Phẫu Thuật Tái Tạo Bàn Tay Và Chi Trên

Amputation
97
I
II
III
IV
V
FIGURE 7.15 Suturing of the intermetacarpal ligaments to close the
cleft.
muscles are closed over the neurovascular bundles using
interrupted or continuous absorbable sutures tied loosely
(Fig. 7.18).
The skin is closed with interrupted absorbable sutures,
typically 5/0 vicryl rapide, with careful contouring of the
soft tissues to give a nice line to the side of the hand. The
incisions should be placed away from the contact surfaces
of the palm (Fig. 7.19).
For the central digits, the intermetacarpal space must
be closed, otherwise the opening will be cosmetically
obvious and allow objects to drop through (see Fig. 7.3).
Some authors advocate simply suturing the intermetacarpal
ligaments together, but this rarely closes the gap completely
(see Fig. 7.15) and almost always stretches out, leaving a
substantial interdigital gap. Immobilization of the whole
hand is recommended to protect the repair, which increases
FIGURE 7.16 The metacarpal is cut at the distal end of the
metaphysis. This would be suitable for a transposition of the index
metacarpal or a suitable level for a ray amputation for a border digit.
FIGURE 7.17 Trough left in the hand after removal of the metacarpal.
FIGURE 7.18 The interosseus muscles have been closed with a
continuous suture. This is an alternative; we prefer interrupted
sutures.
FIGURE 7.19 Closure of the cleft in the hand.

Hand and Upper Extremity Reconstruction
98
B
A
C
D
E
FIGURE 7.20 A Longitudinal incision for transposition of the border digit metacarpal to close the cleft in a ray amputation or revision of an
MCP or PIP joint amputation. B The metacarpals are cut just distal to the CMC joints. C The amputated fi nger is removed. D Transposition of the
border metacarpal. E K-wire fi xation of the border metacarpal to the stump of the amputated metacarpal.

Amputation
99
stiffness. It is therefore better and mechanically preferable
to transpose the border metacarpal, although this does add
to the complexity of the procedure.5 It also allows for some
lengthening of the transposed fi nger, which is particularly
valuable for the little fi nger because its short length relative
to the middle fi nger can be quite obvious following ring
fi nger ray amputation. However, excessive lengthening can
cause stiffness by relative tendon shortening.
For the transposition, the base of the metacarpal of the
border digit is exposed via a longitudinal incision (Fig.
7.20A) and cut just distal to the CMC joint through the
metaphysis (Fig. 7.20B). This is best done with an osteo-
tome after pre-drilling the osteotomy sites, but the bone
cutting can be done with a saw. The use of osteotome
reduces thermal necrosis and enhances bony union. The
diffi cult step is transposing the metacarpal with its muscles
into the site of the previous metacarpal (Fig. 7.20C,D). It
is made particularly diffi cult by the bulk of the interosseii.
At least one may need to be removed, particularly the radial
interosseus of the middle fi nger or ulnar interosseus of the
ring fi nger. The base of the border digit is placed carefully
in line with the metacarpal stump from the amputated
digit. This can be held in various ways using K-wires (Fig.
7.20E) or a T-plate. It is very important to check for angular
alignment and rotation. This construct can be further
secured by a transverse K-wire from the transposed digit
to the remaining central digit and double-breasting and
suturing the intermetacarpal ligaments with an absorbable
suture. The fi nger position is always checked with an image
intensifi er.
After transposition, we add a plaster of Paris volar splint,
replacing it with a full cast after 7–10 days, for a minimum
of 4 weeks of immobilization.
OPTIMIZING OUTCOMES
Pain relief is the greatest concern after amputation, fol-
lowed by function. Patients receive oral analgesics such as
non-steroidal anti-infl ammatory drugs (NSAIDs), unless
contraindicated. If there has been a history of dystrophic
problems amitriptyline can often be added, starting at
10 mg at night for 4 nights and increasing to 20 mg at night
thereafter. If there are major concerns about postoperative
pain an indwelling brachial plexus catheter is used and the
patient kept in hospital for 3–4 days for bupivacaine injec-
tions into the catheter.
The patient will be seen again after 3 days to inspect
the wound and reinforce the need for elevation, early mobi-
lization and adequate analgesia. If there is concern about
adequate pain control, bring the patient into hospital and
give them a regional block with an indwelling catheter. Our
hand therapy protocol emphasizes gentle rather than aggres-
sive physiotherapy.
If there has been a transposition the patients will be
seen at 6 weeks for K-wire removal and mobilization out of
the plaster. Patients are fi tted with wrist splint supports for
an additional few weeks. Bony union is confi rmed with
radiographs at around 12 weeks.
CONCLUSION
Amputation is often a treatment of last resort and in some
ways a failure of other treatments. It can be viewed rather
nihilistically and the operations may be performed poorly.
In appropriate circumstances, with appropriate pre-, peri-,
and postoperative instructions to the patient and attention
to detail, amputation can give very satisfactory results and
substantial improvement in hand function. Pain issues
must be treated early and aggressively.
REFERENCES
1. Melikyan EY, Beg MS, Woodbridge S, Burke FD. The functional
results of ray amputation. Hand Surg 2003; 8: 47–51.
2. Holm A, Zachariae L. Fingertip lesions: An evaluation of
conservative treatment versus free skin grafting. Acta Orthop
Scand 1974; 45: 382.
3. Louis DS, Palmer AK, Burney RE. Open treatment of digital tip
injuries. JAMA 1980; 244: 697–698.
4. Belcher HJ, Pandya AN. Centro-central union for the prevention of
neuroma formation after fi nger amputation. J Hand Surg [Br].
2000; 25: 154–159.
5. Hanel DP, Lederman ES. Index transposition after resection of the
long fi nger ray. J Hand Surg [Am] 1993; 18: 271–277.

101
C H A P T E R
8
Replantation Techniques
Roberto Adani and Riccardo Busa
INTRODUCTION
Since the end of the 1960s, the use of microsurgery has
revolutionized the treatment of amputation and partial
amputation injuries to the upper limb. Upper extremity
replantation was fi rst performed by Malt and McKhann at
the Massachusetts General Hospital in 1962,1 and the fi rst
microsurgical forearm replantation was reported by Chen
in 1963.2 In 1968 Komatsu and Tamai3 achieved the fi rst
successful microsurgical replantation of a thumb that was
completely amputated at the level of the metacarpophalan-
geal joint. Since these early reports, replantation of severed
upper extremities has become an accepted procedure. In the
following years, a number of case reports of replantation
documented the effectiveness of this procedure for restoring
function.4–11 These clinical and experimental studies12–24
made it possible to create precise guidelines for patient
selection (indications and contraindications) and the appli-
cation of particular techniques for unique situations. The
microsurgical replantation of a limb remains a procedure of
great technical diffi culty with high costs. However, the
results can be better than those of other reconstructive or
prosthetic techniques, provided one rigorously follows these
principles: careful selection of the cases to be treated; avail-
ability of an expert microsurgical team; a rigorous postop-
erative and therapeutic clinical protocol; and specialized
rehabilitation aftercare. In recent years, services in replan-
tation surgery have been centralized in many countries. A
replantation center must have the following: more than
three to four experienced microsurgeons who are also
trained hand surgeons; trained assistants and nurses;
microsurgical facilities; an operating room available 24
hours; and a designated ward for hospitalization of these
patients. Research laboratories are necessary for the train-
ing of young surgeons, and the rehabilitation center must
be inside the hospital.25 The survival of the replanted
segment is only the fi rst step towards a satisfactory result
because both surgical and rehabilitation procedures are
often necessary.
PATIENT SELECTION AND TYPES OF LESION
Given the high cost of replantation procedures, correct selec-
tion of cases to be treated is of primary importance. The
overall condition of the patient must permit a long surgical
procedure (generally >4 hours), which is almost always
carried out under general anesthesia and may have consider-
able intra- and postoperative bleeding problems. An unstable,
severely traumatized patient requires their general condition
to be stabilized so as to avoid excessive anesthesiologic or
surgical risks.
The traumatized tissues must be in a suitable condition
for replantation. Restoration of sensation is critical to the
long-term functional recovery of the replanted segment and
is the main advantage of this technique over reconstructive
and prosthetic alternatives.25–28
The ‘ideal’ injury is a clean-cut one, but such a condi-
tion is rare. The injuries caused by industrial machinery
are more common and may have components of crushing,
avulsion, degloving, and sometimes burning and contami-
nation of the tissues.
Amputations and partial amputations
It is useful to distinguish between complete amputation
injuries and those in which some tissue continuity remains
(bone, skin, tendons), albeit without vascularization of the
distal segment. ‘Replantation’ should be used for complete
amputation cases; for ischemic partial amputations, the
procedure is ‘revascularization’.29
The continuity of some tissues in partial amputations
may facilitate the revascularization procedure. For crushing
or degloving injuries, skeletal continuity may impede a

direct revascularization and require vascular and nerve
grafts. In these cases, primary skin closure may be
diffi cult.
Ischemia time
Ischemia time is critical for amputation of parts containing
muscles. In such cases, the warm ischemia time must be
no longer than 6 hours, because of the risk of systemic
damage caused by the anaerobic catabolites and oxygen free
radicals from muscles getting into the circulation. Optimal
preservation of the amputated parts – with or without
muscle – at 4ºC permits replantation even after 12 hours
of ischemia. For cases presenting beyond 8–10 hours of cold
ischemia time, it is recommended to remove the skeletal
muscle completely.30 In partial amputations one should not
exceed the time limit for warm ischemia of the muscle
parts.31
Traumatic mechanisms
The traumatic mechanism is of fundamental importance
in the technique used for replantation.32 For crush/avulsion
injuries, the surgeon can employ vein grafting or vascular
transfer from adjacent fi ngers to bring arterial blood beyond
the traumatized area. Obviously, no microsurgical tech-
nique can ever replace a vessel if it is completely damaged
to its end.
Levels and indications
The importance of the thumb in the prehensile function of
the hand makes an attempt at replantation virtually always
indicated (Tables 8.1 and 8.2; Fig. 8.1). Whatever the level
of amputation and the injury mechanism, a replanted
thumb offers signifi cant advantages over any other recon-
structive or prosthetic technique. The reconstructive tech-
niques that are available today always require substantial
morbidity to the donor area, and current prosthetic devices
are insensate. An amputation of more than two fi ngers
causes severe impairment to hand function, and in such
cases the indication for digital replantation is absolute. In
children replantation (Fig. 8.2), if feasible, must be
attempted in order not to limit the child’s learning abilities
and psychomotor development. Also, in children, there is
greater possibility of sensory restoration and growth of the
replanted parts. Transmetacarpal, wrist, and middle-to-
distal forearm amputations offer satisfactory sensory and
motor recovery, making attempts at replantation highly
indicated (Fig. 8.3). In the case of amputation of a single
fi nger, the indication is relative when the level of amputa-
tion is distal to the insertion of the superfi cialis fl exor
tendon33 (Fig. 8.4).
Ring avulsion injury has some peculiarity of classifi cation
and treatment. Kay’s classifi cation has four categories.34,35
The fourth class includes total cutaneous–subcutaneous
avulsion with preservation of skeletal and tendon integrity.
In these cases, the use of vascular transpositions or vein
grafts may allow replantation with good aesthetic and func-
tional recovery35 (Fig. 8.5; Table 8.2).
Replantation of almost completely degloved skin has
been successfully reported for the hand and fi nger. This
procedure requires suitable vessels for microanastomoses in
the degloved skin fl ap36,37 (Fig. 8.6).
Ishikawa38 classifi es digital distal amputations into four
levels.38 It is possible to obtain excellent functional and
cosmetic results for replantation distal to the distal inter-
phalangeal (DIP) joint if there is at least one arterial
repair18,38–44 (Fig. 8.7). If no vessels are available, it is pos-
sible to resort to alternative non-microsurgical reconstruc-
tive techniques, such as subdermal pocketing and the
Hirase technique.45–49
SURGICAL TECHNIQUE
Preoperative evaluation and preparation
Proper transportation of the amputated part is a critical
aspect of successful replantation.50 The part should be
TABLE 8.1 Absolute indications and contraindications to
replantation
Absolute indications
Absolute
contraindications
Children (any level of amputation)
High surgical risk
Thumb (any level and type of injury)
High anesthesiologic risk
Multiple digit amputations
(more than two amputated fi ngers)
Technical impossibility of
replantation due to local
conditions (see text)
Transmetacarpal amputations
Wrist level amputations
Distal forearm amputations
TABLE 8.2 Relative indications and contraindications to
replantation
Relative indications
Relative contraindications
Individual demand (for
particular functional, cosmetic
or social conditions)
Age >70 years
Degloving with bone integrity
Associated injuries and systemic
diseases
Psychiatric disorders
Self-infl icted injuries
Severe tobacco addition
Alcoholism
Drug abuse
Multiple level injuries
Hand and Upper Extremity Reconstruction
102

A
B
C
D
FIGURE 8.1 A Clean-cut right thumb amputation in a 2-year-old boy. B Amputation at the distal third of the proximal phalanx. C, D Follow-up
after 18 months. E X-ray comparing thumbs at follow-up shows no signifi cant alterations in bone growth.
E

Hand and Upper Extremity Reconstruction
104
A
B
C
D
FIGURE 8.2 A Right index fi nger amputation at the level of the proximal phalanx in an 11-month-old boy. B Radiographic pre-operative
evaluation showing the level of amputation. C Clinical evaluation at 1 year. D Radiographic evaluation at 1 year.

Replantation Techniques
105
A
B
C
FIGURE 8.3 A Left middle-third clean-cut forearm amputation in a
32-year-old man caused by an industrial cutting machine. B Aesthetic
results at 2-year follow-up. C Functional results at 2-year follow-up.

Hand and Upper Extremity Reconstruction
106
cooled to increase its ischemic tolerance, wrapped in a
moist gauze sponge, and placed in a sterile sealed container
on ice to provide protection during transportation.23,50 Isch-
emia time limits for replantation are still a subject of dis-
cussion. Successful microreplantation has been reported
with cold ischemia times up to 40 hours51–53 and longer.54,55
More proximal amputations permit shorter ischemia
times.31 The warm ischemia time should not exceed 6
hours, but this can be prolonged to 10–12 hours by cooling
the amputated part.23
During preparation of the patient for surgery, it is essen-
tial to inspect the amputated parts accurately with the aid
of loupes having 4–6× magnifi cation to debride unusable
tissues and to identify arterial and venous vessels that can
be used for the anastomoses. It is advisable to place a vas-
cular clip on the available vessels so that they can be found
during surgery. The nerves can be tagged with small 6/0
nylon stitches at their ends. This preparatory time is fun-
damental and common to all amputation levels, especially
in cases of multiple digital amputations. The identifi cation
of vascular–nervous structures can be facilitated using dor-
solateral incisions of 1.5–2 cm, which allow separation of
the two cutaneous edges, a dorsal and a palmar one. The
palmar edge will include the two vascular–nervous digital
pedicles, and the dorsal edge will contain the drainage
veins. The subsequent surgical phases must be carried out
using a surgical microscope that should be equipped with
double optics, if possible, with a magnifi cation of at least
20× and foot-controlled levers to allow two operating sur-
geons to work simultaneously.
Preparation of the proximal stump
In the operating room, under regional block with bupiva-
caine or general anesthesia, the severed limb will be debrided
of unusable skin edges, devascularized skeletal fragments,
and any contaminating materials. The dorsolateral inci-
sions can also be made on the proximal stumps in order to
better identify and mark the vascular and nerve structures
and to facilitate osteosynthesis.
Slight skeletal shortening, which is sometimes inevita-
ble owing to loss of bone substance as a result of the trauma
(e.g. an amputation caused by a buzz saw), can in many
cases facilitate the subsequent tendon repair, microsutures,
and primary skin closure. The arterial and venous anasto-
moses must not be performed under tension; however,
excessive vessel length may cause kinking that can lead to
arterial and venous thrombosis.
With regard to the digits as well as the thumb, a slight
shortening of about 5–8 mm at phalangeal or metacarpal
A
B
FIGURE 8.4 A Right index fi nger distal phalanx avulsion lesion in a 25-year-old manual worker. B The amputated segment shows avulsed
tendon and neurovascular pedicles. Replantation was not attempted because of local contraindications.

Replantation Techniques
107
diaphyseal level does not generally create problems for the
motor function of the digit. At the transmetacarpal level,
skeletal shortening must be harmonious for all the meta-
carpals involved in order not to alter the geometry of the
metacarpophalangeal arch of the fi ngers.
The proximal and distal skeletal stumps must be reduced
along the correct axes in order to avoid rotation problems
that could interfere with the movement of the adjacent
healthy fi ngers.
In the case of a degloving injury (Fig. 8.6), the degloved
skin should be carefully examined under magnifi cation to
identify any suitable vessels (arteries and veins) and nerves
for the replantation procedure.36–37
Skeletal fi xation
The ideal skeletal fi xation in a replantation procedure or
revascularization will allow skeletal reduction and early
mobilization in order to avoid tendon adhesions and joint
stiffness. Many methods are available.56–58 We recommend
the simplest and fastest technique employing Kirschner
wires at digital or metacarpal level (Fig. 8.8) and plates with
screws under compression at forearm level. In case of an
amputation with severe joint injury, an arthrodesis with a
slight shortening and minimal bone resection provides
slight digital fl exion (20–35º) at the proximal interphalan-
geal (PIP) joints for functional grip. Even an amputation at
the carpometacarpal level can be treated with a primary
A
B
FIGURE 8.5 A Left ring avulsion injury in a 56-year-old woman; level of amputation is the shaft of the middle phalanx distal to the superfi cialis
tendon insertion. B Amputated digit.

Hand and Upper Extremity Reconstruction
108
joint fusion. An amputation with radiocarpal disarticula-
tion can be treated by wrist arthrodesis using K-wires or
plate and screws after minimal bone resection. The thumb
trapeziometacarpal, the metacarpophalangeal (MCP) or the
interphalangeal joint fusions are well tolerated and do not
cause serious impairment to grip, provided they are set in
a functional position. Sometimes a less than perfect fusion
carried out in an emergency situation will require a second-
ary fusion procedure. Arthrodesis should never be performed
at MCP level in the fi ngers, as MCP joint immobility
severely impedes grip function. It is quite possible to replace
damaged MCP joints with silicone or pyrocarbon implants.
When implants are used, it is important to perform an
accurate primary reconstruction of the capsule and liga-
ments. For amputations distal to the DIP joint, a single
1 mm K-wire is suffi cient, whereas those in Ishikawa zone
II that only involves the soft tissue may not require skeletal
fi xation because stability is obtained by suturing the nail
bed and the soft tissues of the pulp.59
Tendon sutures
The technique to be used must be simple and fast in
order to shorten ischemia time, and strong enough to allow
early mobilization in order to reduce scar adhesions
that may require secondary operations. The fl exor and
extensor tendons are repaired immediately after the skeletal
fi xation and before the vessels and nerves are sutured.
The vessels and nerves are dissected free prior to the
tendon repairs. In zone II, we suggest repairing the fl exor
digitorum profundis only, especially if tendons are not
cleanly cut.
C
D
FIGURE 8.5, cont’d C Dissection and harvesting of the long fi nger ulnar artery. D The ulnar artery of the long fi nger was anastomosed to the
radial artery of the amputated ring fi nger. The proximal radial digital nerve stump was sutured to the distal digital ulnar nerve. This cross-suture
was performed because the distal part of the radial digital nerve was excessively damaged.

Replantation Techniques
109
F
E
FIGURE 8.5, cont’d E Dissection and harvesting of dorsal veins ready for transfer. F Two dorsal veins were transferred and anastomosed.
We prefer to use suture techniques that are easy and
fast, for example the Kessler, Tajima, or Tsuge techniques
using monofi lament prolene 3/0 and an epitendinous con-
tinuous suture with 6/0 nylon. The extensor tendons can
be repaired with resorbable monofi lament 4/0 PDS continu-
ous suture.
Arterial anastomoses
This must be performed under a high-power (>20×) surgical
microscope using microsurgical instruments. A suffi ciently
long segment of the proximal artery must be freed from the
surrounding tissues in order to allow a tension-free repair.
It is necessary to remove any intravascular clots and lacer-
ated vessel edges by washing abundantly with heparin
solution.
The damaged arterial ends will have to be resected using
straight micro-scissors until healthy intima is reached.
Once the vessel ends appear healthy, we excise the adven-
titia and dilate the arterial lumen with 0.2 mm tip dilator
forceps, and irrigate the lumen with heparin solution to
obtain a strong and pulsatile arterial blood fl ow. We advise
not to proceed with suturing without visible pulsatile bleed-
ing from the proximal artery. The use of a small approxima-
tion clamp helps considerably in arterial anastomosis. The
tension of the clamp should not be excessive to avoid dam-
aging the delicate vascular walls. After the two arterial ends
are correctly matched, we proceed to suturing with 9/0
monofi lament nylon using a 100 μm needle for the forearm
and wrist level, and 10/0 monofi lament with a 100 or
75 μm needle at the metacarpal or digital level. Anastomo-
sis in more distal replantations may require a fi ner suture
and a smaller needle (11/0 or 12/0 and a 50 μm needle).
At the forearm and wrist level, we recommend perform-
ing both radial and ulnar arterial anastomoses. When the
vessels are badly damaged, vein grafts are used.

Hand and Upper Extremity Reconstruction
110
G
H
I
FIGURE 8.5, cont’d G Aesthetic results at 3-year follow-up.
H Aesthetic results at 3-year follow-up. I Functional results at 3-year
follow-up showing residual stiff ness of the distal interphalangeal
joint.

Replantation Techniques
111
A
B
C
D
FIGURE 8.6 A Left hand severe degloving injury in a 28-year-old manual worker. B Skin from degloving injury for replantation. C Two dorsal–
radial veins were reconstructed by means of vein grafts harvested from the volar aspect of the forearm. D Long-term follow-up.

Hand and Upper Extremity Reconstruction
112
E
F
FIGURE 8.6, cont’d E, F Long-term functional follow-up.
In clean-cut digital injuries, it is generally possible to
perform anastomoses in both digital arteries, which gives a
greater success rate. Sometimes it is impossible to perform
both arterial repairs; in such cases, just one end-to-end
arterial anastomosis may be enough. Depending on the
injury pattern, we will perform a homodigital cross-shifting
technique in which the proximal vessel is anastomosed
with the end of the contralateral distal artery. It is of the
utmost importance to keep a record, possibly by an illustra-
tive drawing, of the type of anastomoses performed, because
secondary operations may be necessary and it is crucial to
know the vascular anatomy of the reconstruction. When
direct arterial anastomosis is impossible owing to loss of
vessels or extended damage, it is necessary to resort to
alternative reconstructive procedures such as venous
grafting or arterial transfer from an adjacent healthy
fi nger.60–62
Vein grafts at the digital level can be taken from the
volar surface of the wrist. Numerous small veins 2–3 mm
in diameter run through this area. It is necessary to mark
the proximal portion of the vein graft to orient the fl ow
pattern. Such detail is fundamental in avoiding problems.
For radial and ulnar artery repair, vein grafts 3–5 mm
in diameter can be found more proximally in the forearm.
For more proximal arterial repairs, a saphenous vein graft
is suitable.
To restore the continuity of both digital arteries, it is
possible to take a small subcutaneous strip of skin contain-
ing two venous segments that can be used for simultaneous
bridging.
The transposition of a digital artery is a technique that
can be useful in complex soft tissue injuries with a large
arterial gap. We advise resorting to this technique in ring
avulsion lesions and thumb replantations60 (Fig. 8.9). The

Replantation Techniques
113
A
B
C
D
FIGURE 8.7 A Right long and ring fi nger amputations at the DIP level in a 42-year-old man. B DIP joint fusion by means of 1 mm Kirschner
wires. One artery and one vein were anastomosed for each fi nger. C, D Results at 1-year follow-up.

Hand and Upper Extremity Reconstruction
114
A
B
C
FIGURE 8.8 A Right transmetacarpal hand amputation in a 26-year-
old manual worker. B X-ray of amputated hand. C X-ray of arm
showing the level of amputation of the hand.
donating fi nger must be undamaged so as not to jeopardize
its blood fl ow. The dissection of the donor digital artery
must be performed under magnifi cation, while taking
special care when ligating or clamping all the collateral
branches to avoid damaging the digital nerves. The artery
is dissected from the DIP level to the palm. At the palm it
is necessary to free the bifurcation point of the common
digital artery by ligating the digital artery of the adjacent
fi nger to obtain greater mobilization of the freed artery. To
revascularize the ring fi nger, it is possible to transpose the
ulnar digital artery of the long fi nger. The thumb can be
revascularized in a similar fashion, but it is necessary to
create a spacious subcutaneous tunnel to pass the artery
from the palm to the thumb. Furthermore, it is always
necessary to ligate the radial digital artery of the ring fi nger,
so not to cause a point of excessive traction on the trans-
posed long fi nger ulnar artery. The use of the radial digital
artery of the index fi nger is not advisable because its caliber

Replantation Techniques
115
D
E
FIGURE 8.8, cont’d D Bone synthesis by means of two simple Kirschner wires for each fi nger. The ulnar artery and three dorsal veins were
anastomosed. E Early follow-up: 2 months post-operatively the patient is undergoing a rehabilitation program.
and length are insuffi cient. Besides, in amputations of the
thumb this vessel can also be damaged at the level of the
princeps pollicis artery.
For amputations distal to the DIP joint, only one of the
two digital arteries is generally reconstructable and, when
present, anastomosis of the central pulpar artery, which has
a diameter of about 0.3–0.5 mm, is recommended.43,44
Vein repair
To replant parts containing skeletal muscle, one should
fi rst establish arterial blood fl ow.13,31 The oxygenated blood
will reach the tissues and limit ischemia time to the ampu-
tated part, and the venous return will wash out harmful
catabolites that have accumulated in the muscles during
the anaerobic period. It is generally necessary to abide by
the rule that for every reconstructed artery at least two veins
must be reconstructed. At digital level, the veins are located
in the dorsal subcutaneous layer just underneath the dermal
layer. A thin venous vessel is present on the palmar side of
the fi nger, but the anastomosis is more diffi cult. At the
wrist and forearm level, suitable veins can be located either
dorsally, which is more common, or volarly. The digital
veins are extremely thin and must be handled carefully
under high-power magnifi cation.
Endoluminal washing with sterile heparin solution is of
great importance. In suturing the very thin veins, we use
the so-called ‘immersion’ technique, in which the stitches
are applied while the vessel is held immersed in heparinized
physiological solution to prevent collapse of the thin venous
walls.
At wrist and forearm levels 9/0 or 10/0 monofi lament
nylon sutures can be used, but at hand and fi ngers level
it is always advisable to use 10/0 or 11/0 monofi lament
sutures.
When it is not possible to carry out a suffi cient number
of direct end-to-end repairs, one can use venous grafts or
vein transposition from adjacent healthy fi ngers.

Hand and Upper Extremity Reconstruction
116
C
D
A
B
FIGURE 8.9 A Left thumb avulsion–amputation in a 30-year-old manual worker. B The level of fracture was at the neck of the proximal phalanx.
Tendons were completely avulsed at forearm level and primary reconstruction was not possible. Bone synthesis was performed by means of
two Kirschner wires. C A distally bifurcated vein is transferred from the dorsal aspect of the second ray. D The neurovascular ulnar bundle of the
long fi nger is dissected and transferred for anastomosis, preserving the dorsal digital nerve.

Replantation Techniques
117
E
F
FIGURE 8.9, cont’d E, F Clinical follow-up after 20 months showing stiff ness of the interphalangeal joint.
Using a vein graft for vein reconstruction is not simple
because of the thin vessel walls and the tendency of the
vein graft to collapse. Vein grafts can also be harvested from
other non-replantable parts or using the vein transposition
technique.
The vein transposition procedure is relatively simple
and very useful in ring avulsion injuries in which the venous
return is insuffi cient.60 This technique requires a curvilin-
ear incision on the dorsum of the proximal phalanx of the
long fi nger to transpose the vein as far as the DIP joint. It
is then transposed to the ring fi nger under a subcutaneous
tunnel (see Fig. 8.5).
For the thumb, a venous transfer from the dorsum of
the index fi nger can be performed. If the index fi nger is
damaged, the transfer can be carried out from the long
fi nger, but this requires a longer skin incision and a wider
subcutaneous tunnel.
In replantation distal to the DIP joint, it is often impos-
sible to locate suitable dorsal veins for repair. It is therefore
necessary to look for them in the pulp subdermal layer. If
no vein can be found, artifi cial venous drainage is carried
out through controlled bleeding by means of apical inci-
sions and/or leeches (Fig. 8.10). Generally, if the arterial
fl ow is kept patent over a period of 3–5 days, the process
of neoangiogenesis creates vascular connections between
FIGURE 8.10 Distal middle fi nger amputation in a 45-year-old
woman; only the central artery was reconstructed. The venous
drainage was maintained via leeches at 6-hour intervals for 4 days.

Hand and Upper Extremity Reconstruction
118
the distal part and the proximal tissue to promote venous
drainage.43,44
Nerve repair
The restoration of sensory and motor innervation is funda-
mental to the success of replantation.63 An insensate hand
offers few advantages over a prosthesis, and the absence of
vasomotor control sometimes causes considerable intoler-
ance to cold. For this reason nerve repair is very important
and must always be performed whenever possible.
The nerves are dissected and sutured under microscopic
control. The digital nerves are resected with sharp, straight-
bladed microscissors until healthy axons are seen.
The matching of nerve ends is generally made easier by
bone shortening. After fl exor tendon repair, the fl exed
posture of the fi nger facilitates neurorrhaphy. An important
rule is to avoid tension in the nerve sutures. At the digital
nerve level, three stitches at 120º locations may be enough.
At a more proximal level, the fascicles must be matched.
The vessels on the perineurium can work as a spatial refer-
ence for stitch placement. At more proximal levels, six to
eight stitches are required. The continuity of a digital nerve
can be restored by grafting a subcutaneous nerve from the
forearm.64 Median or ulnar nerve grafting requires the har-
vesting of sural nerve grafts to make multiple cables to
match the fascicles. The various sural nerve segments can
be made to stick to each other with fi brin glue to facilitate
suturing.
Heterotopic replantation
In the case of multidigit amputation, reconstructive priority
must be given to the thumb and the ulnar digits: middle/
ring/little. If the amputated thumb is unusable and the
index fi nger is amputated proximally to the proximal inter-
phalangeal joint, it is advisable to replant the index fi nger
to the thumb. Similarly, if the index and long fi ngers are
amputated and the long fi nger is not replantable, it is pref-
erable to replant the index fi nger onto the stump of the long
fi nger to improve hand grip.65–67
Finger bank
A non-replantable fi nger can be a donor for venous and
arterial vessels and even digital nerves.68 The dorsum of the
fi nger can be the donor of a subcutaneous fl ap containing
dorsal veins. The fi ngertip can be harvested on one of the
digital pedicles as a microsurgical pulp fl ap to make up for
a possible tissue loss in another area. Virtually all digital
tissues can be used to make up for losses in other parts,
including bone, tendon, skin, and the nail complex.
Skin closure
If the amputation is a clean cut, minimal skeletal shorten-
ing helps direct skin closure without tension. We apply
several 3 mm silicone rubber strips for drainage to avoid
the formation of a subcutaneous hematoma.69
The majority of amputations have skin loss, which may
be caused by the removal of badly damaged skin. It is a top
priority to supply a soft tissue covering, particularly to criti-
cal repairs of vessels, nerves, tendons and bone. Local rota-
tion fl aps can be used, as well as skin grafts, and rarely,
vascularized island or free fl aps. ‘Arterializable’ venous fl aps
can be useful where there is loss of palmar cutaneous tissues
to simultaneously restore arterial fl ow through the veins in
the fl ap and for soft tissue coverage.70
CONCLUSION
Emergency upper extremity microsurgical reconstruction
after amputation trauma is always a challenging procedure.
Accurate patient selection is one of the key points for
success in this type of surgery.
The indication for replantation is sometimes a diffi cult
decision that should be based on a careful objective and
subjective evaluation of the injury and the patient. Such
decisions always involve psychological, cultural and social
considerations. The patient must be informed that the
replantation procedure represents only the fi rst step of
treatment with a long rehabilitation program; secondary
surgery may be necessary. Patient understanding of the
condition and a strong motivation are also essential for a
satisfactory long term result.
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357–365.

121
C H A P T E R
9
Wrist Arthroscopy and TFCC Repair
Scott F. M. Duncan and Kevin J. Renfree
INTRODUCTION
The indications for diagnostic and therapeutic use of wrist
arthroscopy continue to expand, as it offers many advan-
tages over open procedures for numerous types of condi-
tion. Currently it is used for diagnostic evaluation, loose
body removal, debridement, triangular fi brocartilage
complex (TFCC) repair, distal ulnar resection (‘wafer’ pro-
cedure), evaluation of carpal instability, treatment of distal
radius and scaphoid fractures, dorsal ganglion resection,
evaluation of Kienbock’s disease, treatment of septic wrist,
synovectomy for infl ammatory arthritis and biopsy, as well
as radial styloidectomy and proximal row carpectomy.1–8
The ulnar side of the wrist has sometimes been described
as the ‘black box’ of the wrist. The anatomy is relatively
complex, with overlying areas of potential pathology, and
can provide challenges in diagnosis and surgical access (Figs
9.1 and 9.2). Ulnar-sided wrist pain can be a manifestation
of acute or chronic disorders of the TFCC, extensor carpi
ulnaris tendon along with its subsheath, ulnocarpal liga-
ment, distal radioulnar joint, triquetrum, lunate, pisotriqu-
etral joint, fl exor carpi ulnaris, and/or dorsal ligaments of
the wrist (Table 9.1).9–11 This chapter focuses on wrist
arthroscopy and TFCC repairs.
The TFCC is a cartilaginous and ligamentous structure
that is a composite of several structures.12 The central
articular disc is bordered by ligaments. The disc is made up
of interwoven collagen fi ber sheets with obliquely oriented
fi bers, which can withstand multidirectional stresses. The
disc attaches to the radius as well as to the ulnar styloid.
The dorsal and volar radioulnar ligaments, located along
the dorsal and volar aspects of the articular disc, are thick
and fi brous.13 They function to stabilize the distal radioul-
nar joint. The ulnocarpal ligament complex, located along
the dorsal and volar aspects of the articular disc, consists
of the ulnolunate and ulnotriquetral ligaments. These are
considered extrinsic ligaments and help support the ulnar
carpus. Dorsally, the TFCC is bordered by the extensor
carpi ulnaris and its subsheath, which also stabilizes the
ulnar carpus. On cross-section the articular disc is bicon-
cave: thinner in the center and thicker at its margins. It
functions to transfer loads from the wrist bones to the
ulna.
The vascular supply to the TFCC arises from three
arteries: the ulnar artery, and the palmar and dorsal branches
of the anterior interosseous artery.14 Two branches from the
ulnar artery (the palmar radiocarpal and dorsal radiocarpal)
send vessels in a radial fan-shaped pattern to the peripheral
portion of the TFCC. This supplies the volar and ulnar
aspects of the TFCC. The palmar branch of the anterior
interosseous artery provides blood fl ow to the palmar distal
radioulnar joint ligament and supplies a portion of the
blood to the volar aspect of the TFCC. The dorsal branch
of the anterior interosseous artery gives out several small
branches that supply the dorsal distal radioulnar joint liga-
ments and the dorsal peripheral portion of the TFCC. His-
tologic sections have shown that the penetration only
occurs in the peripheral 10–40%, with the central section
and radial sections remaining avascular. This has impor-
tant implications with respect to healing potential and
results of repairs.
Neural innervation of the TFCC is confi ned to the
periphery of the disc, and arises from the ulnar nerve and
branches of the posterior interosseous nerve.15 Based on
previous studies, it has been assumed that an injury in this
portion of the TFCC could stimulate nerves that may elicit
painful symptoms.
Biomechanical tests by Palmer and Werner, as well as
others, have shown that in ulnar neutral variance 60–80%
of the load is borne by the radius and 20–40% by the
ulna.16–18 With the TFCC removed, the radius transmits
90% of the load and the ulna only 5%. The TFCC was also
noted to be an important stabilizer of the distal radioulnar
joint, both in dorsal and palmar directions. Excision of the
central one-third of the articular disc does not appear to
signifi cantly change the distribution of forces between the
radius and ulna.17 The amount of load transmission also
depends on the rotational position of the forearm.19 With
supination, the radius is relatively distal on the ulna, and

Hand and Upper Extremity Reconstruction
122
Radioscaphocapitate
ligament
Long radiolunate ligament
Short radiolunate ligament
Ulnocapitate ligament
Dorsal distal radioulnar ligament
Triangular articular disc
Dorsal radiocarpal ligament
Ulnotriquetral ligament
Capsule
ECU tendon
Prestyloid recess
Palmar distal radioulnar ligament
Ulnolunate ligament
Scaphoid fossa
Lunate fossa
FIGURE 9.1 Axial anatomy.
Ulnar capsule
Meniscus homologue
Triangular articular disc
Ligamentum
subcruentum
Ulna
Superficial portion of
dorsal DRUL
Deep portion of
dorsal DRUL
Prestyloid recess
Ulnolunate ligament
Scaphoid fossa
Lunate fossa
Short radiolunate ligament
Radius
Radioscaphocapitate
ligament
Scaphoid
Lunate
Triquetrum
Ulnotriquetral ligament
Pisiform
Intercarpal ligaments
Long radiolunate ligament
FIGURE 9.2 Coronal anatomy.

Wrist Arthroscopy and TFCC Repair
123
this creates an ulnar negative variance (less load on ulna).
Conversely, in pronation, the radius is relatively proximal
compared to the ulna, resulting in a relative ulnar positive
variance (more load on the ulna).
As the forearm rotates, the dorsal and volar radioulnar
ligamentous portions of the TFCC tighten, which affects
the stabilizing force on the head of the ulna. Thus, the
TFCC appears to have two functions, fi rst to transmit load
and second to stabilize the distal radioulnar joint. Based
on these biomechanical considerations, injuries could be
caused by a direct compressive load from the ulnar carpus
to tear the disc.15,20 The other would be a chronic injury
that repeatedly grinds or compresses the TFCC, such as a
gripping pronation maneuver or ulnar positive variance
(congenital or acquired).
OPERATIVE CONSIDERATIONS
Operative intervention for acute TFCC injuries can be con-
sidered after a trial of immobilization. DRUJ instability, as
well as ECU subluxation, should be ruled out when possi-
ble. If X-rays are negative without evidence of instability on
clinical examination, 4 weeks of immobilization in a long
arm or Muenster cast with the forearm in mid-supination
is reasonable.9,21 With a subacute injury, a cortisone injec-
tion may reduce synovitis and ECU tendinitis, resulting in
symptomatic improvement. Central tears of the disc can
become asymptomatic despite not healing. TFCC tears that
are associated with ulnar positive variance may worsen over
time.22,23 One study has suggested a correlation between age
and TFCC perforations;24 however, these have been identi-
fi ed even in fetal cadavers. Therefore, central TFCC tears
can be found incidentally, and may not be the cause of a
patient’s symptoms.
PATIENT HISTORY
The patient may describe a specifi c injury, such as a fall on
an outstretched hand. This applies an extension–pronation
force on an axially loaded wrist, resulting in TFCC injury.
Forced rotation, such as when a drill binds and rotates the
wrist instead of the drill bit, and distraction forces to the
volar forearm and wrist, have also been noted to result in
TFCC tears.
However, the most common source of TFCC tears is
probably distal radius fractures. It is diffi cult to isolate
TFCC injuries from other problems on the ulnar side of the
wrist based solely on history and physical examination.
Repetitive pronation and ulnar deviation in a patient with
ulnar positive variance can result in TFCC compromise.
Gripping and twisting activities (twisting of a jar lid or
screwdriver), as well as activities that result in ulnar devia-
tion of the wrist (pushing oneself up from a seated position
on an arm rest) can localize pain to the ulnar aspect of the
wrist. Mechanical symptoms such as clicking or popping
during activities may also be noted. Patients may present
with reduced forearm rotation or wrist motion secondary
to a TFCC tear.
The physical examination often localizes tenderness
over the volar–ulnar aspect (‘foveal’ region) of the wrist;
however, gross inspection typically shows no signifi cant
swelling, erythema, ecchymosis, or other signs of injury
unless there is an underlying fracture. Neurovascular exam-
ination and range of motion are usually normal, unless
there is distal radioulnar joint instability resulting in a
decrease in pronation/supination motion. A ‘TFCC com-
pression test’ can be performed by axially loading while
simultaneously rotating an ulnar-deviated wrist. This pro-
vocative test is positive when it results in pain, with or
without a click. One should compare the fi ndings to those
on the contralateral side. Direct pressure over the dorsal
aspect of the TFCC at the ulnocarpal joint may also cause
pain in patients who have TFCC trauma.
A ‘lunotriquetral ballottement test’ can be useful in
trying to assess any instability between the lunate and tri-
quetrum that may be contributing to the ulnar-sided wrist
TABLE 9.1 Diff erential diagnosis of ulnar-sided wrist pain
TFCC tears
ECU subluxation
Lunotriquetral ligament injury and instability
Pisotriquetral arthritis
Chondral lesions of the ulnocarpal or midcarpal joints
Ulnar artery thrombosis
Ulnar neuropathy
Summary Box: Indications and contraindications
Indications for traumatic TFCC repair
●
TFCC tears that have an ulnar neutral/ulnar negative variance
are amenable to repair
●
TFCC injuries with ulnar-sided wrist symptoms that are
signifi cant enough to prevent the patient from engaging in
their usual activities
●
Failure of non-operative interventions, such as anti-
infl ammatory medication, rest, and immobilization
●
Ulnar-positive variant patients with traumatic tears
require shortening of the ulna in addition to repair
Treatment summary
●
Type IA lesions – debride
●
Type IB lesions – repair
●
Type IC lesions – repair plus ligament capsulodesis or repair
●
Type ID lesions – repair if possible, otherwise debride
Treatment summary – degenerative TFCC lesions
●
Type IIA – ulnar shortening osteotomy
●
Type IIB – ulnar shortening osteotomy
●
Type IIC – debride and also perform arthroscopic wafer or
ulnar shortening
●
Type IID – debridement with arthroscopic wafer or ulnar
shortening if the lunotriquetral ligament is unstable
●
Type IIE – ulnar shortening with debridement and pinning of
the lunotriquetral ligament if unstable despite shortening of
the ulna

Hand and Upper Extremity Reconstruction
124
pain.25 This is performed by holding the triquetrum in one
hand and the lunate in the other; the motion between the
two bones is ascertained and compared with the contralat-
eral side. Increased motion, especially if painful, can indi-
cate lunotriquetral instability. Point tenderness over the
lunotriquetral interval or ulnar snuffbox can also be an
indication of lunotriquetral instability.
Distal radioulnar joint stability should be assessed with
a ‘piano key’ maneuver. This is performed by stabilizing
the radius and applying pressure to the ulna. Increased
prominence or motion of the ulna relative to the radius is
a sign of potential instability and is compared to the con-
tralateral side. The test is usually performed with the
forearm in supination, neutral, and pronation. If there is
gross laxity of the ulna, this usually represents severe dis-
ruption and tearing of the triangular fi brocartilage complex.
This type of signifi cant instability usually cannot be treated
by arthroscopic methods alone; however, mild to moderate
instability can usually be treated with arthroscopic repair.
The ulnar aspect of the carpus should also be checked for
any evidence of sag, which may represent a type IB or IC
tear.
Concomitant ECU tendinitis is not uncommon. The
ECU tendon should be checked for subluxation with com-
bined active ulnar deviation of the wrist and forearm rota-
tion. A Jamar dynamometer may demonstrate weakened
grip strength curves relative to the opposite side. TFCC
injuries can also be part of a larger problem involving the
wrist, and any ulnocarpal clicks, pops, and grinds that the
patient may describe can represent several different simul-
taneously occurring pathologies. Diagnostic injection(s) of
local anesthetic can help localize the pathology. Advanced
imaging studies or arthroscopy may also be helpful.
DIAGNOSTIC IMAGING
Plain radiographs should include views with posteroante-
rior (PA) and lateral images with the shoulder in 90º abduc-
tion (Fig. 9.3), elbow fl exed 90º, and the forearm in neutral
rotation (‘ulnar variance views’).26 These are used to evalu-
ate carpal alignment, ulnar variance, the distal radioulnar
joint, and ulnar styloid anatomy. Cystic lesions can some-
times be seen on the ulnar aspect of the lunate in chronic
abutment in patients with ulnar positive variance.27 This
should not be confused with Kienbock’s disease. Clenched-
fi st views with ulnar deviation and pronation may accentu-
ate ulnar positive variance not seen on the neutral static
images.19,28
More advanced imaging studies include wrist arthrogra-
phy, CT scans, triple-phase bone scans, MRI, and MRI
arthrography. Normally there is no communication between
the distal radioulnar joint, radiocarpal joint, and midcarpal
joints. A triple injection arthrogram involves placing dye
into each of these previously mentioned joints and watch-
ing for any fl ow of dye from one compartment to the
other.29–31 Tears of the lunotriquetral ligament and scaph-
olunate ligaments are easily evaluated with this technique;
however, the extrinsic capsular ligaments are not visual-
ized. Unfortunately, there is a very high rate of false positive
studies, with 74% of patients who have a positive arthro-
gram on the symptomatic side also having a positive exami-
nation on the asymptomatic side.32 This rate probably
increases with age as a result of degenerative asymptomatic
perforations in these structures.33
Triple-phase bone scans may be useful in identifying
infl ammation of the wrist, but probably have limited value.
The bone scan may be helpful where there is an occult
fracture or ulnar impaction with bone changes. The utility
of CT scan is mainly for carpal instability and checking for
DRUJ subluxation or joint incongruity, particularly after a
distal radius fracture.34 For instability, fi ne cuts (1 mm)
through the DRUJ in supination, pronation, and neutral
positions are done, comparing to the opposite side. MRI is
currently a highly utilized imaging study for TFCC and
other potential ulnar-sided pathology.35 Potter et al.35
showed that MRI had a diagnostic sensitivity of 100% and
accuracy of 97% for TFCC tears.
A dedicated wrist coil should be used whenever possible
to improve accuracy, especially for diagnosis of LT ligament
tears. The T2-weighted image in the coronal plane is usually
the most helpful view for the latter. MRI may show marrow
changes in the lunate, allowing the surgeon to differentiate
Kienbock’s disease (diffuse changes) from ulnar impaction
syndrome (localized to the proximal–ulnar aspect). A com-
bination of arthrography and MRI is probably the most
accurate. Contrast material (gadolinium) is injected into
the radiocarpal joint under fl uoroscopic guidance and then
the patient is placed into the MRI scanner with the wrist
coil. These images provide superior contrast and show
leakage between torn ligaments or torn TFCC, while still
allowing evaluation of the extrinsic ligaments. The key
with any study is that the pathology must correlate with
the symptoms, history, and physical examination.36
A commonly used classifi cation of TFCC injuries has
been proposed by Palmer.21 His system is defi ned by the
type and location of the lesion, two main factors affecting
treatment. The two basic categories are type I (traumatic
FIGURE 9.3 Pronated view with 90º of shoulder abduction.

Wrist Arthroscopy and TFCC Repair
125
tears), and type II (degenerative tears). A class IA tear of the
TFCC is an isolated central disc tear (Fig. 9.4). It is usually
several millimeters away from the radial attachment and is
usually in a volar to dorsal direction that can result in a
fl ap. Type IB tears represent a peripheral tear from the
insertion on the distal ulna (Fig. 9.5). This can happen with
a fracture or fracture of the ulnar styloid. Because the
peripheral region of the TFCC is continuous with the fl oor
of the ECU subsheath, a type IB injury may be associated
with disruption of the ECU tendon sheath. Clinically, this
can be demonstrated by subluxation of the ECU tendon.
Occasionally instability of the DRUJ is also found with type
IB tears.
A type IC tear is from the lunate or triquetrum through
the ulnocarpal ligaments (Fig. 9.6). Disruption of these
volar ulnocarpal extrinsic ligaments can result in a supina-
tion deformity of the carpus on the ulna, otherwise known
as a ‘sag’ sign. Finally, Palmer type ID tears are traumatic
avulsions of the TFCC from its radial insertion (Fig. 9.7).
These tears are usually oriented in a volar to dorsal direc-
tion and are located within 1–2 mm of the sigmoid notch;
they are frequently seen with distal radius fractures.
Type II tears describe degenerative changes to the TFCC.
The classifi cation is based on the natural progression of
these degenerative changes. In type IIA there is wearing of
the TFCC without perforation or chondromalacia, and this
represents the earliest stage of degeneration. Type IIB
lesions have wearing or fraying of the TFCC with some
chondromalacia of the lunate, and/or ulna, and/or
FIGURE 9.4 Type IA tear: isolated central disk tear.
FIGURE 9.5 Type IB tear: peripheral tear from insertion on distal
ulna.
FIGURE 9.6 Type IC tear: disruption of volar ulnocarpal extrinsic
ligaments.

Hand and Upper Extremity Reconstruction
126
triquetrum. Again, there is no perforation of the cartilagi-
nous disc. Type IIC tears (Fig. 9.8) have a perforation of
the TFCC that is usually centrally located, and this is
combined with lunate chondromalacia. Again, this repre-
sents a natural progression of this degenerative process.
Type IID perforations have lunate and/or ulnar chondro-
malacia and lunotriquetral ligament perforation. Carpal
instability patterns such as VISI (volar intercalated segment
instability) are not seen. The fi nal stage is type IIE, where
there is degenerative arthritis of the ulnocarpal joint and
distal radioulnar joint, as well as perforation of the TFCC.
There are usually lunotriquetral tears, and VISI may be
seen in this later-stage process.
TECHNICAL CONSIDERATIONS
Arthroscopic treatment of type IA tears is an outpatient
procedure under regional or general anesthesia. A well-
padded tourniquet is placed just above the elbow. The wrist
is examined under anesthesia for any evidence of mechani-
cal symptoms, particularly for DRUJ instability. The upper
arm is then secured to the table with a Velcro strap and
prepared and draped. The arm is then placed in a traction
tower with nylon or plastic fi nger traps. If the fi nger traps
cannot hold adequately, or if the skin is quite fragile, Coban
is then used to protect the skin or enhance the girth of the
fi ngers. Twelve pounds of traction is usually placed across
the wrist joint.
A number 15 blade is used to make a small, superfi cial
incision where the 3/4 portal will be placed. Blunt dissec-
tion is carried out down to the capsule. A curved mosquito
is then used to gently enter the joint. Trocar and cannula
are then placed in the joint. A diagnostic arthroscopy is
performed, fi rst on the radial side of the wrist looking at
the radial styloid, prestyloid recess, checking the scapholu-
nate ligament, and lunotriquetral ligaments. An ulnar
portal is then created by again incising the skin. The
author’s preference is a 6R portal. A probe is then inserted
and the structures examined with its assistance. The probe
is used to examine the TFCC tear as well. A full radius
motorized shaver is then inserted: a 2–3 millimeter size is
usually adequate. The tourniquet is infl ated if signifi cant
bleeding is found. The shaver is used to remove any syno-
vitis tissue and to debride the central tear. Radiofrequency
probes are commonly used in our practice, and these can
quickly remove some of this fi rm, fi brous, and cartilaginous
tissue. It is important to also examine the midcarpal joint.
This can be done prior to TFCC debridement or at the end
of the ulnocarpal procedure.
Once the synovitis has been debrided, the probe can be
very useful to assess tear stability, tension of the TFCC
(‘trampoline test;’ Fig. 9.11), ligamentous integrity, and to
look for any evidence of ulnotriquetral ligament tears.
Occasionally the surgeon may need to switch the viewing
and working portals in order to make sure the debrided
TFCC area is nice and smooth. Again, it is important to
excise only the unstable or frayed portion; the peripheral
attachments need to be left alone.37 Portal sites are usually
closed with 4/0 or 5/0 nylon. Postoperative therapy is per-
formed as described earlier. Over 80% of patients require
FIGURE 9.8 Type IIC tear: perforation of the TFCC.
FIGURE 9.7 Type ID tear: avulsion of TFCC from its radial insertion.

Wrist Arthroscopy and TFCC Repair
127
no further intervention and have a good or excellent
result.38–41
TYPE IB LESIONS
Type IB lesions can occur in association with or without a
fracture of the ulnar styloid. If there is a fracture of the
styloid, fi xation of this fracture is the preferred method of
treatment when possible. The distal radioulnar joint should
be tested for stability. If it is unstable but the styloid frac-
ture is relatively non-displaced, then long-arm immobiliza-
tion in neutral forearm rotation is treatment. Casting is
usually needed for up to 6 weeks. If the fractured ulnar
styloid is displaced and the distal radioulnar joint unstable,
then open reduction and internal fi xation is recommended.
The arthroscopy setup is similar to what was described for
type IA tears. The author’s preference is to try and repair
these lesions when and if at all possible (Fig. 9.12A,B,C).
Debridement of type IB lesions is reserved for those that
are, for some reason, irreparable.
The author’s preference is to use a technique similar to
that described by Trumble et al.6 After completion of the
diagnostic arthroscopy, the scope is placed in the 6R portal
and the cannula in the 3/4 portal. A 2/0 PDS meniscal
repair type suture is used, with a double-armed suture. The
needle is then passed through the cannula and directed
towards the TFCC tear. The needle exits through the ulnar
wrist capsule and skin along the ulnar border of the wrist;
a second needle is placed in a similar fashion, and this also
exits through the ulnar border of the wrist,42 leaving a hori-
zontal mattress suture for repair. Usually two sutures are
suffi cient. An incision is made between the extensor carpi
ulnaris and fl exor carpi ulnaris tendons, adjacent to the
ulnar head. Care is taken to dissect out the soft tissue
structures, particularly the dorsal ulnar sensory branch.43
Once the soft tissues have been cleared, the sutures are tied
over the ulnar capsule. Arthroscopic reinspection should
confi rm reapproximation of the TFCC and restoration of
the ‘trampoline’ effect.44,45
In cases of DRUJ instability the author will consider
pinning the radius and ulna with two 0.062 K-wires and
utilizing a Munster cast for 6 weeks. If the DRUJ was stable
prior to TFCC repair, then usually immobilization in a
Munster cast for 6 weeks is adequate. In patients who have
had treatment that has been delayed for over 6 months, we
consider performing ulnar shortening with our repairs.46
After the 6 weeks of immobilization, a therapy program is
started and any K-wires are removed to allow aggressive
forearm and wrist range of motion.
TYPE IC LESIONS
Type IC lesion tears involve the volar aspect of the articular
disc and represent an avulsion of the disc from the ulnar
extrinsic ligament complex (ulnolunate and ulnotriquetral
ligaments). In these cases the patient’s examination may
show a carpal supination (‘sag’) deformity. Diagnostic
studies may not be helpful. Arthrography can be falsely posi-
tive as a result of a normal communication between the
radiocarpal and pisotriquetral joints. At the time of arthros-
copy, excessively lax ulnar extrinsic ligaments are noted, as
well as wide visualization of the pisotriquetral joint through
the 6R portal. Osterman47 has described a technique for
repairing smaller tears arthroscopically. A similar approach
and technique is used as when repairing type IB lesions. For
larger tears, an open procedure is recommended.48 Because
of the location of these volar tears, care is taken to avoid
injuring the ulnar artery or nerve. As described in the previ-
ous section, needles with 2/0 PDS suture are passed through
the tear (capsular area) where the defect lies, and this helps
close and tighten the ulnar extrinsic ligaments and repair
the tear.49 A technical point to consider is also to reef some
of the dorsoulnar portion of the TFCC so that it helps
‘tighten’ the ulnocarpal ligaments.
FIGURE 9.9 Wafer procedure; burring of the ulnar head.
FIGURE 9.10 Wafer fl uoroscopic image.

Hand and Upper Extremity Reconstruction
128
For large defects that are not amenable to arthroscopic
repair, an open repair is performed. The author favors the
volar approach as this permits direct shortening of the ulnar
extrinsic ligaments. The repair is usually augmented with
a segment of fl exor carpi ulnaris tendon. This is a strip of
the tendon that is based distally and brought through in a
dorsal direction. Cooney9 has described performing an
osteotomy as well, but we have no experience with this
approach.
TYPE ID LESIONS
Type ID lesions represent avulsion of the TFCC from its
normal attachment on the radius and sigmoid notch.
Repairing these can be challenging, and in many cases
debridement is acceptable. Cooney et al.48 have reported
excellent results in treating these injuries by open repair.
Trumble et al., Jantea et al., Segerman, and Short have also
described repair techniques.6,49–51 The authors prefer the
technique described by Short.51
The arthroscope is placed in the 3/4 portal and a 6U
portal is developed. Using the 6U portal, motorized burs
are brought in and the ulnar aspect of the radius is debrided
to bleeding bone. A 0.062 K-wire is then introduced and
directed towards the debrided area of the sigmoid notch.
Multiple drill holes are then made through the bone, tra-
versing across the radius and exiting between the fi rst and
second dorsal compartments. Usually four holes are
required. The 2/0 PDS meniscal repair kit sutures are used.
This double-armed suture has the fi rst needle placed
through the cannula and passes through the TFCC approxi-
mately 3 mm from its free edge. The needle is then passed
through one of the drill holes on the radius and pulled
through the skin. The second needle is then passed through
the cannula and TFCC in a similar fashion, and then
passes down a different drill hole. These steps are usually
repeated once more so that a total of two sutures is used
to repair the TFCC. Once these have been passed, a small
incision is made between the fi rst and second dorsal com-
partments. Blunt dissection is carried down to bone. The
sutures are then collected and tied over cortical bone, reduc-
ing the TFCC against the sigmoid notch. The radius and
ulna are pinned together in neutral rotation with two 0.062-
in K-wires. Patients are placed in a Munster cast for 6
weeks. In patients whose treatment was delayed more than
6 months, Trumble has noted an improvement in outcome
if ulnar shortening is also performed.46 Unfortunately, there
is a lack of long-term studies comparing TFCC debride-
ment to repair of type ID lesions. If repair fails, one may
then consider debridement for these injuries.52
TYPE II DEGENERATIVE TFCC LESIONS
Type II degenerative TFCC lesions are frequently thought
of as ulnocarpal impaction syndrome. Some patients may
be asymptomatic. Symptomatic degenerative tears are
usually the result of chronic overloading of the ulnocarpal
joint. In addition to the TFCC tear, there can also be
changes involving the ulna and carpus. Causes for ulnar
impaction syndrome can be congenital, idiopathic, or
sequelae of trauma such as radial shortening after fracture.
Other potential causes of secondary ulnar impaction include
distal radial growth arrest after an epiphyseal fracture or
proximal migration of the radius due to a radial head resec-
tion after Essex–Lopresti injury. Dynamic ulnar impaction
has been described, and this occurs with activities such as
forceful rotation or excessive gripping that loads the ulno-
carpal joint. Wrist arthroscopy can be helpful in the treat-
ment of primary ulnar impaction. Secondary ulnar
impaction, however, usually requires other reconstructive
measures. Palmer’s classifi cation system rates these pro-
gressive degenerative changes into fi ve subtypes, mentioned
earlier.21
On examination the TFCC compression (foveal tender-
ness) test is usually positive. Pain with forced ulnar devia-
tion (impaction sign) is frequently positive. This maneuver
should be performed in neutral pronation and supination.
A ‘shuck’ test should also be performed for lunotriquetral
instability. Compressing the DRUJ may also elicit symp-
toms if arthritic changes have occurred.53 Another test that
can be helpful in evaluation is measurement of grip strength
in both pronation and supination.
If arthroscopy is carried out it is important to visualize
the midcarpal joint for thorough evaluation of the lunotri-
quetral ligament. In some cases, chondromalacia of the
hamate may also be discovered as a cause of ulnar-sided
wrist pain in a patient with a bifacet lunate. Chondroplasty
of the hamate can then be performed. In general, treatment
is designed to decompress the ulnar carpus and head. An
advantage of the wafer procedure is that, if done correctly,
it does not disturb the DRUJ.54 For symptomatic distal
radioulnar joint arthritis, hemiresection, tendon interposi-
tion, Sauve–Kapandji, modifi ed Darrach resection, or ulnar
head implant may be considered.53 Treatment of type IIA
and IIB tears is usually by arthroscopy and open ulnar
shortening.55 See Figures 9.12, 9.13 and 9.14 for arthroscopic
FIGURE 9.11 Normal trampoline test.

Wrist Arthroscopy and TFCC Repair
129
FIGURE 9.12 A Case 1: Degenerative tear with ulnocarpal abutment.
B After central debridement of the TFCC with RF ablation. C Unstable
LT joint as seen from the midcarpal portal.
FIGURE 9.13 A Case 2: Radiofrequency ablation of the TFCC with a
central tear. B After debridement of the TFCC down to a stable rim.
C Normal midcarpal LT joint view with probe.
A
B
C
A
B
C

Hand and Upper Extremity Reconstruction
130
views of before and after treatment pictures, as well as views
of normal and torn lunotriquetral ligaments.
Treatment of type IIC tears depends on ulnar variance.
If non-operative intervention does not alleviate the patient’s
symptoms adequately, arthroscopic debridement of the
TFCC tear, as well as a potential wafer procedure or ulnar
shortening, is done to address ulnar positive variance. The
wafer procedure, as described by Felden et al.,56 was initially
performed through an open procedure. This has subse-
quently been modifi ed to be performed arthroscopically.55,57
For this diagnosis we look specifi cally at the articular sur-
faces of the lunate and triquetrum and carefully probe the
lunotriquetral ligament.
Synovectomy is frequently required to remove some of
the infl ammatory tissue so that these structures can be
better visualized. Through the hole in the TFCC, the ulnar
head can be examined and the articular surface seen by
moving the forearm in pronation and supination. If there
is instability of the lunotriquetral joint, either with a dias-
tasis or a frank tear, a wafer procedure is not recommended.54
In this circumstance, an open ulnar shortening procedure
is performed to help tighten the extrinsic ligaments.37 For
the wafer procedure, a radiofrequency wand and shaver are
alternated back and forth to debride the central TFCC per-
foration. This provides excellent exposure of the ulnar head.
A 4 mm bur is then usually brought in through the 6R or
the 4/5 portal, and 3–4 mm of the ulnar head is removed
(Fig. 9.9). Passive supination and pronation of the forearm
is helpful in reaching the entire surface.
Fluoroscopic imaging is also used to assess the amount
of resection and reassess our positioning (Fig. 9.10). Great
care must be taken to resect the distal ulna evenly so that
there is a nice horizontal plane to its surface. The goal is
to try and create approximately 1–2 mm of ulnar negative
variance. The peripheral aspects of the ulna are quite chal-
lenging to bur down with a standard 4/5 or 6R portal, so a
DRUJ portal can be useful. This is done by making a small
longitudinal incision on top of the ulnar head just a few
millimeters ulnar to the sigmoid notch and proximal to the
TFCC proper. The forearm should be in pronation when
this is done. The hemostat is then used to spread down
between the ulnar head and the TFCC, and a trocar cannula
can then be inserted into the DRUJ joint. The scope then
may be placed in the 6R portal and the bur in the DRUJ
portal, and the remaining bone removed by gradually supi-
nating and pronating the forearm. Again, fl uoroscopy is
used to confi rm the amount of resection.
Wnorowski and colleagues58 have shown that excision
of 3 mm of subchondral bone can reduce the force trans-
missions across the ulnar head by approximately 50%.
Once this is completed, the instruments are removed and
the incisions closed. The joint is injected with local
anesthetic with epinephrine. A volar short arm splint is
applied. This is usually removed at 1 week and the patient
placed in a removable Orthoplast splint. Hand therapy is
begun with active range of motion exercises. At approxi-
mately 8–10 weeks postoperatively, a strengthening program
is begun. Both surgeon and patient should be aware that it
can take 6 or more months for the symptoms to resolve
A
B
C
FIGURE 9.14 A Case 3: Passing suture from outside to inside in order
to repair the TFCC. B Repair prior to being tied down. C Repair tied
and tightly secured.

Wrist Arthroscopy and TFCC Repair
131
completely. It is the author’s opinion, based on published
results and personal experience, that patients with a full-
thickness degenerative TFCC tear predictably improve after
a TFCC debridement and a wafer resection for ulnar
impaction.8
Extra-articular ulnar shortening can be accomplished
with a variety of techniques or jig systems.59,60 Describing
these techniques goes beyond the scope of this chapter.
Most published series have shown improvement of ulnar-
sided wrist symptoms after ulnar shortening.61 Potential
complications include non-union or delayed union of the
osteotomy site. Patients often complain of irritation sec-
ondary to the hardware, which may require hardware
removal once the osteotomy has healed.
OPTIMIZING OUTCOMES
For traumatic TFCC tears, one may simply excise the
unstable central portion (up to two-thirds of the disc)
leaving the peripheral attachments intact. This prevents
any instability problems, and no demonstrable negative
effects on forearm load transmission or stability have been
shown. The work of Adams62 has shown that the peripheral
2 mm of the TFCC must be maintained so that instability
does not develop. If there is a traumatic central tear in
positive ulnar variance, the surgeon should consider ulnar
shortening or a wafer procedure as well. For ulnar impac-
tion, diagnostic arthroscopy is the best method for staging
the amount of impaction. If a wafer procedure is chosen,
pronating and supinating the wrist during the arthroscopy,
rather than moving the scope and the shaver, can help
‘plan’ the resected distal ulna.
Minimize trauma to the wrist during entry and exit of
instruments. Bear in mind the dorsal ulnar sensory branch
and branches of the dorsal radial sensory nerve. It is possi-
ble to incarcerate the dorsal ulnar sensory branch while
cinching down the repair.
COMPLICATIONS
Fortunately, complications after wrist arthroscopy are rela-
tively uncommon, and usually involve portal injuries to
nerves or tendons.63 Other potential complications are
related to traction and arm positioning. Complications
related to hand surgery in general can include complex
regional pain syndrome, dorsal sensory branch injuries, and
tendon injuries. Rupture of the extensor pollicis longus
after arthroscopy has been reported. Complications tend to
be correlated with the diffi culty of the procedure, with
TFCC debridement less likely to result in complications
than stabilization of fractures and ligaments.63 Precautions
include avoiding iatrogenic injury to the cartilaginous sur-
faces, and minimizing the duration of arthroscopy to avoid
MCP and PIP joint problems (as well as nerve injury from
traction). Short surgical time also reduces the amount of
fl uid extravasation that can sometimes occur, which can
cause swelling and potential carpal tunnel syndrome or
compartment syndrome in the hand or forearm.
A
B
C
FIGURE 9.15 A Case 4: Central degenerative (type II) tear. B RF
ablation of the tear, leaving a stable rim. C LT ligament tear.

Hand and Upper Extremity Reconstruction
132
POSTOPERATIVE CARE
For traumatic TFCC tears, early motion exercises follow
simple debridement. However, if a TFCC repair was per-
formed, most people utilize a sugar-tong or Munster type
cast for at least 4–6 weeks, with the forearm in a position
that best opposes the edge of repair determined at the time
of surgery (usually mid-supination). After that, the patient
is converted to an Orthoplast removable Munster splint and
begins working on gentle wrist range of motion and forearm
pronation/supination. At 10–12 weeks, strengthening is
initiated.
For degenerative-type tears, a resting short-arm splint
can be used for 4 weeks, with gentle active range of motion
and exercise of the wrist and forearm. Strengthening can be
started at 6–8 weeks. If pinning of the lunotriquetral joint
is required, then a short-arm cast for 6–8 weeks with pin
removal at the time of cast removal is appropriate. Hand
therapy or wrist range of motion exercises are then begun,
and splinting discontinued by 12 weeks with a gradual
progressive strengthening program. The importance of
supervised hand therapy cannot be overstated.
CONCLUSION
Tears of the TFCC can occur as a result of trauma as well
as from repetitive degenerative mechanisms. The ulnar side
of the wrist can be a diagnostic enigma because of its
complex anatomy and multiple conditions that can cause
pain in this region. A thorough history and physical exami-
nation, as well as diagnostic studies, are usually required
to elucidate the cause of the pain. Arthroscopy is the gold
standard for diagnosis, but must be weighed against its
invasiveness. Palmer’s classifi cation is useful for formulat-
ing treatment. Type IA lesions are usually debrided, whereas
types IB, IC and ID are usually repaired by arthroscopic or
open means. Type IIA/IIB degenerative tears are usually
treated conservatively. Type IIC lesions may be treated by
a wafer procedure or ulnar shortening. The type IID lesion
may be addressed with arthroscopy, a wafer procedure, or
ulnar shortening, the latter especially if there is an associ-
ated lunotriquetral ligament tear. For type IIE lesions, distal
ulnar resection, Sauve–Kapandji arthrodesis, or prosthetic
replacement are possible options. If there is a fi xable or
intercalated segmental instability accompanying a type IID
lesion, then both ulnar shortening and pinning of the
lunotriquetral joint should be considered. Diagnosis and
treatment of these injuries can be challenging, but can also
be quite rewarding.
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13. Kihara H, Short WH, Wernver FW, et al. The stabilizing
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in the diagnosis of ulnar-sided wrist pain. J Hand Surg [Br] 1997;
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26. Steyers CM, Balir WF. Measuring ulnar variance; a comparison of
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28. Tomaino MM. The importance of the pronated grip X-ray view in
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33. Hermansdorfer JD, Kleinman WB, Management of chronic
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42. Bohringer G, Schadel-Hopfner M, Petermann J, Gotzen L. A
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529–535.

135
C H A P T E R
10
Wrist Reconstructive Procedures
(Fractures and Dislocations)
Akio Minami and Tatsuya Masuko
SCAPHOID FRACTURES AND NONUNION
Scaphoid fractures are common, generally occurring as a
result of a fall on an outstretched hand or high-energy
trauma. Waist fractures comprise about 75% of scaphoid
fractures, proximal pole fractures about 20%, and distal
pole or tubercle fractures about 5%. The retrograde blood
supply to the scaphoid is from branches of the radial artery
fl owing from distal to proximal. Therefore, avascular necro-
sis of the proximal fragment occurs because of the tenuous
blood fl ow to the proximal pole, which presents as a non-
union of the fractured scaphoid. Avascular scaphoid frac-
ture or non-union may require vascularized bone graft,
although the use of this technique is still controversial.
Because the treatment of scaphoid non-union is quite
diffi cult, early diagnosis of acute fractures and appropriate
treatment, whether conservative or surgical, may prevent
non-union. Untreated scaphoid non-union may lead to
scaphoid non-union advanced collapse, or ‘SNAC’ wrist, for
which there is no effective treatment.
Preoperative history and considerations
Mechanism of fracture
The most common mechanism is a fall with the wrist
extended because the scaphoid becomes vertical to the axis
of forearm and the load is applied directly to the waist of
the scaphoid.
Physical examination
Swelling, ecchymosis, and tenderness are typically seen at
the snuffbox. Limited and painful motion with radial and
ulnar deviation is also observed. Grip strength is usually
decreased. However, these signs are less prominent in
chronic scaphoid fractures.
Imaging techniques
Radiography
Posteroanterior, lateral, and oblique views are necessary.
In addition, ‘scaphoid views’ are strongly recommended
because non-displaced or minimally displaced scaphoid
fractures are sometimes undetectable on these standard
views. One of the scaphoid views is taken with the wrist
extended and ulnarly deviated. However, even scaphoid
views may not reveal occult or completely non-displaced
fractures.
In the normal wrist the scapholunate angle is between
30º and 60º and the capitolunate angle 0º. In contrast, >60º
indicates a dorsal intercalated segmental instability (DISI)
deformity.
Bone scintigraphy
Bone scintigraphy (technetium-99; 99mTc) is very useful
when clinical signs of fracture are clear but the fracture
cannot be detected by radiographs. A positive scan may
reveal selected uptake at the fracture site, whereas diffuse
uptake may suggest synovitis.
CT
CT is useful for evaluating the alignment of fractures.
‘Humpback’ deformity is detectable in sagittal images paral-
lel to the long axis of the scaphoid. CT is also helpful for
the assessment of bone bridging in healing scaphoid
fractures.
MRI
For the evaluation of occult scaphoid fracture or avascular
necrosis, MRI is the most suitable and reliable imaging
technique. The fracture site exhibits low signal intensity on
T1-weighted images.

Hand and Upper Extremity Reconstruction
136
Indications and contraindications
Acute scaphoid fracture
Primary treatment
An acute scaphoid fracture should be immobilized in a
thumb spica cast. Even when the suspected fracture is not
clear, it should be splinted. Repeated radiographs are taken
after 2 weeks to detect whether a fracture exists or not, by
showing bone resorption at the fracture site. MRI may be
useful for early detection of fractures.
Conservative treatment
Non-displaced (<1 mm) waist or distal tubercle fractures
are a good indication for conservative treatment because
these types of fracture are usually stable and should heal
with proper immobilization in a long or short arm cast for
more than 6 weeks.
Operative treatment
The following are indications for operative fi xation: (1)
displaced (>1 mm); (2) apparent angulation; (3) proximal
pole fracture; (4) fracture comminution; and (5) fracture
collapse. Open reduction and internal fi xation has become
more common because of better instrumentation and the
availability of headless screws. Patients who are active and
want to recover as early as possible should consider opera-
tive treatment.
Proximal pole fractures are often diffi cult to treat suc-
cessfully because the fracture is usually small and displaced,
and the blood supply for the scaphoid is retrograde and
sometimes not suffi cient for union. The immobilization
period is prolonged, and this may cause some complica-
tions, such as reduced motion and grip strength. Even with
a long period of immobilization, the proximal pole fracture
is likely to result in non-union or delayed union. For this
fracture pattern, early open reduction and internal fi xation
may be preferable.
Approach
A dorsal approach is suitable for proximal pole fractures
and the volar approach is used for waist and distal pole
fractures.
Implant
Headless screws are used for scaphoid fractures. Other
fi xation devices include K-wires, screws, and staples. Less
displaced fractures are fi xed without bone grafting, but dis-
placed ones need grafting. Minimally displaced or non-
displaced fractures may be treated with percutaneous
fi xation as reported by Slade et al.1 to minimize soft tissue
damage.
Immobilization
The wrist is immobilized in a short arm thumb spica splint
for 2 weeks, followed by a short arm splint for 6–8 weeks
until union.
Scaphoid non-union
Delayed diagnosis and treatment of proximal pole fractures
is the crucial risk factor for scaphoid non-union as well as
insuffi cient immobilization, insuffi cient fi xation, and com-
minution. After curettage and removal of non-viable bone
from the proximal and distal scaphoid, a large corticocancel-
lous bone graft is placed into the excavated cavity. The graft
is usually from the corticocancellous iliac crest or radius.
Scaphoid non-union may lead to a progressive arthritis
so called SNAC (scaphoid non-union advanced collapse).
Once symptomatic SNAC wrist deformity sets in, salvage
operations include proximal row carpectomy, prosthetic
or allograft replacement, partial scaphoid excision, wrist
denervation, and arthrodesis.
Operative treatment
MRI and CT are useful for evaluation of non-union. Avas-
cular necrosis is detectable on MRI. ‘Humpback’ deformity
means that the fractured scaphoid is collapsed and needs
internal fi xation with a volar wedge bone graft. Sagittal CT
scan views can detect the ‘humpback’ deformity and are
useful for preoperative planning.
● With or without avascular necrosis Scaphoid non-
union with avascular necrosis may be treated with inter-
nal rigid fi xation and vascularized bone graft, whereas
scaphoid non-union without avascular necrosis is treated
with internal fi xation and non-vascularized cancellous
bone graft, although the most appropriate treatment
for this condition is still debated. One, two, or two/three
intercompartmental supraretinacular artery (ICSRA)
grafting is used for vascularized bone grafting. Both
arteries are branches of the radial artery that lies between
the fi rst, second, or second and third extensor compart-
ments, and the blood fl ow is retrograde.
● Approach Proximal pole necrosis is approached dorsally,
and waist and distal pole necrosis volarly.
● Implant Headless screws are preferred. Rigid fi xation
can shorten the time to union. K-wires are used only for
preliminary fi xation or as a ‘joystick’ to distract the
scaphoid fracture, not as the sole fi xation method.
● Immobilization The wrist is immobilized in a short
arm thumb spica splint for 2 weeks, followed by a short
arm cast or splint for 6–8 weeks until union. In non-
union cases the period until union is usually longer than
for acute fractures.
Operative approach
Dorsal percutaneous fi xation
Dorsal percutaneous fi xation without bone grafting is
applied to non-displaced or minimally displaced scaphoid
fractures. Image intensifi er is necessary. Slade et al.1,2
reported using this method with satisfactory results. They
also reported using this technique for scaphoid non-unions3
(Fig. 10.1).
Procedure
The wrist is pronated and fl exed to make a radiograph ‘ring
sign’ of the scaphoid. A guide wire is inserted from dorsal
to volar, aiming at the center of the scaphoid as the
fracture is reduced. Another wire is inserted to prevent
fragment displacement or rotation during drilling with the

Wrist Reconstructive Procedures
137
cannulated hand reamer. Alternatively, the guide wire is
advanced to exit the volar skin and a hemostat is clamped
on the volar wire.
Appropriate screw length is key to this procedure. The
screw is typically 2–4 mm shorter than measured because
the headless screw will be countersunk and the differential
pitch of the screw will shorten the scaphoid after compres-
sion. The screw is inserted under image intensifi er guid-
ance (Fig. 10.2).
Volar percutaneous fi xation
Minimally displaced waist and distal pole fractures are
treated with volar percutaneous fi xation. After an incision
at the scaphotrapezial joint, a guide wire is inserted from
the volar, distal to the dorsal, proximal scaphoid with the
wrist extended. Image intensifi cation is used to guide the
selection of screw length. This procedure requires a great
deal of precision to prevent impingement of the screw on
the surrounding structures, or misdirected placement.
Dorsal approach for the proximal scaphoid fracture
The dorsal approach is preferable for proximal pole frac-
tures because the exposure is easier and more screw threads
can engage the pole. An incision is made between the third
and fourth compartments. The EPL is retracted radially and
the dorsal capsule over the scapholunate joint is incised.
The fracture site is identifi ed and the fi brous tissue and
necrotic bone at the site of non-union are debrided using a
curette or burr. The displaced fragment is reduced with K-
wires. After reaming and measuring the length, a screw is
placed with the wrist fl exed. Image intensifi cation is neces-
sary for checking screw position and length.
Volar approach to the scaphoid
A volar approach is indicated for waist and distal fractures.
A 4–5 cm longitudinal incision is placed along the radial
border of the thenar eminence and along the fl exor carpi
radialis (FCR) tendon. This is released and retracted ulnarly,
and the radioscaphocapitate ligament the capsule incised
longitudinally. The fracture site is identifi ed and the fi brous
tissue and necrotic bone at the non-union site are debrided.
Assisting K-wire is recommended to prevent scaphoid
rotation during screw fi xation. The screw is inserted distally
at the scaphotrapeziotrapezoidal joint to the proximal
fragment.
Humpback deformity or comminution requires bone
grafting from the radius or iliac bone. The grafted bone is
wedge-shaped to fi t into the fracture site and fi xed inter-
nally with a Herbert screw.
Rüsse4 reported using a corticocancellous strut graft to
the scaphoid fracture. The cortex of the grafted bone is
wedged into the non-union site to give structural support
for better union (Fig. 10.3).
Dorsal approach to the scaphoid with
vascularized bone graft
One, two, or two/three ICSRA is selected for the bone graft.
The waist or proximal pole non-union is approached dor-
sally for ease of harvesting the vascularized bone graft. An
incision is placed between the third and fourth compart-
ments and the extensor pollicis longus (EPL) tendon is
retracted radially. The wrist capsule is incised longitudi-
nally and the scaphoid non-union site identifi ed. The
fi brous tissue and necrotic bone at the non-union site are
debrided and curetted. One, two, or two/three ICSRA are
identifi ed between the fi rst and second compartments or
the second and third compartments, respectively. These
retinacula are released and the bone graft is harvested. We
mark the appropriate size of graft using K-wire drilling.
Then an osteotome is used to chisel along the drill holes
to avoid fracturing the graft. The vessel is mobilized with
the bone graft to rotate and insert into the non-union site.
A headless screw is then placed.
Volar approach to the scaphoid with
vascularized bone graft
A volar approach is indicated for scaphoid non-union with
avascular necrosis or humpback deformity. The vascular-
ized bone graft is supplied by the radial branch of the
palmar radiocarpal arch.
A 4–5 cm longitudinal incision is placed along the radial
border of the thenar eminence and along the FCR tendon.
The FCR sheath is released and the FCR retracted ulnarly,
and the capsule is incised longitudinally. The non-union
site is identifi ed and debrided. The vascularized bone graft
is harvested and elevated from the ulnar aspect of the distal
FIGURE 10.1 Dorsal percutaneous fi xation reported by Slade et al.

Hand and Upper Extremity Reconstruction
138
A
B
C
D
FIGURE 10.2 Radiographs after dorsal percutaneous fi xation followed by the Slade procedure. A Preoperative radiograph (oblique view). The
scaphoid fracture is undisplaced. B MRI (T1-weighted image). The fractured scaphoid shows low intensity; the triquetrum is also fractured. C MRI
(T2-weighted image). The fractured scaphoid shows high intensity. D Four-week postoperative radiograph showing the healed fracture line.
radius and crafted into a wedge shape to fi t the humpback
deformity, if present. The fracture is fi xed internally with
a Herbert screw.
Complications and side eff ects
Conservative treatment using cast immobilization can
lead to pressure neuritis, capsular stiffness, or complex
regional pain syndrome. In operative treatment, sensory
neuritis, displaced or extruded grafts, pin tract infections,
non-union, or recurrence of deformity are potential
complications.
Postoperative care
Casts are usually changed at 3 and 8 weeks, and repeated
radiographs are taken to confi rm healing and alignment of
bone fragments. If scaphoid union is suspected not to occur,
a tomogram or CT scan may be considered. An additional
4 weeks of casting may be warranted.
Conclusions
Scaphoid fractures are very common. Non-displaced or
minimal displaced fractures are sometimes diffi cult to

Wrist Reconstructive Procedures
139
diagnose. It is not rare for tenderness at the snuff-box to be
the only symptom. Improper or delayed treatment causes
delayed union or non-union, and can lead to SNAC wrist.
Given the gravity of non-healing scaphoid fractures, in sus-
pected cases CT and MRI are helpful for diagnosing and
planning treatment.
Conservative immobilization in a long or short arm
spica cast for more than 6 weeks is the standard treatment
for non-displaced or minimally displaced fractures. However,
conservative treatment requires a long period of immobili-
zation and non-union occasionally occurs. We recommend
operative treatment even for non-displaced or minimally
displaced fractures, especially for manual workers or highly
active patients.
PERILUNATE DISLOCATIONS
Perilunate dislocations are rare. The mechanism of injury
is severe trauma, such as a traffi c accident or a fall from a
height onto a hyperextended wrist. Perilunate dislocation
is classifi ed into two types: perilunate or lunate. This cate-
gorization can be further subdivided into those with or
without associated fractures. The former is a greater arc
injury and the latter is a lesser arc injury (Fig. 10.4). The
lesser arc injury is a pure ligamentous disruption, whereas
a greater arc injury involves fractures of the surrounding
carpal bones, such as the scaphoid and/or capitate. This
section describes the lesser arc injury.
Preoperative history and considerations
Mechanism of injury
From laboratory research the mechanism of perilunate
dislocation is thought to occur with wrist extension, ulnar
deviation, and intercarpal supination sustained during
high-velocity trauma or falls from a considerable height.
Mayfi eld et al.5 reported that the disruption of ligaments
may cause lunate dislocation, and this injury is classifi ed
into four stages (Fig. 10.5).
● Stage I: Scapholunate dissociation. The relationship
between the scaphoid and the lunate disrupts.
● Stage II: Lunocapitate dissociation. The relationship
between the capitate and the lunate disrupts.
● Stage III: Dissociation at lunotriquetral joint. The rela-
tionship between the lunate and the triquetrum dis-
rupts. The dorsal perilunate dislocation occurs.
● Stage IV: Complete palmar lunate dislocation. The
lunate is completely dislocated palmarly.
Other injuries such as a palmar perilunate dislocation
and an isolated dorsal lunate dislocation are quite rare and
not reproducible.
Physical examination
The injured wrist has signifi cant swelling, local heat, ecchy-
mosis, and pain. Pain with motion in the wrist and fi ngers
is quite severe, causing reduced motion. Carpal tunnel syn-
drome symptoms are observed. The palmarly dislocated
lunate may compress the medial nerve, and the direct injury
may damage the median or ulnar nerves.
Imagings
Radiographs
Anteroposterior (AP) or posteroanterior (PA), lateral, and
oblique wrist views are taken. If these standard radiographs
tfarg d
e
g
ni
W
tfarg e
s
s
ü
R
dra
d
n
atS
FIGURE 10.3 A corticocancellous strut bone graft reported by Rüsse.4
Greater arc
Lesser arc
FIGURE 10.4 A greater arc and a lesser arc injury.

Hand and Upper Extremity Reconstruction
140
are unclear, traction views can be useful. The lateral view
should be a true lateral with the wrist in neutral to prevent
misdiagnosis. Normally, perilunate dislocations are easily
visualized on true lateral views. Gilula et al.6,7 reported
three carpal lines (or arcs), named ‘Gilula’s lines (or arcs),’
in the AP view (Fig. 10.6). One of these three lines contains
the proximal articular surface of the proximal carpal row.
The second is an outline of the distal articular surface of
the proximal row. The third is a line over the proximal
articular surface of the distal carpal row. Disruption of
Gilula’s lines reveal ligamentous injuries or fractures of the
wrist. The ‘ring sign’ is seen when the scaphoid is fl exed
because of scapholunate ligamentous injury in which the
distal pole of the scaphoid superimpose on the rest of the
bone. The ‘Terry Thomas sign’ is an increased gap between
the scaphoid and lunate of more than 2 mm, suggesting
scapholunate dissociation and perilunate injury. Fractures
of the scaphoid, capitate, hamate, or triquetrum indicate a
greater arc injury.
The midcarpal joint is displaced or dislocated dorsally,
as shown in Figure 10.5 (stage III). The triangular or wedge-
shaped lunate in AP view means that the lunate is dislo-
cated. The ‘spilled teacup’ sign in a true lateral view shows
that the lunate is dislocated palmarly and palmarly fl exed.
The fl exed scaphoid suggests disruption of the relationship
between the scaphoid and the lunate.
An increased radiolunate angle (>15º) and/or an increased
scapholunate angle (>70º) indicates DISI (dorsifl exed inter-
calated segment instability) deformity.
Arthrography
Arthrography is a useful method for diagnosing wrist liga-
mentous injuries. Perilunate dislocations, however, are
I
II
III
IV
Scapholunate
dissociation
Lunocapitate
dissociation
Lunotriquetral
dissociation
Palmar flexion
of lunate
FIGURE 10.5 Classifi cation of perilunate dislocations. Stage I: Scapholunate dissociation. Stage II: Lunocapitate dissociation. Stage III:
Dissociation at lunotriquetral joint. Stage IV: Complete palmar lunate dislocation.

Wrist Reconstructive Procedures
141
usually clear on plain radiographs. Therefore, arthrography
is rarely indicated.
CT, MRI, and bone scintigraphy
These are usually not needed for this condition, unless an
occult fracture is suspected.
Treatments
Acute treatment
Closed reduction and cast immobilization
Closed reduction is useful as a temporary measure for
pain relief and restoration of anatomical architecture. After
continuous traction, closed reduction is performed by
manipulation: the wrist is extended and the lunate pushed
dorsally from the volar wrist to engage the dorsal lip of
the lunate on the capitate. Then the wrist is gradually
fl exed and direct pressure applied to the capitate to seat it
on the lunate. After reduction, the alignment is checked by
radiographs. If the alignment is acceptable, one may choose
cast immobilization for 10 weeks, but the choice of non-
operative treatment is controversial because healing the
avulsed ligaments may be more secure with an open
approach.
Closed reduction and percutaneous pinning
If the wrist is not stable after the closed reduction, an addi-
tional procedure is necessary to restore carpal alignment
and maintain the reduction. Percutaneous pinning may be
carried out.
Procedure After anatomical reduction, a 0.045-inch K-wire
is inserted percutaneously from the radius to the lunate,
and then from the triquetrum to the lunate. Next, the
fl exed scaphoid is reduced and fi xed percutaneously. The
wrist is immobilized in a short arm cast for 10 weeks.
Open reduction and repair of scapholunate
interosseous ligament (SLIL)
The authors8 previously reported the open reduction and
ligament repair procedure. A dorsal longitudinal incision
centered over Lister’s tubercle exposes the dorsal retinacu-
lum, which is divided over the EPL. This tendon is retracted
radially, and the joint is exposed through a straight capsular
incision in line with Lister’s tubercle. The entire capsulo-
ligamentous complex is refl ected. The proximal pole of the
scaphoid, having rotated dorsally and radially, will protrude
vertically into the wound. Retracting the scaphoid radially
exposes the head of the capitate, which is frequently dislo-
cated dorsal to the lunate. On the palmar side, a routine
carpal tunnel incision is extended proximally across the
wrist. The fl exor tendons and median nerve are retracted
radially, revealing a consistent transverse rent in the palmar
capsule. This tear is present in all the authors’ patients with
both dorsal perilunate and palmar lunate dislocations.
The lunate is now easily reduced under direct vision
from the palmar approach by manually pushing it back
between the capitate and radius while an assistant applies
gentle longitudinal traction on the hand. Although it is
virtually impossible to identify and repair the individual
intercapsular ligaments, it is relatively easy to repair the
volar rent in the capsuloligamentous complex using inter-
rupted non-absorbable sutures. It is important to preserve
the continuity of the palmar capsuloligamentous complex,
which is the important stabilizer for the wrist.
Dorsally the proximal pole of the capitate is reduced
into the distal concavity of the lunate under direct vision.
The proximal pole of the scaphoid, which has been dis-
placed dorsally and radially by the injury, is rotated back
into its normal anatomic position. The SLIL is usually torn
from its scaphoid attachment. Minimum debridement of
the torn end of the SLIL is performed, and then three drill
holes are made at the notch of the scaphoid (lunate facet).
Non-absorbable sutures are tightly tied to approximate the
edge of the torn SLIL through drill holes in the scaphoid,
after anatomic reduction of the carpal bones. Three K-wires
are inserted to stabilize the three key elements: scaphoid,
lunate, and capitate.
The wrist is immobilized in a long arm splint with
thumb spica for 2 weeks. K-wires are removed 6–8 weeks
postoperatively. Part-time splinting is continued for an
additional 6 weeks.
Open reduction and reconstruction of the SLIL
The authors8 have reported the procedure of open reduction
and reconstruction of the SLIL for symptomatic chronic
scapholunate ligament tear. Combined palmar and dorsal
approaches as described for repair of the SLIL are employed.
From the dorsal incision, the gap between the scaphoid and
lunate is often fi lled with fi brous tissue, and extensive soft
tissue dissection may be required to free up the scaphoid
adequately to permit correction of its subluxation. Exces-
II
III
I
FIGURE 10.6 Gilula’s line (or arc). I: proximal articular surface of the
proximal carpal row. II: distal articular surface of the proximal carpal
row. III: proximal articular surface of the distal carpal row.

Hand and Upper Extremity Reconstruction
142
sive soft tissue stripping should be avoided because it may
create further instability and result in devascularization of
the scaphoid. A 10-cm strip of the ulnar half of the ECRL
is prepared, leaving the distal end attached at its insertion.
A hole is drilled from the dorsal aspect of the proximal pole
of the scaphoid, emerging on the scapholunate interarticu-
lar surface palmar to its center. A similar hole is drilled
from the dorsal aspect to the lunate, emerging opposite the
scaphoid tunnel. The fi nal diameter of this tunnel should
be large enough to accept a 4 mm Hunter tendon implant,
which is used as the tendon passer. A curved ligature carrier
can also be used to thread the tendon graft through the
holes. The graft is then passed from scaphoid to lunate,
prior to actual reduction and fi xation of the bones. After
the bones have been reduced and stabilized with K-wires,
the graft is pulled through the tunnel and placed under
slight tension. The graft, which emerges from the dorsal
opening in the lunate, is then brought back across the
scapholunate interval, sutured to itself, and further rein-
forced by tacking it to the strong dorsal capsular fi bers over
the triquetrum or, alternatively, into the dorsal periosteum
of the distal radius. All possible repairs of available ligamen-
tous tissue are then carried out to further reinforce the
dorsal capsule.
The wrist is immobilized in a long arm splint with
thumb spica for 2 weeks. K-wires are removed 6–8 weeks
postoperatively. Part-time splinting is continued for an
additional 6 weeks.
Chronic perilunate dislocations
(delayed presentation)
If the injury occurred 3–12 weeks before presentation, open
reduction of the perilunate dislocation and ligament repair
are indicated. The procedures of the open method for
chronic perilunate dislocation are the same as those of the
acute one. However, the outcomes of chronic perilunate
dislocations are worse than those of acute dislocation. If
reduction is not possible, salvage methods such as proximal
row carpectomy, partial wrist arthrodesis, or total wrist
arthrodesis are considered. Wrist arthrodesis is a good indi-
cation for patients who need maximum strength.
Complications
Complications of perilunate dislocations are common.
Symptomatic arthritic changes can be treated with salvage
procedures. Median nerve neuropathy is also common.
Early reduction of the dislocated lunate may prevent the
neuropathies.
Avascular necrosis of the scaphoid or the lunate has
been reported. The former may occur with greater arc inju-
ries, and the latter when the blood supply to the lunate is
damaged.
Carpal instability may occur at the scapholunate or
lunotriquetral articulation and will require a salvage
procedure.
Conclusions
Perilunate dislocations are rare injuries. Diagnosis is not
diffi cult, especially for stages III and IV. However, the treat-
ments are troublesome because most dislocations are a
result of high-energy injuries. Early reduction and ligament
repairs are crucial.
SCAPHOLUNATE INSTABILITY
Scapholunate instability is the most frequent form of carpal
instability. The characteristics of scapholunate instability
are abnormal scaphoid and lunate motion; dorsifl exed
intercalated segment instability (DISI) deformity; dorsal
subluxation of the lunate; and proximal migration of the
capitate. The separation between scaphoid and lunate is
often shown in neutral posteroanterior (PA) radiographs
without provocative tests. This means that this instability
or dissociation is static. Scapholunate instability that
appears only after provocative tests are performed is termed
dynamic.
Preoperative history and considerations
Mechanism of injury
Armstrong9
reported
that
scapholunate
dissociation
occurred when the wrist was in extension and in ulnar
deviation for activities such as grasping a cylindrical object,
for example a racquet handle or motorcycle handlebar.
Mayfi eld et al.5 also reported that this injury happened with
the wrist in extension, ulnar deviation, and midcarpal supi-
nation. The dissociation of scaphoid and lunate causes the
scaphoid to fl ex while the other proximal carpal row bones,
such as the lunate and triquetrum, extend.
Physical examination
Patients usually complain of pain dorsally over the SLIL
and weakness with loading of the wrist. The Watson
maneuver or the scaphoid shift test is well known for the
diagnosis of scapholunate instability.
Scaphoid shift test
The wrist is moved manually into full ulnar deviation with
the forearm pronated. In this position, the scaphoid is
moved to be in extension. As the wrist is moved into radial
deviation, the distal pole of the scaphoid is prevented from
fl exing by the examiner’s thumb. The proximal pole of
the scaphoid is forced to sublux dorsally and produce pain,
which reveals a scapholunate dissociation.
Scaphoid displacement test
The scaphoid tuberosity is pushed from volar to dorsal with
the wrist in ulnar deviation. If the scaphoid is displaced to
ride out of the radial fossa over the dorsal rim and accom-
panied by a painful snap, the test is positive.
Imaging
Radiography (AP or PA views)
● Scapholunate gap: A diastasis between the scaphoid and
lunate >2 mm is abnormal and is suspicious for scaph-
olunate instability.

Wrist Reconstructive Procedures
143
● Ring sign: The distal pole of the fl exed, perpendicular
scaphoid appears as a ‘ring’ because of disruption of the
scapholunate relationship.
● Quadrilateral appearance of the lunate: As the
lunate rotates dorsally, it appears to be quadrilateral in
shape.
● Disruption of Gilula’s lines: Disruption of one of three
arcs means a ligamentous injury or a carpal fracture.
Radiography (lateral views)
● Subluxation of the proximal pole of scaphoid: As the
scaphoid is fl exed, the proximal pole is driven to the
dorsal rim of the radius.
● Increased radiolunate angle: More than 15º is suspi-
cious of DISI deformity.
● Increased scapholunate angle: The normal range of the
scapholunate angle is 30–60º. More than 70º means the
link between the scaphoid and lunate is broken.
Magnetic resonance imaging (MRI)
MRI can identify the scapholunate ligament as a low-inten-
sity band on T1-weighted scans. Usually the intact ligament
can be seen as two successive images. MRI can also dem-
onstrate loss of continuity, fraying, thinning, and irregular-
ity of the ligament.
Arthrography
The main indication for arthrography is ‘dynamic’ instabil-
ity of a scapholunate ligament. Although routine radio-
graphs can detect ‘static’ instability, ‘dynamic’ instability
is sometimes diffi cult to evaluate from normal X-rays.
Arthrography can allow direct inspection of the SLIL and
evaluation of other ligaments.
Treatments
Acute scapholunate dissociation
Cast immobilization
After manual reduction of the scaphoid, cast immobiliza-
tion is applied. However, this treatment is often
unsuccessful.
Open repair
The carpal bones are exposed through a dorsal longitudinal
incision. A triangular incision between the radiotriquetral
and triquetroscaphoid ligaments is made to expose the
wrist joint; 0.062-inch K-wires are drilled into the lunate
and scaphoid and used as joysticks to manipulate the two
bones. Because the SLIL is usually torn off the scaphoid,
multiple small drilling holes are made from the proximal
convex rim of the scaphoid to the dorsolateral ridge. After
reduction and pinning of the scaphoid and lunate, several
mattress sutures are tied through the scapholunate interos-
seous membrane and the dorsal ligament, and the scaph-
olunate relationship is internally fi xed with a number of
K-wires for 8–10 weeks. The midcarpal joint may be fi xed
with K-wires for greater stability. Bone anchors are also
useful for repairing the SLIL (Fig. 10.7).
Chronic scapholunate dissociation
without osteoarthritis
Dorsal capsulodesis
Blatt10 reported that a capsuloligament from the dorsal
capsule of the wrist can be attached to the distal pole of
the scaphoid to prevent its fl exed posture. Although this
method is not directly effective in dissociation of the scaph-
oid and the lunate, satisfactory clinical results were
reported.
Procedure A 1–1.5 cm wide fl ap is harvested from the ulnar
dorsal wrist capsule. The distal insertion is released and
attached to the distal pole of the scaphoid using a bone
anchor. The wrist is immobilized for 4 weeks in a long arm
cast, and then for 4 weeks in a short arm splint.
Ligament reconstruction
Brunelli et al.11 reported the ligament reconstruction proce-
dure using a slip of the FCR tendon.
Procedure The wrist is approached dorsally through a 4-cm
longitudinal incision and the extensor retinaculum divided
between the second and third compartments. The scar
tissue between the scaphoid and lunate is excised. The
fi brous sheath of the FCR tendon is incised and a 2–3 mm
strip of the tendon harvested longitudinally, leaving it
attached to the base of the index metacarpal. The tendon
slip is passed from volar to dorsal through a 2.5-mm diam-
eter tunnel in the distal scaphoid, parallel to its distal
articular surface. The scaphoid is reduced and the scapholu-
nate dissociation corrected. The distal part of the scaphoid
and the capitate are fi xed with K-wires, and the tendon slip
is sutured to the dorsum of the SLIL and to the dorsal distal
lip of the radius. The new modifi cation of this technique
does not suture the tendon graft to the radius to avoid
reduced wrist motion. The wrist is immobilized for 4–6
weeks (Fig. 10.8).
The authors8 have reported another procedure for liga-
ment reconstruction, as follows. From the dorsal incision,
a 10-cm strip of the ulnar half of the ECRL is harvested,
leaving the distal end attached at its insertion. A hole is
drilled from the dorsal aspect of the proximal pole of the
scaphoid, emerging on the scapholunate interarticular
surface palmar to its center. A similar hole is drilled from
the dorsal aspect to the lunate, emerging opposite the
scaphoid tunnel. The fi nal diameter of this tunnel should
be large enough to accept a 4 mm Hunter tendon implant,
which is used as the tendon passer. A curved ligature carrier
can also be used to thread the tendon graft through the
tunnel. The graft is then passed from scaphoid to lunate,
prior to actual reduction and fi xation of the bones. After
the bones have been reduced and stabilized with K-wires,
the graft is pulled through the tunnel snugly and placed
under slight tension. The graft, which emerges from the
dorsal opening in the lunate, is then brought back across
the scapholunate interval, sutured to itself, and further
reinforced by tacking it to the strong dorsal capsular fi bers
over the triquetrum, or alternatively, into the dorsal peri-
osteum of the distal radius. All possible repairs of available
ligamentous tissue are then carried out to further reinforce
the dorsal capsule.

144
A
B
C
D
FIGURE 10.7 Open repair procedure for acute scapholunate dissociation.
1/2 of FCR tendon passed
through distal pole of scaphoid
FCR tendon sutured to
scapholunate interface and
ulnar side of distal radius
FIGURE 10.8 Ligament reconstruction procedure reported by
Brunelli et al.11

Wrist Reconstructive Procedures
145
A
B
FIGURE 10.9 Radiograph of four-corner fusion procedure for SNAC wrist (not for SLAC wrist). A Preoperative radiograph. Osteoarthritic change
is shown at the radiocarpal joint. The articular surface between the radius and the lunate is not aff ected. B Postoperative radiograph. The non-
united scaphoid is excised and the lunate, capitate, triquetrum, and hamate are fi xed with K-wires.

Hand and Upper Extremity Reconstruction
146
C
FIGURE 10.9, cont’d C Postoperative radiograph showing the united
carpal bones.
● Stage II: arthritis at the entire radiocarpal joint Arthri-
tis has progressed to the radiocarpal joint. An attempt
to relocate and preserve the scaphoid by ligament recon-
struction or by STT fusion will fail. Four-corner fusion
or proximal row carpectomy is indicated.
● Stage III: arthritis at the capitolunate joint Arthritis
has progressed to the capitolunate joint. The articular
surface of capitate is too degenerate to use for proximal
row carpectomy. The indicated operations are four-
corner fusion, total wrist fusion, or total wrist
arthroplasty.
● Four-corner fusion The scaphoid is excised and the
other carpal bones are fused. The resultant bone
block articulates on the lunate fossa.
● Procedure The wrist is approached through a
longitudinal dorsal incision and the scaphoid
excised piece by piece or as a block. The articular
surfaces of the lunate, capitate, triquetrum, and
hamate are denuded and decorticated. The lunate
is reduced into a neutral position if DISI defor-
mity is present. These bones are fi xed with K-
wires, screws, staples, or plates such as a circular
plate. The bone graft from the excised scaphoid
is tightly packed into the intercarpal spaces. The
wrist is immobilized in a short arm cast for 4–8
weeks until union (Fig. 10.9).
● Proximal row carpectomy After removal of the prox-
imal carpal row bones, the capitate articulates with
the radius in the lunate fossa. Usually, the lunate
fossa of the radius remains intact in stage II. If severe
degenerative change is present, other operations
should be selected.
● Procedure A longitudinal dorsal exposure of the
wrist is used. The carpus is exposed between
the third and fourth compartments, and fl aps are
raised ulnarly and radially. The proximal carpal
bones are excised by fi rst removing the lunate.
The new radiocapitate joint is temporally fi xed
with K-wires, if necessary. A volar short arm
splint is placed with the wrist in 10º of extension
for 3–6 weeks. K-wires are removed after 3–4
weeks (Fig. 10.10).
Conclusions
Scapholunate instability is the most frequent form of carpal
instability. The dissociation of the scaphoid and lunate may
not be clear, and wrist arthrography is useful to establish
the diagnosis and plan treatment. A variety of approaches
outlined above will tailor treatment based on the progres-
sion of disease.
Arthrodesis
Fusion of the scaphoid, trapezium, and trapezoid (STT) Peter-
son et al.12 reported a partial wrist arthrodesis for the scaph-
oid, trapezium, and trapezoid in the treatment of rotatory
subluxation of the scaphoid. Watson et al.13 applied STT
fusion to the treatment of chronic scapholunate dissocia-
tion before the appearance of osteoarthritic changes. This
procedure can restore the height of the radial carpus. It
decreases the fl exion–extension motion arc by 20–30% and
radioulnar deviation motion by 34–40% postoperatively.
Chronic scapholunate dissociation with osteoarthritis
(SLAC wrist)
Watson et al.14 called osteoarthritis resulting from scaph-
olunate instability or dissociation ‘scapholunate advanced
collapse’ (SLAC). SLAC wrist is classifi ed into three stages
and operations are designed based on these stages.
● Stage I: arthritis at the radial styloid Arthritic change
in SLAC wrist usually begins between the scaphoid and
the radial styloid. Styloidectomy or STT fusion with
radial styloidectomy is performed for pain relief.

Wrist Reconstructive Procedures
147
A
B
FIGURE 10.10 Radiograph of the proximal row carpectomy procedure for SLAC wrist. A Preoperative radiograph showing osteoarthritic change
at the radiocarpal joint and scapholunate dissociation. B Postoperative radiograph. The scaphoid, the lunate, and the triquetrum are excised
and the new radiocapitate joint is temporally immobilized with K-wires.
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technique. Orthop Clin North Am 2001; 32: 247–261.
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fi xation of scaphoid fractures via an arthroscopically assisted dorsal
approach. J Bone Joint Surg [Am] 2002; 84-A: 21–36.
3. Slade JF 3rd, Geissler WB, Gutow AP, Merrell GA. Percutaneous
internal fi xation of selected scaphoid non-unions with an
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4. Rüsse O. Fracture of the carpal navicular. Diagnosis, non-operative
treatment, and operative treatment. J Bone Joint Surg [Am] 1960;
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pathomechanics and progressive perilunar instability. J Hand Surg
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[Am] 1996; 21: 561–566.
8. Minami A, Kaneda K. Repair and/or reconstruction of scapholunate
interosseous ligament in lunate and perilunate dislocations. J
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Surg 1968; 11: 306–314.
10. Blatt G. Capsulodesis in reconstructive hand surgery. Dorsal
capsulodesis for the unstable scaphoid and volar capsulodesis
following excision of the distal ulna. Hand Clin 1987; 3:
81–102.
11. Brunelli GA, Brunelli GR. A new technique to correct carpal
instability with scaphoid rotary subluxation: a preliminary report. J
Hand Surg [Am] 1995; 20: S82–85.
12. Peterson HA, Lipscomb PR. Intercarpal arthrodesis. Arch Surg
1967; 95: 127–134.
13. Watson HK, Hempton RF. Limited wrist arthrodeses.
I. The triscaphoid joint. J Hand Surg [Am] 1980; 5:
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149
C H A P T E R
11
Arthrodesis Techniques
Takaya Mizuseki
INTRODUCTION
With the advancement of medical technology and the
pursuit of a better quality of life, new types of arthroplasty
procedure are being devised for small joints. Some of them
have withstood the test of time and are being accepted in
place of arthrodesis, whereas others have not. Even with
the revolutionary improvement in arthroplasty procedures,
arthrodesis is still the most reliable method to stabilize the
joint and alleviate pain. When appropriately indicated and
performed, arthrodesis provides reasonable results.
PREOPERATIVE CONSIDERATIONS
Before embarking on arthrodesis, it is mandatory to look
for every possible way to preserve joint function, including
debridement and osteotomy.1 To fuse the joint means to
stabilize and alleviate pain by sacrifi cing motion. The cost
of fusion is substantial.
Position of arthrodesis
The optimal position for arthrodesis differs by joint loca-
tion, gender, and disease type.
The recommended position of wrist fusion differs from
disease to disease and from person to person. Generally
speaking, in the normal working population fusion in slight
extension is preferred, with the wrist in a neutral degree of
radioulnar deviation.2 For the rheumatoid wrist, the pre-
ferred angle of fusion is still debatable.3–6 The author prefers
a slightly fl exed wrist position on the dominant hand, and
a slightly extended position on the non-dominant hand, as
for the rheumatoid patient hygiene and perineal care are
easier with a fl exed wrist.
For thumb fusion, the recommended angle of the car-
pometacarpal (CMC) joint fusion is 45º of palmar abduc-
tion and 20º of radial abduction for manual workers, and
30–40º radial abduction for women (Fig. 11.1). Women and
non-manual workers more often complain of inability to
make a ‘fl at hand’ after surgery than do manual workers,
for whom stronger grasp is more important, so that for
those to whom push-up with an open hand is important it
is wise to give the thumb more radial abduction. The thumb
metacarpophalangeal (MP) joint is fused in slight fl exion if
the interphalangeal (IP) and the CMC joints are intact. It
should be fused with more fl exion if the thumb IP joint has
a tendency towards hyperextension contracture. The thumb
IP joint is fused in 0–15º of fl exion.
For the distal interphalangeal (DIP) joints of the fi nger
a slight fl exion of 10–20º is advised. Some women patients,
however, prefer straight fusion. Therefore, one should
discuss with the patient the desirable fusion angle before
surgery. For the PIP joints, the angle of arthrodesis is
increased 5º towards each of the ulnar digits. For example,
in the index fi nger the recommended fusion angle is 30º,
in the long fi nger 35º, in the ring fi nger 40º and in the little
fi nger 45º.
For the MCP of the fi ngers it is better not to fuse,
because the arc of motion of the fi ngers is initiated at the
MCP joint. However, when there is no other choice but to
fuse, the preferred angle is 20–30º of fl exion in the index
fi nger, with an increasing angle towards the ulnar digits
(Fig. 11.2).
Joint surface preparation
To achieve uneventful fusion, surface preparation is impor-
tant to enable snug contact between the bones and appro-
priate positioning of the joint.
Flat angle
Flat angle preparation is easy because it can be achieved
with a bone saw to prepare the surface, but it is not so easy
to prepare the surface precisely fl at at the intended angle.7
This can inherently result in malposition or poor apposi-