lunate fracture orthobullets

The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. immobilization in a long arm thumb spica cast. Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, 23-Year-Old Skateboarder Falls On An Outstretched Arm With A Scapholunate Full-Thickness Tear: All Those Procedures To Repair Don't Work, I Have The Answer: 'RASL' Dazzle: I Am Not Dead Yet, Look At My Long-Term Results - Melvin P. Rosenwasser, MD, Modified Brunelli for Scapholunate Reconstruction, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, Wrist Scapholunate (SL) Ligament Injury in 52M. Barton's fracture: Dorsal intraarticular fracture which is often associated with dislocation at the radiocarpal joint. DISI (dorsal intercalated segmental instability), scapholunate dissociation causes the scaphoid to flex palmar and the lunate to dorsiflex, if left untreated the DISI deformity can progress into a, DISI deformity may also develop secondary to distal pole of the scaphoid excision for treatment of STT arthritis, DISI is a form of carpal instability dissociative, c-shaped structure connecting the dorsal, proximal and volar surfaces of the scaphoid and lunate bones, dorsal fiber thickened (2-3mm) compared to volar fibers, dorsal component provides the greatest constraint to translation between the scaphoid and lunate bones, proximal fibers have minimal mechanical strength, Overview of wrist ligaments and biomechanics, acute FOOSH injury vs. degenerative rupture, age, nature of injury, duration since injury, degree of underlying arthritis, level of activity, pain increased with loading across the wrist (e.g. Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-80825, see full revision history and disclosures, Mayfield classification of carpal instability, dorsal intercalated segment instability (DISI), volar intercalated segment instability (VISI), scaphoid nonunion advanced collapse (SNAC), triangular fibrocartilaginous complex (TFCC) injuries, ulnar-sided wrist impaction and impingement syndromes, calcium pyrophosphate dihydrate deposition disease. The lunate is the fourth most fractures carpal bone (following the scaphoid, triquetrum, and trapezium). Urgent reduction and surgical repair of disrupted ligaments is required to prevent long-term joint dysfunction. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. At the time the article was last revised Craig Hacking had the following disclosures: These were assessed during peer review and were determined to A 76-year-old male sustains a minimally displaced distal radius fracture and undergoes closed treatment with a cast. Lunate. Improved functional outcomes with open reduction internal fixation (ORIF) through FCR approach vs. closed treatment, No difference in radiographic outcomes after ORIF vs. closed treatment, No difference in functional outcomes after ORIF vs. closed treatment, Improved functional outcomes with closed treatment vs. ORIF, Improved functional outcomes with external fixation and K wire fixation vs. ORIF. In the early stages of this disease, the x-rays may be normal and other tests are needed to confirm the diagnosis. Distal Radius Fracture Non-Spanning External Fixator . A fracture to the lunate may also be associated with injury to the TFCC. Alendronate 700mg once per week for 3 months, Alendronate 70mg once per week for 3 months. Four months post-injury, he presents to the office with an inability to extend his thumb. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. He denies any new trauma, and has followed all post-operative activity restrictions. Follow-up/referral. Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Fracture Non-Spanning External Fixator, Distal Radius Fracture Spanning External Fixator, Type in at least one full word to see suggestions list, 7th Annual Frontiers in Upper Extremity Surgery, Nonoperative Treatment of Distal Radius Fractures - Michael Bednar, MD, Dorsal Plating of Radius Fractures - Nader Paksima, DO, MPH, Fragment Specific Fixation Distal Radius Fractures - Mark Rekant, MD, 12th Annual Orthopaedic Trauma: Pushing The Envelope. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. The proximal 2 Cs indicates the articulation between the lunate and . Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. The mechanism of injury is typically a fall onto an outstretched hand with a hyperextended wrist or during a . What is the appropriate surgical treatment at this time? What additional data is most necessary to obtain before a reduction is attempted? Incompetence of which of the following anatomic structures is the most likely etiology of this finding? Unable to process the form. scaphoid is flexed and lunate is extended as scapholunate ligament no longer restrains this articulation, lunate extended > 10 degrees past neutral, resultant scaphoid flexion and lunate extension creates, abnormal distribution of forces across midcarpal and radiocarpal joints, malalignment of concentric joint surfaces, describes predictable progression of degenerative changes from the radial styloid to the entire scaphoid facet and finally to the unstable capitolunate joint, as the capitate subluxates dorsally on the lunate, key finding is that the radiolunate joint is spared, unlike other forms of wrist arthritis, since there remains a concentric articulation between the lunate and the spheroid lunate fossa of the distal radius, Arthritis between scaphoid and radial styloid, Arthritis between scaphoid and entire scaphoid facet of the radius, While original Watson classification describes preservation of radiolunate joint in all stages of SLAC wrist, subsequent description by other surgeons of "stage IV" pancarpal arthritis observed in rare cases where radiolunate joint is affected, validity of "stage IV" changes in SLAC wrist remains controversial and presence pancarpal arthritis should alert the clinician of a different etiology of wrist arthritis, patients localize pain in region of scapholunate interval, tenderness directly over scapholunate ligament dorsally, will not be positive in more advanced cases as arthritic changes stabilize the scaphoid, with firm pressure over the palmar tuberosity of the scaphoid, wrist is moved from ulnar to radial deviation, positive test seen in patients with scapholunate ligament injury or patients with ligamentous laxity, where the scaphoid is no longer constrained proximally and subluxates out of the scaphoid fossa resulting in pain, when pressure removed from the scaphoid, the scaphoid relocates back into the scaphoid fossa, and typical snapping or clicking occurs, obtain standard PA and lateral radiographs, PA radiograph will reveal greater than 3mm diastasis between the scaphoid and lunate, PA radiograph shows sclerosis and joint space narrowing between scaphoid and the entire scaphoid fossa of distal radius, PA radiograph shows sclerosis and joint space narrowing between the lunate and capitate, and the capitate will eventually migrate proximally into the space created by the scapholunate dissociation, thinning of articular surfaces of the proximal scaphoid, scaphoid facet of distal radius and capitatolunate joint with synovitis in radiocarpal and midcarpal joints, NSAIDs, wrist splinting, and possible corticosteroid injections, prevents impingement between proximal scaphoid and radial styloid, may be performed open or arthroscopically via 1,2 portal for instrumentation, since posterior and anterior interosseous nerve only provide proprioception and sensation to wrist capsule at their most distal branches, they can be safely dennervated to provide pain relief, can be used in combination with below procedures for Stage II or III, contraindicated with caputolunate arthritis (Stage III SLAC) because capitate articulates with lunate fossa of the distal radius, contraindicated if there is an incompetent radioscaphocapitate ligament, excising entire proximal row of carpal bones (scaphoid, lunate and triquetrum) while preserving, provides relative preservation of strength and motion, also provides relative preservation of strength and motion, wrist motion occurs through the preserved articulation between lunate and distal radius (lunate fossa), similar long term clinical results between scaphoid excision/ four corner fusion and proximal row carpectomy, wrist fusion gives best pain relief and good grip strength at the cost of wrist motion, - Scaphoid Lunate Advanced Collapse (SLAC), Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). Treatment involves observation, NSAIDs and splinting in early stages of disease. Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. A 51-year-old female presents with an acute inability to extend her thumb, four months after she was treated with cast immobilization for a minimally-displaced distal radius fracture. This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand. The latter mechanism frequently occurs . Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle > 70 degrees. Fracture geometry, particularly a jagged bone spike, can present a physical barrier in closed reduction of pediatric distal radius-ulna fractures. If time has passed since injury, it can also lead to wrist arthritis. When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. He underwent operative fixation by and presents to your clinic for his 2 week follow-up visit. On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. In P_STAR, 2 distraction pins are placed 1.5 cm proximal and distal to the fracture site in clearance of the distal radial physis. These should not be confused with perilunate dislocations in which the radiolunate articulation is . most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). Which of the following injuries is the most likely cause of this finding? Carpal dislocations: pathomechanics and progressive perilunar instability. The lunate is rotated forming a triangular shape commonly known as the "piece-of-pie" sign. The force of injury in this syndrome can propagate leading to perilunate dislocation as . Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . Thieme Medical Pub. Flashcards. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. He was taken to the local teaching hospital where radiographs were taken, shown in Figures A and B. Evaluation of volar compartment pressures with a needle monitor, Icing and elevation of the arm with follow-up evaluation in 8 hours, Immediate EMG evaluation of the left upper extremity, Closed reduction, carpal tunnel release, and sugar tong splinting, Emergent open reduction internal fixation with carpal tunnel release. In very early stages, the treatment can be as simple as observation, activity changes, and/or immobilization. Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. 2.Meenalochani Shunmugam, Joideep Phadnis, Amy Watts, Gregory I. Bain. 3, Greenberg MI. For more advanced stages, surgery is usually considered. Management should consist of. Hip fractures are strongly associated with BMD in the proximal femur, but there are also many clinical predictors of hip fracture risk that are independent of bone density. Multidetector CT of Carpal Injuries: Anatomy, Fractures, and Fracture-Dislocations1. FlashCards My DeckMaster Create Card Deck . A recent imaging study is seen in Figure A. ADVERTISEMENT: Supporters see fewer/no ads. When performed on 18 children with distal radius-ulna fractures, P . The lunate is one of the eight small bones in the wrist. Thank you. During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program? Copyright 2023 Lineage Medical, Inc. All rights reserved. Lunate Dislocation (Perilunate dissociation) . His radiograph is shown in Figure A. Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. A 65-year-old female sustains a fall onto her outstretched right hand. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. Dependent on the fracture-line and the intraosseous vascularity, partial or total avascular . (SBQ17SE.28) The patient now reports increasing pain and inability to use his wrist. (SBQ17SE.13) Thank you. Wrist with Kienbock's disease and ulna that is short compared to radius, Using this search tool means you agree to the, 2023 American Society for Surgery of the Hand, from the American Society for Surgery of the Hand, Decreased motion or stiffness of the wrist. Radiographs are provided in Figure A. 2.0 screw for a Scaphoid Hand Fracture How to palpate the . Depressed fracture of the lunate fossa (articular surface) Smith's. What is this structure? Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. Lunate fractures account for around 4% of all carpal fractures 1. The lunate is made up of the volar pole, body, and dorsal pole. Terry Thomas sign: This is seen on an AP wrist film and is indicated by a gap >3mm between the scaphoid and lunate bones Cortical Ring sign: occurs when the scaphoid is in a flexed position, making the scaphoid tubercle more prominent.A measure distance less than 7mm between the end of the cortical ring and the proximal end of the scaphoid suggests scapholunate dissociation and instability. Which of the following radiographic views shown in Figures A to E would be most helpful in establishing the diagnosis? toe phalanx fracture orthobullets Epidemiology. How do you counsel him about his post-operative period? (OBQ11.273) A 68-year-old male falls onto his outstretched hand and suffers the injury shown in Figures A and B. A 25-year-old female falls from her horse and injures her left wrist. SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. What is the next most appropriate step in management? Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. The lunate is an important stabilizer of the wrist . There is no median nerve paresthesias. Failure to support the lunate facet with fragment specific fixation, Use of only three bicortical screws in the intact radial shaft proximally. Which of the following has evidence to support its utility in this clinical situation? His physical exam shows dorsal wrist tenderness and is positive for the provocative test shown in Figure V. Standard PA radiograph of the wrist is normal. Diagnosis is confirmed with either a radiographic carpal tunnel view or CT scan. Twelve months after open reduction and internal fixation of a comminuted distal radius fracture as seen in Figure A and B, which of the following tendons is at greatest risk of rupture? A 35-year-old professional football player complains of severe wrist pain after making a tackle. Capitate fractures account for 1-2% of all carpal fractures 1,2. Rathachai Kaewlai, Laura L. Avery, Ashwin V. Asrani, Hani H. Abujudeh, Richard Sacknoff, Robert A. Novelline. A four-stage process to describe perilunar instability has been described,where lunate dislocation represents stage IV 2. disruption of the normally smooth line made by tracing the proximal articular surfaces of the hamate and capitate, lunate overlaps the capitate and has a 'triangular' or 'piece of pie' appearance (also seen in perilunate dislocation), signet ring sign: rounded appearance of the scaphoid tubercle due to rotatory subluxation from injury to the scapholunate ligament, lunate seen displaced and angulated volarly, lunate does not articulate with capitate or radius (as opposed to perilunate dislocation where the lunate remains aligned with the radius). Radiographs show a well-fixed fracture in good alignment. (SBQ17SE.64) Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. - it differs from Colles' or Smith's Fracture in that the dislocation is the most striking radiographic finding; - volar Barton's is more common than dorsal Barton frxs; - mechanism: - usually result from a fall upon an outstretched arm, leading to dorsiflexion stress and tension failure of volar lip of radius; (OBQ06.136) Clifford R. Wheeless, III, M.D. (OBQ08.179) What is the most appropriate next step in management? It rarely affects both wrists. (OBQ13.140) Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. Kienbocks disease is also known as avascular necrosis (AVN) of the lunate. What complication is most likely to occur in this patient? Patients often prefer to hold their fingers in partial flexion due to pain on extension. (OBQ06.102) Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. When he finally does, he is diagnosed with a perilunate dislocation and indicated for a Proximal Row Carpectomy (PRC). The most important differential is of other carpal dislocations, particularly: In addition to stating that a lunate dislocation is present, a number of features should be sought and commented upon: ensure that radiolunate alignment is disrupted, and that you are not looking at a perilunate dislocation(stage II carpal dislocation), evaluate and comment on the degree or palmar rotation of the lunate (this can be up to 270 degrees)4, ensure that the capitate remains co-linear with the long axis of the radius, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. tures, specically non-union of scaphoid fractures. Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. The instrument touches a structure that prevents ulnar translocation of the carpus after a PRC. - knowing position of ECU & ulnar styloid helds to differentiate ECU tendinitisfrom distal radioulnar problems. Radiographs taken in the emergency room are seen in Figure A. Like the scaphoid bone, the lunate also has a tenuous retrograde blood supply off of an interosseus arterial branch, and it has the same inherent risk of poor healing and AVN . (OBQ18.177) Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. Wheeless' Textbook of Orthopaedics. Capitate fractures are typically seen with associated scaphoid fractures, distal radial fractures, or lunate injuries; they are rarely seen in isolation. Which of the following factors has been associated with redisplacement of the fracture after closed manipulation? Thank you. (OBQ09.227) Radiographs obtained at the time of injury are shown in Figure A. (SBQ17SE.47) (SBQ07SM.38) 2020 American Society for Surgery of the Hand. (OBQ16.228) Find a hand surgeon near you. - deviation of more than 15 deg either way between the links of chain may be viewed as lax, diseased, or damaged; - Exam: Figure A is an intraoperative photo. Philadelphia : Lippincott Williams & Wilkins, c2005. There may be other associated injuries that require further investigation via cross-sectional imaging 1,2. It can be difficult to diagnose in its earlier stages. 2. The lunate is made up of the volar pole, body, and dorsal pole. Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. He is not able to see a physician for 4 months. Most hand and wrist fractures (the latter of which is basically an ulnar styloid fracture) are caused by trying to break a fall with your arm outstretched. Worse outcomes on the Mayo wrist score are expected without fixation, Chronic distal radioulnar joint instability can be expected to occur without fixation, Wrist function depends on the level of ulnar styloid fracture and initial displacement, Grip strength and wrist range of motion are improved with fixation, There is no adverse effect on wrist function or stability without fixation. You can rate this topic again in 12 months. toe phalanx fracture orthobulletsdaniel casey ellie casey. (OBQ07.8) Scaphoid Lunate Advanced Collapse (SLAC) d. escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. Treatment requires urgent closed versus open reduction and stabilization. Hand therapy does not change the course of the disease; however, it can help to minimize loss of motion from the disease. Which of the following interventions should be taken? This is an AAOS Self Assessment Exam (SAE) question. The injury is closed and she is neurovascularly intact. Telephone: 410.494.4994, Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius, Difficult wrist fractures. Electromyography and nerve conduction velocity studies, AP and lateral radiographs of the forearm, (SAE07SM.78) A normal wrist without Kienbock's disease. Perilunate fracture-dislocations of the wrist. not be relevant to the changes that were made. - it is palpable just distal to radial tubercle; proximally and the capitate distally. The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. Chronic DISI deformities may be indicated for fusion procedures depending on degree of arthritis and patient symptoms. dorsal fractures commonly axial fracture healing. (OBQ12.105) Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. Classification. A 64-year-old female sustains a nondisplaced distal radius fracture and undergoes closed treatment using a cast. Treatment requires urgent closed versus open reduction and stabilization. Wrist Dislocation by Kadeer M Halimi from emedicine.com. A 32-year-old inebriated male falls from a mechanical bull at a bar and sustains a closed displaced intra-articular distal radius fracture. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. The lunate is displaced and rotated volarly. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. sudden impact force applied to the hand and wrist causing SLIL injury and scapholunate dissociation, injury occurs most commonly with wrist positioned in extension, ulnar deviation and carpal supination, SLIL tearing will position the scaphoid in flexion and lunate extension. Changes for Fat Loss by with a free trial. Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? MR arthrogram of the wrist to assess ligamentous injuries, Type in at least one full word to see suggestions list, Transscaphoid perilunate fracture dislocation management, AO Trauma Hand: Must Know Series HOW I DO IT Perilunate FX-Dislocations, Open reduction of volar lunate dislocation (through dorsal Cape Town approach), Hand Lunate Dislocation (Perilunate dissociation), University of Illinois Orthopaedic Surgery, Lunate Dislocation and Acute Carpal Tunnel Syndrome in 23M. A fracture to the lunate may also be associated with injury to the TFCC. Perilunate dislocations typically occur in young adults with high energy trauma resulting in the loading of a hyperextended, ulnarly deviated hand. A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. Dorsally displaced, extra-articular fracture. Summary. Which of the regions on the patient's injury AP radiograph in Figure A, if not addressed properly during surgery, represents a risk for radiocarpal instability? What is the most likely etiology of her new loss of function? A 32-year-old professional baseball player presents with wrist pain after a fall on his outstretched wrist 10 days ago. Radiographs of the affected wrist are shown in Figure A. Adhesions within the first and third dorsal wrist compartments. push up position), may be associated with wrist instability or weakness, may see swelling over the dorsal aspect of the wrist, tenderness in the anatomical snuffbox or over the, pain increased with extreme wrist extension and radial deviation, when deviating from ulnar to radial, pressure over volar aspect of scaphoid subluxates the scaphoid dorsally out of the scaphoid fossa of the distal radius, and a clunk is palpated when pressure is released as the scaphoid reduces back over the dorsal rim of the radius, a painful clunk during this maneuver may indicate insufficiency of scapholunate ligament, clenched fist (can exaggerate the diastasis), dorsal tilt of lunate leads to SL angle > 70, may be used as screening tool for arthroscopy, always assess the contralateral wrist for comparison, may demonstrate the presence of a tear but cannot determine the size of the tear, positive finding of a tear may indicate the need for wrist arthroscopy, often overused as a screening modality for SLIL tears, requires careful inspection of the SLIL by a dedicated radiologist to confirm diagnosis, Carpal instability nondissociative (CIND), splinting and close follow-up with repeat imaging and clinical response with acute injuries, most people feel casting alone is insufficient, acute scapholunate ligament injury without carpal malalignment, ligament pathoanatomy is ammenable to repair, if pathoanatomy of SL ligament injury is a scaphoid fx than repair with, small incision is made just distal to the radial styloid, care to avoid cutting the radial sensory nerve branches, often added to a ligament repair and remains a viable alternative for a chronic instability when ligament repair is not feasible, place two k-wires in parallel into the scaphoid bone, reduce the SL joint by levering the scaphoid into extension, supination and ulnar deviation and lunate into flexion and radial deviation, confirm reduction of the SL joint under fluoroscopy, FCR tendon transfer (direct SL joint reduction), ECRB tendonosis (indirect SL joint reduction), weave not recommended due to high incidence of late failure.

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