Carpal Instability
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Carpal Instability







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Carpal Instability. Weiling Chang. Carpal Instability - Definition. Inability to maintain normal alignment and distribute load under physiologic conditions. Results from ligamentous and osseous injuries. “Static” pattern: abnormal carpal alignment at rest
Carpal Instability

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Slide 1

Carpal Instability

Weiling Chang

Slide 2

Carpal Instability - Definition

  • Inability to maintain normal alignment and distribute load under physiologic conditions.

    • Results from ligamentous and osseous injuries.

    • “Static” pattern: abnormal carpal alignment at rest

    • “Dynamic” pattern: normal carpal alignment at rest but abnormal alignment with movement or stress.

Slide 3

Carpal Instability - Caveats

  • Little consensus in literature regarding classification.

  • Biomechanics of the many extrinsic and intrinsic ligaments still being investigated.

Slide 4

Diagnosis of carpal disorders

  • Start with plain radiographs to assess alignment.

  • Articular bones have opposing surfaces 2 mm or less.

  • Check Gilulas lines.

  • Three smooth arcs. Disruption in the continuity suggests abnormality at site of broken arc.

Slide 5

Overview of Patterns of Carpal Instability

  • Dissociative

    • Scapholunate dissociation

    • Lunotriquetral dissociation

  • Non-dissociative

    • Radiocarpal

    • Midcarpal

Slide 6

Normal

DISI

VISI

MR imaging of the major carpal stabilizing ligaments: normal anatomy and clinical examples..Radiographics. 1995 May;15(3):575-87

Slide 7

Normal

Slide 8

DISI: SCAPHOLUNATE ANGLE > 60

Slide 9

VISI

SCAPHOLUNATE

ANGLE < 30

Slide 10

Normal Carpal Kinematics

  • At the carpus, OPPOSING torques are always acting:

    • Under axial load or radial deviation, the scaphoid flexes and the triquetrum extends.

    • With ulnar deviation, the scaphoid extends and the triquetrum flexes.

  • Lunate is the intercalated segment b/n these opposing forces of the scaphoid and triquetrum.

  • Forces are balanced by a ligamentous ring.

Slide 11

DISI PATTERN

DISI PATTERN

VISI PATTERN

LUNATE is the intercalated element

Slide 12

Overview of Patterns of Carpal Instability

  • Dissociative

    • Scapholunate dissociation

    • Lunotriquetral dissociation

  • Non-dissociative

    • Radiocarpal

    • Midcarpal

Slide 13

Scapholunate dissociation

  • Scapholunate interosseous ligament is the strongest and stiffest of the interosseous ligaments.

  • Occurs as an isolated injury or with distal radius or scaphoid fractures.

  • Tenderness in the anatomic snuffbox.

  • Rupture site most often at scaphoid attachment sites because fibers less dense.

  • Tears traumatic and degenerative.

Slide 14

Scapholunate ligament

Slide 15

Skeletal Radiol. 2006 Apr 12

Slide 16

Classification of Scapholunate Dissociation

Stage I identified with MRI. Stage II diagnosed with stress views with a clenched hand. Stage III and IV demonstrates DISI pattern.

Eur Radiol. 2006 Mar 1

Slide 17

Scapholunate dissociation

DISI PATTERN

LUNATE is the intercalated element

Slide 19

S/L Dissociation, Scaphoid Rotary Subluxation

DISI

Slide 20

Eur Radiol. 2006 Mar 1

Slide 22

Radiographics. 1995 May;15(3):575-87.

Slide 23

Endstage: SLAC Wrist

Slide 24

Scaphoid Fracture

DISI PATTERN

LUNATE is the intercalated element

Slide 25

Scaphoid Fracture

DISI PATTERN

LUNATE is the intercalated element

Radiographics. 1995 May;15(3):575-87.

Slide 26

Humpback Deformity

Wrist fractures: what the clinician wants to know.Radiology. 2001 Apr;219(1):11-28

Slide 27

Radiographics. 1995 May;15(3):575-87.

Slide 28

Overview of Patterns of Carpal Instability

  • Dissociative

    • Scapholunate dissociation

    • Lunotriquetral dissociation

  • Non-dissociative

    • Radiocarpal

    • Midcarpal

Slide 29

Lunotriquetral Dissociation

  • Like the scapholunate interosseous ligament, disruption may be either traumatic or degenerative.

  • Many tears associated with Palmer II TFCC tears.

  • Studies and literature regarding this ligament is scarce and controversial.

  • Occur both in isolation or part of the perilunate instability.

Slide 30

J Am Acad Orthop Surg. 1998 Mar-Apr;6(2):114-20

Slide 31

Lunotriquetral Dissociation

  • Heterogeneity of clinical symptoms from asymptomatic tears to collapse of the carpus with a fork-like deformity of the wrist.

  • Generally pain aggavated with ulnar deviation.

  • Sensation of weakness or instability.

Slide 32

Normal Lunotriquetral Ligament

Radiology. 2003 Jun;227(3):701-7.

Slide 33

Normal Lunotriquetral Ligament

Skeletal Radiol. 2006 Apr 12

Slide 34

VISI PATTERN

LUNATE is the intercalated element

Slide 36

Eur Radiol. 2006 Mar 1

Slide 38

Eur Radiol. 2006 Mar

Slide 39

Overview of Patterns of Carpal Instability

  • Dissociative

    • Scapholunate dissociation

    • Lunotriquetral dissociation

  • Non-dissociative

    • Radiocarpal

    • Midcarpal

Slide 40

Radiocarpal Instability

  • Results in shift of the entire carpus.

  • Palmar, dorsal, radial, or ulnar translocation.

  • Dorsal and volar translocations with Barton or reverse Barton fractures.

  • Ulnocarpal translocations more frequently occur with RA, CPPD.

Slide 41

Normal. Inclination of the radial articulating surface

Slide 42

Eur Radiol. 2006 Mar 1

Slide 44

CPPDARTHROPATHY

TRAUMA

Eur Radiol. 2006 Mar

Slide 45

Overview of Patterns of Carpal Instability

  • Dissociative

    • Scapholunate dissociation

    • Lunotriquetral dissociation

  • Non-dissociative

    • Radiocarpal

    • Midcarpal

Slide 46

Midcarpal Instability

  • Disruption of normal smooth motion of the proximal carpal row.

Normal carpal kinematics

Slide 49

Midcarpal Instability

  • Occurs from repetitive stress in young patients.

  • Grip strength can be reduced by 50%

  • Painful and audible “snapping” caused by en bloc extension of the proximal carpal row during ulnar deviation.

Slide 50

Dynamic Midcarpal instability

Eur Radiol. 2006 Mar

Slide 51

Static Midcarpal Instability

  • Static MCI results in flexion of the proximal carpal row and VISI

Slide 52

Eur Radiol. 2006 Mar

Slide 53

Conclusion

  • Dissociative

    • Scapholunate dissociation

    • Lunotriquetral dissociation

  • Non-dissociative

    • Radiocarpal

    • Midcarpal


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