Traumatic Volar Carpal Instability Nondissociative: A Case Series

Carpal instability nondissociative (CIND) involves disruption between carpal rows from injury to extrinsic and intrinsic wrist ligaments. CIND traumatic (CINDT) highlights the posttraumatic etiology of some these cases has been gaining increasing attention in literature. We present four CINDT-volar intercalated segmental (VISI). diagnosed two adults with distal radius fractures adolescents Galeazzi fractures, all treated surgically, who developed CINDT-VISI radiolunate angles greater than 15° at 2 weeks after surgery. One adult had progressive deformity but was asymptomatic 33 months. The other underwent volar capsular release 1 year improve alignment. adolescent a fixed required soft tissue releases temporary pinning restore alignment 7 successfully early physiotherapy. No patient radiographic signs arthritis 1–2 years. This is first reported association CINDT-VISI. Contrary existing literature, we report successful outcomes nonsurgical delayed nonfusion surgery relationship radiocarpal, midcarpal, or both articulations. In contrast dissociative, which there bones within single row (eg, scapholunate lunotriquetral disruption), each continues move as unit.1Wolfe S.W. Garcia-Elias M. Kitay A. nondissociative.J Am Acad Orthop Surg. 2012; 20: 575-585Crossref PubMed Scopus (38) Google Scholar may be (CIND-volar [VISI]) dorsal (CIND-dorsal [DISI]).1Wolfe Posttraumatic described several case reports last decades.2Hankin F.M. Amadio P.C. Wojtys E.M. Braunstein flexion proximal associated scapho-trapezial ligament: cases.J Hand Surg Br. 1988; 13: 298-302Crossref (11) Scholar, 3Arms D.M. Martin R.A. Strecker W.B. Gilula L.A. Post-traumatic irreducible instability: report.J Am. 1995; 778-780Abstract Full Text PDF 4O’Flanagan S.J. Ip F.K. Roberts C.J. Chow S.P. malalignment following intra-articular working population.Injury. 26: 231-235Abstract (3) 5Lee S. Yu J.H. Jeon S.H. Fixed lunate fractures.Clin 2016; 8: 228-231Crossref (4) 6Fok M.W.M. Fernandez D.L. Maniglio acute fractures.J 2020; 45: 662.e1-662.e10Abstract (6) 7Loisel F. Orr Ross Couzens G. Leo A.J. Wolfe Traumatic series.J 2022; 47: 285.e1-285.e11Abstract 8Urbanschitz L. Pastor T. Fritz B. Schweizer Reissner Wrist 2021; 10: 290-295Crossref (2) Injuries include fractures,5Lee Scholar,6Fok Scholar,8Urbanschitz radiocarpal fracture dislocations,6Fok triangular fibrocartilage complex injuries,8Urbanschitz scaphoid fractures,2Hankin Scholar,7Loisel and/or ligamentous injuries.2Hankin Scholar,3Arms Recently, Loisel et al7Loisel Fok al6Fok coined term highlight origin injuries. They defined CINDT-DISI angle more extension 20° no interosseous ligament disruption, indicated by normal (30° 60°) angle.6Fok accordance CAse REport (CARE) guidelines approval our institutional review board, that fractures. Written informed consent obtained patients for publication this series accompanying images. To knowledge, an Additionally, previous persistent fracture, were managed nonsurgically, evidence clinical final follow-up. A 29-year-old left hand–dominant healthy man fell on his outstretched hand while playing cricket, sustaining isolated, closed, neurovascularly intact (Fig. 1). Four days later, performed locked plating, he immobilized splint 6 weeks. noted 28.1°, progressed 64.2° months Scapholunate preserved Magnetic resonance arthrography showed lunocapitate capsule At follow-up surgery, range motion 45° 30° full pronosupination. He pain able return activities was, therefore, not interested further treatment. 52-year-old right woman ankylosing spondylitis slipped ice, 2). Three she CIND-VISI 29.2° 3). She early, aggressive physiotherapy achieved 80° 75° initial hardware removal because irritation. Volar shown safe9Kamal R.N. Ruch D.S. 2017; 42: 1034.e1-1034.e6Abstract (12) Scholar,10Suazo Gladwin Douglass N. Behn A.W. Thio Kamal Safety releasing during open treatment fractures: analysis ligaments’ contribution stability.J 1089.e1-1089.e16Abstract (0) concurrently her 32.5° 28.7° Her 26.6° removal, years did have significant limitation functional limitations, intervention performed.Figure 3Case 2, part 2: lateral radiographs demonstrating deformity, 37.6° B C year, resulting improvement 28.7°. remained stable 26.6°. E Anteroposterior D (2 years) show arthritis. CIND, nondissociative; VISI, instability.View Large Image Figure ViewerDownload Hi-res image Download (PPT) 14-year-old boy off bike, 4). plating radius; reduction ulnar head, neck, styloid; radioulnar joint above elbow weeks, followed Muenster cast 4 63.8° 5). Despite course physiotherapy, 25° 65° extensive adhesions contracture Seven Intraoperatively, fluoroscopic examination revealed CINDT 6). Arthroscopic debridement adhesions, locking plate release, manipulation under anesthesia restored alignment, maintained midcarpal joints 8 1-year follow-up, 18.3° 50° any limitations doing push-ups.Figure 5Case 3, comparative affected unaffected wrists (affected side) 13.3° (unaffected 30.7°. 3 demonstrates into aspect joint, suggestive adhesions. remains intact. Sagittal magnetic (orange arrow) thickening (white arrow); (blue (PPT)Figure 6Case 3: intraoperative images extension, correction restoration arthroscopic anesthesia. Removal plate, then performed. F Follow-up demonstrate 18.3°. 7). His missed; month, osteotomy radial shaft buckle styloid, 40.4° 5 8). Owing experience initiated active active-assisted exercises without restrictions upon pin passive stretching improved 19.1° 8) 90° 95° flexion, supination, 70° pronation. activity restriction back basketball difficulty.Figure 8Case 4, 17.5° 32.6°. Final (1 year), showing 19.1°. CINDT-VISI, pathoanatomy attributed “mooring lines” (extrinsic ligaments ligament, Fig. 9).6Fok Similar studies,6Fok imaging exhibited injuries capsule, whereas posit that, setting exacerbates VISI rotating 9); operatively (cases Treatment highly heterogeneous 12-patient dislocation eight surgery: three reducible repair, one radioscapholunate arthrodesis.6Fok eight-patient Acute (average weeks) 14 reconstruction, unsuccessful maintaining alignment.7Loisel series, diagnosis (beyond 12 worse outcomes.6Fok study, observed despite 1, functionally limited deformity. Similarly, experienced irritation motion. These findings are keeping those Urbanschitz al8Urbanschitz can nonsurgically good outcomes. Case initiation when appropriate depending fixation, play role achieving results. elected procedure rather salvage arthrodesis given patient’s young age. Although repair reconstruct ligaments, proper likely allowed scarring tension prevent recurrence Our study its small sample size relatively short durations, precludes ability determine long-term consequences untreated residual 48 neither nor demonstrated arthritis, literature.5Lee Overall, algorithm permitted pattern. Patients achieve continue conservatively. If surgical required, (including adhesions) realign row, joints, considered even Based results, minimum allow injured obviate need reconstruction. approach allows preservation motion, particularly patients, does preclude future fusion options unless pre-existing cartilage degeneration time