Scapholunate Sprains

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Ligament sprains of the wrist usually result from falls on an outstretched hand. Most are mild and resolve with splinting and symptomatic treatment. However, the clinician must be careful not to miss potentially catastrophic injuries that could compromise a patient's hand and wrist function, including carpal dislocations, carpal instability (more specifically, scapholunate ligament instability), scaphoid fractures, and displaced intra-articular distal radius fractures. Injury to the scapholunate joint may be missed by physicians who do not consider it in their differential diagnosis of wrist injuries (Fig. 30-21).

Patients with scapholunate sprains have pain in the wrist with motion, gripping, and lifting and along the dorsal aspect

Self Administered Hand Diagram

Figure 30-22 A, Posteroanterior radiograph of left wrist in 27-year-old soccer player who fell, landed on his left palm, and complained of pain. Note the abnormal widening of the scapholunate interval. B, Comparison view of the uninjured right wrist demonstrates the same scapholunate separation (>3 mm) ("David Letterman" sign). Patient recovered with only splint support.

(From Nicholas J, Hershman E. The Upper Extremity in Sports Medicine, 2nd ed. St Louis, Mosby, 1995, p 456.)

Figure 30-22 A, Posteroanterior radiograph of left wrist in 27-year-old soccer player who fell, landed on his left palm, and complained of pain. Note the abnormal widening of the scapholunate interval. B, Comparison view of the uninjured right wrist demonstrates the same scapholunate separation (>3 mm) ("David Letterman" sign). Patient recovered with only splint support.

(From Nicholas J, Hershman E. The Upper Extremity in Sports Medicine, 2nd ed. St Louis, Mosby, 1995, p 456.)

of the wrist at the scapholunate joint just distal to Lister's tubercle (bump on distal radius) on the dorsal aspect of the wrist. Physical examination typically reveals no gross deformities, although dorsal swelling may be noted. The pain may be exacerbated by flexion and extension while palpating directly over the scapholunate joint on the dorsal aspect of the wrist.

Impacts strong enough to cause scapholunate sprain are sufficient to cause fracture. Therefore, plain radiographs should be obtained in all patients with suspected scapholu-nate sprain to look for associated fracture or avulsion. The series should include a standard AP view, AP with a clenched fist (accentuates scapholunate joint widening), standard lateral view, and posteroanterior (PA) view in ulnar deviation (assess scaphoid bone better for fracture). It is often helpful to obtain a comparison AP view of the opposite wrist. An increased gap between the scaphoid and lunate bones of 2 to 3 mm on the AP projection (e.g., "Terry Thomas" [U.K.] or "David Letterman" [U.S.] sign, for their gapped-tooth grin) is indicative of scapholunate dissociation (Fig. 30-22).

Patients with a "simple" scapholunate sprain require protection and rest with a period of splinting. This can be accomplished with a custom fiberglass or plaster splint, or a prefabricated cock-up wrist splint until the patient is asymptomatic. After initial treatment, the patient is weaned from the wrist splint and begins active ROM and hand-strengthening therapy. In patients with scapholunate dissociation, surgical consultation should be considered early, and referral to a hand specialist is encouraged. Fixation of the joint is often needed to maximize future wrist function (Fig. 30-23).

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