carpal instabilty final

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CARPAL INSTABILITY:

CARPAL INSTABILITY PRESENTER: Dr ANKUR MITTAL

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OVERVIEW OF WRIST JOINT The wrist has complex bony and ligamentous structures It form link between forearm and hand The bony components contribute little to wrist stability. The main stabilizer for wrist is complex ligamentous structure. In general palmar ligaments are stronger and more complex then dorsal ligaments

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RANGE OF MOTION AT WRIST JOINT Wrist flexion 0-60 Wrist extension 0-60 Wrist abduction 0-20 Wrist adduction 0-30

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LIGAMENTS: They are classified into Intrinsic ligaments : Between the carpal bones connecting the carpal bones in the proximal and distal carpal rows and Extrinsic ligaments : Extending from the radius and ulna distally across the carpal rows

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It is located between the distal ulna and the proximal carpal row, stabilizes the distal radioulnar joint, and functions as a cushion of compressing axial forces. the chondroligamentous supports attaching the distal radius and ulnar side of the carpus to the distal ulna, designating it the triangular fibrocartilage complex (TFCC).

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Among these 3 stronger palmar ligaments are Radioscaphocapitate (RSC) Long radio lunate (LRL) Short radiolunate (SRL) The space between RSC and LRL IS SPACE OF POIRIER.. This is the capsular weak point at which lunate dislocation occur.

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IMPORTANCE OF dorsal Intercarpal ligament The intercarpal ligament overlaps the dorsal portion of the scapholunate interosseous ligament, with its origin being the distal and radial aspect of the dorsal tubercle of the triquetrum . A lateral "V" configuration with the apex toward the triquetrum is formed by the dorsal intercarpal and dorsal radiocarpal ligaments, providing indirect dorsal stability to the scapholunate complex during wrist motion. Along with the radiocarpal ligament, the intercarpal ligament maintains carpal stability and alignment while preventing dorsal intercalated segment instability (DISI) and volar intercalated segment instability (VISI) deformities. [1]

Kinematics:

MUN ORTHOPEDICS 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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The center of rotation for most wrist motions is generally considered to be located in the proximal capitate . During flexion and extension, most motion occurs at the radiocarpal joint, with some occurring through the midcarpal area. The main role of hand is to provide a mobile and yet stable joint for the hand to function In the normal wrist , there is minimal movement between the carpal bones of distal row In contrast carpal bones of proximal row are less tightly bounded and they move in variable amounts on wrist movements . The radiocarpal and midcarpal joints contributed equally to wrist flexion, and the midcarpal joint contributed more to extension.

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During radial-to- ulnar deviation, the proximal carpal row rotates dorsally, and the proximal row translocates or shifts radially at the midcarpal and radiocarpal joints, with motion occurring at the radiocarpal and intercarpal joints. During ulnar -to-radial deviation, the proximal carpal row tends toward palmar rotation, with most of the motion occurring in the intercarpal joints. The proximal carpal row is considered to be an intercalated segment in the forearm-to-hand connection, with the scaphoid functioning to stabilize the wrist The scaphoid is the key of the carpal .it lies obliquely across the carpal rows hence it provides stability to both carpal rows as a slider crank (three bar linkage mechanism )preventing the wrist from colapsing . IN normal wrist position most of the load is transmitted through scapholunate capitate column

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For purposes of understanding the ways in which forces are transmitted, and motions and positions of the carpal bones are controlled by ligaments and contact surface contours, the concept of a wrist consisting of three columns was popularized by Novarro : the central (force-bearing) column, the radial column, and the ulnar (control) column.

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Taleisnik's concept of central (flexion-extension) column involves entire distal row and lunate : scaphoid is lateral (mobile) column, and triquetrum is rotary medial column Lichtman's ring concept of carpal kinematics: proximal and distal rows are semirigid posts stabilized by interosseous ligaments; normal controlled mobility occurs at scaphotrapezial and triquetrohamate joints. Any break in ring, either bony or ligamentous (arrows), can produce dorsal intercalated segmental instability or volar intercalated segmental instability deformity

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PATHOMECHANICS Carpal ligaments can be injured by either direct or indirect forces Indirect forces are more common when subject falls on an outstretched hand with variable amount of radial or ulanr deviation and midcarpal supination or pronation .

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A correctly positioned PA view will show the extensor carpi ulnaris groove radial to the midportion of the ulnar styloid . The PA view usually shows what is wrong and the lateral view shows in what direction the bones move. Sometimes an oblique view will also be obtained, especially if you want to look at the trapezium-trapezoid joint in profile. PA VIEW Extensor carpi ulnaris groove (yellow arrow) seen radial to the midportion of the ulnar styloid . How to diagnose carpal instability radiographically ?

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Lateral view Only on a good positioned lateral view one can see the volar edges of respectively scaphoid , pisiform and capitate separately and lined up as shown on the left. Oblique view An oblique view is not routinely performed. It is however the only view showing the trapezio -trapezoidal joint.

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Neutral ulnar variance. (A) As a rule, the radial styloid process rises 9 to 12 mm above the articular surface of the distal ulna. This distance is also known as the radial length. (B) At the site of articulation with the lunate , the articular surfaces of the radius and the ulna are on the same level

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Negative and positive ulnar variance. (A) Negative ulnar variance. The articular surface of the ulna projects 5 mm proximal to the site of radiolunate articulation. (B) Positive ulnar variance. The articular surface of the ulna projects 8 mm distal to the site of radiolunate articulation

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Ulnar slant. The ulnar slant of the articular surface of the radius is determined, with the wrist in the neutral position, by the angle formed by two lines: one perpendicular to the long axis of the radius at the level of the radioulnar articular surface ( a ) and a tangent connecting the radial styloid process and the ulnar aspect of the radius ( b ).

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Palmar inclination. The palmar inclination of the radial articular surface is determined by measuring the angle formed by a line perpendicular to the long axis of the radius at the level of the styloid process ( a ) and a tangent connecting the dorsal and volar aspects of the radial articular surface ( b ).

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The joint spaces of the wrist have a width of 2 mm or less. Only the radiocarpal joint is slightly wider The carpometacarpal joints are slightly narrower than the midcarpal joints. The capitolunate joint is considered the baseline joint width to which other joint spaces can be compared. One should make sure to look at all of them: radiocarpal , proximal intercarpal midcarpal distal intercarpal carpometacarpal joint spaces. Joint spaces: parallelism and symmetry

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Smooth curves joining the surfaces of the carpal bones as shown on the left. The first arc is a smooth curve outlining the proximal convexities of the scaphoid , lunate and triquetrum . The second arc traces the distal concave surfaces of the same bones, and the third arc follows the main proximal curvatures of the capitate and hamate . CARPAL ARCS

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Vulnerable zone of the wrist. The “vulnerable zone” of the carpus is represented by shaded areas. Most fractures, fracture dislocations, and dislocations of the carpal bones occur within it. The lesser arc outlines the “dislocation zone,” whereas the greater arc outlines the “fracture—dislocation zone.”

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Longitudinal axial alignment. On the lateral view of the wrist, the central axes of the radius, the lunate , the capitate , and the third metacarpal normally form a straight line.

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Scaphoid shape The scaphoid shape changes with movement of the wrist. In ulnar deviation or extension the scaphoid elongates to fill the space between the radial styloid and the base of the thumb (the trapezium). Both with radial deviation aswell as flexion of the wrist the space between the radial styloid and trapezium is reduced. As scaphoid fills this space it will foreshorten and tilt towards the palm. This will give scaphoid a signet ring appearance

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Scaphoid axis The true axis of the scaphoid is the line through the midpoints of its proximal and distal poles. Since the midpoint of the proximal pole is often difficult to appreciate, an almost parallel line can be used that is traced along the most ventral points of the proximal and distal poles of the bone (figure). Lunate axis The axis of the lunate runs through the midpoints of the convex proximal and concave distal joint surfaces and can best be drawn by finding the perpendicular to a line joining the distal palmar and dorsal borders of the bone as demonstrated on the left. Scapholunate angle Normal: 30 - 60° Questionably abnormal: 60 - 80° Abnormal: > 80° This indicates instability of the wrist.

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Capitate axis The capitate axis joins the midportion of the proximal convexity of the third metacarpal and that of the proximal surface of the capitate . Capitolunate angle Normal: < 30° Abnormal: > 30°. This indicates instability of the wrist.

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DISI or dorsiflexion instability DISI is short for dorsal intercalated segmental instability. DISI or dorsiflexion instability the lunate is angulated dorsally. If lunate is tilted, measure the scapholunate angle ( 30-60°is normal, 60-80°is questionably abnormal, >80° is abnormal) and the capitolunate angle (<30° is normal. In the figure on the left the scapholunate angle is measured: it is 105 degrees. As mentioned before this angle is considered abnormal if greater then 80 degrees. VISI or volarflexion instability Volar intercalated segmental instability or palmar flexion instability is when the lunate is tilted palmarly too much. While most DISI is abnormal, in many cases VISI is a normal variant, especially if the wrist is very lax.

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Special Imaging Techniques Arthrography , magnetic resonance (MR) wrist arthrography , video radiography, and arthroscopy can assist in the diagnosis of carpal ligament injuries . Computed tomography (CT) scans are helpful in evaluating carpal fractures, malunion , nonunion, and bone loss. Three dimensional imaging is of use in planning reconstructive procedures for malunions and nonunion. Macroradiography does not show any advantage in diagnosing carpal fractures, particularly scaphoid fractures compared with normal x-rays Bone scans can be helpful in confirming occult fractures and avulsion injury However, MRI scans are more sensitive in detecting occult fractures and ON of the carpal bones as well as in detecting soft-tissue injuries, including ruptures of the scapholunate ligament and TFCC injuries.

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Imaging Pearls and Pitfalls Pearls Standard scaphoid views detect most carpal injuries. A DISI pattern is most commonly observed with displaced scaphoid fractures and scapholunate dissociation. A VISI pattern is more likely to be associated with lunotriquetral dissociation. MRI scans are useful in detecting occult fractures, ON of the carpal bones, and ligamentous injuries. Pitfalls Perilunate dislocations are easily missed if the continuity of Gilula's line is not assessed.

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DOBYNS AND COONEY CLASSIFICATION OF CARPAL INSTABILTIY TYPE,SITE,NAME CID(CARPAL INSTABILITY DISSOCIATIVE) 1.1 Proximal carpal row CID a. Unstable scaphoid fracture b. Scapholunate dissociation c.Lunotriquetral dissociation 1.2 Distal carpal row CID a. Axial radial disruption b. Axial ulnar disruption c. combined axial radial and ulnar disruption 1.3 Combined proximal and distal CID

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CIND(Carpal instability Nondissociative ) 2.1 Radiocarpal CIND a. Palmar ligament rupture b. Dorsal ligament rupture c. After “Radial malunion “, Madelung deformity, scaphoid malunion , lunate malunion 2.2 Midcarpal CIND a. Ulnar midcarpal instability from palmar ligament rupture b. Radial midcarpal instability from palmar ligament rupture c. Combined d. Midcarpal instability from dorsal ligament damage 2.3 Combined radiocarpal-midcarpal CIND a. Capitolunate instability pattern b. Disruption of Radial an central ligaments

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CIC(Carpal instability combined or complex – Dissociative and dissociative) a. Perilunate with radiocarpal instability b. Perilunate with axial instability c. Radiocarpal with axial instability d. Scapholunate dissociation with ulnar translation ADAPTIVE CARPUS a. Malposition of carpus with distal radial malunion b. Malposition of carpus with scaphoid malunion c. Malposition of carpus with lunate malunion d. Malposition of carpus with madelung deformity

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Rotary Subluxation of the Scaphoid ( Scapholunate injury) Injuries to the dorsal and volar portions of the scapholunate interosseous ligament , the long radiolunate ligament, and the radioscaphocapitate ligament allow the proximal pole of the scaphoid to rotate dorsally. The scaphoid assumes a more vertical orientation, and eventually the scaphoid separates from the lunate ( scapholunate dissociation). Rotary subluxation of the scaphoid may manifest in four types: dynamic static with degenerative arthritis secondary to a condition such as Kienböck osteochondrosis

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Causes Fall on extended wrist fracture-dislocations of the wrist rheumatoid arthritis degenerative changes in the ligaments . Clinical features Pain with activity followed by aching O/E pain and tenderness over dorsal radiocarpal articulation one finger breadth distal to lister tubercle at scapholunate area Scaphoid test or Watson’s test: places four fingers on the dorsum of the radius with the thumb on the scaphoid tuberosity , Ulnar deviation of the wrist aligns the scaphoid with the long axis of the forearm . Applying thumb pressure to the scaphoid tuberosity , the wrist is returned to radial deviation, maintaining the thumb pressure on the scaphoid tuberosity . If the scaphoid is sufficiently unstable, the proximal pole is driven dorsally, and pain results.

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Finger extension test: patient is asked to extend the index and middle figer against resistance with wrist held in 90 degree flexion Pain is elicited at the ligament in presence of acute dislocation The scaphoid rotation leads to the development of dorsal intercalated segment instability, in which the scapholunate angle is more than 60 degrees, and the capitolunate angle is more than 20 degrees

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the diagnosis of static rotary subluxation of the scaphoid can be made on an anteroposterior radiographic view when a gap of more than 2 mm is noted between the scaphoid and the lunate bones. This gap is seen to increase with an anteroposterior view taken with the fist clenched. Other findings on the anteroposterior view include apparent shortening of the scaphoid and the so-called cortical ring appearance of the axial projection of the scaphoid . Terry thomas sign Cortical ring app

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DIAGNOSIS: Wrist arthrography is commonly used in the diagnosis of SL ligament tear. In normal wrist , there si normally no communication between radiocarpal and intercarpal joint Any abnormal flow of contrast from one articular space to another is pathogenic. Wrist aarthroscopy is the gold standard for diagnosing a carpal ligament injury.

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TREATMENT: Closed treatment for acute rotary subluxation of the scaphoid consists of attempting reduction by placing the wrist in neutral flexion and a few degrees of ulnar deviation Percutaneous pinning with one Kirschner wire placed through the scaphoid into the capitate and a second placed through the scaphoid into the lunate . If closed reduction is unsuccessful, arthroscopic reduction and percutaneous pin fixation can be attempted; however, open reduction through a dorsal approach with closure of the scapholunate gap, Kirschner wire internal fixation of the lunate to the scaphoid , and ligament repair usually are indicated. Management of an old rotary subluxation of the scaphoid may require reconstruction of the scapholunate interosseous ligament with a segment of the extensor carpi radialis brevis tendon plus Kirschner wire fixation after the graft has been passed through the scaphoid into the adjoining lunate .

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Anterior Dislocation of the Lunate The most common carpal dislocation .On a lateral radiographic view of the normal wrist, the half-moon–shaped profile of the lunate articulates with the cup of the distal radius proximally and with the rounded proximal capitate distally. On an anteroposterior view, the normal rectangular profile of the lunate when dislocated becomes triangular because of its tilt.

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An anteriorly dislocated lunate can cause acute compression of the median nerve which if prolonged can result in a permanent palsy. If a patient's condition permits, and if swelling is not excessive, the lunate bone should be reduced promptly. When the injury is treated early, manipulative reduction usually is possible, and immobilization for 3 weeks with the wrist in slight flexion is required. When treated after 3 weeks, the injury can be difficult to reduce by manipulation, and open reduction may be necessary. Campbell et al. suggested a dorsal approach to clean out the space to receive the lunate . Hill suggested a palmar approach, however, to decompress the median nerve as the lunate is reduced. At times, a combined dorsal and palmar approach may be required. When the lunate cannot be reduced by open reduction, a reconstructive procedure, such as proximal row carpectomy or arthrodesis , may be necessary.

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RADIOCARPAL INSTABILITY The radiocarpal joint is constrained by the palmar and ulnar inclined distal radius and proximal row is held to distal radius by Strong radioscaphoid RSC long Short RL UL Disruption of these anatomical constraints lead to radiocarpal instability This usually caused by inflamatory arthritis and less commonly by trauma Clinically , proximal carpal row can be displaced radially or ulnarly In ulnar translocation The whole carpal is displaced ulnarly and palmarly So space between radial styloid and scaphoid is widened

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TREATMENT Treatment of this injury is difficult therefore fusion of radiolunate joint is best for stable wrist. Radial translocation is rare and occur with malunited radius fracture and treatment is correction of malunited radius.

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MIDCARPAL INSTABILITY It involves dissociation between proximal and distal carpal row and sometime involves radiocarpal joint as well The midcarpal is stabilized by midcarpal crossing ligaments particularly Palmar triquetral hamate capitate , dorsal STT, scaphocapitate ligaments These ligament help in smooth transition of proximal row from flexion to extension as the wrist deviates ulnarly Hence damage too these ligaments allows wrist to fall in VISI deformity and lose smooth transition an produce sudden clunk on ulnar deviation It is commonly associated with generalized ligament laxity and rarely due to trauma. Palmar MCI IS common where proximal row is held in flexion producing VISI instability Clasicaly there is sagging of midcarpal palmarly and painful clunk when wrist is ulnarly deviated and pronated and sag is corrected in ulnar deviation.

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These patients are treated conservatively initially with nsaids and splinting then strenghtening programme started If this treatment fails then surgery is indicated : Triquetral hamate joint fusion or tenton recontruction with ECRB tendon. TREATMENT

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Sequential stages of lesser-arc injury. Stage I represents a scapholunate failure that results in a scapholunate dissociation or rotary subluxation of the scaphoid . Stage II represents a capitolunate failure that results in a dislocation of the capitate ( perilunate dislocation). Stage III represents a triquetrolunate failure because the articulation between the lunate and triquetrum is disrupted, leading to a midcarpal dislocation. Stage IV represents a complete lunate disruption, caused by dorsal radiocarpal ligament failure.

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Carpal instability adaptive This is carpal instability secondary to pathology outside the wrist joint. Most common recognized cause is Malunited Distal Radius fracture. In dorsally displaced malunited fracture , the lunate is dorsiflexed in relation to capitate This will lead to progressive pain at midcarpal joint with occasional midcarpal click. Corrective osteotomy of distal radius provides resolution of pain and midcarpal instability.

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AXIAL INSTABILITIES Axial (longitudinal) instabilities are a type of carpal instability in which the injury affects longitudinal support or alignment of the wrist rather than transverse alignment of the proximal and distal carpal rows. Crush injuries that flatten the hand cause this axial instability The basic pathophysiology is collapse of the carpal arch, often with tearing or avulsion of the bony origins of the transverse carpal ligament. The focus of this injury is usually in the distal carpus and adjacent metacarpals The most common pattern is separation of either radial or ulnar column of the carpus with their metacarpal rays from the central carpus . Provocative stress x-rays, CT scanning, or MRI should be obtained preoperatively. Evidence of neurological, vascular, musculotendinous , and ligamentous damage is usually present, often to a severe degree.

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Urgent surgical intervention is often indicated to salvage neurovascular function and restore skeletal alignment. Traction can help reduce the axial displacement. Fractures and dislocations, once reduced, can be maintained by Kirschner wires and lag screws. Early active motion of the hand helps prevent adhesions of the flexor and extensor tendons. Rehabilitation is often prolonged, and the prognosis depends mainly on the severity of soft-tissue damage

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Treatment Options for Wrist Ligament Injuries and Instability Acute wrist ligament injuries : closed or arthroscopically controlled manipulation and percutaneous pinning. If closed methods are unsuccessful, open repair or reconstruction of ligaments may be required. Instability problems that are seen later and have no significant arthrosis , ligament reconstruction, capsular imbrication , and limited intercarpal arthrodesis are considered. If there is fixed deformity, arthrosis , pain, or interference with function, excisional arthroplasty (e.g., proximal row carpectomy ), limited intercarpal arthrodesis , and wrist fusion can preserve function and relieve pain.

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Geissler et al. proposed a classification of carpal instabilities and treatment options, based on arthroscopic findings Classification of Carpal Instability Grade Description Treatment 1 Attenuation or hemorrhage of interosseous ligament Immobilization in as seen from radiocarpal space.No incongruency of cast capal alignment in midcarpal space 2 Attenuation or hemorrage of interosseous ligament as Arthroscopic seen from radiocarpal space.Incongruency or step-off pinning sign in midcarpal space.Slight gap may be present in carpal bones 3 Incongurency or step off of carpal alignment as seen Arthoscopic raiocarpal or midcarpal space.Probe may passed through pinning or open gap between carpal bones repair 4 Incongurency or step off of carpal alignment as seen open repair fom radiocarpal or midcarpal space.gross instability with manipulation. A 2.7 mm arthroscope may be passed through gap between carpal bones

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Ligament repair It is done when closed reduction of rotary subluxation of scaphoid and other carpal instability cannot be done satisfactorily Technique Incision on dorsum of hand ulnar to lister tubercle Extensor tendons retracted

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ligament reconstruction Indications: patients whose ligament ruptures cannot be maintained with closed reduction patients who have their diagnosis made after about 1 month. Contraindication: patients with associated degenerative joint disease Ligament reconstruction can be accomplished with free tendon grafts or tenodesis using prolonged slips of wrist flexors and extensors. Possible Complications : Tendons, used as substitute ligaments, may stretch and become lax. Bone tunnels for passage of tendon slips may lead to fracture and possibly avascular changes

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Capsulodesis Blatt found capsulodesis useful for two conditions causing impairment of wrist function— Scapholunate dissociation The caput ulnae syndrome caused by DRUJ incongruity. Blatt found it particularly useful in patients with symptomatic dynamic instability and a static deformity and applied it to all patients with reducible scapholunate dissociations . A single criterion for this procedure is the ability to anatomically reduce the scaphoid at the time of surgery.”

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Dorsal capsulodesis ( Blatt ). A, Proximal-based ligamentous flap is developed from dorsal wrist capsule. Notch for ligament insertion is created in dorsal cortex of distal scaphoid pole. B, Scaphoid has been derotated , and ligament has been inserted with pull-out wire suture

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LIMITED WRIST ARTHRODESIS: Successful fusion of the scaphoid , trapezium, and trapezoid is called Triscaphe arthrodesis . Indication degenerative arthritis of the scaphotrapezial -trapezoid joint with normal thumb carpometacarpal joint, radial hand dislocations rotary subluxation of the scaphoid . Contraindication: radioscaphoid arthritis early phases of degenerative changes in the wrist progressing to the scapholunate advanced collapse wrist.

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Arthrodesis of the scaphoid , capitate , and lunate ; capitate , hamate , lunate , and triquetrum ; hamate and triquetrum ; radius to lunate ; and radius to scaphoid can be done similarly Non union was the most frequent problem .

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