Nondissociative wrist instability: What is it and how to manage it

Management of nondissociative instability of the wrist Zelenski, N, & Shin, A. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Diagnostic/Therapeutic Topic: Carpal instability non dissociative - Diagnosis and treatment This is a narrative review on presentation, diagnosis, and treatment of non dissociative carpal instability (CIND), which is reported as a rare condition. This pathology is defined as a loss of synchronous movement of the carpal rows associated with pathology of extrinsic ligaments of the wrist with intact intrinsic ligaments. In contrast, a carpal instability dissociative disorder (e.g. DISI, VISI) is characterised by an intrinsic ligament pathology of the wrist. Patients with CIND often report absence of trauma, achiness following activity, and relief by rest. Objectively, generalised ligament laxity has been reported in 70% of people with symptomatic CIND. The midcarpal shift test and axial load radioulnar deviation test are often performed. These tests should only be considered positive if there is an obvious hypermobility and patients report wrist pain. X-rays can identify volar intercalated segment instability (VISI) and/or subluxation of the carpus in relation to the radius. The authors suggest that pain is the only indication for treatment of CIND. Non operative treatment includes proprioceptive and resistance training, short time splinting, and taping as required. Surgical and conservative treatment outcomes are similar, making the non-operative option the first line treatment for these patients. If conservative treatment fails, surgical intervention with ligament reconstruction or arthrodesis may be performed. Clinical Take Home Message: Non dissociative carpal instability is a rarely encountered pathology. A history of atraumatic wrist pain, the objective presence of laxity (pain associated with hypermobility), a positive midcarpal shift test and axial load radioulnar deviation test may direct the hand therapist towards a diagnosis of CIND. First line treatment involves proprioceptive and strength training, escalated to surgical management if conservative treatment fails. URL: https://www.jhandsurg.org/article/S0363-5023(19)31472-8/fulltext

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