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Carpal
Instability
By: Fahad Al Hulaibi
Orthopedic Resident
National Guard Hospital - 2015
- Definitions
- DISI
- VISI
- Mid-carpal CIND
- Radio-carpal
dislocation
- Peri-lunate
dislocation
Objective:
definitions
Definitions:
 Dynamic instability - (incomplete injury)
maintains normal alignment at rest but will
collapse under applie...
 Static Instability - (complete injury)
abnormal intercarpal alignment on static
radiographs.
Carpal Instability
 Carpal Instability – Dissociative:
Instability occurs between the individual
bones. (in the same row) E.g: DISI & VISI
C...
 Carpal Instability – Non-Dissociative:
Instability occurs between the row of
bones
Carpal Instability
DISI “Dorsal intercalated segmental instability”
Carpal Instability
DISI
 Scapholunate ligament disruption.
 Dorsal ligaments are stronger.
 scaphoid will hyperflex. and the lunate will
h...
Presentation
 Hx:
acute FOOSH injury vs. degenerative
rupture
 Symptoms:
dorsal and radial-sided wrist pain
Carpal Insta...
 Examination:
- Dorsal wrist pain.
- Diminished grip strength.
- pain increased with extreme wrist
extension and radial d...
Watson test
Palpable clunk
Carpal Instability
Terry Thomas sign Static &
Dynamic
>3 mm
Carpal Instability
Terry Thomas sign Static &
Dynamic
>3 mm Clenched-fist
Carpal Instability
cortical ring sign
Duo to frontal projection of volar tubercle
Carpal Instability
SL angel:
Carpal Instability
Treatment
• acute, undisplaced
• chronic, asymptomatic
NSAIDS, rest +/-
immobilization
• SL ligament injury W/o carpal
mal...
Scapholunate advanced
collapse (SLAC)
 untreated DISI deformity
Carpal Instability
VISI “Volar intercalated segmental instability”
VISI
 Instability of the lunotriquetral ligament.
 Volar ligaments are stronger.
 scaphoid & Lunate will hyperflex.
Car...
Presentation
 Symptoms:
Ulnar side wrist pain
Increase with ulnar deviation
Carpal Instability
Ballottement test
Laxity, crepitation or reproduction of pain
Carpal Instability
Gilula arc on AP
Break this line
Carpal Instability
< SL angel on Lateral
Carpal Instability
Treatment
• acute instabilityCRPP with
lunotriquetral
repair
• chronic instability
LT fusion
• chronic instability
seconda...
Carpal instaability
Dissociative(CIND)
CIND
Midcarpal
instability
Radiocarpal
dislocation
Carpal Instability
 Extrinsic ligamentous
disruption.
- radioscaphocapitate (SRC)
- long radiolunate
- short radiolunate
- radioscapholunate...
Carpal Instability
Associated conditions:
 Intracarpal injury (scapholunate or
lunotriquetral ligament)
 acute carpal tunnel syndrome
 com...
Prognosis:
 Volar dislocation more severe than dorsal.
Carpal Instability
Presentation:
 No history of trauma (midcarpal)
 High energy trauma (radiocarpal)
 generalized ligamentous laxity
 irr...
Radiocarpal dislocation
Carpal Instability
Carpal Instability
Treatment
• first line of treatmentimmobilization
+/- splinting
• ulnar translation with
styloid fractures
open repair,
re...
Peri-lunate dislocation
mechanism
Forced dorsflextion,
Ulnar deviation
Supination.
Carpal Instability
25% are missed in the ER
diagnosed
75%
missed
25%
Carpal Instability
Mayfield
commonly associated with a scaphoid fracture
Carpal Instability
Stage I :
scapholunate dissociation
Stage II:
+ l...
space of
Poirier
break in Gilula's arc
Carpal Instability
triangular lunate
"piece-of-pie sign"
Treatment
• definitive
management
Closed
reduction and
casting
• all acute injuries <8
weeks old
closed reduction/splintin...
Summery:
Carpal Instability
Case 1
Lunate dislocation
Sources:
 Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R.
Thompson MBBS MEd FRCSC, Jennifer Hart MPAS ...
Carpal instability - Orthopedic
Carpal instability - Orthopedic
Carpal instability - Orthopedic
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Carpal instability - Orthopedic

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i present this lovely topic at Notional Guard Hospital in Al-Ahsa in the Orthopedic department.

hope you enjoy

Fahad Al Hulaibi
Orthopedic Resident
NGH-A

Publié dans : Santé & Médecine
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Carpal instability - Orthopedic

  1. 1. Carpal Instability By: Fahad Al Hulaibi Orthopedic Resident National Guard Hospital - 2015
  2. 2. - Definitions - DISI - VISI - Mid-carpal CIND - Radio-carpal dislocation - Peri-lunate dislocation Objective:
  3. 3. definitions
  4. 4. Definitions:  Dynamic instability - (incomplete injury) maintains normal alignment at rest but will collapse under applied load. Carpal Instability
  5. 5.  Static Instability - (complete injury) abnormal intercarpal alignment on static radiographs. Carpal Instability
  6. 6.  Carpal Instability – Dissociative: Instability occurs between the individual bones. (in the same row) E.g: DISI & VISI Carpal Instability
  7. 7.  Carpal Instability – Non-Dissociative: Instability occurs between the row of bones Carpal Instability
  8. 8. DISI “Dorsal intercalated segmental instability”
  9. 9. Carpal Instability
  10. 10. DISI  Scapholunate ligament disruption.  Dorsal ligaments are stronger.  scaphoid will hyperflex. and the lunate will hyperextend. Carpal Instability
  11. 11. Presentation  Hx: acute FOOSH injury vs. degenerative rupture  Symptoms: dorsal and radial-sided wrist pain Carpal Instability
  12. 12.  Examination: - Dorsal wrist pain. - Diminished grip strength. - pain increased with extreme wrist extension and radial deviation Carpal Instability
  13. 13. Watson test Palpable clunk Carpal Instability
  14. 14. Terry Thomas sign Static & Dynamic >3 mm Carpal Instability
  15. 15. Terry Thomas sign Static & Dynamic >3 mm Clenched-fist Carpal Instability
  16. 16. cortical ring sign Duo to frontal projection of volar tubercle Carpal Instability
  17. 17. SL angel: Carpal Instability
  18. 18. Treatment • acute, undisplaced • chronic, asymptomatic NSAIDS, rest +/- immobilization • SL ligament injury W/o carpal malalignment • reducible SL ligament injuries SL reconstruction • rigid and unreducible • DISI with severe DJDwrist fusion Carpal Instability
  19. 19. Scapholunate advanced collapse (SLAC)  untreated DISI deformity Carpal Instability
  20. 20. VISI “Volar intercalated segmental instability”
  21. 21. VISI  Instability of the lunotriquetral ligament.  Volar ligaments are stronger.  scaphoid & Lunate will hyperflex. Carpal Instability
  22. 22. Presentation  Symptoms: Ulnar side wrist pain Increase with ulnar deviation Carpal Instability
  23. 23. Ballottement test Laxity, crepitation or reproduction of pain Carpal Instability
  24. 24. Gilula arc on AP Break this line Carpal Instability
  25. 25. < SL angel on Lateral Carpal Instability
  26. 26. Treatment • acute instabilityCRPP with lunotriquetral repair • chronic instability LT fusion • chronic instability secondary to ulnar positive variance arthroscopic debridement with ulnar shortening Carpal Instability
  27. 27. Carpal instaability Dissociative(CIND)
  28. 28. CIND Midcarpal instability Radiocarpal dislocation Carpal Instability
  29. 29.  Extrinsic ligamentous disruption. - radioscaphocapitate (SRC) - long radiolunate - short radiolunate - radioscapholunate Carpal Instability
  30. 30. Carpal Instability
  31. 31. Associated conditions:  Intracarpal injury (scapholunate or lunotriquetral ligament)  acute carpal tunnel syndrome  compartment syndrome Carpal Instability
  32. 32. Prognosis:  Volar dislocation more severe than dorsal. Carpal Instability
  33. 33. Presentation:  No history of trauma (midcarpal)  High energy trauma (radiocarpal)  generalized ligamentous laxity  irritating clunking sign  complain of wrist giving way Carpal Instability
  34. 34. Radiocarpal dislocation Carpal Instability
  35. 35. Carpal Instability
  36. 36. Treatment • first line of treatmentimmobilization +/- splinting • ulnar translation with styloid fractures open repair, reduction, and pinning • failed nonoperative management midcarpal joint fusion • distal radius malunion Osteotomy • failure of above treatments wrist arthrodesis Carpal Instability
  37. 37. Peri-lunate dislocation
  38. 38. mechanism Forced dorsflextion, Ulnar deviation Supination. Carpal Instability
  39. 39. 25% are missed in the ER diagnosed 75% missed 25% Carpal Instability
  40. 40. Mayfield commonly associated with a scaphoid fracture Carpal Instability Stage I : scapholunate dissociation Stage II: + lunocapitate disruption Stage III: + lunotriquetral disruption, "perilunate“ Stage VI: Lunate Dislocation Most severe of carpal instabilities
  41. 41. space of Poirier
  42. 42. break in Gilula's arc Carpal Instability triangular lunate "piece-of-pie sign"
  43. 43. Treatment • definitive management Closed reduction and casting • all acute injuries <8 weeks old closed reduction/splinting followed by open reduction, ligament repair, fixation, possible carpal tunnel release • chronic injury (defined as >8 weeks after initial injury) Proximal row carpectomy • chronic injuries with degenerative changes Total wrist arthrodesis Carpal Instability
  44. 44. Summery: Carpal Instability
  45. 45. Case 1
  46. 46. Lunate dislocation
  47. 47. Sources:  Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012  AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009  Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011  Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009  Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012  Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

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