285-1291.
2. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb
carpometacarpal joint. J Bone Joint Surg Am. 1973;55(8):1655-1666.
3. Giuffre JL, Bishop AT, Spinner RJ, et al. Wrist, first carpometacarpal joint,
and thumb interphalangeal joint arthrodesis in patients with brachial plexus
injuries. J Hand Surg Am. 2012;37(12):2557-2563.e1.
4. Rizzo M. Thumb arthrodesis. Tech Hand Up Extrem Surg. 2006;10(1):43-46.
5. Goldfarb CA, Stern PJ. Indications and techniques for thumb carpometacarpal
arthrodesis. Tech Hand Upper Extrem Surg. 2002;6(4):
178-184.
6. Carroll RE, Hill NA. Arthrodesis of the carpo-metacarpal joint of the thumb. J
Bone Joint Surg Br. 1973;55(2):292-294.

7. Stark HH, Moore JF, Ashworth CR, Boyes JH. Fusion of the first
metacarpotrapezial joint for degenerative arthritis. J Bone Joint Surg Am.
1977;59(1):22-26.
8. Bamberger HB, Stern PJ, Kiefhaber TR, et al. Trapeziometacarpal joint
arthrodesis: a functional evaluation. J Hand Surg [Am]. 1992; 17A:606-611.

14
CHAPTER
Section IV: Wrist Fractures
and Carpal Instability
Arthroscopic Examination of
the Wrist
Emily Krauss and Amy M. Moore
DEFINITION
■ Wrist arthroscopy is a diagnostic and therapeutic tool to evaluate radiocarpal,
intercarpal, and carpal pathology. Wrist arthroscopy has been described using
both wet (fluid infiltrate) and dry techniques. Treatment applications include
arthroscopic surgical procedures and arthroscopic-assisted open procedures.
ANATOMY
■ Standard wrist arthroscopy portals are dorsal due to the relative lack of
neurovascular structures (FIG 1).
■ Portals to assess the radiocarpal joint are named relative to their location
between extensor tendons. Volar portals, if used to assess the radiocarpal joint,
are placed to avoid the major neurovascular bundles. The midcarpal joint can
be assessed either by the dorsal midcarpal portals or by the volar radial
midcarpal portal. The volar portals are used in select situations to evaluate the
dorsal ligaments and are not standard portals for most situations.
■ Standard diagnostic arthroscopy ports are described in Table 1.1
■ Portals with special indications are listed in Table 2.1

FIG 1 • Dorsal wrist arthroscopy portals.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Wrist arthroscopy is a diagnostic adjuvant to patient history and clinical
examination.
■ Patient evaluation is not complete without a thorough history of onset,
aggravating and alleviating factors, history of trauma, occupational and
repetitive motion history, and a complete history of interventions including
injections, imaging, and surgical procedures.
■ Physical examination should include an evaluation of wrist tenderness,
tendinous pathology, carpal instability, distal radioulnar joint (DRUJ)
pathology, and reproduction of symptoms with wrist loading. Details of a
complete wrist physical examination are essential but beyond the scope of this
chapter.
IMAGING

■ Plain radiographs including posteroanterior, lateral, oblique, and clenched-fist
views of the wrist may contribute to the differential diagnosis.
■ A wrist arthrogram to test for triangular fibrocartilage complex (TFCC) tear
can be unreliable in ulnar-sided wrist pain (sensitivity of 76%).2
■ Wrist arthroscopy continues to be of value as a diagnostic tool in these cases.
Arthroscopy is also useful in patients unable to obtain a 3T MRI or in patients
suspicious for injury that could benefit from arthroscopic-assisted surgical
intervention.
NONOPERATIVE MANAGEMENT
■ Wrist arthroscopy is indicated as a diagnostic technique in patients with
persistent wrist pain with no response to an appropriate trial of conservative
management, including activity modification, splinting, nonsteroidal anti-
inflammatories (NSAIDs), and cortisone injection.
■ It may also be used as a diagnostic technique to stage the degree of injury
(extent of ligament tear and articular wear) or pathology for further surgical
planning.
SURGICAL MANAGEMENT
■ Diagnostic indications:
■ Cartilage injuries
■ Chondromalacia
■ TFCC injury staging
■ Ligamentous instability (scapholunate interosseous ligament [SLIL] injury,
lunotriquetral interosseous ligament [LTIL] injury)
Table 1 Standard Dorsal Wrist Arthroscopy Portals
Portal Name
Anatomic Landmarks
Purpose
1-2
Radial to EPL tendon at
dorsum of snuff box
Inflow. Allows access
to the radial styloid,
scaphoid, lunate, and
articular surface of the
distal radius
3-4
Distal to Lister tubercle,
between EPL and EDC
tendons
Used as the main
radiocarpal
arthroscopic viewing
portal

4-5
Distal to DRUJ. Follow ring
finger metacarpal proximally,
between EDC and EDM
Used as the main
instrumentation portal
for the radiocarpal
joint; allows
visualization of TFCC
6R
Radial (R) to ECU tendon
Instrumentation
portal, visualize the
TFCC and the ulnar
wrist ligaments
(ulnolunate,
ulnotriquetral, and
lunotriquetral)
6U
Ulnar (U) to ECU tendon
Outflow; allows
access to dorsal rim
of the TFCC or for
instrumentation when
debriding the volar
LTIL
Radial midcarpal
In line with second metacarpal
proximal to the capitate;
identified by a depression
between the capitate and
scaphoid
Allows visualization of
the scapholunate and
lunotriquetral
articulations, the STT
joint, and the distal
pole of the scaphoid
Ulnar midcarpal
In line with the 4th
metacarpal, 1 cm distal to the
4-5 portal; identified by a
depression at the
lunotriquetral-capitate-hamate
joint
Allows further
visualization of the
lunotriquetral
articulation, distal
lunate, and triquetral
hamate articulation;
used for
instrumentation of the
articulations
ECU, extensor carpi ulnaris; EDC, extensor digitorum communis; EDM,
extensor digitorum minimi; EPL, extensor pollicis longus; DRUJ, distal
radial ulnar joint; STT, scaphotrapeziotrapezoid joint; TFCC, triangular
fibrocartilage complex.
■ Wrist arthritis evaluation (intactness of lunate facet and midcarpal joint in

salvage procedure surgical decision-making)
■ Kienbock disease diagnostic staging (using 3-4 portal only to preserve
vascular pedicle for a 4-5 extensor compartment artery vascularized bone
graft)
■ Treatment indications:
■ Ganglion excision
■ TFCC tear debridement or repair of foveal tears
■ Resection of radial styloid (radial styloidectomy in impingement)
■ Ulnar styloid excision
■ Proximal hamate excision (proximal arthritis in type II lunate)
■ Chondroplasty
■ Arthroscopic-assisted fracture reduction
• Distal radius factures (comminuted or depressed articular fragments,
evaluation of associated scapholunate ligament injuries)
• Scaphoid fractures (using 4-5 portal for waist and proximal pole fractures)
Table 2 Special Indication Portals
Portal Name
Anatomic Landmarks
Purpose
Scaphotrapeziotrapezoid
radial (STT-R)
In line with the index
metacarpal just radial to the
EPL at the level of the STT
joint
Allows visualization
and debridement of
STT joint
Scaphotrapeziotrapezoid
ulnar (STT-U)
In line with the index
metacarpal just ulnar to the
EPL at the level of the STT
joint
Allows visualization
and debridement of
STT joint
Triquetrohamate
Ulnar to the ECU tendon at
the level of the TH joint
Inflow/outflow. Allows
visualization and
debridement of the
TH joint
Volar radial
Radial to the FCR tendon at
the proximal wrist flexion
crease, essentially through
the floor of the FCR tendon
sheath
Visualization of the
DRCL and the volar
aspect of the SLIL,
visualization during
DRUJ fracture
reduction
Volar ulnar
Interval between flexor
Visualization of the

tendons and flexor carpi
ulnaris and the ulnar
neurovascular bundle
dorsal radioulnar
ligament and volar
aspect of the
lunotriquetral
ligament. Aids in
repair or debridement
of dorsal TFCC tears
Volar DRUJ port
Accessed through same
skin incision of the volar
ulnar portal, but the capsular
entry is 5 mm to 1 cm
proximal to the ulnocarpal
capsular entry point
Volar aspect of DRUJ
ECU, extensor carpi ulnaris; EPL, extensor pollicis longus; DRCL, dorsal
radial carpal ligament; DRUJ, distal radial ulnar joint; FCR, flexor carpi
radialis; SLIL, scapholunate intercarpal ligament; STT,
scaphotrapeziotrapezoid joint; TFCC, triangular fibrocartilage complex;
TH, triquetrohamate.
■ Septic wrist (complete irrigation through radiocarpal and midcarpal portals)
■ Dorsal wrist capsular release
■ Volar wrist capsular release (standard dorsal portals such as 3-4 and 6R;
protect radioscaphocapitate ligament to prevent ulnar translation of carpus,
and volar neurovascular structures and tendons can be at risk during release)
■ Contraindications:
■ Marked wrist swelling
■ Distortion of surface landmarks
■ Large capsular tears
■ Neurovascular compromise
■ Bleeding disorders
■ Infection
■ Specifically for dry wrist arthroscopy: using thermal probes, lasers, any heat-
generating instrument
Preoperative Planning
■ Equipment (FIG 2A)
■ 2.7-mm, 30-degree-angle scope with camera for the standard wrist
arthroscopy and evaluation of the carpus

■ 1.9-mm, 30-degree-angle scope with camera for the DRUJ
■ Fiberoptic light source
■ Video monitor, printer for intraoperative photos, or digital system for direct
video recording
■ Instrumentation:
• 3-mm hook probe
• Motorized shaver for debridement
• Diathermy unit
■ Ancillary equipment:
• Motorized 2.9-mm bur for bony debridement or resection
• Suture repair kits including TFCC repair kit or Tuohy needle for facilitating
ligament repairs
■ Equipment setup (FIG 2B)
■ Commercially available wrist arthroscopy traction tower
■ Above-elbow tourniquet
■ Shoulder holder
■ 5- to 10-lb sand bags or weights attached to arm sling for countertraction
Positioning
■ The patient is positioned supine on the operating room table with the arm
abducted at the shoulder and placed on an arm table.
■ An above-elbow tourniquet is placed and the arm rested in a shoulder holder,
with 5- to 10-lb weights attached to the arm sling (for countertraction).
■ The arm is exsanguinated and the tourniquet insufflated prior to placing the
fingers of the examination hand in the traction tower. Total traction force is
generally 10 lb (4.5 kg).
■ For use of dorsal arthroscopic examination portals, the surgeon sits at the
patient’s head facing the dorsum of the patient’s wrist. For volar portals the
surgeon sits over the patient’s axilla (FIG 3).
■ Ensure the arthroscopy camera is white-balanced and that the light source does
not rest on the drape or the patient while turned on, as burns can occur.

FIG 2 • A. Arthroscopy equipment. Top row from left to
right: 22-gauge needle with 5-cc syringe of normal
saline, 15 blade scalpel, mosquito or tenotomy scissors,
blunt cannula, scope introducer port, 2.7-mm 30-degree
arthroscopy, 18-gauge Jelco needle, small arthroscopy
shaver, shaver apparatus. Bottom row from left to right:
3-mm probe, straight foreign-body grasper. B.
Intraoperative ConMed Linvatec TractionTower
Extremity Traction Device setup with diagram.

FIG 3 • Patient positioning for left wrist arthroscopy.
Above elbow sterile tourniquet, countertraction above-
elbow straps, traction device with 10 lb of traction.
Surgeon sits at patient head for dorsal approach.
Approach
Classic “Wet” Wrist Arthroscopy
■ A structured approach to wrist arthroscopy is important for efficiency and
good visualization.
■ Portals are established by palpating surface anatomic landmarks, prior to
inserting a 22-gauge needle into the joint space. If inserting into the 3-4 portal
first, the needle should be inserted 10 degrees palmar to account for the volar
inclination of the radius.
■ The joint is then injected with 5 cc of saline and subsequent aspiration to
confirm position within the wrist joint.
■ Vertical or transverse (within natural wrist creases) shallow incisions are made

to avoid injury to dorsal sensory nerve branches, and a blunt mosquito or
spreading tenotomy dissection is used to dissect the soft tissue down to the
wrist capsule.
■ The wrist capsule is then pierced (by holding the instrument like a dart) and a
blunt trocar fitted with an inflow valve is inserted to introduce the scope
cannula into the wrist.
■ An 18-gauge angiocatheter can be placed in the 6U portal for sufficient
outflow if wet technique performed.
■ Structures that should be visualized in any standard arthroscopy include radius
articular surface; the proximal scaphoid, lunate, and triquetrum; the SLIL both
from radiocarpal and midcarpal; the LTIL both from radiocarpal and midcarpal;
the radioscaphocapitate ligament; the ulnolunate (UL) ligament; the
ulnotriquetral (UT) ligament; the articular disc of the TFCC; and the radial and
peripheral TFCC attachments.
■ Diagnostic wrist arthroscopy usually begins with the dorsal 3-4 portal to
evaluate the volar ligaments. However, establishing dorsal portals first but
beginning the examination using the volar radial portal to visualize the palmar
SLIL and dorsal radiocarpal ligament (DRCL) can minimize iatrogenic trauma
to the dorsal capsular structures and errors in diagnosis.
■ A standard dorsal diagnostic arthroscopic examination uses primarily the 3-4
portal and combinations of the 4-5 portal and 6R to fully visualize the
structures. From the 3-4 portal, visualization of the entire radiocarpal joint
should be possible, using the 4-5 or 6R portals for probe insertion. 6U is
primarily used for fluid outflow or for instrumentation for the palmar LTIL
treatment.
Dry Wrist Arthroscopy
■ Dry wrist arthroscopy is less commonly performed but has some theoretical
advantages. However, with regard to safety with shaving or thermal
procedures, we recommend the wet technique.
■ Advantages:
■ Avoids fluid extravasation
■ Avoids risk of fluid-associated compartment syndrome
■ Less soft tissue swelling, capsular distention, possibly resulting in less
postoperative pain
■ Larger portals and larger instruments
■ Larger portals facilitate more surgical procedures using arthroscopic

technique (eg, partial wrist fusion).3
T E C H N I Q U E S
■ Diagnostic Arthroscopy
■ Begin with the 3-4 portal distal to Lister tubercle between extensor pollicis
longus (EPL) and extensor digitorum communis (EDC) tendons.
■ After placement of a 22-gauge needle with a 10-degree volar tilt trajectory,
inject and aspirate 5 cc of saline to confirm placement within the radiocarpal
joint.
■ Make a short superficial incision followed by blunt dissection using
tenotomy scissors to the wrist capsule and bluntly puncture the dorsal wrist
capsule. Gently insert the blunt trocar for the arthroscope (2.7-mm 30-degree
angle).
■ An 18-gauge angiocatheter can be inserted at the 6U portal for fluid drainage
■ The 3-4 portal is a “workhorse” portal of wrist arthroscopy allowing a nearly
panoramic examination of the radiocarpal joint.
■ Throughout the arthroscopy, evaluation should include articular surfaces,
synovitis, loose body identification and removal, and the integrity of wrist
ligaments.
■ Radial Structures
■ Begin radially to examine the articular surfaces of the distal radius, proximal
scaphoid, and proximal lunate. The dorsal aspect of the scaphoid is also
visualized. Some features of the DRC joint capsule are also seen radially.
■ The radioscaphocapitate (RSC) ligament is seen originating from the tip of
the radial styloid and passing distally anterior to the proximal pole of the
scaphoid.
■ Identify the interligamentous sulcus separating the RSC and the long
radiolunate (LRL) ligaments as a landmark for orientation (TECH FIG 1).
The LRL arises from the palmar rim of the distal radius and passes anterior to
the proximal pole of the scaphoid.
■ The short radiolunate ligament (SRL) is just ulnar to the LRL, seen as an

amorphous structure with surface blood vessels. The ligament passes
vertically and integrates with the SL ligament in the proximal anterior third.
■ The scapholunate ligament can then be seen covering the remaining
proximal and distal aspects of the scapholunate joint and is fibrocartilaginous
in this section. The ligament is frequently the same color and brightness as
the articular surfaces and may be a concave or a convex bulge across the
scapholunate joint. The SL ligament should be followed, by lowering the
arthroscope parallel to the long axis of the forearm and turning the scope
camera, as it courses dorsally to the reflected dorsal radiocarpal (DRC)
ligament of the joint capsule. Note any signs of hemorrhage, synovitis, and
attenuation (TECH FIG 2).
■ Just ulnar to the SL ligament, the SRL ligament originates from the volar rim
of the radius at the lunate fossa and forms the volar joint capsule, insetting on
the proximal lunate. Ulnar and continuous with the SRL is the UL ligament.
There may be a perceptible fold between the two ligaments.
■ The DRC joint capsule may be visualized dorsally, generally after
examination of the LT and TFCC. The DRC is normally generously lined
with synovium in this region.
■ Table 3 covers the 3-4 portal field of view.
TECH FIG 1 • A. Diagram of a right wrist from dorsal
approach, with 3-4 portal view marked. Note the

radioscaphocapitate (RSC) ligament radially and the
long radiolunate ligament (LRL) in the field of view. B.
Radioscaphocapitate and long radiolunate ligaments
as viewed intraoperatively from the 3-4 portal,
scaphoid above.
TECH FIG 2 • A. Diagram of right wrist, dorsal
arthroscopy, indicating arthroscopic view of the
scapholunate (SL) ligament from radiocarpal joint
using the 3-4 portal. B. Intraoperative view of synovitis
of the SL ligament from the radiocarpal joint. C. SL
ligament probed by 3-mm probe from radiocarpal joint.
Table 3 3-4 Portal Field of View
Surface Anatomic Landmark: Distal to Lister tubercle, between EPL and
EDC
Portal Field of View
Portal
Name
Radial
Central
Volar
Dorsal/Distal Ulnar
3-4
Portal
Scaphoid
and
lunate
fossa,
volar rim
of radius
Proximal
scaphoid
and lunate,
dorsal and
membranous
SLIL
RSC,
RSL,
LRL,
ULL
Oblique
views of
DRCL
insertion
onto dorsal
SLIL
TFCC radial
insertion,
central disk,
ulnar
attachment,
PRUL,
DRUL, PTO,

PSR
■ Ulnar Structures
■ A 4-5 portal can also be used to visualize the UL ligament and UT ligaments;
however, in most patients, adequate examination can be accomplished by 3-4
portal plus a midcarpal arthroscopy.
■ From the radiocarpal joint, immediately ulnar to the UL ligament is the UT
ligament inserting on the volar edge of the triquetrum. The prestyloid recess
can then be visualized at the junction between the UT and the palmar
radioulnar (PRU) ligaments.
■ Using the 4-5 portal, the pisotriquetral orifice can be visualized just anterior
to the proximal articular surface of the triquetrum. Reposition the arthroscope
to visualize the articular surface of the pisiform and the flexor carpi ulnaris
(FCU) tendon passing through the orifice.
■ Moving dorsally, the proximal region of the lunotriquetral ligament (LT) is
localized by identifying the sulcus or concavity in the otherwise convex
articular surfaces of the lunate and triquetrum (TECH FIG 3). Note any signs
of hemorrhage, synovitis, or attenuation.
■ Table 4 covers the 4-5 portal field of view.
TECH FIG 3 • A. Diagram of right wrist, dorsal

arthroscopy, indicating arthroscopic view of the
lunotriquetral (LT) ligament from the radiocarpal joint
using the 3-4 portal. B. Intraoperative view of the LT
ligament from the radiocarpal joint.
Table 4 4-5 Portal Field of View
Surface Anatomic Landmark: Between EDC and EDM in Line with Ring
Metacarpal, Slightly Proximal to the 3-4 Portal
Portal Field of View
Portal
Name
Radial
Central
Volar
Dorsal/Distal Ulnar
4-5
Portal
Lunate
fossa,
volar rim
of radius
Proximal
lunate,
triquetrum,
dorsal and
membranous
LTIL
RSL,
LRL,
ULL
Poorly seen
TFCC radial
insertion,
central disk,
ulnar
attachment,
PRUL,
DRUL, PTO,
PSR
■ TFCC Evaluation
■ From the 4-5 portal, the articular disc of the TFCC can be seen proximal,
interposed between the dorsal radioulnar (DRU) and palmar radioulnar
(PRU) ligaments. The articular disc is fibrocartilage and may be the same
color and brightness at the articular surface of the lunate fossa (TECH FIG
4A,B).
■ A 3-mm probe inserted from the 6R portal can be used to palpate the
transition from the articular surface of the distal radius to the articular disc.
The probe can be used to estimate the resting tension of the disc by pushing
and releasing the probe pressure on the disc. Hypermobility of the articular
disc is described as a trampoline sign (TECH FIG 4C).
■ The dorsal radioulnar (DRU) and palmar radioulnar (PRU) ligaments should
be identified as they converge toward their ulnar attachments.
■ In patients with ulnar-sided wrist pain, it may be useful to use the volar ulnar
portal to assess the palmar LTIL and dorsal radioulnar ligament and the

region of the extensor carpi ulnaris subsheath. This portal also allows for
assessment of the radial TFCC attachment.
■ TFCC tears can be arthroscopically classified according to Palmer’s
classification to guide conservative, arthroscopic, or open treatment (TECH
FIG 5).4
■ TFCC repair can be accomplished using instrumentation introduced through
the 6U portal, although some authors advise open repair, particularly at the
ulnar styloid, to avoid injury to the dorsal cutaneous branch of the ulnar nerve
at the 6U portal.
■ Table 5 covers 6R portal fields of view.
TECH FIG 4 • A. Diagram of right wrist, dorsal
arthroscopy, indicating arthroscopic view of the
triangular fibrocartilage complex (TFCC) using the 3-4
portal. B. Intraoperative view of the TFCC articular
disc (bottom), fovea (far center), and lunate proximal
articular surface above. C. Intraoperative arthroscopic
view of a 3-mm probe, inserted through the 4-5 portal,
testing an intact TFCC articular disc.