Download PDF
Rofo 2021; 193(02): 139-150
DOI: 10.1055/a-1219-8158
Review

Imaging of Carpal Instabilities

Bildgebende Diagnostik karpaler Instabilitäten
Jan-Peter Grunz
  Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Germany
,
Carsten Herbert Gietzen
  Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Germany
,
Katharina Grunz
  Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Germany
,
Thorsten Bley
  Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Germany
,
Rainer Schmitt
  Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Germany
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background The term “carpal instability” describes different debilitating wrist conditions, in which the carpus is unable to maintain its physiological range of motion and load transfer. Depending on the cause and location of the dysfunction, four groups can be defined: dissociative, non-dissociative, complex, and adaptive carpal instability. As the most common form by far, dissociative carpal instability can further be categorized as dorsal or palmar intercalated segment instability, contingent on the afflicted interosseous ligament.

Method This review article outlines the different entities of carpal instability, their pathophysiology, and their clinical presentation. It further discusses the diagnostic significance of different imaging methods as well as the established treatment options for each form of instability in context with the current literature.

Results and Conclusion Early detection and treatment of carpal instability are essential for preventing carpal osteoarthritis. Traumatic lesions of the scapholunate interosseous ligament are the most frequent cause of instability. They can occur in an isolated fashion or in context with other carpal injuries. While stress imaging and fluoroscopy facilitate the differentiation between dynamic and static forms of carpal instability, only MRI and CT/MR arthrography can directly reveal the extent of ligament discontinuity.

Key Points:

  • Carpal instability can manifest only in motion (dynamic) or at rest (static).

  • Dissociative forms must be distinguished from non-dissociative, adaptive, or complex entities.

  • Most instabilities are related to traumatic injuries or CPPD arthropathy.

  • Fluoroscopy, stress imaging, and MR and CT arthrography are helpful for diagnosis.

Citation Format

  • Grunz JP, Gietzen CH, Grunz K et al. Imaging of Carpal Instabilities. Fortschr Röntgenstr 2021; 193: 139 – 150

Zusammenfassung

Hintergrund Karpale Instabilität bezeichnet verschiedene Formen von Handgelenkbeschwerden, bei denen die Handwurzel ihren physiologischen Bewegungsumfang einbüßt und die normale Kraftübertragung auf den Unterarm bzw. die Metacarpalia nicht aufrechterhalten werden kann. Je nach Ursache und Pathoanatomie werden 4 Hauptgruppen unterschieden: dissoziative, nicht dissoziative, komplexe und adaptive karpale Instabilität. Dabei machen dissoziative Gefügestörungen den größten Anteil aus. Sie werden weiter unterteilt entsprechend der zugrunde liegenden karpalen Bandverletzung und der resultierenden dorsalen oder palmaren Fehlstellung der mittleren karpalen Säule.

Methode Dieser Übersichtsartikel beschreibt die verschiedenen Formen karpaler Instabilität, ihre Pathophysiologie und typische klinische Beschwerden. Darüber hinaus werden die diagnostische Bedeutung verschiedener bildgebender Verfahren sowie die etablierten Behandlungsmöglichkeiten im Kontext der aktuellen Literatur diskutiert.

Ergebnisse und Schlussfolgerung Die frühzeitige Erkennung und Behandlung von karpalen Gefügestörungen ist unerlässlich, um einer progredienten Arthrose vorzubeugen. Traumatische Läsionen des skapholunären Bandes sind die häufigste Ursache für eine karpale Instabilität. Sie können isoliert oder im Rahmen multilokulärer Verletzungen auftreten. Während Stressaufnahmen und Fluoroskopie die Unterscheidung zwischen dynamischen und statischen Formen der karpalen Instabilität erleichtern, gelingt die direkte Darstellung einer intrinsischen Bandläsion nur mittels MRT und CT- bzw. MR-Arthrografie.

Kernaussagen:

  • Karpale Instabilität kann sich unter Belastung (dynamisch) oder in Ruhe (statisch) manifestieren.

  • Dissoziative Formen müssen von nicht dissoziativen, adaptiven oder komplexen Entitäten unterschieden werden.

  • Am häufigsten werden karpale Instabilitäten durch ein Trauma oder die CPPD-Arthropathie verursacht.

  • Fluoroskopie, Stressbildgebung, MR- und CT-Arthrografie können die Diagnosefindung erleichtern.

Key words

arthrography - hand - radiography - MR imaging


Publication History

Received: 11 February 2020

Accepted: 13 July 2020

Article published online:
03 September 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Cooney W. The Modern History of the Wrist. J. Wrist Surg 2012; 01: 95-102
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Schmitt R, Froehner S, Coblenz G. et al. Carpal instability. Eur. Radiol 2006; 16: 2161-2178
    CrossrefPubMedGoogle Scholar
  • 3 Lee RKL, Griffith JF, Ng AWH. et al. Intrinsic carpal ligaments on MR and multidetector CT arthrography: comparison of axial and axial oblique planes. Eur. Radiol 2017; 27: 1277-1285
    CrossrefPubMedGoogle Scholar
  • 4 Shin AY, Battaglia MJ, Bishop AT. Lunotriquetral Instability: Diagnosis and Treatment. J. Am. Acad. Orthop. Surg 2000; 8: 170-179
    CrossrefPubMedGoogle Scholar
  • 5 Schmitt R, Lanz U. [Diagnostic Imaging of the Hand]. 3. Edition. Stuttgart: Thieme; 2014
    Google Scholar
  • 6 Grunz J-P, Gietzen CH, Schmitt R. et al. [Distal Radius Fractures: Update on imaging]. Radiologe 2018; 58: 159-174
    CrossrefPubMedGoogle Scholar
  • 7 Gilula L. Carpal injuries: analytic approach and case exercises. Am. J. Roentgenol 1979; 133: 503-517
    CrossrefPubMedGoogle Scholar
  • 8 Kani KK, Mulcahy H, Chew FS. Understanding carpal instability: a radiographic perspective. Skeletal Radiol 2016; 45: 1031-1043
    CrossrefPubMedGoogle Scholar
  • 9 Amadio PC. Carpal kinematics and instability: A clinical and anatomic primer. Clin. Anat 1991; 4: 1-12
    CrossrefPubMedGoogle Scholar
  • 10 Garcia-Elias M. Kinetic analysis of carpal stability during grip. Hand Clin 1997; 13: 151-158
    CrossrefPubMedGoogle Scholar
  • 11 Short WH, Werner FW, Green JK. et al. Biomechanical Evaluation of the Ligamentous Stabilizers of the Scaphoid and Lunate: Part III. J. Hand Surg. Am 2007; 32: 297.e1-297.e18
    CrossrefPubMedGoogle Scholar
  • 12 Pliefke J, Stengel D, Rademacher G. et al. Diagnostic accuracy of plain radiographs and cineradiography in diagnosing traumatic scapholunate dissociation. Skeletal Radiol 2008; 37: 139-145
    CrossrefPubMedGoogle Scholar
  • 13 Klempka A, Wagner M, Fodor S. et al. Injuries of the scapholunate and lunotriquetral ligaments as well as the TFCC in intra-articular distal radius fractures. Prevalence assessed with MDCT arthrography. Eur. Radiol 2016; 26: 722-732
    PubMedGoogle Scholar
  • 14 Schmitt R, Christopoulos G, Meier R. et al. [Direct MR arthrography of the wrist in comparison with arthroscopy: A prospective study on 125 patients]. Rofo 2003; 175: 911-919
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Haims AH, Moore AE, Schweitzer ME. et al. MRI in the Diagnosis of Cartilage Injury in the Wrist. Am. J. Roentgenol 2004; 182: 1267-1270
    CrossrefPubMedGoogle Scholar
  • 16 Lee RKL, Ng AWH, Tong CSL. et al. Intrinsic ligament and triangular fibrocartilage complex tears of the wrist: comparison of MDCT arthrography, conventional 3-T MRI, and MR arthrography. Skeletal Radiol 2013; 42: 1277-1285
    Google Scholar
  • 17 Moser T, Dosch J-C, Moussaoui A. et al. Wrist Ligament Tears: Evaluation of MRI and Combined MDCT and MR Arthrography. Am. J. Roentgenol 2007; 188: 1278-1286
    CrossrefPubMedGoogle Scholar
  • 18 Crema MD, Zentner J, Guermazi A. et al. Scapholunate Advanced Collapse and Scaphoid Nonunion Advanced Collapse: MDCT Arthrography Features. Am. J. Roentgenol 2012; 199: W202-W207
    CrossrefPubMedGoogle Scholar
  • 19 Schmid MR, Schertler T, Pfirrmann CW. et al. Interosseous Ligament Tears of the Wrist: Comparison of Multi–Detector Row CT Arthrography and MR Imaging. Radiology 2005; 237: 1008-1013
    CrossrefPubMedGoogle Scholar
  • 20 Grunz J-P, Gietzen CH, Kunz AS. et al. Twin Robotic X-Ray System for 3D Cone-Beam CT of the Wrist: An Evaluation of Image Quality and Radiation Dose. Am. J. Roentgenol 2020; 214: 422-427
    CrossrefPubMedGoogle Scholar
  • 21 Shaw CB, Foster BH, Borgese M. et al. Real-time three-dimensional MRI for the assessment of dynamic carpal instability. PLoS One 2019; 14: e0222704
    CrossrefPubMedGoogle Scholar
  • 22 Rauch A, Arab WA, Dap F. et al. Four-dimensional CT Analysis of Wrist Kinematics during Radioulnar Deviation. Radiology 2018; 289: 750-758
    CrossrefPubMedGoogle Scholar
  • 23 Kijima Y, Viegas SF. Wrist Anatomy and Biomechanics. J. Hand Surg. Am 2009; 34: 1555-1563
    CrossrefPubMedGoogle Scholar
  • 24 Ramamurthy NK, Chojnowski AJ, Toms AP. Imaging in carpal instability. J. Hand Surg (European Vol) 2016; 41: 22-34
    CrossrefPubMedGoogle Scholar
  • 25 Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: Pathomechanics and progressive perilunar instability. J. Hand Surg. Am 1980; 5: 226-241
    CrossrefPubMedGoogle Scholar
  • 26 Linscheid RL, Dobyns JH, Beabout JW. et al. Traumatic Instability of the Wrist. J. Bone Jt. Surgery-American Vol 2002; 84: 142
    CrossrefPubMedGoogle Scholar
  • 27 Prommersberger K-J, Mühldorfer-Fodor M, Kalb K. et al. Die skapholunäre Bandverletzung. Unfallchirurg 2014; 117: 723-739
    CrossrefPubMedGoogle Scholar
  • 28 Suojärvi N, Haapamäki V, Lindfors N. et al. Radiocarpal Injuries: Cone Beam Computed Tomography Arthrography, Magnetic Resonance Arthrography, and Arthroscopic Correlation among 21 Patients. Scand. J. Surg 2017; 106: 173-179
    CrossrefPubMedGoogle Scholar
  • 29 Cheriex KCAL, Sulkers GSI, Terra MP. et al. Scapholunate dissociation; diagnostics made easy. Eur. J. Radiol 2017; 92: 45-50
    CrossrefPubMedGoogle Scholar
  • 30 Linn MR, Mann FA, Gilula LA. Imaging the symptomatic wrist. Orthop. Clin. North Am 1990; 21: 515-543
    CrossrefPubMedGoogle Scholar
  • 31 Watson HK, Ashmead D, Makhlouf MV. Examination of the scaphoid. J. Hand Surg. Am 1988; 13: 657-660
    CrossrefPubMedGoogle Scholar
  • 32 Sulkers GSI, Strackee SD, Schep NWL. et al. Wrist cineradiography: a protocol for diagnosing carpal instability. J. Hand Surg (European Vol) 2018; 43: 174-178
    CrossrefPubMedGoogle Scholar
  • 33 Padmore C, Stoesser H, Langohr GD. et al. Carpal Kinematics following Sequential Scapholunate Ligament Sectioning. J. Wrist Surg 2019; 08: 124-131
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Frankel VH. The Terry-Thomas Sign. Clin. Orthop. Relat. Res 1978; 135: 311-312
    PubMedGoogle Scholar
  • 35 Krimmer H, Lanz U. [Post-traumatic carpal collapse. Follow-up and therapeutic concept]. Unfallchirurg 2000; 103: 260-266
    CrossrefPubMedGoogle Scholar
  • 36 Laulan J, Marteau E, Bacle G. Wrist osteoarthritis. Orthop. Traumatol. Surg. Res 2015; 101: S1-S9
    CrossrefPubMedGoogle Scholar
  • 37 Watson HK, Ballet FL. The SLAC wrist: Scapholunate advanced collapse pattern of degenerative arthritis. J. Hand Surg. Am 1984; 9: 358-365
    Google Scholar
  • 38 Moran SL, Cooney WP, Berger RA. et al. Capsulodesis for the treatment of chronic scapholunate instability. J. Hand Surg. Am 2005; 30: 16-23
    CrossrefPubMedGoogle Scholar
  • 39 Wyrick JD. Proximal Row Carpectomy and Intercarpal Arthrodesis for the Management of Wrist Arthritis. J. Am. Acad. Orthop. Surg 2003; 11: 277-281
    CrossrefPubMedGoogle Scholar
  • 40 Theumann NH, Etechami G, Duvoisin B. et al. Association between Extrinsic and Intrinsic Carpal Ligament Injuries at MR Arthrography and Carpal Instability at Radiography: Initial Observations. Radiology 2006; 238: 950-957
    CrossrefPubMedGoogle Scholar
  • 41 van de Grift TC, Ritt MJ. Management of lunotriquetral instability: a review of the literature. J. Hand Surg (European Vol) 2016; 41: 72-85
    CrossrefPubMedGoogle Scholar
  • 42 Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist—Anatomy and function. J. Hand Surg. Am 1981; 6: 153-162
    CrossrefPubMedGoogle Scholar
  • 43 Watanabe A, Souza F, Vezeridis PS. et al. Ulnar-sided wrist pain. II. Clinical imaging and treatment. Skeletal Radiol 2010; 39: 837-857
    CrossrefPubMedGoogle Scholar
  • 44 Buijze GA, Ochtman L, Ring D. Management of Scaphoid Nonunion. J. Hand Surg. Am 2012; 37: 1095-1100
    CrossrefPubMedGoogle Scholar
  • 45 Toms AP, Chojnowski A, Cahir JG. Midcarpal instability: a radiological perspective. Skeletal Radiol 2011; 40: 533-541
    CrossrefPubMedGoogle Scholar
  • 46 Garcia-Elias M. The Non-Dissociative Clunking Wrist: A Personal View. J. Hand Surg (European Vol) 2008; 33: 698-711
    CrossrefPubMedGoogle Scholar
  • 47 Taleisnik J. Classification of carpal instability. Bull. Hosp. Jt. Dis. Orthop. Inst 1984; 44 (02) 511-531
    PubMedGoogle Scholar
  • 48 Niacaris T, Ming BW, Lichtman DM. Midcarpal Instability. Hand Clin 2015; 31: 487-493
    CrossrefPubMedGoogle Scholar
  • 49 Youm Y, McMurthy RY, Flatt AE. et al. Kinematics of the wrist. I. An experimental study of radial-ulnar deviation and flexion-extension. J. Bone Jt. Surg 1978; 60: 423-431
    CrossrefPubMedGoogle Scholar
  • 50 Nattrass GR, King GJW, McMurtry RY. et al. An alternative method for determination of the carpal height ratio. J. Bone Jt. Surg 1994; 76: 88-94
    CrossrefPubMedGoogle Scholar