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Romanian Journal of Hand and Reconstructive Microsurgery vol.

6 III/2001

29

CLASIFICAREA LEZIUNILOR CAPSULO-LIGAMENTARE


ALE PUMNULUI
THE CLASSIFICATION OF CAPSULO-LIGAMENTAR
INJURIES OF THE WRIST
Radu Necula, Iosif amot, Claudiu Butum
Orthopaedic Department, Transylvania University of Braov

Rezumat

Abstract

Leziunile capsulo-ligamentare ale carpului sunt nc


insuficient clasificate i ncadrarea deficitar face ca un
numr de leziuni distincte s treac neobservate n faza
acut sub diferite diagnostice generice, ns cu preul
sechelelor de tipul instabilitilor, necrozelor aseptice sau a
artrozelor. Aceasta constatare proprie ct i din literatura
de specialitate ne-a determinat s elaborm o clasificare n
care s fie cuprinse toate subtipurile de leziuni capsuloligamentare ale carpului ct i asocierile lor.

The carpal capsulo-ligamentar injuries are still insufficiently classified and their inappropriate framing results in
a number of distinct injuries which, in the acute phase, are
labeled with various general diagnoses. As a result, instabilities, avascular necrosis or arthrosis of the carp may
occur. Our own experience as well as the specialized literature made us elaborate a classification which includes all
subtypes of capsulo-ligamentar injuries together with
their associations.

Introducere

Introduction

Leziunile carpului reprezint o pondere important


ntre urgenele ce se prezint la camera de gard. Din literatura de specialitate i din experiena proprie se constat
o ncadrare lezional cu tendin la generalizare, aprnd
situaii n care sub denumirea de entors se ascund leziuni
complexe ce determin instabiliti restante ale carpului.
O alt situaie o reprezint precizarea insuficient a leziunilor n cadrul unei luxaii la nivelul articulaiei pumnului i surprinderea unor leziuni tardive de tipul necrozei
aseptice a semilunarului. Este esenial corecta ncadrare
ntr-un tip (clas) de leziuni pentru elaborarea unei conduite terapeutice corecte.

The carpal injuries prevail among the cases that present


in the emergency room. The specialized literature as well
as our own experience proves that there is a tendency of
classifying the injuries of the wrist in a more general way.
Therefore, situations may appear in which we may find
complex injuries that determine remaining instabilities of
the carp, or late arthrosis under the general name of
sprain. A different situation is represented by the insufficient specification of the injuries as part of a dislocation at
the level of the wrist joint, and by the finding of some late
injuries such as the aseptical necrosis of the lunate. It is
essential to attribute correctly the injury to a type in order
to elaborate an adequate therapy.

Principii de clasificare
Complexitatea capsulo-ligamentar i arhitectonic a
articulaiei pumnului suscit discuii i interpretri diferite
ncepnd de la abordarea cinematicii, la ncadrarea, clasificarea i nomina leziunilor de la acest nivel.
n cele ce urmeaz vom expune abordarea noastr
asupra clasificrii leziunilor capsulo-ligamentare ale articulaiei pumnului punctnd considerentele i criteriile care
stau la baza clasificrii.
A. Implicarea unei biomecanici complexe
Unii autori1 consider c teoria cinematic primeaz fa de celelalte teorii i sunt menionate conceptele de instabilitate ale aspectelor radial, central i ulnar ale carpului.
Mai mult, instabilitile carpului sunt interpretate ca rezultatul leziunilor ligamentare i osoase ale acestor coloane.

Classification principles
The capsulo-ligamentar architectural complexity of the
wrist joint determine various discussions and interpretations from the cinematic approach to the classification and
to the name of the injuries at this level.
The following article presents our approach on the
classification of capsulo-ligamentar injuries of the wrist
joint, emphasizing the reasons and the criteria on which
this classification is based.
A. Implication of complex biomechanics
Some authors consider the cinematic theory as being
more important than other theories. They mention the
instability concepts of the radial, central, and ulnar of the
carp1. Moreover, carpal instabilities are interpreted as the

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Romanian Journal of Hand and Reconstructive Microsurgery vol. 6 III/2001


Fig. 1. Mobilitatea variabil la nivel carpal mediu. Figura prezint: aria
de mobilitate maxim (a); aria de mobilitate relativ (b); stlpii
stabilizatori reprezentai de ligamentele colaterale. LCU ligament
colateral ulnar; LCR ligament colateral radial; a articulaie
mediocarpian intern; b articulaie mediocarpian extern;
MI membrana interosoas / The variable mobility at middle
carpal level. The figure shows: area of maximum mobility (a);
area of relative mobility (b); and the stabilizing pillars represented
by the collateral ligaments. LCU ulnar collateral ligament;
LCR radial collateral ligament; a middle carpal internal joint;
b middle carpal external joint; MI interosseus membrane

Fig. 2. Arcurile vulnerabile proximale (1) i distale (2) n articulaia


mediocarpian. Figura arat fracturile osoase asociate
cu leziunile articulare / The proximal (1) and distal (2) vulnerable
arcs in the middle carpal joint. The figure shows bone fractures
associated to joint injuries.

Teoria coloanelor carpului este prezentat n diferite versiuni, Navrro, Taleisnik, sau Weber fiind autorii care s-au
impus cu modele ce explic fiecare n parte cinematica
pumnului2. Aceast mprire a leziunilor pe coloane nu
ine seama de rezistena variabil de-a lungul coloanelor (mai
ales neuniformitatea structural a coloanei centrale) i de
strnsele legturi existente spre extremitatea distal a
coloanelor.
Elementul central, osul cheie al instabilitilor carpului este descris de toi autorii ca fiind semilunarul. La
aceasta adugm ca i articulaie cheie, articulaia mediocarpian.
Articulaia mediocarpian are o tendin la mobilitate
maxim central prin prezena unei caviti glenoide format de osul scafoid i semilunar n care ptrunde capul
capitatului, i de o zon stabilizatoare extern datorit
articulaiei dintre scafoid cu trapez i trapezoid unde se
formeaz o articulaie plan sau selar3. Din punct de vedere biomecanic, considerm ca un prim element al patternului lezional interdependena ntre dou articulaii cu
grade diferite de mobilitate i tendina de distribuire a forelor
destabilizatoare spre centrul zonei de maxim mobilitate, unde
vom ntlni principalele efracii capsulo-ligamentare. La
aceasta se adaug ca element favorizant prezena zonei
centrale de slbiciune dintre braele ligamentului radiat al
carpului, care permite realizarea unei bree capsulare palmare i vduvete de o aciune frenatoare un impuls spre
dorsal al semilunarului. Ligamentul dorsal al carpului contribuie insuficient i inconstant la stabilizarea carpului.
Dou fascicule fine, unul unind semilunarul i scafoidul,
cellalt semilunarul i piramidalul, sunt ataate la suprafaa proximal a acestora, parte a suprafeei convexe radiocarpiene, formnd un ax de rotaie la acest nivel3. Fr a
intra n amnuntele mobilitii primului rnd carpian,
vom preciza tendinele principale ale poziiilor extreme.
Aceste poziii devin puncte de plecare ale instabilitilor n
cazul aplicrii unor fore nocive fiind legate de geometria
variabil a rndului carpian proximal1.

result of bony and ligamentar injuries of these columns.


The theory of the carpal columns has various versions.
Navrro, Taleisnik or Weber are authors who compelled
recognition by models which explain the kinematics of the
wrist2. This division of injuries on columns does not take
into account the variable resistance along the columns (especially the structural diversity of the central column) and
the tight connections existing towards the distal extremity of the columns.
The central element, the key-bone of the carpal instability is considered by all authors to be the lunate. The
key-joint is the middle carpal joint.
The middle carpal joint has tendency to maximum
central mobility due to the presence of a compound glenoidian cavity formed by the scaphoid and lunate, which
articulate with the capitat head and hamate. The lateral
compartment represents a stabilizing area-due to the
scapho-trapezum joint and scapho-trapezoidum joint
resulting in a plain or sellar joint3. From the biomechanical
point of view, we consider the independence between two
joints with different degrees of mobility and the tendency of
distribution of destabilizing forces towards the center of the maximum mobility area as a first element of injury pattern. The
main capsulo-ligamentar disruptions can be found there.
As an element which favours the injuries we may add the
presence of the central area of weakness between the arms
of the radiat ligament of the carp, which allows a palmar
capsular gap and deprives the dorsal impulse of the lunatum of a delaying action. The dorsal ligament of the carp
has an inconstant and insufficient contribution to the stabilization of the carp.
Two narrow bundles, one connecting the lunate and
scaphoid, the other the lunate and triquetral, are attached
near their proximal surfaces forming part of the convex
radiocarpal surface determine an axis of rotation at that
level3. Without getting into details regarding the mobility
of the first carpal row, we will specify the main tendencies
of extreme positions. These positions become departure

The Classification of Capsulo-Ligamentar Injuries..., R. Necula, I. amot, C. Butum


Flexia dorsal a articulaiei pumnului n nclinaie
cubital (adducie) aduce un surplus de forare a extensiei
rndului carpian proximal, cu tendin la dislocarea perilunar dorsal a carpului, iar n momentul apariiei breei
capsulo-ligamentare palmare se poate ajunge la expulzia
anterioar a semilunarului. Aceste dou situaii apar ca
momente de stabilitate vicioas de sine stttoare, cu leziuni specifice, pe care le considerm entiti separate n
clasificarea noastr.
n flexie dorsal asociat nclinaiei radiale (abducie), se
nasc fore de forfecare, care vor solicita mai cu seam scafoidul, care n aceast poziie se plaseaz n centrul suprafeei radiale, i care va nsoi semilunarul (mai frecvent prin
polul su proximal fracturat i rmas ataat semilunarului),
n constituirea luxaiei dorsale a carpului fa de cele dou
oase, sau luxarea lor simultan anterior carpului rmas
aliniat la antebra. Prin adugarea i a dou entiti mai rar
ntlnite i anume luxaia scafoidului, cu sau fr un fragment cortical din capul osului mare, i a asocierii unui fragment din piramidalul fracturat la semilunarul dislocat,
putem mpri aceste leziuni n dou grupuri.
Luxaii dorsale ale carpului, cu subtipurile:
1. perilunar
2. transscafo-perilunar
3. periscafo-perilunar
4. transstiloradial-perilunar
5. transpiramidal-perilunar
6. periscafoid
Luxaii volare ale carpului
16. aceleai subtipuri
Flexia palmar, asociat deviaiilor radial sau ulnar,
duce la un spectru lezional mult mai redus, mprit ns
tot n dou categorii:
Luxaii volare ale semilunarului
Luxaii dorsale ale semilunarului
Modelul elaborat de Mazfield, Kicoyne i Johnson1
realizeaz trasarea a dou arcuri vulnerabile la nivelul
carpului, transstilo-perilunar, respectiv la limita articulaiei
mediocarpiene cotiliene, cu prelungirea acestei linii transscafoidian i transpiramidal. Asociaz i leziuni parcelare
ale polului proximal al capitatului i osului cu crlig.
Aducem o completare teoretic privind extremitatea radial a arcului la interliniul piramidalo-hamat (Fig. 2). Considerm a avea un rol deosebit n nelegerea asocierilor
lezionale cu aplicabilitate n clasificarea luxaiilor mediocarpiene.
Luxaie mediocarpian volar, cu subtipurile:
1. transscafoidian, pe care o descriem ca luxaie-fractur mediocarpian proximal. n acest tip ncadrm asocierea fracturilor proximale (capul) ale
osului mare sau de la nivelul articulaiei hamatopiramidale
2. transcapitat* i transpiramidal*4 pe care le ncadrm ca luxaia-fractur mediocarpian distal
*leziuni descrise asociate de WatsonJones
Luxaie mediocarpian dorsal, cu aceleai subtipuri
B. Asocierea unor leziuni distincte, pe baza patternului comun
Luxaia dorsal a osului mare (Delbet), denumit de
Mouchet, Jeanne i Tavernier luxaie subtotal retrolunar
a carpului, consacrat ca luxaie retrolunar a carpului, reprezint o etap intermediar n mecanismul producerii
luxaiei anterioare a semilunarului. Cu toate acestea,

31

points of the instabilities when there are some negative


forces applied, being connected to the variable geometry
of the proximal carpal row1.
The dorsal flexion of the wrist joint in adduction
increases the tension in the proximal carpal row extension,
with a tendency of dorsal perilunate carpal dislocation.
When the palmar capsulo-ligamentar gap is formed the
lunatum may be ejected forward. These two situations
appear as moments of self-dependent vicious stability,
with specific injuries, which we consider as separate entities in our classification.
In dorsal flexion associated to radial inclination (abduction), shredding forces appear, which will solicit especially
the scaphoid. In this position the scaphoid is placed in the
center of the radial surface and it will accompany the lunatum (more frequently by its pole proximally fractured and
remained attached to the lunatum) for constituting the
dorsal dislocation of the carp with respect to the two
bones, or their simultaneous dislocation anterior to the
carp which remains in line with the forearm. These
injuries may be divided into two groups by adding two
more entities more seldom found. These are the dislocation of the scaphoid, with or without a cortical fragment
from the head of the capitat, and the association of a fragment of the fractured triquetral to the dislocated lunate.
Dorsal dislocation of the carp, with the subtypes:
1. perilunate
2. trans-scaphoid perilunate
3. periscaphoid perilunate
4. trans-radial-styloid perilunate
5. trans-triquetral perilunate
6. periscaphoid.
Volar dislocation of the carp, with the subtypes:
1 to 6 (the same subtypes as for dorsal dislocation).
Palmar flexion, associated to ulnar and radial deviations, leads to much more reduced injury spectrum, which
is also divided into two categories:
Volar perilunate dislocations of the carp.
Dorsal lunate dislocations.
The model elaborated by Mazfield, Kicoyne and
Johnson1 describes two vulnerable arcs at the level of the
carp, the lesser arc trans-stylo perilunate, and the greater
arc at the limit of cotilian sector of the middle carpal joint,
with the extension of this line in trans-scaphoidian and
trans-triquetral direction. It also associates small injuries
of the proximal pole of the capitat, and of the hamate. We
bring a theoretical completion regarding the radial extremity of the arc at the triquetro-hamate line (Fig. 2). We consider it has an important role in understanding the injury
associations applicable in the classification of the middle
carpal dislocations:
Volar middle carpal dislocation, with the subtypes:
1. trans-scaphoidal, which is described as proximal
middle carpal fracture-dislocation. This type
includes the associations of the proximal fractures
(the head) of the capitate or at the level of hamatotriquetral joint
2. Trans-capitat* and trans-triquetral*4 which may
be attributed as the distal middle carpal fracturedislocation
*described by WatsonJones as associated fractures
Dorsal middle carpal dislocation, with the same subtypes.

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Romanian Journal of Hand and Reconstructive Microsurgery vol. 6 III/2001

Fig. 3. Aspecte ale leziunilor n luxaiile carpului. A Luxaia dorsal


a carpului; B Luxaia volar a semilunarului; C Expulzia
semilunarului; LRLd ligamentul dorsal radio-lunar;
LRLa ligamentul anterior radio-lunar; R radius; C capitat;
Mtc III metacarpian III / Aspects of the injury in carpal
dislocations. A. Dorsal dislocation of the carp; B. Anterior
dislocation of the lunate; C. Expulsion of the lunate;
LRLd The dorsal radio-lunate ligament; LRLa The anterior
radio-lunate ligament; R radius; C capitate;
Mtc III metacarpal III

luxaia retrolunar a carpului reprezint o poziie stabil,


pn n momentul ruperii ligamentului radiolunar dorsal
(frna posterioar a semilunarului dup Delbet) i a efraciei totale capsulare volare a semilunarului. Pe baza aspectelor anatomopatologice diferite, apreciem fiecare dintre
cele dou luxaii entiti diferite (Fig. 3 A, B). Aceste constatri le extrapolm asupra celorlalte componente ale rndului carpian proximal, izolate, asociate, sau n asociaii
pariale (luxaii fracturi asociate). Apare urmtoarea regul
general privind leziunile ligamentare ale oaselor carpiene
proximale.
Luxaii dorsale ale carpului, cu subtipurile:
Peri-os carpal (sau asocieri cu trans carpian). Se poate
asocia traiectul de fractur transstiloradial.
Luxaii volare ale osului carpal.
Ca rezultat al aceluiai mecanism, luxaia anterioar a
semilunarului prezint aspecte imagistice diferite de rotaie, pivotnd n jurul ligamentului radiolunar anterior, iar
n momentul ruperii acestuia se descrie o leziune distinct,
enucleerea total a semilunarului (Fig. 3 C).
C. Concordana ncadrrilor ntre diferii autori
Conceptul instabilitilor disociative ale carpului (CID)
introdus de Fisk i Linschind1, i cel mai nou de instabiliti
nondisociative CIND, i regsesc corespondena n:
CID: A diastazis intercarpian;
B fracturi instabile ale carpului;
C asocieri.
CIND: entorse instabile prin lezarea ligamentelor
extrinseci, cele interosoase fiind intacte*
*tehnicile imagistice moderne vor permite o ncadrare
cu acuratee n aceast clasificare
Instabilitile disociative ale carpului (CID)
a) Un alt aspect lezional la nivelul articulaiilor pumnului sunt rupturile ligamentelor interosoase dintre dou
carpiene ale aceluiai rnd, cu distanarea suprafeelor lor
articulare. Fiind articulaii plane cu ligamente intraarticulare, dei nu sunt sindesmoze, le ncadrm ca diastazisuri,
n cadrul instabilitilor disociative ale carpului:
1. Diastazis scafo-semilunar
2. Diastazis capitato-hamat (descris de Garcia Eliaas2, cu
prelungirea diastazisului i ntre metacarpienele 3 i 4)
3. Alte diastazisuri
b) Poziiile vicioase ale semilunarului n flexie volar,
respectiv dorsal, pot fi asimilate unor subluxaii (sunt

B. Association of the distinct injuries, on the basis of


the common pattern
The dorsal dislocation of the capitate (Delbet), named
by Mouchet, Jeanne and Tavernier subtotal retrolunate
carpal dislocation, acknowledged as retrolunate carpal dislocation, represents an intermediary stage in the producing
mechanism of the anterior dislocation of the lunate.
Nevertheless, the retrolunate dislocation of the carp represents a stable position until the moment of the disruption
of the dorsal radio-lunate ligament (the posterior break of
the lunate according to Delbet) and of the total volar capsular displacement of the lunate. On the basis of the different anatomo-pathological aspects, we appreciate each
of the two dislocations as different entities (Fig. 3 A, B).
We extend these findings on the other compounds of the
proximal carpal row, which are isolated, associated or partially associated (associated fractures-dislocations). The
following general rule concerning ligaments injuries of the
proximal carpal bones occurs:
Dorsal dislocations of the carp, with the subtypes:
Carpal peri-bone (or associations with carpal transbone) dislocations. The trans-styloradially fracture line
can be associated.
Volar dislocations of the carpal bone.
As a result of the same mechanism, the anterior dislocation of the semilunate shows different imagistic rotation
aspects, turning around the anterior radio-lunate ligament,
and at the moment of its disruptions a distinct injury is
described, the total displacement of the lunate (Fig. 3 C).
C. The conformity of classification of different authors
The concept of carpal dissociative instability (CID)
introduced by Fisk and Linschind1, and the newer concept
of nondissociative instability (CIND), find their correspondent in:
CID: A intercarpal diastasis;
B unstable fractures of the wrist;
C associations.
CIND: unstable sprain by damaging the extrinsec ligaments, the interosseus ligaments remain intact*
*the modern imagistic techniques will allow an accurate classification
The carpal dissociative instability (CID)
a) Another aspect of the injury at the level of the wrist
joint is represented by the disruptions of interosseus liga-

The Classification of Capsulo-Ligamentar Injuries..., R. Necula, I. amot, C. Butum


clasificate de Green i OBrien2 n cadrul instabilitilor
carpiene disociative), deoarece semilunarul nu prsete
suprafaa articular radial i nici suprafaa articular a
capului osului mare, ci i schimb poziia n aceste articulaii meninnd caracterul instabil al acestor situaii. Astfel se descriu:
1. Instabilitate prin nclinare dorsal a semilunarului
(DISI)
2. Instabilitate prin nclinare volar a semilunarului
(VISI)
c) Sechelele dup fracturi ale carpului se refer la instabiliti ale carpului dup pseudartroze sau fracturi vicios
consolidate. Sindromul scafo-capitat este o asociere a fracturilor scafoidului i polului proximal al osului mare, cu
instabilitate secundar a carpului.
D. Aspecte privind ncadrarea nosologic
Un alt aspect este cel al terminologiei i al asocierilor
nosologice sub titlul de instabiliti ale articulaiei pumnului. Exist clasificri (Mayo) n care termenul este
extins asupra luxaiilor i fracturilor-luxaii5. n clasificarea pe care o formulm, mprim leziunile articulaiei
pumnului n entorse stabile, entorse instabile, instabiliti
prin diastazis i subluxaii, luxaii, fracturi-luxaii, fracturi ale articulaiei pumnului. Instabilitile pumnului
cuprind o categorie restrns dintre aceste leziuni, i
anume entorsele instabile, instabilitile prin diastazis, la
care se adaug laxitile de cauz netraumatic. Celelalte
leziuni acute ale carpului dei pot asocia micri anormale
n primele ore, sunt caracterizate prin scderea dramatic
a amplitudinii micrilor avnd un aspect clinic mai
apropiat de blocajul articular dect de cel al unei articulaii
instabile.
Entorsele instabile se suprapun nosologic instabilitilor carpiene nondisociative (CIND), ca i instabiliti ale
rndului carpian proximal2:
1. Entors grav cu instabilitate n articulaia radio-triangularo*-carpian.
* articulaia dintre radius i ligamentul triangular cu
rndul carpian proximal
2. Entors grav cu instabilitate n articulaia mediocarpian.
La aceste categorii se pot aduga cte dou subtipuri, i
anume:
a. Instabilitate sagital (sertar anterior/posterior).
b. Instabilitate lateral (radial/cubital).
Instabilitile carpiene disociative le asociem instabilitilor prin subluxaii, diastazis i fracturi instabile.

Concluzii
n concluzie, formulm urmtoarea clasificare:
ENTORSA SIMPL (ENTORSA STABIL)
ENTORSA GRAV (INSTABIL)
1. Entors grav cu instabilitate n articulaia radio-triangularo-carpian.
2. Entors grav cu instabilitate n articulaia mediocarpian.
La aceste categorii se pot aduga cte dou subtipuri, i
anume:
a) Instabilitate sagital (sertar anterior/posterior).
b) Instabilitate lateral (radial/cubital).
INSTABILITATE CARPIAN DISOCIATIV

33

ments between two carpians of the same row, with a


movement of their joint surface. Being plane joints with
intraarticular ligaments, even if they are not syndesmoses,
we classify them as diastases, as part of the dissociate
instabilities of the carp:
1. scapho-lunate diastasis;
2. capitate-hamate diastasis (described by Garcia
Eliaas2, with the extension of the diastasis between
the metacarpals 3 and 4);
3. other diastases.
b) The vicious positions of the lunate in volar flexion,
and dorsal flexion respectively, may be assimilated to
some subluxation (Green and OBrian2 classify them as a
part of the dissociate instabilities of the carp). This assimilation is due to the fact that the lunate does not leave neither the radial joint surface nor the joint surface of the big
bone, but it changes its position inside these joints. The
result is the unstable character of these situations.
Therefore we may describe:
1. Dorsal intercalated segmental instability (DISI)
2. Volar intercalated segmental instability (VISI)
c) Unstable fractures of the wrist refer to instability of
the wrist after mal-union or non-union fractures. Scaphocapitate syndrome is in association of the scaphoid and the
proximal pole of the big bone fractures, with a secondary
instability of the carp.
D. Aspects regarding nosological affiliation
Another problem concerns the nosological aspect of the
instabilities of the wrist joint. There are classifications
(Mayo) in which the term is extended on dislocations and
fracture-dislocations5. The classification formulated by us
divides the injuries of the wrist joint in stable sprains,
unstable sprains, instabilities due to diastasis and subluxation, dislocations, fracture-dislocations, fracture of the
wrist joint. The wrist instabilities include a limited category of these injuries, namely the unstable sprains, the instabilities due to diastasis, to which we may add the laxities
which result of nontraumatical causes. The other acute
injuries of the carp, even if they may associate abnormal
movement during early hours, are characterized by the
dramatical lowering of the amplitude of the movements
having a clinical aspect which is closer to the articular
blocking than it is to that of an unstable joint.
Unstable sprains overlap nosologically the nondissociative instabilities of the carp (CIND), as instabilities of the
proximal carpal row2:
1. Serious sprain with instability in the carpal-triangular *-radial joint
* the joint between the radius and the triangular ligament with the proximal carpal row
2. Serious sprain with instability in the middle carpal joint.
We may add to these categories two subtypes for each,
as it follows:
a) Sagital instability (anterior/posterior drawer)
b) Lateral instability (radial/ulnar).
The dissociate instabilities of the carp may be associated to the instabilities due to subluxations, diastasis and
unstable fractures.

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Romanian Journal of Hand and Reconstructive Microsurgery vol. 6 III/2001

Asociem n aceast grup instabilitile prin subluxaii,


diastazis i fracturi instabile.
A. Instabilitate prin diastazis:
1. Diastazis scafo-semilunar
2. Diastazis capitato-hamat ( prelungirea diastazisului
i ntre metacarpienele 3 i 4)
3. Alte diastazisuri
B. Instabilitate a semilunarului:
1. Instabilitate prin nclinare dorsal a semilunarului
(DISI)
2. Instabilitate prin nclinare volar a semilunarului (VISI)
C. Scafoidul orizontal (Watson-Jones), consecin a
reducerii luxaiei perilunare
D. Fracturi instabilizante instabilitate aprut dup
consolidarea vicioas sau lipsa de consolidare a fracturilor
(pseudartroz):
1. Instabilitate radio-triangularo-carpian
este consecina injuriilor ce apar ca rezultat al fracturilor articulare cu deplasare a epifizelor distale ale
radiusului i ulnei (cea din urm aprnd cu malpoziia
complexului triangular)
a. instabilitate radial
b. instabilitate ulnar
c. asocieri
2. Fracturi izolate ale scafoidului cu evoluie spre
pseudartroz
3. Sindromul scafo-capitat este o asociere a fracturilor
scafoidului i polului proximal al osului mare, cu
instabilitate secundar a carpului
LUXAII ALE ARTICULAIILOR PUMNULUI
Asociem n aceast grup i luxaiile fracturi.
TIP I:
Luxaii n rndul carpian proximal:
A. Luxaii dorsale ale carpului, cu subtipurile:
1. perilunar
2. transscafo-perilunar
3. periscafo-perilunar
4. transstiloradial-perilunar
5. transpiramidal-perilunar
6. periscafoid
B. Luxaii volare ale carpului
16. aceleai subtipuri
C. Luxaii volare ale unui os carpian, solitar sau asociat
( fracturi asociate)
D. Luxaii dorsale ale unui os carpian, solitar sau asociat
( fracturi asociate)
E. Enucleerea semilunarului
TIP II:
Luxaiile mediocarpiene:
A. luxaie mediocarpian volar, cu subtipurile:
1. transscafoidian pe care o descriem ca luxaie-fractur
mediocarpian proximal. n acest tip ncadrm
asocierea fracturilor proximale (ale capului) ale osului
mare sau de la nivelul articulaiei hamato-piramidale.
2. transcapitat*, i transpiramidal* pe care le ncadrm ca
i luxaia-fractur mediocarpian distal
* leziuni descrise ca asociate de Watson Jones4
B. luxaie mediocarpian dorsal, cu aceleai subtipuri
TIP III:
Luxaie carpo-metacarpian
Clasificarea prezentat, care aduce o serie de aspecte i
ncadrri originale, are aplicabilitate n creterea eficienei
trialului diagnostic la serviciul de urgene, o mai bun

Conclusions
As a conclusion, we formulate the following classification:
THE SIMPLE SPRAIN (STABLE SPRAIN)
THE UNSTABLE SPRAIN:
1. sprain with instability in the carpal-triangular radial
joint
2. sprain with instability in the middle carpal joint.
To each of these categories two more subtypes may be
added, as it follows:
a) Sagital instability (anterior/posterior drawer)
b) Lateral instability (radial/cubital).
DISSOCIATIVE INSTABILITY OF THE CARP
We associate in this category the instabilities due to
subluxation, diastasis and unstable fractures.
A. Instability due to diastasis:
1. Scapho-lunate diastasis
2. Capitate-hamate diastasis ( the extension of the
diastasis between metacarpals 3 and 4)
3. Other diastasis.
B. Instability of the lunate:
1. Dorsal intercalated segmental instability (DISI)
2. Volar intercalated segmental instability (VISI).
C. The horizontal scaphoid (Watson Jones), as a consequence of reducing a perilunate dislocation.
D. Unstable fractures:
The instability occurs after mal-union or non-union of
fractures.
1. Radial triangular carpal instability.
They are consequent injuries that appear as a result of
articular fractures with displacement of the distal epiphyses the radius and ulna (the last one appears with the malposition of the triangular complex).
a. radial instability
b. ulnar instability
c. associations.
2. Isolated fractures of the scaphoid.
3. Scapho-capitate syndrome is an association of the
scaphoid and the proximal pole of the big bone fractures
with a secondary instability of the carp.
DISLOCATIONS OF THE WRIST JOINT.
We associate in this category the fracture-dislocations
as well:
TYPE I:
Dislocations in the proximal carpal row:
A. Dorsal dislocations of the carp, with the subtypes:
1. perilunate
2. trans-scapho perilunate
3. periscapho perilunate
4. trans-styloradial perilunate
5. trans-triquetral perilunate (peritriquetral perilunate)
6. periscaphoid.
B. Volar dislocations of the carp, with same subtypes.
C. Volar dislocations of the carpal bone or associations
(associated fractures).
D. Dorsal dislocations of the carpal bone or associations (associated fractures).
E. Expulsion of the lunate.
TYPE II:
Middle carpal dislocations:
A. Volar middle carpal dislocation, with the subtypes:
1. Trans-scaphoidal which we described as proximal
middle carpal fracture-dislocation. The association of

The Classification of Capsulo-Ligamentar Injuries..., R. Necula, I. amot, C. Butum

35

apreciere a complexitii lezionale i implicit a conduitei


terapeutice.
Considerm demersul nostru perfectibil, dar totodat
un ajutor n stabilirea cu precizie diagnosticului leziunilor
capsulo-ligamentare ale carpului.

the proximal fractures (of the head) of the big bone


or at the level of the hamato-triquetrum joint is part
of this type.
2. Trans-capitate* and trans-triquetral* which are classified in the same way as the distal middle carpal fracture-dislocation.
* Injuries described as associated by Watson-Jones4.
B. Dorsal middle carpal dislocation, with the same subtypes.
TYPE III:
Carp metacarpal dislocation
The present classification highlights a series of original
aspects and types, is applicable for increasing the efficiency in establishing the diagnosis in the emergency room, for
a better appreciation of the complexity of the injuries and
treatment implicitly.
We consider our approach as perfectible, but at same
time it represents a real help in establishing a precise diagnosis of the capsulo-ligamentar injuries of the carp.

Bibliografie / References

Coresponden / Correspondence to

1. Dobyns JH, Linscheid RL: Fractures and Dislocation of the Wrist. In


Rockwood CA, Jr. Green DP (eds): Fractures in adults, 2-nd
edition, vol 1. Philadelphia: JB Lippincott Company, 1984
2. Green DP: Carpal dislocations and instabilities. In Green DP (ed):
Operative Hand Surgery 2-nd edition, vol.II. New York:
Churchill Livingstone 1988.
3. Soames RW: Wrist joint. In Williams PL (ed.): Grays Anatomy, 38-th
edition. Edinburgh: Churchill Livingstone, 1995.
4. Fisk GR: Injuries of the wrist. In Wilson JN (ed.): Watson-Jones
Fractures and Joint Injuries, 6-th edition, vol. II. Edinburgh:
Churchill Livingstone,1982.
5. Wright PE: Wrist. In Campbells, Mosby Electronic Library of
Orthopaedic Surgery,1996.

RADU NECULA
Orthopaedic Department II.
Braov County Hospital
Calea Bucuretilor nr. 2527
2200 Braov, Romania