Introduction Scapholunate ligament is important for carpal stability chronic scapholunate deficiency leads to DISI (see below) Epidemiology incidence acute injury occurs in approximately 10-30% of intra-articular distal radius fractures or carpal fractures degenerative injury degenerative tears in >50% of people over the age of 80 years old location ligament has 3 components that span between the scaphoid and lunate bones dorsal, proximal and volar components incomplete tears > complete tears Pathophysiology mechanism of injury sudden impact force applied to the hand and wrist causing SLIL injury and scapholunate dissociation injury occurs most commonly with wrist positioned in extension, ulnar deviation and carpal supination pathoanatomy osseous SLIL tearing will position the scaphoid in flexion and lunate extension ligamentous diastasis of the scapholunate complex occurs with complete SLIL tears and capsule disruption. Associated injuries DISI (dorsal intercalated segmental instability) scapholunate dissociation causes the scaphoid to flex palmar and the lunate to dorsiflex if left untreated the DISI deformity can progress into a SLAC wrist DISI is a form of carpal instability dissociative Anatomy Scapholunate interosseous ligament location c-shaped structure connecting the dorsal, proximal and volar surfaces of the scaphoid and lunate bones dorsal fiber thickened (2-3mm) compared to volar fibers biomechanics dorsal component provides the greatest constraint to translation between the scaphoid and lunate bones proximal fibers have minimal mechanical strength Overview of wrist ligaments and biomechanics Presentation History acute FOOSH injury vs. degenerative rupture age, nature of injury, duration since injury, degree of underlying arthritis, level of activity Symptoms usually dorsal and radial-sided wrist pain pain increased with loading across the wrist (e.g. push up position) clicking or catching in the wrist may be associated with wrist instability or weakness Physical exam inspection may see swelling over the dorsal aspect of the wrist palpation tenderness in the anatomical snuffbox or over the dorsal scapholunate interval (just distal to Lister's tubercle) motion pain increased with extreme wrist extension and radial deviation provocative tests Watson test when deviating from ulnar to radial, pressure over volar aspect of scaphoid produces a clunk secondary to dorsal subluxation of the scaphoid over the dorsal rim of the radius dorsal wrist pain or a clunk during this maneuver may indicate instability of scapholunate ligament Imaging Radiographs recommended views AP and lateral views of the wrist additional views radial and ulnar deviation views flexion and extension views clenched fist (can exaggerate the diastasis) findings AP radiographs SL gap > 3mm with clenched fist view (Terry Thomas sign) cortical ring sign (caused by scaphoid malalignment) humpback deformity with DISI associated with an unstable scaphoid fracture scaphoid shortening Lateral radiographs dorsal tilt of lunate leads to SL angle > 70° on neutral rotation lateral capitolunate angle > 20° DISI normal carpal alignment increased SL angle Arthrography indications may be used as screening tool for arthroscopy views radiocarpal and midcarpal views always assess the contralateral wrist for comparison findings may demonstrate the presence of a tear but cannot determine the size of the tear positive finding of a tear may indicate the need for wrist arthroscopy MRI indications often overused as a screening modality for SLIL tears findings requires careful inspection of the SLIL by a dedicated radiologist to confirm diagnosis low sensitivity for tears Arthroscopy indications considered the gold standard for diagnosis Treatment Nonoperative NSAIDS, rest +/- immobilization indications acute, undisplaced SLIL injuries chronic, asymptomatic tears technique splinting and close follow-up with repeat imaging and clinical response with acute injuries outcomes most people feel casting alone is insufficient may be effective with incomplete tears Operative scapholunate ligament repair indications acute scapholunate ligament injury without carpal malalignment chronic but reducible scapholunate ligament injuries (can peform if < 18 months from the time of injury) ligament pathoanatomy is ammenable to repair scapholunate reconstruction indications acute scapholunate ligament injury without carpal malalignment where pathoanatomy is not ammenable to repair reducible scapholunate ligament injuries > 18 months from the time of injury scaphoid ORIF vs. CRPP (+/- arthroscopic assistance) indications if pathoanatomy of SL ligament injury is a scaphoid fx than repair with ORIF vs. CRPP (+/- arthroscopic assistance) stabilization with wrist fusion (STT or SLC) indications rigid and unreducible DISI deformity DISI with severe DJD technique scaphotrapezialtrapezoidal (STT) fusion scapholunocapitate (SLC) fusion scapholunate fusion alone has highest nonunion rate Technique Scapholunate ligament direct repair SLIL with k-wires approach small incision is made just distal to the radial styloid care to avoid cutting the radial sensory nerve branches methods SL joint pinning with k-wires suture anchors with k-wires Blatt dorsal capsulodesis often added to a ligament repair and remains a viable alternative for a chronic instability when ligament repair is not feasible repair technique place two k-wires in parallel into the scaphoid bone reduce the SL joint by levering the scaphoid into extension, supination and ulnar deviation and lunate into flexion and radial deviation pass the k wires into the lunate confirm reduction of the SL joint under fluoroscopy place patient in short arm cast post-operative care remove k-wires in 8-10 weeks no heavy labor for 4-6 months Scapholunate ligament reconstruction approach same as for repair reconstruction FCR tendon transfer (direct SL joint reduction) ECRB tendonosis (indirect SL joint reduction) weave not recommended due to high incidence of late failure Complications Disease progression (e.g. SLAC wrist) Arthritis Post-operative pain, stiffness, fatigue Reduced grip strength
QUESTIONS 1 of 4 1 2 3 4 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07SM.78) A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. A radiograph is shown in Figure 21. Management should consist of Review Topic | Tested Concept QID: 8740 FIGURES: A Type & Select Correct Answer 1 immobilization in a short arm thumb spica cast. 6% (27/451) 2 immobilization in a long arm thumb spica cast. 1% (4/451) 3 arthroscopic repair and percutaneous pinning. 21% (94/451) 4 open repair and percutaneous pinning. 71% (320/451) 5 dorsal capsulodesis. 1% (5/451) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07SM.38) A 28-year-old woman fell on her right wrist while rollerblading 6 days ago. She was seen in the emergency department at the time of injury and was told she had a sprain. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. Standard wrist radiographs are normal. What is the next most appropriate step in management? Review Topic | Tested Concept QID: 8700 Type & Select Correct Answer 1 Arthroscopy of the wrist 1% (4/578) 2 CT of the wrist 8% (47/578) 3 Bilateral PA clenched fist radiograph 78% (449/578) 4 Electromyography and nerve conduction velocity studies 0% (1/578) 5 AP and lateral radiographs of the forearm 12% (72/578) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (SBQ07SM.38) 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? Review Topic | Tested Concept QID: 1423 FIGURES: V A B C D E Type & Select Correct Answer 1 A 75% (1860/2488) 2 B 9% (218/2488) 3 C 8% (203/2488) 4 D 5% (114/2488) 5 E 3% (68/2488) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept
All Videos (3) Podcasts (0) Login to View Community Videos Login to View Community Videos Frontiers in Upper Extremity Surgery - 2016 Scapholunate Reconstruction - Brandon Earp, MD (Frontiers #4, 2016) Brandon Earp Hand - Scapholunate Ligament Injury & DISI 2/17/2017 721 views (3) Login to View Community Videos Login to View Community Videos Frontiers in Upper Extremity Surgery - 2016 Scapholunate Repair - Michael S. Bednar, MD (Frontiers #3, 2016) Hand - Scapholunate Ligament Injury & DISI 2/17/2017 859 views (1) Upgrade to View Premium Videos Upgrade to View Premium Videos Scapholunate ligament reconstruction - Nicole Deal, MD Hand - Scapholunate Ligament Injury & DISI 10/31/2016 589 views (4)
Frontiers in Upper Extremity Surgery Wrist Scapholunate (SL) Ligament Injury in 52M (C2706) Jason Nydick Hand - Scapholunate Ligament Injury & DISI B 10/15/2016 5696 64 7 Wrist ligament injury (C2560) Youssif Al Nahas Hand - Scapholunate Ligament Injury & DISI E 4/11/2016 982 10 4