Carpal Ligament Instability Workup

  • Author: Sunjay Berdia, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Feb 17, 2012
 

Imaging Studies

Standard radiographic examination of the wrist should include a posteroanterior (PA) view in neutral rotation and also lateral views. The symptomatic and asymptomatic wrist should be evaluated.

  • Static instability patterns can be seen with these radiographs.
  • Additional radiographs, such as a PA grip, PA maximum radial deviation, PA maximum ulnar deviation, lateral maximum flexion, and lateral maximum extension views, can also be obtained and can help diagnose dynamic instability.

To determine scapholunate dissociation, the scapholunate gap can be measured on PA and PA grip radiographs. However, obtaining a PA view that clearly shows the scapholunate gap without some bony overlap can be difficult. Findings should always be compared side-to-side.[26]

  • Kindynis et al suggested angling the x-ray tube to obtain a clearer view of the scapholunate joint and to measure the space at the level of the midportion of the flat ulnar facet of the scaphoid.[27]
  • The amount of gap that is diagnostic of scapholunate dissociation is not agreed upon. Many authors define the gap to be pathologic if it is greater than 3 mm.[23, 28] In 1991, Cautilli and Wehbe measured the gap on 100 normal radiographs and found a mean distance of 3.7 mm (range, 2.5-5 mm).
  • Given the wide range, comparing the injured wrist with the contralateral uninjured wrist is crucial before scapholunate dissociation is diagnosed.

If the lunate is dorsiflexed more than 15º than the capitate on lateral radiography, a diagnosis of a DISI deformity is confirmed. Conversely, VISI is defined if the lunate if volarly flexed more than 15º.

  • A DISI deformity is associated with scapholunate instability, while a VISI deformity is associated with lunotriquetral instability.
  • In addition, the scapholunate angle can be measured on lateral radiography. In scapholunate instability, the scaphoid tends to assume a volarly flexed posture. As such, the scapholunate angle, which normally measures 30-60º (average, 46º), increases to more than 70º.[1]
  • Conversely, in lunotriquetral instability, the lunate is usually palmarly flexed, and the scapholunate angle can be less than 30º.[28]

McMurty et al defined a method to determine ulnar translocation on PA radiography, as shown below.[29]

McMurty ulnar translation measurement. McMurty ulnar translation measurement.
  • The distance between the center of the capitate and a line extending from the intermedullary axis of the ulna is divided by the length of the third metacarpal.
  • McMurty et al found that this ratio is 0.30 ± 0.03 in normal wrists but smaller in patients with ulnar translocation.

Leng et al studied a proposed dynamic 4D CT imaging technique that generated high spatial and high temporal resolution images without requiring periodic joint motion. Preliminary results from this cadaveric study demonstrate the feasibility of detecting joint instability using this technique.[30]

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Other Tests

  • Other studies include fluoroscopy, wrist arthrography, CT scanning, MRI, and ultrasonography.[31]
    • Because the false-positive rate is relatively high for arthrography (especially in those >40 y), some have suggested comparing images of the injured wrist with images in the contralateral uninjured wrist.[32]
    • Communication between the different compartments of the wrist may not necessarily be a result of trauma, but rather a result of age-related degenerative changes.[33]
  • Arthroscopy remains the criterion standard in diagnosing specific ligament injuries in the wrist.[34, 35, 36, 37]
    • Both the radiocarpal and midcarpal joints should be evaluated.
    • More importantly, surgical management can take place in the same setting.
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Staging

Many schemes have been described to classify the different degrees of carpal instability.

Linscheid et al described the easiest and one of the earliest classification schemes.[24, 1] They separated most instabilities into 2 groups depending on the orientation of the proximal row relative to the distal row. In their classification, the orientation of the proximal row is defined by the position of the lunate. The capitate is used to define the orientation of the distal row because it is most easily seen on lateral radiography. Thus, if the lunate is dorsally flexed relative to the distal row (capitate) on lateral radiography, the instability is considered a DISI. The proximal row is the intercalated segment because no tendons directly insert on it. Similarly, a palmarly flexed lunate relative to the distal row is defined as a VISI.

These 2 patterns have been further classified as dissociative and nondissociative types. The dissociative type occurs when the injury results in instability between adjacent carpal bones within a row. For example, scapholunate instability is most commonly associated with a dorsiflexed lunate; this pattern is called a DISI deformity, dissociative type. A nondissociative type occurs when the DISI or VISI pattern is secondary to an injury that results in instability between rows. This nondissociative pattern has also been called midcarpal instability.

Two patterns that do not fit this classification include ulnar translocation and dorsal subluxation of the carpus. Ulnar translocation is defined as an ulnar shift of the entire carpus relative to the radius. This type of instability is seen in wrists with rheumatoid arthritis after chronic attrition of radial-sided extrinsic ligaments and bony changes. Dorsal subluxation describes a dorsal shift of the entire carpus relative to the radius. This pattern, also called adaptive carpal instability, is often seen after malunion of distal radius fractures where the radius has lost its normal volar tilt.

Two other adjectives commonly used in classifying carpal instabilities are static and dynamic. A static instability is one that can be clearly recognized on routine radiography by a loss of the normal alignment.[38] A dynamic instability is any instability that requires external forces placed on the carpus to elicit an instability pattern. Therefore, the diagnosis of dynamic instability relies on other means, such as dynamic radiography, physical examination with provocative maneuvers, and/or arthroscopic evaluation.

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Contributor Information and Disclosures
Author

Sunjay Berdia, MD  Adjunct Assistant Professor, Department of Orthopedic Surgery, Shady Grove Adventist Hospital

Sunjay Berdia, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Medical Association, American Orthopaedic Association, American Society for Surgery of the Hand, and MedChi

Disclosure: Nothing to disclose.

Coauthor(s)

Alexander Y Shin, MD  Associate Professor, Department of Orthopaedic Surgery, Mayo Clinic College of Medicine; Consulting Surgeon, Department of Orthopaedic Surgery, Division of Hand Surgery, Mayo Clinic

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael S Clarke, MD  Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Arthroscopy Association of North America, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, and Missouri State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Thomas R Hunt III, MD  John D Sherrill Professor and Director of Orthopedic Surgery, Director of Hand and Upper Extremity Fellowship, University of Alabama at Birmingham School of Medicine; Surgeon-in-Chief, UAB Highlands Hospital

Thomas R Hunt III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Society for Surgery of the Hand, AO Foundation, Mid-America Orthopaedic Association, and Southern Orthopaedic Association

Disclosure: Tornier Royalty Independent contractor; Tornier Ownership interest None; Lippincott Royalty Independent contractor

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

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(Click image to enlarge.) Dorsal carpal ligaments. Copyright Mayo Clinic, used with permission of Mayo Foundation.
(Click image to enlarge.) Volar carpal ligaments. Copyright Mayo Clinic, used with permission of the Mayo Foundation.
The wrist is a simple link between the proximal and distal rows. The pivot point is at the center of rotation of the capitate and lunate. This joint, without other supporting structures, is stable only in tension. It is unstable in compression, as this figure depicts, and tends to collapse.
The scaphoid acts like a bridge between the proximal and distal row and protects the link from collapsing.
Mayfield perilunate instability pattern. Copyright Mayo Clinic, used with permission of the Mayo Foundation.
(Click Image to enlarge.) Watson scaphoid shift test.
(Click Image to enlarge.) Kleinman shear test.
Reagan shuck test.
Linscheid compression test.
McMurty ulnar translation measurement.
Mayo dorsal intercarpal (DIC) capsulodesis. Copyright Mayo Clinic, used with permission of Mayo Foundation.
 
 
 
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