Carpal Instability Is Any Mal-Alignment

Carpal instability is any mal-alignment of the carpus, which becomes evident on plain radiography as a static deformity (Bernia and Shin 2005). It may appear after a single traumatic event or secondary to the chronic attenuation of supporting ligaments after the traumatic event or on account of an underlying disease process. Examples of disease processes are rheumatoid arthritis and pseudo-gout. Authoritative studies found that 10% of all carpal injuries resulted in instability. The most widely used diagnostic technique was dynamic radiography.

Reviews of 134 distal radius fractures found radiographic evidence of carpal instability in 30% of the cases. The incidence of carpal instability has thus been highly associated with specific fractures. Carpal instability results from an injury of one or more of the bony constraints on the wrist. Injuries can be wrist sprains, distal radius fractures and fractures to the scaphoid and other carpal bones (Berdia and Shin). There are four stages to carpal instability. Stage I consists of injury to the scapholunate interosseous ligament or SLIL (Berdia and Shin 1999).

It is Stage II if there is dorsal subluxation of the capitate relative to the lunate. If the increasing load injures the lunotriquetral interosseous ligament or LTIL, and leads to a perilunate dislocation, it is Stage III. And if there is dislocation of the lunate from the radiolunate fossa, it is Stage IV, the final stage. Diagnosis includes radiography, physical examination, and tests. These may be the scaphoid test, the Kleinman shear test, the Reagan shuck test, a pivotal shift test, a compression test, or a dorsal-displacement stress test.

Surgical treatment is complex and the performed according to the instability. it, thus, has become controversial. The types of instabilities are scapholunate, lunotriquetral, midcarpal and ulnar translocation. Recommended treatments for scapholunate instability, according to the stage of the injury, were an initial splinting and/or casting, athroscopic debridement with or without pinning. For lunotriquetral instability, the most common treatments were immobilization, arthroscopic evaluation and percutaneous pinning, dirirect repair and ulnar shortening. In lieu of the controversial lunotriquetral fusion, lunotriquatrohamate or triquetrohamate was recommended (Berdia and Shin).

The diagnosis of wrist or carpal instability has been stable for almost four decades (Berdia and Shin 2005). Treatment, however, has remained controversial and subjected to much debate among hand surgeons. This study will explore and evaluate existing and new treatments and their results and implications towards a greater understanding and management of the condition. II. LITERATURE REVIEW Givissis, P., et al. Neglected Trans-Scaphoid Trans-Styloid Volar Dislocation of the Lunate. Journal of Bone and Joint Surgery: British Editorial Society of Bone and Joint Surgery.

May 2006 The author and his group presented a rare case of radiocarpal dislocation, wherein the lunate and proximal pole of the scaphoid was displaced in a volar and proximal direction. Despite the risk of avascular necrosis and nonunion of the affected carpal bones, the authors performed the open reduction and internal fixation of the scaphoid to restore the anatomy of the carpus. The injury constituted 8% of all carpal dislocations. The viability of the proximal pole of the scaphoid and the lunate is at risk in this type of injury.

A reduction in blood supply can lead to nonunion of the scaphoid, avascular necrosis of the lunate or the proximal pole of the scaphoid, of wrist instability. The prognosis with delayed presentation is poor as compared with those treated immediately. Open injuries, those inadequately reduced and with nonunion have poor outcome. The authors, however, believed that satisfactory outcome was achievable by using open reduction and k-wire fixation despite the potential risk of late carpal instability.

The potential risk can be nonunionof the scaphoid, necrosis of the lunate or poorly-healed carpal ligaments. Other surgeons thought that, if open reduction failed and only partial reduction was achieved, it would be a better option to observe how the patient functioned, instead of performing an immediate reconstruction procedure. According to the authors, a patient with a high risk of osteonecrosis could recover faster with the use of late reduction and internal fixation. This suggested that the method should be the best primary option for unreduced carpal dislocation. Kreder H.

et al. Indirect Reduction and Percutaneous Fixation vs. Open Reduction and Internal Fixation for Displace Intra-Articular Fractures of the Distal Radius. Journal of Bone and Joint Surgery: British Editorial Society of Bone and Joint Surgery, June 2005 Using a sample total of 179 adult patients with displaced intra-articular fractures of the distal radius, the authors sought to compare the two methods. They found that the recovery could be faster and superior functional outcome could be obtained with indirect reduction and percutaneous fixation than with open reduction and internal fixation.

This could be achieved if the intra-articular step and gap deformity were minimized. They found that the functional outcomes became stable after a year and that further follow-ups were unnecessary. Deterioration of function did not present surface after a year. The authors recommended the performance of minimally invasive percutaneous reduction, which would make open reduction unnecessary and assure superior function. Takase, K., et al. Palmar Dislocation of the Radio-Carpal Joint Percutaneous Pin Fixation.

Journal of Orthopedic Surgery: Western Pacific Orthopedic Association, December 2004 The authors wrote that the condition is not common, as only 21 cases had been reported. Closed reduction and surgery were also reported to be successful treatments. The team used percutaneous pin fixation with 2 radio-scaphoid Kischner wires to keep the radio-carpal joint in neutral position. The results were a subluxation of the radio-carpal joint, a marked decrease in grip strength and slight limitation in the range of motion in the patients surveyed 6 months after operation.

The authors believed these were because of the patients' inability to maintain a reduced position soon after the injury. Early reduction of the radio-carpal joint and the repair of the disrupted ligament would be the treatment of choice for the dislocation. A patient with radiographic osteo-arthritic changes could develop clinical symptoms and may require arthrodesis of the wrist. The avulsion fracture of the radius later formed a new joint for the subluxated carpal bones and a congruity joint would develop.

A long-term follow-up would reveal the clinical and radiographic progress of the radio-carpal joint and the distal radioulnar joint. Pinal, Fidel. Treatment of Nonunion of the Scaphoid. Journal of Bone and Joint Surgery: British Editorial Society of Bone and Joint Surgery, January 2001 Pinal described the treatment of seven patients with nonunion of the scaphoid with a limited combined approach. It used a palmar wedge graph with insertion of a dorsal Herbert screw through small incisions.

The approach allows optimal purchase of the proximal fragment, as the screw can be placed in a more palmar or dorsal position according to the location of the bone stock. It also requires minimal dissection of the palmar ligaments of the wrist, as only a small portion of the radioscaphocapitate ligament needs to be resected for debridement of the pseudarthrosis and placement of the graft. It does not impinge upon the scaphotrapezial joint. The approach relies on the surgeon's spatial orientation and image intensification.

Complications can develop from an intraoperative misplacement of the screw and an oversized graft. This means that the procedure is demanding and that image intensification can mislead. The appropriate regime of immobilization has also been disputed as to its necessity or even detriment to healing of the fracture itself. The approach will take a lot of the patient's time away from work. But the experiment had more favorable results than early movement, recommended by other authors.

The aim of this procedure is to correct the deformity and rigid fixation in this difficult condition. The author recommended its use as a therapeutic alternative in non-avascular nonunion of the scaphoid with a "difficult" proximal fragment and a palmar deficiency. The procedure can correct the deformity and rigid fixation without adverse effects, as its use demonstrates until recently. Jakob, M. et al. Fractures of Distal Radius Treated by Internal Fixation and Early Function.

Journal of Bone and Joint Surgery: British Editorial Society of Bone and Joint Surgery, April 2000 Jakob and his team treated 73 patients with these fractures by using two 1 mm titanium plates Fractures of the distal radius treated by internal. The plates were placed on the radial and intermediate columns at a 50-70 degree apart. All of the surveyed patients were able to return to work and their daily activities without limitations. The anatomical results were excellent in almost all the patients. Overall results compared favorably with other treatments of such fractures.

The authors attributed the success of their experiment to the range of movement, grip strength, and pain due to the restoration of the joints and the extra-articular anatomy. The team's experiment concentrated on the clinical evaluation of the relatively new technique of internal fixation. The team found no instability of the carpal or distal radioulnar joints in its clinical and radiological evaluation. Follow-up after a year would not yet provide a definite statement but the authors suggested further clinical and biomechanical investigation on the condition.

When using open reduction of dorsal displaced fractures of the radius to restore congruency and extra-articular anatomy, the authors recommended the use of their double-plating method. This method is reliable in providing stable internal fixation and in allowing early function. It is, however, and as earlier mentioned, a demanding technique, as ot requires careful; attention to detail. Carter, P.B. And PR Stuart. The Sauva-Kapankji Procedure for Post-Traumatic Disorders of the Distal Radio-Ulnar Joint.

Journal of Bone and Joint Surgery: British Editorial Society of Bone and Joint Surgery, September 2000 Only one surgeon performed all the operations on a total of 37 patients for pain on the ulnar side of the wrist and decreased rotation of the forearm. The authors reported that most of the tested patients were better after the operation, although a significant number had some pain. Relief from pain could not be guaranteed and that residual pain associated with the wrist damage could occur.

On the whole, the procedure was clearly a good choice for the restoration of forearm rotation. The authors advocated mobilization in the immediate postoperative period to achieve restoration. Close supervision was necessary and the patient may spend an average of 4.5 days in the hospital. Grip strength was usually satisfactorily restored, although the patient would usually experience weakness. From among the tested patients, only two-thirds were able to return to work. The results of this study were less favorable than those of previous studies.

Patients who performed heavy manual work were the last ones to return to work. They would still experience residual mild to moderate pain in the so-called "high-demand wrist." Only a few patients did not benefit from the operation. Its poor results were limited to the young and thus be restricted in those with high demands on the wrist. The study yielded good results from older patients without a high level of complications. Problems of the ulnar stump have been linked to this procedure.

After the injury, the structure supporting the shaft of the ulna could be damaged. These structures are the interosseous membrane, the tendons of ECU and FCU and the pronator quadratus muscle. The rupture of the interosseous membrane could lead to a very mobile ulna. Problems with pain and clicking of the ulna stump have been largely reported, but these are only minor inconveniences. The subject patients were not too troubled by the symptoms of instability an experienced only minor discomfort. Modifications have been introduced to decrease these symptoms.

Good results continued to be reported. Intraperiosteal resection was recommended to increase stability. No correlation between the size of the ulnar gap and the results of the operation was found. But the recommendation was to leave a short distal ulnar fragment, shape the ulnar gap as far distally as possible and create a pseudarthrosis of 10 mm could reduce instability and retain gap strength. Bridging heterotropic calcilification of the pseudarthrosis is a complication. However, the results showed no increased risk of ossification in the pseudarthrosis when an intraperiosteal excision was done.

Shih, Jui-Tien et al. Chronic Triangular Fibro Cartilage Complex Tears with Distal Radioulna Joint Stability. Journal of Orthopedic Surgery: Western Pacific Orthopedic Association, June 2000 From September 1996 to September 1997, the team used the new procedure reconstruction with partial extensor carpi ulnaris tendon combined with or without ulnar shortening on 27 adult patients. Their average age was 22.4 years. There was a follow-up period from 22 to 28 months with a mean of 26.2 months. Using the Mayo Modified Wrist Score, 5 out of 27 patients rated their wrists as excellent, 18 as good and 4 as fair.

On the whole, 23 or 85% of them rated their condition as satisfactory and returned to work or sports activities. The 4 patients who rated their condition as fair had mild pain at work or exercise. They had mildly limited supination, but their grip strength was improved to at least 54%, as compared with the opposite hand. This experiment demonstrated that TFCC reconstruction with partial ECU combined with the ulnar shortening procedure was an alternative method for chronic TFCC tears with distal radioulna joint instability.

It provides a potentially satisfactory combination, restores the TFCC integrity and stability, maintains the motion of supination and pronation of the joint, and decreases the force transmitted to the ulna. These benefits would reduce the patients' symptoms and improve their wrist functions. The patients would, thus, be able to tolerate work, sport and military training. Doets H.C. And EEJ. Raven. Radioulnate Arthrodesis.

Journal of Bone and Joint Surgery: British Editorial Society of Bone and Joint Surgery, November 1999 Radioulnate arthrodesis yields good clinical results at five years, although there has been some radiological deterioration. The authors studied 38 patients between 1989 and 1994. Results with the use of the method produced a stable and comfortable wrist with improved mobility after five years. Conversion to a total wrist arthrodesis is seldom required. It should be recommended in early-to-medium-stage wrist disease with persistent symptoms. Grechenig, W., et al. Denervation of the Radiocarpal Joint.

Journal of Bone and Joint Surgery: British Editorial Society of Bone and Joint Surgery, May 1998 Denervation surgery has been a traditional mode of management of chronic pain in the wrist. It has been the choice if there remains useful movement at the wrist, the preference would be denervation over arthrodesis. It was used on a sampling of 22 patients at 50 months. Of the 22, 17 were very satisfied or improved, 3 were satisfied and only 2 rated the surgery as unsatisfactory. None was made worse.

The patients did not have adverse symptoms or had only minor pain when stressing the wrist. Six of them had pain during the normal use of the joint, while 2 had no improvement of their symptoms. Twelve had improvement in strength and 10 found no change. The patients had no postoperative complications, although 11 reported a loss of sensation in the first dorsal interosseous space. Their mean hospital stay was 3 days. Early movement resulted in pain and swelling in 2 patients but both returned to heavy work before their stitches could be removed.

Their symptoms, however, disappeared after four weeks of conservative care. They were advised to use a removable splnt for two to four weeks after surgery between sessions of physiotherapy. The team, however, noted that some patients were influenced by social security and disability payments. Symptoms could also recur after years of complete absence of pain. This could be on account of the simultaneous innervating of the joint by several nerves. All the nerve trucks in the wrist could contribute to its innervation. There are extensive connections between individual nerve branches.

A successful procedure would involve meticulous evaluation and surgery and adequate motivation in patients. Bozentka, David J. Scapholunate Instability. UPOJ. Vol 12, Spring 1999 Bozentka discusses scapholunate instability as the most common type of carpal instability, its evaluation and treatment controversial and the outcome unpredictable. It occurs between the scaphoid and lunate after a traumatic event or from repetitive use. Patients often complain of weakness and pain of the wrist. Care for the injury requires a consideration of the findings on the patient's history, physical examination and correlation with the diagnostic studies.

Options for therapy are many. The best depends on the chronicity of the injury, the integrity of the SL limagement, the reducibility of the carpus, the presence or absence of wrist arthritis and other patient-related factors. Treatment modes improve with increased and improved understanding of altered kinematics. Hambridge, J.F., et al. Acute Fractures of the Scaphoid. Journal of Bone and Joint Surgery: British Editorial Society of Bone and Joint Surgery, January 1999 The author and his team treated 121 fractures by cast immobilization with either 20% wrist 20% flexion or extension.

After six months, 108 of these had united. The team observed that the nonunion was not influenced by the position of immobilization. Fractures of the scaphoid are usually immobilized with the wrist slightly extended. Some authors, however, advocated a flexed position. Results of the team's experiment suggested that the position in which the wrist was immobilized did not influence the rate of the nonunion of fractures of the wrist and distal pole. The reason for immobilization at 20 degrees flexion was unknown, although extension would have improved with time.

Increased flexion of the fracture could have caused mild malunion. The team's results confirmed the preference for immobilization of the wrist, rather than the position of immobilization, is important for the union of the fractured scaphoid. The team recommended that fractures be immobilized in a Colles' cast with the wrist at roughly 20 degrees extension. Cooney, William P., et al. Post-Traumatic Arthritis of the Wrist.

The Library of Congress: Mosby-Year Book, Inc., 1998 The authors recommended radial styloid excision cobined with either STS fusion or scaphocapitate fusion for Stage I of scapholunate advanced collapse or SLAC; PRC or scaphoid excision and midcarpal fusion or scaphocapitate fusion for Stage II; and scaphoid excision and limited wrist fusion for Stage III.

For patients with scaphpod nonunion advanced collapse or SNAC, the authors recommended radial styloid excision alone in elderly patients or combined with bone grafting of the scaphoid nonunion for Stage I; scaphoid excision and midcarpal fusion, radial-styloid excision, scapholunate capitate fusion or midcarpal fusion can be used for Stage II; and scaphoid excision and mid-carpal fusion or total writ fusion for Stage III. Saffar, Ph. Carpal Instability. Institut Francais de Chirurgie de la Main-France Saffar recommended treating axial instability by reduction and internal fixation of the fractures and longitudinal dissociation.

He would manage isolated radiocarpal with an anterior approach and suture the plane of the volar ligament or reattach it to the radius anterior margin. He also recommended soft tissue repair and limited carpal arthrodesis for luno-triquetral instability. His goal would be to restore a normal orientation to the scaphoid and recover normal congruency of the scapoid proximal pole with the scaphoid facet of the dstal radius. His treatment of SLAC would also depend on the stage of the injury. Stage I could require a radial styloidectomy.

Proximal rox carpectory could be the choice for Stage II. Reconstruction of the carpus could be the mode for Stage III. His experiments indicated that the choice between the two types of arthrodeses should be based on the severity of the displacement of the lunate raltive to the capitate. When the lunate has been substantially moved ulnarly, reduction would be difficult. Four-corner arthrodesis should then be preferred. Nonunions were approximately 20%. Orthopedics and traumatologists should watch for carpal ligament injuries in order to avoid post-traumatic wrist arthritis.

Total wrist arthrodesis is an obsolete procedure when arthritis is present. Numerous other techniques can keep some wrist motion and preserve automatic tenodesis movement of the flexor and extensor tendons as the wrist moves. Garcia-Elias, M. The Treatment of Wrist Instability. Journal of Bone and Joint Surgery: British Editorial Society of Bone and Joint Surgery, July 1997 Garcia classified wrist instability into dissociative carpal instability or CID, non-dissociative carpal instability or CIND, complex carpal instability of CIC, and adaptive carpal instability or CIA.

There is no single treatment for carpal instability and the surgeon must adapt the choice of method to individual needs. The choice should be determined by the chronicity or healing potential of the involved ligaments, dynamic or static constancy, etiology, location, direction of the abnormal rotation and/or translocation of the carpal bones, and pattern of instability. A pattern of instability (CID, CIND, CIC or CIA). Atkinson, Larry S. And Elizabeth G. Baxley. Scapholunate Dissociation.

American Family Physician: American Academy of Family Physicians, June 1994 Atkinson and Baxley recommended that a patient with a long-standing condition of this kind should first consult with a hand specialist before resorting to surgical repair. The condition could include extensive degenerative changes of the radial-scaphoid and capitate-lunate joints, which would require extensive wrist reconstruction. They recommended midcarpal fusion, wrist implant arthroplasty or wrist fusion as reconstructive procedures. While the procedures would reduce wrist pain, they should be considered salvage operations only.

Following these procedures, the wrist would lose mobility and long-term wrist degeneration could continue. Patients with this condition would not likely recover with conservative management. Early recognition would improve the chances of success and reduce the probability of long-term wrist instability and the development of degenerative arthritis. Delayed recognition wuld require prolonged rehabilitation. An injury could also develop, whch could cause chronic wrist pain, reduce wrist mobility and increase the risk of degenerative arthritis. Danikas, Dimitrius, et al. Scapholunate Advanced Collapse. Orthopedic Surgery.

WebMD: eMedicine.Com, Inc., February 7, 2006 The authors wrote that initial treatment of the cause of SLAC wrist could prevent subsequent degeneration. They described Stage IA as the narrowing of th radiocscaphoid joint at the radial syloid aspect. With the progress of the disease, the rest of the radioscaphoid joint is destroyed in Stage IB. The entire scaphoid fossa is involved in this Stage. Shear stress destroys the cartilage in the capitolunate joint leading to the most advanced stage, State 2. In Stage 2, the capitolunate joint is more narrowed and sclerotic.

The progressive arthritic pattern shifts from the scaphoid fossa of the radius to the midcarpal capitate articulation. Medical therapy would include periodic steroid injections, splinting and NSAIDs, limited wrist fusion, the use of percutaneous Kirschner wires or K. wires, proximal row carpectory, total wrist arthrodesis, total wrist arthoroplasty, and SLAC reconstruction. Bozentka, David J. Scapholunate Instability. UPOJ. Vol 12, Spring 1999 Bozentka discusses scapholunate instability as the most common type of carpal instability, its evaluation and treatment controversial and the outcome unpredictable.

It occurs between the scaphoid and lunate after a traumatic event or from repetitive use. Patients often complain of weakness and pain of the wrist. Care for the injury requires a consideration of the findings on the patient's history, physical examination and correlation with the diagnostic studies. Options for therapy are many. The best depends on the chronicity of the injury, the integrity of the SL limagement, the reducibility of the carpus, the presence or absence of wrist arthritis and other patient-related factors.

Treatment modes improve with increased and improved understanding of altered kinematics. Hambridge, J.F., et al. Acute Fractures of the Scaphoid. Journal of Bone and Joint Surgery: British Editorial Society of Bone and Joint Surgery, January 1999 The author and his team treated 121 fractures by cast immobilization with either 20% wrist 20% flexion or extension. After six months, 108 of these had united. The team observed that the nonunion was not influenced by the position of immobilization. Fractures of the scaphoid are usually immobilized with the wrist slightly extended.

Some authors, however, advocated a flexed position. Results of the team's experiment suggested that the position in which the wrist was immobilized did not influence the rate of the nonunion of fractures of the wrist and distal pole. The reason for immobilization at 20 degrees flexion was unknown, although extension would have improved with time. Increased flexion of the fracture could have caused mild malunion. The team's results confirmed the preference for immobilization of the wrist, rather than the position of immobilization, is important for the union of the fractured scaphoid.

The team recommended that fractures be immobilized in a Colles' cast with the wrist at roughly 20 degrees extension. Cooney, William P., et al. Post-Traumatic Arthritis of the Wrist. The Library of Congress: Mosby-Year Book, Inc., 1998 The authors recommended radial styloid excision cobined with either STS fusion or scaphocapitate fusion for Stage I of scapholunate advanced collapse or SLAC; PRC or scaphoid excision and midcarpal fusion or scaphocapitate fusion for Stage II; and scaphoid excision and limited wrist fusion for Stage III.

For patients with scaphpod nonunion advanced collapse or SNAC, the authors recommended radial styloid excision alone in elderly patients or combined with bone grafting of the scaphoid nonunion for Stage I; scaphoid excision and midcarpal fusion, radial-styloid excision, scapholunate capitate fusion or midcarpal fusion can be used for Stage II; and scaphoid excision and mid-carpal fusion or total writ fusion for Stage III. Saffar, Ph. Carpal Instability. Institut Francais de Chirurgie de la Main-France Saffar recommended treating axial instability by reduction and internal fixation of the fractures and longitudinal dissociation.

He would manage isolated radiocarpal with an anterior approach and suture the plane of the volar ligament or reattach it to the radius anterior margin. He also recommended soft tissue repair and limited carpal arthrodesis for luno-triquetral instability. His goal would be to restore a normal orientation to the scaphoid and recover normal congruency of the scapoid proximal pole with the scaphoid facet of the dstal radius. His treatment of SLAC would also depend on the stage of the injury. Stage I could require a radial styloidectomy.

Proximal rox carpectory could be the choice for Stage II. Reconstruction of the carpus could be the mode for Stage III. His experiments indicated that the choice between the two types of arthrodeses should be based on the severity of the displacement of the lunate raltive to the capitate. When the lunate has been substantially moved ulnarly, reduction would be difficult. Four-corner arthrodesis should then be preferred. Nonunions were approximately 20%. Orthopedics and traumatologists should watch for carpal ligament injuries in order to avoid post-traumatic wrist arthritis.

Total wrist arthrodesis is an obsolete procedure when arthritis is present. Numerous other techniques can keep some wrist motion and preserve automatic tenodesis movement of the flexor and extensor tendons as the wrist moves. III. DISCUSSION Givissis and his team believed that carpal dislocation can be treated satisfactorily by using open reduction and k-wire fixation despite the potential risk of late carpal instability.