In a middle‑aged patient with chronic dorsal wrist pain, clicking, reduced grip strength and limited motion after a prior sprain, is proximal row carpectomy (PRC) indicated, and what are its indications, contraindications, and expected outcomes?

Proximal Row Carpectomy for Chronic Wrist Pain After Sprain

Proximal row carpectomy is indicated for this patient if advanced imaging confirms scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC) without capitolunate arthritis, and should be performed only after MR arthrography or CT arthrography definitively characterizes the ligamentous injury and excludes capitate head or lunate fossa degeneration. 1, 2

Diagnostic Workup Required Before Considering PRC

Initial Imaging

• Obtain three-view wrist radiographs (posteroanterior, lateral, and 45° semipronated oblique) to assess scapholunate interval widening, carpal collapse patterns, and stage of degenerative arthritis 1, 3
• Radiographs must evaluate the capitate head and lunate fossa of the distal radius for any arthritic changes 1, 2

Advanced Imaging to Guide Surgical Decision

• CT arthrography is the preferred next study, offering near-100% sensitivity and specificity for scapholunate ligament tears and 94-100% accuracy for articular cartilage abnormalities 1
• CT arthrography is superior to 1.5T MRI for visualizing tears of the biomechanically critical dorsal segment of the scapholunate ligament 1
• MR arthrography is an acceptable alternative with 63-100% sensitivity for scapholunate ligament tears and can identify which ligament segments remain repairable 1
• Standard 3.0T MRI without contrast demonstrates only 70-87% sensitivity for scapholunate ligament tears and is insufficient for definitive surgical planning 1

Critical pitfall: Relying on non-contrast MRI alone may miss significant scapholunate injuries and lead to inappropriate surgical selection 1

Indications for Proximal Row Carpectomy

Primary Indications

• SLAC wrist (stage II or III without capitolunate arthritis) 2, 4, 5
• SNAC wrist 6, 2
• Kienböck's disease 6, 2
• Chronic perilunate dislocations 2

Patient Selection Criteria

• Age older than 35 years 2
• Intact capitate head (no chondral defects or arthritis) 2, 4
• Intact lunate facet of the distal radius (no degenerative changes) 2, 4
• Failed conservative management with persistent pain and functional limitation 2, 7

Absolute Contraindication

The presence of capitolunate arthritis is an established relative-to-absolute contraindication for PRC 6, 4, 5

• In stage III SLAC wrist with capitolunate arthritis, PRC provides unsatisfactory pain relief and four-corner arthrodesis is recommended instead 4, 5
• If capitolunate arthritis is present, scaphoid excision with four-corner arthrodesis reliably diminishes pain while maintaining a 54° flexion-extension arc 5

Expected Outcomes After PRC

Range of Motion

• Flexion-extension arc of 70-71° (best motion preservation among salvage procedures) 5, 7
• Radial and ulnar deviation of 33° 7
• PRC preserves significantly greater range of motion than limited wrist arthrodesis 4, 5

Grip Strength

• Approximately 54% of the contralateral unaffected side 7
• Grip strength improves for at least 1 year postoperatively and does not decline with time 4

Pain Relief

• 87% of patients report pain improvement compared to preoperative status 7
• Satisfactory pain relief in patients without capitolunate arthritis 4, 5

Functional Scores

• Mayo wrist score: 66 points 7
• Krimmer wrist score: 69 points 7
• DASH score: 27.8 7

Long-term Considerations

• Postoperative progressive radiographic changes at the radiocapitate articulation are documented but tend to remain asymptomatic 2
• Conversion to total wrist arthrodesis occurs in approximately 12% of cases (6 of 51 motion-sparing procedures in one series) 5
• Symptomatic radiocarpal arthritis requiring conversion to arthrodesis can develop 4

Technical Advantages of PRC

• Greater range of motion compared to limited wrist arthrodesis 4, 5
• Technical ease of the procedure 6, 7
• Decreased immobilization time compared to arthrodesis procedures 6
• Eliminates complications specific to arthrodesis: nonunion, hardware irritation, and impingement 6
• No risk of nonunion (unlike four-corner or capitolunate arthrodesis, which have nonunion rates of 9-50%) 5

Postoperative Protocol

• Immobilize wrist in neutral position with forearm in neutral rotation for minimum of 4 weeks 1
• Obtain follow-up radiographs at 3 weeks and at end of immobilization to confirm healing and assess carpal alignment 1
• Initiate gentle active wrist motion only after 4-week immobilization period 1
• Begin strengthening exercises at 8-12 weeks postoperatively 1
• Return to heavy manual tasks or sports no earlier than 3 months after surgery 1

Critical pitfall: Inadequate immobilization duration predicts poor postoperative results including ongoing pain and limited function 1

Surgical Decision Algorithm

For Stage II SLAC wrist (no capitolunate arthritis):

• PRC is the preferred option, providing best motion preservation (71° flexion-extension arc) 5
• Alternative options include radioscaphoid arthrodesis or four-corner arthrodesis 5

For Stage III SLAC wrist (with capitolunate arthritis):

• Four-corner arthrodesis is recommended over PRC 4, 5
• PRC may provide unsatisfactory pain relief in this setting 4