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Carpal Bone Pathology and Instability

Carpal instability and bone pathology, including SLAC wrist, Kienböck's disease, and CIND, with a focus on ligamentous dissociation and osteonecrosis.

Overview

Carpal instability remains an unresolved clinical problem with inconsistent results and ongoing concerns regarding complications [6]. While diagnostic and treatment options have evolved, objective evidence on long-term outcomes for the unstable wrist is lacking, highlighting the need for collaborative working and referral to specialized centers to run randomized controlled trials [5]. Anatomical anterior and posterior reconstruction for scapholunate dissociation showed that no patients in a preliminary series of ten required secondary surgery or treatment related to carpal stabilization [7].

Long-term functional results vary by procedure. Long-term results of dorsal intercarpal ligament capsulodesis for chronic scapholunate instability show that while ongoing instability resulted in early arthritic degeneration, most patients had acceptable long-term wrist function [1]. Modified Brunelli tenodesis for static scapholunate instability resulted in arthritic changes in only 1 of 8 cases over 10 years, suggesting carpal stability obtained is sufficient for good functional long-term results [2]. Proximal row carpectomy (PRC) is not recommended for the management of scapholunate dissociation in the absence of degenerative changes due to disappointing results compared to other treatments [25].

Diagnostic accuracy is critical. There is convincing evidence supporting the role of arthroscopy in diagnosis and assessment of factors involved in the development of carpal instability [14]. Correct diagnosis and proper surgical indications are necessary to reduce the number and enhance the efficacy of operations required to treat carpal boss [23]. Terminology has shifted: the terms 'carpal instability nondissociative' or 'proximal row instability' are recommended instead of 'midcarpal instability' because the pathology involves both the radiocarpal and midcarpal joints [9].

Non-scaphoid carpal fractures are exceedingly rare, comprising approximately 1.1% of all fractures [12]. Management of non-scaphoid carpal fractures depends on specific fracture pattern, displacement, and associated ligamentous injuries [12]. Outcomes for isolated non-scaphoid carpal fractures are generally good, but are complicated by nonunion and instability in cases with concomitant injuries [12]. Distal scaphoid resection for arthritis secondary to scaphoid nonunion is a durable procedure with good long-term results, with 94% of patients remaining satisfied and no further wrist collapse or radiocarpal arthritis developing [10]. Excisional arthroplasty is highly recommended for idiopathic, symptomatic, isolated scaphotrapeziotrapezoidal (STT) osteoarthritis without midcarpal instability [26]. Excisional arthroplasty for isolated STT osteoarthritis provides reliable results, is less technically demanding, requires less prolonged immobilization, and has fewer complications than localized arthrodesis [26].

Anatomy & Pathophysiology

Carpal instability represents a complex array of maladaptive and posttraumatic conditions that lead to the inability of the wrist to maintain anatomic relationships under normal loads [3]. The distal carpal row exhibits negligible intercarpal motion, whereas the proximal row drives motion [17]. Three-dimensional and four-dimensional imaging provide insight into carpal kinematics, the function of individual ligaments, and their roles in joint motion, stability, and injuries [28].

Ligamentous Stability: During simple unresisted wrist motions, force in the scapholunate interosseous ligament does not exceed 20 N [29]. A pattern of kinematic changes is established after scapholunate ligament injury, despite individual variance [32]. The effect of ligament sectioning on producing carpal instability may be moderated by the bone geometry of the radiocarpal joint [34]. Injury to the dorsal wrist extrinsic carpal ligaments exacerbates volar radiocarpal instability [39]. There is a relationship between scapholunate kinematics and laxity at the level of the interosseous ligaments [40].

Osseous and Kinematic Variants: Resection of up to 25% of the distal scaphoid did not significantly influence carpal kinematics and induced mild lunate extension deformity [35]. Performing a trapeziectomy followed by up to 4 mm of proximal trapezoid resection has a negligible effect upon carpal, specifically lunocapitate and scapholunate, stability [43]. The four-corner kinematics of the wrist joint are different between type 1 and type 2 lunates [45]. Type 2 lunates exhibit increased lunotriquetral shearing motion during radioulnar deviation [45]. In type 2 lunates, the hamate contacts the lunate at ulnar deviation and ulnar flexion [45].

Classification

Row Theory: This model more clearly accounts for wrist function than the column theory [20]. Advances in 3-dimensional and 4-dimensional imaging establish that the distal carpal row has negligible intercarpal motion while the proximal row drives motion [17]. Carpal instability is a complex array of maladaptive and posttraumatic conditions that lead to the inability of the wrist to maintain anatomic relationships under normal loads [3].

Midcarpal Instability: This term represents multiple distinct entities involving abnormal force transmission across the midcarpal joint [51]. The pathology often involves dissociative ligament disruptions rather than being truly nondissociative [48]. Consequently, the terms 'carpal instability nondissociative' or 'proximal row instability' are recommended instead of 'midcarpal instability' because the pathology involves both the radiocarpal and midcarpal joints [9].

Other Considerations: Carpal fractures other than the scaphoid are exceedingly rare, comprising approximately 1.1% of all fractures [12]. Management of carpal fractures depends on the specific fracture pattern, displacement, and associated ligamentous injuries [12]. Outcomes for isolated carpal fractures are generally good but complicated by nonunion and instability in cases with concomitant injuries [12]. Scapholunate dissociation is associated with two-part articular fractures of the distal radius [54].

Clinical Presentation

Carpal instability represents a complex array of maladaptive and posttraumatic conditions that lead to the inability of the wrist to maintain anatomic relationships under normal loads [3]. Carpal fractures other than the scaphoid are exceedingly rare, comprising approximately 1.1% of all fractures [12]. These injuries, along with ligament injury and resulting carpal instability, represent a spectrum of conditions in the athletic patient, occurring in both acute traumatic settings and chronic overuse syndromes [42].

Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [18]. Early accurate diagnosis of intrinsic carpal ligament injuries provides for the best outcomes [13]. Delayed diagnosis of intrinsic carpal ligament injuries leads to arthritis within 10 years if not treated [13].

Carpal instability nondissociative or proximal row instability involves pathology in both the radiocarpal and midcarpal joints [9]. Management of carpal fractures depends on the specific fracture pattern, displacement, and associated ligamentous injuries [12]. Outcomes for isolated carpal fractures are generally good, but are complicated by nonunion and instability in cases with concomitant injuries [12].

Patients with scaphotrapezium-trapezoidal (STT) arthritis may present with carpal instability not related to radiographic scapholunate instability, characterized by a normal scapholunate angle with scaphoid extension [15]. Distinguishing clinical and radiographic features of neoplasms affecting the carpus are often absent due to the small size of carpal bones [46].

Investigations

Carpal instability represents a complex array of maladaptive and posttraumatic conditions that lead to the inability of the wrist to maintain anatomic relationships under normal loads [3]. Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [18].

Plain radiography: Measurements in the middle of the scapholunate joint in neutral and 30° of ulnar deviation under fluoroscopic imaging best capture all stages of ligamentous disruptions [70]. Patients with scaphotrapeziotrapezoid (STT) arthritis may present with carpal instability not related to radiographic scapholunate instability, characterized by a normal scapholunate angle with scaphoid extension [15]. Acute intra-articular fractures can destabilize the proximal carpal row into a pattern of nondissociative carpal instability, associated with concomitant radiocarpal ligament lesions and residual articular incongruity [27].

MRI: Magnetic resonance imaging using advanced multiparametric sequences may facilitate accurate, noninvasive assessment of articular cartilage changes after distal radius fracture without the need for a contrast agent [68]. MRI may be more helpful to exclude potential alternative diagnoses in the patient with ulnar wrist pain, specifically for detecting longitudinal split tears of the ulnotriquetral ligament [63]. A scaphoid fracture is the most common injury in patients with posttraumatic radial wrist tenderness, but it is not clear whether diagnosis of subtle injuries only demonstrated on MRI improves outcomes [66].

CT: CT or MR imaging is recommended for the detection of carpal collapse in Kienböck’s disease because the presence or absence of collapse is important for surgical decision-making [47].

Cineradiography: Cineradiography has a high diagnostic value for diagnosing scapholunate dissociations [69]. However, cineradiography is a qualitative rather than a quantitative tool for diagnosing carpal instability, and more research is needed to determine its exact role [58].

Other Considerations: Dorsal wrist capsular impingement is a clinical diagnosis, although magnetic resonance imaging may be helpful in evaluating for other pathologies [53]. The clinical implications of osteolysis in the smaller bones of the hand and wrist following the use of polyetheretherketone suture anchors remain unclear [21].

Treatment

Non-Operative

Conservative management is generally insufficient for complex instability patterns. Nonsurgical management of perilunate fracture-dislocations results in progressive arthritis and poor long-term outcomes [64]. Conservative management failed in two cases of post-traumatic palmar carpal subluxation at extremes of the condition [22]. However, spontaneous healing of an established proximal pole scaphoid non-union can occur without surgical intervention or immobilization [62].

Operative

Indications: Correct diagnosis and proper surgical indications are necessary to reduce the number and enhance the efficacy of operations required to treat carpal boss [23]. Proximal row carpectomy is not recommended for the management of scapholunate dissociation in the absence of degenerative changes due to disappointing results compared to other treatments [25]. Static carpal malalignment does not preclude radius-shortening osteotomy for advanced Kienböck's disease, given the high percentage of successful clinical outcomes [24]. Primary wrist fusion is recommended for pancarpal dissociation with palmar capitate fracture-dislocation in cases of significant displacement with unsalvageable devascularized fragments [52]. The indication for using intramedullary nail fixation should continue to be limited to extra-articular and simple intra-articular distal radius fractures until additional data can be obtained [57].

Surgical Approach / Technique: Dorsal intercarpal ligament capsulodesis for chronic scapholunate instability results in ongoing scapholunate instability and early arthritic degeneration, but most patients have acceptable long-term wrist function [1]. Modified Brunelli tenodesis for static scapholunate instability resulted in arthritic changes in only 1 of 8 cases over 10 years, suggesting carpal stability is sufficient for good functional long-term results [2]. Anatomical anterior and posterior reconstruction for scapholunate dissociation resulted in no patients requiring secondary surgery or treatment related to carpal stabilization in a preliminary study of ten patients [7]. Radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique at an average follow-up of 17.9 months [16]. The Minimally Invasive Radiolunate Imbrication Neutralization (MIRLIN) procedure addresses critical stabilizers to prevent carpal instability and collapse [67]. Distal scaphoid resection for arthritis secondary to scaphoid nonunion is a durable procedure with good long-term results, with 94% of patients remaining satisfied and no further wrist collapse or radiocarpal arthritis developing [10]. Excisional arthroplasty is highly recommended for idiopathic, symptomatic, isolated STT osteoarthritis without midcarpal instability, as it provides reliable results, is less technically demanding, requires less prolonged immobilization, and has fewer complications than localized arthrodesis [26].

Alignment / Balancing Strategy: Correction of carpal alignment in cadaver models may correlate with improved carpal dynamics and improved clinical outcomes [19]. Prompt recognition and surgical treatment with anatomic reduction of carpal malalignment in perilunate dislocations and fracture-dislocations improve the likelihood of optimal, long-term clinical success and patient satisfaction [41].

Other Considerations: The ideal treatment for scapholunate instability remains an unresolved problem with inconsistent results and ongoing concerns regarding complications despite the evolution of diagnostic and treatment options [6]. There is a lack of objective evidence on long-term outcomes for the unstable wrist, highlighting the need for collaborative working and referral to specialized centers for randomized controlled trials [5]. There is convincing evidence supporting the role of arthroscopy in the diagnosis and assessment of factors involved in the development of carpal instability, but weak evidence for the effectiveness of arthroscopic techniques in the actual treatment of this condition [14]. Trapeziectomy should be performed with caution in wrists with dynamic or static carpal instability due to the risk of carpal collapse with a nondissociative pattern of dorsal intercalated segment instability [61]. Acute intra-articular fractures can destabilize the proximal carpal row into a pattern of nondissociative carpal instability due to concomitant radiocarpal ligament lesions and residual articular incongruity [27]. The terms 'carpal instability nondissociative' or 'proximal row instability' are recommended instead of 'midcarpal instability' because the pathology involves both the radiocarpal and midcarpal joints [9].

Complications

Instability: Carpal instability represents a complex array of maladaptive and posttraumatic conditions that lead to the inability of the wrist to maintain anatomic relationships under normal loads [3]. Chronic scapholunate instability can result in early arthritic degeneration [1]. The ideal treatment for scapholunate instability remains an unresolved problem with inconsistent results and ongoing concerns regarding complications [6]. Delayed diagnosis of intrinsic carpal ligament injuries leads to arthritis within 10 years if not treated [13]. Patients with scaphotrapezium-trapezoidal (STT) arthritis may present with carpal instability not related to radiographic scapholunate instability, characterized by a normal scapholunate angle with scaphoid extension [15]. Radiographic carpal collapse and ulnar translocation can occur without corresponding patient symptoms [4].

Other Considerations: Avascular necrosis (AVN) of the carpal bones other than Kienböck disease is a rare cause of chronic wrist pain with a poorly understood natural history [65]. Carpal bone tunnel collapse is an underreported complication of ligament reconstruction for chronic scapholunate instability requiring the creation of a bone tunnel, with potentially substantial consequences [50].

Recovery

Light activity (weeks): Evidence does not specify a week range for light activity or desk work in the provided data.

Full activity (months): Evidence does not specify a month range for full activity or manual work in the provided data.

Complete recovery / outcome plateau (months): Long-term outcomes are assessed at intervals ranging from 10 years to adolescence (age 17), indicating that functional stability and pain resolution are durable endpoints. Anatomical front and back reconstruction (ANAFAB technique) for scapholunate dissociation demonstrated improved radiographic and patient-reported outcome parameters at an average follow-up of 17.9 months [16].

Rehabilitation protocol: Specific rehabilitation protocols, including PT phasing, immobilisation duration, or weight-bearing progression, are not detailed in the provided evidence.

Functional milestones: * Scapholunate Instability: Long-term results of dorsal intercarpal ligament capsulodesis show that although ongoing instability resulted in early arthritic degeneration, most patients had acceptable long-term wrist function [1]. Modified Brunelli tenodesis for static scapholunate instability resulted in arthritic changes in only 1 of 8 cases over 10 years, suggesting carpal stability is sufficient for good functional long-term results [2]. Early accurate diagnosis of intrinsic carpal ligament injuries provides the best outcomes, while delayed diagnosis leads to arthritis within 10 years if not treated [13]. * Kienböck Disease: Scaphocapitate arthrodesis resulted in radiographic carpal collapse and ulnar translocation, but patients remained asymptomatic [4]. Joint leveling via radius-shortening osteotomy for advanced Kienböck's disease yields a high percentage of successful clinical outcomes despite static carpal malalignment [24]. Long-term follow-up at age 17 for Kienböck disease in a child with cerebral palsy showed no pain, normal wrist motion, and no radiocarpal osteoarthritis [60]. Proximal row carpectomy is a reliable and durable procedure for Lichtman stage IIIA or IIIB Kienböck's disease at an average follow-up of 10 years [71]. Radiographic progression of Kienböck disease over 1 year or more is slight on average, regardless of whether treatment involves radial shortening or no surgery [73]. * Scaphoid Nonunion: Distal scaphoid resection for arthritis secondary to scaphoid nonunion is a durable procedure with good long-term results, with 94% of patients remaining satisfied and no further wrist collapse or radiocarpal arthritis developing [10].

Other Considerations: * Madelung’s Deformity: Double bone forearm osteotomy in adolescence for Madelung’s deformity provided long-lasting functional improvement and long-term correction of distal radioulnar and radiocarpal subluxations [59].

Key Evidence

  • [L3] Although the consequent ongoing scapholunate instability resulted in early arthritic degeneration, most patients had acceptable long-term function of the wrist. (10.1302/0301-620x.94b12.30007)
  • [L4] The fact that we observed arthritic changes in only 1 of 8 cases suggests that carpal stability obtained by this procedure is probably sufficient to obtain good functional long-term results. (10.1016/j.jhsa.2013.02.022)
  • [L5] Carpal instability is a complex array of maladaptive and posttraumatic conditions that lead to the inability of the wrist to maintain anatomic relationships under normal loads. (10.1016/j.hcl.2015.04.011)
  • [L4] Although radiographic carpal collapse and ulnar translocation occurred, patients were not symptomatic. (10.1016/j.jhsa.2014.12.013)
  • [L5] The aim of this themed issue is to provide answers regarding the investigation and management of the unstable wrist, highlighting the need for collaborative working and the referral of cases to specialized centers to run randomized controlled trials due to the lack of objective evidence on long-term outcomes. (10.1177/1753193415617100)
  • [L5] Despite the evolution of diagnostic and treatment options, the ideal treatment for scapholunate instability remains an unresolved problem with inconsistent results and ongoing concerns regarding complications. (10.1177/17531934221148009)
  • [L4] No patient required secondary surgery or treatment related to the carpal stabilization. (10.1177/1753193419886536)
  • [Letter] The authors recommend using the terms 'carpal instability nondissociative' or 'proximal row instability' instead of 'midcarpal instability' because the pathology involves both the radiocarpal and midcarpal joints. (10.1016/j.jhsa.2022.05.009)
  • [L4] Distal scaphoid resection is a durable procedure with good long-term results. 94% of patients remained satisfied, and no further wrist collapse or radiocarpal arthritis developed. (10.1016/s0363-5023(11)60002-6)
  • [L4] Carpal fractures other than the scaphoid are exceedingly rare and comprise approximately 1.1% of all fractures; management depends on the specific fracture pattern, displacement, and associated ligamentous injuries, with outcomes generally good for isolated injuries but complicated by nonunion and instability in cases with concomitant injuries. (10.1016/j.jhsa.2013.10.030)
  • [L5] Early accurate diagnosis of intrinsic carpal ligament injuries provides for best outcomes, while delayed diagnosis leads to arthritis within 10 years if not treated. (10.1016/j.hcl.2015.01.003)
  • [L4] There is convincing evidence supporting the role of arthroscopy in diagnosis and assessment of factors involved in the development of carpal instability, but weak evidence for the effectiveness of arthroscopic techniques in the actual treatment of this condition. (10.1177/1753193415616276)
  • [L4] Patients with STT arthritis may present with carpal instability not related to radiographic scapholunate instability, characterized by a normal scapholunate angle with scaphoid extension. (10.1016/j.jhsa.2006.10.021)
  • [L4] At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique. (10.1016/j.jhsa.2023.12.012)
  • [L5] Advances in 3-dimensional and 4-dimensional imaging have provided clearer insight into carpal kinematics, establishing that the distal carpal row has negligible intercarpal motion while the proximal row drives motion. (10.1016/j.jhsa.2016.07.105)
  • [L5] This correction might correlate with improved carpal dynamics and improved clinical outcomes. (10.1016/j.jhsa.2010.06.029)
  • [L5] The article summarizes current thinking regarding the diagnosis and treatment of clinically important carpal instabilities, emphasizing that the row theory more clearly accounts for the function of the wrist than the column theory. (10.2106/00004623-199503000-00019)
  • [L4] The clinical implications of osteolysis in the smaller bones of the hand and wrist remain unclear. (10.1016/j.jhsa.2023.05.024)
  • [L4] These two cases show the results of the failure of conservative management in two extremes of palmar carpal subluxation. (10.2106/00004623-198365070-00016)
  • [L4] Correct diagnosis and proper surgical indications are necessary to reduce the number and enhance the efficacy of operations required to treat carpal boss. (10.1016/j.jhsa.2007.11.029)
  • [L4] Static carpal malalignment does not preclude radius-shortening osteotomy given the high percentage of successful clinical outcomes. (10.1016/j.jhsa.2010.08.017)
  • [L4] The authors do not recommend PRC for the management of scapholunate dissociation in the absence of degenerative changes due to disappointing results compared to other treatments. (10.1177/1753193410382719)
  • [L4] Excisional arthroplasty is highly recommended for idiopathic, symptomatic, isolated STT osteoarthritis without midcarpal instability, as it provides reliable results, is less technically demanding, requires less prolonged immobilization, and has fewer complications than localized arthrodesis. (10.1016/j.jhsa.2010.12.016)
  • [L4] This article highlights the existence of possible concomitant radiocarpal ligament lesions and residual articular incongruity associated with acute intra-articular fractures that destabilize the proximal carpal row into a pattern of nondissociative carpal instability. (10.1016/j.jhsa.2019.11.018)
  • [L5] This additional knowledge helps provide further understanding of wrist kinematics, the function of individual ligaments, and their roles in joint motion, stability, and injuries. (10.1016/j.hcl.2006.08.003)
  • [L5] However, during simple unresisted wrist motions, the force did not exceed 20 N. (10.1016/j.jhsa.2015.04.007)
  • [L5] Despite individual variance, a pattern of kinematic changes was established after scapholunate ligament injury. (10.1177/1753193415600669)
  • [L5] The effect of ligament sectioning on producing carpal instability may be moderated by the bone geometry of the radiocarpal joint. (10.1016/j.jhsa.2006.10.018)
  • [L5] Resection of up to 25% of the distal scaphoid did not significantly influence carpal kinematics and induced mild lunate extension deformity. (10.1177/1558944720966717)
  • [L5] Injury to the dorsal wrist extrinsic carpal ligaments exacerbates volar radiocarpal instability. (10.1177/1558944719851210)
  • [L5] Our findings support the theory that there is a relationship between scapholunate kinematics and laxity at the level of the interosseous ligaments. (10.1016/j.jhsa.2019.10.024)
  • [L4] Prompt recognition and surgical treatment with anatomic reduction of carpal malalignment improve the likelihood of optimal, long-term clinical success and patient satisfaction. (10.1016/j.jhsa.2012.07.034)
  • [L5] Carpal fractures, ligament injury, and resulting carpal instability represent a spectrum of injuries to the wrist in the athletic patient, both in the acute traumatic setting and in the more chronic overuse syndromes. (10.1016/j.hcl.2009.05.002)
  • [L5] This biomechanical cadaveric study shows that performing a trapeziectomy followed by up to 4 mm of proximal trapezoid resection has a negligible effect upon carpal, specifically lunocapitate and scapholunate, stability. (10.1016/j.jhsa.2019.06.015)
  • [L4] The four-corner kinematics of the wrist joint are different between type 1 and 2 lunates, with increased lunotriquetral shearing motion in type 2 lunates during radioulnar deviation and hamate contact with the type 2 lunate at ulnar deviation and ulnar flexion. (10.1177/1753193417744420)
  • [L5] The hand surgeon must be familiar with neoplasms affecting the carpus to accurately diagnose and treat patients with wrist pain, as distinguishing clinical and radiographic features are often absent due to the small size of carpal bones. (10.1016/j.hcl.2006.07.006)
  • [L3] CT or MR imaging is recommended as the presence or absence of carpal collapse is important for surgical decision-making. (10.1177/17531934231153966)
  • [Letter] The authors propose that the term midcarpal instability be subclassified into traumatic and nontraumatic categories, as the pathology often involves dissociative ligament disruptions rather than being truly nondissociative. (10.1016/j.jhsa.2022.05.005)
  • [L4] Although the incidence of carpal bone tunnel collapse is unknown, the consequences could be substantial; therefore, patients should be warned of this possibility when discussing complications of ligament reconstruction for chronic scapholunate instability requiring the creation of a bone tunnel. (10.1016/j.jhsa.2023.07.008)
  • [L5] Midcarpal instability is a term representing multiple distinct entities involving abnormal force transmission across the midcarpal joint. (10.5435/jaaos-d-22-00777)
  • [Case_report] They recommend primary wrist fusion in cases of such significant displacement with unsalvageable devascularized fragments. (10.1016/j.otsr.2016.12.023)
  • [L4] Dorsal wrist capsular impingement is a clinical diagnosis; magnetic resonance imaging may be helpful in evaluating for other pathologies. (10.1016/j.jhsa.2016.12.012)
  • [L3] These findings support the need for a higher index of suspicion for scapholunate dissociation in these distal radial fracture subtypes. (10.1177/1753193419826490)
  • [L4] The indication for using the intramedullary nail should continue to be limited to extra-articular and simple intra-articular distal radius fractures until additional data can be obtained. (10.1016/j.jhsa.2008.07.004)
  • [L3] Cineradiography is a qualitative rather than a quantitative tool, and more research is needed to determine its exact role in diagnosing carpal instability. (10.1177/1753193417694820)
  • [L4] Double bone forearm osteotomy in adolescence brought long-lasting functional improvement and provided long-term correction of distal radioulnar and radiocarpal subluxations. (10.1054/jhsb.1999.0304)
  • [Case_report] Long-term follow-up at age 17 showed no pain, normal wrist motion, and no radiocarpal osteoarthritis. (10.2106/00004623-199610000-00016)
  • [L3] In wrists with dynamic or static carpal instability, trapeziectomy should be performed with caution due to the risk of carpal collapse with a nondissociative pattern of dorsal intercalated segment instability. (10.1177/1558944720939198)
  • [L4] This report documents the first case of spontaneous healing of an established proximal pole scaphoid non-union without surgical intervention or immobilization. (10.1007/s11552-011-9328-6)
  • [L3] MRI may be more helpful to exclude potential alternative diagnoses in the patient with ulnar wrist pain. (10.1016/j.jhsa.2013.05.040)
  • [L5] AVN of the carpal bones other than Kienböck disease is a rare cause of chronic wrist pain with a poorly understood natural history. (10.1016/j.jhsa.2019.05.022)
  • [L2] A scaphoid fracture was by far the most common injury, but it is not clear whether diagnosis of subtle injuries only demonstrated on MRI improves outcomes. (10.1016/j.jhsa.2012.09.034)
  • [L4] The technique addresses critical stabilizers to prevent carpal instability and collapse. (10.1016/j.jhsa.2024.10.019)
  • [L4] Magnetic resonance imaging using advanced multiparametric sequences may facilitate accurate, noninvasive assessment of articular cartilage changes after distal radius fracture without the need for a contrast agent. (10.1016/j.jhsa.2020.02.009)
  • [L3] Cineradiography has a high diagnostic value for diagnosing scapholunate dissociations. (10.1177/1753193413489056)
  • [L5] Measurements in the middle of the scapholunate joint in neutral and 30° of ulnar deviation under fluoroscopic imaging best capture all stages of ligamentous disruptions. (10.1177/1558944717729219)
  • [L4] At an average follow-up of 10 years, proximal row carpectomy is a reliable and durable procedure for patients with Lichtman stage IIIA or IIIB Kienböck's disease. (10.1016/j.jhsa.2008.02.031)
  • [L4] Radiographic progression of Kienböck over 1 year or more seems slight on average regardless of treatment. (10.1016/j.jhsa.2016.02.016)

See Also

References

[1] Long-term results of dorsal intercarpal ligament capsulodesis for the treatment of chronic scapholunate instability. The Journal of Bone and Joint Surgery. British volume. 2012. DOI: 10.1302/0301-620x.94b12.30007

[2] Treatment of Static Scapholunate Instability With Modified Brunelli Tenodesis: Results Over 10 Years. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.02.022

[3] Carpal Ligament Injuries, Pathomechanics, and Classification. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.04.011

[4] Scaphocapitate Arthrodesis for Kienböck Disease. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.12.013

[5] Special issue: the unstable wrist. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415617100

[6] Scapholunate instability: why are the surgical outcomes still so far from ideal?. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934221148009

[7] Anatomical anterior and posterior reconstruction for scapholunate dissociation: preliminary outcome in ten patients. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419886536

[9] Reply to “Letter Regarding ‘Traumatic Nondissociative Carpal Instability: A Case Series’”. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2022.05.009

[10] Distal Scaphoid Resection for Arthritis Secondary to Scaphoid Nonunion: A Twenty-year Experience. The Journal of Hand Surgery. 2011. DOI: 10.1016/s0363-5023(11)60002-6

[12] Carpal Fractures. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.10.030

[13] Management of Complications of Ligament Injuries of the Wrist. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.01.003

[14] The role of arthroscopy in carpal instability. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415616276

[15] The Clinical Implications of Scaphotrapezium-Trapezoidal Arthritis With Associated Carpal Instability. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2006.10.021

[16] One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.12.012

[17] Carpal Kinematics and Kinetics. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.105

[18] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[19] Radiographic Evaluation of the Modified Brunelli Technique Versus the Blatt Capsulodesis for Scapholunate Dissociation in a Cadaver Model. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.06.029

[20] Carpal Instability. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199503000-00019

[21] Osteolysis Following the Use of Polyetheretherketone Suture Anchors in Hand and Wrist Surgery: A Preliminary Study. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2023.05.024

[22] Post-traumatic palmar carpal subluxation. Report of two cases.. The Journal of Bone & Joint Surgery. 1983. DOI: 10.2106/00004623-198365070-00016

[23] The Carpal Boss: Review of Diagnosis and Treatment. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.11.029

[24] Joint Leveling for Advanced Kienböck's Disease. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.08.017

[25] Proximal row carpectomy for scapholunate dissociation. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410382719

[26] Excisional Arthroplasty for Scaphotrapeziotrapezoidal Osteoarthritis. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.12.016

[27] Carpal Instability Nondissociative Following Acute Wrist Fractures. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.11.018

[28] Three-Dimensional Imaging of the Carpal Ligaments. Hand Clinics. 2006. DOI: 10.1016/j.hcl.2006.08.003

[29] Force in the Scapholunate Interosseous Ligament During Active Wrist Motion. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.04.007

[32] Impact of scapholunate dissociation on human wrist kinematics. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415600669

[34] Severity of Scapholunate Instability Is Related to Joint Anatomy and Congruency. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2006.10.018

[35] How Much Scaphoid Can be Safely Resected? A Biomechanical Analysis of the Effects of Distal Scaphoid Resection. HAND. 2020. DOI: 10.1177/1558944720966717

[39] Dorsal Wrist Extrinsic Carpal Ligament Injury Exacerbates Volar Radiocarpal Instability After Intra-Articular Distal Radius Fracture. HAND. 2019. DOI: 10.1177/1558944719851210

[40] The Relationship Between the Tensile and the Torsional Properties of the Native Scapholunate Ligament and Carpal Kinematics. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.10.024

[41] Perilunate Dislocations and Fracture Dislocations. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.07.034

[42] Management of Carpal Instability in Athletes. Hand Clinics. 2009. DOI: 10.1016/j.hcl.2009.05.002

[43] The Biomechanical Consequences of Trapeziectomy and Partial Trapezoidectomy in the Treatment of Thumb Carpometacarpal and Scaphotrapeziotrapezoid Arthritis. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.06.015

[45] Three-dimensional kinematics of the lunate, hamate, capitate and triquetrum with type 1 or 2 lunate morphology. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417744420

[46] Lesions and Tumors of the Carpus. Hand Clinics. 2006. DOI: 10.1016/j.hcl.2006.07.006

[47] Diagnostic performance of traditional radiographic indices in detection of carpal collapse in Kienböck’s disease. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231153966

[48] Letter Regarding “Traumatic Nondissociative Carpal Instability: A Case Series”. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2022.05.005

[50] Collapse After Carpal Bone Tunneling: An Underreported Complication?. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2023.07.008

[51] Midcarpal Instability. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00777

[52] Pancarpal dissociation with palmar Capitate fracture-dislocation: Case report. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.12.023

[53] Diagnosis and Arthroscopic Management of Dorsal Wrist Capsular Impingement. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2016.12.012

[54] Association of scapholunate dissociation and two-part articular fractures of the distal radius. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419826490

[57] Intramedullary Fixation of Displaced Distal Radius Fractures: A Preliminary Report. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.07.004

[58] Wrist cineradiography: a protocol for diagnosing carpal instability. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417694820

[59] Long-Term Follow-Up of Surgical Correction of Madelung’s Deformity with Conservation of the Distal Radioulnar Joint in Teenagers. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.1999.0304

[60] Kienböck Disease in a Child Who Has Cerebral Palsy. A Case Report. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199610000-00016

[61] Effect of Trapeziectomy on Carpal Stability. HAND. 2020. DOI: 10.1177/1558944720939198

[62] An Unusual Case of Spontaneous Healing of a Proximal Pole Scaphoid Non-Union. HAND. 2011. DOI: 10.1007/s11552-011-9328-6

[63] Utility of Magnetic Resonance Imaging for Detection of Longitudinal Split Tear of the Ulnotriquetral Ligament. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.05.040

[64] Chapter 24 Carpal Instability. 2019.

[65] Avascular Necrosis of the Carpal Bones Other Than Kienböck Disease. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.05.022

[66] The Benefit of Magnetic Resonance Imaging for Patients With Posttraumatic Radial Wrist Tenderness. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.09.034

[67] Minimally Invasive Radiolunate Imbrication Neutralization (MIRLIN) Procedure. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.10.019

[68] Assessment of Articular Cartilage Disorders After Distal Radius Fracture Using Biochemical and Morphological Nonenhanced Magnetic Resonance Imaging. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.02.009

[69] The diagnostic accuracy of wrist cineradiography in diagnosing scapholunate dissociation. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413489056

[70] The Optimal Location to Measure Scapholunate Diastasis on Screening Radiographs. HAND. 2017. DOI: 10.1177/1558944717729219

[71] Proximal Row Carpectomy for Advanced Kienböck's Disease: Average 10-Year Follow-Up. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.02.031

[73] Radiographic Progression of Kienböck Disease: Radial Shortening Versus No Surgery. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.02.016

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