The Non-Dissociative Clunking Wrist: A Personal View

Abstract

Clunking of the wrist is often the result of a combined radiocarpal and midcarpal ligament insufficiency, coupled with inadequate neuromuscular coordination. When symptomatic, these wrists may benefit from splinting, isometric exercising of specific muscles and advice on activity modification. Failing this, different surgical strategies have been proposed, depending on the location of dysfunction. When the clunking derives from an isolated injury of one joint, reconstruction of its inadequate ligaments may be an effective solution. However, soft tissue procedures tend to fail when clunking results from multilevel instability. In these cases, partial carpal arthrodesis is an alternative. Although effective in eliminating the clunking, midcarpal fusion is associated with alteration of the so-called "dart-throwing" motion, the most common rotation in daily activities, and hence is not recommended. Radiolunate fusion, by contrast, appears to be a less morbid alternative, with the benefit of eliminating the painful clunking while preserving a good range of dart-throwing motion.

Estimation of hand and wrist muscle capacities in rock climbers

“…Given that climbers present a stronger imbalance, it is probable that they have more difficulties in controlling and protecting their joints and are, therefore, more exposed to joint instability, joint surface over-use and/or ligament tears (Centomo et al 2008;Stokes and Gardner-Morse 2003). This finding could explain why wrist medio-carpal instability (Garcia-Elias 2008;Lichtman et al 1981;Lichtman and Wroten 2006) is often observed in climbers, although no medical reports have been published recently. This important imbalance may also be implicated in finger pulley ruptures, since the extensor muscle action is also required during the crimp grip technique .…”

Musculoskeletal wide detector CT: Principles, techniques and applications in clinical practice and research

“…In cases of patellar maltracking, abnormal motion is present at some point of the first 30 • of knee flexion when the patella engages the trochlea. Similarly, in cases of midcarpal instability there is abrupt, abnormal motion of the whole first carpal row at some point of radio-ulnar deviation or dart throwing maneuver [20]. In the wrist, there are variations in bone position (or angulation) that are specific of a motion path, a phenomenon called hysteresis.…”

Wrist Instability

“…Again several additional views are described as being helpful. GarciaElias describes the forced ulnar and radial deviation and the anterior and posterior drawing views to determine ligament laxity (Garcia-Elias 2008). The absence of normal values for these views and the degrees of laxity in healthy subjects without wrist pain make the use of these views in general practice debatable.…”

“…If this is painful the test is called positive and is considered a diagnostic indicator of a symptomatic midcarpal instability. The anterior and posterior drawer tests as described by Garcia-Elias (2008) are also important. The anterior drawing test is aimed at demonstrating laxity of the palmar ligaments especially the scaphotrapezial ligament; the posterior drawer test, in which the hand is translated dorsally compared to the wrist stresses the dorsal ligaments, especially the dorsal scaphotriquetral ligament.…”

“…A clunk is described as a low-pitched dull sound, caused by sudden subluxation or reduction of a partially dislocated carpal bone (Gilula et al 2002). Various types are described (Garcia-Elias 2008). The origin may be from a particular carpal row with disruption of the SL ligament within the proximal carpal row the most frequently described entity (Amadio 1991).…”