A BRIEF TALK ON CARPAL INSTABILITY AND PERILUNATE DISLOCATIONS

1. CARPAL INSTABILITY
&
PERILUNATE DISLOCATIONS
By Dr.Dhidhi George
Final year post graduate resident
DEPT of Orthpaedics
KMCT Medical college

2. INTRODUCTION
 WRIST JOINT –MARVEL OF EVOLUTION (UNLIKE
OUR DEVELOPMENTAL ANCESTORS)
 PARTICIPATING CARPAL BONES
 PROXIMAL ROW- SCAPHOID, LUNATE,
TRIQUETRIUM, PISIFORM
 DISTAL ROW- TRAPEZIUM, TRAPEZOID,CAPITATE,
HAMATE

3. ANATOMY - BONES
SOME LOVERS TRY
POSITIONS /
THAT THEY CANNOT
HANDLE

4. Anatomy of the Wrist
 Carpal bones tightly linked by capsular and
interosseous ligaments.
 Capsular (extrinsic) ligaments originate from the
radius and insert onto the carpus.
 Interosseous (intrinsic) ligaments traverse the
carpal bones.
 The lunate is the key to carpal stability.

5. Lunate
 Connected to both scaphoid and triquetrum by strong
interosseous ligaments.
 Injury to the scapholunate or lunotriquetral ligaments
leads to asynchronous motion of the lunate and
leads to dissociative carpal instability patterns.

6. EXTRINSIC LIGAMENTS
 THREE MAJOR GROUPS
1. PALMAR RADIOCARPAL
2. PALMAR ULNOCARPAL
3. DORSAL RADIOCARPAL
 ULNA AND CARPUS – NO DORSAL CONNECTING
LIGAMENTS

7. PALMAR RADIOCARPAL
LIGAMENTS
1. RADIOSCAPHOID (RS)
2. RADIOSCAPHOCAPITATE (RSC)
3. LONG RADIOLUNATE (LONG RL)
4. SHORT RADIOLUNATE LIGAMENTS (SHORT RL)

8. APPLIED ANATOMY

9. PALMAR ASPECT- APPLIED
ANATOMY
 SPACE OF POIRIER

10. KHABIB VS POIRIER

11. WEAK

12. SPACE OF POIRIER

13. Wrist Ligaments
Extrinsic
Connect radiusto carpus &carpus to metacarpals
Intrinsic
Connect carpal to carpal bone.
o Space of Poirier: ligamentfree areabtw
radioscapholunatelig&longradiolunate ligament-at
levelof midcarpal joint;an areaofpotentialweakness.

14. Pathomechanics
Classically, the radius, lunate, and capitate have
been described as a central “link” that is colinear in
the sagittal plane.
 Scaphoid serves as a connecting strut. Any flexion
moment transmitted across the scaphoid is balanced
by an extension moment at the triquetrum.

15. APPLIED ANATOMY

16. RADIO-LUNATE LIGAMENTS
 PIVOTAL ROLE IN PREVENTING THE DORSAL
DISLOCATION OF LUNATE IN WRIST INJURIES
CAUSED BY HYPEREXTENSION OF WRIST

17. EXTRINSIC LIGAMENTS
 THREE MAJOR GROUPS
1. PALMAR RADIOCARPAL
2. PALMAR ULNOCARPAL
3. DORSAL RADIOCARPAL
 ULNA AND CARPUS – NO DORSAL CONNECTING
LIGAMENTS

18. PALMAR ULNOCARPAL LIGAMENTS
1. ULNOCAPITATE
2. ULNOTRIQUETRAL
3. ULNOLUNATE

20. COMPONENTS OF TFCC
 The articular disc.
 The dorsal and volar radioulnar ligaments.
 The meniscus homologue.
 The extensor carpi ulnaris tendon sheath.
 The Ulnocarpal ligaments.
1. ULNOCAPITATE
2. ULNOLUNATE
3. ULNOTRIQUETRAL

21. EXTRINSIC LIGAMENTS
 THREE MAJOR GROUPS
1. PALMAR RADIOCARPAL
2. PALMAR ULNOCARPAL
3. DORSAL RADIOCARPAL
 ULNA AND CARPUS – NO DORSAL CONNECTING
LIGAMENTS

22. DORSAL RADIOCARPAL LIGAMENTS
 RADIOTRIQUETRAL LIGAMENT
 APPLIED SIGNIFICANCE- ONLY DORSAL
EXTRINSIC LIGAMENT

23. INTRINSIC CARPAL LIGAMENTS
 FIBERS THAT CONNECT EITHER THE PROXIMAL
AND DISTAL TRANSVERSELY OR CONNECT THE
TWO ROWS TOGETHER
 SCAPHOLUNATE INTEROSSEUS LIGAMENT
 LUNOTRIQUETRAL INTEROSSEUS LIGAMENT

24. SL
LT
TFCC
Interosseous Ligaments:
looking dorsal to volar

25. CARPAL INJURIES
GREATER ARC- PERILUNATE
FRACTURE DISLOCATION
• LIGAMENTOUS INJURY WITH
ONE OR MORE FRACTURES OF
SURROUNDING BONE . TRANS-
SCAPHOID, TRANSCAPITATE-
PERILUNATE FRACTURES
LESSER ARC-PURE LIGAMENTOUS
INJURY
• DISRUPTION OF THE CAPSULAR
AND LIGAMENTOUS
CONNECTIONS OF LUNATE TO
ADJACENT CARPAL BONE OR
RADIUS WITHOUT FRACTURE.
PERILUNATE AND LUNATE
DISLOCATIONS

26. MAYFIELDS CLASSIFICATION
 4 stages
 Originally described by Mayfield.
 Each stage represent a sequential intercarpal
injury.
 Can be associated with specific bony fractures
including the radial styloid, scaphoid, capitate and
triquetrum.

27. Mayfield Classification
STAGE
1 Scapholunate dissociation
2 + Lunocapitatedisruption
3 + Lunotriquetral disruption,"perilunate"
4 Lunate dislocated from lunate fossa(usually volar)
•associatedwith mediannerve compression
(1) SL (2) SL + CL (3) SL + CL + LT (4) Lunate dislocates

28. Pathoanatomy
->
ion -->
ation-->
Sequence ofevents (Mayfield)
1. Scapholunate ligamentdisrupted -
2. disruption ofCapitolunate articulation
3. disruption ofLunotriquetral articulation
4. Failure ofDorsal radiocarpal ligament
lunate rotates anddislocates, usuallyinto carpal tunnel.
‘Spilled Teacup Sign’

29. 1.SCAPHOLUNATE
DISSOCIATION
2. LUNOCAPITATE
DISRUPTION

30. 3. LUNOTRIQUETRALDISRUPTION,
“PERILUNATE"
4.LUNATEDISLOCATION

31. Mayfields stage 4

32. CARPAL INSTABILITY-CLASSIFICATION
DOBYNS CLASSIFICATION
1. CARPAL INSTABILITY DISSOCIATIVE (CID)
2. CARPAL INSTABILITY NONDISSOCIATIVE (CIND)
3. CARPAL INSTABILITY COMBINED (CIC)

34. Gilula arcs outline proximal and distal surfaces of the proximal carpal row and
the proximal cortical margins of capitate and hamate.

35.  Proximal carpal row has no tendinous attachments
and is called intercalated segment.
 Movement between the carpal bones is determined
by ligamentous attachments and mechanical forces
crossing the wrist.

36. CARPAL INSTABILITY DISSOCIATIVE
1. PROXIMAL (SCAPHOLUNATE-DISI &
LUNOTRIQUETRAL-VISI DISSOCIATIONS)
2. DISTAL (CAPITATE-HAMATE AXIAL
DISRUPTIONS)

37. CARPAL INSTABILITY DISSOCIATIVE
 DISI-DORSAL INTERCALATED SEGMENT
INSTABILITY
 SCAPHOLUNATE DISSOCIATION OR ROTARY
SUBLUXATION OF SCAPHOID
 SL GAP > 3mm ON PA VIEW (TERRY THOMAS SIGN)
 BREAK IN GILULA’S ARC AT THE SL INTERVAL
 CORTICAL RING SIGN
 SL ANGLE > 60 Degrees
 RL ANGLE > 15 Degrees
 Watsons test – palpable clunk on Radial or Ulnar deviation

38. TERRY THOMAS SIGN

40. Watson Shift Test

41. Wrist arthroscopy
• Gold standard for detecting Scapholunate and
lunotriquetral injury.
• Direct visualisation.
• Location and size of insult.
• Presence of arthritic changes within the joint
space.

42. Geisslers classification

43. STAGES OF SL INSTABILITY
A. OCCULT/ PREDYNAMIC
A. PARTIAL TEAR OF SL
B. NORMAL XRAYS
C. POSSIBLE ABNORMALITIES IN ARTHROSCOPY
B. DYNAMIC INSTABILITY
A. PARTIAL OR COMPLETE TEAR OF SLIL
B. STREE XRAY ABNORMAL
C. ABNORMAL ARTHROSCOPY GEISSLER II OR III
C. STATIC INSTABILITY
A. COMPLETE SL TEAR
B. ABNORMAL RADIOGRAPHY
C. DISI PATTERN ON RADIOGRAPHS
D. SLAC WRIST (SCAPHOLUNATE ADVANCE COLLAPSE)
A. DUE TO LONG STANDING ABNORMAL POSTIONING OF SCAPHOID,
ARHTHRITIC CHANGES OCCUR.

44. SLAC – WATSON CLASSIFICATION
 STAGE I- ARTHRITIS BETWEEN THE SCAPHOID
AND RADIAL STYLOID
 STAGE II- ARTHRITIS BETWEEN THE SCAPHOID
AND THE ENTIRE SCAPHOID FACET OF THE
RADIUS
 STAGE III- STAGE I&II PLUS ATHRITIS BETWEEN
THE CAPITATE AND LUNATE.

45. SLAC

46. TREATMENT
 CLOSED REDUCTION
 TRACTION TO THE WRIST
 GRADUAL EXTENSION OF WRIST
 COUNTER PRESSURE OVER LUNATE TO PREVENT
VOLAR DISLOCATION
 GRADUAL FLEXION OF WRIST
 POSTREDUCTION XRAY IS OBTAINED

47. CURRENT TREATMENT
 CLOSED REDUCTION AND PERCUTANEOUS
PINNING
 REPAIR OF SL LIGAMENT (LINKAGE PROCEDURE)
IF POSSIBLE WITH TISSUE AUGMENTATION FROM
EXTENSOR OR FLEXOR TENDONS OR WITH
CAPSULODESIS
 IF NOT REPAIRABLE-
SCAPHOTRAPEZIALTRAPIZOIDAL FUSION-
TRISCAPHE FUSION (STT)
 CHRONIC CASES- CAPSULODESIS

48. MECHANISM OFINJURY
FOOSH; axial compressive force
wrist hyperextension,
ulnar deviation,and
intercarpal supination

49. VISI-VOLAR INTERCALATED
SEGMENT INSTABILITY
 DISRUPTION OF THE LUNO-TRIQUETRAL
INTRAOSSEOUS LIGAMENT
 BREAKIN GILULA’S ARC
 RADIOLUNATE OR CAPITATE ANGLE >15 DEGREES
 LUNATE FACES VOLARLY

50. VISI
When the triquetrum is
destabilized (usuallyby
disruptionofthe
lunotriquetral ligament
complex), theopposite
pattern (volar
intercalated segmental
instability[VISI]) isseen
asthe lunate
(intercalated segment)
volar flexes.

51. MECHANISM OFINJURY
FOOSH; axial compressive force
wrist hyperextension,
RADIAL deviation,and
intercarpal supination

52. DISTAL CID
 UNCOMMON AND DEVELOPS DUE TO RUPTURE
OF TRANSVERSE INTERCARPAL LIGAMENTS
BETWEEN BONES OF DISTAL ROW
 ALSO KNOWN AS ‘AXIAL DISLOCATION’
 ONE COLUMN DISPLACES WHILE THE OTHER
REMAINS ALIGNED WITH ONE OF THE FOREARM
BONE (RADIUS)
 AXIAL RADIAL
 AXIAL ULNAR
 AXIAL RADIAL ULNAR

53. CIND-CARPAL INSTABILITY NON-
DISSOCIATIVE
 MEANS UNDISSOCIATED CARPAL BONES THAT
REMAIN AS A UNIT
 MOST COMMON CAUSES:
 MALUNION OF DISTAL RADIUS (DISI PATTERN)
 DISTAL RADIUS DEVELOPMENTAL MALPOSITION
(VISI PATTERN)
 INSUFFICIENCY OF THE EXTRINSIC RADIOCARPAL
LIGAMENTS
 TWO TYPES
 RADIOCARPAL INSTABILITY
 MIDCARPAL INSTABILITY

54. LICHTMAN TEST
 PROVOCATIVE TEST FOR MIDCARPAL
INSTABILITY
 FOREARM IN PRONATION
 GENTLY MOVE THE HAND FROM RADIAL TO
ULNAR DEVIATION WHILE LOADING THE CARPUS
INTO RADIUS
 POSITIVE TEST WHEN MIDCARPAL ROW APPEARS
TO JUMP OR SNAP

55. CIC-CARPAL INSTABILITY
COMBINED
 PRESENTS AS REPETITIVE CLICKS WHILE LIFTING
HEAVY OBJECTS
 CLIP- PATTERN-CAPITATE-LUNATE INSTABILITY
PATTERN
 DORSAL SUBLUXATION OF MIDCARPAL AND
RADIOCARPAL JOINTS
 CONGENITAL LIGAMENTOUS LAXITY.

56. High energyinjurywithpoorfunctional
outcomes.
Commonly missed(~25%) on initial
presentation.

57. MANAGEMENT
 NO N OPERATIVE
Closed reduction and casting
Indications
o no indications when used as definitive
management
Outcomes
o universally poor functional outcomes with non-
operative management
o recurrent dislocation is common

58. Closed Reduction techniqueOFTAVERNIER
1. finger traps, elbowat 90degreesof flexion
2. hand 5-10 lbstraction for15minutes
3. dorsal dislocationsarereduced through wrist
extension, traction, and flexion ofwrist.
4. apply sugartongsplint
5. follow withsurgery.
6. GUNN’S LAW- REVERSING THE FORCE(OLD,
>FAILURES)

59. Outcomes
Emergent closedreduction leadsto
Decreased riskof mediannerve damage
Decreased riskofcartilagedamage
Return to fullfunctionunlikely
Decreased gripstrengthandstiffnessare
common

60. Treatment concepts
• Acute injuries- Closed or arthroscopically
controlled manipulation and percutaneous
pinning; Open reconstruction/repair.
• Instability w/o arthrosis- ligament
reconstruction, capsular imbrication and
limited intercarpal arthrodesis.

61. • Dorsal capsulodesis to limit scaphoid flexion.
• Fixed deformity, arthrosis, pain or interference
with function- excisional arthroplasty, limited
intercarpal arthrodesis and wrist fusion.

62. Ligament repair

63. Ligament Reconstruction
• Free tendon grafts or tenodesis using
prolonged slips of wrist flexors or extensors.
• Linscheid and Dobyns suggested that
procedure be limited to patients whose
ligament ruptures cannot be maintained with
closed reduction, patients diagnosed after 1
month.

64. • Not indicated in patients with degenerative
joint disease.
• Complications-
– Tendons may stretch and become lax
– Bone tunnels may lead to fracture and vascular
changes.
– Tightness required to maintain bony apposition
may eventually limit wrist motion.

65. Palmer, Dobyns and Linscheid

68. Almquist repair- 4 bone ligamentous
repair

69. Taleisnik and Linscheid

70. Brunelli and Brunelli

71. Talesnik
VISI (FCU) DISI (ECRB)

72. Capsulodesis (Blatt)
• Useful for scapholunate
dissociation and caput
ulnae syndrome (DRUJ
incongruity)
• Ability to anatomically
reduce the scaphoid.

73. Limited Wrist (Triscaphe) Arthrodesis
• Pain relief with functional arc of motion.
• Indications
– Degn arthritis of STT joint with normal thumb CMC
joint
– Radial hand dislocations
– Rotary subluxation of scaphoid
– Scapholunate diastasis of > 2mm
– Scaphoid angle of >60 deg on true lateral.
– Foreshotening of scaphoid in AP view.

74. STT fusion (Watson)

75. • Scaphocapitate arthrodesis
• Scaphocapitolunate arthrodesis
• Lunotriquetral arthrodesis.

76. Approaches – Dorsal, Volar, Combined.
Dorsal approach
longitudinal incision centered at Lister's tubercle
excellent exposure of proximal carpal row and
midcarpal joints
does not allow for carpal tunnel release
Volar approach
extended carpal tunnel incision just proximal to
volar wrist crease

77.  Technique
 Fix associatedfractures
Repair scapholunate ligament
Protect scapholunate ligament repair
Repair of lunotriquetral interosseous ligament
Post-op
Short arm thumb spica splint converted to short arm
cast at first post-op visit
Duration of casting varies, but at least 6 weeks

78. 2) Proximal row carpectomy
Technique
Dorsal andvolarincisionsifmediannervecompressionis
present
Volar approachallowsmediannervedecompressionwith
excisionoflunate
Dorsal approachfacilitatesexcisionofthescaphoid
andtriquetrum

79. Complications
MedianN neuropathy.
Chronic perilunateinjury.
Post traumaticarthritis.

80.  Operative
SURGERY INDICATION
SL Ligament repair acute scapholunate ligament injury
without carpal malalignment
SL reconstruction Acute, SL lig not ammenable to repair
Scaphoid ORIF vs. CRPP SL ligament injury is d/t scaphoid #
Stabilization with wrist fusion
(STT/SLC)
rigid and unreducible DISI deformity

84. THANK YOU