87: Four-Corner Fusion

Procedure 87 Four-Corner Fusion



Jeffrey A. Greenberg


imageSee Video 65: 4-Corner Fusion Using Kirschner Wires



Indications




image Scapholunate advanced collapse (SLAC)


image Scaphoid nonunion advanced collapse (SNAC)


image Radiocarpal arthrosis


image Carpal instability patterns


image Failed soft tissue reconstructions



Examination/Imaging



Clinical Examination




image Radial fullness


image Decreased range of motion


image Decreased grip strength


image Painful range of motion


image Crepitus


image Painful extension loading


image Watson maneuver eliciting pain


image Styloid tenderness


image Carpal tunnel syndrome possible



Imaging




image Plain radiographs are usually sufficient for diagnosis. SLAC wrist, stage 3, demonstrates abnormal position of the scaphoid, scapholunate widening, radioscaphoid degenerative change and midcarpal arthrosis (Fig. 87-1).


image In cases in which there is uncertainty about the status of the radiolunate joint, advanced imaging (computed tomography) may be used.


image

FIGURE 87-1



Surgical Anatomy




image In either SLAC or SNAC, there will be widening at the scapholunate interval.


image Significant scaphoid flexion, lunate extension, and dorsal lunate prominence develop.


image Radioscaphoid degenerative change with styloid prominence and osteophytes is noted.


image Proximal scaphoid pole necrosis and/or arthrosis is present (Fig. 87-2).


image Synovitis is present.


image Scaphotrapeziotrapezoid arthrosis may be present.


image The dorsal ligaments of the wrist—dorsal radiocarpal (DRC) and dorsal intercarpal (DIC)—have a conjoined insertion on the triquetrum. They provide the capsulotomy landmarks for wrist exposure.


image The volar extrinsic ligaments (radioscaphocapitate, short and long radiolunate) originate from the volar radius and extend obliquely to the carpus. These should be respected during scaphoid excision (Fig. 87-3).


image

FIGURE 87-2


image

FIGURE 87-3



Positioning




image The patient is positioned supine, the hand and forearm are supported on a hand surgery table, and a proximal tourniquet is used.


image Operating on the wrist is easier if the surgeon is positioned at the head of the patient as opposed to at the axilla.



Exposures




image A dorsal midline incision centered over the radiocarpal joint is used.


image Thick flaps are elevated dorsal to the retinaculum, keeping cutaneous nerves within these flaps.


image The retinaculum over the third dorsal compartment is incised.


image Retinacular flaps are raised, exposing the second through fifth compartments (Fig. 87-4).


image The extensor tendons are retracted using retractors placed between the second and fourth compartments.


image A posterior interosseous neurectomy is performed.


image A capsulotomy is performed by dividing the dorsal capsule along the dorsal intercarpal and dorsal radiocarpal ligaments (Fig. 87-5). The flap is elevated off the dorsum of the triquetrum and reflected, keeping it radially based (Fig. 87-6).


image

FIGURE 87-4


image

FIGURE 87-5

Related posts:

28: Pronator Teres Rerouting 34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity 32: Crossed Intrinsic Tendon Transfer 26: Reconstruction of Key Pinch in Tetraplegia Patients 33: Correction of Swan-Neck Deformity in the Rheumatoid Hand 30: Synovectomy

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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 87: Four-Corner Fusion

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