Wrist Instabilities in Ankara, Turkey

Wrist instabilities are disorders characterized by pain and loss of function that develop due to weakness or tearing of the ligamentous structures in the wrist joint. They are usually trauma-related, and when not recognized early, they can progress into chronic instability. Timely intervention is important to prevent functional loss.

The scapholunate and lunotriquetral ligaments play a critical role in wrist stability. Injuries to these ligaments cause abnormal motion between the carpal bones. Clinically, patients may experience pain, clicking, reduced grip strength, and recurrent sprains.

In addition to clinical tests, diagnostic tools include magnetic resonance imaging (MRI), wrist arthrography, and dynamic radiographs. In delayed cases, carpal malalignment patterns (DISI/VISI) may be seen. Accurate diagnosis is key to selecting the appropriate treatment.

Treatment may be conservative or surgical. In mild instabilities, splinting, rest, and physical therapy may be sufficient, while ligament tears or chronic instability often require reconstructive surgery. Long-term rehabilitation after surgery helps restore wrist function.

What Is Wrist Instability and Why Does It Occur?

Wrist instability is the loss of stable alignment between the bones and ligamentous structures that form the wrist joint. It most commonly develops due to trauma, ligament tears, repetitive overload, and sports injuries. Rheumatic diseases and congenital ligament laxity can also contribute. This condition may lead to pain, weakness, and restricted motion; treatment is planned according to the underlying cause.

How Do Patients Recognize Wrist Instability Through Their Symptoms?

In clinical practice, patients often present with a very typical story. Most describe a fall that happened months earlier and was dismissed as “just a sprain,” but the pain never fully resolved or changed in character over time. The patient no longer feels the wrist is as “secure” as before.

The most common complaints include:

• Sharp pain that worsens with motion
• Reduced grip strength
• Clicking sounds from the wrist
• A feeling of insecurity
• Limited range of motion
• Locking in certain positions
• Swelling around the wrist
• Tenderness with pressure

These findings reflect the underlying mechanical problem. In particular, the “giving way” sensation when lifting a heavy object or turning a doorknob is one of the most characteristic signs of instability.

What Is the Relationship Between Wrist Anatomy and Instability?

To understand this, we need to talk a bit more deeply about anatomy. The eight carpal bones are arranged in two rows: the proximal row (closer to the forearm) and the distal row (closer to the fingers). The proximal row—scaphoid, lunate, and triquetrum—is the most strategic part of the wrist. These bones act as a “bridge” between the forearm and the hand. Like a suspension bridge, their stability depends entirely on the tension of the “cables” (ligaments).

When the wrist moves, these bones perform a synchronized dance. If the scaphoid tends to flex forward while the lunate tends to extend backward, and the ligament that holds them together (the scapholunate ligament) is torn, a condition called “dissociative instability” occurs. In other words, the “partners” in the same row separate and move in different directions. This is the most common and most damaging type of wrist instability we see. There are also situations where the ligaments between bones are intact, but the entire row moves abnormally—this is called “nondissociative instability.” Identifying which type is present completely changes the surgical plan.

Which Physical Examination Tests Are Used to Diagnose Wrist Instability?

The diagnostic process begins the moment the patient walks in, but the most valuable clues often come from hands-on examination. MRI and X-rays are important, but the fingertips of an experienced hand surgeon can sometimes reveal even more than technology. The exact location of pain often “whispers” which ligament is injured.

The most commonly used examination maneuvers include:

• Watson test
• Reagan ballottement test
• Kleinman shear test
• Linscheid test
• Midcarpal shift test
• Distal radioulnar joint stress test

For example, in the Watson test, we apply pressure to the scaphoid with the thumb while moving the wrist. If the ligament is torn, the bone shifts and a distinct “clunk” can be felt under the examiner’s finger—often reproducing the patient’s familiar pain. These tests are critical for revealing the dynamic (motion-related) nature of instability.

How Does Wrist Instability Appear on Imaging?

Standard X-rays are always the first step, but there is a trap here: while the wrist is at rest, the bones may remain aligned and the X-ray can look completely normal. That is why we often request “stress views.” These films, taken while the patient makes a fist or loads the wrist, can reveal widened gaps between bones under stress.

There are a few classic radiographic signs we look for. One of the most famous is the “Terry Thomas” sign—named after a comedian known for a gap between his front teeth—where the distance between the scaphoid and lunate exceeds 3 mm. Another key finding is the “ring sign,” which reflects excessive scaphoid flexion that makes the scaphoid look like a ring on X-ray.

For more detailed assessment, MRI comes into play. However, a standard MRI may miss small ligament tears. Therefore, “MR arthrography,” where contrast is injected into the joint before imaging, is much more reliable. The contrast can seep through a torn ligament and clearly demonstrate the injury site. Despite all of this, the gold standard for diagnosis remains wrist arthroscopy—direct visualization with a camera inside the joint—because it leaves no room for doubt.

How Is Acute Wrist Instability Treated?

Timing is everything in wrist surgery. If a patient presents within the first 8 weeks after injury, we call this the “acute phase.” During this period, ligament tissue often remains viable, vascularized, and has not significantly shortened—an ideal scenario for repair.

Surgical options in the acute phase include:

• Primary ligament repair
• Suture anchor fixation
• Temporary K-wire stabilization
• Dorsal capsule repair

In these operations, we reattach the torn ligament ends back to bone using special suture anchors. Ligament healing takes about 6–8 weeks. To protect the repair during this time, we temporarily stabilize the carpal bones with thin metal wires called “K-wires.” Once the healing period is over, these wires are easily removed in the outpatient setting. Early intervention is the most effective way to preserve native anatomy.

Which Surgical Methods Are Used for Chronic Wrist Instability?

When the patient presents months or years later, the scenario changes. The torn ligament ends may have degenerated, retracted, and become scarred, making direct end-to-end repair impossible. At this point, creative reconstructive solutions come into play—either rebuilding a new ligament using the patient’s tissues or creating biomechanical stabilization systems.

Modern techniques used at this stage include:

• Arthroscopic Dorsal Ligamentocapsulodesis (Mathoulin Technique):

This is one of the most popular and patient-friendly approaches in recent years. It is performed fully arthroscopically. The dorsal wrist capsule is shifted and fixed over the injured ligament area, acting like a natural patch. Over time, this patch heals into a strong scar tissue that helps keep the bones aligned. Because large incisions are avoided, recovery tends to be faster.

• Arthroscopic Suture-Button Reconstruction:

This is an excellent technological option. Small titanium buttons connected by very strong sutures are placed between the bones. Tunnels are created through the carpal bones, the system is inserted, and the sutures are tensioned to pull the bones closer together. It functions mechanically like the torn ligament—almost like an “invisible internal seatbelt.”

• Tenodesis and Tendon Transfers:

If ligament tissue is completely deficient and the bones are significantly unstable, we may harvest a strip from a forearm tendon (often the flexor carpi radialis) and use it as a ligament substitute. Techniques such as the Brunelli procedure pass this tendon graft through bone tunnels to “weave” a new ligament. This is a more extensive procedure but can provide very strong stability.

Can TFCC Tears Cause Wrist Instability?

The wrist is not only about bones. On the ulnar (little finger) side of the wrist, between the ulna and the carpal bones, there is a cartilage structure that resembles the knee meniscus: the Triangular Fibrocartilage Complex (TFCC). This is a key stabilizer during rotational movements of the wrist.

In TFCC tears, common findings include:

• Persistent ulnar-sided wrist pain
• Restriction during rotation
• Clicking with wrist bending
• Sharp pain while carrying weight

TFCC is the “hidden hero” of wrist stability. It can be overlooked, but it may severely impact quality of life. Fortunately, in hand surgery practice, it can often be treated arthroscopically—either by repairing the torn portion or debriding unstable tissue—in a roughly one-hour procedure with highly satisfying outcomes.

Why Is Postoperative Rehabilitation Important for Wrist Instability?

Even the most perfect surgery can fail without a good rehabilitation process. Physical therapy after wrist surgery is an essential part of recovery. The goal is not only to heal the ligament but also to restore the wrist’s fine, agile movements. The hand has no tolerance for immobility; if it stays still for too long, it stiffens quickly.

Recovery typically progresses through these stages:

• Full protection phase
• Passive motion phase
• Active motion phase
• Strengthening phase
• Return-to-work phase

During the first weeks (typically 3–6 weeks), the wrist is protected with a cast or splint. This is the “quiet phase” necessary for the repair to heal and secure to bone. However, finger motion is started immediately. Once protection is discontinued, passive motion begins under the guidance of a therapist, followed by gradual progression to active movement and strengthening. This process can take 3 to 6 months and requires patience, but the reward is a stable, strong, and less painful wrist.

What Conditions Can Wrist Instability Be Confused With?

Not every patient presenting with wrist pain has instability, but instability can mimic—or even trigger—other conditions. One of the most commonly associated or confused diagnoses is Carpal Tunnel Syndrome.

Key points in differential diagnosis include:

• Presence of finger numbness
• Severity of nighttime pain
• Nerve conduction study results
• Tinel sign
• Phalen test result

Interestingly, instability can increase joint swelling and inflammation, raising carpal tunnel pressure and contributing to nerve compression. A patient may present with “numbness,” while the underlying issue is mechanical. In such cases, both problems can sometimes be addressed in the same surgical session—repairing instability and releasing the carpal tunnel—to avoid a second operation and accelerate recovery.

What Is the Success Rate and What Can Be Expected Long Term?

In wrist instability surgery, “success” can vary from patient to patient. For a professional athlete, success means returning to sport; for an office worker, it means pain-free typing. In general, the goal is a stable, functional, and less painful wrist.

Outcome scoring systems (such as Mayo or DASH) commonly show meaningful improvement in grip strength and quality of life after appropriate treatment. It is also important to be honest: after major ligament repairs, there may be about a 10–20% reduction in wrist range of motion compared to the healthy side. In other words, the wrist may not be as “flexible” as before. However, this is often far more acceptable than living with an unstable and painful wrist. Stability matters more than extreme mobility.

Looking ahead, more biological solutions are on the horizon: bioresorbable implants, ligament repairs supported with the patient’s own regenerative cells, and less invasive techniques are becoming increasingly prominent.