Painful left wrist in a rt handed doctor

 

From the above  xrays  the patient has  a grade 3A Litchman lunatomalacia. 

AP shows a flexed scaphoid ( ring sign) with the carpal ratio altered suggesting lunate foreshortening. 

Radial styloid appears sharp - radial styloid  OA. 

clenched fist AP ( Why)does not show a flexed scaphoid.( cannot explain). is it a correctable scaphoid flexion

Definite ulnar minus

 What would you do?

1. joint levelling procedure ie; radail shortening

2. radial styloidectomy and Scapholunate fusion to unload the lunate with or without lunate excision

3. STT fusion

4. revascularisation  with interacarpal vessel

 my suggestion would be to scope to see if radioscaphoid (styloid OA is present) if present my choice would be no 2. if not 1.

 Any valid advise is welcome for the friend who asked for my opinion