Carpal Instabilities Definition by IFSSH

Orthopaedic Hand Conference Wrist is unstable only if it exhibits • symptomatic dysfunction Bernard F. Hearon, M.D. inability to bear loads Clinical Assistant Professor, Department of Surgery • University of Kansas School of Medicine - Wichita May 7, 2019 • abnormal carpal kinematics Garcia-Elias, JHS 1999

Carpal Instability

Mayo Classification CID - Dissociative Wright, JHS (Br) 1994 Instability within carpal row usually due to intrinsic ligament injury • Carpal Instability Dissociative (CID) • Carpal Instability Non-Dissociative (CIND) • Scapholunate dissociation • Carpal Instability Adaptive (CIA) • Lunotriquetral dissociation • Carpal Instability Complex (CIC) • Scaphoid fracture

Carpal Instability Carpal Instability CIND - Nondissociative Instability between carpal rows due CIA - Adaptive to extrinsic ligament injury Extra-carpal derangement causing carpal malalignment • CIND - Volar Intercalated Segment Instability (VISI) Midcarpal instability caused by malunited • CIND - Dorsal Intercalated fractures of the distal radius Segment Instability (DISI) Taleisnik, JHS 1984 • Combined CIND

Carpal Instability Carpal Instability

CIC - Complex Instability patterns with qualities of both CID and CIND patterns • Dorsal perilunate dislocations (lesser arc) Perilunate • Dorsal perilunate fracture-dislocations (greater arc injuries) Instability • Volar perilunate dislocations • Axial dislocations, fracture-dislocations

Carpal Instability Carpal Instability Perilunate Dislocations Mayfield Classification Progressive Perilunar Instability • Uncommon, 7% of all carpal injuries • High-energy axial load (MVA, fall from height, I - Rupture SLIL, RSCL contact sports) • • II - CL dissociation • Mechanism - Hyperextension, ulnar deviation, intercarpal supination (Mayfield, 1980) • III - Rupture LTIL, dorsal carpal dislocation Present w/wrist pain, swelling, limited motion • IV - Palmar lunate dislocation (LRL & SRL • ligaments intact) • Dx often missed, radiographs misinterpreted

Carpal Instability Carpal Instability

Greater or Lesser Arc Injuries Imaging • Perilunate injuries may involve bones, ligaments or both • PA XR - Disruption Gilula’s arcs • Greater arc injuries include fractures of scaphoid, Lateral XR - Loss of carpal colinearity capitate (slower force application) • CT scan to assess carpal fractures • Lesser arc injuries involve ligaments only (more • rapid force application)

Carpal Instability Carpal Instability Immediate ORIF for Best Result Closed Reduction Volar, Dorsal or Combined Approach • Volar - release carpal canal, reduce lunate, • Prompt reduction to decompress median repair LTIL and volar capsule (space of Poirier) nerve in carpal canal • Dorsal - restore carpal alignment, repair SLL, • IV sedation in emergency room setting address carpal fractures, repair DRCL • Longitudinal traction for 5-10 minutes • K-wire stabilization of SL, LT and midcarpal reductions • Dorsal-directed pressure on lunate with wrist palmar flexion • Suture anchors for capsular repair, capsulodesis

Carpal Instability Carpal Instability

Perilunate Dislocations & Transscaphoid Perilunate Fx–Disl: 10-Year Follow-Up Perilunate Summary Forli et al., JHS 2010 35A: 62-68 • Goal is stable wrist, minimal pain, functional arc of motion • Retrospective review 18 pts, avg 13-yr F/U • Most patients will not regain normal motion • Mayo score - 5 exc, 3 good, 7 fair, 3 poor or grip strength • Radiographic arthrosis observed in 12 pts • If diagnosis missed in patient < 30 yrs, ORIF should be attempted • Post-traumatic arthrosis well-tolerated • Older patients more than 4 wks post-injury • Therapeutic Level IV study (France) should have salvage proximal row carpectomy

Carpal Instability Reading List Carpal Instability Scapholunate Interosseous Ligament

Scapholunate • Prime stabilizer SL joint • C-shaped 3-part ligament Instability - Dorsal is thickest, strongest - Palmar is thinner, weaker - Proximal is thin, weakest • Secondary stabilizers are RSC, DRC, DIC, ST ligaments

Carpal Instability Carpal Instability

Acute Scapholunate Injury Natural History • FOOSH mechanism with wrist in extension, • Secondary stabilizers stretch leading to DISI ulnar deviation, supination • Lunate extends, scaphoid flexes with wrist RD • Rarely present acutely < 6 weeks from injury • Abn wrist mechanics over time leads to SLAC • Pain with wrist loading such as push-ups • Radioscaphoid, then capitolunate arthrosis • Focal swelling, tenderness at SL interval • Timely rx SL dissociation may prevent SLAC • Positive scaphoid shift test (if tolerated)

Carpal Instability Carpal Instability Scaphoid Shift Test Kinematics of the Scaphoid Shift Test Wolfe et al., JHS 1997; 22A: 801-06 • Apply pressure to scaphoid tuberosity as wrist is 25 uninjured subjects (50 wrists) examined moved from ulnar to radial deviation • • 36% subjects had positive scaphoid shift test • SLIL tear allows scaphoid proximal pole to subluxate dorsally wrt scaphoid fossa • Dorsal and axial displacement correlated with positive test • Release pressure, scaphoid reduces into scaphoid fossa with reduction “clunk” • Positive test results should be confirmed by fluoroscopic exam

Carpal Instability Carpal Instability Reading List

Imaging Radiographic Findings • PA projection • XR - PA, lateral, scaphoid views (UD) - SL interval widened XR - bilateral clenched pencil views - SL asymmetry • - Triangle lunate • MRI - high-resolution, small-field - Scaphoid ring sign technique • Lateral projection - Increased SL angle >70 degrees

Carpal Instability Carpal Instability Wrist Arthroscopy Geissler Classification • I - redundant ligament, no tear, occult instability Gold standard for diagnosing SLIL injury • • II - partial tear (proximal, volar), minimal gap, • Better sensitivity & specificity vs MRI, MRA predynamic • Permits injury classification (Geissler) • III - partial tear, articular incongruence, moderate gap, dynamic instability • Allows diagnosis concomitant pathology Able to treat partial SLIL arthroscopically • IV - complete tear/dissociation, gross static • instability Geissler, JBJS 1996

Carpal Instability Carpal Instability

Treatment Considerations Prognostic Factors Is the dorsal SLIL intact? Age of Patient Stage of Injury • Young - > 30 yrs Predynamic • If dorsal SLIL disrupted, can it be repaired? Middle - 30-60 yrs Dynamic (mid-substance vs avulsion) Older - > 60 yrs - Repairable • Are the secondary scaphoid stabilizers intact? - Not repairable (rotatory subluxation) Age of Injury Static Acute - < 3 wks - Reducible • Is the carpal malignment easily reduced? Subacute - 3-6 wks - Not reducible • What is the status of the articular cartilage? Chronic - > 6 wks Arthrosis (radiocarpal and midcarpal joints)

Garcia-Elias, JHS 2006 Carpal Instability Carpal Instability • Benign neglect Basis for Treatment • Intermittent splinting • Arthroscopic debridement • Symptom severity Treatment • Arthroscopic thermal annealing • Degree of instability (predynamic, Options • Arthroscopic reduction & pinning dynamic, static) • Open reduction & repair • Chronicity (acute, subacute, chronic) • Open reduction & capsulodesis • Arthroscopic findings (Geissler grade) • Open reduction & association • Open reduction & reconstruction Combined procedures Carpal Instability Carpal Instability •

Arthroscopic Debridement Alone ARIF: Arthroscopic for Intercarpal Ligament Tears Reduction Internal Fixation Weiss et al., JHS 1997; 22A: 344-49 • Group I - < 3 months sx, < 3 mm increase • 127 pts w/wrist pain had arthroscopic SL interval - 83% improved debridement of ICL tears, early wrist motion • Group II - > 3 months sx, > 3 mm increase • 85% w/partial SLIL tears improved, 66% with in SL interval - 53% improved complete tears improved • Worse prognosis for older injury, wider gap • For LTIL, 100% w/partial, 78% w/complete • ARIF recommended for Group I patients tears improved Whipple, Hand Clinics 1995 • Majority pts improve w/debridement alone Carpal Instability Carpal Instability Reading List Partial SLIL Injuries Rx With Arthroscopic Radiofrequency Thermal Shrinkage Debridement and Thermal Shrinkage Darlis et al., JHS 2005; 30A: 908-14 • Thermal probe denatures collagen at 70°C • 16 pts (mean age 34 yrs) w/partial SLIL tears • Effective for rx Geissler I and II • Rx arthroscopic thermal shrinkage volar & • Long-term effect on instability unknown proximal portions of ligament, early motion • Outflow portal avoids thermal necrosis • Mean F/U 19 months, 14 pts good pain relief, 2 were unchanged • Contraindicated for pts w/pacemakers • Longer follow-up needed to establish efficacy Sotereanos, JHS 2009

Carpal Instability Reading List Carpal Instability

Open Treatment Postoperative Protocol of Acute SLIL Tear • Short-arm splint/cast immobilization x 6 wks • Dorsal approach, PIN neurectomy • Removable short-arm orthosis x 6 wks Plan for dorsal capsulodesis • • Remove K-wires and allow motion at 12 wks Create bed for SLIL repair on lunate • • Strengthening initiated at 4 to 4.5 months Carpal reduction, K-wire stabilization • • Unrestricted activity allowed at 6 months • SLIL repair, dorsal capsulodesis

Carpal Instability Carpal Instability RASL: Long-term Follow-up of Recon Contraindications Technique for Chronic SL Dissociation White et al., ASSH 2010 • SL subluxation NOT easily reduced 36 pts (1991-2008), avg age 50 yrs, F/U 6.4 yrs • Lunate is NOT stable (carpal ulnar • translocation) • Majority reported improved pain, function Cartilage is NOT normal • Flexion-extension arc 80% preserved • • Grip & pinch strength comparable other side • Surgeon is NOT experienced • XR - decreased SL gap and SL angle vs preop • Patient is manual laborer

Carpal Instability Carpal Instability

Treatment Algorithm SLIL Tears and DRFx • I - Thermal annealing or shrinkage • Isolated SLIL tears rarely present < 6 wks II - Debridement, thermal shrinkage • • Prevalence of SLIL tears assoc w/DRFx = 40% III acute - Arthroscopic debridement, pinning • • Radial styloid or lunate facet fx should raise • III chronic - Capsulodesis vs reconstruction suspicion for SLIL tear • IV acute - Open reduction, pinning, repair • High-grade SLIL tears are problematic • IV chronic - Reconstruction vs arthrodesis • Operative treatment of both DRFx and SLIL tear should be considered Sotereanos, ASSH 2015 Carpal Instability Carpal Instability Intracarpal Soft Tissue Lesions Associated Can Cast Immobilization Successfully Treat with Intra-Articular Distal Radius Fractures SL Dissociation Associated with DRFx? Geissler et al., JBJS 1996; 78A: 357-65 Tang et al., JHS 1996; 21A: 583-90 • Multi-center study 60 DRFx rx w/manipulation, • Answer is NO! Consider early operative rx. redux, fixation w/fluoro & arthroscopic control • 20 of 424 consecutive pts w/DRFx had SL • 26 pts (43%) had TFC tears, 19 pts (32%) had dissociation on traction flouroscopy SLIL tears, 9 pts (15%) had LTIL tears • At 1-yr F/U, study group had worse function • Soft tissue injuries were most often associated than control group w/mean SL gap = 3.8 mm w/lunate facet DRFx • 8 of 20 pts required operation for SL symptoms

Carpal Instability Reading List Carpal Instability Reading List

Intracarpal Ligament Injuries Associated with Distal Radius Fractures Forward et al., JBJS 2007; 89A: 2334-40 • Prospective study 51 pts w/displaced DRFx who had standard rx & wrist arthroscopy, 1-yr F/U Lunotriquetral • Radial shortening >2mm = 4x increase SLIL tear Instability • Geissler grade III pts had greater likelihood of wrist pain, wider SL dissociation, higher SL angle • Prognostic Level I study (UK)

Carpal Instability Reading List Carpal Instability Lunotriquetral Interosseous Ligament Acute LTIL Injuries • Primary stabilizer of the LT joint • Trauma in contact sport athletes • C-shaped, 3-part ligament • Ulnar-sided wrist pain, grasp weakness - Palmar is strongest vs translation • Prominent distal ulna, volar ulnar carpal sag, - Dorsal is strongest vs rotation LT tenderness, positive ballottement test - Proximal is thin membraneous part • With LTIL tear, lunate flexes with intact SLIL Secondary LT stabilizers are ulnar • Attenuation secondary stabilizers leads to VISI volar arcuate ligament, DRC, DIC •

Carpal Instability Carpal Instability

Clinical Findings LT Ballottement Test

• Ulnar wrist zig-zag deformity • Stabilize lunate btwn thumb, index finger Limited wrist range of motion • With other hand, translate triquetrum & • pisiform dorsal & volar Decreased grip strength • • Pain on shear stress indicates LTL tear • Tenderness at ulnar snuff box

Carpal Instability Carpal Instability Reverse Perilunate Mechanism of Injury Imaging

• Fall onto hypothenar eminence • PA XR - Break in Gilula’s arcs, LT overlap, no gap • Lateral XR - VISI deformity (late) • Wrist DF, RD, pronated • Arthrography - 13% normal wrists have LTIL tear • LT, then LC, then SL dissociation

Carpal Instability Carpal Instability

Treatment Algorithm Other Diagnostics for Acute LTIL Injuries

• Fluroscopy - may see abnormal carpal motion • Geissler I - Arthroscopic debridement • MRI - unreliable unless done with contrast • II & III - Debridement, closed pinning, • Arthroscopy is gold standard for dx LTIL tear 8 wks wrist immobilization • IV - Open repair, pinning, capsulodesis, LAC 6-8 wks, pins removed at 10 wks

Carpal Instability Carpal Instability Treatment of isolated LT injuries ligament: Arthrodesis, ligament repair or reconstruction Shin et al., JBJS 2001; 83B: 1023-28 • Outcomes of 57 pts w/LT injuries, F/U 9.5 yrs Midcarpal • Mean age 30.7 yrs, 98% subacute or chronic • 27 repairs, 22 arthrodeses, 8 reconstructions Instability • LT fusions - 41% nonunions, 23% UC impaction • Pain relief, satisfaction, motion, strength all better for repair or recon than for fusion

Carpal Instability Reading List Carpal Instability

Midcarpal Instability Physical Exam

• Proximal carpal row instability under load • Volar sag ulnar carpus • Typical patient is 20-30 yrs c/o clunking with Ulnar-sided tenderness wrist twisting, at extemes of motion • Audible clunk w/ulnar deviation reduces volar sag • Post-traumatic or congenital ligamentous laxity • • Proximal row sags into volar flexion due to • Positive midcarpal shift test reproduces wrist pain volar arcuate, DRC ligament incompetence • Dorsal pressure on pisiform eliminates the clunk

Carpal Instability Carpal Instability “Catch-Up Clunk” Diagnosis

History & exam - raise suspicion • Extrinsic ligament (THCL, STL) attenuation leads • to CIND-VISI • XR - may be normal or show VISI • Proximal row remains volar-flexed during ulnar deviation • Videofluoroscopy - diagnostic • Hamate abuts triqetrum & proximal row abruptly • Lateral view - VISI to DISI jump extends with clunk with wrist ulnar deviation

Carpal Instability Carpal Instability

Nonsurgical Treatment Surgical Options • NSAIDs • Thermal capsulorrhaphy • Activity modification • Reefing or reconstruction of • 3-point dynamic orthosis volar arcuate, DRC ligaments loading pisiform dorsally • Midcarpal arthrodesis (CL, TH • Proprioceptive training or four-corner)

Carpal Instability Carpal Instability Arthroscopic Thermal Capsulorrhaphy Palmar Midcarpal Instability: Results of for Palmar Midcarpal Instability Treatment With 4-Corner Arthrodesis Mason et al., JHS 2007; 32E: 411-16 Goldfarb et al., JHS 2004; 29A: 258-63 13 pts, 15 wrists had thermal rx w/monopolar • 8 pts w/PMCI over 10 yrs rx w/4-corner fusion radiofrequency probe for PMCI • 7 pts were satisfied, 6 had no pain or mild pain • Mean F/U 42 months (range 14 to 67) • • All pts improved (4 resolved, 11 near complete) • Flex-ext arc decreased to 75° from 135° • DASH scores improved from 38 to 17 • Grip strength increased from 20 kg to 32 kg • Thermal capsulorrhaphy is effective w/short F/U • Four-corner arthrodesis reasonable option

Carpal Instability Reading List Carpal Instability Reading List

Carpal Instability Carpal Instability Summary Comments Summary Comments • Conservative treatment, benign neglect, • Injuries resulting in carpal instability are rare arthroscopic options are preferred • Acute injuries may be missed, so be vigilant. • Be aware of narrow surgical indications Reduction, pinning, ligament repair indicated. for soft tissue procedures • Chronic injuries are difficult to classify, treat. • Limited intercarpal arthrodeses may be Outcome comparisons may not be valid. most reliable method to achieve stability

Carpal Instability Carpal Instability