453414

2012
JHS38710.1177/1753193412453414Short report lettersJournal of Hand Surgery (European Volume)

Short report letters

JHS(E)
The Journal of Hand Surgery

Letters to the Editor (European Volume)

38E(7) 805­–810
jhs.sagepub.com
Short Report Letters

A modified dorsal capsulotomy for

improved radiocarpal exposure
Dear Sir,

The dorsal approach to the wrist is well established

and the ligament splitting technique described by
Berger et al. (1995) is commonly used. This approach
splits the oblique dorsal radiolunotriquetral (DRLT)
and the transversely orientated dorsal intercarpal
(DIC) ligaments, raising a radially based flap that can
be reliably repaired. In order to access the ulnocarpal
joint and the ulnar corner of the radiocarpal joint,
an additional ulnar and proximally based flap is
described. The combination of these flaps (Figure 1)
allows excellent surgical access to the wrist and car-
pus, however, access to the most radial part of the
wrist, particularly the scaphotrapezial-trapezoid joint
and radial styloid, may remain difficult (Berger and
Bishop, 1997). We describe a modification of this clas-
sic dorsal capsulotomy to allow improved access to
the radiocarpal joint and the whole of the mid-carpal
joint. This has been used by the senior author rou-
tinely over the past seven years and allows excellent
exposure of the wrist and carpus.
We routinely use a longitudinal incision over the
wrist and carpus. Once the routine exposure to
the capsule is completed, it is often the case that the
dorsal ligaments may not be clearly defined and Figure 1. Line drawing of Berger’s dorsal capsulotomy
their localization is, therefore, assisted by key land- showing standard incisions for radiocarpal access marked
by a solid line and an additional capsulotomy for ulnar-sided
marks. The DRLT ligament passes from the dorsal
access using a dotted line.
rim of the distal radius, ulnar to Lister’s tubercle, to DIC: dorsal intercarpal ligament; DRLT: dorsal radiolunotriquetral
the triquetrum. It traverses the lunotriquetral joint ligament; DRU: dorsal radioulnar ligament; LT: Lister’s tubercle.
and its deepest fibres blend with this and the dorsal
surface of the lunate. The DIC ligament is usually
more obvious. It passes from the dorsal and distal dorsal margin of the distal radius and is completed
ridge of the scaphoid and/or scaphotrapeziotrape- distally and longitudinally along the radial border of
zoidal joint to the trapezoid and triquetrum, crossing the distal radius and scaphoid. The exact posi-
the mid-carpal joint. tions of the capsulotomies over the distal radius are
A distally based flap is raised by splitting the chosen so that a cuff of tissue is left for subsequent
fibres of the DRLT ligament creating a full thickness repair of the capsule (Figure 2). This usually lies in
capsulotomy, but taking care not to injure the under- the bed of the second extensor compartment or
lying scapholunate and lunotriquetral ligaments. between the first and the bed of the second extensor
This capsulotomy is extended radially along the compartments. Stay sutures may be inserted into

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806 The Journal of Hand Surgery (Eur) 38(7)

scaphoid non-union surgery and scapholunate

advanced collapse reconstruction. This improved
exposure results from a broader distally based
capsulotomy that might be expected to also have
better vascularity. In this modified capsulotomy,
the DIC ligament is preserved uninjured and the
DRLT ligament is split in the midline allowing
repair. Both ligaments are thought to contribute to
carpal stability, and while they can be repaired,
we have found that it is unnecessary to injure both
in order to achieve good exposure and a reliable
repair.
If additional exposure is required to the ulno-
carpal joint, we are able to augment our modified
capsulotomy with the classically described ulnar-
sided approach shown in Figure 1. In our experi-
ence this is only required for specific distal ulnar
and distal radioulnar joint pathology and not to
address the ulnar corner of the distal radius,
which is typically well exposed using our modified
technique.
This modified technique follows the established
and sound principles advocated by Berger et al.
(1995) for a safe capsulotomy that can be repaired
reliably: the use of identifiable landmarks to aid
incision; ligament splitting techniques to allow the
repair of stout tissue; and ligament preservation
where possible. We commend this as an alternative
Figure 2. Line drawing of modified distally based dorsal capsulotomy for exposure of the wrist and
capsulotomy. carpus, particularly where access to the most
DIC: dorsal intercarpal ligament; DRLT: dorsal radiolunotriquetral radial aspect of the wrist or mid-carpal joint is
ligament; LT: Lister’s tubercle.
required.

the margins of the flap if required. Closure is Conflict of interests

achieved by simply laying the flap back into place. None declared.
We use interrupted absorbable 4-0 Polydiaxonone
sutures to repair the split fibres of the DRLT References
ligament and to tack the other capsular edges into Berger RA, Bishop AT, Bettinger PR. A new dorsal capsul-
place without tension. otomy for the surgical exposure of the wrist. Ann Plast
In the standard Berger technique radial exposure Surg. 1995, 35: 54–9.
beyond the dorsal ridge of the scaphoid is not Berger RA, Bishop AT. A fiber-splitting capsulotomy
advised so as to avoid injury to the predominant technique for dorsal exposure of the wrist. Tech Hand
radial and dorsal blood supply at the dorsal scaph- Up Extrem Surg. 1997, 1: 2–10.
oid ridge (Berger and Bishop, 1997). To our knowl-
edge, this complication has not been reported, and R. E. Anakwe, S. D. Middleton and M. J. Hayton
limiting the capsulotomy to the ulnar side of the Upper Limb Unit, Wrightington Hospital, Wigan, UK
dorsal scaphoid ridge can make access to the distal Email: raymundus@doctors.org.uk
scaphoid and most radial part of the wrist and
mid-carpal joint difficult. Our modified capsulotomy
allows distal retraction of the flap and improved
access to these areas.
This exposure allows excellent visualization © The Author(s) 2012
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