Scaphoid Shift Research Articles

Preliminary Outcomes of Scapholunate Ligament Augmentation with Internal Brace Technique

Injury to the scapholunate (SL) interosseous ligament (SLIL) is a common cause of carpal instability. Internal brace augmentation has been used in various ligament repair procedures; however, further investigation of its outcomes in hand surgery is needed. This study aimed to examine outcomes for patients who underwent SLIL repair with internal brace augmentation. Patients who underwent SLIL repair with the internal brace technique and had at least 1 year of follow-up were contacted. Available patients returned for an in-person evaluation with new radiographs and physical examination. If patients could not be contacted but had x-rays and physical examinations performed at greater than 1 year after surgery, these data were collected from their medical records. Participating patients completed the QuickDASH and Patient-Rated Wrist Evaluation surveys and rated their satisfaction with the surgery. Outcomes assessed included wrist range of motion, grip strength, scaphoid shift test, SL gap, SL angle, and radiographic evidence of radiocarpal arthritis. We collected outcomes for 14 SLIL repairs among 13 patients (12 male). Mean length of the follow-up was 41 months (n= 14, 17-64). Mean QuickDASH and Patient-Rated Wrist Evaluation scores were 6.1 (0-43.2) and 9.6 (0-65), respectively. Radiographic measurements remained stable from immediate to latest follow-up, and no radiocarpal arthritic changes were noted. However, SL gap decreased from a mean of 5.33 mm (3.4-6.7) before surgery to 3.34 mm (2-4.6) at the latest follow-up, and SL angle decreased from a mean of 79.5° (67°-97°) before surgery to 67.3° (51°-85°) at the latest follow-up. All scaphoid shift tests were stable. Therefore, SL internal brace augmentation has favorable short-term results with improvements in pain, function, satisfaction, and carpal alignment at greater than 1 year postoperatively. This technique can be an effective option for the management of SL instability in the short term. Therapeutic IV.

Relevance of the Scaphoid Shift Test for the Investigation of Scapholunate Ligament Injuries

Background: Although it is part of the common clinical examination of scapholunate ligament pathologies, there are only little data on the diagnostic value of the scaphoid shift test. The aim of this study was to evaluate the scaphoid shift test in a large cohort of patients. Materials and Methods: We retrospectively analysed 447 patients who underwent the scaphoid shift test and wrist arthroscopy because of various suspected injuries of the wrist, correlating the results of clinical examination with data obtained during the wrist arthroscopy. Sensitivity, specificity, and positive and negative predictive values were calculated and evaluated. Results: The sensitivity of the scaphoid shift test was low (0.50) when examining the whole cohort. In a subgroup of patients specifically referred for suspected scapholunate ligament injury, the sensitivity was higher (0.61), but the specificity was low (0.62). In detecting more serious lesions (Geissler 3 + 4), the scaphoid shift test demonstrated higher sensitivity (0.66). Conclusions: An isolated scaphoid shift test may only be of limited value in the diagnosis of scapholunate ligament lesions and should, therefore, be viewed as a useful tool for a preliminary assessment, but a negative test should not prevent the surgeon from indicating a more extensive diagnostic workup.

Relation Between the Phase-Lag Index and Lagged Coherence for Assessing Interactions in EEG and MEG Data

Descriptive Epidemiological Study.Ligament tears between carpal bones are easily missed on initial presentation, but can have potentially debilitating effects on the patient if they progress to an instability. They are usually the result of a fall onto an outstretched hand with the wrist in hyperextension. Current incidence of carpal instability after these falls is unknown.Using established clinical and radiological measures, we sought to establish the cumulative incidence of carpal instability in people who have fallen onto an outstretched hand in the second year after injury. We also sought to describe its relationship with functional impairment.We used emergency department records of an inner-urban tertiary hospital to contact all patients who presented with wrist pain following fall onto outstretched hand who were between one and two years after injury. Carpal instability was defined by blinded radiological evaluations and provocative clinical tests, including Scaphoid Shift (Watson’s) test, Ballottement, and mid-carpal shift test. Wrist-related pain and disability was measured using the Patient-Rated Wrist and Hand Evaluation.Of the 279 potentially eligible cases, only 146 were contactable, and fifty (28 male, 22 female; mean age of 48 years) attended for assessment. We found a cumulative incidence of 44% of carpal instability within the second year after injury. Of these, 12 (24%) cases had scapho-lunate instability, 12 (24%) had luno-triquetral instability and 7 (14%) had mid-carpal instability. There were no significant correlations between clinically confirmed carpal instability and pain, function, or work participation.This study found a higher than anticipated cumulative incidence of carpal instability in the second year after injury, which may reflect volunteer bias. Patients should be advised to monitor symptoms in the year after injury and seek a review if symptoms of pain, clicking or clunking arise.II

The clinical significance of magnetic resonance imaging of the hand: an analysis of 318 hand and wrist images referred by hand surgeons

Magnetic resonance imaging (MRI) is a common diagnostic tool in hand surgery. However, there is limited knowledge on the kind of findings that are relevant in treatment planning. We analysed the findings and utility of arm, wrist, metacarpal, and finger MRIs taken in a tertiary hand surgery clinic of 318 consecutive images from 316 patients referred by a hand surgeon or hand surgeon resident. Ganglions (28%), findings on the extensor carpi ulnaris tendon (18%) and on the triangular fibrocartilage (18%) were the most common findings and increased with patient age; the clinical significance of these findings was minimal. The correlation between the clinical scaphoid shift test or the fovea sign test and MRI was also non-significant. Despite findings on MRI, the diagnosis remained unsolved in 76 (24%) cases. However, MRI had a role in reassuring the patient, and in 70% of the cases, further follow-up was unnecessary. This study demonstrates that the indications for wrist and hand MRI must be considered thoroughly and interpretation of the MRI report requires knowledge.

Treatment Recommendations for Suspected Scapholunate Ligament Pathology.

Background The diagnosis and treatment of scapholunate interosseous ligament (SLIL) pathology is debated and notably variable. This study assessed the influence of diagnostic arthroscopy on treatment recommendations and the interobserver reliability of the arthroscopic classification of SLIL pathology. Methods The influence of diagnostic arthroscopy on treatment recommendations and the reliability of the arthroscopic classification of SLIL pathology were tested in a survey-based experiment. Seventy-seven surgeons evaluated 16 scenarios of people with wrist pain with variation in symptoms, scaphoid shift, time of symptom onset, and MRI appearance of the SLIL. Participants were randomized to view or not to view diagnostic wrist arthroscopy. Factors associated with recommendation for repair, capsulodesis, or tenodesis were analyzed. Results Viewing arthroscopic videos was associated with both offering surgery and a more reconstructive option. Other factors independently associated with recommendation for surgery included greater pain intensity and activity intolerance, women surgeons, an asymmetric scaphoid shift, and a recent onset of symptoms. The interobserver reliability of SLIL classification was slight. Conclusions Diagnostic arthroscopy leads to more surgery, and more invasive surgery, in spite of unreliable assessment of pathology. Clinical Relevance This points to the need to measure the potential benefits and harms of diagnostic wrist arthroscopy among people with wrist pain and no clear diagnosis on interview, examination, and radiographs. Level of Evidence Not applicable.

Feasibility of ultrasound-based measurement of dorsal scaphoid displacement: A 3D-model study

The present study aimed to develop a reliable dynamic measurement technique, which can be used directly in the outpatient setting, based on dorsal subluxation of the scaphoid on scaphoid shift test. This study was designed to evaluate feasibility and to quantify dorsal subluxation of the scaphoid in relation to the lunate. Based on a scaphoid shift test under ultrasonography, a standardized 3D test model was developed to measure subluxation. Sagittal subluxation ranged between 0 and 6 mm, as checked on the implemented scale. Four hand surgeons trained in ultrasonography (experience level II–V) performed blinded measurements (total of 52, n = 13 per investigator) with a standardized measurement protocol. Dorsal subluxation of the scaphoid was measured in relation to the lunate. Interobserver reliability on intraclass correlation coefficient (ICC) was excellent, at 0.97 (95% confidence interval, 0.930–0.992). Mean overall absolute measurement error was 0.27 mm ± 0.21. Dorsal subluxation of the scaphoid can thus be accurately measured on ultrasound with excellent interobserver reliability, quantifying and improving clinical assessment of scapholunate instability.

Arthroscopic electrothermal collagen shrinkage for partial scapholunate ligament tears, isolated or with associated triangular fibrocartilage complex injuries: a prospective study.

To present the outcomes of arthroscopic electrothermal shrinkage for partial scapholunate (SL) ligament tears, isolated or with associated triangular fibrocartilage complex (TFCC) injuries. A prospective study of 20 patients with symptomatic instability of SL ligament (14 of them also with TFCC wrist injuries) treated with arthroscopic electrothermal shrinkage was conducted using a monopolar radiofrequency probe. No patient showed radiologic signs of static dissociation (mean SL interval 2.2 ± 0.6mm; mean SL angle 41.4° ± 6.7°) before surgery. All patients underwent follow-up at our clinic regularly for an average of 50.6months (range 29-80months). The modified Mayo wrist score improved from a mean of 59 ± 17.1 points preoperatively to 88.3 ± 16.2 points at the final follow-up. At the final clinical examination, a painful Watson scaphoid shift test was found in 3 patients (15%). The mean flexion-extension arc was unchanged (132° ± 19°), and mean grip strength improved 12kg. No patient showed radiologic signs of arthritis or instability after surgery (mean SL interval 1.9 ± 0.7mm; mean SL angle 42.7° ± 7.3°). Of the 14 patients with combined TFCC injuries, 3 patients continued complaining of ulnar-sided point tenderness. At the end of the follow-up, 80% of the subjects were satisfied or very satisfied. SL ligament and TFCC electrothermal shrinkage effectively provided pain relief and grip strength increase for most of the patients treated. Level IV.

Cumulative incidence of carpal instability 12-24 months after fall onto outstretched hand

Study DesignDescriptive Epidemiological Study. IntroductionLigament tears between carpal bones are easily missed on initial presentation, but can have potentially debilitating effects on the patient if they progress to an instability. They are usually the result of a fall onto an outstretched hand with the wrist in hyperextension. Current incidence of carpal instability after these falls is unknown. Purpose of the StudyUsing established clinical and radiological measures, we sought to establish the cumulative incidence of carpal instability in people who have fallen onto an outstretched hand in the second year after injury. We also sought to describe its relationship with functional impairment. MethodsWe used emergency department records of an inner-urban tertiary hospital to contact all patients who presented with wrist pain following fall onto outstretched hand who were between one and two years after injury. Carpal instability was defined by blinded radiological evaluations and provocative clinical tests, including Scaphoid Shift (Watson’s) test, Ballottement, and mid-carpal shift test. Wrist-related pain and disability was measured using the Patient-Rated Wrist and Hand Evaluation. ResultsOf the 279 potentially eligible cases, only 146 were contactable, and fifty (28 male, 22 female; mean age of 48 years) attended for assessment. We found a cumulative incidence of 44% of carpal instability within the second year after injury. Of these, 12 (24%) cases had scapho-lunate instability, 12 (24%) had luno-triquetral instability and 7 (14%) had mid-carpal instability. There were no significant correlations between clinically confirmed carpal instability and pain, function, or work participation. Discussion and ConclusionThis study found a higher than anticipated cumulative incidence of carpal instability in the second year after injury, which may reflect volunteer bias. Patients should be advised to monitor symptoms in the year after injury and seek a review if symptoms of pain, clicking or clunking arise. Level of EvidenceII

Capsuloplastie dorsale scapho-lunaire sous arthroscopie dans les cas de ressaut scapho-lunaire EWAS 3

Arthroscopic scapholunate tenodesis for pre dynamic scapholunate instability EWAS 3. Purpose For predynamic scapholunate (SL), denervation have been an option but many papers showed the importance of the proprioceptive function of the NIOP. We evaluated retrospectively the results of arthroscopic scapholunate tenodesis without pinning and a simple cast immobilization post operatively for one month. Methods Twelve patients (mean age, 36.5 years) presenting with persistent posttraumatic pain and weakness to the wrist were diagnosed with pre SL instability (positive Watson scaphoid shift test result, SL gapping on grip-view radiographs, arthroscopic findings of a EWAS III B or C tear) and treated. Range of motion, grip strength, radiographic measurements, and the Mayo wrist score were used to evaluate the results. Results The mean delay between trauma and surgery was 19 months (range, 2–36). None patients had subsequent surgery before the procedure. The mean follow-up period was 17,7 months (range, 3–41). Asymptomatic scapholunate instalibity was noted. The mean EVA score for pain at rest and activities were signicantly better at last follow up, respectively at rest from 6.3 to 0.91, in activities from 7.3 to 2.4. The mean range of motion was 65 degrees of extension to 73.5 degrees of flexion with more than 75% of mean mobility to controlateral side in 83% of patients. The mean QuickDash, PRWE and MWS are: 15.2, 11.2 and 93. No persistent radiographic SL gapping in grip views was noted in all patients but one progressed to dorsal intercalated segment instability. Conclusions The results of this technique are suboptimal, however, it may be an conservative option for patients with predynamic painful wrist and prevent from stiffness. This procedure doesn’t cut the way to any further procedure in case of bad result.

Carpal Instability After a Fall Onto Outstretched Hand

Objective/Hypothesis: Carpal dislocations are easily missed on initial presentation, as x-rays can appear unremarkable. It is thought that perilunate injuries in general make up around 10% to 19% of all wrist sprains; however, no incidence or prevalence studies have been undertaken. We aimed to establish the incidence of carpal instability between 1 and 2 years post acute wrist injury as the result of a fall using established clinical and radiological measures and secondarily, attempt to estimate its relationship with functional impairment. Materials and Methods: This incidence study used multiple overlapping sources to ascertain all patients presenting to a major urban hospital with wrist pain following fall onto outstretched hand between 1and 2 years post injury. Carpal instability was defined by blinded radiological evaluations and provocative clinical tests, including Scaphoid Shift (Watson) test, ballottement, and midcarpal shift test. Wrist-related pain and disability were measured using the patient-rated wrist and hand evaluation. Results: Fifty participants (28 male, 22 female) with a mean age of 47.8 years met inclusion criteria. We found a cumulative incidence of 40% of carpal instability within the second year post injury, based on clinical testing. X-ray evaluations were inconsistent with clinical findings. There were no significant correlations between clinically confirmed carpal instability and presence of fracture at the time of injury, pain, function, age, sex, high energy trauma, or sick days from work. Conclusions: This study found a higher than anticipated cumulative incidence of carpal instability in the second year post injury. Patients should be advised to monitor symptoms in the year post injury and seek a review if symptoms of pain, clicking, or clunking arise.

Wrist Pain- Baseball Pitcher

HISTORY: A 16 year old high school baseball pitcher presented in July with persistent right wrist pain for 2 months after slipping at the beach. Initial exam revealed only ulnar sided wrist tenderness. A radiograph showed no fractures, with a small lucency in the capitate resembling a bone cyst. He was managed as a sprain with splinting, rest, ice and NSAIDs. He returned to daily activities, but noted worsening pain in September, specifically with weightlifting and deadlifts. His course was complicated by acute severe hand swelling, prompting an urgent clinic visit. PHYSICAL EXAM: BP: 122/80; HR: 78; Temp: 36.6 Severe swelling noted on the dorsal right wrist without erythema, bruising, lacerations, nail infection or skin breakdown, and no extension proximally. He had 5/5 strength in all directions, but with pain on flexion and extension of the wrist without a humpback deformity. Dorsal and volar aspects of the wrist were painful over the capitate and lunate, without anatomic snuffbox tenderness or scaphoid shift. Distal radioulnar joint tenderness was not as severe as his previous visit. Radial pulses and sensation to light touch bilaterally were normal. Concern over the acuity and severity of his wrist swelling prompted repeat imaging with an x-ray and MRI, as well as blood work. DIFFERENTIALS: 1.Wrist sprain 2.Carpal stress fracture 3.Synovitis 4.Infection 5.Tumor 6.Rheumatoid Arthritis TESTS/RESULTS: WBC- 7 Hemoglobin/Hematocrit- 15/45 Platelet- 257 Rheumatoid Factor- 6.7 Vitamin D25- 40 ANA- negative CRP- 3 ESR- 2 Right Wrist X-Ray: _ No acute fracture or dislocation _ Persistent stable lucency in proximal capitate. Right Wrist MRI _ diffuse signal abnormality in lunate with negative ulnar variance in keeping with Kienbock’s Disease _ Soft tissue edema on dorsal wrist adjacent to lunate and capitate and deep to extensor tendons _Thickening and heterogenous signal involving dorsal extrinsic ligaments predominantly at capitate and lunate compatible with sprain FINAL/WORKING DIAGNOSIS: Kienbock’s Disease Stage 1 TREATMENT/OUTCOME: 1.Intermittent immobilisation during the day when symptomatic and continuously at night 2.Counseled on disease progression and future need for surgery 3.Referred to an Orthopedic Hand Specialist for surgical options, with a re-evaluation in 6 months by MRI

Comparisons of three radiographic views in assessing for scapholunate instability.

Multiple wrist x-ray images have been described to assess for scapholunate (SL) instability. Some views may be redundant. The purpose of this study was to compare three plain x-ray views in identifying a traumatic diastasis of the SL interval. Nineteen patients (19 wrists) with a positive scaphoid shift test and surgically confirmed SL ligament damage were identified. There were 15 males and 4 females with a mean age of 39years. Pre-operative x-rays were reviewed, including posteroanterior (PA) neutral and PA ulnar deviation views of the injured wrist, and PA clenched fist views of the injured and uninjured wrists. Dynamic SL instability was defined by an SL mid-interval gap of <3mm and static SL instability by a gap of ≥3mm in the PA neutral views. The mid-interval measurements were compared between x-ray images. There were 10 dynamic and 9 static SL instability cases. The PA ulnar deviation and the PA clenched fist views showed significantly greater SL gaps in comparison to the PA neutral views in dynamic but not static SL instability cases. In both categories of instability, there was no significant difference in the SL gaps between the two stress images. The PA clenched fist view of the uninjured wrist revealed SL gapping of >3mm in 50% of patients but with generally greater gapping in the clenched fist view of the injured wrist. The PA ulnar deviation and clenched fist stress views were equally effective in showing a dynamic SL diastasis following wrist injury. Neither view was more effective than a neutral PA view in diagnosing static SL instability.

Ligamentous Hyperlaxity and Dorsal Wrist Ganglions

To determine whether symptomatic dorsal wrist ganglions are associated with generalized ligamentous hyperlaxity. Ninety-six patients (61 females) presenting to hand surgeons for a symptomatic dorsal wrist ganglions were prospectively enrolled in this case-control investigation. Beighton scores were calculated to quantify generalized ligamentous laxity in each patient, and a scaphoid shift test (scapholunate capsuloligamentous laxity evaluation) was performed. Apositive scaphoid shift test was defined by both pain and a palpable clunk. Ninety-six individuals without ganglions were then enrolled to form an age and sex frequency-matched control cohort. The control group was similarly assessed for Beighton score and scaphoid shift test. Binary logistical regression was performed to assess the association of ganglions with generalized ligamentous hyperlaxity (Beighton score ≥ 4) while accounting for effects of age and sex. Patients with symptomatic dorsal wrist ganglions demonstrated significantly increased rates of generalized ligamentous hyperlaxity. Among those with ganglions, 27 of 96 (28%) patients exhibited generalized ligamentous hyperlaxity, compared with 12 of the 96 (13%) age- and sex-matched individuals in the control group. Patients with symptomatic dorsal wrist ganglions were also significantly more likely to demonstrate localized scapholunate hyperlaxity with a positive scaphoid shift test (25% positive scaphoid shift test with ganglions vs 1% in controls). In logistical modeling, patients with dorsal wrist ganglions had 2.9 (95% confidence interval [CI] 1.3-6.2) times greater odds of generalized ligamentous hyperlaxity compared with patients without a dorsal wrist ganglion after accounting for patient age and sex. Symptomatic dorsal wrist ganglions were associated with both generalized ligamentous hyperlaxity and a positive scaphoid shift test. Although an association between wrist ganglions and ligamentous hyperlaxity does not prove causation, the possibility of the same underlying pathological entity causing both can be envisioned (ie, abnormal formation or organization of dense regular connective tissue). Prognostic III.

The value of provocative tests for the wrist and elbow: A literature review

To describe and determine the usefulness of provocative tests for the wrist and elbow a literature search was performed. A total of 31 diagnostic studies were identified, assessed, and ranked. The highest ranking tests had a mean positive likelihood ratio of ≥2.0, or a mean negative likelihood ratio of ≤0.5, from more than one study. The highly recommended tests were found to be the Phalen's, Tinel's test for carpal tunnel and cubital tunnel, and modified compression test, scaphoid shift test, and elbow flexion test. A total of 14 tests met our requirements to be considered a recommended test. A greater number of provocative tests either do not have adequate data to support their usefulness or their clinical utility has not been assessed. This information may assist hand therapists in choosing which provocative tests are considered clinically useful in improving the probability of the presence or absence of pathology in the hand, wrist, and elbow. Level of evidenceNA.

Traitement de l’instabilité scapholunaire par capsulodèse au ligament scaphotriquétral selon Berger

Objectives Scapholunate ligament injuries may lead to scapholunate instability and wrist osteoarthritis. Many surgical techniques have been described to repair these injuries. The goal of our study is to assess the clinical results after capsulodesis with the scaphotriquetral ligament for scapholunate instabilities. Methods Twenty-eight patients, 22 men and six women, were operated for scapholunate instability between January 2006 and December 2008. The average age was 37, 8 years, and the average time between trauma and surgery was 9,9 months. The scaphoid shift test was present in 26 patients. All patients underwent static and dynamic X-rays of the wrist and scan. A capsulodesis with scaphotriquetral ligament was performed in all patients. Results At 24 months follow-up, a 13° significant decreased of wrist range-of-motion was noted. The strength was significantly improved after surgery. The wrist stability was improved in 26 patients. Concerning pain, a significant reduction was noted with Analogical Visual Scale after surgery ( p < 0.005). Twenty-one patients returned to their previous work. Complications were reflex dystrophy in one patient and wrist infection in one patient. Conclusion Many techniques were described for treatment of scapholunate injuries, from the simple scapholunate ligament suture to partial wrist arthrodesis. Capsulodesis with scaphotriquetral ligament improves grip strength, decreases wrist instability and pain with a slight lost of range-of-motion.

Provocative wrist tests and MRI are of limited diagnostic value for suspected wrist ligament injuries: a cross-sectional study

What is the diagnostic value of provocative wrist tests and magnetic resonance imaging (MRI) for suspected wrist ligament injuries? Cross-sectional study. 105 people presenting to hand clinics with wrist pain and suspected wrist ligament injuries were evaluated prospectively. The integrity of wrist ligaments was tested with seven provocative tests. The results were compared to the reference standard of arthroscopy. In a subgroup of 55 participants, MRI findings were also compared to arthroscopy. The provocative tests were the scaphoid shift test (SS test), lunotriquetral test (LT test), midcarpal test (MC test), distal radioulnar joint test (DRUJ test), triangular fibrocartilage complex (TFCC) stress test (TFCC test), TFCC stress test with compression (TFCC comp test), and the gripping rotatory impaction test (GRIT). Most provocative tests and MRI findings were of little or no value for diagnosing wrist ligament injuries. Exceptions were the SS test (+ve LR 2.88 and -ve LR 0.28), MC test (+ve LR 2.67) and DRUJ test (-ve LR 0.30), all of which were of mild diagnostic usefulness. MRI was moderately useful for diagnosing TFCC injuries (+ve LR 5.56, -ve LR 0.15), and was mildly useful for diagnosing scapholunate (SL) ligament injuries (+ve LR 4.17, -ve LR 0.32) and lunate cartilage damage (+ve LR 3.67, -ve LR 0.33). Adding MRI to provocative tests improved the accuracy of diagnosis of TFCC injuries slightly (by 13%) and lunate cartilage damage (by 8%). Provocative wrist tests of SL ligament injuries and midcarpal ligament injuries are mildly useful for diagnosing wrist injuries. MRI diagnostic findings of SL ligament injuries, lunate cartilage damage, and TFCC are mildly to moderately useful. MRI slightly improves the diagnosis of TFCC injury and lunate cartilage damage compared to provocative tests alone.

Clinical Examination of Scaphoid Fractures

Undetected scaphoid fractures may lead to complications, including nonunion, malunion, avascular necrosis, and wrist arthritis. A competent physical examination is essential for the diagnosis of scaphoid fractures in the setting of occult fractures presenting with normal radiographs. The differential diagnosis of occult scaphoid fractures includes acute tears of the scaphoid-lunate ligament, Kienbock's disease, occult ganglion, nondisplaced radial styloid fractures, and injury to the radial aspect of the radio-scapho-capitate ligament. All of these may have normal plain radiographs but often can be distinguished based on physical examination findings. The 2 key points of such an examination include the exact location of point tenderness and provocative special tests. Although Watson's scaphoid shift test is classically described for scaphoid instability, we highlight its significance in the setting of scaphoid fractures.

Current Practice in the Diagnosis and Treatment of Carpal Instability—Results of a Survey of Australian Hand Therapists

A postal survey of all 85 full Australian Hand Therapy Association (AHTA) members was carried out to determine the current practice of the diagnosis and treatment of carpal instability by AHTA members. There was an 87% return rate. On average therapists saw 3.8 patients/month with carpal instability. Time from onset of pain or injury was a median of eight weeks (inter-quartile range 0–26 weeks). Ulnar pain was reported in 39% of patients, central pain in 17%, radial pain in 13%, and combined in 34%. Mean pain intensity at rest was 3.5/10 (SD 2.8), and with aggravating activity was 7.7 (SD 2.2). Forty-seven percent of patients reported difficulties with grip-related activities. Mean grip strength was 67% of the contralateral side. The most commonly used tests used were scaphoid shift, lunotriquetral ballotment, triangular fibrocartilage complex, and midcarpal stress tests. The most used treatments were patient education (advice and activity modification), splinting the wrist, and isometric exercising of the wrist musculature.

Chronic Wrist Pain - Rock Climbing

HISTROTY: 32yo female rock climber with a history of increasing left wrist pain. As a teen ager she had FOOSH injury to her right wrist while rock climbing and had xrays of both wrists demonstrating “bony abnormalities” needing a “cast.” Since, she has had pain while rock climbing. She never taped or braced. Currently, pain located dorsolateral/medial at the wrist and worse with hyperdorsiflexion such as pushing off and opening doors. No swelling or redness. No mechanical symptoms. No numbness or tingling. Elbow, shoulders and neck negative. Tried ibuprofen as needed but no physical therapy or bracing. History of patellar subluxation. PHYSICAL EXAMINATION: Inspection - no bony deformities, effusions or erythema. Symmetric active range of motion in all planes. Left wrist tender with terminal ulnar deviation. Palpation no nodules or masses but at the dorsal and volar ulnar aspects elicits some tenderness. Clicking at the ulnar aspect occurs with passive radial to ulnar deviation reported as uncomfortable. TFCC loading and table lift off test produces tenderness. Watson's scaphoid shift does not produce clicking or pain. Anatomic snuffbox palpation is negative. Tinel's is negative. Radial and ulnar pulses and sensation is intact and symmetric. Finger opposition strength is full. Hyper extension and abduction indicates laxity. DIFFERENTIAL DIAGNOSIS: TFCC tear. Carpal stress fracture. Scaphoid fracture non-union. Carpal instability. Distal radioulnar junction instability. TEST AND RESULTS: Plain film radiographs show lunotriquetral carpal coaltion. No scapholunate widening. MR Arthrography shows partial tears of ulnar attachment of TFCC without positive ulnar variance. Volar radioulnar ligament disruption with dorsal distal radioulnar joint subluxation. Lunotriquetral coalition, ulnar impaction. FINAL WORKING DIAGNOSIS: TFCC tear. DRUJ instability with dorsal subluxation. Lunotriquetral coalition. Ulnar impaction. Hyperlaxity. TREATMENT AND OUTCOMES: High dose NSAIDS and bracing. Cast immobilization deferred. Relative rest from rock climbing. At 4 months, intermittent pain with hyper dorsiflexion left greater than right. Refer to hand PT. At 6 months, improvement with relative rest but some symptoms with ADL's. Ortho Hand. Wrist taping for rock climbing.

Arthroscopic Debridement and Closed Pinning for Chronic Dynamic Scapholunate Instability

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. 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. 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. 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. Therapeutic, Level IV.