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DISI - Dorsal Intercalated
Segmental Instability
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Sagittal scans demonstrate a
dorsally tilted lunate with an increased capitolunate (CL) angle of 58
degrees. |
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Radioscaphocapitate
ligament (RSC) |
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A coronal T2 fat suppressed scan shows the
radioscaphocapitate (RSC) ligament coursing along the volar sulcus of
the scaphoid, and blending with the distal band of the
palmar scaphotriquetral ligament
(this latter one also called "V" ligament because
it travels from the scaphoid to the capitate to the triquetrum), forming
the arcuate or deltoid ligament
http://www.uphs.upenn.edu/ortho/oj/1999/html/oj12sp99p27.html
and Resnick and Gilula, Radiology 2003;
226: 171. Proximal to this ligament, and limited by
the long radiolunate ligament, lies the space of Poirier. The space of
Poirier constitutes an area of ligamentous weakness through which
perilunate and lunate dislocations occur.
Notice that in this case the lunate shows a roughly triangular
morphology as it slides underneath the deltoid ligament.
Although the palmar radiocarpal ligaments (RSC and
RLT) are the most important ligaments for carpal instability, the dorsal
radiocarpal ligament (=dorsal radiotriquetral ligament) prevents the
development of VISI, whereas the dorsal
scaphotriquetral ligament (= dorsal
intercarpal) prevents the development of DISI. The dorsal
scaphotriquetral ligament inserts to the dorsal ridge of the scaphoid.
Gilula. Radiology 2006; 238: 950
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Dorsal scaphotriquetral
ligament or dorsal intercarpal ligament |
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In this case, there is an increased SL
interval. Therefore, this pattern would correspond to a CID-DISI, or carpal
instability dissociative - dorsal intercalated instability. If no
fracture is present, and the intrinsic ligaments of the proximal row are
intact, the case would fit into the definition of a CIND-DISI, or carpal
instability non-dissociative - dorsal intercalated instability. |
Comments
Although MR is considered unreliable in assessing patterns of intercapal
instability, the presence of an abnormal CAPITOLUNATE angle with a third metacarpal aligned with the distal radius
on sagittal scans, and congruency between the lunate facet of the distal radius
and the proximal lunate articular surface on coronal scans, should tip us
off to the presence of a DISI.
The reason for considering MR unreliable in the diagnosis of DISI is the
tendency to obtain abnormally increased capitato-lunate angles on MR, even with
strictly normal values on radiography (<30 degrees) and perfect positioning.
However, the maximum overestimation of an otherwise normal CL was of 14.5
degrees (Zanetti and Gilula. Radiology 1998; 206:339). Consequently, it sounds
safe to assume that an angle of 58 degrees, such as in the example above, is at
least suggestive of DISI.
DISI cases will also show an abnormal radiolunate angle ( more than 15 degrees);
however, simple scapholunate dissociation can also present a posteriorly tilted
lunate with a capitolunate angle within normal limits - at least as measured on
radiography. Therefore, the radiolunate angle is of secondary importance in the diagnostic process.
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