A

Radiologist’s Guide to
Wrist Alignment:
The Good, Bad, and Ugly
Wilson Lin, MD, Bao Do, MD, Michelle Nguyen, MD
Diagnos@c Radiology
Stanford Hospital and Clinics
VA Palo Alto Healthcare System
 Objec@ves
1.  Review basic adult wrist anatomy

2.  Discuss how to evaluate alignment on radiographs:

•  Distal radius, distal ulna, distal radioulnar joint (DRUJ)
•  Carpal bones
•  Carpometacarpal bones

3.  Discuss the trauma@c and non-trauma@c disorders that cause wrist
malalignment

4.  Review the classifica@on of carpal instability

 Osseous Anatomy
Scaphoid (S)
Lunate (L)
Triquetrum (Tq)
* * *
Pisiform (P) * *
Tm Td H
Hamate (H) C P Tm
Capitate (C) S Tq C
P
Trapezoid (Td) L L
S
Trapezium (Tm) U
R
Radius (R)
Ulna (U)
Metacarpals (*)

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Anatomy: Main Ligaments

LT ST DST
SL

RSC RLT UL UT DRT

Intrinsic ligaments Volar carpal ligaments Dorsal carpal ligaments

Scapholunate (SL) Radioscaphocapitate (RSC) Dorsal scaphotriquetral (DST)
Lunotriquetral (LT) Scaphotriquetral (ST) Dorsal radiotriquetral (DRT)
Radiolunotriquetral (RLT)
Ulnolunate (UL)
Ulnotriquetral (UT)

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Evalua@on of the Wrist
•  Radiograph (4 standard views)
•  Posteroanterior (PA) –
shoulder abducted 90º, elbow
flexed 90º, forearm in neutral
posi@on
•  Oblique –radial side of wrist
S C
elevated 30o from table, ulnar
side of wrist res@ng on table
•  Lateral – shoulder adducted, P
elbow flexed 90o, distal PA
forearm and hand res@ng on
ulnar side
•  Scaphoid –PA view with wrist
in ulnar devia@on
•  Many other dedicated views Lateral view
•  CT – especially helpful for 3D (1) Pisiform should be located
reconstruc@on for surgeon PA view b/t the volar cor@ces of
•  MRI – evaluate sob @ssues, Extensor carpi ulnaris tendon scaphoid and capitate
ligaments, tendons, marrow edema. groove should be profiled at (2) Radial styloid should overlap
radial base of ulnar styloid with carpus
(3) Ulna should overlap radius

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Distal Radius: Volar Tilt
•  Lateral view: angle between (1) tangent of distal
radius ar@cular surface and (2) line perpendicular to
the mid-radius shab
2
•  Normal: average 11 degrees (2 to 20 degrees)
1
•  Aka palmar @lt, volar inclina@on
Normal
•  Purpose: to assess deformi@es associated with
fractures of distal radius and opera@ve planning in
correc@ng deformi@es
•  Colles fracture: dorsal angula@on > 15 º may be
associated with unsa@sfactory grip strength and 1
endurance
•  Dorsal angula@on of > 30º volar @lt from normal 2
posi@on can increase load on ulnocarpal joint by
200%
Colles fx with dorsal angula@on of volar @lt

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Radial Inclina@on Angle
•  PA view: angle between (1) line connec@ng radial
styloid @p and ulnar aspect of distal radius and (2) line
perpendicular to longitudinal axis of radius
1
•  Normal: 21-25º
2
•  Aka radial devia@on or ulnar inclina@on

•  Purpose: Normal
•  Decreased: may predict poorer func@onal
outcome following distal radial fractures (< 5º)
•  Increased: may be seen in deformi@es such as
Madelung deformity or posirauma@c growth 1
arrest (of ulnar side of radius)

Madelung deformity with ↑ angle

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Radial Length
•  PA view: distance between (1) @p of radial
styloid and (2) ulnar head ar@cular surface
(draw lines perpendicular to radial shab)

•  Average: 10-13 mm 1

2
•  Purpose: quan@fies distal radial deformity
from fractures or developmental
abnormali@es
Normal
•  Loss of radial length = predictor of less
favorable outcome in distal radial fractures

1
2

Colles fx with ↓ radial length

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Ulnar Variance
•  PA view: draw line perpendicular to mid shab radius and
at most ulnar aspect of distal radius, then measure
distance between this line and ulnar dome

•  Posi@ve = distal ulna is distal to line
•  Nega@ve = distal ulna is proximal to line

•  Normal values vary by ethnic group

•  Purpose: evaluate fracture deformi@es of distal radius,
opera@ve planning/follow-up of radioulnar length-
equaliza@on procedures

•  Relates to anatomy and biomechanics
•  Thicker triangular car@lage (i.e. nega@ve ulnar
variance) allows greater tension transfer and
decrease in risk of perfora@on of disk Normal: the distal radius and ulna are
•  Change in 1 mm ulnar variance can alter mechanical aligned
transfer by 25%

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Nega@ve Ulnar Variance
•  Thicker triangular fibrocar@lage, which
may be protec@ve
Ulnar impingement
•  Associated with Kienboch’s disease, Nega@ve ulnar variance,
posirauma@c acute scapholunate c o r @ c a l r e m o d e l i n g a n d
sclerosis of the ulna as it
dissocia@on, radial ulnar impingement
contacts the medial radius.

•  Kienbock’s disease
•  Short ulna leads to increased shear
forces on ulnar wrist and par@cularly the
lunate
•  Osteonecrosis of the lunate
•  Radiographs may show lunate sclerosis,
lunate cor@cal collapse and advanced
osteoarthri@s

Kienbock’s disease: Lunate sclerosis and ulnar

nega@ve variance on PA view (A); abnormal
marrow signal in lunate and scapholunate
ligament par@al tear on coronal T2 FS MRI (B)

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Posi@ve Ulnar Variance
•  Thinner triangular fibrocar@lage, which may be
predisposed to rupture

•  May be associated with poorer outcomes if
associated with fractures, for example:
•  Poor outcomes seen in 40% of pa@ent’s with
Colles fracture and > 5 mm + ulnar variance
•  In Galleazzi fractures, > 10 mm + ulnar
variance indicates complete disrup@on of
interosseous membrane at the DRUJ

•  May lead to ulnocarpal impac@on
•  Chronic degenera@on from ulnar impac@on
•  TFCC progressively deteriorates, leading to
chondromalacia of the lunate, triquetrum, and
ulna
•  Radiographs: + ulnar variance and Ulnocarpal impac@on with posi@ve ulnar
variance, subchondral sclerosis of the lunate
degenera@ve changes of involved bones
and distal ulna, and cor@cal remodeling of the
•  MRI may show edema or LT ligament tear proximal lunate.

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 DRUJ Disloca@on
•  Cause: may be isolated or associated with
other injuries (Galleazzi fracture, Essex-
Lopres@ injuries, distal radius fractures)

•  Radiographic findings:
•  Abnormal rota@on of ulna with ulnar
styloid overlying central por@on of distal
ulna (PA view)
•  Widening of radioulnar distance (PA
view)
•  Superimposi@on of radius and ulna (PA)
•  Posterior or anterior displacement of
ulna (lateral view)

The radioulnar distance is widened, consistent with

DRUJ disloca@on. There is also a comminuted fracture
of the mid radial shab in this Galleazzi fracture
disloca@on.

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Carpal Alignment: Gilula Arcs
3 smooth carpal arcs on neutral PA view
•  Arc 1: proximal surfaces of the scaphoid,
lunate, and triquetrum
PA view (A) of type II
•  Arc 2: distal surfaces of the same bones Lunate with disrup@on
•  Arc 3: curvature of proximal surfaces of of 2nd Gilula arc, also
capitate and hamate seen on coronal T1 (B)
and T2 (C) weighted
Disrup@on suggests ligamentous disrup@on/laxity MR sequences
or carpal fracture
A
2 common variants:
•  Triquetrum shorter in proximal-distal
dimension than adjacent lunate (abnormal 1st
arc)
•  Type II lunate (proximal hamate with apposing
hamate facet on lunate, leading to disrupted
2nd arc)
Note: Lunate should be trapezoid-shaped. A B C
“triangular lunate” may reflect @l@ng, disloca@on,
or fracture

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Carpal Height
Carpal height (CH): distance from base of 3rd
metacarpal to distal radial ar@cular surface
•  Purpose: quan@fy carpal collapse

•  Carpal height ra@o: Carpal height / length of 3rd
metacarpal
•  Normal: 0.54 ± 0.03 CH

•  Alterna@ve: Carpal height / capitate length
•  Normal: 1.57 ± 0.05

•  Carpal height index: Carpal height ra@o of diseased
hand / that of normal hand
•  Normal: 1.000 ± 0.015
Alterna@ve carpal height ra@o
CH / Capitate length – adjusts for the
•  Carpal collapse associated with rheumatoid individual and can be used when the
arthri@s, scapholunate advanced collapse, and en@re 3rd metacarpal is not included in
Kienbock disease
the field of view

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Joint Space
•  All joint spaces should be 1-2 mm and of similar width
All joint spaces are
•  Causes of widening: ligamentous abnormali@es, similar width and
increased joint fluid, synovial hypertrophy measure < 2 mm,
•  Causes of narrowing: arthri@s, trauma, carpal coali@on i n c l u d i n g t h e
scapholunate (yellow)
•  Scapholunate distance: measured at mid-por@on and and lunotriquetral
may be abnormal if > 2 mm (red) joints
•  Widening can imply scapholunate dissocia@on

Carpal coali@on
PA view (A) and coronal T1
weighted MR image (B) show
absence of lunotriquetral joint
space from osseous coali@on.
Ulnar styloid fracture also
present.
A B

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Carpal Axes
•  Measured on lateral view
•  Longitudinal axes of the 3rd metacarpal, capitate,
lunate, and radius should fall on the same line, usually
within 10º

Radial axis (R): Line parallel to radial shab

Lunate axis (L): Line drawn through midpoints of proximal
and distal surfaces

Capitate axis (C): Line drawn through centers of head and
distal surface

Scaphoid axis (S): Line drawn through midpoints of S
proximal and distal poles C
L

R

Distal Radius Carpal
Anatomy Carpal bones CMC
& Ulna Instability
 Carpal Angles
•  Purpose: To iden@fy instability of the proximal carpal row (intercalated segment)
•  Normally, proximal carpal bones are constrained to one another and flex/extend as a unit, with normal carpal
angles measured on LATERAL view, as seen below
•  Abnormal carpal angles can reflect underlying carpal malalignment: Volar and Dorsal intercalated segmental
instability (VISI and DISI)
Normal Scapholunate (SL) angle Normal Capitolunate (CL) angle Normal Radiolunate (RL) angle
30-60º 0-30º -15 to +15º

S
L C L
L R

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Volar Intercalated Segmental Instability (VISI)

•  Causes: Disrup@on of lunotriquetral

interosseous ligament +/- midcarpal
stabilizers (triquetrohamatocapitate, dorsal
radiocarpal ligaments)

•  Abnormal flexion of unconstrained proximal

carpal row (scaphoid and lunate)

•  Volar @lt of the lunate and scaphoid, dorsal S
@lt of the capitate
L
•  SL angle is decreased (<30º), CL angle is
C
increased (>30º).

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
Dorsal Intercalated Segmental Instability (DISI)

•  Causes: Disrup@on of scapholunate

interosseous ligament or scaphoid fracture-
S
scaphoid is no longer constrained to lunate
and proximal carpal row

•  Volar @lt of the scaphoid and dorsal @lt of the
lunate
L
•  Both the SL and CL angles are increased
(SL>60o; CL>30º) C

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Pisotriquetral Joint
Major stabilizers: Flexor carpi ulnaris tendon
(FCU), pisohamate ligament (PHL),
pisometacarpal ligament (PML), and
pisotriquetral ulnar ligament

Radiographic evalua@on:
•  AP view: pisiform should be
superimposed over triquetrum A B
•  Lateral view: pisiform should be
superimposed over scaphoid tuberosity,
between volar convexi@es of scaphoid
and capitate
•  Semi-supinated oblique view and ulnar
border view may improve visualiza@on of
joint

C D
Pisiform subluxa@on. (A) PA view of wrist shows inferior displacement of pisiform rela@ve to triquetrum with
normal contralateral wrist for comparison (B). Axial (C) and sagiial (D) fat-suppressed T2 weighted MR images
demonstrate tear of pisotriquetral joint capsule and widening of joint.

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Carpometacarpal Joint Alignment
•  Width of 2nd through 5th CMC joint spaces should
be uniform, measuring 1-2 mm
•  Radiographic evalua@on: Parallel M lines
•  on PA view, two parallel lines resembling
“M”
•  Proximal line = curvatures of distal surfaces
of trapezoid, capitate, and hamate
•  Distal line = bases of 2nd through 5th
metacarpals A B
•  Break in line suggests abnormality

C D

PA view shows disrup@on of the ulnar aspect of the

“M” line. Mul@planar CT (B, C, D) images confirm 4th
and 5th CMC fracture disloca@ons.

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Mayo Classifica@on of Carpal Instability
Biomechanics

•  Movement of the wrist starts at the distal carpal row, then passive following of the proximal row
(mostly at the capitolunate por@on).
•  For radial and ulnar devia@on, proximal row moves together (flexed for radial devia@on and
extended for ulnar devia@on)
•  Stability can be affected at any level of the wrist, by diseases that affect morphology of bones,
ligaments, and muscles of this region

4 types of Carpal Instability (Mayo Classifica@on)

Carpal instability dissocia@ve (CID) Derangement within or between bones of same

carpal row
Carpal instability non-dissocia@ve (CIND) Derangement between radius and proximal carpal
row or between proximal and distal carpal rows
Carpal instability complex (CIC) Combina@on of CID and CIND
Carpal instability adap@ve (CIA) Origin of instability is proximal or distal to wrist

Distal Radius Carpal

Anatomy Carpal bones CMC
& Ulna Instability
 Carpal Instability Dissocia@ve (CID)
Derangement within or between bones of same carpal row

Proximal carpal row

•  Scapholunate dissocia@on
•  Lunotriquetral dissocia@on
•  Scaphoid fracture

Distal carpal row
•  Axial carpal disloca@ons

Carpal
CID CIND CIC CIA
Instability:
 Proximal Carpal Row CID:
Scapholunate Dissocia@on
•  Most frequent carpal instability paiern
•  Causes: trauma@c injuries to SL ligament, unstable
scaphoid fractures, rheumatoid arthri@s, CPPD, and
Kienbock’s disease
•  Possible findings:
•  Widening of SL distance A
•  Par@al to complete tear of SL ligament on MRI
•  If severe failure of scaphoid stabilizers,
scaphoid and lunate will rotate in opposite
direc@ons, leading to SL > 60º and DISI
•  Chronic progression leads to scapholunate advanced
collapse (SLAC)
•  Severe RS narrowing and progressive proximal B C
migra@on of capitate to between scaphoid and
lunate (A) PA view shows SLD. (B) PA view of SLAC wrist
with widened SLD, carpal collapse (decreased CH),
•  Carpal height will decrease
and proximal migra@on of capitate. (C) Lateral view
of SLAC wrist shows increased SL angle (DISI).

Carpal
CID CIND CIC CIA
Instability:
 SLAC and SNAC
Scaphoid non-union advanced collapse (SNAC)
Progression of arthrosis in SLAC and
SNAC (Watson)
Wrist arthri@s that develops following a non-union
scaphoid fracture Stage I: Arthrosis of radial styloid-
distal scaphoid ar@cula@on
S
Stage II: Involvement of proximal
radioscaphoid joint (SLAC) or
scaphocapitate joint (SNAC)

Stage III: Involvement of
L
scaphocapitate and lunocapitate joints

A B Stage IV: Pancarpal arthrosis with
preserva@on of radiolunate joint
PA view (A) shows non-union scaphoid fracture and (ar@cula@on b/t proximal pole of
arthrosis of the distal scaphoid, radial styloid, and scaphoid and radius oben preserved
midcarpal joint. Lateral view (B) shows DISI (SL angle > in SNAC)
60º), which implies the lunate is unrestrained from the
scaphoid.

Carpal
CID CIND CIC CIA
Instability:
 Proximal Carpal Row CID:
Lunotriquetral Dissocia@on
•  Results from injury to LT ligament

•  Causes: airi@on by age, posi@ve ulnar
variance, perilunate injuries

•  May see:
•  Normal radiograph (including
normal LT joint space)
•  Disrup@on of Gilula’s arcs, A B
proximal migra@on of triquetrum
•  Volar transla@on of lunate axis
from flexion of scaphoid, leading PA view (A) shows disrup@on of the lunotriquetral
to VISI ar@cula@on and 1st and 2nd carpal arcs. Lunate is
•  May see par@al to complete tear triangular in shape. Lateral view (B) shows VISI with
on MRI (only 50% sensi@ve), may a decreased scapholunate angle < 30o.
only see fluid about torn ligament

Carpal
CID CIND CIC CIA
Instability:
 Distal Carpal Row CID:
Axial Carpal Disloca@ons
•  Rare - there is high degree of intrinsic biomechanical stability in distal carpal row
•  Causes: blast or crush injuries
•  3 groups, with spliwng of distal carpus into two columns (radial and ulnar)
1.  Axial ulnar disrup@on: Radial column remains stable with regard to radius while column
displaces in ulnar and proximal direc@on
2.  Axial radial disrup@on: Ulnar column remains stable with regard to radius while radial
column displaces in radial and proximal direc@on
3.  Combined disrup@on
•  May be purely ligamentous or associated with carpal bone fractures

Axial ulnar Axial radial

disrup@on disrup@on

Carpal
CID CIND CIC CIA
Instability:
 CIND: Radiocarpal Instability
Derangement b/t radius and proximal carpal row

•  Derangement of extrinsic radiocarpal ligaments

allow proximal row to slide along ar@cular surface of
distal ar@cular radius, in radial or ulnar fashion
•  Causes: injury of extrinsic carpal ligaments, carpal
malposi@oning from distal radius/ulna anatomic
abnormali@es (RA, Madelung deformity), following
excision of distal ulna A
•  3 common forms:
•  Ulnar transloca@on – proximal carpal row
slides in ulnar direc@on along distal ar@cula@ng
radius
•  Radial disloca@on – proximal carpal row slides
in radial direc@on
•  Pure radiocarpal disloca@on B C

•  Evaluate with radial inclina@on, radial length, and PA views of pa@ent with rheumatoid arthri@s taken
volar @lt baseline (A), 2 years (B), and 5 years (C) show
progressive ulnar transloca@on of proximal row.

Carpal
CID CIND CIC CIA
Instability:
 CIND: Midcarpal Instability
Derangement b/t between proximal and distal carpal rows

•  Dysfunc@on of both radiocarpal and midcarpal joints,

•  Major stabilizers: Triquetrohamocapitate (THC), dorsalateral scaphotrapeziotrapezoid, and
radioscaphocapitate (RSC) ligaments
•  4 major types:
•  Anterior: en@re proximal carpal row flexes volarly leading to VISI paiern
•  Failure of mostly THC ligament
•  Posterior: dorsal subluxa@on of capitate and dorsal @l@ng of scaphoid and lunate
•  From addi@onal failure of volar RSC ligament, usually in young pa@ents with
hypermobile wrists
•  Combined: addi@onal dorsal subluxa@on of lunate, scaphoid, and capitate
•  Extrinsic: from injury or osseous injury outside wrist, causing dorsal @l@ng of distal
ar@cula@ng radius and dorsal @lt of lunate, usually from malunited distal radius fracture

Carpal
CID CIND CIC CIA
Instability:
 Carpal Instability Complex (CIC)/
Perilunate Instability
•  Carpal instability complex combines features of both CID and CIC,
mostly from perilunate injuries
•  2 paierns of perilunate injuries:
1.  Perilunate disloca@on (lesser arc injury) – purely ligamentous
disrup@on surrounding lunate
2.  Perilunate fracture-disloca@on (greater arc injury) – disrup@on
of ligament(s) about the lunate PLUS fracture of one of
adjacent bones (scaphoid, trapezium, capitate, hamate, or
triquetrum
•  Nomenclature: trans – ”fractured bone”, i.e. transcaphoid
perilunate disloca@on Lesser arc injury

Mayfield Classifica@on
Greater arc injury
Stage 1 Scapholunate dissoca@on
Stage 2 + Lunocapitate disrup@on
Stage 3 + Lunotriquetral disrup@on
Stage 4 Lunate disloca@on

Carpal
CID CIND CIC CIA
Instability:
 4 Stages of Perilunate Instability
A P
Stage 1: Scapholunate dissocia@on or scaphoid fracture
•  Hyperextension of the distal carpal row pulls the scaphoid into extension
•  Since the lunate cannot extend as much as the scaphoid, the scapholunate ligament
ruptures, from palmar to dorsal
•  If wrist is radially deviated, scaphoid fractures instead of SLD

Stage 2: Lunocapitate disloca@on
•  With further wrist extension, scaphoid-distal row complex dislocates dorsally rela@ve to
lunate

Stage 3: Lunate triquetrum disrup@on or triquetrum fracture
•  With further hyperextension, the ulnar limb of THC ligament pulls the triquetrum dorsally,
either tearing the lunotriquetral ligament or fracturing the triquetrum

Stage 4: Lunate disloca@on
•  Intact radioscaphocapitate ligament pulls capitate into radiocarpal space, then pushes the
lunate in palmar direc@on un@l it dislocates in a rotary manner

Carpal
CID CIND CIC CIA
Instability:
 Carpal Instability Complex (CIC)
Features of both CID and CIND

A B C D

Transcaphoid perilunate disloca@on (stage II) Lunate disloca@on (stage IV).

PA view (A) shows triangular shaped lunate, Frontal view (C) shows a “pie-shaped” lunate
displaced scaphoid waist fracture, and with disrup@on of the 1st and 2nd Gilula
disrup@on of all 3 Gilula arcs. Lateral view (B) Arcs. Lateral view (D) demonstrates
demonstrates dorsal disloca@on of the migra@on of the capitate in the radiocarpal
scaphoid-distal row complex rela@ve to the space with disloca@on of lunate in a rotary
lunate. Prefix “trans-” denotes the fractured fashion, producing a ”spilled-teacup“
bone. appearance.

Carpal
CID CIND CIC CIA
Instability:
 Carpal Instability Adap@ve (CIA)
Origin of instability is proximal or distal to wrist

Similar to radiocarpal instability in CIND, except cause related

to carpal malposi@oning from distal radius/ulna abnormali@es:
•  Malunion of distal radial fracture:
•  Dorsal angula@on of distal ar@cula@ng surface of radius
causes proximal row to conform to abnormal @lt
A B
•  Leads to flexion of the midcarpal joint with slackening
of the palmar midcarpal ligaments
•  Madelung deformity:
•  Developmental growth disturbance of distal radial
physis, star@ng in adolescence
•  Bowing of distal radius leading to volar @lt while ulna C D
con@nues to grow linearly Madelung deformity. PA view (A) and
•  Poten@al causes: dyschondrosteosis, coronal T1 weighted MR (C) of the wrist
enchondromatosis, hereditary mul@ple exostoses, show markedly increased radial inclina@on
mesomelic dwarfism, and Turner syndrome angle and foreshortening of the ulnar
aspect of the distal radius. Lateral view (B)
•  Important to exclude intracarpal ligament injury and sagiial T1 weighted MR (D) show
marked dorsal subluxa@on of the distal
ulna.
Carpal
CID CIND CIC CIA
Instability:
 Summary
A P
•  Evalua@on of the wrist starts with the plain radiograph, which should include at least
posteroanterior, oblique, and lateral views
•  Alignment of the distal radius and ulna is evaluated with volar @lt, radial inclina@on angle, radial
length, and ulnar variance
•  Alignment of the carpal bones is evaluated with Gilula arcs, carpal height, joint space, and carpal
angles
•  Alignment of the CMC joint is evaluated by the parallel “M” lines
•  The two main paierns of carpal malalignment are volar and dorsal intercalated segmental
instability (VISI and DISI), which are determined by carpal angles
•  The 4 types of carpal instability according to the Mayo classifica@on are: dissocia@ve (CID), non-
dissocia@ve (CIND), complex (CIC), and adap@ve (CIA)
•  CID implies derangement between bones of same carpal row, most commonly from
scapholunate or lunotriquetral disrup@on
•  CIND results from radiocarpal or midcarpal instability
•  CIC results from perilunate injuries, which are categorized based on the Mayfield classifica@on
– including perilunate and lunate disloca@ons
•  CIA results from instability proximal or distal to the wrist
 References
1. Tan S, Ghumman SS, Ladouceur M, Moser TP. Carpal angles as measured on CT and MRI: can we simply translate radiographic measurements?
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