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Ligaments of the Wrist

This is a detailed step by step instruction through a Modified Corella arthroscopic assisted  reconstruction of the scapho-lunate interosseous ligament (SLIL).

The operation is performed to restore carpal mechanics following a SLIL injury and often subsequent attrition of the secondary stabilisers leading to a dorsal-intercalated segment instability (DISI). SLIL injuries over 4-6 weeks old are often very difficult to repair primarily and may require reconstruction if symptoms persist. If the wrist remains symptomatic despite appropriate rehabilitation, splintage and analgesia therapy, surgery may be required.

This can be the case in Geissler grade 3 or 4 ligament tears seen arthroscopically and may also be the operation of choice in grade 1 scapho-lunate advanced collapse (SLAC) in conjunction with a radial styloidectomy.

The operation uses a third to a half of the flexor carpi radialis (FCR) tendon which is passed through the scaphoid, across to the lunate and then dorsal to volar though the lunate and onto the volar radio-scapho-capitate (RSC) ligament. This aims to reconstruct the volar secondary stabiliser of the scapho-trapezial-trapizoid ligament (STT), the dorsal and volar limbs of the SLIL. The operation is performed as a daycase procedure and the patient is placed in cast for 2 weeks following the procedure and then a splint with focussed rehabilitation with a specialist therapist.

Patients often return to light work at 8 weeks, heavy work at 3 months and continue to improve up to a year post-operation.

Readers will also find of use the following OrthOracle techniques : Diagnostic Wrist Arthroscopy (using Acumed ARC Tower ) 

and Modified Brunelli procedure : Scapho-lunate ligament reconstruction for wrist instability using Biotenodesis screw(Arthrex)

Compared to the open Modified Brunelli procedure, which is commonly the treatment choice for SLIL reconstruction, the Modified Corella is certainly a more complex procedure and requires arthroscopy skills in addition to wrist surgery skills. There is however little of the procedure which is wholly arthroscopic and therefore it is better termed arthroscopic assisted. The rationale behind this surgery compared with the Modified Brunelli is 2 fold. Firstly, with no large wound in the dorsal wrist capsule, the range of movement in the published series appears to be better post-operatively than with the Modified Brunelli. Secondly the use of the interference screws in the scaphoid and lunate, lock the ligament reconstruction and avoid it slacking off. Having performed both procedures I get the impression that the scaphoid is more firmly pulled and fixed to the lunate with the Corella compared to the modified Brunelli.  One note of caution is that the Corella should not be used if there is any instability between the lunate and triquetrum as it is liable to exacerbate this instability by stabilising just the radial side of the proximal carpal row.

The original description of this operation and report of its originators series is published in Hand Clinics:

Corella F, Del Cerro M, Ocampos M, Simon de Blas C, Larrainzar-Garijo R. Arthroscopic scapholunate ligament reconstruction, volar and dorsal reconstruction. Hand Clin. 2017 Nov; 33(4):687-707.

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- Volar Wrist Ligaments:
- ligaments of wrist are most highly developed on palmar side of wrist;
- palmar wrist ligaments originate laterally from radial styloid, & are directed in a distal ulnar direction;
- intrinsic ligaments:
- radial ligaments arise on palmar facet of radial styloid passing on to capitate;
- ulnar sided intrinsic ligaments:
- capitohamate ligaments:
- three distinct ligaments: dorsal, volar, and deep portions;
- lunotriquetral ligaments:
- c-shaped ligament with three parts: the dorsal, volar (most important), and intramembranous portions;
- between these arcades, is space of Poirier;
- thru this interval escapes of distal carpal row from lunate in perilunar dislocation;
- palmar ulnar extrinsic ligaments
- ulnotriquetral (medial)
- ulnolunate (medial)
- this is a key ligament along w/ the TFC;
- on occassion, may avulse from its insertion on lunate, and this injury will allow dye extension both into distal RU joint and into mid-carpal joint;
- references:
- An anatomical study of the ligaments of the ulnar compartment of the wrist
- An anatomic study of the ligamentous structure of the triangular fibrocartilage complex.
- palmar radial extrinsic ligaments:
             - ref: MRI of Wrist Ligaments

- Dorsal Wrist Ligaments:
    - dorsal extrinsic ligaments are seen after incising extensor retinaculum and retracting the extensor tendons;
- superficial layer: dorsal approach to the wrist: splits the dorsal radiotriquetral ligament proximally and the dorsal intercarpal ligament distally;
- dorsal transverse intercarpal (trapezoidal-triquetral ligament):
- this ligament has some fibers which insert on the dorsal ridge of scaphoid but none that insert on the distal pole of the scaphoid;
- major portion of the ligament originates on the trapezium, runs radially and inserts on the dorsal ridge of scaphoid  the trapezium, and the trapezoid;
- deep portion of ligament augments the scapholunate and lunotriquetral ligaments;
- dorsal radiocarpal ligament: (dorsal oblique radiotriquetral ligaments)
- arises from the distal radius at Lister’s tubercle
- it attaches to the dorsal horn of the lunate and then attaches to superficial component courses to attach to the dorsum of the triquetrum;

- references:
- The Incidence of Dorsal Radiocarpal Ligament Tears in Patients Having Diagnostic Wrist Arthroscopy for Wrist Pain
- deep layer:
- scapholunate interosseous ligament;
- lunotriquetal interosseous ligament;
- scaphocapitate and scaphotrapezium-trapezoid ligaments: attach to distal pole of the scaphoid and resists scaphoid flexion;
- references:
- The dorsal ligaments of the wrist: anatomy, mechanical properties, and function.
- The dorsal ligaments of the wrist.
MRI of Wrist Ligaments

- Wrist Ligament Injuries: (see carpal instability);
- most of tension injuries to wrist occur w/ wrist hyperextenion;
- radiocarpal ligaments will exceed their normal elastic limits w/ extreme hyperextension;
- injuries that result may be characterized as part of spectrum of injuries including scapholunate dissociation and perilunar dislocation;
- interosseous ligaments of distal row seldom fail clinically

The Ligaments of the Wrist.

Disruption of the ulnolunate ligament as a cause of chronic wrist pain.

Wrist Ligamentous Anatomy and Pathogenesis of Carpal Instability.

The ligaments of the wrist. A current overview of anatomy with considerations of their potential functions.

The anatomy of the ligaments of the wrist and distal radioulnar joints

Biomechanical function of the distal radioulnar and ulnocarpal wrist ligaments