Updated: 10/4/2016

Four Corner Wrist Fusion

Preoperative Patient Care


Basic Outpatient Evaluation and Management (including Post Op Care)


Perform focused history and physical exam

  • recognizes implications of soft tissue injury


Orders/ interprets advanced imaging:

  • CT scan


Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention
  • surgical indications
  • pain with motion
  • instability
  • end stage osteoarthritis of the wrist


Modify and adjust post-op plan when indicated

  • postop: 2-3 week postoperative visit
  • wound check and remove sutures
  • diagnose and management of early complications
  • continue immobilization for 8-10 weeks
  • continue non-weightbearing
  • postop:3 months
  • start strengthening exercises
  • postop: 1 year postoperative visit

Preoperative H & P


Perform history and physical exam

  • check radial/ulnar artery patency of operative extremity with Allen’s test


Orders and interprets basic imaging studies

  • need biplanar films of wrist


Perform operative consent

  • describe complications of surgery including
  • neurovascular injury
  • superficial and deep infections
  • wound breakdown
  • implant failure
  • malunion and nonunion

Operative Techniques


Preoperative Plan


Execute surgical walkthrough

  • describe key steps of the procedure to the attending verbally prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • fusion plate and screws


Room setup and equipment

  • setup OR with standard operating table and radiolucent hand table
  • turn table 90° so that operative extremity points away from anesthesia machines
  • c-arm perpendicular to hand table with monitor in surgeon's direct line of site


Patient positioning

  • supine with shoulder at edge of bed centered at level of patient’s shoulder
  • hand centered on hand table, supinate arm
  • arm tourniquet placed on arm with webril underneath (optional)

Superficial Dissection Between 3rd and 4th Extensor Compartment


Mark incision and make the incision

  • make a standard dorsal longitudinal incision between the third and fourth extensor compartment
  • use the tubercle of Lister as a landmark


Divide the third and fourth compartments

  • incise the retinaculum over the third extensor compartment
  • incised the radial septum of the fourth extensor compartment


Retract tendons

  • retract the tendons ulnarly

Dorsal Wrist Capsulotomy and Joint Inspection


Expose the dorsal wrist capsule

  • elevate the fourth and fifth extensor compartments ulnarly
  • translocate the EPL tendon with the radial wrist extensor tendons radially


Expose the midcarpal joint and the radial half of the radiocarpal joint

  • longitudinally split the dorsal radiocarpal and dorsal intercarpal ligaments with the apex of the triquetrum


Elevate the flap radially

  • this will detach the dorsal capsule from the radius to the level of the styloid process


Expose the ulnocarpal joint

  • split the dorsal radiocarpal ligament longitudinally
  • incise the capsule along the ECU tendon subsheath proximally to the level of the TFCC with the apex of the triquetrum


Elevate this flap proximally


Inspect the radio lunate joint for articular cartilage wear


Scaphoid Excision


Excise the scaphoid

  • identify and excise the scaphoid either in a piecemeal fashion with a rongeur or sharply using a scalpel
  • take care to protect the volar radioscaphocapitate ligament

Fusion Preparation


Prepare the wrist for fusion

  • decorticate the opposing joint surfaces of the lunate, triquetrum, capitate and hamate
  • remove the volar third cartilage from the lunate and the capitate
  • this corrects the pre-existing DISI deformity but will shorten the intercarpal bone distance


Harvest distal radius bone graft and place into the fusion bed


Carpal Reduction


Place Kwires

  • place a .06 2K wire through the distal radius articular surface
  • place another Kwire in the lunate
  • use a separate K wire as a joystick to hold the lunate reduced and neutral alignment
  • advanced the K wire across the radio lunate joint from dorsal to volar


Verify Kwire placement

  • obtain images to verify the correction of the dorsally tilted lunate


Reduce the capitate

  • applied dorsal pressure to volarly translate the capitate on the lunate
  • this should fully correct the DISI deformity


Place 2 more Kwires

  • secure the triquetrum to the hamate and the lunate to the capitate with two additional K wire
  • place these K wire’s as volar as possible
  • this prevents interference with rasping and plate placement


Place the rasp

  • center the power rasp over the four bones in both the AP and lateral planes
  • bury the rasp down to subchondral bone


Pack bone graft

  • pack bone graft obtained from the distal radius between the four prepared bones

Plate Fixation


Position the plate

  • center the plate over the four bones in the AP and lateral planes
  • place the circular plate into the bony crater created by the rest
  • rotate the plate to maximize screw purchase into each of the four bones


Set the plate

  • place two screws in each of the four carpal bones
  • place the screws unicortically
  • place the first screw through the plate into the lunate
  • do not tighten the screw completely
  • place a second screw into the hole opposite the first screw
  • the plate position should now be set


Check imaging for placement of the plate

  • check a lateral x-ray to ensure the plate is well seated and there is no impingement with wrist extension


Fill the plate with screws

  • fill the remainder of the holes with screws
  • placing screws opposite one another and tightening them sequentially will help prevent Mal positioning of the plate


Obtain final imaging

  • obtain final images to check screw links position carpal reduction and construct stability

Wound Closure


Irrigation, hemostasis, and drain

  • irrigate wounds thoroughly and deflate tourniquet (if utilized)
  • coagulate any bleeders carefully


Deep closure

  • close the capsule with absorbable suture
  • repair the extensor retinaculum
  • leave the EPL tendon transposed subcutaneously


Superficial closure

  • close skin
  • close subcutaneous layer with 3-0 absorbable suture
  • 3-0 nylon vertical/horizontal mattress for skin
  • alternatively, can use running 4-0 or 5-0 Monocryl for subcuticular stitch


Dressing and splint

  • place a short arm cast

Postoperative Patient Care


Perioperative Inpatient Management


Discharges patient appropriately

  • pain meds
  • wound care
  • prescribe outpatient physical therapy
  • non-weightbearing

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