Selected

Instructional
Course
Lectures

THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS *

FRANKLIN H. SIM, Editor, Vol. 50

COMMITTEE
JAMES H. BEATY, Chairman
FRANKLIN H. SIM
S. TERRY CANALE
DONALD C. FERLIC

EX OFFICIO
FRANKLIN H. SIM, Editor, Vol. 50
DEMPSEY S. SPRINGFIELD, Deputy Editor of
The Journal of Bone and Joint Surgery
for Instructional Course Lectures
JAMES D. HECKMAN

*Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other
lectures presented at the Academy’s Annual Meeting, will be available in March 2001 in Instructional Course
Lectures, Volume 50. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726
(8 A.M.-5 P.M., Central time).
 Carpal Instability*†
BY RICHARD H. GELBERMAN, M.D.‡, WILLIAM P. COONEY, III, M.D.§,
AND ROBERT M. SZABO, M.D., M.P.H.#

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Anatomy Poirier. The short radiolunate ligament, which is con-

The intracapsular ligaments of the wrist are divided tiguous with palmar fibers of the triangular fibrocarti-
into intrinsic and extrinsic components1-9. The two most lage complex, originates from the palmar margin of the
important intrinsic (interosseous) ligaments, the scapho- distal part of the radius and inserts into the proximal
lunate and lunotriquetral ligaments, are divided into dor- part of the palmar surface of the lunate. The radioscaph-
sal, proximal, and palmar regions (Fig. 1)1,10. The thickest olunate ligament (the ligament of Testut), previously
and strongest region of the scapholunate ligament is lo- thought to be an important stabilizer of the scaphoid, is
cated dorsally10, and that of the lunotriquetral ligament is
located palmarly10.
There are three strong palmar extrinsic radiocarpal
ligaments: the radioscaphocapitate, long radiolunate,
and short radiolunate ligaments2. The radioscaphocapi-
tate ligament, which extends from the radial styloid pro-
cess through a groove in the waist of the scaphoid to the
palmar aspect of the capitate, acts as a fulcrum around
which the scaphoid rotates (Fig. 2). The long radiolu-
nate ligament, which lies parallel to the radioscaphocap-
itate ligament, extends from the palmar rim of the distal
part of the radius to the radial margin of the palmar
horn of the lunate. The long radiolunate ligament and
the palmar region of the lunotriquetral interosseous lig-
ament, thought to be in continuity in earlier studies,
were previously labeled the radiotriquetral ligament7.
Located between the radioscaphocapitate and long ra-
diolunate ligaments, at the level of the midcarpal joint, FIG. 1
is an area of capsular weakness known as the space of Illustration demonstrating the scapholunate and lunotriquetral in-
terosseous ligaments (arrows). S = scaphoid, L = lunate, and T = tri-
*No benefits in any form have been received or will be received quetrum. (Reproduced, with modification, from: Berger, R. A.: The
from a commercial party related directly or indirectly to the subject gross and histologic anatomy of the scapholunate interosseous liga-
of this article. No funds were received in support of this study. ment. J. Hand Surg., 21A: 172, 1996. Reprinted with permission.)
†Printed with permission of the American Academy of Ortho-
paedic Surgeons. This article, as well as other lectures presented at the
Academy’s Annual Meeting, will be available in March 2001 in In- now considered to be a neurovascular pedicle derived
structional Course Lectures, Volume 50. The complete volume can be from the anterior interosseous and radial arteries and
ordered online at www.aaos.org, or by calling 800-626-6726 (8 A.M.-5
P.M., Central time). from the anterior interosseous nerve3. The ulnolunate
‡Department of Orthopaedic Surgery, Barnes-Jewish Hospital at and ulnotriquetral ligaments arise from the volar edge
Washington University, One Barnes Plaza, Suite 11300, St. Louis, of the triangular fibrocartilage and insert into the lunate
Missouri 63110. E-mail address: gelbermanr@msnotes.wustl.edu.
§Department of Orthopaedic Surgery, Mayo Graduate School of and the triquetrum, respectively. The dorsal radiocarpal
Medicine, 1085 Orchard Acres Lane S.W., Rochester, Minnesota 55902. ligament originates from the dorsal margin of the distal
E-mail address: cooney.william@mayo.edu. part of the radius and extends ulnarly and distally to at-
#Division of Plastic Surgery, Department of Surgery, University of
California, Davis, School of Medicine, 4860 Y Street, Sacramento, tach to the lunate, the lunotriquetral interosseous liga-
California 95817. E-mail address: rmszabo@ucdavis.edu. ment, and the dorsal tubercle of the triquetrum (Fig.

578 THE JOURNAL OF BONE AND JOINT SURGERY

 CARPAL INSTABILITY 579

umn (Fig. 5)8. The scaphoid is considered to be the

stabilizing link for the midcarpal joint, and the tri-
quetrum is thought to be the pivot point for carpal
rotation8,9. Flexion and extension occur through the
central column, and radial and ulnar deviation occur by
rotation of the scaphoid laterally and the triquetrum
medially. With the proximal row independence and oval
ring concepts, Linscheid13 and Lichtman et al.14 charac-
terized the carpus as a ring that allows reciprocal mo-
tion during radial and ulnar deviation and flexion and
extension of the wrist (Fig. 6). Central to this concept is
the observation that radial and ulnar deviation and flex-
ion and extension occur reciprocally between the radio-
carpal and midcarpal joints (that is, movement by one
row is in the opposite direction from that by the other).
An interruption of the proximal carpal row at any point
FIG. 2
in the ring results in carpal instability.
Illustration demonstrating the palmar wrist ligaments. UT = ulno-
triquetral, UL = ulnolunate, SC = scaphocapitate, RSC = radio-
scaphocapitate, LRL = long radiolunate, and SRL = short radiolunate.
Terminology
The space between the long radiolunate and short radiolunate liga- The carpus is considered clinically unstable if it ex-
ments is where the ligament of Testut (or the radioscapholunate liga-
ment), now known to be a neurovascular pedicle, enters the radiocar- hibits symptomatic malalignment, is not able to bear
pal joint. loads, and does not have normal kinematics during any
portion of its arc of motion15. Static instability refers to
carpal malalignment that can be detected on standard
posteroanterior and lateral radiographs16. Dynamic in-
stability refers to carpal malalignment that is repro-
duced with physical examination maneuvers and when
stress radiographs are made. With dynamic instability,
there is no evidence of carpal bone malalignment on
plain radiographs. The terms dorsal intercalated insta-
bility and volar intercalated instability refer to the ap-
pearance of the lunate, the intercalated segment, on the

FIG. 3
Illustration demonstrating the dorsal wrist ligaments. DIC = dorsal
intercarpal, DRC = dorsal radiocarpal, and DRU = dorsal radioulnar.

3)11. The dorsal intercarpal ligament originates from the

triquetrum and extends radially to insert into the lunate,
the dorsal groove of the scaphoid, and the trapezium11.

Kinematics
There are two prevailing theories, the columnar and
oval ring concepts, that have been used to characterize
carpal kinematics. The columnar carpus concept, intro- FIG. 4
duced by Navarro in 1921, describes the carpus as a se-
Illustration demonstrating Navarro’s columnar carpus12. The lateral
ries of three longitudinal columns (the central [flexion- column comprises the scaphoid, trapezium, and trapezoid; the central
extension], lateral [mobile], and medial [rotational] col- column comprises the lunate, capitate, and hamate; and the medial col-
umns) (Fig. 4)12. Taleisnik modified Navarro’s theory, umn comprises the triquetrum and pisiform. (Reproduced, with modi-
fication, from: Lichtman, D. M.; Schneider, J. R.; Swafford, A. R.; and
adding the trapezium and trapezoid to the central col- Mack, G. R.: Ulnar midcarpal instability — clinical and laboratory
umn and eliminating the pisiform from the medial col- analysis. J. Hand Surg., 6: 522, 1981. Reprinted with permission.)

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580 R. H. GELBERMAN, W. P. COONEY, III, AND R. M. SZABO

ous patterns of carpal instability. Carpal instability

dissociative connotes an injury to one of the major in-
trinsic carpal ligaments, such as that seen in scapho-
lunate dissociation and perilunate dislocation. Carpal
instability nondissociative indicates an injury to a ma-
jor extrinsic ligament, such as occurs in dorsal carpal
subluxation, midcarpal instability, volar carpal sublux-
ation, or capitate-lunate instability. Carpal instability
adaptive refers to carpal instability resulting from an
external cause, such as that seen at the radiocarpal or
midcarpal joint following severe malunion of the distal
part of the radius.

Mechanisms of Injury
In an experimental study, Mayfield et al. determined
that the mechanism of injury for most carpal dislocations
is a fall on the outstretched hand causing wrist extension,
FIG. 5 ulnar deviation, and intercarpal supination18,19. Sequential
Illustration demonstrating Taleisnik’s modification of the columnar ligamentous injury, called progressive perilunar instabil-
carpus8. The trapezium and trapezoid are included in the central col- ity, was noted to be initiated on the radial aspect of the
umn, and the pisiform is eliminated from the medial column. (Repro-
duced, with modification, from: Lichtman, D. M.; Schneider, J. R.;
wrist and to extend across the perilunate ligaments to the
Swafford, A. R.; and Mack, G. R.: Ulnar midcarpal instability — clin- ulnar aspect of the wrist. Four stages of progressive per-
ical and laboratory analysis. J. Hand Surg., 6: 522, 1981. Reprinted ilunar instability were defined, including scapholunate
with permission.)
dissociation caused by injury to the scapholunate in-
terosseous and palmar radioscaphocapitate ligaments
(stage I), dislocation of the capitolunate joint through the
space of Poirier (stage II), separation of the triquetrum

FIG. 6
Illustration demonstrating the oval ring concept of Lichtman et al.14.
(Reproduced, with modification, from: Lichtman, D. M.; Schneider,
J. R.; Swafford, A. R.; and Mack, G. R.: Ulnar midcarpal instability —
clinical and laboratory analysis. J. Hand Surg., 6: 522, 1981. Reprinted
with permission.)
FIG. 7
17
lateral radiograph . In dorsal intercalated instability, Gilford et al. described the wrist as a link joint (Fig. 7, A), noting
that instability occurs in compression because of the intercalated seg-
the lunate is angulated dorsally in the sagittal plane and ment (the proximal carpal row represented by the lunate [L]) (Fig. 7,
the capitate is displaced dorsal to the radiometacarpal B). The scaphoid (S in Fig. 7, C) links the radius to the distal carpal
axis (radiolunate angle, more than 10 degrees) (Fig. 7). row and provides stability against compression forces during wrist
flexion and extension. C = capitate, and R = radius. (Reprinted, with
In volar intercalated instability, the lunate angulates permission, from: Green, D. P.: Carpal dislocation and instabilities. In
palmarly (radiolunate angle, 10 degrees in a palmar di- Operative Hand Surgery, edited by D. P. Green. Ed. 3, p. 863. New
rection), which causes the capitate to become displaced York, Churchill Livingstone, 1993. [Green noted that the figure was
modified from: Gilford, W. W.; Bolton, R. H.; and Lambrinudi, C.: The
palmar to the radiometacarpal axis. mechanism of the wrist joint with special reference to fractures of the
Other terms have been introduced to clarify vari- scaphoid. Guy’s Hosp. Rep., 92: 52-59, 1943.])

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 CARPAL INSTABILITY 581

scanning is not as helpful as other studies in the evalua-

tion of wrists with suspected carpal instability.
Arthrography of the wrist, performed alone or with
videofluoroscopy, is a useful study in the evaluation of a
wrist with carpal instability23. While wrist dynamics are
best assessed with fluoroscopy, arthrography remains
the standard study for the carpal ligaments and the tri-
angular fibrocartilage complex24. Midcarpal, radiocar-
pal, and distal radioulnar arthrography (triple-phase
injection) provides valuable definitive data on the integ-

FIG. 8-A
Figs. 8-A, 8-B, and 8-C: Midcarpal arthrograms diagnostic for a
lunotriquetral ligament tear.
Fig. 8-A: Contrast material is injected into the midcarpal joint.

from the lunate with associated injury to the lunotrique-

tral and ulnotriquetral ligaments (stage III), and palmar
lunate dislocation due to injury to the dorsal radiocarpal
ligament (stage IV). Transradial styloid, transscaphoid,
and transcapitate fractures are associated with perilunate
injuries that progress from lateral to medial, ultimately
involving the lunotriquetral ligament, the volar ulnocar- FIG. 8-B
pal ligaments, and the ulnar styloid process20. Contrast material is noted to extend across the lunotriquetral joint
(arrow).
Radiographic and
Other Diagnostic Studies
Six radiographs are made for wrists with suspected
carpal instability. These include posteroanterior, lateral,
radial and ulnar deviation, and flexion and extension
views21. An additional posteroanterior radiograph of the
wrist with a clenched and loaded fist is made to rule out
scapholunate instability. The alignment of the proximal
and distal carpal rows is measured with Gilula’s method.
The midcarpal joint is visualized as an acetabulum or
cup where the capitate and hamate articulate with the
proximal carpal row. Interruption of the normal carpal
arc of either the proximal or the distal carpal row indi-
cates an instability pattern.
The use of radionuclide bone scans as screening
tools is indicated for the localization of the cause of
obscure wrist pain such as that due to a chondral frac-
ture22. While a positive bone scan provides information
on the location of a wrist abnormality, it is rarely diag-
nostic. A negative bone scan, which suggests that a seri-
ous injury has not occurred, does not rule out carpal FIG. 8-C
instability, especially in the early stages when reactive Contrast material fills the scapholunate interval but does not cross
bone changes have not yet taken place. Overall, bone- at this location into the radiocarpal joint.

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582 R. H. GELBERMAN, W. P. COONEY, III, AND R. M. SZABO

complex, selective injection of the distal radioulnar joint

is carried out. However, in some cases, both the radio-
carpal and the distal radioulnar joint must be inspected
to show a communicating defect. While false-positive
and false-negative arthrograms have been reported, ar-
thrography is of considerable value as a primary study
for intrinsic carpal ligament injury.
Tomography of the wrist (polytomography or com-
puted tomography), which is useful for evaluating the
alignment of the carpal bones, is most helpful for assess-
ing the fractures and fracture-dislocations that are fre-
quently associated with carpal instability25. Complex
motion polytomography is of special value for obtaining
biplanar images of the carpus. Computed axial tomog-
raphy26, which provides useful cross-sectional images, is
particularly helpful if three-dimensional reconstruction
is performed. In the evaluation of wrist injuries, tomog-
raphy is generally limited to cases in which a carpal frac-
FIG. 9 ture is suspected.
Figs. 9 and 10: A wrist with acute static scapholunate dissociation.
Magnetic resonance imaging, used frequently for
Fig. 9: Posteroanterior radiograph. The scaphoid is flexed (fore- the evaluation of wrist pain, is less helpful than other
shortened), there is a scaphoid ring sign, the distance between the studies for the assessment of a wrist with carpal in-
proximal aspect of the ring and the proximal pole of the scaphoid is
less than seven millimeters, and there is a gap between the scaphoid
stability27,28. Magnetic resonance imaging is most useful
and the lunate of greater than three millimeters (arrow). In addition, for evaluating suspected cases of osteonecrosis of bone
the lunate and the triquetrum are dorsiflexed (the lunate is quadrilat- and tumors of bone or soft tissue. While it can be help-
eral in shape, and the triquetrum is displaced distally on the hamate),
while the scaphoid is flexed (the ring sign), which indicates an inter-
ful for visualizing the triangular fibrocartilage com-
ruption in the proximal carpal row at the scapholunate interval. plex, it is not particularly useful for the evaluation of
carpal ligament injuries unless gadolinium enhance-
ment is performed28,29. The consistency with which both
rity of the intrinsic intercarpal ligaments. Contrast ma- the radiocarpal and the interosseous ligaments are
terial injected into the midcarpal joint does not extend demonstrated, however, is not sufficient for this to be a
into the radiocarpal joint unless there is either an acute primary method of evaluation.
or a degenerative intrinsic ligament tear (Figs. 8-A, 8-B, Arthroscopy has replaced arthrography in many cen-
and 8-C). For injuries of the triangular fibrocartilage ters30,31 as the definitive diagnostic study for wrists with

FIG. 10
Lateral radiograph demonstrating an increased scapholunate angle as measured with the tangential measurement method. The longitudi-
nal axis of the scaphoid is demonstrated by creating a line that connects the proximal surfaces of the two poles of the scaphoid. The angle is
90 degrees.

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 CARPAL INSTABILITY 583

the midcarpal joint. In the radiocarpal joint, triangulation

probing of the scapholunate interosseous ligament, the
lunotriquetral interosseous ligament, and the triangular
fibrocartilage complex is carried out. The volar carpal lig-
aments are assessed in a radial-to-ulnar direction to de-
termine whether extrinsic ligament injury has occurred.
Midcarpal arthroscopy, with use of a triangulation probe,
is performed routinely. The space between the scaphoid
and lunate bones is assessed for evidence of ligamentous
laxity. A diagnosis of partial or complete carpal ligament
injury is established on the basis of the ease of separation
of the scaphoid from the lunate and of the lunate from
the triquetrum. If the probe can be rotated within the
joint, a tear of the scapholunate or lunotriquetral in-
terosseous ligament is suggested. If either the probe or
the arthroscope can be passed from the midcarpal to the
radiocarpal joint, rotatory subluxation of the scaphoid (a
complete scapholunate ligament tear with extrinsic liga-
ment laxity) is confirmed. Within the radiocarpal joint, a
triangulation probe assists in the assessment of the size,
location, and extent of tears of the triangular fibrocarti-
lage complex. Associated osseous injuries (fractures of
the proximal pole of the scaphoid or dorsal triquetral
chip fractures) can be visualized also. Wrist arthrography
and arthroscopy may be carried out in sequence within
the operating room. Comprehensive intraoperative as-
FIG. 11
sessment currently includes fluoroscopy of the wrist with
Figs. 11 through 14: A wrist with acute stage-III dorsal perilunate
dislocation according to the system of Mayfield et al.18,19. the patient under anesthesia in the operating room, fol-
Fig. 11: Preoperative posteroanterior radiograph demonstrating lowed by wrist arthrography and then by wrist arthros-
overlap of the carpal bones (normally only the trapezium and the copy, if indicated. Dynamic fluoroscopic imaging studies
trapezoid, and the triquetrum and the pisiform, overlap on the pos-
teroanterior radiograph), a triangular shape to the lunate, and a and arthroscopy are particularly useful when performed
scapholunate gap of seven millimeters. sequentially in the operating room to confirm the pres-
ence of a ligamentous injury and to plan the appropriate
suspected carpal instability. Recent reports have indi- operative approach.
cated that arthroscopic evaluation of the wrist is more ac-
curate and specific than arthrography in detecting the site Acute Static Scapholunate Dissociation
and extent of ligament injury21,32. Diagnostic wrist arthros- Acute static scapholunate dissociation, which may
copy includes an examination of both the radiocarpal and occur as an isolated entity or as a late sequela of a peri-

FIG. 12
Preoperative lateral radiograph demonstrating that while the lunate is palmar flexed it rests in the lunate fossa of the radius. The scaphoid
and the capitate are displaced dorsal to the longitudinal axis of the radius.

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584 R. H. GELBERMAN, W. P. COONEY, III, AND R. M. SZABO

lunate dislocation, results from injury to the scapholu- eziotrapezoid and scaphocapitate arthrodeses to avoid
nate interosseous and palmar radioscaphoid ligaments33. radial styloid-scaphoid impingement. Following both of
Depending on the extent of ligamentous injury, there is these limited intercarpal arthrodeses, residual flexion and
either diffuse tenderness of the carpus or point tender- extension of the wrist is 50 to 60 percent of that on the
ness over the scapholunate interval. Radiographs reveal contralateral side and residual radial and ulnar deviation
all five key features of rotatory subluxation of the scaph- is 60 to 70 percent of that on the contralateral side48,49,52-54.
oid (Figs. 9 and 10). While ligamentous repair within The most common complications are nonunion, which is
three weeks after the injury34,35 is preferred, delayed re- seen in as many as 30 percent of patients, and radio-
pair can be carried out as long as four to six months scaphoid impingement55-57.
from the time of the injury. Several factors govern the
feasibility of delayed ligamentous repair (repair later Acute Perilunate Dislocation
than three weeks after the time of the injury); these fac- With acute perilunate dislocation, the typical find-
tors include the identification of a substantial, reparable ings on physical examination are swelling, pain, and
scapholunate interosseous ligament and the isolation of deformity of the wrist and the typical finding on radio-
a palmar flexed scaphoid that can be reduced without graphic examination is gross disturbance of the inter-
the necessity for extensive circumferential dissection. carpal relationships (Fig. 11). With dorsal perilunate
The extent to which the scaphoid becomes fixed in pal- dislocation, lateral radiographs demonstrate that the
mar flexion is dependent on the magnitude of the initial longitudinal axis of the capitate is displaced dorsal to
capsular injury, with scarring and capsular contracture the longitudinal axis of the radius (Fig. 12). With lunate
increasing over time. dislocation, the longitudinal axis of the capitate is co-
Neither closed reduction alone nor closed reduction
and percutaneous pin fixation is uniformly successful in
maintaining carpal alignment and in achieving satisfac-
tory long-term outcomes in wrists with acute scapho-
lunate instability. The preferred method of treatment is
open reduction of the carpus through a dorsal approach,
pinning of the scaphoid to the lunate and to the capi-
tate with two 0.045-inch (0.114-centimeter) Kirschner
wires36-40, and direct repair of the scapholunate ligament.
Ligament repair is carried out either with direct suture
for ligaments torn in their midsubstance or with pull-out
sutures or suture anchors for ligaments avulsed from
bone. The wrist is immobilized in neutral position in an
above-the-elbow thumb-spica cast for eight weeks34, fol-
lowing which time the pins are removed and active mo-
tion is initiated.

Chronic Scapholunate Dissociation

For wrists in which the scapholunate interosseous lig-
ament cannot be repaired primarily, attempts to recon-
struct the dorsal and palmar ligaments of the scaphoid
with any combination of late ligamentous repair, tendon-
grafting, and capsulodesis, while feasible41, have not pro-
vided consistent pain relief and have not maintained the
alignment of the carpus over the long term36,42,43. Either
scaphotrapeziotrapezoid or scaphocapitate intercarpal
arthrodesis is effective operative management. Each has
been shown to produce similar reductions in the global
range of motion of the wrist and comparable effects on
relative intercarpal motion44. While some experimental
FIG. 13
studies have shown that these intercarpal arthrodeses
cause increased loads across the radioscaphoid joint45,46, Postoperative posteroanterior radiograph demonstrating reduction
of the scaphoid with fixation of the scaphoid to the lunate with two
increased shear stresses on the lunate, and increased 0.045-inch (0.114-centimeter) Kirschner wires. A third Kirschner wire
tension on the surrounding ligaments44, others have indi- secures the scaphoid to the capitate. The scapholunate interosseous
cated that the long-term functional results are satisfac- ligament was reattached to the lunate with a suture anchor. The
lunotriquetral joint was reduced, and the triquetrum was secured to
tory46-51. Most authors have recommended that radial the lunate with a 0.045-inch Kirschner wire. The lunotriquetral liga-
styloidectomy be carried out at the time of scaphotrap- ment was repaired by direct suture.

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 CARPAL INSTABILITY 585

FIG. 14
Postoperative lateral radiograph demonstrating that the capitate and the lunate are colinear with the radius and that the capitate is concen-
tric with the articular surface of the lunate.

linear with the axis of the radius and the lunate is dis- duction of an acute perilunate dislocation, with or with-
placed palmarly17. Distortion of the concentric arcs of out percutaneous pin fixation58. Currently, the treatment
the proximal and distal rows indicates that the injury of choice is immediate closed reduction followed by open
has extended to the ulnar side of the carpus. If initial ra- ligamentous repair through a dorsal approach. Closed re-
diographs are confusing, it is helpful to make distraction duction is carried out in the emergency room with trac-
radiographs with ten to fifteen pounds (4.5 to 6.8 kilo- tion (ten pounds [4.5 kilograms] for ten minutes) applied
grams) of fingertrap traction. Radiographs of the con- to the hand with fingertraps. The fingertraps are re-
tralateral wrist in neutral alignment are made, and moved, and manual longitudinal traction is applied. As
measurements are made from reference points on the the wrist is extended, the lunate is stabilized by the exam-
lunate and scaphoid. iner’s thumb. With traction maintained, the wrist is grad-
Previous investigators have noted that there is a low ually palmar flexed and the capitate is reduced into the
likelihood of achieving long-term success with closed re- concavity of the lunate59. The patient is then taken to the

FIG. 15
Photograph demonstrating how point tenderness over the scapholunate interval is elicited in wrists with dynamic scapholunate instability.

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586 R. H. GELBERMAN, W. P. COONEY, III, AND R. M. SZABO

FIG. 16-A

FIG. 16-B

FIG. 16-C
Figs. 16-A, 16-B, and 16-C: Photographs demonstrating the scaphoid shift maneuver.
Figs. 16-A and 16-B: Volar and lateral views showing how the maneuver is performed by applying pressure over the scaphoid while the wrist
is held in ulnar deviation.
Fig. 16-C: As the wrist is brought from ulnar to radial deviation, the scaphoid’s proximal pole returns to its position in the scaphoid fossa of
the radius. The patient notes wrist pain with the maneuver, and both the patient and the examiner note a clunking sensation.

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 CARPAL INSTABILITY 587

FIG. 17
Figs. 17 and 18: Photograph and radiograph demonstrating the technique of dorsal capsulodesis.
Fig. 17: Dorsal capsulodesis is performed by creating a transversely directed trough in the distal portion of the scaphoid. A one-centimeter-
wide dorsal radius-based capsular flap, aligned with the longitudinal axis of the thumb metacarpal (arrows), is attached to the scaphoid with su-
ture anchors.

operating room, and regional or general anesthesia is ad- ation of the scaphoid is performed with insertion of a
ministered. A longitudinal dorsal incision is made from compression screw through a dorsal incision. Injury to
the base of the index and long metacarpals, over Lister’s the dorsolateral branches of the radial artery, which
tubercle to the distal aspect of the forearm. Dissection of enter the scaphoid through the dorsal ridge, can be
the carpus is carried out beneath the infratendinous reti- avoided by direct visualization and protection of the
naculum of the fourth dorsal compartment. The scapho- dorsolateral vascular leash. An additional Kirschner
lunate and lunotriquetral interosseous ligaments are
inspected. After reduction of the scapholunate joint,
three to four 0.045-inch (0.114-centimeter) Kirschner
wires are inserted, extending from the scaphoid to the lu-
nate, from the scaphoid to the capitate, and on occasion
from the radius to the lunate. If the lunotriquetral liga-
ment is torn, the lunotriquetral joint is reduced and
pinned with an additional 0.045-inch Kirschner wire
(Figs. 13 and 14). The scapholunate and lunotriquetral in-
terosseous ligaments are repaired with direct suture with
4.0 braided Dacron or with suture anchors. Currently, a
palmar incision is made in addition, particularly if there
is a palmar lunate (stage-IV18,19) dislocation that cannot
be reduced closed or if there are findings indicative of
acute carpal tunnel syndrome.
Postoperatively, the wrist is immobilized in an above-
the-elbow plaster-reinforced compression dressing for
fourteen days. A below-the-elbow thumb-spica cast is
then applied and is maintained for an additional six
weeks. Eight weeks postoperatively, the cast is removed,
the pins are removed, and active motion is initiated60. In a
recent multicenter study of perilunate dislocations and
fracture-dislocations, the authors noted that both open
injury and a delay in treatment had adverse effects on
outcomes and that postoperative arthritis was common
(seen in as many as 56 percent of cases)20,58,61.
FIG. 18
Transscaphoid Perilunate Dislocation One or two 0.045-inch (0.114-centimeter) Kirschner wires, inserted
through the scaphoid’s distal pole, provide stabilization to the capi-
Initial evaluation and treatment is similar to that tate. The wrist is immobilized postoperatively in 20 degrees of exten-
carried out for perilunate dislocation20,58,60,61. Internal fix- sion and ulnar deviation for six weeks.

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588 R. H. GELBERMAN, W. P. COONEY, III, AND R. M. SZABO

wire may be placed in the scaphoid to provide rotational

stability. Immobilization in a thumb-spica cast is main-
tained until there are clinical and radiographic signs of
scaphoid union as evidenced by the absence of tender-
ness in the anatomical snuffbox on physical examina-
tion and the appearance of trabeculae extending across
the fracture site on plain radiographs.

Scaphoid Dislocation
Palmar radial displacement of the proximal pole of
the scaphoid from the scaphoid fossa of the distal part of
the radius is diagnostic of a scaphoid rather than a perilu-
nate dislocation. The interposition of capsular or liga-
mentous tissue may prevent closed reduction. Treatment,
which is similar to that recommended for acute scapho-
lunate dissociation, consists of open reduction of the
scapholunate joint, insertion of two 0.045-inch (0.114-
centimeter) Kirschner wires extending from the scaphoid
to the lunate and from the scaphoid to the capitate, and
direct repair of the scapholunate interosseous ligament.
Immobilization in a below-the-elbow thumb-spica cast is
maintained for eight weeks, after which time active mo-
tion is initiated.

Dynamic Scapholunate Instability

Initially described by Taleisnik in 198062, dynamic
scapholunate instability is the most common cause of
wrist pain and instability in adolescents and young
adults63. Although a precise anatomical cause has not
FIG. 19
been determined, it is likely that attenuation of the pal-
mar radioscaphoid and scapholunate interosseous liga- Posteroanterior radiograph of the wrist, demonstrating stage-III
scapholunate advanced collapse. There is severe narrowing of the ra-
ments is the basis for this instability pattern8,62,64-67. While dioscaphoid joint space, from the tip of the styloid process of the ra-
radiographic findings are frequently normal61,64,68, con- dius to the lateral edge of the scaphoid fossa, and narrowing of the
sistent findings on physical examination confirm the capitolunate joint space (arrows). The radiolunate joint is preserved.
diagnosis. There is point tenderness over the scapholu-
nate interval (Fig. 15), and provocative tests reproduce In a recent study, nineteen patients (twenty wrists)
symptoms of instability. The scaphoid shift maneuver, with dynamic instability were treated nonoperatively
performed as described by Watson et al.69, is the most with splinting of the wrist, oral administration of non-
useful clinical test. To perform this maneuver, pressure steroidal anti-inflammatory medication, and modifica-
is applied to the palmar tubercle of the scaphoid by the tion of activities63. No patient in that study, however,
examiner’s thumb with the wrist in ulnar deviation had a substantial reduction in symptoms, even after
(Figs. 16-A and 16-B). In wrists with instability, the twelve weeks and longer durations of nonoperative
scaphoid is displaced dorsally over the lip of the radius. treatment.
As the wrist is brought from ulnar to radial deviation, For wrists with persistent incapacitating pain and
the scaphoid’s proximal pole returns to its position in instability after a trial of nonoperative care, dorsal cap-
the scaphoid fossa of the radius (Fig. 16-C). As the sulodesis, as described by Blatt64,71 and as modified by
scaphoid reduces, a clunking sensation and wrist pain Wintman et al.63, is the treatment of choice (Figs. 17 and
are noted. Although 110 (11 percent) of 1000 randomly 18). Results, reported in three recent studies, have been
examined wrists were found to have unilateral, asymp- consistent with regard to the effectiveness of this proce-
tomatic increased scaphoid mobility on the scaphoid dure in eliminating symptoms of instability and pain in
shift test70, patients with dynamic instability are distin- more than 90 percent of patients and in the achievement
guished by their symptoms of instability and pain with of high levels of satisfaction as reported on question-
this maneuver. The unaffected wrist is examined, and an naires36,63,64. Patients reported that substantial improve-
assessment for generalized ligamentous laxity is carried ments occurred in activities such as brushing teeth,
out. Additional studies, such as three-portal wrist ar- opening automobile doors, shoveling, sweeping, throw-
thrography and wrist arthroscopy, have not been found ing, and using a screwdriver63. While dorsal capsulodesis
to be helpful in confirming the diagnosis63. has been shown to cause a mean loss of wrist flexion of 15

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 CARPAL INSTABILITY 589

such as triscaphoid arthrodesis, which causes a far greater

loss of wrist motion in all planes36.

Dorsal Wrist Ganglia and

Dynamic Carpal Instability
Dorsal wrist ganglia, which most often originate
from the scapholunate interosseous ligament in young
adults, have been shown to be associated with symp-
toms and signs of dynamic scapholunate instability. In a
recent study72 of eighteen patients (nineteen wrists) with
a dorsal wrist ganglion and dynamic scapholunate insta-
bility, treatment consisted of excision of the ganglion to
the level of the scapholunate interosseous ligament and
postoperative immobilization of the wrist in 20 degrees
of extension for two weeks. On follow-up evaluation,
two patients had continued wrist pain and one had a re-
current ganglion. All but one patient in this series, in-
cluding two who had signs of generalized ligamentous
laxity, had a stable nontender wrist on follow-up physi-
cal examination at one year. It appears that postopera-
tive dorsal capsular scarring following ganglion excision
and two weeks of wrist immobilization stabilizes the
scaphoid sufficiently to alleviate symptoms and signs of
dynamic scapholunate instability.

Scapholunate Advanced Collapse

The most common form of wrist arthritis, scapholu-
nate advanced collapse, evolves in a predictable se-
quence73. Injury to the scapholunate interosseous and
FIG. 20-A
palmar radioscaphoid ligaments has been shown to lead
to a progressive shift of the pressure centroid of the
Figs. 20-A and 20-B: Posteroanterior and lateral radiographs show-
ing a malunion of the distal part of the radius. Dorsal lunate sublux- scaphoid74, resulting in a change in the regions of peak
ation occurs secondary to increased dorsal tilt. There is evidence of a intra-articular contact between the scaphoid and the
zigzag collapse pattern of the lunate and the capitate. distal part of the radius. Three distinct time-related de-
generative changes occur in scapholunate advanced col-
degrees, this procedure appears to provide superior out- lapse; these consist of joint-space narrowing between
comes when compared with the alternative methods that the tip of the styloid process of the radius and the distal
have been used for the treatment of dynamic instability, outer aspect of the scaphoid in stage I, degenerative

FIG. 20-B

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590 R. H. GELBERMAN, W. P. COONEY, III, AND R. M. SZABO

to the longitudinal axis of the radius when the wrist is in

neutral position, and each is effective in reducing pain
and slowing the progression of degenerative arthritis. Ra-
dial styloidectomy, performed simultaneously and con-
sisting of removal of seven millimeters of the radial
styloid process dorsally and four millimeters palmarly,
consistently minimizes symptoms due to abutment and
eliminates pain due to arthritis at the distal aspect of the
radioscaphoid joint.
For wrists with degenerative arthritis involving the
entire radioscaphoid joint (stage II) or the radioscaphoid
and capitolunate joints (stage III), a motion-preserving
reconstructive procedure, either capitate-lunate-hamate-
FIG. 21
triquetrum (four-corner) arthrodesis with scaphoid ex-
Schematic drawing of a wrist with midcarpal instability demon-
strating flexion of the lunocapitate joint. The dotted oblique line cision or proximal row carpectomy, is recommended.
through the distal part of the radius is the site of the proposed correc- Studies by Imbriglia et al.75 and by Neviaser76 on prox-
tive osteotomy. imal row carpectomy have indicated that, while high lev-
els of wrist motion and grip strength are maintained,
changes along the entire articular surface between the there is persistent pain, a failure to return to strenuous
radius and the scaphoid in stage II, and narrowing of the work, and a recommendation for conversion to arthro-
capitolunate joint space in stage III (Fig. 19). The obser- desis in as many as 15 percent of patients. While care-
vation that the radiolunate joint is spared consistently in fully performed four-corner arthrodesis with scaphoid
wrists with scapholunate advanced collapse has served excision provides levels of patient satisfaction and grip
as the anatomical basis for several of the most widely strength that are similar to those seen with proximal row
used treatment methods over the past two decades. carpectomy, values for the range of motion of the wrist
Initial treatment consists of oral administration of are 15 to 20 degrees lower73,77. Attempts to limit the
nonsteroidal anti-inflammatory medication, application arthrodesis to the capitolunate joint in order to achieve a
of a wrist splint, and modification of activities. For wrists higher postoperative range of motion of the wrist have
with stage-I scapholunate advanced collapse that are re- been unsuccessful because of high rates of nonunion78.
sistant to nonoperative measures, operative treatment Recent studies have confirmed that proximal row
designed to stabilize the carpus so that compressive and carpectomy maintains an arc of wrist flexion and exten-
shear forces are transmitted through the normal radio- sion that is approximately 20 degrees greater than the
scapholunate articulation is recommended. As ligament motion arc that is achieved with four-corner arthrodesis.
reconstruction has not proved to be consistently effective While grip-strength values and overall patient-satisfaction
in maintaining correction of the excessively flexed scaph- scores have been similar, specific complications have
oid, intercarpal arthrodesis has become the operative been noted with each procedure. Proximal row carpec-
procedure of choice. Either scaphotrapeziotrapezoid or tomy appears to be particularly unpredictable in laborers
scaphocapitate arthrodesis achieves the goal of maintain- and in wrists with stage-III scapholunate advanced col-
ing the scaphoid in an alignment that is 50 to 55 degrees lapse. Four-corner arthrodesis has been associated with

FIG. 22
Radiograph showing a malunion of the distal part of the radius with 40 degrees of dorsiflexion of the distal part of the radius, a scapholunate an-
gle of 75 degrees, and a lunocapitate angle of 15 degrees.

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 CARPAL INSTABILITY 591

FIG. 23
Schematic drawings of a corrective osteotomy, showing interposition of bone graft from the iliac crest to restore the length and tilt of the dis-
tal part of the radius. The upper-left drawing shows the graft in place with temporary Kirschner-wire fixation, the lower-left drawing is a lateral
view of T-plate fixation with the interposition graft, and the right drawing is a posteroanterior view of the graft and T-plate in place.

failure rates of as high as 30 percent79, and isolated capi- carpal instability83,84. The osseous deformity leads to mal-
tolunate arthrodesis has been associated with a nonunion alignment of the bones of the proximal carpal row, loss
rate of 50 percent (four of eight)80. Studies have indicated of wrist flexion, and radiocarpal or midcarpal instability.
that either scaphotrapeziotrapezoid or scaphocapitate Biomechanical studies have shown that there is a shift of
arthrodesis with radial styloidectomy is indicated for load from the radius to the ulna (from 20 to 67 percent of
stage-I scapholunate advanced collapse52,73. For stage II, the total load) when dorsal angulation is increased be-
either four-corner arthrodesis with scaphoid excision or yond 15 degrees of dorsal tilt (a 26-degree loss of normal
proximal row carpectomy is an effective reconstructive palmar tilt)85,86. Fernandez observed that symptoms oc-
procedure. There is general consensus that either lim- curred most frequently when dorsal angulation of the
ited wrist arthrodesis with scaphoid excision or proximal distal part of the radius was greater than 20 degrees87,
row carpectomy with fascial interposition is the pro- and other authors have recommended that 15 to 30 de-
cedure of choice for stage-III scapholunate advanced grees of dorsal angulation be considered an indication
collapse79-82. for distal radial osteotomy.
Adaptive instability of the carpus may occur at
Adaptive Instability either the radiocarpal or the midcarpal joint88,89. With
Dorsiflexion malunion after fracture of the distal radiocarpal instability, dorsal radiocarpal subluxation
part of the radius is the most common cause of adaptive occurs as the lunate contact area translates dorsally

FIG. 24
Postoperative lateral radiograph showing the scapholunate angle corrected to 45 degrees and the lunocapitate angle corrected to less than 5
degrees after corrective osteotomy for the treatment of malunion of the distal part of the radius.

VOL. 82-A, NO. 4, APRIL 2000

592 R. H. GELBERMAN, W. P. COONEY, III, AND R. M. SZABO

along the inclined plane of the distal part of the radius17 dius or causing palmar or dorsal displacement of the
(Figs. 20-A and 20-B). For the hand to become re- carpus.
aligned with the forearm, flexion takes place at the ra- Patients with adaptive carpal instability most fre-
diolunate joint. With midcarpal instability, the angular quently present with wrist pain, which is often delayed
relationship between the articular surface of the radius in onset for several weeks to months after fracture-
and the longitudinal axis of the lunate remains un- healing, and loss of wrist motion and grip strength. Ad-
changed. For the hand to become realigned with the ditional sequelae may include median neuropathy at the
forearm, palmar flexion occurs at the lunocapitate wrist and tendon rupture83,84.
level (Figs. 21 and 22). Instability occurs gradually, af- The preferred treatment for radial dorsiflexion
ter the fracture has united, as the midcarpal joint is malunion in young patients (those less than fifty years of
stressed during loading of the wrist. With both types of age) who have greater than five millimeters of shorten-
instability, a zigzag collapse deformity of the carpus re- ing consists of operative restoration of both radial
sults. While the condition is initially dynamic, both ra- length and palmar tilt. Recent modifications in preoper-
diocarpal and midcarpal instability may become static ative planning and operative technique have improved
over time90. Adaptive carpal instability results in a the outcome of dorsal opening-wedge osteotomy, which
change of the moment arm of the flexor and extensor is the procedure of choice (Figs. 23 and 24)87,91. Postoper-
tendons, an alteration in carpal kinematics86, and a loss atively, the adaptive instability pattern corrects sponta-
of power transmission across the wrist. With radial neously in most cases and forearm rotation is restored.
shortening and progressively increasing positive ulnar For wrists in which the adaptive instability pattern has
variance, the proximal row of carpal bones abuts the become static, either ligament reconstruction or inter-
distal end of the ulna, either limiting rotation of the ra- carpal arthrodesis is recommended.

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