Distal radioulnar joint injuries

1. DISTAL RADIOULNAR JOINT INJURIES
Presented by Dr Sunil poonia, PGT, Orthopaedics, SMCH
Moderated by Dr S. K. Das, Assoc. Prof of Orthopaedics, SMCH
Binu P Thomas, Raveendran Sreekanth
Dr. Paul Brand Centre for Hand Surgery, CMC Hospital,
Vellore, Tamil Nadu, India

2. DISTAL RADIOULNAR JOINT (DRUJ)
 Part of the complex forearm articulation
 Functionally and anatomically integrated with the
ulnocarpal articulation of wrist.
 Important joint in pronosupination and load transmission

3. EVOLUTION OF DRUJ
 From the syndesmotic DRUJ of brachiating
primates with limited forearm rotation, three major
changes occurred
 (a) development of a distinctly separate DRUJ,
 (b) recession of the distal ulna from the ulnar carpus,
 (c) development of a distinct ulnocarpal meniscus
the primitive pectoral fin of early fish
the bipedal primate wrist
Current human wrist

4. Distal
radioulnar
joint injuries
Acute injury
Chronic
instabilty or
arthritis
Isolated
injuries
along with
fractures

5. ANATOMY
 diarthrodial trochoid synovial joint
 two parts
 the bony radioulnar articulation and
 soft tissue stabilizers.

6. Transverse section
through the DRUJ
in a cadaver,
showing the
sigmoid notch of
the radius (white
arrow) and the
head of the ulna
along with the
radioulnar
ligaments
THE RADIOULNAR ARTICULATION

7. ANATOMY
 The shape of sigmoid notch is not uniform and has
been classified into-
 1) flat face,
 2) ski slope,
 3) C type, and
 4) S type
 The distal articular surface of the ulna (dome or pole) is
mostly covered by articular cartilage.
 At the base of the ulnar styloid is a depression called
fovea, which is devoid of cartilage.
 Differential arc of curvature of ulna and sigmoid notch
 In pronation, the ulna translates 2.8 mm dorsally and distally
from a neutral position
 in supination, the ulna translates 5.4 mm volarly and
proximally from a neutral position

8. TRIANGULAR FIBROCARTILAGINOUS COMPLEX
(TFCC).
 also known as as ulnoligamentous complex
 It consists of
 The triangular fibrocartilage (TFC or articular disk),
 Meniscal homologue,
 Ulnocarpal [ulnolunate (UL) and lunotriquetral] ligaments,
 The dorsal and volar radioulnar ligaments,
 Ulnar collateral ligament, and
 The extensor carpi ulnaris (ECU) subsheath.
 The radioulnar ligaments (dorsal and volar) are the
primary stabilizers of the DRUJ.

9. TRIANGULAR FIBROCARTILAGINOUS COMPLEX (TFCC).
(a) Diagrammatic
representation of the
TFCC, superimposed on a
dissected specimen,
(b) Diagrammatic
representation of
triangular fibrocartilage
(TFC) inserting into the
fovea (deep layer) and
ulnar styloid (superficial
layer), RUL: Radioulnar
ligament, TFC: triangular
fibrocartilage, UL:
ulnolunate ligament, UT:
Ulnotriquetral ligament,
ECU: extensor carpi
ulnaris in its subsheath,
SP: styloid process of ulna
providing attachment to
these structures-R:
Radius, U: Ulna, S:
scaphoid, L: lunate, T:
triquetrum

10. CLINICAL EVALUATION
 trauma, eg, a fall on the outstretched hand
(FOOSH).
 ulnar-sided wrist pain (USWP), especially on
loading the hand and rotating the forearm,
 Persistence of USWP and stiffness following distal
radius fractures (DRF)
 Clicking sounds
 Obvious instability

11. SPECIAL TESTS
 Impingement sign
 The ulna fovea sign
 The piano-key test
 The table top test
 The Grind test

12.  Ulnar deviation of the wrist with the forearm in neutral produces
ulnar wrist pain and occasional clicking
 A painful click may be elicited by having the patient clench and
ulnarly deviate the wrist and then repeatedly pronate and
supinate the wrist
 The ulnar impaction test—wrist hyperextension and ulnar
deviation with axial compression—also will elicit pain.
 The “press test” is another useful provocative test: the seated
patient is asked to push the body weight up off a chair using the
affected wrist, creating an axial ulnar load. If this reproduces the
patient’s pain, the test is considered positive
 With the wrist in pronation, an unstable distal ulna may translate
dorsally and can be manually reduced with dorsal thumb pressure
(“piano key test”).
 Tenderness and pain identified when external pressure is applied to
the area of the fovea (fovea sign) is indicative of an ulnocarpal
ligament lesion.
 TFCC instability also is suggested by excessive motion with the
“shuck test”—with the radial aspect of the wrist stabilized,
anteroposterior stress is applied to the ulnar side of the wrist

13. RADIOLOGICAL INVESTIGATIONS
 Radiographs
 Posteroanterior (PA)
 True lateral X-ray
 Pronation and supination views
 A clenched fist PA view in pronation
 Weighted lateral stress view in pronation

14. X-RAY EVALUATION OF DRUJ
a)True PA views should
show the groove for
ECU radial to the ulnar
styloid (red arrow). True
lateral view should show
the palmar edge of
pisiform (red dotted line)
midway between palmar
borders of distal pole of
scaphoid and capitate
(yellow lines);
(b) Scheker-weighted
lateral view with patient
holding 3 lb weight in the
hand showing dorsal
instability of the distal
ulna. Weighted views
provide loading of the
DRUJ, bringing out
instability, which may not
be visible in routine X-
rays

15. COMPUTED TOMOGRAPHY
 Useful to delineate sigmoid notch fractures and
DRUJ injuries
 Ligament injuries can be assessed indirectly by
assessing the radioulnar articulation in various
positions and also by loading views
 Three-dimensional (3D) reconstructions are helpful
in assessing spatial relationship between the radius
and ulna

16. MRI HAS 86% SENSITIVITY FOR DETECTION OF TFCC
TEARS.
a) MRI T2-weighted
fat suppression
image, showing a
radial TFCC tear,
fluid seen adjacent to
DRUJ.
b) Proton density-
weighted MRI,
coronal view
suggestive of ulnar
impaction syndrome.
There is articular
cartilage loss with
erosion, marrow
edema, subchondral
cyst, and sclerosis of
triquetrum and lunate

17. ARTHROSCOPY IS THE GOLD STANDARD FOR EVALUATION
OF TFCC INJURIES.
(a)Central TFCC
tear,
(b) Foveal
detachment of
the TFCC,
(c) Reattachment of
TFCC, and
(d) Degenerative
tears of TFCC.

18. INJURIES OF DRUJ AND TFCC- A WORKING
CLASSIFICATION

19. TRIANGULAR FIBROCARTILAGINOUS COMPLEX
INJURY
 “the traumatic TFCC disruption as a continuum of
injury”– Melone
 It was classified into five stages of increasing severity
 Stage I: detachment of TFC from ulnar styloid,
 stage II: ECU subsheath injury,
 stage III: ulnocarpal ligament disruption,
 stage IV: lunotriquetral ligament injury, and
 stage V: midcarpal ligament injury

20. PALMER’S CLASSIFICATION OF TFCC INJURIES

21.  Currently, management of class 1A TFCC (central perforation)
lesions includes nonoperative measures initially. If significant
symptoms persist, arthroscopic débridement may provide relief
 For class 1B lesions (avulsion from the ulna, with or without
ulnar styloid fracture), immobilization for 6 weeks followed
by rehabilitation may be sufficient
 If symptoms persist, and if there is DRUJ instability,
arthroscopic repair using either an inside-out or an outside-in
technique may produce satisfactory relief of pain and
improvemen
 class 1C lesions (distal avulsion of ulnocarpal ligaments), which
result in a volar ulnar “sag” of the carpus, late open or
arthroscopic repair may relieve symptoms

22. TREATMENT OF TFCC INJURIES
Non operative
splinting or AE
cast
Pharmacological
NSAIDS
Steroid
injections
modification of
activity
occupational
therapy
Operative
arthroscopic
Open
techniques

23. ISOLATED DRUJ DISLOCATIONS
 Uncommon injuries
 Dorsal or volar
 Simple or complex
 The dorsal dislocation is more common
 closed manipulation and reduction under anesthesia is
usually successful.
 Once the joint is reduced, stability must be verified

24. ISOLATED DRUJ DISLOCATIONS
 Immobilize dorsal dislocations in an above elbow plaster
of Paris (POP) cast in supination, and volar dislocations
in pronation for a period of 6 weeks
 If instability persists after reduction, radioulnar pinning is
done in reduced position to allow soft tissue healing
 TFCC repair, either open or arthroscopic, needs to be
also considered in case of severe disruptions
 Soft tissue interposition can result in irreducibility

25. DRUJ INJURIES ASSOCIATED WITH FRACTURES AND
FRACTURE-DISLOCATIONS
 The most common cause of residual wrist disability after
DRF is the DRUJ involvement
 Three basic causes that result in radioulnar pain and
limitation of forearm rotation are
 instability,
 joint incongruence, and
 ulnocarpal abutment
 it is found that severely displaced DRF result in disruption of
TFCC in the absence of ulna styloid fractures
 USF through the base results in DRUJ instability if the
fragment involves the foveal insertion of the TFCC.

26. DRUJ INJURIES ASSOCIATED WITH FRACTURES
AND FRACTURE-DISLOCATIONS
 Fractures through the sigmoid notch produce stiffness and
late onset arthritis of the DRUJ.
 Despite the severity of these injuries, with proper diagnosis
and reduction, most patients will have a satisfactory outcome
 Assessment of DRUJ stability following DRF are best done
intraoperatively after fixation of the radius fracture by
translation of the ulna in a dorsopalmar direction

27. DRUJ INJURIES ASSOCIATED WITH FRACTURES
AND FRACTURE-DISLOCATIONS
 Careful assessment of the preoperative X-rays can
indicate a possibility of DRUJ instability
 1) shortening of radius >5 mm relative to ulna,
 2) fracture of the base of ulnar styloid,
 3) widening of the DRUJ interval on PA view,
 4) dislocation of the DRUJ on lateral view.
 Computed tomography scans subluxation and
fractures of the ligamentous margins of radius and
ulna

28. DRUJ INJURIES ASSOCIATED WITH FRACTURES
AND FRACTURE-DISLOCATIONS
 Fragment-specific fixation is helpful
 About 61% of DRF are associated with ulna styloid fractures
 No significant relationship between functional outcome and
ulnar styloid fractures (USF), which were not fixed following
stable fixation of distal radius fracture

29. ULNA STYLOID FRACTURES
 may also be seen in isolation
 While styloid tip fractures are stable, basal fractures of
the styloid are associated with DRUJ instability
 Fixation of styloid fracture makes the DRUJ stable,
provided the TFCC is not otherwise injured
 various fixation techniques
 closed pinning,
 tension band wiring
 compression screw fixation,
 suture anchor technique
 symptomatic nonunions of styloid?
 Comminuted, unstable, or displaced distal ulna neck
fractures?

30. GALEAZZI FRACTURE-DISLOCATION
 Palmer Type IB TFCC injury is classically seen
 80% of these injuries presented with complete
dislocation of DRUJ
 operative fixation of the radius is necessary due to
inherent instability.
 When the radius fracture is within 7.5 cm of the distal
radius, DRUJ injury is highly likely

31. GALEAZZI FRACTURE-DISLOCATION
Stabilize radiusDRUJ reduced
spontaneously check instability
soft tissue interposition
DRUJ is pinned
open reduction

32. X-RAY OF WRIST WITH DISTAL FOREARM AND HAND
ANTEROPOSTERIOR AND LATERAL VIEWS
(a) Ulnar styloid
with DRUJ
instability
(b) treated by open
reduction and
tension band
fixation. Joint
was stable
following union
of fracture.
(c) Pre- and
postoperative X-
rays of a patient
with fracture of
the ulnar head
(d) treated by
ORIF with
screws

33. (a)Acute fracture
involving the sigmoid
notch with DRUJ
instability and ulnar
translation of carpus.
(b) Open reduction,
internal fixation (ORIF)
of the fragment and
repair of volar wrist
ligaments
(radioscaphocapitate
ligament) were done.
Galeazzi fracture-
dislocation with ulnar
styloid fracture and
grossly unstable DRUJ
treated by ORIF of
radius and trans fixation
of radius and ulna.
DRUJ was stable
following POP removal
after 6 weeks

34. THE ESSEX-LOPRESTI INJURY
 A hard fall on the outstretched hand can result in a fracture of the radial
head or neck, disruption of the distal radioulnar joint, and tearing of the
interosseous membrane for a considerable distance proximally
 if the radial head is resected, rapid proximal migration of the radius can
occur, resulting in wrist pain from ulnar carpal impingement and elbow
pain from radiocapitellar impingement
 Pain in the distal radioulnar joint with a displaced fracture of the radial
head or neck should alert the surgeon to the possibility of this injury
combination
 MRI and ultrasound evaluation of soft tissue damage of IOM is helpful
 Excision of radial head is contraindicated in these injuries.

35. CLASSIFICATION OF ESSEX-LOPRESTI AND
SUGGESTED MANAGEMENT

36. CHRONIC DRUJ INSTABILITY
 Chronic DRUJ instability can result from fractures of the
distal radius and ulna following inadequate treatment or
malunion
 If untreated, these lead to chronic pain and disability due to
stiffness, decreased grip strength, and arthritis
 There are reports suggesting that anatomical reduction of
DRF is more critical in avoiding persistent DRUJ issues
rather than associated fixing or union of ulna styloid
fractures.

37. MANAGEMENT
 Management of chronic DRUJ instability depends
primarily on the underlying cause
 Correct malunion, length discrepancies first
 Soft tissue reconstruction indicated in symptomatic
patients in whom TFCC is irreparable & sigmoid notch
incompetent
 Arthritis of DRUJ requires salvage procedures

38. X-ray anteroposterior and
lateral views
(a) Malunited distal radius
fracture following an old
gunshot injury with gross
deformity and relative
ulnar lengthening, treated
by corrective osteotomy
and bone grafting of
radius using a volar
approach, and volar plate
fixation. Intraoperatively,
a distractor was used to
correct the deformity,
(b) Postoperation follow-
up X-rays showing
deformity correction, the
restitution of DRUJ and
correction of radial
inclination and height

39. MANAGEMENT
 Various soft tissue procedures directed at stabilizing the
DRUJ
 1) extrinsic radioulnar tether (Fulkerson & Watson)
 2) extensor retinaculum capsulorrhaphy (Herbert sling procedure)
 3) ulnocarpal sling (Hui & Linshead)
 4) reconstruction of volar and dorsal radioulnar ligaments.
 Adams identified three categories of soft tissue reconstruction for
chronic DRUJ instability: (1) distal ulnar tenodesis, with the extensor
carpi ulnaris or flexor carpi ulnaris tendon; (2) ulnocarpal tether; and
(3) radioulnar tether.

41. Diagrammatic
representation of
Adams-Berger
procedure for
chronic DRUJ
instability. The
dorsal and volar
radioulnar
ligaments are
reconstructed with
a palmaris longus
graft.

42. ULNAR IMPACTION SYNDROME
 Due to repetitive loading of the ulnocarpal joint, especially in
the presence of ulna plus variance, degenerative changes
occur in the TFC,ulnar head, lunate and triquetral surface,
lunotriquetral articulation and is referred to as ulnar
impaction or ulnocarpal abutment syndrome
 progressive wear of TFCC  perforation  ulnocarpal
arthritis
 the most common cause  acquired ulna plus variance and
dorsal tilt caused by malunited distal radius fracture
ulna impingement
syndrome??

43. ULNAR IMPACTION SYNDROME
 Typical clinical features are ulnar-sided wrist pain,
especially on loading and rotation movement
 Investigations
 The PA view demonstrates the ulna plus.
 MRI is useful for observing changes in the lunate and
triquetrum
 Arthroscopy demonstrates the classical stages described by
Palmer.

44. TREATMENT
 Splinting
 NSAIDs
 Modification of
activities
 wafer resection of the
distal ulna as described
by Feldon
 ulna shortening
osteotomy
conservative Surgical
Author prefers an ulna shortening osteotomy
and compression plate fixation

45. (a) X-ray, and computed
tomography
reconstruction showing
the impingement to the
lunate and triquetrum
ulnar impaction syndrome
secondary to long-
standing malunited distal
radius fracture presenting
as USWP with painful
supination/pronation on
loading the wrist, a
positive impingement
sign.
(b) X-ray posteroanterior
and lateral views showing
Ulna was shortened by
cuff resection and
compression plating with
relief of pain and
improved movement

46. DRUJ ARTHRITIS
 Causes
 DRF through the sigmoid notch or the distal ulna
 Malunions
 chronic instability of DRUJ
 failed reconstruction of the DRUJ
 Various options are available
 Resection of distal ulna (Darrach procedure)
 Sauve-Kapandji procedure
 Hemiresection-interposition arthroplasty
 DRUJ implant arthroplasty

47. DARRACH PROCEDURE
 removes the distal articular surface of
the ulna
 useful in the elderly and in patients with
limited activity
 FCU or ECU tendon slings have been
fashioned to attach to the distal ulna to
address the ulna instability
 Complications
 ulna impingement syndrome
 loss of grip strength
 possible ulnar translation of carpus

48. SAUVE-KAPANDJI PROCEDURE
 Originally described in
1936
 DRUJ arthrodesis +
surgical pseudarthrosis
of the distal ulna
 Prefered procedure in
young active adults
 painful instability of the
proximal ulna stump
can be a problem

49. HEMIRESECTION-INTERPOSITION
ARTHROPLASTY-BOWER
 partial resection of the
articular surface of ulna
 interposing a capsular
flap
 Ulnocarpal impaction is
a relative
contraindication
 Preferred for DRUJ
arthrosis with mild
degree of ulna plus
variance

50. DRUJ IMPLANT ARTHROPLASTY
 Indications
 primary DRUJ arthrosis
 failed DRUJ surgery
 Prosthesis commonly used
 Swanson and Herbert prosthesis for distal ulna replacement.
 Scheker’s semiconstrained modular implant for total
replacement of the DRUJ (APTIS DRUJ prosthesis)
 Though long term results are still awaited, the implant
shows great promise

51. SCHEKER TOTAL DRUJ ARTHROPLASTY (APTIS DRUJ
PROSTHESIS) FOR DRUJ ARTHRITIS
(a) Peroperative
photograph
showing incision
mark.
(b) X-rays lateral
and posteroanterior
views showing
degenerative
changes in the
DRUJ.
(c) Peroperative
photograph
showing ulnar head
devoid of cartilage
with sigmoid notch
osteophytes

52. SCHEKER TOTAL DRUJ ARTHROPLASTY (APTIS DRUJ
PROSTHESIS) FOR DRUJ ARTHRITIS
Ulnar head was
excised and DRUJ
replacement with
APTIS size 20
radial plate
assembly and a 4.0
mm diameter 1-cm
ulnar stem. The
patient had
excellent recovery
with full range of
motion and is able
to lift weight without
any pain. She
returned to her
regular occupation

53. CONCLUSION
 The DRUJ injuries presents as ulna sided wrist pain
resulting most commonly from traumatic episodes
 Clinical examination provide information regarding
the anatomical structures injured
 Arthroscopy is considered the gold standard in
diagnosis
 Treatment include splinting, ORIF of fractures and
repair of torn ligaments and TFCC by arthroscopy
or open methods
 DRUJ arthroplasty is emerging as a treatment in
cases of arthrosis of the joint.

60. CARPAL LIGAMENT INJURIES AND
INSTABILITY PATTERNS
 Linscheid et al. grouped carpal instabilities into four types:
(1) dorsiflexion instability
(2) palmar-flexion instability
(3) ulnar translocation
(4) dorsal subluxation
Instability in the carpus has been considered to be static if
the radiographic intercarpal relationships do not change with
motion and dynamic if the intercarpal relationships change
with manipulation and motion

61.  Radiographic evaluation of the proximal carpal row in the lateral
projection in which the radius, lunate, capitate, and third
metacarpal should have collinear axes within an approximately
15-degree tolerance.
 On this projection, the wrist-collapse patterns include (1) patterns in
which the distal articular surface of the lunate is tilted to face
dorsally, known as dorsal intercalated segment instability (2)
patterns in which the distal articular surface of the lunate faces
toward the palm, known as volar intercalated segment instability.
 Linscheid et al. advocated the concept of dissociative and
nondissociative instabilities in the wrist. Dissociative carpal
instabilities are those in which there is disruption of the intrinsic
interosseous ligaments between the bones of the proximal carpal
row. Nondissociative instabilities are those in which the extrinsic
radiocarpal ligaments may be disrupted, with intact intrinsic
ligaments between the carpal bones.

62. PROGRESSIVE PERILUNAR INSTABILITY
 Mayfield, Johnson, and Kilcoyne described four stages of
progressive disruption of ligament attachments and
anatomical relationships to the lunate resulting from forced
wrist hyperextension
 Stage I represents scapholunate failure;
 stage II, capitolunate failure
 III, triquetrolunate failure
 IV, dorsal radiocarpal ligament failure, allowing lunate
dislocation

63. ROTARY SUBLUXATION OF THE SCAPHOID
 Injuries to the dorsal and volar portions of the scapholunate
interosseous ligament, the long radiolunate ligament, and the
radioscaphocapitate ligament allow the proximal pole of the
scaphoid to rotate dorsally. The scaphoid assumes a more
vertical orientation, and eventually the scaphoid separates
from the lunate .
 Watson and Black observed that rotary subluxation of the
scaphoid may manifest in four types: (1) dynamic, (2) static,
(3) with degenerative arthritis, and (4) secondary to a
condition such as Kienböck osteochondrosis.
 a fall on the extended wrist is the usual cause.

64.  On examination, pain and tenderness are present along the dorsal
radiocarpal articulation at the scapholunate area.
 Edema may be present with limitation of motion, particularly in
flexion.
 The following maneuvers are considered to be helpful in evaluating
rotary instability of the scaphoid
 “scaphoid test,” in which the examiner places four fingers on the
dorsum of the radius with the thumb on the scaphoid tuberosity,
using the right hand for the right wrist and the left hand for the left
wrist. Ulnar deviation of the wrist aligns the scaphoid with the long
axis of the forearm. Applying thumb pressure to the scaphoid
tuberosity, the wrist is returned to radial deviation, maintaining the
thumb pressure on the scaphoid tuberosity. If the scaphoid is
sufficiently unstable, the proximal pole is driven dorsally, and pain
results

65.  As the wrist under load progresses from radial deviation to
ulnar deviation, the scaphoid normally moves smoothly into
extension, aligning with the forearm axis. If scaphoid rotary
subluxation is present, the lunate remains in a volar-flexed
and dorsal position until sufficient pressure is applied, so
that it suddenly shifts from the volar-flexed position and
“catches up” with the scaphoid with a “clunking” sensation
 the diagnosis of static rotary subluxation of the scaphoid
can be made on an anteroposterior radiographic view when
a gap of more than 2 mm is noted between the scaphoid
and the lunate bones. This gap is seen to increase with an
anteroposterior view taken with the fist clenched. Other
findings on the anteroposterior view include apparent
shortening of the scaphoid and the so-called cortical ring
appearance of the axial projection of the scaphoid.

69. MANAGEMENT
 Closed treatment of acute rotary subluxation of the scaphoid
consists of attempting reduction by placing the wrist in neutral
flexion and a few degrees of ulnar deviation.
 Percutaneous pinning can be done with one 0.045-inch (1.16-mm)
Kirschner wire placed through the scaphoid into the capitate and a
second placed through the scaphoid into the lunate.
 If closed reduction is unsuccessful, arthroscopic reduction and
percutaneous pin fixation can be attempted
 open reduction through a dorsal approach with closure of the
scapholunate gap, Kirschner wire internal fixation of the lunate to
the scaphoid, and ligament repair usually are indicated.
 Management of an old rotary subluxation of the scaphoid may
require reconstruction of the scapholunate interosseous ligament
with a segment of the extensor carpi radialis brevis tendon plus
Kirschner wire fixation

70. ANTERIOR DISLOCATION OF THE LUNATE
 The most common carpal dislocation is anterior dislocation of the
lunate
 On a lateral radiographic view of the normal wrist, the half-
moon–shaped profile of the lunate articulates with the cup of the
distal radius proximally and with the rounded proximal capitate
distally
 AP view, the normal rectangular profile of the lunate when
dislocated becomes triangular because of its tilt.
 An anteriorly dislocated lunate can cause acute compression of
the median nerve
 When the injury is treated early, manipulative reduction usually is
possible and immobilization for 3 weeks with the wrist in slight
flexion is required.
 When treated after 3 weeks, the injury can be difficult to reduce by
manipulation, and open reduction may be necessary. A dorsal
approach has been recommended

71. TREATMENT OPTIONS FOR WRIST LIGAMENT
INJURIES AND INSTABILITY
 For acute injuries, options include closed or arthroscopically
controlled manipulation and percutaneous pinning
 If closed methods are unsuccessful, open repair or
reconstruction of ligaments may be required
 For late diagnosed problem – limited arthrodesis
 Dorsal capsulodesis can be added to limit scaphoid flexion
 Excision arthroplasty – proximal raw carpectomy