PART III WRIST
chapter
15  Carpal Instability
Marc Garcia-Elias
Carpal instability remains a challenge to upper extremity
specialists, not only because there are aspects of its pathome­
chanics that still need to be clarified, but also because these
problems may have substantial adverse social consequences
in terms of disability and morbidity when not properly
solved.70 There is great level of interest in advancing in this
field. Since the fifth edition of this book, more than 200 new
important contributions have been published. Although some
old concepts seem to be questioned, some other aspects have
been validated more recently through laboratory and clinical
research. New perspectives are opened every day in this
area. This chapter presents our current understanding of the
pathomechanics and treatment of one of the most compli­
cated joints of the human body.
ANATOMY AND FUNCTION
Knowledge of normal carpal anatomy and function is essen­
tial for proper treatment of carpal instability, which is syn­
onymous with carpal dysfunction.4 The terminology used
throughout this chapter is in accordance with the sugges­
tions published by the International Wrist Investigators
Workshop.51
Osseous Anatomy
The wrist is the link between the forearm and the hand, and
involves articulations between 14 bones and the pisiform.
The pisiform acts as a sesamoid, providing a lever arm for
the flexor carpi ulnaris (FCU) tendon, and has its own pathol­
ogy. The distal ends of the radius and ulna articulate with the
two carpal rows (proximal and distal), and these articulate
with the bases of the five metacarpal bones (Figure 15.1).
The proximal row consists of the scaphoid, lunate, and tri­
quetrum. The distal row contains the trapezium, trapezoid,
capitate, and hamate bones. Accessory carpal bones exist
in less than 2% of the population. For readers interested in
the evolution of the carpal bone nomenclature, the well-
documented study by Johnson53 is recommended.
The radiocarpal joint consists of the antebrachial glenoid,
formed by the distal articular surface of the radius in conjunc­
tion with the triangular fibrocartilage, and the proximal con­
vexities of the carpal bones. The distal articular surface of
the radius is biconcave and tilted in two planes. In the sagittal
plane, there is an average 10 degrees of tilt, and in the frontal
plane there is an ulnar inclination averaging 24 degrees.92
The proximal joint surface of the scaphoid is more curved
than that of the lunate. To ensure articular congruency, the
radius has two articular facets (the scaphoid and lunate
fossae), separated by a cartilaginous sagittal ridge, called the
interfacet prominence. The scaphoid facet has a smaller
radius of curvature than that of the lunate, which is shallower
and less inclined toward the ulnar side.
The midcarpal joint is a combination of three different
types of articulation. Laterally, the convex distal surface of
the scaphoid articulates with the concavity formed by the
trapezium and trapezoid (scaphotrapeziotrapezoid [STT]
joint) and lateral aspect of the capitate (scaphoid capitate
joint). The central portion of the midcarpal joint is concave
proximally and convex distally (lunocapitate joint). The
medial hamate-triquetral articulation is ovoid or slightly heli­
coid (triquetral-hamate joint).74 The lunate may have one
distal facet articulating only with the capitate (lunate type I)
or have two distal surfaces to receive the capitate and proxi­
mal pole of the hamate (lunate type II).110
In the transverse plane, the bones of the carpus form a
concavity enclosed palmarly by the transverse carpal liga­
ment (flexor retinaculum) to create the carpal tunnel. The
most narrow portion of the carpal tunnel is located at the
level of the distal carpal row.
Ligamentous Anatomy
Multiple ligaments connect the bones of the wrist to each
other.9,28 Their arrangement is complex, and their size and
shape vary from one individual to another. As suggested by
Hagert and colleagues,41 their function may be more intricate
than previously assumed. Although some ligaments are
formed by tightly packed bundles of collagen fibers, and are
important mechanically, other ligaments are less structurally
packed, but contain abundant mechanoreceptors, and are
important for the provision of relevant proprioception infor­
mation to the central nervous system. A general description
of the most common patterns of ligament arrangement
follows. For readers interested in the anatomic variations
of carpal ligaments, the work by Feipel and Rooze28 is
recommended.
Wrist ligaments are either intracapsular or intra-articular
except for the transverse carpal ligament and the two distal
connections of the pisiform to the hamate and the base of the
fifth metacarpal, which are located outside the wrist capsule.
The intracapsular ligaments are contained within capsular
sheaths of loose connective tissue, making recognition of
465
PART
III
15 
Figure 15.1  A, Frontal section of a wrist
specimen, showing the proximal row of the
Wrist

carpus intercalated between the distal row

and the two forearm bones. The triangular
fibrocartilage (asterisk) is interposed
between the radiocarpal joint space and the
distal radioulnar joint space. C, capitate; H,
hamate; L, lunate; S, scaphoid; Td,
trapezoid; Tq, triquetrum. B, Sagittal section
of the wrist along the lateral column. The
scaphoid (S) appears obliquely oriented
relative to the long axis of the forearm.
Because of this configuration, when the
axially loaded trapezoid (Td) migrates
proximally, the scaphoid tends to rotate
into flexion.

A B

15 15
6 7 20 20
13 5
5 14 14 17
2 12 11
4 1 10 18 19
3 9 8 16

A B C
Figure 15.2  Schematic representation of the most consistently present wrist ligaments. These drawings do not aim to replicate
the exact shape and dimensions of the actual ligaments, or their frequent anatomic variations. A, Palmar superficial ligaments:
radioscaphoid (1); radioscaphoid-capitate (2); long radiolunate (3); ulnar capitate (4); scaphoid capitate (5); pisohamate (6); and
flexor retinaculum or transverse carpal ligament (7). B, Palmar deep ligaments: short radiolunate (8); ulnar lunate (9); ulnar
triquetrum (10); palmar scapholunate (11); palmar lunate triquetrum (12); triquetral-hamate-capitate, also known as the ulnar
limb of the arcuate ligament (13); dorsolateral STT (14); and palmar transverse interosseous ligaments of the distal row (15).
C, Dorsal ligaments: radial triquetrum, also referred to as dorsal radiocarpal (16); triquetrum-scaphoid-trapeziotrapezoid, also
known as the dorsal intercarpal ligament (17); dorsal scapholunate (18); dorsal lunate triquetrum (19); and dorsal transverse
interosseous ligaments of the distal row (20). Asterisk, triangular fibrocartilage.

them difficult when surgically approaching the joint. By con­
trast, when viewed from inside the joint with an arthroscope,
the intra-articular (scapholunate and lunate triquetrum proxi­
mal membranes) and the intracapsular ligaments can be
clearly identified, the latter under a thin synovial sheath.
Two categories of intracapsular ligaments exist: extrinsic
and intrinsic (Figure 15.2). Extrinsic ligaments connect the
forearm bones with the carpus, and intrinsic ligaments origi­
nate and insert within the carpus. Anatomic, histologic, and
biochemical differences exist between the two types. The
extrinsic ligaments are stiffer but with lower yield strength
than the intrinsic ligaments. The intrinsic ligaments have a
466
relatively larger area of insertion into cartilage than into
bone and much less content of elastic fibers compared with
the extrinsic ligaments. Different modes of failure under
stress are implied: The extrinsic ligaments tend to sustain
mid-substance ruptures, whereas the intrinsic ligaments are
more frequently avulsed than ruptured.
Extrinsic Carpal Ligaments
Extrinsic ligaments may be subdivided into three major
groups: palmar radiocarpal, palmar ulnocarpal, and dorsal
radiocarpal ligaments. There are no dorsal ligaments between
the ulna and the carpus.
Palmar Radiocarpal Ligaments
Four palmar ligaments connect the radius to the carpus: the
radioscaphoid, radioscaphoid-capitate, long radiolunate, and
short radiolunate ligaments. The first three ligaments origi­
nate from the lateral third of the palmar margin of the distal
radius and take an oblique course to insert into the scaphoid
tuberosity (radioscaphoid), the palmar aspect of the capitate
(radioscaphoid-capitate), and the lunate (long radiolunate).
The short radiolunate ligament originates from the medial
anterior rim of the radius and has a vertical direction until it
inserts into the palmar aspect of the lunate. The radioscaph­
oid-capitate ligament courses around the palmar concavity of
the scaphoid, forming a hinge over which the scaphoid
rotates. Between the two diverging radioscaphoid-capitate
and long radiolunate ligaments, there is the so-called inter­
ligamentous sulcus (space of Poirier), which represents a
weak zone through which perilunate dislocations frequently
occur. In many instances, the long radiolunate ligament
appears to be in continuity with the intrinsic palmar lunate
triquetrum interosseous ligament. The so-called radioscaph­
oid-lunate ligament, although long considered a deep intra­
capsular ligament, may not be a true ligament, but a bundle
of loose connective tissue containing vessels supplying the
scapholunate interosseous membrane and adjacent osseous
structures.9
Palmar Ulnocarpal Ligaments
Arising from a rough surface at the base of the ulnar styloid
(the so-called basistyloid fovea), the superficial extrinsic
ulnar capitate ligament courses obliquely to attach to the
neck of the capitate. The distal insertions of the ulnar capitate
and radioscaphoid-capitate ligaments form the distal “V,” or
arcuate ligament.62 Dorsal to the ulnar capitate ligament,
arising from the triangular fibrocartilage, are the ulnar trique­
trum and ulnar lunate extrinsic ligaments, which run verti­
cally toward their distal insertion into the anterior aspect of
the lunate and triquetrum. These ligaments and the superfi­
cial ulnar capitate ligament form the so-called ulnocarpal
ligamentous complex. The ulnocarpal and radiolunate liga­
ments form the proximal “V” of the palmar ligamentous
complex.
Dorsal Radiocarpal Ligaments
The only dorsal extrinsic radiocarpal ligament is the dorsal
radial triquetrum ligament, also known as the dorsal radio­
carpal ligament; this is a wide, fan-shaped ligament that con­
nects the dorsal edge of the distal articular surface of the
radius to the dorsal rim of the triquetrum, with some
deep fibers inserting onto the lunate, and rarely onto the
scaphoid.
Intrinsic Carpal Ligaments
Intrinsic carpal ligaments are collections of relatively short
dorsal and palmar fibers that connect the bones of the same
carpal row (palmar and dorsal interosseous ligaments) or link
the two rows to each other.
Scapholunate Interosseous Ligaments
The scapholunate linkage consists of three distinct structures:
the two scapholunate ligaments (palmar and dorsal) and the
proximal fibrocartilaginous membrane.9 The latter follows
the arc of the proximal edges of the two bones from dorsal PART
to palmar, separating the radiocarpal and midcarpal joint III
spaces. The dorsal scapholunate ligament is located in the
depth of the dorsal capsule and connects the dorsal-distal
15 
corners of the scaphoid and lunate bones. It is formed by a
Wrist: Carpal Instability
thick collection of fibers, slightly obliquely oriented, with a
key role in scapholunate stability. Its anterior counterpart,
the palmar scapholunate ligament, has longer, more obliquely
oriented fibers, allowing substantial sagittal rotation of the
scaphoid relative to the lunate,55 and playing a lesser role in
carpal stability. The dorsal scapholunate ligament has the
greatest yield strength (260 N average), followed by the
palmar scapholunate ligament (118 N) and the proximal
membrane (63 N).9 The proximal portion of the membrane
often appears perforated in older individuals, which does not
indicate increased instability.
Lunate Triquetrum Interosseous Ligaments
The lunate triquetrum joint also has two interosseous
ligaments (palmar and dorsal) formed by short fibers
connecting the palmar and dorsal aspects of the two
bones.88 In between the two, a fibrocartilaginous mem­
brane closes the joint proximally. In contrast to the scapholu­
nate ligaments, the palmar lunate triquetrum ligament is
thicker and stronger than the dorsal one (average yield
strengths 301 N and 121 N) with the proximal portion the
weakest (64 N). Unless perforated by age or injury, this
proximal membrane prevents communication between the
radiocarpal and midcarpal joint spaces. The fibers of the
two interosseous lunate triquetrum ligaments are more
taut through all ranges of motion than the fibers of the scaph­
olunate ligaments, making for a closer kinematic relation­
ship.9,88 The most distal fibers of palmar and dorsal lunate
triquetrum ligaments are often connected to the distal fibers
of the scapholunate joint, forming the so-called palmar and
dorsal scaphoid triquetrum ligaments. These structures
not only may contribute to the stability of the lunocapitate
joint by providing some enhancement to the depth of the
midcarpal fossa, but also provide stability to the scapholu­
nate joint.71
Midcarpal Ligaments
The only dorsal midpalmar ligament is the so-called dorsal
intercarpal ligament. It arises from the dorsal ridge of the
triquetrum, courses transversely along the distal edge of the
lunate, and fans out to insert on the dorsal rim of the scaph­
oid, the trapezium, and the trapezoid bones. Often undistin­
guishable from the dorsal scaphoid triquetrum ligament, this
structure contributes to increase the depth of the midcarpal
socket, having a stabilizing role to the lunocapitate joint.71
On the palmar side, the midcarpal joint is crossed by numer­
ous ligaments. Medially, a group of thick fibers connects the
triquetrum to the hamate and capitate. This triquetrum-
hamate-capitate ligamentous complex, also known as the
ulnar arm of the arcuate ligament, varies substantially accord­
ing to the type of lunate (I or II).62 Laterally, the scaphoid
tuberosity is linked to the distal row by two groups of
fascicles, the anteromedial scaphoid capitate ligament
and the dorsolateral STT ligament. These ligaments are
very important in the maintenance of the scaphoid normal
alignment.33,98
467
PART There are no ligaments, palmar or dorsal, between the
III lunate and the capitate; there are no true radial or ulnar col­
lateral ligaments of the wrist. Because the wrist is not a hinge
15  joint, vertically oriented collateral ligaments do not exist;
their presence would constrain the wrist’s extraordinary arc
Wrist
of motion.55 Their absence may be functionally substituted
to some extent by the actions of the extensor carpi ulnaris
(ECU) tendon medially and the abductor pollicis longus
tendon laterally.
Distal Carpal Row Interosseous Ligaments
The distal carpal row bones have numerous strong and taut
transverse interosseous ligaments (dorsal, palmar, and deep
intra-articular). They are particularly important in the protec­
tion of the carpal tunnel contents by maintaining the trans­
verse carpal arch during dorsal-palmar compression.34
BIOMECHANICS
The wrist is a very mobile composite articulation that is able
to sustain substantial load without yielding; this can be
achieved only through a perfect interaction between wrist
tendons, joint surfaces, and soft tissue constraints. In the past,
different theories have been proposed to explain the intricate
mechanism of the wrist25 (see box). A brief description
follows of how the wrist moves (wrist kinematics) and
how it sustains physiologic loads without yielding (carpal
kinetics).
Carpal Kinematics
The wrist can be moved passively by an external force or
actively by contracting the forearm muscle-tendon units that
cross the joint. The kinematic effects of contraction of one
particular muscle depend on the location and distance
(moment arm) of its tendon relative to the instantaneous
center of rotation of the carpus at any given wrist position.
The proximal carpal row has no direct tendon attachments.
The moment generated by muscle contraction results in rota­
tion that is initiated at the distal carpal row. The bones of the
proximal row follow passively, when tension within the mid­
carpal capsule reaches a certain level. Consequently, wrist
motion immediately about the neutral wrist position mostly
occurs at the scapholunate-capitate articulation.74
In normal wrists, very little motion exists between the
bones of the distal carpal row. In kinematic terms, the distal
carpal row can be thought of as one rigid functional unit.
The bones of the proximal carpal row seem to be less tightly
bound to one another than the bones of the distal carpal
row (Figure 15.3). Although moving synergistically (in
similar directions), considerable differences in direction and
amount of rotation exist among the scaphoid, lunate, and
triquetrum. When the wrist is constrained along the sagittal
plane, the scaphoid has a larger amount of rotation (average
90% of the total arc of motion) than the lunate (50%) and
the triquetrum (65%). The average scapholunate angle
is 76 degrees in full wrist flexion and 35 degrees in full
extension.22,72,117
During radioulnar deviation of the wrist, the three proxi­
mal carpal bones move synergistically from a flexed position
in radial deviation to an extended position in ulnar deviation
(Figure 15.4). The magnitude of such an out-of-plane motion
468
B
A
C
D
Figure 15.3  Schematic representation of the oval ring concept of
the wrist suggested by Lichtman and Wroten.62 The distal carpal
row, as a fixed unit, is connected medially to the triquetrum (link
A) and laterally to the scaphoid (link B). These two bones are
connected to the lunate by means of two more links (links C
and D). Failure of any one of these four ligamentous links is likely
to result in an alteration of motion or load transfer coordination
or both.
varies substantially among individuals. In most individuals,
the proximal carpal row rotates around the flexion-extension
axis during radioulnar deviation (so-called column wrists),
whereas in a few individuals there is more lateromedial trans­
lation than flexion-extension during radioulnar deviation (so-
called row wrists).21 In between the two extremes, there is a
spectrum of combined behavior depending on numerous
individual variables, including wrist laxity, shape of the cap­
itate-hamate proximal surface, or type of lunate.23,74 The aim
of such complex rotations is to maintain the articular congru­
ency between the radius and the distal row in all wrist
positions.
During unconstrained flexion of the wrist, the distal row
synchronously rotates into flexion, but also into some degree
of ulnar deviation. In contrast, during wrist extension, the
tendency of all distal carpal bones is to rotate into extension
and a slight radial deviation. The so-called dart-throwing
motion, from radial-extension to ulnar-flexion, occurs almost
entirely at the midcarpal joint, and during this motion, the
proximal carpal row remains practically stationary.23,74 For
readers interested in carpal kinematics, contributions by
Short and colleagues,98 Crisco and coworkers,22,23 Moritomo
and colleagues,74 and Moojen and associates72 are strongly
recommended.
THEORIES PROPOSED TO EXPLAIN HOW THE WRIST
MOVES (CARPAL KINEMATICS)
 Johnston (1907): The carpal bones are arranged into
two carpal rows (proximal and distal) each moving as
a rigid functional unit around two transverse joints
(radiocarpal and midcarpal).

Figure 15.4  Direction of rotation of the proximal carpal row
during lateral deviations of the wrist. From neutral to radial
deviation of the wrist, the trapezium and trapezoid push the
scaphoid proximally; this results in flexion and ulnar deviation of
the entire proximal row (curved arrow). During ulnar deviation,
the hamate exerts compression onto the triquetrum, inducing
extension, ulnar deviation, and slight pronation of the entire
proximal row. Consequently, the scaphoid adopts an extended
posture (straight arrow). The amounts of flexion-extension rotation
differ, however, from one individual bone to another.
THEORIES PROPOSED TO EXPLAIN HOW THE WRIST
MOVES (CARPAL KINEMATICS)—cont’d
 Navarro (1935): The carpal bones are arranged into
three vertical, interdependent columns: (1) the central
column (lunate, capitate, and hamate) controls
flexion-extension of the wrist; (2) the lateral column
(scaphoid, trapezium, and trapezoid) controls load
transfer across the wrist; and (3) the medial or
rotational column (triquetrum and pisiform) controls
pronosupination.
 Taleisnik (1978): Modification of the columnar theory:
The pisiform does not function as a carpal bone, so it
is excluded from the model. Trapezium and trapezoid
are part of the central column.
 Weber (1980): Two columns are the load-bearing
column (capitate, trapezoid, scaphoid, and lunate) and
the control column (triquetrum and hamate). Of key
importance is the helicoidal joint between the
triquetrum and hamate.
 Lichtman and colleagues (1981): The carpus functions
as an oval ring formed by four interdependent
elements (distal row, scaphoid, lunate, and triquetrum)
connected to the adjacent segments by ligamentous
links (see Figure 15.3).
 Craigen and Stanley (1995): There are two patterns of
motion during radioulnar deviation: the proximal row
rotates mostly along the frontal plane (row pattern) or
mostly along the sagittal plane (column pattern).
Carpal Kinetics
During heavy manual work, the joints of the wrist sustain
considerable compressive and shear forces, not only as the
result of the external forces being applied, but also from
contraction of the different muscles necessary to ensure hand
stability. In vivo studies on force transmission across the
radiocarpal joint have disclosed that compressive forces at
that level may be 25 kg during active unrestricted flexion-
extension.87 During pinch, the trapeziometacarpal intra-
articular force may reach values 1.5 to 4.2 times the applied
force. Accordingly, the total force being transmitted by all
the metacarpals to the distal carpal row can reach values
greater than 10 times the applied force at the tip of the
fingers.33 If we consider that the average maximum grip PART
strength is 52 kg for a man and 31 kg for a woman, we can III
estimate that the wrist may bear loads of 520 kg in men or
310 kg in women; this estimation was validated in a series
15 
of in vivo studies by Rikli and coworkers.87
Wrist: Carpal Instability
Within the wrist, such loads are distributed following spe­
cific patterns, depending on many factors, such as magnitude,
direction, and point of application of these loads; orientation
and shape of the different articular surfaces; and elastic prop­
erties of the constraining ligaments. According to in vitro
studies by Viegas and colleagues,110 at the midcarpal level,
about 60% of the load borne by the distal row is transmitted
across the scapholunate-capitate joint. More proximally, the
forces distribute as follows: radioscaphoid joint, 50% to 56%
of the total load; radiolunate joint, 29% to 35%; and ulnar
lunate joint, 10% to 21%. These figures vary substantially
with wrist position. The lunate fossa is increasingly loaded
with ulnar deviation, whereas the scaphoid fossa is over­
loaded with radial deviation.87 The so-called functional
position, which involves slight extension and radial devia­
tion, results in an increased force transmission through the
lunate.109
THEORIES TO EXPLAIN HOW THE WRIST SUSTAINS LOAD
WITHOUT YIELDING (CARPAL KINETICS)
 Gilford and colleagues (1943): The scaphoid, as an
intercalated bridge between the proximal and distal
rows, prevents collapse under load.
 Landsmeer (1960): The proximal row, as an
intercalated segment between the distal row and the
carpus, undergoes a “zigzag” collapse, unless
constrained by the obliquely oriented scaphoid
 Fisk (1970): The concept of the concertina deformity is
introduced.
 Linscheid and colleagues (1972): The scaphoid provides
stability as a slider-crank mechanism (three-bar linkage)
owing to its oblique placement between the radius
and the distal row.
 Kauer (1974): Under load, the obliquely oriented
scaphoid tends to rotate into flexion. The lunate,
owing to its palmar wedge-shaped configuration,
tends to rotate into extension. If the scapholunate
ligaments are intact, the two opposite tendencies
reach a stable equilibrium.
 Weber (1980): The helicoidal shape of the triquetral
hamate joint is a factor that ensures stability of the
proximal carpal row and contributes to lunate
extension through the intact lunate triquetrum
ligament.
Stabilizing Mechanisms of the Wrist
Under load, all carpal bones tend to rotate into specific direc­
tions depending on many factors, including position of the
carpal bone at the time of loading, direction of the load,
congruency of the articular surfaces through which the load
is applied, the status of the capsule and ligaments linking the
bone to the surrounding structures, and the magnitude of the
applied load. Tendons passing in approximation to individual
469
PART
III
15 
Wrist
DISI Normal
carpal bones may also modulate their degree of motion. Such
reactive displacements are maintained until the load is dis­
continued, at which point the original equilibrium of forces
is re-established, with the bones returning to their initial
position and orientation. Any injury or disease modifying
bone geometry, articular inclination, ligament integrity, or
muscle dysfunction may change the degree of carpal motion
or the return to an equilibrium state; this is termed carpal
instability. Knowledge of the different stabilizing mecha­
nisms is crucial to understand fully and treat this problem
successfully.33
Stabilizing Mechanism of the Distal Row
Tendons included in the carpal tunnel have divergent direc­
tions when they emerge in the palm. If their corresponding
muscles contract, the flexor tendons of the little finger gener­
ate a compressive force to the hook of the hamate toward
the ulnar side. This force would be opposite in direction to
the force that is generated when the flexor pollicis longus
contracts against the inner surface of the trapezium. Such
opposite forces would tend to open the palmar carpal concav­
ity (the trapezium toward the radial side, the hamate toward
the ulnar side) if it were not for the presence of the flexor
retinaculum and the strong and taut transverse intercarpal
ligaments. Their annular disposition maintains adequate
transverse stability to the carpal arch. Catastrophic failure of
these intrinsic carpal ligaments creates a particular type of
carpal instability, termed axial or longitudinal, with the
tunnel splitting into two or more unstable columns and dis­
placing in divergent directions.34
Stabilizing Mechanism of the Midcarpal Joint
Under axial load, the distal carpal row exerts an axial com­
pressive force onto the proximal row. Because of its oblique
orientation relative to the long axis of the forearm, the
loaded scaphoid tends to rotate into flexion and pronation.
If the scapholunate and lunate triquetrum interosseous
ligaments are intact, the flexion moment generated by the
scaphoid is transmitted to the lunate and the triquetrum.
Consequently, the unconstrained proximal row would rotate
into flexion if it were not for the presence of the midcarpal
crossing ligaments.58 Especially important midcarpal stabiliz­
ers are the STT and scaphoid capitate ligaments laterally and
470
Figure 15.5  The two major patterns of
sagittal malalignment as described by
Linscheid and Dobyns.64 In DISI and
VISI (also known as palmar intercalated
segment instability [PISI]), a midcarpal
subluxation is possible (arrows).
VISI
triquetrum-hamate-capitate ligament (the so-called ulnar leg
of the arcuate ligament) medially.62 Failure of these ligaments
results in a typical carpal collapse characterized by abnormal
flexion of the unconstrained proximal row, a fairly typical
pattern of carpal malalignment, known as volar intercalated
segment instability (VISI) (Figure 15.5).
Stabilizing Mechanism of the Proximal Row
When axially loaded, the three proximal bones are not
equally constrained by the palmar-crossing midcarpal liga­
ments. Because of the peculiar arrangement of the STT and
scaphoid capitate ligaments, the scaphoid is allowed larger
rotation into flexion and pronation than the lunate, whereas
the triquetrum is tightly constrained by its attachments to the
distal row. If palmar and dorsal scapholunate and lunate
triquetrum ligaments are intact, such differences in angular
rotation are likely to generate increasing torque and inter­
carpal coaptation of the scapholunate and lunate triquetrum
joints, contributing further to their stability. If the scapholu­
nate ligaments are completely torn, the scaphoid no longer
is constrained by the rest of the proximal row and tends to
collapse into an abnormally flexed and pronated posture (the
so-called rotatory subluxation of the scaphoid), whereas the
lunate and triquetrum are pushed by the distal row into an
abnormal extension, known as a dorsal intercalated segment
instability (DISI) (see Figure 15.5).64 If, instead of the scaph­
olunate, the lunate triquetrum ligaments fail, the scaphoid
and lunate tend to adopt an abnormal flexed posture (VISI),
whereas the triquetrum remains solidly linked to the distal
row.65
Stabilizing Mechanism of the
Radiocarpal Joint
The proximal convexities of the scaphoid, lunate, and trique­
trum are interconnected by fibrocartilaginous tissue (scaph­
olunate and lunate triquetrum interosseous membranes),
forming what has been called the carpal condyle. Such a
biconvex structure does not articulate with a horizontal, flat
surface, but with an ulnarly and palmarly inclined antebrach­
ial glenoid, formed by the distal articular surfaces of the
radius and the triangular fibrocartilage complex (TFCC). In
such circumstances, the loaded carpal condyle has an inher­
ent tendency to translate ulnarly and palmarly.84 Such a
 PART

1 III
1 15 

Wrist: Carpal Instability

4 5

3 6
2

I II III

IV

Figure 15.6  Schematic representation of the four stages of perilunate instability, viewed from the ulnar side. Stage I: As the distal
carpal row is forced into hyperextension (red arrows), the scaphotrapezioid-capitate ligaments (1) pull the scaphoid into
extension, opening the space of Poirier (asterisk). The lunate cannot extend as much as the scaphoid because it is directly
constrained by the short radiolunate ligament (2). When the scapholunate torque reaches a certain value, the scapholunate
ligaments may fail, usually from palmar to dorsal. A complete SLD is defined by the rupture of the dorsal scapholunate ligament
(3). Stage II: When dissociated from the lunate, the scaphoid–distal row complex may dislocate dorsally relative to the lunate
(red arrow). The limit of such dorsal translation is determined by the radioscaphoid-capitate ligament (4). Stage III: If
hyperextension persists, the ulnar limb of the arcuate ligament (5) may pull the triquetrum dorsally, causing failure of the lunate
triquetrum ligaments (6). Stage IV: Finally, the capitate may be forced by the still intact radioscaphoid-capitate ligament (4) to
edge into the radiocarpal space and push the lunate palmar-ward until it dislocates into the carpal canal in a rotary fashion.
(Modified from Mayfield JK, Johnson RP, Kilcoyne RK: Carpal dislocations: pathomechanics and progressive perilunar instability, J Hand
Surg [Am] 5:226-241, 1980.)

tendency is constrained by the obliquity of the palmar and
dorsal radiocarpal ligaments, which is perfectly adjusted to
resist such a subluxing tendency. Failure of these obliquely
oriented ligaments results in a very dysfunctional ulnar and
palmar translocation of the carpus relative to the radius.
PATHOMECHANICS OF CARPAL
LIGAMENT INJURIES
Two mechanisms of injury may result in a carpal derange­
ment: direct and indirect. In the first mechanism, the force is
spent directly from the injury-causing object to the dislocat­
ing bone, whereas in indirect mechanisms, the deforming
load is initially applied at a distance from the injured joint.
In the latter, the tensile forces are usually transmitted by
ligaments, and compressive forces are transferred by the
adjacent articular surfaces.
A typical direct mechanism of carpal instability occurs
when the transverse carpal arch is crushed by a power press
or a wringer-type machine. Another is the injury produced
by an explosion. In both of these cases, the dislocating force
is applied over a wide surface area of the wrist, creating a
global dislocation following a typical axial pattern.34 By con­
trast, when the dislocating force is exerted over a small area
of the wrist, a localized fracture-dislocation may occur.47,48
Most dorsal perilunate dislocations are the result of an
indirect mechanism of injury, usually an extreme extension
of the wrist, associated with a variable degree of ulnar devia­
tion and midcarpal supination, often secondary to violent
trauma such as sustained from a fall from a height or a motor­
cycle accident. Hyperextension has also been linked to other
wrist injuries, such as distal radial fractures or scaphoid frac­
tures. Although radial fractures may accompany a perilunate
dislocation, such a combination is uncommon. Many factors
may explain the occurrence of one or another type of injury,
including age-related differences in bone stock, differences in
direction and magnitude of the deforming forces, and differ­
ences in position of the wrist at the time of impact.
In an effort to ascertain the sequence of injury and the
progression of ligamentous damage, Mayfield and colleagues68
undertook several cadaver studies. Their findings confirmed
that most carpal dislocations around the lunate (a broad
spectrum of injuries ranging from minor scapholunate sprains
to a complete palmar dislocation of the lunate) are the con­
sequence of a similar pathomechanic event—so-called pro­
gressive perilunate instability. Four stages of progressive
carpal destabilization have been identified (Figure 15.6).
471
PART Stage I: Scapholunate Dissociation or
III Scaphoid Fracture
When the distal carpal row is forced into hyperextension by
15  an external force, the palmar midcarpal STT and scaphoid
capitate ligaments become increasingly taut. A progressive
Wrist
extension moment to the scaphoid is created, which is trans­
mitted to the lunate via the scapholunate ligaments. The
lunate is tightly constrained, however, by the long and short
radiolunate ligaments. Such an increasing torque may result
in a progressive tearing of the scapholunate interosseous
membrane and ligaments, from palmar to dorsal, eventually
leading to complete scapholunate dissociation (SLD). If the
same process occurs when the wrist is radially deviated, the
lunate and the proximal pole of the scaphoid are strongly
constrained by the radioscaphoid-capitate ligaments. In such
circumstances, instead of SLD, fracture of the scaphoid is
likely. Rarely, hyperextension results in neither scaphoid
fracture nor SLD, but creates a more distal dissociation at the
scaphoid-trapezium level.
Stage II: Lunocapitate Dislocation
When the scapholunate joint is disrupted, or the scaphoid is
fractured, if wrist extension increases, the distal row may
translate dorsally and dislocate relative to the lunate, or a
capitate fracture may appear, and its distal portion dislocate
dorsally with the rest of the distal row. In both instances,
displacement of the distal row may be associated with a
detachment of the radioscaphoid-capitate ligament off the
radial styloid. As a consequence of the dislocation, a curved
capsular rent across the space of Poirier appears, through
which the midcarpal joint is exposed palmarly.
Stage III: Lunate Triquetrum Disruption
or Triquetrum Fracture
As the capitate displaces dorsally, the triquetrum-hamate-
capitate ligamentous complex becomes extremely tensed,
creating an extension moment and a dorsal translation vector
to the triquetrum. Such forces may result either in the separa­
tion of the triquetrum from the lunate, owing to tearing of
the lunate triquetrum ligaments, or a sagittal fracture of the
triquetrum.
Stage IV: Lunate Dislocation
When all perilunate ligaments are torn, only the dorsal
capsule and palmar radiolunate ligaments can hold the lunate
in place. In such circumstances, the dorsally displaced capi­
tate may exert a palmar translation force to the dorsum of
the lunate, resulting in a palmar lunate extrusion. Such dis­
location is often associated with a variable degree of palmar
rotation into the carpal tunnel. Depending on the amount of
lunate rotation, stage IV has been subdivided into three cat­
egories: (1) lunate dislocation type I, in which the lunate
exhibits a minor rotation (<90 degrees); (2) lunate dislocation
type II, in which the lunate is rotated more than 90 degrees
around an intact, undisrupted, palmar capsule (short radiolu­
nate ligament); and (3) lunate dislocation type III, which is
complete enucleation of the lunate with rupture of the palmar
capsule.44
The concept of progressive perilunate instability offers a
rational explanation for instabilities on the radial side of the
472
carpus, but it does not offer much help in explaining the ulnar
carpal instabilities. Mayfield and colleagues68 did not see any
ulnar perilunate instability without a radial component in
their experimental studies. Lunate triquetrum injury may
represent a perilunate dissociation stage III, but also may be
the result of a “reversed perilunate instability” as suggested
by some authors.85,109 If the wrist is forcefully twisted into
extension and radial deviation, instead of ulnar deviation,
tensile loads may concentrate on the triquetrum-hamate-
capitate ligaments. If, in addition, the wrist is hyperpronated
at the time of the injury, and an external force is applied on
the hypothenar area (as when falling backward on an out­
stretched, internally rotated hand), the triquetrum may be
forced by the pisiform to displace dorsally relative to the
lunate. This displacement could be the beginning of a reversed
destabilization pattern of the wrist in which the lunate tri­
quetrum dissociation would be stage I, the lunocapitate dis­
location would be stage II, and SLD would be stage III. This
alternative mechanism, although thought to be likely by dif­
ferent authors,109 has not yet been confirmed by a laboratory
investigation.
DIAGNOSIS OF CARPAL DISORDERS
Two clinical situations can be found in association with post-
traumatic carpal disorders. At one extreme is a patient who
presents after violent trauma, such as a fall from a height, a
motorcycle accident, or a crush injury to the wrist, who is
likely to have a major dislocation. At the other extreme is a
patient who may or may not recall a specific traumatic event
and presents with a symptomatic wrist. In the former patient,
the diagnosis of a major carpal derangement may be obvious,
but in the latter, the identification of a precise carpal injury
is often difficult.112 In this section, the essential clinical and
radiographic examinations of acute or chronic carpal insta­
bilities are discussed. Supplemental information on the pecu­
liar features of each entity is provided separately under each
specific heading.
Clinical Examination
Physical examination always needs to be preceded by a thor­
ough investigation of the patient’s history, with special
emphasis on the mechanism of injury. The patient should also
be encouraged to provide details about the location, duration,
and characteristics of pain; about aggravating and relieving
factors; and about previous treatments, if any. With chronic
problems, it is also important to inquire about the patient’s
job, and whether there has been exposure to repetitive stress,
vibrating tools, or other potential offending agents.
Except in the case of open dislocations, the external
appearance of most wrist instabilities may not be dramatic.
Frequently, major dislocations are missed at presentation
because of a lack of obvious deformity.50 Swelling is gener­
ally moderate, and bone displacements may be evident only
if the patient is seen immediately after trauma. By contrast,
if there has been a delay since the accident, swelling may
have increased significantly, making visualization of the dis­
placed segments more difficult. When present, skin abrasions,
contusions, or ecchymosed areas may be helpful in determin­
ing the mechanism of injury and the potential areas of
damage.
 ZERO LAT. ZERO PA(AP)
A B
Figure 15.7  A-D, Taleisnik102 illustrated two methods of obtaining standardized neutral posteroanterior and lateral radiographs of
the wrist. The arrows indicate the direction of the x-ray beam, which is centered directly over the radiocarpal joint. A and C are
the most adequate to measure ulnar variance. In the presence of shoulder stiffness, A and B may be the only way to obtain
correct projections. (From Taleisnik J: The Wrist, New York, Churchill Livingstone, 1985.)
Palpation for areas of maximal tenderness is one of the
most useful tools in the diagnosis of wrist pathology, espe­
cially in patients with chronic instability. In acute disloca­
tions, because of extensive soft tissue damage, tenderness is
seldom elicited in specific points, but rather in a diffuse
pattern. Nonetheless, palpation should always be done, and
it should be done in an orderly manner. In acute cases, range
of motion is usually limited by pain, whereas it may be
normal in chronic cases. In the latter, passive mobilization of
the joints is valuable not only in determining the presence of
abnormal motion or crepitus, but also, and most importantly,
in reproducing the patient’s pain. Grip and pinch strength
also need to be investigated in chronic instabilities to uncover
underlying pathology. Strength can be reduced by actual loss
of strength or by inhibition caused by pain. In the latter case,
a local anesthetic injection should normalize the dynamom­
eter readings.
A careful assessment of the neurovascular status is impera­
tive, with particular attention to the median and ulnar nerves,
which may be injured by direct contusion at the moment of
impact or by compression from displaced bones or swelling
in the carpal canal. Associated soft tissue, bone, and joint
injuries known to be caused by a similar mechanism (carpo­
metacarpal [CMC] dislocation, radioulnar joint dislocation,
radial head fracture, and elbow dislocation) should be specifi­
cally sought as well.
Radiographic Examination
Routine Views
The initial routine radiographic examination in a patient
with a suspected carpal injury should include at least four
views of the wrist: posteroanterior, lateral, scaphoid (pos­
teroanterior in ulnar deviation), and 45-degree semipronated
oblique.120 If some of these projections are omitted, or if their
quality is inadequate, the likelihood of missing important
information is high. The posteroanterior view should be
obtained with the patient’s shoulder abducted 90 degrees, the
elbow flexed 90 degrees, and the forearm in neutral rotation
(Figure 15.7). The lateral view must be a true lateral view
PART
III
ZERO PA ZERO LAT. 15 
Wrist: Carpal Instability
C D
taken with the elbow adducted to the patient’s side, with the
wrist in neutral rotation. The dorsal surfaces of the metacar­
pals, radius, and ulna should be straight to show any possible
alteration of the alignment of the carpal bones. In a true
lateral projection, the palmar surface of the pisiform should
lie between (and equidistant to) the palmar surfaces of the
distal scaphoid tuberosity and the capitate head. The postero­
anterior ulnar-deviated projection must be centered on the
scaphoid, and the 45-degree semipronated view should
profile the dorsal ulnar and radiopalmar aspects of the carpus.
In the posteroanterior view, three fairly smooth radio­
graphic arcs (Gilula’s lines) can be drawn to define normal
carpal relationships (Figure 15.8).120 A step off in the continu­
ity of any of these arcs indicates a displaced derangement at
the site where the arc is broken.85 Articulating bones nor­
mally have parallel apposing surfaces separated by 2 mm or
less. Any overlap between well-profiled cortices of carpal
bones or joint spacing that substantially exceeds that found
in the uninjured wrist strongly suggests an intercarpal
abnormality.91
In the posteroanterior view of a neutral positioned wrist,
the normal lunate has a trapezoidal configuration. It has long
been taught that a triangular or wedge-shaped lunate is diag­
nostic of lunate dislocation (Figure 15.9). When the lunate
tilts abnormally in either direction (flexion or extension), it
assumes an abnormal shape, however. It is possible to dif­
ferentiate a flexed from an extended lunate on a posteroan­
terior view based on the shape of the lunate contour. In DISI
(dorsal tilting of the lunate), the lunate is a triangular wedge
shape; in VISI (palmar tilting of the lunate), it has a typical
moonlike configuration.85
In the evaluation of carpal bone injuries, soft tissue changes
around the joint are important. Obliteration or bulging of the
fat stripe situated on the radial aspect of the scaphoid is sug­
gestive of injury to this bone.
Additional Views
When the initial radiographic evaluation of a patient with a
suspected carpal dysfunction does not confirm the clinically
473
PART suspected diagnosis, additional views are recommended.120
III The following views are the most commonly used:
15   Anteroposterior (palm up) view with clenched fist: Axial
compression of the carpus by having the patient make a
Wrist
fist or by applying a longitudinal compression force on the
wrist may accentuate the gap that often appears in SLD
(Figure 15.10). It is preferable to obtain this view without
extension or flexion of the wrist to enable evaluation of
the mid-portion of the scapholunate joint because the
dorsal and palmar portions of this joint are normally wider
than its mid-portion.91 Correct positioning of the wrist can
be objectively evaluated by looking at the third CMC
joint. This joint should be in clear profile when the wrist
is not extended or flexed.
 Posteroanterior (palm down) view with 10 degrees of tube
angulation from the ulna toward the radius: This view best
120
Figure 15.8  Yin and Gilula defined three smooth, curved lines
(1, 2, and 3) joining the proximal and distal cortical surfaces of
the carpal bones that help assess normal carpal relationships. A
disruption or step off in any one of these lines may indicate a
major carpal derangement.
A B
Figure 15.9  The shape of the lunate on a posteroanterior view may help differentiate a dislocated from a malaligned lunate.
A, The lunate in a DISI position tends to have an obliquely oriented ovoid configuration, with a prominent wedge-shaped ulnar
corner pointing toward the medial aspect of the wrist. B, The lunate in VISI has a “C”-shaped or moonlike appearance. C, In
dorsal perilunate dislocations, minor palmar rotation of the lunate gives this bone the appearance of an isosceles triangle
pointing distally.
474
shows the scapholunate interval. Measurement of its sepa­
ration (scapholunate gap) is made at the mid-portion of
the joint where its anatomy is more consistent (Figure
15.11).91 Discrete measurements of a normal scapholunate
gap are unreliable; instead, the spacing should be com­
pared with the opposite wrist and with the surrounding
carpal articulations.
 Oblique view at 20 degrees of pronation off lateral posi-
tion: This view is used to visualize the dorsum of the tri­
quetrum, where avulsion fractures frequently occur, and
to evaluate the distal pole and the waist of the scaphoid.
This view also shows fracture-subluxations of the fifth
CMC joint.
 Oblique view at 30 degrees of supination off the lateral
position: The pisotriquetral relationship and hook of the
hamate are seen in this view.
 Lateral view with wrist radially deviated: The hamate
hook can be well profiled on a lateral view with the wrist
radially deviated and the first metacarpal palmarly dis­
placed from the other metacarpals as with spreading the
metacarpals at the first web space. This position places the
hamate hook between the bases of the first metacarpal and
the other metacarpals.
 Carpal tunnel view: By profiling the carpal concavity of
the wrist, a clearer sight of the hook of the hamate, the
pisiform, and the palmar ridge of the trapezium may be
obtained. In patients with acute injuries, however, pain
produced by extending the wrist may not allow this projec­
tion to be taken.
 Static “motion” views: Obtaining a routine “motion”
series for any patient in whom there is a suggestion of
carpal instability may be recommended.120 This series
includes posteroanterior and anteroposterior views in
radial deviation and ulnar deviation, plus additional lateral
views in extension and flexion.
Measurement of Carpal Bone Alignment
Carpal malalignment has traditionally been determined mea­
suring specific distances and angles on posteroanterior or
lateral radiographs. The angles more frequently used are the
capitolunate, scapholunate, and radiolunate, and are based
on axes traced on lateral radiographs (Figure 15.12). The
more commonly used distances, measured on a posteroante­
C

Figure 15.10  Compression of the carpus by having the patient
make a fist (large arrow) may accentuate the gap in complete SLD
(small arrows).
rior projection of the wrist in neutral position, are ulnar
variance, carpal height ratio, capitate-radius index, and ulnar
translocation ratio. When interpreting these data, however,
one must be aware that the normal ranges of all these param­
eters are quite wide, that the reproducibility of these mea­
surements is low, and that small errors in rotational
positioning of the hand at the time of x-ray exposure may
result in substantial variation in angle determinations.92,120
Capitolunate Angle
Theoretically, the long axes of the radius, lunate, capitate,
and third metacarpal are colinear. In practice, this positioning
occurs in less than 11% of normal subjects. Even so, every
attempt should be made to standardize the lateral film by
ensuring that the long axis of the third metacarpal and radius
are as close to parallel as possible, and that neutral rotation
has been achieved by aligning the pisiform and scaphoid
tubercle. When the hand is positioned correctly, the capitolu­
nate angle is helpful to quantify midcarpal malalignment. The
standard method of defining the line representing the lunate
is to draw a line perpendicular to a line connecting the palmar
and dorsal tips of the lunate. The capitate axis is identified
by connecting a point in the center of the convexity of the
head to a point at the center of its distal articular surface with
the third metacarpal.
The normal capitolunate axis should be 0 degrees with the
wrist in neutral, but the range of normal is ±15 degrees. An
alternative method to assess the alignment of the capitolu­
nate joint has been proposed by Loewen and coworkers.66
According to this method, the ratio between the distances
that separate the palmar and dorsal tips of the lunate and the
PART
III
15 
Wrist: Carpal Instability
Figure 15.11  The scapholunate space is most clearly shown in a
posteroanterior view with the tube angled 10 degrees from the
ulnar side.120 The gap is to be measured in its mid-portion, the
landmark being the middle of the flat medial facet of the
scaphoid (arrows).
point where the axis of the third metacarpal crosses the CMC
joint is 0.74 ± 0.07 in normal wrists (Figure 15.13).
Scapholunate Angle
According to the tangential method, the scaphoid is repre­
sented by a line tangential to the two proximal and distal
convexities of the palmar aspect of the bone.120 The angle
formed by this line and that of the lunate has been quoted
extensively in the literature as one of the major determinants
of SLD. Normal values range from 30 to 60 degrees (average
47 degrees).65 Although angles greater than 80 degrees indi­
cate scapholunate ligament disruption, smaller readings do
not rule out this pathology. Values less than 30 degrees are
not unusual in patients with STT joint osteoarthritis.
Radiolunate Angle
The radiolunate angle gives objective evidence of the dorsal
or palmar tilt of the lunate if the angle is greater than 15
degrees or less than −15 degrees. This angle is the best esti­
mate of DISI and VISI deformities, but its utility can be
compromised by radiographs without true neutral alignment
of the hand and wrist.
Ulnar Variance
The relative lengths of the radius and ulna—so-called ulnar
variance—and the possible effects of this parameter on
various carpal disorders have long been investigated. Ulnar
variance needs to be measured on standard posteroanterior
radiographs, obtained with the shoulder 90 degrees abducted,
the elbow 90 degrees flexed, the wrist in neutral position,
and the central x-ray beam centered directly over the wrist.
475
PART L C
III
15 
S
R
Wrist

A B C D
Figure 15.12  Carpal angle determination is based on tracing axes to the carpal bones on true lateral radiographs. The most
reproducible methods of axis determination are as follows: A, The scaphoid (S) is represented by a tangential line that connects
the two palmar convexities of the bone. B, The lunate (L) axis is perpendicular to a line that joins the two distal horns of the
bone. C, The capitate (C) axis is determined by the center of the two proximal and distal articular surfaces. D, The axis of the
radius is obtained by tracing perpendicular lines to its distal third and connecting the center of these lines.

metacarpal and the distal articular surface of the radius mea­

sured along the proximal projection of the axis of the third
metacarpal (Figure 15.14). The carpal height ratio (carpal
height divided by length of third metacarpal) was found to
be 0.54 ± 0.03 in normal wrists.120 Because wrist radiographs
often fail to include the entire third metacarpal, some authors
have proposed using the length of the capitate instead of the
third metacarpal (carpal height divided by capitate length;
B normal range 1.57 ± 0.05). This method has greater accuracy
than the original method using the third metacarpal as the
reference.

Capitate-Radius Index
When carpal collapse affects only one side, it may be moni­
A tored by comparing the closest capitate-radial styloid dis­
C tance to the contralateral normal side. As shown by
Zdravkovic and Sennwald,122 the left/right capitate-radius
index has higher diagnostic accuracy than all other methods
to determine carpal height ratio.

Ulnar Translocation Ratio

Figure 15.13  The alignment of the capitolunate joint can also be
assessed, as proposed by Loewen and coworkers.66 According to
this method, the ratio between the distances that separate the
palmar (A) and dorsal (C) tips of the lunate and the point B
where the axis of the third metacarpal crosses the CMC joint is
0.74 ± 0.07 in normal wrists.
One may objectively determine that a posteroanterior radio­
graph was obtained correctly when the ECU groove is pro­
jected radial to the mid-portion of the ulnar styloid. Some
studies suggested higher incidence of ulnar-minus variance
among patients with carpal instabilities compared with the
normal population. A conclusive explanation for this vari­
ance has not yet been provided.
Carpal Height Ratio
Another helpful parameter in the evaluation of progression
of carpal collapse is the carpal height ratio. The term carpal
height designates the distance between the base of the third
476
In some instability conditions, there is an ulnar shift of the
carpal bones. The amount of translation can be quantified
using different techniques. The more commonly used tech­
nique measures the perpendicular distance from the center
of the head of the capitate to a line from the radial styloid
that extends distally and parallel to the longitudinal axis of
the radius (Figure 15.15). The carpal translocation ratio (cal­
culated as the ratio of this distance to the length of the third
metacarpal) in normal wrists is 0.28 ± 0.03.120 Other similar
methods use the axis of the ulna or the axis of the radius as
a reference. Their accuracy may not be as high, however, as
the former method.
Other Diagnostic Tests
Computed Tomography
In the wrist, computed tomography (CT) scans are usually
taken at 2-mm intervals, along the axial, sagittal, coronal, or
any other plane in which the structure of interest can be
better visualized. CT scan oriented along the true axis of the
scaphoid (i.e., at approximately 45 degrees to the long axis

L1
L2
Figure 15.14  Carpal height ratio is calculated by dividing the
carpal height (L2) by the length of the third metacarpal (L1). The
normal ratio is 0.54 ± 0.03.117
of the radius) is an ideal way to show the amount of collapse
in the “humpback” scaphoid deformity (see Chapter 18). CT
is also useful in evaluating union of fractures or arthrodeses,
although in many instances the image is compromised by
the presence of retained hardware. CT has the added advan­
tage of allowing computer manipulation to obtain three-
dimensional images of the carpal bones, which help visualize
the structure to be analyzed (Figure 15.16). When surgery
is planned on a malunited scaphoid or on a complex carpal
dislocation, a three-dimensional reconstruction provides
excellent visual information about the amount and direction
of the displacement. Because three-dimensional imaging
reconstructs smooth bone surfaces, subtle defects may be
discovered. All the information provided by a three-dimen­
sional reconstruction was already present on the original CT
image, however.
Distraction Views
In patients with acute fracture-dislocations, the four routine
views described earlier are sufficient to establish the diagno­
sis. Sometimes these are difficult to interpret, however,
because of overlapping of the displaced carpal bones. To
investigate these injuries further, anteroposterior and lateral
radiographs with the hand suspended in finger traps are rec­
ommended (Figure 15.17). When using these distraction
views, it is not unusual to discover new injuries or a larger
extent of bone damage than seen on routine films. In less
severe clinical situations, distraction views may also be
helpful, such as in identifying dynamic dissociations of the
scapholunate or lunate triquetrum joints in the form of step
off deformities that are evident only under traction. Offset
or breaking of Gilula’s lines may occur at these joints,
however, with traction in hyperlax individuals.
Stress Views
In some instances, dynamic instabilities cannot be diagnosed
with a motion series, and require stressing the joints in dif­
PART
III
15 
L1
Wrist: Carpal Instability
a
b
c
d
e
g
f
Figure 15.15  Ulnar translocation of the carpus can be monitored
according to different methods.51,84,92,102,120 McMurtry and
colleagues suggested using the axis of the ulna as a reference to
determine if there is an ulnar shift of the center of the capitate
head. In normally positioned wrists, the distance b divided by the
length of the third metacarpal (L1) should equal 0.3 ± 0.003.
According to Chamay and coworkers, a vertical line extending
distally from the radial styloid offers a more reliable reference to
measure the ulnar shift of the capitate. Normal values for the
distance c divided by L1 are 0.28 ± 0.03. A similar method was
described by DiBenedetto and colleagues by using the
longitudinal axis of the radius as a reference. The distance a
divided by L1 should be 0.015 ± 0.024. The so-called lunate
uncovering index has been suggested by Linn and colleagues as
another method to determine the relative position of the lunate
with respect to the radius. According to Schuind and associates,92
the ratio between the length of uncovered lunate (f) and the
maximal transverse width of this bone (f + g) should equal 32.6 ±
11. To measure lunate translocation, Bouman and associates
found it more reproducible to use the ratio e/d, which in normal
wrists equals 0.87 ± 0.04. The last two methods are more likely to
detect ulnar translocations of the lunate than the first three
methods, at the expense of being strongly dependent on the
wrist being precisely positioned in neutral. Even minor degrees of
radial or ulnar deviation may significantly alter the results.
ferent directions to visualize the abnormality. A common
technique for investigating midcarpal instabilities involves
the examiner applying a dorsal or palmar translation of the
distal carpal row relative to the radius (“drawer test”).77 Less
commonly used, yet productive in terms of discovering
abnormal behavior of the radial column, are the views of the
wrist in maximal radial or ulnar deviation (Figure 15.18). A
flexion lateral view can be useful to reveal dynamic scaphoid
subluxation of the proximal pole from the scaphoid fossa of
the radius. If the scapholunate ligament is disrupted, the
lunate remains in a neutral or extended posture, substantially
increasing the measured scapholunate angle.
Cineradiography or Fluoroscopy with Videotape
Cineradiography examination of the wrist provides consider­
able information in the evaluation of a patient who has a
kinematic instability in the form of a painful “clunking”
477
PART
III
15 
Wrist

Figure 15.16  CT is useful in the evaluation of carpal
malalignment. Three-dimensional rendering of the bone surfaces
provides excellent visual information about the amount and
direction of the displacement.
Figure 15.17  Anteroposterior and lateral radiographs taken with
the fingers suspended in finger traps to show the carpus
distracted often provide additional information not well visualized
in the initial injury films, such as osteochondral fragments seen
here in the capitolunate joint.

A B C
Figure 15.18  Stress views are particularly important to assess dynamic instabilities. A, In this 15-year-old girl with hyperlax
wrists, dorsal stress shows that the radiocarpal and midcarpal joints are prone to subluxation. B, A palmarly directed force seems
to be better tolerated, without any noticeable subluxation. C, In a 23-year-old patient, a combination of traction (black arrow)
and ulnar deviation (UD) showed an increased scaphotrapezial gap (white arrow), which was not present on the contralateral
side. Because this finding coincided with the location of major tenderness, a ligament injury was suspected and treated
nonoperatively.

wrist, in whom routine and special views do not show the
underlying pathology. These are patients in whom abnormal
joint subluxation appears only under certain loading condi­
tions. Alternatively, active motion can be studied by the use
of fluoroscopy. Videotape recording of the fluoroscopy is
recommended because it allows a detailed study of the carpal
kinematics. Routinely, cineradiography includes observation
of active movement from radial to ulnar deviation in pos­
teroanterior views, flexion and extension in the lateral view,
and radial and ulnar deviation in the lateral view. If the
patient has a painful clunk, it is important to reproduce
it during the examination. Sometimes the patient can
reproduce this with active motion, and sometimes pro­
vocative stress (passive) maneuvers are required by the
radiographer.
478
Arthrography
Although long considered the gold standard in the assessment
of intracarpal derangements, wrist arthrography is now
rarely performed as an isolated procedure in most centers.
The technique was originally introduced based on the assump­
tion that any flow of intra-articularly injected contrast agent
from the radiocarpal to the midcarpal space or vice versa is
to be interpreted as pathologic. With time, clinicians have
learned that asymptomatic degenerative tears of the proxi­
mal scapholunate or lunate triquetrum membranes are not
unusual, especially in older adults. There seems to be a poor
correlation between the site of symptoms and the defects
seen on arthrography. With new refinements, arthrography
still has some potential, however. Particularly in association
with high-resolution tomography or CT (arthroscan), the
technique seems to be more accurate than magnetic reso­
nance imaging (MRI) in assessing cartilage and ligament
status.104 When injecting the joint, it is imperative to watch
the pattern and the location of the dye flow; this provides
additional data, allowing better detection and estimation of
the size of communication defects, while detecting unidirec­
tional communications owing to valvular effect of the liga­
ment remnants.120
Magnetic Resonance Imaging
In the past, MRI seldom showed subtle ligament injuries
clearly. Compared with arthroscopy, traditional MRI without
dedicated wrist coils showed a sensitivity and specificity of
63% and 86% in the diagnosis of scapholunate ligament
injury, a modest result that did not improve with the use of
intravenous contrast medium.75 MRI with interarticular con­
trast medium (magnetic resonance arthrography) is used with
increasing frequency throughout the world, and some author­
ities believe that this technique is able to show ligament
disruptions better than intravenous MRI contrast medium.120
Improvements in hardware and software technology, imaging
sequences, and advanced wrist imaging algorithms have
enabled high-resolution detail of articular cartilage, intrinsic
and extrinsic ligaments, and the articular disk. Because of its
superior soft tissue contrast, direct multiplanar acquisition,
and lack of ionizing radiation, MRI is an effective means by
which to evaluate the primary stabilizers of the wrist. High-
resolution noncontrast techniques have proven efficacious in
evaluation of the triangular fibrocartilage82,83 and intrinsic
ligaments, but require a dedicated wrist coil, spatial resolu­
tion of less than 200 µm, and slice thickness of no more than
1 mm.
Arthroscopy
Wrist arthroscopy has revolutionized the practice of ortho­
paedics by providing the technical capabilities to examine
and treat intra-articular abnormalities without an extensive
arthrotomy.24,37,67,78,115 Aside from allowing direct visualiza­
tion of the articular surfaces, synovial tissue, and interosse­
ous ligaments, arthroscopy has proved to be a useful adjunct
in the management of various acute and chronic lesions of
the wrist. Arthroscopy is one of the most important tools in
wrist surgery at present, warranting a separate chapter in the
new edition of this book. Although the indications of arthros­
copy are mentioned throughout this chapter, the techniques
are reviewed in detail in Chapter 19.
CARPAL INSTABILITY
Definition
Injuries to the wrist that result in transient or permanent
carpal malalignment have long been recognized in the
medical literature.25 The 1972 landmark article by Linscheid
and coworkers65 helped popularize this condition. The true
meaning of the term instability has been controversial,
however. Initially, the term instability was considered syn­
onymous with malalignment. A wrist was said to be unstable
when there was a substantial alteration in the sagittal or
frontal alignment of the carpal bones beyond the limits of
what was considered normal. From that viewpoint, instability
could always be diagnosed using plain radiographs.
Such a concept of instability was soon criticized by differ­ PART
ent authors, who claimed that an alteration of the carpal III
alignment cannot always be considered pathologic. Congeni­
tal hyperlax wrists often appear grossly malaligned, yet they
15 
frequently remain asymptomatic, are able to handle most
Wrist: Carpal Instability
activities of daily living, and seldom require treatment. By
contrast, other wrists remain asymptomatic most of the time,
are well aligned, and are able to sustain physiologic loads,
only to become painful when performing specific tasks (e.g.,
opening a jar, lifting heavy objects). The term instability
cannot be used as a synonym for malalignment.4
From a biomechanical point of view, stability is defined as
the ability of a joint to maintain a normal relationship
between the articulating bones under physiologic loads
throughout its range of motion.4,33 According to this defini­
tion, a wrist joint should be considered unstable when it is
incapable of preserving a normal kinematic and kinetic con­
nection between the radius, carpal bones, and metacarpals.
Stability implies the ability to transfer functional loads
without yielding or losing its internal joint congruency and
the capacity to maintain motion throughout its range without
sudden alterations of intercarpal alignment.4
When a stable wrist is progressively loaded, the joint
contact forces should increase smoothly and synchronously,
without unexpected changes in direction, magnitude, or loca­
tion of contact. When a stable wrist moves throughout its
entire range of motion, sudden changes in carpal alignment
should not occur. Consequently, the term instability should
be associated not only with the concept of abnormal transfer
of loads (dyskinetics), but also with the concept of abnormal
motion (dyskinematics).
From this point of view, a grossly malaligned wrist with
degeneration of the articular cartilage may be able to bear
substantial loads; however, because it cannot experience
smooth, painless motion without producing sudden changes
of stress on specific areas of cartilage, it fulfills the criteria of
a true carpal instability. Similarly, a wrist with a ligament
disruption may have a completely normal carpal alignment
when unloaded; however, if it is incapable of sustaining func­
tional stress without experiencing abrupt changes in the
alignment of the carpal bones, it must be regarded as an
unstable wrist.
Based on this definition, carpal instability may result from
a wide spectrum of injuries or diseases. Congenital anoma­
lies, such as Madelung’s deformity, scaphoid hypoplasia, or
carpal synostosis, may create abnormal conditions of carpal
instability that eventually require specific treatment. Simi­
larly, avascular necrosis, infections, inflammatory arthritis, or
any other process modifying the shape of the carpal bones
may also alter the necessary interaction between carpal
bones and result in instability. Management of these nontrau­
matic carpal instabilities is discussed elsewhere. This chapter
discusses only trauma-related carpal instabilities.
Classification
Many clinical conditions may eventually result in an unstable
wrist. Classifying such diversity of conditions is not easy.90
Some classifications are based on the location of the predomi­
nant dysfunction. Others emphasize the direction of the
abnormal alignment. Others classify instability according to
severity. None of these classifications is exhaustive enough
479
PART
ANALYSIS OF CARPAL INSTABILITY
III
15  Category II— Category III— Category IV— Category V—
Category I—Chronicity Constancy Etiology Location Direction Category VI—Pattern
Wrist

Acute, <1 wk (maximum Predynamic Congenital Radiocarpal VISI rotation Carpal instability dissociative
healing potential) primary (CID)
Dynamic Traumatic Proximal DISI rotation Carpal instability nondissociative
intercarpal (CIND)
Subacute, 1-6 wk (some Static reducible Inflammatory Midcarpal Ulnar translation Carpal instability complex (CIC)
healing potential) Static irreducible Neoplastic Distal Dorsal translation Carpal instability adaptive (CIA)
intercarpal
Iatrogenic CMC Other
Chronic, >6 wk (little Miscellaneous Specific bones
healing potential)
Modified from Larsen CF, Amadio PC, Gilula LA, et al: Analysis of carpal instability, I: description of the scheme, J Hand Surg [Am] 20:757-764, 1995.

Table 15.1  Analysis of Carpal Instability

to allow categorization of all types of carpal instability
yet simple enough to be easily remembered and used clini­
cally. The controversy about which classification is best is
meaningless because none can be ideal. Instead, more effort
should be spent in providing tools to help the clinician inter­
pret the particular features of each individual case. With this
in mind, Larsen and coworkers59 developed an analytic
scheme that seems to be useful in the assessment of carpal
instability. According to this scheme, to characterize any
carpal instability, six features need to be investigated
(Table 15.1).
Chronicity
Traditionally, ligament injuries have been classified depend­
ing on the time elapsed from injury to diagnosis into three
categories: acute, subacute, and chronic. When the injury is
diagnosed soon after the accident (acute injury), the ligament
healing potential is likely to be optimal. Between 1 and 6
weeks (subacute injury), the deformity is still easily reduc­
ible, but the ligaments may have reduced healing potential
because of retraction or necrosis of ligament remnants or
both. After 6 weeks (chronic cases), the possibility of achiev­
ing an acceptable reduction and primary ligament healing,
although possible, is very unlikely. The exception would be
ligament avulsions. There are instances where the ligament
is detached, but not ruptured, and remains capable of being
repaired with good healing potential beyond the time limit
expressed for mid-substance ligament ruptures.18 In short, it
is not the time from injury itself that counts, but the fact that
time implies a progressive loss of the healing potential of the
damaged ligaments.
Severity
Any carpal instability can be analyzed according to the
severity of the resulting subluxation. If carpal malalignment
appears only under high stress in specific wrist positions,
the case is less severe than if it is permanently present.
Based on this idea, three groups of conditions exist: (1) pre­
dynamic instabilities (partial ligament tears with no
malalignment under stress), (2) dynamic instabilities (com­
480
plete ruptures exhibiting carpal malalignment only under
certain loading conditions), and (3) static instabilities
(complete ruptures with permanent alteration of the carpal
alignment).114
Etiology
Although most instability problems are caused by trauma,
certain diseases (e.g., inflammatory arthritis) may also be
responsible for a similar type of disorder.90 In traumatic
cases, especially if diagnosed early, good repair of the rup­
tured ligaments can be obtained. If ligament rupture results
from rheumatoid arthritis, normal healing is unlikely.
Location
It is important to investigate the location of major dysfunc­
tion; this may or may not coincide with the location of the
initial injury. It is also important to review whether there is
a single problem affecting only one joint, or a multilevel
dysfunction exists.
Direction
When present, the direction of the carpal malalignment is an
important factor to consider. Several patterns of carpal
malalignment have been recognized65; the most common are
(1) DISI, when the lunate, regarded as an intercalated
segment, appears abnormally extended relative to the radius
and capitate; (2) VISI, when the lunate appears abnormally
flexed; (3) ulnar translocation, when a portion of or the entire
proximal row is (or can be passively) displaced ulnarly
beyond normal limits; (4) radial translocation, when the
proximal row can be passively displaced radially beyond
normal; and (5) dorsal translocation, when the carpal condyle,
often as a result of a dorsally malunited fracture of the radius,
is or can be passively subluxed or dislocated in a dorsal direc­
tion (see Figure 15.5).
Pattern
There are four major patterns of carpal instability51,118: (1)
carpal instability dissociative (CID), when there is a major
derangement (fracture or ligament avulsion, or both) within
or between bones of the same carpal row; (2) carpal instabil­
ity nondissociative (CIND), when no disruption exists
between bones of the same row, yet there is dysfunction
between the radius and the proximal row or between the
proximal and distal rows; (3) carpal instability complex
(CIC), when there are features of both CID and CIND types;
and (4) carpal instability adaptive (CIA), in which the reason
for the malalignment is not located within the wrist, but
proximal or distal to it. Perilunate dislocations are a good
example of a complex (CIC) pattern because a ligament
injury coexists at radiocarpal and intercarpal levels, often
resulting in scapholunate or lunate triquetrum dissociation,
or both, and an ulnar translation of the lunate. A carpal
malalignment often seen as an adaptation of an otherwise
normal carpus to a malunited distal radius fracture is a good
example of a CIA pattern.102
CARPAL INSTABILITY DISSOCIATIVE
When a carpal instability is caused by disease or injury result­
ing in a malfunction of a joint between bones of the same
row, the case is classified as CID.51 Dissociative instabilities
are common and may result from various conditions, includ­
ing SLD, lunate triquetrum dissociation, unstable scaphoid
fracture, nonunion or malunion, inflammatory synovitis, and
advanced Kienböck’s disease.
Scapholunate Dissociation
The term scapholunate dissociation has long been used to
describe the dysfunction that results from rupture of the
mechanical linkage between the scaphoid and lunate.
Although the condition was recognized in the early 20th
century,25 it was not until 1972 that the clinical features of
SLD were broadly publicized by Linscheid and associates.65
SLD is probably the most frequent carpal instability and may
appear either as an isolated injury or in association with other
local injuries, such as distal radial fractures or displaced
scaphoid fractures. Although the condition is commonly
found in adults, it has also been documented in skeletally
immature patients.
The term rotary subluxation of the scaphoid frequently has
been used as a synonym for SLD.114 This is not always appro­
priate. The term rotary subluxation of the scaphoid should
be used to describe only cases in an advanced stage of the
injury, in which the ligaments attached to both ends of the
scaphoid have failed, and the bone has collapsed into flexion
and pronation. In less advanced cases, in which only the
proximal ligaments are disrupted, the scaphoid may remain
normally attached to the distal row, preventing collapse of
the bone.36 In between the two extremes, there is a broad
spectrum of pathology that may or may not exhibit carpal
malalignment.114
Pathomechanics of Scapholunate Dissociation
Most cases of SLD are the first stage of progressive carpal
destabilization around the lunate and result from an injury
involving wrist hyperextension, ulnar deviation, and midcar­
pal supination.68 There is a spectrum of injuries—from minor
scapholunate sprains to complete perilunar dislocations, all
being different stages of the same progressive perilunar
destabilization process.
PART
III
15 
Wrist: Carpal Instability
Figure 15.19  Schematic representation of the typical
displacements that occur in static SLD. The scaphoid tends to
rotate into flexion and slight pronation, whereas the
unconstrained triquetrum and lunate supinate and extend into a
DISI pattern of malalignment.
Different authors have investigated the kinematic and
kinetic consequences of the loss of the scapholunate liga­
ments.98 If only the palmar scapholunate ligament and the
proximal membrane are sectioned, only minor kinematic
alterations are created (predynamic instability). These may
be sufficient to promote a symptomatic synovitis, however,
and require medical attention. Complete sectioning of the
scapholunate membrane and ligaments in cadaver specimens
results in substantial alterations of kinematic and force trans­
mission parameters, but not a permanent carpal malalign­
ment. The scaphoid becomes proximally unconstrained, and
radioscaphoid motion increases, whereas radiolunate motion
decreases.
Permanent carpal malalignment does not occur unless
there is a concomitant failure of the secondary scaphoid
stabilizers—the palmar radioscaphoid-capitate and scaphoid
capitate ligaments and the anterolateral STT ligament.98 This
failure may occur acutely, as a result of the hyperextension
stress, or secondarily, with progressive stretching of these
structures. In such conditions, the loaded lunate and trique­
trum rotate into an abnormal extension (DISI), supination,
and radial deviation, and the scaphoid rotates around the
radioscaphoid-capitate ligament into an abnormal flexion,
ulnar deviation, and pronation posture (Figure 15.19).
The reason for these bones to dissociate in such consistent
directions is controversial. According to Kauer,55 the uncon­
strained lunate has a natural tendency toward displacing into
extension owing to its wedge-shaped configuration. Watson
and coworkers112 found that 23% of examined lunates had a
reversed wedge-shaped configuration, however, and sug­
gested that in those cases SLD would induce a VISI rather
than a DISI deformity. Other authors33,62,110 believed that the
lunate, when free from the scaphoid influence, tends to
481
PART follow the triquetrum toward extension under the influence
III of the helicoid triquetral hamate joint surfaces.
When the scapholunate joint has been completely dissoci­
15  ated, with the proximal pole of the scaphoid being subluxed
dorsoradially, the forces crossing the wrist cannot be distrib­
Wrist
uted normally. An increased compressive and shear stress
appears on the dorsal and lateral aspect of the radioscaphoid
fossa, a situation that Watson and associates114 compared
with two spoons sitting one on the other while the handles
are not aligned. Such peripheral contact may explain the
frequent development of long-term degenerative changes at
the dorsolateral edge of the radioscaphoid joint. The lunate
appears rotated into extension, but still in contact with
normal cartilage thanks to the constraining action of the short
radiolunate ligament and the nearly perfectly concentric
shapes of the opposing articular surfaces. This may explain
why the radiolunate joint seldom is affected by the degenera­
tion process. The term scapholunate advanced collapse
(SLAC) has been proposed by Watson and associates114
to refer to the clinical condition in which there has been a
progression of degenerative changes from an isolated
radial styloid–scaphoid impingement (stage I), to complete
radioscaphoid osteoarthritis (stage II), midcarpal arthritis
(stage III), or pancarpal arthritis (stage IV) (see Chapter 14).
Clinical Forms of Scapholunate Dissociation
Owing to the progression of perilunate destabilization and
joint degeneration that follows from untreated instability,
different clinical forms of SLD have been recognized.
Depending on the degree of ligament rupture, their healing
potential, the status of secondary stabilizers, reducibility, and
the presence or absence of cartilage defects, six stages of SLD
exist.36
Stage I: Partial Scapholunate Ligament Injury
In stage I, the scapholunate ligamentous complex is only
stretched or partially ruptured. The injury is usually diag­
nosed by arthroscopy. These patients still have a dorsal
scapholunate ligament intact. The degree of scapholunate
ligament incompetence varies from minimal distention (grade
I, according to Geissler’s classification)37 to a partial rupture
of the proximal membrane without gross instability (grades
II or III) (Table 15.2). At this stage, wrists do not exhibit
malalignment or widening of the scapholunate joint space on
standard or stress radiographs.120 Based on this finding,
some authors have suggested using the term predynamic or
occult instability to refer to such cases.114 Dysfunction basi­
cally derives from an increased motion between the two
bones, generating shear stress, accompanied by local synovi­
tis and pain.
Stage II: Complete Scapholunate
Ligament Injury, Repairable
Stage II is characterized by complete disruption of the scaph­
olunate ligamentous complex, with good healing potential
because of a repairable dorsal component. The carpal bones
are relatively normally aligned, without cartilage degenera­
tion. The distal-palmar connections of the scaphoid to the
distal row (STT and scaphoid capitate ligaments) are still
intact, and there is no rotary subluxation of the scaphoid, a
normal radioscaphoid angle, and little or no scapholunate gap.
482
ARTHROSCOPIC CLASSIFICATION OF CARPAL
INTEROSSEOUS LIGAMENT TEARS ACCORDING
TO GEISSLER AND COLLEAGUES
Grade Description
I Attenuation/hemorrhage of interosseous ligament
seen from the radiocarpal joint; no incongruency of
carpal alignment in the midcarpal space
II Attenuation/hemorrhage of interosseous ligament
seen from the radiocarpal joint; incongruency/step
off seen from midcarpal space; slight gap (less than
the width of a probe) between carpals may be
present
III Incongruency/step off of carpal alignment seen in
radiocarpal and midcarpal space; probe may be
passed through the gap between carpals
IV Incongruency/step off of carpal alignment seen in
radiocarpal and midcarpal space; gross instability
with manipulation noted; 2.7-mm arthroscope may
be passed through the gap between carpals
Modified from Geissler WB, Freeland AE, Savoie FH, et al: Intracarpal
soft-tissue lesions associated with an intra-articular fracture of the distal
end of the radius, J Bone Joint Surg Am 78:357-365, 1996.
Table 15.2  Arthroscopic Classification of Carpal Interosseous
Ligament Tears According to Geissler and Colleagues
Stage III: Complete Scapholunate Ligament Injury,
Nonrepairable, Normally Aligned Scaphoid
Stage III is characterized by the presence of a complete
rupture of the scapholunate ligaments, but without a repair­
able dorsal component and poor healing capacity. Carpal
malalignment is not yet present because the scaphoid is con­
strained by the distal-palmar STT, the scaphoid capitate liga­
ments, and the most proximal fibers of the dorsal intercarpal
ligament—the so-called dorsal scaphoid-triquetral liga­
ment.71,98 No permanent malalignment exists at this stage; an
increased scapholunate gap may appear only under specific
loading conditions. The wrist may yield or give way, however,
when attempting specific tasks in specific wrist positions.112
From a radiologic point of view, stages II and III are
“dynamic” instabilities.120
Stage IV: Complete Scapholunate Ligament Injury,
Nonrepairable, Reducible Rotary Subluxation of
the Scaphoid
Stage IV is characterized by a complete loss of the scapholu­
nate linkage, including complete detachment of the dorsal
scaphoid triquetral ligament off the distal margin of the
lunate, plus insufficiency of the distal scaphoid stabilizers
(STT and scaphoid capitate ligaments). The scaphoid appears
definitively subluxed in a rotatory fashion (radioscaphoid
angle >45°), whereas the lunate may appear abnormally
ulnarly translated and in DISI. For this second feature to
appear, there must be attenuation of the long and short
palmar radiolunate ligaments.98 To be included in this group,
the malalignment needs to be easily reducible, and no carti­
lage damage should be present. Because the resultant
malalignment, owing to failure of the secondary stabilizers,
is constant, stage IV is categorized as a static instability.
Clunking secondary to self-reduction of the subluxation is a
common finding.
Stage V: Complete Scapholunate Ligament
Injury with Irreducible Malalignment,
but Normal Cartilage
Chronic rupture or insufficiency of primary and secondary
scapholunate ligament stabilizers may result in fibrosis
between the scaphoid and surrounding bones. In such
instances, carpal malalignment is irreducible. If there is no
substantial cartilage degeneration, the case fulfills the criteria
of static fixed SLD.
Stage VI: Complete Scapholunate Ligament Injury with
Irreducible Malalignment and Cartilage Degeneration
Long-lasting carpal malalignment with irreducible sublux­
ation of the scaphoid induces degenerative osteoarthritis that
precludes successful ligament repair or reconstruction. Stage
VI represents SLAC wrist, which is treated by relieving
pain through a combination of bony excision or intercarpal
fusion or both, while accepting some functional loss (see
Chapter 14).
Diagnosis of Scapholunate Dissociation
SLD is frequently missed at presentation, especially when the
injury is isolated (predynamic or dynamic stages I or II) or
masked by other, more obvious injuries.111 When SLD is
static or results from a perilunate dislocation, the problem is
more often recognized. A history of a fall on an outstretched
hand should warn the clinician about the possibility of a
scapholunate injury, even if there is a distal radial fracture
or a scaphoid fracture. Many distal radial fractures (30%
according to Geissler and colleagues37) are associated with
variable degrees of carpal ligament disruptions. Aside from
wrist trauma, SLD may also result from a fall on the elbow,
from excessive capsular excision when removing dorsal gan­
glions, from joint deterioration in different rheumatoid and
congenital diseases, and from infection. In children, although
SLD is rare, the diagnosis is even more difficult. A high index
of suspicion is recommended to avoid missing this injury. The
symptoms of SLD vary markedly, depending on the magni­
tude and extent of the associated injuries and on the time
since the accident. Weakness of grasp, limited motion, dor­
soradial swelling, and point tenderness over the dorsal aspect
of the scapholunate interval are frequent findings.112 Pain
is common and may be aggravated by heavy use, and is
sometimes associated with a clunking sensation during
movement.
Clinical Examination
The external appearance of scapholunate instabilities may
not be dramatic. Even in the acute phase, swelling may be
moderate. Palpation for areas of maximal tenderness is useful
in the diagnosis of wrist pathology, especially in patients with
chronic scapholunate instability. By flexing the wrist and
palpating the dorsum of the capsule distal to Lister’s tubercle,
one can obtain important information about the scapholunate
joint. If sharp pain is elicited by pressing this area, the prob­
ability of either a recent injury or a chronic localized syno­
vitis is high. Most of these patients also have tenderness in
the anatomic snuffbox and over the palmar scaphoid tuberos­
PART
III
15 
Wrist: Carpal Instability
Figure 15.20  Watson and colleagues112 described the scaphoid
shift test. Firm pressure is applied to the palmar tuberosity of the
scaphoid while the wrist is moved from ulnar to radial deviation
(curved arrow). In normal wrists, the scaphoid cannot flex because
of the external pressure by the examiner’s thumb. This may
produce pain on the dorsal aspect of the scapholunate interval
owing to synovial irritation. A “positive” test is seen in a patient
with a scapholunate tear or in a patient with a lax wrist; the
scaphoid is no longer constrained proximally and subluxates out
of the scaphoid fossa (straight arrow). When pressure on the
scaphoid is removed, the scaphoid goes back into position, and a
typical snapping occurs.
ity. In acute cases, range of motion is usually limited by pain,
whereas it may be normal in chronic cases.
Scaphoid Shift Test
Passive mobilization of the dysfunctional scapholunate joint
is valuable not only in determining the presence of abnormal
radioscaphoid subluxation, but also in reproducing the
patient’s pain. A positive scaphoid shift test, as described by
Watson and colleagues,112 is said to be diagnostic of SLD
(Figure 15.20). The examiner places four fingers behind the
radius. The thumb is placed on the tuberosity (distal pole) of
the scaphoid, and the other hand is used to move the wrist
passively from ulnar to radial deviation. In ulnar deviation,
the scaphoid is extended and assumes a position more in line
with the forearm. In radial deviation, the scaphoid is flexed.
Pressure on the tuberosity while the wrist is moved from
ulnar deviation to radial deviation prevents the scaphoid
from flexing. In such circumstances, if the scapholunate liga­
ments are completely insufficient or torn, the proximal pole
subluxates dorsally out of the radius, inducing pain on the
dorsoradial aspect of the wrist. When pressure is released, a
typical clunking may occur, indicating self-reduction of the
scaphoid over the dorsal rim of the radius.
When performing the scaphoid shift test, one should be
aware of its low specificity. If the scapholunate ligaments are
intact, but there are other local problems inducing local syno­
vitis (occult ganglion or dorsal radioscaphoid impingement),
483
PART
III
15  the space between the scaphoid and lunate appears abnor­
Wrist
Figure 15.21  Posteroanterior view of the wrist of a 35-year-old
man who sustained a hyperextension injury 4 months before
seeking medical attention. Note the foreshortened scaphoid with
the ring sign (arrowheads), representing the frontal projection of
the palmar tuberosity, and the increased scapholunate joint space
(arrow), indicating the presence of SLD with rotatory subluxation
of the scaphoid.
this test may also provoke sharp pain, and it is difficult to
discern whether there is an abnormally subluxable proximal
scaphoid. Alternatively, patients with generalized laxity may
exhibit painless “clunks” during this maneuver, which more
likely emanate from the midcarpal joint. Comparison of the
two sides is important, although sometimes the opposite
“asymptomatic” wrist has a painful scaphoid shift test as
well.112 Experience with this test is necessary before it can be
evaluated with confidence.
Resisted Finger Extension Test
The ability of the proximal pole of the scaphoid to carry load
without producing pain can be explored by asking the patient
to extend the index and middle fingers fully against resistance
with the wrist partially flexed.112 In the presence of an injury
or insufficiency of the dorsal scapholunate ligament, sharp
pain is elicited at the scapholunate area. This maneuver is
very sensitive but not specific for this pathology.
Scapholunate Ballottement Test
The lunate is firmly stabilized with the thumb and index
finger of one hand, while the scaphoid, held with the other
hand (thumb on the palmar tuberosity and index on the
dorsal proximal pole), is displaced dorsally and palmarly with
the other hand. A positive result elicits pain, crepitus, and
excessive mobility of the scaphoid.
Radiographic Examination
SLD can be suspected by the presence of one or more radio­
graphic features on standard radiographs. Dynamic instabili­
ties require special projections or loading conditions for these
features to be observed.120
484
Increased Scapholunate Joint Space
The so-called Terry Thomas sign (named after the English
film comedian’s dental diastema) is considered positive when
mally widened compared with the contralateral side (Figure
15.21). The scapholunate gap should be measured in the
middle of the flat medial facet of the scaphoid.91,120 Any
asymmetric scapholunate gap greater than 5 mm is diagnostic
of SLD. If there is no recent or remote history of a specific
traumatic episode, and yet if there is obvious scapholunate
diastasis, one must consider either a congenitally increased
scapholunate gap (probably bilateral) with or without hyper­
lax ligaments or other, less common causes of SLD, including
rheumatoid arthritis, gout, and calcium pyrophosphate depo­
sition disease.91
Scaphoid Ring Sign
When the scaphoid has collapsed into flexion (rotary sublux­
ation), it has a foreshortened appearance in the anteroposte­
rior view.120 In such circumstances, the scaphoid tuberosity
is projected in the coronal plane in the form of a radiodense
circle or ring over the distal two thirds of the scaphoid (see
Figure 15.21). This so-called ring sign is present in all cases
in which the scaphoid is abnormally flexed, regardless of the
cause. The presence of this sign does not always indicate
SLD, and its absence does not eliminate the possibility of this
problem.
Lack of Parallelism
In a normal wrist, when the scapholunate joint is carefully
profiled by orienting the x-ray beam properly, the two appos­
ing articular surfaces are flat and parallel. Lack of parallelism
in a patient with other supporting findings may indicate the
presence of SLD.91
Increased Scapholunate Angle
In the lateral view, when the scaphoid lies more perpendicu­
lar to the long axis of the radius and the lunate appears
normally aligned or abnormally extended (DISI), SLD should
be suspected (Figure 15.22). In such circumstances, the
scapholunate angle is greater than the usual 45 to 60 degrees;
this value increases with progressive increases in lunate
dorsal tilt (DISI).65
Palmar “V” Sign
In the lateral view of a normal wrist, a wide “C”-shaped line
can be drawn by uniting the palmar margins of the scaphoid
and radius. When the scaphoid is abnormally flexed, the
palmar outline of the scaphoid intersects the palmar margin
of the radial styloid at an acute angle, forming a sharper,
“V”-shaped pattern.102
Other Diagnostic Tests
Cineradiography
Even in static SLD, in which the diagnosis can be made on
standard radiographs, obtaining further information using
cineradiography is recommended. Cineradiography shows
not only abnormal movement between the scaphoid and
lunate, but also substantial changes in the movement of the
midcarpal joint. The hamate-triquetrum relationship nor­
mally changes from full engagement in ulnar deviation to

Figure 15.22  Lateral view of the same patient shown in Figure
15.21. The outlined scaphoid appears abnormally flexed, resulting
in an increased scapholunate angle despite the normal alignment
of the lunate relative to the radius. L, lunate axis; S, scaphoid axis.
complete disengagement in radial deviation; in SLD patients
with DISI, this joint remains permanently engaged.
Arthroscan
Injecting dye sequentially in the midcarpal and radiocarpal
joints and analyzing scans obtained after each injection may
be useful in further defining partial tears of the scapholunate
ligaments, and in discovering other local problems, such as
osteochondral defects or capsular ligament ruptures.104 When
interpreting these scans, care must be taken not to confuse
degenerative perforations of the scapholunate membrane
with true ligament ruptures. One must also be aware that
such abnormalities are bilateral in a high percentage of
patients.91 Because of these limitations, the use of arthrogra­
phy has diminished substantially in favor of arthroscopy.
Arthroscopy
Regarded by many authors as the gold standard technique in
the diagnosis of intracarpal derangements, arthroscopy also
is useful in describing the degree of injury to the interosseous
ligaments. Chapter 19 provides information for a correct
arthroscopic diagnosis of SLD dissociation.
Treatment of Scapholunate Dissociation
Treatment of SLD is difficult, not always predictable, and
seldom entirely satisfactory.65,73,111 Numerous factors may
explain this. When the initial injury is a partial scapholunate
ligament derangement, radiographs are usually normal, and
it is frequently missed at presentation. Even if diagnosed
early, the ligament remnants are short and difficult to repair.
Because the scapholunate ligament is exposed to consider­
able tension and torsion, it is not unusual for successful
repairs to deteriorate with time. There is no guarantee that PART
a repaired scapholunate ligament injury will retain good III
functional strength and adequate stabilizing capability, even
with early diagnosis and proper treatment. More commonly,
15 
SLD is discovered in the subacute or chronic phase, when the
Wrist: Carpal Instability
derangement is evident on plain radiographs; this occurs
because the progressive instability has deteriorated the sec­
ondary stabilizers, particularly the palmar scaphotrapezial
ligaments. At this stage, the underlying pathology no longer
involves a single structure, but consists of a complex multi­
level ligament injury. Some ligament remnants are retracted,
whereas others are attenuated and are insufficient to stabilize
the joint.98 If substantial time has elapsed from the initial
injury, degenerative arthritis may have appeared, making an
acceptable outcome less likely.114
Treating the injury in the acute phase, when the healing
potential is best, is always more rewarding than trying to
treat old unresolved injuries. In this section, the treatment
alternatives proposed for the different forms or stages of SLD
are discussed. Patient selection is very important when decid­
ing which treatment is best.36 The patient’s age, occupation,
recreational demands, and level of symptoms all must be
considered.
Stage I: Partial Scapholunate Ligament Injury
The most frequent scenario involves a disruption of the
palmar and proximal connections of the scapholunate joint,
but not the dorsal ligament. Occasionally, the dorsal ligament
may have failed first, the palmar ligament retaining some
stability to the joint. In both circumstances, a painful dysfunc­
tion caused by increased shear stress at the scapholunate
level is often present. Arthrography may suggest this diag­
nosis, but most commonly this is made arthroscopically.37 If
the condition is diagnosed in the acute phase, when the
healing potential of the disrupted ligaments is best, a percu­
taneous or arthroscopically guided Kirschner wire fixation is
recommended.24
In more chronic cases of so-called predynamic or occult
instability, three different approaches have been proposed:
proprioception reeducation of the flexor carpi radialis (FCR)
muscle, arthroscopic débridement of the torn ligament edges,
and electrothermal ligament shrinkage. Arthroscopic tech­
niques for acute and chronic stage I instability are discussed
in Chapter 19.
Percutaneous Kirschner Wire Fixation of the
Scapholunate Joint
For acute partial ruptures of the scapholunate ligaments
without carpal malalignment, pinning the joint with Kirsch­
ner wires may obtain good ligament healing and excellent
results.24,111 To maximize correct alignment of the scaphoid
and the lunate, introducing the wires under arthroscopic
control is recommended (see Chapter 19). Reduction of the
displaced bones can be facilitated by placing two Kirschner
wires percutaneously into the dorsal aspects of the scaphoid
and lunate to be used as “joysticks” to facilitate reduction.
If there is no soft tissue interposition, the slight displacement
may be reduced by pulling the scaphoid wire proximally and
ulnarly while the lunate wire is directed distally and radially.
A small incision is made distal to the radial styloid, and
blunt dissection is continued with a hemostat so that a soft
485
PART
III
15  scaphoid tuberosity makes this tendon an
Wrist
FCR
A B C
tissue protector can be placed directly on the scaphoid to
avoid injury to the dorsal sensory branches of the radial
nerve. Two or more 1.2-mm Kirschner wires are inserted
across the scapholunate joint to keep the two bones together
during the ligament healing process. To ensure maximal sta­
bility, a third wire transfixing the scaphoid capitate joint can
be used.
The wrist is immobilized in a below-elbow cast, and the
pin tracts are evaluated every 2 weeks. Physical therapy for
range of motion exercises of the fingers is initiated immedi­
ately. The wires are usually left in place for 8 to 10 weeks
with protection in a removable splint for an additional 4
weeks. Range of motion and grip strength exercises of the
wrist are begun at 3 months. Strenuous activities are discour­
aged for the first 6 months.
Reeducation of Wrist Proprioception
The role of proprioception reeducation in the treatment of
mild scapholunate instability should not be underestimated.41
Particularly in partial scapholunate injuries, when the dorsal
scapholunate ligament is intact, optimization of the time
response of specific forearm muscles to wrist loading may
re-establish the necessary equilibrium for adequate transfer
of loads. Because the FCR tendon uses the scaphoid tuberos­
ity as a hinge toward its distal insertion into the second
metacarpal base, it may act as a “dynamic” scaphoid stabi­
lizer. The extensor carpi radialis brevis (ECRB) muscle may
also act as a lunate stabilizer by promoting extension of the
capitate, increasing pressure on the palmar portion of the
lunocapitate joint and counteracting the lunate extension
tendency.
When the FCR and ECRB muscles cocontract, the two
opposing rotation tendencies (scaphoid flexion and lunate
extension) may be mutually neutralized (Figure 15.23). If the
dorsal scapholunate ligament is not completely torn, such a
dynamic stabilizing capability may be enhanced through pro­
prioception training of these two muscles. If the dorsal scaph­
olunate ligament is disrupted, however, the dorsally directed
vector produced by the FCR muscle would not control the
bone, but it would induce a scaphoid dorsal translation with
subluxation of its proximal pole. Adequate evaluation of the
extent of ligament damage is a prerequisite for this type of
approach. Long-term results of dynamic scaphoid sublux­
486
Figure 15.23  A, The direct relationship that
exists between the FCR tendon and the
important dynamic stabilizer of the wrist, as
long as the dorsal scapholunate ligament
and dorsal radioscaphoid capsule are intact.
B, In that circumstance, contraction of the
FCR tendon induces a supination moment to
the scaphoid (arrows) that counteracts the
inherent flexion and pronation tendency of
this bone. C, If the dorsal scapholunate
ligament is disrupted, the dorsally directed
vector induced by the FCR tendon results in
a dorsal scaphoid subluxation. Reeducation
of the FCR tendon is recommended only in
partial scapholunate tears, when the dorsal
scaphoid stabilizers are intact.
ation using FCR and ECRB rehabilitation have not been
reported.
Stage II: Complete Scapholunate
Ligament Injury, Repairable
Stage II is characterized by a complete disruption of all
scapholunate ligaments (including the dorsal ligament) and
by preservation of the secondary distal scaphoid stabilizers
(STT and scaphoid capitate ligaments). By definition, carpal
malalignment is dynamic, not static; it appears only under
certain loading conditions (e.g., clenched fist, loaded ulnar
deviation). The condition is characterized by substantial
alteration of intracarpal mobility and inability to sustain full
load in most wrist positions. If the healing potential, sub­
stance, and vascular supply of the disrupted ligament is
optimal, a direct repair of the dorsal scapholunate ligament
is always recommended. This needs to be augmented with a
percutaneous Kirschner wire fixation. Frequently, the liga­
ment is avulsed, with or without a small piece of bone; this
occurs most commonly from the scaphoid. In these cases, a
successful repair can be expected beyond the time limits of
what could be expected from an intrasubstance rupture.
Open Reduction, Internal Fixation, and Repair of the
Dorsal Scapholunate Ligament
Direct ligament repair is recommended only when the
dorsal scapholunate ligament has good healing potential, the
secondary distal scaphoid stabilizers are still intact, and there
is no cartilage damage (traumatic or degenerative). This
approach offers the same advantages as found when treating
acute ligament injuries in other joints, including (1) assurance
that the subluxation is reduced, (2) visualization and treat­
ment of any associated osteochondral damage, and (3) direct
repair of torn ligaments. The drawbacks explaining most
failures are (1) the high forces produced by the capitate
trying to separate the scapholunate joint, (2) the poor healing
potential of the frequently devascularized ends of the dis­
rupted ligaments, and (3) the prolonged immobilization
required after surgery. Despite these factors, and considering
the drawbacks of other alternatives, many authors believe
that there is a place for primary repair.* Repairing the palmar
*References 11, 18, 64, 69, 81, 93, 108, 111, 119.
 PART
III
15 

Wrist: Carpal Instability

A B C
Figure 15.24  Open reduction and scapholunate ligament repair in a 27-year-old man who sustained SLD 6 weeks before
surgery. A, Through a dorsal approach, a proximally based capsular flap is created (arrow) for later capsulodesis, according to
Blatt.76 With forceps, the scapholunate interval is opened, allowing inspection of the anterior aspect of the joint. B, Method of
reduction of the joint using two Kirschner wires as joysticks. By pulling the wire inserted into the scaphoid (S) (1) proximally and
ulnarly, while the wire in the lunate (L) (2) is held distally and radially, the joint usually becomes anatomically reduced. C, At this
point, the transosseous sutures are tied, and then Kirschner wires securing the reduced carpal bones are inserted.

scapholunate and dorsal scapholunate ligaments through a
double palmar and dorsal approach would be ideal, but the
difficulties of approaching the palmar component without
damaging the palmar extrinsic ligaments have led to aban­
doning this idea.64 In any case, more recent biomechanical
research in cadaveric specimens concluded that only the
dorsal scapholunate ligament needs to be repaired to achieve
relatively normal carpal kinematics.9,111
Dorsal ligament repair is performed as follows. The inci­
sion may be longitudinal, “Z”-shaped, or transverse; the
last-mentioned incision results in a more aesthetic scar at the
expense of a less adequate exposure. A dorsal approach to
the wrist capsule by elevating two retinacular flaps—one
radial-based flap uncovering the second extensor compart­
ment and another ulnar-based flap exposing the third and
fourth extensor compartments—is recommended. A dorsal
capsulotomy following the “fiber splitting” concept described
by Berger10 is made. The incision starts at the tip of the radial
styloid and progresses medially along the dorsal rim of the
radius until approximately the center of the lunate fossa,
where it takes a distal-oblique course following the fibers of
the dorsal radial triquetrum ligament until its distal insertion
onto the dorsal ridge of the triquetrum. Another incision is
made at the level of the STT joint and progresses medially,
splitting the fibers of the dorsal intercarpal ligament until its
medial insertion onto the dorsum of the triquetrum.
By connecting the two incisions on the dorsum of the tri­
quetrum, a radially based capsular flap is created. This flap is
carefully elevated by sectioning its connections to the dorsal
edge of the three bones of the proximal row. Care is taken to
leave enough dorsal radial triquetrum ligament attached to
the triquetrum to facilitate later tensioning of the ligament
reconstruction. Because the proximal transverse capsular
incision necessarily divides the posterior interosseous nerve,
a portion of this nerve is excised proximal to the joint. Should
this nerve be sectioned at the level of the capsule, a neuroma
could form, leading to painful wrist flexion.
Frequently, when operating early on a torn dorsal scaph­
olunate ligament, there is sufficient ligamentous tissue to
permit a reasonable repair. If the ligament is not ruptured
but avulsed, the repair is more effective and consists of reat­
taching the avulsed ligament to the freshened dorsal edge of
the scaphoid or lunate by using transosseous sutures (Figure
15.24)18,102 or by using tag suture anchors.11 When there is a
bone fragment attached to the ligament, this can be tacked
back down into its bed. The repair is protected by transfixing
the scapholunate and scaphoid capitate joints with Kirschner
wires. Several authors recommended augmentation with a
dorsal capsulodesis, as described later.81,93 The wires are
maintained for 8 to 10 weeks with protection in a removable
splint for an additional 4 weeks.
Several series of patients with SLD treated by means of
direct repair have been published.18,81,93,119 By combining the
data from about 100 cases with an average follow-up of 37
months, pain was absent or significantly reduced in about
70% of the patients, with more than 80% grip strength and
75% wrist motion compared with the normal contralateral
side. Radiographs showed only minimal degenerative changes
in less than a third of the patients, and the condition had not
progressed to an advanced collapse pattern in most patients
except for individuals who place high demands on the wrist
on a daily basis.81
Stage III: Complete Scapholunate Ligament Injury,
Nonrepairable, Normally Aligned Scaphoid
When the dorsal scapholunate ligament is disrupted through
its mid-substance, the two ends tend to degenerate quite
rapidly, so the chances for a successful repair diminish. If the
dorsal ligament cannot be repaired, yet the secondary scaph­
oid stabilizers are still efficient in the prevention of carpal
collapse, one alternative is to recreate the ligament by using
either local tissues from adjacent ligaments or using a bone-
ligament-bone autograft. Another alternative—one of the
most commonly used by most hand surgeons—is to perform
487
PART
III
15  Figure 15.25  Repair of the scapholunate
Wrist
A B
a capsulodesis. Closed reduction and cast immobilization
cannot be considered an acceptable approach to complete
scapholunate disruption in an active patient.
Dorsal Capsulodesis
When detached from the lunate, the scaphoid has a natural
tendency to collapse into flexion and pronation. To prevent
such collapse, several forms of dorsal capsulodesis have been
recommended.32,64,73,76 The most commonly used technique
was popularized by Blatt76 and consists of tightening the
radioscaphoid capsule to prevent excessive scaphoid rotation
into flexion. A 1-cm-wide capsular checkrein is created,
leaving its proximal edge attached to the dorsal rim of the
radius. When the scaphoid is reduced by manipulation and
maintained with one or two Kirschner wires passed obliquely
from the distal pole of the scaphoid into the capitate, the flap
is tightly inserted into a notch created on the dorsum of the
scaphoid at a point distal to the axis of rotation of the scaph­
oid (scaphoid neck) (Figure 15.25). Sutures within the capsu­
lar flap are passed through the scaphoid using Keith needles
and tied over a button on the thenar skin. Anchor sutures
are favored by some surgeons. Postoperatively, these patients
wear a thumb spica cast for 2 months, after which active
range of motion exercises are begun. The wires may be left
in place for an additional month, allowing intercarpal motion
to begin 3 months postoperatively.
Different modifications of Blatt’s technique have been
published. Linscheid and Dobyns64 used one half of the
dorsal intercarpal ligament, released from the triquetrum
and freed from the dorsal rim of the lunate, inverted, and
pulled to the dorsum of the radius, where it is strongly
anchored. Another option, suggested by Gajendran and col­
leagues,32 is to advance the scaphoid insertion of the dorsal
intercarpal ligament from its dorsal ridge to a more distal
position at the scaphoid neck to control flexion and pronation
deformities.
Corroborating the positive predictions made in the labora­
tory, many clinical series have reported good results with
these procedures.16,32,73,76,119 All series agree that tensioning
the dorsal capsular attachments to the distal scaphoid offers
less surgical morbidity than other alternatives. At an average
488
ligaments is frequently associated with a
dorsal capsulodesis. Different modalities
have been published, all aiming at
preventing recurrence of the scaphoid
flexion tendency. A, The most popular
method was described by Nathan and
Blatt,76 which uses a proximally based
capsular flap. B, Linscheid and Dobyns64
preferred using a strip of the dorsal
intercarpal ligament. C, Filan and
Herbert31 suggested a distally based
capsular flap.
C
2 years of follow-up, these studies found absence of symp­
toms in two thirds of patients, with 75% grip strength com­
pared with the contralateral side. When examined with MRI,
these patients show an increased capsular thickening that
prevents scaphoid rotary subluxation at the expense of limit­
ing wrist flexion an average of 20 degrees.76 The long-term
stabilizing efficacy of most capsulodeses tends to diminish,
but still the overall results are satisfactory when used in
dynamic instabilities.16,119 These methods can be used suc­
cessfully in the skeletally immature carpus, without adverse
effects on growth.
Soft Tissue Reconstruction of the
Dorsal Scapholunate Ligament
More recent publications have reported acceptable results in
the treatment of dynamic scapholunate instabilities by replac­
ing the nonrepairable dorsal scapholunate ligament with a
strip of either the dorsal intercarpal ligament or the dorsal
radial triquetrum ligament.64,73,108 Both methods involve
using a portion of dense connective tissue with a triquetral
attachment. The attachment is left intact, while the other end
is tightly reinserted onto the dorsal ulnar corner of the proxi­
mal scaphoid. The method uses anchor sutures to facilitate
incorporation of the ligament into the previously denuded
dorsal and distal cortices of the scaphoid and lunate. Both
propositions seem very interesting for their simplicity and
low local morbidity. Early results are said to be satisfactory;
however, these techniques are to be considered experimental
until further clinical research and long-term results are
presented.
Bone-Ligament-Bone Grafts
Based on the proven success of replacing knee ligaments with
bone-ligament-bone grafts, several investigators addressed
the in vitro feasibility of using allografts to replace a dorsal
scapholunate ligament. Weiss116 reported transferring a bone-
retinaculum-bone autograft harvested from the region of
Lister’s tubercle. Harvey and associates43 advocated the use
of the third metacarpal–capitate ligament. The surgical
approach is identical to a direct repair. After the two

ECRB
ECRB
A B
bones are reduced and transfixed by wires, a deep trough is
carved at both sides where the bone-ligament-bone graft
will be buried and fixed with mini-screws or small wires or,
alternatively, by interference fit of the impacted bone
fragments.
Theoretically, by providing tissue with similar elasticity
and strength as the original structure, there is a better chance
of achieving a more adequate scapholunate linkage. Several
potential problems may arise, however: (1) Because the
proximal scaphoid is a vascularly compromised area, consoli­
dation of the graft may not be easily achieved; (2) after a
long period of immobilization, the mechanical properties of
the ligament in the graft may deteriorate and subsequently
fail under the amount of stress that will be exerted on it; and
(3) reconstructing the dorsal scapholunate ligament alone
does not solve the palmar-distal ligament insufficiency that
exists by definition in static scapholunate instabilities. The
early clinical results are encouraging in the cases in which the
secondary stabilizers are still functional (dynamic instabili­
ties).43 The reported failures of this technique when used in
static instabilities makes this technique less desirable.
Stage IV: Complete Scapholunate Ligament Injury,
Nonrepairable, Reducible Rotary Subluxation of
the Scaphoid
SLD is in stage IV when the primary and the secondary
scaphoid stabilizers have failed, inducing a static rotary sub­
luxation of the bone. The abnormal carpal posture is still
reducible, and no cartilage deterioration is present. If the
dorsal scapholunate ligament has avulsed cleanly off the
scaphoid or the lunate, ligament repair can still be attempted,
provided that the repair is augmented with a dorsal capsu­
lodesis to compensate for the loss of the secondary stabiliz­
ers. Many of these repairs tend to attenuate or fail because
the chronicity of the malalignment has stretched out the
overall wrist capsule. For all such cases, where there is more
PART
III
FCR
Figure 15.26  Despite the initial
discouraging results obtained after 15 
the first attempts to reconstruct the
Wrist: Carpal Instability
scapholunate linkage using tendons,
reports suggest that there may still
be a role for this type of procedure.
An ideal indication would be a
reducible SLD in which ligaments
cannot be optimally repaired (stage
IV SLD).36 A-C, Three methods have
been described by Almquist and
associates3 (A), Linscheid and
Dobyns64 (B), and Brunelli and
Brunelli15 (C). The effectiveness of
the last two methods is based on the
stabilization of the proximal and the
distal ends of the subluxating
scaphoid, without creating bone
holes in the vicinity of the vascularly
compromised scapholunate joint.
C
global soft tissue attenuation, two different strategies have
been proposed: tendon reconstructions and reduction-
association of the scapholunate joint (RASL procedure).
Tendon Reconstruction of the Scapholunate Ligaments
The use of tendon grafts to reconstruct the scaphoid stabiliz­
ing ligaments has evolved considerably since first introduced
in the early 1970s.65,79 The initial idea was to pass a tendon
graft through holes in the scaphoid and lunate to provide
immediate stability by tightly looping it around the joint. The
method was based on creating large drill holes in vascularly
compromised areas, interfering with blood supply, resulting
in fractures or joint degeneration or both. Poor long-term
results followed, and the method fell out of favor.79 In the
1990s, new alternatives using tendon grafts were considered
(Figure 15.26).3,15,64
Almquist and associates3 reported good results with the use
of the so-called four-bone ligament reconstruction. The joint
is approached dorsally and palmarly. Holes are made in the
capitate, scaphoid, and lunate, and a slip of the ECRB tendon,
the distal end of which is left attached to the third metacar­
pal, is passed through the holes to reproduce the transverse
direction of the dorsal scapholunate ligament. The scapholu­
nate joint is stabilized further with a wire loop, and the wrist
is protected with splints for 16 weeks.63
Linscheid and Dobyns64 proposed another option. A strip
of the extensor carpi radialis brevis tendon is used to tether
the distal scaphoid to prevent its excessive flexion while
reconstructing the transverse course of the dorsal scapholu­
nate ligaments. Two transverse incisions are used—one short
palmar incision over the scaphoid tuberosity and one wide
transverse incision on the dorsum of the wrist. The freed strip
of tendon is left attached distally and passed through a drill
hole made from the dorsal aspect of the distal scaphoid to
the tuberosity. The tendon is passed intra-articularly around
the scaphoid waist to emerge in the dorsal incision. The strip
489
PART
III
15 
Wrist
A B
Figure 15.27  Schematic representation of the “three-ligament tenodesis” (modified Brunelli) technique to reconstruct the
nonrepairable dorsal scapholunate ligament.36,103 A, FCR tendon is passed obliquely from the palmar scaphoid tuberosity to the
dorsal ridge of the scaphoid where the dorsal scapholunate ligament inserts. B, The tendon is buried in a trough created on the
dorsum of the lunate by means of an anchor suture. To adjust the tension of the graft, a slit in the distal portion of the dorsal
radial triquetrum ligament is made through which the tendon is looped around and sutured onto itself. C, In contrast to the
original Brunelli method, this method does not attempt to cross the radiocarpal joint with the graft.
of tendon is passed under the dorsal fibers of the lunate
triquetrum ligament, looped around itself, and pulled taut
distally to maintain the lunate reduction.
In 1990, Brunelli and Brunelli15 advocated the use of a strip
of FCR tendon to address the proximal and distal aspects of
the instability that is present in the rotary subluxation of the
scaphoid. Two small transverse palmar incisions are made to
identify and obtain a strip of FCR tendon that is left attached
distally. Through a separate dorsal incision, all scar tissue
formed between the two bones and the scar tissue formed
between the scaphoid, trapezium, and trapezoid are removed.
The scaphoid subluxation should be reduced with the removal
of scar tissue. The split tendon is passed through a drill hole
made across the distal scaphoid.
According to the initial technique, the split tendon that
emerges off the scaphoid hole is sutured to the remnants of
the dorsal scapholunate ligament before being pulled taut
proximally and anchored to the dorsal ulnar corner of the
distal radius. This method was subsequently modified by Van
den Abbeele and associates,107 who suggested not to cross the
radiocarpal joint, but to use the dorsal radial triquetrum liga­
ment as a solid anchoring point to the tendon graft. The
overall results of the modified Brunelli and Brunelli proce­
dure, also known as three-ligament tenodesis (Figure
15.27),36,103 are very encouraging, with most patients having
returned to their previous occupation with relief of pain,
excellent grip strength, and an average 45 degrees loss of
flexion compared with the opposite hand.
The differences between the old and new methods of
tendon reconstruction are substantial. Not only is the scaph­
olunate joint instability addressed, but also, and more impor­
tantly, the distal palmar component of the scaphoid instability
is controlled. The drill holes are not in the vicinity of the
scapholunate joint, but in an area of the scaphoid with better
vascularization, so that the weakening effect is minimal. A
retrospective cohort study comparing the four-bone weave
with the modified Brunelli reconstruction showed improve­
ments in motion, strength, DASH (Disabilities of Arm, Shoul­
der, and Hand) scores, and pain relief in the latter group at
2.5 years of follow-up.63
490
C
CRITICAL POINTS: SCAPHOLUNATE STABILIZATION
(THREE-LIGAMENT TENODESIS)36
Indications
 Dynamic SLD, reducible, with normal cartilage (stage
III)
 Static SLD, reducible, with normal cartilage (stage IV)
Preoperative Evaluation
 Routine x-ray examination
 Clenched-fist view
 Fluoroscopic evaluation of abnormal carpal motion
 MRI to check integrity of FCR tendon
 Arthroscopy to rule out cartilage degeneration or
lunate triquetrum injury or both
Technical Points
 Perform a dorsal (zigzag, lazy “S,” or longitudinal)
approach centered at Lister’s tubercle.
 Remove a section of the extensor retinaculum along
the third compartment.
 Open septa between II-III, III-IV, and IV-V; coagulate
intraseptal arteries.
 Perform a dorsal capsulotomy following the “fiber
splitting” technique by Berger.10
 Reducibility is checked by traction or by direct
manipulation with Kirschner wires as “joysticks.”
 Enter the scaphoid with a 2.7-mm cannulated drill
hole at the point of insertion of the dorsal
scapholunate ligament.
 Direct the drill hole along the axis of the scaphoid
aiming at the palmar tuberosity.
 Make a 1-cm palmar incision over the scaphoid
tuberosity and release the FCR tendon sheath.
 Obtain a distally based 8-cm strip of tendon
(× approximately 3 mm).
 Retrieve the tendon strip from the dorsum using a wire
or a tendon passer.
 Carve a transverse trough over the dorsum of the
lunate with a rongeur (see Figure 15.30C).
 Insert a 1.8-mm anchor suture into the lunate.
 Localize the dorsal radial triquetrum ligament, and
loop the tendon strip around its distal insertion.

CRITICAL POINTS: SCAPHOLUNATE STABILIZATION
(THREE-LIGAMENT TENODESIS)36—cont’d
 While tensioning the tendon using the radial
triquetrum ligament as a pulley, transfix the
scapholunate and scaphoid capitate joints (usually two
1.5-mm Kirschner wires are used; eventually three are
used) (see Figure 15.30E).
 Without releasing the tendon tension, use the anchor
suture to bury the tendon against the lunate cancellous
bone in the previously created trough.
 Suture the tendon loop onto itself.
 Close the capsule over the tendon strip carefully.
 Reconstruct the extensor retinaculum.
Postoperative Regimen
 Short arm thumb spica cast for 6 weeks, changed at
10 days for stitch removal and x-rays
 Removal of wires at 6 weeks and protection in a
removable splint for an additional 4 weeks
 Rehabilitation after cast removal to regain motion and
grip strength
 Contact sport not allowed until 6 months
postoperatively
 Probable outcome: a painless wrist with 20 degrees loss
of flexion and 75% grip strength
Reduction-Association of the Scapholunate Joint
(RASL Procedure)
Based on the observation that failed scapholunate fusions
tend to do clinically better than cases that achieve fusion,
Filan and Herbert31 proposed a novel approach to static
scapholunate instabilities. The method consists of an open
reduction, repair of the ligament remnants, and protection of
the repair by internally blocking the scapholunate joint with
a transverse Herbert screw for 12 months or more. The goal
is to create fibrous union of the scapholunate joint to allow
loading of the two bones without yielding. The early reported
results have been good, with most patients exhibiting almost
full range of motion and a strong grip.31,89 Whether these
results will deteriorate with time remains unknown.
Stage V: Complete Scapholunate Ligament Injury
with Irreducible Malalignment, but Normal
Cartilage
Chronic rupture or insufficiency of primary and secondary
scapholunate ligament stabilizers results in the formation of
fibrosis between the malrotated scaphoid and surrounding
bones. With time, subluxed joint surfaces tend to deform,
making the carpal malalignment even more irreducible. If,
despite this, there is still not substantial cartilage degenera­
tion, the case fulfills the criteria of SLD stage V. When cases
are symptomatic, the most frequently recommended treat­
ment is a partial fusion. Compared with total wrist fusion,
the advantages of arthrodesis of only the diseased joint have
long been recognized.* Descriptions of the partial arthrode­
ses most commonly used for the treatment of SLD follow.
Further details about the techniques and their results are
provided in Chapter 14.
*References 35, 46, 80, 113, 121, 123.
Scaphoid-Trapezium-Trapezoid Arthrodesis PART
The goal of the procedure is to realign the proximal pole III
of the scaphoid relative to the scaphoid fossa so that the
radioscaphoid congruency is restored, and the chance of
15 
developing later degenerative changes is reduced.113 When
Wrist: Carpal Instability
planning such a procedure, it is important that the external
dimensions and alignment of the resultant fused block are the
same as the external dimensions of the bones in the normal
wrist. Underreduction (scaphoid flexed) fails to close the
scapholunate gap correctly, and overreduction (scaphoid
extended) may result in more restricted motion and more
severe radioscaphoid impingement postoperatively.
As experience with STT joint fusion has accumulated, com­
plications and long-term effects have been reported.56 The
average rate of nonunion among all the reported series is
14%.99 Range of motion and strength are frequently decreased
postoperatively, and the results in terms of pain relief are not
uniformly predictable. Painful radioscaphoid impingement is
a frequent problem, owing to the fact that in radial deviation
the distally fused scaphoid can no longer rotate into flexion,
resulting in an increased pressure on the scaphoid fossa. To
solve this problem, Watson and coworkers113 recommended
incorporating a dorsolateral radial styloidectomy as a routine
part of the STT joint fusion; this is likely to prevent periph­
eral (not central) impingement. Any preexisting cartilage
degeneration between the scaphoid and radius is a formal
contraindication to STT joint fusion.
Scapholunate Arthrodesis
Previously believed to be the ideal method of treating SLD,
fusion of the scapholunate joint has proved to be one of the
least reliable treatments for this condition.46,99 The small
articular surfaces in contact and the magnitude of forces by
the capitate tending to separate the two bones combine to
make this fusion difficult to achieve. After this intervention,
the mutual shift between the two bones is no longer possible;
this results in increased demands on the arthrodesis site,
predisposing the fusion to refracture. Bony union occurs in
only about 50% of the cases.80,99,123 The nonhealed fusions
may have created enough fibrosis between the scaphoid and
lunate, however, to decrease the patient’s symptoms.31,89
Scaphoid-Capitate Arthrodesis
Theoretically, scaphoid-capitate fusion should have conse­
quences similar to STT joint fusion. In the laboratory, the
kinematic and kinetic carpal behavior after both types of
fusion are similar; both cause abnormal transfer of load and
significant loss of midcarpal joint motion, especially in radial
and ulnar deviation. Watson and coworkers113 found less
reduction of motion after STT joint fusion, however, than
after scaphoid-capitate fusion, probably because of the adap­
tive motion occurring at the trapezoid-capitate level. The
long-term results of this procedure are quite acceptable,
however, with more than two thirds of patients being satis­
fied, with minimal disability.121
Scaphoid-Lunate-Capitate Arthrodesis
Adding the lunate to the scaphoid-capitate fusion offers a
method of controlling the scaphoid and the lunate malalign­
ment, at the expense of a 50% reduction of wrist motion. It
is indicated in a patient with severe fixed instability without
491
PART
III
15 
Wrist

C
Figure 15.28  A 36-year-old man presented with a complaint of pain, lack of strength, and mild reduction of motion 1 year after
a twisting injury to his right wrist. A, Posteroanterior view disclosed the presence of static SLD, more evident in the CT scan than
in the normal posteroanterior view. B, Surgical exploration disclosed severe cartilage damage on the proximal pole of the
scaphoid. C, Because the patient was a heavy manual worker, we decided to preserve his midcarpal joint by fusing the
radioscaphoid-lunate joint, plus excision of the distal half of the scaphoid. This allows better mobility of the midcarpal joint in
flexion and radial deviation.35 D, The patient was asymptomatic 7 months after surgery, back to his former job, with acceptable
“dart-throwing” motion, and only a 24% reduction of grip strength.

degenerative changes on the proximal pole of the scaphoid
and apposing articular surface of the radius.
Radioscaphoid-Lunate Fusion plus
Distal Scaphoidectomy
As stated in the biomechanics section of this chapter,
most activities of daily living involve motion along the so-
called dart-throwing or physiologic flexion-extension plane—
from extension–radial deviation to flexion–ulnar deviation.
Such motion occurs mostly at the midcarpal joint.23,74
Consequently, if the fixed malalignment or degenerative
arthritis of the scaphoid and lunate requires an arthrodesis,
and the midcarpal joint is unaffected, it is reasonable to fuse
the radioscaphoid-lunate joint rather than the midcarpal
joint. If, aside from the dissociation, there are abnormalities
in the radiocarpal joint, but the midcarpal articulation is
normal, an arthrodesis of the radioscaphoid-lunate joint is the
best choice. Fusing the radioscaphoid-lunate joint eliminates
pain induced by local synovitis, while stabilizing the proxi­
mal component (scapholunate acetabulum) of the midcarpal
joint.
After this fusion, the STT joint may become symptomatic
and degenerate with time because of the inability of the
492
scaphoid to flex during wrist flexion or radial deviation or
both, creating a local impingement. To avoid such a compli­
cation, and to increase the resultant motion, I have suggested
excision of the distal third of the scaphoid.35 With this modi­
fied technique, the midcarpal ball-and-socket articulation is
freed from its lateral constraint and allows more than 50%
of the overall wrist motion. The early published results are
very encouraging (Figure 15.28).35
Stage VI: Complete Scapholunate Ligament
Injury with Irreducible Malalignment and
Cartilage Degeneration)
Long-standing SLD progressively deteriorates the adjacent
joint cartilage in a SLAC wrist sequence.114 The cartilage
wear begins between the tip of the radial styloid and the
distal scaphoid and progresses proximally until the entire
radioscaphoid joint is involved. At a later stage, the midcar­
pal joint may also degenerate, usually starting at the luno­
capitate interval. In advanced cases, the rest of the carpus
may be involved, with the exception of the radiolunate joint,
which typically is spared from this degenerative process
(Figure 15.29). SLAC wrists are not always symptomatic.
When they are, soft tissue procedures are not likely to relieve

Figure 15.29  Typical SLAC wrist. Note the osteophyte formation
at the radial styloid–scaphoid articulation (arrow), which is
probably an attempt by the joint to stop the destabilization
process.
pain. These operations are contraindicated in the presence of
extensive joint arthrosis.36 The problem is that all the other
alternatives have relative disadvantages. Some points to be
considered when using these techniques in patients with SLD
follow. Further detailed information of most of the following
procedures is provided in Chapters 14 and 19.
Arthroscopy
Wrist arthroscopy plays a limited salvage role in patients
with SLAC wrist. It can be used to evaluate the degree and
extent of articular degeneration to determine which salvage
procedure is best for the case. Particularly in the decision-
making process between a four-corner fusion or proximal
row carpectomy, wrist arthroscopy can be a valuable adjunct
in determining the status of the radial and capitate articular
cartilage.
Radial Styloidectomy
Radial styloidectomy is one of the oldest interventions used
to relieve wrist pain caused by an impingement between the
tip of the radial styloid and a malpositioned distal scaphoid.
Despite removing the osteophytic radial styloid process, the
underlying cause of the scaphoid malalignment (nonunion,
SLD, STT joint fusion) is not treated, and the SLAC wrist
sequence can progress. When performing a radial styloidec­
tomy through an open lateral approach, caution is required
to protect the dorsolateral branches of the radial nerve. On
its palmar margin, it is important to avoid detaching the
origin of the radiocarpal ligaments, which would lead to
further instability.9 In individuals who desire minimal surgi­
cal intervention, arthroscopic débridement and radial styloid­
ectomy may be an option.
Scaphoidectomy plus Midcarpal Fusion PART
Popularized by Watson and coworkers,113 the SLAC proce­ III
dure (scaphoid excision plus a capitate-lunate-triquetrum-
hamate fusion, also known as four-corner fusion) has gained
15 
an excellent reputation for the treatment of chronic SLD. For
Wrist: Carpal Instability
the operation to be successful, good articular cartilage at the
radiolunate level is required. A frequent complication is the
development of dorsal impingement between the dorsal edge
of the radius and the capitate. An important step to avoid
this is to correct the DISI deformity fully before stabilizing
the midcarpal joint. Low-profile circular plates have been
designed to be countersunk below the dorsal intersection of
the four bones so that radial impingement is avoided.
In selected cases, fusion is limited to the lunocapitate joint,
particularly in ulnar-plus wrists in which an excessively rigid
triquetrum could precipitate ulnocarpal abutment. Another
alternative, which is particularly useful in cases with chronic
combined scapholunate and lunate triquetrum instability
(perilunate instability), is to excise the scaphoid and trique­
trum before fusing the lunocapitate joint.
Proximal Row Carpectomy
Proximal row carpectomy is a controversial salvage opera­
tion consisting of the entire excision of scaphoid, lunate, and
triquetrum, creating a neoarticulation between the capitate
and the lunate fossa of the radius.86 Although usually per­
formed through a dorsal approach, it can also be done
through a palmar capsulotomy. In most series, the procedure
has proved to be good in terms of pain relief and restoration
of functional wrist motion and grip strength, with high overall
patient satisfaction.
In mechanical terms, this operation converts a complex
composite articulation into a single ball-and-socket joint with
nonmatching articular surfaces. The wrist can adjust to such
an incongruity only if there is good articular cartilage on the
proximal pole of the capitate and in the lunate fossa of the
radius. Compared with the SLAC procedure, this technique
avoids long immobilization and the risk of nonunion. It
has the added advantage of being convertible to a wrist
arthrodesis or arthroplasty if at a later date it evolves into a
painful osteoarthritis. Long-term radiocapitate degeneration,
although often asymptomatic, is present in about one third
of patients with more than 10 years of follow-up.86
Total Wrist Arthroplasty
Advances in total joint replacement of the wrist have made
this option a reasonable treatment for patients who place low
demands on the wrist. Most patients with late post-traumatic
instability are young and active individuals or manual labor­
ers, for whom a prosthesis is seldom an acceptable choice.
Total Wrist Arthrodesis
Although many surgeons believe that a total wrist arthrodesis
should rarely be considered in a heavy laborer with post-
traumatic unstable osteoarthritis of the wrist, arthrodesis
may be the procedure of choice sometimes. According to
some sources, total pain relief is expected in 85% of patients
with wrist fusion, with 65% returning to their former occupa­
tions. As shown in many clinical series, most patients with
total wrist fusion are able to accomplish all daily tasks by
learning to compensate for the loss of wrist motion.
493
PART Author’s Preferred Methods of Treatment:
III Scapholunate Dissociation
Partial ruptures of the scapholunate ligamentous complex
15  (stage I, predynamic, occult SLD) may respond well to
physiotherapy. Particularly promising are the results of
Wrist
proprioception reeducation of the wrist muscular stabilizers,
particularly promoting the combined action of the FCR
and ECRB muscles. Failing proprioception reeducation,
arthroscopic electrothermal shrinkage of the injured or
stretched proximal membrane is a promising option in
Geissler’s grades I and II.
In more advanced partial injury, I believe in resecting the
unstable remnants of disrupted membrane, plus percutane­
ous pinning of the scapholunate joint with two or more
Kirschner wires for 8 weeks. It is always important to check
for the integrity of the dorsal scapholunate ligament. If insuf­
ficient or torn, but repairable (stage II SLD), I prefer the open
technique of joint reduction, ligament repair, and dorsal cap­
sulodesis as proposed by Cohen and Taleisnik.18 Although
recognizing its potential future use, I have little experience
in the reconstruction of the dorsal scapholunate ligament
with bone-ligament-bone grafts in stage III SLD, a technique
that, in my opinion, should never be considered in more
advanced stages where the secondary stabilizers are lost and
there is already rotary subluxation of the scaphoid. I no
longer consider scapholunate ligament repair, even if repair­
able, when there is already some malalignment present.36 The
presence of DISI indicates a more global problem that can
hardly be solved by addressing only the dorsal scapholunate
ligament.
If the subluxation is easily correctable (stage IV SLD) and
no cartilage defect exists, I have had excellent results with
the three-ligament tenodesis (modified Brunelli) tendon
reconstruction as described by Van den Abbeele and col­
leagues107 with the following modifications: (1) a trough on
the dorsal surface of the lunate is created so that the tendon
graft is placed in full contact with cancellous bone; (2) an
anchor suture is used to compress the tendon graft against
the lunate; and (3) to get the right tension to the tenodesis,
the distal portion of the radial triquetrum ligament is used as
a pulley around which the tendon is looped and sutured onto
itself. This last modification has been shown to be beneficial
because it pulls the ulnar-side carpus toward the scaphoid,
helping in the closure of the scapholunate gap (Figure
15.30).36
When the malalignment is irreducible (stage V SLD), but
no cartilage damage is present, good results have been
obtained by fusing the radiocarpal joint and excising the
distal third of the scaphoid.35 In my experience, most mid­
carpal-crossing arthrodeses provided excellent short-term
results, but poor long-term outcomes. When the radioscaph­
oid and the midcarpal joints are involved by the arthritic
process (stage VI SLD, SLAC wrist), I prefer a total scaph­
oidectomy plus a midcarpal fusion. Being skeptical of the
long-term viability of a joint with mismatched articular
surfaces, I perform proximal row carpectomies only
occasionally.
Lunate Triquetrum Dissociation
Lunate triquetrum dissociation, from either a traumatic or a
degenerative etiology, is not unusual. The literature concern­
494
ing these problems is scarce, however, and often misleading
in terms of pathogenesis, diagnosis, and treatment. The
general awareness of this problem is often poor, which
explains why many lunate triquetrum dissociations still are
currently missed or confused with other ulnar-sided wrist
problems, such as midcarpal instabilities or TFCC injuries.*
Although the first case of lunate triquetrum dissociation was
graphically represented in the early 20th century,25 it was not
until the 1970s, with the detailed descriptions by Linscheid
and associates65 and later on by Reagan and coworkers85 that
wide attention was focused on this pathologic process. Since
then, new information has been added that helps to differen­
tiate this problem from similar entities and achieve better
results from treatment.†
Pathomechanics of Lunate
Triquetrum Dissociation
Most isolated injuries to the lunate triquetrum ligaments
occur secondary to a fall backward on an outstretched hand,
the arm being externally rotated, the forearm supinated, and
the wrist extended and radially deviated. In such circum­
stances, the impact concentrates on the hypothenar area, and
particularly on the pisiform, which acts as a punch against
the extended triquetrum.85,109 Such a dorsally and proximally
directed vector to the triquetrum induces its dorsal transla­
tion. The lunate does not follow the triquetrum because it is
effectively constrained dorsally by the radius, and palmarly
by the long radiolunate ligament. Consequently, substantial
shear stress appears at the lunate triquetrum joint, causing
progressive stretching, and ultimately tearing of the different
lunate triquetrum–stabilizing ligaments. If, aside from this,
there is violent rotation of the distal row into further prona­
tion, the palmar triquetrum-hamate-capitate ligament adds
the extra destabilizing force that is required for the palmar
lunate triquetrum ligament to fail. Supporting this explana­
tion is the fact that the two ligaments (palmar lunate trique­
trum and triquetrum-hamate-capitate) are seldom both
disrupted.
Injury to the lunate triquetrum ligaments often seems to
be associated with peripheral tears of the TFCC and distal
avulsion of the ulnar triquetrum ligament.97 The mechanism
of production of these combined injuries is similar to the
mechanism discussed for the isolated lunate triquetrum injury
except for the predominance of radial deviation and prona­
tion as torque-inducing vectors. In this respect, any ligament
avulsion of the palmar rim of the triquetrum is to be inter­
preted as a sign of a combined ulnocarpal and lunate trique­
trum injury.
Another quite typical association seems to be secondary to
a direct perilunate destabilization process, as postulated by
Mayfield and colleagues.68 In such instances, the wrist has
undergone violent extension, ulnar deviation, and midcarpal
supination, often owing to falls from heights or in motorcycle
accidents. In such instances, injury to the lunate triquetrum
ligaments occurs in stage III, after rupture of the scapholu­
nate ligaments (stage I) and lunocapitate dislocation (stage II)
(see Figure 15.6). If the scapholunate is successfully treated,
but the lunate triquetrum problem remains unsolved, symp­
*References 17, 38, 65, 85, 95, 109.
†
References 17, 40, 78, 94, 95, 97.
 PART
III
15 

Wrist: Carpal Instability

A B C

D E F
Figure 15.30  A 32-year-old lawyer sustained an injury to his left wrist 8 months before while playing soccer. A, Posteroanterior
radiograph shows relatively shortened scaphoid with mildly increased scapholunate interval. B, The scaphoid viewed from the
dorsum could easily sublux because the entire scapholunate ligamentous complex was ruptured and could not be repaired (static
reducible SLD). C, A transverse trough was created on the dorsal aspect of the lunate. To ensure that the tendon would be
permanently in contact with the lunate cancellous bone, an anchor suture was placed in the trough. D, A strip of FCR was
harvested at the palmar side, but left attached distally. Its proximal end was passed through a tunnel emerging at the distal-
medial corner of the scaphoid. E, The tendon used the dorsal radial triquetrum ligament as an anchor point for adequate tension
before being sutured onto itself. Two Kirschner wires were used to immobilize the reconstructed ligament for 6 weeks, with 4
more weeks in a removable splint. F, Posteroanterior view obtained 8 months postoperatively. The patient had resumed his
former sport activities at 6 months. At 18 months, the wrist remained stable and pain-free with 90% grip strength and 85%
motion compared with the contralateral side.

toms from the lunate triquetrum instability may predominate
and require specific treatment.
The lunate triquetrum joint may become progressively dis­
rupted as the result of a long-standing ulnocarpal abutment.97
In the presence of an ulnar-plus variant, attritional degenera­
tion of the proximal membranous portion of the lunate tri­
quetrum joint is frequent and should never be confused, or
treated, as if it was the result of an isolated traumatic event.
In the laboratory, several attempts to ascertain the conse­
quences of lunate triquetrum ligament disruptions have been
made.88 When the lunate triquetrum and dorsal radial trique­
trum ligaments were experimentally sectioned in axially
loaded cadaver wrists, the flexion moment by the scaphoid
became unconstrained, inducing a conjoint rotation in flexion
of the scaphoid and lunate, with subsequent anterior sublux­
ation of the capitate (Figure 15.31). This represents the more
advanced stage of the disease, resulting in a static VISI
pattern of instability. By contrast, when only the palmar and
dorsal lunate triquetrum ligaments were sectioned, increased
mobility of the lunate triquetrum joint was detected (dynamic
instability), and not a complete destabilization of the carpus.
Viegas and colleagues,109 using intra-articular pressure-
sensitive film, did not find significant changes in force trans­
mission across the radiocarpal joint compared with the
normal wrist after complete lunate triquetrum ligament
sectioning. These findings may explain the relatively low
incidence of radiocarpal arthrosis in late static lunate trique­
trum dissociations.
Clinical Forms of Lunate
Triquetrum Dissociation
Lunate triquetrum injuries may be acute or chronic. They
may involve only the lunate triquetrum interosseous liga­
ments and exhibit normal alignment, or have a more global
intrinsic and extrinsic ligament insufficiency with carpal col­
lapse. They may appear as an isolated ulnar-side problem or
495
PART
III
15  Acute Perilunate Instability (Scapholunate
Wrist
Figure 15.31  Schematic representation of typical carpal bone
displacement that occurs when the extrinsic and intrinsic lunate
triquetrum supporting ligaments have failed. The scaphoid and
lunate as a unit fall into flexion (CID-VISI) (curved arrow), and the
unconstrained triquetrum migrates proximally, especially in ulnar
deviation (straight arrow).
be part of a more global perilunate instability. There are dif­
ferent clinical conditions in which there is substantial damage
to the lunate triquetrum–supporting ligaments, each having
its own prognosis and treatment. A description of five more
common forms of lunate triquetrum injury seen in clinical
practice follows.78
Acute Lunate Triquetrum Injury without
Carpal Collapse
So-called dynamic or occult lunate triquetrum instability is
usually diagnosed by arthroscopy. The degree of lunate tri­
quetrum ligament incompetence varies from a minimal dis­
tention to complete rupture of the proximal membrane and
the two palmar and dorsal lunate triquetrum ligaments, and
yet the wrist does not exhibit malalignment because of the
presence of competent extrinsic ligaments. The condition
may be painful as a result of increased motion between the
two bones, generating shear stress and local synovitis.
Chronic Lunate Triquetrum Injury without
Carpal Collapse
Lunate triquetrum instability is considered chronic when the
two ends of the disrupted ligaments have degenerated,
diminishing the chances for a successful repair. If the extrinsic
ligaments maintain their secondary stabilizing efficacy, carpal
alignment may still be normal.
Lunate Triquetrum Dissociation with
Carpal Collapse
Lunate triquetrum dissociation with carpal collapse is char­
acterized by complete disruption of the intrinsic lunate tri­
quetrum ligaments and attenuation or disruption of the
secondary extrinsic stabilizing ligaments (dorsal and palmar
radiocarpal ligaments). As a result of such a global ligament
496
insufficiency, the carpus collapses into a dissociative VISI
pattern of malalignment.
Dissociation plus Lunate Triquetrum Injury)
Stage III perilunate instabilities involve an association of
injuries around the lunate, including complete rupture of the
scapholunate and lunate triquetrum interosseous ligaments.
The prognosis of the lunate triquetrum injury, if untreated,
is worse than that of an isolated injury, and instability is more
likely.
Chronic Perilunate Instability (Scapholunate plus
Lunate Triquetrum Instability)
When not adequately addressed, most perilunate injuries
evolve into a state of permanent subluxation (carpal collapse
into either VISI or DISI) with reduced wrist motion, decreased
grip strength, progressive joint degeneration, and painful
synovitis.
Diagnosis of Lunate Triquetrum Dissociation
Lunate triquetrum dissociation may manifest as a spectrum
of clinical conditions, ranging from asymptomatic partial
tears to painful complete dissociation with static collapse,
causing a forklike deformity of the carpus and prominence
of the distal ulna.65,85,97 Some patients describe painful crepi­
tation or frank clunking as they ulnarly deviate the hand.
Symptomatic injuries invariably exhibit point tenderness
directly over the dorsal aspect of the joint. Pain is usually
aggravated with ulnar deviation and supination. Wrist motion
is seldom diminished except in the more advanced cases with
carpal collapse. A frequent complaint is weakness and a
giving-way sensation. Some patients may have ulnar nerve
paresthesias.
Clinical Examination
A pathognomonic finding is a positive ballottement test, as
described by Reagan and coworkers.85 The lunate is firmly
stabilized with the thumb and index finger of one hand, while
the triquetrum and pisiform are displaced dorsally and pal­
marly with the other hand. A positive result elicits pain,
crepitus, and excessive displaceability of the joint. A modifi­
cation of the ballottement test is the “shear test” described
by Kleinman (Figure 15.32).112 By stabilizing the dorsal
aspect of the lunate, the pisiform is loaded in a dorsal direc­
tion, creating a shear force at the lunate triquetrum joint that
causes pain. A variation of the shear test is the so-called
Derby test reported by Christodoulou and Bainbridge.17 This
test involves pushing the pisiform dorsally with the wrist in
extension and radial deviation. This maneuver reduces the
subluxed lunate triquetrum joint, and the feeling of instabil­
ity disappears, and grip strength increases as long as pressure
over the pisiform is maintained. A further screening test is
the ulnar snuffbox test.112 It involves applying lateral pres­
sure over the medial aspect of the triquetrum, just palmar to
the ECU, while the wrist is radially deviated. If this pressure
reproduces the patient’s symptoms, either a lunate trique­
trum injury or an ulnar styloid–triquetrum impingement syn­
drome should be suspected. When this test is positive, the
possibility of a TFCC problem is less likely.
 Most of these provocative maneuvers are sensitive, but tenosynovitis, and entrapment of the dorsal branch of the PART
poorly specific. Numerous conditions cause pain on the ulnar ulnar nerve. III
side of the wrist and elicit a painful response to most of these
tests, including symptomatic lunate triquetrum synchondrosis Radiographic Examination
15 
secondary to fracture of an incomplete congenital coalition, Standard wrist views appear normal in most patients with

Wrist: Carpal Instability

degenerative changes of the proximal pole of the hamate
secondary to triquetrum-hamate impingement, avulsion frac­
tures of the dorsum of the triquetrum, pisotriquetral arthrop­
athies, traumatic or degenerative tears of the TFCC,
ulnocarpal impaction syndrome (ulnar-plus variant), ECU
ULNAR BORDER WRIST
Piso-triquetral mass
Dorsal lunate
Figure 15.32  The “shear test” as described by Kleinman is similar
to the ballottement test described by Reagan and coworkers.85
This test is painful for a patient with a sprain or instability in the
lunate triquetrum joint. (Courtesy of William B. Kleinman,
Indianapolis, IN.)
partial tears of the lunate triquetrum interosseous membrane.
Occasionally, in chronic dynamic instabilities, a slight nar­
rowing of the lunate triquetrum joint with subchondral cyst
formation on the apposing sides of the joint may appear. This
finding should not be confused, however, with similar find­
ings in patients with injury of an incomplete lunate trique­
trum coalition.120
When there is complete rupture or attenuation of intrinsic
and extrinsic lunate triquetrum–supporting ligaments, result­
ing in a static VISI pattern of malalignment, radiographic
diagnosis is obvious. Most characteristic is the disruption of
the normal convex arc of the proximal carpal row (Gilula’s
line) (Figure 15.33). This is visualized as a step off between
the lunate and the triquetrum and a swallow-appearing dorsal
outline of the joint on a posteroanterior radiograph. Rarely,
there is an increased gap between the two dissociated bones.
If the carpus has collapsed into a static VISI, one could
wrongly suspect SLD because of the presence of a slightly
increased scapholunate gap and a positive ring sign of the
flexed scaphoid. The gap does not represent a rupture of the
scapholunate ligaments, but the result of axial load being
applied to the most palmar scapholunate ligament fibers,
which are longer and obliquely oriented, allowing an
increased, but normal, separation of the two bones.120
In static VISI, the lunate has a triangular (moonlike)
appearance, such that its dorsal pole is superimposed on the
middle to distal part of the capitate, implying an abnormal
flexion of the scapholunate complex (see Figure 15.33). This
appearance does not change in ulnar-deviated views except
for the increased proximal displacement of the triquetrum
relative to the rest of the proximal carpal row (Figure 15.34).
In collapsed cases, the carpal height ratio may be abnormal.
In the lateral projection, aside from the VISI pattern of

Figure 15.33  Posteroanterior and lateral view of static lunate triquetrum dissociation in a 40-year-old man whose left wrist had
been injured in a motor vehicle accident 3 years before this radiograph was taken. The initial radiographs had been normal. One
year after the accident, a minor sprain initiated a process of progressive weakness and increasingly painful snapping during
lateral deviations. Note the moonlike configuration of the lunate in VISI and “swallow”-appearing outlines of the proximal and
distal lunate triquetrum borders (yellow lines). The scapholunate joint space is widened anteriorly. This widening probably
represents attenuation rather than rupture, the consequence of the palmar fibers of this joint being longer than the dorsal ones.

497
PART
III
15  a traumatic injury, a chronic age-related perforation, or liga­
Wrist
Figure 15.34  Dynamic radiographs of static lunate triquetrum
dissociation. During radial deviation (right), the scaphoid and the
lunate are abnormally palmar flexed, but the triquetrum is
normally aligned relative to the lunate. During ulnar deviation
(left), there is a significant step off between the lunate and the
triquetrum (arrow).
14°
A Cases in which there is degeneration of the lunate triquetrum
–16°
B
Figure 15.35  A and B, The lunate triquetrum angle may be
difficult to measure in a lateral radiograph, but the angle has
been shown by Reagan and coworkers85 to be decreased in a
patient with lunate triquetrum static VISI. (From Reagan DS,
Linscheid RL, Dobyns JH: Lunotriquetral sprains, J Hand Surg [Am]
9:502-514, 1984.)
malalignment, it is sometimes possible to find a decreased
lunate triquetrum angle. Normal average lunate triquetrum
angle is 14 degrees, according to Reagan and coworkers85
(Figure 15.35). Assessment of this angular measurement
requires films of excellent quality and considerable
practice, however, and even then its determination is often
impossible.
Other Diagnostic Tests
Bone scans are particularly useful when doubt exists about
the etiology of a chronic lunate triquetrum tear. If the injury
is due to a chronic ulnocarpal impingement, the bone scan
frequently shows an area of increased uptake in the lunate.
In pure lunate triquetrum instabilities, the scan is seldom
positive.
498
Arthrography may show a communication of dye between
the radiocarpal and midcarpal joints. An arthrographic
communication is nonspecific, however, and may indicate
ment degeneration caused by an ulnocarpal impaction
syndrome.104
Cineradiography may be helpful and is always recom­
mended. In relatively acute situations, the wrist may still
exhibit a sudden reduction of the abnormally flexed lunate
during ulnar deviation, manifesting as a dramatic clunk. Such
a self-reducing capability is quite rapidly lost, however, and
the VISI malalignment becomes statically fixed. In such
instances, as the wrist moves from radial to ulnar deviation,
the triquetral hamate joint is always engaged (in the “low”
position), and the scapholunate complex remains in the
flexed position in ulnar deviation.
Arthroscopy has become an increasingly important diag­
nostic and therapeutic tool for the evaluation of lesions on
the ulnar side of the carpus, and it may identify previously
unrecognized types of ligamentous disruptions.78 Further
technical details are provided in Chapter 19.
Treatment of Lunate Triquetrum Dissociation
As with all other forms of carpal instability, treatment always
needs to be individualized according to the patient’s age,
occupation, recreational demands, and intensity of symp­
toms. The treatment alternatives proposed for the different
forms of lunate triquetrum instability are reviewed next.
proximal membrane as a result of a chronic ulnocarpal abut­
ment are not included in this section (see Chapter 16).
Acute Lunate Triquetrum Injury without
Carpal Collapse
Acute lunate triquetrum injuries without carpal collapse are
formed by acute, isolated, partial or complete disruption of
the lunate triquetrum interosseous ligaments, without radio­
graphic evidence of malalignment. For a case to be included
into this group, the diagnosis has to have been made early,
when the healing capacity of the disrupted ligaments is
optimal, and there must be disruption of only the intrinsic
ligaments, with the secondary constraints (extrinsic liga­
ments) intact and competent.
In the past, most authors agreed that acute lunate trique­
trum injuries should be treated conservatively, in a carefully
molded cast or splint, with a pad beneath the pisiform and
over the dorsum of the distal radius to maintain optimal
alignment.85 Failures from that approach were not unusual,
however, with some cases progressing toward a static VISI
type of carpal instability. Lack of ligament healing and the
subsequent attenuation of the secondary constraints explained
most failures. Unless pronosupination is blocked by including
the elbow in the cast, the amount of motion that occurs in
the lunate triquetrum joint during forearm rotation is sub­
stantial owing to the “pistonage” effect of the ulna against
the carpus through the TFCC (see Chapter 16). Such micro­
motion prevents proper connective tissue formation at the
repair site. Conservative treatment is only exceptionally rec­
ommended, in which case an above-elbow cast is required.
The introduction of arthroscopy as a routine exploration
in wrist trauma allowed much better and earlier recognition

A B
of the extent of these lesions (often larger than expected),
resulting in an increased awareness of the potential risk of
these injuries.78 This increased awareness and the occasional
poor results obtained by immobilization alone induced many
authors to recommend multiple percutaneous pinning of the
joint as the gold standard in the treatment of early dynamic
lunate triquetrum instability. Osterman and Seidman78
reported an 80% success rate with this treatment strategy.
The arthroscopic method of pinning the joint is discussed in
Chapter 19.
Chronic Lunate Triquetrum Injury without
Carpal Collapse
A ligament rupture is considered chronic when its two ends
have degenerated, diminishing the chances for a successful
repair. In such circumstances, a more aggressive approach is
necessary to re-establish the synchronicity of motions
between the triquetrum and lunate. Different strategies have
been proposed, including simple arthroscopic débridement,
electrothermal shrinkage, ligament reconstruction using a
strip of the ECU tendon, and lunate triquetrum intercarpal
arthrodesis.40,94,95,97 No approach has enjoyed consistent
success in these chronic injuries.
The different arthroscopic techniques for the management
of chronic tears of the lunate triquetrum interosseous liga­
ment are reviewed in Chapter 19. These include débridement
of the unstable fragments of the disrupted proximal mem­
brane, capsular shrinkage, and closing the interval between
the ulnar lunate and ulnar triquetrum ligaments with
polydioxanone (PDS) sutures under arthroscopic control.
Tendon reconstruction of complete disruption of the lunate
triquetrum ligaments associated with chronic instability is
another alternative.95,97 The technique recommended by Shin
and colleagues97 consists of reconstructing the lunate trique­
trum linkage with a strip of ECU tendon, left attached distally
and passed through holes in the lunate and triquetrum. By
tightly looping the tendon graft around the lunate triquetrum
PART
III
Figure 15.36  A 28-year-old
15 
woman who could not recall
Wrist: Carpal Instability
any traumatic event had
chronic ulnar-side wrist pain.
A, Increased hypermobility and
complete rupture of the lunate
triquetrum interosseous
ligaments were shown at
operation, so a local fusion was
done. Currently, after the
publications by Guidera and
colleagues,40 we tend to use
compression screw to improve
the chances of healing. B, The
fusion was solid 15 months
after surgery, but some
tenderness persisted.
joint, immediate stability is achieved. The reconstruction is
secured by transfixing the joint with Kirschner wires for 8
weeks, followed by 4 more weeks of protective splint. A
series of 8 patients treated with this technique showed
encouraging results.94 Shahane and coworkers95 published a
slightly different approach using a strip of ECU tendon to
tether the dorsal aspects of the triquetrum-hamate joint. This
approach seems to control the abnormal triquetral motion
and provides good pain relief and acceptable function in
isolated chronic lunate triquetrum dissociations.95
Fusing the unstable lunate triquetrum joint is another alter­
native.40,94 The procedure has met with variable success, a
relatively high nonunion rate, and considerable complica­
tions. According to Guidera and colleagues,40 most complica­
tions of lunate triquetrum fusion result from technical
problems. By using cancellous bone graft to fill a biconcave
space created in the adjoining bones and stabilizing the joint
with multiple Kirschner wires (Figure 15.36), these authors
reported a 100% consolidation rate. In their series of 26
wrists, postoperative flexion-extension averaged 78% of the
range measured at the contralateral side, with good or excel­
lent pain relief in 83% of the cases and with 88% of patients
returning to their previous occupations.40 A meta-analysis of
143 lunate triquetrum fusions showed lunate triquetrum
fusion is not devoid of problems, however, when incorrectly
planned or executed: A nonunion rate of 26% and a compli­
cation rate of 43%, mostly in the form of persistent pain,
were reported.94,99 The procedure should not be performed
in the presence of VISI deformity.
The only series of patients comparing ligament reconstruc­
tion versus lunate triquetrum fusion has been reported by
Shin and colleagues.97 It consisted of 57 patients treated for
an isolated traumatic tear of the lunate triquetrum joint and
retrospectively reviewed with an average follow-up of 9.5
years. Patients who underwent tendon reconstruction of the
lunate triquetrum ligaments had higher subjective and objec­
tive outcomes and a much lower complication rate than
patients having arthrodesis (Figure 15.37).
499
PART
III
15 
Wrist
A B
Figure 15.37  A 44-year-old policeman who was injured in a fight had painful chronic dynamic lunate triquetrum dissociation.
A-C, Complete nonrepairable lunate triquetrum injury was found arthroscopically, so it was decided to perform an open tendon
reconstruction of the palmar and dorsal lunate triquetrum ligaments using a slip of the ECU tendon, according to Shin and
colleagues.97 The patient had regained normal hand function 6 months after surgery with 35% reduced flexion, but a strong and
painless grip.
Figure 15.38  Late degenerative changes of static lunate
triquetrum dissociation. Note the typical step off in the lunate
triquetrum interval, a break in Gilula’s line (arrow), and the
midcarpal (hamate-lunate) articular deterioration involving cystic
formation within the head of the capitate. Radioscaphoid-lunate
joints are usually spared.
Lunate Triquetrum Dissociation with
Carpal Collapse
Lunate triquetrum dissociation with carpal collapse com­
prises complete disruption of the intrinsic lunate triquetrum
ligaments with attenuation or traumatic disruption of the
secondary dorsal and palmar extrinsic stabilizers. As a result
of such a global capsular slackening, the carpus has collapsed
into a dissociative VISI pattern of malalignment (Figure
15.38). Because the underlying pathology is intrinsic and
500
C
extrinsic, localized fusions of the lunate triquetrum joint are
unsuccessful in controlling the malalignment. Neither an iso­
lated fusion of the lunate triquetrum joint nor any sort of
tendon reconstruction is likely to correct such a complex
unstable condition reliably, and a more extended intercarpal
arthrodesis is recommended. Halikis and associates42 sug­
gested adding a radiolunate fusion to the lunate triquetrum
fusion. As an alternative, the ulnar midcarpal joint may be
included in the fusion site. There is little guidance in the
literature about this condition.
Acute Perilunate Instability (Scapholunate
Dissociation plus Lunate Triquetrum Injury)
Owing to their inherent instability, all perilunate dislocations
are better managed surgically. Many authors favor a com­
bined palmar and dorsal approach, emphasizing anatomic
reduction of the proximal row, direct ligament repair (par­
ticularly the most important palmar lunate triquetrum com­
ponent), and percutaneous Kirschner wire fixation. If the
scapholunate injury has healed correctly, but the lunate tri­
quetrum joint remains unstable, dissociative VISI may result.
By contrast, if scapholunate and lunate triquetrum levels
remain unstable, the wrist collapses most commonly in the
form of DISI. Treatment of perilunate dislocations is dis­
cussed in more detail later in this chapter.
Chronic Perilunate Instability (Scapholunate plus
Lunate Triquetrum Instability)
When perilunate injuries are inadequately addressed, they
evolve into a state of permanent subluxation (carpal collapse
into either VISI or DISI) with reduction of mobility and grip
strength and eventually painful joint degeneration. Dealing
with chronic bipolar instability is difficult, and results obtained
through soft tissue reconstructions are seldom acceptable.
There is little information in the literature about this specific
problem. Generally, when the proximal row presents a com­
bined scapholunate and lunate triquetrum dissociation, most
authors recommend a proximal row carpectomy.86 Alterna­
tively, excision of the scaphoid and triquetrum while fusing
the lunocapitate joint may also produce good results. Long-
term results of those approaches are unavailable.
Author’s Preferred Methods of Treatment:
Lunate Triquetrum Dissociation
Acute tears of the lunate triquetrum ligaments are best
treated by percutaneous lunate triquetrum joint fixation. The
morbidity of pinning the joint is minimal compared with the
benefits of a good ligament healing. By ensuring complete
immobilization of the joint with wires, the wrist can be mobi­
lized earlier (at 4 weeks), which allows a much faster recov­
ery of motion. We also strongly recommend repairing the
palmar lunate triquetrum ligament rupture in acute perilu­
nate dislocations, as is emphasized later in this chapter.
Trying to repair the dorsal component is probably unneces­
sary, aside from the difficulties of placing useful sutures in
such small and thin ligament—hence the need for a pro­
longed Kirschner wire fixation.
I have little, but encouraging experience with the ECU
tendon reconstruction suggested by Shin and colleagues97
(see Figure 15.37). It is an anatomically sound solution for
chronic, dynamic lunate triquetrum dissociation because it
replaces the most important stabilizer of the joint, the palmar
lunate triquetrum ligament. Despite criticisms, however, I am
still relying on lunate triquetrum fusions, using cancellous
bone from the distal radius and multiple Kirschner wires, as
described by Guidera and colleagues.40 If there is a relatively
long ulna, lunate triquetrum fusions may remain symptom­
atic. In such instances, I prefer adding a “wafer” procedure
(open or arthroscopic) or an ulnar shortening to the lunate
triquetrum fusion. I do not recommend a localized fusion if
there is already a static collapse into VISI carpal malalign­
ment or a bipolar chronic scapholunate and lunate triquetrum
dissociation. First, I prefer fusing the radiolunate joint
together with the lunate triquetrum joint, and, second, a
proximal row carpectomy is preferred.
CRITICAL POINTS: LUNATE TRIQUETRUM ARTHRODESIS
Indications
 Dynamic lunate triquetrum instability secondary to
complete intrinsic ligament rupture, in the absence of
an ulnocarpal abutment syndrome (normal TFCC) and
normal midcarpal joint
 Perilunar scapholunate and lunate triquetrum instability
 No radiographic evidence of VISI
Preoperative Evaluation
 Positive lunate triquetrum ballottement test
 Fluoroscopic evaluation of abnormal proximal-distal
shift of the triquetrum during radioulnar deviation
 Arthroscopy to rule out TFCC degeneration or
triquetrum-hamate impingement
Technical Points
 Perform a dorsal (zigzag, lazy “S,” or longitudinal)
incision centered at IV-V septum.
PART
Longitudinal Incision of the Extensor Retinaculum III
Along the V Compartment
 Open the septum between IV-V; coagulate intraseptal 15 
artery.
 Perform a “Z” capsulotomy creating two flaps
Wrist: Carpal Instability
following the “fiber splitting” concept.10
 Complete section of the remnants of lunate triquetrum
ligaments.
 Open the lunate triquetrum as a book, and remove
the adjacent articular surfaces with a dental rongeur to
expose cancellous bone. Do not excise the rim of the
opposing cortical edges to preserve the normal
interosseous separation.
 Cancellous bone is harvested from the radius through
a window created under the infratendinous sheath at
the floor of the IV compartment.
 Two 1.5-mm nonparallel Kirschner wires are preset in
the ulnar aspect of the triquetrum. Bone graft is
densely packed in the biconcave cavity.
 The joint is reduced, and two Kirschner wires are
driven into the lunate and their position verified.
 One wire is used to insert a headless cannulated
compression screw. Beware of the dorsal branch of the
ulnar nerve.
 Cut the second wire below the skin surface.
 Perform standard capsular and retinacular closure.
Postoperative Regimen
 Short arm thumb spica cast for 6 weeks, changed at
10 days for stitch removal and x-rays
 At 6 weeks, cast removal, x-rays, and new cast applied
 Out-of-cast x-rays until healing is obvious, at which
point wires are removed under local anesthesia
 Rehabilitation after cast removal to regain motion and
grip strength
 Contact sport not allowed until 6 months
postoperatively
 Probable outcome: 75% of patients have a painless
wrist with 80% of global motion and 75% grip
strength
Carpal Instability Secondary to
Scaphoid Fracture
When an unstable wrist is axially loaded, the scaphoid pre­
vents what Fisk termed the concertina deformity, that is,
carpal collapse.25 Not only is its alignment important, but also
its own geometry needs to be normal so as not to create a
global carpal destabilization. If the scaphoid has fractured
into two or more unstable fragments, the distal portion has
a tendency to follow the motion of the distal row, whereas
the proximal fragment acts in concert with the proximal
row.8 In such circumstances, the necessary coordination of
motion of the two carpal rows is lost, resulting in an obvious
dyskinematic behavior of the midcarpal joint. When frac­
tured, the scaphoid cannot transfer load normally, acting as
an imperfect kinetic linkage between the two rows. Under
load, its proximal part tends to follow the unconstrained
lunate and triquetrum by rotating into extension, whereas
the distal fragment is forced into flexion by the axial force
exerted by the trapezoid and trapezium.106
If not properly reduced and stabilized, the fractured scaph­
oid is likely to develop a pseudarthrosis. Stable nonunions
rarely have global mechanical consequences. If the nonunion
501
PART
III
15  IIIb, it has collapsed. Fragmentation of the lunate results not
Wrist
Figure 15.39  Schematic representation of the forces (arrows)
involved in the development of a “humpback” deformity after an
unresolved unstable scaphoid fracture. The distal fragment tends
to flex, while the proximal fragment follows the lunate and
triquetrum into an extended position (DISI configuration).
is unstable and substantial motion occurs at the nonunion site,
the scaphoid frequently undergoes severe deterioration of its
palmar cortex, with the subsequent loss of bone stock. In
these instances, the “humpback” deformity may appear: The
two scaphoid fragments become malrotated and angulated
into flexion and ulnar deviation (dorsolateral convexity)
(Figure 15.39). The resultant carpal instability can be catego­
rized as CID because the disruption occurs within the proxi­
mal row and typically progresses into a DISI pattern of carpal
malalignment. In the presence of a scaphoid fracture, a dorsal
tilting of the lunate (DISI configuration) should be regarded
as an indirect sign of scaphoid fracture displacement.
If the scaphoid fracture finally heals, but in a deformed
palmar-flexed posture, its external dimensions are not
normal, and the orientation and congruency of its articular
facets are inadequate to cope with its important stabilizing
role. Scaphoid malunions can also be the source of painful
instability; weak grip strength; and reduced motion, espe­
cially wrist extension.
Surgery of an unstable scaphoid is technically demanding.
The surgeon must be aware of the necessity of obtaining
fracture consolidation and, most importantly, of re-
establishing the normal length and shape of the scaphoid
so that the anatomic relationship between the bone and the
rest of the carpus is normalized. A thorough description
of the techniques to achieve these goals is provided in
Chapter 18.
Carpal Instability in Kienböck’s Disease
Although Kienböck’s disease is discussed fully in Chapter 18,
a brief comment about the peculiar features of the carpal
instability that appears when the diseased lunate has col­
lapsed is appropriate here. One of the prognostic factors of
502
Kienböck’s disease is the absence (stage IIIa) or presence
(stage IIIb) of a rotary subluxation of the scaphoid. In stage
IIIa, the carpus remains relatively stable, whereas in stage
only in loss of the mechanical strength of the central column,
but also in disruption of the kinematic linkage of the proxi­
mal row, owing to failure of scapholunate and lunate trique­
trum ligament attachments. In such circumstances, the loaded
scaphoid tends to follow its natural tendency and progres­
sively collapses into flexion, whereas the triquetrum migrates
proximally. Conceptually, the resultant instability would be
categorized as CID pattern; depending on which part of the
lunate is most involved (palmar, dorsal, or global), the
resultant carpal malalignment may range from neutral to
VISI or DISI.
In the past few years, numerous limited intercarpal arthro­
deses have been found to be beneficial in the treatment of
Kienböck’s disease. Some of them, especially procedures
eliminating motion between the scaphoid and the distal
carpal row (STT and scaphoid capitate joints), are said to be
most effective at unloading the lunate.121 Despite controver­
sies about their relative effects on lunate load, these interven­
tions have proved valuable in preserving carpal stability by
preventing scaphoid rotary subluxation.
CARPAL INSTABILITY NONDISSOCIATIVE
When there is symptomatic carpal dysfunction between the
radius and the proximal row or between the proximal and
distal rows, and there is no disruption within or between the
bones of the proximal and distal rows, the case is considered
a CIND.51,118 Depending on which joint is mostly affected,
CIND problems can be subdivided further into radiocarpal
and midcarpal.
Radiocarpal Carpal
Instability Nondissociative
Included in the radiocarpal CIND group are patients with
excessive laxity, insufficiency, or rupture of the radiocarpal
ligaments, whose carpus has displaced down the slope of the
radius and appears ulnarly translocated.84,102 The condition is
more commonly seen in rheumatoid patients, in patients with
developmental deformities such as Madelung’s deformity,
after excessive excisions of the distal ulna, and, more rarely,
after pure radiocarpal dislocations.26 In the first group, liga­
ment insufficiency results from the attritional effects of
chronic synovitis. In Madelung’s deformity, the ligaments fail
owing to fatigue because they must constrain excessive shear
forces. Pure traumatic dislocations are very rare, but they
frequently result in chronic radiocarpal instability.7,26 The
three most common forms of radiocarpal CIND—ulnar trans­
location, radial translocation, and pure radiocarpal disloca­
tion—are reviewed next.
Ulnar Translocation
The first traumatic ulnar translocation of the carpus caused
by complete disruption of the extrinsic ligaments was
described by Rayhack and associates.84 In partial injuries, the
carpus may translate palmarly rather than ulnarly. Taleis­
nik102 pointed out that there are two distinct types of ulnar

A B
translation: In type I, the entire carpus, including the scaph­
oid, is displaced, and the distance between the radial styloid
process and the scaphoid is widened (Figure 15.40). In type
II, the relationship between the distal row, the scaphoid, and
the radius remains normal; the scapholunate space is widened,
and the lunate triquetrum complex is ulnarly translocated.
The distinction between type I and type II is important for
different reasons. Conceptually, type I is a true CIND insta­
bility, whereas type II has features of CIND (ulnar transloca­
tion of the lunate and triquetrum) and CID (SLD), and this
makes it a CIC pattern of instability. In practice, distinction
between the two patterns is useful because there is a com­
pletely different ligament involvement, each requiring dis­
tinct treatment: Type I injuries result from failure of all
radiocarpal ligaments, including the radioscaphoid and
radioscaphoid-capitate. In type II injuries, neither the
radioscaphoid-capitate ligament nor the radioscaphoid liga­
ment is ruptured, but there is complete scapholunate and
radiolunate ligament disruption. When presented with a
widened scapholunate joint, the possibility of an ulnar trans­
lation of the lunate triquetrum complex (type II injury) must
be kept in mind to avoid an erroneous diagnosis. If a type
II ulnar translocation is treated only by stabilizing the
apparent SLD, the underlying radiocarpal instability remains
unresolved.
As described in the discussion of the radiographic examina­
tion of carpal instabilities, different methods of assessing
ulnar translation have been reported (see Figure 5-15). The
indices using the center of the capitate head as a carpal refer­
ence should not be used in type II injuries because only the
lunate triquetrum complex is significantly displaced in these
cases.122 By contrast, when using the lunate as a reference, if
the wrist is slightly radially or ulnarly deviated, the measure­
ments may be unreliable.
Rayhack and associates84 reported a single series of
eight patients with traumatic ulnar translation of the carpus.
Their experience indicates that this is a difficult problem
to treat effectively. They had disappointing results with
PART
III
15 
Wrist: Carpal Instability
Figure 15.40  Ulnar translocation
(Taleisnik’s type I)102 in a
50-year-old woman with
rheumatoid arthritis. A, Widened
radial styloid–scaphoid space
(white arrow). B, This unstable
situation can be easily reduced
by laterally directed pressure
(black arrow).
delayed ligament repairs and suggested that radiolunate
fusion is probably the only reliable alternative in these
patients.42
Radial Translocation
Radial translocation instability is usually caused by radial
malunion with concomitant loss of radial height. In this situ­
ation, the normal 23 degrees of ulnar inclination in the
coronal plane is partially or completely reversed. Aside from
the malunion, if the ulnocarpal ligaments are attenuated,
ruptured, or avulsed, the loaded carpus tends to sublux in a
radial direction, causing substantial discomfort, reduced grip
strength, and a giving-way sensation when the patient
attempts to lift a weight. The condition may also occur after
an excessive radial styloidectomy. Even less commonly, com­
plete ulnar-side ligament injury may generate a dynamic
radial translation instability even if the radius is normally
inclined. In such cases, the lateral radiocarpal subluxation is
visible only when the wrist is stressed in a radial direction.2
These conditions are probably not as infrequent as previously
thought, and they respond well to corrective osteotomy of
the radius and surgical reattachment of the ulnar capitate
ligaments.
Pure Radiocarpal Dislocation
According to Dumontier and coworkers,26 there are two
types of radiocarpal dislocation. Type I includes patients
with a pure radiocarpal dislocation, without an associated
fracture of the distal radius. Type II involves a radiocarpal
dislocation with an avulsion fracture of the radial styloid,
which contains the origin of the palmar radioscaphoid and
radioscaphoid-capitate ligaments. The first type is exceed­
ingly rare; no more than 20 cases have been reported.7,26
Usually, they are the result of severe shear and rotational
injury in young subjects. Associated neurovascular damage
is not unusual. Reduction is easy by external manipulation,
but maintenance of reduction is difficult because of the loss
of radiocarpal ligament attachments. Type II radiocarpal dis­
503
PART locations with an associated avulsion fracture of the radial
III significant difference between patients treated
styloid have been more frequently reported. These have a
operatively and nonoperatively.
much better prognosis, provided that the styloid fracture,
15  which contains the avulsed radiocarpal ligaments, is anatomi­
 Apergis (1996): Emphasis on the frequent involvement
of radiocarpal and midcarpal ligaments in most
cally reduced and fixed. midcarpal instabilities.
Wrist

 Feinstein and colleagues (1999): Quantitative

Midcarpal Carpal Instability
Nondissociative
The term midcarpal instability is commonly used to describe
a group of diverse conditions in which there is no dissociation
between bones of the proximal carpal row, but a dysfunction
of radiocarpal and midcarpal joints, the latter tending to
predominate. The term instability of the proximal carpal
row, as suggested by Wright and colleagues,118 would be
more appropriate because most of these patients have abnor­
malities of midcarpal and radiocarpal joints. For historical
reasons, and to avoid confusion, we maintain the term mid-
carpal instability. Although the literature concerning these
conditions is scarce, substantial contributions have been
made that provide a better understanding of one of the most
intriguing dysfunctions of the wrist.5,27,61,62
IMPORTANT CONTRIBUTIONS RELATED TO
MIDCARPAL INSTABILITY
assessment of the midcarpal shift test, allowing
grading of the severity of midcarpal ligament
insufficiency.
Pathomechanics of Midcarpal Instability
As discussed in the biomechanics section of this chapter,
under axial compressive load, the proximal row tends to
rotate into flexion and pronation, a tendency that seems to
be counteracted by the palmar midcarpal crossing liga­
ments.58 Especially important stabilizers are the palmar tri­
quetrum-hamate-capitate ligament, the dorsolateral STT
ligament, and the scaphoid capitate ligament.33 These liga­
ments not only play a key kinetic role in preventing midcar­
pal collapse, but also are essential to ensure a smooth,
progressive transition of the proximal row from flexion
to extension as the wrist deviates ulnarly (Figure 15.41).

 Mouchet and Belot (1934): First description of a

“snapping wrist,” diagnosed as “anterior midcarpal
subluxation.”
 Sutro (1946): Report of two patients with symptomatic
clunking of their wrists, one of whom was cured by
fusing the midcarpal joint.
 Linscheid and colleagues (1972): Description of five
patients with a palmar flexion instability, two of whom
could voluntarily subluxate their wrists, “to the
amusement of friends and the consternation of their
doctors.” Suggested etiology was congenital or
sequela of ligamentous laxity.
 Lichtman and colleagues (1981): First description of the
so-called ulnar midcarpal instability as a characteristic
pattern of radiologic signs (VISI pattern of
malalignment) and symptoms (painful, spontaneous
wrist click with ulnar deviation) related to failure of the
ulnar limb of the palmar arcuate ligament.
 Taleisnik and Watson (1984): Introduction of the term
extrinsic midcarpal instability, referring to a painful
snapping of the midcarpal joint secondary to injuries
outside the midcarpal joint, most commonly a distal
radial malunion.
 Louis and colleagues (1984): Description of the
capitate-lunate instability pattern (CLIP), which
combines a midcarpal and a radiocarpal instability. The
authors suggested establishing this diagnosis with the
aid of fluoroscopy by applying traction and palmar- Figure 15.41  Suggested mechanism of action of the triquetrum-
dorsal translation and observing the increased hamate ligaments during wrist ulnar deviation. Because the center
translation of radiolunate and lunocapitate joints. of rotation of the wrist during radioulnar inclinations lies around
 Lichtman and colleagues (1993): Identification of four the center of the head of the capitate, all ligament fibers inserted
different groups of patients with clinical midcarpal proximal to it are likely to increase in tension (small arrow) as the
instability. wrist ulnarly deviates (large arrow). These fibers play a role in the
 Wright and colleagues (1994): The largest series of soft initiation of the progressive extension of the triquetrum relative to
tissue reconstruction in carpal instability the radius (curved arrow). When these fibers fail, the proximal row
nondissociative (CIND) problems (34 reviewed does not extend until a more advanced ulnar deviation is
patients). In a 5- to 8-year follow-up, there was no achieved, and the hamate-triquetrum articular surfaces fully
contact each other, forcing sudden extension of the triquetrum.

504

I II III
Consequently, any injury resulting in increased laxity of the
triquetrum-hamate-capitate, STT, and scaphoid capitate liga­
ments is likely to have two consequences: a kinetic defect
characterized by the loss of the ability to transfer loads
adequately without collapsing into a nondissociative VISI
deformity, and a kinematic defect in which the rotation of
the proximal row from flexion to extension is not smooth and
progressive, but sudden and sometimes painful when the
wrist reaches a certain amount of ulnar deviation.
In the laboratory, several investigations have addressed
the intricate mechanism of midcarpal stabilization. The con­
sequences of sectioning the midcarpal crossing ligaments are
better understood, but comparatively little is known about
what causes these ligaments to fail.62
Clinical Forms of Midcarpal Instability
There are two major types of midcarpal instability (Figure
15.42). One results from injury or bone alteration outside the
carpus (extrinsic midcarpal instability). The second derives
from insufficiency or injury of one or several radiocarpal or
midcarpal crossing ligaments (intrinsic midcarpal instability).
The first type is discussed later in this chapter. There are
three major patterns of instability in the intrinsic type: ante­
rior midcarpal, posterior midcarpal, and combined radiocar­
pal-midcarpal instability.61,62
Anterior Midcarpal Instability
Anterior midcarpal instability was first described in 1934 by
Mouchet and Belot.25 It is often seen in patients with attenu­
ation or rupture of the triquetrum-hamate-capitate, STT, and
scaphoid capitate ligaments, often associated with insuffi­
ciency of the dorsal radiocarpal ligament.62 In these cases, the
proximal row remains palmar flexed until near the end of
ulnar deviation, where it suddenly rotates into extension,
sometimes with a palpable thud. This phenomenon has been
termed the catch-up clunk.51 Although most cases have a
combined medial and lateral ligament insufficiency, there are
instances in which the dysfunction clearly predominates at
the STT joint (anterolateral midcarpal instability), whereas in
others it prevails at the triquetrum-hamate-capitate joint
(anteromedial midcarpal instability).
PART
Figure 15.42  Classification of midcarpal III
instabilities. I, In anterior midcarpal instability,
the whole proximal row appears abnormally 15 
flexed in the lateral view. II, Posterior
Wrist: Carpal Instability
midcarpal instability has normal alignment in
standard radiographs, but abnormal midcarpal
subluxation when a dorsally directed force
(arrow) is applied. III, In combined radiocarpal
and midcarpal instability, both joints are
abnormally subluxable in a palmar and dorsal
direction, usually the consequence of
increased global laxity. IV, Adaptive
dysfunction secondary to an extracarpal
problem, usually a malunited distal radius,
may produce a similar dysfunction as in
midcarpal instabilities; they have been called
IV extrinsic midcarpal instabilities.62
Posterior Midcarpal Instability
Usually present in young patients with bilateral hypermobile
wrists, posterior midcarpal instability is secondary to attenu­
ation of the palmar radioscaphoid-capitate ligament plus
insufficiency or congenital absence of the dorsal intercarpal
ligament. The proximal row is normally aligned or slightly
extended in most wrist positions. As the wrist rotates toward
ulnar deviation, however, the capitate subluxes over the
edge of the scapholunate socket inducing hyperextension of
the proximal row. When the capitate is subluxed dorsally, if
there is a reactive contraction of wrist extensors (ECU,
extensor carpi radialis longus, and ECRB), the distal row
returns abruptly to its normal alignment, often with an
audible clunk. Included in this group are so-called capitate-
lunate instability pattern (CLIP) wrists.5,54
Combined Radiocarpal-Midcarpal Instability
Combined radiocarpal-midcarpal instability is frequent
among teenagers with global hyperlax joints, particularly
individuals with increased frontal tilt of the distal radial
articular surface and ulnar-minus variance. The pattern of
clunking in these instances is similar to anterior midcarpal
instability, but there is additional mobility at the radiocarpal
joint, implying an abnormally flexed and ulnarly translocated
proximal row in radial deviation. When moved into ulnar
deviation, abnormal extension and capitate dorsal sublux­
ation occurs. Included in this group would be the so-called
proximal carpal row instabilities.118
Diagnosis of Midcarpal Instability
Intrinsic midcarpal instability seldom results from injury of
one specific ligament. Most have congenital laxity with poor
neuromuscular control, plus some sort of repetitive stress
initiating the symptoms. Asymptomatic clunking wrists need
no treatment. Despite exhibiting a different pattern of
motion, most of them have excellent proprioceptive stability
through proper neuromuscular control.
In anterior midcarpal and combined radiocarpal-midcarpal
instabilities, there is an obvious sag of the wrist in the palmar
direction, indicating a palmar translation plus supination of
the distal row relative to the forearm, a malalignment that
505
PART
III
15 
Wrist
A B
Figure 15.43  A, Anterior midcarpal instability in a 23-year-old woman with hyperlaxity who became symptomatic (painful
catch-up clunk) soon after starting a new job in a meat processing plant. B, Note the palmar sag (arrow) owing to the carpal
malalignment. Conservative treatment and activity modification yielded good results.
corrects itself in ulnar deviation (Figure 15.43).62 In posterior
midcarpal clunking, the wrist appears normally aligned
except in ulnar deviation where a dorsal subluxation of the
capitate may appear often with a clunk.
A useful maneuver to determine the amount of midcarpal
joint laxity is the midcarpal shift test, described by Lichtman
and colleagues.27,61 It consists of reproducing the painful
clunk by passive palmar translation and ulnar deviation of
the wrist in pronation. Based on how much resistance is
necessary to maintain the wrist palmarly subluxed in ulnar
deviation, wrists are classified into five grades.27 In grade I,
the palmar midcarpal ligaments are so tight that the distal
row can hardly be displaced palmarly. Grades II and III can
still be found in normal individuals and represent increasing
levels of midcarpal laxity allowing the palmar sag to be
obtained in ulnar deviation, although it reduces when the
applied force is released. In grade IV, subluxation is easily
achieved, and the wrist remains subluxed when the external
force is released. Grade V instability occurs when the patient
can actively reproduce and maintain the palmar sag in ulnar
deviation without assistance from the examiner.
Except for patients with posterior midcarpal subluxation,
radiographs show a VISI pattern of malalignment, especially
on unsupported lateral views compared with the opposite
wrist.120 In the posteroanterior view, the scaphoid is fore­
shortened and exhibits the typical ring sign, whereas the
lunate has a moonlike appearance, its distal concave surface
facing the scaphoid.
Stress views are very useful to define the level of laxity or
ligament insufficiency of the different radiocarpal-midcarpal
joint stabilizers. Such stress tests may produce abnormal find­
ings in congenitally lax individuals, however, so it is manda­
tory to compare these views with the contralateral normal
side. Aside from a traction view, which is useful to rule out
disruptions between the bones of the proximal row, four
stress views are recommended (see Figure 15.18).77
Anterior Drawer Test
Under fluoroscopy control, the distal row is translated pal­
marly, and the relationship between the scaphoid, lunate,
and distal row is observed. If the STT joint widens palmarly
(so-called open mouth sign), the STT and scaphoid capitate
ligaments are probably stretched or excessively lax, indicat­
ing the possibility of an anterolateral midcarpal instability. If
506
there is also palmar lunocapitate subluxation, a combined
anterolateral and anteromedial midcarpal instability is likely.
Posterior Drawer Test
If the capitate can be passively translocated beyond the
dorsal edge of the lunate with manual dorsal translation of
the hand while stabilizing the radius, the dorsal intercarpal
ligament is probably too lax or congenitally absent. In ulnar
deviation, slight subluxation of the capitate may occur. In
normal wrists, the alignment should return back to normal
after the dorsal directed force is released. When minimal
force is necessary to dislocate the capitate in neutral position,
a posterior midcarpal instability (CLIP wrist) is likely.5
The posterior drawer test is also useful to assess radiocarpal
instability. A dorsal tilt of the lunate causing anterior widen­
ing of the joint is indicative of a lax palmar radiolunate
ligament.
Forced Ulnar Deviation Test
When the wrist is forced into extreme ulnar deviation, if the
STT and scaphoid capitate ligaments are torn or insufficient,
the scaphoid remains foreshortened and a gap appears at the
joint. Any asymmetric gap beyond 4 mm indicates anterolat­
eral midcarpal instability.
Forced Radial Deviation Test
When the joint is axially loaded in radial deviation, the
proximal row is brought into maximal flexion. If the dorsal
radiocarpal ligament is disrupted or elongated, the axial load
induces abnormal ulnar translation of the lunate beyond the
sigmoid notch of the radius.
Cineradiography is helpful for the diagnosis of most insta­
bility problems, particularly problems with a predominant
kinematic dysfunction. In a normal wrist, there is synchro­
nized motion of the proximal carpal row from flexion to
extension as ulnar deviation occurs. In anterior midcarpal
and combined radiocarpal and midcarpal instabilities, the
proximal carpal row remains flexed throughout the entire
range of motion except when the wrist reaches a certain ulnar
deviated position, at which point it suddenly snaps into an
extended position, occasionally with a dramatic and some­
times audible clunk (Figure 15.44). Frequently, one finds
similar but asymptomatic laxity on the contralateral side. The
study tends to be normal in flexion-extension.

A B
C D
The role of arthroscopy in the diagnosis and grading of
nondissociative instability is minimal. Under traction, the
elongated palmar capsule allows larger than normal separa­
tion of the joint, but the palmar ligaments usually look
normal. In long-standing cases, recurrent subluxation may
have caused degenerative changes on the proximal pole of
the hamate, which can be assessed, and often treated,
arthroscopically (see Chapter 19).
When radiographs of a painful wrist reveal abnormal
flexion of the proximal row (VISI), the differential diagnosis
must include lunate triquetrum instability. The diagnosis can
be established by using the lunate triquetrum ballottement
and shear maneuvers.85,112 Both tests are negative in nondis­
sociative instabilities, and induce pain and a typical grinding
sensation when there is lunate triquetrum dissociation.
Radiographically, the scapholunate and lunate triquetrum
angles are normal in nondissociative instabilities, whereas
they may be altered in wrists with dissociative instability.
When the lunate triquetrum ligaments are completely torn,
the triquetrum appears proximally migrated relative to the
lunate in the ulnar deviation stress test; this does not
PART
III
15 
Wrist: Carpal Instability
Figure 15.44  A 21-year-old man
sustained a hyperextension injury to
the right wrist 2 years earlier. Since
then, there has been painful clunking
during radioulnar deviations. A and B,
Dynamic radiographs showed a
sudden shift (arrow) of the lunate and
scaphoid from a flexed (A) to an
extended (B) position as the wrist
reached a certain degree of ulnar
deviation. Conservative treatment did
not succeed in relieving the patient’s
symptoms, and a triquetrum-hamate
fusion was performed. Four months
after surgery, the patient was back to
his former occupation, without any
complaint. At 18 months of follow-up,
the clunking had not recurred, but an
obviously altered carpal kinematics
was evident. C and D, From radial (C)
to ulnar (D) deviation, little midcarpal
motion exists. Whether such increased
radiocarpal shear would result in early
degeneration is unknown, but is a
good possibility.
occur in a wrist with nondissociated instability. When in
doubt, high-resolution MRI or arthroscopy is recommended.
Arthroscopic inspection with a probe shows a tightly closed
lunate triquetrum interosseous space in nondissociative
instabilities and an easily opened space if there is substantial
ligament damage of the lunate triquetrum–stabilizing
ligaments.67
Treatment of Midcarpal Instability
Several strategies have been recommended for patients with
painful midcarpal instability. Generally, the more the therapy
is focused on solving the underlying pathology, the better the
results.5,61,62,67,118 Treatment modalities recommended for
each type of instability are described.
Anterior Midcarpal Instability
Patients with an intrinsic anterior midcarpal instability
should be initially treated by splint immobilization, anti-
inflammatory medication, and avoidance of activities
reproducing the painful clunk. In the initial inflammatory
phase, the wrist should be protected by a three-point splint
507
PART that maintains the proximal row neutrally aligned. When the
III symptoms have subsided, a supervised therapy program to
re-establish adequate proprioceptive control of the wrist is
15  recommended.62,118 Excessive flexion of the proximal row can
be dynamically controlled by the coupled action of the FCU
Wrist
and ECU muscles. Isometric contraction of the FCU muscle
generates a dorsally directed force onto the triquetrum, via
the pisiform, which helps stabilize the proximal row in
neutral position. Aside from this, if there is a concomitant
contracture of the ECU, the distal row is forced into extreme
pronation relative to the proximal row, further promoting
reduction of the VISI malalignment. Poor proprioception and
inadequate neuromuscular control characterize these symp­
tomatic wrists.41 When all conservative measures have failed
to control the symptoms of an anterior midcarpal instability,
different surgical options exist depending on the location of
the predominant injury that has caused the problem.
Anterolateral Midcarpal Instability
When the primary injury is in the STT joint, two basic strate­
gies have been proposed: a soft tissue reconstruction of the
STT ligaments or a limited intercarpal fusion. These are short
structures, difficult to reconstruct in chronic situations
because retraction and degeneration of these ligaments are
often found. In such circumstances, the tenodesis technique
described by Brunelli and Brunelli15 may be considered. The
technique consists of obtaining a slip of FCR, leaving it
attached distally, and passing it through a tunnel across the
distal scaphoid, roughly replicating the direction of the STT
ligaments. For this technique to be successful, it is mandatory
that the cartilage at the joint be normal; otherwise, painful
ankylosis may follow. If the STT joint is already degenerated,
but the proximal pole of the scaphoid still has good cartilage,
an STT joint fusion is a good alternative.113
Anteromedial Midcarpal Instability
When the predominant injury inducing an anterior midcarpal
instability involves primarily the triquetrum-capitate-hamate
joint, three surgical options exist: capsular shrinkage, liga­
ment reconstruction, and limited intercarpal arthrodesis.
Capsular Shrinkage
Based on the experience collected in other joints, electrother­
mal shrinkage of insufficient or stretched ligaments has been
proposed for the stabilization of anteromedial midcarpal
instability.67 Local heat is applied to the loose palmar mid­
carpal and dorsal radiocarpal capsule to create areas of col­
lagen damage. Fibroblasts grow into the injured tissues,
building a new structure simulating normal tissue. See
Chapter 19 for further details about this technique. Despite
promising results, the use of capsular shrinkage in this field
is still considered experimental.
Soft Tissue Reconstructions of Midcarpal Ligaments
In the past, most attempts to resolve anteromedial midcarpal
instability through a soft tissue procedure were based on the
assumption that the underlying pathology was an elongation
of the ulnar arm of the arcuate ligament.61 In most instances,
surgery consisted of reefing or advancing that portion of
capsule. Most such attempts were considered failures, based
on the presence of persistent symptoms.62 Recreation of
508
the palmar triquetrum-capitate-hamate and dorsal radio­
carpal ligaments with a tendon graft is another promising
alternative.62,118
Limited Arthrodesis
Limited midcarpal arthrodeses (mostly triquetrum-hamate
fusions) have also been recommended in this type of instabil­
ity.38,61 In a study comparing the results of fusions with results
of soft tissue reconstructions, Lichtman and colleagues61 con­
firmed the advantage of fusing the triquetrum-hamate joint
for anteromedial midcarpal clunking. All patients who had
a fusion were able to return to their activities with less
than one third loss of motion and no clunking. Later publica­
tions have been less enthusiastic about such an approach,
however.99 Although this type of procedure is effective in
eliminating the carpal clunking, this is achieved at the expense
of creating a painful radioscaphoid impingement (see Figure
15.44). When the midcarpal joint is fused, “dart-throwing”
motion is unnaturally performed by the radiocarpal joint, and
this eventually results in either a dorsolateral overload of the
scaphoid fossa or a progressive deterioration of the lunate
triquetrum.
More recently, a different approach has been proposed,
based on the fact that carpal clunking may also be eliminated
by fusing the radiolunate joint instead of the midcarpal
joint.42 By fixing the lunate to the radius, the keystone of the
carpus is placed in a neutral position, allowing more stable
midcarpal motion. The lunate is fused with crossed Kirschner
wires and a corticocancellous graft to preserve normal carpal
height, allowing the scaphoid and triquetrum to move nor­
mally. Not only does the clunking disappear, but also the
wrist retains a substantial amount of motion, mostly along
the “dart-throwing” plane, allowing a more natural way of
moving the wrist (see Figure 15.28).23,74
Posterior Midcarpal Instability
Patients with posterior midcarpal instability should always
undergo a dedicated program of physical rehabilitation. In
this case, hand therapy should emphasize proprioception
reeducation of the ECU, extensor carpi radialis longus, and
ECRB muscles. When these muscles contract, an extension
moment to the distal row is generated that results in a shift
of the midcarpal joint contact forces from a dorsal position
to a more palmar one. Such compressive forces prevent
excessive extension of the proximal row. Failing propriocep­
tion reeducation, the method described by Johnson and
Carrera54 seems adequate. Through an extended anterior
approach to the carpal tunnel, the sulcus that exists between
the long radiolunate and radioscaphoid-capitate ligaments
(space of Poirier) is obliterated with sutures to avoid dorsal
translocation of the capitate. According to its proponents,
most patients obtain good or excellent results, with little
loss of motion, especially in extension.5,54 Alternatively, a
transverse dorsal midcarpal capsulodesis to reinforce the
dorsal intercarpal ligament, similar to the one suggested by
Gajendran and colleagues,32 may be as effective and
satisfying.
Combined Radiocarpal-Midcarpal Instability
When carefully assessed, most (68%) apparent midcarpal
instabilities also have increased laxity of the radiocarpal
ligaments.118 In such multidirectional radiocarpal-midcarpal
instabilities, a radiolunate fusion is probably the best strategy
to adopt.42 As stated earlier, the lunate should be fused using
a structural graft to maintain carpal height, allowing the
scaphoid and the triquetrum to move normally. With this
technique, not only does the clunking disappear, but also the
wrist retains a substantial amount of motion, mostly along
the “dart-throwing” plane.23,74
Author’s Preferred Method of Treatment:
Midcarpal Instability
When examining a patient with a painful clunking wrist,
stress views are my preferred test to identify the type of
midcarpal instability and the optimal treatment strategy.
Generally, most midcarpal dysfunctions respond well to con­
servative treatment. Splinting and avoidance of activities that
produce the painful snapping are helpful measures, but
should always be associated with a program designed to
maximize the neuromuscular dynamic stabilizers of the joint.
Surgery is indicated for patients who fail a rigorous course
of nonoperative treatment and strengthening. I have no
experience with arthroscopic palmar midcarpal-dorsal
radiocarpal capsular shrinkage, but I believe it is a possible
solution for multidirectional instability in teenagers with
hyperlaxity.
In the past at our institution, most patients with palmar
midcarpal instability were treated by fusing the triquetral
hamate joint. We failed to reproduce the encouraging results
reported by Lichtman and colleagues.61 Some patients com­
plained of radioscaphoid impingement pain, whereas others
disliked not being able to move the hand normally because
midcarpal fusion prevents the “dart-throwing” motion.
We designed a tenodesis procedure to recreate the trique­
trum-hamate-capitate ligament and augment the dorsal
radiocarpal ligament (Figure 15.45). Two longitudinal inci­
sions (dorsal and palmar) are used. Two drill holes 3.2 mm
ECRB
Figure 15.45  The author’s preferred tenodesis procedure to
reinforce the two major ligament problems in anterior midcarpal
instability. A distally attached strip of the ECRB tendon is raised
and passed through holes in the capitate and triquetrum to
recreate the ulnar limb of the arcuate ligament (triquetrum-
capitate fascicles) and the dorsal radial triquetrum ligament.
in diameter are made: one from the dorsal aspect of the PART
capitate into the carpal canal and another from the palmar III
aspect of the triquetrum to its dorsal ridge. A strip of ECRB
tendon is passed through the capitate hole, retrieved pal­
15 
marly, and passed again through the triquetrum hole. The
Wrist: Carpal Instability
tendon is pulled taut, and sutures reinforcing the remnants
of the palmar triquetrum-hamate-capitate ligament are
placed. Back on the dorsum, the tendon is tightly sutured on
the origin of the dorsal radiocarpal ligament. Kirschner wires
to stabilize the construct further are usually used. The results
obtained in seven patients have been very promising, with
minimal discomfort, excellent grip strength, and minimal loss
of motion. All patients returned to their occupations without
clunking.
When surgery is required for dorsal midcarpal instability,
I no longer use the method described by Johnson and
Carrera54 of obliterating the space of Poirier with nonabsorb­
able sutures. In my experience, a dorsal reinforcement of the
midcarpal capsule by using the capsulodesis technique
described by Gajendran and colleagues32 is easier, less
morbid, and as effective as with reefing of the palmar mid­
carpal capsule.
My experience in the use of radiolunate fusion for the
treatment of combined radiocarpal and midcarpal instability,
although limited to nine patients, is most satisfying. After an
average follow-up of 19 months (range 9 to 67 months), all
patients had returned to their previous activities. Range of
flexion-extension was slightly reduced, grip strength was
normal, and no clunking has recurred (see Figure 15.43).
Based on these preliminary findings, radiolunate fusion has
become our method of choice in most clunking wrists with
more than one dysfunctional joint.
CARPAL INSTABILITY ADAPTIVE
Carpal dysfunction is not always the consequence of intra­
carpal injury. Sometimes the wrist may exhibit different pat­
terns of malalignment, even with substantial clunking, and
yet the underlying pathology is not within the carpus, but
outside of it.1 A typical example is a dorsally malunited distal
radial fracture that has induced a postural adaptation of the
proximal carpal row to conform to the abnormal radial tilt.
Most often, there is permanent flexion of the midcarpal joint
with slackening of the palmar midcarpal ligaments. In such
circumstances, the lack of function of palmar midcarpal liga­
ments may lead to progressive pain; tenderness to palpation
at the midcarpal joint; and occasionally a painful, audible
snap. Such dysfunction disappears when the radial deformity
is corrected via an osteotomy, although the postural abnor­
mality of the lunate may remain.102
The concept of adaptive instability was introduced in 1982
by Allieu and associates,1 emphasizing the fact that this type
of dysfunction should not be confused with dysfunction
secondary to ligament injury within the carpus. In 1985,
Taleisnik102 confirmed these ideas when they reported on 13
patients with dorsally malunited distal radial fractures and
secondary midcarpal dysfunction and malalignment, which
were solved after a corrective radial osteotomy. These
authors used the term extrinsic midcarpal instability to dif­
ferentiate these cases from midcarpal instabilities deriving
from intracarpal pathology. For a diagnosis of adaptive
509
PART carpus to be made, it is important to rule out the existence
III of any significant intracarpal ligament injury. Chapter 17
contains a detailed description of how to plan and execute a
15  corrective radial osteotomy to solve this problem.
Wrist

CARPAL INSTABILITY COMPLEX

When the carpal derangement has impaired the relationship
between bones within the same row (CID features) and
between rows (CIND features), the resultant dysfunction is
categorized as a CIC.51 Except for pure radiocarpal disloca­
tions, which are classified with nondissociative instabilities,
all other carpal dislocations are complex and fulfill the crite­ A
ria of CIC. Within this category of injuries, five groups of
carpal dislocations have been identified20,39:

1. Dorsal perilunate dislocations (lesser arc)

2. Dorsal perilunate fracture-dislocations (greater arc)
3. Palmar perilunate dislocations (lesser or greater arc)
4. Axial dislocations
5. Isolated carpal bone dislocations

The first two groups have in common a carpal derangement

occurring around the lunate—the first as a pure ligament
disruption problem, the second involving one or more frac­ B
tures of the adjacent bones. The third group, although peri­
lunate, results from a different mechanism producing a
palmar displacement of the distal row relative to the lunate.
The fourth and fifth groups represent various nonperilunate
dislocations, usually the result of high-energy trauma.

Dorsal Perilunate Dislocations

(Lesser Arc Injuries)
Different forms of carpal injury exist under the diagnosis of
dorsal perilunate dislocation, confined to a relatively vulner­
able area around the lunate. They can be pure ligamentous
injuries or a combination of ligament injuries and fractures
of the bones around the lunate. Johnson52 suggested using
the term lesser arc injuries to refer to pure perilunate disloca­
tions, as opposed to greater arc injuries, in which one or
several bones around the lunate have a concomitant fracture.
This section focuses on lesser arc injuries—dorsally displaced
perilunate dislocations without an associated fracture.
Throughout the literature, there has been a tendency to
consider dorsal perilunate dislocations and palmar lunate
dislocations as separate and distinct entities. In reality, as
discussed in the pathomechanics section of this chapter, the
two conditions represent different stages of the same
pathomechanism—the so-called progressive perilunate insta­
bility pattern (Figure 15.46).68 When one attempts to reduce
a palmarly dislocated lunate, a dorsal perilunate dislocation
can be easily reproduced. In other words, the position of the
bones when the patient is seen in the emergency department
does not reflect the degree of instability or the full extent of
the ligamentous damage. Perilunate and lunate dislocations
are pathogenically equivalent lesions, and their management
is almost identical.
Another frequent misconception is that when the lunocapi­
tate joint dislocates (Mayfield’s stage II), the scaphoid has
either fractured or torn its ligamentous attachments to the
lunate, but not both. In the literature, many perilunate dis­
510
C
Figure 15.46  Carpal dislocations constitute a spectrum of injury,
and the initial lateral radiograph in a patient with carpal
dislocation may depict a configuration at any point on that
spectrum. A, “Pure” dorsal perilunate dislocation. B, Intermediate
stage. C, “Pure” volar lunate dislocation.
locations with simultaneous scaphoid fracture and SLD have
been reported, however, showing that the two lesions are not
mutually exclusive.44,49 Most experimentally produced scaph­
oid fractures have an associated partial scapholunate interos­
seous ligament failure.68 In a multicenter study of 166
perilunate dislocations, Herzberg and coworkers44 found six
cases (3.8%) with a concomitant scaphoid fracture and SLD.
Treatment of Perilunate Dislocations
In the literature, three major methods of treating carpal dis­
locations have been suggested: closed reduction and cast
immobilization, closed reduction and percutaneous pinning,
and open reduction and internal fixation.39
Closed Reduction and Cast Immobilization
Since the 1920s, when case reports of lunate dislocations
began to appear, many methods have been suggested for
closed reduction. Of importance is the contribution by Böhler,
who emphasized the necessity of prolonged continuous
traction before attempting to reduce the dislocation.39
Some authors even considered the use of an external fixator
spanning the wrist in old unreduced dislocations to
not. An initial period of 10 minutes of uninterrupted traction PART
with the elbow flexed 90 degrees is helpful before reduction. III
During traction, posteroanterior and lateral radiographs with
the carpus distracted are obtained (see Figure 15.17). These
15 
films are valuable in delineating the full extent of carpal

Wrist: Carpal Instability

neutralize muscle contraction and help reduction through
ligamentotaxis.30,101
Complete muscle relaxation is essential for an atraumatic
reduction of a carpal dislocation. General anesthesia, axillary
block, and intravenous regional anesthesia (Bier block) all
provide satisfactory muscle relaxation; local anesthesia does
2 extended gradually while the lunate is pushed dorsally with
1 sooner after injury this technique is performed, the easier is
3
Figure 15.47  Schematic representation of Tavernier’s method39 of
reduction of dorsal perilunate dislocations. With the wrist slightly
extended, gentle manual traction is applied (1). Without releasing
such traction, and while the lunate is stabilized palmarly by the
surgeon’s thumb, the wrist is flexed, until a snap occurs (2). This
indicates that the proximal pole of the capitate has overcome the
dorsal horn of the lunate. At this point, traction is released, and
the wrist is brought back to neutral (3).
damage. When the wrist has been distracted for 10 minutes,
traction is released, and the method of reduction described
by Tavernier is attempted as follows (Figure 15.47).39
With one hand, the patient’s wrist is extended (maintaining
longitudinal traction), while the thumb of the other hand
stabilizes the lunate on the palmar aspect of the wrist.
Gradual flexion of the wrist allows the capitate to snap back
into the concavity of the lunate. To facilitate this maneuver,
the operator’s thumb stabilizes the lunate to prevent its being
displaced forward by the capitate. When the lunocapitate
joint is reduced, and without releasing traction, the wrist is
the thumb, and a full reduction is usually achieved. The
the reduction.
Postreduction radiographs are taken. It is imperative to
take enough different views and assess “very critically” the
relationship of the capitate and lunate and the position of the
scaphoid. A scapholunate angle greater than 80 degrees and
a scapholunate gap greater than 3 mm have been shown to
indicate poor prognosis if not corrected. The wrist is initially
immobilized with a dorsal short arm and thumb spica plaster
splint with the wrist in neutral. The period of plaster immo­
bilization has been a subject of controversy in the literature.
In the few cases in which closed reduction alone is indicated,
most authors recommend at least 12 weeks of immobiliza­
tion, with a weekly radiographic reassessment of the reduc­
tion for at least the first 3 weeks. If gradual loss of reduction
occurs, surgical treatment should be considered (Figure
15.48). Closed treatment should be continued only when a
strictly anatomic reduction has been achieved, or when other
medical reasons contraindicate surgical intervention.

A B C
Figure 15.48  Nonoperative treatment of this dorsal perilunate dislocation, which consisted of reduction, cast immobilization
for 7 weeks, and physical rehabilitation, was considered successful, until the patient was assessed 8 years after the injury.
A-C, Chronic SLD (black arrow) associated with a type II ulnar translation of the lunate (white arrow) was the result of this
suboptimal reduction.

511
PART Closed Reduction and Percutaneous Fixation
III Because of the inherent instability of the proximal row bones
after closed reduction, some authors favor percutaneous pin
15  fixation. This technique is acceptable only if the reduction
achieved by closed manipulation of all the perilunate joints
Wrist
is completely anatomic. Minor degrees of scaphoid malrota­
tion would prevent the scapholunate ligaments to be in
contact for proper healing, leading to later scapholunate or
lunate triquetrum instability, or both. The technique of per­
cutaneous fixation is as follows.
When reduction has been achieved, traction is released,
and the hand is prepared with a standard surgical prepara­
tion. The procedure starts by inserting from the dorsum two
Kirschner wires, one into the lunate and another into scaph­
oid, which are used as “joysticks” to maintain the alignment
of the carpus, or to improve the reduction if this is believed
to be suboptimal. Reduction is assessed by image intensifier
or, ideally, by arthroscopic direct vision.115 While the lunate
wire is held in the reduced position relative to the radius by
a knowledgeable assistant, a 1.2-mm or 1.5-mm oblique pin
from the lateral aspect of the radial metaphysis is inserted
across the radiolunate joint under fluoroscopy.
The scaphoid “joystick” wire is used to reduce the scaph­
olunate joint anatomically, and two slightly divergent pins
are inserted transversely from the anatomic snuffbox across
the scapholunate joint. The wrist is slightly radially deviated
to bring the triquetrum up into a reduced position relative to
the lunate, and two more Kirschner wires are inserted from
the medial aspect of the wrist across the lunate triquetrum
joint. At this point, lunocapitate joint mobility is inspected
under fluoroscopy. If there is a tendency for the capitate to
sublux dorsally in flexion, a further pin is passed across the
scaphoid capitate joint. In all cases, before inserting any pin,
subcutaneous neurovascular injury should be prevented by
means of small skin incisions, followed by blunt dissection to
identify and protect structures such as the radial artery and
the superficial branches of the radial or ulnar nerves. A small
drill guide or an angiocatheter sleeve is helpful to avoid soft
tissue injury from the drill torque.
The Kirschner wires are left protruding through the skin,
bent at right angles, or cut just under the skin to facilitate
later removal. A padded thumb spica splint is applied imme­
diately after the final radiographs have been obtained. This
is converted to a thumb spica cast at 7 to 10 days after swell­
ing has subsided and assuming the pin tracts are free of
infection. Radiographs are taken in the new cast to ensure
proper maintenance of reduction. The cast and pins are
removed at 8 weeks, and immobilization in a dorsal splint is
continued for an additional 4 weeks, for a total of 12 weeks
after reduction. Scarce long-term results are available to cri­
tique this technique adequately, but closed treatment fails to
address the disruption of the critical dorsal component of the
scapholunate interosseous ligament, a factor that has been
shown to lead to diminished long-term outcomes.69
In the literature, there is strong evidence to discourage
accepting suboptimal reductions of perilunate dislocations.
These inevitably lead to poor long-term results.39,44 Even
when an acceptable restoration of the anatomy has been
obtained, one must consider the benefits of an open proce­
dure to avoid the frequently missed osteochondral defects
and loose intra-articular bodies that can cause a poor result.
512
Open Reduction, Internal Fixation,
and Ligament Repair
Generally, open surgery of any carpal dislocation is likely to
achieve better results than closed treatment because it allows
(1) complete recognition of all bone and soft tissue damage,
(2) removal of any intra-articularly interposed soft tissue, (3)
removal or synthesis of any unstable chondral fragment, (4)
a more accurate reduction of bone displacements, and (5)
suture of any repairable ligament. Many long-term follow-up
studies have shown the superiority of open reduction, liga­
ment repair, and percutaneous Kirschner wire fixation over
any other alternative in the treatment of perilunate disloca­
tions.6,20,39,44 Although some authors still prefer using only a
dorsal approach to treat perilunate dislocations,57 the alterna­
tive of combining a dorsal and a palmar approach to allow
repair of the palmar lunate triquetrum ligament, while assess­
ing from the dorsum the reduction and repairing the dorsal
scapholunate ligament, is gaining wide recognition.13,100,105
Some authors recommend using an external fixator to
facilitate exposure while protecting the repair.30,101 This is
especially indicated in long-standing dislocations with exten­
sive fibrosis. In these cases, several days of progressive
stretching of the joint may facilitate surgery. A description
of the dual-approach treatment of a perilunate dislocation
follows.
The dorsal capsule is exposed through a longitudinal inci­
sion centered on Lister’s tubercle, dividing the extensor reti­
naculum between the second and third compartments. The
fourth compartment is also opened by sectioning the septum
between the third and fourth compartments. The capsule is
found often disrupted at its proximal insertion off the radius.
This tear is extended medially following the fibers of the
dorsal radiocarpal ligament,10 and a distally based capsular
flap is elevated uncovering the radiocarpal and midcarpal
joints.
The palmar approach consists of a carpal tunnel incision
extended proximally in a zigzag fashion. The flexor tendons
and median nerve are carefully elevated and protected. This
allows inspection of the floor of the carpal tunnel, where an
“L”-shaped transverse capsular rent along the sulcus between
the radioscaphoid-capitate and long radiolunate ligaments is
identified. This capsular rent typically curves proximally
across the palmar lunate triquetrum ligament. Through this
rent, the distal articular surface of the lunate can be easily
inspected by carefully reproducing the dislocation (Figure
15.49).39 Before reducing the dislocation, all unstable rem­
nants of capsule are removed, and the joints are freed from
any incarcerated soft tissue. The lunate is reduced under
direct vision by manually pushing it in a dorsal direction
while a gentle longitudinal traction on the hand is applied.
The ulnar corner of the capsular rent, which contains the
disrupted palmar lunate triquetrum ligament, is repaired with
nonabsorbable sutures (Figure 15.50). The palmar scapholu­
nate ligament cannot be repaired because it is covered by the
intact long radiolunate ligament.
The carpus is inspected from the dorsum, and the scapholu­
nate and lunate triquetrum joints are reduced and stabilized
as described previously when addressing closed percutaneous
fixation. Some authors use wire cerclage around the scaph­
olunate joint to provide further stability and allow earlier
mobilization.105 When possible, direct repair of the dorsal
 PART
III
15 
Figure 15.49  A 31-year-old male

Wrist: Carpal Instability

professional motorcycle racer fell
during a race. A, CT scan and
three-dimensional reconstruction
of unreduced perilunate
dislocation obtained 3 days after
the injury. The dislocation had
been missed at presentation.
B, Surgical approach using an
extended carpal tunnel incision
allows visualization of the distal
A B surface of the lunate (L). After
reduction, the disrupted palmar
lunate triquetrum ligament
(arrow) was repaired adding
further stability to the proximal
row. C, Placement of stabilizing
Kirschner wires, across the
scapholunate and lunate
triquetrum joints.
D, Posteroanterior view obtained
8 months after injury. The
patient had resumed his racing
activities with about 25%
reduction of wrist motion.

C D

contact to ensure adequate healing. If there is an associated

1 radiodensity should not be interpreted as post-traumatic
2
A B
Figure 15.50  A, Schematic representation of the two levels of
ligament disruption that need to be addressed when approaching
a perilunate dislocation palmarly: the origin of the radioscaphoid-
capitate ligament may have avulsed off the radial styloid (1), and
the palmar lunate triquetrum ligament often is disrupted through
its mid-substance and only occasionally shows an avulsion type of
rupture (2). B, When properly reduced, the two ligament injuries
need to be repaired with mattress sutures (black lines). The
apparent rent that exists between the avulsed radioscaphoid-
capitate ligament and the long radiolunate ligament needs no
repair because it is an anatomic sulcus (space of Poirier).
scapholunate and lunate triquetrum interosseous ligaments
using nonabsorbable sutures is recommended.11 Viegas and
colleagues108 used a reduction clamp to approximate the dis­
sociated bones and facilitate a more reliable ligament repair.
The two ends of all disrupted ligaments should be left in
radial styloid fracture, the dorsal approach is used to reduce
it anatomically and fix it with an additional screw. The post­
operative regimen for open treatment of perilunate disloca­
tions is identical to the closed method.
Frequently, during the first months after reduction, the
lunate may show increased radiodensity. This increased
Kienböck’s disease, however, because it tends to progress
toward slow recovery without bone collapse in most cases.
In the literature, very few cases of lunate fragmentation and
collapse after carpal dislocations have been published.
According to a multicenter study by Herzberg and col­
leagues,44 the functional results of open reduction, ligament
repair, and Kirschner wire fixation are significantly better
than the results with other alternatives, with an average
Green and O’Brien39 wrist functional score of 86 points in
stages II and III, and 79 points in stage IV (normal score 100
points). Similar results have been published by Minami and
Kaneda.69 Patients require a long period of rehabilitation to
regain their maximal possible range of motion (about 70%
of their normal side) and grip strength. Less than one third
of patients are able to return to heavy manual work.
Author’s Preferred Method of Treatment:
Perilunate Dislocations
All perilunate dislocations need to be reduced by closed
means in the emergency department as soon as possible. The
513
PART reason for such urgency is to decompress the median nerve
III at the carpal tunnel and to release tension on the vascular
supply to the displaced carpal bones. When the dislocation
15  has been reduced, a well-padded bandage is applied, and the
forearm is maintained elevated until a definitive surgical
Wrist
treatment can be instituted. If the dislocation has been
reduced, delaying the definitive treatment several hours or
even a few days to get the right equipment and trained per­
sonnel is not a problem, as long as the patient is comfortable
with proper analgesia.
I strongly recommend a double-approach open reduction,
dorsal scapholunate and palmar lunate triquetrum ligament
repair, and scapholunate and lunate triquetrum Kirschner
wire fixation. I have not used the alternative of reducing
displacements anatomically under arthroscopic guidance and
stabilizing the scapholunate and lunate triquetrum joints with
temporary screw fixation, as is done in the RASL procedure
for SLD.89 I believe that surgery is always indicated, regard­
less of the quality of reduction obtained by closed means,
unless an underlying medical condition contraindicates
surgery. If the patient is reluctant to allow open surgical
treatment, or if an unstable medical condition is likely to
persist for more than 1 week, closed reduction and percuta­
neous fixation are considered. Operative treatment for dorsal
perilunate (Mayfield’s stage II or III) and palmar lunate (stage
IV) dislocations is identical.
CRITICAL POINTS: PERILUNATE DISLOCATIONS:
TECHNIQUE FOR OPEN REDUCTION AND KIRSCHNER WIRE
FIXATION (COMBINED DORSAL AND PALMAR APPROACH)
Indication
 All perilunate dislocations, unless unstable medical
condition contraindicates surgery
Preoperative Evaluation
 Under axillary block, the dislocation is reduced in the
emergency department (Tavernier’s maneuver).
 During reduction, traction views are obtained.
 The forearm is placed in elevation in a well-padded
above-elbow cast until definitive surgery is possible.
Surgical Approach
 Perform a dorsal 6-cm straight incision centered on
Lister’s tubercle.
 Open the extensor retinaculum along the third
compartment, and expose the second through fourth
compartments. Elective neurectomy of the posterior
interosseous nerve may be performed.
 Perform a palmar carpal tunnel incision, extended
proximally across the wrist in a zigzag fashion. Flexor
tendons and median nerve are retracted radially.
Usual Findings
 The dorsal capsule is usually found avulsed off the
radius. If the dislocation has not been reduced, an
obvious empty space between the capitate and radius
appears.
 Exploration of the palmar capsule reveals a consistent
arciform rent, coinciding with the space of Poirier,
coursing along the sulcus between the radiocarpal and
long radiolunate ligaments, and ulnarly curving across
the palmar lunate triquetrum ligament (see Figure
15.49B). If the dislocation is unreduced, one can see the
distal articular surface of the lunate through this rent.
514
Reduction and Fixation
 The lunate can be easily reduced under direct vision
by manually pushing it back in between the capitate
and radius, while applying gentle longitudinal traction
on the hand.
 The ulnar portion of the capsular rent (the disrupted
palmar lunate triquetrum ligament) is repaired with
3-0 nonabsorbable sutures.
 The lateral portion of the palmar capsular
derangement does not need to be repaired because it
is an anatomic defect—the interligamentous sulcus
between the long radiolunate ligament and the
radioscaphoid-capitate ligament.
 Through the dorsal approach, reduce the lunate
triquetrum joint and stabilize it with a Kirschner, and
repair the dorsal ligaments.
 Reduce, stabilize, and carefully repair the dorsal
scapholunate ligament (see Figure 15.49C).
 If the lunocapitate joint feels unstable, stabilize it with
two crossed Kirschner wires—one through the
scaphoid and the other across the triquetrum.
 Obtain radiographs, and assess the quality of reduction
and the purchase of the pins.
 Except for the flexor retinaculum, all anatomic planes
are closed with sutures, leaving drains.
Important Tips
 Even if repair of the dorsal ligaments is impossible,
their remnants should be tacked back into position.
Suboptimal repairs may still result in acceptable
function.
 Make sure that no osteochondral fragments are left
inside the articulation.
 If there is substantial damage of the cartilage of the
lunate, proximal row carpectomy may be an
acceptable solution.50
 When present, radial styloid fractures should be
reduced anatomically and held with additional
Kirschner wires or screw fixation. If the fracture is
comminuted, do not excise the unstable fragments so
as not to destabilize the radiocarpal ligaments.
Molding the fragments back into place as anatomically
as possible is recommended.
Postoperative Regimen
 A short arm thumb spica cast is worn for 6 weeks; it is
changed at 10 days for stitch removal and x-rays.
 At 8 weeks, cast and wires are removed and
rehabilitation to regain motion and grip strength
starts. A protective removable splint is used between
sessions.
 Most patients have some permanent limitation of
motion, and several months of rehabilitation are
required to regain range of motion and grip strength.
Return to heavy labor is rarely possible before 6
months and more commonly requires up to 12
months.
Dorsal Perilunate Fracture-Dislocations
(Greater Arc Injuries)
Strictly speaking, only a transscaphoid, transcapitate, trans­
triquetral perilunate dislocation should truly be called a
greater arc injury. This modality is extremely unusual.60 Most
perilunate fracture-dislocations combine ligament ruptures,

A B
Figure 15.51  A 19-year-old man sustained trauma in a motorcycle accident. A, Posteroanterior view of wrist shows a transscaphoid
perilunate dislocation. B, Three-dimensional reconstruction of CT scan obtained soon after the injury shows transscaphoid perilunate
dislocation. C, Dorsal surgical approach provided excellent visualization of the structures involved. The two fragments of the
scaphoid (S) were completely displaced to each other. Cartilage injury to the proximal pole of the capitate (arrow) is quite frequent
in this sort of injury, explaining why some patients develop rapid midcarpal degenerative arthritis later on.
bone avulsions, and fractures in various clinical forms. The
most frequent is the dorsal transscaphoid perilunate disloca­
tion.45 Much less common, but interesting from a pathome­
chanic point of view, are dislocations involving displaced
fracture of the capitate,14,29,106 and dislocations with displaced
fracture of the triquetrum in the sagittal plane.
Transscaphoid Perilunate
Fracture-Dislocations
According to most series, approximately 60% of all perilu­
nate dislocations manifest with a displaced scaphoid fracture,
usually in the middle third.20,44 Most often, the proximal frag­
ment remains connected to the lunate, even if this has under­
gone a palmar dislocation. The exceptions are rare instances
in which there is a concomitant SLD, with the proximal
scaphoid being extruded dorsally.49
The initial management of transscaphoid perilunate dislo­
cations, including the need for adequate anesthesia and pre­
liminary traction, is identical to management described for
dorsal perilunate dislocations. Radiographs taken with the
hand suspended in finger traps are particularly helpful in the
assessment of bone damage and should be obtained rou­
tinely. Rigid screw fixation of the scaphoid fracture simplifies
treatment and rehabilitation because motion can be begun
before complete healing of the scaphoid fracture. Alternative
methods of treatment are as follows.
Closed Reduction and Cast Immobilization
Although rarely recommended, the technique for closed
reduction is the same regardless of whether the lunate is
palmarly displaced or normally aligned, and it is almost iden­
tical to that described for lesser arc injuries.6,39 While main­
taining some longitudinal traction, the surgeon stabilizes the
lunate by pressing the palmar aspect of the wrist with the
thumb. From extension, the wrist is gradually flexed. Unless
there is some soft tissue interposition, this maneuver brings
the capitate back into the concavity of the lunate, sometimes
with a snap. The wrist is held in slight flexion and radial
deviation, and a padded thumb spica cast is applied. At this
PART
III
15 
Wrist: Carpal Instability
C
point, it is important to take enough radiographic views to
assess the scaphoid fracture reduction. Not only must the
scaphoid be anatomically reduced, but also the DISI defor­
mity has to be corrected. If one of these two factors is not
completely resolved (usually because of capsular interposi­
tion between the two scaphoid fragments), reduction should
be reattempted, or, preferably, open treatment should be
performed.
It is essential to perform weekly radiographic evaluation
of the scaphoid alignment for at least 3 weeks. If at this time
the reduction is still acceptable, the wrist is brought from
flexion to neutral and immobilized in a short arm and thumb
spica cast until the scaphoid fracture is healed. According to
Cooney and associates,20 the healing time reported for this
type of fracture averages 16 weeks. The rate of nonunion
after treatment approaches 50%.39
Closed Reduction and Percutaneous Fixation
If surgery is contraindicated, or the patient refuses open
treatment, and provided that the dislocation has been accept­
ably reduced by closed means, percutaneous treatment is an
alternative to avoid progressive loss of reduction. Two or
more percutaneous Kirschner wires are driven across the
fracture, and two additional ones are used to stabilize the
lunate triquetrum joint. If available, arthroscopically guided
percutaneous screw fixation may achieve improved results
over the results obtained using only the fluoroscope.115 No
long-term results have been published to compare these tech­
niques, however.
Open Reduction and Internal Fixation
Open reduction and internal fixation is the most reasonable
alternative for achieving anatomic reduction of the many
structures that need to be repaired. The same dorsal approach
that is used in lesser arc injuries is recommended (Figure
15.51). Palmarly, the Russe approach as described for
grafting scaphoid nonunions is adequate.20 This approach is
mostly used to free the scaphoid fracture from interposed soft
tissue, to apply bone graft if necessary to address palmar
515
PART comminution, and to repair the anterior capsular rent that
III typically coincides with the scaphoid fracture. The sequence
of joint reduction is identical to that described earlier.
15  Usually, bone reduction is better controlled from the dorsum
by using Kirschner wires as “joysticks.” If the fracture is to
Wrist

be stabilized with a headless compression screw, this can be

done from either approach. Many surgeons prefer freehand
insertion of the screw from the dorsal aspect of the proximal
pole aiming at the palmar-distal scaphoid tuberosity.
Different outcome studies using this open approach have
been published.6,20,39,45,57 According to Herzberg and Foris­
sier,45 the average Mayo wrist function score obtained at 8 I II III
years of follow-up in 14 transscaphoid perilunate dislocations A
treated with early surgery was 79 points, which is considered
a good outcome. Most authors agree that this approach
allows recovery of about 110 degrees of active flexion-
extension and 75% of grip strength. Most reports emphasize,
however, that fixation of the scaphoid alone is insufficient.
Very often, the bad results come from not having stabilized
the lunate triquetrum joint or from an ulnar translation of
the carpus. The worst results are found among more severely
displaced dislocations (stage IV), especially if treatment was
delayed for any reason.

Transscaphoid, Transcapitate Perilunate

Fracture-Dislocations
Since the landmark paper by Fenton29 in 1956, numerous
cases of the so-called scaphocapitate syndrome have been
reported.14,106 The injury consists of a variation of a greater
arc dislocation in which the scaphoid and the capitate are
fractured, the latter being displaced with the proximal pole
rotating 90 or 180 degrees. Although not fully understood,
the capitate fracture seems to be produced by direct impact
of the bone against the dorsal lip of the radius when the wrist
is hyperextended and ulnarly deviated. Rotation of the proxi­
B
mal fragment seems to occur secondarily, forced by the distal
fragment as it returns to the neutral position (Figure 15.52). Figure 15.52  A, Probable mechanism of fracture-dislocation of
Because radiographic interpretation of this injury may be the capitate as part of the scaphocapitate syndrome, popularized
confusing, films with the hand suspended in finger trap trac­ by Fenton.29 Extreme wrist hyperextension may result in
tion should be obtained routinely. The squared-off end of the impaction of the neck of the capitate against the dorsal lip of the
radius, causing its fracture (I). When the wrist is brought back
proximal capitate is easily seen in this view. Many of these
into neutral position, the roughened surface of the fracture may
fractures are not recognized at presentation, however. contribute to further displacement of the unconstrained proximal
Fenton29 advocated excision of the proximal pole of the pole of the capitate in a rotatory fashion (II). In some cases, the
capitate as primary treatment because he believed that avas­ subsequent axial compression may displace the proximal
cular necrosis and nonunion were inevitable. Rarely, the fragment further, which now appears fully (180 degrees) rotated
proximal capitate fragment may heal in its malrotated posi­ (III). B, Posteroanterior view of a wrist with scaphocapitate
tion, but this is the distinct exception, and numerous necrotic syndrome, with the proximal capitate fragment fully rotated, its
articular portion facing distally (arrow).
nonunions have been reported in patients treated nonopera­
tively. By contrast, most cases treated by open reduction
through a dorsal approach and internal fixation with Kirsch­
ner wires or screws healed uneventfully 2 to 6 months after using the techniques previously described. Transient avascu­
surgery.14 lar changes in the proximal pole of the capitate are common,
In comminuted cases, primary bone grafting may be indi­ but healing usually occurs. The overall long-term results after
cated. Vance and coworkers106 recognized six forms of dis­ open reduction and internal fixation have invariably been
placement and recommended that the first step in the good.
operative treatment be reduction and fixation of the capitate
fracture. The capitate is generally fixed with a headless screw. Transtriquetrum Perilunate
If capitate fixation is not done, the distal fragment of the Fracture-Dislocations
scaphoid tends to migrate medially, making its reduction and As previously explained, the third stage of Mayfield’s “pro­
stabilization difficult. It is equally important to achieve ana­ gressive perilunate instability” is defined by the occurrence
tomic reduction and stabilization of the scaphoid and lunate of lunate triquetrum dissociation. The lunate is constrained
516

A B
by the two strong radiolunate ligaments (long and short), and
a sudden extension moment is exerted by the dislocating
distal row via the triquetrum-hamate-capitate ligaments.
Such opposite forces usually result in rupture or avulsion,
from palmar to dorsal, of the lunate triquetrum ligaments. In
about a fourth of patients, instead of ligament derangement
there is either a sagittal fracture of the body of the triquetrum
or a proximal pole avulsion fracture, representing a ligament
detachment (Figure 15.53). During the open procedure, this
fragment should not be excised, but should be replaced care­
fully in its original position to ensure correct lunate trique­
trum ligament stability. The triquetrum is a well-vascularized
bone, and no cases of necrosis or nonunion have been pub­
lished after a wrist dislocation.
Late Treatment of Unreduced
Fracture-Dislocations
Despite increased awareness of their clinical and radiologic
features, diagnosis of perilunate dislocation is still frequently
missed at presentation (in 16% to 25% of the cases, accord­
ing to different series) resulting in chronic wrist dysfunction
and degenerative arthritis.50,86 Delay in treatment has repeat­
edly been found to be an important factor influencing the
long-term outcome of these patients. Although it is unclear
how late an open reduction can be accomplished, successful
cases have been reported 35 weeks after injury.18 This repair
generally requires dorsal and palmar approaches. The use of
wrist distraction with an external fixator for 1 week before
surgery seems to facilitate open reduction of old disloca­
tions.30,101 If the bones can be reduced and fixed anatomically,
satisfactory results can be expected. If reduction cannot be
accomplished, or if there is significant cartilage damage,
either a proximal row carpectomy or a total wrist arthrodesis
is indicated.50,86 The results of isolated excision of only the
lunate are uniformly poor.50
Palmar Perilunate Dislocations
Palmar dislocation of the capitate relative to the lunate is a
very rare injury, representing less than 3% of all wrist dislo­
PART
III
15 
Wrist: Carpal Instability
Figure 15.53  A and B,
Transscaphoid, transtriquetrum,
perilunate dislocation. In this case,
there is a sagittal fracture of the
triquetrum (arrow). The interosseous
lunate triquetrum ligaments are
probably intact.
cations.20,39 The dislocation may occur in association with a
fracture of the lunate in the frontal plane12,19 or as a result of
a progressive perilunate instability induced by a combination
of forced hyperflexion and supination of the wrist relative to
the radius.109 In the first case, the capitate subluxation is mild
and is the consequence of the dorsally displaced lunate frac­
ture (Figure 15.54). In these circumstances, closed treatment
is seldom effective, owing to the inherent instability of the
fracture. Open reduction using palmar and dorsal approaches
and internal fixation of the lunate fracture with wires or
screws is the method of choice.
In palmarly displaced perilunate dislocations without
lunate fracture, either SLD or scaphoid fracture is inevitably
present. The scaphoid fracture typically has a very unstable
vertical orientation in the frontal plane, making recognition
of fracture difficult on a standard posteroanterior view. The
diagnosis is most easily made on the lateral view. Reported
cases with concomitant rupture of extensor tendons suggest
that the mechanism of injury is violent. In acute injuries,
closed reduction using finger trap traction should be the
initial step in management. Although successful treatment
has been reported with closed reduction alone, these are
exceedingly unstable injuries; in most cases, the only reliable
way to realign and stabilize the scaphoid and perilunate
injury is operative treatment.19
Axial Fracture-Dislocations
When the palmar concavity of the carpus is involved in a
high-energy dorsal palmar compression (crush mechanism),
longitudinal disruption of the carpal arch may occur.34 In
most instances, the wrist splits into two axial columns, one
remaining normally aligned with the radius and the other
displacing in a radial or ulnar direction. The metacarpals
usually follow the displacement of their corresponding carpal
bones, causing an intermetacarpal derangement (Figure
15.55). As the carpal arch flattens, the flexor retinaculum
may either disrupt or avulse from its lateral insertions.
Because carpal derangement appears more or less parallel
to the long axis of the forearm, Cooney and associates20
517
PART
III
15 
Wrist
A B
Figure 15.54  Example of a rare translunate anterior dislocation of the wrist. A, Initial posteroanterior view could be easily
diagnosed as a static lunate triquetrum dissociation because the lunate shows the typical moonlike configuration. B, Careful
assessment of the lateral view shows the presence of a fracture of the palmar lip of the lunate and an anterior dislocation of the
distal row. C, Schematic representation of the sagittal view, demonstrating a capitate (C) subluxation relative to the fractured
lunate (L).
Figure 15.55  Perihamate, peripisiform axial-ulnar dislocation.
Vertical disruption involves the distal carpal row and the base of
the third and fourth metacarpals. The pisiform is ulnarly displaced
because it remains attached to the FCU tendon complex.
coined the term axial dislocation to describe these injuries.
Other descriptive terms, such as longitudinal disruption,
sagittal splitting, or intercarpal diastasis, may also be
appropriate.34
Axial dislocations are common in developing countries,
where safety measures for wringer-type machines, roller
presses, and molding presses are lacking. Because of the high
energy involved in production of injury, most patients present
with severe associated damage to the soft tissue, including
518
C
disruption of the flexor retinaculum and resulting traumatic
decompression of the carpal tunnel and nerve and vascular
injuries.
Two major groups of injuries have been described (Figure
15.56): axial ulnar dislocations and axial radial dislocations.
In the former, the carpus splits into two columns, with the
radial column aligned and stable with respect to the radius,
and the ulnar column unstable and displaced proximally and
ulnarly. In the latter, the ulnar part of the carpus remains
normally aligned with the radius, and the radial aspect of the
carpus is displaced and unstable.
When dealing with these complex fracture-dislocations, a
careful assessment of the associated neurovascular and mus­
culotendinous injury is necessary. A radical débridement of
devitalized muscle, subcutaneous tissue, and skin is critical.
Closed reduction and percutaneous fixation of the displaced
bones may be successful, but open reduction and Kirschner
wire or screw fixation has yielded more reliable results. A
dorsal approach to control bone reduction and an extended
palmar approach to assess the associated soft tissue injuries
are usually required. Repair of the damaged intercarpal liga­
ments is seldom possible because of the high energy of injury
and ligamentous shredding. In many instances, decompres­
sion of the carpal tunnel is unnecessary because the flexor
retinaculum has been disrupted or avulsed already by the
trauma. In case of doubt, however, inspection of the carpal
tunnel is recommended. Immobilization in a cast for 6 to 8
weeks, depending on the extent of injury, is advisable. Early
intensive physical and occupational therapy facilitate reha­
bilitation. The long-term results are not good, in most part
because of the associated tendon and neurovascular
involvement.34
In less severe dorsal palmar compressions of the carpal
concavity, complete rupture of the transverse intercarpal
ligaments between bones of the distal row may occur. If not
properly healed, these patients may complain of localized
discomfort and lack of stability at the dissociated site. These
cases have been categorized as dynamic axial instabilities96

Peri-trapezoid Peri-trapezium
A Peri-trapezium B C
Trans-hamate Peri-hamate
D Peri-pisiform E Peri-pisiform F Trans-triquetrum
and usually respond well to a localized partial intercarpal
fusion.
Isolated Carpal Bone Dislocations
When a localized, direct or indirect force is concentrated
over a single bone of the wrist, the resulting pressure may
be sufficient to cause a localized fracture-dislocation.12,47,48
Although rare, each carpal bone has been reported to be
dislocated. In contrast to axial disruptions, isolated carpal
bone dislocations do not imply a global carpal derangement.
Actually, except for the lunate and scaphoid, the carpal dys­
function created by removing the enucleated bone seems to
be well tolerated. Following is a review of the special features
of only individual carpal bone dislocations with more than
10 cases reported in the literature.
Dislocation of the Scaphoid
Palmar dislocation of the scaphoid is a rare injury, with less
than 30 cases having been completely detailed in the litera­
ture.34 Two clinical forms have been reported: isolated antero­
lateral dislocation of the proximal pole of the scaphoid (type
I), and scaphoid dislocation associated with an axial derange­
ment of the capitate-hamate joint (type II) (Figure 15.57).
PART
III
15 
Wrist: Carpal Instability
Figure 15.56  Schematic
representation of the most
frequently reported axial fracture-
dislocations. A-C, In axial-radial
Trans-trapezium dislocations, there is an unstable
segment displacing in a radial
direction. D-E, The opposite
instability is seen among the
axial-ulnar derangements. (From
Garcia-Elias M, Dobyns JH, Cooney
WP III, et al: Traumatic axial
dislocations of the carpus, J Hand
Surg [Am] 14:446-457, 1989.)
Peri-hamate
The most probable mechanism of type I injuries involves
a violent hyperpronation injury to an extended and ulnarly
deviated wrist, causing SLD first, followed by the enucleation
of the proximal pole of the scaphoid around the radioscaph­
oid-capitate ligament. These injuries also could be the result
of a self-reduced palmar perilunate dislocation, the scaphoid
having been left unreduced by capsular interposition. Type
II injuries are theorized to involve a high-energy axial com­
pressive load along the third and fourth metacarpals, creating
enough shear stress to the capitate-hamate joint to disrupt its
strong ligament attachments. None of these mechanisms has
been proved, however.
Diagnosis of the condition is straightforward. An abnormal
bony prominence adjacent to the radial styloid has frequently
been described. In posteroanterior and lateral views, the
proximal scaphoid appears enucleated forward and outward,
whereas its distal end remains attached to the trapezium. In
type II dislocations, there is also a proximal migration of the
capitate and an obvious derangement of the capitate-hamate
joint.
Closed reduction is easily accomplished by traction and
direct manual pressure in most cases treated acutely, all
with good results. More recent publications have advocated
519
PART
III
15 
Wrist
Figure 15.57  Anterolateral dislocation of the scaphoid, type I
(without concomitant hamate-capitate axial-ulnar dislocation).
(Courtesy of F. Urraza, Rosario, Argentina.)
an open reduction through a dorsal approach, however.
Avascular necrosis of the scaphoid has not been reported.
Dislocation of the Trapezium
Most reported cases of trapezium dislocation could be
described as peritrapezium axial-radial dislocations; that is,
the trapezium appears displaced together with the first meta­
carpal (Figure 15.58). By contrast, complete enucleations
with proximal and distal joint disruption are very rare, and
are usually the result of a blow to the dorsolateral aspect of
the wrist or the consequence of a hyperextension-supination
injury to the radial-deviated wrist. Although some reported
cases were openly reduced,47 excision seems to be a reason­
able solution, as shown by the many instances that trapezi­
ectomy alone has been done for the treatment of
trapeziometacarpal arthritis with good patient satisfaction.
Dislocation of the Trapezoid
Most trapezoid dislocations described in the literature
manifested with a concomitant displacement of the second
metacarpal. According to a literature review by Inoue and
Inagaki,48 only 20 complete dislocations of the trapezoid
have been reported, 13 of which were isolated extrusions of
the bone without other associated fractures or dislocations of
adjacent bones. Five of these were palmar dislocations, with
one having caused an attritional rupture of flexor tendons.
There is no clear explanation as to how a wedge-shaped bone
(wider dorsally) dislocates palmarly. It is plausible that a
direct blow, associated with hyperextension of the midcarpal
joint, is involved. Successful closed reduction of the dislo­
cated bone was achieved only in dorsal dislocations. Most
cases resulted in a localized fusion with acceptable results.
520
Figure 15.58  Dislocation of the trapezium (arrow) is often
incomplete, and it remains attached to the base of the first
metacarpal. When this occurs, the case should be categorized as a
peritrapezium axial-radial dislocation.
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