Palmer Midcarpal Instability: An Algorithm of Diagnosis and Surgical Management

Abstract

Background Palmar midcarpal instability (PMCI) is an uncommon form of nondissociative carpal instability. However, it is an important cause of chronic ulnar wrist pain. Diagnosis can be difficult and high index of suspicion is mandatory. Pathomechanics and optimal treatment of PMCI remain uncertain. We propose an algorithm of clinical diagnosis and evaluate the outcome of our management.

Materials and Methods Between 2000 and 2011, 16 patients, including 7 males and 9 females, of a mean age of 33.9 diagnosed with PMCI were reviewed for their clinical, radiologic, and arthroscopic features. All patients presented with ulnar wrist pain in their dominant hands except in one. Initial management included a disease-specific anticarpal supination splint. Refractory cases were evaluated by arthroscopy and treated by arthroscopic thermal shrinkage using radiofrequency appliance as an interim or definite surgical intervention. Shrinkage was targeted at the ulnocarpal ligament at the radiocarpal joint and triquetrohamate ligament at the midcarpal joint. Nonresponsive or recurrent cases were managed by a novel technique of dorsal radiocarpal ligament reconstruction procedure using a pisiform-based split flexor carpi ulnaris (FCU) tendon graft.

Results In all cases, the midcarpal clunk test was positive with pain. Other common clinical features included lax ulnar column, carpal supination, volar sagging of the wrist, increased pisostyloid distance, wrist pain aggravated by passive hand supination and not by passive forearm supination, and increased wrist pain upon resisted pronation, which could be partially alleviated by manually supporting the pisostyloid interval. Common arthroscopic findings were excessive joint space at triquetrohamate interval and reactive synovitis over the ulnar compartments. Nine patients (56.3%) responded well to splinting alone at an average follow-up of 3.3 years. Arthroscopic thermal shrinkage was performed in five patients with recurrence in two patients. Five patients received split FCU tendon graft for ligament reconstruction. All patients showed improvement in the wrist performance score (preop 21.0, postop 36.6 out of 40) and pain score (preop 10.0, postop 2.2 out of 20) at the final follow-up of average 86 months (range: 19–155 months). Grip strength improved from 66.9 to 82.0% of the contralateral side. Wrist motion slightly decreased from a flexion/extension arc of 132 to 125 degrees. Three patients were totally pain free, one had mild pain, and one had moderate fluctuating pain. All patients returned to their original works. X-ray showed no arthrosis.

Conclusion PMCI is an uncommon but significant cause of chronic ulnar wrist pain. We have developed a clinical algorithm for diagnosis of the condition. The natural history seems to favor a benign course. Conservative treatment with an anticarpal supination splint is recommended as the initial management. Surgical options for resistant cases include arthroscopic thermal shrinkage or soft tissue reconstruction. The reconstruction of the dorsal radiocarpal ligament using a pisiform-based split FCU tendon graft provides reliable restoration of the carpal stability with good long-term outcome and few complications. This should be considered a viable alternative to limited carpal fusion.

Keywords

carpal instability - ligament reconstruction - thermal shrinkage - wrist - surgery - palmar midcarpal instability

• References

• 1 Dobyns JH, Linscheid RL, Macksoud WS. Proximal carpal row instability-non dissociative. Orthop Trans 1985; 9: 574
• 2 Mouchet A, Belot J. Poignet a'ressaut: subluxation mediocarpienne en avant. Bull Mem Soc Chir 1934; 60: 1243-1244
• 3 Lichtman DM, Schneider JR, Swafford AR, Mack GR. Ulnar midcarpal instability-clinical and laboratory analysis. J Hand Surg Am 1981; 6 (05) 515-523
• 4 Lichtman DM, Bruckner JD, Culp RW, Alexander CE. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg Am 1993; 18 (02) 307-315
• 5 Lichtman DM, Gaenslen ES, Pollock GR. Midcarpal and proximal carpal instabilities. In: Lichtman DM, Alexander AH. , eds. The Wrist and Its Disorders. 2nd ed. Philadelphia: Saunders; 1997: 36-28
• 6 Lichtman DM, Wroten ES. Understanding midcarpal instability. J Hand Surg Am 2006; 31 (03) 491-498
• 7 Trumble TE, Bour CJ, Smith RJ, Glisson RR. Kinematics of the ulnar carpus related to the volar intercalated segment instability pattern. J Hand Surg Am 1990; 15 (03) 384-392
• 8 Viegas SF, Patterson RM, Peterson PD. , et al. Ulnar-sided perilunate instability: an anatomic and biomechanic study. J Hand Surg Am 1990; 15 (02) 268-278
• 9 Caputo AE, Watson HK, Weinweig J. Midcarpal instability. In: Watson HK, Weinzweig J. , eds. The Wrist. Philadelphia, PA: Lippincott Williams and Wilkins; 2001: 511-520
• 10 Garcia-Elias M. Carpal instability. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. , eds. Green's Operative Hand Surgery. Churchill Livingston, Philadelphia, PA: Elsevier; 2011: 504-509
• 11 Niacaris T, Ming BW, Lichtman DM. Midcarpal instability: a comprehensive review and update. Hand Clin 2015; 31 (03) 487-493
• 12 Wolfe SW, Garcia-Elias M, Kitay A. Carpal instability nondissociative. J Am Acad Orthop Surg 2012; 20 (09) 575-585
• 13 Ming BW, Niacaris T, Lichtman DM. Surgical techniques for the management of midcarpal instability. J Wrist Surg 2014; 3 (03) 171-174
• 14 Hargreaves DG. Arthroscopic thermal capsular shrinkage for palmar midcarpal instability. J Wrist Surg 2014; 3 (03) 162-165
• 15 Feinstein WK, Lichtman DM, Noble PC, Alexander JW, Hipp JA. Quantitative assessment of the midcarpal shift test. J Hand Surg Am 1999; 24 (05) 977-983
• 16 Park MJ. Normal anteroposterior laxity of the radiocarpal and midcarpal joints. J Bone Joint Surg Br 2002; 84 (01) 73-76
• 17 Sachar K. Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. J Hand Surg Am 2012; 37 (07) 1489-1500
• 18 Ritt MJ, de Groot PJ. A new technique for the treatment of midcarpal instability. J Wrist Surg 2015; 4 (01) 71-74
• 19 Beighton P, Horan F. Orthopaedic aspects of the Ehlers-Danlos syndrome. J Bone Joint Surg Br 1969; 51 (03) 444-453
• 20 Rhee PC, Sauvé PS, Lindau T, Shin AY. Examination of the wrist: ulnar-sided wrist pain due to ligamentous injury. J Hand Surg Am 2014; 39 (09) 1859-1862
• 21 Wong JMW, Kwan MWW, Au FLY, Ho PC. Dynamic wrist splint for palmer mid-carpal instability: an enhanced design. HK J Occup Ther 2010; 20 (01) 25-29
• 22 Ong MT, Ho PC, Wong CW, Cheng SH, Tse WL. Wrist arthroscopy under portal site local anesthesia (PSLA) without tourniquet. J Wrist Surg 2012; 1 (02) 149-152
• 23 Moore NFE, Filipek A, Di Mascio L. Wrist arthroscopy. Orthop Trauma 2015; 29 (06) 384-392
• 24 Nelson DL. Functional wrist motion. Hand Clin 1997; 13 (01) 83-92
• 25 Cheng HS, Hung LK, Ho PC, Wong J. An analysis of causes and treatment outcome of chronic wrist pain after distal radial fractures. Hand Surg 2008; 13 (01) 1-10
• 26 Toms AP, Chojnowski A, Cahir JG. Midcarpal instability: a radiological perspective. Skeletal Radiol 2011; 40 (05) 533-541
• 27 Wright TW, Dobyns JH, Linscheid RL, Macksoud W, Siegert J. Carpal instability non-dissociative. J Hand Surg Br 1994; 19 (06) 763-773
• 28 Chinchalkar S, Yong SA. An ulnar boost splint for midcarpal instability. J Hand Ther 2004; 17 (03) 377-379
• 29 Mason WT, Hargreaves DG. Arthroscopic thermal capsulorrhaphy for palmar midcarpal instability. J Hand Surg Eur Vol 2007; 32 (04) 411-416
• 30 Lichtman DM, Culp RW, Joshi A. Palmar midcarpal instability. In: Litchman DM, Alexander AH. , eds. The Wrist and its Disorders. Philadelphia: W.B. Saunders; 1997: 316-328
• 31 Goldfarb CA, Stern PJ, Kiefhaber TR. Palmar midcarpal instability: the results of treatment with 4-corner arthrodesis. J Hand Surg Am 2004; 29 (02) 258-263
• 32 Rao SB, Culver JE. Triquetrohamate arthrodesis for midcarpal instability. J Hand Surg Am 1995; 20 (04) 583-589
• 33 Chaudhry T, Shahid M, Wu F, Mishra A, Deshmukh S. Soft tissue stabilization for palmar midcarpal instability using a palmaris longus tendon graft. J Hand Surg Am 2015; 40 (01) 103-108