Uploaded byAaron Venouziou
SL tears
The document discusses scapholunate tears, noting that the scapholunate interosseous ligament (SLIL) is the primary stabilizer of the scapholunate joint. It describes the spectrum of injury from partial to complete tears and the importance of early diagnosis. The principles of management involve determining if the dorsal SL ligament is intact and repairable, and if carpal malalignment is reducible. Treatment options range from arthroscopic debridement for partial tears to open repair and reconstruction for complete tears.
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SL tears
- 1. Scapholunate Tears: The ImportanceOf Early Diagnosis Aaron Venouziou, MD Orthopaedic, Hand and Upper Extremity Surgeon St. Luke’s Hospital Thessaloniki www.handsurgery.gr
- 2. www.handsurgery.gr ScaphoLunate Interosseous Ligament(SLIL) • C-shaped ligament • Proximal SL joint • Primary stabilizer
- 3. www.handsurgery.gr ScaphoLunate Interosseous Ligament(SLIL) • C-shaped ligament • Proximal SL joint • Primary stabilizer
- 4. www.handsurgery.gr ScaphoLunate Interosseous Ligament(SLIL) • C-shaped ligament • Proximal SL joint • Primary stabilizer
- 5. www.handsurgery.gr ScaphoLunate Interosseous Ligament(SLIL) STRENGTH Berger et al., 1999 Palmar DorsalProximal 118 ± 21 63 ± 32 260 ± 118
- 6. www.handsurgery.gr ScaphoLunate Interosseous Ligament(SLIL) INNERVATION PROPRIOCEPTION Garcia-Elias et al., 2013 Palmar DorsalProximal
- 7. www.handsurgery.gr ScaphoLunate Ligament Complex(SLLC) • Secondary stabilizers – Volar static ➡ RSC & STT – Volar dynamic ➡ FCR Elsaidi 2004, Short 2007, Salva-Coll 2011, Garcia-Elias 2012
- 8. www.handsurgery.gr ScaphoLunate Ligament Complex(SLLC) • Secondary stabilizers – Dorsal static ➡ DRC, DIC, DCSS Short 2007, Van Overstraeten & Mathoulin 2013 DRC
- 9. www.handsurgery.gr The extent ofinjury required to disrupt the normal kinematics of the scapholunate interval is not well understood and is controversial A spectrum of injury to the SLIL is seen Scapholunate Injury
- 10. www.handsurgery.gr Spectrum of Injury •Pre-dynamic (occult) • Dynamic • Static • DISI • SLAC Scott Wolfe 2001
- 11. www.handsurgery.gr Occult Instability • Latepresentation • Symptoms w/ mechanical loading • Decreased grip strength • Localized SL interval tenderness • Scaphoid shift (Watson) test • Normal static & stress X-rays
- 12. www.handsurgery.gr Occult Instability • MRI(high resolution) • Arthroscopy • Attenuation or partial SLIL tear – Geissler grade I – Geissler grade II
- 13. www.handsurgery.gr Dynamic Instability • Dorsalwrist syndrome • Stress X-rays positive • Partial or complete SLIL tear – Geissler grade III – Geissler grade IV • Partial extrinsic lig. tear
- 14. www.handsurgery.gr Static Instability • CompleteSLIL tear • Extrinsic lig. tear • Positive X-rays – SL interval > 3mm – Scaphoid shortening – Scaphoid ring sign • Arthroscopy – Geissler grade IV
- 15. www.handsurgery.gr DISI • Complete SLILtear • Complete extrinsic lig. tear • Chronic instability • Biplanar • Reducible vs. fixed – SL interval > 3 mm – SL angle >60o – CL angle >30o
- 16. www.handsurgery.gr SNAC • Chronic instability •Chondral lesions • Arthritic changes • Salvages procedures
- 17. www.handsurgery.gr Principles of Management 1.Is the dorsal SL ligament intact? 2. Is the dorsal SL ligament repairable? 3. Is the scaphoid posture normal? 4. Is any carpal malalignment reducible? 5. Is the cartilage on the radiocarpal and midcarpal surfaces normal? Garcia-Elias 2006
- 18. www.handsurgery.gr Principles of Management Garcia-Elias2006 I II III IV V VI Partial injury yes no no no no no Repairable yes yes no no no no Normal alignment yes yes yes no no no Reducible yes yes yes yes no no Normal cartilage yes yes yes yes yes no
- 19. www.handsurgery.gr Occult Instability -Partial SLIL Tear • Early diagnosis => splinting / casting • Persistent symptoms after 4 weeks => MRI • Positive MRI => arthroscopic evaluation of SLIL I II III
- 20. www.handsurgery.gr Occult Instability -Partial SLIL Tear • Debridement • Pinning for 6-8 wks • Thermal Shrinkage in chronic cases – Volar SLIL – RSC lig • PT after 8 wks
- 21. www.handsurgery.gr Occult Instability -Partial SLIL Tear GROUP I symptoms <3 m SL interval <3 mm • 83% of the pts were symptom-free GROUP II symptoms >3 m SL interval >3 mm • 53% of the pts were symptom-free Whipple TL, 1995 Chronicity and static instability are negative prognostic factors
- 22. www.handsurgery.gr Occult Instability -Partial SLIL Tear • Ruch and Poehling, 1996 Arthroscopic Debridement Good results in all pts with partial SLIL tears No progression to instability (min. FU 2 yrs) • Weiss et al, 1997 Arthroscopic Debridement 11/13 pts (85%) good results @ mean FU of 27 mo. 10/15 (67%) good results for complete tears • Darlis et al, 2005 Thermal Shrinkage 14/16 good results (mean FU 19 mo.) No signs of arthritis or instability during the FU
- 23. www.handsurgery.gr • Dynamic orstatic instability • Coronal plane instability • Arthroscopy – Debridement – SL interval reduction – Pinning – Dorsal capsulodesis • Mini open SLIL repair + capsulodesis Complete Repairable SLIL Tear
- 24. www.handsurgery.gr Complete Repairable SLILTear • Mathoulin & Messina, 2010 66 pts w/ acute injuries (<6 wks) 92% good results
- 25. www.handsurgery.gr Complete Repairable SLILTear • 57 pts w/ chronic injuries (3-24 mo) • Pain & positive Watson test
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- 28. www.handsurgery.gr Complete Repairable SLILTear • 56/57 patients (98.2%) were satisfied • Mean DASH score improved from 43 to 8.3 • Improvement of pain, motion, and grip strength
- 29. www.handsurgery.gr Complete Repairable SLILTear • Open SLIL repair + capsulodesis
- 30. www.handsurgery.gr Non Repairable SLIL– Reducible SL Dissociation • Ligament reconstruction w/ tendon graft – FCR: Brunelli, Garcia-Elias – ECRB: Brunelli – ECRL: Bleuler, Petterson • Bone–ligament–bone graft • RASL procedure w/ Herbert screw • Intercarpal fusions
- 31. www.handsurgery.gr Non Repairable SLIL– Reducible SL Dissociation
- 32. www.handsurgery.gr Non Repairable SLIL– Reducible SL Dissociation
- 33. www.handsurgery.gr Non Repairable SLIL– Reducible SL Dissociation
- 34. www.handsurgery.gr Non Repairable SLIL– Reducible SL Dissociation
- 35. www.handsurgery.gr Non Repairable SLIL– Reducible SL Dissociation • Darlis et al., 2006 Aggressive arthroscopic debridement 6/11 pts good results (chronic cases)
- 36. www.handsurgery.gr DISI • Massive ligamentdisruption at the time of injury • Gradual attrition of the secondary stabilizers • Fixed deformity – STT fusion – Scapho-capitate fusion – Scapho-capito-lunate fusion – PIN & AIN neurectomy + styloidectomy
- 37. www.handsurgery.gr Arthritis (SLAC) • StageI ➡ styloidectomy • Stage II ➡ radio-scapho-lunate fusion ➡ PRC • Stage III ➡ 4 corner fusion ➡ luno-capitate fusion • Stage IV ➡ wrist fusion ➡ wrist arhtoplasty
- 38. www.handsurgery.gr • SLIL isthe critical stabilizer • Carpal alignment may be maintained acutely after disruption of SLIL because of secondary stabilizers • Any injured wrist that is symptomatic during mechanical and load-bearing activities should be considered as scapholunate instability Conclusions
- 39. www.handsurgery.gr • High resolutionMRI is mandatory in this cases • Each case is unique and therefore should be treated with tissue specific repairs • Treatment of acute injuries have good to excellent prognosis Conclusions
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Editor's Notes
- #22 Whipple TL, Hand Clin 1995 Diagnosis of scapholunate instability is made using clinical provocative maneuvers such as the Watson test and a two-compartment arthrogram. The history of treatment options for this instability pattern is reviewed. A technique for arthroscopic treatment is described in which anatomic reduction and multiple pin fixation precipitate fibrous ankylosis to stabilize the joint. 40 patients were treated with ARIF. Follow up was from 1 year up to 3 years. Best results were seen in patients with less than 3 months' symptom duration and less than 3-mm side-to-side gap difference. This treatment offers less loss of motion and minimal surgical surgical trauma to the wrist than other techniques currently in use.
- #29 technique appears to be a reliable method to stabilize Stage 2, 3 and 4 scapholunate dissociations without the issue of wrist stiffness due to extensive open dissection techniques as reported in most of the studies.
- #35 there is no technique that consistently provides long-term carpal stability to this challenging patient cohort.