Scandinavian Journal of Surgery 97: 324332, 2008

Wrist instability
b. t. Carlsen1, a. y. shin2
1, 2
1

Division of Hand Surgery

Division of Plastic Surgery, 2 Department of Orthopaedic Surgery
Mayo Clinic, Rochester, Minnesota, U.S.A.

abstraCt

the topic of wrist or carpal instability has been a source of confusion and miscommunication for decades. the terminology can often be difcult to understand and one surgeons concept of instability may be completely different from anothers. this is by no
means a comprehensive review of carpal instability, which has often been the focus of
numerous multi-volume textbooks. the purpose of this paper is to detail the basics of
carpal instability, the anatomy, pathomechanics, terminology and basic principles of
treatment.
Key words: Wrist instability; carpal instability; carpal dysfunction; scapholunate dissociation;
lunotriquetral dissociation; VISI; DISI; CID; CIND

OSSEOUS ANAtOMY

LIgAMENtOUS ANAtOMY

the wrist is the link between the forearm and hand

which allows the complex motions that enable the
hand to be the most versatile terminal device known
to man. Its osseous framework includes the radius
and ulna, the proximal carpal row (scaphoid, lunate,
triquetrum and pisiform), the distal carpal row (trapezium, trapezoid, capitate, hamate), and the ve
metacarpal bones. Overall, there are 15 bones and 20
or more articulations that make up the wrist. Motion
is afforded through three joint types; the radiocarpal
joint, the mid-carpal joint and the carpometacarpal
joints. the radius articulates with the scaphoid and
lunate at the radiocarpal joint. the mid-carpal joint
includes the scaphotrapezial-trapezoid articulation,
the scaphocapitate/lunocapitate articulation, and the
triquetrohamate articulation.

Outside of the exor carpi ulnaris, there are no tendinous insertions into the carpal bones. therefore,
carpal motion, complex as it is, is determined by passive forces; joint surface conguration, load, and
static stabilizers (ligaments). the ligaments are static
restraints that control motion between individual
bones and groups of bones by reciprocal tension as
the wrist is loaded by muscle tension traversing the
carpus. therefore, a detailed understanding of ligamentous anatomy is a mandatory prerequisite to understanding carpal motion and instability.
With the exception of the transverse carpal ligament, the pisohamate ligament, and the pisometacarpal ligament, all wrist ligaments are intracapsular,
contained within loose connective tissue and fat.
thus, visualization is poor from an external approach
making identication of distinct structures difcult.
Because of this, the true ligament anatomy of the
wrist has been uncertain and often the topic of debate
amongst anatomists and surgeons. Better visualization is afforded by an intra-articular view, such as
through an arthroscopic approach. the ligaments of
the wrist are divided into extrinsic (radius or ulna to
carpus) and intrinsic (within the carpal bones) ligaments (Figs 1A and 1B). generally speaking, the extrinsic ligaments course medially (toward the capitate). the volar extrinsic ligaments include the ra-

Correspondence:
Alexander Y. Shin, M.D.
Mayo Clinic
Division of Hand Surgery, Department of Orthopaedic
Surgery
200 First Street, S.W.
Rochester, MN 55905, U.S.A
Email: shin.alexander@mayo.edu

Wrist instability

325

Fig. 1. Volar wrist ligaments, supercial dissection (A) and deeper dissection (B). R radius, U ulna, S scaphoid, L lunate, t triquetrum, P pisiform, tm trapezium, td trapezoid, C capitate, H hamate AIA anterior interosseous artery, RA radial artery,
PRU proximal radioulnar ligament, UC ulnocarpal ligament, Ut ulnotriquetral ligament, UL ulnolunate ligament, SRL short
radiolunate ligament, LRL long radiolunate ligament, RSC radioscaphocapitate ligament, tH triquetrohamate ligament, tC triquetrocapitate ligament, SC scaphocapitate ligament, CH capitohamate ligament, tC trapezoidcapitate ligament, tt trapeziumtrapezoid ligament, SL scapholunate, Lt lunotriquetral ligament, Stt scaphotrapezium-trapezoid ligament. (Published with permission of the Mayo Foundation).

dioscaphocapitate, the long radiolunate, the short

radiolunate, the ulnolunate, the ulnocapitate, and the
ulnotriquetral-capitate ligaments (1). there is a single
dorsal extrinsic ligament, the dorsal radiocarpal or
radiotriquetral ligament. this ligament has attachments to the lunate and has been shown to help stabilize the lunate from volar exion and is also a passive pronator of the wrist (2, 3) (Fig. 2).
the intrinsic ligaments are oriented transversely.
the proximal row intrinsic ligaments include the
scapholunate (SL) and lunotriquetral (Lt) ligaments
(Fig. 1). Each of these has dorsal, proximal and volar
components. the SL ligament is strongest in its dorsal
component. In contrast, the Lt ligament is strongest
in its volar component. the proximal aspect of both
ligaments is thin and membranous and does not contribute to intercarpal stability (1,4). the primary stabilizer of the scapholunate relationship is the SL ligament (57). An important secondary stabilizer,
through its attachments dorsally, is the dorsal intercarpal (DIC) ligament which runs from the scaphoid
to the triquetrum (8).
the reader desiring more on this essential topic is
referred to the comprehensive review published by
Berger in 1997 (1).

CARPAL ALIgNMENt
On a lateral plain lm X-ray, axes can be drawn and
carpal relationships can be inferred based on the angle of these axes (Fig. 3). the longitudinal axes of the
long nger metacarpal, capitate, lunate, and radius
should all fall on the same line. the longitudinal axis
of the scaphoid is drawn through the mid-points of
its proximal and distal poles or as a line tangential to
the proximal and distal tuberosities (911) (Fig. 4).
the scapholunate angle normally ranges from 30 to
60 degrees, average 47 degrees. As the scaphoid exes
and the lunate extends, the scapholunate angle increases. A scapholunate angle greater than 70 degrees
(10) or 80 degrees indicates carpal instability (9). In
the seminal paper on wrist instability, Linscheid,
Dobyns, et al. described the importance of the position of the lunate in carpal instability (10). When the
lunate was extended dorsally, they termed it dorsal
intercalated segment instability (DISI) and when it
was tipped volarly, it was called volar intercalated
segment instability (VISI). this concept of the position of lunate in the proximal carpal row spurred on
decades of research on wrist kinematics, etiology of
instability and treatment.

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B. T. Carlsen, A. Y. Shin

Fig. 3. Longitudinal axes of the radius, lunate, scaphoid, and capitate as measured using the axial and tangential technique (see
text). (Published with permission of the Mayo Foundation).

Fig. 2. Dorsal wrist ligaments. DRC- dorsal radiocarpal ligament,

DIC- dorsal intercarpal ligament. (Published with permission of
the Mayo Foundation).

CARPAL KINEMAtICS
the wrist functions to provide motion in two planes;
exion/extension and radial deviation/ulnar deviation (Figs 4A and 4B). Flexion and extension occur
between the radiocarpal and mid-carpal articulations.
Although debated, relatively more motion occurs at
the radiocarpal articulation (1215). the distal carpal
row is rigidly xed and can be considered a single
functional unit. the proximal carpal row, however, is
loosely bound, lacks any tendinous attachments, and
affords considerable motion between the bones of the
proximal row.
the most unique aspect of wrist motion is what
occurs in radial and ulnar deviation (Fig. 4B). In radial deviation the proximal carpal row exes and the
scaphoid moves out of the way to allow the trapezoid/trapezium to move radially. In ulnar deviation,
the proximal carpal row extends, and the triquetrum
moves out of the way to allow the hamate to move
ulnarly. An absolute precision of motion occurs to
allow a smooth transition from radial to ulnar without changing the distance between the capitate and
radius. If the reciprocal motion of the proximal carpal
row did not occur, there would be a lengthening or
shortening of the wrist in radial-ulnar motions.
Although many theories on carpal motion have
been described by pioneers in the eld (10, 1624),
essentially, an understanding of this reciprocal motion is the key concept to all the theories.

Fig. 4. Carpal motion in extension, neutral and exion (A). Carpal

motion in radial deviation, neutral, and ulnar deviation (B). (Published with permission of the Mayo Foundation).

HIStORY
Relative to many medical conditions, wrist instability
has had a short but intense history. In 1923, Destot, of
Canthop Hospital Dieu in Lyons, France used an
early X-ray tube to rst identify scapholunate dissociation (25, 26). In 1943, gilford and Lambrinudi
identied the scaphoid as an important connecting
rod, the loss of which results in longitudinal collapse
(19). In 1972, Linscheid and Dobyns penned their
landmark paper, traumatic instability of the wrist:
diagnosis, classication, and pathomechanics (10).
this work dened DISI and VISI and dened important concepts in wrist instability, in particular, dening the zig-zag deformity resulting in loss of scapholunate integrity by ligamentous injury or fracture
and adaptive changes after radius malunion. In
1980, Mayeld described perilunate instability as a

327

Wrist instability

result of progressive ligamentous failure (27). In recent years, published work on wrist instability has
grown exponentially (23). Although much has been
learned, our knowledge is still incomplete and, undoubtedly, great discoveries are still on the horizon
(28).
INStABILItY PAttERNS
Obtaining a clear understanding of wrist instability
is difcult due to complex anatomy, complex kinematics and complex patterns of injury. Attempts to
simplify our understanding have lead to the development of multiple schemes for classication of carpal
instability patterns (2,2931). Perhaps the most widely
adopted is the Mayo Classication (32). this scheme
classies carpal instability into four major categories:
1. Carpal instability dissociative (CID) includes instability within a row;

2. Carpal instability nondissociative (CIND) includes

instability between rows;
3. Carpal instability complex (CIC) includes combinations of CID and CIND, or instability within and
between rows;
4. Adaptive carpus refers to secondary malposition
of the carpus (table 1). It is important to note that
any instability of the wrist can be the result of an
acute injury or a chronic, attritional condition.
CID
CID can occur within the proximal (1.1) or distal row
(1.2). Distal row CID is uncommon and is the result
of axial carpal dislocation (radial or ulnar). Proximal
row CID is probably the most common and is radiographically seen with DISI deformity from a displaced scaphoid fracture or SL dissociation and VISI
deformity as a result of lunotriquetral (Lt) ligament
disruption. Finally, CID includes combined proximal
and distal row dissociation (1.3) (Fig. 1B).

tABLE 1
Carpal Instability - Mayo Classication
type
I. CID

Name

Radiographic pattern

1.1 Proximal row CID

a. Unstable scaphoid fracture
b. Scapholunate dissociation
c. Lunotriquetral dissociation

DISI
DISI
VISI

1.2 Distal carpal row CID

a. Axial radial disruption
b. Axial ulnar disruption
c. Combined
II. CIND

1.2 Radiocarpal CIND

a. Palmar ligament rupture

b. Dorsal ligament rupture

c. After radius malunion, Madelungs deformity, scaphoid
malunion, lunate malunion (see Adaptive carpus below)

III. CIC

IV. Adaptive carpus

Rt, Pt
Ut, Pt

DISI, Ut of entire proximal carpal row

Ut with increased SL space; Pt
(actually CIC)
VISI, Dt
VISI, Dt

2.2 Midcarpal CIND

a. Ulnar MCI from palmar ligament damage
b. Radial MCI from palmar ligament damage
c. Combined UMCI and RMCI, palmar ligament damage
d. MCI from dorsal ligament damage

VISI
VISI
VISI
DISI

2.3 Combined radiocarpal-midcarpal CIND

a. CLIP
b. Disruption of radial and central ligaments

VISI, DISI, alternating

Ut with or without VISI or DISI

a.
b.
c.
d.

Perilunate with radiocarpal instability

Perilunate with axial instability
Radiocarpal with axial instability
Scapholunate dissociation with Ut

DISI and Ut
AxUI and Ut
AxRI and Ut
DISI and Ut

a.
b.
c.
d.

Malposition of carpus with distal radius malunion

Malposition of carpus with scaphoid nonunion
Malposition of carpus with lunate malunion
Malposition of carpus with Madelungs deformity

DISI or Dt
DISI
DISI or VISI
Ut, DISI, Pt

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B. T. Carlsen, A. Y. Shin

Fig. 5. Axial radial carpal dislocations (top row). Axial ulnar carpal dislocation (bottom row). (Published with permission of the Mayo
Foundation).

Scapholunate instability (SLI) is the most common

CID pattern and can either be an isolated injury or
part of a continuum of ligamentous injury (see CIC).
Lunotriquetral injuries are less common and are to
confusion with alternative diagnoses of the ulnar
wrist and more subtle radiographic ndings. Isolated
Lt injuries are relatively uncommon, but do occur.
Although a VISI deformity has been associated with
Lt injuries, they only occur when there are injuries to
the secondary ligamentous restraints (dorsal intercarpal ligament) (33, 34).
Distal carpal row dissociations are typically part of
an axial disruption and are rare (Fig. 5) (35, 36).
CIND is more difcult to diagnose due to confusion with alternative diagnoses of the ulnar wrist and
more subtle radiographic ndings. Isolated Lt injuries are relatively uncommon, but do occur. Although
a VISI deformity has been associated with Lt injuries,
they only occur when there are injuries to the secondary ligamentous restraints (dorsal intercarpal ligament) (33, 34).
Distal carpal row dissociations are typically part of
an axial disruption and are rare (Fig. 5) (35, 36).

CIND
As the name carpal instability non-dissociative
(CIND) implies there is no instability or dissociation
between bones of the proximal carpal row or distal
carpal row. CIND encompasses pathology of the entire carpal row including midcarpal instability, radiocarpal instability, or both. Unlike CID, there is no
unifying injury pattern or pathology and the pathoanatomy is poorly understood. Often, patients will
have a hypermobility syndrome with generalized
ligamentous laxity (37). traumatic injury is not uniform with many patients unable to recall a specic
injury (38). this type of carpal instability is one of the
most controversial. Although many authors agree it
exists, classication and treatment have been difcult.
RADIOCARPAL CIND
Radiocarpal instability results from injury, rupture or
loss of integrity of the radiocarpal ulnocarpal liga-

Wrist instability

329

ments (39) (40). the result is ulnar translation of the

carpus. taleisnik classied these into two different
types (30). In type I the entire proximal carpal row is
ulnarly translated as a unit. In type II there is an associated scapholunate dissociation. the scaphoid remains associated with the distal radius and the lunate
and triquetrum slide ulnar. this type technically belongs in the carpal instability complex (CIC) classication (IIId in table 1). treatment in type I is focused
on repair of the radioscaphocapitate ligament, where
as in type II repair is targeted at the scapholunate
dissociation.
MIDCARPAL CIND
Laxity of the midcarpal joint was rst described by
Mouchet and Belot in 1934 as a snapping wrist (41,
42). Many patients with midcarpal CIND have joint
hypermobility with ligamentous laxity and no history
of trauma (37, 43). In 1986, Johnson and Carrera reported on 12 patients with chronic capitolunate instability eleven of which were treated surgically. Although no ligamentous pathology was found, treatment consisted of suture closure of the radioscaphocapitate ligament to the long radiolunate ligament to
tighten the space of Poirer. they report 9 of 11 patients with good or excellent results at a mean of 54
months post-op.
CIC
Carpal instability complex (CIC) includes injury patterns found in CID and CIND. the majority of these
injuries fall into perilunate dislocations. Perilunate
dislocation occurs with forced wrist extension, thenar
impaction, ulnar deviation, and midcarpal supination. these injuries were rst described and classied
in the classic article by Mayeld (27). He classied
the injuries by sequential ligament injury from radial
to ulnar (Fig. 6). Stage I refers to injury to the scapholunate ligament with partial disruption. In stage II
there is complete SL injury and further capitolunate
dissociation. In stage III there is injury to the Lt ligament with scapholunate and capitolunate dissociations. Finally, stage IV includes rupture of the dorsal
radiocarpal ligament allowing the lunate to dislocate
in a volar direction. the Mayeld classication refers
to lesser arc injuries where there is only ligamentous
injury (27). greater arc injury refers to perilunate
fracture dislocation where there is concomitant fracture of one of the surrounding carpal bones. the most
common greater arc injury is the trans-scaphoid perilunate dislocation (Figs 7A-D and 8) (44). CIC also
includes axial dislocation injuries that were discussed
previously.

ADAPtIVE CARPUS
Adaptive carpus instability results from extracarpal
pathology at radius level. this is often a result of

Fig. 6. Perilunate disruption begins at the scapholunate ligament

and progresses in an ulnar direction around the lunate.

radius fracture malunion (45), but may also occur as

a result of Madelungs deformity. the extracarpal malalignment results in secondary midcarpal instability (31, 46). the process can progress to intrinsic ligament failure by attrition. Correction is directed at
correction of the malunion (31, 46).

DIAgNOSIS
the keystone to diagnosis is a detailed physical examination. Every bone of the wrist and every ligament that can be palpated should be palpated. Provocative maneuvers to stress the intrinsic and extrinsic ligaments should also be performed. Although a
description of these maneuvers is beyond the scope
of this paper, it should be stressed that a majority of
carpal instability can be diagnosed on physical examination.
Radiographic evaluation is an integral part of the
diagnosis. However, radiographs are often normal.
Multi-view stress radiographs or motion series can
elicit subtle abnormalities. Additionally comparison
lms are often useful. Further imaging can be performed with computed tomography to evaluate for
osseous abnormalities, MRI for soft tissue abnormalities or other invasive radiographic tests such as traditional arthrograms or MR arthrograms.
the gold standard for evaluation of carpal instability has been the use of wrist arthroscopy which provides a direct visualization of the articular surfaces
and volar and dorsal extrinsic ligaments. Indirect
evaluation of the stability of the intrinsic ligaments
can be determined by probing the interval between
the carpal bones.

330

B. T. Carlsen, A. Y. Shin

Fig. 7. trans-scaphoid perilunate dislocation. Injury lms, PA (A) and lateral (B) views. Reduction/xation views, PA (C) and lateral (D).

PRINCIPLES OF tREAtMENt
A description of treatment of carpal instability is a
voluminous task as there are so many variations of
carpal instability. the basic determinants of treatment
include
1.
2.
3.
4.

the presence or absence of arthritic changes

Chronicity of injury
Quality of tissues to repair
Reducibility of deformity (i.e. not xed)

If there are no arthritic changes, in a relatively acute

injury with good quality of soft tissues and reducible

deformity, the principles of treatment include the restoration of normal anatomy whenever possible. this
implies ligament repairs, restoration of normal carpal
angles and anatomic reconstructions. In similar cases
where tissue quality is poor, ligament reconstruction
or salvage procedures should be considered. Salvage
procedures include intercarpal arthrodesis, PRC or
total wrist arthrodesis. In cases of arthritic changes,
chronic non reducible deformities, salvage options
should be considered.

Wrist instability

Fig. 8. Lesser arc injuries involve ligamentous injury about the

lunate. greater arc injuries involve a fracture of one of the surrounding carpal bones. (Published with permission of the Mayo
Foundation).

CONCLUSIONS
Wrist instability is often a confusing and challenging
topic for generalists as well as wrist specialists. A
foundation of knowledge of anatomy, normal and
pathomechanics forms the basis of understanding the
diagnosis, radiographic ndings, exam and ultimately treatment of these potentially debilitating injuries.
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Received: October 7, 2008