Traumatic Nondissociative Carpal Instability: A Case Series

Scapholunate Instability: Diagnosis and Management - Anatomy, Kinematics, and Clinical Assessment - Part I

Injuries to the scapholunate joint are the most frequent cause of carpal instability. The sequelae of these injuries account for considerable morbidity, and if left untreated, may lead to scapholunate advanced collapse and progressive deterioration of the carpus. Rupture of the scapholunate interosseous ligament and its critical stabilizers causes dyssynchronous motion between the scaphoid and lunate. Additional ligament injury or attenuation leads to rotary subluxation of the scaphoid and increased scapholunate gap. Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. In the first section of this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical ligament stabilizers. We provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. The purpose is to provide an update regarding the anatomy of the scapholunate ligament complex, importance of the critical ligament stabilizers of the proximal carpal row, introduction of safe technique to surgically expose the scaphoid and lunate, as well as pathoanatomy as it pertains to the treatment of scapholunate dissociation. In the second section of this review, we propose a novel ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes.

Traumatic Volar Carpal Instability Nondissociative: A Case Series

Carpal instability nondissociative (CIND) involves disruption between carpal rows from injury to extrinsic and intrinsic wrist ligaments. CIND traumatic (CINDT) highlights the posttraumatic etiology of some of these cases and has been gaining increasing attention in the literature. We present four cases of CINDT-volar intercalated segmental instability (VISI). We diagnosed two adults with distal radius fractures and two adolescents with Galeazzi fractures, all treated surgically, who developed CINDT-VISI with radiolunate angles greater than 15° at 2 weeks after surgery. One adult had progressive deformity but was asymptomatic at 33 months. The other underwent volar capsular release at 1 year to improve alignment. One adolescent with a fixed deformity required soft tissue releases and temporary pinning to restore alignment at 7 months. We treated the other successfully with early physiotherapy. No patient had radiographic signs of arthritis at 1-2 years. This is the first reported association between Galeazzi fractures and CINDT-VISI. Contrary to existing literature, we report successful outcomes with nonsurgical and delayed nonfusion surgery of CINDT-VISI.

All-Dorsal Arthroscopic Ligamentoplasty (ADAL) in Scapholunate Instability Management: Surgical Technique

In advanced scapholunate instability, a scapholunate repair by open or arthroscopic ligamentoplasty is indicated. Although the radiographic results and functional scores are more or less satisfactory for open ligamentoplasty, it is often responsible for a decrease in joint amplitude postoperatively. Arthroscopic techniques are therefore of great interest, since they respect the joint capsule, but they remain technically difficult and demanding surgeries, requiring a good deal of experience in arthroscopy and using bone tunnels that are potentially a source of complications, as well as pinning to the palmar side of the wrist, which is potentially dangerous for the palmar structures of the wrist. We present a surgical technique of scapholunate ligamentoplasty under arthroscopy, focusing only on the dorsal scapholunate complex: all-dorsal arthroscopic ligamentoplasty. The advantages of all-dorsal arthroscopic ligamentoplasty are that it requires little material, does away with palmar approaches, and focuses only on the dorsal side, simplifying surgery and avoiding the creation of bone tunnels potentially at risk of fracture or avascular necrosis.

Periarticular distal radius fractures and complex ligamentous injury: The role of arthroscopic evaluation

Purpose

Distal radius fractures are associated with a high incidence of concomitant soft tissue injuries, including lesions of the triangular fibrocartilage complex and intercarpal ligaments. While advanced imaging has allowed for greater identification of such tears, discerning which lesions pose a functional consequence remains a challenge for the hand surgeon. A review and guideline for arthroscopic evaluation of suspected combined injuries is presented.

Results

Arthroscopic evaluation of distal radius fractures provides several unique advantages in such instances. Articular reduction can be performed via direct visualization with improvement in step-off and gapping. Furthermore, ligamentous injuries and carpal alignment can be directly assessed and treated.

Conclusions

Subtle features of combined ligamentous trauma may be overlooked in the presence of more obvious fracture patterns. Wrist arthroscopy allows not only for a gold-standard method of evaluating of these soft tissue injuries, but also a means of treatment.

Wide arthroscopic dorsal capsuloligamentous repair in patients with severe scapholunate instability

A conventional arthroscopic capsuloligamentous repair is a reliable surgical solution in most patients with scapholunate instability. However, this repair does not seem to be sufficient for more advanced injuries. The aim of this study was to evaluate the functional results of a wide arthroscopic dorsal capsuloligamentous repair (WADCLR) in the management of severe scapholunate instability. This was a prospective single-centre study undertaken between March 2019 and May 2021. The primary outcome was the evaluation of the reduction of the radiological deformity and the functional outcomes after WADCLR. A secondary outcome was the evaluation of the effectiveness of this technique in patients with the most severe instability (European Wrist Arthroscopy Society (EWAS) stage 5). The patients were reviewed postoperatively at three, six, and 12 months. The study included 112 patients (70 male and 42 female). Their mean age was 31.6 years (16 to 55). A total of three patients had EWAS stage 3A injuries, 12 had stage 3B injuries, 29 had stage 3C injuries, 56 had stage 4 injuries, and 12 had stage 5 injuries. There was a significant improvement of the radiological signs in all patients with a return to normal values. There was also a significant improvement in all aspects of function except for flexion, in which the mean increase was negligible (0.18° on average). There was also a significant improvement in all criteria for patients with a stage 5 injury, except for some limitation of extension, flexion, and radial and ulnar deviation, although these showed a trend towards improvement (except for flexion). WADCLR is a minimally invasive, easy, and reproducible technique with few complications, offering a clear improvement in function and a reduction in the radiological deformity at one year postoperatively.

Surgical Technique: Wide Arthroscopic Dorsal Capsuloligamentous Repair for Advanced Scapholunate Instability

In the most advanced cases of scapholunate instability with dynamic or static signs, classical arthroscopic repair seems impossible. Ligamentoplasties or open surgery procedures are technically demanding, hampered by significant operative complications and often stiffening. Therapeutic simplification is therefore necessary for the management of these complex cases of advanced scapholunate instability. We propose a minimally invasive, reliable, and easily reproducible solution that requires little equipment other than arthroscopic material.

Midcarpal Instability: A Historical and Etymological Review

Although midcarpal instability was first described almost 45 years ago, this uncommon condition is still poorly understood by most clinicians today. Adding to the confusion, it is known by 2 different names: midcarpal instability and carpal instability nondissociative. In this article, we describe the history of the recognition of instability of the midcarpal joint, including its pathomechanics, classification, and treatment. We hope that a more complete understanding of the etymology and kinematics of the disorder will facilitate its future recognition and assist in appropriate treatment decision making.