CARPAL INSTABILITY NON-DISSOCIATIVE (CIND)

Question 1

CIND definition

Answer 1

• form of carpal instability between carpal rows
• extrinsic instability due to dysfunction/ disruption of extrinsic ligaments
• intercarpal row instability
• can be radiocarpal, midcarpal or both

Question 2

Diagnosis of CIND

Answer 2

CIND is a dynamic pathology so diagnosis is based on

• ulnar shift test = pain and clunk with radioulnar deviation
• fluoroscopy = carpal subluxation with radioulnar deviation

Question 3

Radiocarpal instability in CIND

Answer 3

Caused by dysfunction/ disruption of extrinsic ligaments from distal radius to proximal carpal row
Results in ulnar translocation of carpus
Atraumatic aetiology (RA) more common
Reconstructive options have poor outcomes
Limited (radiolunate) or complete fusion

Question 4

3 forms of midcarpal instability in CIND

Answer 4

1. Volar CIND or CIND-VISI
2. Dorsal CIND or CIND-DISI
3. Combined CIND

Question 5

Volar CIND or CIND-VISI

Answer 5

Seen in patients with generalised ligament laxity
Involves dorsal radiocarpal ligament
Results in palmar flexion of entire proximal carpal row
Carpus initially has a volar sag. As the wrist is moved from radial to ulnar deviation, lunate clunks into position

Question 6

Dorsal CIND or CIND-DISI

Answer 6

Involves capitolunate instability
Carpus is initially neutrally aligned. As the wrist is moved from radial to ulnar deviation, capitate subluxes dorsally on lunate
Pain on supination is characteristic

Question 7

3 risk factors for combined CIND

Answer 7

1. Female gender
2. Generalised ligament laxity
3. Increased radial inclination

Question 8

Carpal instability adaptive (CIA)

Answer 8

Carpal instability due to extrinsic malalignment
Classically malunited DR fracture
Lunate extends and follows dorsally tilted DR, capitate flexes to compensate for lunate extension

Question 9

Management options for CIND

Answer 9

Generally nonoperative (NSAIDs, splints, injections)
Reconstructive options unpredictable with generally poor outcomes
Limited or complete fusion