Well described anatomy of corpus and instability & management.

1. Carpal Instability and
Management
By: Dr.T.Raghunath
Post graduate.
SVS medical college
Moderator:
1

2. INTRODUCTION
• WRIST JOINT –MARVEL OF EVOLUTION (UNLIKE
OUR DEVELOPMENTAL ANCESTORS)
• PARTICIPATING CARPAL BONES
• PROXIMAL ROW- SCAPHOID,
LUNATE, TRIQUETRIUM, PISIFORM
• DISTAL ROW- TRAPEZIUM, TRAPEZOID,CAPITATE,
HAMATE
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3. Anatomy of the Wrist
• Carpal bones tightly linked by capsular and interosseous ligaments.
• Capsular (extrinsic) ligaments originate from the radius and insert
onto the carpus.
• Interosseous (intrinsic) ligaments traverse the carpal bones.
• The lunate is the key to carpal stability.
• Connected to both scaphoid and triquetrum by strong interosseous
ligaments.
• Injury to the scapholunate or lunotriquetral ligaments leads to
asynchronous motion of the lunate and leads to dissociative carpal
instability patterns.
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4. EXTRINSIC LIGAMENTS
• Three major groups
1. Palmar radiocarpal
2. Palmar ulnocarpal
3. Dorsal radiocarpal
* Ulna and carpus – no dorsal
connecting ligaments
4

5. PALMAR RADIOCARPAL LIGAMENTS
1. Radioscaphoid (rs)
2. Radioscaphocapitate (rsc)
3. Long radiolunate (long rl)
4. Short radiolunate ligaments (short rl)
5

6. • SPACE OF POIRIER : ligamentfree
areabtw radioscapholunatelig&
long radiolunateligament-at level
of midcarpal joint;
• an area of potentialweakness.
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7. Pathomechanics
• Classically, the radius, lunate, and capitate
have been described as a central “link” that
is colinear in the sagittal plane.
• Scaphoid serves as a connecting strut. Any
flexion moment transmitted across the
scaphoid is balanced by an extension
moment at the triquetrum.
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8. Radio-lunate ligaments
• Pivotal role in preventing the dorsal
dislocation of lunate in wrist injuries
caused by hyperextension of wrist
Components of TFCC
• Volar radioulnar ligaments
• Dorsalradioulnar ligaments.
• The meniscus homologue.
• Ulnar collateral ligament.
• The extensor carpi ulnaris tendon
sheath.
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9. The palmar ulnocarpal ligaments.
1. Ulnocapitate
2. Ulnolunate
3. Ulnotriquetral
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10. Dorsal radiocarpal ligaments
• Radiotriquetral ligament
• Only dorsal extrinsic ligament
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11. Intrinsic carpal ligaments
• Fibers that connect either the
proximal and distal transversely or
connect the two rows together
• Scapholunate interosseus ligament
• Lunotriquetral interosseus ligament
11

12. CARPAL INJURIES
 Greater arc injuries are fractures that involve the
wrist's zone of vulnerability that includes:
• Radial styloid
• Scaphoid
• Capitate
• Triquetrum
• Ulnar styloid
 Lesser arc sits within the greater arc, centered on
the lunate; lesser arc injuries are pure
ligamentous - perilunate injuries.
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13. 13

14. Gilula lines / arcs:
- Are used in the assessment of normal
alignment of the carpus on PA wrist
They entail:
•first arc: A smooth curve outlining the
proximal convexities of the scaphoid,
•second arc: traces the distal concave
surfaces of the same bones.
•third arc: follows the main proximal
curvatures of the capitate and hamate
14

15. MAYFIELDS CLASSIFICATION
• 4 stages
• Each stage represent a sequential intercarpal injury.
• Can be associated with specific bony fractures including the radial styloid,
scaphoid, capitate and triquetrum.
(1) SL (2) SL + CL (3) SL + CL + LT (4) Lunate dislocates 15

16. Pathoanatomy
->
ion-->
ation-->
Sequence ofevents(Mayfield)
1. Scapholunateligamentdisrupted -
2. disruption ofCapitolunate articulation
3. disruption ofLunotriquetral articulation
4. FailureofDorsalradiocarpalligament
-lunaterotates anddislocates,usuallyinto
carpal tunnel. ‘SpilledTeacup Sign’
16

17. 1.SCAPHOLUNA
TE
DISSOCIATION
2. LUNOCAPIT
A
TE
DISRUPTION
3.LUNOTRIQUETRAL
DISRUPTION (Perilunate).
4.LUNA
TE
DISLOCA
TION
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18. Mayfields stage 4
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19. CARPAL INSTABILITY-CLASSIFICATION
Dobyns classification:
1. Carpal instability dissociative (CID)
2. Carpal instability non dissociative (CIND)
3. Carpal instability combined (CIC)
 Proximal carpal row has no tendinous attachments and is called
intercalated segment.
 Movement between the carpal bones is determined by ligamentous
attachments and mechanical forces crossing the wrist.
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20. CARPAL INSTABILITY DISSOCIATIVE
1.Proximal
- Scapholunate dissociations -DISI
- Lunotriquetral dissociations -VISI
2.Distal
- Capitate-hamate axial disruptions.
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21. 1. DISI – Dorsal Intercalated Segmental Instability
• Scapholunate dissociation or rotary
subluxation of scaphoid
• SL GAP > 3mm ON PA VIEW (TERRY THOMAS SIGN)
• Break in gilula’s arc at the SL interval
• Cortical ring sign
• SL angle > 60 to 70 degrees
• RL angle > 15 degrees
• Watsons shift test – palpable clunk on radial or ulnar
deviation
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22. 22

23. MECHANISM OFINJURY
FOOSHwithaxialcompressive force
-wrist hyperextension,ulnar
deviation,
and intercarpal supination.
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24. Watson Shift Test
•when deviating from ulnar to radial, pressure
over volar aspect of scaphoid subluxates the
scaphoid dorsally out of the scaphoid fossa of
the distal radius, and a clunk is palpated when
pressure is released as the scaphoid reduces
back over the dorsal rim of the radius.
•a painful clunk during this maneuver may
indicate insufficiency of scapholunate ligament
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25. Wrist arthroscopy
• Gold standard for detecting Scapholunate and
lunotriquetral injury.
• Direct visualisation.
• Location and size of insult.
• Presence of arthritic changes within the joint
space.
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26. Geissler's arthroscopic
classification
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27. STAGES OF SL INSTABILITY
1. Occult/ pre-dynamic
-Partial tear of SL
- normal x-rays
- Possible abnormalities in arthroscopy
2. Dynamic instability
- Partial or complete tear of SLIL
- Stress x-ray abnormal
- Abnormal arthroscopy (Geissler ii or iii)
3. Static instability
- Complete SL tear
- abnormal radiography
- Disi pattern on radiographs
4. SLAC wrist (scapholunate advance
collapse)
- Due to long standing abnormal
positioning of scaphoid, arthritic changes
occur.
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28. SLAC – WATSON CLASSIFICATION
 Stage i- arthritis between the
scaphoid and radial styloid
 Stage ii- arthritis between the
scaphoid and the entire scaphoid
facet of the radius
 Stage iii- stage i&ii plus arthritis
between the capitate and lunate.
 Stage iv- Diffuse arthritis of carpus.
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29. Treatment.
 Nonoperative
NSAIDS, rest +/- immobilization
indications
- acute, undisplaced SLIL injuries
- chronic, asymptomatic tears.
 splinting and close follow-up with repeat imaging and
clinical response with acute injuries.
 outcomes
- most people feel casting alone is insufficient.
- may be effective with incomplete tears
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30. Operative
 Scapholunate ligament repair
Indications:
- Acute scapholunate ligament injury without carpal malalignment
- Chronic but reducible scapholunate ligament injuries (can peform
if < 18 months from the time of injury)
- Ligament pathoanatomy is ammenable to repair
 Scapholunate reconstruction
Indications
- Acute scapholunate ligament injury without carpal malalignment
where pathoanatomy is not ammenable to repair
- Reducible scapholunate ligament injuries > 18 months from the
time of injury
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31.  Scaphoid ORIF vs. CRPP (+/- arthroscopic assistance)
indications
- if pathoanatomy of SL ligament injury is a scaphoid fx than repair
with ORIF vs. CRPP (+/- arthroscopic assistance).
 Stabilization with wrist fusion (STT or SLC)
indications
- Rigid and unreducible DISI deformity
- DISI with severe DJD
technique
- scaphotrapezialtrapezoidal (STT) fusion
- scapholunocapitate (SLC) fusion
scapholunate fusion alone has highest nonunion rate
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32.  Operative
SURGERY INDICATION
SL Ligament repair acute scapholunate ligament injury
without carpal malalignment
SL reconstruction Acute, SL lig not ammenable to repair
Scaphoid ORIF vs. CRPP SL ligament injury is d/t scaphoid #
Stabilization with wrist fusion
(STT/SLC)
rigid and unreducible DISI deformity
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33. 2. VISI-VOLAR INTERCALATED SEGMENT INSTABILITY
 Disruption of the luno-
triquetral intraosseous ligament
 Break in gilula’s arc
 volar flexion of lunate leads to SL angle
< 30° (normal is 47°) and VISI deformity.
 Radio-lunate or radio-capitate angle >15
degrees
 Lunate faces volarly.
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34. MECHANISM OFINJURY
FOOSH; axialcompressiveforce with
wrist in hyperextension, RADIAL
deviation,and intercarpal supination
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35. Management
Nonoperative
 Observation
- may be attempted initially
Operative
 CRPP (multiple K-wire fixation) with acute ligament repair +/- dorsal
capsulodesis
Indications
- acute instability
• ligament reconstructions with bone-ligament-bone autograft and LT fusion have
fallen out of favor in acute setting.
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36. LT fusion
• indications
- chronic instability
- complications
- nonunion is a known complication
Arthroscopic debridement of LT ligament with ulnar
shortening
• indications
- chronic instability secondary to ulnar positive variance
- long ulna chronically impacts the triquetrum, resulting in LT
tear with instability
- often associated with degenerative tear of triangular
fibrocartilage complex (TFCC).
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37. DISTAL CID
 Uncommon and develops due to rupture of
transverse intercarpal ligaments between bones
of distal row
 Also known as ‘axial dislocation’
• One column displaces while the other remains aligned
with one of the forearm bone (radius)
• Axial radial
• Axial ulnar
• Axial radial ulnar
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38. CIND-CARPAL INSTABILITY NON- DISSOCIATIVE
 Means undissociated carpal bones that remain as a
unit.
 Most common causes:
 Malunion of distal radius (DISI Pattern)
 Distal radius developmental malposition (VISI
Pattern)
 Insufficiency of the extrinsic radiocarpal ligaments
 Two types
 Radiocarpal instability
 Midcarpal instability
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39. LICHTMAN TEST
 Provocative test for
midcarpal instability
• Forearm in pronation
• Gently move the hand from radial to
ulnar deviation while loading the
carpus into radius
• Positive test when midcarpal row
appears to jump or snap
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40. CIC-CARPAL INSTABILITY COMBINED
 Presents as repetitive clicks while lifting heavy
objects
 CLIP pattern - capitate-lunate instability pattern.
 Dorsal subluxation of midcarpal and
radiocarpal joints.
 Congenital ligamentous laxity.
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41. MANAGEMENT
NON OPERATIVE
 Closed reduction and casting
Indications
• no indications when considered
as definitive management
Outcomes
• universally poor functional outcomes
with non- operative management
• recurrent dislocation is common
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42. Closed Reduction techniqueofTAVERNIER
1. Finger traps, elbowat90degreesof flexion
2. Hang 5-10 lbstraction for15minutes
3. Dorsal dislocationsarereduced through
wrist extension, traction, and flexion of
wrist.
4. Apply sugartongsplint
5. followed by surgery.
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43. Outcomes:
 Emergent closedreduction leadsto
Decreased riskofmediannerve damage
 Decreased riskofcartilagedamage
 Return to fullfunctionunlikely
 Decreased gripstrengthandstiffnessare
common.
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44. Treatment concepts
 Acute injuries-
- Closed or arthroscopically controlled manipulation and percutaneous pinning;
- Open reconstruction/repair.
 Instability w/o arthrosis-
- ligament reconstruction,
- capsular imbrication and limited intercarpal arthrodesis.
 Dorsal capsulodesis to limit scaphoid flexion.
 Fixed deformity, arthrosis, pain or interference with function- excisional
arthroplasty, limited intercarpal arthrodesis and wrist fusion.
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45. Ligament Reconstruction
• Free tendon grafts or tenodesis using
prolonged slips of wrist flexors or extensors.
• Linscheid and Dobyns suggested that
procedure be limited to patients whose
ligament ruptures cannot be maintained with
closed reduction, patients diagnosed after 1
month.
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46. Ligament repair
46

47. • Not indicated in patients with degenerative joint
disease.
• Complications-
– Tendons may stretch and become lax
– Bone tunnels may lead to fracture and
vascular changes.
– Tightness required to maintain bony
apposition
may eventually limit wrist motion.
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48. Capsulodesis (Blatt)
• Useful for scapholunate
dissociation and DRUJ
incongruity.
• Ability to anatomically reduce
the scaphoid.
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49. Limited Wrist (Triscaphe) Arthrodesis
• Pain relief with functional arc of motion.
• Indications
– Degenerative arthritis of STT joint with normal
thumb CMC joint
– Radial hand dislocations
– Rotary subluxation of scaphoid
– Scapholunate diastasis of > 2mm
– Scaphoid angle of >60 deg on true lateral.
– Foreshotening of scaphoid in AP view.
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50. STT fusion (Watson)
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51. Proximal row carpectomy
 The proximal row of carpal bones are excised, converting
the wrist joint into a simple hinge-type radiocarpal
articulation.
 The procedure reduces pain from the joint
while still preserving motion.
Indications
Advanced arthritis from:
•scapholunate advanced collapse (SLAC wrist)
•scaphoid nonunion advanced collapse (SNAC wrist)
•scaphoid non union
•Kienboch disease
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52. Wrist Arthrodesis
• Indications:
- painful or unstable wrist joint w/ advanced
destruction due to OA, RA.
- post traumatic arthritis,
- SLAC wrist,
- Scaphoid non-union,
- unsuccessful wrist arthroplasty, and Keinbock's dz
- This procedure is more beneficial for young, active
pts or middle aged pts, but not for elderly pts.
Wrist Position : The wrist is placed in 10 to 15
degrees of dorsiflexion and slight ulnar
deviation to optimize handgrip strength.
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53. References:
• Campbell's Operative Orthopaedics.
• Tureks text book of orthopedics.
• Wheeless' Textbook of Orthopaedics
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