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Scapholunate Ligament Injury

SL interosseous ligament injury: instability spectrum to SLAC, scaphoid-shift and imaging, arthroscopic grading, and repair/capsulodesis/tenodesis by chronicity.

134 citationsUpdated Oct 2026

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Overview

Scapholunate ligament injury is a common complication of scaphoid waist fractures, with an incidence higher than previously reported [3]. The occurrence of this ligament injury alongside scaphoid fractures may be more frequent than generally thought [7], emphasizing the need for careful assessment before determining treatment. Arthroscopy is considered the gold standard for complete evaluation of scapholunate interosseous ligament injury and is often performed as a first step before repair or reconstruction [72]. Volar arthroscopic portals of the wrist are easy to perform, safe, and useful in indications for ligament or bony intracarpal repairs [51]. The palmar portion of the scapholunate ligament plays a stabilizing role and should be considered for surgical repair [195].

No strong evidence currently supports any one treatment for scapholunate ligament injuries [14]. Strong evidence (level 1 or 2) for management of scapholunate instability in the absence of arthritis is lacking, and published recommendations are largely experience-based [73]. Despite the evolution of diagnostic and treatment options, the ideal treatment for scapholunate instability remains an unresolved problem with inconsistent results and ongoing concerns regarding complications [8]. Current opinion supports repairing or reconstructing the scapholunate interosseous ligament in active individuals with instability symptoms and minimal or no carpal arthritis, though no clear consensus exists for all scenarios [16]. Surgical repair with augmentation ligamentoplasty is indicated for disabling scapholunate interosseous ligament disruption before the occurrence of static, fixed scapholunate dissociation [186].

Surgical techniques for scapholunate ligament repair or reconstruction are proposed based on clinical stages and anatomic-pathologic findings, with specific indications ranging from dorsal capsulodesis to tenodesis procedures [58]. The primary repair of the scapholunate interosseous ligament is indicated in acute or subacute disruption of the ligament [66]. Arthroscopic capsulodesis appears to offer significant functional improvement and a low complication rate in higher grade scapholunate ligament injuries [63]. Both versions of the scapholunate intercarpal ligamentoplasty yield satisfactory clinical and radiological results in the short to mid-term [34]. Scapholunate ligament reconstruction using a part of the extensor carpi radialis brevis tendon through a dorsal approach resulted in long-term, improved outcomes compared with other techniques, even in scapholunate advanced collapse type I wrists [21]. At final follow-up, there was a certain loss of scapholunate reduction following modified Brunelli tenodesis for static scapholunate instability [17]. The scapholunate angle improved an average of 28° after reconstruction using a volar and dorsal approach in a cadaver model [19]. Surgical treatment of six scapholunate dislocations was described for injuries occurring from 2 days up to 6 months after injury [20]. Repair techniques for isolated volar scapholunate interosseous ligament injuries appear promising with the limited data available [159]. The outcomes of intraarticular fractures of the distal radius with operatively treated associated scapholunate ligament injury are comparable with the outcomes of intraarticular fractures of the distal radius without associated scapholunate ligament injury [18]. In carefully selected cases of severe carpal trauma, acute salvage procedures may be a viable alternative to ORIF and ligament repair/reconstruction [180].

Anatomy & Pathophysiology

Bony Anatomy

The wrist comprises the distal radioulnar, radiocarpal, and ulnocarpal joints, along with the eight carpal bones and their proximal and distal articulations and attached ligaments [79]. The proximal carpal row consists of the scaphoid, lunate, triquetrum, and pisiform [79], while the distal row includes the trapezium, trapezoid, capitate, and hamate [79]. Radiocarpal articulation occurs between the distal radius and the scaphoid and lunate via their respective concave facets, with the triquetrum articulating on the triangular fibrocartilage [79]. The distal concave articular surfaces of the proximal row form the midcarpal articulations with the distal row [79].

The distal radius articular surface features two concave facets, the scaphoid and lunate facets, separated by the scapholunate or anterior-posterior ridge [90]. Along the ulnar border, the sigmoid notch forms a shallow concavity for the articulating ulnar head at the distal radioulnar joint [90]. The ulnar styloid projects distally, and its base contains the fovea, which serves as the insertion site for the triangular fibrocartilaginous complex (TFCC) [90]. Morphologically, the lunate is broader palmarly than dorsally [90]. The capitate head often relies on a retrograde vascular supply [90], and the pisiform functions as a sesamoid bone within the flexor carpi ulnaris tendon [90].

Ligamentous Anatomy

Extrinsic carpal ligaments connect the radius or ulna to the carpus, with volar ligaments generally stronger than dorsal ligaments [85]. The scapholunate interosseous ligament (SLIL) is a major wrist stabilizer and the most commonly injured wrist ligament [85]. It is C-shaped, comprising dorsal, palmar, and interosseous portions, with the dorsal portion being the strongest and thickest [85]. Due to its attachment to the scaphoid, the SLIL provides a flexion force on the lunate [85]. Conversely, the lunotriquetral interosseous ligament (LTIL) is C-shaped with a thickest and strongest volar portion, providing an extension moment on the lunate via its attachment to the triquetrum [85].

The dorsal intercarpal ligament extends from the dorsal tubercle of the triquetrum to the distal pole of the scaphoid [85]. It reinforces the elastic dorsal wrist capsule and stabilizes the scapholunate articulation, contributing to the dorsal SLIL through its deep fibers [85]. The space of Poirier is a ligament-free area adjacent to the proximal capitate, situated ulnar to the radioscaphocapitate ligament and radial to the long radiolunate ligament in the floor of the carpal tunnel [85]. This weak area is vulnerable to instability, serving as the site where the distal carpal row separates from the lunate during perilunate dislocation [85].

The dorsal radiocarpal ligament is trapezoidal, passing from the dorsal rim of the distal radius to the lunate and triquetrum [85]. Its fibers insert onto the dorsal lunotriquetral interosseous ligament [85]. Damage to this ligament, when combined with other intrinsic ligament injuries, confers further carpal instability [85]. The radioscaphocapitate ligament connects to the scaphoid waist and limits ulnar translation of the carpus [85]. The long radiolunate ligament also helps limit ulnar translocation [85], while the short radiolunate ligament controls lunate position [85]. The radioscapholunate ligament, also known as the ligament of Testut, is a vascular conduit rather than a true ligament [85].

Ulnar-sided extrinsic ligaments include the ulnolunate ligament, which attaches to the palmar radioulnar ligament and the lunate [85]. The ulnocapitate ligament attaches to the ulnar head and is the most superficial or palmar ulnocarpal ligament [85]. The ulnotriquetral ligament attaches to the palmar radioulnar ligament and the triquetrum [85]. The TFCC is formed by the central meniscus homolog, dorsal and volar radioulnar ligaments, the floor of the extensor carpi ulnaris tendon sheath, and volar ulnocarpal ligaments [90]. It arises from the radial border of the distal radius and inserts into the base of the ulnar styloid and distal ulna through the ligamentum subcruentum [90]. The dorsal and volar radioulnar ligaments are the primary stabilizers of the distal radioulnar joint [90]. Only the peripheral 10% to 40% of the volar, ulnar, and dorsal TFCC has a vascular supply [90].

Dorsal wrist ligament insertions stabilize the scapholunate interval [9]. The main cyst of a dorsal wrist ganglion is usually located directly over the scapholunate ligament [37]. A small, mucin-filled duct is invariably seen piercing the transverse fibers of the scapholunate ligament, connecting the underlying scapholunate joint with the main cyst [37].

Kinematics and Biomechanics

The wrist functions as a two-joint system linking the hand to the forearm around the highly mobile bones of the proximal carpal row [91]. The two principle articulations are the radiocarpal and midcarpal joints, situated proximal and distal to the mobile proximal carpal row [91]. The proximal row forms an intercalated segment between the distal carpal row and the distal radius, bound into a functional unit by the SLIL and LTIL [85]. The distal row is rigid, with little motion between its bones due to stout intercarpal ligaments, and acts as a functional unit with the scaphoid bridging both rows [85].

During wrist flexion from neutral, the distal row flexes and ulnarly deviates slightly while the scaphoid pronates [85]. The proximal row flexes differentially, with more rotation through the scaphoid, followed by the triquetrum and the lunate [85], and translates dorsally [85]. During wrist extension from neutral, the distal row extends and radially deviates slightly while the scaphoid supinates [85]. The proximal row extends differentially, with more motion in the scaphoid, followed by the triquetrum and then the lunate [85], and translates palmarly [85].

Approximately 62° of wrist extension occurs through the radiocarpal joint, and 62% of wrist flexion occurs through the midcarpal joint [85]. The midcarpal joint is mostly responsible for 20° and 40° of radial and ulnar deviation, respectively [85]. It is also responsible for the “dart thrower’s motion,” which involves moving from radial extension into ulnar flexion positioning of the wrist [85]. The radius bears 80% of the axial load transmitted through the radiocarpal joint, while the ulna bears 20% in neutral ulnar variance [85]. With axial loading through the neutral wrist, approximately 80% of forces are transmitted through the distal radius (60% scaphoid facet, 40% lunate facet) and 20% through the distal ulna [90]. With wrist flexion, 60% of the motion is midcarpal and 40% is radiocarpal [90]. With wrist extension, 33% of the motion is midcarpal and 66% is radiocarpal [90]. With ulnar deviation, the proximal row extends relative to the forearm/distal row [90]. With radial deviation, the proximal row flexes relative to the forearm/distal row [90].

The wrist behaves kinematically consistent but kinetically variable, implying that mechanical behavior is predominantly determined by articular geometry rather than ligament constraints [77]. Most carpal ligaments lengthen only during one half of a full movement cycle, constraining either dorsal- or palmar-directed, or ulnar- or radial-directed motion [118]. During simple unresisted wrist motions, the force in the scapholunate interosseous ligament did not exceed 20 N [100]. Clinically, a dart-throwing motion at approximately 30° to 45° from the sagittal plane allows continued functional wrist motion while minimizing radiocarpal motion [99]. The dart-thrower’s motion occurs almost exclusively through the midcarpal joint, with rotation occurring along the mechanical axis of the wrist [91].

Division of either of the proximal row’s interosseous ligaments in isolation does not result in a postural deformity of the lunate [91]. Similar “collapse” deformities of proximal row alignment (VISI or DISI) can occur with or without disruption of an interosseous ligament [91]. The proximal carpal row has its own critical intrinsic and extrinsic ligament stabilizers [91]. A stable wrist is defined as one which, while being loaded within a physiological range of stress, does not deviate from a stable state of equilibrium at any point within the whole physiological range of motion [114]. A wrist joint should be considered biomechanically unstable when it is not able to bear loads and does not exhibit normal kinematics throughout its arc of motion [76].

Traction (distraction) changes normal carpal kinematics, and motion of the wrist combined with traction induces abnormal patterns of motion [96]. Scaphoid kinematics are altered considerably in radial-ulnar deviation after division of the transverse carpal ligament [113]. Scaphoid nonunions have a dramatic impact on carpal kinematics, partially uncoupling the proximal and distal carpal rows [116]. The kinematic consequences of resecting the distal scaphoid are different: the flexion-extension motion of the proximal row during deviations is diminished at the expense of increased radioulnar translational motion [117]. Both surgical groups for scapholunate advanced collapse demonstrated decreased wrist kinematic motion and functional performance compared with individuals with normal wrists [75].

Four-dimensional computed tomography (4DCT) is a promising, non-invasive, and affordable method to assess and quantify wrist kinematics, extending conventional CT by incorporating the temporal dimension [98]. Four-dimensional CT complements conventional imaging and arthroscopy by providing functional information on wrist biomechanics and should be used selectively when dynamic instability is suspected and conventional imaging is inconclusive [108]. Kinematic changes in scapholunate instability may predict the development of radioscaphoid arthritis and help identify a kinematically abnormal wrist [103]. The etiology of abnormal wrist kinematics in the asymptomatic wrist of patients with unilateral tears of the scapholunate ligament is not known [106].

Pathomechanics

Carpal instability exists when the wrist is unable to maintain its normal alignment as it moves through its motion arc under physiologic loads [38]. Most carpal instabilities are traumatic in nature, but any condition that alters the relationship between the radius, ulna, and carpal bones may result in instability, including inflammatory arthritis, infections, or congenital disorders [38]. Progressive perilunate instability describes the global pattern of injury propagation centered on the lunate [38]. Two of the most common malalignment patterns are volar intercalated segment instability and the more common dorsal intercalated segment instability [38].

Perilunate dislocations occur when forces are applied to the thenar area with the wrist in a position of dorsiflexion and ulnar deviation [182]. The resulting intercarpal supination leads to a progressive injury pattern from a radial to ulnar direction following either a bony or purely ligamentous corridor about the lunate [182]. Mayfield stage III is the specific stage of injury to the lunotriquetral support structures, which follows injury to the scapholunate ligament or scaphoid proper from a fracture [182]. These injuries typically lead to a dorsal intercalated segment instability deformity, except in situations in which the scapholunate ligament heals spontaneously or with intervention [182]. In situations where the scapholunate ligament heals spontaneously or with intervention, ulnar-sided pathology predominates [182].

Biomechanical analysis confirmed that intrinsic wrist ligaments could be completely disrupted while extrinsic ligaments are only partially injured [64]. Such a scenario of partial extrinsic injury could account for the residual stability that prevents the development of perilunate dislocations [64]. Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics [33].

Classification

Arthroscopic Staging Systems

Geissler: The Geissler classification is a commonly used arthroscopic system to describe and grade the severity of injury to the scapholunate interval [171]. In a cadaveric model, arthroscopically determined Geissler grade was associated with specific anatomic lesions of the scapholunate supporting ligaments [172]. Grade 1 is characterized by minimal attenuation of the proximal scapholunate membrane, sometimes with hemorrhagic points within the ligament substance, and no step-off in the scapholunate joint visible from the midcarpal space [189]. Grade 2 is characterized by substantial attenuation of the proximal scapholunate membrane with a narrow scapholunate gap, less than the width of a 2 mm probe, visible through the midcarpal portal [189]. A Geissler stage 2 lesion correlated with varying degrees of sectioning to the intrinsic ligaments only, with all extrinsic ligaments being intact [171]. In 4 of 6 cadaveric specimens, the dorsal scapholunate interosseous ligament was sectioned to correlate with a Geissler stage 2 lesion [171]. Grade 3 is characterized by ligament disruption sufficient to allow an arthroscopy probe to enter the scapholunate joint space from both the radiocarpal and midcarpal joints [189].

EWAS: The EWAS classification of scapholunate dissociation includes Stage I, defined as no passage of the probe in the scapholunate space but presence of synovitis [189]. Stage IIA is defined as volar passage in the scapholunate space without widening [189]. Stage IIB is defined as dorsal passage in the scapholunate space without widening [189]. Stage IIC is defined as complete passage in the scapholunate space without widening [189]. Stage IIIA is defined as volar partial widening at dynamic instability test from the midcarpal joint [189]. Stage IIIB is defined as dorsal partial widening at dynamic instability test from the midcarpal joint [189]. Stage IIIC is defined as complete widening of the space at dynamic test [189]. Stage IV is defined as a gap with passage of the arthroscope from the midcarpal to the radiocarpal joint [189].

Garcia-Elias: The Garcia-Elias classification subdivides scapholunate dissociations into six different stages based on five questions answered during clinical and arthroscopic assessment [190]. Stage 2 indicates the ligament is amenable to repair and carpal alignment is preserved [190]. Stage 3 indicates the ligament is irreparable and carpal alignment is preserved [190]. Stage 4 indicates carpal mal-alignment that is amenable to correction [190].

Other Arthroscopic Systems: An arthroscopic staging system for scapholunate instability following dorsal capsulo-scapholunate septum sectioning has been established [162].

Radiographic and Clinical Classification

Arthroscopic classification of scapholunate instability is more precise and close to the reality than radiographic classification [161]. The diagnosis of scapholunate dissociation should be based on the difference between the injured and uninjured wrists rather than solely on the scapholunate gap of the injured wrist [6]. A scapholunate angle greater than 80 degrees is considered pathological [11]. A scapholunate interval greater than the lunotriquetral interval is considered pathological [11]. The lateral scapholunate angle most closely reflected the progressive nature of scapholunate ligament injury in a cadaveric study of selective ligament sectioning [173]. Significant ligamentous injury must occur before commonly used radiographic limits are exceeded [173]. The scapholunate C-sign is a valuable clinical indicator demonstrating good diagnostic accuracy in detecting high-grade, through-and-through scapholunate interosseous ligament injuries [24]. Findings from a validation study question the utility of stress radiographs when assessing for scapholunate ligament injuries [29].

General Classification Concepts

Many different classification schemes have been used to better understand the mechanistic evolution and pathophysiology of carpal instability [38]. Recent classifications have emphasized the relationships within and between the rows of carpal bones, including carpal instability dissociative, carpal instability nondissociative, carpal instability adaptive, and carpal instability complex [38]. Two of the most common malalignment patterns are volar intercalated segment instability and dorsal intercalated segment instability [38]. Scapholunate reconstruction procedures are best stratified according to preoperative stages of dissociative instability, injury chronicity, and arthrosis [170]. A ligament-based treatment algorithm is proposed based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes [33]. The natural history of scapholunate ligament injuries is poorly understood, and it is unknown which injuries lead to wrist arthritis [10].

Clinical Presentation

History and Mechanism

A substantial fall on an outstretched wrist should raise concern for scapholunate ligament complex injury, as wrist extension and intercarpal supination are the primary mechanisms of injury [126]. Scapholunate dissociation is the most common form of carpal instability in athletes, usually resulting from excessive wrist extension with the wrist in ulnar deviation [127]. While trauma is typical, scapholunate dissociation may occur without a history of trauma and may be bilateral [31]. An undescribed mechanism involving a fall on the elbow has caused scapholunate dissociation [47]. Additionally, an axial loading injury without hyperextension or hyperflexion of the wrist can cause acute scapholunate dissociation [131]. Injuries to the scapholunate and lunotriquetral interosseous ligaments occur in approximately one third of distal radius fractures [42]. Scapholunate ligament tears are rare in skeletally immature people because the force of impact is absorbed by the cartilaginous carpus [133].

Physical Examination

Systematic palpation reveals tenderness over the dorsal scapholunate ligament, located just distal to Lister's tubercle [126]. In athletes, physical examination findings may include pain dorsally over the scapholunate interval, decreased grip strength, or decreased range of motion [127]. The scaphoid shift test is the principal provocative maneuver to assess scapholunate pathology [126]. This test evaluates scaphoid motion during radial deviation and wrist flexion while applying pressure to the scaphoid tubercle in a dorsal direction [126]. A complete injury to the scapholunate ligament complex reveals subluxation of the proximal pole from the scaphoid fossa during this test [126]. Conversely, a partial tear may reveal only pain along the dorsal scapholunate ligament [126]. Crepitation at the radioscaphoid articulation during the scaphoid shift test indicates cartilage degeneration and an old injury [126]. The test should be performed on both the injured and noninjured wrist to assess inherent laxity [126]. The Watson shift test may be positive for pain or an audible clunk in patients with scapholunate injuries [127]. A characteristic clinical pattern for predynamic scapholunate ligament attenuation includes chronic dorsal wrist pain especially under loading in wrist extension, a positive Watson test, or apprehension with pain during the examination but without a reduction clunk [45]. Conjugate motion between the scaphoid and lunate on live fluoroscopic examination determines the presence or absence of mechanically relevant tissue between the scaphoid and lunate [128].

Imaging

Plain radiographs and cineradiography remain key elements of primary diagnostic strategies for suspected traumatic scapholunate dissociation [4]. The diagnosis of scapholunate dissociation should not be solely based on the scapholunate gap of the injured wrist, but on the difference between the injured and uninjured wrists [6]. Standard radiographs should include a PA view with clenched fist to assess for static and dynamic scapholunate diastasis and should be compared to the contralateral side [127]. Measurements in the middle of the scapholunate joint in neutral and 30° of ulnar deviation under fluoroscopic imaging best capture all stages of ligamentous disruptions [55]. Radiographs detect dorsal scaphoid translation in scapholunate dissociation [125]. A scapholunate angle greater than 80° and a scapholunate interval greater than the luno-triquetral interval are felt to be pathological [11]. Plain radiographs are not reliably diagnostic for intercarpal ligament injuries associated with distal radius fractures [42]. Traction radiography is recommended as a simple and valuable diagnostic procedure for suspected scapholunate ligament injury [27], though it might not be sufficient to reliably diagnose an acute, complete scapholunate interosseous ligament tear [46]. Findings question the utility of stress radiographs when assessing for scapholunate ligament injuries [29]. MRI is more sensitive and specific to accurately distinguish scapholunate injuries from other carpal ligament and tendon injuries [127]. An early MRI scan at 2 weeks allows the clinician to make the appropriate decision for patients with occult scaphoid fractures, other occult carpal and radial fractures, ligamentous injuries, and those without apparent injuries [25]. The arthrogram should not be considered a definitive study for the diagnosis of a clinically important injury of a ligament in the wrist [135].

Arthroscopy

Wrist arthroscopy is the gold standard for diagnosis of scapholunate instability [45] and is considered the gold standard to assess for dynamic instability in scapholunate injuries [127]. Arthroscopy is extremely sensitive for detecting the spectrum of injury to the scapholunate interosseous ligament [26]. Accurate diagnosis of the ligament injuries is usually difficult without an arthroscopic evaluation [124]. In patients with suspected scapholunate tears, midcarpal arthroscopy often leads to a change in diagnosis and procedure performed [44]. Early arthroscopic diagnosis of scapholunate injury is mandatory for establishing the prognosis of the injury [40].

Investigations

Plain radiography: Diagnosis of scapholunate dissociation relies on comparing the injured wrist to the uninjured side, rather than assessing the scapholunate gap in isolation [6]. Radiographs are moderately reliable and are more effective at ruling out than ruling in scapholunate dissociation associated with type C distal radius fractures [198]. While injuries to the scapholunate and lunotriquetral interosseous ligaments occur in approximately one third of distal radius fractures, plain radiographs are not reliably diagnostic for these injuries [42]. Radiologists often identify scapholunate ligament injury in the setting of distal radius fractures at a higher rate than treating surgeons [183]. Cineradiography offers high diagnostic value for scapholunate dissociations [145]. Increased scapholunate widening observed on Twist views correlates positively with clinical findings and MRI results [197].

MRI: MRI is not recommended for the diagnosis of scapholunate ligament injury [43]. However, 3.0-T MRI is moderately sensitive and very specific for detecting complete scapholunate ligament tears, potentially reducing the need for invasive diagnostic techniques in some cases [201]. High anatomic resolution allows for the diagnosis of scapholunate dissociation and exact evaluation of wrist morphology changes [69]. A properly performed, high-resolution MRI aids in evaluating wrist ligament injuries [107]. For analyzing interosseous, intrinsic, and extrinsic ligament insertions, a static magnetic field strength of at least 1.5 T using a dedicated wrist coil is recommended [107]. The volar extrinsic, scapholunate interosseous, dorsal intercarpal, and lunotriquetral ligaments are best visualized using 1 mm slices with no interslice gap in the coronal plane [107]. The dorsal radiocarpal and intercarpal ligaments are best viewed on both coronal and sagittal images [107]. Oblique axial views along the longitudinal axes of these ligaments allow further analysis, especially when injury is suspected [107]. Concomitant cartilage-sensitive imaging is integrative for assessing and managing scapholunate advanced collapse (SLAC) wrist, as cartilage integrity influences clinical and surgical management [107]. Real-time MRI has been used to investigate dynamic instabilities, although its routine clinical use remains undetermined [107]. With optimal technique and equipment, the integrity of the scapholunate and lunotriquetral ligaments can be consistently assessed [112]. Adding arthrographic contrast improves the visualization of these ligaments on MR images [112]. MRI-detectable carpal lesions at the time of radial fracture are common, but only a few decompensate later to become symptomatic and therapeutically relevant [158]. While MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, findings are often discordant when compared with diagnostic arthroscopy [175].

Arthroscopy: Arthroscopy is considered by many to be the diagnostic intervention of choice for determining the degree of wrist injury [107]. It assesses cartilage condition, the ability to reduce the carpus, and any other associated injuries [107]. The degree of intrinsic and extrinsic ligament injury can be identified from arthroscopic evaluation [107]. Geissler grade II scapholunate interosseous ligament injuries tend to be isolated, whereas grade IV injuries often involve complete dorsal extrinsic ligament disruption [107].

CT: Four-dimensional computed tomography aids assessment of chronic scapholunate instability, allowing differentiation between patients without and those with definite or questionable scapholunate instability [202]. CT scanning enables 3D analysis of carpal dysfunction [107]. By adding motion in real time (4D CT), this modality may hold promise in the future to potentially quantify the location and degree of injury noninvasively and help surgeons plan surgical treatment [107].

Other Considerations: Dynamic fluoroscopy shows abnormal motion between the scaphoid and lunate and changes in the kinematics of the midcarpal joint [107]. In scapholunate dissociation patients with dorsal intercalated segmental instability (DISI), the triquetrum-hamate relationship remains permanently engaged, whereas normally it changes from full engagement in ulnar deviation to complete disengagement in radial deviation [107]. Live imaging shows whether the DISI is reducible, providing valuable information for treatment planning [107]. The scapholunate C-sign is a valuable clinical indicator, demonstrating good diagnostic accuracy in detecting high-grade, through-and-through scapholunate interosseous ligament injuries that may warrant surgical intervention [24].

Treatment

General Principles and Evidence Status

The ideal treatment for scapholunate instability remains an unresolved problem, characterized by inconsistent results and ongoing concerns regarding complications [8]. A systematic review highlights the variability in arthritis patterns following scapholunate ligament injuries and underscores the lack of consensus regarding management strategies [22]. The treatment algorithm for patients with scapholunate ligament injuries of acute or chronic nature is not well defined [138]. However, an algorithm of treatment based on prognostic factors has been presented to help decide which surgical technique is best for each individual case of scapholunate dissociation [48]. Acute intervention (within 6 wk) was preferable to chronic intervention for scapholunate interosseous ligament injuries [57]. The management of chronic scapholunate instability is highly variable among respondents, and the choice of either a soft tissue or bony procedure may depend to a large extent on intraoperative findings [154]. Surgical management of stage-one scapholunate instability may include debridement, electrothermal shrinkage, or other interventions, but optimal management has not been established [136].

Non-Operative and Arthroscopic Debridement

Arthroscopic debridement of a torn (complete or partial) scapholunate ligament has been advocated as effective in providing symptom relief in a clear majority of patients with average 2-year follow-up periods [138]. Scapholunate ligament debridement and thermal shrinkage effectively provided pain relief for most of the patients treated [137].

Thermal Shrinkage

Capsular shrinkage has special application in the treatment of Geissler grade 1 and 2 scapholunate ligament tears [45]. Arthroscopic thermal collagen shrinkage is a treatment option for predynamic scapholunate ligament attenuation (Geissler grade 1 or 2) [45]. Preliminary findings suggest that arthroscopic electrothermal collagen shrinkage may be a viable treatment option for symptomatic scapholunate interosseous ligament laxity without complete ligament disruption [50]. Treatment of scapholunate injuries grade I with shrinkage is more effective than arthroscopic debridement [156]. For lesions of grade II and III, treatment associated with pinning with K-wire is more effective than only arthroscopic debridement and pinning [156].

Ligament Repair and Reconstruction

Direct bony fixation of the ruptured scapholunate ligament using a suture anchor is generally successful in restoring scapholunate stability and has produced acceptable functional mid-term results [32]. The surgical procedure of primary repair is indicated in acute or subacute disruption of the scapholunate interosseous ligament [66]. Scapholunate dissociation can be treated successfully by direct ligament repair and dorsal capsular augmentation [143]. The RASL (Reduction and Association of the Scaphoid and Lunate) procedure is a safe and effective procedure for the treatment of chronic scapholunate dissociation [134]. The RASL procedure specifically focuses on the region of injury, namely the scapholunate joint, and does not violate other carpal bones [163]. Scapholunate stability is maintained by a whole anatomic complex rather than the scapholunate ligament alone, and mini-invasive arthroscopic dorsal repair is an efficient technique sufficient for achieving long-term stability [65]. The ANAFAB (anatomical anterior and posterior) repair achieved excellent realignment of the carpus with a median postoperative scapholunate gap of 3 mm and recovery of more than 75% of grip strength and range of motion [152]. Early reports have indicated that the bone-tissue-bone (BTB) graft will be an important part of scapholunate dissociation treatment, though the lack of long-term outcome measurements makes it difficult to determine appropriate use [71]. In lunate and perilunate dislocations, the scapholunate angles averaged 50° in the repair/reconstruction group versus 69° in the non-repair group [157]. At final follow-up of modified Brunelli tenodesis for static scapholunate instability, there was a certain loss of scapholunate reduction [17]. A voral approach is a feasible and safe procedure to evaluate and treat the volar region of the scapholunate interosseous ligament [140]. Inside-out methods to develop volar arthroscopic portals of the wrist were easy to perform, safe, and seemed useful in indications for ligament or bony intracarpal repairs [51].

Arthrodesis and Salvage Procedures

Scaphocapitolunate arthrodesis and radial styloidectomy is a treatment option for posttraumatic degenerative wrist disease [23]. The LCF (lunate-capitate fusion) is not less efficient than the 4CF (four-corner fusion) in the treatment of SNAC II and III wrist injuries [149]. Distal scaphoidectomy is recommended in all cases where a badly damaged radiocarpal joint needs to be fused [166]. The authors do not recommend proximal row carpectomy (PRC) for the management of scapholunate dissociation in the absence of degenerative changes due to disappointing results compared to other treatments [200].

Contraindications and Complications

Concomitant scaphoid fracture and scapholunate ligament injury may represent a relative contraindication to the use of a scapholunate screw [129].

Complications

Natural History and Degenerative Progression

Complete scapholunate dissociation with carpal malalignment leads to gradual arthritic degeneration of the wrist [160]. The determinants of progression rate, ultimate severity, and symptom degree remain unknown, as does whether surgical intervention alters the natural history or outperforms nonsurgical treatment in the short or long term [160]. Ongoing scapholunate instability resulting from dorsal intercarpal ligament capsulodesis has resulted in early arthritic degeneration [30]. Reconstructing both volar and dorsal limbs of the scapholunate interosseous ligament aims to prevent progression to scapholunate advanced collapse arthritis [185]. Long-term clinical prospective trials are needed to examine whether scapholunate dysfunction and osteoarthritic changes are prevented by capsuloligamentous plicature [177].

Surgical Complications and Outcomes

Persistent Pain: Persistent wrist pain despite radiographic evidence of scaphocapitate bony union is the second most common complication of scaphocapitate arthrodesis, occurring in 4/30 patients (13%) [54]. Two of seven patients with coincident scapholunate and lunotriquetral ligament disruptions had pain only at the extremes of motion after treatment with lunotriquetral fusion and scapho-trapezio-trapezoid fusion [64].

Bone Tunnel Collapse: Carpal bone tunnel collapse is an underreported complication of ligament reconstruction for chronic scapholunate instability requiring the creation of a bone tunnel [187]. The incidence is unknown, but the consequences could be substantial; patients should be warned of this possibility when discussing complications [187].

Instability and Reduction Loss: At final follow-up, a certain loss of scapholunate reduction was noted in patients treated with modified Brunelli tenodesis for static scapholunate instability [17]. Two of seven patients with coincident scapholunate and lunotriquetral ligament disruptions required additional surgery after treatment with lunotriquetral fusion and scapho-trapezio-trapezoid fusion [64].

Vascular Compromise: Transient vascular compromise of either the lunate or the proximal scaphoid fragment was noted in three patients undergoing open reduction of chronic lunate and perilunate dislocations [192].

Carpal Tunnel Syndrome: Carpal tunnel syndrome can occur as a secondary problem from a decreased volume of the carpal canal as a result of degenerative wrist condition [23].

Radiographic Changes: Radiographic changes in the radiolunate joint occurred in 73% of patients at long-term follow-up after 4-corner fusion for SLAC and SNAC wrist [49].

Diagnostic and Management Uncertainties

No clear consensus exists for all scenarios regarding the repair or reconstruction of the scapholunate interosseous ligament in active individuals with instability symptoms and minimal or no carpal arthritis [16]. SLL injuries may complicate acute scaphoid fractures more frequently than previously recognized [60]. Further prospective studies with standardized diagnostic protocols and long-term follow-up are required to clarify prognostic impact and optimize management strategies for SLL injuries complicating acute scaphoid fractures [60].

Recovery

Natural History and Prognosis: In patients with chronic wrist pain attributed to scapholunate interosseous ligament injuries and normal radiographs, the injury occurred on average 4.5 years prior to diagnosis [11]. All 20 patients with signs of scapholunate dissociation on x-ray examination at the time of injury had clinical signs in the scapholunate joint and positive x-rays findings of dissociation 1 year later [13]. Scapholunate instability was uncommon in patients with distal radius volar plating, either from initial injury or possible progression of occult ligament injury, despite early motion without operative treatment of the ligament [12]. At a mean follow up of 6.2 years following an extraarticular distal radial fracture, no surgical treatment is usually needed with a scapholunate gap of between 2.1 -3.4 mm [70].

Operative Outcomes: Those patients with less than 3 months' history of instability symptoms and with less than 3 mm of side-to-side difference in the scapholunate interval maintained reduction of the interval and symptom relief with an 83% incidence [68]. At final follow-up there was a certain loss of scapholunate reduction in patients treated with modified Brunelli tenodesis [17]. Although the consequent ongoing scapholunate instability resulted in early arthritic degeneration, most patients had acceptable long-term function of the wrist after dorsal intercarpal ligament capsulodesis [30]. Functional results were good at long-term follow-up for 4-corner fusion for SLAC and SNAC wrist despite radiographic changes in the radiolunate joint in 73% of patients [49]. The scapholunate gap in all patients was within the normal range after a mean of 8.1 years of follow-up following dorsal intercarpal ligament capsulodesis with scapholunate interosseous ligament repair [67]. At a minimum of two years of follow-up, patients with acute or subacute symptomatic dissociation of scapholunate ligament instability who underwent arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor treatment had satisfactory results [167]. At follow-up 70 months after injury for palmar dislocation of the trans-scaphoid-lunate unit, there is no osteonecrosis and the wrist function is almost normal [168]. There has been no long term deterioration of wrist function following costo-osteochondral grafts in the wrist [153]. For patients followed up for an average of 66 months after surgery for dynamic scapholunate instability, the results, clinically and radiographically, appear to deteriorate in those who place high demands on the wrists on a daily basis [205]. With a majority of patients experiencing early radiographic failure of the reduction and association of the scaphoid and lunate procedure in the short term, the procedure should be abandoned despite the relatively low outcomes measures scores [204]. The cable augmented, quad ligament scapholunate ligament reconstruction offers theoretical advantages but long term follow up is required [188]. The lack of long-term outcome measurements for bone–tissue–bone repairs makes it difficult for the hand surgeon to determine the appropriate use of these treatment modalities, but early reports have indicated that the BTB graft will be an important part of scapholunate dissociation treatment [71].

Limitations and Unresolved Issues: A proper ligament repair is recommended within four to six weeks after trauma [40].

Key Evidence

• [L3] This incidence is higher than previously reported and emphasizes the need for careful assessment of the intrinsic and extrinsic ligaments, particularly the scapholunate ligament, before deciding on treatment. [3] (10.1016/j.jhsa.2009.12.023)
• [L4] Both methods remain key elements of primary diagnostic strategies for suspected traumatic scapholunate dissociation, and may facilitate the selection of additional tests. [4] (10.1007/s00256-007-0410-7)
• [L3] The diagnosis of scapholunate dissociation should not be solely based on the scapholunate gap of the injured wrist, but on the difference between the injured and uninjured wrists. [6] (10.1016/s0363-5023(84)80203-8)
• [L4] The authors conclude that the occurrence of scapholunate ligament injury with a scaphoid fracture may be more common than generally thought. [7] (10.1016/j.jhsb.2004.09.017)
• [L5] Despite the evolution of diagnostic and treatment options, the ideal treatment for scapholunate instability remains an unresolved problem with inconsistent results and ongoing concerns regarding complications. [8] (10.1177/17531934221148009)
• [L5] [9] (10.1097/01.blo.0000136836.78049.45)
• [L5] The natural history of scapholunate ligament injuries is poorly understood, and it is unknown which injuries lead to wrist arthritis. [10] (10.1007/s11552-013-9499-4)
• [L4] [11] (10.1016/s0266-7681(03)00079-2)
• [L4] Scapholunate instability was uncommon in this population, either from initial injury or possible progression of occult ligament injury, despite early motion without operative treatment of the ligament. [12] (10.1007/s11552-015-9779-2)
• [L4] All 20 patients with signs of scapholunate dissociation on x-ray examination at the time of injury had clinical signs in the scapholunate joint and positive x-rays findings of dissociation 1 year later. [13] (10.1016/s0363-5023(96)80007-4)
• [L5] No strong evidence currently supports any one treatment for scapholunate ligament injuries. [14] (10.5435/jaaos-d-14-00254)
• [L5] Current opinion supports repairing or reconstructing the scapholunate interosseous ligament in active individuals with instability symptoms and minimal or no carpal arthritis, though no clear consensus exists for all scenarios. [16] (10.1016/j.jhsa.2009.03.019)
• [L4] At final follow-up there was a certain loss of scapholunate reduction. [17] (10.1016/j.jhsa.2013.02.022)
• [L3] The outcomes of intraarticular fractures of the distal radius with operatively treated associated scapholunate ligament injury are comparable with the outcomes of intraarticular fractures of the distal radius without associated scapholunate ligament injury. [18] (10.1007/s00402-013-1797-3)
• [L5] The scapholunate angle improved an average of 28° after reconstruction. [19] (10.1053/jhsu.2001.26025)
• [L5] The authors describe the results of the surgical treatment on six scapholunate dislocations, from 2 days up to 6 months after injury. [20] (10.1177/1753193408101666)
• [L4] This technique, even in scapholunate advanced collapse type I wrists, resulted in long-term, improved outcomes compared with other techniques. [21] (10.1177/17531934221143679)
• [L1] The systematic review highlights the variability in arthritis patterns following scapholunate ligament injuries and underscores the lack of consensus regarding management strategies. [22] (10.1016/j.jhsg.2025.100827)
• [L4] [23] (10.1055/s-0032-1329592)
• [L2] The scapholunate C-sign is a valuable clinical indicator, demonstrating good diagnostic accuracy in detecting high-grade, through-and-through scapholunate interosseous ligament injuries that may warrant surgical intervention. [24] (10.1016/j.jhsa.2025.06.011)
• [L2] An early MRI scan at 2 weeks allows the clinician to make the appropriate decision for patients with occult scaphoid fractures, other occult carpal and radial fractures, ligamentous injuries, and those without apparent injuries. [25] (10.1016/s0020-1383(98)00115-6)
• [L4] It is extremely sensitive for detecting the spectrum of injury to the scapholunate interosseous ligament. [26] (10.1055/s-0033-1343354)
• [L4] We recommend traction radiography as a simple and valuable diagnostic procedure for suspected scapholunate ligament injury. [27] (10.1016/j.jhsb.2005.04.017)
• [L4] These findings question the utility of stress radiographs when assessing for scapholunate ligament injuries. [29] (10.1177/15589447231223774)
• [L3] Although the consequent ongoing scapholunate instability resulted in early arthritic degeneration, most patients had acceptable long-term function of the wrist. [30] (10.1302/0301-620x.94b12.30007)
• [L5] This case report suggests that scapholunate dissociation may occur in the absence of a history of trauma and may be bilateral. [31] (10.1016/s0363-5023(79)80138-0)
• [L4] Direct bony fixation of the ruptured scapholunate ligament using a suture anchor is generally successful in restoring scapholunate stability and has produced acceptable functional mid-term results for this difficult-to-treat injury. [32] (10.1054/jhsb.1999.0340)
• [L5] [33] (10.1016/j.jhsa.2023.06.016)
• [L3] Both versions of the scapholunate intercarpal ligamentoplasty yield satisfactory clinical and radiological results in the short to mid-term. [34] (10.1177/1753193420940498)
• [L5] [38] (10.1016/j.hcl.2015.04.011)
• [L5] Early arthroscopic diagnosis of scapholunate injury is mandatory for establishing the prognosis of the injury, as a proper ligament repair is recommended within four to six weeks after trauma. [40] (10.1302/2058-5241.2.170016)
• [L4] Injuries to the scapholunate and lunotriquetral interosseous ligaments occur in approximately one third of distal radius fractures, but their diagnosis is challenging as plain radiographs are not reliably diagnostic. [42] (10.5435/jaaos-d-18-00503)
• [L3] MRI is not recommended for the diagnosis of scapholunate ligament injury. [43] (10.1054/jhsb.2000.0450)
• [L3] In patients with suspected scapholunate tears, midcarpal arthroscopy often leads to a change in diagnosis and procedure performed. [44] (10.1016/j.jhsa.2013.08.040)
• [L4] [45] (10.1016/j.hcl.2011.06.005)
• [L5] The findings suggest that traction radiography might not be sufficient to reliably diagnose an acute, complete scapholunate interosseous ligament tear. [46] (10.1177/1753193411434038)
• [L5] We report an undescribed mechanism of injury that caused scapholunate dissociation. [47] (10.1016/s0363-5023(84)80063-5)
• [L4] The article presents an algorithm of treatment based on prognostic factors to help decide which surgical technique is best for each individual case of scapholunate dissociation. [48] (10.1016/j.jhsa.2005.10.011)
• [L4] Functional results were good at long-term follow-up despite radiographic changes in the radiolunate joint in 73% of patients. [49] (10.1177/1558944716681949)
• [L4] Our preliminary findings suggest that this may be a viable treatment option in the management of patients with symptomatic scapholunate interosseous ligament laxity without complete ligament disruption. [50] (10.1016/j.jhsb.2005.07.011)
• [L5] They were easy to perform, safe, and seemed useful in indications for ligament or bony intracarpal repairs. [51] (10.1177/1558944716660555hr)
• [Paper] The second most common complication is persistent wrist pain despite radiographic evidence of scaphocapitate bony union, occurring in 4/30 patients (13%). [54] (10.1097/00130911-200206000-00003)
• [L5] Measurements in the middle of the scapholunate joint in neutral and 30° of ulnar deviation under fluoroscopic imaging best capture all stages of ligamentous disruptions. [55] (10.1177/1558944717729219)
• [L3] Acute intervention (within 6 wk) was preferable to chronic intervention for scapholunate interosseous ligament injuries. [57] (10.1016/j.jhsa.2014.06.139)
• [L4] The paper reviews various surgical techniques for scapholunate ligament repair or reconstruction based on clinical stages and anatomic-pathologic findings, proposing specific indications for each type of tear from dorsal capsulodesis to tenodesis procedures. [58] (10.1055/s-0033-1343092)
• [L4] Arthroscopic capsulodesis appears to offer significant functional improvement and a low complication rate in higher grade scapholunate ligament injuries. [63] (10.1177/17531934261472361)
• [L4] [64] (10.1016/s0363-5023(09)91117-0)
• [L5] Scapholunate stability is maintained by a whole anatomic complex rather than the scapholunate ligament alone, and mini-invasive arthroscopic dorsal repair is an efficient technique sufficient for achieving long-term stability. [65] (10.1177/1753193420956319)
• [L5] The surgical procedure described is indicated in acute or subacute disruption of the scapholunate interosseous ligament (SLIL). [66] (10.1097/00130911-199812000-00007)
• [L4] The scapholunate gap in all patients was within the normal range after a mean of 8.1 years of follow-up. [67] (10.1016/j.jhsg.2022.01.007)
• [L4] Those patients with less than 3 months' history of instability symptoms and with less than 3 mm of side-to-side difference in the scapholunate interval maintained reduction of the interval and symptom relief with an 83% incidence. [68] (10.1016/s0749-0712(21)00024-x)
• [L4] High anatomic resolution allows the diagnosis of scapholunate dissociation with exact evaluation of changes in wrist morphology. [69] (10.1016/0266-7681(94)90351-4)
• [L3] At a mean follow up of 6.2 years following an extraarticular distal radial fracture, no surgical treatment is usually needed with a scapholunate gap of between 2.1 -3.4 mm. [70] (10.1055/s-0034-1372514)
• [L4] The lack of long-term outcome measurements for these BTB surgeries makes it difficult for the hand surgeon to determine the appropriate use of these treatment modalities, but early reports have indicated that the BTB graft will be an important part of scapholunate dissociation treatment. [71] (10.1016/j.jhsa.2006.11.011)
• [L5] Arthroscopy is considered the gold standard for complete evaluation of scapholunate interosseous ligament injury and often is performed as a first step before repair or reconstruction. [72] (10.5435/00124635-200201000-00006)
• [L5] Strong evidence (level 1 or 2) for management of scapholunate instability in the absence of arthritis is lacking and published recommendations are largely experience-based. [73] (10.1177/1753193412473861)
• [L2] Both surgical groups demonstrated decreased wrist kinematic motion and functional performance compared with individuals with normal wrists. [75] (10.1016/j.jhsa.2015.04.035)
• [L5] A wrist joint should be considered biomechanically unstable when it is not able to bear loads and does not exhibit normal kinematics throughout its arc of motion. [76] (10.1053/jhsu.1999.0866)
• [L5] However, the wrist behaves kinematically consistent but kinetically variable, implying that mechanical behavior is predominantly determined by articular geometry rather than ligament constraints. [77] (10.1002/jor.1100100620)
• [L5] Traction (distraction) changes normal carpal kinematics and motion of the wrist combined with traction induces abnormal patterns of motion. [96] (10.1053/jhsu.1999.jhsu24a0113)
• [L5] Four-dimensional computed tomography (4DCT) is a promising, non-invasive, and affordable method to assess and quantify wrist kinematics, extending conventional CT by incorporating the temporal dimension. [98] (10.1177/17531934251326028)
• [L5] Clinically, a DTM at approximately 30° to 45° from the sagittal plane allows continued functional wrist motion while minimizing radiocarpal motion. [99] (10.1016/j.jhsa.2007.08.014)
• [L5] However, during simple unresisted wrist motions, the force did not exceed 20 N. [100] (10.1016/j.jhsa.2015.04.007)
• [L3] These kinematic changes may predict the development of radioscaphoid arthritis and help identify a kinematically abnormal wrist. [103] (10.1177/17531934241242676)
• [L4] The etiology of abnormal wrist kinematics in the asymptomatic wrist of patients with unilateral tears of the scapholunate ligament is not known. [106] (10.1016/s0363-5023(03)00422-2)
• [L5] Four-dimensional CT complements conventional imaging and arthroscopy by providing functional information on wrist biomechanics and should be used selectively when dynamic instability is suspected and conventional imaging is inconclusive. [108] (10.1530/eor-2026-0051)
• [L5] Scaphoid kinematics are altered considerably in radial-ulnar deviation after division of the TCL. [113] (10.1053/jhsu.2003.50055)
• [L5] A stable wrist can be defined as one which, while being loaded within a physiological range of stress, does not deviate from a stable state of equilibrium at any point within the whole physiological range of motion. [114] (10.1016/s0266-7681(05)80043-9)
• [L4] Scaphoid nonunions have a dramatic impact on carpal kinematics, partially uncoupling the proximal and distal carpal rows. [116] (10.1016/j.jhsa.2008.03.008)
• [L4] The kinematic consequences of resecting the distal scaphoid are different: the flexion-extension motion of the proximal row during deviations is diminished at the expense of increased radioulnar translational motion. [117] (10.1097/00130911-199909000-00004)
• [L5] Most carpal ligaments lengthen only during one half of a full movement cycle, constraining either dorsal- or palmar-directed, or ulnar- or radial-directed motion. [118] (10.1002/jor.1100090509)
• [L4] [124] (10.1007/s11552-008-9155-6)
• [L3] [125] (10.1055/s-0038-1677536)
• [L4] [126] (10.1016/s0749-0712(21)00178-5)
• [L5] [127] (10.1016/j.hcl.2009.05.002)
• [L5] [128] (10.1016/j.hcl.2012.05.001)
• [Case_report] The authors suggest that concomitant scaphoid fracture and SL ligament injury may represent a relative contraindication to this procedure. [129] (10.1007/s11552-012-9463-8)
• [L5] [131] (10.1016/j.jhsa.2004.11.009)
• [L5] Scapholunate ligament tears are rare in skeletally immature people because the force of impact is absorbed by the cartilaginous carpus. [133] (10.1016/s0363-5023(05)80184-4)
• [L4] The RASL procedure is a safe and effective procedure for the treatment of chronic scapholunate dissociation. [134] (10.1016/s0363-5023(10)60091-3)
• [L4] The report strongly suggests that the arthrogram should not be considered a definitive study for the diagnosis of a clinically important injury of a ligament in the wrist. [135] (10.2106/00004623-199508000-00010)
• [L4] [136] (10.1177/17589983241268056)
• [L4] Scapholunate ligament debridement and thermal shrinkage effectively provided pain relief for most of the patients treated. [137] (10.1016/j.jhsa.2005.05.013)
• [L4] [138] (10.1016/s0363-5023(98)80115-9)
• [L4] Volar approach is a feasible and safe procedure to evaluate and treat the volar region of the scapholunate interosseous ligament. [140] (10.1053/jhsu.2003.50020)
• [L5] Scapholunate dissociation can be treated successfully by direct ligament repair and dorsal capsular augmentation. [143] (10.1097/00130911-199803000-00003)
• [L3] Cineradiography has a high diagnostic value for diagnosing scapholunate dissociations. [145] (10.1177/1753193413489056)
• [L4] The LCF is not less efficient than the 4CF in the treatment of SNAC II and III wrist injuries. [149] (10.1186/s12891-024-07755-w)
• [L4] The ANAFAB repair achieved excellent realignment of the carpus with a median postoperative scapholunate gap of 3 mm and recovery of more than 75% of grip strength and range of motion. [152] (10.1177/1753193419886536)
• [L4] There has been no long term deterioration of wrist function. [153] (10.1097/00130911-200109000-00008)
• [L4] The management of chronic scapholunate instability is highly variable among respondents and the choice of either a soft tissue or bony procedure may depend to a large extent on intraoperative findings. [154] (10.1016/j.jhsa.2004.05.008)
• [L2] Treatment of scapholunate injuries grade I with shrinkage is more effective than arthroscopic debridement, and associated with pinning with K-wire is more effective than only arthroscopic debridement and pinning for lesions of grade II and III. [156] (10.1016/j.arthro.2007.03.077)
• [L4] The scapholunate angles averaged 50° in the repair/reconstruction group versus 69° in the non-repair group. [157] (10.1016/0363-5023(93)90410-5)
• [L3] MRI-detectable carpal lesions at the time of the radial fracture are common, but only a few of them seem to decompensate later, give symptoms and became of therapeutic relevance. [158] (10.1007/s00402-015-2357-9)
• [L4] Although fewer in number, repair techniques for isolated volar scapholunate interosseous ligament injuries appear promising with the limited data available. [159] (10.1016/j.jhsg.2023.03.015)
• [L5] [160] (10.1016/j.jhsa.2010.07.015)
• [L4] The goal of this work is to show that arthroscopic classification of scapholunate instability is much more precise and close to the reality than radiographic classification. [161] (10.1016/s0363-5023(03)80340-4)
• [Paper] The study provides an anatomical description of the DCSS and establishes an arthroscopic staging system for scapholunate instability following DCSS sectioning. [162] (10.1055/s-0033-1338256)
• [L4] The RASL procedure is appealing because it specifically focuses on the region of injury, namely the scapholunate joint, and does not violate other carpal bones. [163] (10.1097/00130911-199712000-00007)
• [L3] Therefore, distal scaphoidectomy is recommended in all cases where a badly damaged radiocarpal joint needs to be fused. [166] (10.1016/s0363-5023(03)80413-6)
• [L4] At a minimum of two years of follow-up, patients with acute or subacute symptomatic dissociation of scapholunate ligament instability who underwent arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor treatment had satisfactory results. [167] (10.1186/s13018-023-04148-y)
• [L5] At follow-up 70 months after injury there is no osteonecrosis and the wrist function is almost normal. [168] (10.1016/s0266-7681(05)80175-5)
• [L4] Scapholunate reconstruction procedures are best stratified according to preoperative stages of dissociative instability, injury chronicity, and arthrosis. [170] (10.2106/jbjs.rvw.o.00060)
• [Paper] [171] (10.1016/s0363-5023(09)60081-2)
• [L5] In this cadaveric model, arthroscopically determined Geissler grade was associated with specific anatomic lesions of the scapholunate supporting ligaments. [172] (10.1016/j.jhsa.2015.02.017)
• [L5] [173] (10.1016/0363-5023(90)90003-a)
• [L2] While MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, findings are often discordant when compared with diagnostic arthroscopy. [175] (10.1016/j.jhsa.2024.04.015)
• [Paper] Long-term clinical prospective trials are needed to examine whether scapholunate dysfunction and osteoarthritic changes are prevented by this capsuloligamentous plicature. [177] (10.1016/j.eats.2024.103424)
• [Case_report] In carefully selected cases of severe carpal trauma, acute salvage procedures may be a viable alternative to ORIF and ligament repair/reconstruction. [180] (10.1007/s11552-012-9462-9)
• [L5] [182] (10.1016/j.hcl.2015.04.005)
• [L2] Radiologists demonstrate a low threshold to identify scapholunate ligament injury (SLI) in the setting of distal radius fractures, while the number of SLIs identified by the treating surgeon is a remarkably smaller number. [183] (10.1055/s-0038-1654699)
• [L4] The technique aims to approximate the original anatomy and restore normal carpal mechanics to prevent progression to scapholunate advanced collapse arthritis. [185] (10.1016/j.jhsa.2013.05.026)
• [L4] Surgical repair with augmentation ligamentoplasty is indicated for disabling scapholunate interosseous ligament disruption before the occurrence of static, fixed scapholunate dissociation. [186] (10.1016/j.hcl.2012.05.002)
• [L4] Although the incidence of carpal bone tunnel collapse is unknown, the consequences could be substantial; therefore, patients should be warned of this possibility when discussing complications of ligament reconstruction for chronic scapholunate instability requiring the creation of a bone tunnel. [187] (10.1016/j.jhsa.2023.07.008)
• [L4] The cable augmented, quad ligament scapholunate ligament reconstruction offers theoretical advantages but long term follow up is required. [188] (10.1055/s-0035-1564984)
• [Paper] [189] (10.1016/j.hansur.2016.09.002)
• [L4] [190] (10.1016/j.main.2011.04.007)
• [L4] [192] (10.1007/bf00573451)
• [L5] These results appear to agree with other reports about the stabilizing role of the palmar portion of the scapholunate ligament and suggest that the palmar portion of the ligament should be considered for surgical repair. [195] (10.1016/j.clinbiomech.2011.04.009)
• [L4] The increased scapholunate widening seen on the Twist views has correlated positively, both clinically and with MRI results. [197] (10.1055/s-0038-1673344)
• [L3] Radiographs are moderately reliable and are better at ruling out than ruling in scapholunate dissociation associated with type C fracture of the distal radius. [198] (10.1016/j.jhsa.2013.05.039)
• [L4] The authors do not recommend PRC for the management of scapholunate dissociation in the absence of degenerative changes due to disappointing results compared to other treatments. [200] (10.1177/1753193410382719)
• [L2] 3.0-T MRI of the wrist is moderately sensitive and very specific for detection of complete SLL tears, reducing the need for invasive diagnostic techniques in some cases. [201] (10.1055/s-0032-1333425)
• [L2] Four-dimensional computed tomography aids assessment of chronic scapholunate instability, which allows the differentiation between patients without and those with definite or questionable scapholunate instability. [202] (10.1177/1753193419893890)
• [L4] With a majority of patients experiencing early radiographic failure of the procedure in the short term, our experience suggests that the reduction and association of the scaphoid and lunate procedure should be abandoned despite the relatively low outcomes measures scores. [204] (10.1016/j.jhsa.2014.07.014)
• [L4] For patients followed up for an average of 66 months after surgery, the results, clinically and radiographically, appear to deteriorate in those who place high demands on the wrists on a daily basis. [205] (10.1016/j.jhsa.2006.07.005)

See Also

• Wrist Arthroscopy
• Wrist Ligament Injuries
• Proximal Row Carpectomy
• Scaphoid Fracture
• Carpal Tunnel Syndrome
• SLAC and SNAC Wrist

References

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[4] Diagnostic accuracy of plain radiographs and cineradiography in diagnosing traumatic scapholunate dissociation. Skeletal Radiology. 2007. DOI: 10.1007/s00256-007-0410-7

[6] Posttraumatic scapholunate dissociation detected by wrist cineradiography. The Journal of Hand Surgery. 1984. DOI: 10.1016/s0363-5023(84)80203-8

[7] Scapholunate Ligament Injury Occurring with Scaphoid Fracture – A Rare Coincidence?. Journal of Hand Surgery. 2005. DOI: 10.1016/j.jhsb.2004.09.017

[8] Scapholunate instability: why are the surgical outcomes still so far from ideal?. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934221148009

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