Recognition and conservative management for a spectrum of sport-related scapholunate interosseous ligament injuries: a case series

This case series presents four cases of scapholunate interosseous ligament (SLIL) injury. We discuss the process of early recognition and highlight difficulties encountered in current diagnostic and conservative management strategies. The cases profile interdisciplinary management of four scapholunate (SL) injuries that have different clinical presentations and injury mechanisms. Three sport-related SL injuries were managed conservatively by a sport specialist chiropractor and one sport-related case was self-managed. Management strategies included early wrist immobilization, soft tissue manual therapy, low-level laser therapy, proprioceptive and strengthening exercises, and early orthopedic referral. This case series highlights: (1) the spectrum of SL injuries (2) the importance of early specialty referral, (3) the paucity of literature with respect to conservative management of these injuries and (4) the role of manual therapy and rehabilitation professionals as part of the healthcare team in detecting and helping manage these wrist injuries.     

Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique

Different surgical techniques have been proposed to treat traumatic scapholunate instability. Deciding which treatment is best for each individual case is not easy. In this article we report an algorithm of treatment based on a number of prognostic factors that may help in this matter. We also report on the promising results obtained using a new technique, the 3-ligament tenodesis, for the treatment of nonrepairable complete scapholunate ligament rupture, causing a reducible carpal malalignment without secondary osteoarthritis. This technique incorporates features from 3 previously described techniques.     

Dynamic repair of scapholunate dissociation with dorsal extensor carpi radialis longus tenodesis

This study investigates the results of a technique using an extensor carpi radialis longus (ECRL) tenodesis for symptomatic scapholunate instability. Symptomatic scapholunate instability has been corrected so far either by limited wrist fusion or by various techniques of soft tissue repair. Limited wrist fusion greatly reduces wrist motion and increases the probability of osteoarthritis in the remaining mobile wrist segments. On the other hand, most types of soft tissue repair are technically difficult to perform and have disappointing results due to the inherent laxity. The presented dynamic approach was used in 20 wrists of 19 patients with static scapholunate instability. Preoperative evaluation included in all patients clinical examination, radiologic evaluation, and arthroscopy for establishing the diagnosis of static scapholunate instability. The technique involves the fixation of the ECRL tendon on the dorsal aspect of the scaphoid by means of a cancellous screw and a special washer. Dynamic ECRL tenodesis of the scaphoid is a safe and simple procedure that enhances the extension forces on the scaphoid in all wrist positions. The results of this preliminary report in 20 wrists showed dynamic ECRL tenodesis to be an effective treatment option for treating symptomatic static scapholunate instability.     

Long-term outcomes of dorsal intercarpal ligament capsulodesis for chronic scapholunate dissociation

PURPOSE: Chronic scapholunate dissociation is the most common cause of symptomatic wrist instability. In an attempt to restore normal carpal mechanics and prevent wrist arthrosis, we developed and tested biomechanically the dorsal intercarpal ligament capsulodesis (DILC). Previously, we reported good early clinical results for this procedure at an average follow-up period of 25 months. Here, we report on the functional and radiographic outcomes at a longer follow-up period of a minimum of 5 years. METHODS: Records of patients undergoing the DILC for chronic (greater than 6 weeks), flexible, static scapholunate dissociation were reviewed. Only patients with follow-up evaluation of greater than 60 months were included. Physical examination, radiographs, and validated outcome instruments were used to evaluate the patients. RESULTS: Twenty-one patients (22 wrists) met the inclusion criteria. Fifteen of 21 patients (16 wrists) were available for follow-up evaluation. Average follow-up period was 86 months. Physical examination revealed average wrist flexion and extension of 50 degrees and 55 degrees , respectively, radial and ulnar deviation of 17 degrees and 36 degrees , respectively, and grip strength of 43 kgf. Disabilities of the Arm, Shoulder and Hand, Short Form-12, and Mayo wrist scores averaged 19, 78, and 78, respectively. Radiographs revealed an average scapholunate angle and gap of 62 degrees and 3.5 mm, respectively. Eight of the 16 wrists in our study demonstrated arthritic changes on radiographs. CONCLUSIONS: The DILC does not consistently prevent radiographic deterioration and the development of arthrosis in the long-term; however, the level of functionality and patient satisfaction remained relatively high in 58% of our patients, suggesting a lack of correlation between the radiographic findings and development of arthrosis and the functional outcomes and patient satisfaction. We believe that the DILC is still a reasonable option for treating flexible static scapholunate dissociation in patients without radiographic signs of arthritis presenting with wrist pain despite conservative treatment. Prevention of radiographic deterioration and arthrosis remains an unsolved problem.     

Arthroscopic debridement and closed pinning for chronic dynamic scapholunate instability

PURPOSE: For chronic dynamic scapholunate (SL) instability (>3 months after injury) open procedures (capsulodesis, limited intercarpal fusions, tenodesis, SL ligament reconstruction) have become popular in recent years but their long-term results have been suboptimal. We evaluated retrospectively the results of aggressive arthroscopic debridement of the SL ligament to bleeding bone in an effort to induce scar formation and closed pinning of the SL joint in patients unwilling to have an open procedure. METHODS: Eleven patients (mean age, 37 y) presenting with persistent posttraumatic pain and weakness to the wrist were diagnosed with dynamic SL instability (positive Watson scaphoid shift test result, SL gapping on grip-view radiographs, arthroscopic findings of a Geissler grade III or IV SL tear) and treated. Range of motion, grip strength, radiographic measurements, and the Mayo wrist score were used to evaluate the results. RESULTS: The mean follow-up period was 33 months (range, 12-76 mo). Three patients had subsequent surgery 9 to 11 months after the procedure. Subsequent surgeries included a dorsal capsulodesis, a four-corner fusion, and a wrist arthrodesis. Of the 8 remaining patients there were 2 excellent, 4 good, 1 fair, and 1 poor result based on the Mayo wrist score. In these patients the mean range of motion was 65 degrees of extension to 59 degrees of flexion and the mean grip strength was 82% of the uninjured contralateral extremity. Although persistent radiographic SL gapping in grip views was noted in all 8 patients none progressed to static instability or dorsal intercalated segment instability. CONCLUSIONS: The results of this technique are suboptimal; however, it may be an option for patients unwilling to have more than an arthroscopic procedure or those requiring maintenance of wrist motion, provided they understand the risks and benefits of this approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Radiologic measurement of the scapholunate joint: implications of biologic variation in scapholunate joint morphology

To determine the optimal location for measurement of the scapholunate (SL) joint intercortical width, normal biologic variation in SL joint morphology was evaluated in 40 normal, skeletally mature wrists (16 volunteers, 24 cadavers) using thin-section 1.5T magnetic resonance imaging performed in the axial and coronal planes. The integrity of the SL ligaments was confirmed by magnetic resonance imaging and verified with anatomic dissection of the cadaver wrists. Patterns of SL articular morphology were qualitatively determined using similarity grouping. Scapholunate interval measurements were made at 3 locations each on the mid-SL joint image from both the axial and coronal planes: the articular margins (dorsal-palmar and proximal-distal) and midjoint. Three patterns of midjoint space cortical conformation were observed: parallel congruent (78%), inverted Y (15%), and point-like (8%). The most consistent and narrowest distance between the scaphoid and lunate was found at midjoint: coronal 1.45 mm (44% coefficient of variation) and axial 1.00 mm (22% coefficient of variation). This study demonstrated that measurement of the apparent SL joint interval in an inappropriate site, as with extended or flexed clenched fist views, may provide inaccurate SL joint interval distance assessments. Regardless of SL joint configuration, the midportion of the SL joint shows only moderate biologic variation and the least absolute measurement variance in width and should be the most precise part of the joint to measure. On magnetic resonance imaging, the normal SL joint interval measures less than 2 mm.     

Dorsal intercarpal ligament capsulodesis for chronic,static scapholunate dissociation: clinical results

The purpose of this study was to review and report the results of using a new procedure, the dorsal intercarpal ligament capsulodesis (DILC), to treat a group of patients with chronic flexible scapholunate dissociation. This was a prospective study of 21 patients (22 wrists), ranging in age from 16 to 62 years followed up for 1 to 4 years. For this study all patients returned to complete a questionnaire and have a physical examination performed by physicians and therapists independent of the treating surgeons and to obtain standardized radiographs of the wrists. Patient demographics, mechanism of injury, range of motion, and grip strength were recorded. Patients completed the Mayo wrist, Short-Form (SF)-12, and Disabilities of Arm, Shoulder and Hand (DASH) questionnaires. Results showed there were significant improvements in scapholunate angle and scapholunate gap at final follow-up examination, with minor loss of range of motion and grip strength. Patients were satisfied with the outcomes, showing an average score of 17 on the DASH and 83 on the SF-12. The DILC procedure is a reasonable option for treating chronic scapholunate dissociation. The procedure has conceptual advantages to recommend it: it avoids a tether between radius and scaphoid and keeps the proximal carpal row linked as a functional unit. It reduces the scapholunate angle and gap. Overall the results to date are quite encouraging.     

Outcomes of dorsal capsulodesis and tenodesis for treatment of scapholunate instability

PURPOSE: The ideal treatment for scapholunate (SL) instability has not yet been established. This study examined the results of 2 procedures for the primary treatment for chronic SL dissociation of dorsal capsulodesis and flexor carpi radialis tenodesis. METHODS: A retrospective analysis was conducted that examined dorsal capsulodesis and tenodesis procedures performed for chronic SL instability between January 1995 and February of 2003. Twenty-nine patients were identified with isolated chronic SL instability. Of the 29 patients, 14 had a dorsal capsulodesis procedure and 15 had a tenodesis procedure. The follow-up period averaged 38 months in the capsulodesis group and 36 months in the tenodesis group. Results were reviewed clinically and radiographically. Groups were compared with a Student t test. RESULTS: Postoperative wrist motion decreased in both groups after surgery. Final wrist range of motion was 64% of the unaffected side in the capsulodesis group and 63% of the unaffected side in the tenodesis group. Postoperative grip strength remained unchanged in both groups; grip strength measured 91% of the unaffected side in the capsulodesis group and 87% of the unaffected side in the tenodesis group. The average Mayo wrist scores were 77 in the capsulodesis group and 74 in the tenodesis group. One frank failure occurred in the tenodesis group resulting in a wrist fusion. There was no statistical difference in the overall wrist motion, grip strength, or wrist scores between the capsulodesis and tenodesis groups. CONCLUSIONS: Dorsal capsulodesis and tenodesis provided improvement in symptoms for patients with chronic SL instability. Both procedures appear to provide similar results in the treatment of this difficult problem.     

Early results of reconstruction of the dorsal scapholunate ligament

Abstract

We present the clinical results of a study of chronic dynamic scapholunate (SL) dissociation treated by reconstruction of the dorsal SL ligament. A total of 35 patients who presented with chronic dynamic SL instability had the scapholunate ligament reconstructed with a tendon graft. Twenty-nine patients were available for follow-up evaluation after a minimal interval of 17 months (range 17–72). Patients' satisfaction was good in 26/29 patients. Postoperative range of movement was reduced in extension and improved for flexion and ulnar deviation. Mean wrist movements were 75% of those on the opposite side. Most patients had good pain relief and recovered their grip strength, and returned to their regular employment. Follow-up stress radiographs showed a reduction in the SL angle and gap. Reconstruction of the dorsal SL ligament provides sufficient restoration of stability, pain relief, and functional improvement of the wrist for patients with dynamic SL instability. Although the short-term results are encouraging, we think that this method should be verified by longer follow-up.     

Scapholunate instability: current concepts in diagnosis and management

Injuries to the scapholunate joint are the most frequent cause of carpal instability and account for a considerable degree of wrist dysfunction, lost time from work, and interference with activities. The complex arrangement and kinematics of the 2 rows of carpal bones allows for an enormous degree of physiologic motion, and a hierarchy of primary and secondary ligaments serves to balance an inherently unstable structure. Although insufficient to cause abnormal carpal posture or collapse on static radiographs, an isolated injury to the scapholunate interosseous ligament may be the harbinger of a relentless progression to abnormal joint mechanics, cartilage wear, and degenerative change. Intervention for scapholunate instability is aimed at arresting the degenerative process by restoring ligament continuity and normalizing carpal kinematics. In this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate articulation and provide a foundation for understanding the spectrum of scapholunate ligament instability. We propose an algorithm for treatment based on the stage of injury, degree of secondary ligamentous damage, and arthritic change.     

An all-inside technique for arthroscopic suturing of the volar scapholunate ligament

Repair of the volar scapholunate ligament has not been performed arthroscopically. We present an all-inside technique that presents closure of the anterior scapholunate interval. A Tuohy needle and a resorbable suture are all that is required.     

Arthroscopic electrothermal collagen shrinkage for symptomatic laxity of the scapholunate interosseous ligament

The medical records, radiographs and operative reports of ten consecutive patients of average age 37 (range 19-67) years with wrist pain secondary to structural disruption of the scapholunate interosseous ligament (Geissler Type 2 injuries) who were treated with wrist arthroscopy and electrothermal collagen shrinkage of the scapholunate interosseous ligament were reviewed. Functional outcomes were assessed using the DASH scoring system at an average follow-up of 28 (range 12-44) months. At latest follow-up, nine patients (90%) were asymptomatic and had returned to their pre-injury functional level. The mean score on the DASH questionnaire was 20 (range 11-48). One patient developed wrist discomfort and mechanical symptoms 7 months postoperatively and required revision surgery. Our preliminary findings suggest that this may be a viable treatment option in the management of patients with symptomatic scapholunate interosseous ligament laxity without complete ligament disruption. Additional study is needed to better understand the role of this treatment modality.