Carpal Instability

Chris Oliver FRCS (Orth) DM Royal Infirmary of Edinburgh

http://www.orthopaedic.ed.ac.uk
c.w.oliver@ed.ac.uk

Definition Carpal Instability ?

carpal injury where loss of normal alignment of the carpal bones develops inability to bear physiological load with an associated loss of normal carpal alignment carpal dysfunction

Key Issue ~ Carpal Instability

instability versus malalignment

Key Issue ~ Carpal Instability

static versus dynamic kinetic versus kinematic

Epidemiology Carpal Instability

10% of all carpal injuries result in instability

Aetiology ~ Carpal Instability

variable congenital trauma
after sprain fracture+/- dislocation end stage of mal or non-union

rheumatoid arthritis neoplastic

Pathomechanics Carpal Instability

intercalated segment lunate is in state of dynamic balance

scaphoid induced to flex under compressive load and induces flexion force on lunate
triquetral inherently prefers to extend and induces extension force on lunate dynamic balance interrupted, lunate follows unbalanced force

Instability Patterns

Classification
Complex Amadio (1991) dissociative carpal Instability CID non-dissociative instability CIND complex carpal instability CIC adaptive carpal instability CIA

Groups CID
carpal instability dissociative Instability due to loss of linkage between individual carpal bones bones of same row

short ligaments
Includes DISI and VISI

Unstable scaphoid non-union

Proximal CID DISI pattern of carpal malalignment volar wedge shaped graft

Groups CIND
nondissociative carpal instability dysfunction between rows longer ligaments instability at radiocarpal or midcarpal joints

Groups CIC
carpal instability complex CID & CIND perilunate dislocation instabilities not otherwise classifiable

Groups CIA
adaptive carpal instability instability not in wrist malunited wrist #

Treatment of Carpal Instability

no single treatment (Larsen 1995) chronicity constancy aetiology location direction pattern

Proximal Dissociative Carpal Instability

unstable scaphoid non-union scapholunate dissociation lunotriquetral dissociation

Unstable Scaphoid Malunion

proximal scaphoid # follows unconstrained lunate and triquetrum and rotates into extension DISI zigzag radiolunatocapitate alignment

treat the scaphoid fracture

Most common

Scapholunate Instability
complete disruption of SL ligament scaphoid rotates around the radiocapitate ligaments repair dorsal portion of SL interosseous membrane stabilise with K wires two months

Chronic SL instability
degenerative changes midcarpal fusion with resection of scaphoid SLAC procedure

Intermediate SL dissociation
no degenerative changes fusion scaphoid-trapezium-trapezoid fuse midcarpal joint arthroscopic repair

Lunotriquetral dissociation
dissociative VISI loss of ulnar support from triquetral lunate flexes palmar flexion of lunate less common acute repair late lunotriquetral arthrodesis

Dissociative Distal Carpal Instability CID

very rare rupture of transverse ligaments, distal row

axial radial, axial ulnar, axial-radial-ulnar

repair/fuse

Non-dissociative radiocarpal instability

dorsally malunion of distal radius

not a true carpal instability

adaptive corrective osteotomy

Other Carpal Instabilities

midcarpal non-dissociative instability
soft tissue reconstructions

combined radiocarpal and midcarpal

CLIP capito-lunate

carpal instability complex

failed treatment for perilunate dislocation

Reference
The treatment of wrist instability
ICL - JBJS(b) ~ July 97 Garcia-Elias 684-690

End