Wrist Biomechanics and Carpal Instability

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Wrist Biomechanics
Anatomy Kinematics Force transmission

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Anatomy
8 bones Complex interlocking shapes Intrinsic and extrinsic ligaments

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Wrist ligaments

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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
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Kinematics
Three axes of motion
FEM 90 70 degrees Flex/ext split between radiocarpal & midcarpal RUD 20 50 degrees PSM 90 90 degrees

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Axes of Motion

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Kinematics
Rows Columns (Navarro) Oval ring Longitudinal columns (Weber) Link Joint

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Link Joint

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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
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Kinematics
Center of rotation : head of capitate

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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

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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

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Force Transmission
Principal force transmission is through capitate lunate and proximal pole of scaphoid 75% radius 25% ulna

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Classification of Carpal Instability

CID (dissociative)
DISI VISI

CIND (non-dissociative)
Radiocarpal,Midcarpal,Ulnar translocn

CIC (complex)
Perilunate Dislocation
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Progressive periLunate Instability

Stage I scapholunate instability Stage II capitate dislocation Stage III triquetral dislocation Stage IV lunate dislocation Spectrum of injury

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PLI

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Mechanism of injury
Impact on thenar side of wrist causes hyperextension , ulnar deviation and intercarpal supination Progressive damage around lunate Bony or ligamentous

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Normal wrist

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Volar Intercalated Segment Instability

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Dorsal Intercalated Segment Instability

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Gilula lines

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Carpal Angles

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Carpal Height
L2/L1 = 0.54 New ratio L2/capitate = 1.57

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Scapholunate Instability
Most common form Rarely diagnosed acutely Local tenderness Scaphoid shift(Watson) Associated with other injuries eg distal radius
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Scapholunate Instability: Classification

Type 1 dynamic
Neg Xray;+ve Watson:+ve cine

Type 2 static
+ve plain films

Type 3 degenerative Type 4 secondary

Kienbocks ; SNAC
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Scapholunate Instability: Radiographs

Scapholunate gap >2mm Foreshortened scaphoid Cortical ring sign Taliesnik,s V sign Lack of parallelism?

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Scapholunate Instability

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DISI

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Scapholunate Instability

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Scapholunate Instability: Treatment

Acute (0-3 wks) : open repair vs arthroscopically-assisted PCP x 8wks Chronic (>4 wks) : repair + reconstruction
STT Blatt SLC

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Scapholunate instability

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Acute repair SLIL

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Blatt Capsulodesis

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STT Fusion

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STT Arthrodesis

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Scapholunate Instability: Arthrosis

SLAC PRC Arthrodesis RSL

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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
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VISI

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Perilunate Dislocation
Perilunate & Lunate are same basic injury Still missed in ER Rx of choice : open reduction & repair of ligaments/bones Dorsal and volar approach Late: fusion or PRC
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Lesser and Greater arcs

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Perilunate Dislocation

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Perilunate repair

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Ulnar Translocation
Rare Difficult to treat Non-traumatic causes : RA,Madelungs

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Ulnar Translocation

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Carpal Instability: Unresolved Issues

Role of arthroscopy Method of reconstruction SLIL eg bonetendon-bone Ulnar side pathomechanics Role of MRI

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Grade III

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Grade IV

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