Carpal Instability

Presentor : Dr. Momin mohammad farhan

Moderator : Dr. Mohammed Asimuddin
 Definition
 Carpal instability are the conditions in which wrist is not capable
of preserving a normal alignment, kinematic and kinetic
relationship between the radius , carpal bones, and metacarpals
under physiological load, that leads to hand dysfunction.
 History
In 1991, Navarre attempted to describe carpal mechanics with the
columnar theory.
In 1943, Lambinudi first expounded the principle of zigzag buckling.
In 1978, Palmer described a ligament repair for chronic scapholunate
injuries.
In 1987, Dobyns et al introducd the term carpal instability
dissociative.
Anatomy
The wrist is the link between the forearm and the
hand.
It involves the distal ends of the radius and ulna,
the two carpal rows ( proximal and distal) , and the
bases of the five metacarpal bones.
o A core structure of eight bone
o More than twenty radiocarpal, intercarpal and
carpometacarpal joints
o Twenty-six named intercarpal ligaments .
o The six or more parts of the triangular
fibrocartilage complex(TFCC).
Anatomy
Carpal Bones:
 The proximal carpal row
consist of scaphoid ,
lunate , triquetrum and
pisiform.
 The distal row contains
the trapezium , trapezoid ,
capitate, and hamate.
 Accessory carpal bones
exist in less than 2% of
the population, the os
centrale being one of the
most common.
Anatomy
JOINTS
1. Distal radio-ulnar joint
o A double pivot joint that unites the distal radius and ulna and
an articular disc (TFCC)
o The rounded head of the ulnacontacts both the ulnar notch of
the radius laterally, and the TFCC distally.
o The ulnar styloid process is approximately one half inch
shorter than the radial styloid process, resulting in more ulnar
deviation than radial deviation.
2. Radiocarpal joint
o Formed by the distal articular surface of the radius in conjunction with
the triangular fibrocartilage , and the proximal convexities of the carpal
bones.
o The distal articular surface of the radius is biconcave and tilted in two
planes. In the sagittal plane there is an average 10 degrees of tilt, and in
the frontal plane there is a radial inclination averaging 24 degrees.
Anatomy
3. Midcarpal joint
o It is a combination of three different types of articulation.
o Laterally , the convex distal surface of the scaphoid articulates
with the concavity formed by the trapezium and trapezoid
( scaphotrapezoid-trapezial joint) and lateral aspect of the
capitate ( scaphocapitate joint).
o The central portion of the midcarpal joint is concave
proximally and convex distally (lunocapitate joint)
o The medial hamate-triquetral articulation is ovoid or slightly
helicoid ( triquetrohamate joint).
 In the horizontal plane, the bones of the carpus are situated
in an arciform manner with a palmar concavity. This arch is
closed palmarly by the transverse carpal ligament ( flexor
reinaculum).
Anatomy
Ligaments
The major ligaments of the wrist include the palmar
intrinsic ligaments, the volar extrinsic and the dorsal
extrinsic and intrinsic ligaments.
The extrinsic palmar ligaments provide the majority of
the wrist stability.
The intrinsic ligaments serve as rotational restraints,
binding the proximal row into a unit of rotational
stability.
Anatomy
A. EXTRINSIC CARPAL LIGAMENTS
a) Palmar radiocarpal ligaments
• Four palmar ligaments connect the radius
to the carpus: the radioscaphoid,
radioscapho-capitate, long radiolunate and
short radiolunate ligaments.
• Between the two diverging RSC and long
RL ligament there is so called space of
Poirier, which represents a relatively
weak zone through which perilunate
dislocations frequently occur.
Space of Poirier
Anatomy
b) Palmar ulnocarpal ligaments
• Arising from the fovea of the ulna, there is a superficial
extrinsic ligament called the ulnocapitate (UC) ligament.
• Underneath the UC ligament , arising from the triangular
fibrocartilage, are the ulnotriquetral (Utq) and ulnolunate
(UL) deep extrinsic ligaments.

c) Dorsal radiocarpal ligaments

• The only dorsal extrinsic radiocarpal ligament is the
Radiotriquetral ligament (RTq), a wide fan shaped ligament
that connects the dorsal edge of the distal articular surface of
the radius to the triquetrum.
Anatomy
B. INTRINSIC CARPAL LIGAMENTS
 Intrinsic carpal ligament are collection of relatively short fibers
either connecting transversly the bones of the proximal and distal
carpal bones( palmar and dorsal interosseous ligaments) or linking
the two rows to each other.
d) Scapholunate interosseous ligaments
• The two SL ligaments ( palmar and dorsal)
• The dorsal SL ligament is located in the depth of the dorsal capsule
and connects the dorsal aspects of the scaphoid and lunate
• The palmar SL ligament has longer, more obliquely oriented fibers,
allowing substantial sagittal rotation of the scaphoid relative to the
lunate.
e) Lunotriquetral interosseous ligaments
• Two interosseous ligaments
• Unlike the SL ligament, the palmar LTq ligament is stronger than the
dorsal one.
Anatomy
f) Midcarpal Ligaments
• The only dorsal midpalmar crossing ligament is the so called
dorsal intercarpal ligament.
• It arises from the dorsal ridge of the triquetrum , courses
transversly along the distal edge of the lunate , and fans out to
insert on the dorsal rim of the scaphoid, the trapezium and the
traoezoid.
• On the palmar side , the midcarpal joint is crossed by a
number of ligaments.
• Medially triquetral-capitate-hamate ligamentous complex,
laterally SC and dorsolaterally STT ligament.
g) Distal carpal row interosseous ligaments
• Connecting transversly, the distal carpal row bones have
numerous strong and taut interosseous ligaments( dorsal,
palmar and deep intra-articular).
Triangular fibrocartilage complex (TFCC)
 A ligamentous and cartilagenous
structure which suspends the distal
radius and ulnar carpus from the
distal ulna.
 It is madeup of cartilagenous disc,
volar and dorsal distal radio-ulnar
ligaments, ulnar collateral
ligament, floor of extensor carpi
ulnaris subsheath, ulnolunate and
ulnotriquetral ligaments.
 Function of the TFCC is to
improve joint congruency and to
cushion against compressive
forces.
 The TFCC transmits about 20% of
the axial load from the hand to the
forearm.
Biomechanics
 To facilitate positioning of the hand to manipulate objects,
lift loads, or perform specific tasks of daily living, the
wrist needs to be highly mobile to sustain substantial
forces.
 Perfect interaction between wrist motor tendon, joint
surface and soft tissue constraints.
 In the past , different theories has been proposed to explain
the mechanism of the wrist.
 Jhonston (1907) : the
carpal bones are arranged
into two carpal rows,
each moving as a rigid
functional unit about two
transverse joint.
Biomechanics
 Navarro ( 1953): the carpal
bones are arranged into three
vertical interdependent columns.
1. Central column- (lunate ,
capitate, hamate) controls
flexion-extension of the wrist
2. Lateral column- (scaphoid,
trapezium, trapezoid) controls
load transfer across wrist
3. Medial or rotational column-
controls pronosupination
Biomechanics
 Taleisnik (1978) : modification of
the columnar theory. The pisiform
does not function as a carpal bone
because it is excluded from the
model.
 Weber (1980) : two column : the
load bearing column ( capitate,
trapezoid, scaphoid, and lunate) and
the control column ( triquetrum and
hamate).
 Lichtman, et al (1981): the carpus
functions as an oval ring formed by
four interdependent element ( distal
row, scaphoid, lunate an triquetrum)
connected to the adjacent segments
by ligamentous links. This became
widely accepted theory.
Biomechanics
 Movements
 Muscle crossing the wrist contribute to wrist motion
 Movement starts at distal row
 Proximal row starts moving as tension builds in midcarpal
ligaments because proximal row doesn’t have muscular
attachment
 Movements occur in two planes
1. Sagittal:
 Flexion : 60% at radiocarpal joint
 40% at midcarpal joint
 Extension : 65% at midcarpal joint
 35% at radiocarpal joint
2. Coronal:
 Ulnar deviation : radiocarpal joint
 Radial deviation: midcarpal joint
 Biomechanics
 Movements
 Midcarpal motion :
 Distal row is rigid and no movements occurs between the bones
 So it moves as one functional unit
 In flexion : flexion and ulnar deviation
 In extension : extension and radial deviation

 Proximal row motion:

As proximal row is not a single unit
Scaphoid, lunate and triquetrum move
differentially but synergistically
In flexion of wrist: flexion of all the three
In extension: extension
In radial deviation: flexion
In ulnar deviation : extension
 How The Wrist Sustains Load Without Yielding (Carpal
kinetics)
During motion of fingers and hand, wrist sustains
considerable compressive and shearing forces
These are not only the external forces , but by contraction of
muscle crossing the wrist too
So the forces applied to distal carpal row are greater than ten
times the force applied to tips of the fingers.
At midcarpal jont, 60% of this load is transmitted via the
capitate-scaphoid-lunate.
At radiocarpal joint, load distributed by RS (50%),
RL(30%), UL(20%).
RS load > with radial deviation
RL load > with ulnar deviation
 Carpal stabilizers

 Distal carpal row

Stabilizers: transverse interosseous ligament
Failure : Divergent axial dislocation

 Midcarpal joint
Stabilizers: triquetro-hameto-capitate ligament, scapho-
trapezio-trapezoid ligament, scapho-capitate ligament
Failure : proximal row falls in flexion
 Carpal stabilizers

 Proximal carpal row

Stabilizers :
1. Scapho-lunate ligament – important role in flexion
2. Luno-triquetral ligament – important role in extension
Failure:
SL ligament: extension of uncontrained triquetrum and lunate
LT ligament: flexion of unconstrained scaphoid and lunate

 Radiocarpal joint:
Stabilizer: Radiocarpal ligament, TFCC
 Failure : ulnar and palmar subluxation of carpals
Pathomechanics
Two mechanism of injury may result in a carpal ligament
injury: direct and indirect
Direct injury:-
The force is spent directly to the dislocating bone
Crush injury by RTA, a power press or winger type machine
So, the wide surface area is exposed causing global
dislocation.
Indirect injury :-
The deforming load is initially applied at a distance from the
injured joint
Hyper extension injury of the wrist due to fall from height or
RTA
The tensile forces are transmitted by ligaments and
Analysis
 To analyze carpal instability , following Six features need to be
investigated
 Chronicity
1) Acute : Upto 1 week,
2) Sub acute : 1-6 week
3) Chronic: > 6 week
 Severity
 If carpal malalignment appears only under high stress , the case is less
severe than if it is permanently present. Based on this , three groups of
conditions exist:
1. Pre dynamic instability
 Partial ligament tears with no malalignment under stress
2. Dynamic instability
 Complete ruptures but carpal malalignment only under certain loading conditions
3. Static instability
 Complete ruptures with permanent carpal malalignment
Analysis
 Etiology
 Traumatic - fracture, dislocation, ligament injury, malunion/
nonunion
 congenital - scaphoid hypoplasia, carpal synostosis
 Rheumaoid arthritis
 Infections
 Neoplastic
 Location
1. Radiocarpal instability
2. Proximal row instability
3. Midcarpal instability
4. Distal row instability
5. Carpometacarpal instability
Analysis
 Direction
1. DISI (dorsal intercalated segment instability) – Lunate
extends due to injured SL ligament
2. VISI ( Volar intercalated segment instability) – Lunate
flexes due to injured LTq ligament
3. Ulnar translocation _ due to injured Radiocarpal
ligament
4. Radial translocation – due to injured TFCC
5. Dorsal translocation – due to dorsaly malunited distal en
radius #
6. Volar Translocation – due to vilarly malunited distal end
radius #
Analysis
Analysis
 Pattern ( Mayo clinic classification)

1. Carpal instability dissociative ( CID):

 Derangement within or between bones of the same carpal row

2. Carpal instability nondissociative (CIND):

 Dysfuntion between the radius and the proximal row and or
between the proximal and distal row
3. Carpal instability complex (CIC):
 Features of both CID and CIND types

4. Carpal instability adaptive (CIA):

 Adaptation to an extrinsic deformity i.e malunited distal end
radius #
Radiographic examination
Wrist series :-
PA view:
Gilula’s Lines- three fairly
smooth radiographic arcs
drawn to define normal carpal
relationships. Stepoff in the
continuity of any of these arcs
indicates a intercarpal
derangement at he site where
the arc is broken.
Parallel apposing surfaces
seperated by 2mm or less
Radial height : 11mm
Radial inclination :22mm
Radiographic examination
Scaphoid view ( PA view in ulnar deviation): focus on
scaphoid
AP with clenched fist: to diagnose dynamic
scapholunate instabilities
Oblique 20˚ pronated : dorsum of triquetrum
Oblique 30˚ supinated : pisiform, triquetrum and
hamate hook
Radiographic examination
Lateral view :
Scapholunate angle
 Normal: 30-60˚ degree
 >80˚ : DISI
 <30˚ : VISI
Capito-lunat angle
 Normal : 0˚
 Range +/_ 15˚
 Abnormal >15˚
Radiolunate angle
 Normal : 0˚
 Range +/_ 15˚
 Abnormal >15˚
Volar tilt of radius
 Normal : 11˚
Radiographic examination
Computed tomography
Demonstrate the amount of collapse in the scaphoid deformity &
useful in evaluating union after intercarpal fusion.
Arthrograms :
Although long considered the gold standard in the assessment of
intracarpal derangements, wrist arthrography has seen a
substantial reduction of its indication.
MRI : allows clear recognition of subtle ligmaent injuries
Arthroscopy :
It has revolutionized the practice of orthopaedics providing the
technical capabilities to examine and treat intrarticular
abnormalitis.
It has become a gold standard for wrist injuries.
 CARPAL INSTABILITY – DISSOCIATIVE
(CID)
DEFINITION
When a carpal instability is caused by disease or injury
resulting in a major malfunction of a joint between bones of the
same row.
 Caused by following conditions
1. Scapholunate dissociation
2. Lunotriquetral dissociation
3. Scaphoid disorders
 Unstable fractures
 Nonunion
 Malunion

4. Advanced kienbock’s disease

 1) SCAPHOLUNATE DISSOCIATION

Also known as rotational subluxation of scaphoid

It result from rupture of the scapholunate ligament with or
without secondary scaphoid stabilizers ( STT & SC lig)
May be associated with d/e of radius #or displaced
scaphoid #
Mechanism of injury :
Hyperextension injury with ulnar deviation & midcarpal
supination
This is the 1st stage of progressive perilunate instability
 1) SCAPHOLUNATE DISSOCIATION
Depending on dgree of ligament rupture, their healing
potential , reducibility and presence or absence of cartilage
defect five clinical form of SLD exist.
1. Predynamic / occult SLD
 SL membrane is only streched or partially ruptured
 Wrist do not exhibit malalignment
 Dysfunction basically derives from an increased motion
between the two bones, generating shear stress, hence the local
synovitis , pain and discomfort.
 No radiographic abnormality
 Diagnosed by arthroscopy or MRI
 1) SCAPHOLUNATE DISSOCIATION
2. Dynamic SLD
 Complete disruption of the all SL connections
 Ligaments are still reparable , with good healing potential
 Secondary distal scaphoid stabilizers are still intact (STT & SC )
 No cartilage damage
 No permanent malalignment exists at this stage, only under specific
loading conditions an increased SL gap may appear

3. Static – Reducible SLD

 Failur of the secondary stabilizers
 Scaphoid will flex, Lunate & Triquetrum will extend
 So, dorsal intercalated segment instability will develop (DISI)
 Permenant instability but reducible
 No cartilage damage
 1) SCAPHOLUNATE DISSOCIATION
4. Static – irreducible SLD
 Chronic rupture of both primary and secondary SL ligament
stabilizers
 Formation of fibrosis within the surrounding capsule and
spaces
 Carpal malalignment is hardly reducible
 No significant cartilage damage
 1) SCAPHOLUNATE DISSOCIATION
5. OA secondary to SLD
 Long lasting carpal malalignment with irreducible subluxation of
the scaphoid induces degenerative arthritis
 So, it is called Scapho-Lunate Advanced Collapse ( SLAC
WRIST)
 1) SCAPHOLUNATE DISSOCIATION
 DIAGNOSIS :
 History
 Fall on out streched hand
 30% of d/e radius # are associated with some degree of carpal ligament
injury
 Symptoms:
 Pain which may be aggravated by movement
 Dorsoradial swelling
 Limited motion
 Weakness of grasp
 Snapping or clicking sensation with movement
 Examination
 Tenderness over dorsum of capsule distal to listers tubercle, in
anatomical snuffbox, over palmar scaphoid tuberosity.
 1) SCAPHOLUNATE DISSOCIATION
 Watson’s scaphoid shift test
 Firm pressure is applied to the palmar tuberosity of the scaphoid
while the wrist is moved from ulnar to radial deviation
 A “positive” test is seen in a patient with an SL tear
 The scaphoid will subluxate out of the scaphoid fossa
 When pressure on the scaphoid is removed, the scaphoid goes back
into position, and a typical snapping occurs.
 1) SCAPHOLUNATE DISSOCIATION
 Scapholunate Ballotment test
 The lunate is firmly stabilized
with the thumb and index finger
of one hand while the scaphoid is
held with the other hand
 Now scaphoid is displaced
dorsally and palmarly with the
other hand
 A positive result elicit pain,
crepitus, and excessive
displaceability of the joint
 Resisted finger extension test
 Ask the patient to full extend the index and middle fingers
against resistence with the wrist partially flexed
 In positive test, sharp pain is elicited at the SL area
 1) SCAPHOLUNATE DISSOCIATION
 Radiographic Examination
 Terry Thomas sign
 Increased SL joint space
 SL gap greater than 5 mm is said to be diagnostic of SLD
 1) SCAPHOLUNATE DISSOCIATION

 “Scaphoid ring”
sign
 Because of the
scaphoid is
abnormally
flexed
 1) SCAPHOLUNATE DISSOCIATION

 Scaphoid appears flexed

 Increased SL angle
 Lunate appears extended
 1) SCAPHOLUNATE DISSOCIATION
 Treatment :-
 Goal is to restore SL stabilization, improve function,
prevention of instability
1. Predynamic (occult) SLD:
 Acute cases :-
 percutaneous / arthroscopy guided K-wire fixation of SL joint
 Thumb spica cast for 6-8 weeks
 Remoal of k-wires after 8 weeks & protected mobilization in
removable splint for 3-6 months
 Heavy work only after 6 months.
 Chronic cases :-
 Arthroscopic debridement of partial interosseous ligament tear.
 1) SCAPHOLUNATE DISSOCIATION
2. Dynamic SLD:
 Open reduction and internal fixation and repair of the dorsal SL
ligament through dorsal approach.
 Fixation of scaphocapitate , scapholunate and radiolunate joint .
 Dorsoscapholunate ligament repair with transosseous suture.
 Dorsal capsulodesis of radio-scaphoid joint
 To neutralize the forceful palmar flexion of scaphoid by tightening the
dorsal capsule between radius and scaphoid
 BLATT’S procedure: the dorsal capsule is detached from scaphoid &
attached back more distally
 HERBERT’S procedure: the dorsal capsule is detached from radius &
attached back more proximally to Lister’s tubercle.
 LINSCHIELD’S procedure : half of the dorsal Scapho-triquetral ligament
is detached from triquetrum & attached proximally t Lister’s tubercle.
 1) SCAPHOLUNATE DISSOCIATION
 BLATT’S procedure
 1) SCAPHOLUNATE DISSOCIATION
3. Static - reducible SLD:
 Tendon reonstruction
The tendon grafts are used to reconstruct the SL ligaments
Drill holes are made in bones & tendon strip is made from
ECRB/FCR
Then it is passed through the holes to augment SL ligament
Almquist repair
1) SCAPHOLUNATE DISSOCIATION

Linscheid

LTq
 Brunelli and Brunelli’s

SL
lig

FCR
 1) SCAPHOLUNATE DISSOCIATION
4. Static - irreducible SLD :-
 Most recommended treatment is “Partial
Fusion”
 Here , only diseased joints are fused.
 Goal is to realign the proximal pole of the
scaphoid relative to scaphoid fossa , so
that the RS congruency is restored and the
chance of developing later degenerative
changes is reduced.
 Fixed with K- wires and immobilized in
long arm thumb spica cast with volar
support to hand in functional position for
6-8 weeks.
a) Scapho –Trapezoid – trapezial
arthrodesis (“Triscaphe” fusion).
 1) SCAPHOLUNATE DISSOCIATION
b) Lunato – triquetral arthrodesis
c) Scapho-capito-lunate arthrodesis.
d) Radio-scaphoid-lunate fusion with distal scaphoidectomy.
 1) SCAPHOLUNATE DISSOCIATION
4. SLAC wrist
Stage 1 : arthroscopic radial styloidectomy :
only symptomatic relief.
Stage 2 : radio-scapho-lunate arthrodesis.
SLAC procedure
a. Scaphoid excision plus a capitate – lunate
– triquetrum – hamate fusion.
b. Also known as “ four corner” fusion with
pins , screws or plate.
c. “spider” plate , a low profile circular plate
designed specifically to be countersunk on
the intersection of the four bones so that
dorsal impingement is avoided and wrist
can be mobilized early.
 Proximal row carpectomy
 Total wrist arthroplasty
 Total wrist arthrodesis.
 2) LUNO–TRIQUETRAL DISSOCIATION
Luno – triuetral ligament is injured.
 Displacement
Scaphoid and lunate flex
Triquetrum migrates proximally

 Mechanism of injury :
Forced hyperextension , radial deviation and pronation.

 Severity :
Incomplete rupture(dynamic instability)
Complete rupture ( static instability)
 2) LUNO–TRIQUETRAL DISSOCIATION
 DIAGNOSIS :
 SYMPTOMS :
 Pain on ulnar side of wrist.
 Aggravated by ulnar deviation and supination.
 Crepitus on ulnar deviation.
 Fork like deformity and prominence of distal ulna in more advanced cases.
 CLINICAL EXAMINATION
 Tenderness distal to ulnar styloid
 Instability tests:
 Ballotment test
 Shear test
 Ulnar snuff box test
 Radiographic examination :
 Proximal migration of triquetrum , break in the Gilula’s lines , Step off b/w
Tq & L, VISI
 Cineradiography
 Arthrography
 Arthroscopy
 2) LUNO–TRIQUETRAL DISSOCIATION
TREATMENT
1. Dynamic LTq dissociation
(acute)
 Arthroscopic ligament repair and
K- wire fixation.
 Arthroscopic debridement

2. Dynamic LTq
dissociation(chronic)
 Ligamentous reconstuction using
flexor carpi ulnaris tendon
 Lunato – triquetral fusion.

3. Static LTq dissociation

 Lunato – triquetral fusion with
Radio-lunate fusion.
 3) SCAPHOID DISORDERS

Instability can be due to

1. Unstable #.
2. Non unioun.
3. Malunioun.
 Proximal fragement follows unconstrained lunate and
triquetrum rotates into extension
 DISI pattern develops.
 Zig zag radio-lunato-capitate alignment.
 CARPAL INSTABILITY – NONDISSOCIATIVE
(CID)
DEFINITION
When carpal dysfunction occurs b/w the radius and the
proximal row and/or between the proximal and distal rows .
 2 Types:
1. Radiocarpal instability
 Ulnar translocation
 Radial translocation

2. Midcarpal instability
 Palmar instability
 Dorsal instability
 Combined instability
 1) RADIOCARPAL INSTABILITY
 Ulnar translocation
Rupture of the radiocarpal ligaments ,
commonly RS & RSC ligaments.
Carpus is displaced down the slope of
the radius and appears ulnarly
translocated.
Common cause is Rheumatoid arthritis
> Madelung’s deformity > excessive
excision of ulna > Traumatic.
 Diagnosis : increased gap b/w radial
styloid and scaphoid.
 TREATMENT :
Radio-Lunate fusion
Acute cases : ligament repair and
fixation with K-wires can be
attempted.
 1) RADIOCARPAL INSTABILITY
Radial translocation
Short RL and Ulno-carpal ligaments are attenuated , ruptured ,
or avulsed
Carpus may sublux in a radial direction.
CAUSES :
Traumatic
Badly malunited distal radial fractures where the distal surface
healed slightly radially inclined.
After an excessive radial styloidectomy.
Treatment : surgical reattachment of the ligaments.
 2) MIDCARPAL INSTABILITY
 There is no dissociation between bones of the proximal carpal row
 But a dysfunction of both RC and midcarpal joints.
 There will be instability of proximal carpal row.
 Stabilizers :
TqHC ligament
STT ligament.
SC ligament.

 CLASSIFICATION (LICHTMAN)
1. Palmar MCI : palmar midcarpal ligaments are injured
 Ulnar palmar MCI : Triquetro-hamato-capitate ligament injured.
 Radio palmar MCI : Scapho-trapezio-trapezoid / scaphocapitate ligament injured.
2. Dorsal MCI : radiocarpal ligaments injured.
3. Combined MCI
 2) MIDCARPAL INSTABILITY
 DIAGNOSIS
 Painful clunk during activities.
 Radiographs : normal Gilula’s lines.

Lunate shape : Triangular

VISI pattern
Increased RL and CL angle
Normal SL angle.
Treatment :
Immobilization in neutral position
Tendon transfer reconstruction using ECRB tendon.
Limited fusion.
 CARPAL INSTABILITY – ADAPTIVE (CIA)

The reason for the malalignment is not located within

the wrist
Occurs secondary to malunited distal radial fractures
The radiological findings are similar to midcarpal
instability
But the cause is not in the carpals, so it’s also called
extrinsic midcarpal instability
Treatment: corrective osteotomy
 CARPAL INSTABILITY – COMPLEX (CIC)
 DEFINITION
When the carpal derangement has impaired both the
relationship between bones within the same row(CID
feature) and between rows (CIND features).

 Divided into 5 types

1. Dorsal perilunate dislocation(lesser arc)
2. Dorsal perilunate fracture-dislocations (greater arc)
3. Palmar perilunate dislocations (lesser or greater arc)
4. Axial dislocations
5. Isolated carpal bone disloactions
 1) DORSAL PERILUNATE DISSLOCATION
 It’s also called retrolunate dislocation
 It’s a pure ligamentous injury
 Mechanism of injury
Hyperextension of wrist
Radial deviation
Midcarpal supination
 Lunate remains in normal position in relation to distal radius,
capitate is dislocated dorsally with other carpals.
 Features of scapholunate / lunotriquetral dislocation can also be
present
 Treatment
Closed reduction and cast immobilization ( thumb spica)
Closed reduction and percutaneous pinning
Open reduction and internal fixation with ligament repair
2. DORSAL PERILUNATE FRACTURE- DISLOCATION
 This type includes
Trans Scaphoid perilunate dislocation
Trans Capitate perilunate dislocation
Trans Triquetral perilunate dislocation
 ORIF IS MANDATORY.

3. PALMAR PERILUNATE DISLOCATION

The dislocation may occur in association with a fracture
of the lunate In the frontal plane
 Mechanism of injury: hyperflexion and supination of the
wrist relative to the radius
 Treatment
Temporary closed reduction and ORIF
4. AXIAL FRACTURE DISLOCATION OF CARPUS

Longitudinal disruption of the carpal arch specially the distal

row
 Mechanism of injury:
high-engery dorsopalmar compression(crush injury)

The wrist splits into two axial columns, and displacing in a

radial or ulnar direction.
The metacarpals usually follow the displacement of their
corresponding carpal bones.
Associated injuries: the flexors retinaculum, neurovascular
injuries, severe soft tissue injuries
Treatment: OR and pinning
Axial radial
fracture
dislocation

Axial ulnar fracture

dislocation
5. ISOLATED CARPAL BONE DISLOCATION
 A very rare injury
 Any carpal bone can dislocate
 Among them lunate is the
commonest to dislocate
 It’s the final stage of “Progressive
perilunate instability”
 Most severe of carpal instabilities
 Produces volar dislocation and
forward rotation of lunate. Capitate
takes its place.
 Always ORIF and possible
ligament repair is needed
 Otherwise proximal row
carpectomy is the treatment of
choice
Thank you