Distinguishing Which Scapholunate Ligament Injuries with Distal Radius Fracture Need Surgical Repair

Radiographic diagnosis of scapholunate ligament injury (SLI) in the setting of distal radius fracture (DRF) can be challenging, even when combined with an adequate history and proficient clinical assessment. For example, one study suggests that radiography is better suited for excluding SLI rather than diagnosing it.

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Hand and Upper Extremity Orthopaedic Surgeon Chaitanya S. Mudgal, MD, in the Department of Orthopaedics at Massachusetts General Hospital, and colleagues retrospectively studied the influence of radiographic diagnosis of SLI on the surgeon's treatment decision-making for DRF. They found that only 3.5% of patients with DRF who had SLI diagnosed by a radiologist had a recorded a clinical concern by the treating surgeon.

In the Journal of Wrist Surgery, the researchers discuss how the understanding of SLI pathology has evolved and share their current procedures for treating it.

A Database Analysis

The researchers identified 2,923 adults who underwent surgery for DRF in a single-institution research database between 2005 and 2015. When dictating reports following plain radiographs, radiologists diagnosed SLI in 200 of these patients. SLI was diagnosed on preoperative radiographs in 36% of patients.

The treating surgeon recorded a clinical concern about SLI for seven of the 200 patients (3.5%), of whom only four had operative treatment of SLI (2%). In the three other cases, the surgeon did not feel treatment was warranted based on intraoperative fluoroscopy.

Insight into the Pathology of SLI

The researchers note that the first reports of SLI concurrent with DRF were published 25 years ago. Since then, cadaver studies have demonstrated that SL separation does not occur unless there are several ligamentous injuries at the same time. In addition, it is now known if increased SL distance or altered carpal relationships indicate pathology. In addition, it is now known that increased SL distance or altered carpal relationships do not always indicate pathology.

Procedures at Mass General

Dr. Mudgal and his colleagues have stopped recommending routine exploration and repair when SLI is noted on preoperative films. Instead, they advise the following process:

1. At the initial office visit, zero-rotation posteroanterior and lateral radiographs are taken of the affected wrist and contralateral wrist
2. If the two wrists differ with regard to SL distance, the patient is alerted to the possibility of SLI. They are cautioned that this issue may need to be repaired, and informed that such an injury—and its subsequent repair—can result in some degree of permanent loss of wrist motion
3. The DRF is fixed operatively
4. The wrist is then imaged intra-operatively, using fluoroscopy, during flexion and extension, as well as during radial and ulnar deviation
5. If SL relationships have been restored and the scaphoid and lunate move as one unit, then no further treatment is performed
6. If there is a loss of the normal SL relationships, in addition to an increased SL distance, then the SLI is operatively repaired

The authors add that according to recent studies, surgical repair of SLI is especially worthwhile in patients who have radiographic signs of severe SLI and/or those whose activities put high functional demands on their injured wrist.

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