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Commentary: Wrist instability
Commentary: Wrist Instability Roy A. Meals, MD, Los Angeles, CA
In 1943, Gilford, Bolton, and Lambrinudi first compared the wrist joint to a link mechanism stabilized by the scaphoid. They recognized that ligamentous or bony disruption of the scaphoid allowed "crumpling of the link, that is subluxation of the lunate.'" Not much light was shed on wrist instability until nearly 30 years later when Linscheid, Dobyns, Beabout, and Bryan published their landmark paper, "Traumatic Instability of the Wrist: Diagnosis, Classification, and Pathomechanics. ''2 They introduced the terminology of dorsal and volar intercalary instability and embellished the mechanical analysis put forth by Gilford and colleagues. This 1972 paper initiated the modern era of interest in wrist instability patterns. Understanding of this important topic has blossomed concomitant with our growing knowledge of anatomy, biomechanics, and imaging, both indirect and arthroscopic. The list of acronyms describing the various instabilities has expanded accordingly from the initial VISI and DISI now to include SLAC, STT, SLC, LT, CID, CIND, and CIC. Intelligence abounds; even CIA is involved. Diagnosis no longer seems much of a challenge. Consistently effective treatment for most of these instability patterns, however, remains elusive. To compare results presented by various authors, a thorough, inclusive classification system is overdue. Without one, the treatment results from mixed diagnoses are erroneously contrasted. Thus, the six-part classification proposed in the preceding paper has great potential for boosting us to
the next level of understanding----effective treatment. Appropriate to our high-tech imaging era, radiologists and hand surgeons have collaborated on its structure. As the authors sought, the system seems both inclusive and exclusive--any instability can be classified, but only in one way. The six categories (chronicity, constancy, etiology, location, direction, and pattern) make the latest addition to the acronymintensive region: CCELDP. I encourage investigators to use this system to form homogeneous patient groups for comparison within individual studies and for eventual comparison against other studies. Following the system's logic, clinicians also may find it useful to categorize individual patients by CCELDP to ensure that their diagnostic analyses are thorough and precise. In the foreward to their 1943 article, Gilford and Bolton dedicated the paper to the memory of their deceased coauthor Lambrinudi: " . . . his fertile imagination and skeptical disregard of many generally accepted ideas provided the essential background..." Good for him. See what he stirred up. To go farther we need a straight starting line: CCELDP.
References 1. Gilford WW, Bolton RH, Lambrinudi C: The mechanism of the wrist joint with special reference to fractures of the scaphoid. Guy's Hospital Report 1943;92:52-9. 2. Linscheid RL, Dobyns JH, Beabout JW, Bryan RS:
Traumatic instability of the wrist: diagnosis, classification, and pathomechanics.J Bone Joint Surg 1972;54A:1612-32.
From the Department of Orthopaedic Surgery, University of Californiaat Los Angeles, Los Angeles,CA. Received for publicationJuly 12, 1995; accepted for publicationJuly 12, 1995. Reprint requests: Roy A. Meals, MD, 100 UCLA Medical Plaza, Suite 305, Los Angeles,CA 90024-6970.
The Journal of Hand Surgery 777
In 1943, Gilford, Bolton, and Lambrinudi first compared the wrist joint to a link mechanism stabilized by the scaphoid. They recognized that ligamentous or bony disruption of the scaphoid allowed "crumpling of the link, that is subluxation of the lunate.'" Not much light was shed on wrist instability until nearly 30 years later when Linscheid, Dobyns, Beabout, and Bryan published their landmark paper, "Traumatic Instability of the Wrist: Diagnosis, Classification, and Pathomechanics. ''2 They introduced the terminology of dorsal and volar intercalary instability and embellished the mechanical analysis put forth by Gilford and colleagues. This 1972 paper initiated the modern era of interest in wrist instability patterns. Understanding of this important topic has blossomed concomitant with our growing knowledge of anatomy, biomechanics, and imaging, both indirect and arthroscopic. The list of acronyms describing the various instabilities has expanded accordingly from the initial VISI and DISI now to include SLAC, STT, SLC, LT, CID, CIND, and CIC. Intelligence abounds; even CIA is involved. Diagnosis no longer seems much of a challenge. Consistently effective treatment for most of these instability patterns, however, remains elusive. To compare results presented by various authors, a thorough, inclusive classification system is overdue. Without one, the treatment results from mixed diagnoses are erroneously contrasted. Thus, the six-part classification proposed in the preceding paper has great potential for boosting us to
the next level of understanding----effective treatment. Appropriate to our high-tech imaging era, radiologists and hand surgeons have collaborated on its structure. As the authors sought, the system seems both inclusive and exclusive--any instability can be classified, but only in one way. The six categories (chronicity, constancy, etiology, location, direction, and pattern) make the latest addition to the acronymintensive region: CCELDP. I encourage investigators to use this system to form homogeneous patient groups for comparison within individual studies and for eventual comparison against other studies. Following the system's logic, clinicians also may find it useful to categorize individual patients by CCELDP to ensure that their diagnostic analyses are thorough and precise. In the foreward to their 1943 article, Gilford and Bolton dedicated the paper to the memory of their deceased coauthor Lambrinudi: " . . . his fertile imagination and skeptical disregard of many generally accepted ideas provided the essential background..." Good for him. See what he stirred up. To go farther we need a straight starting line: CCELDP.
References 1. Gilford WW, Bolton RH, Lambrinudi C: The mechanism of the wrist joint with special reference to fractures of the scaphoid. Guy's Hospital Report 1943;92:52-9. 2. Linscheid RL, Dobyns JH, Beabout JW, Bryan RS:
Traumatic instability of the wrist: diagnosis, classification, and pathomechanics.J Bone Joint Surg 1972;54A:1612-32.
From the Department of Orthopaedic Surgery, University of Californiaat Los Angeles, Los Angeles,CA. Received for publicationJuly 12, 1995; accepted for publicationJuly 12, 1995. Reprint requests: Roy A. Meals, MD, 100 UCLA Medical Plaza, Suite 305, Los Angeles,CA 90024-6970.
The Journal of Hand Surgery 777