Dorset County Hospital Orthopaedic Surgeon Sean Walsh · Sean Walsh Orthopaedic Surgeon Dorset...
Transcript of Dorset County Hospital Orthopaedic Surgeon Sean Walsh · Sean Walsh Orthopaedic Surgeon Dorset...
Sean WalshOrthopaedic Surgeon
Dorset County Hospital
Southampton Hand Course 28th June 2013
● Shapes and orientation of articular surfaces● Ligaments● Oblique positioning of scaphoid● Tendons surrounding the joints● Other soft tissues● Peripheral and central nervous system
Southampton Hand Course 28th June 2013
● Initially synonymous with Malalignment● Diagnosed on plain radiograph● But not every alteration in carpal alignment is
pathological e.g. hyper lax wrists● Redefined as inability to bear physiological loads with
an associated loss of carpal alignment● But some patients are asymptomatic most of time with
well aligned wrists and are able to sustain physiological loads. Symptomatic on specific tasks with typical sensation of “giving way”
Southampton Hand Course 28th June 2013
● Dynamic instability with sporadic malalignment under certain loading conditions
● Static instability when malalignment is permanent regardless of loading conditions
Southampton Hand Course 28th June 2013
● Carpal dysfunction● In a normal wrist there is the ability to
transfer loads without sudden changes in stress on the articular cartilage ( normal Kinetics) and the capacity to move throughout the normal range without sudden alterations of intercarpal alignment (normal Kinematics)
Southampton Hand Course 28th June 2013
● Osseous Anatomy
Southampton Hand Course 28th June 2013
● Laterally convex distal surface of scaphoid articulates with concavity if trapezium and trapezoid – STT joint
● Central portion – lunocapitate joint● Medial hamate-triquetral articulation helicoid joint (
screw shaped). ● Type I lunate – single facet, Type II an extra facet articulating with hamate
Southampton Hand Course 28th June 2013
● Tightly packed collagen bundles, mechanically important
● Mechanoreceptors● Proprioception to CNS – dynamic
stabilisation● Wrist proprioception through SLL
needs an intact PIN
Southampton Hand Course 28th June 2013
● Extrinsic● Palmar radiocarpal, Palmar ulno carpal and
dorsal radio carpal.● There are no dorsal ligaments between the
ulna and the carpus
Southampton Hand Course 28th June 2013
● Radioscaphoid● Radioscapho-capitate● Long Radiolunate Short Radiolunate
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● Ulnar Lunate, Ulnar Triquetrum● Ulnar Capitate
Southampton Hand Course 28th June 2013
● Dorsal Radial Triquetrum Ligament● Wide fan shaped ligament inserting onto dorsal
rim of triquetrum (deep fibres onto lunate)
Southampton Hand Course 28th June 2013
Berger R , Ann Plast Surg. 1995 Jul;35(1):54-9.
● Dorsal midpalmar /intercarpal ligament● Dorsal ridge triquetrum, along distal edge lunate,
inserts dorsal rim of scaphoid , trapezium and trapezoid.
Southampton Hand Course 28th June 2013
● Dorsal and palmar● Connect bones of the same carpal row (palmar and
dorsal interosseous)● Or link the two rows to each other
Southampton Hand Course 28th June 2013
● 3 distinct structures● Dorsal and palmar SL ligaments, central
fibrocartilaginous membrane
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● Palmar and Dorsal● Fibrocartilaginous membrane between ● Palmar Lig. Thicker and stronger 301N
Southampton Hand Course 28th June 2013
● Distal row is a fixed unit attached to metacarpals● Proximal row functions as an “Intercalated Segment”.● The term ‘intercalated segment’ refers to it being the
part in between the proximal segment of the wrist consisting of the radius and the ulna and the distal segment
● This intercalated segment is the keystone in the coordination of motions of the wrist and in the control of forces that are transmitted from the hand to the forearm and vice versa.
Southampton Hand Course 28th June 2013
● Wrist radial deviation, scaphoid flexes, lunate flexes.● Wrist ulnar deviation triquetrum extends, lunate
extends● Scaphoid tends to flex, Triquetrum tends to extend and
the lunate follows
Southampton Hand Course 28th June 2013
● Lunate is influenced by Triquetrum and extends● DISI, Dorsal Intercalated Segmental Instability
Southampton Hand Course 28th June 2013
● Lunate is influenced by Scaphoid and flexes● VISI Volar Intercalated Segmental Instability● VISI can be normal in a lax wrist
Southampton Hand Course 28th June 2013
● Scapho Lunate Interosseous Ligament SLIL● Primary stabiliser of the SL joint● SLIL failure force of 300N● Secondary stabilisers● Scaphoid Capitate and STT ligaments● Palmar - RSC, LRL,SRL - stabilise scaphoid ● Dorsal –Dorsal Radio Carpal Ligament, Dorsal Inter
Carpal Ligament● Dynamic stabilisers – Flexor carpi radialis, Extensor
carpi ulnaris
Southampton Hand Course 28th June 2013
● Wrist Kinematics - how the wrist moves
● Carpal Kinetics – how it sustains physiological loads without giving way
Normal wrist : Perfect interaction between wrist tendons, joint surfaces and soft tissue constraints, allows motion and loading without yielding
Southampton Hand Course 28th June 2013
● Kinetic Instability - unable to bear physiological loads without yielding
● Kinematic Instability- abnormal movements, click or clunk
Southampton Hand Course 28th June 2013
Mechanical instability( Kinetic or Kinematic)
+Symptoms
=CLINICAL INSTABILITY
Southampton Hand Course 28th June 2013
● Four major patterns● Carpal Instability Dissociative (CID)● Carpal Instability Non-dissociative (CIND)● Carpal Instability Complex (CIC)● Carpal Instability Adaptive (CIA)
Southampton Hand Course 28th June 2013
● Acute● <1 week● Maximum potential to
heal● Sub-acute
● From 1 to 6 weeks● Possible to heal
● Chronic● > 6 weeks● Unlikely to heal
Southampton Hand Course 28th June 2013
● Pre-dynamic● Dynamic● Static reducible● Static not
reducible
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● DISI● VISI● Volar translation● Dorsal translation● Radial translation● Ulnar translation● Proximal translation● Distal translation
Southampton Hand Course 28th June 2013
● Between bones of same carpal row● Scaphoid-Lunate, Lunate-
Triquetrum ● Capitate-Hamate
Southampton Hand Course 28th June 2013
● Unstable scaphoid non-union – distal scaphoid follows distal carpal row
● Proximal fragment follows the proximal carpal row● Scapholunate dissociation● Scaphoid rotates around the RC ligament
Southampton Hand Course 28th June 2013
Southampton Hand Course 28th June 2013
Extension + Ulnar Deviation +Supination
Southampton Hand Course 28th June 2013
Southampton Hand Course 28th June 2013
Southampton Hand Course 28th June 2013
Southampton Hand Course 28th June 2013
Southampton Hand Course 28th June 2013
Yin and Gilula: Imaging of the symptomatic wrist, 2001
● Lunotriquetral dissociation
Southampton Hand Course 28th June 2013
● Very unusual● Rupture of transverse intercarpal
ligaments binding bones of the distal row
● Dorsopalmar crush or blast injury
Southampton Hand Course 28th June 2013
● Radiocarpal, between radius and proximal carpal row
● Midcarpal, between proximal and distal rows
● No disruption between the bones of the proximal or distal rows
Southampton Hand Course 28th June 2013
● Excessive laxity● Rupture of radiocarpal ligaments – carpus
displaced down slope of radius● Rheumatoid arthritis● Madelung’s deformity due to fatigue of
ligaments – excessive shear forces● Trauma- radiocarpal dislocation with or
without radius fracture
Southampton Hand Course 28th June 2013
Southampton Hand Course 28th June 2013
● Group of conditions● Dysfunction of the radiocarpal and
midcarpal joints
Southampton Hand Course 28th June 2013
Southampton Hand Course 28th June 2013
I. Anterior- entire proximal row flexed on lateral viewII. Posterior-Normal alignment in standard radiographs, dorsal subluxation with dorsally directed force. III. Combined radiocarpal and midcarpal, both joints abnormally subluxable in a palmar and dorsal direction as a result of increased global laxityIV. Adaptive dysfunction secondary to an extra carpal problem – usually a malunited distal radius fracture.
● Attenuation or rupture of triquetro-hamate-capitate, STT and scaphocapitate ligaments
● Often with insufficiency of the dorsal radiocarpal ligament
● Proximal row remains flexed until near the end of ulnar deviation, where it suddenly rotates into extension with a palpable thud.
● “Catch up clunk”● Most cases have combined medial and lateral
insufficiency
Southampton Hand Course 28th June 2013
Southampton Hand Course 28th June 2013
● Extra carpal pathology● Dorsally malunited distal radius fracture● Postural adaption of proximal carpal row to
conform to the abnormal radial tilt● Flexed midcarpal joint● Slackening of palmar midcarpal ligaments● Pain , tenderness at midcarpal joint● Improves when radial deformity corrected with an
osteotomy
Southampton Hand Course 28th June 2013
Southampton Hand Course 28th June 2013
● CID + CIND● Derangement within same row of carpal
bone● Derangement between rows● Within this category 5 groups of carpal
dislocations have been identified
Southampton Hand Course 28th June 2013
● Dorsal perilunate dislocations - lesser arc● Dorsal perilunate # dislocation - greater arc● (Extreme wrist extension, ulnar deviation,
midcarpal supination, e.g.motorcycle RTA)● Palmar perilunate dislocations – lesser or
greater arc● Axial dislocations● Isolated carpal dislocations
Southampton Hand Course 28th June 2013
Greater arc
Lesser arc
Southampton Hand Course 28th June 2013
Southampton Hand Course 28th June 2013
Southampton Hand Course 28th June 2013
● Mechanisms of wrist stability● Definitions of Instability – kinetic and
kinematic● Common instabilities in clinical practice● Carpal malalignment● Classifications of wrist instability
Southampton Hand Course 28th June 2013
● Carlos Heras-Palou for loan of clinical photographs and videos
● Marc Garcia Elias
Southampton Hand Course 28th June 2013
QUESTIONS ?
Southampton Hand Course 28th June 2013