Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Dorsal tMCPJ Dislocations
Most dorsal dislocations are reducible. As with other MCPJ dislocations, the maneuver should avoid
longitudinal traction. Instead, hyperextend and then use volar and distal pressure on the base of the
proximal phalanx. This can be aided by local anesthetic block, and intra-articular insufflation.
When a dorsal dislocation cannot be reduced, it is usually due to volar plate or FPL interposition. Volar
plate obstruction is often made worse by the inclusion of the sesamoid bones, and when this occurs
operative intervention is usually required. The FPL can create a noose around the metacarpal head/neck
with the displaced thenar muscles, also making the dislocation irreducible.
If open reduction is required, the surgical approach can be dorsal, volar, or lateral. If using a dorsal
approach, the goal is to find the interval between the extensor pollicis longus and extensor pollicis brevis
tendons to approach the joint capsule. If approaching volar, be cautious about the potential for displaced
neurovascular bundles directly under the skin.
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Volar tMCPJ Dislocation
Volar tMCPJ dislocations are very rare, and in general are not reducible closed.
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Thumb Carpometacarpal Joint
The articular surfaces of the thumb carpometacarpal joint (tCMC)—connecting the base of the thumb
metacarpal with the distal aspect of the trapezium—resemble two opposed saddles. This arrangement
facilitates motion in three planes: flexion-extension, pronation-supination, and abduction-adduction. The
concavoconvex relationship confers some stability, but a complex ligamentous system and thick joint
capsule are the primary sources of tCMC stabilization. 42 The four major ligaments are volar (aka volar
oblique, anterior oblique), intermetacarpal, dorsal-radial, and dorsal oblique (aka posterior oblique).
Abductor pollicis longus inserts over the dorsal joint, stabilizing the dorsal ligamentous structures. The
volar oblique ligament connects the trapezium to the volar beak of the thumb metacarpal, and although
there have been recent debates on this issue, the volar oblique ligament is largely believed to provide the
major stabilizing force against dorsal metacarpal displacement. This stability is critical in pinch forces.
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Thumb CMC Dislocation
These injuries are generally all dorsal dislocations. Although debated, it is generally believed that the
dorsal-radial ligament must be torn, along with avulsion of the volar oblique ligament off of the
metacarpal beak, to facilitate dislocation of the tCMC. 42,43
Although a complete dislocation is easier to identify, it is also quite rare. More commonly, these injuries
are partial dislocations.
Evaluate plain radiographs as well as stress radiographs.
Standard PA and lateral views
Stress view is PA of both thumbs, parallel to the X-ray plate, with distal phalanges pressed
together along the radial borders.
Confirm no associated metacarpal base fracture.
Considering that these injuries are rare, and that partial dislocations/tears are often missed due to the
subtle nature of the presentation, the clinical experience with these injuries is limited. 44
Closed reduction is often possible, but it is important to confirm that reduction is maintained and
that the joint is stable.
If stable after reduction, immobilize with plaster.
Reexamine in 5 to 7 days, and if still stable treat with casting for a total of 6 weeks.
If the joint remains unstable, surgical intervention is required.
Closed reduction augmented with pin fixation has been attempted, but in limited series this
treatment still resulted in long-term instability.
Many providers go directly to ligament reconstruction techniques to treat tCMC injuries with
persistent instability after initial reduction.
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Finger Carpometacarpal Joints
The carpometacarpal joints (CMC) of the index, middle, ring, and small fingers have different degrees of
inherent stability and range of motion, with the ring and small finger CMCs being most mobile. As a
result, these CMC joints are also most likely to sustain dislocation. The most difficult aspect in managing
finger CMC dislocations is identifying these injuries, as the findings are often subtle, and radiographs can
be difficult to interpret.
In evaluating X-rays of possible CMC dislocation, any of the following should raise concern 45 :
Loss of parallel M lines (Figure 80.9)
Asymmetry of the CMC joint spaces: all should be 1 to 2 mm wide
Loss of parallel joint lines for each CMC on PA view
Cortical overlap at the CMC interface
Indistinct cortical rims of the metacarpals
Metacarpal axis (on lateral/oblique view) that does not parallel the other metacarpals
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FIGURE 80.9 Parallel M-lines guide the evaluation of finger CMC joint congruency.
If X-rays are inadequate, evaluate under active fluoroscopy if available. CT scan may be needed to assess
for dislocation/joint alignment if unable to clearly visualize via X-ray or fluoroscopy.
Once a CMC dislocation is identified, the reduction maneuver is relatively easy compared to other hand
joints. Longitudinal traction with associated volarly directed pressure on the dorsal metacarpal base is
often adequate.
However, these injuries tend to be unstable and will redislocate, indicating need for operative
intervention.
In isolated dislocations, reduction and K-wire fixation are usually adequate.
If a fracture component is associated, management can be K-wires or ORIF depending on the extent
of injury.
Long-term outcomes after dislocation are relatively good with low incidence of long-term pain or
instability. Delayed presentation can result in worse outcomes. 46 Fracture-dislocations have mixed long-
term outcomes, especially for ring/small finger CMC fracture dislocations, with some patients having
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persistent pain after initial repair that necessitates conversion to fusion.
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Acknowledgments
The work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24-
AR053120-06) to Kevin C. Chung. The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of Health.
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Questions
1. An 18-year-old hit his finger on another player’s helmet during a football game and felt a pop. He
grabbed his finger and pulled it into place. However, he cannot extend the PIP joint beyond 35° of
flexion, and his distal phalanx is positioned in notable hyperextension. What soft tissue structure in
the finger is most likely injured?
a. Volar plate
b. Collateral ligament
c. Central slip
d. Sagittal band
e. Lateral band
2. A 45-year-old man presents 8 weeks after his left ring finger had been hit with a softball. He noted
pain and swelling, as well as difficulty using the finger, but did not seek treatment until now. The
patient has 90° of mildly painful active flexion at the PIP joint, and the finger deviates ulnarly during
flexion. X-ray reveals destruction of 45% of the volar base of the middle phalanx with dorsal
subluxation of the middle phalanx. What treatment should be offered to help preserve range of
motion while correcting the deviation and improving pain?
a. PIP fusion
b. Buddy straps and therapy
c. Volar plate arthroplasty
d. Hemihamate arthroplasty
e. Dynamic external fixation
3. A 20-year-old female presents 8 weeks after jamming her long finger. On examination, a passively
correctable boutonniere deformity is identified. Active range of motion is preserved at the PIP and
DIP joints. X-ray reveals no fracture. What is the best initial treatment?
a. Splinting of the PIP and DIP in extension
b. Volar plate arthroplasty
c. Splinting of the PIP in extension while allowing active ROM at the DIP
d. DIP fusion
e. Kirschner wire pinning of the DIP and PIP in full extension
4. A 48-year-old man presents with thumb pain 3 days after an injury. He has swelling over the
thumb MCP joint. He is unable to pinch due to pain, and radial deviation stress of the MCP is painful
and unstable. X-ray shows a small fracture off the proximal phalanx base with a displaced fracture
fragment seen at the level of the proximal MCP joint. What is the appropriate treatment?
a. Closed reduction and splinting
b. Open ligament repair
c. Early occupational therapy
d. Closed reduction and percutaneous pinning
5. A 32-year-old police officer presents after feeling a pop in her hand during a training exercise. No
soft tissue injuries or lacerations. On examination, she has pain over the dorsum of her hand. No
limitations in range of motion. She has notable painful subluxation of the middle finger extensor
tendon during range of motion. What is the most likely diagnosis and the best initial treatment?
a. Sagittal band rupture; splinting with middle finger MCP in extension
b. Sagittal band rupture; open repair
c. Sagittal band rupture; buddy straps and early active range of motion
d. Central slip rupture; splinting with PIP joint in extension and DIP active flexion therapy
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e. Central slip rupture; open repair
1. Answer: c. The patient has an acute boutonniere deformity, identified by the fixed position of PIP
flexion and DIP hyperextension. This is caused by a rupture of the central slip over the dorsal
PIP/middle phalanx. With the central slip detached, the lateral bands (which are held in position in
part by their attachments to the central slip) are able to subluxate volarly on the finger, creating the
boutonniere deformity.
2. Answer: d. The patient has a delayed presentation of fracture/dislocation of the PIP joint with
subluxation of the middle phalanx. Although his range of motion is reasonable (the reconstructive
PIP options do not reliably restore more than 90° of flexion), he has notable scissoring and
discomfort. The hemihamate arthroplasty is the only option on the list that is adequate for such a
substantial injury to the PIP and preserves motion. Fusion will leave no motion, buddy straps will
not correct the scissoring long term, volar plate arthroplasty is unreliable for a fracture that involves
so much of the volar base of P2 especially with a delayed presentation, and the external fixator will
only work in the acute setting when the fracture is still malleable.
3. Answer: c. With a passively correctable boutonniere deformity due to a central slip injury, even
when presenting 8 weeks after injury, splinting the PIP in extension is the best first-line treatment.
The extension position provides better continuity for the central slip to heal in appropriate position,
while allowing DIP range of motion helps pull the lateral bands more dorsal and prevents
unnecessary stiffness. Holding both joints in full extension is unnecessary, and by not allowing DIP
flexion may even prevent the deformity from properly correcting. None of the other options will
correct the deformity.
4. Answer: b. Patient presents with an UCL injury and associated Stener lesion. The fracture
fragment represents a distal avulsion of the ligament with displacement preventing successful closed
treatment. The appropriate treatment is open repair.
5. Answer: a. Sagittal band ruptures can be quite painful without notable functional limitation.
Localizing the site of pain and identifying the subluxation of the extensor tendon help confirm the
diagnosis. Especially when identified early, most sagittal band ruptures can be treated closed using a
reverse yoke splint that keeps the MCP in extension while allowing active range of motion of the
finger to prevent stiffness in other joints.
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References
Eaton, RG, Littler, JW. Joint injuries and their sequelae. Clin Plast Surg. 1976;3:85-98.
Eaton, RG, Glickel, SZ, Littler, JW. Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb. J
Hand Surg. 1985;10A:645-654.
Hart, DP, Blair, WF. Acute dorsal fracture-dislocation of the proximal interphalangeal joint. J Iowa Med Soc. 1983;73:359-363.
Haase, SC, Chung, KC. Current concepts in treatment of fracture-dislocations of the proximal interphalangeal joint. Plast Reconstr Surg.
2014;134:1246-1257.This article provides an excellent comprehensive review of the available techniques and evidence for treating fracture-dislocations
of the PIP joint. The approach to these challenging injuries has evolved in recent years, and this article presents a clear review and summary of key
studies.
McElfresh, EC, Dobyns, JH, O’Brien, ET. Management of fracture-dislocation of the proximal interphalangeal joints by extension-block
splinting. J Bone Joint Surg Am. 1972;54A:1705-1711.
Viegas, SF. Extension block pinning for proximal interphalangeal joint fracture dislocations: preliminary report of a new technique. J Hand
Surg Am. 1992;17A:896-901.
Badia, A, Riano, F, Ravikoff, J, et al. Dynamic intradigital external fixation for proximal interphalangeal joint fracture dislocations. J Hand
Surg Am. 2005;30A:154-160.
Ellis, SJ, Cheng, R, Prokopis, P, et al. Treatment of proximal interphalangeal dorsal fracture-dislocation injuries with dynamic external
fixation: a pins and rubber band system. J Hand Surg Am. 2007;32:1242-1250.
Ruland, RT, Hogan, CJ, Cannon, DL, Slade, JF. Use of dynamic distraction external fixation for unstable fracture-dislocations of the proximal
interphalangeal joint. 
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Eaton, RG, Malerich, MM. Volar plate arthroplasty of the proximal interphalangeal joint: a review of ten years’ experience. J Hand Surg.
1980;5A:260-268.
Calfee, RP, Kiefhaber, TR, Sommerkamp, TG, Stern, PJ. Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic
proximal interphalangeal fracture-dislocations. J Hand Surg Am. 2009;34:1232-1241.This case series presents 33 patients after hemihamate
arthroplasty. Although the study is retrospective, the manuscript nicely reviews the procedure, indications, critical elements of the technique,
postoperative management, and comprehensive outcomes. It is one of the more complete representations of this relatively new procedure and helped
clarify approach and outcomes expectations as the hemihamate has become more frequently used in PIP reconstruction.
Williams, RM, Kiefhaber, TR, Sommerkamp, TG, Stern, PJ. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using
a hemi-hamate autograft. J Hand Surg Am. 2003;28:856-865.
Baugher, WH, McCue, FC III. Anterior fracture-dislocation of the proximal interphalangeal joint: a case report. J Bone Joint Surg Am.
1979;61A:779-788.
Rosenstadt, BE, Glickel, SZ, Lane, LB, Kaplan, SJ. Palmar fracture dislocation of the proximal interphalangeal joint. J Hand Surg Am.
1998;23:811-820.
Ali, MS. Complete disruption of collateral mechanism of proximal interphalangeal joint of fingers. J Hand Surg Br. 1984;9:191-193.
McCue, FC, Honner, R, Johnson, MC, Gieck, JH. Athletic injuries of the proximal interphalangeal joint requiring surgical treatment. J Bone
Joint Surg Am. 1970;52:937-956.
Kamnerdnakta, S, Huetteman, HE, Chung, KC. Complications of proximal interphalangeal joint injuries: prevention and treatment. Hand
Clin. 2018;34:
 267-288.This is another review article that should be seen by anyone learning about and treating PIP joint injuries. The authors provide
a very clear and thoughtful approach to the development of complications and recovery limitations after PIP injuries, and take a stepwise approach to
diagnosing and treating the various complications that can arise after these difficult injuries.
Abouzahr, MK, Poblete, JV. Irreducible dorsal dislocation of the distal interphalangeal joint: case report and literature review. J Trauma.
1997;42:743-745.
Naito, K, Sugiyama, Y, Igeta, Y, et al. Irreducible dislocation of the thumb interphalangeal joint due to displaced flexor pollicis longus
tendon: case report and new reduction technique. Arch Orthop Trauma Surg. 2014;134:1175-1178.
Kubota, R, Nozawa, M, Matsuda, K, Kim, S. Closed irreducible dislocation of the interphalangeal joint of the thumb: report of two cases. Chir
Organi Mov. 2009;93:85-88.
Grandizio, LC, Klena, JC. Sagittal band, boutonniere, and pulley injuries in the athlete. Curr Rev Musculoskelet Med. 2017;10:17-22.
Lee, JH, Baek, JH, Lee, JS. A reconstructive stabilization technique for nontraumatic or chronic traumatic extensor tendon subluxation. J Hand
Surg Am. 2017;42:e61-e65.
ElMaraghy, AW, Pennings, A. Metacarpophalangeal joint extensor tendon subluxation: a reconstructive stabilization technique. J Hand Surg
Am. 2013;38:578-582.
Ishizuki, M. Injury to collateral ligament of the metacarpophalangeal joint of a finger. J Hand Surg Am. 1988;13:444-448.
McLaughlin, HL. Complex “locked” dislocation of the metacarpophalangeal joints. J Trauma. 1965;5:683-688.
Patterson, RW, Maschke, SD, Evans, PJ, Lawton, JN. Dorsal approach for open reduction of complex metacarpophalangeal joint dislocations.
Orthopedics. 2008;31:1099.
Durakbasa, O, Guneri, B. The volar surgical approach in complex dorsal metacarpophalangeal dislocations. Injury. 2009;40:657-659.
Vadala, CJ, Ward, CM. Dorsal approach decreases operative time for complex metacarpophalangeal dislocations. J Hand Surg Am.
2016;41:e259-e262.
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Renshaw, TS, Louis, DS. Complex volar dislocation of the metacarpophalangeal joint: a case report. J Trauma. 1973;13:1086-1088.
Moberg, E, Stener, B. Injuries to the ligaments of the thumb and fingers: diagnosis, treatment and prognosis. Acta Chir Scand. 1953;106:166-
186.
Frank, WE, Dobyns, J. Surgical pathology of collateral ligamentous injuries of the thumb. Clin Orthop Relat Res. 1972;83:102-114.
Smith, RJ. Post-traumatic instability of the metacarpophalangeal joint of the thumb. J Bone Joint Surg Am. 1977;59A:14-21.A classic article that
reviews 86 patients with thumb ligamentous and bony injuries. It was one of the earliest comprehensive reviews of the approach to thumb collateral
ligament injuries and indications for repair.
Carlsen, BT, Moran, SL. Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries. J Hand Surg Am.
2009;34:945-952.
Pulos, N, Shin, AY. Treatment of ulnar collateral ligament injuries of the thumb: a critical analysis review. JBJS Rev. 2017;5.
Mahajan, M, Tolman, C, Wurth, B, Rhemrev, SJ. Clinical evaluation vs magnetic resonance imaging of the Skier’s thumb: a prospective
cohort of 30 patients. Eur J Radiol. 2016;85:1750-1756.
Wilppula, E, Nummi, J. Surgical treatment of ruptured ulnar collateral ligament of the metacarpophalangeal joint of the thumb. Injury.
1970;2:69-72.
Pai, S, Smit, A, Birch, A, Hayton, M. Delayed anatomical repair of ruptured ulnar collateral ligament injuries of the thumb using a
dissolvable polylactic acid bone anchor. J Trauma. 2008;65:1502-1506.
Wong, TC, Ip, FK, Wu, WC. Bone-periosteum-bone graft reconstruction for chronic ulnar instability of the metacarpophalangeal joint of the
thumb—minimum 5-year follow-up evaluation. J Hand Surg Am. 2009;34:304-308.
Edelstein, DM, Kardashian, G, Lee, SK. Radial collateral ligament injuries of the thumb. J Hand Surg Am. 2008;33:760-770.
Melone, CP Jr, Beldner, S, Basuk, RS. Thumb collateral ligament injuries: an anatomic basis for treatment. Hand Clin. 2000;16:345-357.
Doty, JF, Rudd, JN, Jemison, M. Radial collateral ligament injury of the thumb with a Stener-like lesion. Orthopedics. 2010;33:925.
Strauch, RJ, Behrman, MJ, Rosenwasser, MP. Acute dislocation of the carpometacarpal joint of the thumb: an anatomic and cadaver study. J
Hand Surg Am. 1994;19:93-98.
Bosmans, B, Verhofstad, MH, Gosens, T. Traumatic thumb carpometacarpal joint dislocations. J Hand Surg Am. 2008;33:438-441.
Simonian, PT, Trumble, TE. Traumatic dislocation of the thumb carpometacarpal joint: early ligamentous reconstruction versus closed
reduction and pinning. J Hand Surg Am. 1996;21:802-806.A retrospective case series comparing patients treated with two different approaches to a
rare condition. Although the manuscript has flaws, due to the uncommon nature of this injury it presents helpful information in the treatment
algorithm, favoring early open intervention with ligamentous reconstruction.
Fisher, MR, Rogers, LF, Hendrix, RW. Systematic approach to identifying fourth and fifth carpometacarpal joint dislocations. AJR Am J
Roentgenol. 1983;140:319-324.An early and very thoughtful review of how to approach these often-missed injuries. The helpful diagnostic and
radiographic parameters are reviewed. This article is a high-yield read to help avoid the all too common mistake of missing the CMC dislocation injury.
Zhang, C, Wang, H, Liang, C, et al. The effect of timing on the treatment and outcome of combined fourth and fifth carpometacarpal fracture
dislocations. J Hand Surg Am. 2015;40:2169-2175.
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C H A P T E R 8 1
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Ligament Injuries of the Wrist
Brett F. Michelotti
Key Points
Early identification and treatment of wrist ligamentous injury will result in the best clinical
outcomes.
Arthroscopy remains the reference standard for diagnosing wrist ligamentous injuries.
The type of operation to be performed depends on the chronicity of the injury, the presence of
reparable ligament, and presence or absence of wrist arthritis.
A salvage operation, such as a partial wrist fusion or hemiresection ulna arthroplasty, should be
considered when there is clinical and radiographic evidence of wrist arthritis.
The wrist is an extremely complex arrangement of bony and soft-tissue structures. Understanding the
normal anatomy and kinematics of the wrist helps identifying and treating the breadth of the pathology.
Soft-tissue and ligamentous injury can disrupt normal kinematic processes and lead to inflammation,
pain, and joint destruction. Ranging from partial caspuloligamentous tears to complete ligamentous
disruption and instability, degree and location of injury, as well as timing of diagnosis can impact the
type of intervention and predictability of outcomes. Delayed or missed injuries can result in irreversible
joint damage and may require a salvage operation such as a proximal row carpectomy (PRC) or
arthrodesis.
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Anatomy and Kinematics
The wrist is the connection between the forearm bones and the hand. It consists of the distal radius and
ulna, five metacarpal bases, seven tightly articulated carpal bones, and the pisiform, a sesamoid bone that
acts as a lever arm for the flexor carpi ulnaris tendon. The radius and ulna articulate with the proximal
carpal row, forming the radiocarpal and ulnocarpal joints. The proximal carpal row is made up of the
scaphoid, lunate, and triquetrum. The midcarpal joint is the articulation of the proximal and distal carpal
rows. The distal carpal row is formed by the trapezium, trapezoid, capitate, and hamate. These carpal
bones articulate with the bases of the five metacarpals.
The stability of the carpus is influenced by bony constraints and intrinsic and extrinsic ligaments. Intrinsic
ligaments originate and end within the carpus, otherwise referred to as intercarpal connections. Extrinsic
ligaments originate outside the carpus and end within the carpus.
Extrinsic ligaments may be subdivided into three major groups: palmar radiocarpal, palmar ulnocarpal,
and dorsal radiocarpal (DRC) ligaments. There are no dorsal ligaments between the ulna and the carpus.
Palmar radiocarpal ligaments consist of the radioscaphoid, radioscaphocapitate (RSC), and long and
short radiolunate ligaments. The space of Poirier is the palmar interligamentous space ulnar and
proximal to the RSC ligament. This is a weak soft-tissue space through which lunate dislocation occurs.
Arising from the base of the ulnar styloid, the ulnar capitate ligament courses obliquely to attach to the
neck of the capitate. The ulnar capitate and RSC ligaments form a V, otherwise known as the arcuate
ligament. Originating from the triangular fibrocartilage complex (TFCC) are the ulnar triquetral and ulnar
lunate ligaments.
The DRC is a wide, fan-shaped ligament connecting the dorsal edge of the distal radius to the dorsal
triquetrum; there are some deeper fibers that connect to the dorsal surfaces of the lunate and scaphoid.
The dorsal intercarpal ligament (DIC) arises from the dorsal triquetrum, traverses along the distal edge of
the lunate, and inserts with its fan-shaped terminal extensions on the dorsal rim of the scaphoid, the
trapezium, and the trapezoid bones.
Intrinsic ligaments of the proximal carpal row include the scapholunate interosseous ligament (SLIL) and
the lunotriquetral interosseous ligament (LTIL). There are many strong ligamentous attachments between
the bones of the distal carpal row, named after the bones in which they connect.
There are no tendinous attachments to the bones of the proximal carpal row. With normal wrist
mechanics, motion of the proximal carpal row is passive, meaning that it functions as an intercalated
segment with movement of bones around their articulations dictated by extrinsic ligamentous forces, bony
geometry, and interosseous ligamentous connections. The distal carpal row functions as a fixed unit, its
articulations held tightly by stout intercarpal ligaments. Movement of the radiocarpal, ulnocarpal, and
midcarpal joints is dictated by forces exerted by the tendons crossing the joints.
With radial deviation of the wrist, the scaphoid flexes. This is caused by the forces exerted on the
proximal carpal row by the bones of the distal row. A proximally directed force from the hamate into the
triquetrum forces the triquetrum to flex. With tight interosseous connections through the lunate (LTIL) to
the scaphoid (SLIL), the scaphoid is forced into a flexed position. The opposite is true during ulnar
deviation (Figure 81.1). The triquetrum extends, the lunate and scaphoid follow, assuming an extended
posture.
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FIGURE 81.1 Intrinsic ligaments of the wrist. A. Dorsal extrinsic and intrinsic ligaments of the wrist. B. Volar extrinsic and
intrinsic ligaments of the wrist. AIA, anterior interosseous artery; C, capitate; CH, capitohamate; CT, capitotrapezoid; DIC,
dorsal intercarpal ligament; DRC, Dorsal radiocarpal ligament; H, hamate; L, lunate; LRL, long radiolunate; LT, lunotriquetral; P,
pisiform; PRU, palmar radioulnar; R, radius; RA, radial artery; S, scaphoid; SC, scaphocapitate; SL, scapholunate; SRL, short
radiolunate; T, triquetrum; Td, trapezoid; Tm, trapezium; TC, triquetrocapitate; TH, triquetrohamate; TT, trapezium-trapezoid
ligaments; U, ulna; UC, ulnocapitate; UL, ulnolunate; UT, ulnotriquetral.
(Reprinted from Mayfield, JK. Wrist ligamentous anatomy and pathogenesis of carpal instability. Orthop Clin North Am. 1984;15(2):209-216. Copyright ©
1984 Elsevier. With permission.)
Disruption of intercarpal ligaments and secondary stabilizing ligaments leads to carpal instability and
altered biomechanics.
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Carpal Instability
Carpal instability, defined broadly, is abnormal carpal motion that results from injuries to the carpal
bones and intrinsic or extrinsic ligaments. Altered kinematics or dyssynchronous motion can occur within
bones of the same carpal row or between carpal rows.
Carpal instability dissociative (CID): Instability caused by injury or disease affecting the articulation
and motion of bones within the same carpal row. Examples of common dissociative instabilities
include scapholunate (SL) dissociation, lunotriquetral dissociation (LT), unstable scaphoid fracture,
nonunion or malunion, inflammatory synovitis, and advanced Kienböck disease.
Carpal instability nondissociative: Symptomatic carpal dysfunction between the radius and the
proximal row or between the proximal and distal rows, but without disruption of the interosseous
ligaments or between the bones of the same row.
Carpal instability complex: Carpal derangement that has features of carpal instability dissociative and
carpal instability nondissociative in which there is an altered relationship between the bones of the
same row and between rows. These include carpal bone dislocations, such as a perilunate dislocation
or carpal bone fracture dislocation, such as a trans-scaphoid perilunate dislocation.
Carpal instability adaptive: Instability within the carpus as a result of a deformity outside of the
proximal and distal rows. An example of carpal instability adaptive is a malunited or poorly reduced
distal radius fracture that results in altered biomechanics and arthritis of the midcarpal joint. This can
be corrected by performing a radial osteotomy, in that the surgical planning is not aimed at the
symptomatic midcarpal joint itself.
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Scapholunate Ligament Injury
Diagnosis
Early recognition and treatment of SL ligament injury can delay or prevent the onset of arthritis. In a
cadaveric study by Lee et al, 35% of cadaveric wrists had some degree of SL tear, and of those wrists with
SLIL injury, 29% had evidence of arthrosis. 1
The SL ligament is a U-shaped soft-tissue structure that has three parts with measurably different
biomechanical properties. The strongest part of the ligament runs within the deep portion of the wrist
capsule and links the dorsal scaphoid and lunate. The palmar portion of the ligament contains obliquely
oriented fibers that are weaker but permit more rotation around the lunate and play less of a role in
stability than the stronger dorsal ligament. The proximal membranous portion of the ligament does not
play a role in stabilization and often appears perforated in older individuals, but this is not a true
indication of SL instability. 2
Injury to SL ligament occurs during a fall onto an outstretched hand causing wrist hyperextension, ulnar
deviation, and midcarpal supination. With complete disruption of all the SL components, the axial load
generated by extrinsic forces on the wrist results in flexion of the scaphoid and extension of the lunate—
dorsal intercalated segment instability or DISI deformity. Less commonly, SLIL dissociation results from
attritional degeneration owing to rheumatoid arthritis, pseudogout, or Kienbock disease. 3–5 SLIL injury
should be considered along the spectrum of perilunate dislocation as described by Mayfield 6 (Figure
81.2):
Stage I: SL instability resulting from total disruption of the SLIL and secondary stabilizing ligaments
Stage II: Rupture of the midcarpal joint capsule with dorsal and proximal translation of the capitate
over the lunate
Stage III: Lunotriquetral ligament (LT) rupture and tearing of the radio-lunate-triquetral ligaments
Stage IV: Volar lunate dislocation with the remaining carpal bones in line with the radius
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FIGURE 81.2 Stage I is disruption of the scapholunate articulation. Stages II and III are separation of the capitolunate and
lunotriquetral joints. Stage IV is a volar lunate dislocation.
(From Morris, MS, Chung, KC. Lunotriquetral ligament reconstruction using a slip of the extensor carpi ulnaris tendon. In: Chung, KC , ed. Operative
Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. In press.)
SL injury itself can be categorized as predynamic, dynamic, static-
 reducible, static-irreducible, and
scapholunate advanced collapse (SLAC):
Predynamic instability is the result of partial tearing of the ligament that can present as wrist pain,
exacerbated by loading or lifting. In this stage of SLIL, X-rays are normal but the diagnosis can be
confirmed by wrist arthroscopy. 7
Dynamic instability can be diagnosed with clenched fist X-rays, which demonstrate widening of the
SL interval as the capitate is driven from distal to proximal across the SL articulation. 8
Static instability results from a complete disruption of the SLIL and tearing or attenuation of the
secondary stabilizing ligaments (scaphotrapezio-trapezoid ligament [STT], RSC ligament, and DIC
ligament). Gapping between the scaphoid and lunate (normal 1–2 mm, >4 mm with static instability)
can be observed with standard radiographs. Reducibility of the scaphoid, or correction of DISI
deformity, may signify whether a reconstruction can be performed. If the deformity is not reducible,
a salvage operation should be considered, e.g., scaphoidectomy and partial fusion versus PRC.
Long-standing carpal malalignment owing to SL ligament disruption leads to a predictable pattern of
wrist arthritis or SLAC. Standard PA X-rays may reveal radial styloid arthritis (stage I), radioscaphoid
arthritis (stage II), scaphocapitate arthritis (stage III), or pancarpal arthritis (stage IV). The degree of
arthritis and which articular surfaces have been affected or spared become important when deciding
which pain-relieving operation to perform. If the radiolunate or capitolunate joints have been affected,
the patient is not a candidate for PRC (Figure 81.3).
FIGURE 81.3 Scapholunate advanced collapse (SLAC arthritis).
(From Michelotti, BF, Chung, KC. Scaphoid excision and four-corner fusion. In: Chung, KC , ed. Operative Techniques: Hand and Wrist Surgery. 3rd ed.
Philadelphia; PA: Elsevier Saunders; 2017:244; with permission.)
Diagnosis of SL injury begins with a focused history and physical examination. History of fall onto an
outstretched hand, dorsal wrist pain, and pain that is exacerbated with axial loading should prompt
careful examination of the SL interval. Palpation over the SL ligament, just distal to the Lister tubercle
and between the EPL and EDC tendons, may elicit pain. The scaphoid shift test is performed by dorsally
directing pressure through the distal scaphoid tubercle while passively moving the wrist from ulnar to
radial. With laxity or disruption of the SL ligament, the proximal scaphoid will dislocate dorsally. A
clunk is appreciated when the bone is reduced into the scaphoid fossa of the radius. Dislocation in
association with pain should prompt further evaluation with adjunctive tests such as noncontrast MRI or
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wrist arthroscopy.
Standard three-view wrist X-rays may identify widening of the SL interval. More than 4 mm of gapping
(Terry Thomas sign) may be static SL instability but it may also be nonpathologic widening of the interval
as seen in elderly; therefore, this must be considered in the context of history and physical examination
and may be compared with the unaffected side.
A true PA X-ray may reveal the signet ring sign, where the distal pole of the scaphoid projects through the
proximal pole and appears as a ring. With tearing or attrition of the secondary stabilizing ligaments (STT,
DIC, RSC), the scaphoid assumes a flexed position and the lunate extends (DISI deformity). The SL angle
is normally between 30° and 60° (mean 47°) but with DISI deformity, the angle exceeds 60° (Figure 81.4).
FIGURE 81.4 A. Scaphoid ring sign and Terry Thomas sign. B. Lateral radiograph demonstrating an increased SL angle.
(From Michelotti, BF, Chung, KC. Scapholunate ligament reconstruction. In: Chung, KC , ed. Operative Techniques: Hand and Wrist Surgery. 3rd ed.
Philadelphia, PA: Elsevier Saunders; 2017:185; with permission.)
In the patient with pain but normal X-ray findings (possible predynamic instability) or with evidence of
dynamic instability (gapping of the SL interval with wrist loading), arthroscopy may be performed to
further characterize the injury pattern. Geissler described an arthroscopic grading system to classify
interosseous ligament injury 7 :
Grade I: Attenuation and hemorrhage of interosseous ligament seen from radiocarpal joint, with no
step-off present as seen from midcarpal joint
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Grade II: Attenuation and hemorrhage of interosseous ligament seen from radiocarpal joint, with
step-off seen through midcarpal joint; the probe can be placed between the scaphoid and lunate
Grade III: Incongruence or step-off is seen between the scaphoid and the lunate from both the
radiocarpal and midcarpal portals; the probe can be placed and freely rotated between the scaphoid
and lunate
Grade IV: Incongruence or step-off is seen between the scaphoid and lunate from both the
radiocarpal and midcarpal portals; gross instability is noted, and the 2.7 mm arthroscope may be
passed through the gap between the scaphoid and lunate
Grades I to III of the Geissler classification system represent partial injury to the SLIL or predynamic
instability. Grade IV represents complete disruption of the SLIL and dynamic instability.
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Treatment
Treatment of SL pathology is dictated by the degree of ligamentous disruption and the chronicity of the
injury.
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Predynamic Instability
Arthroscopic debridement and percutaneous pinning of SL interval
Proprioceptive rehabilitation
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Dynamic Instability, Direct Repair Possible
Dorsal SLIL repair with or without capsulodesis
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Dynamic Instability, Direct Repair Not Possible
Ligamentous reconstruction from DIC and palmaris graft
Bone-tissue-bone graft
Three-ligament tenodesis
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Static, Reducible Instability
Three-ligament tenodesis
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SLAC
Scaphoidectomy and partial fusion
PRC
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Predynamic Instability
Initial treatment of suspected predynamic SL should consist of a trial of bracing and nonsteroidal anti-
inflammatories. If this fails to reduce pain localizing to the SL interval, Geissler and others suggest that
predynamic instability (Geissler grade I to III) can be treated by arthroscopic debridement and/or
percutaneous pinning of the SL interval. 7,9,10 Chronic predynamic instability has also been treated with
selective proprioceptive rehabilitation, arthroscopic debridement, or capsular shrinkage. Whipple
determined that in patients who were treated within 3 months of injury, 83% remained symptom-free and
maintained their reduction in up to 7-year follow-up. 9
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Dynamic Instability
Treatment of dynamic instability depends on whether the ligament is repairable. Assuming it has been
only 6 weeks from the time of injury (acute), the ligament can either be repaired (midsubstance tear) or
anchored to the bone with bone tunnels or suture anchors. Repair of the dorsal portion of the SL ligament
is all that is required to restore normal relationships between the carpus. 2,11,12
When direct repair of the ligament is not possible, a three-ligament tenodesis, or bone-tissue-bone
ligament reconstruction may be considered 13–15 (Figure 81.5). Proponents of the bone-tissue-bone
construct suggest that bone-to-bone contact may heal more predictably than a bone-tendon interface.
However, studies have shown that the tissue portion of the graft may stretch and fail, the bone graft may
not unite, and, with static instability, rotatory subluxation of the scaphoid cannot be addressed.
FIGURE 81.5 Tendon reconstruction of the scapholunate interosseous ligament (Brunelli and modifications). FCR, flexor carpi
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radialis.
(From Michelotti, BF, Chung, KC. Scapholunate ligament reconstruction. In: Chung, KC , ed. Operative Techniques: Hand and Wrist Surgery. 3rd ed.
Philadelphia, PA: Elsevier Saunders; 2017:199; with permission.)
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Static, Reducible Instability
When the secondary stabilizing ligaments of the scaphoid fail because of an acute, high-energy injury, or
over time with attrition (STT, DIC, RSC), the scaphoid assumes a flexed, pronated posture. It is important
to carefully examine the patient for the ability to reduce or correct the DISI deformity and for the absence
of articular wear, as both are a contraindication for reconstruction.
The initial three-ligament tenodesis uses a portion of the flexor carpi radialis (FCR) tendon to pass
through a bone tunnel in the scaphoid, from palmar to dorsal, to improve the abnormally flexed posture
in addition to reconstructing the dorsal portion of the SL ligament. The distal tendon graft is anchored to
the radius. This was well tolerated but resulted in average loss in wrist flexion of 45% as compared with
the unaffected side. 16 A modified tenodesis addressed the decrease in wrist flexion by anchoring the FCR
tendon to the dorsal lunate instead of crossing the radius. 17 In the patient with dynamic or static-
reducible instability, long-term data suggest that the modified Brunelli tenodesis is effective at reducing
pain, may permit near-normal wrist motion, and will likely improve patient-reported outcome measures.
Some patients still develop SLAC arthritis and will need wrist fusion procedures. 18,19
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Static, Irreducible Instability
When the DISI deformity is fixed and cannot be reduced, or there are signs of articular wear, the patient
is no longer a candidate for ligamentous reconstruction but should be counseled on salvage procedures
for pain relief. Rotatory subluxation of the scaphoid, around the RSC ligament, results in abnormal
contact of the scaphoid with the radial styloid and scaphoid fossa of the radius. Over time, this leads to
articular wear and a predictable progression of arthritis beginning with the radial styloid, progressing to
the radioscaphoid articulation, scaphocapitate and lunocapitate joints, and finally to the lunate fossa. The
most common salvage procedures aimed at relieving wrist pain caused by SL or SLAC are
scaphoidectomy and intercarpal fusion, and PRC. Recent data suggest that the PRC is more cost-effective.
20
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Rehabilitation and Recovery
Painless motion is the goal of an SL repair or reconstruction. Patients are immobilized in a wrist brace for
8 weeks or until K-wires are removed. Gentle range of motion exercises is initiated and gradually
advanced over 3 months. Protecting the reconstruction assures its durability and long-term effectiveness,
therefore, a subtle loss in motion is accepted. Patients are counseled to expect loss of motion after any
type of wrist surgery.
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Lunotriquetral Ligament Injury
Diagnosis
Injury to the LT in isolation is a rare but commonly overlooked diagnosis. This injury may be
encountered in a patient with concomitant ulnar-sided wrist pathology and is often seen in athletes who
participate in high-energy or impact sports. 21 Lunotriquetral injury can occur after a fall onto an
outstretched wrist with a dorsally directed force through a volar-flexed wrist, or as part of the perilunate
instability spectrum with pressure directed through the thenar region as the wrist is extended and ulnarly
deviated.
The LT is similar to the SL in that it is a U-shaped, interosseous ligament, connecting the lunate to the
triquetrum, stabilizing the LT joint. The LT ligament also consists of a dorsal, membranous, and volar
portion but differs from the SL ligament in that its volar portion is the strongest. Secondary stabilizers of
the LT interval include radiolunotriquetral ligament and the DRC.
The triquetrum is tightly articulated with the hamate, and it is through this interaction that the proximal
and distal carpal rows are linked. With radial deviation, the hamate forces the triquetrum to flex, which
translates through the LT and SL ligaments resulting in scaphoid flexion. With ulnar deviation, the
hamate drives the triquetrum into extension, carrying the lunate and scaphoid into extension as well.
With disruption of the LT ligament, and the secondary stabilizing ligaments, in the absence of a
concomitant SL tear, the lunate remains tightly articulated with the scaphoid and assumes a flexed
position (Figure 81.6). LT injury also exists along an injury spectrum with both dynamic and static
instability. With static instability, the SL angle becomes more acute (<30°, normal 30°–60°, mean 47°),
known as volar intercalated segment instability.
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FIGURE 81.6 Radiographic evidence of lunotriquetral ligament dissociation.
(From Morris, MS, Chung, KC. Lunotriquetral ligament reconstruction using a slip of the extensor carpi ulnaris tendon. In: Chung, KC , ed. Operative
Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. In press.)
LT ligament injury can occur with progressive perilunate instability. According to the Mayfield
classification system, stage III perilunate instability occurs after a scaphoid fracture or SL tear, dorsal
dislocation of the capitolunate joint, and tear of the LT.
Patients often present with ulnar-sided wrist pain, weakness with grip, sensation of instability, and
possibly ulnar nerve paresthesias. 22 A systematic examination of the wrist must be performed in an
attempt to rule out other sources of ulnar-sided wrist pain. Tenderness with direct palpation of the LT
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interval, between the fourth and fifth dorsal compartment tendons, should prompt further evaluation for
LT injury. The LT ballottement test will result in pain with compression of the lunate and triquetrum. 23
The shear test is the most specific for LT injuries. While supporting the body of the lunate, the examiner
compresses the pisotriquetral joint and generates a force across the LT interval. Increased pain during this
maneuver may be because of an LT injury.
Standard, three-view wrist X-ray series may reveal gapping of the LT interval or volar intercalated
segment instability deformity. Careful examination of static and dynamic X-rays may demonstrate
disruption of the Gilula arcs (Figure 81.7), overlap of the lunate and triquetrum, or motion of the
scaphoid and lunate independent of the triquetrum. 24 Standard arthrography, MR arthrography, and
arthroscopy have been used to detect LT tears. 25–29 Several studies have demonstrated a high rate of
membranous LT tears, where there is passage of contrast across the LT interval. A tear in this portion of
the LT ligament may not be of biomechanical consequence. Arthroscopy remains the reference standard
for diagnosing, classifying, and possibly treating functionally significant LT injury. 29,30
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FIGURE 81.7 Gilula arcs. 1. Proximal aspect of proximal carpal row, 2. Distal aspect of proximal carpal row, and 3. Proximal
aspect of distal carpal row.
(Reproduced with permission from Chhabra, AB, Miller, CD, Wall, L. Imaging. In: Hammert, WC , et al, eds. ASSH Manual of Hand Surgery. Philadelphia, PA:
Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010:7-28.)
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Treatment
Acute LT Injury
Treatment of LT injuries depends on the degree of instability (dynamic versus static), timing of injury
(acute versus chronic), and the presence of articular degeneration as a result of biomechanical alterations.
For acute injuries, an initial trial of 6 weeks of nonoperative management with brace or cast
immobilization and nonsteroidal anti-inflammatories should be attempted.
31 With failure of
nonoperative treatment, as evidenced by continued pain or instability, operative treatment is performed.
Arthroscopy remains the mainstay of diagnosis and treatment in acute, dynamic LT injury. The LT joint is
best visualized and interrogated via the midcarpal joint. 32 The joint is normally tightly articulated but
gapping may be appreciated when scope is directed between the lunate and triquetrum. Systematic,
diagnostic wrist arthroscopy will also permit identification of other wrist pathologies including TFCC
injury and articular wear.
Arthroscopic debridement of a fraying LT ligament or synovitis may be performed. 33 Following
debridement, reduction of the joint and pin fixation of the LT interval may aid in healing of the ligament.
Where Geissler grade IV instability is noted (arthroscope is passed freely between the lunate and
triquetrum), direct repair should be performed. A direct approach to the wrist permits identification of
the LT interval and reattachment of the ligament to the triquetrum with bone tunnels or suture anchors.
A secondary volar approach (through the floor of the carpal tunnel) may be necessary to repair the volar
portion of the ligament. Supplemental K-wire fixation is left in place for 8 weeks, at which point the wires
are removed and range of motion is initiated. Painless range of motion and prevention of wrist arthrosis
can be achieved. 22,34
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Chronic LT Injury
A trial of NSAIDs and brace immobilization should be attempted for 3 months prior to surgical
intervention. If this fails, a reconstruction or fusion of the LT interval may be considered. A slip of
extensor carpi ulnaris (ECU) tendon can be used to reconstruct the dorsal portion of the LT ligament with
good results. 35 Lunotriquetral arthrodesis is less predictable to achieve fusion. 34,36 In patients with
concomitant ulnocarpal abutment, an ulnar shortening osteotomy may be beneficial. 34,37
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Perilunate Dislocation
Diagnosis
Perilunate dislocations are uncommon high-energy soft-tissue injuries (lesser arc injury) and sometimes
combined bony and soft-tissue injuries (greater arc injury). 38 As previously discussed in this chapter,
perilunate injury progresses as a sequential pattern of ligamentous disruption, starting from the SLIL
(Mayfield stage I). As the energy is transmitted around the lunate, the lunocapitate joint is disrupted
(Mayfield stage II), followed by tear of the LT (Mayfield stage III), and finally volar dislocation of the
lunate from its fossa (Mayfield stage IV). These injuries are most commonly seen in young men as a result
of a fall from height, motor vehicle collision, or sports-related accident.
Patients with perilunate injury or dislocation will complain of pain, swelling, and decreased range of
motion in the affected extremity. It is important to inquire about median nerve symptoms as acute carpal
tunnel syndrome is present in approximately 25% of patients. 39 Patients must be evaluated with a
standard three-view X-ray series. With perilunate injuries, there is a disruption of the Gilula arcs and
overlapping of the normally tightly articulated carpal bones.
Careful examination of the distal radius, scaphoid, capitate, hamate, and triquetrum must be performed,
as there may be associated fractures. 40,41 Radius or carpal bone fractures associated with intercarpal
ligamentous disruption around the lunate are described as trans-bony, perilunate injuries. For example, a
scaphoid fracture associated with a perilunate dislocation is described as a trans-scaphoid, perilunate
dislocation. In stage IV lunate dislocation, the lunate remains attached to the short radiolunate ligament
and is seen on the lateral X-ray, displaced volarly, within the carpal tunnel. With a perilunate dislocation,
the lunate remains within its fossa on the radius, and the remainder of the carpus is dislocated (Figure
81.8).
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FIGURE 81.8 Transradial styloid perilunate fracture dislocation. A-C. Prereduction X-rays. D-F. Postreduction X-rays.
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Treatment
Careful assessment of the median nerve will guide early treatment. In a stage IV perilunate dislocation
(volar lunate dislocation), median nerve symptoms will be present. Reduction of the lunate must be
performed in the acute setting. To reduce the lunate with the goal to decrease the pressure over the
median nerve before definitive repair, the patient may need to be sedated and traction must be applied.
The reduction maneuver involves hyperextending the carpus to recreate the injury, dorsally directing
pressure on the lunate to reduce it to the radius and to permit capitate reduction onto the lunate. With
volar flexion and continued traction, a palpable clunk and gross correction of the deformity will occur.
Postreduction X-rays must be performed to confirm that the lunate has been successfully reduced. If
closed reduction fails, the patient should be taken to the operating room for open reduction. This may be
the result of interposed soft tissue. 42 If closed reduction and splinting can be performed acutely, the
patient must be observed for progression of median nerve symptoms. If the patient has progressively
worsening paresthesias and pain (acute carpal tunnel syndrome) despite a successful reduction, he/she
must be taken to the operating room for release of the carpal tunnel. Mild paresthesias, without
progressing pain, do not require urgent operative decompression.
When closed reduction can be achieved, it is acceptable to delay surgery for up to 2 weeks following the
injury. This permits a reduction in swelling that may make the open ligamentous exploration and repair
easier. Operative treatment with open repair of injured structures may decrease the rate of subsequent
DISI deformity and resulting articular wear as compared with casting or splint immobilization. 43 The
interosseous ligaments may be approached from dorsal or by a combined dorsal and volar approach,
decompressing the carpal tunnel and repairing the volar capsule and interosseous ligaments. 44–46
Supplemental K-wires are used to immobilize the proximal and distal rows where indicated and removed
at 8 weeks following surgery.
Although this is a high-energy injury, many patients return to work and few have permanent disability.
Range of motion, grip strength, and presence of arthritis are variable. 43,47,48
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Distal Radioulnar Joint and Triangular Fibrocartilage Complex Injury
Diagnosis
The ulna is the fixed unit of the forearm, and muscular forces permit radius rotation (pronation and
supination) around the ulna at the level of the distal radioulnar joint (DRUJ). The DRUJ consists of the
sigmoid notch of the radius and ulnar head. Each of these surfaces is covered by articular cartilage. The
curvature of the sigmoid notch is larger than that of the ulnar head, which allows for palmar and dorsal
translation of the radius in relation to the ulna.
Soft-tissue constraints of the DRUJ include the TFCC, the palmar and dorsal radioulnar ligaments, the
ulnar collateral ligament, the joint capsule, and the interosseous membrane. Muscles that act as dynamic
stabilizers include the ECU and pronator quadratus.
The TFCC consists of many soft-tissue structures and acts as both a stabilizer of the DRUJ and shock
absorber of loads transmitted through the ulnar side of the wrist. Structures include the dorsal and
palmar radioulnar ligaments, the articular disk, the ulnocarpal ligaments, the ECU subsheath, and the
meniscus homologue (Figure 81.9).
FIGURE 81.9 Triangular fibrocartilage complex and related anatomy.
(Reproduced with permission from Dy, CJ, Ouellette, EA, Makowski, AL. Extra-articular reconstructive techniques for the distal radioulnar and ulnocarpal
joints. In: Wiesel, S , ed. Operative Techniques in Orthopaedic Surgery. 2nd ed. Vol 3. Philadelphia, PA: Wolters Kluwer; 2016:3016. Figure 64-10.)
Dislocation of the DRUJ may occur as an isolated soft-tissue injury or with a fracture of the radius (distal
radius fracture, Galeazzi fracture). Ulnar-sided wrist problems, including TFCC injury, occur up to 37%
of the time with an associated distal radius fracture. 49,50 Patients present with swelling, pain, and
deformity. TFCC injury with associated fracture may present as ulnar-sided wrist pain, becoming
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clinically apparent after healing of the radius fracture. Radiographic indicators of DRUJ instability
include the following:
Base of ulnar styloid fracture
Dislocation of the DRUJ
Sigmoid notch fracture
Widening of the DRUJ
Radial shortening or loss of radial inclination
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Treatment
Acute DRUJ Injury
Treatment begins with anatomic reduction of a radius fracture when present. An isolated dislocation
should be reduced and the joint assessed for stability in neutral, pronation, and supination. While the
joint is stable in supination, the patient is placed in a long-arm splint or cast, in that position, for 4 to
6 weeks. If the joint is unstable in all directions, and an ulnar styloid fracture is present, the fracture
should be reduced and fixed. If no ulnar styloid fracture is present, the soft-tissue structures (TFCC) may
be repaired, and the reduced DRUJ is pinned for 4 to 6 weeks.
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Chronic DRUJ Instability
In patients with clinically apparent instability of the DRUJ (translation of the radius on the ulna at the
sigmoid notch with associated pain), and no evidence of arthritis, one should consider a reconstruction.
Nonoperative treatment with bracing for 6 to 12 weeks should be attempted prior to operating.
Distal radius or ulnar malunion should be ruled out as a possible cause of instability and corrected where
present. If purely ligamentous failure is suspected, a reconstruction is performed using palmaris longus
tendon. The goal of reconstructive surgery is to permit a painless arc of forearm motion.
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TFCC Injury
Treatment depends on the acuity of the injury. Palmer developed a classification system based on time to
presentation and the location of the TFCC tear and/or the presence of cartilage wear 51 (Figure 81.10; Table
81.1).

FIGURE 81.10 Palmer classification for acute triangular fibrocartilage complex (TFCC) injuries. A class 1A lesion involves a
tear in the central, horizontal portion of the TFCC. A class 1B lesion is a tear of the TFCC from the distal ulna with or without an
ulnar styloid fracture. A class 1C lesion is a tear of the TFCC distal attachment to the lunate and triquetrum through the
ulnolunate and ulnotriquetral ligaments. A class 1D lesion is a detachment of the TFCC from its insertion on to the radius at the
distal sigmoid notch.
(Reproduced with permission from Osterman, AL. Arthroscopic and open triangular fibrocartilage complex repair. In: Wiesel, S , ed. Operative Techniques in
Orthopedic Surgery. Vol 3. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and Wilkins; 2011:2520. Figure 49-2A.)
TABLE 81.1
Palmer Classification of Triangular Fibrocartilage Complex (TFCC) Tears
Type
Description
Type 1
Acute, traumatic
IA
Isolated central TFCC articular disk
IB
Peripheral ulnar-sided TFCC tear (with or without ulnar styloid fracture)
IC
Distal TFCC disruption (disruption from distal ulnocarpal ligaments)
1D
Radial TFCC disruption (with or without sigmoid notch fracture)
Type 2
Degenerative
2A
TFCC wear
2B
TFCC wear with lunate and/or ulnar chondromalacia
2C
TFCC perforation with lunate and/or ulnar chondromalacia
2D
TFCC perforation with lunate and/or ulnar chondromalacia and with lunotriquetral ligament peroration
2E
TFCC perforation with lunate and/or ulnar chondromalacia, lunotriquetral ligament perforation, and ulnocarpal arthritis
Initial treatment of TFCC injuries is nonsurgical with bracing or casting, activity modification, NSAIDs,
and occupational therapy. If a trial of 6 weeks of conservative therapy fails to improve symptoms,
arthroscopic evaluation and/or open treatment is considered. The central portion of the TFCC is often
debrided, as this area has less potential to heal. Type 1B, 1C, and 1D injuries may be amenable to
arthroscopic or open repair. 52,53
Degenerative tears may benefit from arthroscopic debridement and/or DRUJ stabilizing, or ulnar
shortening procedures when indicated. 54 When DRUJ arthritis exists, the patient may benefit from a
salvage operation such as a hemiresection arthroplasty, ulnar head resection, or implant arthroplasty.
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Conclusion
Wrist ligamentous injuries must be identified and treated early to avoid the sequelae of altered motion,
including pain and joint degeneration. Surgical strategies may be employed to repair or reconstruct soft
tissues and to restore normal anatomic relationships and kinematics. Salvage operations are considered
when there is evidence of articular wear and pain that can be localized to the site of joint destruction.
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Questions
1. A 45-year-old roofer presents to the emergency department 45 minutes after he sustained an injury
to the right wrist when he fell off a 10-foot ladder. He has extensive swelling of the wrist as well as
progressively worsening numbness and pain in the fingers and thumb. Which of the following is the
most appropriate management?
a. Elevation of the hand and monitoring of compartment pressures by invasive means
b. Carpal tunnel release only
c. Carpal tunnel release and intercarpal arthrodesis
d. Carpal tunnel release and PRC
e. Carpal tunnel release, relocation of the lunate, and repair of the volar and dorsal extrinsic and
intrinsic ligaments
2. A 25-year-old woman fell from a 15-foot ladder and sustained a dorsal perilunate dislocation. The
injury was reduced in the emergency department, and she has no clinical evidence of acute carpal
tunnel syndrome. Two-week follow-up X-rays demonstrate a widened SL interval (10 mm) and
evidence of DISI (SL angle 90°). No bony abnormality is appreciated. What is the most appropriate
management?
a. Long-arm cast application for 8 to 12 weeks
b. PRC
c. SL arthrodesis
d. Operative repair of the SL and LT ligaments through a dorsal wrist incision
e. Percutaneous pin fixation of the SL interval
3. A 70-year-old retired steel worker is seen in the clinic complaining of chronic wrist pain and
stiffness. He reports a history of falling from a roof onto an outstretched hand in his youth. X-rays
are obtained that demonstrate widening of the SL injury, peaking of the radial styloid, narrowing of
the radioscaphoid articulation, and preservation of the radiolunate and midcarpal joints.
Conservative management has failed, and his pain is interfering with activities of daily living. Which
is the most appropriate surgical treatment?
a. Total wrist arthrodesis
b. PRC
c. Scaphoidectomy alone
d. Reconstruction of the SL ligament
e. Radial styloidectomy
4. A 45-year-old woman is seen in the office 3 months after an ice skating injury in which she fell
onto an outstretched left wrist. X-rays are obtained which reveal static SL (8 mm SL gap, SL angle
80°). There is no evidence of articular wear or other bony abnormality. All other intercarpal
articulations are normal. Which of the following is the best surgical treatment option?
a. Dorsal SL ligament repair
b. SL ligament reconstruction with modified three-ligament tenodesis
c. Scaphoidectomy and partial fusion
d. Distal scaphoid excision
e. Arthroscopic reduction of the SL interval and percutaneous pinning
5. A 35-year-old woman is a restrained driver in a motor vehicle collision in which her left dominant
wrist is driven into the steering wheel, resulting in pain and swelling. She is seen in consultation
1 week following the injury and localizes her pain to the ulnar side of her wrist. Examination
demonstrates stability of the DRUJ but ulnar foveal tenderness, as compared with the contralateral
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