Current Physical Medicine and Rehabilitation Reports (2023) 11:212–222

https://doi.org/10.1007/s40141-023-00400-y

Evaluation and Management of Carpal Instability

Ryan Wei1,2 · James E. Gardner3 · Stephen Schaaf3,4 · J. Bradford Hill5 · Zachary Bailowitz2,6

Accepted: 17 April 2023 / Published online: 2 May 2023

© The Author(s) 2023

Abstract
Purpose of Review This paper sets out to review the past and current literature on the evaluation and management of the
various types of carpal instability.
Recent Findings Carpal instability has many sub-types, and therefore, its evaluation and management widely differ. There
are recent studies that indicate that while MRI and MR arthrography are the mainstays for evaluation, certain CT and radio-
graphic measurements may be better at diagnosing scapholunate ligament tears. In addition, recent research has proposed
multiple sonographic protocols in the evaluation of carpal ligament pathology. However, the comparison of ultrasound to
other imaging modalities is limited. The research for operative and non-operative management of carpal instability is limited
and often guided by expert opinion. To date, no studies exist on the use of novel injection techniques to treat carpal instability.
Summary Evaluation of carpal instability is evolving, and ultrasound may play an increased role. Evidence regarding non-
operative management of carpal instability is limited.

Keywords Carpal instability · Scapholunate · Wrist pain · Wrist instability

Introduction

Carpal instability is an important cause of acute and chronic

* Zachary Bailowitz wrist pain and can lead to long-term dysfunction if not managed
[email protected] appropriately. Carpal instability is caused by the disruption of
Ryan Wei key ligaments or articular geometry from either fractures, chronic
[email protected] repetitive overuse injuries, or less commonly rheumatological
James E. Gardner conditions [1]. If these are unaddressed, ligamentous laxity and
[email protected] instability can ensue. Injury patterns are commonly from sports-
Stephen Schaaf related hand or wrist injuries, acute trauma, and occupational
[email protected] activities typically stemming from a fall on an outstretched hand
J. Bradford Hill [2]. In sports, it has been reported that up to 25% of injuries
[email protected] involve the hand and wrist [3]. Recognizing, diagnosing, and
1 treating these injuries early is key to the prevention of long-term
Department of Family and Community Medicine, University
of California San Francisco, San Francisco, CA, USA disability [4]. While certain instability patterns require surgical
2 attention, there is a paucity of literature regarding non-operative
Department of Orthopedic Surgery, University of California
San Francisco, San Francisco, CA, USA options. This review focuses on the pathoanatomy, evaluation,
3 and treatment of carpal instability, with special attention paid to
Department of Physical Medicine and Rehabilitation,
Vanderbilt University Medical Center, Nashville, TN, USA recent studies regarding non-operative indications and treatment.
4
Department of Orthopedic Surgery, Vanderbilt University
Medical Center, Nashville, TN, USA
5
Department of Plastic Surgery, Vanderbilt University
Anatomy
Medical Center, Nashville, TN, USA
6 The wrist is composed of eight carpal bones that abut the
Department of Orthopedics, Podiatry, & Sports Medicine,
Kaiser Permanente Oakland Medical Center, Kaiser radius and ulna. The bones are arranged into proximal and
Permanente, 3600 Broadway, Oakland, CA 94611, USA distal rows. The proximal consists of the scaphoid, lunate,

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Current Physical Medicine and Rehabilitation Reports (2023) 11:212–222 213

and triquetrum, with the hamate, capitate, trapezoid, and section [7]. Additionally, the wrist anatomy is further char-
trapezium in the distal row, and the pisiform, a sesamoid acterized by the arcs of Gilula, which are helpful in the
bone, sitting palmar to the triquetrum within the flexor evaluation of wrist anatomy on radiography and suggestive
carpi ulnaris tendon [5]. The proximal row is mobile as of wrist injury when they are disrupted. The first arc traces
it conforms to the radius and ulna while the distal row the proximal surface of the proximal row at the articula-
is rigid and functions to articulate with the metacarpals tion with the radius and ulna. The second arc follows the
[5]. The rows are stabilized by interosseous ligaments and distal surface of the proximal row at its articulation with
secondary stabilizers known as the capsular ligaments, the distal row. Finally, the third arc traces the proximal
consisting of the “proximal palmar V” and the “dorsal V” surface of the distal row [8].
groups (Fig. 1) [6]. Typically, the interosseous, or intrin-
sic, ligaments originate and insert between carpal bones,
whereas the extrinsic ligaments connect the carpal bones Carpal Instability Patterns
to the radius and ulna. Attachments and functions of the
extrinsic ligaments are beyond the scope of this review; Carpal instability has been classically divided into four pat-
however, it is important to note that disruption of both terns of injury based on the Mayo classification:
intrinsic and extrinsic ligaments simultaneously result in
instability visible at rest without dynamic motion, while 1. Carpal instability dissociative (CID)
sole intrinsic ligament disruption may not initially be 2. Carpal instability non-dissociative (CIND)
apparent without stress or dynamic imaging [7]. 3. Carpal instability complex (CIC)
The most common ligament injuries resulting in carpal 4. Carpal instability adaptive (CIA) [9].
instability clinically involve the scapholunate interosseous
ligament (SLIL) and lunotriquetral interosseous ligament CID: DISI and VISI
(LTIL), with the latter being less frequently injured [7].
These two ligaments have three bands, the dorsal, central, CID refers to an instability pattern within the proximal row
and volar, with the dorsal band being the most robust and of carpal bones. These injuries typically result from hyper-
primary stabilizer for the SLIL and the volar being impor- extension or hyperpronation injuries [9]. In general, the
tant for rotational stability [7]. Thus, disruption of the dor- scaphoid has a tendency to flex while the triquetrum has a
sal band of the SLIL enables dorsal intercalated segment tendency to extend. When both the SLIL and LTIL are intact,
instability (DISI), and the disruption of the volar band this results in a neutral lunate. However, if one of these liga-
of the LTIL creates volar intercalated segment instability ments is disrupted, the force from the other intact ligament
(VISI) which will be further discussed in a subsequent “wins” causing a dorsal or volar tilt to the lunate. Within

Fig. 1  Schematic display of intracapsular carpal ligaments. a Palmar capitoscaphoid ligament (TCSL = arcuate ligament) constitutes its
“V” ligaments. The proximal palmar “V” consists of the palmar radi- ulnar leg. b Dorsal “V” ligaments. In contrast to the palmar side, the
olunotriquetral ligament (pRLTL) on the radial side and the ulnolu- ligamentous anatomy of the dorsal carpus resembles a horizontal “V”
nate (ULL) and ulnotriquetral ligaments (UTL) on the ulnar side. The with the dorsal radiolunotriquetral ligament (dRLTL) as the proximal
radial leg of the distal palmar “V” is formed by the radioscaphocapi- leg and the intercarpal dorsal ligament (ICDL) as the distal leg. (with
tate (RSCL) and scaphocapitate ligament (SCL), while the triquetro- permission)

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the proximal row, scapholunate injury is the most common CIND-DISI, the click originates during ulnar deviation
disruption, representing a spectrum of pathology includ- occurring from dorsal subluxation of the capitate, while
ing SLIL sprain or tear, DISI, and scapholunate advanced the proximal row extends during ulnar deviation. This is
collapse (SLAC) [7]. This spectrum of pathology generally due to injury or failure of the dorsal intercarpal ligament
begins with the compromise of the dorsal component of the and/or the radioscaphocapitate ligament [11, 12]. Given
SLIL, the main stabilizer of the complex, usually through a the location of ligamentous disruption, in a retrospective
fall on an outstretched hand (FOOSH) or other forced wrist case series by Fok et al, the most common fracture pat-
extension injury, though atraumatic causes are also possi- terns in acute wrist trauma that produced CIND included
ble (calcium pyrophosphate deposition disease, rheumatoid fractures of the radial styloid and the dorsal rim [10].
arthritis, or neuropathic arthropathies). Regardless of the
cause, the disrupted SLIL leads to abnormal kinematics of
the carpal bones given the lack of restrained lunate over CIND‑Combined
the scaphoid, which may be seen clinically and on imaging
studies. This generally leads to an extended posture of the CIND combined exhibits features of both CIND-VISI and
lunate over the scaphoid called DISI (as described above). CIND-DISI, resulting from injury or laxity of the volar
Also included in this category of CID are scaphoid nonunion and dorsal ligaments. Similar to CIND-VISI, when the
and Kienbock’s disease IIb and IV [9]. Continued chronic patient’s hand is moved from radial to ulnar deviation, the
loading of the wrist in the setting of pathological mechanics proximal row clicks while moving from a flexed posture
leads to degenerative arthritis at the radioscaphoid articula- to an extended posture. Similar to CIND-DISI, at further
tion as well as midcarpal instability consistent with progres- ulnar deviation, dorsal subluxation of the capitate occurs.
sion to the true SLAC wrist. There are several recognized CIND combined typically occurs from extension injuries
grading systems for this degenerative cascade based on the and repetitive overuse sports or tasks that involve gripping
number and severity of joints involved and the level of mid- and striking, and in populations with greater ligamentous
carpal instability that are beyond the scope of this review. laxity [13].
The second most common cause of proximal row instabil-
ity is LTIL injury. Given the importance of the volar band
to the lunotriquetral interface, disruption results in VISI— CIA and CIC
referring to a volar tilt of the lunate with respect to the
scaphoid. This condition is sometimes referred to as palmar- CIA is a pattern that occurs due to abnormalities extrinsic
flexed intercalated segment instability (PISI). Of note, VISI/ to the carpus, such as distal radius fractures with derange-
PISI is commonly associated with triangular fibular cartilage ment of extrinsic ligaments [11]. Intrinsic ligaments are
complex (TFCC) injuries involving axial load applied to a typically intact, though they may have slackened; the
pronated wrist [6]. intrinsic distances between carpal bones are decreased,
and consequently, if ligaments are injured, it is due to attri-
CIND tion rather than a discrete tear [14]. Common causes of
injury are fractures to the distal radius, fracture disloca-
CIND refers to instability patterns of the entire proximal tions, distal radius malunions, and Madelung’s deformity
carpal row with respect to the radiocarpal articulation or [14]. CIC is a combination of both CID and CIND patho-
the distal carpal row without proximal row dissociation logically; however, CIC has a different injury etiology.
[10]. This pattern of injury is defined by its clinical find- There are four categories of CIC: dorsal perilunate dis-
ings of snapping or clicking with the articulation of the locations, dorsal perilunate fracture dislocations, palmar
mid-carpal joints during extreme ulnar deviation. Thereby, perilunate dislocations, and axial dislocations [11]. Each
this pattern can be created by injury at either the radiocar- of these is associated with their own pathomechanics sec-
pal and/or the midcarpal joint [10]. Similar to CID, CIND ondary to injury to the ligament or ligament complex of
has a classification involving CIND-VISI and CIND-DISI interest, which is beyond the scope of this review [11, 15].
and combined and adaptive patterns. In CIND-VISI, the
proximal row kinematics are disrupted due to injury of
the scaphotrapezium trapezoid (STT), scaphocapitate, Epidemiology
triquetrum capitate, or triquetrohamate ligaments. Conse-
quently, the proximal row will remain palmar flexed during Wrist pain and injury are fairly common complaints; how-
ulnar deviation and the distal row sags volar until the wrist ever, high-level studies evaluating the incidence of car-
reaches further ulnar deviation, at which the proximal row pal instability are lacking. One study by Tang reports an
rotates and the definitive “catch-up click” occurs [11]. In incidence of carpal instability of 30.6% in 132 patients

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presenting for a distal radius fracture [16]. Some inves- or LTIL, may represent specific sites of injury. Diminished
tigations suggest that 10% of wrist injuries and 19% of active range of motion with wrist flexion/extension or ulnar/
sprains without fracture result in perilunate instability radial deviation compared to the contralateral side or pain at
[17, 18]. A more recent study by O’brien and colleagues the end range of motion could all signal carpal instability.
investigated carpal instability in patients presenting to the Multiple dynamic exams have been described to test for
emergency department for wrist pain following a fall on carpal instability. The scaphoid shift or Watson test is used
an outstretched hand found a cumulative incidence of 44% to confirm scapholunate ligament instability [23]. This test
within two years of injury [19]. These included scapholu- uses the oppositional force of the examiner’s thumb while
nate ligament instability (24%), lunotriquetral instability translating the wrist both volar and radial to see if the scaph-
(24%), and midcarpal instability (14%). Another important oid translates dorsally with pressure. Removing pressure will
finding of this study was that at up to 2 years after injury, result in a “clunk” if it displaced, signaling a positive test
there remained no significant relationship between clinical and has a mean positive likelihood ratio of 4.7 for scapholu-
instability and pain and function. This suggests that many nate injury [24]. The ballottement test for the lunotriquetral
of these cases of instability likely persist undiagnosed until joint entails placing the thumb on the triquetrum with radial
they progress to a symptomatic state. Unfortunately, this pressure in a rocking or balloting motion [25]. A painful
progression generally involves progression to DISI or even response or reproduction of instability is considered positive
arthrosis which could limit treatment options. Despite this [26]. Unfortunately, this test is not specific to lunotriquetral
study’s relatively low response rate to follow-up question- instability and has a positive likelihood ratio of 1.12 only
naires, this may be the largest study investigating inci- [24]. The shuck test is another test for the LQ ligament with
dence of carpal instability in the traumatic setting. a similar utility to the ballottement test in which the exam-
iner repeatedly “shucks” the LQ joint [25]. The midcarpal
shift with a “catch up clunk” is a common test for midcar-
pal instability. A positive test causes a midcarpal clunk and
Clinical Presentation: History and Exam pain as the examiner provides palmar pressure and deviates
toward the ulna in pronation and extends the wrist [27, 28].
Most cases of acute carpal instability begin with a traumatic This test has a mean positive likelihood ratio of 2.67, mak-
injury to the hand, especially a fall on an outstretched hand ing it a highly recommended test for midcarpal instability
[20]. In the acute period, these patients generally report [24]. It is important to compare findings to the contralateral
increased wrist pain, swelling, and mild instability. Noting wrist, since some patients may have a baseline and therefore
the mechanism of injury is valuable in determining poten- symmetric laxity.
tially affected structures. The most severe injuries may result
in complete loss of hand function due to frank instability
about the wrist during regular daily activities [21]. Many Diagnosis/Imaging
patients, especially those with initially mild instability,
may present with subacute or chronic symptoms that have Imaging modalities available to visualize carpal instabili-
progressed, complaining of continued pain, loss of grip ties include radiography (x-ray), computerized tomography
strength, clicking, catching, or other mechanical symptoms. (CT), cone beam CT, magnetic resonance imaging (MRI),
Unfortunately, the relationship between instability, pain, magnetic resonance arthrography (MRA), and sonography
and function is often low, especially in those with subacute (ultrasound). Radiography is often the first line imaging for
symptoms [19]. Late detection of instability can lead to the the diagnosis and evaluation of carpal instability. Anterior-
progression of the deformity and early arthritic changes [22]. posterior and lateral radiographs are recommended [29].
Some cases of carpal instability may concurrently present These views allow tracing of the Arcs of Gilula, where
with a ganglion cyst. Carpal instability can also occur with- disruption of any of the three lines supports the diagnosis.
out trauma in the setting of rheumatological conditions such These also can provide measurements of the scapholunate
as calcium pyrophosphate dihydrate crystal deposition dis- interval, scapholunate, and radiolunate angles [7]. For fur-
ease arthropathy and rheumatoid arthritis. ther evaluation, stress and dynamic views can help evaluate
Examination of the wrist should begin with an inspection. scapholunate joint instability. These images can be used to
For carpal instability, obvious bony deformity, especially classify injury according to the European Wrist Arthroscopy
compared to the unaffected, side is crucial. For acute inju- Society (EWAS); however, their utility has only been shown
ries, a neurovascular exam is always necessary, as neuro- for higher severity scapholunate instability [29]. While the
logical deficits or pulselessness require emergent attention. cutoff for scapholunate widening on x-ray has been debated,
Palpation over specific structures, especially the proximal widening of > 2 mm has been correlated with a higher
carpal row and the ligaments of interest, such as the SLIL Geissler grading in a study by Rachunek et al. [30]. Based on

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their findings, they proposed an algorithm for the classifica- helpful to evaluate for concurrent DRUJ injury which is
tion of SLD in which those with < 1.9 mm of scapholunate commonly associated with carpal instability [1]. A recent
widening on static PA views, < 2.7 mm in ulnar inclination case report of ten posttraumatic patients with either CIND-
views, and a scapholunate angle of < 63° without tenderness DISI or CIND-VISI found that all ten patients had MRI evi-
as unlikely for SLIL injury [30]. Novel devices have been dence of radiolunate ligament rupture [37].
created to better measure SLIL instability, but these have not Ultrasound is another useful imaging modality for evaluat-
become part of standard practice to date [31]. Therefore, in ing carpal instability and is gaining popularity as it allows for
those complex cases when carpal pathomechanics remains high-resolution point of care and dynamic evaluation. Due
in question after static imaging, we recommend the use of to the fact that ultrasound requires user competency and a
fluoroscopy to dynamically evaluate the motion of carpal strong knowledge of the anatomy of the wrist, there are newer
structures for concerns of instability, and live imaging and publications which outline scanning techniques and anatomy
recording should be available [32]. For scapholunate insta- in a comprehensive fashion [38, 39•, 41]. Wang et al. have
bility, there is a reported sensitivity of 90%, specificity of proposed specific protocols to visualize both the intrinsic and
97%, and diagnostic accuracy of 93% [29]. Additionally, extrinsic ligaments both volarly (Fig. 2) and dorsally (Fig. 3);
intra-articular injections of non-ionic iodine-based positive however, this paper did not examine the validity of any of
contrast medium are the best method to elucidate interos- these diagnostic techniques in comparison to MRI [39•].
seous ligament injuries as contrast extravasation into non- While the I-WRIST work group does not recommend ultra-
communicating compartments is indirect proof of ligamen- sound for the standard workup for SLJ instability due to its
tous injury [32]. low sensitivity and necessity for an experienced and subspe-
Computerized tomography has two major benefits for cialized examiner, the authors do note that ultrasound can
consideration in the diagnosis of carpal instability: [1] late- help delineate radioscaphocapitate ligament, long radiolunate,
phase diagnosis, as this modality visualizes articular sur- dorsal radiocapitate, and dorsal intercarpal ligament ligamen-
faces, cartilage abnormalities, and subchondral sclerosis in tous injuries. Additionally, the work group notes that dynamic
the radioscaphoid and midcarpal joints; and [2] visualization evaluation of SLJ instability for Garcia-Elias staging has equal
of occult scaphoid fractures, especially on high-resolution recommendation between dynamic fluoroscopy, ultrasound,
CT, as scaphoid injuries are a source of CID given the scaph- kinematic CT, and kinematic MRI as there is not enough data
oid’s location in the proximal row [6]. A recent study com- to implicate superiority [29]. Kasiyama et al. attempted to cre-
pared multidector CT (MDCT—traditional) to 3D-conebeam ate an ultrasound-based criteria for SLIL injuries post distal
CT, reporting similar image quality at lower radiation doses, radius fractures, comparing ultrasound to arthroscopy, finding
while also providing a more comfortable imaging position for that for their 40 patients, ultrasound had a high specificity but
patients [33]. Additionally, a recent prospective study evalu- low sensitivity for SLIL diagnosis [40]. Additionally, Gitto
ated 305 patients for acute wrist trauma and compared cone et al. in 2017 outlined a comprehensive scanning technique
beam CT vs. scout x-ray and found good intra-observer reli- for various intrinsic and extrinsic ligaments [41]. There have
ability given similar wrist positions and protocols [34]. Spe- also been studies involving scapholunate injury detection with
cifically for scapholunate interosseous tears, CT arthrography sonography due to its frequency of occurrence in wrist injuries
has higher diagnostic accuracy than MRI [29]. An interest- and consequential instability. Traditionally, it has been shown
ing frontier currently being investigated is the utility on the that ultrasound has a high specificity and high accuracy, but
diagnostic accuracy of 4D CT for insatiable scapholunate low sensitivity in identifying scapholunate ligament injuries
dissociation [35]. Finally, a prospective study of 160 patients [42]. Figure 4 demonstrates sonographic findings in a patient
with suspected scapholunate ligament tears comparing MR, with a surgically confirmed SLIL tear. The corresponding
CT, and x-ray found that the posterior radioscaphoid angle intra-operative findings can be seen in Fig. 5. A recent cohort
on CT was most valuable for differentiating torn and partially of 40 patients with ten normal SLL and 30 suspected or con-
torn scapholunate ligaments [36•]. firmed SLL injuries were evaluated by ultrasound compared
MRI and MRA are used similarly to CT as a further with either MRI or arthroscopy, and the authors found reliable
investigative tools for carpal injuries and instability. The measurements by sonography of 5 mm, 2 mm, and 5.1 mm for
I-WRIST international wrist radiologic evaluation for the dorsal, middle, and palmar aspects of the SLL, respectively,
instability of the scapholunate joint and the DRUJ/TFCC for a normal wrist, compared to 6.4 mm, 3 mm, and 6.3 mm
2021 group states in their consensus statement that MRI for an injured SLL [43]. A difference in distance between the
and MRA can delineate most extrinsic and intrinsic liga- injured SLL and contralateral normal SLL of more than 1.15
ments. MRA was preferred to MRI based on providing better mm dorsally had the highest true-positive rate. No studies yet
diagnostic accuracy for SLIL tears than conventional MRI have established standardized static or dynamic measurements
[29]. It must be noted that both CTA and MRA were equally for an injured SLL [44]. In addition, there is no consensus
recommended for cartilage defects. MRI and MRA are also regarding the optimal dynamic ultrasound test for the SLL.

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Fig. 2  Proposed algorithm for scanning the volar wrist ligaments. Licensee MDPI, Basel, Switzerland

Techniques described include wrist radial and ulnar devia- Ultrasound is an emerging imaging modality that is gaining
tion, clenched fist, and pencil grip views. In our experience, utility for the evaluation of carpal instability.
wrist radial and ulnar deviation allow for the greatest and
most reliable stress on the SLL. Outside of imaging for carpal
instabilities, US was used to measure scapholunate interos- Indications for Operative and Non‑Operative
seous ligament finding that in athletic volunteers the dorsal Management
SLIL is thicker and longer in the dominant vs. non-dominant
hand—suggesting the accuracy and repeatability of locating Given that carpal instability patterns exist on a spectrum, early
the SLIL [45]. Finally, ultrasound can accurately evaluate for identification is important due to the disability associated
dorsal ganglion cysts which can present with an injured SLL. with an unstable wrist and the long-term consequences of an

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Fig. 3  Proposed algorithm for

scanning dorsal wrist liga-
ments. Licensee MDPI, Basel,
Switzerland

undiagnosed or untreated injury (e.g., progression to scapholu- CID

nate advanced collapse, early osteoarthritis). It is therefore
important to recognize which types of injury can be treated CID is, by definition, a biomechanically less stable condition
operatively or non-operatively. Unfortunately, there is limited than CIND, and is thus less likely to respond to conservative
data available to help with these clinical decisions aside from treatments without correcting the underlying pathomechan-
case series and expert opinion. Furthermore, there is varying ics [47].
consensus amongst hand specialists on how to best manage A scapholunate ligament injury is the most common
the variation within carpal instability patterns. Clinicians must cause of CID. Traditionally, it is thought that a SLIL injury
therefore strongly hold the consideration of the etiology, chro- will progress to a SLAC. This however may be nuanced as
nicity, symptom severity, location, and instability pattern when grading the injury may provide guidance for operative vs.
deciding on the appropriate treatment for their patient [46]. non-operative management. Conservative treatment may be

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Current Physical Medicine and Rehabilitation Reports (2023) 11:212–222 219

Fig. 4  The long-axis view of the

SLL shows a hypoechoic cleft
in the middle of the ligament
consistent with a complete tear.
There is also evidence of peri-
osteal avulsions of the lunate. S,
scaphoid; L, lunate

appropriate for Geissler grades I and II, as a case series of chronic lunotriquetral instability. Of those, four patients had
11 patients followed for 7 years with scapholunate injuries non-dissociative tears, and one of those became asympto-
did not show progression to DISI or SLAC [48]. Conserva- matic following conservative treatment with either casting or
tive treatments in the acute phase focus on proprioceptive splinting. The two with dissociative injuries required surgi-
and neuromuscular training and may improve sensorimotor cal treatment [25].
function long term [49]. However, given the gross instability
of higher-grade injuries, failure to treat them surgically in CIND
the acute or subacute phase injury can lead to deterioration
of hand function and acceleration of post-traumatic arthritis Management for CIND is generally nonsurgical and typi-
[50]. In patients who are not fit for surgery or who prefer cally successful in symptomatic patients. However, it should
not to undergo surgical intervention, nonsurgical treatment be noted that this varies based on subtype. Non-surgical
options exist, although evidence is limited. This typically treatment should focus on educating the patient about the
includes immobilization with bracing, topical or oral medi- condition. This includes an explanation of anatomy and bio-
cations such as NSAIDs, and intraarticular corticosteroid mechanical forces that have led to instability. Activity modi-
injection for symptom relief [51]. If these measures do fication is often a mainstay of treatment once patients under-
not provide symptom relief then surgical treatment is war- stand which movements may lead to worsening symptoms.
ranted either with a repair or reconstruction. The decision Topical or oral NSAIDs and bracing may be helpful [13].
to repair or reconstruct is complex and beyond the scope of Similar to CID, the literature for CIND often lacks a direct
this review. In general, however, repairs are considered for comparison between surgical and non-surgical treatments.
more acute injuries and reconstructions for more chronic Despite this, case series reporting outcomes on both patients
injuries. The choice can also depend on the ability to reduce who improved with conservative treatment and those requir-
the deformity and the presence or absence of degenerative ing surgical treatment do provide important information to
changes [52]. guide management. One study by Urbanschitz et al. reports
In lunotriquetral instability, there is a similar paucity of 10 patients who developed post-traumatic CIND. Three of
evidence. The majority of case series available in the litera- the ten patients improved with conservative treatment alone
ture report outcomes of patients with chronic symptoms that (all three CIND-DISI) while seven others required further
had failed conservative treatment and moved to operative operative management [37]. Another study by Wright et al.
management, thus our understanding of the natural course reports the outcomes of 45 patients with CIND [28]. Seven
of symptoms and the likelihood of success with conserva- underwent non-operative management with splints (usually
tive treatments remains low [53]. Reagan and colleagues ulnar gutter splint with a pisiform boost), NSAIDs, and occa-
published a landmark paper in 1986 of six patients with sional steroid injections. They also underwent a structured

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220 Current Physical Medicine and Rehabilitation Reports (2023) 11:212–222

conservative treatment, but determining which patients will

improve vs. progress to surgical intervention is difficult.
Importantly, the landscape of conservative treatments
for joints, tendons, and ligament pathology throughout
the body has broadened in recent years to include a vari-
ety of novel injections beyond corticosteroids, such as
platelet-rich plasma (PRP) and prolotherapy. The use of
these novel treatments on ligamentous injury has focused
mainly on the anterior cruciate ligament, and the evidence
for their use in carpal instability remains limited [54].
There are several studies examining novel treatments in
the wrist, especially carpometacarpal (CMC) osteoarthri-
tis (OA). For example, one study by Abselsabor Sabaah
et al. found that patients receiving either PRP or corti-
costeroid injections for CMC OA experienced a similar
improvement in pain in the acute phase [55]. Another trial
examining pain due to trapeziometacarpal OA found that
the PRP injection group had improved pain relief up to
12 months following injection when compared with cor-
ticosteroids [56•]. Reeves and Hassanein studied a small
cohort of patients with OA of a variety of joints of the
hand, including the CMC and trapeziometacarpal joints,
and found that prolotherapy provided similar pain relief
to saline placebo at various time points up to 6 months
following injection [57]. One observational study investi-
gating PRP for a variety of musculoskeletal problems of
the hand included a patient with wrist pain found to have
a dorsal intercarpal ligament sprain. This patient received
a series of two PRP injections over 2 weeks which resulted
in a 95% improvement in pain that persisted over nine
months of follow up [58]. While it is useful to recognize
that these novel treatments exist and are being used for
a variety of musculoskeletal pathology, the evidence for
their use for carpal instability is lacking.

Fig. 5  Corresponding operative image of a complete SLL tear

Conclusion

Carpal instability is a complex condition involving vari-

therapy program focusing on strengthening and avoiding able interactions between the wrist, carpal, and metacarpal
provocative maneuvers. The other 38 patients underwent structures. Knowledge of these interactions enables us to
primary operative treatment. There was no significant dif- better evaluate and manage patients in the early, middle,
ference between operative and non-operative management and late phases of injury to ultimately prevent conditions of
with only ~56% of patients in each group achieved “good or chronic pain and dysfunction. The diagnosis of these carpal
excellent results.” However, there was significant heteroge- instability patterns continues to improve with new imaging
neity in subtype and surgical treatments performed in the techniques, especially as the use of and interest in ultrasound
surgical group. Overall, the sparse literature on conservative continues to grow in popularity and availability. Surgical
treatment of carpal instability suggests that those with obvi- indications for CID are often clearer, while the literature
ous, more severe instability found in CID will benefit from and evidence for CIND’s management are still in its early
early surgical treatment. These surgical options often include phase. Currently, there is limited evidence regarding the use
salvage-type surgery, such as proximal row carpectomy or of novel injection techniques for wrist pain and no specific
midcarpal fusions. Those with CIND may benefit more from data supporting its use in carpal instability.

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Current Physical Medicine and Rehabilitation Reports (2023) 11:212–222 221

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contain any studies with human or animal subjects performed by any hcl.​2015.​04.​011.
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as you give appropriate credit to the original author(s) and the source, 14. Carlsen BT, Shin AY. Wrist instability. Scand J Surg. 2008;
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were made. The images or other third party material in this article are 15. Garcia-Elias M, Dobyns JH, Cooney WP, Linscheid RL. Trau-
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