Carpal

BY An Instructional LEONARD Course K. RUBY, Lecture, The

Instability*
M.D.t. American BOSTON. Academy MASSACHUSETTS ofOnthopaedic Surgeons

Although the have been studied phasis on this

anatomy and since medieval dates from

function of the times, the current the classic 1972

wrist emstudy

ligament tniquetrolunate are

between they

the interosseous are

tniquetrum ligament). attached to of the distally

and the

the These

lunate

(the palmar,

ligaments

subject

c-shaped:

dorsal,

by Linscheid et al.9, which increased matic instability of the wrist and its

interest in traupathomechanics.

and proximal edges of each proximal row. They are open

three bones of the into the mid-carpal

That study was based on the works of several authors, including Destot5, Navarro24, Gifford et al.9, and Fisk7. The present lecture describes the recent advances in the understanding and summarizes agnosis and instabilities. of the structure the current treatment of the and function of the wrist thinking regarding the diclinically important carpal

joint, so that an anthrogram of a normal mid-canpal joint shows contrast medium between the three bones. The ligaments are thickened dorsally and palmarly and have a relatively thin membranous portion centrally (Figs. 1 and 2). Recent studies have shown that the central portions are not nearly as strong as the dorsal and palmar portions and, therefore, may not be as important mechanically. Mayfield et al.2 and Logan et al.9 measured the failure ligaments strength in cadavenic and stress-strain specimens ligament pounds) and behavionis reported f that these the

Anatomy
Bones The radio-ulnar joint, and carpus joint, the includes the carpometacarpal four radiocarpal sets of joints: joint. joints. the In this the distal lecture, mid-canpal

scapholunate 10.9 newtons lunate (79.5 ments their

interosseous (52.3 2.5

failed at 232.6 and the tniquetro-

I will
carpal as lying scaphoid,

limit my discussion joints. The bones

to the radiocarpal and midof the carpus can be thought of consists of the The pisiform is

interosseous ligament, at 353.7 69.2 newtons 15.6 pounds). Furthermore, both of these ligaelongated by as much as 50 to 100 per cent of original In addition length before failure. to the interosseous and palmar of the wrist well described capsular and Mayfield dorsal ligament ligaments, capsular capsule. by several and dorsal ligaments the the wrist

in two rows. The proximal row the lunate, and the tniquctrum.

a sesamoid bone in the tendon and, as such, is not a functional The distal row is composed and the articulation The the the mid-carpal proximal zoid, the capitate, is the confluent distal tion, ous carpal link rows. as it spans between

of the flexor carpi ulnanis part of the proximal row. of the trapezium, the trapejoint and posian osse-

contains which ments including

the dorsal are thickenings also have The been Taleisnik32, radiocanpal

ligaments, These ligaauthors, and the include intercarpal Berger

hamate. The mid-carpal between the proximal occupies joint and and distal a unique forms rows7.

et al.si,

Landsmeeni. dorsal

scaphoid

ligament (Fig. 3); the former tant as an accessory stabilizer radiocarpaljoints37.Taleisnik32 sular ligaments the radiolunate,

may be especially imporof the tniquetrolunate and described the palmar capnadioscaphocapitate, the ulnolunate, In addition, he deand tniquetrocapitate joint and, together, or arcuate ligaments. were described again that into the the

Ligaments Each bone is relatively tightly and securely bound

as consisting of the the radioscapholunate,

to its neighbors by strong interosseous ligaments. The interosseous ligaments of the distal row seldom fail dinically. The interosseous ligaments of the proximal row include nate (the
*printed

and the ulnotriquetral ligaments. scnibed the radioscaphocapitate ligaments as crossing the mid-carpal forming The the so-called V. deltoid, palmar ligaments recently Landsmeen, ligament

the

ligament scapholunate
with permission This
45,

between

the

scaphoid ligament)
Academy

and

the and

luthe

interosseous
of The American

of OrthoCourse SurBoston,

by Bergen and nadioscaphocapitate scaphoid and the radiolunate nate ligament nadiolunate

who suggested inserts strongly

article will appear in Instructional The American Academy of Orthopaedic geons, Rosemont. Illinois, March 1996. tNew England Medical Center, 750 Washington Street. Massachusetts 02111.
Lectures, Volume

paedic

Surgeons.

weakly into the capitate. They renamed ligament, calling it the long nadioluin order to distinguish it from the short ligament,
THE

which
JOURNAL

originates
OF BONE

from
AND

the

palman
SURGERY

476

JOINT

CARIAL

INSTABILITY

477

Fio.
Cross-section

of the

SLI = scapholunate interligamentous

ofadultand fetal

proximal carpal row of a cadaveric wrist. C = capitate. R = radius. P = pisiform. S = scaphoid. L = lunate. T = triquetrum. interosseous ligament. LTI = triquetrolunate interosseous ligament. LRL = long radiolunate ligament. and is sulcus. (Reprinted. with permission. from: Berger. R. A.. and Landsmeer. J. M. E.: The palmar radiocarpal ligaments: a study human wristjoints.J. Hand Surg.. 1SA:851. 1990.)

edge and

of the distal part of the radius at its lunate facet inserts into the palmar pole of the lunate (Fig. 4). radiolunate ligament and it should not ligament of Poirier, had be not been confused by weak described with the Talcisnik-3. area of the

imal tion, far

row functions as an intercalated segment. In addithe motors of the wrist arc located peripherally. as from the center of motion of the wrist (that is, the

The short previously. The space

radioscapholunate

described

a mechanically

palmar wrist capsule between the proximal and distal carpal rows. is continuous with the ligamentous sulcus between the radioscaphocapitate ligament and the long radiolunate ligament. Stress-strain testing of palmar tons radiocarpal (33.9 6.7 ligaments ligament pounds) and in cadavera failed that the at showed 151 long that 30 radiolunate 3.3 30 per the newradioscaphocapitate ligament pounds); cent the mcnts Tetidons The musculotendinous originate at the No The the flexor extensor muscles primary carpi carpi attach tiexors ulnanis. radialis units that move the hand and and insert on the metacarproximal flexor and primary radial primary carpal carpi cxtensons the deviator ulnar all of these extensor is the deviator tendons row. radialis are and the carpi abducis the inare proxFi;.
Drawing 2

failed at 107.2 14.8 the ligaments elongated of

newtons (24.1 approximately as indicated the proximal

before failure. Therefore. interosseous ligaments and that more have elastic been tested. than

previously, row are liga-

stronger

any

of the

capsular

wrist pals.

elbow are The

to the the

longus

radialis brevis. The primary tor pollicis longus. and the extensor carpi ulnanis.

Because

sent on the metacarpals and because pal joints and the articulations of relatively
VOL.
77-A.

the carpomctacanthe distal row row, the entire

immobile.
NO. 3. MAR(ll

as is the
1995

distal

showing the dorsal view of the carpal interosseous ligaments. SL = scapholunate ligament. LT = triquetrolunate ligament. -F-F = trapeziotrapezoid ligament. CT = capitotrapezoid ligament. and CH = capitohamate ligament. ( Reprinted. with permission. from: An. K-N.: Berger. R. A.: and Cooney. W. P.. Ill: Biomechanics of the Wrist Joint. p. 13. New York. Springer. 1991.)

47;

I.. K.

RUBY

cent grees tion; joint.

occurs is radial

at the

radiocarpal and

joint. 30 degrees

The

total is ulnar

amount 20 dedevia-

of nadio-ulnan

deviation deviation

is 50 degrees.

of which

60 per cent of this motion occurs at the and 40 per cent occurs at the radiocarpal

mid-carpal joint29.

Not only do the mid-carpal contribute different amounts but they also allow movement when the wrist viation. As the tion, flexion ulnar from the entire to one

and radiocarpal joints of motion to the total arc, in different directions radial radial from wrist the and ulnar deto ulnar deviaa position moves of from

is moving between wrist moves from proximal of extension: row rotates as

to radial extension

deviation, the entire back into flexion

proximal row rotates (Figs. 5-A and 5-B).

Although the mechanism by which this occurs is not completely understood, most authors have agreed that it is a combination of the geometry of the carpal hones, their ligamentous restraints. and the wrist motors acting through the distal carpal row that causes this conjoined synchronous motion of the proximal carpal row. Linscheid and Dobyns7 pressure on the distal zium and trapezoid
1) R(
=

Ft(. I)rawitig
(if the dorsal

3 liganients. dorsal radiocar-

suggested that, in radial deviation, pole of the scaphoid by the trapecauses the scaphoid to flex. This through the lunate ligament proximal the scapholunate and through the to the tniquetrum, row to flex. The

capsular

PZLl ligiiiient. E)l( = dorsal intercarpal liganient. C = capitate. S = scaphoid. 1 = triquetrum. R = radius. and 1.1 = ulna. (Reprinted. with pernlission. from: i\ii, K-N.: Berger, R. A.: and Cooney. W. P., III: Biomeehanies of the Wrist Joint, p. 10. New York. Springer. 1991.)

flexion

force

is transmitted ligament to interosseous the entire

interosseous tniquetrolunate thereby causing

head

of the

capitate) niotion. more

as possible.

which

maximizes

their

effect on wrist tors are located head wrist of the motion.

Conversely. centrally (that which diminishes

the digital mois, closer to the their effect on

capitate).

Kinematics Over theory explain row

can

the and the

last

seventy

years. theory of the

two
-

theories

the used to

row to the

the column kinematics

have been wrist. According

and

theory. as described earlier. the hones of the wrist he thought of as lying in two rows. the proximal row the distal row. According to the column theory. as

originally stated by Navarro4, the wrist is composed of three columns: the radial column (including the scaphoid. the trapezium. and the trapezoid), the central column ulnar mate). more (including column Recent clearly the lunate and the capitate). and the (including the triquetrum and the hastudies have shown that the row theory accounts for the function of the wrist. the total arc of extension one-half of motion averages and 80 degrees of total arc of moother half to full cxoccurs Fu;.
4

In a normal wrist, l5() degrees: 70 degrees flexion. tion

occurs at

Approximately occurs

of this

at the mid-carpal the radiocarpal joint. 66 per

joint and the From neutral cent of the

tension.

approximately

motion

at the radiocarpal joint and 33 per cent occurs at the mid-carpal joint. From neutral to full tiexion. 60 per cent 01 the motion occurs at the mid-carpal joint and 40 per

Drawing of the palmar capsular ligaiiients. RSC = radioscaphocapitate ligament. LRL = long radiolunate ligament. SRL = short radiolunate ligament. UL = ulnolunate ligament. UT = ulnotriquetral ligament. C = capitate. L = lunate, and S = scaphoid. (Reprinted. with permission. from: An. K-N.: Berger. R. A.: and Cooney. W. P.. III: Biomechanics of the Wrist Joint, p. 6. New York. Springer. 1991.)

IHE

Jt)URNAL

OF

BONE

\NI)

JOINT

SURGERY

CARIAL

INSTABILITY

479

Fit;.
Figs.

5-A

FRi.

5-B and and scaphoid). scaphoid) and of the lunate.

5-A and 5-B: Lateral radiographs of the wrist of the author. C = capitate. L = lunate. and Fig. 5-A: Radiograph made with the wrist in radial deviation. Note the flexion of the proximal Fig. 5-B: Radiograph made with the wrist in ulnar deviation. Note the extension ofthe proximal translation of the distal row (the capitate) (black arrow). The white arrows signify the direction

R = radius. row (the lunate row (the lunate of rotation-extension

the

dorsal

reverse occurs ing extended

in ulnar through

deviation, tension

on

with the scaphoid the scaphotrapezial the

behelicauses deviaof the devia-

forces at the radiocarpal in simulated abnormal showed position, radius resected

joint in normal conditions. Palmer

cadavera and and Werner29 neutral by the head is is re-

ligament. Alternatively. coidal shape of the the distal

OW

Weher4 triquetrohamate dorsally

proposed that articulation during ulnar

that. in an intact cadaveric 82 per cent of the total and 18 per or the cent. by the ulna. triangular

wrist in the load is carried If the ulnar complex

to translate

tion. therehy putting pressure on the dorsal aspect proximal OW and causing it to extend. In radial tion. the pressure
causing

fibrocartilage

distal row translates on the palmar aspect exact

palmarly, of the

thereby proximal there

putting row and is a be-

moved, the axial load that duced to 0 or 5 per cent, were confirmed by Trumble intact specimens, the radius and who studied fibrocantilage found that (ten ular kilograms). surface

is borne by the ulna is rerespectively. These findings et aI.#{176}. who found that. in was borne by Viegas et al.9.

it to flex. Whatever the amount

mechanism.

normally motion

83 per cent of the load 17 per cent, by the ulna.

predictable

of smooth,

synchronous

tween and within the two carpal rows. There is less than 9 degrees of motion between the capitate. the trapezoid. and the radial the lunate hamate and and deviation in all arcs of motion of the wrist. There
is 10 3 degrees tniquetrum

the contact areas of the radius-triangular complex in axial-loaded cadaveric wrists, with a light load of twenty-three pounds only of the 20 per was cent of the available with the anticbones forty-six area indid not They radius in contact

of motion between the scaphoid and 14 6 degrees of motion between the the lunate as the wrist moves from full to full ulnar deviation. There is 25 15

of the pounds creased increase concluded

proximal now. With a heavier load of (twenty-one kilograms) or more. this to a maximum further even that there of 40 per cent and if the load was doubled. normally is a great deal joint. They also found load normally is borne per cent, by the lunate et al.5 joint.

degrees of motion between the scaphoid and the lunate and l 2 degrees of motion between the triquetrum and the lunate as the wrist moves from full flexion to full extension. These data were derived from cadaveric studies, and it is possible that the actual values are greater (Figs. 6-A and 6-B). Partly on the these cadavenic studies, we agree with Destot proximal carpal mcnt with variable the radius-triangular row functions as an intercalated geometry between the distal fibrocartilage complex. in vivo basis of that the row segand

of inconthat 60 by the facet.

gruity at the radiocarpal per cent of the radial scaphoid facet and 40 Honii et distribution al. and at the

Viegas mid-carpal

calculated the load Honii et al. reported load joint; was transmitjoint; 19 29 per cent. through similar

that 31 per cent of the total axial ted through the scaphoid-trapezium-trapezoid per cent, through the scapholunate through the capitolunate joint: and the tniquetrohamate joint. Viegas

Force Transmission
Several quantitative the carpus4. recent studies have dealt with the subject through transmisof assessment For of force transmission technical reasons, force

21 per cent. Ct al. reported

The areas that transmitted the higher loads comewell with the reported distribution of osteoarthrosis at the radiocarpal and mid-carpal levels. Carpal Carpal ment. instability Instability as carpal such malalignas a perilu-

data. lated

sion has been and continues to be a difficult area to study. Nevertheless, with use of load-cells, pressuresensitive film. and cadaveric specimens. data have been generated
OI.. 77-A.

is defined dislocations.

that
NO.

describe
3. NIARCII

the
1995

magnitude

and

location

of

Therefore,

all wrist

4k) nate hility. dislocation, Carpal and dissociation. instability all wrist are is not subluxations, examples always synonymous such of carpal

I..

K.

RUBY

as instawith

scapholunate

increased joint laxity, as a malaligned stiff. It also is important to realize wrists to the
common

wrist may he very that not all unstable will be limited the more (that is. of some of instabilities

are

painful.

The and suhtle

present treatment intercarpal

discussion

diagnosis and subluxations).

Classification

There wrist
Ofl

is no

universally In my opinion.

accepted the

classification system that is based most logical instabilities.

of and Ac-

instability. the row theory fits the known

best

of wrist motion is the clinically important

cording thought

to Linscheid et al.5, most instabilities can be of as mid-carpal malalignments. These midcan he classified either instability (commonly as dorsal known as (comaxis on instato the be sub-

carpal malalignments intercalated-segment DISI) monly

or as volar intercalated-segment known as VlSI). In dorsal proximal is extended row

instability intercalated-segment

instability. the of the lunate) lateral hility. radius divided radiographs.

(as defined with respect

by the long to the radius

In volar

intercalated-segment with respect patterns can and

Radial deviation

#{247}
Fi;. 6-A

the proximal row is flexed on lateral radiographs. These further into non-dissociative

dissociative

carpal instability4. the proximal row

In non-dissociative is intact: in dissociative

canpal instability, carpal instabil-

ity. as occurs in association with a fracture of the scaphoid, the proximal row is not intact. Thus, there are four basic patterns of carpal instability that can he seen on posteroanterior dissociative instability. This elude these scope based and lateral radiographs dorsal of the wrist: nonvolar and dissociative and non-dissociative of classification and axial are present time intercalated-segment and dissociative

Figs. 6-A and 6-B: Diagrams showing the relative motion of selected carpal hones with respect to one another and to the radius. The numbers indicate degrees of motion. Fig. 6-A: Relative motion as the wrist moves from radial to ulnar deviation. Note the minimum amount of motion between the bones of the proximal row.

neuvers maneuver in which from sally

that

can

be

helpful.

Watson

et al.5

described

for the detection of scapholunate the examiner moves the wrist to radial pressure deviation over the while scaphoid

dissociation of the patient donto proxidorsal tubercle the the

ulnar directed

maintaining

intercalated-segment system radiocarpal patterns of the on the

instability. can he expanded to inmalalignment as well. hut and are Additional (that beyond the subdivision is. as acute or

prevent flexion of the scaphoid and to cause mal pole of the scaphoid to subluxate over edge of the radius. A positive result was characteristic painful clunk on reduction mal pole of the scaphoid into its radial examiner deviation. detection sult was moves Reagan

less common discussion. since the

injury

defined as a of the proxifacet as the

chronic) is possible. nition, are produced vers4 can he added classification. stabilities here. Clinical Diagnosis of

Dynamic instabilities only by evocative to expand further importance and will

that, by defior stress maneuthe system of in-

the wrist of the patient back into ulnar et al.7 used a ballottement test for the dissociation; to displace with respect a positive rethe tniquetrum to the lunate. instability

The clinical is controversial

of dynamic not be considered

of tniquetrolunate defined as the ability direction volar

in a dorsal-to-volar Non-dissociative

intercalated-segment

ness,

Symptoms giving-way,

wrist instability and a so-called examination synovitis has of articular ligaments may

include clunk,

pain, weaksnap, or click

is considered to be present if a characteristic clunk. signifying sudden extension or flexion of the proximal row, occurs as the examiner moves the wrist of the patient from radial to ulnar deviation and hack while placing axial compression Plain radiographs Routine as well wrist Radiographs
IHE JOURNAL

during use. Physical in an area in which to the overloading situation. however. physician the torn wrist pain to localize.

may reveal tenderness developed in response surfaces. In the acute be discretely tender: and ma-

on the hand. can be used studies should as posteroantenior in radial of the

OF

to screen

for

carpal lateral made in ulnar can be

instability. radiograph with the deviation.

include a true radiographs deviation, and wrist

JOINT

often is difficult for the patient There are several provocative

in neutral,

contralateral
BONE ANt)

SURGERY

CARPAL

INSTABILITY

481 side; a so-called and the projecting ring sign; through and with the an increased the head blunt of the overlap volan pole pheis seen of capitate

mal

of the of the

lunate lunate

capitate,

(Figs. 7-A nomenon end-on

and 7-B). The ring sign is a radiographic in which the distal half of the scaphoid of the abnormally there also the fixed vertical

because

position

the bone. In this condition, height as determined by length drawn pant made of

is decreased carpal ratio between the

of the third metacarpal and the length of a line from the base of the third metacarpal to the distal the radius the wrist on the posteroantenion neutral position; radiograph the instability instability), normal (disthe with in the has

ratio2#{176} 0.54 0.02. is When a patient sociative volar

tniquetrolunate

intercalated-segment

posteroantenion radiograph shows a flexed scaphoid (that is, a positive ring sign) and a flexed lunate, with the sharp dorsal pole of the lunate overlapping the capitate (Fig. 8-A). In addition, there is a step-off at the tniquetrolunate joint, with the triquetrum proximal to the lunate radial deviation. creased volar
FIG. 6-B

in ulnan deviation and The lateral radiograph angle lunate of less and the than scaphoid

distal shows 30 degrees (Fig.

to it in a deand 8-B). instaof sharp but (Fig. or nonand a

scapholunate flexion of the

In non-dissociative volan bility, the postenoantenion

from flexion to extension.

intercalated-segment radiograph shows (as evidenced the by

flexion the

Relative

motion

as the

wrist

moves

the (disthe anof the

entire

proximal

row

made

for comparison.

In scapholunate

dissociation instability), scapholunate angulation

dorsal pole of the lunate overlapping no scapholunate gap on triquetrolunate 9-A). The lateral mal scapholunate decreased (Fig. capitolunate has 9-B). Anthrognaphy radiography invasive and because

capitate) step-off

sociative dorsal intercalated-segment lateral radiograph shows an increased gle of more than 60 degrees, dorsal

radiograph shows a reduced angle, flexion of the lunate, angle been in the because the of less than 15 next of carpal

degrees step and afonly de-

lunate and the tniquetrum, and an increased capitolunate angle of more than 15 degrees. The postenoantenior radiognaphs made with the wrist in neutral and in ulnar deviation show an increase in the scapholunate interval of more than four millimeters compared with the non-

traditional diagnosis straightforward it can

ten stress bility minimally

insta-

it is technically

demonstrate

FIG. Figs. Fig. and an Fig. extended

7-A is a scapholunate dissociation. gap of more than four millimeters, and R = radius. scaphoid with dorsal subluxation

Fo.

7-B a palmar flexed scaphoid pole of the (S) (the ring and sign), the

7-A and 7-B: Radiographs of a wrist in which there 7-A: Posteroanterior radiograph showing a scapholunate extended lunate (L) and triquetrum (T). H = hamate 7-B: Lateral radiograph showing the palmar flexed lunate and triquetrum.

of the

proximal

scaphoid

VOL.

77.A,

NO.

3. MARCH

1995

482

L. K.

RUBY

Ft..

8-A

Figs. 8-A and 8-B: Radiographs of a wrist in which there is a triquetrolunate dissociation. = capitate. II = hamate. 1. S = scaphoid. and T = triquetrurn. Fig. 8-A: Posteroanterior radiograph showing a flexed scaphoid (the ring sign) and a flexed lunate. with the sharp dorsal overlapping the capitate. There is a step-off at the triquetrolunate joint. with the triquetrum proximal to the lunate. Fig. 8-B: Lateral radiograph showing a decreased scapholunate angle and volar flexion of the lunate and the scaphoid.

Fia.

8-B
=

lunate. pole

radius, lunate

of the

fects of the tniquetrolunate lam fibrocartilage sensitivity achieved

scapholunate interosseous complex

interosseous ligament. reasonably

and

ligament. the the tnianguGreater can be into the reliof laxde-

nique is not the

for the detection of avascular cost-effective for the detection of the the wrist3.

necrosis, it currently of partial tears of

welP. rate) medium

ligaments

(that is. a lower false-negative by injection of the contrast However, arthrography the degree or the damage. subtle of the articulan

mid-carpal joint. ably demonstrate interosseous-ligament ity, the grees find condition of synovitis22. Other useful

does not exact location ligamentous or small

Because of other non-invasive becoming more

limitations of arthrography and diagnostic modalities, arthroscopy is popular for the evaluation of patients

suspected of having carpal instability94. In my experience, anthroscopy often has led to a definitive diagnosis been and arthroscopically With ligamentous the of guided arthroscopy, injuries; presence and treatment the the extent condition often and of has exact the successful. surface:

surfaces,

non-invasive modalities include cineradiography. and magnetic resonance imaging

that I occasionally stress radiography. resonance imaging. Altechis an excellent

location articulan and, ment

location

of synovitis;

bone-scanning. though magnetic

in some instances, can be ascertained.

the degree of carpal displaceThe disadvantages of this tech-

Figs. 9-A and 9-B: Radiographs of a wrist in whtch there is non-dissociative volar intercalated-segment lunate. R = radius. S = scaphoid. and T = triquetrum. Fig. 9-A: Posteroanterior radiograph showing flexion of the entire proximal row. Note the lack scapholunate gap. Fig. 9-B: Lateral radiograph showing the decreased scapholunate angle. The appearance is the intercalated-segment instability because the triquetrum is difficult to visualize. L
=

instability. of same any as

capitate.

hamate. or volar

triquetrolunate that of dissociative

step-off

THE

JOURNAL

OF

BONE

ANI)

JOINT

SURGERY

CARPAL

INSTABILITY

483

nique include of nerve and

a steep learning tendon damage,

curve, an increased and increased expense. Carpal Instabilities Instability:

risk

Treatment
Dissociative Scapholunate A patient dissociation after a fall scapholunate actenistic of more scaphoid Dorsal who often

of Selected

Intercalated-Segment has an acute has a history

Dissociation complete scapholunate of a donsiflexion injury tenderness show the at the charof gap the pole,

with immediate interval. Plain

pain and radiographs

changes noted previously: a scapholunate than four millimeters, palmam flexion with dorsal subluxation of the proximal lunate and tniquetrum still is uncertainty as

and an extended 7-B). If there

(Figs. 7-A and to the diagnosis,

arthrography or arthroscopy, on both, can be performed. For an acute injury (one that occurred less than six weeks previously) with a partial tear of the scapholunate interosseous ligament, closed reduction and throscopically and radiographically guided pinning be performed. Closed reduction is performed with patient under first translating with respect nate joint with Kirschner by direct mal pole multiple axillary block or general the capitate (and distal to the lunate and stabilizing a smooth 0.062-inch gap pressure stabilized ancan the

anesthesia by row) volanly the capitoluthen is closed on the proxieither with Kirschner wires

FI1.

10

(0.157-centimeter)

wire. The scapholunate volarly directed thumb of the scaphoid and 0.045-inch (0.1 14-centimeter) interval placed

Posteroanterior radiograph made after open reduction and internal fixation of a scapholunate dissociation (dorsal intercalatedsegment instability). The capitolunate wire was placed first. and then the scapholunate and scaphocapitate wires were placed.

dissociation

is reduced and the the

and

stabilized

with

0.062-inch preF). The care

across the scapholunate (0.157-centimeter) wire joint and another 10). The wires are for eight supported the

or with one 0.062-inch across the scapholunate joint (Fig. left in place

( 0.157-centimeter)
viously, adjacent to reinforce is the ready prefer same dorsal

Kirschner sutures are capsule primary for or a total the

wires as described tied (Fig. 11, E and wrist The injury. can be postoperative

across the scaphocapitate cut off under the skin and

of the repair. acute

imbnicated

to ten weeks while in a below-the-elbow joints

the hand and wrist are cast that extends from to distal to the and the three elbow. wristwrist is to four

as that

metacarpophalangeal

If the dissociation has occurred, to perform

is irreducible, soft-tissue mid-carpal

osteoarthrosis alrepair has failed, I or a complete wrist area, and many aulimited arthrodesis, anthrodesis for or a capitate-

After removal strengthening protected months For seous tion even and with

of the wires, range-of-motion exercises are begun, and a removable operation. injuries or more splint of the chronic until scapholunate conditions,

arthrodesis. thors have

This is a controversial recommended a more

after the complete ligament

intenosopen reduc-

such as a scaphoid-trapezium-trapezoid chronic instability without osteoarthrosis hamate-tniquetnum-lunate scaphoid excision nate, capitolunate,

and formal anthrodesis adequate

ligamentous repair, usually is necessary fixation cannot be

reconstruction, or because reduction achieved with visualization ligament, closed of the

(four-corner) arthnodesis and if osteoarthrosis is present43. Scapholuand scaphocapitate anthrodeses arthrodeses and without for the and a

capitate-hamate-tniquetrum-lunate excision treatment

means95. the tear displaced lunate, capitate scaphoid duction.

A dorsal approach of the scapholunate

is used for interosseous scaphoid, proximal wires are

of the scaphoid also have been used of chronic instability39. My experience

proximal pole of the and the dorsally displaced (Fig. 11. A). Kirschner and The lunate lunate and facet

the extended head of the placed in the to aid in meis cleared of

careful review of the literature both have demonstrated high rates of complications and unpredictable results after all of these partial arthrodeses. Dissociative Triquetrolunate Volar Intercalated-Segment Dissociation Instability:

used as joysticks of the scaphoid

scar tissue, and a trough is created. Drill-holes are placed in this trough, and heavy non-absorbable sutures are placed lunate the
77.A, NO.

in the

ligamentous

remnant

that sutures (Fig.

is attached are passed 11, D).The

tion drill

A patient who has often has a history as the result bit has jammed.

an acute tniquetnolunate of a notational injury of holding The patient a power has pain

dissociaof the wrist, drill in the when wrist the on

to the through
VOL.

(Fig. 1 1 . B and C). The drill-holes in the scaphoid

3. MARCH 1995

commonly

484

I..

K.

RUBY

5.

B
I

,/

C
I

1
.\.

F
N

E
1.

,,,t.T

N.

FIG.

11

Drawings
interosseous sutures

showing

the

repair

of

a scapholunate

interosseous

ligament
=

with

adjunct

capsular

repair.

A,

The

tear

in

the

scapholunate mattress drill-holes scaphoid. M. S.;

ligament of 0 non-absorbable from the are

(SLIL)

is visualized material are waist to the

through a dorsal approach (L placed in the ligament. C. A trough trough. D. Keith needles are used are after which dissociation the sutures by ligamentous

lunate. R = radius. is created along the the sutures (Modified, with and capsulodesis.J.

and S = scaphoid). lunate facet of the the drill-holes. from: Surg..

B. Horizontal scaphoid. and E and F,The

are

placed

scaphoid

to pass

through permission. Hand

lunate, and capitate and liileisnik.J.:Treatment

reduced and pinned. ofscapholunate

tied. repair

Lavernia. 17A: 355.

C. J.; Cohen, 1992.)

THE

JOURNAL

OF

BONE

ANI)

JOINT

SURGERY

CARPAL

INSTABILITY

485

FIG.

12-A

FIG.

12-B with secondary non-dissociative dorsal

Figs. 12-A and 12-B: Radiographs intercalated-segment instability. Fig. I 2-A: Posteroanterior radiograph. Fig. 12-B: Lateral radiograph.

of

a malunited Note the

fracture

of position

the

distal of the

part entire

of

the

radius row.

dorsiflexed

proximal

the injury plex. tween

ulnar The

side. especially examiner must injuries usually extensor distal test

at the tniquetrolunate joint. he careful to distinguish fibrocartilage in the interval and the flexor

this combecarpi of a pre-

atic, sion neutral

irreducible osteotomy ulnar

tniquetrolunate alone, especially variance. Volar

teams with ulnar mecesif there is positive or

from which the

of the triangular cause tenderness carpi ulnanis

Non-Dissociative

Intercalated-Segment

Instability problem with gen-

ulnanis just hallottement viously. step-off

to the ulnar head. The result may be positive. as described

that

This condition is almost always a chronic begins insidiously; usually. it is associated

The diagnosis is confirmed by the presence of a at the tniquetrolunate interval on the posteroconfirmation is no volar percutaneous of the instability pinning

anterior radiograph. Arthroscopic tear may he necessary. If there (indicating guided mended. only a partial tear),

emalized ligamentous of a characteristic wrist in radial and the signs on plain and Anthrogmaphy

laxity. It is diagnosed on the basis clunk on axial compression of the ulnam deviation and on the basis of radiogmaphs arthnoscopy has instability, described typically not previously. reveal normal

by arthroscopy or radiography, or both, is recomIf volar instability has developed or the deopen repair of the with dorsal capsulosimilar to that deto realize is to preparticularly ligament. of Poinier I reduce capsular this meplace the the repair4. It on

findings. As osteoarthrosis velop as a result of this

been shown to deand because the con-

formity is chronic hut still reducible, triquetrolunate ligament combined desis scnihed that. vent also the can for he performed dorsal in a manner instability.

dition may represent a systemic problem, non-operative treatment consisting of forearm-strengthening exercises and intermittent splinting should be tried first. If this treatment tion and formed fails, anterior temporary in a manner and posterior capsular mid-carpal pinning can similar to the technique imbnicabe perused for to

It is important

in this instance, excessive flexion of the side the the may palmar he helpful

the goal of capsulodesis of the proximal row, dorsal to imbricate the radiotniquetral the dorsal space

by imbnication

tniquetrolunate relieve symptoms. Secondary

dissociation. mid-carpal

If this procedure fails anthrodesis is an option. Dorsal

to reinforce

and pin sutures: pair. sutures, anterior If

is present.

capitolunate use of suture to make

joint before tying the anchors can facilitate exposure first,

Non-Dissociative Instability of instability

Intercalated-Segment This increasing Taleisnik pattern

I prefer

the dorsal

has

been

recognized

with by disor-

and reduce approach soft-tissue

and pin the wrist. I then perform and close the space of Poirier. repair has failed or osteoanthrosis treatment seems have this by procedure. tniquetroluulnar-head is the arthrodesis

frequency and Watson

since it was first described in 1984. It is not a primary

choice. ical. high reported4. It also nate

mid-carpal anthrodesis Although tniquetrolunate rates and has been of failure I no longer noted4 often that ulnar is no to treat
MARCh

of logbeen

den of the wrist; rather, proximal-now extension of a malunited fracture (Figs. 12-A and 12-B). dorsal opening-wedge dius should be curative.

it is an adaptive posture of secondary to dorsal angulation of the distal pant of the radius If the instability is symptomatic, of the maconnective osteotomy

and

of complications recommend symptomatic

instability

is accompanied

abutment. is indicated. instability.

\OI.. 77-A.

Therefore. If there I prefer

NO.
3.

recession osteotomy volar intercalated-segment chronic. complete.

often A great years with deal respect to

Summary
of progress has been made the in recent normal and understanding

symptom-

1995

486 pathological knowledge anatomy is incomplete. of the wrist. Nonetheless. so theme still is room

L.

K.

RUBY

for

our di-

with a critical review of the standard radiographs. supplemented by additional studies as indicated, allow the astute clinician and to formulate patient. to identify specific patterns of instability an effective treatment program for the

vemsity of opinion regarding of most of the presently A careful history and

the diagnosis and treatment recognized wrist instabilities. examination combined

physical

References
I . Berger, ISA: 2. 3. Botte, Coone Coin.se tI)rthopaedic 4. 5. 6. 7. 8. 9. 10. Cooney,
Onthop.,

R. A., 847-854.

and 1990.

Landsmeer, W. P.; and Linscheid, A,nenican 1992. Garcia-Elias, oft/u The

J. M.

E.:

ihe

palmar

radiocarpal

ligaments: of the wrist: Vol.

a study anatomy treatment 41, pp.

of adult and 33-44. and 1925.

and

fetal

human Hand

wrist Sung.. of the The

joints. 14A: wrist. American

].

I/and

Sung.. 1989.

M. J.; Cooney, W. P., III; Lectures, Surgeons. W. P., III;

Linscheid. R. L.; and Acade,n M.; Wrist:

R. L.: Arthroscopy Dobyns, of J. H.: Carpal Ont/zopuedic J. H.; and Studs.

technique.]. of ligament Park Ridge.

313-316,

instability:

injuries Illinois.

In Instructional Academy Sung. Rounds of

Surgeons. Linscheid, London,

Dobyns, a Radiological W.

R. L.: Anatomy Ernest Benn, Jan. Sung., wrist of

mechanics

of carpal

instability.

9: 15-24. 1989.
E. A. J.: Injuries J. H.; Linscheid, Academy instability 92: 52-59. C. R.: Carpal I/osp. Rep.. R. L.; Macksoud, of Orthopaedic and 1943. I. E.; and Surgeons. Stewart, C.: Carter, 1965. Microvascular scapholunate K. N.; used An, Ha,ul M. S.; and 1992. Schneider, 1981. Dobyns,J. Dobyns, Bone Nowak, 1986. V.; Flatt, R. P.; and of the A. E.; and Kilcoyne, wrist joint: Gillespie, R. F.: The T. E.: Kinematics of the study.]. Helms, of the human Bone C. A.: wrist. wrist andfoint Current Montevideo, C/in. Hand Orthop.. Sung., in the 9A: intercarpal
].

Destot, Dobyns, The Fisk, Gifford, Heck, Academy Hixson, 282.

S.;

and San

Siegert, Francisco, Ann. mechanism Motion: of

J. J.: Carpal California, Ro% Co/I. of the Method the for

instability. 46: 63-76. area Measuring

nondissociative. 1970. special and ligament dissociation. Chao, 1990. and 68-A: Chao, 1164-1 393-4(X). R. Sung., L.; reference

Read

at the

Annual

Meeting

of

American

Surgeons. fractured Lambrinudi, R.

24, 1987. with to fractures p. 14. Chicago. wrist. I/and

].

the

scaphoid. C.: The R.: Joint anatomy

W. W.; Bolton, C. V.; Hendryson, of Orthopaedic M. L., and

R. H.; and

of the The Sung., 16A: 334-339.

scaphoid. American iSA: 2791991.

Recording. of the

radioscapholunate chronic Hand W. scapholunate Sung.. 15A:

I/and

199(). S., and the E.; Ruby, L. K.: Attempted M.; M.; Carrera, An, in procedures
dissociations.].

1 1 . Horn, 12. 13. 14. Horii, across Horii, Johnson, Sung., 16. 17. 18. I 9. 20. Lichtrnan,
].

arthrodesis A. T.; Cooney, A. T.; Cooney, 1991. instability. Kienh#{246}cks disease.

].

Surg.. on A 1986. and and

E.; Carcia-Elias, carpus Garcia-Elias, R. P., and 17A:3S4-359. D. M.;

Bishop, Bishop, l6A:

W. P.; Linscheid,
].

R. L.; and

E. Y. S.: Effect E. 176. repair Y. S.: Oct.

force kinematic

transmission study of

to treat N.; Sung..

K.

P.; Linscheid, Bone and Joint

luno-triquetral I S. Lavernia,

355-362.

G. F.: Chronic Taleisnik, Swafford,

capitolunate J.: Treatment A. instability. J. W.; 54-A: and Weeks, 1612-1632. R.; and

].

C. J.; Cohen,

of scapholunate Mack,
Onthop.,

dissociation Ulnar midcarpal 1989.

by ligamentous instability

capsulodesis. laboratory

].

hand

J. R.;

G.

R.:

clinical

analysis.

hlandSung.. R. S. E.;

6:515-523, R. L.,and L.;

Linscheid, Linscheid, pathomechanics.]. Logan,

I,istnuni.,

H.: Carpal J. H.; Beabout, Sung.. Gould,

Curn.

3: 106-114, R. S.: Traumatic

Bryan, Dec. P. NI.:

instability
behavior of

of the

the

wrist: scapholunate applications.

diagnosis.

classification. ligament. Bone and Anat. 1984. imaging of the Hnos. 328-333. Anthnoscopv. a kinematic 153-159. Biomed.
Joint

and Sci.
Sung..

out/Joint M. D.;

1972. Biomechanical

P. L.; and

22: 81-85. 955-961. 1976. Oct.

McMurtry, 60-A:

R. Y.; Youm, 1978. J. K.; Johnson,

II. Clinical and Sung.. status their

].

2 1 . Mayfield, 417-428. 22. 23. 24. 25. 26. 27. 28. 29. 30. 32. 33. 34. 35. 36. MikIc, Munk, Ca,iwlian Navarro, Palmer, Pisano, Reagan. Roth, 234-243. Ruby, analysis Sarrafian,

ligaments

functional 371-378.

significance. March

Rec.,

I 86:

Z. I). J.: Arthrography P. L.; Vellet, Ass,z. Radiol. A.: Aizales A. K., and S. M.; Peirner, D. S.; Linscheid, J. H., 1986. L. K.; Cooney, and Haddad, A.

an experimental L. S.; and

v Ciungia

66-A: of magnetic

D.; Levin,

M. F.; Steinbach, (IC Clinica

Quimgica

resonance

wrist. 1935. 1991. 2:

.1., 43: 8- 18, 1992. Experimental. radioulnarjoint. F.: Scaphocapitate sprains. and arthrography Chao, Imprenta 187: arthrodesis.J. 502-514. of diagnosis motion and 1994. of the of after of various distal the surgical load radius. methods treatment paths and bland for Sung., 9A: 350extension. 26-35. Artistica 1984. Hauid 1984. ulnar wrist carpal On/top., pain. Sung., l6A: de Dornaleche F. W.: Biomechanics D. R.; and Dobyns, Radiocarpal K. N.; R. L.; and R. G.: An, of the Sherwin, arthroscopy Linscheid, J. H.: distal

de In.stitute Werner,

C. A.; Wheeler,

Lunotriquetral

W. P.. III;

R. L.; and

E. Y. S.: Relative motion 76-B(S): in flexion 691-7(X), fractures

of selected (lii,.

hones: 126:

of the normal wrist.]. bland S. K.; Melarned, J. L.; and J. K., and J., and Trail, Watson, I. A.: H. Carpal K.: ligamentsofthe

Sung.. 13A: Goshgarian, instability.

].

1-10. 1988. G. M.: Study Bone 1: 110-118. caused

of wrist Sung., 1976. by

1977.

3 1 . Stanley, Taleisnik, 357. disease. Trumble, joint Viegas. load 1984. Trurnble,

(111(1 Joint

Taleisnik,J.:The

wrist.]. Midcarpal A. 1986.

hlandSung.. instability Urbaniak, Urbaniak,

malunited

].

T.; Glisson,
]. bland

R. R.; Seaber, I I A: 88-93. R. R.; Seaber, 12A: of the R.; Peterson,

V.; and

J. R.:

A biomechanical force S.: The

comparison transmission effects

treating of distal different

Kienb#{246}cks radioulnar loads on the

Sung..

T.; Glisson, S. F.; Patterson,

A. V.; and 196-202, wrist. P.; Roefs,

].

J. R.: Forearm A.; and 458-465, Choi, 1989.

disorders.]. transfer

11(1,1(1 Sung., characteristics

1987. J.; Tencer, Sung., 14A: hand

THE

JOURNAL.

OF

BONE

AND

JOINT

SURGERY

CARPAL 37. 38. 39. 40. 41. 42. 43. 44. Viegas, instability: Viegas, of the Watson. 358-365. Watson, Watson, 18-B: Weber, 193-207. Weil, Zinberg.
308.

INSTABILITY D. 268-278, 1987. advanced ofthe subluxation intercalated Hand triple collapse scaphoid.]. of the segment Sung., I IA: pattern bland scaphoid: of the of degenerative Sting., 13A: arthritis. 657-660. 1988.
]. ].

487
K.; Sweo, 1990. C.; and Williamson, J. B.: Load transfer characteristics bland Sung.. 9A: T. D.; and Hokanson, J. A.: Ulnar-sided perilunate

S. F.; Patterson, an anatomic S. F.; Tencer, wrist. H. 1984. H. K.; Ashmead, H. 62-64, E. C.. and 1988. 1984. Rub K.; Ottani, 1993. R.: Concepts Part K., and I. The

R. M.; and normal

Peterson,

P. D.; study.].

Pogue, Hand M.; Clegg, 12A:

D. J.; Jenkins, Sung., 971-978. iSA: R.; Hicks,

hiomechanic joint.].

A. F.; Cantrell, Ballet, F. L.: The D., IV; and

J.; Chang, Hand SLAC Makhlouf,

C.; OMeara,

Sung.. wrist:

scapholunate M. V.: Examination

L.; Pitts, governing

E. C.; and the

Handal,

A. G.: shift of

Rotary the

a spectrum carpus. 1986. Ontliop.

of instability. C/in. North

hand A,nenica.

Sting., 15:

rotational to the

L. K.: The Coren,

dorsal

approach

wrist Palmer,

revisited.].

91 1-912. wrist

E. M.:

A. B.; Levinsohn,

E. M.; and

A. K.: The

injection

arthrogram

labstract].

].

biwul

Sung..

13A:

Vol..

77-A.

NO.

3.

MARCEl

995