Explain how DISI and VISI occur in different injuries.
presence or absence of scapholunate ligament injury. In order to perform this test, the examiner sits across from the patient with a table in between. The physician grasps the radial side of the injured wrist with his same hand (eg, right hand grasps right wrist). The thumb is placed over the palmar prominence of the scaphoid while the fingers provide counterpressure on the dorsum of the wrist proximal to the carpal row. The examiner’s other hand provides ulnar to radial deviation by grasping the metacarpals.
Drive through sign, I- immobilisation in cast, II- arthroscopic pinning, III- open repair +/- scopy IV- open repair
• C shaped ligament composed of dorsal,
central and palmar subregions.
• Dorsal aspect most thick.
• Central aspect separated from the volar region
by radioscapholunate ligament.
• Ligament of Testut
• The Scaphocapitate and STT ligaments present
dorsally resist palmar flexion of scaphoid.
• The RSC ligament and short and long
radiolunate ligament on palmar aspect.
• The Lunotriquetral ligament also has 2 layers,
with the volar region more thick.
• Proximal carpal row has no tendinous
attachments and is called intercalated
• Movement between the carpal bones is
determined by ligamentous attachments and
mechanical forces crossing the wrist.
• Lunate exists in suspension between the
scapholunate ligament and lunotriquetrum lig.
• Scaphoid and triquetrum exert flexion and
extension moment respectively.
• Tendons crossing the carpus exert
compressive force on lunate through capitate.
Mechanism of injury
• Fall on outstretched hand, high energy
• Hyperextension of wrist.
• Mayfield- 4 stage progression.
– Wrist extension.
– Ulnar deviation.
– Carpal supination.
Progressive Perilunar Instability
• I- dorsal migration of
proximal pole of
• II- extension, supination
and ulnar deviation
leads to force
space of Poirier.
• Triquetrum translates
away from lunate LT
• Dorsal radiocarpal
lunate rotates on its
palmar hinge and
dislocates with capitate
articulating with the
• Arthritic changes may occur in the setting of
chronic scapholunate ligament injury and
deformity of lunate, capitate and scaphoid
may become static.
• Scapholunate advanced collapse (SLAC)
• H/o specific injury to the wrist.
• Position of wrist.
• Pain, swelling and instability; progressing to
inability to use the hand.
• Carpal Tunnel Syndrome.
• Subacute or chronic injuries may present with
pain and decreased grip.
• Localise point tenderness.
• Pain elicited by radial or ulnar deviation of
• Tenderness over the lunotriquetral ligament
or scapholunate ligament.
• Pain with subjective or palpable clicking or
• Pain, apprehension and subluxation of
• Movement of the wrist- smooth or with
• Positive clunk on releasing pressure as
• Examine opposite side for laxity which can
give false positive results.
• PA, Lateral and Oblique
• Evaluate static
• PA films in radial/ ulnar
• Clenched fist/Pencil
• Flexion and extension
• Dynamic stability.
• Forearm in neutral
• 3-T MRI has sensitivity of 86% for detecting
scapholunate tears and 82% for detecting
lunotriquetral tears compared with
Magee T.Comparison of 3-T MRI and arthroscopy of intrinsic wrist ligament and TFCC tears.
AJR Am J Roentgenol 2009;192:80–5
• Injection of gadolinium into the midcarpal
joint should show the flow of dye into the
midportion of the scapholunate interval, but
not into the radiocarpal joint.
Tirman RM, Weber ER, Snyder LL, et al. Midcarpal wrist arthrography for detection of tears
of the scapholunate and lunotriquetral ligaments. AJR Am J Roentgenol 1985;144:107–8.
• Gold standard for detecting Scapholunate and
• Direct visualisation.
• Location and size of insult.
• Presence of arthritic changes within the joint
• Carpal instability dissociative( CID)
– Dissociation between interosseous ligaments
• Carpal instability non dissociative(CIND)
– Instability of carpal row as a whole
• Carpal Instability Complex (CIC)
– Combination of above two injuries
• Carpal Injury Adaptive (CIA)
– Secondary changes in carpus resulting from non
union or malunion or the carpal bones
• 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.
• 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
• Not indicated in patients with degenerative
– Tendons may stretch and become lax
– Bone tunnels may lead to fracture and vascular
– Tightness required to maintain bony apposition
may eventually limit wrist motion.
• Useful for scapholunate
dissociation and caput
ulnae syndrome (DRUJ
• Ability to anatomically
reduce the scaphoid.
Limited Wrist (Triscaphe) Arthrodesis
• Pain relief with functional arc of motion.
– Degn arthritis of STT joint with normal thumb CMC
– 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.