Journal of Hand Surgery (European Volume)

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TWENTY QUESTIONS ON CARPAL INSTABILITY I. A. TRAIL, J. K. STANLEY and M. J. HAYTON J Hand Surg Eur Vol 2007 32: 240 DOI: 10.1016/J.JHSB.2007.02.008

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TWENTY QUESTIONS ON CARPAL INSTABILITY

I. A. TRAIL, J. K. STANLEY and M. J. HAYTON From the Centre for Hand and Upper Limb Surgery, Wrightington, Wigan and Leigh NHS Trust, Hall Lane, Appley Bridge, Wigan, Lancs, UK

THE QUESTIONS exhibit normal kinematics during any portion of its arc of motion’. 1. What is carpal instability? 2. How common is it? 3. How does it occur? 2. HOW COMMON IS IT? 4. Is carpal instability always associated with a In 1975, Dobyns et al. reviewed their own experience traumatic event? and that of the Bohler Clinic and reported that 10% of 5. Does ligament laxity play a part? all carpal injuries resulted in instability. Jones (1988) 6. What is unstable? studied a consecutive series of 100 patients who had 7. How does this affect the normal bio-mechanics of suffered wrist injuries with no radiological evidence of the wrist? fracture; he took special radiographs of the wrist 8. How do we diagnose it clinically? including a clenched-fist view. In 19 patients, there was 9. What is the value of X-rays, including arthrogra- an increase in the scaphoid–lunate gap and five of these phy? had definitive scaphoid–lunate instability. Kelly and 10. What is the value of MRI/CT? Stanley (1990) reviewed 98 consecutive wrist arthrosco- 11. Does arthroscopy have a place? pies and identified numerous ligamentous injuries, 12. What are the complications of arthroscopy? findings that were confirmed by Sennwald et al. (1993), 13. How do we classify carpal instability? who carried out arthroscopy on 41 injured wrists and 14. Is treatment necessary? found at least one ligamentous lesion in 25% and two, 15. What treatment is available in the first instance? or more, distinct lesions in 75% of the wrists. 16. What soft tissue procedures are available for The incidence of carpal instability in association with treating chronic carpal instability? other injuries is unclear. In a large series of fractures of 17. What bony procedures are available for treating the distal radius, Tang (1992) found radiological chronic carpal instability? evidence of carpal instability in just over 30%. However, 18. What other procedures are sometimes undertaken? Nakamura et al. (1991), having performed an arthro- 19. What are the long-term effects of carpal instability? scopy on the wrists of a group of patients with ununited 20. Can these be treated? scaphoid fractures, found that most did not have any serious ligamentous injuries. In rheumatoid arthritis, the incidence of the radiological signs of carpal instability appears to be much 1. WHAT IS CARPAL INSTABILITY? commoner, particularly in the early stages. Kushner and Dawson (1992) and Kushner et al. (1993) from Instability is defined in the Oxford English Dictionary as Rochester, New York, analysed X-ray patterns in 52 ‘a lack of stability’. The latter being defined as ‘abiding, patients with proven rheumatoid arthritis. Of these, 19 fair, steady, constant’. patients exhibited one, or more, patterns of instability. In the Western World, injuries to the carpal ligaments The most common isolated pattern was volar inter- resulting in malignment were, probably, first recognised calated segmental instability (VISI), seen in six patients. by Destot (1926) and, somewhat later, by Gilford et al. Five patients showed more than one pattern, most (1943). The latter were the first to describe the wrist as a commonly a combination of ulnar translocation and link joint which was stable under tension because of the volar carpal subluxation. They concluded that carpal position and size of the scaphoid. Fisk (1970) described instability is a frequent mechanical consequence of carpal instability arising from non-union of the scaphoid rheumatoid arthritis. as a zig-zag, or concertina deformity. Linscheid et al. (1972) proposed a classification and offered a definition of a carpal injury in which a loss of normal alignment of 3. HOW DOES IT HAPPEN? the carpus develops early or late. More recently, the Anatomy and Biomechanics Committee of the Interna- There is much debate as to the exact mechanism of tional Federation of Societies for Surgery of the Hand injury that produces the various types of carpal concluded that ‘a wrist joint should be considered instability. However, most researchers and experts clinically unstable only if it exhibits a symptomatic accept that this injury is usually the result of a fall on dysfunction, is not able to bear loads and does not the outstretched hand with the wrist in hyperextension.

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A study on cadaveric wrists by Mayfield (1984) 5. DOES LIGAMENT LAXITY PLAY A PART? identified four stages of lunate instability. These were: Undoubtedly, the answer to this question is yes. Patients with joint-laxity often have excessive mobility in the (1) Instability limited to the scapholunate joint. wrist joint, with X-ray appearances of a hyperflexed (2) Added instability of the capitolunate joint. scaphoid and lunate. Garcia-Elias et al. (1995) analysed (3) Added damage to the triquetrolunate joint. the kinematic behaviour of the scaphoid during radio- (4) Dorsal disruption of the radiocarpal ligament ulnar deviation of the wrist in 60 normal volunteers. leaving the lunate completely unstable. They also assessed wrist laxity using criteria set out by Larsen et al. (1987). They concluded that there was a linear relationship between scaphoid rotation and the Using a cadaveric model, the forces to reproduce amount of wrist joint laxity. More specifically, during these types of injury were mimicked by having the wrist lateral deviation of the wrist, joints that were more lax in extension, ulnar deviation and intercarpal supination. had a scaphoid rotating mainly along the sagittal plane This supination occurs as a result of the thenar eminence of flexion–extension, with little lateral deviation. striking the ground first. If, however, the hypothenar Whereas, in the volunteers with decreased laxity, the eminence strikes first, then the resulting pronation scaphoids mostly rotated along the frontal plane, with disrupts, predominantly, the dorsal ulna-triquetrial minimal flexion–extension. Fortunately, most patients complex, the triquetrolunate interosseous ligament were asymptomatic. There is no doubt, however, on and the anterior carpal capsule. The result of this is occasion and often after relatively minor trauma, the that the instability is predominantly on the ulnar side of wrist can become symptomatic. This often presents as a the wrist. painful clunking which the patient is readily able to demonstrate. Examination under image-intensifier de- monstrates obvious instability at the mid carpal joint, 4. IS CARPAL INSTABILITY ALWAYS particularly between the capitate and lunate, with the ASSOCIATED WITH A TRAUMATIC EVENT? head of the capitate subluxing out of the distal, convex articular surface of the lunate. Most researchers and clinicians accept that, in the overwhelming majority of cases, carpal instability will follow a single traumatic event as described above. It should also be noted that intercarpal ligament damage 6. WHAT IS UNSTABLE? can also occur in association with both scaphoid (Wong et al., 2005) and distal radial fractures (Laulan and To understand what structures are damaged following Bismuth, 1999). At this time, there is little published trauma, it is important to have a thorough knowledge of evidence to suggest that these conditions can follow the normal anatomy of the wrist and carpus. repeated, or repetitive, lesser traumas. Schroer et al. The ligaments of the wrist are divided into intrinsic (1996) looked at the prevalence of carpal instability in a and extrinsic components. The two most important paraplegic population. Of 162 paraplegic patients, 9 had intrinsic (interosseous) ligaments, viz. the scapholunate a static carpal instability and none of these patients had and lunotriquetral ligaments, are divided into dorsal, a history of acute injury to the wrist. The predominant proximal and palmar parts. The thickest and strongest pattern of instability in 11 of the wrists, in 6 patients, part of the scapholunate ligament is located dorsally was non-dissociative volar intercalated segmental in- (Berger et al., 1999)(Fig 1) and that of the lunotrique- stability. They also noted that the prevalence of carpal tral ligament is located palmarly. instability increased with the duration of weight bearing With regard to the extrinsic ligaments, there are on the upper extremity. Eighteen per cent of the patients several described on both the palmar and dorsal aspects in whom the spinal cord injury had occurred more than of the wrist. It is generally accepted that those on the 20 years before the study had carpal instability. They palmar aspect provide greater restraint to instability concluded that this increased incidence of carpal (Katz et al., 2003). There are three strong palmar instability in weight bearing upper extremities, particu- extrinsic radiocarpal ligaments, viz. the radioscaphoca- larly the increase in prevalence with the duration of the pitate, the long radiolunate and the short radiolunate forces transmitted across the wrist, demonstrated an ligaments (Fig 2). The radioscaphocapitate ligament, association between chronic repetitive stress on the wrist which extends from the radial styloid process through a and carpal instability. groove on the waist of the scaphoid to the palmar aspect Finally, the presence of a static dorsal intercalated of the capitate, acts as a fulcrum around which the segmented instability (DISI) can often be seen in scaphoid rotates. The long radiolunate ligament, which patients suffering with scapho-trapezio-trapezoid lies parallel to the radioscaphocapitate ligament, extends (STT) osteo arthritis. Ferris et al. (1994) found this from the palmar rim of the distal part of the radius to combination in 16 of 63 wrists of patients with this the radial margin of the palmar surface of the lunate. condition. Located between the radioscaphocapitate and long

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the volar edge of the triangular fibrocartilage and insert into the lunate and the triquetrum, respectively. With regard to the radio-scapholunate ligament, Berger et al. (1991) felt that this structure could not be considered a true ligament, although this was disputed by Taleisnik (1984). Most authors agree that when the wrist and the carpus are injured, both the intrinsic and extrinsic ligaments are damaged. Generally, however, it is felt that for significant carpal instability to exist, the interosseus ligaments, specifically the scapholunate and lunotriquetral, have to be permanently damaged. On the ulnar side, Trumble et al. (1988) found that the pattern of volar intercalated segmental instability (VISI) required the rupture of both the triquetrohamate and Fig 1 Scapholunate interosseous ligament (by permission of D triquetrolunate ligaments. Berger). Returning to the radial side of the wrist, a number of authors believe that the principal area of ligament damage lies distally between the scaphoid and trapezium. Work by Short et al. (2005), however, confirmed that the scapholunate interosseous ligament is the primary stabiliser of the wrist and that the radio-scapho capitate and scapho-trapezial ligaments act only in a secondary capacity. Finally, we should also remember that the constitu- tion of these ligaments changes with age. Weiss et al. (1994), in a cadaveric study, were able to identify scapholunate and lunar triquetral ligament defects in approximately 30% of cases. It should be noted, however, that most of these were in the central, or weakest, part of the ligament and did not represent true tears, lesions or defects. In addition, over half of the cadavers also had triangular fibro-cartilage tears.

7. HOW DOES THIS AFFECT THE BIOMECHANICS OF THE WRIST? Whilst our knowledge of the biomechanics of the wrist remains incomplete, it is not possible to understand the effect of these ligament injuries and instability patterns without having some knowledge of what is believed to be normal. The distal row of bones, viz. the trapezium, Fig 2 Volar extrinsic ligaments: C ¼ capitate; L ¼ lunate; trapezoid, capitate and hamate, form a stable platform S ¼ schaphoid; LRL ¼ long radiolunate ligament; RSC ¼ ra- upon which the metacarpals are fixed. There is very little dioscaphocapitate ligament; SRL ¼ short radiolunate liga- motion between these bones. Similarly, the distal radius ment; UL ¼ ulnolunate ligament; UT ¼ ulnotriquetral and ulna, although they move in pronation and supina- ligament. tion, are essentially a stable construct. The proximal row of the carpus, however, is an intercalated segment with no muscle or tendon insertions, the stability of which depends radiolunate ligaments, at the level of the midcarpal joint, entirely on the capsular and interosseous ligaments is an area of capsular weakness known as the space of between the scaphoid, lunate and triquetrum. Flexion Poirier. The short radiolunate ligament, which is and extension of the wrist results from movement between contiguous with the palmar fibres of the triangular the radius and the lunate and between the lunate and the fibrocartilage complex, originates from the palmar capitate in the centre of the wrist, between the trapezium, margin of the distal part of the radius and inserts into trapezoid and scaphoid on the lateral side and between the proximal part of the palmar surface of the lunate. the triquetrum and the hamate on the medial side. Further The ulnolunate and ulnotriquetral ligaments arise from research has shown that movement of the intercarpal

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TWENTY QUESTIONS ON CARPAL INSTABILITY 243 joints of the proximal row (radiocarpal) accounts for 40% of flexion, 33% of extension and 10% of ulnar deviation (Seradge et al., 1990). In radial deviation, the distance between the trapezium and the radial styloid shortens. This distance lengthens in ulnar deviation (Figs 3 and 4). Two principal movements allow this to occur. Firstly, there is sliding of the scaphoid over the lunate fossa during radial deviation and sliding of the lunate over the scaphoid fossa during ulnar deviation. Secondly, there is a movement which can be described as simple flexing of the scaphoid under the trapezium during radial deviation and extension during ulnar deviation. The triquetrum passively follows the other two bones of the proximal row. Most wrists show both types of motion, but in varying proportions (Nuttall et al., 1998). Wrists which mainly slide are called ‘row’ types and those in which flexion predominates are called ‘column’ types.

Fig 5 Taleisnik’s modiﬁcation of Navario’s concept.

The triquetrum articulates with the hamate at a helical joint which allows sliding and flexing to occur. Flexion at the scaphoid, however, is greater than that of the triquetrum and the lunate, therefore, becomes an intercalated torque converter between the scaphoid and triquetrum during radial and ulnar deviation. The lunate is also an intercalated segment between the radius and the capitate. Taleisnik’s (1984) modification of Navario’s concept of longitudinal columns (Fig 5) has made the collapse Fig 3 Radial deviation of the wrist. deformities of the wrist much easier to understand. When the ligamentous supports of the scaphoid are ruptured, longitudinal compression forces the scaphoid into a flexed position. The lunate, being narrower anteriorly than dorsally, tends, normally, to extend under compression. Coincident extension of the lunate with flexion of the scaphoid can occur only when there is severe ligament injury on the radial side of the carpus and this pattern is termed ‘‘dorsal intercalated segment instability’’ (DISI). If, however, the damage affects the dorsal ulnotriquetral ligament complex, the triquetrolunate interosseous ligament and the anterior midcarpal capsule, this allows the capitate to hyperextend in relation to the lunate, which compensates by flexing. Subluxation of the midcarpal joint is seen at rest on lateral radiographs and this pattern is termed ‘‘volar intercalated segment instability’’ (VISI). The normal kinematics of radial/ulnar deviation and Fig 4 Ulnar deviation of the wrist. flexion/extension were further investigated in detail by

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Youm et al. (1978). They found that rotation occurred 8. HOW DO WE DIAGNOSE IT CLINICALLY? around a ﬁxed axis in the middle of the head of the Of paramount importance for the diagnosis of carpal capitate and that this was independent of the position of instability are a careful history and physical examina- the hand. The distance from the base of the third tion. Attention must be paid to the position of the wrist metacarpal to the distal articular surface of the radius at the time of injury and the location of pain. Swelling (the carpal height), measured along the axis of the third metacarpal, was constant throughout radial and ulnar and local tenderness are noted and the ranges of motion and grip strengths of the injured and uninjured sides are deviation; the perpendicular distance of the ﬁxed axis of measured and compared. The most important differ- rotation from the distally projected longitudinal axis of ential diagnosis for pain on the radial side of the wrist is the ulna was also constant (Fig 6). These measures can a fracture of the scaphoid. The problems of early be used to quantify carpal collapse and carpal translo- diagnosis of this injury are well known, but, after two to cation, respectively. three weeks, the standard tests for carpal instability can Viegas et al. (1989, 1993) considered how loads were be performed. The pseudoinstability test, described by transmitted across the wrist. They found that the Kelly and Stanley in 1990, in which there is a loss of the scaphoid fossa constituted approximately 60% of the normal anteroposterior translation of the carpus (Fig 7), total contact area and the lunate fossa approximately 40%. At the midcarpal joint, load was distributed as is useful. Lack of this motion due to protective spasm is akin to the positive apprehension sign of shoulder follows: 23% at the scapho-trapezio-trapezoid (STT) instability. Other tests include that of Watson et al. joint, 28% at the scaphocapitate joint, 29% at the lunocapitate joint and 20% at the triquetrohamate joint. (1986), which stresses the scapholunate interosseous ligament (Fig 8). In a normal wrist, radial deviation

Fig 7 Pseudoinstability test.

Fig 6 Carpal height. Fig 8 Watson’s manoeuvre.

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TWENTY QUESTIONS ON CARPAL INSTABILITY 245

Fig 9 Reagan’s test for lunotriquetral instability. causes scaphoid flexion, which is able to overcome the resistance of an examining thumb on the scaphoid tubercle. In a scapholunate dissociation with radial Fig 10 Widened scapholunate interval. deviation, the scaphoid flexes, but is unable to overcome the volar resistance of the thumb. The scaphoid has to escape and is forced dorsally, with the proximal pole clunking dorsally. Scapholunate or lunotriquetral ballot- ment may reveal specific joint instability and Lichtman et al. (1981) described a pivot shift test for midcarpal instability (Fig 9). All of these tests are specific for a particular ligamentous lesion, but overlap is not un- common. Perhaps, the most specific and reliable test is point tenderness over the affected ligament. Fig 11 Exaggerated flexion of the scaphoid compared to the lunate.

Scintigraphy has been used to diagnose Preiser’s and 9. WHAT ARE THE VALUE OF X-RAYS Kienbock’s diseases and avascular necrosis of the INCLUDING ARTHROGRAPHY? capitate, as well as to exclude various bone tumours. Generally, however, this investigation is considered not The work of Schernberg (1990) on the radiological to be particularly useful in the diagnosis of longstanding examination of the normal wrist has shown the carpal instability. importance of the quality and reproducibility of the images obtained. On the posterior/anterior views, the width of the scapholunate gap should be no greater than 10. WHAT IS THE VALUE OF MRI/CT SCAN that of the triquetrolunate gap, which is no more than 3mm (Fig 10). Gilula and Weeks (1978) found that a CT and MRI scans are increasingly being used in the scapholunate angle greater than 801 was indicative of investigation of chronic wrist pain. Certainly, the CT DISI (Fig 11). Schernberg also found that stress views scan has replaced other forms of tomography for the were needed to diagnose 18 out of 27 cases of wrist investigation of complex injuries of the carpus (Stewart injury. In addition, Degreif et al. (1990) advocated and Gilula, 1992). MRI, however, appears to have the comparison of both wrists because of the considerable greatest potential (Zlatkin and Greenan, 1992) variations in normal anatomy. Other authors (Lichtman although, like CT, it only gives static images. Initially, et al., 1981) have found that examination under an MRI scans often failed to reveal small tears of the image intensiﬁer can be particularly useful for dynamic interosseous ligaments (Munk et al., 1992). Work by instabilities. Scha¨del-Ho¨pfner et al. (2001) from Germany revealed More sophisticated investigations, including arthro- that the addition of intravenous contrast did not graphy and scintigraphy, may be of value. Arthrography improve the accuracy of MRI scanning signiﬁcantly. can, undoubtedly, demonstrate leakage of contrast Certainly, it did not compare with wrist arthroscopy. At between the various intercarpal joints. Herbert et al. our hospital, however, with the additional use of surface (1990), however, showed that an arthrogram is of little coils and improved software, we believe that the diagnostic value unless it can be compared with that of diagnostic value of MRI arthrograms have improved the opposite, undamaged wrist. considerably.

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11. DOES ARTHROSCOPY HAVE A PLACE? facilitated by unloading the wrist and stressing the various joints. Geissler, initially, classified the arthro- Arthroscopy of the radiocarpal and midcarpal joints scopic findings of a scapholunate ligament injury. These remains the gold standard in the diagnosis of carpal were, if the probe can be rotated within the space, a tear instability. Roth and Haddad (1986), Kelly and Stanley of the scapholunate or lunotriquetral interosseous (1990) and Cooney (1993) have all advocated its use and ligament is probable. If either the probe, or the there is no doubt that it can provide much information arthroscope, can be passed from the midcarpal to the about the altered mechanics and pathology of the wrist at radiocarpal joint, rotatory subluxation of the scaphoid all levels. Kelly and Stanley (1990) and Dautel et al. (a complete scapholunate ligament tear with extrinsic (1993) examined groups of patients with symptoms ligament laxity) is confirmed. This has been further suggestive of a scapholunate interosseous ligament tear, classified by Kozin (1999) (Table 1). Returning to the but with normal radiographs and established the radiocarpal joint, a triangulation probe assists in diagnosis by dynamic manoeuvres undertaken during the assessment of the size, location and extent of tears radiocarpal and midcarpal arthroscopy. Fischer and of the triangular fibrocartilage complex. Associated Sennwald (1993) detected ligament tears by arthroscopy osseous injuries (fractures of the proximal pole of the in every wrist, in 20 cases of carpal instability. Other, and scaphoid or dorsal triquetral chip fractures) can be more recent, reports have indicated that arthroscopic visualised also. evaluation of the wrist is more accurate and specific than arthrography in detecting the site and extent of ligament injury (Cooney et al., 1990; Weiss and Akelman, 1995). 12. WHAT ARE THE COMPLICATIONS OF At the radiocarpal level, the volar carpal ligaments WRIST ARTHROSCOPY? are assessed in a radial to ulnar direction to determine Wrist arthroscopy is a relatively safe procedure when whether an extrinsic ligament injury has occurred. performed correctly. Of particular note, are potential Midcarpal arthroscopy with the use of a triangulation traction injuries, including degloving of the finger skin by probe is also performed routinely. The space between the finger traps. However, with the application of these the scaphoid and lunate bones is assessed for evidence of traps to a minimum of three fingers, the advent of plastic, ligamentous laxity. A diagnosis of partial, or complete, rather than metal, traps and traction of no more than carpal ligament injury is established on the basis of 2.5 kg (5 lbs), the risk is negligible. Compartment syn- the ease of separation of the scaphoid from the lunate drome is also a potential complication, although, again, if (Fig 12) and of the lunate from the triquetrum. This is gravity inflow is used, it is extremely unlikely. If a fluid management system is required, then this should be used judiciously. An Esmarch bandage pre-wrapped around the forearm to prevent over distension may be useful. Finally, tourniquet palsy and infection are also possibilities. With regard to nerve injury, damage to the dorsal sensory branch of the ulnar nerve can follow the use of the 6U portal. This results in a painful neuroma, which can persist. In addition, patients can be left with a small permanent area of anaesthesia distally. Another sensory nerve particularly at risk is the dorsal cutaneous branch of the superficial radial nerve. This is particularly at risk when the 1/2 portal is used. Finally, branches of the posterior interosseous nerve can be damaged when the 3/4, 4/5 and midcarpal portals are used. Whilst not reported, neuromas of these branches have been seen following other surgical procedures. Finally, it should be remembered that the radial nerve, or its terminal branches, may be damaged when the 1/2 portal is Fig 12 Scapholunate gapping as seen on midcarpal arthroscopy. fashioned.

Table 1—–Arthroscopic classiﬁcation of scapholunate ligament injuries (Kozin, 1999)

Grade Description

Grade 1 Attenuation or haemorrhage, no incongruency Grade 2 Incongruency or step-off of carpal space, slight gap less than width of probe Grade 3 Incongruency or step-off of carpal space, probe passed between scaphoid and lunate Grade 4 Incongruency or step-off of carpal space, scope (2.7 mm) passed through gap between scaphoid and lunate

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TWENTY QUESTIONS ON CARPAL INSTABILITY 247

There is also a potential for damage to the extensor ment injury, but without any radiological signs of either tendons with all the dorsal portals. Surprisingly, few DISI deformity or scapholunate gapping. The average cases have been reported, although the authors are follow-up of these patients was 7 years. At review, all aware of two in which the extensor pollicis longus patients were still experiencing pain with a mean tendon was transected while a 3/4 portal was being measurement on the visual analogue pain scale of 3.2 formed (Fortems et al., 1995). The injuries only became at rest, worsening to 6.5 after activity. This was obvious after surgery and both patients required tendon compared to a pain score measured at diagnosis of 7.6 repair. at rest and 8.2 after activity. All patients took oral analgesia from time to time and, occasionally, wore a splint. Wrist movement in all of the patients was diminished compared to the contralateral side, with 13. HOW DO WE CLASSIFY CARPAL grip strength 60% of normal. All, but one, of the INSTABILITY? patients had altered their occupation and all were The most frequently used terms are those introduced by generally performing lighter work. Radiologically, there Linscheid et al. (1972) and Dobyns et al. (1975), who had been no deterioration in X-ray appearances, identified four groups of carpal instability, viz. dorsal although one patient had developed some very early intercalated segment instability (DISI), volar interca- radiocarpal osteoarthritis, seen at the tip of the radial lated segment instability (VISI), ulnar translocation and styloid. dorsal subluxation. The radiological appearances of the dorsi-flexion and volar-flexion instability patterns have already been 15. WHAT TREATMENT IS AVAILABLE IN THE discussed. Ulnar translocation describes ulnar shift of FIRST INSTANCE? the carpus on the radius and is seen commonly in patients with rheumatoid arthritis. Dorsal subluxation (a) Scapholunate dissociation describes dorsal shift of the carpus, often seen after malunion of distal radial fractures (Dias and McMohan, When this condition is diagnosed early and treatment is 1988). indicated, an attempt should be made to bring about Taleisnik, in 1984, introduced the concepts of static healing of the torn interosseous ligament. Palmer et al. and dynamic instability. Static instability is an end state, (1978) reported good results from immobilisation for with marked scapholunate dissociation, fixed flexion of eight weeks in plaster, if treatment started within four the scaphoid and fixed extension of the lunate. Dynamic weeks of injury and if an anatomical reduction was instability exists in the presence of partial ligament maintained. This often required the use of supplemen- injuries resulting in pain, but with minimal, or even no, tary closed pinning with a K-wire under radiographic changes on the plain radiographs. The diagnosis is made control. Cases that cannot be reduced and held by this by dynamic radiology or arthroscopy. technique, and those diagnosed later, do poorly with The terms carpal instability dissociative (CID), carpal immobilisation and often require surgery. Ligament instability non-dissociative (CIND) and carpal instabil- reconstruction, whether undertaken through a volar or a ity complex (CIC) were introduced by Dobyns and dorsal approach (Taleisnik, 1984), also, often, needs Gabel (1990). CID describes instability due to loss of supplementary K-wire fixation and the results range linkage between the individual bones of either row, from good to fair, depending on the quality of the tissue CIND means that there is no dissociation between available for repair. At this time, it is normal practice to individual carpal bones, but instability at the radio- repair the scapholunate ligament through a dorsal carpal or midcarpal joints. CIC includes instabilities approach and the triquetrolunate ligament through a which were not otherwise classifiable. palmar approach, when possible, as this addresses the stronger parts of those ligaments. The results of direct repair were reported by Wyrick et al. (1998). They had 17 patients available for follow-up for an average of 30 14. IS TREATMENT NECESSARY? months. In this series, it should be noted that the If the disability is minor, with more than 80% of the scapholunate ligament repair had been augmented by a normal range of motion and grip strength retained, no dorsal capsulodesis. At follow up, no patient was pain treatment is required (Dobyns et al., 1975). Certainly, in free, average wrist motion was 60% of normal and grip our practice, a number of patients choose not to strength 70%. Radiologically, the scapholunate angle undergo reconstructive surgery and, with some mod- had improved from 781, pre-operatively, to 471 at ifications of life style, seem to cope extremely well with a surgery. Unfortunately, at long-term follow-up, the chronic scapholunate ligament injury. scapholunate angle had deteriorated back to 721. Similar A study from Wrightington Hospital (O’Meeghan et changes were noted for the scapholunate interval. al., 2003) summarised the outcome of 11 patients with Overall, only 2 patients had an excellent or good result, arthroscopically proven interosseous scapholunate liga- with 6 of the 17 having good, or excellent, results on

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X-ray analysis. As a consequence, these authors advocated a cautious approach when describing the outcome of this form of surgery. Bickert et al. (2000) from Heidelberg, Germany, reported a retrospective analysis of acute scapholunate ligament repair using Mini bone anchors. At follow-up at a mean of 19 months after surgery, results were found to be good or excellent in 8 patients, satisfactory in 2 and poor in a further 2. Assessments were by pain score, grip strength and DASH. Radiological assessment revealed stable scapholunate ligaments in 10 patients: by this, it was meant that the mean scapholunate angle was 551 with a scapholunate gap of no more than Fig 13 Blatt’s procedure (Blatt, 1987). 3.2 mm.

(b) Lunotriquetral dissociation described the results of direct scapholunate ligamentous repair supported by a dorsal radio scaphoid capsulod- This condition is less common and, again, if diagnosed esis. The results of 21 patients treated by this technique early, can be treated by either simple immobilisation or between 1972 and 1988 were reported. Grip strength, acute ligament repair. Reagan et al. (1984) found that pain and X-ray appearances improved in all cases. There simple immobilisation was only useful for acute injuries, was, however, some reduction in movement, particularly capsulodesis, tenodesis and arthrodesis being reserved palmar flexion, which averaged 11.51. Only one patient for chronic cases. had to change his occupation after surgery and, at follow-up, three had X-ray findings of early degenerative change. Otherwise, there were no significant complications. This favourable outcome was further 16. WHAT SOFT TISSUE PROCEDURES ARE supported by Wintman et al. (1995). AVAILABLE FOR TREATING CHRONIC CARPAL Further work by Schweizer and Steiger (2002) from INSTABILITY? Switzerland, Szabo et al. (2002) from the United States Soft tissue procedures used to treat chronic scapholu- and Busse et al. (2002) from Germany also reported nate ligament injuries fall into two categories. The first satisfactory results. Movements of the wrist, however, include a capsulodesis, alone, or with an accompanying were reduced, as was grip strength, to a minor degree. direct repair. The second involve some form of tendon Schweizer and Steiger (2002) identified early arthritis, graft augmentation. It is an obvious pre-requisite for particularly affecting the mid carpal joint, in five cases. either of these approaches that the scapholunate Busse et al. (2002) noted that 5 out of 12 of their patients instability itself is reducible and that there is no evidence needed further surgery because of persistent pain. of osteoarthritis or, indeed, cartilage wear. Certainly, An alternative view was expressed by Wyrick et al. soft tissue reconstructions are contraindicated if the (1998), when they reviewed their experience of 17 1 dissociation is fixed, or in the presence of arthritis. If patients with a mean follow-up of 22 years. At final there is any doubt about this, it is essential that the follow-up, no patient was pain free and wrist movement patient undergoes an examination under X-ray control was only 60% of normal, with grip strength 70% of that and wrist arthroscopy, if necessary. of the opposite side. Radiologically, there was no Capsulodesis was first described by Blatt (1987), who significant difference between X-ray parameters prior fashioned a ligament from the dorsal capsule of the to surgery and at follow-up. Overall, only two patients wrist, which, when inserted into the dorsal aspect of the had an excellent or good outcome, as graded by Green distal scaphoid, acted as a checkrein to flexion (Fig 13). and O’Brien (1980). They concluded that repair of the The rationale behind this procedure is that, whilst no scapholunate ligament with dorsal capsulodesis failed to attempt is made to reduce the persistent scapholunate provide satisfactory results. Similarly, Deshmukh et al. dissociation, the attachment distally prevents scaphoid (1999) reviewed 44 cases of chronic scapholunate malrotation. It should be noted, however, that many dissociation treated by Blatt’s dorsal capsulodesis alone surgeons now combine this capsulodesis with a direct with a minimum follow-up of 2 years. Postoperatively, repair of the scapholunate interosseous ligament. again, there were significant reductions in wrist move- In 1987, Blatt both described his technique and ment, particularly palmar flexion, as well as grip reported the long-term results in 12 patients. All patients strength. Overall, using a locally described scoring recovered full extension with less than 201 loss of wrist system, only 39% were satisfied and 61% partially flexion. Grip strength improved to 80% of normal. satisfied with the outcome of the procedure. Forty six Subsequent to this, there have been a number of other per cent were graded objectively as a fair or poor reported series, the first by Lavernia et al. (1992), who outcome. The factors that influenced these figures were

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TWENTY QUESTIONS ON CARPAL INSTABILITY 249 delay to surgery and, also, an outstanding compensation claim. Complications included three cases of CRPS 1 (Algodystrophy or Reflex Sympathetic Dystrophy) and two cases of pin tract infection. Finally, in an additional radiological study, it was noted that patients who had a high ‘‘column row’’ index, that is those patients with scaphoids that normally flexed rather than translated on ulnar deviation, had better results than those that predominantly translated. Scapholunate stabilisation using tendon grafts as an augmentation, or an alternative for ligament reconstruction, has been used for many years (Dobyns et al., 1975; Glickel and Millender, 1984). Most share a common goal, that is to recreate a scapholunate ligament and, as such, a more normal scapholunate relationship. Gen- erally, however, these are technically demanding procedures. Another disadvantage of tendon graft stabilizations, in general, is that the modulus of elasticity Fig 14 Brunelli procedure. of the original ligaments of the wrist is much greater than that of any tendon graft. As a consequence, this may result in an alteration, or stiffening, of the normal intercarpal kinematics. Almquist et al. (1991) reported the results of a four bone ligamentous weave reconstruction which incorpo- rated a long strip of the extensor carpi radialis brevis tendon with an average follow-up of almost 5 years. The patients had a grip strength of 73% of the uninvolved side, with an average of 521 of extension and 371 of flexion. Eighty-six per cent of patients returned to their pre-injury activity, including heavy labour in some cases. Pre-operatively, X-rays of the scapholunate intervals measured greater than 4 mm, whereas, at review, these measured 3.3 mm. There was no X-ray evidence of advancing arthritic change. In 1995, Brunelli and Brunelli described their technique of treating scapholunate dissociation. This entailed using a slip of the flexor carpi radialis (FCR) tendon, pulled through the distal pole of the scaphoid to exit on Fig 15 Extensor carpi ulnaris tenodesis. the dorsal aspect, then be inserted into the dorsal ulnar side of the radius. This technique has subsequently been modified by Van Den Abbeele et al. (1998). In this extension arc. Unfortunately, 24 of the 162 patients were author’s technique, the tendon slip was inserted into the obliged to change their occupation to one of lighter dorsum of the lunate or tunnelled under the dorsal work and six patients had undergone further surgery. radio-lunotriquetral ligament and sutured back on itself On the ulnar side of the wrist most surgeons prefer to (Fig 14). This modification was made to avoid tethering treat chronic lunotriquetral instability by arthrodesis. and, as a consequence, excessive loss of flexion at the Soft tissue reconstructions, including direct repair or radiocarpal joint. Of the 22 patients who underwent this reinsertion of the ligament together with ligament procedure, 17 had complete relief of pain. Movements reconstruction with tendon graft, have all been tried. postoperatively were reduced, with on average 101 loss At Wrightington Hospital, we have used a slip of of both flexion and extension. Otherwise, there was little extensor carpi ulnaris tendon passed through a tunnel in change in grip strength or function. The authors have the triquetrum bone and sutured back on to itself as a recently reviewed their longer term outcome in 162 form of dynamic stabilisation for some time. The results patients over 10 years. On average, 78% of patients were of this technique were reported by Shahane et al. (2005) very satisfied, or satisfied, with the procedure and 88% (Fig 15). Of the 46 patients reviewed, 29 had excellent or said they would have the operation again. In addition, good, 11 satisfactory and only 6 poor results, using the the vast majority of patients reported a statistically Mayo wrist score. Eighty-seven per cent of patients significant reduction in pain and an average of 79% of asked said that the surgery substantially improved the grip strength of the opposite side and 74% of the flexion condition of their wrist.

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At the midcarpal joint, various soft tissue reconstruc- however, Eckenrode et al. (1986) reported less good tion procedures have been tried, including palmar results. Voche et al. (1991) found that their patients only capsular reefing, dorsal radiocarpal capsulodesis, ad- maintained 60% of their pre-operative range of motion vancement of the ulnar arm of the arcuate ligament and and that X-rays revealed styloid impingement in 34% of triquetrohamate ligament reconstruction. Lichtman et cases. Fortin and Louis (1993) also showed that 8 out of al. (1993) reported their results with these procedures 14 patients had significant residual symptoms and 11 and concluded, generally, that they were inferior to a had complications, including radiocarpal and trapezio- limited midcarpal arthrodesis. metacarpal arthritis, as well as non-union. Scaphocapitate arthrodesis has the same effect, but is easier to perform (Fig 17). Pisano et al. (1991) found 17. WHAT BONY PROCEDURES ARE that grip strength was good, although it reduced wrist AVAILABLE TO TREAT CHRONIC movement, particularly radial deviation. Only 2 of 17 SCAPHOLUNATE LIGAMENT INJURY? patients required re-operation for non-union. Whilst lunotriquetral dissociation occurs less com- The indifferent results of ligament reconstruction have monly than scapholunate dissociation, it can also, on persuaded many surgeons to perform intercarpal ar- occasion, require surgical treatment. Reagan et al. throdeses, the most logical of which is scapholunate (1984) found that simple immobilisation was only useful arthrodesis. Hom and Ruby (1991) reported their for acute injuries, with capsulodesis, tenodesis or experience of this procedure and found that, only one arthrodesis being reserved for chronic cases. Pin et al. of seven patients, ultimately, attained radiographic (1989) reported their results of lunotriquetral fusion fusion and three still had significant symptoms. Alnot (Fig 18) and found that three patients had persistent et al. (1992) had similar problems, although Zubairy and pain, although fusion occurred in all 8 cases. In Jones (2003) found that 10 of the 13 patients were addition, whilst range of motion was preserved, only subjectively satisfied with the treatment, although only 4 50% of grip strength was maintained. Kirschenbaum achieved fusion. et al. (1993) also advocated fusion, although Nelson In view of these difficulties, attention turned to the et al. (1993) reported problems of non-union and STT joint (Fig 16). Watson and Hempton (1980) found that STT fusion was more readily obtained and was successful in controlling rotatory subluxation of the scaphoid, preserving 80% of the normal range of flexion/extension and 66% of the normal range of radial and ulnar deviation. Such good results were reported again by these authors in a further publication in 1999. Kleinman et al. (1982) also reported good results with this procedure in that 9 of their 12 patients returned to pre-injury activities, without wrist pain and with 80% of the pre-operative range of motion. More recently,

Fig 16 Scapho-trapezio-trapezoid (STT) fusion. Fig 17 Scapho-capitate fusion.

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continuing pain. Seven patients, however, reported some improvement and were able to return to work. Overall wrist movement was 50% and grip strength 65% of their normal side. Rao and Culver (1995) reported their results of 11 wrists in 10 patients which had undergone triquetrohamate arthrodesis for symptomatic midcarpal instability. At follow-up, averaging 26 months, there were 6 good to excellent, 3 fair and 2 poor results. Compared to the contralateral side, range of motion averaged 55% ﬂexion, 69% extension, 61% radial deviation and 64% ulnar deviation. Grip strength averaged 64% of the normal wrist. The author ended with a cautionary note that the stability provided by this arthrodesis failed to control symptoms in almost half of the cases. Post-traumatic ulnar translation of the carpus has not been successfully treated by soft tissue repair (Chamay et al., 1983; Rayhack et al., 1987) and most authors now advocate radiolunate fusion for this problem. The principal difﬁculty with small bone arthrodesis is non-union, as one would expect. This was addressed by Larsen et al. (1997), who undertook a meta-analysis of the literature. In the published literature, scapho-trapezium-trapezoid arthrodesis has a 14% non-union rate, lunotriquetral arthrodesis has a 27% non-union rate and scapholunate arthrodesis has a 47% non-union rate.

18. WHAT OTHER PROCEDURES ARE Fig 18 Lunotriquetral fusion. SOMETIMES UNDERTAKEN? Because of the complexity of both soft tissue and bony reconstruction for carpal instability, the results are often recommended using a Herbert screw as well as a K-wire unpredictable. A number of surgeons have, therefore, for fixation and a cast for at least eight weeks. Finally, advocated alternate procedures. Conyers (1990) per- Sennwald et al. (1995), in a review of 33 patients, formed an imbrication of the palmar ligaments and concluded that lunotriquetral fusion cannot be consid- chondrodesis between the scaphoid and lunate for ered as a routine procedure and that results are chronic scapholunate instability and reported improve- unpredictable. ment of the pinch and grip strengths and of the range of With regard to the midcarpus, Lichtman et al. (1981) motion. originally described this instability and investigated its Ruch and Poehling (1996) reported a satisfactory pathomechanics. They also described a diagnostic test, outcome in 14 patients with isolated partial scapholu- specifically a painful click on ulnar deviation, compres- nate and lunotriquetral ligament injuries who had sion and pronation of the wrist. The radiographs are undergone arthoscopic debridement with early mobili- usually normal but cinefluoroscopy can show dissocia- sation. Weiss (1998) reported their results of 43 wrists tion between the proximal and distal carpal rows, with a which underwent not only a diagnostic wrist arthro- volar collapse deformity. Laboratory studies have scopy but also a debridement of the torn area using a shown volar subluxation of the capitate and hamate resector, or a suction punch, for a mixture of isolated on the lunate and triquetrum. Johnson and Carrera scapholunate or lunotriquetral ligament injuries. Sur- (1986) identified attenuation of the radiocapitate liga- gery was undertaken, on average, 8 months after injury. ment as the cause of this condition and advocated At an average follow-up of over 2 years, 10 of the 15 tightening the ligament to obliterate the space of Poirier. patients with complete scapholunate ligament injuries Generally, however, soft tissue reconstructions have reported a complete resolution of symptoms, although usually failed and midcarpal arthrodesis is preferred five patients had persistent pain and required subsequent (Lichtman et al., 1993). Siegel and Ruby (1996) reported reconstruction. Of the 13 patients who had a partial their results of midcarpal arthrodesis in 11 patients scapholunate ligament injury, 11 reported complete 1 followed up for an average of 52 years. Four of the 11 resolution of symptoms. Whether this was maintained patients had ultimately undergone total wrist fusion for long-term remains uncertain.

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Shin et al. (1998) investigated the possibility of advanced collapse (SLAC) wrist is an inevitable reconstructing the scapholunate ligament with a bone- consequence of a scapholunate disruption there is still retinaculum-bone autograft preparation from Lister’s little conclusive evidence of this. Larsen and Brondum tubercle. Essentially, this was a cadaveric study to assess (1993) performed a retrospective review of 18 cases of the tensile strength of this construct against that of the carpal instability diagnosed by clinical and radiological normal scapholunate ligament. The results indicated means, most of which had been treated surgically. Their that, although this autograft was significantly weaker mean follow-up was 9 years, with a range from 1 to 20. with a failure load of less than a quarter of the normal At review, 4 of their 18 cases had undergone a wrist ligament, considering the cross sectional areas, the arthrodesis and another 4 had radiological signs of failure stress was more equal. Hofstede et al. (1999) significant osteoarthritis. Twelve of the 18, however, examined the biomechanical properties of 9 dorsal tarsal were satisfactory in terms of pain and grip strength, ligaments from the foot. They concluded that the medial despite persistent radiographic instability in nine. dorsal cuneonavicular ligament was the strongest and, The long-term effects of instability on the wrist were therefore, the most suitable for use as an autograft for also evaluated by Blevens et al. (1989), who used reconstruction of the scapholunate ligament. pressure-sensitive films to record changes in the radio- Weiss (1998) reported the early results using a bone- scaphoid and radiolunate contact areas after sequential retinaculum-bone autograft for chronic scapholunate ligament section in cadavers. They found that the ligament reconstruction. The graft used initially was scapholunate interosseous ligament was essential for from the third dorsal compartment, although, subse- preventing scapholunate diastasis and that the change in quently, and in the majority of cases, the graft was taken contact area after its division would explain the later from Lister’s tubercle, this being technically easier. The development of degenerative arthritis. In our series of bone blocks were then inserted into the scaphoid and patients with arthroscopically proven interosseous lunate, which were reduced and held by K wires. At scapholunate injury without any radiological signs of 1 follow-up at an average of 32 years, 12 of the 14 patients DISI or scapholunate gapping, there was no real with dynamic instability had no pain and two had pain evidence of any rapid deterioration to radiocarpal following heavy activity only. All recovered satisfactory osteoarthritis over an average of 7 years, although ranges of motion and grip strength and none of the patients remained symptomatic (O’Meeghan et al., patients were dissatisfied. Thirteen of the 14 returned to 2003). their former work. Of the five patients with static scapholunate dissociation, two had continuing pain postoperatively and one had pain after heavy activity. 20. CAN THESE BE TREATED? Recovery of movements and grip strength were not as good as in the dynamic group, grip strength being only The loss of motion and altered biomechanics which half of that of the contralateral side. In this group, two result from either untreated carpal instability, or, patients were dissatisfied and underwent further surgery. sometimes, its treatment may give rise to symptomatic Complications occurred in six patients, including skin secondary osteoarthritis in the long term. STT fusion breakdown over a prominent K-wire and neuropraxia and scaphocapitate fusion have been found to produce a involving the superficial branch of the radial nerve in significant reduction in range of motion. Both proce- five patients, which persisted in two. dures increase the sliding motion of the lunate on the Weinstein and Berger (2002) reviewed their experience radius such that Garcia-Elias et al. (1995) and Viegas et in 19 patients who had isolated anterior and posterior al. (1993) found that virtually all the load was interosseous neurectomies for chronic wrist pain and no transmitted to the scaphoid fossae. Other fusions, viz. previous, or concurrent, wrist surgery. At an average of scapholunate, scapholunocapitate and capitolunate, all 1 22 years follow-up, 80% of the patients reported a distributed the load more equally through both the decrease in pain, 45% reported normal or increased grip scaphoid and lunate fossa. The position of the scaphoid strength and 73% of patients had returned to work. in STT fusions is crucial. If it is vertical, there is a Three patients had undergone additional procedures. greater loss of flexion and ulnar deviation. If it is These authors felt that failures tended to occur in the horizontal, extension and radial deviation are lost. If the first postoperative year. scaphoid is in a more anatomical position, STT and scaphocapitate fusion result in similar patterns of motion (Ambrose et al., 1992). The treatment of carpal instability when there are 19. WHAT ARE THE LONG-TERM EFFECTS OF already arthritic changes in the wrist was described by CARPAL INSTABILITY? Watson and Ballet (1984). They defined scapholunate The natural history of an isolated scapholunate ligament advanced collapse (SLAC), a sequential pattern of injury remains unclear. Although Harrington et al. arthritis affecting, first, the radial fossa and, then, (1987) and Watson et al. (1997, 1999) stated that the capitolunate joint, but sparing the radiolunate joint secondary osteoarthritis in the form of a scapholunate (Fig 19). They recommend reduction of the so-called

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operated on 55 patients with SLAC and obtained the best results with scaphoid excision and a ‘four-corner fusion’. Saffar and Fakoury (1992) compared proximal row carpectomy with partial wrist arthrodesis and found that the latter gave better results. The results of radioscapholunate arthodesis and distal scaphoidectomy for the treatment of radiocarpal degenerative osteoarthritis were reported by Garcia-Elias et al. (2005). This procedure was undertaken for patients who, predominantly, had an intraarticular fracture of the distal radius and continuing incongruity. Two patients, however, had suffered a perilunar fracture dislocation. The scaphoid and lunate were arthrodesed to the distal radius and the distal quarter of the scaphoid removed. At an average follow-up of just over 3 years, complete pain relief was obtained in 10 patients with a signiﬁcant reduction in the other six. Movement was 321 of ﬂexion, 351 of extension, 141 of radial deviation and 901 of ulnar deviation. Two patients, ultimately, did develop secondary midcarpal degenerative change.

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