Updated: 1/16/2020

Carpal Instability Nondissociative (CIND)

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https://upload.orthobullets.com/topic/6044/images/Ulnar translation with text_moved.jpg
Introduction
  • Defined as instability between rows (either radiocarpal or midcarpal)
    • radiocarpal instability (between radius and proximal row)
    • midcarpal instability (between proximal and distal row)
  • Epidemiology
    • incidence
      • rare
  • Pathophysiology and Mechanism
    • 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
  • Prognosis
    • volar dislocation is more severe than dorsal
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
 

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Technique Guides (1)
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? Tested Concept

QID: 3475
FIGURES:
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Radial wrist pain with sudden ulnar deviation

1%

(33/3466)

2

Tenderness to palpation distal to the ulnar styloid

0%

(17/3466)

3

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

40%

(1383/3466)

4

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

6%

(193/3466)

5

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

52%

(1816/3466)

L 4 C

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