Updated: 5/20/2021

Carpal Instability Nondissociative (CIND)

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  • Summary
    • Carpal instability nondissociative (CIND) is defined as instability between carpal rows (either radiocarpal or midcarpal)
      • radiocarpal instability (between radius and proximal row)
      • midcarpal instability (between proximal and distal row)
  • Epidemiology
    • incidence
      • rare
        • < 1 per 100,000 annually
  • Etiology
    • Pathophysiology 
      • radiocarpal instability ("inferior arc injury")
        • high-energy injury
        • ulnar translation signifies global rupture of extrinsic ligaments
        • distal radius malunion is the most common cause
        • may be purely ligamentous or have associated ulnar and radial styloid fractures
    • Associated conditions
      • intracarpal injury (scapholunate or lunotriquetral ligament)
      • acute carpal tunnel syndrome
      • compartment syndrome
  • Anatomy
    • Volar extrinsic ligaments
      • radioscaphocapitate (RSC)
      • long radiolunate
      • short radiolunate
      • radioscapholunate
  • Classification
    • Overview table of wrist instability
  • Presentation
    • History
      • usually no history of trauma (midcarpal)
      • high energy trauma (radiocarpal)
    • Symptoms
      • subluxation that may or may not be painful
      • complain of wrist giving way
      • irritating clunking sign
        • "clunk" when wrist is moved ulnarly from flexion to extension with an axial load
    • Physical exam
      • generalized ligamentous laxity
  • Imaging
    • Radiographs
      • recommended views
        • required
          • AP and lateral of the wrist
        • optional
          • cineradiographs
      • findings
        • sudden subluxation of proximal carpal row with active radial or ulnar deviation on cineradiograph
        • ulnar translation
          • diagnosis made when >50% of lunate width is ulnarly translated off the lunate fossa of the radius
  • Treatment
    • Nonoperative
      • immobilization +/- splinting
        • indications
          • first line of treatment
          • midcarpal instability is most amenable to splinting
    • Operative
      • immediate open repair, reduction, and pinning
        • indications
          • ulnar translation associated with styloid fractures
        • outcomes
          • poor results with late repair
          • ligament reconstruction has poor long term results
      • midcarpal joint fusion
        • indications
          • midcarpal instability (preferred over ligamentous reconstruction)
          • late diagnosis that failed nonoperative management
        • outcomes
          • will lead to 20-35% loss of motion
      • osteotomy with malunion correction
        • indications
          • distal radius malunion
      • wrist arthrodesis
        • indications
          • failure of above treatments
        • outcomes
          • fusion of radiocarpal joint leads to a 55-60% loss of motion
  • Prognosis
    • volar dislocation is more severe than dorsal
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Questions (1)

(OBQ11.52) A 22-year-old gymnast with known ligamentous laxity has been treated in the hand therapy clinic for 6 months for left wrist pain and discomfort. Radiographs of her left wrist are seen in Figures A and B. Which of the following physical exam findings would be most diagnostic for midcarpal instability?

QID: 3475
FIGURES:
1

Radial wrist pain with sudden ulnar deviation

1%

(33/3702)

2

Tenderness to palpation distal to the ulnar styloid

1%

(19/3702)

3

Pain and a clunk on ulnar to radial deviation of the wrist while pressure is held on the scaphoid

40%

(1469/3702)

4

Pain in the lunate with volar directed pressure on the dorsum of hand

6%

(210/3702)

5

Pain and a clunk with axial and palmarly directed forces as the wrist is moved from neutral to ulnar deviation

53%

(1946/3702)

L 4 C

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