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Journal of the American Academy of Orthopaedic Surgeons
170
The earliest known report of a
lunotriquetral (LT) ligament injury
was made by Hessert, who de-
scribed three patients with LT joint
dislocations in 1903. Ten years
later, Chaput and Vaillant pub-
lished a classic example of a volar
intercalated segmental instability
(VISI) deformity in a radiographic
study of carpal injuries. Also in
1913, von Mayersbach noted a
carpal dissociation in a 72-year-old
man, reporting that the cuneiform
bone (i.e., triquetrum) was separated
from the semilunar bone (i.e., lu-
nate) but was not substantially
changed in position. Other authors
described similar carpal deformi-
ties, but it was not until 1984 that
Reagan et al
1
first described the role
of the LT ligament in the develop-
ment of the VISI pattern.
In 1972, Linscheid et al
2
pub-
lished an article that described the
volar instability pattern but did not

elucidate its etiology. They applied
the concept of intercalated segmen-
tal instability to the carpus, utiliz-
ing the lunate position in either
flexion or extension to identify the
volar and dorsal patterns, respec-
tively. The role of the scapholunate
ligament in the pathomechanics of
the dorsal intercalated segmental
instability (DISI) deformity was
well recognized, but the role of the
LT ligament in some VISI deformi-
ties had not yet been elucidated.
Such deformities were initially
attributed to traumatic or congeni-
tal laxity of the palmar radiocarpal
ligaments.
Since the 1984 report by Reagan
et al,
1
other authors have further
defined the role of LT ligament
injury in VISI deformities.
3-7
Al-
though LT ligament dissociation
with attenuation of secondary liga-
mentous restraints results in a VISI
deformity, not all VISI deformities
can be attributed to LT ligament

injury. Some appear to have a final
common pathway but multiple
mechanisms, all of which depend
on LT ligament attenuation.
In describing injuries of the LT
ligament, distinguishing between
dynamic and static instability is
imperative. Injuries with a normal
appearance on conventional radio-
graphs and dynamic instability that
are present only under load or in
certain positions are classified as LT
tears. Fixed carpal collapse (VISI)
on conventional radiographs repre-
sents static instability and is classi-
fied as LT ligament dissociation.
Dr. Shin is Director, Division of Hand and
Microvascular Surgery, Department of
Orthopaedic Surgery, Naval Medical Center,
San Diego, Calif. Dr. Battaglia is Staff
Surgeon, Department of Orthopaedic Surgery,
Naval Hospital, Naples, Italy. Dr. Bishop is
Professor and Chairman, Division of Hand and
Microvascular Surgery, Department of
Orthopaedic Surgery, Mayo Clinic, Rochester,
Minn.
The Chief, Bureau of Medicine and Surgery,
Navy Department, Washington, DC, Clinical
Investigation Program, sponsored this report
#84-16-1968-788 as required by HSETCINST

6000.41A. The views expressed in this article
are those of the authors and do not reflect the
official policy or position of the Department of
the Navy, the Department of Defense, or the
United States Government.
Reprint requests: Dr. Bishop, Mayo Clinic
E14A, 200 First Street Southwest, Rochester,
MN 55905.
Abstract
Isolated injury of the lunotriquetral interosseous ligament complex and associ-
ated structures is less common and is poorly understood compared with the
other proximal-row ligament injury, scapholunate dissociation. The spectrum
of injuries ranges from isolated partial tears to frank dislocation, and from
dynamic to static carpal instability. The diagnosis may be difficult to establish
because of the many possible causes of ulnar-sided wrist pain and the often nor-
mal radiographic appearance. The mechanism of injury is variable and includes
attrition by age, positive ulnar variance, and perilunate or reverse perilunate
injury. Appropriate treatment requires assessment of the degree of instability
and the chronicity of the injury. Options include corticosteroid injection,
immobilization, ligament repair, ligament reconstruction with tendon grafts,
limited intercarpal arthrodesis, and ulnar shortening.
J Am Acad Orthop Surg 2000;8:170-179
Lunotriquetral Instability: Diagnosis and Treatment
Alexander Y. Shin, MD, CDR, USNR, Michael J. Battaglia, MD, LCDR, USN, and
Allen T. Bishop, MD
Alexander Y. Shin, MD, CDR, USNR, et al
Vol 8, No 3, May/June 2000
171
Anatomy
The scapholunate and LT ligaments

are arguably the most important
intrinsic ligaments of the carpus.
The scapholunate and LT interos-
seous ligaments are both C-shaped,
spanning the dorsal, proximal, and
palmar edges of the joint surfaces.
Microscopically, they have similar
organization, being true ligaments
in the dorsal and palmar subre-
gions and becoming membranous
in the proximal fibrocartilaginous
subregion. In an elegant study of
the anatomy and histology of the
scapholunate ligament, Berger
8
demonstrated that its dorsal region
is thickest and strongest when tested
to failure and is biomechanically
the most important region. In a
similar study of the properties of
the LT ligament, Ritt et al
4
demon-
strated that the palmar region is the
thickest and strongest. These find-
ings support the Òbalanced lunateÓ
concept, which holds that the lu-
nate is torque-suspended between
the scaphoid and the triquetrum,
exerting a flexion moment through

the scapholunate ligament and an
extension moment through the LT
ligament. The dorsal LT ligament
region is most important as a rota-
tional constraint, whereas the pal-
mar region of the LT ligament is the
strongest and transmits the exten-
sion moment of the triquetrum as it
engages the hamate. The membra-
nous proximal portion of the LT lig-
ament complex is of little signifi-
cance with respect to constraining
rotation, translation, or distraction.
Mechanism of Injury
The exact mechanism of LT liga-
ment injury remains controversial;
it is likely that more than one
mechanism plays a role. For exam-
ple, perilunar dislocations occur
when a force is applied to the
thenar area with the wrist posi-
tioned in dorsiflexion and ulnar
deviation.
9,10
This injury pattern
has been well described and results
in a progressive injury pattern in a
radial to ulnar direction, following
either an osseous or a purely liga-
mentous path about the lunate.

Injury to the LT support structures
occurs in Mayfield stage III perilu-
nate injury, after either scapholu-
nate injury or scaphoid fracture.
These injuries will usually result in
a DISI deformity, unless the scapho-
lunate portion heals either sponta-
neously or after intervention, in
which case the ulnar-sided LT dis-
order will predominate. Some of
the existing case reports of LT liga-
ment sprains do indeed demon-
strate evidence of previous perilu-
nar injury (Fig. 1).
An isolated LT ligament tear
may be the result of a reverse peri-
lunate injury originating on the
ulnar side of the wrist.
1
A recent
biomechanical study has confirmed
this mechanism,
11
which occurs by
a fall on the outstretched hand
positioned in pronation, extension,
and radial deviation. The resultant
intercarpal pronation overloads the
ulnar-volar ligament structures and
causes LT ligament injury without

scapholunate disruption. Weber
12
has postulated that isolated LT lig-
ament tears may occur with the
wrist palmar-flexed. The dorsally
applied force allows the interos-
seous fibers of the LT ligament to
fail, sparing the palmar radioluno-
triquetral ligaments. The integrity
of this ligament tethers the palmar
pole of the lunate, creating an axis
for palmar flexion. In patients with
no history of trauma, LT instability
Figure 1 Images of a 48-year-old man with chronic ulnar-sided left wrist pain. A, Posteroanterior radiograph shows normal GilulaÕs arcs
1, 2, and 3. Arcs 1 and 2 are formed by the proximal and distal joint surfaces of the proximal carpal row. Arc 3 is formed by the proximal
joint surface of the distal carpal row. Midcarpal arthroscopy revealed wide gaping of the scapholunate interval (B) and LT interval (C), as
well as incongruity of the LT articulation, consistent with a chronic perilunate injury. In this case, the scapholunate instability was asymp-
tomatic, and the LT disorder predominated.
A B C
Lunate
Scaphoid
Triquetrum
Lunate
Lunotriquetral Instability
Journal of the American Academy of Orthopaedic Surgeons
172
may be the result of degenerative LT
lesions or inflammatory arthritis.
13
Positive ulnar variance may facili-

tate LT ligament degeneration by
means of a wear mechanism or alter-
ation of intercarpal kinematics.
14
Pathomechanics
In an uninjured wrist, the scaphoid
imparts a flexion moment to the
proximal carpal row, while the tri-
quetrum imparts an extension
moment. These opposing moments
are balanced by the ligamentous
attachment to the lunate. With loss
of the integrity of the scapholunate
ligament, the scaphoid tends to
flex, while the lunate and tri-
quetrum tend to extend, imparting
a DISI orientation. Conversely,
with loss of the integrity of the LT
ligament, the triquetrum tends to
extend, while the scaphoid and
lunate attempt to flex. However, a
complete LT ligament tear is not
sufficient to cause a static carpal
collapse into a VISI orientation.
Sectioning of the volar and dorsal
subregions of the LT ligament
results in slight divergence of the
triquetrum and lunate at extremes
of wrist flexion and radial deviation
but not collapse, unless consider-

able compressive force is applied.
1
Additional tear or attenuation of
secondary restraints is necessary to
create static carpal instability.
Both palmar and dorsal carpal lig-
aments may play roles as secondary
restraints. Two recent anatomic
studies have implicated palmar liga-
ment injury in the development of
VISI in LT dissociation. Trumble et
al
6
created carpal collapse with divi-
sion of the ulnar arcuate ligament.
Horii et al
5
demonstrated that sec-
tioning of the dorsal radiotriquetral
(dorsal radiocarpal) and dorsal
scaphotriquetral (dorsal intercarpal)
ligaments also produced static VISI
following LT ligament injury. Loss
of dorsal ligament integrity allows
the lunate to flex more easily, in part
by shifting the point of capitate con-
tact palmar to the lunate axis of rota-
tion (Fig. 2).
Clinical Presentation and
Examination

The spectrum of LT ligament injury
ranges from partial tears with vari-
able pain and weakness to com-
plete dissociation with static col-
lapse, causing a forklike deformity
of the wrist and prominence of the
distal ulna. However, some patients
with radiographic evidence of per-
sistent LT malalignment after perilu-
nate dislocation experience minimal
symptoms and will have a satisfac-
tory outcome. Symptomatic sprains
invariably present with ulnar wrist
pain.
1
Symptoms are usually inter-
mittent and are especially prominent
with wrist deviation or pronation-
supination. They include dimin-
ished motion, weakness, a sensation
of instability or giving way, and
ulnar nerve paresthesias. A painful
wrist clunk with deviation is often
present.
1
A history of a specific injury is
usually present,
1
which may allow
determination of the mechanism of

injury. A history of a fall on the dor-
siflexed wrist with a hypothenar
contact point should increase the
suspicion of ulnar-sided instabil-
ity.
15
Injuries that are often classi-
fied as annoying sprains may be
unrecognized LT ligament injuries.
A careful examination of the
wrist is needed in the evaluation of
ulnar-sided wrist pain to differenti-
ate LT injury from other lesions. A
variety of lesions may cause ulnar
wrist symptoms (Table 1).
16,17
Examination should encompass the
entire ulnar side of the wrist.
Ulnar deviation with pronation
and axial compression will elicit
dynamic instability with a painful
snap if a nondissociative midcarpal
joint or LT ligament injury is pres-
ent. Palpation will always demon-
strate point tenderness at the LT
joint.
1
A palpable wrist click with
radioulnar deviation may be signif-
icant if it occurs with pain. Pro-

vocative tests that demonstrate LT
laxity, crepitus, and pain are help-
ful in accurately localizing the site
of pathologic change.
Ballottement of the triquetrum,
as described by Reagan et al,
1
is per-
formed by grasping the pisotrique-
Figure 2 A, The dorsal extrinsic ligaments of the wrist include the dorsal radiotriquetral
ligament (DRT) and the dorsal scaphotriquetral ligament (DST). B, The normal integrity of
the dorsal ligaments prevents volar flexing of the lunate (shown at left). Loss of dorsal lig-
ament integrity allows the lunate to flex more easily, in part by shifting the point of capi-
tate contact palmar to the lunate axis of rotation (shown at right). (Reproduced from Shin
AY, Bishop AT: Treatment options for lunotriquetral dissociation. Techniques Hand Upper
Extremity Surg 1998;2:2-17. By permission of Mayo Foundation.)
A B
DST
DRT
Alexander Y. Shin, MD, CDR, USNR, et al
Vol 8, No 3, May/June 2000
173
tral unit between the thumb and
index finger of one hand and the
lunate between the thumb and
index finger of the other (Fig. 3, A
and B). If the test is positive, pain
and increased anteroposterior laxity
will be noted during manipulation
of the joint. The shear test is per-

formed with the subjectÕs forearm in
neutral rotation and the elbow on
the examination table. The examin-
erÕs contralateral fingers are placed
over the dorsum of the lunate. With
the lunate supported, the examin-
erÕs ipsilateral thumb loads the
pisotriquetral joint from the palmar
aspect, creating a shear force at the
LT joint (Fig. 3, C). Pressure on the
triquetrum in the Òulnar snuffboxÓ
creates a radially directed compres-
sive force against the triquetrum
(Fig. 3, D). Pain elicited with this
maneuver may be of LT origin, but
may also arise from abnormalities of
the triquetrohamate joint or triangu-
lar fibrocartilage complex.
15
These
tests are considered positive when
pain, crepitus, and abnormal mobil-
ity of the LT joint are demonstrable.
Comparison with the contralateral
wrist is essential to elicit subtle dif-
ferences.
Other findings on physical
examination commonly include
decreased range of motion and
diminished grip strength. Crepitus

may be palpable with wrist devia-
tion. A nondissociative instability
pattern secondary to midcarpal lax-
ity at the triquetrohamate joint
should be ruled out, as symptoms
may be very similar. The possibili-
ty of injury at both levels should be
considered.
18,19
Diagnostic Studies
Imaging modalities useful in the
evaluation of LT injuries include
routine wrist radiography, motion
studies, tomography, arthrography,
videofluoroscopy, scintigraphy, and
magnetic resonance imaging. Ap-
propriate study selection is based
on patient presentation (Fig. 4).
The radiographic appearance of
wrists with LT ligament tears is
often normal (Fig. 1). Lunotrique-
tral dissociation will result in dis-
ruption of the smooth arcs that are
formed by the proximal and distal
joint surfaces of the proximal car-
pal row (GilulaÕs arcs 1 and 2) and
the proximal joint surfaces of the
distal carpal row (GilulaÕs arc 3).
Table 1
Lesions Causing Ulnar-sided

Wrist Pain
Distal radioulnar joint subluxation
or arthrosis
Ulnar-head chondromalacia
Triangular fibrocartilage injury
Triquetrohamate instability
Hamate fractures
Ulnar styloid impingement
syndrome
Pisotriquetral arthritis
Extensor carpi ulnaris tendon
subluxation
Periarticular calcification
Ulnar neurovascular syndromes
A B
C D
Figure 3 A and B, The ballottement test is performed by securing the pisotriquetral unit
with the thumb and index finger of one hand and the lunate with the other hand. Anterior
and posterior stresses are placed on the LT joint. The criteria for a positive test are
increased laxity and accompanying pain. C, In the shear test, the pisotriquetral joint is
loaded by placing a palmar-to-dorsal stress across the LT joint. The lunate is supported by
the examinerÕs ipsilateral fingers while the contralateral thumb loads the pisotriquetral
joint. Pain with translation represents a positive test. D, Compression of the triquetrum
from the ulnar snuffbox applies a radially directed force against the LT joint. Pain may
indicate a disorder of the LT or triquetrohamate joint.
Lunotriquetral Instability
Journal of the American Academy of Orthopaedic Surgeons
174
The LT dissociation results in prox-
imal translation of the triquetrum

and/or LT overlap (Fig. 5).
1,20
Un-
like scapholunate injuries, no LT
gap occurs.
Provocative radiographic views,
including radial or ulnar deviation
and clenched-fist anteroposterior
views, are often helpful. In LT dis-
sociation, the normal reciprocal
motion of the scaphoid, the lunate,
and the distal row is accentuated in
deviation while triquetral motion is
diminished.
15
This increased pal-
mar flexion of the scaphoid and
lunate in radial deviation without
change of the triquetrum is a mani-
festation of loss of the proximal-
row integrity present in the normal
wrist.
1
Careful evaluation of the lunate
and triquetrum on lateral radio-
graphs may reveal malalignment
in the absence of frank carpal col-
lapse. The perimeters of the tri-
quetrum and lunate may be traced
and their relationship assessed.

1
The longitudinal axis of the tri-
quetrum, defined as a line passing
through the distal triquetral angle
and bisecting the proximal articu-
lar surface, forms on average a 14-
degree angle (range, +31 to Ð3
degrees) with the lunate longitudi-
nal axis, defined as a line passing
perpendicular to a line drawn from
the distal dorsal and volar edges of
the lunate. Lunotriquetral dissoci-
ation results in a negative angle
Positive
Plain
radiography
Normal
Arthrography
Arthroscopy
Relief
Observe
No relief
Abnormal Abnormal
No reliefRelief*
Observe
Initial relief*
Arthroscopy
Acute or sub-
acute condition
Chronic

condition
LT reconstruction
or
LT fusion ± recession
or
Repair if possible
LT reconstruction
or
LT fusion ± recession
or
Repair if quality LT
ligament available
LT repair
Repair
Normal
Negative
X-ray motion
studies
Injection and
immobilization
LT dissociation
± VISI
Optional
three-phase
arthrogram
Abnormal
findings
Normal
appearance
Injection and

immobilization
Acute or
subacute
condition
Chronic
condition
Provocative test
History of wrist
pain
Consider
other
causes
Consider
other
causes
If recurrence,
injection,
immobilization,
observation
Figure 4 Algorithm for treatment of LT injuries. * = Relief is categorized as follows: ÒInitial reliefÓ designates transient relief secondary
to anesthetic. ÒReliefÓ designates lasting relief secondary to effects of corticosteroid administration.
Alexander Y. Shin, MD, CDR, USNR, et al
Vol 8, No 3, May/June 2000
175
(mean value, Ð16 degrees) (Fig. 6).
1
If a VISI deformity is present with
LT dissociation, the scapholunate
and capitolunate angles will be
altered. The scapholunate angle

may be diminished from its nor-
mal 47 degrees to 40 degrees or
less but is often normal.
2
The lu-
nate and capitate, which are nor-
mally colinear, will collapse in a
zigzag fashion, resulting in an
angle greater than 10 degrees.
Arthrography can be valuable,
demonstrating leakage or pooling
of dye at the LT interspace. How-
ever, age-related LT membrane
perforations, other communica-
tions between the radiocarpal and
midcarpal joints, and asympto-
matic LT tears on arthrography of
normal wrists have been reported.
Therefore, the results of arthrogra-
phy must be correlated with clini-
cal examination findings. A video-
taped arthrogram with motion
sequences in flexion-extension and
radioulnar deviation can further
confirm the presence of LT injury
by demonstrating abnormal pool-
ing of the dye column and abnor-
mal proximal-row kinematics.
Videofluoroscopy is useful in
demonstrating the site of a ÒclunkÓ

that occurs with deviation. In LT
sprains, this occurs with a sudden
Òcatch-upÓ of the triquetrum into
extension as the wrist moves into
maximal ulnar deviation.
Technetium-99m diphosphate
bone scanning can be useful in
identifying the site of acute injury,
but is less specific than arthrogra-
phy.
20
Bone scans prove helpful
when standard films and motion
studies are negative. Magnetic
resonance imaging technology is
not yet reliable for LT ligament
imaging.
Selective midcarpal injection of
local anesthetic is also useful as a
diagnostic tool. In our experience,
resolution of pain with increased
grip strength after injection has
been a reliable indicator of LT in-
jury. A poor response to injection
suggests an extra-articular cause of
the patientÕs symptoms.
In the evaluation of LT injuries,
wrist arthroscopy is both diagnos-
tic and therapeutic. Wrist arthros-
copy provides a means of directly

evaluating the integrity of the LT
ligament and allows identification
and treatment of any associated
pathologic changes. In our experi-
ence, arthroscopy is the most accu-
rate diagnostic modality and may
replace all other studies. Carpal
instability can be assessed by direct
visualization and probing of the
carpal articulations, and provoca-
tive maneuvers can be performed
at the same time. In the uninjured
wrist, the articulations of the proxi-
mal and distal rows are very inti-
mate, with no separation between
the carpal bones. However, in the
injured wrist with carpal instability,
these articulations are gapped or
incompetent. Instability is graded
with use of the Geissler classifica-
tion
21
(Table 2).
The LT ligament is best visual-
ized from the radiocarpal arthros-
copy portal between the fourth and
fifth extensor compartments or
from the portal radial to the sixth
extensor compartment. The dorsal,
volar, and membranous portions of

the LT ligament must be visualized
and palpated with a probe to eval-
uate the integrity of the ligament.
Midcarpal arthroscopy is the key to
assessing the stability of the LT
Figure 5 Images of a 27-year-old man with an LT ligament tear after a fall on the out-
stretched dorsiflexed and ulnarly deviated wrist. A, Anteroposterior radiograph demon-
strates the break in GilulaÕs arcs 1 and 2, with overlap of the lunate and triquetrum. B,
Lateral radiograph demonstrates the VISI collapse of the carpus, implying injury to other
supporting ligaments of the lunate and triquetrum.
A B
Figure 6 A, The normal LT angle averages +14 degrees. B, With LT dissociation, the
average LT angle decreases to −16 degrees. (Reproduced from Shin AY, Bishop AT:
Treatment options for lunotriquetral dissociation. Techniques Hand Upper Extremity Surg
1998;2:2-17. By permission of Mayo Foundation.)
A B
Lunotriquetral Instability
Journal of the American Academy of Orthopaedic Surgeons
176
joint (Fig. 7). From the midcarpal
perspective, the normal LT joint is
smooth without a step-off or dias-
tasis. Placement of a probe into the
LT joint enables further assessment
of the severity of any instability. In
addition to the LT and scapholu-
nate joints, the capitohamate articu-
lation and the articular surfaces of
the hamate, triquetrum, capitate,
and lunate should also be inspected,

as they may show changes due to
abnormal kinematics.
Treatment
Several factors should be consid-
ered in choosing the optimal treat-
ment for LT injuries (Fig. 4). These
include the amount of instability
(static or dynamic), the elapsed
time between injury and treatment
(acute or chronic), and the presence
of associated injury or degenerative
changes. Symptoms of pain in LT
ligament tears may be due to dy-
namic instability or local synovitis
or a combination thereof.
Initial management of most
acute and chronic tears without
dissociation or VISI deformity
should probably be nonoperative,
with cast or splint immobilization.
1
Careful molding with a pad under-
neath the pisiform will maintain
optimal alignment as healing pro-
gresses. Midcarpal corticosteroid
injections can be helpful in decreas-
ing synovitis. For acute and chron-
ic dissociations with VISI collapse
and chronic tears unresponsive to
conservative management, opera-

tive treatment is indicated.
The goal of surgical intervention
is the realignment of the lunocapi-
tate axis and reestablishment of the
rotational integrity of the proximal
carpal row. A variety of procedures
have been described, including LT
arthrodesis, ligament repair, and
ligament reconstruction. If con-
comitant negative or positive ulnar
variance or midcarpal or radiocarpal
arthrosis is present, additional pro-
cedures, such as ulnar lengthening
or shortening, midcarpal arthrode-
sis, or proximal-row carpectomy,
may be indicated. Total wrist ar-
throdesis may be appropriate if de-
generative changes make other sal-
vage procedures impossible.
Repair of the LT ligament has
been described by several authors.
Reagan et al
1
demonstrated good
results, as did Favero et al.
22
In the
latter study, only 1 of 21 ligament
repairs failed, and 90% of patients
were satisfied with their outcome.

The LT interosseous ligament is re-
attached to the site of its avulsion,
generally from the triquetrum. The
technique is demanding, requiring
use of multiple sutures passed
through drill holes or suture anchors
(Fig. 8). As the strong volar ligament
is also disrupted, a combined dorsal-
volar approach, as well as augmenta-
tion of the repair by plication of the
dorsal radiotriquetral and dorsal
scaphotriquetral ligaments, may be
of some value. Protracted immobi-
lization is necessary. Patients who
engage in strenuous pursuits or who
have chronic instability or a poor-
quality LT ligament may be best
treated by ligament reconstruction.
Table 2
Arthroscopic Classification of Tears of the Intracarpal Ligaments
*
Grade Description
I Attenuation or hemorrhage of the interosseous ligament as seen
from the radiocarpal space. No incongruency of carpal
alignment in the midcarpal space.
II Attenuation or hemorrhage of the interosseous ligament as seen
from the radiocarpal space. Incongruency or step-off of carpal
space. There may be slight gap (less than width of probe)
between carpal bones.
III Incongruency or step-off of carpal alignment as seen from both

radiocarpal and midcarpal space. Probe may be passed
through gap between carpal bones.
IV Incongruency or step-off of carpal alignment as seen from both
radiocarpal and midcarpal space. There is gross instability
with manipulation. A 2.7-mm arthroscope may be passed
through gap between carpal bones.
*
Reproduced with permission from Geissler WB, FreelandAE, Savoie FH, McIntyre
LW, Whipple TL: Intracarpal soft-tissue lesions associated with an intra-articular
fracture of the distal end of the radius. J Bone Joint Surg Am 1996;78:357-365.
Figure 7 Midcarpal arthroscopic view of a
25-year-old man with left wrist pain after a
fall onto the pronated and extended wrist.
Clinical evaluation was consistent with iso-
lated LT instability, which was confirmed
by arthroscopy. Significant mobility and
diastasis (curved arrow) and incongruity of
the midcarpal articular surfaces (solid
arrows) were found on both palpation and
exploration with an arthroscopic probe.
Triquetrum
Lunate
Probe
Alexander Y. Shin, MD, CDR, USNR, et al
Vol 8, No 3, May/June 2000
177
Ligament reconstruction with a
distally based strip of extensor
carpi ulnaris tendon graft is one
option (Fig. 9). Unlike scapholu-

nate ligament reconstruction, this
technique, although demanding,
yielded uniformly good results in
two studies.
1,22
Unlike LT arthrod-
esis, reconstruction preserves LT
motion and offers the greatest like-
lihood of restoration of normal
carpal interactions.
The observation of asympto-
matic congenital LT coalitions and
the finding of relatively little rela-
tive motion between the lunate and
the triquetrum led to the concept of
LT arthrodesis (Fig. 10).
23
Perhaps
technically less demanding than
ligament reconstruction or repair,
LT arthrodesis has become the
technique of choice of many authors.
However, the method is not with-
out substantial problems. The re-
ported nonunion rates range from
0% to 57%.
1,22,24-28
Use of Kirschner
wires has been shown to result in
an unacceptably high nonunion

rate of 47%.
26
Use of compression
screws may improve results, but
nonunion remains a significant
problem. A 9% nonunion rate has
been reported with the Herbert
screw, and use of conventional cor-
tical screws has been associated
with nonunion rates as high as
57%.
26-28
In a comparison of outcomes an
average of 6.5 years after arthrode-
sis, ligament repair, or reconstruc-
tion in 65 patients with LT ligament
injury, Favero et al
22
demonstrated
that LT arthrodesis was inferior to
reconstruction or repair. Of 21 pa-
tients who underwent LT arthrode-
sis, 52% had persistent pain and a
31% decrease in motion from pre-
operative measures; 71% required
A B
C D
Figure 8 Technique of LT ligament repair. A, After appropriate exposure of the dorsal
proximal carpal row (ligament-sparing capsulotomy is shown) and determination that
enough LT ligament is present to be repaired, the ligament is detached from either the tri-

quetrum (as illustrated) or the lunate. B, The recipient bone bed is prepared, and several
parallel Kirschner wires are placed to create a tunnel for sutures. C, Nonabsorbable hori-
zontal mattress sutures are placed. D, Before securing the sutures, the lunate and tri-
quetrum are immobilized in their anatomic positions by additional Kirschner wires.
(Reproduced from Shin AY, Bishop AT: Treatment options for lunotriquetral dissociation.
Techniques Hand Upper Extremity Surg 1998;2:2-17. By permission of Mayo Foundation.)
Figure 9 Reconstruction is recommended if there is insufficient LT ligament. A, Kirschner wires are placed as guides for drill holes such
that the tips meet along the volar corners of the lunate and triquetrum. B, Holes are created with the use of graduated hand awls. A distal-
ly based radial strip of extensor carpi ulnaris is harvested and woven through the drill holes. C, The lunate and triquetrum are immobilized
by Kirschner wires, and the tendon graft is secured to itself. (Reproduced from Shin AY, Bishop AT: Treatment options for lunotriquetral
dissociation. Techniques Hand Upper Extremity Surg 1998;2:2-17. By permission of Mayo Foundation.)
A B
C
Lunotriquetral Instability
Journal of the American Academy of Orthopaedic Surgeons
178
further surgery; and 62% experi-
enced significant complications.
The nonunion rate was 38%. Ulno-
carpal impingement necessitated
additional surgery in 14% of pa-
tients who underwent LT arthrode-
sis; this complication was not seen
with LT repair or reconstruction.
In contrast, persistent pain was
present in only 1 (12%) of 9 patients
who underwent LT reconstruction
and in only 3 (14%) of 21 patients
who underwent LT repair. Motion
was diminished only 11% with

repair and actually increased 9%
with reconstruction. All patients
who underwent reconstruction
returned to their previous occupa-
tions, and only 1 required subse-
quent surgery. The lower compli-
cation rates, higher patient satisfac-
tion, greater range of motion, and
lower rate of subsequent reopera-
tion suggest that LT ligament re-
pair or reconstruction should be
the primary method of treatment
for LT injuries that require surgical
intervention.
Summary
Lunotriquetral ligament injuries
are often neglected, missed, or
misdiagnosed, resulting in pro-
longed ulnar-sided wrist pain. A
careful history followed by a sys-
tematic physical examination can
often identify an injury to the LT
ligament. Confirmation of the
diagnosis by means of radiogra-
phy, arthrography, or arthroscopy
is essential before initiating treat-
ment. Although treatment of LT lig-
ament injuries remains controver-
sial and several surgical options
are available, our preference is liga-

ment repair or reconstruction, which
has demonstrated consistently better
results than arthrodesis. Although
surgical repair or reconstruction is
technically challenging, it pre-
serves LT ligament motion and
offers the greatest likelihood of
restoration of normal carpal kine-
matics.
A B
C D
Figure 10 Several methods of LT arthrodesis can be utilized. A corticocancellous slot (A
and B) or winged graft bone (C) can be wedged in an appropriately created slot in the
lunate and triquetrum and can then be secured with Kirschner wires. D, A preferred
method is the denuding of the LT articular cartilage with preservation of the volar and
proximal rims with placement of corticocancellous graft and fixation with a compression
screw. (Reproduced from Shin AY, Bishop AT: Treatment options for lunotriquetral dis-
sociation. Techniques Hand Upper Extremity Surg 1998;2:2-17. By permission of Mayo
Foundation.)
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