Lunate Instability

Contents

Clinically Relevant Anatomy

The lunate is one of the eight carpal bones located in the wrist. These eight bones are arranged into two rows with four bones in each. The proximal row, laterally to medially, consists of the scaphoid, lunate, triquetrum, and pisiform. The distal row, going in the same direction, consists of the trapezium, trapezoid, capitate and hamate. The lunate articulates laterally with the scaphoid, medially with the triquetrum, and inferiorly with the capitate and hamate.

Palmar View

                                                                              Palmar View

                                                    http://handsonhealingpt.com/article.php?aid=384


There are several different ligaments that attach to the dorsal and palmar surfaces of the carpal bones and hold them together and provide stability in the wrist. Most of the ligaments are named with respect to the two bones they connect.

 
RSL.jpg

                                                                       Radioscapholunate Ligaments

                                                                             [[Image:|gr9-midi.jpg]]


Dorsal View with Ligaments

                                                                  Dorsal View with Ligaments

                                                                 http://wapedia.mobi/en/Wrists

 
Interosseous.jpg

                                                             Scapholunate Interosseous Ligaments

                                           Netter FH. Atlas of human anatomy: 4th edition. 2006: 452-456.

Mechanism of Injury / Pathological Process

Scapholunate instability (the most common instability in the wrist) occurs when a person experiences falls on an outstretched hand (FOOSH) with the wrist positioned in extension, ulnar deviation, and intercarpal supination.[1][2] Scapholunate instability is considered to be present if at least two of the following three ligaments are injured: volar radioscapholunate ligament, scapholunate interosseous ligament, and dorsal scapholunate ligament. [3] If not treated, dynamic scapholunate instability can progress to rotatory subluxation of scaphoid, scapholunate dissociation, dorsal intercalated segment instability, and then scapholunate advanced collapse.[2]

Clinical Presentation

A patient presenting with lunate instability will most likely have a history of trauma to the wrist that has resulted in some type of lesion to the stabilizing ligaments of the carpal bones. Additionally, a patient with a history of certain degenerative inflammatory diseases such as chondrocalcinosis, gout, aseptic bone necrosis of the scaphoid or lunate bones, or Madelung deformity (a form of misalignment) can also lead to carpal instability. [4] The patient will have complaints of pain in the involved wrist, specifically around the scaphoid and lunate bones. The pain can be chronic if there is no history of trauma, or acute if the injury is the result of trauma. The pain is typically exacerbated by overuse activities, such as typing on a computer or doing push-ups, or gripping. The patient may deny “clicking” in the wrist, but report a feeling of “instability” with some activities.

Diagnostic Procedures

Physical Exam:

The wrist will most likely not be edematous or tender when palpated if there has been no history of trauma. Full range of motion may be preserved with a chronic type of injury. A tender dorsal scapholunate interval may be evident but it may appear normal in radiographs and the scaphoid shift test will either cause a “clunking” sound or it will be painful to the patient.[5]


Palpation of Scapholunate Articulation:

Palpate Lister’s tubercle on the distal radius. Move slightly distal to the tubercle and you will find the scapholunate joint.

Lister's Tubercle.jpg

                                                                  Palpating Lister's Tubercle

                                                         http://www.aafp.org/afp/2004/0415/p1941.html


Scaphoid Shift Test (Watson Test)

-How to Perform:
    1.) Examiner palpates and provides compression force over scaphoid (thumb on volar surface of hand—use anatomical snuff box for reference—and first finger on palmar surface) with one hand, while grasping the hand at the level of the metacarpal with the other.
    2.) Examiner passively moves patient’s wrist into ulnar deviation and slight extension.
    3.) Examiner passively and slowly moves patient’s wrist into radial deviation and slight flexion.
    4.) Examiner releases compression on the scaphoid.
-Interpreting Findings: 
    The test is positive if a “thunk” is produced OR the patient’s symptoms are reproduced when compression of the scaphoid is released.
-Diagnostic Accuracy[5]:

    Sensitivity = .69
    Specificity = .66
    +LR = 2.0


Diagnostic Exam:

Scapholunate Interval—This measurement is the distance between the proximal medial corner of the lunate and the proximal lateral corner of the scaphoid. A separation of greater than 2 mm may be indicative of scapholunate instability and it is referred to as the “Terry Thomas sign.” This can be measured through radiographs and should be compared with the patient’s uninvolved side. A “clenched-fist” view in a radiograph may help accentuate the space between the two bones.

Terry Thomas-Cartoon.jpg

                                                                                    Dorsal View
                                               http://www.wikiradiography.com/page/The+Terry-Tomas+Sign

Terry Thomas-Radiograph2.jpg

                                                                            Dorsal View- Radiograph

                                                    http://radiopaedia.org/articles/scapholunate-dissociation

Outcome Measures

Potential self report measures for individuals presenting with wrist pain are listed below.

-Disability of Arm, Shoulder, and Hand questionnaire (DASH)

-Quick DASH –This outcome measure is a shortened version of the DASH and is used to determine the patient’s physical function and symptoms.

-Brigham and Women’s Hospital Carpal Tunnel Questionnaire (CTQ) – This outcome measure is intended to assess functional status along with severity of symptoms in patients with carpal tunnel syndrome.

-Patient-Rated Wrist Evaluation Score (PRWE) – This outcome measure attempts to quantify wrist pain and disability, according to the patient, to assess the potential outcome for patients with distal radius fractures.

-Gartland and Werley Score – This is one of the most widely used outcome measures used in the clinic to evaluate wrist and hand function.

Management / Interventions

Conservative:

Conservative treatments are performed to provide symptom relief. The patient may benefit from immobilization with a long opponens or a wrist control splint, shown below. The patient should also be instructed to avoid any axial loading of the wrist (i.e. resistive fisting), which can be done by using a splint with a distal block that prevents finger flexing.[6]

                                                Image:Long_Opp..jpgWrist Control.jpg

                                               Long Opponens Splint                     Wrist Control Splint

                                                  http://www.ncbi.nlm.nih.gov/books/NBK27177/
                                                  http://www.3pointproducts.com/wrist-control/

Surgical:

Surgery is recommended if there is a significant degree of injury to the ligaments in question or if conservative interventions fail.[3]

Surgery can be performed to repair the damaged ligaments that are causing instability or to fixate or fuse the carpal bones.[3][7]  It has been found that soft tissue repair is the preferred surgical intervention in acute cases, while there is no stated preference in chronic cases.[8]

Outcomes are best after soft tissue repair, but there is no significant different between acute and chronic cases.[8]


Post-Surgical Management:

Patients may benefit from early, controlled mobilization post-operatively through the use of a hinged wrist splint.[9] After surgical repair by use of a tendon transfer, the wrist is immobilized. However, immediate mobilization should occur at the shoulder, elbow, forearm, and digits and the patient should resume light activities.[10] At 4 weeks post-operatively, protected wrist exercises may begin; torsion and the use of hand tools are to be avoided. Progressive strengthening and conditioning may begin at 6-8 weeks post-operatively and progress is determined per patient. Manual work and recreation may resume (slowly) at 3 months.

Differential Diagnosis

As with all other cases, other potential diagnoses must be ruled out before a final diagnosis of lunate instability can be determined. These other potential diagnoses for the wrist can be categorized depending on the location of the patient’s pain/symptoms.


Radial Wrist Pain:

Carpal Tunnel Syndrome

First Carpometacarpal Osteoarthritis

DeQuervain’s (Stenosing tenosynovitis of the tendons on the lateral border of the anatomical snuffbox)

Colles' Fracture

Scaphoid Fracture

C6-C7 Radiculopathy


Non-Specific Wrist Pain:

Mechanical Wrist Pain – Individuals who have symptoms suspicious of scapholunate instability with unremarkable findings on further work up may have an injury such as wrist strain or sprain, joint dysfunction, or repetitive strain injuries. Tests that differentiate between these diagnoses often do not have known reliability or diagnostic accuracy. Thus, if a specific diagnosis cannot be made with certainty, and red flags are ruled less likely, the most accurate diagnosis may be referred to as “mechanical wrist pain,” which is largely a diagnosis of exclusion. Intervention would consist of addressing the identified impairments such as joint hypomobility, decreased muscle length, or decreased strength.

Key Evidence

Outcome measures for wrist and hand – which one to choose?

Scapholunate stabilization with dynamic extensor carpi radialis longus tendon transfer

Controlled active mobilization after dorsal capsulodesis to correct capitolunate dissociation

Resources

Links to relevant documents are cited throughout this page.

Case Studies

Scapholunate instability following dorsal wrist ganglion excision: a case report

Recent Related Research (from Pubmed)

References

  1. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5 (3): 226-41
  2. 2.0 2.1 Wheeless C. Scapholunate Instability. Duke Orthopaedics presents Wheeless' Textbook of Orthopaedics Web site. http://www.wheelessonline.com/ortho/scapholunate_instability. Updated 2011. Accessed 03/02, 2011
  3. 3.0 3.1 3.2 Scapholunate Instability. UW MSK Resident Projects Web site. http://uwmsk.org/residentprojects/scapholunate.html. Updated 2005. Accessed 03/02, 2011.
  4. Redeker J, Vogt PM. Carpal instability. Chirurg. 2011 Jan; 82(1):85-93.
  5. 5.0 5.1 Dyer GS. Predynamic scapholunate instability. J Hand Surg Am. 2010 Nov;35(11):1879-1880.
  6. LaStayo P, Michlovitz S, Lee M. Wrist and Hand. In: Kolt GS, Snyder-Mackler L, eds. Physical Therapies in Sport and Exercise. 2nd ed. Philadelphia, PA: Elsevier Limited; 2007:338-346.
  7. Wheeless C. Lunotriquetral Dissociation. Duke Orthopaedics presents Wheeless' Textbook of Orthopaedics Web site. http://www.wheelessonline.com/ortho/lunotriquetral_dissociation. Accessed 03/02, 2011.
  8. 8.0 8.1 Zarkadas PC, Gropper PT, White NJ, Bertrand HP. A survey of the surgical management of acute and chronic scapholunate instability. J Hand Surg Am. 2004;29(5):848-57.
  9. Chinchalkar SJ, Pipicelli JG, Richards R. Controlled active mobilization after dorsal capsulodesis to correct capitolunate dissociation. J Hand Ther. 2010;23(4):404-10.
  10. Peterson SL, Freeland AE. Scapholunate stabilization with dynamic extensor carpi radialis longus tendon transfer. J Hand Surg Am. 2010;35(A):2093-2100.