of Painful Constitutional Laxities

Fig. 1

Park’s type II pattern of midcarpal laxity: standard and anteroposterior radiological views. Extension and dorsal displacement stress of the lunate

In 2002, Kuhlman established that the discomforting SNAP-type trigger was due to a rupture or a loosening of the dorsal radiocarpal ligament [4]. He did not refer to a non-pathologic state.

2 Casuistics

The patients are often young adults from 12 to 20 years old who have no trauma but sometimes suffer from a dorsal wrist pain in the median long fingers as they practise manual activities (gymnastics, gardening, move, athletics). This pain is often associated with the extension of the wrist when we lean on the heel of the hand, by writing, and by ball sports [1]. A dorsal wrist pain spreads to the median long fingers. It can happen at rest and be latent but scarcely engender cramps.

There was no mention of swelling or abnormality. There is no dysesthesia, but cracks or snaps are reported. A shoot up sometimes precedes the painful episode.

The clinical exam usually points out a hypermobility, particularly in the sagittal plane with ranges which come close to or exceed 90°.

The ligamentous testing underlines a sensitive triquetro-lunate ballottement and a midcarpal trigger, sometimes with a CLIP. This trigger is the consequence of the fixing of the dorsal horn of the lunate with the dome of the capitate.

The standard radiographic report is normal.

The differential diagnosis can be established with:

Hidden arthrosynovitis cysts
Dorsal synovial pinching
Early aseptic necrosis of the lunate (Kienböck)
RUD instability
Extensor carpi ulnaris instability
Radiocarpal instability with a deficiency of the extrinsic ligaments

It is a diagnosis of exclusion for which it can sometimes be relevant to resort to scan or NMR.

3 Medical Management

This is a medical, easy and often rapid treatment. Night immobilization in a small antebrachio-palmar orthosis and strengthening of the extrinsic muscles participate in lessening the pain within 2 or 3 weeks. Kapandji proposed to ‘reinforce the tendinous cage’ [15].

This ‘sheath’ effect is maintained by daily and long-term exercises of isotonic strengthening of the common flexors of the fingers and the extensor carpi ulnaris. After a few weeks, the orthosis is removed but can be put back whenever necessary.

There is no surgical necessity except in exceptional cases. A fibrosis around the dorsal intercarpal ligament artificially stiffens these hyperlax wrists.

4 Particular Cases: Minor Intracarpal Joint Upsets

Minor joint upsets are rare. The patients who suffer from these upsets are usually hyperlax and the pain, sharp and brutal, spontaneously arises without any initial trauma. The pain can be compared to that of a blade.

The pain is often dorsal and transfixing.

The medical exam of a painful wrist is particularly difficult considering the intensity of the pain.

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