TFCC tears

SL instability

Dorsal wrist ganglion

Scaphoid fracture with percutaneous pinning

Distal radius fracture






Finger Traps Index & middle


Overhead traction device


Wrist Scope set up


2.7 mm scope / small joint instrumentation

- insufflate with saline first at 3-4


Wrist Scope Insufflation


Radiocarpal Joint


RCJ is U shaped


Portals are between extensor compartments

- longitudinal incisions to protect extensor tendons

- blunt dissection to preserve SRN branches

- angle 30o volar due to shape distal radius


Wrist scope portalsWrist scope radiocarpal portal


3-4 Portal

- feel Lister's tubercle

- 1 cm distal is soft spot between 3 and 4

- between distal radius and scapholunate

- primary viewing portal


4-5 Portal

- roll finger over mobile 4th compartment

- feel soft spot

- slightly proximal to 3-4 because of slope of radius

- between distal radius and lunatetriquetral

- instrumentation


6-R and 6-U

- Named after their position about ECU

- 6-R working

- 6-U inflow


Midcarpal Joint




MCJ is S shaped

- midcarpal & radiocarpal have separate synovial cavities unless the SLL is torn


Midcarpal radial / MCR Portal

- 1 cm distal to 3/4 portal

- radial side of the third metacarpal axis 

- in line with Lister's tubercle

- soft depression between the capitate and scaphoid

- working portal


Midcarpal ulna / MCU Portal

- 1 cm distal to 4/5 portal

- in line with 4th metacarpal

- distal to lunate-triquetral joint

- proximal to capitate and hamate


Wrist scope portalsWrist Scope Midcarpal Scope


Radiocarpal Joint


Start at radial styloid and scaphoid

- work radial to ulnar


Distal radius


RSC Ligament

- immediately beside is Long RLL

- is extremely wide usually x3 RSCL

- next is short RLL

- often see blood vessels along this ligament


Scapholunate ligament

- examine from membranous prox portion to thicker dorsal ligamentous portion


Wrist scope SL Ligament Radiocarpal joint




Follow ulnarly along lunate and its fossa 

- should be taut like a trampoline 

- actual ballottement with probe should give same feeling 

- trampoline test


Wrist Scope TFCC


Examine for tears 

- central or peripheral

- ulnar styloid recess is normal finding at base of styloid not a tear


Lunate chondromalacia


Midcarpal joint


Curved of head of capitate


Wrist scope midcarpal joint


SL joint


Wrist scope midcarpal joint SL jointWrist scope Midcarpal Joint Normal SL ligament


Lunate-triquetral joint


Wrist Scope Midcarpal Normal Lunate Triquetrum


Specific Conditions


Carpal Instability


SL and LT Ligaments

- must look from radiocarpal and midcarpal joints

- both joint ligaments should be tight and concave

- if inflow in RCJ with midcarpal outflow have tear in ligament


Arthroscopic classification


1.  Attenuation or haemorrhage within ligament

- no step

- can debride partial tears with good results

- Rx cast immobilisation


II. Incongruency or step-off in midcarpal space

- Use k-wire as joy stick to reduce

- treat with arthroscopic pinning

- 80% reported good results


III. Step-off on both sides

- pprobe may be passed between bones

- treat with arthroscopic or open repair


IV. Gross instability

- open repair


TFCC Injuries


Use 4-5 portal as visual portal and 6-R as working portal



- degenerative or traumatic

- central or peripheral

- with or without DRUJ instability

- without or without chondromalacia

- radial or ulnar avulsions

- +/- Styloid fracture




Debride central tears acute or degenerative


Attempt repair of peripheral tears


Unstable DRUJ

- reinforce DRUL or PRUL with strip of ECU


Degenerative tear and ulnar plus 

- add ulnar shortening to debridement

- can perform arthroscopic wafer procedure

Base of Thumb OA



Degenerative arthritis at trapeziometacarpal joint (CMC)

- trapezoid - metacarpal




Commonest hand joint involved in OA 


Most common in older women                                      

- 90% are females > 50 years                                                

- asymptomatic degenerative changes common


Associated with arthritis in scapho-trapezial joint in 50%




1.  Trapeziometacarpal Joint (TMJ)

2.  Scaphotrapezial Joint (STJ)

3.  Trapeziotrapezoidal Joint

4.  Trapezium - Index Metacarpal Joint


The last two joints are rarely involved with OA


Saddle shaped

- allows movement in 3 planes

- flexion / extension

- adduction / abduction

- opposition


Volar, palmar oblique "beak" ligament

- provides stability of TMT

- origin is volar tubercle trapezium

- insertion ulna base of MC

- resists dorsal subluxation


Palmar 1/2 loaded > dorsal

- 13 x pressure with pinch






Combination of                                                                

- high compressive loads                                          

- relatively unstable joint                                              

- complex range of movement


May be related to ligamentous laxity





Rheumatoid arthritis                                              




Eaton Classification


Stage 1 


Joint normal with synovitis 


Stage 2 


Joint space narrowed                                                    

- may be mild subluxation (< 1/3) 


CMC OA Stage 2


Stage 3 


Joint space obliterated                                                


Subluxation base of thumb

- adducted position

- proximally is anchored by adductor pollicis

- base subluxes radially / beak ligament ruptured


CMC OA Stage 3


Stage 4 


Involvement of multiple joint surfaces especially STT joint


CMC OA Stage 4CMC OA Stage 4




Pain at base of thumb especially with pinch grip 


Becomes constant / difficulties with ADL 


Stiff thumb 


Weak pinch grip




Base of Thumb OA


Tenderness around CMC joint


Swelling from 

- synovitis 

- osteophytes 


Positive grind test 

- passive thumb circumduction and axial loading 

- causes pain 


Web space contracture

- fixed flexion-adduction contracture of 1st MC 

- compensatory MCPJ extension




De Quervain's

Radiocarpal OA


Scaphoid nonunion

Carpal tunnel syndrome 

FCR synovitis 

Volar ganglion

SRN neuroma




Nonoperative Management


Majority of patients do not require surgery




Rest / static splinting / thumb spica


Oral analgesics and NSAIDS


Intra-articular steroids / US guided


Operative Management


1.  Reconstruction of the volar ligament



- stage 1 disease

- non responsive to non operative management



- minimises progression of degenerative changes



- reconstruction of the volar ligament with slip FCR

- tendon passed through MC base and trapezium 

- create stabilising ligament (tenodesis) 


2.  CMC Arthrodesis



- stage II and III disease 

- young manual workers 

- ligamentous laxity and neurological conditions



- pantrapezial OA

- i.e. involvement of STJ



- pain-free 

- strong pinch 

- allows heavy use




1.  Limits mobility of thumb MC 

- loss of abduction / adduction

- unable to put palm flat on table


2.  Increases stress on adjacent joints 



- thumb position when fist made 

- 30-40o palmar abduction 

- 10-15o radial abduction



- dorsal incision at base of thumb over CMCJ

- dorsal to APL, between EPL and EPB

- protect SRN

- protect radial artery as it passes dorsally over STJ

- transverse incision capsule

- cut articular surfaces with saw

- ensure can pinch grip with IF / MF

- ensure can place across palm

- headless compression screws / plate

- POP for 6 weeks


3.  Hemitrapeziectomy


Removal of distal half of trapezium only


4.  Excisional arthroplasty / trapeziectomy


Thumb Trapeziectomy



- stage II & III disease

- no significant MC subluxation



- simple excision of trapezium



- simple procedure 

- minimal immobilisation



- shortening of thumb ray 

- weakness of pinch 

- thumb adduction



- trapeziectomy without interposition / ligament reconstruction

- no evidence has worse results than any other more complicated procedure


5.  Trapeziectomy and LRTI



- stage III and IV disease 



- trapeziectomy +

- ligament reconstruction of beak ligament with FCR / PL

- tendon interposition (FCR / PL / Capsule)


Supposed Advantages

- maintains strength / pinch grip

- prevents shortening



- tendon harvest

- longer / more involved procedure

- no evidence of improvement of pinch grip / prevention of shortening





- dorsoradial

- junction of volar and dorsal skin



- protect SRN

- between APL and opponens

- radial artery over ST Joint 

- open capsule over trapezium 

- elevate thenar muscles from trapezium and 1st MC 


Excise trapezium 

- remove bone piecemeal / or in one piece 

- take care not to damage underlying FCR 


LRTI Technique 1


Make hole in base of MC 

- perpendicular to plane of thumbnail 

- from radial cortex to base 


Harvest lateral half FCR

- 10 - 12 cm strip

- 2 - 3 transverse incisions in forearm over FRC

- split all the way to base of second MT

- pass through base second MT then radial cortex

- pass around base to resurface

- suture to itself whilst pushing MC base medially


Make spacer 

- anchovy tendon on itself 

- insert it into trapezium fossa 


Stabilise with K wire

- MC reduced and out to length


Close wound & apply thumb spica 



- ROS and K wire at 10 days 

- splint for another 3 weeks 

- progressive exercises


LRTI Technique 2


Harvest PL

- leave attached distally

- pass into base of thumb under FCR to where trapezium used to be

- ligament suspension by passing through radial capsule and FCR multiple times

- tightens the capsule and FCR into the gap


Capsular interposition technique


Open capsule as a distally base flap

- after trapeziectomy suture into base of wound as interposition



- > 90% satisfactory results long-term 

- > 95% pain relief

- > 90% increased grip strength

- average loss of height is 13% at 9 years


6.  Silicone replacement arthroplasty



- stage III and IV disease 

- low-demand patient

- rheumatoid



- trapeziectomy

- insert silicone trapezium



- retains movement at CMC joint



- subluxation or dislocation 

- prosthesis breakage (50% at 4 years) 

- silicone synovitis 



- address subluxation by soft tissue reconstruction 

- strip of APL can be passed through hole in prosthesis 


7.  Joint replacement


High revision rate

- pain

- lysis

- loosening


Carpal Instability




Loss of normal ligamentous and / or bony constraints of wrist




Overall alignment maintained by extrinsic and intrinsic  ligaments


1.  Intrinsic ligaments


Carpal bone to carpal bone

- support the lunate in a balanced position


A.  Scapho-lunate ligaments


SL ligament can be divided into three different zones

- dorsal ligamentous zone (structurally the most important)

- palmar ligamentous zone 

- proximal membranous fibrocartilaginous zone


B.  Luno-triquetral ligaments 

- also 3 components

- volar most strong


2.  Extrinsic Ligaments


Radius to carpus 

- obliquely oriented

- resist the tendency of the carpus to migrate ulnarly and palmarly


A.  Palmar extrinsic ligaments


A. Radioscaphocapitate ligament

B. Radiolunate ligament

C. Radioscapholunate ligament

- probably just a vascular fold

D. Ulnocarpal ligaments

E. Lunotriquetral ligament


Space of Poirier

- weak area of the palmar ligaments


B.  Dorsal Extrinsics


A. Dorsal radiotriquetral ligament / Dorsal radiocarpal ligament (DRC)

B. Dorsal radioulnar ligament

C. Triquetroscaphoid ligament / Dorsal intercarpal ligament (DIC)


No tendons attach to proximal row



- acess to dorsal carpus

- raise a radially based flap

- between radiotriquetral and triquetroscaphoid

- between DRC and DIC






Capitate is centre of rotation


Flexion / Extension

- 120o

- 50% midcarpal

- 50% radiocarpal


Radial / ulna deviation

- 60% midcarpal

- 40% radiocarpal


Radial deviation

- 20o

- proximal row and scaphoid flexes


Ulnar deviation

- 30o

- proximal row and scaphoid extends


Load transfer


Radius 80%

Ulna 20% (all via TFCC)




Division of the scapholunate ligament 

- allows the lunate to follow the triquetrum's unrestrained position of extension

- dorsal intercalated segmental instability pattern (DISI)

- scaphoid flexes, lunate extends


Lunotriquetral ligament disruption 

- allows the lunate to follow the scaphoid into its position of unrestrained flexion

- lunate flexes

- volar intercalated segmental instability pattern (VlSI)


Classification of Carpal Instabilities (Amadio)


I. Carpal instability dissociative (CID)


Transverse injury


Injury inter-osseous ligaments

- within the carpal rows

- disassociative rather than associative motion between the bones of each row


A.Dorsiflexion (DISI)

- scapholunate ligament injury


B. Palmar flexion (VISI)

- triquetrolunate injury


II. Carpal instability non-dissociative (CIND)


Transverse injury


Normal associative motion between the bones of each carpal row 

- the dissociation is between rows


A. Radiocarpal Dislocation


CIND Dislocated Radiocarpal Joint APDislocated Radiocarpal Joint lateral


Radiocarpal Dislocation CT 1Radiocarpal Dislocation CT 2Radiocarpal Dislocation CT 3


B. Midcarpal


C. Ulnar Translocation




Secondary to radial malunion

- treat with radial osteotomy if symptomatic


DISI CIND Secondary Radial Fracture




Secondary to ligamentous laxity

- non operative treatment

- no progression to OA


Whole proximal row is flexed

- lunate triangular

- scaphoid cortical ring sign

- no SL disassociation


III. Carpal instability complex (CIC)


Hyperextension injury


As the hand is forced into hyperextension

- ulnar deviation and intercarpal supination

- the ligamentous disruption


Mayfield Cadaver study 

- extend, ulna deviate, supinate


Stage 1 

- SL dissociation 


Stage 2

- CL dissociation 

- capitate dislocates


Stage 3

-  LT dissociation


Stage 4

-  Lunate dislocates




A. Perilunate Dislocation

1. Dorsal (10%)

2. Volar (90%)


B. Trans-scaphoid Perilunate


IV. Carpal instability longitudinal (axial)


Longitudinal injury


The carpus may also be disrupted in a longitudinal fashion, as opposed to the perilunate transverse pattern




A.  Axial Ulnar (AU)

B.  Axial Radial (AR)

C. Axial Ulnar-Radial (AUR) / Combined


These are severe injuries

- crush, blast or compression

- may be open injuries

- not a diagnostic dilemma


Usually wrist is split into two columns

- metacarpals follow their corresponding carpus




Deal with wounds and nerve / tendon injuries


K wire fixation


Greater and Lesser Arc Injuries


Greater arc injury

- fracture-dislocation of the scaphoid, capitate, hamate, triquetrum

- may include radial styloid


Lesser arc injury 

- a pure ligamentous injury

- around the lunate






Radiocarpal & Midcarpal Dislocation

A. Radiocarpal Dislocation


Dislocated Radiocarpal Joint Dislocated Radiocarpal Joint AP


Dislocated Radiocarpal Joint CT 1Dislocated Radiocarpal Joint CT 2Dislocated Radiocarpal Joint CT 3


Dorsal Radiocarpal Dislocation ORIF 1Dorsal Radiocarpal Dislocation ORIF 2


B. Midcarpal Dislocation



SLAC Wrist


SLAC Wrist


Scapho-lunate advanced collapse

- caused by malalignment of scaphoid on radius

- due to scapholunate disruption


Most common cause of wrist OA




1.  Radio-scaphoid degenerative changes

- from abnormal flexion of scaphoid

- scaphoid fossa is elliptical causing incongruence with flexion of proximal scaphoid

- loads scaphoid fossa of radius peripherally


2.  Radiolunate joint preserved

- lunate fossa and proximal lunate spherical and congruent


3.  Capitate under increasing load descends into gap

- increasing loads on capitolunate joint

- separation of scaphoid and lunate

- capitate shears off radial edge of lunate

- get destruction on both lunate and proximal capitate 




OA radio-scaphoid joint

Preservation of radiolunate joint




1.  Styloid OA


Stage 1 SLAC Radial Styloid OA


2.  Scaphoid Fossa OA




3.  Lunato-capitate OA

- capitate descends in SL gap


SLAC Lunate Capitate OA


4.  Pancarpal OA





- preservation of scaphoid fossa and proximal scaphoid congruence

- arthritis at scapho-capitate joint




Stage 1



- styloid OA

- degeneration between the radial styloid and distal pole scaphoid




1.  Styloidectomy

- early disease can respond well to styloidectomy

- remove at level A / no removal of scaphoid fossa


2.  Scapholunate Reconstruction 


A.  Excise fibrous tissue and insert SL screw

- fibrous ankylosis

- remove screw at 12/12


B.  Bone blocks with ligament


Stage 2 



- scaphoid fossa OA

- OA extends to involve scaphoid fossa and proximal pole scaphoid




A.  Scaphoidectomy & four corner fusion

B.  Proximal Row Carpectomy


Scaphoidectomy & Four Corner Fusion


Scaphoidectomy and 4 corner fusion



- fusion of lunate to capitate

- loading is through normal lunate fossa

- fusion of lunate-capitate can be difficult

- add hamate and triquetrum in so called 4 corner fusion

- greatly increases fusion rates

- seemingly no deleterious effects

- if leave out scaphoid replacement tends to drift into radial deviation

- can use scaphoid for bone graft (but may not be high quality)



- increased stability comared with PRC

- increased ROM compared with total wrist arthrodesis



- universal posterior approach

- base of EPL (3/4 interval)

- can use Lister's tubercle for BG

- make window on radial side so as not to get late rupture of EPL

- denervate wrist / remove terminal branch PIN

- ligament sparing exposure / open capsule between dorsal intercarpal and radiocarpal

- closure ER under EPL at end of case



- resect scaphoid

- denude surfaces of lunate / capitate / hamate / triquetrum

- use good quality BG from distal radius

- must reduce the lunate out of extension or will impinge dorsally


Scaphoidectomy 4 corner Fusion APScaphoidectomy 4 corner Fusion Lateral



- headless compression screws

- dorsal circular plate

- K wires



- strength 75-80% normal

- ROM 40 - 60% of normal


B.  Proximal row carpectomy


Proximal Row Carpectomy



- for capitate to articulate with distal radius



- proximal capitate often devoid of good cartilage

- discard good lunate cartilage

- weakness ensues due to lengthening of tendons

- reported pain / instability / degeneration



- probably best in low demand patients

- not in stage 3 SLAC



- perform through standard dorsal approach



- RCT of 4 corner fusion v PRC are comparable


Stage 3 




Capito-lunate OA 

- capitate migrates proximally between the scaphoid and the lunate




A. Scaphoid excision & 4 corner fusion

B. Proximal Row Carpectomy

C. Wrist Arthrodesis



- PRC may be bad options in stage 3

- they depend on the capitate and by definition the capitate is arthritic


Stage 4




Collapse / pancarpal OA




Wrist arthrodesis



Scapholunate Ligament Injury / DISI

Scapholunate Disassocation




Dorsal Intercalated Segmental Instability / CID




Scapholunate joint

- C shaped

- 2-3 mm thick dorsally with transverse fibres

- thin palmar


Dorsal extrinsic ligaments

- V shaped, onto trapezium


1.  Dorsal RC ligament / DRC

- radius to triquetrum


2.  Dorsal Intercarpal Ligament / DIC

- trapezius to scaphoid


Between these two ligaments is access to SL joint


Volar extrinsic ligaments



- ligament of Testut




Most common form of carpal instability







- SL diastasis



- positive Kirk Watson test

- nil SL diastasis without dynamic / stress imaging



- secondary to radial malunion

- adaptive posture of proximal row

- lunate extends

- capitate translates dorsally and get OA

- treat with radial osteotomy if symptomatic






Scapholunate dissociation

- Mayfield Stage 1


Wrist extended / ulna deviated / supinated

- capitate driven into interval between scaphoid and lunate




CID (Complex Instability Dissociative)

- disassociation between scaphoid and lunate

- Palmarflexion of scaphoid

- dorsiflexion of lunate


The scaphoid will move into flexion

- due to its ligamentous attachments to the distal carpal row


Lunate extends

- due to ligamentous attachment to triquetrum




History of injury 

Pain on radial side of wrist 

Weakness of wrist 


Certain movements may cause clicking or snapping




DR / scaphoid fracture




STT, wrist, RC OA




Swelling and tenderness over SLJ

- most specific 


Pain with dorsiflexion and radial deviation


Kirk-Watson test 


Kirk Watson Test 1Kirk Watson Test 2


1.  Passive wrist ulnar deviation

- thumb on dorsum wrist / index finger on scaphoid tuberosity 

- in wrists with instability, the scaphoid is displaced dorsally over the lip of the radius


2.  Passive wrist radial deviation 

- the scaphoid's proximal pole returns to its position in the scaphoid fossa of the radius 

- as the scaphoid reduces, a clunking sensation and wrist pain are noted


1000 randomly examined wrists 

- 11% had unilateral, asymptomatic increased scaphoid mobility on KW test


Patients with dynamic instability are distinguished by

- symptoms of instability and pain with KW test




Look for signs of SLAC wrist

- degenerative changes of scaphoid fossa with relative sparing lunate fossa

- indicates long standing




Terry Thomas sign 

- increased scapholunate interval 

- > 3 mm compared with other side


Scapholunate diasstasis


Stress views

- bilateral wrists clenched 

- in ulnar deviation 

- in radial deviation 

- may show Terry Thomas sign


Cortical Ring sign 

- end-on view of cortex of distal pole of scaphoid


Scapholunate Disassocation Cortical Ring Sign


Scaphoid shortened

- due to palmar flexion


SL injury shortened scaphoid




Palmarflexion of scaphoid 


Dorsiflexion of lunate 


Increased scapholunate angle 

- > 70o

- usually 30 - 60o


Scapholunate Angle IncreasedScapholunate Angle IncreasedIncreased Scapholunate Angle


Increased luno-capitate angle

- normally < 10o


Scapholunate Injury Increased Lunate Capitate AngleIncreased Scapholunate Angle


Increased radio-lunate angle

- normally < 10o

- lunate extended > 10o




Can demonstrate tear

- need experienced radiologist

- need MRI in correct plane

- sensitivity may be as low as 40%




Best method of diagnosis

Gold Standard


Acute Management




Within 3-6 weeks





- immobilise 6 / 52



- SL diastasis

- usually torn off scaphoid

- repair





- dorsal midline approach

- 3 / 4 interval (3rd and 4th extensor compartments)

- open capsule between DRC and DIC ligaments

- radially based flap



- K wires into scaphoid and lunate

- use as joystick to reduce

- extend scaphoid, some flexion of lunate

- K wire fixation to hold in place (SL and SC x 2)

- neutralises rotational forces during healing



- micro anchors ain scaphoid

- or can place drill holes in scaphoid to pass sutures

- 2.0 ethibond


+ / - Augmentation

- Blatt capsulodesis

- SL screw / pseudoarthrosis


Post op

- 8 weeks POP

- remove K wires

- patient will lose some ROM






> 12 weeks 




Failed reconstruction / missed injury


Failed Scapholunate Reconstruction


Surgery only for significant disability 

- no reconstructive technique excellent

- inconsistent results, loss of reduction, loss of pain relief over time




Ligament repair

Ligament reconstruction

Blatt capsulodesis

Reverse Blatt capsulodesis

Brunelli Tendodesis

Limited wrist fusion


1.  Ligament repair and capsulodesis


Sufficient tissue available for repair

Reinforce with Blatt capsulodesis


2.  Ligament reconstruction


Scapholunate Ligament Reconstruction APScapholunate Ligament Reconstruction Lateral


3.  Blatt Capsulodesis



- chronic DISI with insufficient tissue for repair

- to augment ligament repair

- dynamic instability



- dorsal, proximally based capsular flap 1 cm wide

- reduce scaphoid out of flexion and K wire (SL / SC)

- suture anchor distal pole scaphoid and attach capsular flap

- prevents flexion of scaphoid

- may combine with SLL reconstruction with PL


Post op

- plaster for 2/12

- removal K wires


The patients end up with a stiff wrist


4.  Reverse Blatt



- leave capsule attached distally

- advance proximally

- limits wrist flexion


5.  Brunelli Wrist Tenodesis


Harvest half FCR

- pass volar to dorsal through hole distal scaphoid

- insert dorsally into distal radius

- serves to derotate scaphoid


6.  Limited fusion 


Radial styloidectomy and STT fusion



- stabilise scaphoid in extended position


Kleinman J Hand Surg Am 1998

- no progression of arthritis seen in 16 wrists






Volar Intercalated Segmental Instability

- secondary to injury to the lunate-triquetral ligament




Less common




Caused by fall on outstretched extended wrist

- hypothenar eminence strikes ground first 

- isolated LT ligament injury


Can be part of perilunate dislocation

- SL heals

- residual LT laxity




LT ligament

- also C shaped

- strongest palmar





- scaphoid imparts a flexion moment on proximal row

- triquetrum imparts an extension moment

- balanced by ligamentous attachments to lunate


Palmarflexion of lunate with dorsiflexion of triquetrum


Probably need injury to dorsal extrinsics to impart static collapse

- DRC ligament (radio-triquetral)

- ulnocarpal ligament












Secondary to ligamentous laxity

- seen in teenage girls

- clunk on radial and ulna deviation with axial compression


Whole proximal row is flexed

- lunate triangular

- scaphoid cortical ring sign

- no SL disassociation


Non operative treatment

- no progression to OA




History of injury 


Pain on ulnar side of wrist 


Weakness of wrist




Swelling and tenderness over triquetro-lunate joint 


Ulna deviation / pronation / axial compression

- pain and clicks


Reagan Ballotment 

- Triquetro-lunate ballottement

- pisiform-triquetral with thumb and index finger

- lunate with other hand


Lunate Triquetral Ballotment




DRUJ instability

TFCC tear

Ulna head OA

Pisiform triquetral OA

Hamate fracture

ECU subluxation


AP Xray


Palmarflexion of scaphoid 

- Scaphoid shortened 

- Ring sign 


Palmarflexion of lunate 

- Appears triangular 

- Triquetrum distally displaced 


Broken Shenton's line (of proximal carpal row)


Lateral Xray


Decreased scapholunate angle 

- < 30o


Palmarflexion of lunate 

- capitate - lunate angle > 10o

- radio - lunate angle > 10o




Diagnostic and therapeutic








A.  Repair

- dorsal approach

- restore LT orientation with K wires

- repair ligament with intra-osseous sutures


B Reconstruct with ECU

- if insufficient ligament for repair

- radial half of ECU

- pass through drill holes




> 6 weeks 


Lunate-triquetral fusion

- very difficult

- high failure with k wires

- need compression screws

- insert bone graft



DDx Radial wrist pain



De Quervain tenosynovitis


G   Ganglion - volar 


W  Wartenberg's Syndrome (Compression Superficial Branch Radial nerve)

R   Radial artery thrombosis

I    Intersection syndrome (ECRL/B crossed by APL & EPB)

S   Scaphoid fracture / non-union / SL instability / SLAC wrist

T   Tumour


R   RA - more common ulna 

I    Infection

F   FCR synovitis 








1.  TFCC 

- central articular disc

- TFCC is major stabiliser of DRUJ

- arises ulnar aspect of lunate fossa of radius

- inserts fovea at base of ulna styloid


2.  Dorsal and Palmar Radio-Ulna ligaments 


Thick fibrous structures

- from ulna styloid

- important stabilises of DRUJ


In normal wrist

- Dorsal RU ligament tight in pronation

- Palmar RU ligament tight in supination


Unstable wrist is opposite

- in pronation wants to dislocate dorsally 

- PRUL which tightens

- in supination wants to dislocate volar

- DRUL tightens


3.  ECU Sheath


4.  Ulna Collateral ligament

- arises base of ECU sheath


5.  Ulnotriquetral / Ulnolunate ligaments

- ulno-carpal ligaments

- play important role 

- not part of TFCC




TFCC tears

DRUJ instability (acute or chronic)

DRUJ arthritis




DRUJ Arthritis


DRUJ ArthritisDRUJ Arthritis





- distal ulna excision

- best for elderly RA patient


Bower's interpositional hemiarthoplasty



- best for young OA

- excision of arthritic portion through 5/6 compartment / hemiresection

- intact TFCC for interposition



- young OA

- not suitable in RA as TFCC damaged


DRUJ Hemiresection





- distal radio-ulna arthrodesis with distal ulna pseuodoarthrosis

- distal ulna fused to distal radius with 2 screws

- distal ulna stabilised with half FCU

- interposition with pronator quadratus


DRUJ Replacement


DRUJ ReplacementDRUJ Replacement



DRUJ Instability




- most common


Dislocated DRUJDislocated DRUJ






1.  Acute traumatic peripheral tear TFCC with DRUJ dislocation

- usually major trauma

- dorsal or volar


2A.  Distal radial fracture

- Galleazzi fracture

- sigmoid notch fracture


2B.  Radial Malunion


Radial Malunion


3.  Ulna styloid fracture


4.  Essex Lopresti 

- fracture radial head with dislocation DRUJ





- need true lateral

- ensure radial styloid overlies proximal scaphoid / lunate / triquetram



- Axial view shows DRUJ incongruency


1A.  Dorsal Dislocation DRUJ



- hyperpronation

- tear of dorsal distal RUJ ligament

- with partial or complete TFCC tear



- dorsal prominence

- forearm locked in pronation

- attempted supination painful


CT scan




1.  Closed reduction

- maintain in supination 4/52


2.  Open reduction

- rarely needed

- failure closed reduction (ECU incarceration)

- chronically dislocated

- may require acute repair TFCC +/- K wires


TFCC Repair + K wire


1B.  Volar Dislocation DRUJ



- forced supination

- usually complete tear TFCC



- arm locked in supination


CT scan



- closed reduction

- maintain in pronation 4 weeks

- rarely need open reduction or in chronic cases


2A.  Acute Distal radial fracture / Galleazzi



- up to 60%



- Anatomical reduction of radius

- usually makes DRUJ stable

- rarely need to repair TFCC / K wire for stability


2B. Radial malunion / Non anatomical ORIF


A. Short radial fracture

- lengthening radius difficult

- ulna shortening


B.  Angulation / rotation

- radial osteotomy

- TFCC repair

- +/- TFCC reconstruction with strip ECU


3.  Displaced ulna styloid




Type 1

- tip fracture

- stable DRUJ


Ulna Styloid Tip FractureUlna Styloid Tip Fracture


Type 2

- base fracture

- unstable DRUJ


Wrist Ulna Styloid Fracture




POP immobilisation in neutral rotation and UD for 6/52 

- ensure DRUJ remains located


Rarely need ulnar styloid ORIF if displaced and DRUJ unstable


4. Essex-Lopresti injury



- fracture radial head with dislocation DRUJ

- Essex-Lopresti variant - radial neck fracture with dislocation DRUJ


Type 1

- acute radial head fracture



- reconstruct or replace radial head

- assess stability in supination

- occasionally need TFCC repair +/- K wire


Type 2

- late

- following excision of radial head with injury to interosseous membrane

- usually occurs within first two years following injury




Nil degenerative changes

- ulna shortening with plate to reduce DRUJ

- radial head replacement to prevent recurrence


Degenerative changes

- Hemiresection / Darrach's / Kapandji

TFCC Tears



Present with pain but not instability







Different treatment algorithms for each




Ulna side wrist pain

- may be worse with rotation

- opening doors and jars


History of trauma




Local tenderness DRUJ


Supinate / pronate

- pain

- click


Forcibly ulna deviate and pronate wrist

- grinds carpus against TFCC
- generates pain


Check for DRUJ instability / Piano Key


Ulna variance




Xray in neutral supination / pronation


Variance is not static

- Pronation increases ulnar variance

- Supination decreases variance

- May be up to 3 mm




Transverse line of lunate fossa

Transverse line of ulna head




Population is on average 1 mm ulna plus

- wide variation

- 1/4 wrists are ulna negative




Neutral variance

- Takes < 20% of load


Ulna Variance Neutral


2.5mm Ulnar negative

- 4.3% of load


Ulna NegativeUlna Variance Negative


2.5mm Ulnar positive

- 42% of load


Ulna Variance PositiveUlna Positive with abutmentUlna Variance Positive




Ulna Variance


Evidence ulnocarpal abutment / arthritis




Look for discontinuity of TFCC

- radial / ulna / central / carpal


TFCC Tear Ulna Side


Palmer Classification TFCC Lesions


Class 1 Traumatic


A. Central perforation

B. Ulnar avulsion 

- With distal ulnar fracture

- Without distal ulnar fracture

C. Carpal / Distal avulsion

- ulno-carpal ligament injury

D. Radial avulsion (+/- sigmoid notch fracture) 


Class 2 Degenerative 




A. TFCC wear

B. TFCC wear

+ lunate and/or ulnar chondromalacia

C. TFCC perforation

+ lunate and/or ulnar chondromalacia 

D. TFCC perforation

+ lunate and/or ulnar chondromalacia

+ Luno-Triquetral ligament perforation

E. TFCC perforation

+ lunate and/or ulnar chondromalacia

+ Luno-Triquetral ligament perforation

+ ulnocarpal arthritis


TFCC Degenerative Tear with Chondromalacia




Diagnose central tears


Trampoline test

- TFCC should bounce on probe

- if very soft, likely has a peripheral tear





- acute repair if DRUJ unstable

- delayed repair if continued symptoms and ulna / radial tear

- debridement of central tears + ulna shortening if ulna positive

- ulna shortening if ulnocarpal abutment / arthritis


Class 1 Traumatic


A.  Ulna


Acute Injury


1.  Stable DRUJ

- immobilise in neutral rotation

- need long arm cast

- surgical repair if continued symptoms / non healing


2.  Unstable DRUJ


A.  Obtain closed reduction / supination

- immobilise


B.  Failure closed reduction

- open / arthroscopic TFCC repair to stabilise DRUJ


Operative repair



- acute instability

- continues pain / late presentation



- good success as very vascular

- 5/6 approach / bed of EDM

- interval between EDM and ECU

- open capsule

- sutures in TFCC, pass  through drill holes in base ulna styloid

- immobilise in cast




B.  Radial



- difficult to access / repair / very avascular


Open repair

- 5/6 approach

- drill holes through dorsal radius into ulna fossa

- use suture retriever

- stabilise with RU K wires if continued instability


C.  Central 



- usually occur along avascular origin from radius 

- usually 1-2mm from origin

- may be traumatic or degenerative


Neutral ulna variance

- Arthroscopic debridement

- 73% success complete pain relief

- Can take central 2/3 of disk without problems


Positive ulna variance

- do worse if debride disc alone

- consider combining with ulnar shortening as well


Class 2 Degenerative 


Class 2A - C



- TFCC wear or perforation

- lunate and / or ulna chondromalacia

- lunate triquetral ligament intact


1.  Positive ulna variance


Shorten ulna +/- arthroscopic debridement TFCC




A.  Ulnar shortening and plate fixation

- specific plates (Trimed)

- have advantage of rotational control throughout procedure

- midportion ulna, apply plate dorsal

- fix distally, sliding screw proximally

- oblique osteotomy through jig

- 5 or 8 mm

- shorten, lag screw through plate

- apply proximal screw


Ulna PositiveUlna Shortening


B.  Wafer / Bower's hemiresection procedure

- open or arthroscopic

- remove 2-3 mm ulna head

- aim to make ulna negative

- not indicated if > 4mm ulna positive

- leave ulna styloid / TFCC intact


2.  Ulna neutral

- arthroscopic debridement

- +/- ulna shortening


Class 2D



- Lunotriquetral ligament perforation



- Arthroscopic debridement / ulna shortening 

- LT fusion if unstable


Type 2E / Ulnocarpal Impaction Syndrome



- LT ligament perforated

- ulnocarpal abutment / arthritis


Associated with positive ulnar variance

- from repetitive loading


Ulnocarpal Abutment




1.  Bower's ulna head hemiresection

- resect 2mm ulna head leaving ulna styloid

- +/- interposition of dorsal capsule

2.  Darrach's

- excision of distal ulan

- +/- stabilisation with tendon transfer

3.  Suave-Kapandji

- distal radioulna fusion



De Quervain Syndrome



Stenosing tenosynovitis of the first dorsal compartment of wrist




Most are middle aged women




Repetitive thumb movements

- abduction & extension

- combined with RD & UD movements


Any mechanical irritation

- foreign body

- prominent bony surface

- restricted fascial compartment

- abnormal muscle to epitenon




1st dorsal compartment

- over styloid process

- in osseoligamentous tunnel 

- shallow groove in styloid 

- roofed by dorsal ligament 

- attached by fibrous septa to bone

- tunnel ~1cm long

- 20% have 2 compartments



- phylogenetically young muscle

- found only in humans & gorillas as separate from APL

- EPB absent 5-7% 

- inserts base of P1



- larger

- 75% of population has 2 or 3 or more tendinous slips

- varous insertions

- base of 1st MC / trapezium / volar carpal ligament /  opponens pollicis / APB





Pseudogout / Gout




Vascular Disease


Post Trauma




Clinical Features


Pain & swelling over styloid


Positive Finkelstein's test

- grasp the patient's thumb  / ulna deviation of wrist


Finkelstein Test


Eichoff maneuver

- patient grasps own thumb in fist, ulna deviation of wrist


Eichoff Test






Exclude base of thumb OA

Look for bony spur that may need resection




Wartenberg's Syndrome 

- compression superficial branch radial nerve






Intersection syndrome

- ECRL/B crossed by APL & EPB 








Thumb spica splint




Prolonged conservative treatment

- pregnancy, DM etc






Transverse / Longitudinal incision

- longitudinal protects nerve

- transverse gives better scar


Identify and protect SRN


Divide Annular Ligament 

- ensure all compartments are decompressed

- may be more than one

- make incision ulna side to prevent radial instability


Assess floor of compartment for pathology


Asses for instability

- Z lengthen and repair fascial roof if present




Very common

- radial nerve neuroma / division

- hypertrophic scar from longitudinal incision

- volar subluxation of tendon if remove too much sheath

- insufficient release


Distal Radial Malunion



Unacceptable position of radius post fracture


1.   Radial Shortening > 4mm at DRUJ


Radial Malunion Shortening


2.   Radial Inclination < 15°


Distal Radial Malunion APRadial Maluion Loss Radial Inclination


3.   Radial Tilt 

- > 15° Dorsal 

- > 20° Volar


Distal Radial Malunion Dorsal Tilt


4.   Articular incongruity > 2mm


Distal Radial Step OADistal Radial Step OA 2


5.  Positive ulna variance > 4mm


Radial Malunion




Dorsal Tilting 


1.  Increases dorsal load

- maintain midcarpal alignment



- midcarpal instability

- get DISI pattern without interosseous ligament disruption

- may be increased in patients with ligamentous laxity


Radial shortening


1.  Alter kinematics of DRUJ


2.  Ulnocarpal abutment


Clinical Presentation


DDx Pain 

- synovitis

- RC OA 

- ulnocarpal abutment


- TFCC tear



Functional Loss of ROM

- DF loss > PF

- supination loss > pronation

- weak grip




PA film in neutral 

- wrist neutral

- elbow & shoulder at 90°


5 Measurements


1.  Radial inclination

2.  Radial length 

3.  Ulnar Variance 

4.  Radial Tilt  

5.  Radial Shift 

- radial Styloid from longitudinal axis

- compare to contralateral side


NHx Painless malunion


No evidence for development OA


Operative Management









OA in RCJ / carpus 






Early > late results

- Jupiter 1996

- < 2/12 since fracture best


However, period of non operative treatment is often desirable


Surgical Options


1.  Ulna shortening

2.  Radial osteotomy

3.  Radial osteotomy + ulna shortening

4.  Radial osteotomy + ulna ablation

5.  Intra-articular ostetomy

6.  Soft tissue releases


Ulnar Shortening



- short radius, positive ulna variance

- acceptable alignment distal radius

- acceptable DRUJ articular surface


Distal Radial Osteotomy



- positive ulna variance / shortening

- dorsal tilt

- DRUJ reducible by radial osteotomy

- acceptable DRUJ articular surface



- dorsal opening wedge

- volar opening wedge

- volar closing wege


Dorsal Opening wedge osteotomy


Distal Radial Malunion Dorsal OsteotomyDistal Radial Malunion Dorsal Osteotomy



- lengthens the distal radius

- may be easier to correct in coronal and sagittal plane

- this makes it the most popular



- dorsal approach / dorsal plate (extensor tendon issues)

- usually requires bone graft

- increased instability

- increased risk of non union



- xray normal wrist

- calculate correction / size of bone graft


Dorsal opening wedge

- 3rd dorsal compartment

- expose distal radius

- can use half pins to control distal fragment

- check osteotomy site with II (metaphyseal, site of deformity)

- protect structures with homan retractors

- osteotomy with microsagittal saw

- correct radial articular surface in sagittal & coronal planes

- trapezoidal bi-cortical iliac crest autograft / synthetic graft

- dorsal locking plate


Volar opening wedge


Radial Malunion Volar Opening Wedge OsteotomyRadial Malunion Volar Opening Wedge Osteotomy Lateral



- volar approach

- apply volar plate to gain correction



- require dorsal approach to bone graft



- bed of FCR approach

- protect radial with homans, osteotomy

- apply volar plate

- then either leave gap dorsally or

- second dorsal approach to insert bone graft


Closing wedge osteotomy



- volar approach  / plate better tolerated

- nil bone graft, direct bone to bone contact



- can shorten radius / may need to perform ulna shortening as well


Distal Radial Osteotomy & Ulnar Shortening



- unacceptable radial alignment

- DRUJ not reduced by radius osteotomy

- acceptable DRUJ articular surface


Distal Radial Osteotomy & Ulnar Ablation



- unacceptable radial alignment

- DRUJ irreducible by radial osteotomy

- unacceptable DRUJ articular surface



- Bower's hemiresection

- Darrach's

- Suave-Kapandji


Intra-articular Osteotomy




A.  Scaphoid facet malunion

- intra-articular osteotomy

- radial styloidectomy

- proximal row carpectomy


B.  Lunate facet malunion

- osteotomy 

- radio-lunate fusion


C.  Global wrist involvement

- early intra-articular osteotomy

- total wrist fusion


D.  Anterior / Posterior rim malunion

- simple bone resection


Soft Tissues Releases




DRUJ volar capsulotomy 

- restores supination


DRUJ dorsal capsulotomy 

- restores pronation


+/-  Pronator Quadratus release



Distal Radius Fracture



2 groups


1.  Elderly

- low velocity injury

- osteoporotic

- need to start bisphosphonates


2.  Young patients

- high velocity injury




Distal Radius Angles

- radial volar tilt 11°

- radial inclination  22°

- radius is 11 mm longer than ulna 

- ulna variance 2mm positive on average


Distal Radius NormalNormal Radial InclinationNormal Radial Length


3 independent articular surfaces

1.  Scaphoid facet

2.  Lunate facet

3.  Sigmoid notch


Base of ulna styloid

- insertion point TFCC

- insertion point ulno-carpal ligaments

- crucial for stability DRUJ


3 Columns


1.   Lateral radial

2.   Medial radial

- dorsal medial radial

- volar medial radial

3.  Ulna column

- ulna styloid and TFCC


Volar radius

- subject to compressive forces

- thicker and stronger


Dorsal radius

- subject to tensile forces 

- thinner and cancellous


Associated  Injuries

- TFCC tears

- SL ligament

- LT ligament


Fracture Patterns


Radial Styloid and Lunate Fragments


Distal Radius Fracture Undisplaced Intraarticular


Dorsal ulna / volar ulna


Distal Radius Volar and Dorsal Ulna FragmentsDistal Radial Fracture CTDistal radius volar ulnar fracture


Distal Radius Dorsal Ulna FragmentDRUJ FractureDistal Radius Radioulna Fragments




Colle's Fracture

- distal radial fracture with dorsal displacement


Wrist Colle's Fracture


Smith's Fracture

- distal radial fracture with volar displacement

- need long arm cast in supination


Distal Radius Smiths Fracture


Volar Barton's

- volar intra-articular fragment

- inherently unstable

- usually need volar buttress plate


Wrist Volar BartonsVolar Bartons CTVolar Bartons Buttress Plate


Dorsal / Reverse Barton's

- dorsal intra-articular fragment


Wrist Dorsal BartonsWrist Dorsal Bartons CT


Chauffeur's Fracture

- radial styloid fracture

- ORIF displaced > 2mm (K wires / partially threaded screws / radial styloid plate)

- ensure not missing perilunate dislocations


 Radial styloid fractureRadial Styloid K wires.jpgRadial Styloid ORIF APRadial Styloid ORIF Lateral






All fractures should be reduced initially and reassessed

- conscious sedation

- 2 minutes of traction / reduction of deformity

- backslab / elevation in gallows

- re-xray


Distal Radius Fracture Severely Displaced.jpgDistal Radius Post Reduction.jpg


CT for further evaluation of articular congruency


Indications for surgery



- open fracture

- acute severe CTS



- failure to obtain and maintain adequate reduction

- instability

- articular incongruency

- likely unstable / dorsal comminution


Distal Radius Fracture Dorsal Comminution


Unacceptable reduction


1.  Distal radial Step > 2mm

- leads to RC OA radiographically

- not proven to lead to dysfunction


Distal Radius Fracture Articular Step Coronal CTDistal Radius Fracture Articular Step Sagittal CT


2.  Articular incongruency sigmoid notch / DRUJ > 2 mm


Distal Radius Fracture DRUJ incongruent


DRUJ FractureDRUJ Fracture CT


3.   Radial shortening > 5 mm

- leads to ulnocarpal abutment


4.  Radial inclination < 15o


5.  Sagittal tilt

- > 15o dorsal

- > 20o volar

- +/- marked dorsal comminution


7.   Risk carpal subluxation

- Barton's fracture / dorsal Barton's


8.  Ulna styloid

- no indication to treat unless unstable DRUJ




K wires

Volar / Dorsal plates

External Fixation




Operative v Nonoperative


Arora et al JBJS Am 2011


- MUA & cast v plate fixation in > 65 year olds with displaced fractures

- no significant difference in functional outcome at one year

- improved grip strength in operative group, and better xray measurements but increased complications


K wire v Plates


Marcheix et al J Hand Surg Eur Vol 2010

- RCT of pins v fixed angle plate in dorsally displaced unstable fractures in patients > 50

- extra and intra-articular

- fewer loss of reduction and better functional scores at 6 months with fixed angle plates


Rozental et al JBJS Am 2009

- RCT of ORIF v K wire in 45 patients

- ORIF better functional scores early

- similar outcomes at one year


Plates v External Fixation


Abramo et al Acta Orthop 2009

- RCT of 50 patients unstable comminuted distal radial fractures

- at one year better ROM and fewer malunions in group treated with trimed plate

- no difference in subjective outcome


Leung JBJS Am 2008

- RCT of pins / external fixator v locking plates for intra-articular fractures

- significantly better outcome in locking plate group


Grewal et al J Hand Surg 2011

- RCT ORIF v external fixation

- ORIF better function early

- similar outcomes at one year


Surgical Techniques


1.  Percutaneous K Wire


Distal Radius Fracture K wiresDistal Radius Fracture K wires APDistal Radius Fracture K wires LateralDistal Radius K Wires



- extra-articular unstable fractures

- young people without osteoporosis 

- minimal comminution


Technique of Colles / Extra-articular fracture / Dorsal displacement



- reduction of fracture

- check under II


Radial K wire

- distal to proximal

- insert percutaneously to bone

- can make small incision / blunt dissect to protect branches SRN

- Kapandji technique or simply cross fracture site

- engage other cortex

- 1.6 or 2 mm K wire


Dorsal K wire Kapandji technique

- percutaneous

- insert by hand into fracture site

- tilt to reduce dorsal displacement of distal fragment

- drive into proximal radius and engage volar cortex


2.  ORIF with locking plates


Distal Radius Plate APDistal Radius Plate Lateral



- accurate restoration of intra-articular anatomy

- stable fixation

- early mobilisation




Locking plates

- volar / radial styloid / dorsal plates

- screws act as fixed angle devices

- screws variable angle


Radial Styoid Plate


Fragment specific sets

- pin fixators / paper clips

- good for dorso-ulna fragments

- variable angle screws




Volar / Henry approach

- can extend into CTD if required

- floor of FCR

- divide fascia

- radial artery laterally

- palmar cutaneous branch median nerve medial side FCR

- elevate pronator quadratus from radial to ulna

- release BR if required

- do not incise volar capsule (cut RSC / RL and other important ligaments)

- doing so can lead to volar RC instability


Reduce fragments

- pull out to length / correct angulation

- temporarily stabilise with K wires

- check alignment

- apply volar plate

- check orientation of distal screws with K wire to ensure not in joint

- on lateral, raise hand 30o to view joint

- screw fixation in scaphoid and lunate fragments

- long screws to engage dorsal cortex (24 - 26mm)

- radial styloid plate if required


Volar ulna approach indications

- perform CTD

- use interval between long flexors and FCU to access DRUJ and volar-ulna radius


Dorsal approach

- if unstable dorso-ulna fragment

- midline incision

- open 3rd compartment

- open 4th and sharply dissect radially

- may wish to close ER under tendons to protect from plate


Post op

- POP backslab for 10 days

- early ROM if stable


3.  External Fixation + / - Supplemental K wires


Distal Radius External Fixation



- compound fractures

- severe unreconstructable injuries

- very osteoporotic bone



- 2 x half pins dorsal radius (4mm)

- 2 x half pins IF / MF metacarpal (3 mm)




1.  Tendon problems

- most common problem


A.  FPL ruptures

B.  FCR tenosynovites

C.  Dorsal extensor tendon involvement from protruding screw or from dorsal plates


2.  Stiffness


Can continue for up to 18 months

- difficulty regaining full supination / pronation


3.  Median nerve dysfunction


4.  CRPS 2

- excessive traction on median nerve / long surgery


4.  Radial artery pseuodoaneurysm

EPL Rupture



Undisplaced wrist fracture

- interrupts blood supply at a watershed area

- between 3 weeks and 3 months post injry



- RA / SLE




Just distal to extensor retinaculum at Lister's tubercle




Place hand flat on table

- lift only thumb






Direct repair


Often not possible

- poor tendon

- retracted


Palmaris longus graft


Extensor Indicis tendon transfer


IPJ fusion - RA


EI Transfer



- independently able to extend finger

- keep other fingers flexed, ask to extend IF
- indicates IE intact





- incision at MCPJ

- EI is medial to EDC tendon



- incision distal to extensor retinaculum

- incision at MCPJ thumb

- tunnel in straight line subcutaneously


Suture to EPL

- tension

- need to be able to obtain full flexion with wrist extended

Kienbock's Disease



Avascular necrosis & subsequent disintegration of lunate




50-75% history of trauma


Occasionally seen in sickle cell / steroid use




Vascular Theory


Trauma disrupting vascularity

- single incident with disruption of blood supply

- multiple compression fracture with loss of blood supply to fragments



- high incidence of coronal fractures seen on CT

- not apparent on AP film

- disrupts intra-osseous anastomoses


Lunate Vascularity (Gelberman)


Group 1

- 10% 

- single incomplete palmar blood vessel

- higher risk AVN

- severe hyperextension may disrupt it


Group 2

- 90% 

- dorsal & palmar blood vessel

- well vascularized 

- need intra & extraosseous disruption

- low risk AVN


AVN not seen in lunate dislocation

- flap of volar capsule usually remains attached


Mechanical Theory


Normal ulna plus

- +2 to -6 mm

- +2 SD mean


Ulna minus variance

- subjects lunate to greater compression & shear forces

- increased radioulnar forces

- seen in 75% Kienbock's

- only 25% normal population


Ulna Minus


Lichtmann Classification


Stage 1 

- no radiological change 

- diagnosed on bone scan / MRI


Stage 2 

- sclerosis


Kienbocks Disease Stage 2


Stage 3 

- collapse / fragmentation


A: Normal carpal height

B: Loss of carpal height / scaphoid flexed / capitate migrates proximally


Stage 4 

- degeneration

- pan carpal arthritis (radiocarpal / midcarpal)




Occurs in young active adults 

- age 20-40 

- usually dominant hand 

- rarely bilateral

- men > women




Gradual onset of stiffness & pain 

50% history of trauma




Decreased ROM

Poor grip strength

Tender over lunate

Passive dorsiflexion middle finger gives pain





- progressive changes of AVN

- mottling / collapse / OA

- look for scaphoid flexion / capitate descent


Ulna Variance


Supination and pronation alter values

- need zero rotation view


90 / 90 view

- PA film with wrist in neutral

- elbow 90° / shoulder Abducted 90°


Line from lunate fossa and ulna head

- mean ulna variance is 1 mm (range 2 - 4)


Ulna Negative


Bone Scan / MRI


Demonstrate AVN




Often show coronal fracture with palmar fragment extruded

- ? Cause of decreased palmar flexion




Usually one of progressive collapse

- cccasionally can arrest and even reverse

- these patients may not be seen

- the usual patient presents late 

- makes interpreting treatment options difficult


Non-operative Management




Rarely effective

- Stage 1

- trial of immobilisation for 3/12 to aid revascularisation


1.  Stage II / IIIA Negative Ulna Variance


Radial Shortening ~ 2mm 




With negative variance often have thick healthy TFCC 

- can tolerate loading well


Radius normally takes 80% of load

- with ulnar minus is increased to 96%


Redistribute stresses 

- 2mm: 20% decrease radiolunate load

- 4mm: 40% decrease in radiolunate load

- less stress on lunate / revascularisation 

- relative lengthening of tendons may decrease compressive forces



- aimed for neutral or +1 mm ulnar variance

- if >1mm positive then risked ulnar abutment



- volar approach

- resection of desired amount

- can use cutting guides which give 2 parallel oblique osteotomies of set distance

- ensure not violating DRUJ

- application volar plate

- can be done dorsally but plate can become problem




Quenzer J Hand Surg 1997

- 68 patients

- diminished pain 90%

- increased grip strength 75%

- increased ROM 50%

- 1/3 had signs lunate revascularisation


2.  Stage II / IIIA with Neutral or Positive Ulna Variance


Capitate Shortening + Capitohamate fusion



- unload the lunate




Almquist Hand Lin 1993

- 83% revascularisation and healing


Vascularised Bone graft 



- best success in stage II / precollapse

- can combine with capitate shortening



- 2nd dorsal intermetacarpal A & V

- distal radius pronator quadratus pedicle

- dorsal distal radius on pedicle


3.  Stage IIIB


Limited fusion


A.  STT 



- lunate collapsing 

- scaphoid takes more of load and goes into flexed position much like DISI

- STT fusion gives stable radial column for load bearing

- prevents radiocarpal degeneration



- dorsal approach 3/4

- take scaphoid out of flexion / extend

- K wire into position

- fuse to trapezium and trapezoid using bone graft from distal radius


B.  4 corner fusion 



- provides ulnar load bearing column



- lunate is poor quality / necrotic


Proximal Row Carpectomy


Always consider adding denervation


4.  Stage IV



- contraindicated with severe capitate degeneration



- manual worker


Perilunate Fractures and Dislocations



Young men in 20's and 30's




High energy injuries

- fall from heights



Mayfield Classification


Injury progresses from radial to ulna

- usually disruption proximal row either side of lunate


1.  Capitate usually displaces dorsally initially

- volar lunate dislocation is end stage


2.  Volar capitate dislocations do occur

- dorsal lunate dislocation as end stage


Spontaneous reduction can also occur


Cadaver study 


Stage 1 - SL dissociation 


Stage 2 - CL dissociation / capitate dislocates


Stage 3 - LT dissociation


Stage 4 - Lunate dislocates




Swollen and painful wrist

- +++ clinical suspicion


Volar lunate dislocations

- fingers semiflexed


1/3 have median nerve symptoms


Unusual to have compound wound

- usually palmar




Disruption of Gilula's 3 smooth carpal arcs


Progressive Injury


1.  Capitate dorsal

- lunate remains with radius

- lunate looks triangular on AP


Scapholunate Dislocation Capitate Dorsal


Perilunate Dislocation 1Perilunate Dislocation 2


2.  Lunate dislocates

- usually volar


2 main groups of injury


1.  Dorsal trans-scaphoid dislocation

- 2/3 of cases


Transscaphoid Perilunate DislocationTransscaphoid Perilunate Dislocation Lateral


2.  Dorsal perilunate dislocation

- 1/3 of cases


Associated Injuries


Scaphoid fracture

Radial styloid fracture

Capitate fracture


Chronic presentations


Missed in 20%

- reasonable ROM

- little pain


May present with CTS


May present with flexor tendon ruptures




A.  Acute perilunate dislocation


Initial Reduction


Traction under anaesthesia / conscious sedation

- dorsiflex wrist

- counterpressure on palmar lunate

- gradual wrist flexion with pressure on dorsal capitate


Perilunate Reduced 1Perilunate Reduced 2




Poor results with non operative management

- require anatomical repair of proximal row

- wait 3-5 days for swelling to settle


1.  No scaphoid fracture


Reduce lunate

- closed reduction

- open reduction


Dorsal approach

- longitudinal incision

- 3/4 extensor compartment

- mobilise EPL laterally

- open dorsal between DRC and DIC ligaments

- joysticks in scaphoid and lunate

- reduce DISI deformity

- K wires SC / SL / LT (areas of ligament rupture)

- repair SL ligament back onto scaphoid with anchors / transosseous sutures

- ORIF any capitate fractures

- repair LT ligament + augment with capsule


+/- Volar approach

- difficulties reducing lunate

- perform CTD

- repair rent in volar capsule / Space of Poirier


Perilunate Dislocation ORIF APPerilunate Dislocation ORIF Lateral


Perilunate Dislocation APPerilunate Dislocation Lateral ORIF


Perilunate ORIF 1Perilunate ORIF 2


Recent trends

- add SL screw

- add Blatt capsulodesis

- repair rent in volar capsule

- make wrist as stiff as possible to prevent late OA


2.  Trans Scaphoid Perilunate


Perilunate Dislocation Closed ReductionTrans scaphoid Perilunate Pre ORIF


Trans scaphoid Perilunate ORIF


Dorsal approach

- ORIF scaphoid fracture

- repair LT ligament

- K wires LT and TC (SL ligament is intact)

- ORIF capitate


+/- Volar approach


- repair rent in capsule


Post op


Aim is for a stable but stiff wrist

- 8 weeks in cast, then removal of K wires

- begin ROM




80% strength


Reduced ROM

- usually 100o F/E


Chronic unreduced perilunate dislocations


< 6 months


Attempt open reduction





- scaphoidectomy + 4 corner fusion


- wrist arthrodesis

Rheumatoid Wrist

EpidemiologyRheumatoid Wrist


Extremely common

- 90% by 10 years have wrist problems




Landsmeer 1961

- treat wrist at same time as treat fingers or will recur


Frequently combine procedures

- synovectomy

- tendon transfer

- ulna procedure


Treatment Priorities


1. Pain Control

2. Slow progression

3. Restore /  Function

4. Cosmetic Improvement




1. Synovitis



- ulna styloid

- ulna head

- scaphoid midportion


Radial side 

- synovitis scaphoid midportion

- RCL & RSCL become attenuated 

- subluxation of scaphoid & scapholunate dissociation

- radiocarpal shortening


Ulnar side 

- synovitis begins ulna styloid

- TFCC, ULL & UTL attenuated 

- DRUJ stretches

- volar subluxation of ulnar carpus & supination

- develop caput ulna

- ulnar becomes prominent because carpus is falling away from it

- carpus volar translated & supinated


Wrist RA


2.  Loss of ECU mechanical advantage 

- secondary to supinated carpus & carpal collapse 

- ECU subluxes volar to flexion / extension axis

- increases mechanical advantage of radial wrist extensors 

- radial deviation of carpus 


3.  Carpal Collapse

- decreases mechanical advantage of long finger flexors / extensors

- leads to intrinsic plus deformity


Rheumatoid WristRheumatoid Wrist Carpal Collapse


Failure to address wrist deformity will lead to failure of MP or IP reconstruction


Operative Management




Failure of optimal rheumatology supervised medical management for 6 months





- synovectomy

- tendon transfers


- tendon repairs



- DRUJ excision

- arthrodesis

- arthroplasty


1.  Synovectomy




Persistent painful wrist synovitis not settling with medical management

-  > 6/12 

- minimal X-ray changes




1.  Relieves pain

- no evidence synovectomy alone will halt progression of wrist deformity


2.  Prevents subsequent tendon rupture

- recurrent tenosynovitis rare

- once one tendon ruptures often followed by multiple ruptures 

- tendon rupture can occur by direct invasion

- seen in up to 50% at time of tenosynovectomy




A.  Flexor tenosynovectomy 


Often difficult to diagnose

- not as easily seen as dorsally

- patients present with limited active finger flexion / CTS



- through incision of CTD


B.  Dorsal Tenosynovectomy + Carpal Synovectomy



- dumbbell shape under extensor retinaculum dorsally


Midline dorsal incision

- divide extensor retinaculum between 5th and 6th extensor compartments (EDM & ECU)

- elevate radially based flap to 1st compartment

- perform partial wrist denervation (PIN in floor of 4th)


RCJ & Intercarpal joints exposed 

- use ligament sparing arthrotomy (between DRC and DIC ligaments)

- synovectomy


DRUJ exposed through longitudinal incision

- debride

- stabilise if unstable


Repair extensor retinaculum underneath tendons to protect bed


2.  Tendon Transfer


ECRL to ECU insertion 



- at time of synovectomy 



A.  Corrects a correctable radial deviation deformity

B.  Holds ECU over ulna head

- prevents ulna subluxation


3.  CTD




Secondary to synovitis



- good results with decompression

- usually perform flexor tenosynovectomy at same time

- may wish to examine floor to ensure no bone protruding which may rupture tendons


4.  Tendon rupture


A.  Extensor tendon rupture


Dropped FingersDropped Fingers 1Dropped Fingers 2



- EDQ > LF > RF > MF > IF > EI

- goes ulna to radial 

- opposite to flexor tendons


Cause of rupture

- tenosynovitis

- caput ulna (EDQ)

- EPL over Lister's tubercle


Extensor Digiti Quinti / Vaughan-Jackson Syndrome


5th dorsal compartment

- can be clinically silent

- EDC and juncturae tendinae compensate



- attempt to hold LF extended whilst other fingers flexed

- indicates that progressive tendon rupture likely and intervention required


DDx dropped finger

- extensor tendon subluxation

- MCPJ dislocation

- dislocated extensor tendons

- PIN palsy (can't extend wrist or thumb)

- locked trigger


Extensor Tendon transfers


LF rupture

- side to side RF



- side to side MF


LF / RF / MF

- LF / RF to EI

- MF to IF

- or RF FDS to LF / RF


LF / RF / MF / EI / IF



B.  Flexor tendon rupture


Mannerfelt lesion

- distal pole of scaphoid and trapezium erode through volar capsule

- FPL most common


- opposite direction to extensors




In severe deformity, may wish to fuse wrist to prevent further ruptures



- bed of FCR

- carpal tunnel incision


Debride bony prominences

- rotated capsule to cover floor


FPL rupture

- fuse IPJ

- young patient transfer FDS IF / RF +/- PL graft



- fuse DIPJ



- fuse DIPJ

- MF FDS transfer


5.  DRUJ


RA Wrist Caput UlnaRA Wrist Caput Ulna 2




Frequently subluxes dorsally

- ECU may also be ruptured


Patient presents with pain with rotation

- may have extensor tendon rupture


Piano Key sign

- reduce the ulna, it simply redislocates




A.  Darrach's 





- excision arthroplasty



- older patient



- same dorsal approach as for synovectomy

- radial based ER flap

- excise distal ulna

- proximal limit is articulation with sigmoid notch

- usually 1.5 cm

- round off radial side

- stabilise with volar capsule + ECU tenodesis

- can stabilise with Pronator Quadratus



- can be unstable

- even with ECU tenodesis

- revise by ECU / FCU tenodesis + pronator quadratus interposition

- or by further shortening!!!


B.  Suave - Kapandji



- fusion DRUJ & ulna pseudoarthrosis



- younger patient



- resection of 10 - 15 mm long segment of ulna proximal to DRUJ

- resect proximal periosteum +/- interposition of pronator quadratus to prevent regrowth

- DRUJ denuded of cartilage

- distal fragment brought slightly proximally to prevent ulno-carpal abutment  

- fuse to distal radius with screws or K wires

- 4 weeks in LA POP in neutral



- may have better result than Darrach's in RA

- less instability


C.  Hemi-resection arthroplasty 


Not usually done in RA

- TFCC and DRUJ soft tissues very poor

- indicated for DRUJ arthritis with good soft tissue stability


D.  Arthroplasty


6.  Wrist Fusion


A.  Partial Wrist Fusion



- Radiolunate / Radioscapholunate fusion 



- isolated arthritis

- midcarpal joint spared



- usually have to do wrist fusion later

- may maintain some movement for 5 years or so 


B.  Total Wrist Fusion


Wrist Fusion APWrist Fusion Lateral



- predictable

- stable and pain free wrist


Indications for Arthrodesis

- poor bone stock

- stiff wrist

- loss of wrist extensors

- painful erosive RA

- high demand




A.  Steinmann pin in third MC / Mannerfelt Fusion


B.  Plate fixation 


RA Wrist Fusion Darrachs APRA Wrist Fusion and Darrachs Lateral


Gold standard

- Synthes low profile contoured plate

- 10o degrees extension

- fused to MF metacarpal

- avoid radial deviation

- ulna deviation OK 


Bilateral one up one down



- functional difficulties

- i.e. opening jar


7.  Arthroplasty



- low demand patient that requires ROM

- intact wrist extensors

- good bone stock




Millander 1986

- 25% revision rate at 5 years






OA of the scapho-trapezium-trapezoidal joints




50% patients with CMC OA have STT OA

F > M




STT OASTT Arthritis 2




Non operative





HCLA injection








Excisional Arthroplasty

STT fusion


STT fusion


Dorsal approach

- base of thumb

- between EPB and EPL

- protect branches SRN

- excise distal scaphoid / proximal trapezium and trapezoid

- fix with K wire

- insert cancellous bone graft




Srinivasan et al J Hand Surg Br 1996

- STT fusion in isolated OA in 8 patients

- good results in 7 patients

- 1 non union






Avascular Necrosis




- sclerosis


Scaphoid Fracture Proximal Pole AVNScaphoid Proximal Pole ORIF AVN




Scaphoid AVN CT



- probably the most sensitive and specific


Bone Graft v Vascularised bone graft


Merrell J Hand Surg Am 2002

- meta-analysis


1.  Bone graft with proximal pole AVN

- union 50%


2.  Vascularised bone graft with proximal pole AVN

- union 88%


Vascularised bone grafting / VBG


1.  Pronator quadratus pedicle graft

- much less common now


2.  Vascularised distal radius graft / Zaidemberg

- most common


3.  2nd metacarpal graft

- very common


Technique Zaidemberg


Dorso-radial approach

- 1/2 intercompartmental supraretinacular branch of the radial artery

- travels distal to proximal

- between tendons of the first and second extensor compartments

- can use 2/3 if 1/2 small or missing

- follow to distal radius

- osteotome 3 sides preserving pedicle


Dorsal approach to scaphoid

- open non union site

- insert VBG

- fixation with screw








Young men





- axial load, dorsiflexion and radial deviation


DISI occurs in ulna deviation


Herbert Classification


Type A    Stable acute fracture


A1 Tubercle

Scaphoid Tuberosity FractureScaphoid Tuberosity Fracture


A2 Incomplete waist fracture

Incomplete Scaphoid FractureScaphoid Fracture Incomplete


Type B    Unstable acute fracture


B1 Distal oblique fracture

Scaphoid Fracture 3D Isolated


B2 Complete waist fracture

Scaphoid Fracture Complete


B3 Proximal pole fracture

Scaphoid Proximal Pole Fracture


B4 Trans-scaphoid perilunate fracture


Type C    Delayed Union


Type D    Established Non-union


D1 Fibrous Union (stable)

D2 Pseudarthrosis (unstable / early deformity)

D3 Sclerotic Pseudoarthrosis (Late deformity)

D4 Avascular Necrosis (fragmented proximal pole)




Scaphoid is Greek for boat

- shaped more like a twisted peanut


Scaphoid 3D VolarScaphoid 3D Dorsal


Majority is articular

- except for dorsal ridge

- this is the site of entry of majority of blood supply




Gelberman & Menon J Hand Surg 1980

- latex injection


2 major vascular leashes


1.  Dorsal ridge artery

- branch of radial artery

- major blood supply

- 70- 80% scaphoid including proximal pole

- enters through the non articular dorsal ridge


2.  Distal tubercle

- palmar & superficial palmar branches of radial artery

- perfuse distal 20% to 30% of scaphoid


Fracture Location


Waist 65%

Proximal third 25%

Distal third 10%




1.  Non union



- union > 95%

- rare with immediate immobilisation



- non union 50%


2.  AVN

- increases the more distal the fracture (50% proximal pole)

- increases with displacement (AVN 50%)


3.  Malunion and DISI

- associated with increased intra-scaphoid angle


Clinical Features


Tender anatomical snuffbox


Reduced ROM




5 images will pick up 99% of fractures

- PA 

- Lateral

- PA in 45° oblique pronation

- PA 45o oblique supination

- PA in ulna deviation


Scaphoid PAScaphoid Fracture LateralScaphoid Fracture ObliqueScaphoid Fracture Long Axis


Increased intra-scaphoid angle / humpback deformity

- > 35o abnormal

- > 45o associated with poor outcome i.e. DISI

- also demonstrated to lead to loss of extension


2 week delay



- tender in ASB

- no sign of fracture on initial x-ray

- usual treatment is to place in cast and xray in 2 weeks

- can be delayed appearance of scaphoid fracture


Leslie and Dixon JBJS 1981 

- 222 fractures

- 98% seen at time of presentation

- 2% became evident over ensuing weeks

- these were only incomplete and located on concave side of scaphoid


Excluding scaphoid fracture

- CT - easy to obtain, inexpensive

- MRI - highly sensitive, but expensive and difficult to obtain




1.  Displacement > 1mm on any film

2.  Intra-scaphoid > 35o

3.  Proximal pole fracture

4.  Comminution

5.  SL > 60o

6.  Radio-lunate angle > 15o

7.  Perilunate trans-scaphoid dislocation


Can be very difficult to assess displacement on plain films

- suggest use of CT




1mm slices in sagittal plane of scaphoid

- plane of metacarpal



- patient prone 

- hand over head

- fully pronated 


Scaphoid Fracture 3D CTScaphoid Fracture 3D CT


Bone Scan


Highly sensitive

- 5% to 15% incidence of false positives




Very sensitive for occult fracture

Identifies AVN

Identifies carpal instability




Non operative Management


1.  Anatomical Snuff Box Tenderness / Normal Xray




1.  POP 2/52, rexray out of plaster

2.  MRI / CT


2.  Acute undisplaced stable



- displaced < 1mm

- incomplete fracture

- tuberosity fracture


Scaphoid cast

- short arm thumb spica cast

- long arm cast not necessary

- some evidence that thumb spica not necessary


Time in cast

- distal / tuberosity  6/52

- middle 1/3 8/52

- proximal 1/3 10/52



- x-ray at 2/52 to ensure no displacement

- x-ray out of cast for union

- see at 6/12 for final xray check union



- union rate 90 - 95%


Operative Management


Indications for Surgery


A.  Instability

- displaced > 1mm

- intra-scaphoid > 35o

- complex instability / perilunate instability


B.  Proximal pole

- high risk of AVN

- 30% rate non union if non displaced

- all theoretically unstable

- could suggest that all need ORIF

- require dorsal approach


C.  Athlete / Manual worker with undisplaced

- percutaneous fixation

- early mobilisation and return to work


D.  Delayed diagnosis

- may have increased non union rates


2.  ORIF



- displaced fractures

- proximal pole




1.  Volar approach

- workhorse for waist fractures

- preserves dorsal blood supply


2.  Dorsal approach 

- for proximal 1/3 fractures


Scaphoid Proximal Pole Fracture


Volar approach technique


Scaphoid ORIF Volar ApproachScaphoid ORIF Volar Approach 2Scaphoid ORIF Volar Approach 3



- supine on arm table

- lead hand

- tourniquet



- volar along FCR

- deviate along thenar edge to STT joint

- elevate thenar muscles

- FCR ulna, deep branch radial artery radially with APL

- divide superficial branch radial artery

- open capsule in line with FCR

- transverse opening at STT

- will divide RSC ligament


Clean and reduce fracture

- K wires as joysticks


Cannulated headless compression screw 

- central third

- more bone contact, longer screws

- increased stability and therefore union rates

- can remove volar beak of trapezium

- pass cannulated screw wire, measure length

- drive wire into distal radius for stability

- pass screw, bury head


Bone graft as required

- very comminuted fracture / unstable

- humpback deformity

- distal radius if small

- iliac crest if large



- close capsule and repair RSC


Post op

- 8/52 in thumb spica

- assess union


Dorsal approach technique


Scaphoid ORIF Proximal Pole Lateral


3/4 Approach

- midline incision on RC joint

- open EPL, reflect radially

- sharply elevate EDC, reflect ulnarly

- open capsule over SL joint


Flex wrist


Insert K wire

- proximal fragment into distal fragment

- entry point is just radial to SL ligament

- drive into trapezium

- check position on multiple views


Insert screw




Herbert ORIF all type B fractures

- B1 90% union (oblique)

- B2 88% union (waist)

- B3 85% union (proximal pole)


Percutaneous fixation



- faster union rates than cast

- union approaching 100%

- less time in cast

- earlier return to work



- minimally displaced fracture in acceptable position

- manual workers / athletes

- anyone who wants to limit time in POP




Set up

- supine, tourniquet / arm table / II


Traction on thumb

- ulna deviation

- flex wrist over roll of drapes

- II shows long axis of scaphoid


Volar stab incision

- over scaphoid tuberosity

- slightly distal

- insert K wire in long axis / central third scaphoid


Check wire position

- AP / lateral / 45o obliques

- drill

- can put K wire into distal radius for stability / second K wire


Insert cannulated screw

- slightly shorter screw to obtain compression

- usually 24 mm


Post op

- POP 2 weeks

- then allow to range out of plaster

- no manual labour / heavy lifting

- check for union at 6/52







Flexed "humpback" deformity

- intrascaphoid angles >35o

- alters kinematics of wrist




Unstable displaced fracture

- non operative treatment

- distal segment flexes

- unites in poor position




DISI deformity

- carpal collapse

- pain and posttraumatic arthritis





- pain

- reduced motion

- reduced grip strength



- arthritis





- volar approach

- osteotomy with osteotome

- cortico-cancellous bone graft

- cannulated screw





Non union

Scaphoid Non union xrayScaphoid Nonunion Xray 2




Convincing association with development of osteoarthritis

- arthritic changes beginning at radial styloid

- progress to scaphocapitate & capitolunate 


End point representing scaphoid nonunion advanced collapse wrist (SNAC)





Humpback deformity (must correct to improve kinematics)

SNAC (contraindication to surgery to achieve union)




Sclerotic margins / no sign of healing


Scaphoid Nonunion Sclerotic Margin


Humpback deformity


Scaphoid Humpback Deformity


Look for signs of AVN


Scaphoid Non union





- exclude AVN

- AVN has low signal on T1 and T2

- if AVN use vascularised bone graft




Identify humpback deformity / plan size and shape of bone graft


Scaphoid Humpback CT 1Scaphoid Humpback CT 2Scaphoid Nonunion Humpback Deformity CT




1.  Russe-type inlay corticocancellous bone graft 

- volar approach

- 2 corticocancellous struts 

- cancellous surfaces facing each other 

- placed longitudinally inside scaphoid

- 85% to 95% union


2.  Fisk wedge graft

- trapezoidal / triangular iliac crest graft

- designed to restore the scaphoid alignment 

- correct humpback deformity

- union rates of 95 - 100% with fixation


Scaphoid NonunionScaphoid Nonunion LateralScaphoid Nonunion Iliac Crest Bone GraftScaphoid Nonunion Iliac crest Bone Graft


Waist Non union




Volar approach

- clean fracture site of fibrous tissue

- osteotomes to reduce deformity

- do not disrupt dorsal cortex

- burrs if needed to remove fibrotic tissue


Scaphoid Approach


Assess for AVN

- look for evidence of punctate bleeding from distal fragment


Place bone graft

- reduce deformity if necessary

- fix with K wire

- place cannulated screw


Scaphoid Bone GraftScaphoid BG ORIF 1Scaphoid BG ORIF 2




90% union

- some loss of ROM and strength 


Proximal pole non union


Scaphoid Proximal Pole Non UnionScaphoid Proximal Pole Nonunion Bone GraftScaphoid Proximal Pole Nonunion Bone Graft 2


Dorsal approach


Lower union rates

- 67%

- ? role for vacularised bone graft




Scaphoid non union advanced collapse




Xray / CT

- non union of scaphoid

- radio-scaphoid OA




Operative Options


1.  Radial Styloidectomy 

- technically straightforward 

- should be considered when arthrosis is localized to this region

- may preserve existing motion in the wrist


2.  Excision of fragment / Soft tissue interposition

- no intercarpal collapse is present

- a small proximal pole non-union 


3.  Scaphoid excision / Silicone replacement 

- shown to be effective when combined with fusion of the capitate to the lunate


4.  Proximal row carpectomy

- may also preserve motion

- grip strength unpredictable

- probably only for low demand elderly


Proximal Row CarpectomyProximal Row Carpectomy LateralProximal Row Carpectomy Lateral


5.  Scaphoidectomy & 4 corner fusion


SNAC AdvancedScaphoidectomy and 4 corner fusion


6.  Wrist arthrodesis

- provides a stable pain free wrist




Ulna Wrist Pain

DDx Wrist Pain Ulna


- dislocation / subluxation

- arthritis 



- degeneration

- tears





- Ulna styloid Fracture

- Carpal fracture / hook of hamate


Ulnocarpal abutment


Ulnocarpal Abutment



- OA

- subluxation


LT instability



- subluxation and rupture

- tendonitis (+/- calcific)








ECU Calcific Tendonitis



Sudden onset of pain without history of trauma

- ulnar aspect of the wrist

- particularly associated with repetitive ulnar deviation




Swelling over the ECU or FCU tendon sheaths 

- occasional crepitation on range of motion




May show calcific deposits within the tendon sheath


ECU Calcific Tendonitis




Generally responds to non operative management

- oral NSAIDS 

- steroid injection with splinting


Subluxation & dislocation




Pisotriquetral view

- forearm positioned 30° supinated off the neutral position

- loss of symmetry between the pisiform and triquetrum is required for the diagnosis

- carpal tunnel view may be helpful in further assessment of the joint






More common problem


Associated with localized tenderness over the pisotriquetral joint

- usually manipulation of the pisiform over the triquetrum causes intense pain

- local anaesthetic injection into the pisotriquetral joint confirms the diagnosis




Often show loss of joint space and osteophyte formation




Rest / NSAID's / HCLA pisotriquetral joint


Pisiform excision from the FCU tendon sheath







Subluxation ECU



6th compartment

- fibro-osseous tunnel overlying 1.5 cm to 2.0 cm of distal ulna

- held tight by the extensor carpi ulnaris tendon sheath

- the extensor retinaculum passes around the ulna to insert on the palmar aspect of the carpus

- extensor retinaculum is a separate structure from the ECU tendon sheath




Forced supination, palmar flexion, and ulnar deviation

- ECU tendon can rupture or attenuate the extensor carpi ulnaris tendon sheath

- dislocate in a palmar and ulnar direction

- the tendon relocates on forearm pronation


Most common in tennis players




Clicking or snapping of ECU with rotation

- may cause pain


Tends to dislocated dorsally with supination




Acute cases


Immobilization in a long-arm plaster splint in pronation 


Chronic cases


Operative reconstruction of the extensor carpi ulnaris tendon sheath

- using extensor retinaculum