Carpal Ligament Instability Clinical Presentation

Updated: Aug 17, 2020
  • Author: Sunjay Berdia, MD; Chief Editor: Harris Gellman, MD  more...
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Presentation

History

The diagnosis of carpal instability in patients with obvious fracture and carpal instability patterns on radiography is sometimes relatively easy. Making the diagnosis in patients with subtle carpal instability can be more difficult. These patients often present with a history of a traumatic event. Noting the position of the wrist at the time of injury and determining the resultant force vector are extremely valuable.

Patients may have pain; if so, its location can be important when making the diagnosis. They may also have weakness and feelings of giving away. They may have clicking or snapping sensations on certain motions or upon loading the wrist.

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Physical Examination

As in many situations, physical examination starts with palpation. Nearly every critical ligament on the wrist can be palpated. Point tenderness over specific carpal ligaments, such as the scapholunate interosseous ligament (SLIL) or the lunotriquetral interosseous ligament (LTIL), may represent injuries to those ligaments. Pain at the extremes of motion may be present. Many dynamic maneuvers have been described to diagnose specific carpal instabilities.

Scaphoid shift test

One of the most common tests is the scaphoid shift test, described by Watson described in 1997 (see the image below). [24] In this test, the examiner's thumb is placed on the scaphoid tuberosity of the volar aspect of the wrist. Pressure is applied to the tuberosity as the wrist is passively brought from ulnar to radial deviation. This pressure attempts to block normal scaphoid flexion.

(Click Image to enlarge.) Watson scaphoid shift te (Click Image to enlarge.) Watson scaphoid shift test.

In theory, if the SLIL is torn and scapholunate instability is present, [25] the proximal scaphoid subluxates dorsally over the rim of the radius. A positive result is obtained if a painful "clunk" is elicited as the scaphoid reduces back into the radial scaphoid fossa when the thumb pressure is released.

Easterling and Wolfe showed that the results of this test may be positive in a significant number of asymptomatic healthy wrists. [26] Therefore, examination of the contralateral uninjured wrist is critical. In addition to the classic definition of a positive result, some surgeons believe that when the maneuver elicits only pain and no subluxation, this may signal a lesser scapholunate instability, such as a partial tear of the SLIL.

Maneuvers for diagnosing lunotriquetral instability

A few maneuvers have been described that can help diagnose lunotriquetral instability. It is important to distinguish lunotriquetral instability from a tear in the triangular fibrocartilage.

The Kleinman shear test (see the image below) is performed with the wrist in neutral position. [27] The examiner's contralateral thumb is placed over the dorsal lunate while the ipsilateral thumb loads the pisotriquetral joint with a dorsally directed force. A shear force is created across the lunotriquetral joint. A positive result is obtained when this maneuver produces pain.

(Click Image to enlarge.) Kleinman shear test. (Click Image to enlarge.) Kleinman shear test.

The Reagan shuck test (see the image below) is similar, except that the examiner's thumb and index finger grasp the whole pisotriquetral unit. [28] The contralateral thumb and index finger hold the lunate. The lunotriquetral joint is stressed by applying dorsally directed force with one hand and volarly directed force with the other hand. This force is switched in the opposite directions in both hands. This creates a shear stress at the lunotriquetral joint. If pain is elicited, the result is positive.

Reagan shuck test. Reagan shuck test.

Linscheid described a compression test in which the examiner uses a thumb to apply a load in the radial direction at the ulnar border of the triquetrum (see the image below). [29] This loading results in a compression force across the lunotriquetral joint. If this maneuver produces pain, the result is considered positive.

Linscheid compression test. Linscheid compression test.

Lichtman et al described a pivot shift test for midcarpal instability. [30] This maneuver is a combination ulnar deviation, axial compression, and pronation of the wrist. A positive result is obtained when this maneuver results in a painful wrist click.

Another test for midcarpal instability (as described above) is a dorsal-displacement stress test. [17] Under fluoroscopic control, a positive result is obtained when the capitate subluxates dorsally as compared with the lunate and when the patient experiences a painful snap or click.

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