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A 32-year-old professional baseball player presents with wrist pain after a fall on his outstretched wrist 10 days ago. He initially thought it was a sprain, but presents due to continued pain worsened by push-ups. His physical exam shows dorsal wrist tenderness and is positive for the provocative test shown in Figure V. Standard PA radiograph of the wrist is normal. Which of the following radiographic views shown in Figures A to E would be most helpful in establishing the diagnosis?
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The clinical description and video of the patient's physical exam are consistent with an acute scapho-lunate ligament tear. The video shown in the question stem demonstrates the Watson test. When positive, the patient will feel dorsal wrist pain and/or a "clunk" when the wrist is brought from extension/ulnar deviation to radial deviation. If plain radiographs are normal, a PA clenched fist radiograph as seen in Figure A should be performed.
In patients with a acute scapho-lunate ligament tear, initial radiographs may not show the characteristic "Terry Thomas" sign, or widening of the SL gap > 3mm. When making a clenched fist, the capitate is drawn proximally, stressing the SL ligament. This is an easy view to obtain during the initial patient visit and should strongly be considered if this diagnosis is suspected.
Walsh et al review the various aspects of scapholunate ligament injuries. While they agree imaging is helpful in establishing the diagnosis, they emphasize that wrist arthroscopy is the gold standard in the diagnosis of SL injuries.
Illustration A shows demonstrates a clenched fist view with obvious widening of the scapho-lunate gap.
Answer 2: Shows a lateral radiograph in 30 degrees of supination. It is excellent for assessment of pisotriquetral arthrosis.
Answer 3: Shows a PA of the wrist in radial deviation. This view will actually close the SL gap.
Answer 4: Shows a a carpal tunnel view, used for assessment of hook of hamate fractures.
Answer 5: Shows a a stardard PA wrist in neutral aligment.
Walsh JJ, Berger RA, Cooney WP.
J Am Acad Orthop Surg. 2002 Jan-Feb;10(1):32-42. PMID: 11809049 (Link to Abstract)
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HPI - 52-year-old female presents with left wrist pain since a fall at work 4 months ago.
The pain is exacerbated by extremes of motion.
Associated with wrist clicking in extension.
Prior to referral to a hand specialist a trial of nonoperative treatment was attempted but did not lead to significant improvement.
After a period of several months of nonoperative treatment patient continued with pain and mechanical clicking during wrist motion & gripping
What further imaging after radiographs, if any, would you order on this patient?
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