DEPARTMENT OF ORTHOPAEDICS &

TRAUMATOLOGY, OSMANIA GENERAL

HOSPITAL, HYD
 Under the Guidance of:
 DR. P.N.PRASAD H.O.D OF ORTHOPAEDICS
 DR. KODANDAPANI ASSOCIATE PROF.
 DR. ASHOK OATHKAR ASSOCIATE PROF.
 DR. Y.THIMMA REDDY ASSISTANT PROF.
 DR. P.L.SRINIVAS ASSISTANT PROF.
 DR. RAMKISHAN ASSISTANT PROF.
 DR. HAMEED S.R.
 TOPIC :
CARPAL INSTABILITY
 BY :
 DR. K. VENKATA SWAMY
 POST GRADUATE
 IN ORTHOPAEDICS

 INTRODUCTION

Cooney et al.1991 based upon

arthroscopic study defined carpal
instability as “The lack of ligamentous and
skeletal support to maintain a stable wrist
even under external forces of pinch and grip ”
Wrist Biomechanics
and Carpal Instability
Wrist Biomechanics

 Anatomy
 Kinematics
 Force transmission
Anatomy

 8 bones
 Complex interlocking shapes
 Intrinsic and extrinsic ligaments
Wrist ligaments
Wrist ligaments

 Volar stronger than dorsal

 Double V shape with weak area ; space
of Poirier
 Important interosseous ligaments are
SLIL and LTIL
 Dorsal ligaments tend to converge on
triquetrum
Kinematics

 Three axes of motion

 Flexion, Extension
 Medial, Lateral movements
 Rotational movements
Axes of Motion
Kinematics

 Rows
 Columns (Navarro)
 Oval ring
 Longitudinal columns (Weber)
 “Link Joint”
Link Joint
Kinematics

 Rows
 Proximal and Distal with scaphoid as a bridge
 Motion within and between rows
 Columns
 Central(flex/ext) lunate,capitate,hamate
 Lateral (mobile) scaphoid,trapezoid,trapezium
 Medial (rotation) triquetrum
Kinematics

 Center of rotation : head of capitate

Kinematics

 Radial deviation : scaphoid flexes

proximal pole goes dorsal “pulling” lunate
into palmar flexion
 Ulnar deviation : scaphoid extends
proximal pole goes volar pulling lunate
into dorsiflexion
Kinematics

 Triquetrohamate helicoid joint

 Ulnar deviation : “low” position distal and
dorsiflexed pulling lunate into dorsiflexion
 Radial deviation : “high”position proximal
and palmar flexed pulling lunate into
palmar flexion
Force Transmission

 Principal force transmission is through

capitate lunate and proximal pole of
scaphoid
 75% radius 25% ulna
Clinical Evaluation

 H/o pain and weakness

 Giving way sensation of the wrist
 Frequently click and snapping sensation
with repetitive motion
 H/o out stretched fall on hand in
extension, ulnar deviation, carpal
supination is usually present
Classification of Carpal
Instability
 CID (dissociative)
 DISI
 VISI
 CIND (non-dissociative)
 Radiocarpal,Midcarpal,Ulnar transloc’n
 CIC (complex)
 Perilunate Dislocation
Progressive periLunate
Instability
 Stage I – scapholunate instability
 Stage II – capitate dislocation
 Stage III – triquetral dislocation
 Stage IV – lunate dislocation
 Spectrum of injury
PLI
Mechanism of injury

 Impact on thenar side of wrist causes

hyperextension , ulnar deviation and
intercarpal supination
 Progressive damage around lunate
 Bony or ligamentous
Normal wrist
Volar Intercalated
Segment
Instability
Dorsal Intercalated
Segment
Instability
Gilula lines
Carpal Angles
Carpal Height
 L2/L1 = 0.54
 New ratio L2/capitate
= 1.57
 Chamay
measurement=U/L1
(0.25-0.31)
 Mc Murtry’s
index=U/L1 (0.27-
0.33)
Scapholunate Instability

 Most common form

 Rarely diagnosed acutely
 Local tenderness
 Scaphoid shift(Watson)
 Associated with other injuries eg distal
radius
Scapholunate Instability:
Classification
 Type 1 – dynamic
 Xray;-ve Watson: +ve
 Type 2 – static
 +ve plain films
 Type 3 – degenerative
 Type 4 – secondary
 Kienbock’s
Scapholunate Instability:
Radiographs
 Scapholunate gap >2mm
 Foreshortened scaphoid
 Cortical ring sign
 Taliesnik,s “V” sign
 Lack of parallelism?
Scapholunate Instability
Grade III
Grade IV
DISI
Scapholunate
Instability

Terry-Thomas sign
Scapholunate Instability:
Treatment
 Acute (0-3 wks) : open repair vs
arthroscopically
 Chronic (>4 wks) : repair + reconstruction
 Blatt
Scapholunate instability
Acute repair SLIL
Blatt Capsulodesis
STT Arthrodesis
Triquetrolunate instabliity

 Limited understanding of ulnar side

 TL or TH ??
 Ulnar pain post injury
 Click
 +ve ballottement test
 Beware ulnar impaction syndrome
 Conservative Rx; rarely need limited fusion
VISI
Perilunate Dislocation

 Perilunate & Lunate are same basic

injury
 Rx of choice : open reduction & repair of
ligaments/bones
 Dorsal and volar approach
 Late: fusion or PRC
Lesser and Greater arcs
Perilunate Dislocation
Perilunate repair
Ulnar Translocation

 Rare
 Difficult to treat
 Non-traumatic causes : RA,Madelung’s
Ulnar Translocation
Carpal Instability:
Unresolved Issues
 Role of arthroscopy
 Method of reconstruction SLIL eg bone-
tendon-bone
 Ulnar side pathomechanics
 Role of MRI
THANK YOU