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 INSTABILITYBY : DR. K. VENKATA SWAMY POST GRADUATE IN ORTHOPAEDICS

INTRODUCTIONCooney 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 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 : highposition 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) (non Radiocarpal,Midcarpal,Ulnar translocn

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(0.25-0.31) Mc Murtrys index=U/L1 (0.27(0.270.33)

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 Xray;-

Type 2 static +ve plain films

Type 3 degenerative Type 4 secondary Kienbocks

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 (0arthroscopically 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,Madelungs Non-

Ulnar Translocation

Carpal Instability: Unresolved Issues Role of arthroscopy Method of reconstruction SLIL eg bonebonetendontendon-bone Ulnar side pathomechanics Role of MRI

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