Operative Technique in Plastic Surgery – Kevin C.Chung

20
CHAPTER
Open Reduction and
Fixation of Acute Perilunate
Fracture Dislocation
Grant M. Kleiber and Amy M. Moore
DEFINITION
■ Perilunate dislocation refers to a pattern of ligamentous injuries and/or
fractures involving the carpus. In a perilunate dislocation, the lunate remains in
its anatomic position, and there is dorsal dislocation of the carpus in relation to
the lunate.
■ In a lunate dislocation, the lunate is volarly displaced outside of the lunate
facet.
■ Lesser arc injury refers to a purely ligamentous injury pattern.
■ Greater arc injury implies at least one fracture in addition to the perilunate
dislocation, the most common being the scaphoid and radial styloid.
■ In the event of a greater arc injury, the injury pattern and the fractures are
described using the nomenclature “trans-[fractured bone]” in addition to
“perilunate dislocation.” For example, a perilunate dislocation with a radial
styloid and scaphoid fracture would be described as a “transradial styloid,
trans-scaphoid perilunate dislocation.”
ANATOMY
■ The carpus is constrained by a network of dorsal and volar radiocarpal
(extrinsic) and intercarpal (intrinsic) ligaments (FIG 1).
■ The lunate is constrained by extrinsic ligaments on its volar surface only: the
long radiolunate, short radiolunate, and ulnolunate ligaments.
■ The lunate is constrained by intrinsic intercarpal ligaments on its radial and
ulnar edges: the scapholunate and lunotriquetral ligaments.
■ The scapholunate ligament is strongest at its dorsal aspect, whereas the

lunotriquetral ligament is strongest at its volar aspect.
■ The space of Poirier is an area of weakness in the volar wrist capsule, allowing
the midcarpal joint to expand and contract during wrist motion. It is located
between the radioscaphocapitate and the long radiolunate ligaments (see FIG
1).
PATHOGENESIS
■ The biomechanical forces resulting in a perilunate dislocation are wrist
hyperextension, ulnar deviation, and intercarpal supination.
■ In a dorsal perilunate dislocation, there is rupture of the scapholunate and
lunotriquetral ligaments, causing the carpus to dislocate dorsally off of the
lunate.
■ The lunate protrudes through the volar wrist capsule through the space of
Poirier.
FIG 1 • A: The volar ligaments of the wrist include from
radial to ulnar: radioscaphocapitate (RSC), long
radiolunate (LRL), short radiolunate (SRL), ulnolunate
(UL), and lunocapitate (UC), which overlies the
ulnocapitate. Distally, the triquetrohamate and
triquetrocapitate ligament stabilize the ulnar carpus
(THC). The space of Poirier lies proximal to the arc

between the radial and ulnar volar ligaments. B: The
dorsal ligaments include the dorsal intercarpal ligament
(DIC) and dorsal radiocarpal ligament (DRC).
FIG 2 • The Mayfield classification of perilunate injuries
proposes a radial-to-ulnar progression of injury. In stage
I, the scapholunate ligament is ruptured. Stage II is
disruption of the capitolunate articulation. Stage III is
disruption of the lunotriquetral ligament and dorsal
dislocation of the carpus from the lunate. Stage IV is
volar dislocation of the lunate out of the lunate fossa of
the radius.
■ The short radiolunate ligament typically remains intact in a perilunate
dislocation, tethering the volar lunate to the volar lip of the radius.
■ Mayfield classified perilunate dislocations as a progression of injury from
radial to ulnar around the lunate1 (FIG 2):
■ Stage I: Scapholunate disruption with rotation of scaphoid
■ Stage II: Capitolunate dissociation
■ Stage III: Lunotriquetral ligament rupture, dislocation of carpus dorsal to
lunate
■ Stage IV: Lunate dislocation: lunate is dislocated volarly out of the lunate
fossa.
■ In a greater arc injury, there is transmission of force through the bony

structures surrounding the lunate, resulting in at least one fracture in addition
to the perilunate dislocation (FIG 3).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients typically report a high-energy injury such as a fall from height or a
motor vehicle collision.
■ A full trauma workup should be initiated depending on the mechanism of
injury.
FIG 3 • A lesser arc injury refers to a purely ligamentous
pattern of injury, as described in the Mayfield
classification. A greater arc injury describes the injury
pattern traveling through at least one bony structure,
such as the radial styloid, scaphoid, capitate,
triquetrum, or ulnar styloid.
■ Patients may present with acute carpal tunnel syndrome, with symptoms
ranging from paresthesias to severe burning pain in their median-innervated
digits.

■ The examiner should perform a complete neurovascular examination of the
hand including two-point discrimination to document sensory disturbance.
■ The wrist is evaluated for edema, gross deformity, and tenderness.
■ Ecchymosis and edema over the volar wrist are often seen.
IMAGING
■ Standard three-view wrist radiographs (PA, lateral, oblique) are sufficient for
diagnosis in most cases.
■ AP views demonstrate irregularity of the carpal rows, with a triangular lunate
silhouette superimposed over other bones (FIG 4A).
■ Lateral views shows the lunate tipped volarly relative to the remainder of the
carpus in a “spilled teacup” sign (FIG 4B).
■ In trans-scaphoid perilunate injuries, the displaced scaphoid proximal pole is
seen attached to the lunate (FIG 4C,D).
■ A CT scan may be helpful to identify and characterize carpal fractures in
greater arc perilunate dislocations. Ideally, this study would be performed after
reduction of the carpus.
DIFFERENTIAL DIAGNOSIS
■ Scapholunate dissociation
■ Scaphoid fracture
■ Radiocarpal dislocation
NONOPERATIVE MANAGEMENT
■ Closed reduction of the lunate should be attempted in all patients using the
Tavernier maneuver (FIG 5).
■ Conscious sedation is recommended for patient comfort and relaxation—
facilitating reduction.
■ The Tavernier maneuver:
■ The wrist is extended and the lunate is palpated volarly with the examiner’s
thumb.
■ Axial traction is placed on the patient’s wrist, and gentle pressure is applied
to the volar aspect of the lunate.
■ The wrist is then flexed forward while maintaining axial traction and volar
pressure on the lunate. Successful reduction is often accompanied by a
palpable “clunk.”
■ Wrist radiographs are taken in traction to verify reduction, and a sugar tong

splint is applied.
■ If reduction is unsuccessful, an open reduction should be performed in the
operating room in an urgent manner.

FIG 4 • A. AP radiograph of a perilunate dislocation
demonstrates disruption of carpal rows and a triangle-
shaped lunate (L) superimposed over the midcarpal
joint. B. Lateral radiograph of a perilunate dislocation
demonstrates dorsal translation of the carpus off the
lunate, which is flexed forward. In this case, the lunate
remains located within the lunate fossa of the radius. C.

AP radiograph of a trans-scaphoid perilunate
dislocation. The triangular shape of the lunate and
disruption of the carpal arcs are demonstrated. D.
Lateral radiograph demonstrates that in a trans-
scaphoid perilunate dislocation the proximal pole of the
scaphoid remains attached the lunate. The remainder of
the carpus is dislocated dorsally. T, trapezium; Tr,
trapezoid; C, capitate; H, hamate; S, scaphoid; Tq,
triquetrum; R, radius; U, ulna.
FIG 5 • The Tavernier’s maneuver consists of (1)
applying distal traction on the wrist while stabilizing the
lunate with the opposite thumb. (2) The wrist is then
extended and volar pressure is applied on the lunate to
prevent dislocation into the carpal tunnel. (3) With
traction and the lunate stabilized, the distal carpal row is
reduced over the lunate into position with gentle wrist
flexion.
SURGICAL MANAGEMENT

■ If successful closed reduction is achieved, operative intervention and
reconstruction can be performed several days later as a scheduled procedure
but ideally within 1 week.
■ Irreducible dislocations must be treated urgently to prevent median nerve
impingement and devascularization of the lunate and displaced carpal bones.
■ A surgical option for irreducible dislocations or for less experienced hand
surgeons taking call is to take the patient to the operating room urgently for the
volar approach to the carpus. An extended carpal tunnel release is performed to
decompress the median nerve followed by open reduction of the carpus and
repair of the volar lunotriquetral ligament and capsule. The dorsal approach
can then later be performed by surgeons with expertise in the wrist.
Preoperative Planning
■ As discussed previously, careful neurological exam should be performed
including two-point discrimination to determine the baseline median nerve
function.
■ Any surgical equipment, such as hardware or suture anchors, should be
available.
■ A perilunate dislocation can be performed under regional or general
anesthesia.
Positioning
■ The patient is positioned supine with affected arm on a radiolucent hand table
centered on the patient’s axilla.
■ A well-padded pneumatic tourniquet is placed on the upper arm.
■ If an assistant is not available to assist with traction, end table traction with
finger traps and 5 to 10 lb of weight will facilitate dissection and reduction
during the procedure.
Approach
■ A combined dorsal and volar approach is recommended for perilunate
dislocations.
■ Dorsal approach
■ A 6- to 8-cm longitudinal incision centered over ulnar aspect of the Lister
tubercle between the third and fourth extensor compartments provides good
exposure. The radiocarpal and midcarpal joints are then exposed using a
ligament-sparing capsulotomy, splitting the dorsal radiocarpal and dorsal

intercarpal ligaments (FIG 6).2
■ The dorsal approach is required in all patients for ligament repair and
stabilization.
■ Volar approach
■ A standard carpal tunnel release incision is extended across the wrist crease
in a zigzag fashion for 2 to 3 cm.
■ The volar approach adds the benefit of open reduction of the lunate under
direct visualization, volar lunotriquetral ligament repair, volar capsular repair,
and median nerve decompression via the extended carpal tunnel release.
FIG 6 • A dorsal ligament-sparing capsulotomy splits the
dorsal radiocarpal (DRC) and dorsal intercarpal (DIC)
ligaments, maintaining their fibers in continuity for
added dorsal stabilization of the wrist with closure.
(From Berger RA, Bishop AT. A fiber-splitting
capsulotomy technique for dorsal exposure of the wrist.
Tech Hand Up Extrem Surg. 1997;1:2-10.)

T E C H N I Q U E S
■ Lesser Arc Perilunate Dislocation
Volar Approach with Extended Carpal Tunnel Release and
Open Reduction
■ An extended carpal tunnel incision is made, crossing at least 2 to 3 cm
proximal to the wrist crease.
■ The transverse carpal ligament is divided along its ulnar aspect to avoid the
median nerve, which may be displaced due to presence of the lunate within
the carpal tunnel. As the carpal tunnel is released, blood is typically seen in
this space.
■ The antebrachial fascia is released proximally under direct vision, and the
median nerve and flexor tendons are retracted radially.
■ The lunate is visualized within the carpal tunnel, protruding from the volar
wrist capsule and typically in a flexed position (TECH FIG 1). It is gently
reduced into its anatomic position with axial traction on the wrist and gentle
extension and pressure on the lunate.
■ The volar lunotriquetral ligament is visualized and is repaired with
nonabsorbable suture.
■ The crescent-shaped tear in the volar wrist capsule is also repaired with
nonabsorbable suture.
Dorsal Approach with Ligament Repair
Exposure
■ The wrist is approached dorsally through a 6- to 8-cm incision centered on
the ulnar aspect of the Lister tubercle via the third and fourth extensor
compartments.
■ Blunt dissection is carried over the extensor retinaculum to raise
subcutaneous flaps radially and ulnarly. The radial sensory nerve and dorsal
cutaneous branch of the ulnar nerve are identified and protected throughout
the case.
■ The extensor retinaculum is incised over the EPL tendon, which is
transposed out of the retinaculum.

■ The extensor retinaculum is then raised off of the fourth dorsal compartment
and the second dorsal compartment, entering each through the open third
compartment. Self-retaining retractors are placed, exposing the wrist capsule.
■ A ligament-sparing capsulotomy is performed to enter the wrist joint,
splitting the fibers of the dorsal radiocarpal ligament and the dorsal
intercarpal ligament. A radially based capsular flap is raised by extending the
proximal incision radially along the dorsal radius (TECH FIG 2).2,3
■ The scaphoid, lunate, and triquetrum are visualized. Dorsal remnants of the
scapholunate and lunotriquetral ligaments are identified. Typically, the
ligaments are torn asymmetrically, with a larger piece on one side of the joint.
TECH FIG 1 • On volar approach to the wrist, the
lunate (L) is seen protruding into the carpal tunnel
through a crescent-shaped rent in the volar wrist
capsule.
Reduction and Fixation
■ Suture anchors are inserted in preparation for ligament repair. The anchor is
inserted to the side of the joint with the smaller ligament fragment, so the
sutures may be passed through the larger fragment.
■ Fluoroscopic imaging and direct visualization are used to ensure adequate
placement of the anchors.

■ The scaphoid is typically found to be flexed, and the lunate is extended. To
correct the scapholunate angle, a 0.062-in. K-wire is inserted into the dorsum
of the scaphoid and the lunate to act as a joystick.
■ Using the K-wire joysticks, the scaphoid and lunate are aligned under lateral
fluoroscopy to restore a scapholunate angle of 40 to 55 degrees (TECH FIG
3A). The K-wires can be provisionally secured together with a hemostat to
hold this reduction.
■ Another option is to place a radiolunate K-wire to hold the reduced lunate
in place and then the scaphoid can be reduced to the lunate using the K-
wire joystick (TECH FIG 3B).
■ The sutures attached to the anchors are now passed through the scapholunate
and lunotriquetral ligaments and left untied until intercarpal pins are placed.
■ Intercarpal pins are placed using 0.045-in. K-wires. Pins are placed to
stabilize the scapholunate interval and the lunotriquetral interval.
TECH FIG 2 • Using a ligament-sparing capsulotomy,

a radially based capsular flap is raised to expose the
carpus. (From Berger RA, Bishop AT. A fiber-splitting
capsulotomy technique for dorsal exposure of the
wrist. Tech Hand Up Extrem Surg. 1997;1:2-10.)
■ A scaphocapitate pin is placed to stabilize the scaphoid from flexing (TECH
FIG 3C). Pins are buried beneath the skin to avoid pin-tract infection that
invariably will occur when pins are left outside the skin for more than a few
weeks.
■ AP and lateral fluoroscopic radiographs are taken to ensure adequate
reduction of the SL and LT interval, and a scapholunate angle of 40 to 55
degrees (TECH FIG 3D).
■ If these films are satisfactory, the suture anchors are tied down.
■ The wrist is irrigated copiously with normal saline to ensure no remaining
osteochondral debris is present in the articular space.
■ The capsulotomy, followed by the extensor retinaculum, is then closed with
nonabsorbable sutures.

TECH FIG 3 • A. The scapholunate angle is restored
using 0.062-in. K-wire joysticks placed into the lunate
and scaphoid. These can be secured together with a

hemostat to hold the reduction temporarily. B. Another
option is to reduce the lunate and then place a
radiolunate K-wire to stabilize the lunate. The
scaphoid can then be reduced to the lunate to restore
the scapholunate angle using a joystick. C. AP
radiograph demonstrates that the carpus is stabilized
with 0.045-in. K-wires after suture anchors have been
place for reconstruction of the ligaments. Two K-wires
are placed in the scapholunate and lunotriquetral
intervals. A scaphocapitate (and/or a triquetrocapitate)
K-wire can also be placed to stabilize the capitolunate
joint if found to be unstable. D. Lateral view of carpus
after K-wire stabilization and ligament repair
demonstrates restoration of acceptable scapholunate
angle.
■ Repair of Greater Arc Injury
Trans-scaphoid Perilunate Dislocation
■ Greater arc injuries result in a fracture of an adjacent bone accompanying the
perilunate dislocation. The scaphoid is the most common bone involved
(TECH FIG 4A,B).
■ The same volar and dorsal approaches are used as outlined above.
■ The scapholunate ligament is most often intact in a trans-scaphoid perilunate
dislocation (TECH FIG 4C), and the proximal pole of the scaphoid is
displaced with the lunate (see FIG 4D).
■ The scaphoid fracture is reduced under direct vision, aligning the
cartilaginous surface of the scaphoid.
■ Joystick K-wires can be placed in the proximal and distal poles to aid in
reduction and stabilization.
■ The scaphoid is fixated with a dorsal cannulated compression screw using
standard technique, with the caveat that the fracture will be less stable than
typical scaphoid fractures.
■ Use of distal radius bone graft is encouraged if significant comminution of

the scaphoid is found. The graft can be easily taken from under the Lister
tubercle in the same exposure.
■ A guidewire is placed for a cannulated screw along the axis of the scaphoid,
beginning proximally at the center of the membranous portion of the
scapholunate ligament
■ An antirotation parallel wire should be placed alongside the guidewire to
stabilize the scaphoid fracture for overdrilling the guidewire.
■ Most cannulated screw systems have a parallel wire guide for placement of
this wire. This step is highly recommended due to the instability of the
fracture.

D

TECH FIG 4 • A. AP radiograph demonstrates a trans-
scaphoid perilunate dislocation. In this greater arc
injury, there is a scaphoid (S) waist fracture instead of
a scapholunate ligament injury. B. The proximal pole
of the scaphoid remains attached to the lunate (L) and
flexes with it. C. Image of right wrist demonstrates
scaphoid fracture with intact scapholunate ligament
(*). D and E. AP and lateral radiographs of open
reduction and fixation of a trans-scaphoid perilunate
injury with K-wire stabilization of the carpus and
cannulated screw fixation of the scaphoid. C, capitate;
R, radius Tq, triquetrum.

TECH FIG 5 • AP radiograph of a greater arc
transradial styloid, trans-scaphoid, transcapitate
perilunate dislocation. The distal radius fracture was
treated with fragment-specific fixation, and cannulated
screws were to repair the capitate and scaphoid
fractures.
■ The guidewire is measured and overdrilled, and an appropriately sized
cannulated compression screw is placed over the wire.
■ A scaphocapitate K-wire can be placed to further stabilize the lunocapitate
joint as well as reinforce the scaphoid fixation if comminuted.
■ The lunotriquetral ligament is repaired with suture anchors in the same
manner described above, and the lunotriquetral interval is pinned with 0.045-
in. K-wires (TECH FIG 4D,E).
Transradial Styloid, Trans-scaphoid, Transcapitate Perilunate
Dislocation

■ Greater arc injuries result in a fracture of an adjacent bone accompanying the
perilunate dislocation. The scaphoid is the most common bone involved, and
the technique for fixation of a trans-scaphoid perilunate is outlined above.
■ Radial styloid fractures involving greater than one-third of the scaphoid
fossa should be repaired to stabilize the volar ligamentous attachments.4 This
can be performed with cannulated screw fixation or a radial column pin plate.
Anatomic alignment of the articular surface is critical.
■ Transverse capitate fractures may be managed with cannulated compression
screws, allowing the screws to be buried beneath the articular surface (TECH
FIG 5).
Perilunate Dislocation Reconstruction with Posterior
Interosseous Neurectomy
■ The terminal branch of the posterior interosseous nerve (PIN) runs in the
floor of the fourth dorsal compartment. It provides sensory innervation to the
wrist joint.
■ Perilunate dislocation and its subsequent reconstruction result in significant
capsular trauma to the wrist joint. A PIN neurectomy should be strongly
considered as an adjunctive procedure to decrease postoperative pain and
improve long-term outcomes.
■ The PIN can be consistently found 3 to 4 cm proximal and 1 cm ulnar to
Lister tubercle, beneath the tendons of the fourth dorsal compartment.
■ The nerve is carefully dissected free from the artery for a distance of 2 to 3
cm. The nerve is crushed proximally with a hemostat and distally 1 to 2 cm is
resected. The proximal nerve is then cauterized.
■ The proximal nerve end is transposed proximally along the course of the
nerve, burying it beneath the forearm musculature to prevent symptomatic
neuroma formation.
PEARLS AND PITFALLS
Irreducible
perilunate
dislocation
■ A closed reduction should be attempted in the emergency room
under sedation.
■ If unable to reduce, open reduction should be performed in the

operating room in an urgent fashion to decompress the median
nerve and improve vascular supply to the displaced carpus.
Median nerve
compression
■ Acute carpal tunnel syndrome commonly accompanies perilunate
dislocation. These patients should be treated with urgent median
nerve decompression and relocation of the lunate through a volar
approach.
■ Carpal tunnel release should be performed in all patients due to
trauma to the median nerve from the perilunate dislocation.
Technique:
Ligament
repairs
■ Suture anchors can be use to repair the scapholunate and/or
lunotriquetral ligaments.
■ The anchors should be placed prior to the reduction and K-wire
fixation of the interval to allow best visualization.
■ Once the interval is reduced and stabilized with K-wires, the
sutures can be tied and secured.
Scapholunate
angle
■ A normal scapholunate angle between 30 and 60 degrees should be
restored, ideally between 40 to 55 degrees.
■ Place joystick K-wires into the scaphoid and lunate to extend the
scaphoid and flex the lunate into an anatomic position (see TECH
FIG 3A).
■ The lunate can also be stabilized with a temporary radiolunate pin
(see TECH FIG 3B).
Posterior
interosseous
neurectomy
■ A PIN neurectomy should be strongly considered at the time of
ligament repair to decrease postoperative pain.
■ The nerve is found in the floor of the fourth dorsal compartment.
POSTOPERATIVE CARE
■ The patient is placed in a sugar tong splint for 2 weeks, followed by 8 to 10
weeks of thumb spica cast immobilization.
■ K-wires are removed at 8 to 10 weeks. Burying pins beneath the skin results in
fewer issues with pin-tract infections, but they may require removal in the OR.
■ Gentle range of motion exercises are begun after K-wire removal. Hand
therapy is initiated to regain wrist motion.
■ A protective removable splint is worn between therapy sessions until pain and
range of motion has stabilized. For greater arc injuries, the splint is worn until
union is achieved.
OUTCOMES
■ Patients should expect decreased wrist range of motion, particularly flexion

and extension, after this significant injury (FIG 7). Near-normal prono-
supination is typically restored.
■ Total arc of motion for flexion/extension is reported from 57% to 83% of the
contralateral side.5–10
■ A recent retrospective review of 65 cases reported that 85% of patients were
able to return to their previous occupation.5
■ Despite adequate fixation and intervention, most patients (range 18%–92%)
develop radiographic signs of radiocarpal and midcarpal arthrosis over time.6,11
■ In a study by Forli et al.,6 67% of their patients developed post-traumatic
degenerative changes; however, they report that the arthrosis is well tolerated
at an average follow-up of 13 years.
■ Proximal row carpectomy can be considered as a secondary salvage procedure
in patients with avascular necrosis of the lunate or in delayed unrecognized
perilunate dislocation.12
COMPLICATIONS
■ Multiple complications can result from the severe wrist trauma at the time of
injury, as well as, from the operative procedure itself.
■ Complex regional pain syndrome has been reported to occur in up to 12% of
patients.5
■ K-wire/pin-tract infections can occur.
■ Osteonecrosis of lunate or scaphoid has been reported at rate of about 8%.5
■ Carpal bone nonunion such as in trans-scaphoid perilunate dislocation is
rare.6,9
FIG 7 • At 6 months postoperatively, functional
extension (A) and flexion (B) have been restored.
However, range of motion is decreased compared to

the uninjured hand.
REFERENCES
1. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics
and progressive perilunar instability. J Hand Surg [Am]. 1980;5:226-241.
2. Berger RA, Bishop AT. A fiber-splitting capsulotomy technique for dorsal
exposure of the wrist. Tech Hand Up Extrem Surg. 1997;1:2-10.
3. Berger RA, Bishop AT, Bettinger PC. New dorsal capsulotomy for the surgical
exposure of the wrist. Ann Plast Surg. 1995;35:54-59.
4. Dumontier C, Meyer zu Reckendorf G, Sautet A, et al. Radiocarpal
dislocations: classification and proposal for treatment: a review of twenty-
seven cases. J Bone Joint Surg Am. 2001;83-A:212-218.
5. Israel D, Delclaux S, Andre A, et al. Peri-lunate dislocation and fracture-
dislocation of the wrist: retrospective evaluation of 65 cases. Orthop Tramatol
Surg Res. 2016;102:351-355.
6. Forli A, Courvoisier A, Wimsey S, Corcella D. Perilunate dislocations and
transscaphoid perilunate fracture-dislocations: a retrospective study with
minimum ten-year follow-up. J Hand Surg [Am]. 2010;35:62-68.
7. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, et al. Perilunate
dislocation and fracture dislocation: a critical analysis of the volar-dorsal
approach. J Hand Surg [Am]. 1997;22:49-56.
8. Trumble T, Verheyden J. Treatment of isolated perilunate and lunate
dislocations with combined dorsal and volar approach and intraosseous
cerclage wire. J Hand Surg [Am]. 2004;29:412-417.
9. Knoll VD, Allan C, Trumble TE. Trans-scaphoid perilunate fracture
dislocations: results of screw fixation of the scaphoid and lunotriquetral repair
with a dorsal approach. J Hand Surg [Am]. 2005;30:
1145-1152.
10. Hildebrand KA, Ross DC, Patterson SD, et al. Dorsal perilunate dislocations
and fracture-dislocations: questionnaire, clinical, and radiographic evaluation.
J Hand Surg [Am]. 2000;25:1069-1079.
11. Herzberg G, Forissier D. Acute dorsal trans-scaphoid perilunate fracture-
dislocations: medium-term results. J Hand Surg Br. 2002;27:498-502.
12. Rettig ME, Raskin KB. Long-term assessment of proximal row carpectomy
for chronic perilunate dislocations. J Hand Surg [Am]. 1999;24:1231-1236.

21
CHAPTER
Dorsal Capsulodesis for
Scapholunate Stabilization
with Extensor Carpi Radialis
Longus Tenodesis
Mark Morris and Kevin C. Chung
DEFINITION
■ Scapholunate (SL) dissociation is the most common cause of carpal instability.
■ SL dissociation can result in static or dynamic carpal instability.
■ Static instability: Radiographic changes are seen on standard wrist
radiographs.
■ Dynamic instability: Standard radiographs are normal, but signs of instability
are seen on stress radiographs.
■ Partial SL interosseous ligament tears do not produce radiographic changes
and often require arthroscopy for diagnosis.
■ SL dissociation left untreated leads to dorsal intercalated instability (DISI) and
eventually scapholunate advanced collapse (SLAC).1
ANATOMY, PATIENT HISTORY, AND PHYSICAL FINDINGS,
IMAGING
■ See Chapter 15 in the Hand section.
SURGICAL MANAGEMENT
■ Dividing the SL interosseous ligament leads to altered radiocarpal kinematics
and causes abnormal radiocarpal and ulnocarpal pressure distributions.2,3
■ The radioscaphoid joint is normally congruent. However, when the scaphoid is
subluxed because of SL instability, the load is shifted and abnormal contact
points are created, leading to degenerative changes (FIG 1).4

■ The goal of dorsal capsulodesis and extensor carpi radialis longus (ECRL)
transfer is to maintain the extended position of the scaphoid in order to restore
normal carpal alignment and avoid abnormal radiocarpal contact pressures that
otherwise lead to pain and degenerative changes.
■ Capsulodesis alone is contraindicated if there is static SL dissociation, whereas
ECRL tendon transfer can be performed with static SL dissociation as long as
reduction is possible in the operating room. Either procedure is contraindicated
if radiocarpal or midcarpal degenerative changes are present.
■ Capsulodesis is indicated for predynamic SL instability secondary to an
isolated partial SL ligament tear (seen on arthroscopy) and for dynamic SL
instability with intact secondary stabilizers and a technically repairable dorsal
capsule.
■ The main advantage of dorsal capsulodesis over tendon transfer is the
technical ease of the procedure.
■ The disadvantage of dorsal capsulodesis is the predilection for attenuation of
the repair over time and progressive carpal collapse.5 Tendon transfer
provides increased strength of repair and the ability to maintain reduction of
the scaphoid over time.
■ Additionally, with a capsulodesis, the scaphoid is theoretically still unstable
through much of the arc of wrist motion until it reaches the limit of flexion
set by the capsulodesis. In contrast, a dynamic transfer should provide an
extension force to the scaphoid throughout the entire range of wrist motion.6
■ ECRL transfer to the scaphoid can be used as an alternative to capsulodesis for
treatment of a partial SL ligament tear. ECRL transfer can be performed if the
capsule is not technically repairable, which would obviously preclude
capsulodesis.
■ The ECRL tendon transfer was designed to re-establish a fluid scaphoid slider-
crank motion and restore midcarpal kinematics without tethering the scaphoid
or limiting wrist flexion.
■ A slider-crank mechanism converts linear motion to rotatory motion or vice
versa, such as with a piston and crank shaft of an engine.

FIG 1 • A. Normal orientation of the scaphoid and radius
shows a congruent articulation between the scaphoid
and the scaphoid facet of the radius. B. An area of
abnormal loading of the radioscaphoid joint occurs
when the scaphoid undergoes rotary subluxation.
Disproportionate loading of the joint leads to
degenerative changes.
■ The slider-crank model of the wrist described by Linscheid et al.7 explains
wrist kinematics as a three-bar linkage composed of the radius, lunate, and
capitate. The three bars are stabilized by the scaphoid, which acts as the
crank. When the wrist is extended, the scaphoid “crank” causes dorsal rotation
of the lunate by a dorsally directed compressive force. With flexion, the
scaphoid causes flexion of the lunate via a palmarly directed tensile force
(FIG 2).

■ ECRL tendon transfer provides a consistent extension force to the scaphoid
throughout the range of motion, as opposed to a dorsal capsulodesis, which
acts merely as a checkrein to flexion of the scaphoid. By doing so, the
scaphoid is able to influence the kinematics of the wrist throughout the arc of
motion rather than just at the point limited by the checkrein.
FIG 2 • The slider-crank model of the wrist joint posits a
three-bar link between the radius, lunate, and capitate,
with the scaphoid acting as the crank. The red arrows
show the direction of force produced by the crank
mechanism—a dorsally directed compressive force with
extension of the wrist and a palmarly directed tensile
force with flexion of the wrist.

Preoperative Planning
■ Wrist arthroscopy has become the standard method of evaluation of
interosseous ligament injuries. Geissler grading of ligament injuries as seen
during arthroscopy is as follows8:
■ Grade 1: Attenuation/hemorrhage of interosseous ligament as seen from the
radiocarpal joint. No incongruency of carpal alignment in the midcarpal
space.
■ Grade 2: Attenuation/hemorrhage of interosseous ligament as seen from the
radiocarpal joint. Incongruency/step-off as seen from the midcarpal space. A
small gap may be seen between the carpal bones but smaller than the width of
a probe.
■ Grade 3: Complete ligament tear seen from the radiocarpal joint.
Incongruency/step-off of carpal alignment is seen from both the radiocarpal
and midcarpal spaces. The probe can be passed through the gap between
carpal bones.
■ Grade 4: Complete ligament tear is seen from radiocarpal joint.
Incongruency/step-off of carpal alignment is seen from both the radiocarpal
and midcarpal spaces. Arthroscope (2.7 mm) can be passed through the gap in
the carpal bones. Gross instability with manipulation.
Positioning
■ The patient is positioned supine on the operating table. The operative arm is on
a hand table.
■ Regional or general anesthesia can be used.
■ A tourniquet is applied.
■ An examination under anesthesia is performed to check for instability.
Approach
■ A dorsal approach to the wrist is utilized, centered over the Lister tubercle
(FIG 3).
■ The third dorsal compartment is identified but does not need to be opened in
most cases.
■ Dissection is performed between the second and fourth compartments to
expose the scaphoid and lunate.

FIG 3 • A dorsal incision is centered over the Lister
tubercle.
T E C H N I Q U E S
■ Dorsal Capsulodesis for Scapholunate Instability
Using Suture Anchors
Exposure
■ A 6-cm dorsal longitudinal incision is made, centered over the radiocarpal
joint in line with the long finger metacarpal.
■ Sharp dissection is carried down to the extensor retinaculum.
■ Skin and subcutaneous tissue flaps are raised.
■ The second and fourth compartments are elevated such that the tendons are
maintained within the compartment.
■ The wrist capsule is incised longitudinally to expose the scaphoid and lunate.
■ The remaining dorsal SL ligament is assessed (TECH FIG 1).
Reduction
■ Two 0.062-in. K-wires are placed into the dorsal scaphoid and lunate to act
as joysticks for reduction.
■ The scaphoid wire is retracted proximally to extend the scaphoid. The lunate
wire is retracted distally to flex the lunate.
■ Fluoroscopy is used to evaluate the reduction.
■ The assistant holds the scaphoid and lunate reduced using the joystick K-

wires while the surgeon drills one K-wire percutaneously from the radial side
of the wrist, through the scaphoid and lunate.
TECH FIG 1 • Exposure of the SL joint in this patient
shows an intact dorsal SL ligament (arrow). This
patient had normal wrist radiographs, and SL diastasis
on wrist arthroscopy.
■ A second K-wire is then drilled through the scaphoid into the capitate to
prevent the scaphoid from rotating. This will hold the reduction.
Fixation
■ A curette is used to debride the cortical bone from the distal dorsal scaphoid
until cancellous bone is visible. This will provide a more favorable
environment for healing the capsule to bone.
■ Drill a hole using the Mitek anchor drill into the most distal part of the
dorsal scaphoid. The drill hole should be placed adjacent to the
scaphotrapezial joint, distal to the scaphoid axis of rotation. Place a 1.8-mm
suture anchor (mini Mitek or similar) into the drill hole.
■ Secure the dorsal capsule to the scaphoid by passing the suture from the

anchor through the overlying capsule. Tie the suture securely to prevent the
scaphoid from flexing.
■ Final fixation is assessed fluoroscopically to confirm that the lunate is in
neutral position and the carpal bones are aligned correctly (TECH FIG 2).
■ The dorsal capsule is repaired using 3-0 Ethibond suture.
Closure
■ The tourniquet is released and hemostasis is obtained.
■ The extensor retinaculum is closed with 3-0 Ethibond suture.
■ Skin is closed with a 4-0 Monocryl suture.
TECH FIG 2 • Postoperative AP and lateral
radiographs show a suture anchor in the dorsal
scaphoid and a K-wire traversing the SL joint.
■ Scapholunate Stabilization with Dynamic ECRL
Tendon Transfer
Exposure and Reduction
■ The skin incision is centered over the dorsal wrist joint between the third and
fourth dorsal compartments and extends from the Lister tubercle proximally

to between the index and long finger metacarpal bases distally.
■ Expose the ECRL and extensor carpi radialis brevis (ECRB) from the distal
edge of the extensor retinaculum to their insertions on the index and long
finger metacarpal bases, respectively.
■ The extensor tendons are retracted ulnarly to expose the wrist capsule. The
wrist capsule is incised longitudinally, just radial to the origin of the dorsal
radiocarpal (DRC) ligament proximally and radial to the insertion of the
dorsal intercarpal (DIC) ligament distally. This will expose the SL joint and
the SL ligament tear.
■ Reduce the scaphoid and lunate and pin in place, as described above in the
capsulodesis section.
Tendon Transfer
■ Prepare the ECRL tendon insertion site at the dorsal distal scaphoid (TECH
FIG 3A,B).
■ A trough is made the dorsal distal scaphoid in the same manner as described
in the capsulodesis section, and one or two mini Mitek anchors are placed.
■ Anchors can alternatively be placed after the tendon is harvested.
■ To harvest the ECRL tendon, it is incised transversely from its insertion on
the dorsal base of the second metacarpal (TECH FIG 3C).
■ The tendon tension should be set to a length that will make it isotonic when
docked into the scaphoid—the tendon transfer should provide equal tension
to the scaphoid throughout the arc of wrist motion.
■ If the tendon is too short, tension will be too high with wrist flexion.
■ If the tendon is too long, tension will be too light with wrist extension.
■ Any adhesions are released so the ECRL has full excursion.
■ To secure the tendon transfer, extend the wrist and have the assistant retract
the tendon distally to reach the scaphoid while the surgeon ties the tendon
down tightly to the anchor. The tendon can otherwise retract during this step.

TECH FIG 3 • A,B. AP and lateral depictions of the
ECRL insertion site in the scaphoid. The red circles
indicate the area of the dorsal distal scaphoid to be
curetted. C. The ECRL graft is harvested from the
base of the second metacarpal. The red circle shows
the location of the docking hole. The red line indicates
where to transect the ECRL tendon from the insertion
site on the index metacarpal base.
■ Use two mini Mitek anchors for more secure attachment (TECH FIG 4).
Closure
■ The dorsal wrist capsule is closed with 3-0 Ethibond suture.
■ The tourniquet is released and hemostasis is achieved prior to further
closure.
■ Skin is closed with a 4-0 Monocryl suture.

TECH FIG 4 • Two mini Mitek anchors secure the
ECRL tendon graft, which pulls the scaphoid back into
extension.
PEARLS AND PITFALLS
Technique
■ When placing joystick K-wires, correction of the deformity will be
easier if the scaphoid wire is directed proximally and the lunate
wire is directed distally.
■ When drilling a hole for a suture anchor, care must be taken to
protect the vascular pedicle that inserts at the dorsal ridge of the
scaphoid.
■ We recommend cutting K-wires under the skin to avoid pin-tract
infection. Infection is common when K-wires are left outside of

the skin for more than 3 weeks.
Postoperative
care
■ Wrist range of motion is expected to decrease by about 20%.
Despite this, most patients have significant improvement in pain
after this surgery.
Rehabilitation
■ Patients are instructed to avoid forceful axial loading of the wrist
(especially activities like weight lifting or push-ups) for 6 months.
POSTOPERATIVE CARE
■ Postoperatively, the patient is placed into a volar wrist splint for 8 weeks.
■ For capsulodesis, the wrist can be splinted in a neutral position.
■ After dynamic ECRL transfer or tenodesis, the wrist is splinted in 15 to 20
degrees of extension to prevent excessive tension at the ECRL insertion site.
■ The wound is examined and sutures are removed (if nonabsorbable sutures are
used) after 10 days.
■ The K-wires are removed 6 to 8 weeks after the initial surgery.
■ After 8 weeks of splinting, the patient is transitioned to a removable volar
splint for an additional 4 weeks. Gentle active wrist range of motion can begin
at this time.
OUTCOMES
■ Dorsal capsulodesis
■ Gajendran et al.9 studied 16 wrists in 15 patients who were treated with
dorsal capsulodesis for chronic, flexible, static SL dissociation with follow-up
of greater than 60 months (average 86 months). At final follow-up, average
wrist flexion and extension were 50 and 55 degrees, respectively. Outcomes
were also measured with disabilities of the arm, shoulder, and hand (DASH;
average score 19), Short Form-12 (average score 78), and Mayo wrist score
(average 78). Mayo scores were “excellent” in 38%, “good” in 19%, “fair” in
31%, and “poor” in 12% of patients. Grip strength was statistically unchanged
from preoperative to final follow-up. Radiographs at final follow-up showed
an average SL angle of 62 degrees, and an SL gap of 3.5 mm. Fifty percent of
wrists (8/16) had evidence of arthritis on radiographs. Radiographic outcome
did not correlate with subjective pain scores. The authors concluded that
although dorsal capsulodesis did not prevent arthritic changes, patient
satisfaction and functionality remained high after this surgery.
■ Megerle et al.5 did a retrospective study of 59 patients who underwent dorsal
capsulodesis, with a mean follow-up of 8.25 years (4.3–12 years). Although

carpal alignment was significantly improved immediately postoperatively,
results at long-term follow-up showed a return to preoperative alignment
(mean SL angle 70 degrees at final follow-up). Eight patients required a
salvage procedure at 2.33 years, and 40 patients had radiographic evidence of
arthritis at final follow-up. Mean DASH and Mayo wrist scores were 28 and
61, respectively. The authors concluded that although capsulodesis did not
prevent degenerative changes, most patients had acceptable clinical outcomes
at long-term follow-up.
■ ECRL tenodesis: Bleuler et al.10 studied 20 patients who were treated with
dynamic ECRL tenodesis. All but one patient were satisfied with the functional
outcome at short-term follow-up and would undergo the same surgery again if
they had the choice. All patients were able to return to their former occupation
between 1.5 and 4 months postoperatively.
■ Combined ECRL tenodesis with dorsal capsulodesis: De Carli et al.11
retrospectively reviewed 8 wrists in 8 patients who underwent combined ECRL
tenodesis-capsulodesis for static SL dissociation with a minimum follow-up of
1 year (average 23 months). Average visual analog scale score (VAS: 0–10)
postoperatively was 3. The mean DASH score was 13. Functional results were
“excellent” in 2 cases and “good” in 6 cases. All patients lost some of their
initial reduction on radiographs, but none had recurrence of carpal collapse.
COMPLICATIONS
■ Infection
■ Chronic regional pain syndrome
■ Damage to the superficial radial nerve
■ Loss of wrist range of motion
■ Pin-tract infection
■ Fracture
REFERENCES
1. Watson K, Ballet FL. The SLAC wrist: scapholunate advanced collapse
pattern of degenerative arthritis. J Hand Surg [Am]. 1984;9:358-365.
2. Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of
the ligamentous stabilizers of the scaphoid and lunate. J Hand Surg Am.
2002;27A:991-1002.
3. Short WH, Werner FW, Fortino MD, et al. A dynamic biomechanical study of
scapholunate ligament sectioning. J Hand Surg Am. 1995;20A:986-999.

4. Rajan PV, Day CS. Scapholunate interosseous ligament anatomy and
biomechanics. J Hand Surg Am. 2015;40(8):1692-1702.
5. Megerle K, Bertel D, Germann G, et al. Long-term results of dorsal
intercarpal ligament capsulodesis for the treatment of chronic scapholunate
instability. J Bone Joint Surg Br. 2012;94B:1660-1665.
6. Bleuler P, Shafighi M, Donati OF, et al. Dynamic repair of scapholunate
dissociation with dorsal extensor carpi radialis longus tenodesis. J Hand Surg
Am. 2008;33A:281-284.
7. Linscheid RL, Dobyns JH, Beabout JW, Bryan RS. Traumatic instability of
the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg.
1972;54(8):1612-1632.
8. Geissler WB. Arthroscopic management of scapholunate instability. J Wrist
Surg. 2013;2(2):129-135.
9. Gajendran VK, Peterson B, Slater RR, Szabo RM. Long-term outcomes of
dorsal intercarpal ligament capsulodesis for chronic scapholunate dissociation.
J Hand Surg Am. 2007;32:1323-1333.
10. Bleuler P, Shafighi M, Donati OF, et al. Dynamic repair of scapholunate
dissociation with dorsal extensor carpi radialis longus tenodesis. J Hand Surg
Am. 2008;33A:281-284.
11. De Carli P, Donndorff A, Gallucci GL, et al. Chronic scapholunate
dissociation: ligament reconstruction combining a new extensor carpi radialis
longus tenodesis and a dorsal intercarpal ligament capsulodesis. Tech Hand Up
Extrem Surg. 2011;15(1):
6-11.

22
CHAPTERProximal Row Carpectomy
Patrick Reavey and Amy M. Moore
DEFINITION
■ First described by Stamm,1 proximal row carpectomy (PRC) is the removal of
the scaphoid, lunate, and triquetrum, resulting in a neoradiocarpal articulation
between the proximal capitate and the lunate fossa of the radius.
■ PRC is one of the “motion-preserving” options for the treatment of
degenerative carpal arthritis.
ANATOMY
■ The proximal carpal row consists of the scaphoid, lunate, and triquetrum, and
the distal carpal row includes the trapezium, trapezoid, capitate, and hamate
(FIG 1A).
■ Removal of the proximal carpal row converts a complex link joint to a simple
hinge joint between the capitate and distal radius.
■ Differences in the capitate and lunate morphology have been described as
possible reasons for failure of PRC. However, biomechanical and clinical
outcome studies have not demonstrated a significant relationship between
carpal shape and failure.2,3
■ The carpal bones are linked to the radius and ulna and to each other by a
complex network of extrinsic and intrinsic ligaments.
■ The radioscaphocapitate (RSC) ligament extends from the radial styloid
across the volar waist of the scaphoid to the capitate (FIG 1B).
■ Identifying and preserving this ligament during PRC is crucial to prevent
ulnar subluxation of the remaining carpus.
PATHOGENESIS

■ A number of conditions can lead to painful radiocarpal arthritis.
■ Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced
collapse (SNAC) occur secondary to chronic scapholunate (SL) ligament
disruption and scaphoid fracture nonunion, respectively.
• Both of these conditions result in progressive radiocarpal arthritis that starts
between the radial styloid and scaphoid.
• In later stages, these conditions can progress to a pancarpal arthritis and
may involve the lunocapitate joint.
■ Kienbock disease is an idiopathic avascular necrosis of the lunate that can
lead to varying degrees of intercarpal and radiocarpal arthritis.
■ Treatment for each of these conditions varies based on the etiology and stage
of disease at presentation. However, once significant arthritis has developed,
conservative measures including splinting and steroid injections can minimize
pain and improve function.
FIG 1 • A. Diagram of the carpus. B. Location of volar
radioscaphocapitate ligament.
Table 1 Radiologic Staging Systems of Common Degenerative Wrist
Arthritidis
Radiographic
Stage
Kienboch’s
SLAC
SNAC
1
No visible
Arthritis between
Arthritis between

changes on x-ray,
decreased
vascularity on
MRI
scaphoid and
radial styloid
scaphoid and
radial styloid
2
Sclerosis of
lunate
Arthritis between
scaphoid and
entire scaphoid
facet of radius
Stage 1 +
scaphocapitate
arthritis
3
A: lunate
collapse, no
scaphoid rotation
B: lunate
collapse, fixed
scaphoid rotation
Arthritis between
capitate and
lunatea
Periscaphoid
arthritis
4
Degenerated
adjacent
intercarpal jointsa
Pancarpal arthritis

Italics indicate stages appropriate for treatment with PRC.
aLunocapitate arthritis is a contraindication to PRC, though capsular
interposition or osteochondral resurfacing modifications may be
performed in the presence of arthritis.
Kienbock, Lichtman classification; SLAC, Watson classification.
■ PRC is usually reserved as a salvage operation for patients who have failed
surgical treatment of earlier stages of the disease and have also failed trials of
conservative management.4,5 Table 1 covers staging of each condition and
indications for PRC.
■ PRC has also been described in the acute treatment of severe radiocarpal or
carpal fracture dislocations6 but is not recommended in the initial treatment of
early SL dissociations.7
NATURAL HISTORY
■ Carpal arthritis frequently presents with patients complaining of wrist pain,
decreased range of motion and grip strength, and inability to perform daily
activities without discomfort.
■ Many patients will have a distant history of trauma or prior surgical
procedures for an acute injury.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ Preoperative evaluation of a patient with wrist arthritis should include a
detailed history, an assessment of functional limitations, measurement of wrist
range of motion, and grip strength.
■ History
■ A patient’s occupation, age, and interests are key factors in determining if
PRC is an appropriate procedure.
• PRC is generally indicated in patients older than 40 who have low physical
demands.
• Younger patients and manual laborers have less ideal outcomes and higher
failure rates after PRC.3,8
■ The operative records from prior surgeries should be obtained and the
outcome of any trial of conservative therapy should be elicited.
■ Use of a patient-reported outcome measure (PROM) such as the Michigan
Hand Questionnaire (MHQ), disability of the arm, shoulder, and hand
(DASH), or Patient-reported Wrist Evaluation (PRWE) can be helpful in
determining the patient’s baseline functional disability and following
postoperative outcomes.
■ Physical examination
■ The skin is evaluated for scarring and/or previous incisions.
■ The wrist is evaluated for edema, gross deformity, and tenderness.
■ Range of motion and grip strength
■ Active wrist flexion and extension as well as radial and ulnar deviation are
measured with the forearm in neutral rotation.
■ Total range of motion as well as the extent of each motion at which the
patient experiences pain is determined.
■ Grip strength is measured with a dynamometer.
■ The bilateral wrist measurements are obtained and compared.
■ Carpal examination
■ A detailed examination of the carpus is performed to elicit sites of discomfort
to palpation and motion.
■ Evaluating for snuffbox tenderness, SL tenderness, and a Watson’s is useful
when determining the primary pathology leading to carpal arthritis but does
not directly impact the decision to perform a PRC.
■ Neurovascular examination
■ The examiner should perform a complete neurovascular examination of the

hand.
IMAGING
■ Standard three-view wrist radiographs (PA, lateral, oblique) are performed to
evaluate for the extent of carpal arthritis.
■ Specific evaluation of the lunocapitate joint on PA view is crucial to
determining if PRC is an option for the patient because arthritic change at this
joint precludes performing a PRC when a normal capitate is needed to
articulate with the lunate fossa on the radius.
■ If there is any evidence of lunocapitate arthritis on x-ray, modifications of a
PRC may be required (see below in techniques).
■ The patients should also be counseled that they may require conversion to an
alternative procedure (ie, wrist fusion) intraoperatively.
■ CT scan or MRI may be helpful in evaluating the pathologies that lead to
carpal arthritis or the presence of synovitis in the intercarpal joints. However,
they are not required prior to performing a PRC as the capitate can be
visualized directly early in the procedure with options to perform alternative
salvage procedures if necessary.
NONOPERATIVE MANAGEMENT
■ Painful radiocarpal arthritis can initially be treated with splinting and/or
steroid injections.
SURGICAL MANAGEMENT
■ PRC is considered an appropriate salvage procedure if nonoperative measures
fail or do not provide durable pain relief.
■ Alternative salvage procedures include limited or total wrist arthrodesis.
Preoperative Planning
■ As discussed above, evaluating the lunocapitate articulation helps in
determining if a patient is a candidate for PRC.
■ Mild arthritis of the proximal capitate may not be visualized on radiographs,
so all patients should be counseled that they may require conversion to a
limited wrist fusion intraoperatively.
■ Any implants required for wrist fusion should be available in case they are
needed.
■ PRC can be performed under regional or general anesthesia.

Positioning
■ The patient is positioned supine with the hand over a radiopaque hand table
centered on the patient’s axilla.
■ A well-padded pneumatic tourniquet is placed on the upper arm.
■ If an assistant is not available to assist with traction, end-table traction with
finger traps and 5 to 10 lb of weight will facilitate dissection during the
procedure.
Approach
■ A dorsal radiocarpal approach between the third and fourth extensor
compartments provides good exposure to inspect the radiolunate and
lunocapitate articulations, remove the proximal carpal row, as well as to
perform modifications to the PRC procedure or other salvage procedures.
■ A volar approach has also been described; however, this requires partial
division and subsequent repair of the crucial RSC ligament.9 This approach
also limits options for alternative salvage procedures and is not recommended
by the authors.
■ A PRC can be performed arthroscopically,10,11 though this requires
significant experience with these techniques and may not have long-term
benefit to patients when compared to the standard procedure.5
■ The key steps of a standard PRC are described below. Two modifications of
PRC that can be performed in the setting of limited proximal capitate arthrosis
are also described.
T E C H N I Q U E S
■ Standard Proximal Row Carpectomy
Exposure
■ Exsanguinate the arm with Esmarch tourniquet and inflate the pneumatic
tourniquet.
■ Make a dorsal longitudinal incision approximately 8 cm in length over the
carpus just ulnar to the Lister tubercle (TECH FIG 1A).
■ Raise subcutaneous flaps ulnarly and radially just above the extensor
retinaculum to protect sensory branches of the superficial radial and dorsal

ulnar nerves.
■ Identify the extensor pollicis longus (EPL) tendon proximal or distal to the
retinaculum and divide the retinaculum sharply along the third dorsal
compartment (TECH FIG 1B). Externalize and retract the EPL radially so
that the EPL does not rupture with swelling around the Lister tubercle after
surgery.
■ Raise the fourth compartment off the distal radius ulnarly in a subperiosteal
fashion, with care not to injure the dorsal ligaments.
■ Identify the extensor carpi radialis brevis (ECRB) tendon and place a
Weitlaner to retract the ERCB and EPL tendons radially and the fourth dorsal
compartment ulnarly.
Capsulotomy
■ To enter the carpus, a longitudinal capsulotomy can be made in line with the
division between the third and fourth dorsal compartments.
■ However, designing an L-shaped capsulotomy provides good exposure for
carpectomy and preserves the dorsal capsule for use in an interposition flap if
needed (see below).
TECH FIG 1 • A. Incision for dorsal exposure of the
carpus. Circle marks the Lister tubercle. B. Exposure
of extensor retinaculum after raising subcutaneous
flaps. The retinaculum is divided along the third
compartment (dashed line).

TECH FIG 2 • A. Markings for L-shaped capsulotomy
(solid line). The dashed line indicates an incision to
convert the capsulotomy into a distally based flap for
capsular interposition. B. The capsular flap is raised
and retracted to expose the carpus (white arrow). A
portion of the dorsal cuff of capsule has been raised
contiguous with the floor of the fourth compartment
(yellow arrow). L, lunate; S, scaphoid; C, capitate.
■ The longitudinal incision should be in line with the native position of the
ECRB and connect to a capsular incision along the radiocarpal joint
extending ulnarly.
■ Leave a small cuff of capsule on the distal radius (TECH FIG 2A).
■ Use a knife to raise the dorsal capsule off the carpal bones to completely
expose the carpus (TECH FIG 2B).
■ Once the carpus is exposed, inspect the lunate fossa of the radius and the
proximal pole of the capitate for arthrosis.
■ If there is some arthrosis of the capitate, a modified PRC may be possible
(see below).
■ In the setting of significant arthrosis, PRC should be aborted and the
surgical plan changed to limited or complete wrist fusion.
■ Once the decision is made to proceed with PRC, the proximal carpal bones
are resected.

Bone Removal
■ Place the patient’s hand under traction with the help of an assistant or finger
traps attached to weights off the end of the hand table. This aids in exposure
and creates space between the carpal rows as well as the radius.
■ Removal of the proximal row can be done in any order—scaphoid first or
scaphoid last. However, there is more room for “error” during removal of the
triquetrum, so surgeons with less experience may want to start with the
triquetrum excision.
■ The general steps to remove each bone is as follows:
■ First, divide any intact dorsal intrinsic ligaments to facilitate independent
mobilization of each bone.
■ Use a penetrating towel clamp (or place small threaded Steinman pins or
K-wires into the bones) to help manipulate each bone during dissection.
Pins are especially useful in the setting of SNAC wrist to separately
manipulate and dissect around the proximal and distal poles of the
scaphoid.
■ Use a Carroll elevator to bluntly begin the dissection around the volar
aspect of each bone. A scraping sensation, as if dissecting subperiosteally,
indicates the proper plane.
■ Once enough of the attachments are released, the bone can be torqued to
directly visualize the volar ligaments. At this point, sharp dissection with a
knife can be used to release the ligaments directly off the bone.
■ Piecemeal resection of the lunate and triquetrum (ie, with a rongeur or
osteotome) is acceptable, but not advisable because it makes grasping and
manipulating the bones difficult during final volar dissection. Thus, this
technique is not recommended for the scaphoid.
■ Key aspects of lunate excision:
■ It is crucial not to damage the cartilage on the proximal capitate and lunate
fossa of the radius during lunate excision.
■ Hohmann retractors (or similar) should not be used around the lunate
during dissection.
■ Consistent traction will provide space to ease dissection around the lunate.
■ Two wet 4 × 4 gauze can be tucked into the lunate fossa and around the
proximal capitate to protect these cartilaginous surfaces during removal.
■ Key aspects of scaphoid excision:
■ Slow and meticulous dissection along the volar waist of the scaphoid is

imperative to preserve the RSC ligament.
■ Until each ligament is clearly visualized, all dissection along the scaphoid
should be done bluntly.
■ Once the scaphoid has been removed, the intact RSC ligament should be
visualized crossing from the radial styloid to the capitate (TECH FIG 3).
Completion and Closure
■ After completing the carpectomy, fluoroscopy should be used to ensure
complete resection. Small, retained portions of the distal scaphoid may not be
symptomatic postoperatively,5 but any other bone fragments should be
removed.
TECH FIG 3 • The proximal row has been resected.
Note the thick radioscaphocapitate ligament in the
volar capsule (white arrow). With forced ulnar
translation, the capitate (C) does not migrate past the
lunate fossa of the radius.
■ Stress the carpus ulnarly to test the volar radiocarpal ligaments.
■ If the RSC ligament is adequately preserved, the capitate should not
translate past the lunate fossa.
■ If the carpus does translate ulnarly, the RSC ligament was likely
compromised and the pinning of the neoradiocarpal joint is recommended.

■ Seat the capitate into the lunate fossa.
■ Repair the dorsal capsulotomy with a 4-0 absorbable suture.
■ Repair the extensor retinaculum with 4-0 suture leaving the EPL
externalized, ie, transposed.
■ Let down the tourniquet and check for hemostasis.
■ A layered skin closure with a running subcuticular 4-0 suture (absorbable or
non-absorbable) leaves a minimal scar.
■ Patients are placed into a volar resting splint for postoperative comfort.
■ Proximal Row Carpectomy with Wrist
Denervation
■ Neurectomy of the posterior and anterior interosseous nerves may decrease
postoperative pain and improve long-term outcomes.8
■ Denervation can be completed at the beginning or end of the case.
■ The tendons of the fourth dorsal compartment are isolated proximal to the
extensor retinaculum and retracted ulnarly (TECH FIG 4A).
■ The posterior interosseous nerve and artery can be identified on the floor of
the fourth dorsal compartment.
■ The nerve is carefully dissected away from the artery, crushed proximally,
and resected for a length of 1 to 2 cm. The proximal nerve end is then
cauterized.
■ The extensor tendons are then shifted radially and the interosseous
membrane just proximal to the distal radioulnar joint is identified.
■ A 2- to 3-cm incision is made on the interosseous membrane and the
anterior interosseous nerve and artery are identified just volar to the cut
membrane (TECH FIG 4B).
■ The nerve is crushed proximally, and a 1- to 2-cm length of the nerve is
resected with cauterization of the ends.
■ After resection of the nerves, the procedure continues as described above.