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Carpal instability - Orthopedic
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Transcript of Carpal instability - Orthopedic
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 applied load.
Carpal Instability
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
Carpal Instability
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
hyperextend.
Carpal Instability
Presentation
Hx:
acute FOOSH injury vs. degenerative
rupture
Symptoms:
dorsal and radial-sided wrist pain
Carpal Instability
Examination:
- Dorsal wrist pain.
- Diminished grip strength.
- pain increased with extreme wrist
extension and radial deviation
Carpal Instability
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 malalignment
• reducible SL ligament injuries
SL reconstruction
• rigid and unreducible
• DISI with severe DJD wrist fusion
Carpal Instability
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.
Carpal Instability
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 instability
CRPP with
lunotriquetral repair
• chronic instability
LT fusion
• chronic instability secondary to ulnar positive variance
arthroscopic debridement
with ulnar shortening
Carpal Instability
Carpal instaability
Dissociative(CIND)
CIND
Midcarpal instability
Radiocarpal dislocation
Carpal Instability
Extrinsic ligamentous
disruption.
- radioscaphocapitate (SRC)
- long radiolunate
- short radiolunate
- radioscapholunate
Carpal Instability
Carpal Instability
Associated conditions:
Intracarpal injury (scapholunate or
lunotriquetral ligament)
acute carpal tunnel syndrome
compartment syndrome
Carpal Instability
Prognosis:
Volar dislocation more severe than dorsal.
Carpal Instability
Presentation:
No history of trauma (midcarpal)
High energy trauma (radiocarpal)
generalized ligamentous laxity
irritating clunking sign
complain of wrist giving way
Carpal Instability
Radiocarpal dislocation
Carpal Instability
Carpal Instability
Treatment
• first line of treatment immobilization +/- 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
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:
+ lunocapitate disruption
Stage III:
+ lunotriquetral disruption,
"perilunate“
Stage VI:
Lunate Dislocation
Most severe of carpal instabilities
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/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
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 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