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Chronic Intercarpal Instability

Chronic Intercarpal Instability

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Chronic Intercarpal Instability

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  1. Chronic Intercarpal Instability Courtesy of Leon Benson

  2. Goals • To review the evaluation and management of patients who have symptomatic, chronic carpal instability

  3. Definitions • Dynamic instability - (incomplete injury) maintains normal alignment at rest but will collapse under applied load • Static Instability - (complete injury) abnormal intercarpal alignment on static radiographs

  4. Definitions • Carpal Instability – Dissociative: Instability occurs between the individual bones. • Carpal Instability – Non-Dissociative: Instability occurs between the row of bones

  5. Stability • 2 Moments • Flexion moment-Scaphoid • Extension Moment- Hamate and capitate to the Triquetrum Courtesy of Leon S. Benson, MD

  6. Conflicting Moments • Scaphoid- Palmar flexes Courtesy of Leon S. Benson, MD

  7. Conflicting Moments • Triquetrum Dorsiflexes • Takes lunate with it Courtesy of Leon S. Benson, MD

  8. Fate of the Lunate • Lunate-Majority of boney moments are in Flexion Courtesy of Leon S. Benson, MD

  9. Fate of the Lunate Will follow the scaphoid into extension Courtesy of Leon S. Benson, MD Courtesy of Leon S. Benson, MD

  10. DISI • Release Lunate from the Scaphoid • Dorsiflexes with the triquetrum • Increases SL and CL angle Courtesy of Leon S. Benson, MD

  11. Unleash the lunate from the triquetrum Follows the scaphoid VISI Courtesy of Leon S. Benson, MD

  12. Mid-Carpal Instability • Dissociation between the Proximal and the Distal Rows Courtesy of Leon S. Benson, MD

  13. Scapholunate Ligament Injuries In 1984, Watson and Ballet described the inexorable degenerative nature of SL injury and coined the term SLAC wrist Courtesy of Leon S. Benson, MD

  14. SLAC • Scaphoid palmarflexes-shifts forces to the dorsum of the radius Courtesy of Leon S. Benson, MD

  15. SLAC • Lunate dorsiflexes-Capitate flexes and incongruous midcarpal joint Courtesy of Leon S. Benson, MD

  16. SLAC Gap Formation Courtesy of Leon S. Benson, MD

  17. SLAC treatment • Attempted Salvage v. arthrodesis Courtesy of Leon S. Benson, MD

  18. Scapholunate Ligament Injuries Partial tear of the Interosseous Ligament Dislocation of the Lunate Courtesy of Leon S. Benson, MD

  19. Anatomy: Palmar Extrinsic Ligaments • Palmar Radial Extrinsics- • Radiocarpal stabilizers Courtesy of Leon S. Benson, MD

  20. Radial Extrinsic Ligaments:Gross/Arthroscopic Anatomy S L Scaphoid RSC RADIAL EXTRINSIC LIGAMENTS LRL RSL RADIUS Courtesy of Leon S. Benson, MD

  21. Radial Extrinsic Ligaments:Gross/Arthroscopic Anatomy S L RSL Courtesy of Leon S. Benson, MD

  22. Radial Extrinsics:Role in SL Instability-??? LRL RSC Radius Courtesy of Leon S. Benson, MD

  23. Radial Extrinsics:Role in SL Instability RSC RLR Courtesy of Leon S. Benson, MD

  24. Radial Extrinsics:Role in Radiocarpal Stability Flexor Tendons Radial Extrinsics Courtesy of Leon S. Benson, MD

  25. Interosseous Ligaments- “3 sided Box”Berger et al JHS 1999 24-A S L Courtesy of Leon S. Benson, MD Berger et al JHS

  26. Interosseous- “3 sided Box”Berger et al JHS 1999 24-A • Palmar-Thin T.S. = (117N) • Central-fibrocartilage T.S. = (62N) • Dorsal-Thick T.S. = (260N) Courtesy of Leon S. Benson, MD Bergeret al JHS

  27. SLIO Anatomy:Central 1/3 (Proximal) Dorsal SLIO Proximal SLIO Courtesy of Leon S. Benson, MD

  28. Dorsal ligaments:DRC/DIC Increasing interest in SL and LT stability through the DRC and the DIC ligaments Courtesy of Leon S. Benson, MD

  29. Anatomy-Dorsal DRC/Dorsal Capsule DIC - 2 parts distal - thin -prox –thick “consistent attachment to the lunate and the scaphoid” Viegas et al 24-A Courtesy of Leon S. Benson, MD

  30. Anatomy: Dorsal SLIO/DIC L SLIO DIC S Courtesy of Leon S. Benson, MD

  31. Anatomy- Dorsal Role of the DRC/DIC DRC “consistent osseus attachment to the dorsal lunate” Viegas et al JHS 24-A C Courtesy of Leon S. Benson, MD

  32. Anatomy: Dorsal Radiocarpal Lig L DRC SLIO S Courtesy of Leon S. Benson, MD

  33. Pathophysiology:Sequential Sectioning Studies:EXTRINSICS + SLIO= NO CHANGE MEAN SL=49.8 +/- 5.6 MEAN CL=1.9 +/-2.2 Courtesy of Leon S. Benson, MD

  34. Pathophysiology:Sequential Sectioning Studies:EXTRINSICS + SLIO= NO CHANGE Courtesy of Leon S. Benson, MD

  35. Pathophysiology:Sequential Sectioning Studies:SLIO+DIC=SCAPHOID ROTATES Courtesy of Leon S. Benson, MD

  36. Pathophysiology:Sequential Sectioning Studies:SLIO+DIC=SCAPHOID ROTATES Courtesy of Leon S. Benson, MD

  37. Pathophysiology:Sequential Sectioning Studies:SLIO+DC+DRC=DISI SL = s 71.4 CL= s 24 + = Courtesy of Leon S. Benson, MD

  38. Pathophysiology:Sequential Sectioning Studies:SLIO+DC+DRC=DISI Courtesy of Leon S. Benson, MD

  39. Assessment of Interosseous Ligament Injury Geissler • Attenuation • Incomplete Tear • Complete Tear interosseous ligament • Complete Tear SLIO S L Courtesy of Leon S. Benson, MD

  40. Assessment of Interosseous Ligament Injury • Attenuation • Incomplete Tear • Complete Tear interosseous ligament • Complete Tear SLIO Courtesy of Leon S. Benson, MD

  41. Assessment of Interosseous Ligament Injury • Attenuation • Incomplete Tear • Complete Tear interosseous ligament • Complete Tear SLIO Perforation (30% asymptomatic pts) Courtesy of Leon S. Benson, MD

  42. Attenuation Incomplete Tear Complete Tear interosseous ligament-1mm Complete Tear Assessment of Interosseous Ligament Injury Courtesy of Leon S. Benson, MD

  43. Attenuation Incomplete Tear Complete Tear interosseous ligament Complete Tear “drive through” Assessment of Interosseous Ligament Injury Courtesy of Leon S. Benson, MD

  44. Assessment of Interosseous Ligament Injury • DIC /DRC insertions on Scaphoid and Lunate L DIC S Courtesy of Leon S. Benson, MD

  45. Assessment of Interosseous Ligament Injury • DIC /DRC insertions on Scaphoid and Lunate Courtesy of Leon S. Benson, MD

  46. Assessment of Interosseous Ligament Injury • Congruity of the SL articulation best viewed from the midcarpal joint Ulnar midcarpal hamate S L Courtesy of Leon S. Benson, MD

  47. Treatment of Interosseous Ligament Injuries-SLIO SLIO Incomplete Tear Dorsal SLIO-INTACT Courtesy of Leon S. Benson, MD

  48. Treatment of Interosseous Ligament Injuries-SLIO SLIO Incomplete Tear • Dorsal SLIO-INTACT Courtesy of Leon S. Benson, MD

  49. Treatment of Interosseous Ligament Injuries-SLIO SLIO Incomplete Tear • Dorsal SLIO-INTACT Courtesy of Leon S. Benson, MD

  50. Treatment of Interosseous Ligament Injuries-SLIO SLIO Incomplete Tear • Dorsal SLIO-INTACT • Debride proximal SLIO Courtesy of Leon S. Benson, MD