Lichtman Test for Midcarpal Instability

The Lichtman test is a provocative test used to assess the midcarpal instability of the wrist. It’s also called Lichtman, Midcarpal Shift, or Catch-Up Clunk Test.

Lichtman Test for Midcarpal Instability was described by David M Lichtman.

How to Perform the Lichtman Test?

The patient is seated with the elbow flexed to 90° and resting on a firm surface and the hand fully supinated. The examiner stabilizes the pronated forearm in 15° ulnar deviation with one hand and with the other hand takes the patient’s hand into full radial deviation with the wrist in neutral and applies an anteriorly directed load through the capitate noting the amount and ease of translation.

While the examiner maintains the patient’s hand position and applies an axial load, the patient’s hand is taken into full passive ulnar deviation.

See Also: SNAC and SLAC of the wrist

What does a positive Lichtman Test mean?

A positive Lichtman Test results if a painful “catch-up” clunk occurs as the capitate “shifts” away from the lunate (i.e., the distal row of carpals snap back together in normal physiological position), indicating injury to the anterior capsule and interosseous ligaments. The clunk represents an abrupt change of the proximal carpal row from flexion to extension as the capitate engages the lunate and the hamate engages the triquetrum under compressive load.

The examiner can then stabilize the pisiform by direct pressure and with the same movement, the active clunk will disappear because stabilizing the pisiform rotates the proximal carpal row out of its flexed position, re-engaging the normal midcarpal joint contact forces

Notes

• Normally as the wrist moves from radial to ulnar deviation, the proximal carpal row rotates smoothly from flexion to extension while the distal row translates from palmar to dorsal.
• With midcarpal instability, the proximal row remains flexed and the distal row remains volarly translated longer than normal during ulnar deviation. As ulnar deviation progresses, the soft tissue and bony restraints cause a sudden “catchup” of the proximal row into extension and the distal row into dorsal translation, which is often an audible or palpable “clunk”.
• The presences of palmar translation or a clunk alone without the reproduced symptoms are not considered positive, because they can occur in normal asymptomatic patients.

Midcarpal instability:

Midcarpal instability This usually emerges as a chronic problem, associated with generalized ligamentous laxity. The proximal and distal rows become unstable through the midcarpal joint.

Treatment includes proprioceptive training (a gyroscopic device can help). Intractable symptoms may respond to arthroscopic shrinkage of the capsule with a diathermy probe. The alternative of a ligament reconstruction is unreliable, and midcarpal fusion causes very significant loss of movement (about 50%)

Reference

• David M Lichtman, Eric S Wroten:Understanding midcarpal instability. J Hand Surg Am. 2006 Mar;31(3):491-8. doi: 10.1016/j.jhsa.2005.12.014. PMID: 16516747
• Waggy C: Disorders of the wrist. In: Wadsworth C, ed. Orthopaedic Physical Therapy Home Study Course – The Elbow, Forearm, and Wrist. La Crosse, WI: Orthopaedic Section, APTA, Inc. 1997.
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• Kleinman WB. Physical examination of the wrist: useful provocative maneuvers. J Hand Surg Am. 2015;40(7):1486–1500.
• Reddy RS, Compson J. Examination of the wrist – soft tissue, joints and special tests. Curr Orthop. 2005;19:180–189.
• Lichtman DM, Reardon RS. Midcarpal instability. In: Slutsky D, ed. Principles and Practice of Wrist Surgery. Philadelphia: Elsevier; 2010
• Niacaris T, Ming BW, Lichtman DM. Midcarpal instability – a comprehensive review and update. Hand Clin. 2015;31:487–493.
• Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.