Carpal Instability

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Definition/Description  

Carpal instability is defined as an injury where there is a loss of normal alignment of the carpal bones and/ or the radioulnar joint. The loss creates a disturbance of the normal balance of the carpal- and radioulnar joints which results in changes to the range of motion. If undiagnosed, carpal instability can lead to progressive limitation of movement, and later to degenerative intercarpal and radiocarpal arthritis, chronic pain and disability.. [6,14] [LoE: 5, 5]

A traumatic event is often at the origin of carpal injury: the trauma causes ligamentous injuries that lead to misalignments of the joint surfaces, or badly healed fractures with consequent articular incongruence. Chronic ligament weakening can also lead to carpal instability in certain cases. [1,2,7] [LoE: 2A, 5, 5]

Carpal instability can be classified in different ways depending on the nature of the instability, its location and its origin. Ligament lesions are frequent in a young population. Resulting from high-energy injuries they principally include perilunate dislocation and scapholunate dissociation (resulting from a fall on an outstretched hand, with wrist in hyperextension and forearm pronated). (see: Scapholunate Dissocation). On the other hand, degenerative lesions are more common in elderly patients. These lesions are related to pathologies such as chondrocalcinosis, rheumatoid arthritis and other rheumatisms. [21] [LoE: 2A]
The main problem with carpal ligament lesions and fractures is the high potential for arthritis. [21] [LoE: 2A]

Clinically Relevant Anatomy

The carpal joint is known to be a fairly complex joint consisting of many different articulations as well as a variety of ligaments, blood vessels and nerves. The ligaments are divided into two distinct categories: the intrinsic and the extrinsic ligaments. The intrinsic ligaments connect the different bones, whereas the extrinsic ligaments connect the distal extremity of the two bones of the forearm to the carpus or the carpus to the metacarpals. Functionally the most important intrinsic ligaments are the scapholunate ligament and the ulnotriquetrum ligament. [21] [LoE: 2A]

Listed below are all the ligaments of the wrist: [8,21,22] [LoE:2A, 2A, 5]

Intrinsic ligaments	Extrinsic ligaments
Dorsal side • Scapholunate ligament (dorsal segment) • Lunotriquetral ligament (dorsal segment) • Dorsal scaphotriquetral ligament • Dorsal scaphotrapeziotrapezoid ligament	Dorsal side • Dorsal radiotriquetral ligament (DRT) • Dorsal ulnotriquetral ligament
Palmar side • Scapholunate ligament (SLIL, palmar segment) • Lunotriquetral ligament (LTIL, palmar segment) • Palmar scaphotriquetral ligament • Radial bundle of the collateral ligament • Ulnar bundle of the collateral ligament • Palmar scaphotrapeziotrapezoid ligament • Interosseous ligament joining trapezium, trapezoid, capitate, and hamate Radial side • Radial collateral ligament Ulnar side • Ulnar collateral ligament (UC)	Palmar side • Radioscaphocapitate ligament (RSC) • Radiolunotriquetral ligament • Radioscapholunate ligament (RSL) • Short radiolunate ligament (SRL) • Ulnolunate ligament (UL) • Palmar ulnotriquetral ligament (UT)

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