Southampton University Hospitals Midcarpal Instability...
Transcript of Southampton University Hospitals Midcarpal Instability...
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Midcarpal Instability: Diagnosis and Treatment
David G HargreavesConsultant Hand Surgeon
Southampton University Hospitals
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TYPES
A.Dissociative SL & LT Lig Rupture
B)Non-DissociativeMidcarpal Instability
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●MCI : Loss of smooth transition of Prox row
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Midcarpal Instability
●Heterogenous group of disorders● Ulnar Midcarpal Instability (Lichtman ‘81)● Capito-Lunate Instability Pattern (CLIP) (Louis ‘84)● Medial anterior midcarpal Instability (MAMI) (Schernberg ‘84)● Chronic Capito-lunate instability (Johnson ‘86)
●Instabilty of Proximal Carpal Row● (Wright - JHand Surg Am 1994)
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Litchman Classification (1993)
●Palmar
●Dorsal
●Combined P & D
●Extrinsic (Adaptive)
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Aetiology
●LAXITY VS INSTABILITY
●Laxity : common (Park JBJS 2002)
●Instability: rare
●Minor Trauma
●Loss of propioceptive control●Generalised Joint Laxity
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Natural History
●Spontaneous improvement
●Joints stiffen with age !!
●Approx 30% improve
●No evidence in Literature
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Diagnosis - History
●Dorsal wrist pain - vague
●Giving way
●Clunk- pron & ulnar dev
●Sportsmen - ↓ performance
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Diagnosis - Examination
●Midcarpal Shift Test ● Catch -up clunk● VISI to DISI in ulnar dev
●Midcarpal Drawer Test● “That’s it” test !!!
●Exclusion of intrinsic ligament ruptures
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Diagnosis- Investigations
●X rays
●MRI
●Dynamic Fluoroscopy
●Arthroscopy
All Normal
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Treatments
●Splints
●Physiotherapy:● Biofeedback
● General Strengthening
● Gyroscope - Spinball
●No proven protocol
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Surgical Options
●Midcarpal fusion:
● Triq-Hamate :50% good (Rao ‘93)
● 4 corner fusion: ROM 45% (Goldfarb 2004)
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●Radio-lunate Fusion
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Surgical Options
●Volar Capsular Reefing●Tenodesis
●66% failure(Lichtman ‘93)
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Thermal Capsular Shrinkage
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Results●ROM : 90%●DASH score
● Pre-op 38% (range 13-70)
● Follow up 17% (range 0-57)● P= 0.0004 Paired t-test
●Instability on Pouring Jug:
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Conclusion: Ulnar sided Instability
●Not so rare
●Diagnosis : can be difficult
●Treatment : Controversial
●Role of Arthroscopic treatments