Download - Carpal Instability 1
DEPARTMENT OF ORTHOPAEDICS & TRAUMATOLOGY, OSMANIA GENERAL HOSPITAL, HYD Under the Guidance of: DR. P.N.PRASAD H.O.D OF ORTHOPAEDICS DR. KODANDAPANI ASSOCIATE PROF. DR. ASHOK OATHKAR ASSOCIATE PROF. DR. Y.THIMMA REDDY ASSISTANT PROF. DR. P.L.SRINIVAS ASSISTANT PROF. DR. RAMKISHAN ASSISTANT PROF. DR. HAMEED S.R. TOPIC :
CARPAL INSTABILITYBY : DR. K. VENKATA SWAMY POST GRADUATE IN ORTHOPAEDICS
INTRODUCTIONCooney et al.1991 based upon arthroscopic study defined carpal instability as The lack of ligamentous and skeletal support to maintain a stable wrist even under external forces of pinch and grip grip
Wrist Biomechanics and Carpal Instability
Wrist Biomechanics Anatomy Kinematics Force transmission
Anatomy 8 bones Complex interlocking shapes Intrinsic and extrinsic ligaments
Wrist ligaments
Wrist ligaments Volar stronger than dorsal Double V shape with weak area ; space of Poirier Important interosseous ligaments are SLIL and LTIL Dorsal ligaments tend to converge on triquetrum
Kinematics Three axes of motion Flexion, Extension Medial, Lateral movements Rotational movements
Axes of Motion
Kinematics Rows Columns (Navarro) Oval ring Longitudinal columns (Weber) Link Joint
Link Joint
Kinematics Rows Proximal and Distal with scaphoid as a bridge Motion within and between rows
Columns Central(flex/ext) lunate,capitate,hamate Lateral (mobile) scaphoid,trapezoid,trapezium Medial (rotation) triquetrum
Kinematics Center of rotation : head of capitate
Kinematics Radial deviation : scaphoid flexes proximal pole goes dorsal pulling lunate into palmar flexion Ulnar deviation : scaphoid extends proximal pole goes volar pulling lunate into dorsiflexion
Kinematics Triquetrohamate helicoid joint Ulnar deviation : low position distal and dorsiflexed pulling lunate into dorsiflexion Radial deviation : highposition proximal and palmar flexed pulling lunate into palmar flexion
Force Transmission Principal force transmission is through capitate lunate and proximal pole of scaphoid 75% radius 25% ulna
Clinical Evaluation H/o pain and weakness Giving way sensation of the wrist Frequently click and snapping sensation with repetitive motion H/o out stretched fall on hand in extension, ulnar deviation, carpal supination is usually present
Classification of Carpal Instability CID (dissociative) DISI VISI
CIND (non-dissociative) (non Radiocarpal,Midcarpal,Ulnar translocn
CIC (complex) Perilunate Dislocation
Progressive periLunate Instability Stage I scapholunate instability Stage II capitate dislocation Stage III triquetral dislocation Stage IV lunate dislocation Spectrum of injury
PLI
Mechanism of injury Impact on thenar side of wrist causes hyperextension , ulnar deviation and intercarpal supination Progressive damage around lunate Bony or ligamentous
Normal wrist
Volar Intercalated Segment Instability
Dorsal Intercalated Segment Instability
Gilula lines
Carpal Angles
Carpal Height L2/L1 = 0.54 New ratio L2/capitate = 1.57 Chamay measurement=U/L1 (0.25(0.25-0.31) Mc Murtrys index=U/L1 (0.27(0.270.33)
Scapholunate Instability Most common form Rarely diagnosed acutely Local tenderness Scaphoid shift(Watson) Associated with other injuries eg distal radius
Scapholunate Instability: Classification Type 1 dynamic Xray;-ve Watson: +ve Xray;-
Type 2 static +ve plain films
Type 3 degenerative Type 4 secondary Kienbocks
Scapholunate Instability: Radiographs Scapholunate gap >2mm Foreshortened scaphoid Cortical ring sign Taliesnik,s V sign Lack of parallelism?
Scapholunate Instability
Grade III
Grade IV
DISI
Scapholunate Instability
Terry-Thomas sign
Scapholunate Instability: Treatment Acute (0-3 wks) : open repair vs (0arthroscopically Chronic (>4 wks) : repair + reconstruction Blatt
Scapholunate instability
Acute repair SLIL
Blatt Capsulodesis
STT Arthrodesis
Triquetrolunate instabliity Limited understanding of ulnar side TL or TH ?? Ulnar pain post injury Click +ve ballottement test Beware ulnar impaction syndrome Conservative Rx; rarely need limited fusion
VISI
Perilunate Dislocation Perilunate & Lunate are same basic injury Rx of choice : open reduction & repair of ligaments/bones Dorsal and volar approach Late: fusion or PRC
Lesser and Greater arcs
Perilunate Dislocation
Perilunate repair
Ulnar Translocation Rare Difficult to treat Non-traumatic causes : RA,Madelungs Non-
Ulnar Translocation
Carpal Instability: Unresolved Issues Role of arthroscopy Method of reconstruction SLIL eg bonebonetendontendon-bone Ulnar side pathomechanics Role of MRI
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