wrist stability

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Scandinavian Journal of Surery 97: 324332, 2008

Wrist instability

b. t. Ce1, a. y. sh2

1, 2 Division of Hand Surery1 Division of Plasic Surery, 2 Deparmen of Orhopaedic Surery

Mayo Clinic, Rocheser, Minnesoa, U.S.A.

abstraCt

the opc of w o cp h ee ouce of cofuo d mcommu-co fo decde. the emoog c ofe e dfficu o uded d oe u-geo cocep of m e compee dffee fom ohe. th ome compeheve evew of cp , whch h ofe ee he focu ofumeou mu-voume exook. the pupoe of h ppe o de he c ofcp , he om, phomechc, emoog d c pcpe ofeme.

Key words: Wris insabiliy; carpal insabiliy; carpal dysfuncion; scapholunae dissociaion;lunoriqueral dissociaion; VISI; DISI; CID; CIND

Correspondence:Alexander Y. Shin, M.D.Mayo ClinicDivision of Hand Surery, Deparmen of OrhopaedicSurery200 Firs Sree, S.W.Rocheser, MN 55905, U.S.AEmail: [email protected]

LIgAMENtOUS ANAtOMY

Ouside of he flexor carpi ulnaris, here are no en-dinous inserions ino he carpal bones. therefore,carpal moion, complex as i is, is deermined by pas-sive forces; join surface confiuraion, load, andsaic sabilizers (liamens). the liamens are saicresrains ha conrol moion beween individualbones and roups of bones by reciprocal ension ashe wris is loaded by muscle ension raversin hecarpus. therefore, a deailed undersandin of lia-menous anaomy is a mandaory prerequisie o un-dersandin carpal moion and insabiliy.

Wih he excepion of he ransverse carpal lia-men, he pisohamae liamen, and he pisomeacar-

pal liamen, all wris liamens are inracapsular,conained wihin loose connecive issue and fa.thus, visualizaion is poor from an exernal approachmakin idenificaion of disinc srucures difficul.Because of his, he rue liamen anaomy of hewris has been uncerain and ofen he opic of debaeamons anaomiss and sureons. Beer visualiza-ion is afforded by an inra-aricular view, such ashrouh an arhroscopic approach. the liamens ofhe wris are divided ino exrinsic (radius or ulna ocarpus) and inrinsic (wihin he carpal bones) lia-mens (Fis 1A and 1B). generally speakin, he ex-rinsic liamens course medially (oward he capi-ae). the volar exrinsic liamens include he ra-

OSSEOUS ANAtOMY

the wris is he link beween he forearm and handwhich allows he complex moions ha enable hehand o be he mos versaile erminal device knowno man. Is osseous framework includes he radiusand ulna, he proximal carpal row (scaphoid, lunae,riquerum and pisiform), he disal carpal row (ra-pezium, rapezoid, capiae, hamae), and he fivemeacarpal bones. Overall, here are 15 bones and 20or more ariculaions ha make up he wris. Moionis afforded hrouh hree join ypes; he radiocarpaljoin, he mid-carpal join and he carpomeacarpaljoins. the radius ariculaes wih he scaphoid andlunae a he radiocarpal join. the mid-carpal join

includes he scaphorapezial-rapezoid ariculaion,he scaphocapiae/lunocapiae ariculaion, and heriquerohamae ariculaion.


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325Wrist instability

dioscaphocapiae, he lon radiolunae, he shorradiolunae, he ulnolunae, he ulnocapiae, and heulnoriqueral-capiae liamens (1). there is a sinledorsal exrinsic liamen, he dorsal radiocarpal orradioriqueral liamen. this liamen has aach-mens o he lunae and has been shown o help sa-bilize he lunae from volar flexion and is also a pas-sive pronaor of he wris (2, 3) (Fi. 2).

the inrinsic liamens are oriened ransversely.the proximal row inrinsic liamens include hescapholunae (SL) and lunoriqueral (Lt) liamens

(Fi. 1). Each of hese has dorsal, proximal and volarcomponens. the SL liamen is srones in is dorsalcomponen. In conras, he Lt liamen is sronesin is volar componen. the proximal aspec of bohliamens is hin and membranous and does no con-ribue o inercarpal sabiliy (1,4). the primary sa-bilizer of he scapholunae relaionship is he SL lia-men (57). An imporan secondary sabilizer,hrouh is aachmens dorsally, is he dorsal iner-carpal (DIC) liamen which runs from he scaphoido he riquerum (8).

the reader desirin more on his essenial opic isreferred o he comprehensive review published byBerer in 1997 (1).

CARPAL ALIgNMENt

On a laeral plain film X-ray, axes can be drawn andcarpal relaionships can be inferred based on he an-le of hese axes (Fi. 3). the loniudinal axes of helon finer meacarpal, capiae, lunae, and radiusshould all fall on he same line. the loniudinal axisof he scaphoid is drawn hrouh he mid-poins ofis proximal and disal poles or as a line anenial ohe proximal and disal uberosiies (911) (Fi. 4).the scapholunae anle normally ranes from 30 o

60 derees, averae 47 derees. As he scaphoid flexesand he lunae exends, he scapholunae anle in-creases. A scapholunae anle reaer han 70 derees(10) or 80 derees indicaes carpal insabiliy (9). Inhe seminal paper on wris insabiliy, Linscheid,Dobyns, e al. described he imporance of he posi-ion of he lunae in carpal insabiliy (10). When helunae was exended dorsally, hey ermed i dorsalinercalaed semen insabiliy (DISI) and when iwas ipped volarly, i was called volar inercalaedsemen insabiliy (VISI). this concep of he posi-ion of lunae in he proximal carpal row spurred ondecades of research on wris kinemaics, eioloy ofinsabiliy and reamen.

Fi. 1. Volar wris liamens, superficial dissecion (A) and deeper dissecion (B). R radius, U ulna, S scaphoid, L lunae, t ri-querum, P pisiform, tm rapezium, td rapezoid, C capiae, H hamae AIA anerior inerosseous arery, RA radial arery,PRU proximal radioulnar liamen, UC ulnocarpal liamen, Ut ulnoriqueral liamen, UL ulnolunae liamen, SRL shorradiolunae liamen, LRL lon radiolunae liamen, RSC radioscaphocapiae liamen, tH riquerohamae liamen, tC ri-querocapiae liamen, SC scaphocapiae liamen, CH capiohamae liamen, tC rapezoidcapiae liamen, tt rapezium-rapezoid liamen, SL scapholunae, Lt lunoriqueral liamen, Stt scaphorapezium-rapezoid liamen. (Published wih per-mission of he Mayo Foundaion).


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326 B. T. Carlsen, A. Y. Shin

CARPAL KINEMAtICS

the wris funcions o provide moion in wo planes;flexion/exension and radial deviaion/ulnar devia-ion (Fis 4A and 4B). Flexion and exension occurbeween he radiocarpal and mid-carpal ariculaions.Alhouh debaed, relaively more moion occurs ahe radiocarpal ariculaion (1215). the disal carpalrow is riidly fixed and can be considered a sinlefuncional uni. the proximal carpal row, however, isloosely bound, lacks any endinous aachmens, andaffords considerable moion beween he bones of heproximal row.

the mos unique aspec of wris moion is whaoccurs in radial and ulnar deviaion (Fi. 4B). In ra-dial deviaion he proximal carpal row flexes and he

scaphoid moves ou of he way o allow he rape-zoid/rapezium o move radially. In ulnar deviaion,he proximal carpal row exends, and he riquerummoves ou of he way o allow he hamae o moveulnarly. An absolue precision of moion occurs oallow a smooh ransiion from radial o ulnar wih-ou chanin he disance beween he capiae andradius. If he reciprocal moion of he proximal carpalrow did no occur, here would be a lenhenin orshorenin of he wris in radial-ulnar moions.

Alhouh many heories on carpal moion havebeen described by pioneers in he field (10, 1624),essenially, an undersandin of his reciprocal mo-ion is he key concep o all he heories.

HIStORY

Relaive o many medical condiions, wris insabiliyhas had a shor bu inense hisory. In 1923, Deso, of

Canhop Hospial Dieu in Lyons, France used anearly X-ray ube o firs idenify scapholunae disso-ciaion (25, 26). In 1943, gilford and Lambrinudiidenified he scaphoid as an imporan connecinrod, he loss of which resuls in loniudinal collapse(19). In 1972, Linscheid and Dobyns penned heirlandmark paper, traumaic insabiliy of he wris:dianosis, classificaion, and pahomechanics (10).this work defined DISI and VISI and defined impor-an conceps in wris insabiliy, in paricular, defin-in he zi-za deformiy resulin in loss of scaph-olunae ineriy by liamenous injury or fracureand adapive chanes afer radius malunion. In1980, Mayfield described perilunae insabiliy as a

Fi. 2. Dorsal wris liamens. DRC- dorsal radiocarpal liamen,DIC- dorsal inercarpal liamen. (Published wih permission ofhe Mayo Foundaion).

Fi. 3. Loniudinal axes of he radius, lunae, scaphoid, and cap-iae as measured usin he axial and anenial echnique (seeex). (Published wih permission of he Mayo Foundaion).

Fi. 4. Carpal moion in exension, neural and flexion (A). Carpalmoion in radial deviaion, neural, and ulnar deviaion (B). (Pub-lished wih permission of he Mayo Foundaion).


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resul of proressive liamenous failure (27). In re-cen years, published work on wris insabiliy hasrown exponenially (23). Alhouh much has beenlearned, our knowlede is sill incomplee and, un-doubedly, rea discoveries are sill on he horizon(28).

INStABILItY PAttERNS

Obainin a clear undersandin of wris insabiliyis difficul due o complex anaomy, complex kine-maics and complex paerns of injury. Aemps osimplify our undersandin have lead o he develop-men of muliple schemes for classificaion of carpalinsabiliy paerns (2,2931). Perhaps he mos widelyadoped is he Mayo Classificaion (32). this schemeclassifies carpal insabiliy ino four major cae-ories:

1. Carpal insabiliy dissociaive (CID) includes insa-biliy wihin a row;

2. Carpal insabiliy nondissociaive (CIND) includesinsabiliy beween rows;

3. Carpal insabiliy complex (CIC) includes combina-ions of CID and CIND, or insabiliy wihin andbeween rows;

4. Adapive carpus refers o secondary malposiionof he carpus (table 1). I is imporan o noe haany insabiliy of he wris can be he resul of anacue injury or a chronic, ariional condiion.

CID

CID can occur wihin he proximal (1.1) or disal row(1.2). Disal row CID is uncommon and is he resulof axial carpal dislocaion (radial or ulnar). Proximalrow CID is probably he mos common and is radio-raphically seen wih DISI deformiy from a dis-placed scaphoid fracure or SL dissociaion and VISIdeformiy as a resul of lunoriqueral (Lt) liamendisrupion. Finally, CID includes combined proximaland disal row dissociaion (1.3) (Fi. 1B).

tABLE 1

Carpal Instability - Mayo Classification

type Name Radioraphic paern

I. CID1.1 Proximal row CIDa. Unsable scaphoid fracure DISIb. Scapholunae dissociaion DISIc. Lunoriqueral dissociaion VISI

1.2 Disal carpal row CIDa. Axial radial disrupion Rt, Pt

b. Axial ulnar disrupion Ut, Ptc. Combined

II. CIND1.2 Radiocarpal CINDa. Palmar liamen rupure DISI, Ut of enire proximal carpal row

Ut wih increased SL space; Pt(acually CIC)VISI, Dt

b. Dorsal liamen rupure VISI, Dtc. Afer radius malunion, Madeluns deformiy, scaphoid

malunion, lunae malunion (see Adapive carpus below)

2.2 Midcarpal CINDa. Ulnar MCI from palmar liamen damae VISIb. Radial MCI from palmar liamen damae VISIc. Combined UMCI and RMCI, palmar liamen damae VISId. MCI from dorsal liamen damae DISI

2.3 Combined radiocarpal-midcarpal CINDa. CLIP VISI, DISI, alernainb. Disrupion of radial and cenral liamens Ut wih or wihou VISI or DISI

III. CICa. Perilunae wih radiocarpal insabiliy DISI and Utb. Perilunae wih axial insabiliy AxUI and Utc. Radiocarpal wih axial insabiliy AxRI and Utd. Scapholunae dissociaion wih Ut DISI and Ut

IV. Adapive carpusa. Malposiion of carpus wih disal radius malunion DISI or Dtb. Malposiion of carpus wih scaphoid nonunion DISIc. Malposi ion of carpus wi h l unae maluni on DISI or VISId. Malposiion of carpus wih Madeluns deformiy Ut, DISI, Pt


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Scapholunae insabiliy (SLI) is he mos commonCID paern and can eiher be an isolaed injury orpar of a coninuum of liamenous injury (see CIC).Lunoriqueral injuries are less common and are oconfusion wih alernaive dianoses of he ulnarwris and more suble radioraphic findins. IsolaedLt injuries are relaively uncommon, bu do occur.Alhouh a VISI deformiy has been associaed wihLt injuries, hey only occur when here are injuries o

he secondary liamenous resrains (dorsal inercar-pal liamen) (33, 34).Disal carpal row dissociaions are ypically par of

an axial disrupion and are rare (Fi. 5) (35, 36).CIND is more difficul o dianose due o confu-

sion wih alernaive dianoses of he ulnar wris andmore suble radioraphic findins. Isolaed Lt inju-ries are relaively uncommon, bu do occur. Alhouha VISI deformiy has been associaed wih Lt injuries,hey only occur when here are injuries o he second-ary liamenous resrains (dorsal inercarpal lia-men) (33, 34).

Disal carpal row dissociaions are ypically par ofan axial disrupion and are rare (Fi. 5) (35, 36).

Fi. 5. Axial radial carpal dislocaions (op row). Axial ulnar carpal dislocaion (boom row). (Published wih permission of he Mayo

Foundaion).

CIND

As he name carpal insabiliy non-dissociaive(CIND) implies here is no insabiliy or dissociaionbeween bones of he proximal carpal row or disalcarpal row. CIND encompasses paholoy of he en-ire carpal row includin midcarpal insabiliy, radio-carpal insabiliy, or boh. Unlike CID, here is nounifyin injury paern or paholoy and he paho-

anaomy is poorly undersood. Ofen, paiens willhave a hypermobiliy syndrome wih eneralizedliamenous laxiy (37). traumaic injury is no uni-form wih many paiens unable o recall a specificinjury (38). this ype of carpal insabiliy is one of hemos conroversial. Alhouh many auhors aree iexiss, classificaion and reamen have been dif-ficul.

RADIOCARPAL CIND

Radiocarpal insabiliy resuls from injury, rupure orloss of ineriy of he radiocarpal ulnocarpal lia-


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mens (39) (40). the resul is ulnar ranslaion of hecarpus. taleisnik classified hese ino wo differenypes (30). In ype I he enire proximal carpal row isulnarly ranslaed as a uni. In ype II here is an as-sociaed scapholunae dissociaion. the scaphoid re-mains associaed wih he disal radius and he lunaeand riquerum slide ulnar. this ype echnically be-lons in he carpal insabiliy complex (CIC) classifi-caion (IIId in table 1). treamen in ype I is focusedon repair of he radioscaphocapiae liamen, whereas in ype II repair is areed a he scapholunaedissociaion.

MIDCARPAL CIND

Laxiy of he midcarpal join was firs described byMouche and Belo in 1934 as a snappin wris (41,42). Many paiens wih midcarpal CIND have joinhypermobiliy wih liamenous laxiy and no hisoryof rauma (37, 43). In 1986, Johnson and Carrera re-pored on 12 paiens wih chronic capiolunae insa-

biliy eleven of which were reaed surically. Al-houh no liamenous paholoy was found, rea-men consised of suure closure of he radioscapho-capiae liamen o he lon radiolunae liamen oihen he space of Poirer. they repor 9 of 11 pa-iens wih ood or excellen resuls a a mean of 54monhs pos-op.

CIC

Carpal insabiliy complex (CIC) includes injury pa-erns found in CID and CIND. the majoriy of heseinjuries fall ino perilunae dislocaions. Perilunae

dislocaion occurs wih forced wris exension, henarimpacion, ulnar deviaion, and midcarpal supina-ion. these injuries were firs described and classifiedin he classic aricle by Mayfield (27). He classifiedhe injuries by sequenial liamen injury from radialo ulnar (Fi. 6). Sae I refers o injury o he scaph-olunae liamen wih parial disrupion. In sae IIhere is complee SL injury and furher capiolunaedissociaion. In sae III here is injury o he Lt lia-men wih scapholunae and capiolunae dissocia-ions. Finally, sae IV includes rupure of he dorsalradiocarpal liamen allowin he lunae o dislocaein a volar direcion. the Mayfield classificaion referso lesser arc injuries where here is only liamenous

injury (27). greaer arc injury refers o perilunaefracure dislocaion where here is concomian frac-ure of one of he surroundin carpal bones. the moscommon reaer arc injury is he rans-scaphoid peri-lunae dislocaion (Fis 7A-D and 8) (44). CIC alsoincludes axial dislocaion injuries ha were discussedpreviously.

ADAPtIVE CARPUS

Adapive carpus insabiliy resuls from exracarpalpaholoy a radius level. this is ofen a resul of

Fi. 6. Perilunae disrupion beins a he scapholunae liamenand proresses in an ulnar direcion around he lunae.

radius fracure malunion (45), bu may also occur asa resul of Madeluns deformiy. the exracarpal mal-alinmen resuls in secondary midcarpal insabil-iy (31, 46). the process can proress o inrinsic lia-men failure by ariion. Correcion is direced acorrecion of he malunion (31, 46).

DIAgNOSIS

the keysone o dianosis is a deailed physical ex-aminaion. Every bone of he wris and every lia-men ha can be palpaed should be palpaed. Pro-vocaive maneuvers o sress he inrinsic and exrin-sic liamens should also be performed. Alhouh adescripion of hese maneuvers is beyond he scopeof his paper, i should be sressed ha a majoriy ofcarpal insabiliy can be dianosed on physical ex-aminaion.

Radioraphic evaluaion is an ineral par of hedianosis. However, radioraphs are ofen normal.

Muli-view sress radioraphs or moion series canelici suble abnormaliies. Addiionally comparisonfilms are ofen useful. Furher imain can be per-formed wih compued omoraphy o evaluae forosseous abnormaliies, MRI for sof issue abnormal-iies or oher invasive radioraphic ess such as ra-diional arhrorams or MR arhrorams.

the old sandard for evaluaion of carpal insabil-iy has been he use of wris arhroscopy which pro-vides a direc visualizaion of he aricular surfacesand volar and dorsal exrinsic liamens. Indirecevaluaion of he sabiliy of he inrinsic liamenscan be deermined by probin he inerval beweenhe carpal bones.


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PRINCIPLES OF tREAtMENt

A descripion of reamen of carpal insabiliy is avoluminous ask as here are so many variaions ofcarpal insabiliy. the basic deerminans of reameninclude

1. the presence or absence of arhriic chanes2. Chroniciy of injury3. Qualiy of issues o repair4. Reducibiliy of deformiy (i.e. no fixed)

If here are no arhriic chanes, in a relaively acueinjury wih ood qualiy of sof issues and reducible

deformiy, he principles of reamen include he res-oraion of normal anaomy whenever possible. thisimplies liamen repairs, resoraion of normal carpalanles and anaomic reconsrucions. In similar caseswhere issue qualiy is poor, liamen reconsrucionor salvae procedures should be considered. Salvaeprocedures include inercarpal arhrodesis, PRC oroal wris arhrodesis. In cases of arhriic chanes,chronic non reducible deformiies, salvae opionsshould be considered.

Fi. 7. trans-scaphoid perilunae dislocaion. Injury films, PA (A) and laeral (B) views. Reduc-ion/fixaion views, PA (C) and laeral (D).

A B

C D


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CONCLUSIONS

Wris insabiliy is ofen a confusin and challeninopic for eneraliss as well as wris specialiss. Afoundaion of knowlede of anaomy, normal andpahomechanics forms he basis of undersandin hedianosis, radioraphic findins, exam and uli-maely reamen of hese poenially debiliain in-juries.

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37. Finserbush A, Porund H: the hypermobiliy syndrome.Musculoskeleal complains in 100 consecuive cases of ener-alized join hypermobiliy. Clin Orhop Rela Res 1982;168:124127

Fi. 8. Lesser arc injuries involve liamenous injury abou helunae. greaer arc injuries involve a fracure of one of he sur -roundin carpal bones. (Published wih permission of he MayoFoundaion).


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38. Wrih tW, Dobyns JH: Carpal insabiliy nondissociaive. thewris: Dianosis and operaive reamen, Ed. W.P. Cooney,R.L. Linscheid, and JH Dobyns. Vol. 1. 1998, S. Louis: Mosby,pp. 550568

39. Vieas SF, Paerson RM, Ward K: Exrinsic wris liamens inhe pahomechanics of ulnar ranslaion insabiliy. J HandSur (Am) 1995;20(2):312318

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46. taleisnik J, Wason HK: Midcarpal insabiliy caused by mal-unied fracures of he disal radius. J Hand Sur (Am) 1984;9(3):350357

Received: Ocober 7, 2008

wrist stability

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