What is a scapholunate ligament injury?
The scapholunate joint is a small joint between two carpal bones at the wrist crease, namely the scaphoid and lunate bones. The scapholunate joint is very important for the stability of the wrist joint. It is often injured during sport, for example, if you fall heavily onto your hand. It can also be injured through chronic overuse, for example, for those who are involved in manual work or lift heavy weights in the gym. It causes localised pain at the wrist, which is often made worse with gripping and weight bearing through the hand, such as during a press-up.
Obtaining the correct diagnosis is essential with scapholunate ligament injuries as a delay or missed diagnosis can result in chronic wrist pain and inability to weight bear through the wrist. Chronic scapholunate ligament injuries can also lead to osteoarthritis. Diagnosis is made using clinical assessment and diagnostic ultrasound. An MRI scan may be required depending on the mechanism and extent of the injury on ultrasound.
Treatment will depend on the severity of the ligament injury. Non-surgical treatment involves physiotherapy, including activity modification, splinting, exercise, and manual therapy. A referral to an orthopaedic surgeon may be required. If the pain does not improve and the ligament injury is a partial tear (not a full tear), then an ultrasound guided steroid injection can be carried out.
What are the symptoms of a scapholunate ligament injury?
The symptoms of scapholunate ligament injury are:
- Pain and swelling at the wrist joint
- Pain aggravated by weight bearing, for example during a press up
- Wrist instability and weakness
What other conditions can mimic scapholunate ligament injury?
If this does not sound like your pain, there are other conditions that can mimic the pain of scapholunate ligament injury, such as:
- Carpal tunnel syndrome
- DeQuervain’s tenosynovitis
- Osteoarthritis of the wrist
- Triangular fibrocartilage complex (TFCC) tear
What is the difference between scapholunate ligament pain and osteoarthritis (OA) of the wrist?
Both scapholunate ligament pain and osteoarthritis of the wrist cause pain at the wrist joint, made worse by putting weight through the wrist, such as leaning on a table.
However, scapholunate ligament pain causes more localised pain on the back of the wrist and is often secondary to a specific incident such as falling onto your hand. Whereas osteoarthritis of the wrist causes more diffuse (less localised) wrist pain and often occurs for no apparent reason. Osteoarthritis of the wrist is also associated with more stiffness and swelling, particularly in the mornings. However, it is important to note that often these conditions co-exist and it is important to differentiate through imaging, such as diagnostic ultrasound.
Anatomy
The wrist is a complex, highly mobile zone comprising of nine bones. The resulting joints articulate with one another to produce the precise, dexterous movements achieved by the wrist and hand.
The wrist complex is made of a series of joints, the radiocarpal joint being the largest. It is created by the radius (long bone of the forearm) and a set of four small known as the proximal carpal row.
The mid carpal joint is created by a series of smaller articulations formed by the eight bones of the carpal rows (the focus of this blog). All the joints which create the wrist complex are surrounded by a common joint capsule. This joint capsule is lined with a lubricating membrane, known as the synovial membrane. This membrane secretes synovial fluid which allows for frictionless movement of the wrist joint.
The mid carpal joints
The proximal carpal row comprises of the following bones:
- Scaphoid
- Lunate
- Triquetrum
- Pisiform
The proximal carpal row in turn articulates with the distal carpal row of the wrist. The articulation between the proximal and distal carpal rows create the mid carpal joint of the wrist.
The distal carpal row comprises of the following bones:
- Trapezium
- Trapezoid
- Capitate
- Hamate
This mosaic of eight carpal bones, which create the mid carpal joint, are attached to one another via a series of small ligaments that stabilise the mid carpal joints during movement.
The Scapholunate joint is formed by the articulation of the scaphoid bone and the lunate bone of the proximal carpal row. It is stabilised by an inter-carpal ligament, known as the scapholunate ligament. Trauma to this ligament has been well documented as the most common cause of radial (Long bone of the forearm leading to the thumb) sided wrist pain (Abe et al., 2006).
Damage to the scapholunate ligament causes the underlying scapholunate joint to become unstable which in turn has been linked with overload of the surrounding mid carpal joints (Abe et al., 2006) and the development of osteoarthritis (Johnson et al. 2013). Scapholunate ligament injury is challenging to diagnose and is often missed or incorrectly diagnosed resulting in chronic wrist pain and instability. It is, therefore, essential, to avoid degenerative changes within the wrist joint, that an accurate diagnosis to made as early as possible to ensure timely treatment is accessed (Coplletta et al., 2020).
How is the scapholunate joint injured?
Scapholunate joint injury occurs predominantly in a young population, mainly of working age and is often linked to trauma. Falling onto an outstretched hand or sustained wrist loading exercising such as weight lifting and gymnastics have been positively cited as common predisposing factors to a scapholunate ligament injury.
What are the symptoms of a scapholunate ligament injury?
Abe et al., (2006) describe scapholunate ligament injury symptoms as;
- Most commonly pain and swelling start after a traumatic event such as falling or a sudden, unexpected movement of the wrist. Often involving a twisting/extension motion.
- Pain during exercise which uses the wrist, including gymnastics or weight lifting.
- Pain which can linger after completing the wrist-based exercise.
- Dull aching sensation in the wrist.
- Pain and tenderness to touch directly over the proximal carpal row of the wrist.
- Pain with twisting and extending the wrist.
How are scapholunate ligament injury diagnosed?
(The below image is an MRI of the wrist the red circle denotes the scaphoid and lunate bones)
As previously discussed, a scapholunate ligament injury is often either missed or incorrectly diagnosed.
Many patients suffering from a traumatic wrist injury attended A&E are imaged using X-ray and sent home with a “soft tissue sprain”. Research has shown X-ray to be highly effective for assessing for scaphoid fractures and degenerative changes such as osteoarthritis however it is not capable of assessing scapholunate ligament injury (Bergh et al., 2012). Bergh et al., (2012) goes further describing MRI as the most appropriate tool for assessing the quality of the scapholunate ligament.
The gold standard imaging tool for assessing the scapholunate ligament is MRI, however, this should be used in conjunction with a clinical assessment (Bergh et al., 2012). With this in mind, if you feel you may have injured your scapholunate ligament you should make an appointment with a physiotherapist or an orthopaedic consultant as soon as possible. If you would like more information or would like to book an appointment please contact us on 0207 4823875 or email injections@complete-physio.co.uk.
A clinical assessment includes an interview and a series of clinical tests which combined help the clinician diagnose the cause of your pain. If a scapholunate ligament injury is suspected then you may be referred for an MRI to confirm your diagnosis.
A clinical assessment includes an interview and a series of clinical tests which combined help the clinician diagnose the cause of your pain. If a scapholunate ligament injury is suspected then you may be referred for an MRI to confirm your diagnosis.
Diagnostic ultrasound imaging
Diagnostic ultrasound imaging is capable of assessing the quality of the ligament and for signs of swelling and inflammation commonly associated with trauma to the scapholunate ligament. The benefits of diagnostic ultrasound include;
- No radiation as with X-ray.
- Short scanning times. The clinician can scan directly over the area of pain quickly and efficiently (a wrist scan often only takes 5 minutes).
- No need to attend the hospital. All clinicians at Complete are fully trained musculoskeletal sonographers (more later).
- Dynamic imaging. The clinician is able to talk to you and direct the scan depending on your symptoms throughout the process. You may be asked to move during the scan to help assess how the scapholunate joint and ligament move (assessing for scapholunate joint stability – instability of the scapholunate joint can be caused by a ligament injury, as previously discussed).
- Diagnostic imaging can be used to accurately direct a needle if an injection is required (again more later).
How is a scapholunate ligament injury treated?
Treatment for a scapholunate ligament injury is dependant on the level damage that has occurred. If the ligament remains intact and the joint remains stable then a short period of immobilisation (wrist brace), icing, rest and a progressive strengthening program (designed by your physiotherapist) will be enough however, if the ligament is ruptured and the underlaying joint is unstable or if conservative treatments have not been successful then an injection of surgical intervention maybe required (Abe et al., 2006).
Tips and tricks, you may like to try
- Avoid aggravating your wrist with movements or activities that cause wrist extension or twisting. This includes racquet sports; weight lifting or press-ups. Continuing to aggravate your wrist could prolong your recovery or can even make your prognosis worse.
- Try wrist support. Use this especially when completing activities such as lifting and carrying. Wearing a brace at night will also help to keep it in a safe, neutral position over night.
- Apply a small bag of peas in a tea towel to the wrist. This can help to reduce pain and inflammation.
- Try applying a topical non-steroidal anti-inflammatory cream. Talk to your pharmacist before using any medication.
What if conservative treatment options don’t work?
In the event that conservative treatment options do not resolve your symptoms it may be appropriate to consider a corticosteroid injection. Corticosteroid injections are regularly used to reduce pain and inflammation associated with injury. This powerful anti-inflammatory medication can be used to control your symptoms allowing you to partake in physiotherapy exercises and therefore, rehabilitate your injury. The current research base reveals steroid injections, guided by ultrasound to be significantly more accurate, cause less complications and are capable of eliciting faster pain relief than Landmark guided injections.
Complete offer a same day service on all ultrasound-guided injections. You do not need to be referred via your GP. We have a team of highly experienced clinicians who are fully qualified medical prescribers, physiotherapists and musculoskeletal sonographers who are able to prescribe and perform an ultrasound-guided injection during your initial assessment. If you would like more information or would like to book an appointment please contact us on 0207 4823875 or email injections@complete-physio.co.uk.
Other Wrist & Hand conditions:
Osteoarthritis (OA) wrist joint
Trigger Finger/thumb
Carpal Tunnel Syndrome
Osteoarthritis of the thumb
Triangular fibrocartilage complex (TFCC)
De Quervain’s Tenosynovitis