Dynamic assessment of scapholunate ligament status by real-time magnetic resonance imaging: an exploratory clinical study.

OBJECTIVE: Clinical-standard MRI is the imaging modality of choice for the wrist, yet limited to static evaluation, thereby potentially missing dynamic instability patterns. We aimed to investigate the clinical benefit of (dynamic) real-time MRI, complemented by automatic analysis, in patients with complete or partial scapholunate ligament (SLL) tears. MATERIAL AND METHODS: Both wrists of ten patients with unilateral SLL tears (six partial, four complete tears) as diagnosed by clinical-standard MRI were imaged during continuous active radioulnar motion using a 1.5-T MRI scanner in combination with a custom-made motion device. Following automatic segmentation of the wrist, the scapholunate and lunotriquetral joint widths were analyzed across the entire range of motion (ROM). Mixed-effects model analysis of variance (ANOVA) followed by Tukey's posthoc test and two-way ANOVA were used for statistical analysis. RESULTS: With the increasing extent of SLL tear, the scapholunate joint widths in injured wrists were significantly larger over the entire ROM compared to those of the contralateral healthy wrists (p<0.001). Differences between partial and complete tears were most pronounced at 5°-15° ulnar abduction (p<0.001). Motion patterns and trajectories were altered. Complete SLL deficiency resulted in complex alterations of the lunotriquetral joint widths. CONCLUSION: Real-time MRI may improve the functional diagnosis of SLL insufficiency and aid therapeutic decision-making by revealing dynamic forms of dissociative instability within the proximal carpus. Static MRI best differentiates SLL-injured wrists at 5°-15° of ulnar abduction.

One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation.

PURPOSE: Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction. METHODS: From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared. RESULTS: Mean follow-up was 17.9 months (range: 12-38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9-4.2 mm), dorsal scaphoid translation (1.2-0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis. CONCLUSIONS: At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Ligamentoplasty in scapholunate instability: short-term results of the "all dorsal scapholunate repair" technique.

Injury to the scapholunate complex is the cause of scapholunate instability which can lead to radiocarpal and medio-carpal osteoarthritis. Several ligamentoplasty techniques have been reported for the treatment of chronic scapholunate instability before the osteoarthritis stage. The objective of this study was to assess the short-term results of an "all dorsal scapholunate repair" ligamentoplasty. We report the clinical, radiological and functional results of a retrospective study including 21 patients, operated between June 2019 and December 2020 for a stage 3 or 4 scapholunate instability according to the Garcia Elias classification. With a follow-up of 14.2 months, the pain was 0.1/10 according to the VAS at rest and 4/10 during exercise. Wrist strength was measured at 65% of the opposite side. The flexion-extension range of motion was 105°. Radiologically, there was a reduction of the diastasis and scapholunate angle. Osteolysis areas around the anchors were described in 47% of patients. The mean QuickDASH was 29.2/100, PRWE 24/100 and Mayo wrist score 67.8/100. Eighty-one percent of patients were satisfied. Seventeen patients had returned to work 5.2 months postoperatively. In the case of work-related injury, the functional scores were poorer, with a delayed return to work. This technique provides encouraging results in the short term. Most patients were improved compared to preoperative state. The work-related injury appears to be a poor prognostic factor. A longer-term study is imperative to confirm the maintenance over time of the correction of carpal malalignment and the evolution of the osteolysis areas.Level of evidence: Level IV Retrospective study.

Scapholunate Instability: Diagnosis and Management - Anatomy, Kinematics, and Clinical Assessment - Part I.

Injuries to the scapholunate joint are the most frequent cause of carpal instability. The sequelae of these injuries account for considerable morbidity, and if left untreated, may lead to scapholunate advanced collapse and progressive deterioration of the carpus. Rupture of the scapholunate interosseous ligament and its critical stabilizers causes dyssynchronous motion between the scaphoid and lunate. Additional ligament injury or attenuation leads to rotary subluxation of the scaphoid and increased scapholunate gap. Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. In the first section of this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical ligament stabilizers. We provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. The purpose is to provide an update regarding the anatomy of the scapholunate ligament complex, importance of the critical ligament stabilizers of the proximal carpal row, introduction of safe technique to surgically expose the scaphoid and lunate, as well as pathoanatomy as it pertains to the treatment of scapholunate dissociation. In the second section of this review, we propose a novel ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes.

Scapholunate Instability: Diagnosis and Management - Classification and Treatment Considerations - Part 2.

Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. Part 1 of this Current Concepts article reviewed the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical stabilizers. In this section, we provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. These updates clarify the importance of the critical stabilizers of the scapholunate interval, ligament-specific considerations in scapholunate ligament reconstruction, and the risks of ligament disinsertion when surgically exposing the dorsal wrist. We propose a ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes.

Scapholunate ligament injuries: an instructional review for the FRCS examination.

An instructional review of the anatomy, investigation, and management of scapholunate ligament injuries. Aimed at the knowledge level required for the trauma and orthopaedic FRCS examination.

Is Midcarpal Arthroscopy for Suspected Scapholunate Pathology Associated With Greater Interobserver Agreement and More Frequent Offer of Surgery?

PURPOSE: This study compared the interobserver agreement of arthroscopic classification of suspected scapholunate interosseous ligament (SLIL) pathology with and without midcarpal arthroscopy to help inform diagnostic strategies. It also measured the association of midcarpal arthroscopy with recommendations for reconstructive surgery. The association of midcarpal arthroscopy with the type of surgery recommended was also studied. METHODS: Fourteen consecutive videos of diagnostic radiocarpal and midcarpal wrist arthroscopy for suspected SLIL pathology were selected. An international survey-based experiment was conducted among upper extremity surgeons of the Science of Variation Group. Participants were randomized to view either radiocarpal arthroscopic videos or radiocarpal and midcarpal videos. Surgeons rated SLIL pathology according to the Geissler classification and recommended surgical or nonsurgical treatment. If surgical treatment was recommended, they indicated the type of procedure. RESULTS: The interobserver agreement for the Geissler classification was slight/fair for observers who reviewed midcarpal and radiocarpal videos and for those who viewed radiocarpal videos only. Viewing midcarpal videos was associated with higher pathology grades, the recommendation for reconstructive surgery, and a preference for tenodesis over scapholunate ligament repair. CONCLUSIONS: Diagnostic wrist arthroscopy for a wrist with normal radiological alignment has poor interobserver agreement. CLINICAL RELEVANCE: The pursuit of a pathology that accounts for wrist symptoms in a nonspecific interview and examination and normal radiographs is understandable; however, the low reliability of the scapholunate pathology of diagnostic arthroscopy might be associated with more potential harm than benefit.

Comparing Patient-Reported Outcomes on Three-Ligament Tenodesis between Partial and Complete Scapholunate Ligament Injuries: A Cohort Study.

PURPOSE: Multiple studies report outcomes after 3-ligament tenodesis (3-LT) in treating traumatic scapholunate interosseous ligament injury (SLIL). However, investigators do not differentiate between patients with partial or complete SLIL injury. The relation between the extent of SLIL disruption and surgical outcomes and if this should be considered when treating a patient with SLIL injury remains unknown. We aimed to evaluate differences in patient-rated wrist evaluation (PRWE) scores, satisfaction and return to work between patients with partial or complete chronic traumatic SLIL injury treated with 3 ligament tenodesis at 12 months after surgery. METHODS: All patients with chronic SLIL injury (partial and complete) who were treated with 3-LT at our clinic and received the same postoperative management between December 2011 and December 2019 were studied. Only patients who had completed the PRWE and return to work questionnaires preoperatively and 12 months after surgery were included. Patients were allocated to the partial (classified as Geissler 2 or 3) or complete SLIL injury group (classified as Geissler 4) by retrospectively assessing wrist arthroscopy reports. RESULTS: Thirty-nine patients with partial and 90 with complete SLIL injuries were included. At 1-year follow-up, PRWE scores had significantly improved in both groups. When adjusting for clinical baseline characteristics, there was no statistically significant difference between patients with partial or complete SLIL injury. Patients with complete SLIL injury had a 70% higher return to work within the first 12 months after 3-LT; however, satisfaction with the treatment result was similar for both study groups 1 year after surgery. CONCLUSIONS: Patients with complete and partial traumatic SLIL injury report better PRWE total scores at 12 months after 3-LT, but there was no statistically significant difference between the groups in PRWE scores or satisfaction with the treatment result. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Is Early Active Motion After 3-Ligament Tenodesis Noninferior to Late Active Motion? A Prospective, Multicenter Cohort Study.

PURPOSE: If early active motion after 3-ligament tenodesis is safe, it may yield more patient comfort and an early return to activities. Therefore, the aim of this study was to investigate whether early active motion is noninferior to late active motion after 3-ligament tenodesis for scapholunate interosseous ligament injuries. METHODS: This prospective, multicenter cohort study, using a noninferiority design with propensity score matching, compared a late active motion protocol (immobilization for 10-16 days, wrist therapy in weeks 5-6) with an early active motion protocol (immobilization for 3-5 days, wrist therapy during week 2). Patients who were older than 18 years, had complete baseline information on demographics, and underwent 3-ligament tenodesis were included. The outcome measures were postoperative Patient-Reported Wrist/Hand Evaluation scores, pain, complications, return to work, range of motion, grip strength, and satisfaction with treatment results at 3 months of follow-up. RESULTS: After propensity matching, a total of 108 patients were included. Patient-Reported Wrist/Hand Evaluation and pain scores during physical load following an early active motion protocol were noninferior compared with scores following a late active motion protocol. Furthermore, early active motion did not lead to an increase of complications, differences in range of motion or grip strength, or less satisfaction with the treatment result. An earlier return to work was not observed. CONCLUSIONS: Early active motion leads to noninferior results without more complications as compared with late active motion. Based on these findings, early active motion can be considered safe, and might be recommended due to its potential benefits compared with late active motion after 3-ligament tenodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Evaluation of Dorsal Subluxation of the Scaphoid in Patients With Scapholunate Ligament Tears: A 4D CT Study.

OBJECTIVE. The purpose of this study was to evaluate the variation of the posterior radioscaphoid (RS) angle in patients with and without scapholunate ligament (SLL) tears during wrist radioulnar deviation. SUBJECTS AND METHODS. Seventy-three patients with clinically suspected scapholunate instability were prospectively evaluated with 4D CT and CT arthrography from February 2015 to April 2018. The posterior RS angle is formed between the articular surface of the scaphoid fossa of the radius and the most posterior point of the scaphoid in the sagittal plane. Two independent radiologists calculated this angle during radioulnar deviation. Posterior RS angles were correlated with the SLL status and the presence of a scapholunate diastasis on conventional stress radiographs. RESULTS. Readers 1 and 2 found mean posterior RS angles of 99° and 98°, respectively, in patients without and 107° and 111°, respectively, in patients with a scapholunate diastasis. The posterior RS angle amplitude varied 7.6-9.3° in the subgroups studied. The reproducibility of posterior RS angle measurement was considered good (intraclass correlation coefficient, 0.73). Mean posterior RS angles increased 6-10% and 12-14% when patients with an intact SLL were compared with those with partial tears and full tears, respectively (p < 0.001). These values also increased 8-13% when patients with diastasis were compared with those without (p < 0.0001). A dynamic acquisition was not necessary to assess this angle, with neutral posterior RS angles yielding a sensitivity of 64% and 72% and specificity of 79% and 94% for the diagnosis of SLL tears by readers 1 and 2, respectively. CONCLUSION. Posterior RS angle tended to increase with the severity of SLL tears and with the presence of scapholunate instability and yielded high sensitivity and specificity for the detection of SLL tears.

ACTION trial: a prospective study on diagnostic Accuracy of 4D CT for diagnosing Instable ScaphOlunate DissociatioN.

BACKGROUND: Early detection of scapholunate ligament (SLL) tears is essential after minor and major trauma to the wrist. The differentiation between stable and instable injuries determines therapeutic measures which aim to prevent osteoarthritis. Arthroscopy has since been the diagnostic gold standard in suspected SLL tears because non-invasive methods have failed to exclude instable injuries reliably. This prospective study aims to determine the diagnostic accuracy of dynamic, 4D computed tomography (CT) of the wrist for diagnosing instable SLL tears. METHODS: Single center, prospective trial including 40 patients with suspected SLL tears scheduled for arthroscopy. Diagnostic accuracy of 4D CT will be tested against the reference standard arthroscopy. Radiologists will be blinded to the results of arthroscopy and hand surgeons to radiological reports. A historical cohort of 80 patients which was diagnosed using cineradiography before implementation of 4D CT at the study site will serve as a comparative group. DISCUSSION: Static imaging lacks the ability to detect instable SLL tears after wrist trauma. Dynamic methods such as cineradiography and dynamic magnetic resonance imaging (MRI) are complex and require specific technical infrastructure in specialized centers. Modern super-fast dual source CT scanners are gaining popularity and are being installed gradually in hospitals and ambulances. These scanners enable dynamic imaging in a quick and simple manner. Establishment of dynamic 4D CT of the wrist in patients with suspected SLL tears in in- and outpatient settings could improve early detection rates. Reliable identification of instable injuries through 4D CT scans might reduce the number of unnecessary diagnostic arthroscopies in the future. TRIAL REGISTRATION: This study was registered prospectively at the German Clinical Trials Register (DRKS) DRKS00021110 . Universal Trial Number (WHO-UTN): U1111-1249-7884.

Accuracy of magnetic resonance imaging of the wrist for clinically important lesions of the major interosseous ligaments and triangular fibrocartilage complex; correlation with radiocarpal arthroscopy.

OBJECTIVE: To demonstrate the utility of MRI in separating clinically relevant from minor or incidental lesions of the triangular fibrocartilage complex and the major interosseous ligaments in the wrist. MATERIALS AND METHODS: In this retrospective study, we identified 89 patients and correlated MRI finding with subsequent arthroscopy. Triangular fibrocartilage complex abnormalities have been subdivided into disc lesions-central and radial-or ulnar-sided tears according to MRI appearances and surgical findings as the clinical and surgical approach is very different. Interosseous ligament tears were subdivided into partial or complete, highlighting the principle of recognising surgically relevant lesions. RESULTS: For simple central to radial tears and perforations of the triangular fibrocartilage complex, MRI was 98.3% accurate. MRI identified all peripheral triangular fibrocartilage complex tears seen at arthroscopy; however, the specificity of 66.7% may reflect partly the use of arthroscopy limited to the radiocarpal joint. MRI proved 95.4% accurate for surgically relevant scapholunate interosseous ligament tears and was highly accurate at separating limited from complete lunotriquetral interosseous ligament tears showing 100% accuracy for complete tears. CONCLUSIONS: The study shows excellent correlation between MRI and arthroscopic findings that determine surgical relevance with a very high sensitivity for triangular fibrocartilage complex lesions and accurate separation of minor versus surgically relevant ligamentous tears.

Is the Dorsal Fiber-Splitting Approach to the Wrist Safe? A Kinematic Analysis and Introduction of the "Window" Approach.

PURPOSE: To compare the kinematic effects of the dorsal fiber-splitting approach for scapholunate ligament repair to a dorsal "window" approach that spares all ligaments. METHODS: We randomized 24 fresh-frozen paired cadaveric forearms to either the dorsal fiber-splitting capsulotomy approach (FSC) or the dorsal window approach (window) following scapholunate interosseous ligament (SLIL) division. Loaded fluoroscopic radiographs were obtained after each of the 4 testing conditions following cyclic loading (200 cycles; 71 N): (1) intact SLIL, (2) SLIL-division, (3) surgical approach, and (4) closure. FSC specimens were randomly allocated to 2 subgroups for closure with either a suture anchor (n = 6) or a simple running suture closure (n = 6). Radiographic parameter measurements included the scapholunate gap, radiolunate angle, scapholunate angle, and dorsal scaphoid translation. RESULTS: Following the FSC, there were significant alterations in all radiographic parameters when compared with the intact and SLIL-division conditions. The window approach did not result in significant changes in any radiographic parameter. When compared to the window approach, all radiographic parameters of the FSC approach were significantly altered. Following closure with suture anchors in the FSC group, radiographic parameters improved, whereas with standard closure they failed to do so. Despite anchor closure, dorsal scaphoid translation, radiolunate angle, and scapholunate angle all remained elevated compared with scapholunate-divided wrists. CONCLUSIONS: The FSC produced significant changes in carpal posture under load, including scapholunate diastasis, dorsal intercalated segment instability, and dorsal scaphoid translation in SLIL-deficient wrists. The window approach preserved the critical dorsal ligament stabilizers and did not produce changes in carpal posture. CLINICAL RELEVANCE: The FSC may create iatrogenic changes in carpal posture that cannot be fully corrected with standard or anchor closure. The window approach does not alter carpal posture and should be considered when performing surgical procedures on the scaphoid or lunate.

Suture Tape Augmentation for Scapholunate Ligament Repair: A Biomechanical Study.

PURPOSE: Scapholunate (SL) ligament tears in the acute setting can be treated by primary repair through various techniques. The purpose of this study was to compare repair of the SL ligament with suture anchors alone versus repair of the SL ligament augmented with suture tape. METHODS: Twelve fresh-frozen cadavers (6 matched pairs) underwent a dorsal approach to the wrist and the SL ligament was sharply dissected off of its scaphoid attachment. Six cadavers underwent direct repair of the SL ligament using 2 suture anchors. The other 6 underwent repair of the SL ligament, which was then augmented with suture tape. All specimens then underwent load to failure testing using tensile distraction forces applied by a universal testing system. Maximum load to failure and mode of failure were recorded. RESULTS: Maximum load to failure (135 N; SD, 44.94 N) for specimens that were repaired and augmented with the internal brace was higher than that for specimens in the repair-only group (68 N; SD, 14.69 N). CONCLUSIONS: Biomechanical testing demonstrated a higher maximum load to failure in SL ligament repairs augmented with suture tape compared with a repair-only technique in this cadaveric model. CLINICAL RELEVANCE: Acute SL ligament injuries may benefit from suture tape augmentation by increasing the stability of the primary repair. This may prove to be beneficial in higher-demand patients.

Evaluation of Dorsal Scaphoid Displacement Using Posterior Radioscaphoid Angle in Patients With Suspected Scapholunate Instability: A Preliminary Study.

PURPOSE: To assess the validity and reliability of the posterior radioscaphoid angle (PRSA), an indicator of dorsal displacement of the scaphoid, in distinguishing wrists with and without chronic scapholunate instability (SLI). METHODS: We prospectively evaluated 40 patients (22 men and 18 women; mean age, 46 ± 13 years) with suspected SLI with radiographs and computed tomography arthrography. Based on these data, 3 groups were defined: positive SLI (n = 16), negative SLI (n = 19), and questionable SLI (n = 5). An independent reader measured the PRSA on sagittal computed tomography images using the same procedure. RESULTS: The PRSA median values were significantly lower in the negative SLI group (98°) compared with the positive SLI (110°) and questionable SLI (111°) groups. The difference between the positive SLI and questionable SLI groups was not significant. The best differentiation between patients with and without SLI was obtained with a PRSA threshold value of 103° (specificity of 86% and sensitivity of 79%). CONCLUSIONS: In this preliminary study, PRSA analysis offers a quantitative tool for the evaluation of dorsal scaphoid displacement in cases of SLI, including for patients presenting with questionable initial radiography findings. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Alterations in forearm muscle activation patterns after scapholunate interosseous ligament injury: A dynamic electromyography study.

STUDY DESIGN: Case control. PURPOSE OF THE STUDY: This study aimed to investigate the alterations seen in the activation patterns of the forearm muscles and to demonstrate the associated functional outcomes, in patients with scapholunate interosseous ligament (SLIL) injury. METHODS: The study involved 15 patients with SLIL injury (instability group) and 11 healthy participants (control group). Both groups were evaluated with regard to their pain, grip strength, and upper extremity functional level (disabilities of the arm, shoulder and hand and patient-rated wrist evaluation questionnaires), and they also underwent a dynamic electromyography analysis of their forearm muscle activity. The activation patterns of the extensor carpi ulnaris (ECU), extensor carpi radialis (ECR), flexor carpi ulnaris, and flexor carpi radialis muscles during wrist extension and flexion were recorded by means of surface electromyography. RESULTS: In the instability group, the pain severity was higher and the functional level was worse than in the control group (P < .05). Furthermore, during wrist extension, the ECR activity was lower and the ECU activity was higher in the instability group than in the control group (P < .05). CONCLUSION: Dynamic stabilization of the wrist, flexor carpi ulnaris, and flexor carpi radialis muscles have been shown to play an active role with ECU and ECR. Increased ECU and decreased ECR activation may pose a potential risk in terms of enhancing the scapholunate gap. We, therefore, propose that appropriate preventive neuromuscular exercise strategies implemented as part of a physiotherapy program for patients with SLIL lesions might increase the contribution of the dynamic stability effect of the relevant muscles.

Dorsal Extrinsic Ligament Injury and Static Scapholunate Diastasis on Magnetic Resonance Imaging Scans.

PURPOSE: Current biomechanical data suggest that static scapholunate (SL) ligament dissociation occurs only when there is loss of competence of the extrinsic ligaments either acutely or with attenuation over time. We aimed to identify whether patients with an SL gap greater than 2 mm demonstrated concomitant dorsal radiocarpal ligament (DRC) and dorsal intercarpal ligament (DIC) ligament changes on magnetic resonance imaging (MRI) scans that were identified as having an SL ligament tear. METHODS: We included 90 patients who had a posttraumatic MRI scan of the wrist diagnosed with an SL injury. We recorded basic demographics; 2 attending fellowship-trained musculoskeletal radiologists evaluated the integrity of the SL, DRC, and DIC ligaments and graded these as normal, low-grade injury (sprain or partial tear) or full-thickness tear. The association between the integrity of the DRC and DIC ligaments and the presence of a scapholunate gap of 2 mm or greater was analyzed. RESULTS: A total of 48 patients (53%) had an SL distance of 2 mm or greater on MRI. Of these patients, 28 (58%) had a partial or total tear of the DIC and/or DRC ligament. Compared with patients with an SL interval less than 2 mm, patients with an SL interval 2 mm or greater more often demonstrated DIC signal change (31% vs 12%), DRC signal change (52% vs 14%), or combined or isolated DIC and/or DRC signal change (52% vs 14%). CONCLUSIONS: Dorsal extrinsic ligaments demonstrate MRI signal change suggestive of acute or chronic injury in patients with an SL interval 2 mm or greater more often than in patients with an SL interval less than 2 mm. These results reinforce that MRI findings of SL ligament tear need to be interpreted in a larger context, perhaps with additional attention to the DIC and DRC appearance upon MRI. In addition, MRI evaluation of dorsal extrinsic ligaments may aid in clinical decision-making for patients with SL injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Update on operative treatment of scapholunate (SL) instability for radiologists: part 1-SL ligament repair, dorsal capsulodesis and SL ligament reconstruction.

Scapholunate instability is the most common form of carpal instability. Imaging (especially radiography) plays an important role in the staging, management and post-operative follow-up of scapholunate (SL) instability. The goals of this article are to review the pre-operative staging of SL instability, the surgical options for repair and reconstruction of the SL ligament, along with the normal postoperative imaging findings as well as complications associated with these surgical options.

Dorsal Scaphoid Subluxation on Sagittal Magnetic Resonance Imaging as a Marker for Scapholunate Ligament Tear.

PURPOSE: To evaluate the diagnostic utility of scaphoid dorsal subluxation on magnetic resonance imaging (MRI) as a predictor of scapholunate interosseous ligament (SLIL) tears and compare this with radiographic findings. METHODS: Thirty-six MRIs were retrospectively reviewed: 18 with known operative findings of complete Geissler IV SLIL tears that were surgically repaired, and 18 MRIs performed for ulnar-sided wrist pain but no SLIL tear. Dorsal subluxation of the scaphoid was measured on the sagittal MRI cut, which demonstrated the maximum subluxation. Independent samples t tests were used to compare radiographic measurements of scapholunate (SL) gap, SL angle, and capitolunate/third metacarpal-lunate angles between the SLIL tear and the control groups and to compare radiographic measurements between wrists that had dorsal subluxation of the scaphoid and wrists that did not have dorsal subluxation. Interrater reliability of subluxation measurements on lateral radiographs and on MRI were calculated using kappa coefficients. RESULTS: Thirteen of 18 wrists with complete SLIL tears had greater than 10% dorsal subluxation of the scaphoid relative to the scaphoid facet. Average subluxation in this group was 34%. Four of 18 wrists with known SLIL tears had no subluxation. No wrists without SLIL tears (control group) had dorsal subluxation. The SL angle, capitolunate/third metacarpal-lunate angle and SL gap were greater in wrists that had dorsal subluxation of the scaphoid on MRI. Interrater reliability of measurements of dorsal subluxation of the scaphoid was superior on MRI than on lateral x-ray. CONCLUSIONS: An MRI demonstration of dorsal subluxation of the scaphoid, of as little as 10%, as a predictor of SLIL tear had a sensitivity of 72% and a specificity of 100%. The high positive predictive value indicates that the presence of dorsal subluxation accurately predicts SLIL tear. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Posterior Radioscaphoid Angle as a Predictor of Wrist Degenerative Joint Disease in Patients With Scapholunate Ligament Tears.

OBJECTIVE: The purpose of this study is to determine whether the posterior radioscaphoid angle, a marker of posterior displacement of the scaphoid, is associated with degenerative joint disease in patients with scapholunate ligament tears. MATERIALS AND METHODS: Images from 150 patients with wrist pain who underwent CT arthrography and radiography were retrospectively evaluated. Patients with and without scapholunate ligament ruptures were divided into two groups according to CT arthrography findings. The presence of degenerative changes (scapholunate advanced collapse [SLAC] wrist) was evaluated and graded on conventional radiographs. Images were evaluated by two readers independently, and an adjudicator analyzed the discordant cases. Posterior radioscaphoid angle values were correlated with CT arthrography and radiographic findings. The association between posterior radioscaphoid angle and degenerative joint disease was evaluated. Scapholunate and radiolunate angles were considered in the analysis. RESULTS: The posterior radioscaphoid angle was measurable in all patients, with substantial interobserver agreement (intraclass correlation coefficient, 0.75). The posterior radioscaphoid angle performed better than did the scapholunate and radiolunate angles in the differentiation of patients with and without SLAC wrist (p < 0.02). Posterior radioscaphoid angles greater than 114° presented an 80.0% sensitivity and 89.7% specificity for the detection of SLAC wrist. CONCLUSION: Posterior radioscaphoid angles were strongly associated with degenerative wrist disease, with potential prognostic implications in patients with wrist trauma and scapholunate ligament ruptures.