Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

289. Lunotriquetral Ligament Repair and Augmentation

Samuel C. Hoxie and Alexander Y. Shin

DEFINITION

images Isolated injury of the lunotriquetral interosseous ligament complex is less common and less well understood compared with the other proximal row ligament injury, scapholunate dissociation.

images Lunotriquetral ligament disruption can occur in isolation or in combination with other wrist pathology, such as a perilunate dislocation.

images It may result from acute trauma or chronic degenerative or inflammatory processes.

images Injuries to the lunotriquetral ligament occur in a spectrum of severity ranging from partial tears with dynamic dysfunction (most common) to complete dissociation with static collapse.

images Lunotriquetral instability can occur when the ligament complex is intact but incompetent or attenuated. If the ligament is stretched and attenuated from chronic or inflammatory degradation, instability can occur in the absence of ligament dissociation (complete disruption).

images When the lunotriquetral ligament is completely ruptured (both dorsal and volar regions), it is called a lunotriquetral dissociation.

images When the dorsal radiotriquetral ligament (and other secondary restraints) is also compromised and the entire ligament complex is disrupted, carpal collapse results. This deformity is termed volar intercalated segment instability (VISI). VISI carpal collapse cannot be reproduced by simply sectioning the dorsal and palmar subregions of the lunotriquetral ligament. Loss of integrity of the radiotriquetral ligament restraint is required to create static carpal instability (FIG 1).

ANATOMY AND KINEMATICS

images Like the scapholunate ligament, the lunotriquetral interosseous ligament is C-shaped, spanning the dorsal, proximal, and palmar edges of the joint surface.

images The palmar portion of the lunotriquetral ligament is the thickest and most biomechanically important region of the entire complex.12 In contrast, the dorsal component of the scapholunate ligament has been shown to be the strongest.3

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FIG 1  A. Intact dorsal ligaments and normal carpal alignment. Loss of integrity of these secondary restraint structures, the volar-flexed position of the lunate, and the resulting volar intercalated segment instability (VISI) carpal collapse. B. Normal anatomic alignment of the carpus as viewed from a lateral radiograph. The lunotriquetral angle is +14 degrees. C. VISI carpal collapse visible on lateral radiograph. The lunate is volar-flexed and the lunotriquetral angle is −16 degrees. D. Rupture of the lunotriquetral interosseous ligament and the dorsal secondary restraint.

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FIG 2  A. Perilunate dislocation. B. Reverse perilunate injury (with permission, Mayo Foundation.)

images The dorsal lunotriquetral ligament is important as a rotational constraint, while the palmar portion is the strongest and transmits the extension moment of the triquetrum as it engages the hamate.

images The membranous region has little effect on rotation, translation, or distraction.

images These findings illustrate the “balanced lunate” concept, which describes the lunate as torque suspended between the scaphoid and triquetrum. The scaphoid has a tendency to palmar flex, while the triquetrum has a tendency to extend. Through the lunotriquetral and scapholunate ligaments the two forces are balanced and the entire proximal carpal row is balanced about the lunate.

PATHOGENESIS

images The exact mechanism of traumatic lunotriquetral ligament injuries is not fully understood. Many mechanisms may play a role.

images Lunotriquetral ligament injuries can occur in Mayfield III and IV perilunate injuries (FIG 2A).

images An isolated traumatic lunotriquetral ligament injury may occur in a reverse perilunate injury (FIG 2B).11

images In the absence of trauma, degenerative lunotriquetral instability can result from inflammatory arthritis.16

images Positive ulnar variance may lead to lunotriquetral ligament degeneration by wear mechanisms or altered intercarpal kinematics (ulnar impaction syndrome).10

NATURAL HISTORY

images The natural history of these injuries has not been fully elucidated but they may lead to degenerative joint changes.

PATIENT HISTORY AND PHYSICAL FINDINGS

images Lunotriquetral ligament injuries present as vague ulnarsided wrist pain either acutely after trauma or as generalized ulnar-sided chronic wrist pain.14

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FIG 3  AP projections of patients with lunotriquetral ligament dissociation. A. The proximal row appears abnormal because both the lunate and scaphoid are volar-flexed. B. Disruption of the arcs of Gilula. C. Wrist arthrography showing contrast dye pooling, indicative of a lunotriquetral ligament injury. D. Bone scan of a patient with lunotriquetral ligament injury demonstrates increased radiotracer uptake centered at the lunotriquetral joint.

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images The examination should encompass the entire wrist, especially the ulnar side.

images Dorsal lunotriquetral joint tenderness should be elicited in lunotriquetral joint injuries.8,11

images Ulnar deviation with pronation and axial compression may elicit dynamic instability with a painful snap “catch-up” clunk.

images A palpable wrist click is occasionally significant, particularly if painful and occurring with radioulnar deviation.

images Provocative tests that demonstrate lunotriquetral laxity, crepitus, and pain are helpful to accurately localize the site of pathology. Three useful tests to perform include:

images Ballottement11 : The test is positive if increased anteroposterior laxity and pain occur.

images Compression: Pain with this maneuver may indicate pathology of the lunotriquetral or triquetral hamate joints.1

images Shear test7 : Positive with pain, crepitance, and abnormal mobility of the lunotriquetral joint

images Other common findings on physical examination include limited range of motion and diminished grip strength.8

images Comparison of findings with the contralateral wrist is essential.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Plain radiographs are often normal in lunotriquetral ligament injuries because the most common presentation is dynamic dysfunction that manifests only with loading or certain positions of the hand and wrist.

images Dissociation of the lunotriquetral ligament can lead to disruption of Gilula arcs I and II, demonstrating proximal translation of the triquetrum, with or without lunotriquetral overlap (FIG 3A,B).

images Often, no lunotriquetral gap occurs, in contrast to scapholunate injuries.

images A static VISI deformity indicates not only lunotriquetral interosseous ligament injury but also damage to the dorsal radiotriquetral ligament.

images Radial and ulnar deviation together with clenched-fist anteroposterior views are often helpful. Lunotriquetral dissociation leads to lessened triquetral motion and increased movement of the lunate, scaphoid, and distal row.2

images Injection of local anesthetic into the midcarpal space can be useful to localize the cause of the patient's pain.

images Addition of corticosteroid to the injection may provide temporary relief by decreasing local inflammation.

images Arthrographic dye pooling or leakage at the lunotriquetral interspace can indicate ligamentous injury (FIG 3C). However, age-dependent degenerative changes and asymptomatic lunotriquetral instability have been reported. Correlation with physical examination is required.

images Real-time videofluoroscopy can illustrate the site of a “clunk” that occurs with wrist deviation. This occurs in lunotriquetral injuries when the triquetrum “catches up” when the wrist is moved into maximal ulnar deviation.

images Technetium-99m diphosphate bone scan can aid in the localization of an acute injury but has been shown to be less specific than arthrography (FIG 3D).6

images Magnetic resonance imaging is improving but is not yet reliable for imaging of lunotriquetral ligament injuries.

DIFFERENTIAL DIAGNOSIS

images The differential diagnosis of ulnar-sided wrist pain can be divided into six categories: osseous, ligamentous, tendinous, vascular, neurologic, and miscellaneous.

images Osseous injuries include the sequelae of fractures (ie, nonunion or malunion) and degenerative processes. Fracture nonunions can affect the hamate, pisiform, triquetrum, base of the fifth metacarpal, ulnar styloid process, and distal part of the ulna or radius.

images Degenerative processes at the pisotriquetral joint, midcarpal (triquetrohamate) articulation, fifth carpometacarpal joint, or distal radioulnar joint can also result in substantial ulnar-sided wrist pain. Ulnar impaction or abutment into the radius or carpus has been reported as well.

images Ligamentous injuries can occur in any of the ulnar-sided intrinsic (lunotriquetral or capitohamate) or extrinsic (ulnolunate, triquetrocapitate, or triquetrohamate) ligaments as well as the triangular fibrocartilage complex.

images Tendinopathy of the extensor carpi ulnaris or flexor carpi ulnaris

images Vascular lesions such as ulnar artery thrombosis or hemangiomas

images Neurologic processes such as entrapment of the ulnar nerve in Guyon's canal, neuritis of the dorsal sensory branch of the ulnar nerve, and complex regional pain syndromes

images The miscellaneous group includes the very unusual etiologies such as tumors, including osteoid osteomas, chondroblastomas, and aneurysmal bone cysts.

NONOPERATIVE MANAGEMENT

images Initial care for most lunotriquetral ligament injuries is immobilization with a splint or cast with a pisiform lift. Initially the wrist is immobilized in a long-arm cast for 4 weeks and then a short-arm cast for an additional 4 weeks. Care should be taken to mold a pad underneath the pisiform (pisiform lift) to maintain optimal alignment as the ligament heals.

images Acute injuries without radiographic changes may be successfully treated nonoperatively.

images Symptoms of chronic injuries often improve with immobilization.

images Midcarpal injections with local anesthetic and corticosteroid often provide significant relief for a prolonged time.

images If conservative management fails for either acute or chronic injuries, surgical treatment can be performed. A trial of nonoperative treatment does not seem to jeopardize the outcome of subsequent surgical intervention.

SURGICAL MANAGEMENT

images Operative management is indicated in acute or chronic injuries unresponsive to conservative treatment.

images The goal of surgery is to return rotational stability of the proximal carpal row and restore the natural alignment of the lunocapitate axis.

images Functional reconstruction of the lunotriquetral ligament can be accomplished with direct ligament repair, ligament reconstruction with a strip of extensor carpi ulnaris tendon graft, or arthrodesis.

images The choice of intervention should be discussed with the patient. Our preference, based on outcomes studies performed at our institution, is tendon repair or reconstruction.13

images Arthrodesis is avoided whenever possible secondary to higher complication rates and lower patient satisfaction.

images If significant degenerative changes have occurred in the lunotriquetral, radiocarpal, or midcarpal joints, partial or total carpal arthrodesis or proximal row carpectomy may be indicated.

images In the presence of significant VISI deformity that cannot be easily reduced (ie, static VISI), intercarpal arthrodesis is recommended.

images In cases of significant ulna-positive or ulna-negative variance, ulna shortening or lengthening may be indicated as well.

Preoperative Planning

images The senior author's preference is to perform diagnostic arthroscopy on patients with lunotriquetral ligament injuries to evaluate the articular surface and assess other intercarpal pathology.

images Anterior interosseous and posterior interosseous nerve neurectomies can be performed at this time as well.

images The findings of the arthroscopy are discussed with the patient at a second meeting and a reconstructive or salvage procedure can then be performed 6 weeks later.

images Alternatively, a definitive surgical procedure can be performed at a single surgical setting following a thorough preoperative discussion with the patient.

images When a lunotriquetral dorsal ligament repair is planned, preparations should also be made to proceed with ligament reconstruction if the quality of the lunotriquetral ligament is poor.

Positioning

images The patient is positioned supine on a standard operating room table with the affected arm on a hand table.

images A long-acting axillary regional anesthetic block placed preoperatively is helpful with postoperative pain control.

images A nonsterile tourniquet is applied above the surgical drapes.

images Preoperative intravenous antibiotics are routinely administered before beginning the procedure.

images The hand and arm are prepared and draped in standard fashion.

images An examination under anesthesia is always performed initially to evaluate for “catch-up” intercarpal clunks and well as radioulnar clunks.

TECHNIQUES

DIRECT LUNOTRIQUETRAL LIGAMENT REPAIR

Incision and Dissection

images  A longitudinal incision is made over the third extensor compartment (TECH FIG 1).

images Alternatively, a curvilinear incision can be used.

images  The dorsal sensory branch of the ulnar nerve is identified and protected.

images  The extensor retinaculum is divided over the extensor pollicis longus, releasing it from the third compartment (TECH FIG 2).

images  Ulnar-based flaps of extensor retinaculum are developed by dividing the septa separating the third through the fifth extensor compartments (TECH FIG 3).

images

TECH FIG 1  A. Axial image of dorsal wrist compartments with arrow indicating location for skin incision over third compartment. B. Skin incision centered over third dorsal compartment with superficial branch of the radial nerve (SBRN) and dorsal sensory branch of the ulnar nerve (DSBUN). Oval indicates tubercle of Lister. (Copyright © Mayo Clinic.)

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TECH FIG 2  A. Superficial dissection with extensor retinaculum visible. B. Dotted line indicates incision of third compartment to release the extensor pollicis longus (EPL) tendon. C. EPL released from third compartment. D. Incision of extensor retinaculum over EPL. E. Incision of extensor retinaculum over EPL. EPL tendon is visible distally. F. EPL released from third compartment. (B,C: Copyright © Mayo Clinic.)

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TECH FIG 3  A. Dissection of septa to create ulnar-based flap of extensor retinaculum. B. Preparing to reflect extensor retinaculum. C. Retinaculum has been reflected ulnarly and extensor tendons are released. (A: Copyright © Mayo Clinic.)

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TECH FIG 4  A. Posterior interosseous nerve (PIN) visible overlying wrist capsule. B. PIN identified and isolated. C. Segment resected from PIN.

images  If not previously performed, a posterior interosseous neurectomy is performed to partially denervate the dorsal wrist capsule (TECH FIG 4).

images  The dorsal radiocarpal and intercarpal ligaments are identified and a ligament-splitting capsulotomy made as described by Berger and Bishop4 (TECH FIG 5AD).

images  When elevating the capsule it is important not to dissect too deep over the region of the lunotriquetral area. The lunotriquetral ligament is intimately related to the radiotriquetral ligament and can be injured if attention is not paid during the capsulotomy.

images

TECH FIG 5  A. Dorsal ligament-splitting capsulotomy planned. B. Dorsal ligament-splitting capsulotomy showing location of the dorsal radiotriquetral and scaphotriquetral ligaments. C. Dorsal capsule reflected radially. D. Dorsal capsule reflected radially showing lunotriquetral ligament disruption. E. Dorsal capsulotomy performed. The dorsal lunotriquetral ligament is visibly torn. (B,D: Copyright © Mayo Clinic.)

images  The midcarpal and radiocarpal joint surfaces are exposed and examined for arthritic changes (TECH FIG 5E).

images  The scapholunate and lunotriquetral ligament are thoroughly examined.

images The dorsal aspect of the lunotriquetral ligament is inspected to determine if it is suitable for repair. The midcarpal joint is also inspected.

images The volar portion of the lunotriquetral joint is examined, and the integrity of the volar lunotriquetral ligament is indirectly inspected. If it is completely incompetent, then a direct repair of the dorsal lunotriquetral ligament is contraindicated and one should proceed to a ligament reconstruction as described later in this chapter.

images Intra-articular step-off of the lunotriquetral articulation is also assessed, as well as the presence of a separate lunate facet (type II lunate).

Reattaching the Ligament

images  The lunotriquetral ligament is reattached to the site of avulsion, usually the triquetrum.

images  Two techniques for reattachment of the ligament exist: the use of drill holes or suture anchors. Multiple horizontal drill holes or suture anchors are placed in the dorsal, nonarticular, surface of the triquetrum (TECH FIG 6A).

images  Numerous strands of nonabsorbable suture (size 2-0) are used to repair the avulsed ligament (TECH FIG 6B).

images  Before tensioning and tying the sutures, the diastasis of the lunotriquetral joint must be reduced and the articular congruity at the midcarpal joint reduced. The reduction is secured by two 0.045-inch smooth Kirschner wires (TECH FIG 6CE).

images  The sutures are then tensioned and tied, but not cut short.

images  Dorsal capsulodesis is then performed to augment the lunotriquetral ligament. A portion of the radiotriquetral ligament can be used to augment the lunotriquetral ligament repair by placing additional suture anchors into the lunate and triquetrum and sewing the radiotriquetral ligament to the lunotriquetral ligament

images  The ligament-splitting capsulotomy is repaired with nonabsorbable sutures (TECH FIG 6F).

images  The extensor retinaculum is repaired with the extensor pollicis longus dorsally transposed.

images  The skin is closed.

images  A long-arm, bulky splint is applied.

images

TECH FIG 6  A. Drill holes in the dorsal, nonarticular surface of the triquetrum. B. Nonabsorbable sutures passed through drill hole and dorsal lunotriquetral ligament. C. Lunotriquetral joint reduced and stabilized with Kirschner wires. Sutures ready to be tied. D,E. Postreduction AP (D) and lateral (E) fluoroscopy showing lunotriquetral joint reduction and position of Kirschner wires. F. Dorsal capsulotomy repaired with heavy, nonabsorbable sutures. (A–C,F: Copyright © Mayo Clinic.)

LUNOTRIQUETRAL LIGAMENT RECONSTRUCTION WITH DISTALLY BASED EXTENSOR CARPI ULNARIS STRIP

Harvesting the Graft

images  To avoid disrupting the extensor carpi ulnaris (ECU) subsheath,15 a 2-cm transverse incision is made through the skin and the ECU sheath 6 cm proximal to the ulnar styloid. The ECU tendon is identified (TECH FIG 7A).

images  A small right-angle clamp or 90-degree retractor is used to isolate and elevate the ECU tendon (TECH FIG 7B).

images  A 4-mm incision is made on the radial side of the ECU tendon to create a strip of tendon graft. A piece of 28gauge wire is tied to the free end of the tendon graft (TECH FIG 7C).

images  The ECU sheath is opened at the level of the carpometacarpal joint. The wire is looped and passed from proximal to distal through the sheath into the distal incision. The wire and tendon are gently pulled distally, creating a distally based tendon graft (TECH FIG 7D).

images  The graft is passed deep to the extensor retinaculum.

images  The 28-gauge wire is left tied to the end of the graft and a moist sponge is wrapped around the graft while the bone tunnels are prepared.

Bone Tunnel Creation and Graft Passage

images  0.045-inch Kirschner wires are advanced through the lunate and the triquetrum.

images  The correct starting points for these Kirschner wires are the dorsal ulnar aspect of the triquetrum and the dorsal radial edge of the lunate.

images  The holes should converge at the volar margin of the lunotriquetral joint and must not be intra-articular (TECH FIG 8A).

images  If a reducible VISI deformity exists, it is important to place the Kirschner wires while the deformity is held reduced. Joysticks in the scaphoid and triquetrum are useful to maintain the reduction while the lunate and triquetral wires are placed (TECH FIG 8B).

images  The position of the wires is checked with fluoroscopy to confirm the ability to safely enlarge the drill holes without fracture.

images  The tunnels are created using a series of sharp awls or drill bits, gradually increasing the diameter until a 4to 5-mm tunnel is created in both the lunate and triquetrum (TECH FIG 8C).

images  Alternatively, a cannulated drill system can be used.

images

TECH FIG 7  A. Location of 2-cm transverse skin incision located 6 cm proximal to ulnar styloid overlying extensor carpi ulnaris (ECU) tendon. B. Isolation of the radial 4 mm of ECU tendon to create tendon strip for reconstruction. Dotted line shows tendon to be transected. C. 28-gauge wire tied around ECU tendon strip and passed through ECU tendon sheath. The wire and tendon strip pass deep to the extensor retinaculum. D. ECU tendon strip has been passed distally through ECU tendon sheath. (Copyright © Mayo Clinic.)

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TECH FIG 8  A. Kirschner wires showing position of drill holes through triquetrum and lunate. The tips converge on the palmar, nonarticular surface of the joint. B. Dorsal exposure showing lunotriquetral ligament disruption and position of Kirschner wires for bone tunnels. C. Enlarging the bone tunnels to a diameter of 5 mm. (Copyright © Mayo Clinic.)

images  The wire previously secured to the end of the graft is looped and passed through the triquetral tunnel toward the lunate (TECH FIG 9AC).

images  An arthroscopic hook or probe is useful to hook the wire loop and pull it through the lunate bone tunnel (TECH FIG 9D,E).

images  The wire is used to pass the tendon graft through the tunnels (TECH FIG 1A).

images  While maintaining tension on the tendon graft, the articular surfaces of the lunate and triquetrum are reduced and two 0.045-inch Kirschner wires are passed percutaneously across the lunotriquetral joint.

images  Reduction, pin position, and length are checked with fluoroscopy.

images  The tendon graft is then woven through itself on the dorsum of the lunate and triquetrum and firmly secured with nonabsorbable suture (TECH FIG 1B,C).

images  Excess tendon is trimmed, and the wound is irrigated with normal saline solution.

images  The wound is closed as previously described in the ligament repair section.

images

TECH FIG 9  A–C. Straight Keith needle used to shuttle wire or heavy suture to assist in passing the extensor carpi ulnaris (ECU) tendon strip through bone tunnels—first through the triquetrum and then through the lunate. D,E. Arthroscopic hook used to pass wire or heavy suture through bone tunnels. (Copyright © Mayo Clinic.)

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TECH FIG 10  A. Passing extensor carpi ulnaris (ECU) tendon strip through bone tunnels. B. ECU tendon has been passed through bone tunnels, tensioned, and sutured into itself. Kirschner wires placed percutaneously to maintain lunotriquetral joint reduction. C. Dorsal view of ligament reconstruction with ECU tendon strip. Ready for capsular repair. (Copyright © Mayo Clinic.)

COMBINED REPAIR

images  Ligament reconstruction with an ECU tendon strip can be combined with direct ligament repair to provide additional strength for the repair (TECH FIG 11).

images  This is especially useful when the volar region of the lunotriquetral ligament is disrupted and the dorsal aspect of the ligament is attenuated.

images

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TECH FIG 11  A. Dorsal exposure before capsulotomy (fingers are to the bottom and the thumb is to the left). B. Lunotriquetral joint diastasis with dorsal lunotriquetral ligament disruption. The ligament remains attached to the dorsal lunate. C,D. Positioning Kirschner wires for drill holes. E. 28-gauge wire passes through bone tunnels. F,G. The tendon graft is first advanced through the triquetrum and then through the lunate. H. The tendon graft is tensioned. I. Reduction should be verified and maintained with lunotriquetral Kirschner wires before final ligament tensioning and suture placement. J. Direct repair of dorsal lunotriquetral ligament utilizing suture form anchors placed into the triquetrum. K. Tensioning direct lunotriquetral ligament repair. L. Final view of the reconstruction after capsulotomy repair. Heavy nonabsorbable sutures secure the capsular repair.

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POSTOPERATIVE CARE

images Edema control and range-of-motion exercises of the digits are initiated immediately postoperatively.

images Seven to 10 days after the procedure, the surgical splint is removed, sutures are removed, and a long-arm cast is applied for 6 weeks. A short-arm cast is then applied for an additional 4 to 6 weeks for a total period of immobilization of 10 to 12 weeks.

images The Kirschner wires are removed at 10 to 12 weeks and wrist range-of-motion exercises are commenced.

OUTCOMES

images A high-quality tendon repair is vital for a successful outcome of the lunotriquetral tenodesis.

images Several studies have shown that direct lunotriquetral ligament repair results in a successful clinical result.5,9,11,15

images Reagan et al11 reported that six of seven cases of direct lunotriquetral ligament repairs were successful.

images Favero et al5 reported patient satisfaction of 90% with only one failure in 21 cases.

images In high-demand patients such as laborers and athletes, rerupture or attenuation can occur and lead to late failure. Reconstruction with a strip of ECU tendon should be considered in this patient subgroup.

images A review of clinical outcomes comparing lunotriquetral ligament repair, ligament reconstruction, and lunotriquetral joint arthrodesis at our institution showed that patients treated with ligament reconstruction have the lowest reoperation rate.13

images Rerupture after trauma and late attenuation appear to be common modes of long-term failure of direct repair.

images Review of the clinical outcomes at our institution showed that reconstruction with a strip of ECU tendon as described can be an effective treatment.3

REFERENCES

1.     Beckenbaugh RD. Accurate evaluation and management of the painful wrist following injury. Orthop Clin 1984;15:289–306.

2.     Beckenbaugh RD. Accurate evaluation and management of the painful wrist following injury: an approach to carpal instability. Orthop Clin North Am 1984;15:289–306.

3.     Berger RA. The gross and histologic anatomy of the scapholunate interosseous ligament. J Hand Surg Am 1996;21A:170–178.

4.     Berger RA, Bishop AT. A fiber-splitting capsulotomy technique for dorsal exposure of the wrist. Tech Hand Upper Extrem Surg 1997;1:2–10.

5.     Favero KJ, Bishop AT, Linscheid RL. Lunotriquetral ligament disruption: a comparative study of treatment methods [abstract SS-80]. American Society for Surgery of the Hand, 46th Annual Meeting, 1991, Orlando.

6.     Gilula LA, Weeks PM. Post-traumatic ligamentous instabilities of the wrist. Radiology 1978;129:641–651.

7.     Kleinman WB. Diagnostic exams for ligamentous injuries. American Society for Surgery of the Hand, Correspondence Club Newsletter, 1985. No. 51.

8.     Linscheid RL, Dobyns JH. Athletic injuries of the wrist. Clin Orthop Relat Res 1985;198:141–151.

9.     Palmer AK, Dobyns JH, Linscheid RL. Management of post-traumatic instability of the wrist secondary to ligament rupture. J Hand Surg Am 1978;3A:507–532.

10. Palmer AK, Werner RW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res 1984;187:26–35.

11. Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J Hand Surg Am 1984;9A:502–514.

12. Ritt MJ, Bishop AT, Berger RA, et al. Lunotriquetral ligament properties: a comparison of three anatomic subregions. J Hand Surg Am 1998;23A:425–431.

13. Shin AY, Weinstein LP, Berger RA, et al. Treatment of isolated injuries of the lunotriquetral ligament: a comparison of arthrodesis, ligament reconstruction and ligament repair. J Bone Joint Surg Br 2001; 83B:1023–1028.

14. Shin AY, Deitch MA, Sachar K, et al. Ulnar-sided wrist pain: diagnosis and treatment. AAOS Instr Course Lect 2005;54:115–128.

15. Shin AY, Bishop AT. Treatment options for lunotriquetral dissociation. Tech Hand Upper Extrem Surg 1998;2:2–17.

16. Taleisnik J, Malerich M, Prietto M. Palmar carpal instability secondary to dislocation of scaphoid and lunate: report of case and review of the literature. J Hand Surg Am 1982;7A:606–612.



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