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DOI: 10.1016/J.JHSB.2007.02.008

2007 32: 240J Hand Surg Eur VolI. A. TRAIL, J. K. STANLEY and M. J. HAYTON

TWENTY QUESTIONS ON CARPAL INSTABILITY

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WENTY QUESTIONS ON CARPAL INSTABIL
T ITY
I. A. TRAIL, J. K. STANLEY and M. J. HAYTON

From the Centre for Hand and Upper Limb Surgery, Wrightington, Wigan and Leigh NHS Trust,Hall Lane, Appley Bridge, Wigan, Lancs, UK

THE QUESTIONS

1.
What is carpal instability? 2. How common is it? 3. How does it occur? 4. Is carpal instability always associated with a
traumatic event?
5. Does ligament laxity play a part? 6. What is unstable? 7. How does this affect the normal bio-mechanics of
the wrist?
8. How do we diagnose it clinically? 9. What is the value of X-rays, including arthrogra-
phy?
10. What is the value of MRI/CT? 11. Does arthroscopy have a place? 12. What are the complications of arthroscopy? 13. How do we classify carpal instability? 14. Is treatment necessary? 15. What treatment is available in the first instance? 16. What soft tissue procedures are available for
treating chronic carpal instability?
17. What bony procedures are available for treating
chronic carpal instability?
18. What other procedures are sometimes undertaken? 19. What are the long-term effects of carpal instability? 20. Can these be treated?
1. WHAT IS CARPAL INSTABILITY?

Instability is defined in the Oxford English Dictionary as‘a lack of stability’. The latter being defined as ‘abiding,fair, steady, constant’.

In the Western World, injuries to the carpal ligamentsresulting in malignment were, probably, first recognisedby Destot (1926) and, somewhat later, by Gilford et al.(1943). The latter were the first to describe the wrist as alink joint which was stable under tension because of theposition and size of the scaphoid. Fisk (1970) describedcarpal instability arising from non-union of the scaphoidas a zig-zag, or concertina deformity. Linscheid et al.(1972) proposed a classification and offered a definitionof a carpal injury in which a loss of normal alignment ofthe carpus develops early or late. More recently, theAnatomy and Biomechanics Committee of the Interna-tional Federation of Societies for Surgery of the Handconcluded that ‘a wrist joint should be consideredclinically unstable only if it exhibits a symptomaticdysfunction, is not able to bear loads and does not

240

by DOMjhs.sagepub.comDownloaded from

exhibit normal kinematics during any portion of its arcof motion’.

2. HOW COMMON IS IT?

In 1975, Dobyns et al. reviewed their own experienceand that of the Bohler Clinic and reported that 10% ofall carpal injuries resulted in instability. Jones (1988)studied a consecutive series of 100 patients who hadsuffered wrist injuries with no radiological evidence offracture; he took special radiographs of the wristincluding a clenched-fist view. In 19 patients, there wasan increase in the scaphoid–lunate gap and five of thesehad definitive scaphoid–lunate instability. Kelly andStanley (1990) reviewed 98 consecutive wrist arthrosco-pies and identified numerous ligamentous injuries,findings that were confirmed by Sennwald et al. (1993),who carried out arthroscopy on 41 injured wrists andfound at least one ligamentous lesion in 25% and two,or more, distinct lesions in 75% of the wrists.

The incidence of carpal instability in association withother injuries is unclear. In a large series of fractures ofthe distal radius, Tang (1992) found radiologicalevidence of carpal instability in just over 30%. However,Nakamura et al. (1991), having performed an arthro-scopy on the wrists of a group of patients with ununitedscaphoid fractures, found that most did not have anyserious ligamentous injuries.

In rheumatoid arthritis, the incidence of the radi-ological signs of carpal instability appears to be muchcommoner, particularly in the early stages. Kushner andDawson (1992) and Kushner et al. (1993) fromRochester, New York, analysed X-ray patterns in 52patients with proven rheumatoid arthritis. Of these, 19patients exhibited one, or more, patterns of instability.The most common isolated pattern was volar inter-calated segmental instability (VISI), seen in six patients.Five patients showed more than one pattern, mostcommonly a combination of ulnar translocation andvolar carpal subluxation. They concluded that carpalinstability is a frequent mechanical consequence ofrheumatoid arthritis.

3. HOW DOES IT HAPPEN?

There is much debate as to the exact mechanism ofinjury that produces the various types of carpalinstability. However, most researchers and expertsaccept that this injury is usually the result of a fall onthe outstretched hand with the wrist in hyperextension.

INIQUE DAVIDSON on July 2, 2011


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TWENTY QUESTIONS ON CARPAL INSTABILITY 241

A study on cadaveric wrists by Mayfield (1984)identified four stages of lunate instability. These were:

(1)
Instability limited to the scapholunate joint. (2) Added instability of the capitolunate joint. (3) Added damage to the triquetrolunate joint. (4) Dorsal disruption of the radiocarpal ligament
leaving the lunate completely unstable.

Using a cadaveric model, the forces to reproducethese types of injury were mimicked by having the wristin extension, ulnar deviation and intercarpal supination.This supination occurs as a result of the thenar eminencestriking the ground first. If, however, the hypothenareminence strikes first, then the resulting pronationdisrupts, predominantly, the dorsal ulna-triquetrialcomplex, the triquetrolunate interosseous ligamentand the anterior carpal capsule. The result of this isthat the instability is predominantly on the ulnar side ofthe wrist.

4. IS CARPAL INSTABILITY ALWAYSASSOCIATED WITH A TRAUMATIC EVENT?

Most researchers and clinicians accept that, in theoverwhelming majority of cases, carpal instability willfollow a single traumatic event as described above. Itshould also be noted that intercarpal ligament damagecan also occur in association with both scaphoid (Wonget al., 2005) and distal radial fractures (Laulan andBismuth, 1999). At this time, there is little publishedevidence to suggest that these conditions can followrepeated, or repetitive, lesser traumas. Schroer et al.(1996) looked at the prevalence of carpal instability in aparaplegic population. Of 162 paraplegic patients, 9 hada static carpal instability and none of these patients hada history of acute injury to the wrist. The predominantpattern of instability in 11 of the wrists, in 6 patients,was non-dissociative volar intercalated segmental in-stability. They also noted that the prevalence of carpalinstability increased with the duration of weight bearingon the upper extremity. Eighteen per cent of the patientsin whom the spinal cord injury had occurred more than20 years before the study had carpal instability. Theyconcluded that this increased incidence of carpalinstability in weight bearing upper extremities, particu-larly the increase in prevalence with the duration of theforces transmitted across the wrist, demonstrated anassociation between chronic repetitive stress on the wristand carpal instability.

Finally, the presence of a static dorsal intercalatedsegmented instability (DISI) can often be seen inpatients suffering with scapho-trapezio-trapezoid(STT) osteo arthritis. Ferris et al. (1994) found thiscombination in 16 of 63 wrists of patients with thiscondition.


5. DOES LIGAMENT LAXITY PLAY A PART?

Undoubtedly, the answer to this question is yes. Patientswith joint-laxity often have excessive mobility in thewrist joint, with X-ray appearances of a hyperflexedscaphoid and lunate. Garcia-Elias et al. (1995) analysedthe kinematic behaviour of the scaphoid during radio-ulnar deviation of the wrist in 60 normal volunteers.They also assessed wrist laxity using criteria set out byLarsen et al. (1987). They concluded that there was alinear relationship between scaphoid rotation and theamount of wrist joint laxity. More specifically, duringlateral deviation of the wrist, joints that were more laxhad a scaphoid rotating mainly along the sagittal planeof flexion–extension, with little lateral deviation.Whereas, in the volunteers with decreased laxity, thescaphoids mostly rotated along the frontal plane, withminimal flexion–extension. Fortunately, most patientswere asymptomatic. There is no doubt, however, onoccasion and often after relatively minor trauma, thewrist can become symptomatic. This often presents as apainful clunking which the patient is readily able todemonstrate. Examination under image-intensifier de-monstrates obvious instability at the mid carpal joint,particularly between the capitate and lunate, with thehead of the capitate subluxing out of the distal, convexarticular surface of the lunate.

6. WHAT IS UNSTABLE?

To understand what structures are damaged followingtrauma, it is important to have a thorough knowledge ofthe normal anatomy of the wrist and carpus.

The ligaments of the wrist are divided into intrinsicand extrinsic components. The two most importantintrinsic (interosseous) ligaments, viz. the scapholunateand lunotriquetral ligaments, are divided into dorsal,proximal and palmar parts. The thickest and strongestpart of the scapholunate ligament is located dorsally(Berger et al., 1999) (Fig 1) and that of the lunotrique-tral ligament is located palmarly.

With regard to the extrinsic ligaments, there areseveral described on both the palmar and dorsal aspectsof the wrist. It is generally accepted that those on thepalmar aspect provide greater restraint to instability(Katz et al., 2003). There are three strong palmarextrinsic radiocarpal ligaments, viz. the radioscaphoca-pitate, the long radiolunate and the short radiolunateligaments (Fig 2). The radioscaphocapitate ligament,which extends from the radial styloid process through agroove on the waist of the scaphoid to the palmar aspectof the capitate, acts as a fulcrum around which thescaphoid rotates. The long radiolunate ligament, whichlies parallel to the radioscaphocapitate ligament, extendsfrom the palmar rim of the distal part of the radius tothe radial margin of the palmar surface of the lunate.Located between the radioscaphocapitate and long



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Fig 2 Volar extrinsic ligaments: C ¼ capitate; L ¼ lunate;

S ¼ schaphoid; LRL ¼ long radiolunate ligament; RSC ¼ ra-

dioscaphocapitate ligament; SRL ¼ short radiolunate liga-

ment; UL ¼ ulnolunate ligament; UT ¼ ulnotriquetral

ligament.

Fig 1 Scapholunate interosseous ligament (by permission of D

Berger).

THE JOURNAL OF HAND SURGERY VOL. 32E No. 3 JUNE 2007242

radiolunate ligaments, at the level of the midcarpal joint,is an area of capsular weakness known as the space ofPoirier. The short radiolunate ligament, which iscontiguous with the palmar fibres of the triangularfibrocartilage complex, originates from the palmarmargin of the distal part of the radius and inserts intothe proximal part of the palmar surface of the lunate.The ulnolunate and ulnotriquetral ligaments arise from


the volar edge of the triangular fibrocartilage and insertinto the lunate and the triquetrum, respectively.

With regard to the radio-scapholunate ligament,Berger et al. (1991) felt that this structure could not beconsidered a true ligament, although this was disputedby Taleisnik (1984).

Most authors agree that when the wrist and thecarpus are injured, both the intrinsic and extrinsicligaments are damaged. Generally, however, it is feltthat for significant carpal instability to exist, theinterosseus ligaments, specifically the scapholunate andlunotriquetral, have to be permanently damaged. On theulnar side, Trumble et al. (1988) found that the patternof volar intercalated segmental instability (VISI) re-quired the rupture of both the triquetrohamate andtriquetrolunate ligaments.

Returning to the radial side of the wrist, a number ofauthors believe that the principal area of ligamentdamage lies distally between the scaphoid and trape-zium. Work by Short et al. (2005), however, confirmedthat the scapholunate interosseous ligament is theprimary stabiliser of the wrist and that the radio-scaphocapitate and scapho-trapezial ligaments act only in asecondary capacity.

Finally, we should also remember that the constitu-tion of these ligaments changes with age. Weiss et al.(1994), in a cadaveric study, were able to identifyscapholunate and lunar triquetral ligament defects inapproximately 30% of cases. It should be noted,however, that most of these were in the central, orweakest, part of the ligament and did not represent truetears, lesions or defects. In addition, over half of thecadavers also had triangular fibro-cartilage tears.

7. HOW DOES THIS AFFECT THEBIOMECHANICS OF THE WRIST?

Whilst our knowledge of the biomechanics of the wristremains incomplete, it is not possible to understand theeffect of these ligament injuries and instability patternswithout having some knowledge of what is believed to benormal. The distal row of bones, viz. the trapezium,trapezoid, capitate and hamate, form a stable platformupon which the metacarpals are fixed. There is very littlemotion between these bones. Similarly, the distal radiusand ulna, although they move in pronation and supina-tion, are essentially a stable construct. The proximal rowof the carpus, however, is an intercalated segment with nomuscle or tendon insertions, the stability of which dependsentirely on the capsular and interosseous ligamentsbetween the scaphoid, lunate and triquetrum. Flexionand extension of the wrist results from movement betweenthe radius and the lunate and between the lunate and thecapitate in the centre of the wrist, between the trapezium,trapezoid and scaphoid on the lateral side and betweenthe triquetrum and the hamate on the medial side. Furtherresearch has shown that movement of the intercarpal



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joints of the proximal row (radiocarpal) accounts for 40%of flexion, 33% of extension and 10% of ulnar deviation(Seradge et al., 1990).

In radial deviation, the distance between the trape-zium and the radial styloid shortens. This distancelengthens in ulnar deviation (Figs 3 and 4). Twoprincipal movements allow this to occur. Firstly, thereis sliding of the scaphoid over the lunate fossa duringradial deviation and sliding of the lunate over thescaphoid fossa during ulnar deviation. Secondly, there isa movement which can be described as simple flexing ofthe scaphoid under the trapezium during radial devia-tion and extension during ulnar deviation. The trique-trum passively follows the other two bones of theproximal row. Most wrists show both types of motion,but in varying proportions (Nuttall et al., 1998). Wristswhich mainly slide are called ‘row’ types and those inwhich flexion predominates are called ‘column’ types.

Fig 3 Radial deviation of the wrist.

Fig 4 Ulnar deviation of the wrist.

Fig 5 Taleisnik’s modification of Navario’s concept.


The triquetrum articulates with the hamate at a helicaljoint which allows sliding and flexing to occur. Flexionat the scaphoid, however, is greater than that of thetriquetrum and the lunate, therefore, becomes anintercalated torque converter between the scaphoidand triquetrum during radial and ulnar deviation. Thelunate is also an intercalated segment between the radiusand the capitate.

Taleisnik’s (1984) modification of Navario’s conceptof longitudinal columns (Fig 5) has made the collapsedeformities of the wrist much easier to understand.When the ligamentous supports of the scaphoid areruptured, longitudinal compression forces the scaphoidinto a flexed position. The lunate, being narroweranteriorly than dorsally, tends, normally, to extendunder compression. Coincident extension of the lunatewith flexion of the scaphoid can occur only when there issevere ligament injury on the radial side of the carpusand this pattern is termed ‘‘dorsal intercalated segmentinstability’’ (DISI).

If, however, the damage affects the dorsal ulno-triquetral ligament complex, the triquetrolunate inter-osseous ligament and the anterior midcarpal capsule,this allows the capitate to hyperextend in relation to thelunate, which compensates by flexing. Subluxation ofthe midcarpal joint is seen at rest on lateral radiographsand this pattern is termed ‘‘volar intercalated segmentinstability’’ (VISI).

The normal kinematics of radial/ulnar deviation andflexion/extension were further investigated in detail by



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Youm et al. (1978). They found that rotation occurredaround a fixed axis in the middle of the head of thecapitate and that this was independent of the position ofthe hand. The distance from the base of the thirdmetacarpal to the distal articular surface of the radius(the carpal height), measured along the axis of the thirdmetacarpal, was constant throughout radial and ulnardeviation; the perpendicular distance of the fixed axis ofrotation from the distally projected longitudinal axis ofthe ulna was also constant (Fig 6). These measures canbe used to quantify carpal collapse and carpal translo-cation, respectively.

Viegas et al. (1989, 1993) considered how loads weretransmitted across the wrist. They found that thescaphoid fossa constituted approximately 60% of thetotal contact area and the lunate fossa approximately40%. At the midcarpal joint, load was distributed asfollows: 23% at the scapho-trapezio-trapezoid (STT)joint, 28% at the scaphocapitate joint, 29% at thelunocapitate joint and 20% at the triquetrohamate joint.

Fig 6 Carpal height.


8. HOW DO WE DIAGNOSE IT CLINICALLY?

Of paramount importance for the diagnosis of carpalinstability are a careful history and physical examina-tion. Attention must be paid to the position of the wristat the time of injury and the location of pain. Swellingand local tenderness are noted and the ranges of motionand grip strengths of the injured and uninjured sides aremeasured and compared. The most important differ-ential diagnosis for pain on the radial side of the wrist isa fracture of the scaphoid. The problems of earlydiagnosis of this injury are well known, but, after two tothree weeks, the standard tests for carpal instability canbe performed. The pseudoinstability test, described byKelly and Stanley in 1990, in which there is a loss of thenormal anteroposterior translation of the carpus (Fig 7),is useful. Lack of this motion due to protective spasm isakin to the positive apprehension sign of shoulderinstability. Other tests include that of Watson et al.(1986), which stresses the scapholunate interosseousligament (Fig 8). In a normal wrist, radial deviation

Fig 7 Pseudoinstability test.

Fig 8 Watson’s manoeuvre.



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Fig 10 Widened scapholunate interval.

Fig 11 Exaggerated flexion of the scaphoid compared to the lunate.

Fig 9 Reagan’s test for lunotriquetral instability.


causes scaphoid flexion, which is able to overcome theresistance of an examining thumb on the scaphoidtubercle. In a scapholunate dissociation with radialdeviation, the scaphoid flexes, but is unable to overcomethe volar resistance of the thumb. The scaphoid has toescape and is forced dorsally, with the proximal poleclunking dorsally. Scapholunate or lunotriquetral ballot-ment may reveal specific joint instability and Lichtmanet al. (1981) described a pivot shift test for midcarpalinstability (Fig 9). All of these tests are specific for aparticular ligamentous lesion, but overlap is not un-common. Perhaps, the most specific and reliable test ispoint tenderness over the affected ligament.

9. WHAT ARE THE VALUE OF X-RAYSINCLUDING ARTHROGRAPHY?

The work of Schernberg (1990) on the radiologicalexamination of the normal wrist has shown theimportance of the quality and reproducibility of theimages obtained. On the posterior/anterior views, thewidth of the scapholunate gap should be no greater thanthat of the triquetrolunate gap, which is no more than3mm (Fig 10). Gilula and Weeks (1978) found that ascapholunate angle greater than 801 was indicative ofDISI (Fig 11). Schernberg also found that stress viewswere needed to diagnose 18 out of 27 cases of wristinjury. In addition, Degreif et al. (1990) advocatedcomparison of both wrists because of the considerablevariations in normal anatomy. Other authors (Lichtmanet al., 1981) have found that examination under animage intensifier can be particularly useful for dynamicinstabilities.

More sophisticated investigations, including arthro-graphy and scintigraphy, may be of value. Arthrographycan, undoubtedly, demonstrate leakage of contrastbetween the various intercarpal joints. Herbert et al.(1990), however, showed that an arthrogram is of littlediagnostic value unless it can be compared with that ofthe opposite, undamaged wrist.


Scintigraphy has been used to diagnose Preiser’s andKienbock’s diseases and avascular necrosis of thecapitate, as well as to exclude various bone tumours.Generally, however, this investigation is considered notto be particularly useful in the diagnosis of longstandingcarpal instability.

10. WHAT IS THE VALUE OF MRI/CT SCAN

CT and MRI scans are increasingly being used in theinvestigation of chronic wrist pain. Certainly, the CTscan has replaced other forms of tomography for theinvestigation of complex injuries of the carpus (Stewartand Gilula, 1992). MRI, however, appears to have thegreatest potential (Zlatkin and Greenan, 1992)although, like CT, it only gives static images. Initially,MRI scans often failed to reveal small tears of theinterosseous ligaments (Munk et al., 1992). Work bySchadel-Hopfner et al. (2001) from Germany revealedthat the addition of intravenous contrast did notimprove the accuracy of MRI scanning significantly.Certainly, it did not compare with wrist arthroscopy. Atour hospital, however, with the additional use of surfacecoils and improved software, we believe that thediagnostic value of MRI arthrograms have improvedconsiderably.



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11. DOES ARTHROSCOPY HAVE A PLACE?

Arthroscopy of the radiocarpal and midcarpal jointsremains the gold standard in the diagnosis of carpalinstability. Roth and Haddad (1986), Kelly and Stanley(1990) and Cooney (1993) have all advocated its use andthere is no doubt that it can provide much informationabout the altered mechanics and pathology of the wrist atall levels. Kelly and Stanley (1990) and Dautel et al.(1993) examined groups of patients with symptomssuggestive of a scapholunate interosseous ligament tear,but with normal radiographs and established thediagnosis by dynamic manoeuvres undertaken duringradiocarpal and midcarpal arthroscopy. Fischer andSennwald (1993) detected ligament tears by arthroscopyin every wrist, in 20 cases of carpal instability. Other, andmore recent, reports have indicated that arthroscopicevaluation of the wrist is more accurate and specific thanarthrography in detecting the site and extent of ligamentinjury (Cooney et al., 1990; Weiss and Akelman, 1995).

At the radiocarpal level, the volar carpal ligamentsare assessed in a radial to ulnar direction to determinewhether an extrinsic ligament injury has occurred.Midcarpal arthroscopy with the use of a triangulationprobe is also performed routinely. The space betweenthe scaphoid and lunate bones is assessed for evidence ofligamentous laxity. A diagnosis of partial, or complete,carpal ligament injury is established on the basis ofthe ease of separation of the scaphoid from the lunate(Fig 12) and of the lunate from the triquetrum. This is

Table 1—–Arthroscopic classification of scapholunate ligament injuries (Koz

Grade

Grade 1 Attenu

Grade 2 Incongruency or step-

Grade 3 Incongruency or step-off

Grade 4 Incongruency or step-off of carpal sp

Fig 12 Scapholunate gapping as seen on midcarpal arthroscopy.


facilitated by unloading the wrist and stressing thevarious joints. Geissler, initially, classified the arthro-scopic findings of a scapholunate ligament injury. Thesewere, if the probe can be rotated within the space, a tearof the scapholunate or lunotriquetral interosseousligament is probable. If either the probe, or thearthroscope, can be passed from the midcarpal to theradiocarpal joint, rotatory subluxation of the scaphoid(a complete scapholunate ligament tear with extrinsicligament laxity) is confirmed. This has been furtherclassified by Kozin (1999) (Table 1). Returning to theradiocarpal joint, a triangulation probe assists inthe assessment of the size, location and extent of tearsof the triangular fibrocartilage complex. Associatedosseous injuries (fractures of the proximal pole of thescaphoid or dorsal triquetral chip fractures) can bevisualised also.

12. WHAT ARE THE COMPLICATIONS OFWRIST ARTHROSCOPY?

Wrist arthroscopy is a relatively safe procedure whenperformed correctly. Of particular note, are potentialtraction injuries, including degloving of the finger skin bythe finger traps. However, with the application of thesetraps to a minimum of three fingers, the advent of plastic,rather than metal, traps and traction of no more than2.5kg (5 lbs), the risk is negligible. Compartment syn-drome is also a potential complication, although, again, ifgravity inflow is used, it is extremely unlikely. If a fluidmanagement system is required, then this should be usedjudiciously. An Esmarch bandage pre-wrapped around theforearm to prevent over distension may be useful. Finally,tourniquet palsy and infection are also possibilities.

With regard to nerve injury, damage to the dorsalsensory branch of the ulnar nerve can follow the use ofthe 6U portal. This results in a painful neuroma, whichcan persist. In addition, patients can be left with a smallpermanent area of anaesthesia distally. Another sensorynerve particularly at risk is the dorsal cutaneous branchof the superficial radial nerve. This is particularly at riskwhen the 1/2 portal is used. Finally, branches of theposterior interosseous nerve can be damaged when the3/4, 4/5 and midcarpal portals are used. Whilst notreported, neuromas of these branches have been seenfollowing other surgical procedures. Finally, it should beremembered that the radial nerve, or its terminalbranches, may be damaged when the 1/2 portal isfashioned.

in, 1999)

Description

ation or haemorrhage, no incongruency

off of carpal space, slight gap less than width of probe

of carpal space, probe passed between scaphoid and lunate

ace, scope (2.7mm) passed through gap between scaphoid and lunate



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There is also a potential for damage to the extensortendons with all the dorsal portals. Surprisingly, fewcases have been reported, although the authors areaware of two in which the extensor pollicis longustendon was transected while a 3/4 portal was beingformed (Fortems et al., 1995). The injuries only becameobvious after surgery and both patients required tendonrepair.

13. HOW DO WE CLASSIFY CARPALINSTABILITY?

The most frequently used terms are those introduced byLinscheid et al. (1972) and Dobyns et al. (1975), whoidentified four groups of carpal instability, viz. dorsalintercalated segment instability (DISI), volar interca-lated segment instability (VISI), ulnar translocation anddorsal subluxation.

The radiological appearances of the dorsi-flexion andvolar-flexion instability patterns have already beendiscussed. Ulnar translocation describes ulnar shift ofthe carpus on the radius and is seen commonly inpatients with rheumatoid arthritis. Dorsal subluxationdescribes dorsal shift of the carpus, often seen aftermalunion of distal radial fractures (Dias and McMohan,1988).

Taleisnik, in 1984, introduced the concepts of staticand dynamic instability. Static instability is an end state,with marked scapholunate dissociation, fixed flexion ofthe scaphoid and fixed extension of the lunate. Dynamicinstability exists in the presence of partial ligamentinjuries resulting in pain, but with minimal, or even no,changes on the plain radiographs. The diagnosis is madeby dynamic radiology or arthroscopy.

The terms carpal instability dissociative (CID), carpalinstability non-dissociative (CIND) and carpal instabil-ity complex (CIC) were introduced by Dobyns andGabel (1990). CID describes instability due to loss oflinkage between the individual bones of either row,CIND means that there is no dissociation betweenindividual carpal bones, but instability at the radio-carpal or midcarpal joints. CIC includes instabilitieswhich were not otherwise classifiable.

14. IS TREATMENT NECESSARY?

If the disability is minor, with more than 80% of thenormal range of motion and grip strength retained, notreatment is required (Dobyns et al., 1975). Certainly, inour practice, a number of patients choose not toundergo reconstructive surgery and, with some mod-ifications of life style, seem to cope extremely well with achronic scapholunate ligament injury.

A study from Wrightington Hospital (O’Meeghan etal., 2003) summarised the outcome of 11 patients witharthroscopically proven interosseous scapholunate liga-


ment injury, but without any radiological signs of eitherDISI deformity or scapholunate gapping. The averagefollow-up of these patients was 7 years. At review, allpatients were still experiencing pain with a meanmeasurement on the visual analogue pain scale of 3.2at rest, worsening to 6.5 after activity. This wascompared to a pain score measured at diagnosis of 7.6at rest and 8.2 after activity. All patients took oralanalgesia from time to time and, occasionally, wore asplint. Wrist movement in all of the patients wasdiminished compared to the contralateral side, withgrip strength 60% of normal. All, but one, of thepatients had altered their occupation and all weregenerally performing lighter work. Radiologically, therehad been no deterioration in X-ray appearances,although one patient had developed some very earlyradiocarpal osteoarthritis, seen at the tip of the radialstyloid.

15. WHAT TREATMENT IS AVAILABLE IN THEFIRST INSTANCE?

(a) Scapholunate dissociation

When this condition is diagnosed early and treatment isindicated, an attempt should be made to bring abouthealing of the torn interosseous ligament. Palmer et al.(1978) reported good results from immobilisation foreight weeks in plaster, if treatment started within fourweeks of injury and if an anatomical reduction wasmaintained. This often required the use of supplemen-tary closed pinning with a K-wire under radiographiccontrol. Cases that cannot be reduced and held by thistechnique, and those diagnosed later, do poorly withimmobilisation and often require surgery. Ligamentreconstruction, whether undertaken through a volar or adorsal approach (Taleisnik, 1984), also, often, needssupplementary K-wire fixation and the results rangefrom good to fair, depending on the quality of the tissueavailable for repair. At this time, it is normal practice torepair the scapholunate ligament through a dorsalapproach and the triquetrolunate ligament through apalmar approach, when possible, as this addresses thestronger parts of those ligaments. The results of directrepair were reported by Wyrick et al. (1998). They had17 patients available for follow-up for an average of 30months. In this series, it should be noted that thescapholunate ligament repair had been augmented by adorsal capsulodesis. At follow up, no patient was painfree, average wrist motion was 60% of normal and gripstrength 70%. Radiologically, the scapholunate anglehad improved from 781, pre-operatively, to 471 atsurgery. Unfortunately, at long-term follow-up, thescapholunate angle had deteriorated back to 721. Similarchanges were noted for the scapholunate interval.Overall, only 2 patients had an excellent or good result,with 6 of the 17 having good, or excellent, results on



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Fig 13 Blatt’s procedure (Blatt, 1987).


X-ray analysis. As a consequence, these authorsadvocated a cautious approach when describing theoutcome of this form of surgery.

Bickert et al. (2000) from Heidelberg, Germany,reported a retrospective analysis of acute scapholunateligament repair using Mini bone anchors. At follow-upat a mean of 19 months after surgery, results were foundto be good or excellent in 8 patients, satisfactory in 2and poor in a further 2. Assessments were by pain score,grip strength and DASH. Radiological assessmentrevealed stable scapholunate ligaments in 10 patients:by this, it was meant that the mean scapholunate anglewas 551 with a scapholunate gap of no more than3.2mm.

(b) Lunotriquetral dissociation

This condition is less common and, again, if diagnosedearly, can be treated by either simple immobilisation oracute ligament repair. Reagan et al. (1984) found thatsimple immobilisation was only useful for acute injuries,capsulodesis, tenodesis and arthrodesis being reservedfor chronic cases.

16. WHAT SOFT TISSUE PROCEDURES AREAVAILABLE FOR TREATING CHRONIC CARPALINSTABILITY?

Soft tissue procedures used to treat chronic scapholu-nate ligament injuries fall into two categories. The firstinclude a capsulodesis, alone, or with an accompanyingdirect repair. The second involve some form of tendongraft augmentation. It is an obvious pre-requisite foreither of these approaches that the scapholunateinstability itself is reducible and that there is no evidenceof osteoarthritis or, indeed, cartilage wear. Certainly,soft tissue reconstructions are contraindicated if thedissociation is fixed, or in the presence of arthritis. Ifthere is any doubt about this, it is essential that thepatient undergoes an examination under X-ray controland wrist arthroscopy, if necessary.

Capsulodesis was first described by Blatt (1987), whofashioned a ligament from the dorsal capsule of thewrist, which, when inserted into the dorsal aspect of thedistal scaphoid, acted as a checkrein to flexion (Fig 13).The rationale behind this procedure is that, whilst noattempt is made to reduce the persistent scapholunatedissociation, the attachment distally prevents scaphoidmalrotation. It should be noted, however, that manysurgeons now combine this capsulodesis with a directrepair of the scapholunate interosseous ligament.

In 1987, Blatt both described his technique andreported the long-term results in 12 patients. All patientsrecovered full extension with less than 201 loss of wristflexion. Grip strength improved to 80% of normal.

Subsequent to this, there have been a number of otherreported series, the first by Lavernia et al. (1992), who


described the results of direct scapholunate ligamentousrepair supported by a dorsal radio scaphoid capsulod-esis. The results of 21 patients treated by this techniquebetween 1972 and 1988 were reported. Grip strength,pain and X-ray appearances improved in all cases. Therewas, however, some reduction in movement, particularlypalmar flexion, which averaged 11.51. Only one patienthad to change his occupation after surgery and, atfollow-up, three had X-ray findings of early degenera-tive change. Otherwise, there were no significantcomplications. This favourable outcome was furthersupported by Wintman et al. (1995).

Further work by Schweizer and Steiger (2002) fromSwitzerland, Szabo et al. (2002) from the United Statesand Busse et al. (2002) from Germany also reportedsatisfactory results. Movements of the wrist, however,were reduced, as was grip strength, to a minor degree.Schweizer and Steiger (2002) identified early arthritis,particularly affecting the mid carpal joint, in five cases.Busse et al. (2002) noted that 5 out of 12 of their patientsneeded further surgery because of persistent pain.

An alternative view was expressed by Wyrick et al.(1998), when they reviewed their experience of 17patients with a mean follow-up of 21

2years. At final

follow-up, no patient was pain free and wrist movementwas only 60% of normal, with grip strength 70% of thatof the opposite side. Radiologically, there was nosignificant difference between X-ray parameters priorto surgery and at follow-up. Overall, only two patientshad an excellent or good outcome, as graded by Greenand O’Brien (1980). They concluded that repair of thescapholunate ligament with dorsal capsulodesis failed toprovide satisfactory results. Similarly, Deshmukh et al.(1999) reviewed 44 cases of chronic scapholunatedissociation treated by Blatt’s dorsal capsulodesis alonewith a minimum follow-up of 2 years. Postoperatively,again, there were significant reductions in wrist move-ment, particularly palmar flexion, as well as gripstrength. Overall, using a locally described scoringsystem, only 39% were satisfied and 61% partiallysatisfied with the outcome of the procedure. Forty sixper cent were graded objectively as a fair or pooroutcome. The factors that influenced these figures were



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Fig 15 Extensor carpi ulnaris tenodesis.

Fig 14 Brunelli procedure.


delay to surgery and, also, an outstanding compensationclaim. Complications included three cases of CRPS 1(Algodystrophy or Reflex Sympathetic Dystrophy) andtwo cases of pin tract infection. Finally, in an additionalradiological study, it was noted that patients who had ahigh ‘‘column row’’ index, that is those patients withscaphoids that normally flexed rather than translated onulnar deviation, had better results than those thatpredominantly translated.

Scapholunate stabilisation using tendon grafts as anaugmentation, or an alternative for ligament reconstruc-tion, has been used for many years (Dobyns et al., 1975;Glickel and Millender, 1984). Most share a commongoal, that is to recreate a scapholunate ligament and, assuch, a more normal scapholunate relationship. Gen-erally, however, these are technically demanding proce-dures. Another disadvantage of tendon graftstabilizations, in general, is that the modulus of elasticityof the original ligaments of the wrist is much greaterthan that of any tendon graft. As a consequence, thismay result in an alteration, or stiffening, of the normalintercarpal kinematics.

Almquist et al. (1991) reported the results of a fourbone ligamentous weave reconstruction which incorpo-rated a long strip of the extensor carpi radialis brevistendon with an average follow-up of almost 5 years. Thepatients had a grip strength of 73% of the uninvolvedside, with an average of 521 of extension and 371 offlexion. Eighty-six per cent of patients returned to theirpre-injury activity, including heavy labour in somecases. Pre-operatively, X-rays of the scapholunateintervals measured greater than 4mm, whereas, atreview, these measured 3.3mm. There was no X-rayevidence of advancing arthritic change.

In 1995, Brunelli and Brunelli described their techni-que of treating scapholunate dissociation. This entailedusing a slip of the flexor carpi radialis (FCR) tendon,pulled through the distal pole of the scaphoid to exit onthe dorsal aspect, then be inserted into the dorsal ulnarside of the radius. This technique has subsequently beenmodified by Van Den Abbeele et al. (1998). In thisauthor’s technique, the tendon slip was inserted into thedorsum of the lunate or tunnelled under the dorsalradio-lunotriquetral ligament and sutured back on itself(Fig 14). This modification was made to avoid tetheringand, as a consequence, excessive loss of flexion at theradiocarpal joint. Of the 22 patients who underwent thisprocedure, 17 had complete relief of pain. Movementspostoperatively were reduced, with on average 101 lossof both flexion and extension. Otherwise, there was littlechange in grip strength or function. The authors haverecently reviewed their longer term outcome in 162patients over 10 years. On average, 78% of patients werevery satisfied, or satisfied, with the procedure and 88%said they would have the operation again. In addition,the vast majority of patients reported a statisticallysignificant reduction in pain and an average of 79% ofgrip strength of the opposite side and 74% of the flexion


extension arc. Unfortunately, 24 of the 162 patients wereobliged to change their occupation to one of lighterwork and six patients had undergone further surgery.

On the ulnar side of the wrist most surgeons prefer totreat chronic lunotriquetral instability by arthrodesis.Soft tissue reconstructions, including direct repair orreinsertion of the ligament together with ligamentreconstruction with tendon graft, have all been tried.At Wrightington Hospital, we have used a slip ofextensor carpi ulnaris tendon passed through a tunnel inthe triquetrum bone and sutured back on to itself as aform of dynamic stabilisation for some time. The resultsof this technique were reported by Shahane et al. (2005)(Fig 15). Of the 46 patients reviewed, 29 had excellent orgood, 11 satisfactory and only 6 poor results, using theMayo wrist score. Eighty-seven per cent of patientsasked said that the surgery substantially improved thecondition of their wrist.



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At the midcarpal joint, various soft tissue reconstruc-tion procedures have been tried, including palmarcapsular reefing, dorsal radiocarpal capsulodesis, ad-vancement of the ulnar arm of the arcuate ligament andtriquetrohamate ligament reconstruction. Lichtman etal. (1993) reported their results with these proceduresand concluded, generally, that they were inferior to alimited midcarpal arthrodesis.

17. WHAT BONY PROCEDURES AREAVAILABLE TO TREAT CHRONICSCAPHOLUNATE LIGAMENT INJURY?

The indifferent results of ligament reconstruction havepersuaded many surgeons to perform intercarpal ar-throdeses, the most logical of which is scapholunatearthrodesis. Hom and Ruby (1991) reported theirexperience of this procedure and found that, only oneof seven patients, ultimately, attained radiographicfusion and three still had significant symptoms. Alnotet al. (1992) had similar problems, although Zubairy andJones (2003) found that 10 of the 13 patients weresubjectively satisfied with the treatment, although only 4achieved fusion.

In view of these difficulties, attention turned to theSTT joint (Fig 16). Watson and Hempton (1980) foundthat STT fusion was more readily obtained and wassuccessful in controlling rotatory subluxation of thescaphoid, preserving 80% of the normal range offlexion/extension and 66% of the normal range of radialand ulnar deviation. Such good results were reportedagain by these authors in a further publication in 1999.Kleinman et al. (1982) also reported good results withthis procedure in that 9 of their 12 patients returned topre-injury activities, without wrist pain and with 80% ofthe pre-operative range of motion. More recently,

Fig 16 Scapho-trapezio-trapezoid (STT) fusion.


however, Eckenrode et al. (1986) reported less goodresults. Voche et al. (1991) found that their patients onlymaintained 60% of their pre-operative range of motionand that X-rays revealed styloid impingement in 34% ofcases. Fortin and Louis (1993) also showed that 8 out of14 patients had significant residual symptoms and 11had complications, including radiocarpal and trapezio-metacarpal arthritis, as well as non-union.

Scaphocapitate arthrodesis has the same effect, but iseasier to perform (Fig 17). Pisano et al. (1991) foundthat grip strength was good, although it reduced wristmovement, particularly radial deviation. Only 2 of 17patients required re-operation for non-union.

Whilst lunotriquetral dissociation occurs less com-monly than scapholunate dissociation, it can also, onoccasion, require surgical treatment. Reagan et al.(1984) found that simple immobilisation was only usefulfor acute injuries, with capsulodesis, tenodesis orarthrodesis being reserved for chronic cases. Pin et al.(1989) reported their results of lunotriquetral fusion(Fig 18) and found that three patients had persistentpain, although fusion occurred in all 8 cases. Inaddition, whilst range of motion was preserved, only50% of grip strength was maintained. Kirschenbaumet al. (1993) also advocated fusion, although Nelsonet al. (1993) reported problems of non-union and

Fig 17 Scapho-capitate fusion.



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Fig 18 Lunotriquetral fusion.


recommended using a Herbert screw as well as a K-wirefor fixation and a cast for at least eight weeks. Finally,Sennwald et al. (1995), in a review of 33 patients,concluded that lunotriquetral fusion cannot be consid-ered as a routine procedure and that results areunpredictable.

With regard to the midcarpus, Lichtman et al. (1981)originally described this instability and investigated itspathomechanics. They also described a diagnostic test,specifically a painful click on ulnar deviation, compres-sion and pronation of the wrist. The radiographs areusually normal but cinefluoroscopy can show dissocia-tion between the proximal and distal carpal rows, with avolar collapse deformity. Laboratory studies haveshown volar subluxation of the capitate and hamateon the lunate and triquetrum. Johnson and Carrera(1986) identified attenuation of the radiocapitate liga-ment as the cause of this condition and advocatedtightening the ligament to obliterate the space of Poirier.Generally, however, soft tissue reconstructions haveusually failed and midcarpal arthrodesis is preferred(Lichtman et al., 1993). Siegel and Ruby (1996) reportedtheir results of midcarpal arthrodesis in 11 patientsfollowed up for an average of 51

2years. Four of the 11

patients had ultimately undergone total wrist fusion for


continuing pain. Seven patients, however, reported someimprovement and were able to return to work. Overallwrist movement was 50% and grip strength 65% of theirnormal side. Rao and Culver (1995) reported theirresults of 11 wrists in 10 patients which had undergonetriquetrohamate arthrodesis for symptomatic midcarpalinstability. At follow-up, averaging 26 months, therewere 6 good to excellent, 3 fair and 2 poor results.Compared to the contralateral side, range of motionaveraged 55% flexion, 69% extension, 61% radialdeviation and 64% ulnar deviation. Grip strengthaveraged 64% of the normal wrist. The author endedwith a cautionary note that the stability provided by thisarthrodesis failed to control symptoms in almost half ofthe cases.

Post-traumatic ulnar translation of the carpus has notbeen successfully treated by soft tissue repair (Chamayet al., 1983; Rayhack et al., 1987) and most authors nowadvocate radiolunate fusion for this problem.

The principal difficulty with small bone arthrodesis isnon-union, as one would expect. This was addressed byLarsen et al. (1997), who undertook a meta-analysis ofthe literature. In the published literature, scapho-trape-zium-trapezoid arthrodesis has a 14% non-union rate,lunotriquetral arthrodesis has a 27% non-union rate andscapholunate arthrodesis has a 47% non-union rate.

18. WHAT OTHER PROCEDURES ARESOMETIMES UNDERTAKEN?

Because of the complexity of both soft tissue and bonyreconstruction for carpal instability, the results are oftenunpredictable. A number of surgeons have, therefore,advocated alternate procedures. Conyers (1990) per-formed an imbrication of the palmar ligaments andchondrodesis between the scaphoid and lunate forchronic scapholunate instability and reported improve-ment of the pinch and grip strengths and of the range ofmotion.

Ruch and Poehling (1996) reported a satisfactoryoutcome in 14 patients with isolated partial scapholu-nate and lunotriquetral ligament injuries who hadundergone arthoscopic debridement with early mobili-sation. Weiss (1998) reported their results of 43 wristswhich underwent not only a diagnostic wrist arthro-scopy but also a debridement of the torn area using aresector, or a suction punch, for a mixture of isolatedscapholunate or lunotriquetral ligament injuries. Sur-gery was undertaken, on average, 8 months after injury.At an average follow-up of over 2 years, 10 of the 15patients with complete scapholunate ligament injuriesreported a complete resolution of symptoms, althoughfive patients had persistent pain and required subsequentreconstruction. Of the 13 patients who had a partialscapholunate ligament injury, 11 reported completeresolution of symptoms. Whether this was maintainedlong-term remains uncertain.



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Shin et al. (1998) investigated the possibility ofreconstructing the scapholunate ligament with a bone-retinaculum-bone autograft preparation from Lister’stubercle. Essentially, this was a cadaveric study to assessthe tensile strength of this construct against that of thenormal scapholunate ligament. The results indicatedthat, although this autograft was significantly weakerwith a failure load of less than a quarter of the normalligament, considering the cross sectional areas, thefailure stress was more equal. Hofstede et al. (1999)examined the biomechanical properties of 9 dorsal tarsalligaments from the foot. They concluded that the medialdorsal cuneonavicular ligament was the strongest and,therefore, the most suitable for use as an autograft forreconstruction of the scapholunate ligament.

Weiss (1998) reported the early results using a bone-retinaculum-bone autograft for chronic scapholunateligament reconstruction. The graft used initially wasfrom the third dorsal compartment, although, subse-quently, and in the majority of cases, the graft was takenfrom Lister’s tubercle, this being technically easier. Thebone blocks were then inserted into the scaphoid andlunate, which were reduced and held by K wires. Atfollow-up at an average of 31

2years, 12 of the 14 patients

with dynamic instability had no pain and two had painfollowing heavy activity only. All recovered satisfactoryranges of motion and grip strength and none of thepatients were dissatisfied. Thirteen of the 14 returned totheir former work. Of the five patients with staticscapholunate dissociation, two had continuing painpostoperatively and one had pain after heavy activity.Recovery of movements and grip strength were not asgood as in the dynamic group, grip strength being onlyhalf of that of the contralateral side. In this group, twopatients were dissatisfied and underwent further surgery.Complications occurred in six patients, including skinbreakdown over a prominent K-wire and neuropraxiainvolving the superficial branch of the radial nerve infive patients, which persisted in two.

Weinstein and Berger (2002) reviewed their experiencein 19 patients who had isolated anterior and posteriorinterosseous neurectomies for chronic wrist pain and noprevious, or concurrent, wrist surgery. At an average of212years follow-up, 80% of the patients reported a

decrease in pain, 45% reported normal or increased gripstrength and 73% of patients had returned to work.Three patients had undergone additional procedures.These authors felt that failures tended to occur in thefirst postoperative year.

19. WHAT ARE THE LONG-TERM EFFECTS OFCARPAL INSTABILITY?

The natural history of an isolated scapholunate ligamentinjury remains unclear. Although Harrington et al.(1987) and Watson et al. (1997, 1999) stated thatsecondary osteoarthritis in the form of a scapholunate


advanced collapse (SLAC) wrist is an inevitableconsequence of a scapholunate disruption there is stilllittle conclusive evidence of this. Larsen and Brondum(1993) performed a retrospective review of 18 cases ofcarpal instability diagnosed by clinical and radiologicalmeans, most of which had been treated surgically. Theirmean follow-up was 9 years, with a range from 1 to 20.At review, 4 of their 18 cases had undergone a wristarthrodesis and another 4 had radiological signs ofsignificant osteoarthritis. Twelve of the 18, however,were satisfactory in terms of pain and grip strength,despite persistent radiographic instability in nine.

The long-term effects of instability on the wrist werealso evaluated by Blevens et al. (1989), who usedpressure-sensitive films to record changes in the radio-scaphoid and radiolunate contact areas after sequentialligament section in cadavers. They found that thescapholunate interosseous ligament was essential forpreventing scapholunate diastasis and that the change incontact area after its division would explain the laterdevelopment of degenerative arthritis. In our series ofpatients with arthroscopically proven interosseousscapholunate injury without any radiological signs ofDISI or scapholunate gapping, there was no realevidence of any rapid deterioration to radiocarpalosteoarthritis over an average of 7 years, althoughpatients remained symptomatic (O’Meeghan et al.,2003).

20. CAN THESE BE TREATED?

The loss of motion and altered biomechanics whichresult from either untreated carpal instability, or,sometimes, its treatment may give rise to symptomaticsecondary osteoarthritis in the long term. STT fusionand scaphocapitate fusion have been found to produce asignificant reduction in range of motion. Both proce-dures increase the sliding motion of the lunate on theradius such that Garcia-Elias et al. (1995) and Viegas etal. (1993) found that virtually all the load wastransmitted to the scaphoid fossae. Other fusions, viz.scapholunate, scapholunocapitate and capitolunate, alldistributed the load more equally through both thescaphoid and lunate fossa. The position of the scaphoidin STT fusions is crucial. If it is vertical, there is agreater loss of flexion and ulnar deviation. If it ishorizontal, extension and radial deviation are lost. If thescaphoid is in a more anatomical position, STT andscaphocapitate fusion result in similar patterns ofmotion (Ambrose et al., 1992).

The treatment of carpal instability when there arealready arthritic changes in the wrist was described byWatson and Ballet (1984). They defined scapholunateadvanced collapse (SLAC), a sequential pattern ofarthritis affecting, first, the radial fossa and, then,the capitolunate joint, but sparing the radiolunate joint(Fig 19). They recommend reduction of the so-called



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Fig 19 Scapholunate advanced collapse (SLAC).

Fig 20 Four-corner fusion with excision of scaphoid.


DISI deformity, excision of the scaphoid and fusion ofthe capitate, hamate, lunate and triquetrum (a so-called‘Four-Corner Fusion’) (Fig 20). Of the 19 patientstreated, 18 had some pain relief while maintaining anadequate range of motion. Krakauer et al. (1994)


operated on 55 patients with SLAC and obtained thebest results with scaphoid excision and a ‘four-cornerfusion’. Saffar and Fakoury (1992) compared proximalrow carpectomy with partial wrist arthrodesis and foundthat the latter gave better results.

The results of radioscapholunate arthodesis and distalscaphoidectomy for the treatment of radiocarpal degen-erative osteoarthritis were reported by Garcia-Elias etal. (2005). This procedure was undertaken for patientswho, predominantly, had an intraarticular fracture ofthe distal radius and continuing incongruity. Twopatients, however, had suffered a perilunar fracturedislocation. The scaphoid and lunate were arthrodesedto the distal radius and the distal quarter of the scaphoidremoved. At an average follow-up of just over 3 years,complete pain relief was obtained in 10 patients with asignificant reduction in the other six. Movement was 321of flexion, 351 of extension, 141 of radial deviation and901 of ulnar deviation. Two patients, ultimately, diddevelop secondary midcarpal degenerative change.

References

Almquist EE, Bach AW, Sack JT, Fuhs SE, Newman DM (1991).Four-bone ligament reconstruction for treatment of chroniccomplete scapholunate separation. Journal of Hand Surgery,16A: 322–327.

Alnot JY, de Cheveigne C, Bleton R (1992). Chronic, post-traumaticscaphoid-lunate instability treated by scaphoid-lunate arthrodesis.Annals de Chirurgie de la Main et du Membre Superieur, 11:107–118.

Ambrose L, Posner MA, Green SM, Stuchin S (1992). The effects ofscaphoid intercarpal stabilizations on wrist mechanics: an experi-mental study. Journal of Hand Surgery, 17A: 429–437.

Berger RA, Imeada T, Berglund L, An KN (1999). Constraint andmaterial properties of the subregions of the scapholunate inteross-eous ligament. Journal of Hand Surgery, 24A: 953–962.

Berger RA, Kauer JM, Landsmeer JM (1991). Radioscapholunateligament: a gross anatomic and histologic study of fetal and adultswrists. Journal of Hand Surgery, 16A: 350–355.

Bickert B, Sauerbier M, Germann G (2000). Scapholunate ligamentrepair using the Mitek bone anchor. Journal of Hand Surgery, 25B:188–192.

Blatt G (1987). Capsulodesis in reconstructive hand surgery. Dorsalcapsulodesis for the unstable scaphoid and volar capsulodesisfollowing excision of the distal ulna. Hand Clinics, 3: 81–102.

Blevens AD, Light TR, Jablonsky WS, Smith DG, Patwardhan AG,Guay ME, Woo TS (1989). Radiocarpal articular contactcharacteristics with scaphoid instability. Journal of Hand Surgery,14A: 781–790.

Busse F, Felderhoff J, Krimmer H, Lanz U (2002). Scapholunatedissociation: treatment by dorsal capsulodesis. HandchirurgieMikrochirurgie Plastische Chirurgie, 34: 173–181.

Chamay A, Della Santa D, Vilaseca A (1983). Radiolunate arthrod-esis. Factor of stability for the rheumatoid wrist. Annals deChirurgie de la Main, 2: 5–17.

Conyers DJ (1990). Scapholunate interosseous reconstruction andimbrication of palmar ligaments. Journal of Hand Surgery, 15A:690–700.

Cooney WP (1993). Evaluation of chronic wrist pain by arthrography,arthroscopy, and arthrotomy. Journal of Hand Surgery, 18A:815–822.

Cooney WP, Dobyns JH, Linscheid RL (1990). Arthroscopy of thewrist: anatomy and classification of carpal instability. Arthroscopy,6: 133–140.



ARTICLE IN PRESS


Dautel G, Goudot B, Merle M (1993). Arthroscopic diagnosis ofscapho-lunate instability in the absence of X-ray abnormalities.Journal of Hand Surgery, 18B: 213–218.

Degreif, J., Benning, R., Rudigier, J., Ritter, G., 1990. Scapholunardissociation—when an accident sequela, when a normal congenitalvariant? Langenbecks Archiv fur Chirurgie. Supplement II,Verhandlungen der Deutschen Gesellschaft fur Chirurgie.Deutsche Gesellschaft fur Chirurgie. Kongress, 731–734.

Deshmukh SC, Givissis P, Belloso D, Stanley JK, Trail IA (1999).Blatt’s capsulodesis for chronic scapholunate dissociation. Journalof Hand Surgery, 24B: 215–220.

Destot E (1926). The classic. Injuries of the wrist. A radiological studyby Etienne Destot. 1926. Clinical Orthopaedics and RelatedResearch, 202: 3–11.

Dias JJ, McMohan A (Eds), (1988) Effect of Colles’ fracture malunionon carpal alignment, Journal of the Royal College of Surgeons(Edinburgh), 33: 303–305.

Dobyns JH, Linscheid RL, Chao EYS, Weber ER, Swanson GE(1975). Traumatic instability of the wrist. AAOS InstructionalCourse Lectures, 24: 182–199.

Dobyns JH, Gabel GT (1990). Gymnast’s wrist. Hand Clinics, 6:493–505.

Eckenrode JF, Louis DS, Greene TL (1986). Scaphoid-trapezium-trapezoid fusion in the treatment of chronic scapholunateinstability. Journal of Hand Surgery, 11A: 497–502.

Ferris BD, Dunnett W, Lavelle JR (1994). An association betweenscapho-trapezio-trapezoid osteoarthritis and static dorsal inter-calated segment instability. Journal of Hand Surgery, 19B:338–339.

Fischer M, Sennwald G (1993). Arthroscopy in diagnosis of carpalinstability. Helvetica Chirurgie Acta, 59: 693–696.

Fisk GR (1970). Carpal instability and the fractured scaphoid. Annalsof the Royal College of Surgeons of England, 46: 63–76.

Fortems Y, Mawhinney I, Lawrence T, Trial IA, Stanley JK (1995).Late rupture of extensor pollicis longus after wrist arthroscopy.Arthroscopy, 11: 322–323.

Fortin PT, Louis DS (1993). Long-term follow-up of scaphoid-trapezium- trapezoid arthrodesis. Journal of Hand Surgery, 18A:675–681.

Garcia-Elias M, Ribe M, Rodriguez J, Cots M, Casas J (1995).Influence of joint laxity on scaphoid kinematics. Journal of HandSurgery, 20B: 379–382.

Garcia-Elias M, Lluch A, Ferreres A, Papini-Zorli I, Rahimtoola ZO(2005). Treatment of radiocarpal degenerative osteoarthritis byradioscapholunate arthrodesis and distal scaphoidectomy. Journalof Hand Surgery, 30A: 8–15.

Gilford WW, Bolton RH, Lambrinudi C (1943). The mechanism of thewrist joint. With special references to fractures of the scaphoid.Guy’s Hospital Reports, 92: 52–59.

Gilula LA, Weeks PM (1978). Post-traumatic ligamentous instabilitiesof the wrist. Radiology, 129: 641–651.

Glickel SZ, Millender LH (1984). Ligamentous reconstruction forchronic intercarpal instability. Journal of Hand Surgery, 9A:514–527.

Green DP, O’Brien ET (1980). Classification and management ofcarpal dislocations. Clinical Orthopaedics and Related Research,149: 55–72.

Harrington H, Lichtman DM, Brockmole DM (1987). Commonpathways of degenerative arthritis of the wrist. Hand Clinics, 4:507–525.

Herbert TJ, Faithfull RG, McCann DJ, Ireland J (1990). Bilateralarthrography of the wrist. Journal of Hand Surgery, 15B: 233–235.

Hofstede DJ, Ritt MJPF, Bos KE (1999). Tarsal autografts forreconstruction of the scapholunate interosseous ligament: abiomechanical study. Journal of Hand Surgery, 24A: 968–976.

Hom S, Ruby LK (1991). Attempted scapholunate arthrodesis forchronic scapholunate dissociation. Journal of Hand Surgery, 16A:334–339.

Johnson RP, Carrera GF (1986). Chronic capitolunate instability.Journal of Bone and Joint Surgery, 68A: 1164–1176.


Jones WA (1988). Beware the sprained wrist. The incidence anddiagnosis of scapholunate instability. Journal of Bone and JointSurgery, 70B: 293–297.

Katz DA, Green JK, Werner FW, Loftus JB (2003). Capsuloligamen-tous restraints to dorsal and palmar carpal translation. Journal ofHand Surgery, 28A: 610–613.

Kelly EP, Stanley JK (1990). Arthroscopy of the wrist. Journal ofHand Surgery, 15B: 236–242.

Kirschenbaum D, Coyle MP, Leddy JP (1993). Chronic lunotriquetralinstability: diagnosis and treatment. Journal of Hand Surgery, 18A:1107–1112.

Kleinman WB, Steichen JB, Strickland JW (1982). Management ofchronic rotary subluxation of the scaphoid by scapho-trapezio-trapezoid arthrodesis. Journal of Hand Surgery, 27A: 125–136.

Kozin SH (1999). The role of arthroscopy in scapholunate instability.Hand Clinics, 15: 435–444.

Krakauer JD, Bishop AT, Cooney WP (1994). Surgical treatment ofscapholunate advanced collapse. Journal of Hand Surgery, 19A:751–759.

Kushner I, Dawson NV (1992). Changing perspectives in the treatmentof rheumatoid arthritis. Journal of Rheumatology, 19: 1831–1834.

Kushner DM, Braunstein EM, Buckwalter KA, Krohn K, White HA(1993). Carpal instability in rheumatoid arthritis. CanadianAssociation of Radiologists Journal, 44: 291–295.

Larsen LG, Baum J, Mudholkar GS (1987). Hypermobility: featuresand differential incidence between the sexes. Arthritis andRheumatism, 30: 1426–1430.

Larsen CF, Brondum V (1993). Posttraumatic carpal instability. A 9-year follow-up of 18 patients. Acta Orthopaedica Scandinavica, 64:465–468.

Larsen CF, Jacoby RA, McCabe SJ (1997). Nonunion rates of limitedcarpal arthrodesis: a meta-analysis of the literature. Journal ofHand Surgery, 22A: 66–73.

Laulan J, Bismuth JP (1999). Intracarpal ligamentous lesionsassociated with fractures of the distal radius: outcome at one year.A prospective study of 95 cases. Acta Orthopaedica Belgica, 65:418–423.

Lavernia CJ, Cohen MS, Taleisnik J (1992). Treatment of scapholu-nate dissociation by ligamentous repair and capsulodesis. Journalof Hand Surgery, 17A: 354–359.

Lichtman DM, Schneider JR, Swafford AR, Mack GR (1981). Ulnarmidcarpal instability-clinical and laboratory analysis. Journal ofHand Surgery, 6A: 515–523.

Lichtman DM, Bruckner JD, Culp RW, Alexander CE (1993). Palmarmidcarpal instability: results of surgical reconstruction. Journal ofHand Surgery, 18A: 307–315.

Linscheid RL, Dobyns JH, Beabout JW, Bryan RS (1972). Traumaticinstability of the wrist. Diagnosis, classification, and pathomecha-nics. Journal of Bone and Joint Surgery, 54A: 1612–1632.

Mayfield JK (1984). Wrist ligamentous anatomy and pathogenesis ofcarpal instability. Orthopaedic Clinics of North America, 15:209–216.

Munk PL, Vellet AD, Levin MF, Steinbach LS, Helms CA (1992).Current status of magnetic resonance imaging of the wrist.Canadian Association of Radiologists Journal, 43: 8–18.

Nakamura R, Imaeda T, Tsuge S, Watanabe K (1991). Scaphoid non-union with D.I.S.I. deformity. A survey of clinical cases withspecial reference to ligamentous injury. Journal of Hand Surgery,16B: 156–161.

Nelson DL, Manske PR, Pruitt DL, Gilula LA, Martin RA (1993).Lunotriquetral arthrodesis. Journal of Hand Surgery, 18A:1113–1120.

Nuttall D, Trail IA, Stanley JK (1998). Movement of the scaphoid inthe normal wrist. Journal of Hand Surgery, 23B: 762–764.

O’Meeghan CJ, Stuart W, Mamo V, Stanley JK, Trail IA (2003). TheNatural history of an untreated isolated scapholunate interosseousligament injury. Journal of Hand Surgery, 28B: 307–310.

Palmer AK, Dobyns JH, Linscheid RL (1978). Management of post-traumatic instability of the wrist secondary to ligament rupture.Journal of Hand Surgery, 3A: 507–532.



ARTICLE IN PRESS


Pin PG, Young VL, Gilula LA, Weeks PM (1989). Management ofchronic lunotriquetral ligament tears. Journal of Hand Surgery,14A: 77–83.

Pisano SM, Peimer CA, Wheeler DR, Sherwin F (1991). Scaphoca-pitate intercarpal arthrodesis. Journal of Hand Surgery, 16A:328–333.

Rao SB, Culver JE (1995). Triquetrohamate arthrodesis for midcarpalinstability. Journal of Hand Surgery, 20A: 583–589.

Rayhack JM, Linscheid RL, Dobyns JH, Smith JH (1987). Posttrau-matic ulnar translation of the carpus. Journal of Hand Surgery,12A: 180–189.

Reagan DS, Linscheid RL, Dobyns JH (1984). Lunotriquetral sprains.Journal of Hand Surgery, 9A: 502–514.

Roth JH, Haddad RG (1986). Radiocarpal arthroscopy and arthro-graphy in the diagnosis of ulnar wrist pain. Arthroscopy, 2:234–243.

Ruch DS, Poehling GG (1996). Arthroscopic management of partialscapholunate and lunotriquetral injuries of the wrist. Journal ofHand Surgery, 21A: 412–417.

Saffar P, Fakhoury B (1992). Resection of the proximal carpal bonesversus partial arthrodesis in carpal instability. Annals de Chirurgiede la Main et du Membre Superieur, 11: 276–280.

Schadel-Hopfner M, Iwinska-Zelder J, Braus T, Bohringer G, Klose KJ,Gotzen L (2001). MRI versus arthroscopy in the diagnosis ofscapholunate ligament injury. Journal of Hand Surgery, 26B: 17–21.

Schernberg F (1990). Roentgenographic examination of the wrist: asystematic study of the normal, lax and injured wrist. Part 1: thestandard and positional views. Journal of Hand Surgery, 15B:210–219.

Schroer W, Lacey S, Frost FS, Keith MW (1996). Carpal instability inthe weight-bearing upper extremity. Journal of Bone and JointSurgery Joint, 78A: 1838–1843.

Schweizer A, Steiger R (2002). Long-term results after repair andaugmentation ligamentoplasty of rotatory subluxation of thescaphoid. Journal of Hand Surgery, 27A: 674–684.

Sennwald G, Fischer M, Jacob HA (1993). Radio-carpal and medio-carpal arthroscopy in instability of the wrist. Annals de Chirurgiede la Main et du Membre Superieur, 12: 26–38.

Sennwald GR, Fischer M, Mondi P (1995). Lunotriquetral arthrodesis. Acontroversial procedure. Journal of Hand Surgery, 20B: 755–760.

Seradge H, Sterbank PT, Seradge E, Owens W (1990). Segmentalmotion of the proximal carpal row: their global effect on the wristmotion. Journal of Hand Surgery, 15B: 236–239.

Shahane SA, Trail IA, Takwale VJ, Stilwell JH, Stanley JK (2005).Tenodesis of the extensor carpi ulnaris for chronic, post-traumaticlunotriquetral instability. Journal of Bone and Joint Surgery, 87B:1512–1515.

Shin SS, Moore DC, McGovern RD, Weiss APC (1998). Scapholunateligament reconstruction using a bone-retinaculum-bone autograft:a biomechanic and histologic study. Journal of Hand Surgery, 23A:216–221.

Short WH, Werner FW, Green JK, Masaoka S (2005). Biomechanicalevaluation of the ligamentous stabilizers of the scaphoid andlunate: Part II. Journal of Hand Surgery, 30A: 24–34.

Siegel JM, Ruby LK (1996). Midcarpal arthrodesis. Journal of HandSurgery, 21A: 179–182.

Stewart NR, Gilula LA (1992). CT of the wrist: a tailored approach.Radiology, 183: 13–20.

Szabo RM, Slater RR, Palumbo CF, Gerlach T (2002). Dorsalintercarpal ligament capsulodesis for chronic, static scapholunatedissociation: clinical results. Journal of Hand Surgery, 27A: 978–984.

Taleisnik J (1984). Classification of carpal instability. Bulletin of theHospital for Joint Diseases Orthopaedic Institute, 44: 511–531.

Tang JB (1992). Carpal instability associated with fracture of the distalradius. Incidence, influencing factors and pathomechanics. ChineseMedical Journal, 105: 758–765.


Trumble T, Bour CJ, Smith RJ, Edwards GS (1988). Intercarpalarthrodesis for static and dynamic volar intercalated segmentinstability. Journal of Hand Surgery, 13A: 384–390.

Van Den Abbeele KL, Loh YC, Stanley JK, Trail IA (1998). Earlyresults of a modified Brunelli procedure for scapholunateinstability. Journal of Hand Surgery, 23B: 258–261.

Viegas SF, Patterson R, Peterson P, Roefs J, Tencer A, Choi S (1989).The effects of various load paths and different loads on the loadtransfer characteristics of the wrist. Journal of Hand Surgery, 14A:458–465.

Viegas SF, Patterson RM, Todd PD, McCarty P (1993). Loadmechanics of the midcarpal joint. Journal of Hand Surgery, 18A:14–18.

Voche P, Bour C, Merle M, Spaite A (1991). Scapho-trapezo-trapezoidal arthrodesis or triscaphe arthrodeses. Study of 36reviewed cases. Revue de Chirurgie Orthopedique et Reparatricede l’Appareil Moteur, 77: 103–114.

Watson HK, Hempton RF (1980). Limited wrist arthrodeses. I. Thetriscaphoid joint. Journal of Hand Surgery, 5A: 320–327.

Watson HK, Ballet FL (1984). The SLAC wrist: scapholunateadvanced collapse pattern of degenerative arthritis. Journal ofHand Surgery, 9A: 358–365.

Watson HK, Rye J, Akelman E (1986). Limited triscaphoid intercarpalarthrodesis for rotatory subluxation of the scaphoid. Journal ofBone and Joint Surgery, 68A: 345–349.

Watson HK, Weinzweig J, Zeppieri J (1997). The natural progressionof scaphoid instability. Hand Clinics, 13: 39–49.

Weinstein LP, Berger RA (2002). Analgesic benefit, functionaloutcome, and patient satisfaction after partial wrist denervation.Journal of Hand Surgery, 27A: 833–839.

Weiss AP, Sachar K, Gendreau M (1994). Conservative managementof carpal tunnel syndrome: a reexamination of steroid injection andsplinting. Journal of Hand Surgery, 19A: 410–415.

Weiss AP, Akelman E (1995). Diagnostic imaging and arthroscopy forchronic wrist pain. Orthopaedic Clinics of North America, 26:759–767.

Weiss AP (1998). Scapholunate ligament reconstruction using a bone-retinaculum-bone autograft. Journal of Hand Surgery, 23A:205–215.

Wintman BI, Gelberman RH, Katz JN (1995). Dynamic scapholunateinstability: results of operative treatment with dorsal capsulodesis.Journal of Hand Surgery, 20A: 971–979.

Wong TC, Yip TH, Wu WC (2005). Carpal ligament injuries withacute scaphoid fractures—A combined wrist injury. Journal ofHand Surgery, 30B: 415–418.

Wyrick JD, Youse BD, Kiefhaber TR (1998). Scapholunate ligamentrepair and capsulodesis for the treatment of static scapholunatedissociation. Journal of Hand Surgery, 23B: 776–780.

Youm Y, McMurthy RY, Flatt AE, Gillespie TE (1978). Kinematicsof the wrist. I. An experimental study of radial-ulnar deviation andflexion-extension. Journal of Bone and Joint Surgery, 60A:423–431.

Zlatkin MB, Greenan T (1992). Magnetic Resonance Imaging of theWrist. Magnetic Resonance Quarterly, 8: 65–96.

Zubairy AI, Jones WA (2003). Scapholunate fusion in chronicsymptomatic scapholunate instability. Journal of Hand Surgery,28B: 311–314.

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r 2007 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rightsreserved.doi:10.1016/j.jhsb.2007.02.008 available online at http://www.sciencedirect.com



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